CMS Updates its Quality Strategy to Build a Better, Smarter, and Healthier Health Care Delivery System

By: Patrick Conway, M.D., MSc, Acting Deputy Administrator and Chief Medical Officer, CMS

At the Centers for Medicare & Medicaid Services (CMS), we are working with public and private partners to build a health care delivery system that delivers improved care, spends health care dollars more wisely, and makes communities healthier. Our goal, set out by the Administration, is to shift Medicare payments from volume to value – tying 30 percent of traditional Medicare payments to alternative payment models and tying 85 percent of all traditional Medicare payments to quality or value – by the end of 2016. And, we are making progress.

Today we are sharing our updated 2016 CMS Quality Strategy (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html), which incorporates this progress made in shifting Medicare payments from volume to value, since the last time we shared the CMS Quality Strategy in 2014. In addition, the updated 2016 version updates progress made on the payment reform initiatives as well as new requirements from the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation. The implementation of MACRA is a major opportunity to put a broad range of health care providers on the path to value through the new Merit-Based Incentive Payment System (MIPS) and incentive payments for participation in certain Alternative Payment Models (APMs).

This document guides the various components of CMS, including Medicaid, Medicare and the Center for Consumer Information and Insurance Oversight, as they work together toward the common goal of health system transformation. We hope that through the communication of the 2016 CMS Quality Strategy Update we continue to build support for and promote the CMS Quality Strategy so that our partners can align initiatives with key CMS desired outcomes.

The 2016 CMS Quality Strategy is built on the foundation of the CMS Strategy (https://www.cms.gov/About-CMS/Agency-Information/CMS-Strategy/), and the HHS National Quality Strategy (NQS) (http://www.ahrq.gov/workingforquality/). 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:

• Better Care: Improve the overall quality of care by making health care more person-centered, reliable, accessible, and safe.
• Healthier People, Healthier Communities: Improve Americans’ health by supporting proven interventions to address behavioral, social, and environmental determinants of health and deliver higher-quality care.
• Smarter Spending: Reduce the cost of quality health care for individuals, families, employers, government, and communities.

The 2016 CMS Quality Strategy goals reflect the six priorities set out in the NQS and identify quality-focused objectives that CMS can drive or enable to further these goals:

• Goal 1: Make care safer by reducing harm caused in the delivery of care.
• Goal 2: Strengthen person and family engagement as partners in care.
• Goal 3: Promote effective communication and coordination of care.
• Goal 4: Promote effective prevention and treatment of chronic disease.
• Goal 5: Work with communities to promote best practices of healthy living.
• Goal 6: Make care affordable.

To meet these six goals CMS will:

• Measure and publicly reporting providers’ quality performance and cost of services provided;
• Provide technical assistance and foster learning networks for quality improvement;
• Adopt evidence-based National Coverage Determinations;
• Create incentives for quality and value;
• Set standards for providers that support quality improvement; and
• Create survey and certification processes that evaluate capacity for quality assurance and quality improvemen

Like the NQS, the 2016 CMS Quality Strategy was developed with the input of stakeholders, led by the CMS Quality Strategy Affinity Group under the CMS Quality Improvement Council (QIC).  We made Affinity Groups to align and coordinate quality and value programs at CMS. The QIC ensures coordination, continuous learning, and the dissemination and spread of quality improvement activities across the agency.

Today’s release of the 2016 CMS Quality Strategy helps to align all of CMS to:

• Drive improvement on specific quality strategy goals and objectives.
• Strengthen our relationships within the agency.
• Build advocacy across HHS agencies.

We are excited to put the updated 2016 CMS Quality Strategy into action so we can do our part   to transform health care.

New CMS Web Tool Will Improve Access to and Transparency of Information on Medicare Enrollment, Utilization, and Expenditures

Niall Brennan, Chief Data Officer, Centers for Medicare & Medicaid Services

CMS continues to develop enhanced web-based data analytic and visualization tools, and I’m excited to announce that the most up-to-date Medicare enrollment information is now available to the public through our new CMS Program Statistics website. The website features web tools for users to explore CMS data, including viewing maps and examining enrollment information, through an interactive dashboard.

The CMS Program Statistics website replaces the former Medicare and Medicaid Statistical Supplement, which was published annually in electronic form from 2001-2013. The website will include over 100 detailed, easy-to- access data tables on national health care, Medicare populations, utilization, and expenditures, as well as counts for Medicare-certified institutional and non-institutional providers. Today, we have released the first two sections, which include information on national health expenditures, life expectancy, population projections, and Medicare enrollment and providers, and we will continue to release other sections on a rolling-basis.

