Performance-Based Health Care Through Implementing Effective Quality and Cost Measures

1. Performance-Based Health Care Through Implementing Effective Quality and Cost Measures

2. June 25, 2008 2 Overview Envisioning a future, performance-based health care system Progress to date Gaps and barriers Premises, objectives, actions steps, and milestones Appendix: additional information

3. June 25, 2008 3 How did we get here? Charge: At its February 29, 2008 meeting, the QASC recommended that a road-map be created to clarify critical tasks and needed functionalities to ensure wide-scale implementation of performance measures across the care continuum based on NQF endorsed measures. Process: Brookings staff was asked to develop discussion documents to allow for ongoing input and feedback. Staff was aided in this effort by Nancy Wilson (AHRQ), Chris Queram (WI Collaborative), John Tooker (ACP), and Peter Lee (PBGH). Multiple feedback mechanisms were built into the design process between March and June Regular input from QASC chair-persons Two conference calls with the QASC Agenda Group Two conference calls with the full QASC membership One call with the QASC Infrastructure Work Group Road-map effort was discussed with HQA and PQA members during their June meetings. Several QASC members provided detailed input, including Janet Corrigan, Chip Kahn, Debra Ness, Gerry Shea, John Tooker, Peter Lee.

4. June 25, 2008 4 A future, performance-based health care system requires � payers, providers, and consumers to act differently than they do today; tools and incentives are available to support these actions; and wide implementation of valid, patient-level performance measures that can confidently be used to support the actions of payers, providers, and consumers

5. June 25, 2008 5 Envisioning the Future

6. June 25, 2008 6 Comprehensive Data Needed to Generate Performance Information

7. June 25, 2008 7 Building the capabilities for performance-based health care relies on�

8. June 25, 2008 8 Many critical partners engaged today

9. June 25, 2008 9

10. June 25, 2008 10 The Quality Alliance Steering Committee The Quality Alliance Steering Committee (QASC) is a collaborative effort among government agencies, physicians, nurses, pharmacists, hospitals, health insurers, employers, consumers, accrediting agencies, foundations and others QASC co-chairs: Carolyn Clancy, MD, Director, Agency for Health Care Research and Quality Mark McClellan, MD, PhD, Director, Engelberg Center for Health Care Reform at the HVHC Project at Brookings Institution. Vision: to advance a high-quality, affordable, patient-centered health care system through the coordination of various groups that are working to provide public information on health care providers� performance. The QASC will actively support the implementation and use of effective health care performance information for: Public reporting and more informed consumer decision-making; Performance improvement by providers; Effective public policies, payment policies, and consumer incentives that reward or foster better provider performance

11. June 25, 2008 11 QASC promotes and facilitates measure implementation across care continuum The Quality Alliance Steering Committee (QASC) facilitates measure implementation by: Regularly convening key implementation stakeholders Providing guidance on and coordination for immediate opportunities for advancing implementation goals, including Data Aggregation (across payers) Data Integration (clinical data with administrative data) Episode-based cost-of care measure development Promoting measurement and analysis of racial/ethnic equity as integral part of measurement implementation efforts Stimulating and assessing progress relative to implementation goals and milestones Identifying and promoting best practices in measure implementation across care sectors Fostering patient-focused measurement and reporting (e.g., coordinated episode- and patient-level measures across care continuum) in implementation efforts Establishing effective interaction/feedback mechanisms with regional collaboratives/AFQ/CVEs and others

12. We have made progress towardsa performance-based health care system�

13. June 25, 2008 13 Progress to date: Foundations

14. June 25, 2008 14 Progress to date: Generating & Reporting

15. June 25, 2008 15 Progress to date: Use of Information

16. but gaps still exist� ��the nation still lacks a coherent, goal-oriented, consistent, and efficient system for assessing and reporting on the performance of the health care system.� - Institute of Medicine, 2006

17. June 25, 2008 17 Gaps & Barriers I

18. June 25, 2008 18 Gaps & Barriers II

19. Strategies toAccelerate Progress

20. June 25, 2008 20 Strategies: Overview Reinforce the Foundations by promoting agreement on health care priorities, measure development, and efficient endorsement and maintenance processes Enable the Generation of Performance Information through collaborative and technologically sound processes for data integration and aggregation Rapidly expand the Distribution of Performance Information Promote effective Use of Performance Information for consumers, providers and payers of health care

