Transcript The Delmarva Team has National Experience

Transparency in the QIO 9th Scope of
Work: Beyond Hospital Compare
Nancy Jane C. Friedley, MD
Medical Director
Delmarva Foundation
May 9, 2008
Delmarva Foundation
Introductions
Delmarva Foundation
Overview
Objectives:
 1) Understand the basic outline of the QIO 9th
SOW
 2) Understand the various CMS comparison tools
for transparency
 3) Understand the PQRI reporting system, how it
works and why it is important to have physicians
involved
Delmarva Foundation
Transparency in the QIO 9th Scope of
Work: Outline

Introduction to Delmarva and the QIO

Evolution of Quality Improvement and Cost Containment at the Centers for
Medicare and Medicaid Services (CMS)
 1965-1986
 1986-1999
 1999-2008

The Quality Improvement Organizations’ 9th Scope of Work 2008-2011
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Impetus for Change
Goals
Process
Translating Process to Outcomes
Measures
Evaluation
Transparency: Online Information about Quality and Cost
PQRI: Encouraging Physicians to Embrace Transparency
Delmarva
‘Call to get a level…’
Delmarva Foundation
Delmarva’s Impact Across the United States
External Quality Review
Medicare Quality Improvement Organization
Maryland Patient Safety Center
Medicare Quality Improvement Organization
External Quality Review (Washington, DC)
Statewide Quality Assurance Program
for Developmentally Disabled
External Quality Review for Medicaid
Program Safeguard Contract
Western Integrity States
Medicare+Choice Quality Assurance/
Performance Improvement Project
Delmarva Foundation
Organizational Structure of Delmarva
Quality Health Strategies, Inc.
Christian Jensen
President and CEO
Delmarva Foundation
for Medical Care
Delmarva Foundation
of the District of
Columbia
HealthWatch
Health Integrity
Quality Health Foundation
Delmarva Foundation
Quality Improvement Organizations in
Maryland and the District of Columbia
 Delmarva Foundation for Medical Care, Inc. (DFMC)
is the CMS-contracted Quality Improvement
Organization (QIO) for Maryland
 Delmarva Foundation of the District of Columbia
(DFDC) is the CMS-contracted QIO for DC
Delmarva Foundation
What is a QIO?
 The Centers for Medicare and Medicaid Services contracts with
one organization in every state, the District of Columbia, Puerto
Rico, and the Virgin Islands to promote safer and more effective care
in hospitals, physician practices, nursing homes, home health
agencies, health plans, pharmacies, and prescription drug plans.
 QIOs provide a range of services for the protection of the nation’s 42
million Medicare beneficiaries
Delmarva Foundation
What Does the QIO Do?
The primary goal of the QIO is to accelerate the diffusion of
evidence-based medicine from the bookshelf to the
bedside. As a community resource, the QIO serve as a
national infrastructure that helps doctors, hospitals, home
health agencies and nursing homes utilize best practices
to improve care.
CMS
Delmarva Foundation
Delmarva Foundation
What Does the QIO Do?
 Improves health care quality through interventions whose
impact on outcomes can be measured
 Provides technical support, mentoring, education and
training
 Works with providers to help them reach specific clinical
goals
 Helps providers collect and publicly report data on
performance measures to prompt improvement
Delmarva Foundation
How Has the QIO Improved Quality?
Increase use of life-saving drugs for MI patients
 Make surgery safer by reducing infection rates
 Improve nursing home care by ensuring limited
use of restraints
 Support home health care to help patients stay
out of the hospital

Delmarva Foundation
Evolution of Quality Improvement and Cost
Containment at CMS
1965-1986
Delmarva Foundation
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS

1965: Medicare legislation


Seniors and the disabled
1966: HCFA (now CMS) sets standards for
hospitals that wish to be reimbursed for Medicare
beneficiaries’ care
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS

1971: EMCROs (Experimental Medical Care Review
Organizations)
 Voluntary physician groups
 Grant funded
 Individual cases for Utilization Review

1972-1982: PSROs (Professional Standards Review
Organizations)
 Medical Necessity
 Professional Standards
 Effectiveness and ‘Economics’ of Care
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS

1982: PROs (Peer Review Organizations)
 Utilization and Quality Control
 Beyond local norms
 More federal oversight
 Funding from Medicare Trust Fund

