Knowledge Base Article

With the New Year looming, it is hard to believe that is has almost been a year since the U.S. Department of Health and Human Services (HHS) announced for the first time in the history of the Medicare program explicit goals for alternative payment models and value-based payments.

Alternative Payment Model Goals

By the end of 2016 have 30% of Medicare payments in alternative payment models.

By the end of 2018 have 50% of Medicare payments in alternative payment models.

Value Based Payment Goals

By 2016 have 85% of Medicare fee-for-service payments tied to quality of value.

By 2018 have 90% of Medicare fee-for-service payments tied to quality of value.

On November 25th, Patrick Conway, M.D., MSc, Acting Deputy Administrator and Chief Medical Officer, CMS announced in The CMS Blog an updated 2016 HHS National Quality Strategy (NQS) indicating that “the main purposes of the 2016 CMS Quality Strategy update are to achieve the broad aims of the NQS and to apply the Administration’s strategy for shifting Medicare payments from volume to value.”

National Quality Strategy: By the Numbers

Three Aims

1. Better Care
2. Healthier People, Healthier Communities
3. Smarter Spending

Six Priorities

1. Make Care Safer by Reducing Harm Caused in the Delivery System
2. Strengthen Person and Family Engagement as Partners in their Care
3. Promote Effective Communication and Coordination of Care
4. Promote Effective Prevention and Treatment of Chronic Disease
5. Work with Communities to Promote Best Practices of Health Living
6. Make Care Affordable

Four Foundational Principles

1. Eliminating racial and ethnic disparities,
2. Strengthening infrastructure and data systems across all settings of care,
3. Enabling local innovations, and
4. Fostering learning organizations.

The Centers for Medicare and Medicaid Services (CMS) has made the six priorities goals in the CMS Quality Strategy. They identified the Four Foundational Principles to help guide their action towards meeting these goals and believe that incorporating these “will drive change to improve quality and cost of care for all. “

CMS Quality Strategy Goals: A Call to Action

To advance the three aims, the CMS Quality Strategy Goals reflect the six priorities for the NQS. There are innumerable activities being implemented to achieve this vision. The remainder of this article will provide you a glimpse of what is being done to achieve each of these Goals.

Goal 1: Making Care Safer by Reducing Harm Caused in the Delivery System

Hospital-Acquired Conditions (HACs)

On December 3rd the Agency for Healthcare Research and Quality (AHRQ) announced that data from the recent report Saving Lives and Saving Money: Hospital-Acquired Conditions Update Interim Data from National Efforts to Make Care Safer, 2010-2014 shows between 2010 and 2014:

• An estimated 87,000 fewer patients died from a HAC,
• The overall incidence of HACs has been reduced by 2.1 million for an estimated savings of $19.8 billion; and
• In 2014 alone, 37,000 fewer patients died than would have died if the rate of adverse events had remained at the 2010 level. Most of the deaths averted resulted from a reduction in rates of pressure ulcers and adverse drug events (ADEs).

HAC Reduction Program

The Affordable Care Act (ACA) established the HAC Reduction Program as an incentive for hospitals to reduce HACs. CMS released the FY 2016 results for the Program on December 10th and they estimate that the total savings in FY 2016 will be $364 million.

Nationwide 758 out of 3,308 eligible hospitals are in the worst performing quartile and will have a one percent payment reduction applied to all Medicare discharges occurring between October 1, 2015 and September 30, 2016. The number of hospitals being penalized is up from the 724 hospitals subject to a payment reduction in FY 2015.

In the FY 2016 HAC Reduction Program, hospitals with a Total HAC Score greater than 6.7500 are subject to a payment reduction. You can find your hospital Total HAC Score at https://www.medicare.gov/hospitalcompare/HAC-reduction-program.html.

Goal 2: Strengthen Person and Family Engagement as Partners in their Care

Everyone with Diabetes Counts (EDC) Program

The Quality Innovation Network Quality Improvement Organizations (QIN-QIOs) are administering the EDC Program. This program offers evidence-based diabetes self-management training and is designed to improve health outcomes and quality of life among disparate and underserved Medicare populations.

Goal 3: Promote Effective Communication and Coordination of Care

CMS cites strengthening the hospital Conditions of Participation (CoP) for Discharge Planning and Bundled Payment Initiatives as two examples to further this goal.

Discharge Planning CoP

On October 29, 2015 CMS announced proposed revisions to the discharge planning requirements that hospitals, including long-term care hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Critical Access Hospitals (CAHs), and Home Health (HH) agencies must meet in order to participate in the Medicare and Medicaid program. They are currently soliciting comments from the healthcare community. You can read more about this in a related article at http://www.mmplusinc.com/news-articles/item/october-29-2015-cms-releases-a-discharge-planning-proposed-rule.

Bundled Payment Initiatives

CMS recently finalized the Comprehensive Care for Joint Replacement (CJR) Model which is set to begin on April 1, 2016 and run through December 31, 2020. CMS expects this model to result in $343 million in savings to Medicare over the 5 performance years. Notable about this model is that for the first time, selected hospitals are required to participate. You can read more about this in a related article at http://www.mmplusinc.com/news-articles/item/comprehensive-care-for-joint-replacement-model-finalized.

Goal 4: Promote Effective Prevention and Treatment of Chronic Disease

CMS indicates that more than 133 million Americans report at least one chronic condition, while many have multiple chronic conditions (MCC) affecting them at the same time. For example a person with diabetes and heart disease has multiple chronic conditions.

Million Hearts® Initiative

CMS cites being a lead partner in the Million Hearts® Initiative as one way they are promoting effective prevention and treatment of chronic disease. This initiative seeks to reduce the incidence of heart attacks and strokes by 1 million by 2017. The Million Hearts® website provides educational material for you and your patients, access to data and research, proven techniques to prevent and treat heart attack and stroke and education regarding risks, costs and consequences and ways to prevent heart disease and strokes.

Goal 5: Work with Communities to Promote Best Practices of Health Living

CMS is committed to partnering with key stakeholders to link Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries, and the providers that serve them, with communities and resources that support good health. One specific federal effort cited by CMS is the WIC Farmers’ Market Nutrition Program (FMNP)

The FMNP is associated with the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and was established by Congress in 1992 “to provide fresh, unprepared, locally grown fruits and vegetables to WIC participants, and to expand the awareness, use of, and sales at farmers’ markets.”

Goal 6: Make Care Affordable

Hospital Value Based Purchasing Program

This program adjusts hospital payments for inpatient services based on hospitals’ performance on measures that fall into a number of domains. For FY 2016 this program is funded by a 1.75% reduction from participating hospitals’ base operating diagnosis-related group (DRG) payments. The resulting funds are redistributed to hospitals based on their Total Performance Score (TPS).

CMS added the following measures for Fiscal Year (FY) 2016:

• IMM-2, Influenza Immunization (Clinical Process of Care domain)
• CAUTI, Catheter-Associated Urinary Tract Infection (Outcome domain)
• SSI, Surgical Site Infection Colon Surgery & Abdominal Hysterectomy (Outcome domain)

For those interested in learning more, CMS held a National Provider call on May 12, 2015 to provide an overview of all Hospital Inpatient Quality Reporting and Value-Based Purchasing Programs. Slides, an audio recording and written transcript are available on the CMS website.

One last valuable resource to find out “where we are now” is the CMS Innovation Center. The Innovation Center has a growing portfolio testing various payment and service delivery models that aim to achieve better care for patients, better health for our communities, and lower costs through improvement for our health care system. I encourage you to visit their website to find out where and what Innovation is happening in your state.