21. June 25, 2008 21 Key premises for strategy development It is urgent to build consensus on a path to wide-scale implementation of prioritized and endorsed measures across care continuum, all payers and an increasingly sophisticated range of clinical data sources. This focus will add further momentum to NQF�s mission of priority setting, promoting needed measure development, endorsement, and education. Build on the QASC-endorsed National Framework developed by the QASC Vision Workgroup. �Flesh out� specific segments of the framework: implementation strategies, aggregation of data, generation of reports Ensure data aggregation and integration over time for the generation of performance information. Ensure harmonization and coordination of measure implementation efforts between all care-sector specific alliances to ensure, among others, an increasing patient-focus (episode-of-care) along the care continuum. Focus first on strategic goals/activities and needed functionalities to inform work plans for QASC and partner organizations. The road-map should tee up critical issues for discussion and resolution including: Effective interactions between regional and national efforts in measure implementation and reporting Feedback mechanisms to ensure that measure implementation experience informs measure maintenance processes of measure developers and NQF.

22. June 25, 2008 22 Discussion Questions Are the outlined strategic objectives and milestones sufficiently bold and clear? Are the outlined next steps appropriate? How do we ensure optimal interaction between regional efforts and QASC? How do we ensure optimal interaction between rapid implementation of endorsed measures, and refinements to NQF prioritization, endorsement, and maintenance processes? Is there anything missing from the outlined strategies?

23. June 25, 2008 23 The Foundations

24. June 25, 2008 24 Generating Information - I

25. June 25, 2008 25 Generating Information - II

26. June 25, 2008 26 Distributing Performance Information

27. June 25, 2008 27 Using Performance Information

28. June 25, 2008 28 Next Steps Refine and finalize the road-map. Update work plans for QASC workgroups based on strategic goals/activities of the road-map Identify key activities and next steps for QASC including support for all sector-specific alliances in implementing work plans and reaching goals Communicate the strategic goals and work efforts widely to private and public sector constituencies and continue to update goals and work efforts based on their input.

29. June 25, 2008 29 Discussion Questions Are the outlined strategic objectives and milestones sufficiently bold and clear? Are the outlined next steps appropriate? How do we ensure optimal interaction between regional efforts and QASC? How do we ensure optimal interaction between rapid implementation of endorsed measures, and refinements to NQF prioritization, endorsement, and maintenance processes? Is there anything missing from the outlined strategies?

30. Appendices:Key public/private initiatives

31. June 25, 2008 31 QASC membership (as of 6/1/08) Mark McClellan (Co-Chair) Carolyn Clancy (Co-Chair) Debra Ness (NPWF) Gerry Shea (AFL-CIO) Jim Guest (Consumers Union) John Rother (AARP) Peter Lee (PBGH) Bruce Bradley (GM) Pam French (Boeing) Clarion Johnson (Exxon Mobil) Brian Marcotte (Honeywell) Andy Webber (NBCH) Karen Ignangi (AHIP) Alan Korn (BCBSA) Nancy Nielsen (AMA) Frank Opelka (ACS) Jeff Rich (STS) John Tooker (ACP) Laura Cranston (PQA) Mary Naylor (Nursing) Bob Dickler (AAMC) Rich Umbdenstock (AHA) Chip Kahn (FAH) Barry Straube (CMS) Peggy O�Kane (NCQA) Janet Corrigan (NQF) Mark Chassin (TJC) Kevin Weiss (ABMS) John Lumpkin (RWJF) Chris Queram (WI Collaborative)

32. Key Initiatives

33. June 25, 2008 33 Ten Simple Rules for the21st Century Health Care System � IOM (2001)

34. June 25, 2008 34 NQF National Priority Partners The National Quality Forum (NQF) has committed itself to working in partnership with leadership organizations to establish national priorities and goals for performance measurement and public reporting. Topic being addressed by National Priority Partners (NPP) Healthcare- Associated Infections (HAIs) Population in health Overuse Avoidable Harms Continuity of Care Patient/ family engagement End of life/ palliative care Reliable and effective care management of chronic/ acute episodes www.qualityforum.org/about/NPP

35. June 25, 2008 35 AHIC Quality Vision Roadmap Charge of Quality workgroup: Make recommendations to the American Health Information Community that specify how certified health information technology should capture, aggregate and report data for a core set of ambulatory and inpatient quality measures. Vision In response to the American Health Information Community (the Community), the Quality Workgroup prepared the following documents to assist the Community in its deliberations on recommendations it will make to the Secretary to address the needs and expectations of health care stakeholders. The Workgroup's vision is predicated on the idea that performance measurement is integral to all aspects of health care in the United States and that every citizen has the right to expect consistent high-quality, safe, and efficient care. The concepts and statements in this document are directed to the Community and subject to further deliberation by the Community. Goals Expanded data element standardization Coding improvements Data exchange and aggregation Quality data set Patient and provider entity record matching Clinical decision support Data stewardship Legal framework for data sharing Patient record de-identification locus Measure set evolution Incentives http://www.dhhs.gov/healthit/ahic