1983: PPS (Prospective Payment System)
introduced (Maryland is waived)
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS
1984-1986
1st SOW
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Era of PRO vs. Providers continues
PROs are focused on “inspecting and detecting” and
sanctioning providers
1st SOW emphasizes financial sanctions on physicians for
inappropriate admissions
Prospective Payment System (PPS) using DRGs raises
concerns about early discharges and readmissions
Delmarva Foundation
Evolution of Quality Improvement and Cost
Containment at CMS
1986-1999
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS
1986-1993
2nd and 3rd SOW
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Medicare Managed Care Organizations
Concerns arise that Medicare MCOs subject providers to
financial incentives to under use services
1986 OBRA: PROs to extend review to other settings
Delmarva Foundation
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS
1986-1990
PRO Problems with Providers
 Punitive
with no positive incentives
 Adversarial
 Redundancy with other programs
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS
1990
Institute of Medicine Report on PRO Program
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Potentially valuable infrastructure
Improve and build on PROs
New priorities
 Emphasize quality review and assurance over UR and cost
control
 More attention to average practice patterns than outliers
 Include additional healthcare settings
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS
1990
IOM Recommendations to QIOs
Undergo ‘self-assessment’
 Demonstrate impact on quality of care for Medicare
beneficiaries
 Include critical provider input
 Develop criteria for evaluation that is objective and
well-vetted
 Have access to a Technical Advisory Panel *

Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS
Late 1980’s-early 1990s

Continuous Quality Improvement:

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According to the principles of continuous quality
improvement, there is no minimum acceptable
level; processes can always be improved.
1991: The Institute for Healthcare
Improvement (IHI) is founded.
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS
1992
Jencks and Wilensky

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Recommended a dramatic course change from
retrospective review that identified a few poor performers
to prospective improvement in quality of care for all
providers
Health Care Quality Improvement Initiative
 Focus on practice patterns and care outcomes at the
institutional and national levels
 Develop practice guidelines
 Initiate Cooperative Cardiovascular Project for AMI
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS
1993-1996
PRO 4th SOW
PROs Evolve
 National quality improvement projects on
Heart Failure and Diabetes
 Emphasis shifts to collaboration between
governments, providers, and consumers
 Data collection methods improve
Delmarva Foundation
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS
1996-1999
PRO 5th SOW
 National Health Care Quality Improvement
Projects (HCQIP)
 HCFA-directed for statewide impact
 Local needs assessments
 Measurable indicators
 Beneficiary protection and complaints
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS
Delmarva Foundation
Evolution of Quality Improvement and Cost
Containment at CMS
Communications
Delmarva Foundation
Evolution of Quality Improvement and Cost
Containment at CMS
1999-2008
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS
1999-2002
PRO 6th SOW
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National HCQIP
Specific disease topics
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AMI, CHF, Pneumonia, Stroke, DM, Breast Cancer
Local projects
Expand beyond acute care
New projects for managed care
Beneficiary Protection (payment error)
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS

2002-2005
7th SOW: ‘PRO’ becomes ‘QIO’
Specific topics with standardized indications for each
setting
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NH, HH, Hospital (AMI, HF, Pneumonia, Surgical infections),
Physician office (DM, Cancer, Immunization)
Projects for underserved and rural populations
Projects for Medicare managed care
Information and Communication

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Hospital-generated performance data
QIO Data Warehouse
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS
2005-2008
QIO 8th SOW
Developing capacity for and achieving
excellence
 Tasks still divided by setting of care
 Physician office expanded to include
underserved, Part D, and HIT
 Beneficiary Protection continues

Delmarva Foundation
Quality Improvement and Cost
Containment at CMS?
Delmarva Foundation
Evolution of Quality Improvement and
Cost Containment at CMS
2008-2011
QIO 9th SOW
Based on all that went before and more…
Delmarva Foundation
Impetus for Change
Delmarva Foundation
Impetus for Change

Improving the Medicare Quality Improvement Organization
Program, 2006 Institute of Medicine (IOM) report to Congress

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Focus more on quality improvement and performance
measurement
Prioritize program resources so that QIO can help providers who
demonstrate the most need, or who face significant challenges
delivering quality care
Strengthen organizational structure and governance of the QIO
Strengthen management of the QIO program by CMS
Strengthen the evaluation system for the QIO program
Delmarva Foundation
Impetus for Change
Nursing Home Report

Nursing Homes: Federal Actions Needed to Improve Targeting
and Evaluation of Quality Improvement Organizations, 2007
Government Accountability Office (GAO) report
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Increase the number of low-performing nursing homes that QIO
assists intensively
Direct QIO to focus intensive assistance on those quality-of-care
areas in which nursing homes most need improvement
Collect more complete and detailed data on the methods QIO are
using to assist nursing homes and the impact that these methods
have on quality of care
Identify a broader spectrum of publicly reported quality
measures to evaluate changes in nursing home quality.
Delmarva Foundation
Result: Transparency

December 2007: CMS publishes its first ever nationwide
list of poor-performing nursing homes.

