Quick Overview of CMS Perspective

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• CMS Strategy and Challenges

• CMS Quality Reporting Programs

- Hospital Setting

• Future Directions

OUR STRATEGIC GOALS

CMS Quality Reporting and Performance Programs

Hospital Quality

•Medicare and Medicaid EHR Incentive Program

•PPS-Exempt Cancer Hospitals

•Inpatient Psychiatric Facilities

•Inpatient Quality Reporting

•HAC payment reduction program

•Readmission reduction program

•Outpatient Quality Reporting

•Ambulatory Surgical Centers

Physician Quality Reporting

•Medicare and Medicaid EHR Incentive Program

•PQRS

•eRx quality reporting

PAC and Other Setting Quality Reporting

•Inpatient Rehabilitation Facility

•Nursing Home Compare Measures

•LTCH Quality Reporting

•ESRD QIP

•Hospice Quality Reporting

•Home Health Quality Reporting

Payment Model Reporting

•Medicare Shared Savings Program

•Hospital Value-based Purchasing

•Physician Feedback/Value-based Modifier

“Population” Quality Reporting

•Medicaid Adult Quality Reporting

•CHIPRA Quality Reporting

•Health Insurance Exchange Quality Reporting

•Medicare Part C

•Medicare Part D

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Hospital Acquired Conditions and the Affordable Care Act

• Public reporting of HAC rates in Hospital

Compare by 2015

• Adjustment to payments for HAC, FY 2015

– 1% decrease for high rates (risk adjusted)

– top quartile compared to national average

– finalized criteria for ranking

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13 Clinical Process of Care Measures 8 Patient Experience of

Care Dimensions 1. AMI-7a Fibrinolytic Therapy Received within 30

Minutes of Hospital Arrival

2. AMI-8 Primary PCI Received within 90 Minutes of Hospital Arrival

3. HF-1 Discharge Instructions

4. PN-3b Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital

5. PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient

6. SCIP-Inf-1 Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision

7. SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients

8. SCIP-Inf-3 Prophylactic Antibiotics Discontinued within 24 Hours After Surgery

9. SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6 a.m. Postoperative Serum Glucose

10. SCIP–Inf–9 Postoperative Urinary Catheter Removal on Postoperative Day 1 or 2.

11. SCIP-Card-2 Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period

12. SCIP-VTE-1 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered

13. SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours

3 Mortality Measures

1. MORT-30-AMI Acute Myocardial Infarction (AMI) 30-day mortality rate

2. MORT-30-HF Heart Failure (HF) 30-day mortality rate

3. MORT-30-PN Pneumonia (PN) 30-day mortality rate

Represents a new measure for the FY 2014 Program not in the FY 2013 Program.

Domain Weights

1. Nurse Communication

2. Doctor Communication

3. Hospital Staff Responsiveness

4. Pain Management

5. Medicine Communication

6. Hospital Cleanliness and Quietness

7. Discharge Information

8. Overall Hospital Rating

Hospital Readmissions Reduction Program

• FY 2014, Based on readmissions for AMI, HF and Pneumonia

– Algorithm introduced to account for planned readmissions

• In FY2015, adding 3 conditions

– Acute exacerbation of chronic obstructive pulmonary disease

– Elective total hip arthroplasty

– Total knee arthroplasty

• Applies to hospital’s base DRG payments for Medicare discharges starting October 1, 2012

– FY 2014 no more than 2% reduction

– FY 2015 no more than 3% reduction

– Calculation methodology finalized in rule-making

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partnershipforpatients.cms.gov

40% G O A L S :

20%

Reduction in Preventable Hospital- Acquired Conditions 1.8 Million Fewer Injuries | 60,000 Lives Saved

Reduction in 30-Day Readmissions

1.6 Million Patients Recover without Readmission

$35 Billion Dollars Saved

Status: • Over 3700 hospitals have signed the pledge • Hospital readmission rates down from 18.9% to 17.7% in first year

(unpublished data)

Results Being Seen Nationally

• Cost trends are down

• Outcomes are improving

• Adverse events are falling

Medicare Per Capita Spending Growth at Historic Lows

Source: CMS Office of the Actuary

9.24%

5.99%

4.63%

7.64% 7.16%

*27.59%

1.98%

4.91%

4.15%

1.36%

2.25%

1.13% 0.35%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

12%

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Medicare Per Capita Growth Medical CPI Growth

*Medicare Part D prescription drug

benefit implementation, Jan 2006

Medicare FFS 30-Day All-Cause Readmission Rate, January 2010-May 2013 (all hospitals)

Reducing Early Elective Deliveries Nationally Improvement from Baseline

Source: August 2013 HEN Submissions. Baseline and Current time periods vary by HEN.

0

0.5

1

1.5

2

2.5 41 %

Reduction

1.133

CLA

BSI

s p

er

1,0

00

ce

ntr

al li

ne

day

s

Quarters of participation by hospital cohorts, 2009–2012

Over 1,000 ICUs achieved an average 41% decline in CLABSI over 6 quarters (18 months), from 1.915 to 1.133 CLABSI per 1,000 central line days.

National Bloodstream Infection Rate

Physician-Based Strategies

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• CMS’ Physician “Toolbox” − Physician Quality Reporting System (PQRS) − ePrescribing Program − EHR Incentive Program − Value Based Payment Modifier (VM) − Accountable Care Organizations − Comprehensive Primary Care initiative

• Progress and Next Steps

• Questions and Comments

CMS Innovations Portfolio: Testing New Models to Improve Quality

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Marketplace

Delivery system and payment transformation

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PUBLIC

SECTOR

Future State – People-Centered Outcomes Driven Sustainable Coordinated Care New Payment Systems (and many more) Value-based purchasing ACOs, Shared Savings Episode-based payments Medical Homes and care mgmt. Data Transparency

Current State – Producer-Centered Volume Driven Unsustainable Fragmented Care FFS Payment Systems

PRIVATE

SECTOR

San Francisco Regional Office

Centers for Medicare & Medicaid Services

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Betsy L. Thompson, MD, DrPH Regional Chief Medical Officer

415-744-3631 Betsy. Thompson@cms.hhs.gov