Value-Based Purchasing Program

1. Value-Based Purchasing Program Community health measures strategy November, 2011

2. 7 Objectives for today’s discussion Develop a strategy for inclusion of community-based measures in VBP and include strategy in FY2015 IPPS rule for public comment • Review high-level objectives of value-based purchasing program and proposed measure selection strategy • Discuss value and feasibility of including community-based measures in the value-based purchasing program • Align on broad areas of interest for measurement of population health • Discuss next steps

3. 7 Purpose statement for Value-Based Purchasing CMS views value-based purchasing as an important driver in revamping how care and services are paid for, moving increasingly toward rewarding better value, outcomes, patient-centeredness and innovations instead of volume

4. VBP measures should be introduced from existing reported measures and transitioned to certification when “topped out” All measures CMS-collected measures VBP measures Certification or adequacy measures NQF endorsed measures PQRS IQR OQR Privately-stewarded unendorsed measures (e.g., ACC, PCPI) HVBP To be determined ESRD/DFC QIP OASIS Federal agency-stewarded unendorsed measures NHSN (CDC) • Measures topped out based on established criteria and agency priorities • Measure still supported by evidence and critical to quality • Able to establish a far “cut off” for certification • Measure is core to National Quality Strategy • Meet MAP criteria for measure set • Inclusion in VBP could significantly improve quality or efficiency • Measure is appropriately defined and sufficiently validated to be used as a basis for payment OSCAR/MDS Screening criteria: • Measures aligned with National Quality Strategy and the “kind of care CMS wants to buy” • Meet NQF criteria for endorsement • Meet CMS-specific operational criteria • Favorable burden/benefit balance • Need for additional refinement before inclusion in VBP program

5. CMS should establish guiding principles for individual measure selection and the measure set for each VBP program The measure set for VBP program should… Each measure included in a VBP program should… • Adequately address each of the National Quality Strategy priorities* • Adequately address high-impact conditions relevant to the program’s intended population* • Promote alignment with specific program attributes* • Include an appropriate mix of measure types* • Enable measurement across the patient-focused episode of care* • Include considerations for disparities* • Promote parsimony* • Emphasize outcome and patient experience measures while mitigating risk and unintended consequences • Minimize burden to providers and rely on electronically-specified measures wherever possible • Align with measures from other CMS programs wherever possible • Meet NQF endorsement criteria*, especially • High impact (1a) • Demonstrated performance gap (1b) • Reliable and valid across Medicare providers (2) • Feasible to collect without undue burden on providers (4) • Harmonized with related measures (5) • Be of relevance to as broad a population of Medicare beneficiaries as possible in the relevant setting • Be a reliable and statistically significant tool for differentiating provider performance and using as a basis to modify payment • Be linked to a significant opportunity for quality improvement • Be appropriately defined and sufficiently validated to be used as a basis for payment , including adjustment for risk or other appropriate patient population or provider characteristics *Recommended by the Measure Applications Partnership

6. Five domains should contribute to total performance for VBP in all settings Significant overlap across settings Care coordination • Transition of care measures • Admission and readmission measures • Other measures of care coordination Clinical quality of care • HAC measures • HHS primary care and CV quality measures • Setting-specific measures • Specialty-specific measures • VBP program should align on • Overall balance across domains • Common measures to be used in multiple or all settings • Principles for selecting measures that may be unique to a given setting or specialty Total performance Efficiency Community health Patient experience • Spend per beneficiary measures • Quality to cost measures • Overutilization and appropriateness measures • Measures that assess health of the community • Measures that reduce health disparities • CAHPS or equivalent measures for each settings • Patient engagement measures

7. CMS programs with current or planned pay-for-performance/value-based component Potential for alignment of measures OCSQ • QIP/ESRD • HVBP/IQR/OQR • Cancer care centers • Psych hospitals • HITECH • LTCH • Hospice • IRFs • SNF (RTC from CM) • HHA (RTC from CM) • ASCs (RTC from CM) CM/PBPP • Physician value-based modifiers • ACOs CMMI • Demonstration projects? • Premier • Others?

8. Considerations for community health measures in VBP • Rationale for including community-based measures in VBP • Reflects the concept of value as a system property • Incentivizes the outcomes of collaboration that process measures attempt to capture • Essential to following the MAP recommendations and is in line with the National Quality Strategy • Recognizes that providers have joint accountability for the patients they serve and that providers play a direct role in the health outcomes of their communities • Brings health care in line with other sectors where system performance contributes to compensation, not just individual performance • Challenges associated with including community-based measures in VBP • Community health measures that are appropriate for VBP are lacking • “Communities” may be difficult to define, given mobility of patients and for appropriate attribution • Measure may require complex adjustment methods to ensure low-income communities are not adversely affected • Concept of joint accountability not aligned with current cultural, legal, or payment constructs in medicine • Need to address potential perception of “double dipping” on areas that are incentivized both at the individual and the community level • Short time horizon to next IPPS rule

9. Key questions to answer as part of strategic proposal • What areas of community health are appropriate to measure and aligned with the National Quality Strategy? • How do we define a community? • Why should providers be held financially accountable for the health of the communities in which they serve patients? • What is the specific link between a health care provider and quality improvement with respect to a community health measure? • What VBP programs and provider types should have community health as a measurement domain? • How feasible is measure development and what is the plan for measure development? • How can we ensure that a community health domain has the effect of reducing disparities?

10. NQF-endorsed community-based measures for consideration “Community” or “City/County” measures • 11 measures • Adult asthma • Annual cervical screening, high risk • Bacterial PNA • COPD • Dehydration • Influenza immunization • LBW • Pediatric sx checklist • Pneumo vaccination • HIV testing in pregnancy • UTI admissions Addresses HHS’s 6 strategic priorities 105 NQF-endorsed “population health” measures No current NQF measures appear to meet necessary criteria 94 measures 11 measures Are there additional inputs from AHRQ? CDC?

11. 7 High-level timeline for population-based measure strategy proposal Dec Jan Feb Mar Apr 5 19 2 16 30 13 27 12 26 ….. • Task • Align on rationale and criteria for community-based measures for VBP • Identify potential existing measures and appropriate areas for measure development • Discuss with other HHS stakeholders (CMMI, AHRQ, CDC) • Identify funding and build population health measure development work plan • Draft language requesting comment for inclusion in IPPS rule • Clearance for IPPS rule • NPRM IPPS rule due • Syndicate with senior leadership

12. Appendix—National Quality Strategy Three aims Better Care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe. Healthy People and Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care. Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government. • Six priorities • Making care safer by reducing harm caused in the delivery of care. • Ensuring that each person and family are engaged as partners in their care. • Promoting effective communication and coordination of care. • Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease. • Working with communities to promote wide use of best practices to enable healthy living. • Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.