Poor-performers display what CMS calls a "yo-yo"
compliance history of providing consistently poor care,
while instituting just enough improvement to pass their
next survey.

These 128 out of 16,000 nationwide nursing homes are
subject to double inspections by state health officials and
risk losing their eligibility to receive Medicare or
Medicaid reimbursements.
Delmarva Foundation
QIO 9th SOW: Overview
Delmarva Foundation
QIO 9th SOW: Overview

Traditional perspectives of care from the hospital,
nursing home, home health, physician office are removed.
Quality Improvement in the QIO 9th SOW
revolves around the patient not the health
care setting or provider.
 Quality Improvement must occur across the
continuum of care.

Delmarva Foundation
QIO 9th SOW: Overview
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Levels
 4 Themes, 10 Components, to 59 Measures, and
beyond
Topic-oriented, not setting oriented
Cross-cutting themes (HIT, disparities, and VDHC)
Outcomes oriented
Patient-centered
 245,000 more patients screened for CKD
 40,000 fewer pressure ulcers
 20,000 more adult immunizations provided
Delmarva Foundation
QIO 9th SOW: Overview
National
 Sub-national
 Special Projects

QIO 9th SOW: Goals
6 Aims
10 Rules
4 Priorities
4 Design Principles
3 Objectives
Delmarva Foundation
QIO 9th SOW: Goals
CMS’ Six Aims for Redesign of
Healthcare Services
 Safe
 Timely
 Effective
 Efficient
 Equitable
 Patient-centered
Delmarva Foundation
Delmarva Foundation
QIO 9th SOW: Goals
CMS’ Ten Rules for Redesign of ClinicianPatient Interactions
 Care based on continuous healing relationships
 Care customized according to patient needs and values
 Patient as the source of control
 Knowledge is shared and information flows freely
 Evidenced-based decision making
 Safety is a system property
 Transparency (we’ll come back to this…)
 Needs are anticipated
 Waste is continuously decreased
 Cooperation among clinicians is a priority
Delmarva Foundation
QIO 9th SOW: Goals
4 Priorities

To improve the health care system through the
application of the HHS/CMS priorities of
 person-centered
care,
 reducing disparities,
 preventing disease, and
 preventing re-hospitalization.
Delmarva Foundation
QIO 9th SOW: Goals
4 Design Principles
More effective management
 Measurement accountability
 Relevance to CMS and DHHS
 Value-Driven Health Care (VDHC)
 Disparities Reduction
 Health Information Technology (HIT)
 Careful evaluation with attribution

Delmarva Foundation
QIO 9th SOW: Goals
3 Objectives

At heart, the goals are to help providers
accomplish the following objectives:
 Prevent
illness
 Decrease harm to patients
 Reduce waste in healthcare
Delmarva Foundation
QIO 9th SOW: Process
3 Business Principles
4 Criteria for Interventions
4+ Overarching Themes -> 200-300 Detailed
Measures
Delmarva Foundation
QIO 9th SOW: Process
3 Business principles
 Focus resources
 Allocate the most resources to the most
capable organizations (introduce competition
and reward good contractor behavior)
 Measure important parameters continuously
during contract management
Delmarva Foundation
QIO 9th SOW: Process
Use interventions that meet the following
criteria:
Employ a well designed, valid, and reproducible
measurement system
 Require standardization, built on 8th SOW base
 Allow the QIO to link interventions to outcomes
 Can be continuously monitored by CMS Central
Office and Regional Offices

Delmarva Foundation
QIO 9th SOW: Process
Emphasize evidence-based and cost-effective
care
 Intervene to prevent and/or slow disease
progression
 Focus on early testing, effective, and timely
interventions

QIO 9th SOW: Translating Process to
Outcomes
‘Themes’
Delmarva Foundation
QIO 9th SOW: Translating Process to
Outcomes
4 Themes (+ Evaluation)
 10 Components
 44 Final Measures
 59 Total Measures
 15 18-month and 44 28-month (Final)
Measures
 200 to 300 Detailed Measures
 Schedule of Deliverables

