CMS & Healthcare Stakeholders: Opportunities for Collaboration

1. CMS & Healthcare Stakeholders: Opportunities for Collaboration Barry M. Straube, M.D. Chief Medical Officer Centers for Medicare & Medicaid Services, Region IX LA Collaborative Meeting December 3, 2004

2. Department of Health & Human Services Veterans Affairs Department of Defense Department of Labor Federal Bureau of Prisons United States Coast Guard Office Personnel Management Federal Trade Commission Office of Management & Budget Department of Commerce National Highway Transportation & Safety Administration Federal Stakeholders in the U.S. Healthcare System

3. Secretary of HHS Administration for Children and Families Administration on Aging Agency for Healthcare Research & Quality Agency for Toxic Substances & Disease Registry Centers for Disease Control Centers for Medicare & Medicaid Services (CMS) Food & Drug Administration Health Resources & Services Administration Indian Health Service National Institute of Health Program Support Center Substance Abuse & Mental Health Services Administration Department of Health & Human Services:Agencies

4. Centers for Medicare & Medicaid Services (CMS) • Health benefits for over 76 million Americans • Medicare • Medicaid • State Children's Health Insurance Program (SCHIP) • Spends over $450 billion annually for health care services in CMS programs

5. Centers for Medicare & Medicaid Services (CMS) • Healthcare Benefits Administration • Establish payment methodology for providers • Conduct research on financing, treatment & management • Assure that contractors & state agencies run CMS programs correctly • Identify fraud & abuse, take appropriate action

6. Centers for Medicare & Medicaid Services (CMS) • Beneficiary-Focused Activities • Benefits and health education • Advocacy: Appeals, Grievances, patient rights • Assuring access and continuity of care • Preventive services • Healthcare data for choice • Promoting partnerships of patients and providers to provide patient-centered care

7. Centers for Medicare & Medicaid Services (CMS) • Quality-Focused Activities • Laboratory Testing (CLIA) • Survey & Certification of Health Care Facilities (Hospitals, LTC, SNF, HHA, etc.) • End-Stage Renal Disease Networks • Organ Procurement Organizations • Quality Improvement Organizations • Quality Improvement Systems in Managed Care (QISMC) • Multiple Demonstration Projects

8. CMS 2005 Priorities • Implementation of the Medicare Modernization Act • Quality, quality, quality……. • Ongoing reimbursement reform • Pay-for-Performance (P4P) • Health Information Technology promotion • Prevention • Contractor reform • A host of other issues…….

9. CMS Quality Initiatives • Nursing Homes • Home Health • Hospitals • Doctor Offices • End Stage Renal Disease Facilities • More initiatives to come…..

10. Medicare Modernization Act: Disease Management Projects • Medicare Health Care Quality Demonstration Programs (Section 646) • 5 year project expanding current physician group practice demonstration • Consumer Directed Chronic Outpatient Services (Section 648a) • 3 demonstration projects aimed at improving the quality of care for Medicare patients with chronic conditions

11. Medicare Modernization Act: Disease Management Projects • Care Management Performance Demonstration (Section 649) • 3 year P4P pilot • Adoption and use of health information technology • Voluntary Chronic Care Improvement Program under traditional fee-for-service (Section 721) • 3 year contracts with chronic care improvement organizations for randomized clinical trials • Guide beneficiaries with chronic disease to disease management programs

12. Medicare Modernization Act: Chronic Disease Sections • Chronically Ill Medicare Beneficiary Research, Data, Demonstration Strategy (Section 723) • Within 6 months of enactment, Secretary must develop a plan to improve quality of care and reduce cost to chronically ill Medicare beneficiaries • Integrate existing datasets, identify new data needs and methodology to address them, plan for new data warehouse, develop research agenda

13. CMS RO IX QIOs Associations Physician Hospital Health Plan Medical group SNF, hospice, etc. Employer groups Pay-for-Performance initiatives NFP health foundations Individual Health Plans Medical Groups Hospital chains SNFs, other providers Private-sector health companies Academic institutions Growing list of others CMS Region IX Quality Forum

