The Business Case for Quality: A CMS Perspective

1. at the Institute for Quality in Laboratory Medicine, April 29, 2005 The Business Case for Quality: A CMS Perspective

2. Vision The right care for every patient every time

3. What is the right care? • Safe • Effective • Efficient • Patient-centered • Timely • Equitable -- Crossing the Quality Chasm The Institute of Medicine

4. Pursuing Perfection in MedicareHospital and Office Care (all states, 24 measures)

5. 2 0 2 4

6. Scope • This vision is transformational, not incremental • To serve Medicare and Medicaid we must transform the entire healthcare system. • Transforming the system requires, in turn, transforming CMS, which is often a part of the problem as well as a part of the solution.

7. Transformational strategies • Work through partnerships • Publish quality measurements • Pay-for-performance/quality • Promote health information technology • Create and use evidence about effectiveness

8. Work through partnerships Includes coordination • within CMS • across Federal agencies • between governmental and nongovernmental partners.

9. Publish quality measurements • Audiences are both professionals, providers, and purchasers and the beneficiary audience. • We must drive out secrecy

10. Pay-for-performance/quality Includes paying for • prevention • disease management • patient-centered care.

11. Promote health information technology Includes • standards development and promotion • systems development • encouraging implementation • payment for HIT results

12. Create and use evidence about effectiveness CMS becomes part of post-marketing surveillance When effectiveness is not absolutely clear, coverage may be conditional on registering data At the same time coverage decisions become faster

13. C A R E S Y S T E M PATI-ENT The Toolkit LEAD ESTABLISH & ENFORCE REQUIRE-MENTS SUPPORT STANDARD METHODS REWARD DESIRED PERFORMANCE PROMOTE PARTNER- SHIPS PROVIDE TECHNICAL ASSISTANCE STRUCTURE COVERAGE AND PAYMENTS PROVIDE PUBLIC INFORMATION

14. The Management Framework SELECT PRIORITY AREAS ADOPT OR DEVELOP MEASURES COLLECT & ANALYZE DATA IDENTIFY IMPROVEMENT OPPORTUNITIES AND SELECT APPROPRIATE IMPROVEMENT INTERVENTIONS 14 MANAGE PROCESS IN PARTNERSHIP WITH STAKEHOLDERS SUPPORT STANDARD METHODS PROMOTE OR CREATE COLLABORA-TIONS AND PARTNER-SHIPS GIVE PLANS, DOCTORS & PROVIDERS TECHNICAL ASSISTANCE GIVE CONSUMERS INFOR-MATION AND ASSISTANCE TO MAKE CHOICES STRUCTURE COVERAGE AND PAYMENTS TO IMPROVE CARE REWARD DESIRED PERFORM-ANCE ESTABLISH & ENFORCE STANDARDS

16. What is the Business Case? CMS believes that we can only keep Medicare and Medicaid solvent by focusing on effective care and eliminating ineffective care. Thus, for us, quality is a survival strategy.

17. Hypothesis on Cost and Quality 90 percent of the benefits of quality improvement will come from free or cost-saving changes.

18. How can this be? • Most of the best-studied treatments with the best evidence that they are effective are also relatively inexpensive. • The current payment system encourages procedures so strongly that a net increase in their use is rarely needed even when current use is not totally appropriate.

19. Does Better Care Save Money? • Waste and rework are expensive. • In general, better outcomes reduce downstream costs, although these savings often accrue to the insurer rather than the provider.