Delmarva Foundation
QIO 9th SOW: Translating Process to
Outcomes
10 Components
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Prevention (3)
 Core
 Focused disparities
 Chronic Kidney Disease (CKD)
Patient Safety (5)
 Pressure Ulcers
 Physical Restraints
 SCIP (Surgical Care Improvement Project)
 MRSA (Methicillin Resistant Staphylococcus Aureus)
 Drug Safety
Care Transitions (1)
Beneficiary Protection (1)
Delmarva Foundation
QIO 9th SOW: Measures
10 Components




Prevention (3)
 Core
 Focused disparities
 Chronic Kidney Disease (CKD)
Patient Safety (5)
 Pressure Ulcers
 Physical Restraints
 SCIP (Surgical Care Improvement Project)
 MRSA (Methicillin Resistant Staphylococcus Aureus)
 Drug Safety
Care Transitions (1)
Beneficiary Protection (1)
Delmarva Foundation
QIO 9th SOW: Measures
Prevention
 Prevention efforts will emphasize evidence based and
cost-effective care proven to prevent and/or slow the
progression of disease.
 Adult immunizations – flu, PN
 Cancer screening – mammography, colorectal cancer
 Chronic kidney disease
 Focused disparities – diabetes
Delmarva Foundation
QIO 9th SOW: Measures
Prevention

Prevention (10 measures)
 Core (4)
 Mammography screening
 CRC screening
 Influenza vaccination
 Pneumococcal pneumonia vaccination
 Focused disparities: Diabetes (3)
 A1C rates
 Lipid examination rates
 Eye exam rates
Delmarva Foundation
QIO 9th SOW: Measures
Prevention

CKD (3)
 Screening for nephropathy
 ACE/ARB therapy to prevent progression
 AV fistula rate (new dialysis patients)
Delmarva Foundation
QIO 9th SOW: Measures
10 Components




Prevention (3)
 Core
 Focused disparities
 Chronic Kidney Disease (CKD)
Patient Safety (5)
 Pressure Ulcers
 Physical Restraints
 SCIP (Surgical Care Improvement Project)
 MRSA (Methicillin Resistant Staphylococcus Aureus)
 Drug Safety
Care Transitions (1)
Beneficiary Protection (1)
Delmarva Foundation
QIO 9th SOW: Measures
Prevention: Core


Goal is to use Electronic Health Records (EHRs) to
report and improve the following
 Colorectal Cancer (CRC) Screening *
 Mammography Screening
 Influenza Vaccination
 Pneumococcal Vaccination
Target will be clinical offices with EHR capability
Delmarva Foundation
QIO 9th SOW: Measures
10 Components




Prevention (3)
 Core
 Focused disparities
 Chronic Kidney Disease (CKD)
Patient Safety (5)
 Pressure Ulcers
 Physical Restraints
 SCIP (Surgical Care Improvement Project)
 MRSA (Methicillin Resistant Staphylococcus Aureus)
 Drug Safety
Care Transitions (1)
Beneficiary Protection (1)
Delmarva Foundation
QIO 9th SOW: Measures
Prevention: Focused Disparities
Emphasize preventive care for underserved
population with diabetes
 Based on evidence collected in research trials
and a special study in the 8th SOW—“Every
Diabetic Counts”
 Will be awarded to a QIO based on population
and need

Delmarva Foundation
QIO 9th SOW: Measures
Disparities
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Data
 Find affected individuals
Providers
 Sensitize providers (continued work from the 8th
SOW)
Interventions
 Use proven interventions, develop effective
partnerships, and help CMS programs be responsive
to need
Messaging
 Get the message out
Delmarva Foundation
QIO 9th SOW: Measures
Disparities
Cross-cutting across the themes
 Data collection on all measures for race,
ethnicity, and zip code
 Analytic report on disparities: findings and
impact of intervention on outcomes

Delmarva Foundation
QIO 9th SOW: Measures
Prevention: Focused Disparities
 Sub-national
 33 states/territories (DC & MD) identified by CMS
 Goal: Improve diabetes measures (HbA1c, eye exam,
lipid, BP) through community-based Diabetes SelfManagement Education (DSME)
 Outcomes measured by CMS FFS claims (utility) and
Physician Quality Reporting Initiative (PQRI) clinical
data (we’ll come back to this, too…)
Delmarva Foundation
QIO 9th SOW: Measures
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
Prevention (3)
 Core
 Focused disparities
 Chronic Kidney Disease (CKD)
Patient Safety (5)
 Pressure Ulcers
 Physical Restraints
 SCIP (Surgical Care Improvement Project)
 MRSA (Methicillin Resistant Staphylococcus Aureus)
 Drug Safety
Care Transitions (1)
Beneficiary Protection (1)
Delmarva Foundation
QIO 9th SOW: Measures
Prevention: CKD
Sub-national
 Optional competitive task
 Will be awarded to a subset of QIOs