14. CMS Region IX Quality Forum Quality Forum Mission • We strive to make healthcare better, safer, and more cost-effective for residents within the region. Quality Forum Vision • Pursue high-quality, safe, accessible and affordable health services for residents in the region • Enhance collaboration and communication among all stakeholders • Detect problems & engage in problem solving • Seek out the best healthcare practices to drive innovation and quality in all aspects of healthcare

15. CMS Region IX Quality Forum Quality Forum Goals • Select projects that affect broad group of healthcare providers • Address evolving health system needs to prepare healthcare for the future • Public health • Evolving information infrastructure needs • Develop 2-3 project plans by May 2005 • Focus on and promote California as the initial pilot location

16. Quality Forum Initial Project List • Collect and Share Physician Performance Data • Create Personalized Beneficiary Health Information Communication • Alleviate Emergency Department Overcrowding • Develop Public Physician and Physician Practice Information Website • Expand Use of e-ICUs

17. Quality Forum Initial Project List • Expand Use of Telemedicine – Target Rural Populations • Promote Fistula First Initiative • Support California Adult Immunization Coalition • Focus on End-of-Life / Palliative Care • Assist Physicians Entering into EHR Capabilities

18. Quality Forum Project Selection • Physician Level Performance Measurement • Data Use for Beneficiary Healthcare Improvement • Emergency Department Overcrowding • Workgroups established • Synopsis of progress to date • Additional function of identifying problems that CMS and stakeholders need to address

19. Physician Level Performance Measurement • Choose measures and validate • Database issues: Medicare FFS is essential • Phase I: Voluntary & confidential physician quality improvement • Phase II: Credentialing, proprietary QI, other proprietary uses • Phase III: Public reporting, P4P, etc. • Complementary beneficiary education

20. E.D. Overcrowding • One in three U.S. hospital E.D.s are routinely on diversion • 34% of hospitals in U.S. report operating over capacity • 28% report at capacity • For large, urban hospitals 61% operating over capacity • 30% operating at capacity

21. E.D. Overcrowding • E.D. visits have increased from 90 million in 1992 to 110 million in 2002 • 23% increase • Over same timeframe number of hospital E.D.s have decreased by 15% • 10% decrease in California

22. E.D. Overcrowding • CMA 2001 Study • E.D.s under-reimbursed by all payers, particularly Medi-Cal • Ranks of uninsured continue to grow • Medi-Cal patients accounted for 40% of all E.D. visits in 1998-1999 • 53% for CA E.D.s with largest E.D. losses • 80% of E.D. visits of Medi-Cal & uninsured did not require an E.D. setting

23. E.D. Overcrowding • Factors leading to overcrowding • More patients • Fewer E.D.s • Inappropriate use of E.D.s by patients • Decreased access to physician offices and other sites • EMTALA restrictions • Downsized E.D. and hospital staffs and facilities • Throughput problems • Fewer discharge setting options

24. E.D. Overcrowding Goals • Obtain more data • Reduce frequent users and inappropriate use of E.D.s • Frequent user grants and initiatives • FQHC, CHC, RHC options • Specialized centers: Alcohol, substance abuse, wound care, etc. • Address barriers to receiving care outside E.D.s • PCP and managed care focus

25. E.D. Overcrowding Goals • Identify & address EMTALA, regulatory & accreditation components • Identify and address “throughput” problems • Tackle discharge barriers • Address quality measurement and payment issues • P4P overlap • CMS E.D. quality metric development

26. Select Other Region IX Priorities • Access to and continuity of care • Fraud & Abuse (Program Integrity) Increase • Ethnic & Racial Health Disparities, cultural competence, health literacy • Rural health issues • Health Information Technology Initiatives • Pay-for-Performance (P4P) initiative collaboration • Employer retirement coverage subsidies

27. Contact Information Barry M. Straube, M.D. Chief Medical Officer Centers for Medicare & Medicaid Services Region IX 75 Hawthorne Street, Suite 408 San Francisco, CA 94105 Email: bstraube@cms.hhs.gov Phone: (415) 744-3503