CMS Continues Progress toward a Safer Health Care System through Integrated Efforts to Improve Patient Safety and Reduce Hospital Readmissions

By: Patrick Conway, MD, MSc, CMS Acting Principal Deputy Administrator and Chief Medical Officer

We know that it is possible to improve national patient safety performance resulting in millions of people avoiding infections and adverse health events. A report released by the Agency for Healthcare Research and Quality back in December showed an unprecedented 39 percent reduction in preventable patient harm in U.S. hospitals compared to the 2010 baseline. This has resulted in 2.1 million fewer patients harmed, 87,000 lives saved, and nearly $20 billion in cost-savings from 2010 to 2014. The nation has also made substantial progress in reducing 30-day hospital readmissions.

I have been working in the field of quality improvement for 20 years, and I have never before seen results such as these. This work, though, is far from done, and it is imperative that we sustain and strengthen efforts to address patient safety problems, such as central line infections and hospital readmissions. Today, we at CMS are excited to continue progress toward a safer health care system by releasing a Request for Proposal (RFP) for Hospital Improvement and Innovation Networks (HIINs).

The HIINs, which will be part of the Quality Improvement Organization (QIO) initiative, will continue the good work started by the Hospital Engagement Networks (HENs) under the Partnership for Patients initiative. These organizations will tap into the deep experience, capabilities and impact of QIOs, hospital associations, hospital systems, and national hospital affinity organizations with extensive experience in hospital quality improvement. The HIINs will engage and support the nation’s hospitals, patients, and their caregivers in work to implement and spread well-tested, evidence-based best practices.

QIOs that have developed strong relationship with HENs under the Partnership for Patients initiative have decades of experience with quality improvement and are currently supporting more than 250 communities nationally in work to improve care transitions and reduce adverse drug events across a wide variety of health care and community-based organizations.  HENs involved in supporting the Partnership for Patients initiative have established relationships and trusted partnerships with over 3,700 acute care hospitals. These efforts involve approximately 80 percent of all people discharged from hospitals across the nation.

The further integration of work across these influential networks will permit the continued and increased systematic use of proven practices to improve patient safety and reduce readmissions, at a national scale in all U.S. hospitals. Through 2019, the new HIINs will commit to and pursue bold new national aims to achieve a 20 percent decrease in overall patient harm and a 12 percent reduction in 30-day hospital readmissions as a population-based measure (readmissions per 1,000 people) from the 2014 baseline, thereby bolstering the impact of both the QIO program and the Partnership for Patients.

The procurement for the HIINs will be a full and open competition, and CMS encourages all interested parties to submit a proposal that will continue to build on the successes achieved so far. Organizations who were a HEN in the first and second rounds of the Partnership for Patients or QIOs and other organizations that meet the RFP criteria are welcome to submit a proposal for the HIIN opportunity, but will compete for selection against all other organizations submitting proposals.

More information about today’s RFP may be found at FedBizOpps.gov.

Round One Health Care Innovation Awards Show Some Promising Results

By: Dr. Patrick Conway, CMS Principal Deputy Administrator and Chief Medical Officer

The Health Care Innovation Awards is a Centers for Medicare & Medicaid Services (CMS) Innovation Center initiative that tests new payment and service delivery models and aims to find better ways to deliver care and bring down costs for Medicare, Medicaid, and/or Children’s Health Insurance Program (CHIP) enrollees. Today we are sharing the second annual independent evaluation reports of round one of the Health Care Innovation Awards. Overall, these evaluation reports show a wide range of experiences that have resulted in tangible benefits for patients and helped inform CMS in the development of new payment and service delivery models.

Where data are available, these reports describe preliminary impact estimates on key outcome measures such as hospitalizations and readmissions. A number of awardees showed favorable results on one or more measures of cost, hospitalizations, readmissions, and emergency room visits. Here are some early highlights of a few of the awards:

• Innovative Oncology Business Solutions, Inc. – through its Community Oncology Medical Home – reached more than 2,100 cancer patients through seven community oncology practices across the United States. Through comprehensive and coordinated oncology care, the model established pathways that:
  • allowed providers to identify and manage symptoms in real time;
  • improved patient access to providers through same-day appointments and extended night and weekend office hours; and
  • provided disease management guidance for providers to improve treatment decision-making, symptom recognition, and assistance with patients’ self care, pain management, and caregiver support.

The evaluation report shows that this award demonstrated a significant reduction in hospital readmissions and emergency room visits. In addition, qualitative findings suggest that staff highly value the triage pathways for making their workflow more efficient, and patients greatly appreciate weekend hours and increased capacity for urgent care visits during the day. Elements of this model were incorporated into the design of the Oncology Care Model.