Delmarva Foundation
QIO 9th SOW: Measures
Prevention: Chronic Kidney Disease
 Detect the incidence and decrease the progression of
CKD
 Provide implementation of clinical tools
Educate beneficiaries on risk factors
Disseminate tools and resources to providers and
beneficiaries
Work to make a lasting impact on prevention and
management of CKD
 Work collaboratively with organizations
 Reduce rate of progression to CKD
Delmarva Foundation
QIO 9th SOW: Measures
Prevention: CKD
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Timely recognition of microscopic proteinuria in
diabetics to reduce rate of kidney failure
Slow progression of kidney disease in persons with
diabetes
 Angiotensin Converting Enzyme (ACE) inhibitor
 Angiotensin Receptor Blocking (ARB) agent
Arteriovenous fistula (AVF) placement and maturation,
where medically appropriate, for individuals starting
hemodialysis
Delmarva Foundation
QIO 9th SOW: Measures
10 Components

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

Prevention (3)
 Core
 Focused disparities
 Chronic Kidney Disease (CKD)
Patient Safety (5)
 Pressure Ulcers
 Physical Restraints
 SCIP (Surgical Care Improvement Project)
 MRSA (Methicillin Resistant Staphylococcus Aureus)
 Drug Safety
Care Transitions (1)
Beneficiary Protection (1)
Delmarva Foundation
QIO 9th SOW: Measures
Patient Safety

Freeing patients from the risk of harm, injury, or loss resulting from
their interaction with the health care delivery system

Components of Patient Safety
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Pressure Ulcers—Nursing Homes and Hospitals
Physical Restraints—Nursing Homes
SCIP—Hospitals
MRSA—Hospitals
Drug Safety—Physician Offices, Nursing Homes, Home Health
Nursing Homes in need of assistance with quality improvement
(QI) efforts
Delmarva Foundation
QIO 9th SOW: Measures
Patient Safety

Patient safety (14 measures)
 PrU 1 (high risk, NH)
 PrU 2 (hospital, acquired)
 Physical restraints (NH)
 SCIP Infection 1,2,3,4,6,7
 SCIP VTE 1,2
 SCIP Cardiology 2
 MRSA 1 (infection rate)
 MRSA 2 (transmission rate)
Delmarva Foundation
QIO 9th SOW: Measures
Patient Safety
Prescription Drug Safety
 Drug-drug interactions
 Potentially inappropriate medication
Delmarva Foundation
Delmarva Foundation
QIO 9th SOW: Outcomes
10 Components




Prevention (3)
 Core
 Focused disparities
 Chronic Kidney Disease (CKD)
Patient Safety (5)
 Pressure Ulcers
 Physical Restraints
 SCIP (Surgical Care Improvement Project)
 MRSA (Methicillin Resistant Staphylococcus Aureus)
 Drug Safety
Care Transitions (1)
Beneficiary Protection (1)
Delmarva Foundation
Delmarva Foundation
QIO 9th SOW: Measures
Care Transitions


Aim of QIO work under Care Transitions Theme
 Improve Medicare beneficiary transitions from
hospitals to other care settings through a
comprehensive community effort
Three general strategies of intervention
 Hospital/community system wide
 Interventions that target specific diseases or
conditions
 Interventions that target specific reasons for
readmission
Delmarva Foundation
QIO 9th SOW: Measures
Care Transitions
Patient Pathways will reduce the unnecessary rehospitalizations of Medicare beneficiaries through:
 Recruitment of hospitals, physicians, home health
agencies, skilled nursing facilities, dialysis facilities.
 Collaboration among QIOs, community health
systems, and professional groups
Delmarva Foundation
QIO 9th SOW: Measures
Care Transitions

Care Transitions (10 measures)
 4 types of re-hospitalization rates
 2 patient assessments of hospital discharge
performance using the Hospital Consumer
Assessment of Healthcare Providers and Systems (HCAHPS)
 1 physician visit post discharge (within 30 days)
before re-admission
 2 measures with Continuity Assessment Record and
Evaluation (CARE) instrument
 1 measure of adoption of interventions
Delmarva Foundation
QIO 9th SOW: Outcomes
10 Components