The website also allows users to search for Medicare information in a visually appealing, easy to navigate format through the new Medicare Enrollment Dashboard. The Dashboard is an interactive online tool presenting monthly Medicare enrollment figures and yearly trends for hospital/medical coverage and prescription drug coverage by geographical areas, including national, state/territory, and county. The figures below provide snapshots of the readily accessible data available in the Dashboard. Figure 1 presents yearly trends in Medicare enrollment. In 2014, over 54 million people were enrolled in Medicare – about 7 million more than in 2010. Over that same period, the share of Medicare beneficiaries enrolled in Medicare Advantage and other health plans increased from 25% in 2010 to 30% in 2014. Figure 2 presents Medicare Advantage penetration rates by state and shows that Medicare Advantage enrollment is highest in California, Florida, Oregon, Minnesota, Ohio, and Pennsylvania, with 40-59% of Medicare beneficiaries enrolled in Medicare Advantage in those states.

Figure 1. Yearly Trends in National Enrollment

Figure 2. Medicare Advantage Penetration Rates by State

 

The CMS Program Statistics web tools are just the latest example of CMS improving data transparency and access for beneficiaries, researchers, and health care leaders. CMS is supporting a better understanding of our nation’s health care system while adding insight into the geographic patterns of Medicare health care and prescription drug coverage. Our goal is to ensure our data are accessible not just to researchers, but also to the general public. We look forward to continuing our efforts to make our data available as a resource to communities across the country.

Get more information about the CMS Program Statistics website on the CMS Program Statistics home page (https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and- Reports/CMSProgramStatistics/index.html)

Reducing Improper Payment: A Collaborative Effort

By Patrick Conway, MD

CMS Principal Deputy Administrator and Chief Medical Officer

CMS is dedicated to promoting better care, protecting patient safety, reducing health care costs, and providing people with access to the right care, when and where they need it. This includes continually strengthening and improving Medicare and Medicaid programs that provide vital services to millions of Americans. We take our responsibility to deliver better care at a better value seriously.

This week, the Department of Health and Human Services released our annual Agency Financial Report, which includes an update on the improper payment rate for a variety of our programs, including Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).

When we talk about improper payments, it’s important to remember what they are and why they happen. To be clear, improper payments are not typically fraudulent payments. Rather, they are usually payments made for items or services that do not meet Medicare or Medicaid’s coverage and medical necessity criteria, that are incorrectly coded, or that do not include the necessary documentation. Correctly recording and documenting medical services is an important part of good stewardship of these programs, and we strive to improve these practices among providers serving Medicare, Medicaid, and CHIP beneficiaries.

I am pleased that this year’s report shows progress is being made to reduce improper payments. The Medicare fee-for-service improper payment rate decreased from 12.7 percent in 2014 to 12.1 percent in 2015. CMS’s “Two Midnight” rule and corresponding educational efforts led to a reduction in improper inpatient hospitals claims, reducing the improper payment rate from 9.2 percent in 2014 to 6.2 percent in 2015. The improper payment rate for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) also decreased from 73.8 percent in 2010 to 40.1 percent as of September 2015. Corrective actions implemented over a six-year period, including the DMEPOS Accreditation Program, contractor visits to large supplier sites, competitive bidding, and a demonstration testing prior authorization of power mobility devices, contributed to the reduction in the improper payment rate for these items and supplies.

While progress has been made, we must continue our work to reduce the improper payment rates in Medicare, Medicaid, and CHIP.

For instance, in the Medicare Part D program, there’s been a 0.3 percent increase in the composite improper payment rate – an increase from 3.3 percent in the 2013 calendar year to 3.6 percent in 2014. This increase is primarily related to long-term care medication orders. We are continuing to work on education and outreach with plans and sponsors to correct for these improper payments. In addition, Medicaid and CHIP experienced increases with their improper payment rates – Medicaid increased from 6.7 percent in the 2014 fiscal year to 9.8 percent in 2015, and the improper payment rate for CHIP increased from 6.5 percent in fiscal year 2014 to 6.8 percent in fiscal year 2015. These increases are largely attributable to new provider enrollment and screening requirements from the Affordable Care Act and Health Insurance Portability and Accountability Act of 1996. We often see such increases when new requirements take effect, as states and providers often need time to modify their operations in order to comply with the updated standards. We believe, however, that these requirements will ultimately strengthen the Medicaid and CHIP programs, and that the improper payment rates will again decrease with state and provider experience. Without these new requirements, the Medicaid improper payment rate would have decreased to 5.1 percent, and the CHIP improper payment rate would have decreased to 5.7 percent.