36. June 25, 2008 36 Consumer-Purchaser Disclosure Project The Consumer-Purchaser Disclosure Project (CPDP) is a collaboration of leading national and local employer, consumer, and labor organizations that advocate public reporting of provider performance information so it can be used for quality improvement, consumer choice, and as part of payment reform. CPDP in April 2008 announced a comprehensive national agreement with leading physician groups and health insurers on principles to guide how health plans measure doctors� performance and report the information to consumers. Called the �Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs,� it creates a national set of principles to guide measuring and reporting to consumers about doctors� performance. www.healthcaredisclosure.org

37. June 25, 2008 37 CMS�s Better Quality Information Project CMS�s Better Quality Information to Improve Care for Medicare Beneficiaries (BQI) Project aims to pioneer the pooling of private data with Medicare claims data to produce more accurate, comprehensive quality measures at the provider level. Participants in the project include: Arizona State University�s Center for Health Information & Research (CHIR) California Cooperative Healthcare Reporting Initiative Indiana Health Information Exchange Massachusetts Health Quality Partners Minnesota Community Measurement Wisconsin Collaborative for Healthcare Quality www.hhs.gov/valuedriven/pilot/index.html

38. June 25, 2008 38 RWJF�s Aligning Forces for Quality Initiative Aligns the three key drivers of quality improvement at the local level: performance measurement and public reporting; capacity to help physicians improve the quality of ambulatory chronic illness care; and consumer engagement. Participants in the program include: Administrator: Center for Health Improvement Collaboratives: Health Improvement Collaborative of Greater Cincinnati, the MetroHealth System (Cleveland), Greater Detroit Area Health Council, Community Health Alliance of Humboldt-Del Norte, Kansas City Quality Improvement Consortium, Quality Counts (Maine), Healthy Memphis Common Table, MN Community Measurement, The Puget Sound Health Alliance (Seattle), Alliance for Health (Western Michigan), P2 Collaborative of Western New York, Oregon Health Care Quality Corporation, Wisconsin Collaborative for Health Care Quality, Healthy York County Coalition www.forces4quality.org

39. June 25, 2008 39 Key Sector-specific alliances HQA (http://www.hospitalqualityalliance.org) The Hospital Quality Alliance facilitates continuous improvement in patient care through: Implementing measures that portray the quality, cost and value of hospital care; Developing and using measure reporting in the nation's hospitals; and Sharing useful hospital performance information with the public. AQA (http://www.aqaalliance.org/) The mission is to: improve health care quality and patient safety through a collaborative process in which key stakeholders agree on a strategy for measuring performance at the physician or group level; collecting and aggregating data in the least burdensome way; and reporting meaningful information to consumers, physicians and other stakeholders to inform choices and improve outcomes. PQA (http://www.pqaalliance.org/) The Mission of the PQA is to improve health care quality and patient safety through a collaborative process in which key stakeholders agree on a strategy for measuring performance at the pharmacy and pharmacist-levels; collecting data in the least burdensome way; and reporting meaningful information to consumers, pharmacists, employers, health insurance plans, and other healthcare decision-makers to help make informed choices, improve outcomes and stimulate the development of new payment models.

40. June 25, 2008 40 HHS-Designated Chartered Value Exchanges Communities designated as Chartered Value Exchanges (CVEs) are working with the Centers for Medicare Medicaid Services to report physician-group level performance information. They are also members of a peer-to-peer Learning Network sponsored by the Agency for Healthcare Research and Quality and have access to HHS experts and new tools, including an ongoing private Web-based knowledge management system. CVE communities include: Wisconsin Healthcare Value Exchange, Madison, Wis. Healthy Memphis Common Table, Germantown, Tenn. Greater Detroit Area Health Council, Detroit, Mich. Niagara Health Quality Coalition, Williamsville, N.Y. Oregon Health Care Quality Corporation, Portland, Ore. Pittsburgh Regional Health Initiative, Pittsburgh, Pa. Puget Sound Health Alliance, Seattle, Wash. Utah Partnership for Value-driven Health Care, Salt Lake City, Utah Louisiana Health Care Quality Forum, Baton Rouge, La. Maine Chartered Value Exchange Alliance, Scarborough, Maine Minnesota Healthcare Value Exchange, St. Paul, Minn. Massachusetts Chartered Value Exchange, Watertown, Mass. Alliance for Health, Grand Rapids, Mich. New York Quality Alliance, Albany, N.Y. www.hhs.gov/valuedriven/communities/valueexchanges/exchanges.html