Prevention (3)
 Core
 Focused disparities
 Chronic Kidney Disease (CKD)
Patient Safety (5)
 Pressure Ulcers
 Physical Restraints
 SCIP (Surgical Care Improvement Project)
 MRSA (Methicillin Resistant Staphylococcus Aureus)
 Drug Safety
Care Transitions (1)
Beneficiary Protection (1)
Delmarva Foundation
Delmarva Foundation
QIO 9th SOW: Measures
Beneficiary Protection
 Case review includes
 Utilization review,
 Quality of care, including beneficiary complaints,
 Beneficiary appeals of certain provider notices, and
 Review of potential anti-dumping cases.
 Link to quality improvement through data analysis and
improvement assistance
Delmarva Foundation
QIO 9th SOW: Measures
Beneficiary Protection

Beneficiary Protection
 Increasing linkage of case review to quality
of care
 Increasing awareness of complaint process
among beneficiaries
 Emphasis on improved efficiency in the
case review process
Delmarva Foundation
QIO 9th SOW: Measures
Beneficiary Protection

Beneficiary Protection (4 measures)
 Timely completion of case reviews
 Beneficiary satisfaction with complaint
process
 Completion of satisfaction survey
 Percent of QIA completion
Delmarva Foundation
QIO 9th SOW: Measures
Beneficiary Protection
Statutorily Mandated Case Review Activities
 Are the items and/or services reasonable and
medically necessary
 Do the quality of services meet professionally
recognized standards of care
 Are services being provided in the appropriate
and most economical setting

Delmarva Foundation
QIO 9th SOW: Measures
Beneficiary Protection
Mandatory Review Activities
Utilization review
 Quality of care review
 Review of beneficiary appeals of certain provider
notices [Benefits Improvement and Protection
Act of 2000 (BIPA)]
 Review of potential Emergency Medical
Treatment & Labor Act (EMTALA) cases

Delmarva Foundation
QIO 9th SOW: Measures
Beneficiary Protection
Case Review Activities
Quality Improvement Activities (QIAs)
 Alternative Dispute Resolution (ADR) sanction
activities
 Collaboration with CMS
 Transparency through reporting quality data

Delmarva Foundation
QIO 9th SOW: Translating Process to
Outcomes
4 (+1) Themes
Prevention
 Patient Safety
 Care Transitions/Patient Pathways
 Beneficiary Protection
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
(Evaluation)
Delmarva Foundation
QIO 9th SOW: Measures
Evaluation
Contract Evaluation
 Measures/deliverables completed and
submitted
 Mid-point evaluation (18 months)
 Program Evaluation
 Independent, outside evaluation contractor
 Independent report on the QIO program is a
final deliverable (2011)
 Attribution of success to QIO interventions

Delmarva Foundation
QIO 9th SOW: Measures
Evaluation

“Attribution” carefully considered
 Well-defined measure set with continuous, highquality data
 CMS chooses participants with specified criteria
 Use of “matched control groups,” when possible
 More ability to control for confounding variables
 Use of standardized interventions, disseminated with
help of support contractors, linked to measures
 Careful management of partnerships
Delmarva Foundation
QIO 9th SOW: Summary
Goals and Objectives


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Interventions are linked to measures
Independent outside evaluation contractor will be
engaged from the beginning
Final independent program evaluation report at end of
contract
New management strategies will be applied to continuous
contract oversight, encouraging high performance
throughout the contract period
New contract responsive to all external stakeholders
Delmarva Foundation
QIO 9th SOW: Summary




9th Statement of Work incorporates a measurement
system (final and interim) and support system structure
Evaluation strategy has been worked out in advance with
quantitative targets and some control groups
Higher degree of competition has been introduced (subnational deployment)
Monitoring now has greater transparency and involves
both DHHS and Office of Management and Budget
(OMB) regularly through contract
Delmarva Foundation
QIO 9th SOW: Summary
Cross Cutting Themes
Reducing Health Care Disparities
 Promoting use of Health Information Technology
 ExpandingValue-Driven Health Care

Delmarva Foundation
QIO 9th SOW: Summary
Cross Cutting Themes


Potential benefits of broad use of HIT
 Improve health care quality
 Prevent medical errors
 Reduce health care costs
 Increase administrative efficiencies
 Decrease paperwork
 Expand access to affordable care
 Improve tracking of chronic disease management
http://www.hhs.gov/healthit/
Delmarva Foundation
Measuring Success in 9th SOW
 Collaboration and Coordination
 Utilizing existing organizations/populations
 Not reinventing a process
 Employing known successful interventions
 Creating lasting change
 Empasizing health information technology
 Integration across settings of care
Delmarva Foundation
What’s in it for Beneficiaries?
245,000 more patients screened for CKD
 39,616 fewer pressure ulcers in nursing homes
 3,687 fewer pressure ulcers in hospitals
 23,610 fewer physical restraints in nursing
homes
 7,875 fewer antibiotic-resistant infections
 14,252 lives saved from postoperative
complications in hospitals