We believe that increased transparency will help us make additional progress towards reducing improper payments in these programs. In an effort to foster increased transparency, CMS is exploring additional improper payment rate data releases in multiple sectors, including Medicare Part C and D Plans, and contractor level information for Medicare (including fee-for-service, Parts C and D) and Medicaid. This increased focus on transparency and accountability can help CMS encourage states and Medicare stakeholders to take additional actions to help reduce future improper payment rates.

As CMS begins these conversations, we will also refine and enhance the technical assistance provided to states and others to ensure compliance with regulations and reporting requirements that impact the improper payment rate.

We believe these steps – and a continued focus on transparency – will lead to a lower rate of improper payments while continuing to transform our health system to achieve better care, smarter spending, and healthier people.

 

CMS Awards 16 Partnership-Driven Special Innovation Projects to 10 Quality Innovation Network-Quality Improvement Organizations

Innovating to Close the Gap Between Best Practice & Common Practice

By: Patrick Conway, MD, MSc

Acting Principal Deputy Administrator

Deputy Administrator for Innovation and Quality

CMS Chief Medical Officer

Jean Moody-Williams, RN, MPP

Deputy Director

Center for Clinical Standards and Quality

Dennis Wagner, MPA

Director, Quality Improvement and Innovation Group

Centers for Clinical Standards and Quality

The Centers for Medicare and Medicaid Services (CMS) has taken another step toward ensuring that beneficiaries receive better care, better health and greater value by awarding 16, two-year Special Innovation Projects (SIPs), to 10 regional Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs). The SIPs address healthcare quality issues such as early detection and management of sepsis, advance care planning, colorectal cancer screening, and disease management in rural settings among other critically important healthcare quality issues. The list of 2015 SIPs can be found on the Quality Improvement Organization Program website (http://qioprogram.org/cms-awards-16-partnership-driven-special-innovation-projects-10-qin-qios).

While it is not the first year of the QIN-QIO contracts, the 2015 SIP awards represent a paradigm shift in how CMS views and utilizes the investment made in special quality innovation work. We recognize that there is tremendous quality work occurring in the field, and by requiring that the QIN-QIOs partner with organizations (Federal, State, local community, and/or Private), we can potentially capitalize on interventions that have not made it into mainstream use.

We are excited to study the results produced by these SIPs in the coming two years and will look to the outcomes of these projects for future use in the QIO Program, creating an exciting opportunity for providers, professional organizations, innovation labs, and others to innovate and impact healthcare quality at local, regional or national levels through the QIO Program Strategic Innovation Engine (SIE). The SIE is a new endeavor aimed at advancing CMS’ six quality strategy goals (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html) by rapidly moving innovative, evidence-based quality practices from research to implementation through the QIO Program and the Medicare program, with the effects spreading throughout the greater healthcare community. The SIE will accomplish this by:

·        Identifying gaps in the quality improvement agenda and recognizing potential innovations through a continuous scan of the quality environment while creating the opportunity for frontline healthcare providers to put forth evidence-based practices for consideration by the SIE;

·       Problem solving, proposing new areas for evidence development in the science of quality improvement, and considering how to rapidly move the nation from best practice to common practice in key healthcare areas; and

·       Working, in conjunction with the QIN-QIOs and their many partners, to purposefully spread evidence-based practices throughout the Medicare program, using multiple channels such as the QIO Program, CMS stakeholder partners, and others, to ultimately provide practical implementation strategies and methods for frontline providers to integrate high impact, high value best practices into their work to ensure patients receive the right care, at the right time, every time.

QIN-QIOs were eligible to submit proposals for two types of Special Innovation Projects in 2015:

Projects addressing issues of quality occurring within the QIN-QIOs’ local service area: “Innovations that Advance Local Efforts for Better Care at Lower Cost.”
Projects focusing on expanding the scope and national impact of quality improvement interventions that have had proven, but limited success: “Interventions that are Ripe for Spread and Scalability.” QIN-QIOs were encouraged to propose interventions intended to reduce mortality, harm, healthcare disparities and costs; provide higher return on investment; link value with quality; and encourage utilization of alternative payment models by providers.
CMS sought proposals with scientific rigor, a strong analytic framework and a reasonable, proposed intervention based on the supporting evidence provided. Additionally, CMS looked for evidence of QIN-QIO partnerships at the community, regional and national levels, and direct links to the CMS Quality Strategy goals.

We look forward to seeing how these SIPs make advances in healthcare quality issues. This program demonstrates our commitment to partner and collaborate with organizations, providers, and people across the country to achieve better care, smarter spending, and healthier people.