41. June 25, 2008 41 List of Key Regional Health Initiatives

42. June 25, 2008 42 List of Key Regional Health Initiatives (continued)

43. June 25, 2008 43 List of Key Regional Health Initiatives (continued)

44. June 25, 2008 44 Key Regional Health Initiative Locations by State

45. June 25, 2008 45 Number of Collaboratives around the country is growing

46. June 25, 2008 46 CMS Quality Initiatives Post Acute Care Reform Plan Home Health Quality Initiatives Hospital Quality Initiatives Nursing Home Quality Initiatives ESRD Quality Initiatives Physician Focused Quality Initiatives Survey and Certification Section Quality Improvement Organizations (in previous slide)

47. June 25, 2008 47 Post Acute Care Reform Plan Improved payment plan and coordination of post-acute care services for individuals who need additional help recuperating from an acute illness or serious medical condition Reviewed current industry practices Established overarching principles and vision for reform

48. June 25, 2008 48 Home Health Quality Initiatives Launched in 2003, the initiative combines new quality of care information for consumers with the resources necessary to improve the quality of home health care. In 2004, the home health quality measures were updated on each Medicare-certified home health agency to give consumers the ability to compare the quality of care provided by the agencies. Home Health Compare Medicare uses the Outcome and Assessment Information Set (OASIS) in connection with the home care industry to foster and monitor improved home health care outcomes.

49. June 25, 2008 49 Hospital Quality Initiative Aims to refine and standardize hospital data, data transmission and performance measures to construct a single robust, prioritized and standard quality measure set for hospitals. Consists of: National Voluntary Hospital Reporting Initiative Provides useful, valid information about hospital quality to the public; standardize data and data collection; and foster hospital quality improvement. Three-State pilot of the Hospital Patient Perspectives on Care Survey (HCAHPS) As there is no current national standard for measuring and collecting data on patients� satisfaction with care, CMS worked with AHRQ to pilot test a survey which would allow consumers to compare patient perspectives at different hospitals. Premier Hospital Quality Incentive Demonstration Recognizes and provides financial rewards to hospitals that demonstrate high quality performance in a number of areas of acute care. Hospital Compare Converts data retrieved from hospitals� patient records to rates that measure how well the hospitals care for patients. The Hospital Quality Alliance (HQA) plans to increase the number of measures and types of conditions/ treatments on which the hospitals report.

50. June 25, 2008 50 Nursing Home Quality Initiatives Began in 2002 as a six state pilot and was soon after expanded to all 50 states Initiative efforts are focused in four areas: Regulation and enforcement efforts conducted by CMS and State survey agencies Continual, community-based quality improvement programs Collaboration and partnership with stakeholders Improved consumer information on the quality of care in nursing homes Nursing home compare Collects data in regular intervals on all residents in a Medicare or Medicaid certified nursing home Information is collected on the resident�s health, physical functioning, mental status and general well-being.

51. June 25, 2008 51 Physician Focused Quality Initiatives Uses multiple approaches to promote the adoption of quality strategies Doctors� Office Quality (DOQ) Project Designed to develop and test a comprehensive, integrated approach to measuring and improving the quality of care for chronic diseases and preventive services in outpatient settings. Doctors� Office Quality-Information Technology (DOQ-IT) Project Aims to support the adoption and effective use of information technology by physicians� offices. Payment Demonstration Projects Examines financial incentives for physicians that demonstrate higher quality performance End Stage Renal Disease (ESRD) Quality Initiatives

52. June 25, 2008 52 ESRD Quality Initiatives Required by the Balanced Budget Act of 1997, CMS developed and implemented a method to measure and report the quality of renal dialysis services provided by Medicare programs. CMS supported the development of 16 clinical performance measures (CPMs) Dialysis Facility Compare Allows patients, families and professionals to compare the quality of dialysis facilities nationally and access a range of kidney and dialysis resources Information is retrieved from SIMS and REMIS

53. June 25, 2008 53 Breakthrough Initiatives Series of projects focused on specific areas where large quality gaps exist and next steps have been identified National Influenza and Pneumococcal Vaccination Campaign Nursing Home Immunizations Dialysis Immunizations