Delmarva Foundation
Transparency
Delmarva Foundation
Transparency: Online Information
about Quality and Cost

Executive Order

August 22, 2006: Aggregated health care quality and price
information to be available to beneficiaries, enrollees, and
providers in a readily usable manner.
Interoperable health IT products be used, and quality and price
data be aggregated and shared.
Federal participants (Medicare beneficiaries) are motivated to
become involved consumers with the power of choice and a
reason to advocate a value-driven health care system.


Delmarva Foundation
Transparency: Sharing Information
Reduce the burden of duplicate data collection
and reporting
Allow hospitals to share quality-of-care data
with patients
Allow for more effective partnership with the
QIO
Encourage every member of your staff to be
involved in quality improvement
Transparent
‘Easily understood; clear’
Delmarva Foundation
Delmarva Foundation
Transparency
Demands critical information about:
1. Quality
2. Patient Satisfaction
3. Pricing
Leavitt 2008

Abouthealthtransparency.org
Delmarva Foundation
News Release
FOR IMMEDIATE RELEASE
Friday, March 28, 2008
Contact: CMS Office of Public Affairs
(202) 690-6145
New Web Site Helps Patients Shop for
Hospital Care Based On Quality and Price
CMS Web Site Features Updated and
More Robust Information to Help
Consumers with Their Health Care
Choices
Delmarva Foundation
Delmarva Foundation
Transparency: Online Information
about Quality and Cost
What is presently available online:
Home Health Compare
 Nursing Home Compare
 Hospital Compare

What’s coming?

Physician Compare
Delmarva Foundation
Transparency: Online Information
about Quality and Cost
Home Health Compare
Three measures related to improvement in
getting around
 Four measures related to meeting the patient's
activities of daily living
 Two measures about how home health care
ends
 Three measures related to patient medical
emergencies

Delmarva Foundation
Transparency: Online Information
about Quality and Cost
Nursing Home Compare


Quality Measures
Nursing Home Inspection

Health

Fire Safety

Nurse Staffing
CNA Staffing

Medicare Coverage

Delmarva Foundation
Delmarva Foundation
Transparency: Online Information
about Quality and Cost
Hospital Compare

Hospital Process of Care Measures:
See how often a hospital gives recommended treatments for certain conditions or procedures.
 Eight measures related to heart attack care
 Four measures related to heart failure care
 Seven measures related to pneumonia care
 Five measures related to surgical infection prevention

Hospital Outcome of Care Measures:
See the results of care or treatment for certain conditions or procedures.

Survey of Patients' Hospital Experiences:
See what hospital patients say about the care they received during a recent hospital stay.

Medicare Payment and Volume:
See how much Medicare paid hospitals on average for certain conditions or procedures. You can
see the number of Medicare patients treated for certain conditions.
Delmarva Foundation
Transparency: Online Information about
Quality and Cost
Consumer
Can consumers use the tools presently available to
make informed decisions about their health care?
Delmarva Foundation
Transparency: Online Information about Quality
and Cost
Consumer
Can consumers use the tools presently available on
line to make informed health care decisions?
Yes and No
Delmarva Foundation
Transparency: Online Information about Quality
and Cost
Consumer
YES
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


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
Geographic location
Specific procedure volume
Patient satisfaction
Begin provider discussion
Basic quality information about treatment for MI, HF,
Pneumonia, Surgical Infection Rate
Potential for regular updating and ‘real time’ information
Delmarva Foundation
Transparency: Online Information about Quality
and Cost
Consumer
NO
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Process of care measures limited
Data is several months out of date
Website is complicated
Requires computer access
Font is tiny
Only outcome measure is 30 day mortality
Hospitals can control access to unflattering data
Measure validity can change
Delmarva Foundation
Transparency: Online Information about
Quality and Cost
Hospital Compare
During the Preview Period, hospitals have the
option to suppress the public reporting of some
of the information contained in the reports.
Information contained in the Preview Reports
will be published on the Hospital Compare
website in July 2008.
Delmarva Foundation
Transparency: Online Information
about Quality and Cost
Volume-outcome relationship for coronary artery bypass
grafting in an era of decreasing volume.
Ricciardi R, Virnig BA, Ogilvie JW Jr, Dahlberg PS,
Selker HP, Baxter NN.
Since 1997, CABG volume has declined in the setting of a
decrease in in-hospital mortality. A lower mortality rate in
the setting of reduced CABG volume is a counterintuitive
finding, suggesting that procedure volume is an
insufficient predictor of outcome on which to base
regionalization strategies.
Delmarva Foundation
Transparency: Online Information about
Quality and Cost
‘Physician Compare’
Physicians need to become familiar with the
methodology that will ‘compare’ them.
This information will eventually be used to
determine physician reimbursement.
The measures used in the Physician Quality
Reporting Initiative (PQRI) are evidence-based
and well-vetted.
Delmarva Foundation
Delmarva Foundation
Delmarva Foundation
Transparency: Online Information
about Quality and Cost
Delmarva Foundation
Transparency: Online Information about
Quality and Cost
PQRI
74 measures
 Consensus developed and endorsed
 Apply to over 95% physician Part B services
 Applicability depends on services rendered, not
designated specialty
 Measures posted on website
www.cms.hhs.gov/PQRI

Delmarva Foundation
Transparency: Online Information
about Quality and Cost

2007 Preliminary Data:

~16% participation - submitted at least 1 qualitydata code

Slightly over half of participants likely to qualify
for bonus
Delmarva Foundation
Transparency: Online Information about Quality
and Cost
PQRI

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
Multiple sources for information
AMA and specialty provider organizations have
developed user friendly forms
Can report with claims data (additional codes)
Can report using registries
May choose measures they wish to report
Must choose at least 3 measures to be eligible for
incentive
Must report on at least 80% of the patients who qualified
for the measure
Delmarva Foundation
Transparency: Online Information about Quality
and Cost
PQRI
Example:




Dr. Friedley chooses three diabetes measures HgbA1C,
lipids, and BP control)
Dr. F has 100 patients that have Medicare claims that
define them as diabetic
Dr. F must report on the 3 measures for at least 80 of her
100 patients for CY08
If she does this successfully, she will earn 1.5% of her
total allowable Medicare charges for 2008
Delmarva Foundation
Transparency: Online Information about Quality
and Cost
PQRI
For 2008, Dr. F will be rewarded for REPORTING
these measures.
Eventually, she will be paid for the RESULTS of
the measures, ie the number of patients whose
LDL cholesterol is < 100.
Delmarva Foundation
Transparency: Online Information about Quality
and Cost
PQRI
The QIO 9th SOW will be using PQRI results to
measure outcome success.
Example: Prevention-Focused Disparities
Diabetes measures
HbgA1c < 9.0; LDL < 100; BP < 140/90
Delmarva Foundation
Transparency: Online Information
about Quality and Cost
Outreach and Education– Engagement through
communication
Website at: https://www.cms.hhs.gov/PQRI
Medicare Carrier/Medicare Administrative
Contractor (MAC) inquiry management
Speakers’ Bureau– Education for participants and
their office staff
Tools to support successful reporting
Delmarva Foundation
Transparency: Online Information
about Quality and Cost
What Percentage of General
Practitioners in Europe Use
Computers?
Delmarva Foundation
Delmarva Foundation
Transparency: Online Information
about Quality and Cost
What percent of primary care physicians in US use
computers in their practices (beyond billing)?
~20%
We have our work cut out for us….
Delmarva Foundation
Transparency: Online Information
about Quality and Cost
Delmarva Foundation
Where are we going?
Delmarva Foundation
Moving from Quality to Value
Better Care Lower Cost
HHS
Delmarva Foundation
Moving from Quality to Value
Economics
 Efficiency
 Cost
 Pricing
 Accountability
 Payment Reform

Delmarva Foundation
Value-Driven Health Care
“The QIO program is a cornerstone in our efforts to
improve the quality and efficiency of care
delivered to Medicare beneficiaries,” said CMS
Administrator Mark B. McClellan, M.D.,
Ph.D. “QIOs have had a positive impact on the
quality of health care in America, and with
enhanced oversight and accountability, and new
initiatives to improve transparency and care, they
will do more to support better care and lower
costs.
Delmarva Foundation
Value Driven Health Care
Four Cornerstones
 Interoperable HIT
 Measure and publish quality information
 Measure and publish price information
 Promote quality and efficiency of care (e.g.,
Value-Based Purchasing)
 http://www.hhs.gov/valuedriven/

Delmarva Foundation
Questions?
[email protected]