• The High-Risk Children’s Clinic at the University of Texas Health Science Center at Houston’s (HRCC) offered dedicated outpatient services (primary, specialty, post-acute, chronic disease management) and around-the-clock phone access for extremely fragile and complex chronically ill children enrolled in Medicaid. Every family in the HRCC has an assigned clinician who involves the parent in all health assessments, empowering parents as experts in their child’s health condition and educating families on exacerbating symptoms. The evaluation found that the program significantly reduced emergency department visits and hospital admissions, which drove savings in medical and hospital cost of care for participating children. In addition, the report finds that the patient and family centered approach appears to have resulted in improved patient and family caregiver experience.

• Welvie is a program that offers education, health information, and decision-making resources regarding preference-sensitive surgeries to Medicare beneficiaries. Welvie conducts regularly scheduled, population-based outreach well before treatment decisions need to be made. Program administrators also review regional health care utilization patterns and mail outreach materials to arrive before periods of increased surgery utilization so that beneficiaries can recall and access the resources when needed. The program has enrolled over 181,000 beneficiaries in Ohio and almost 54,000 beneficiaries in Texas. Enrollees in Ohio had a statistically significant decrease in mortality as well as indications of a reduction in hospital readmissions following surgery-related hospital admissions for the Medicare FFS beneficiaries. The program was also associated with reductions in various surgery-related categories of expenditures among Medicare Advantage beneficiaries.

Diabetes Prevention Program

We recently announced that a round one Health Care Innovation Awards project — the Diabetes Prevention Program – is eligible for expansion under Medicare. The National Council of Young Men’s Christian Associations of the United States of America (Y-USA) enrolled eligible Medicare beneficiaries at high risk for diabetes in a program that could decrease their risk for developing serious diabetes-related illnesses. Beneficiaries in the program attended weekly meetings with a lifestyle coach who trained participants in strategies for long-term dietary change, increased physical activity, and behavior changes to control their weight and decrease their risk of type 2 diabetes. After the initial weekly training sessions, participants could attend monthly follow-up meetings to help maintain healthy behaviors. The main goal of the program was to improve participants’ health through improved nutrition and physical activity, targeting at least a five percent weight loss for each individual.

The independent CMS Office of the Actuary certified that expansion of the Diabetes Prevention Program would reduce net Medicare spending. The expansion was also determined to improve the quality of patient care without limiting coverage or benefits. This is the first time that a preventive service model from the CMS Innovation Center has become eligible for expansion into the Medicare program.

Health Care Innovation Awards Background

In July 2012, the CMS Innovation Center awarded 107 cooperative agreements through round one of the Health Care Innovation Awards to implement the most compelling ideas that aimed to deliver better care while spending health care dollars more wisely. Up to $1 billion were awarded to organizations that tested projects across the country that worked to achieve better quality of care and save money for people enrolled in Medicare, Medicaid and the Children’s Health Insurance Program. The evaluation reports are divided into large topical areas:

• Behavioral health and substance abuse;
• Complex and high risk patient targeting;
• Community resource planning and prevention;
• Disease specific;
• Hospital interventions;
• Primary care redesign; and
• Shared decision making/medication management

The first annual evaluation reports were released in April 2015 and provided qualitative findings largely focusing on the implementation experience covering the period from the award date through summer 2014. The reports released today synthesize findings from additional rounds of interviews and site visits conducted from the award date through summer 2015, preliminary estimates of impacts on four core measures (cost, hospitalizations, readmissions, emergency room visits) depending on the intervention and data availability, and results from select surveys of providers focusing on workforce and primary care.

While the results of the awards are wide-ranging, the evaluation of round one of the Health Care Innovation Awards is still ongoing and future reports will add to the current results. There is still much to learn, and we hope that other public and private entities will continue to invest in initiatives and efforts that improve the health care system in this country.

For more information on round one of the Health Care Innovation Awards and to view the second annual evaluation reports, please visit: https://innovation.cms.gov/initiatives/Health-Care-Innovation-Awards/. 

CMS Finalizes its Quality Measure Development Plan

By: Kate Goodrich, M.D., M.H.S., Director, Center for Clinical Standards & Quality, CMS

On December 18, 2015, we posted our draft Quality Measure Development Plan, a strategic framework for clinician quality measurement development to support the new Merit-based Incentive Payment System (MIPS) and advanced alternative payment models (APMs). Through March 1, 2016, we asked for stakeholder feedback and received responses from 60 individuals and 150 organizations.

Thank you for your comments, which we carefully reviewed and considered as we revised and finalized the plan. I am happy to announce that we posted the final Quality Measure Development Plan on the CMS website today (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Final-MDP.pdf).

CMS aims to drive improvement in our national health care system through the use of quality measures and periodic assessment of the impact of such measurement. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established payment incentives for physicians and other clinicians based on quality, rather than quantity, of care. We recently released the proposed regulation to implement these payment incentives, and more information is available here: https://federalregister.gov/a/2016-10032. The Quality Measure Development Plan is an essential aspect of this transition, which will provide the foundation for building and implementing a measure portfolio to support the quality payment programs under MACRA.

Highlights from the comments we received on the draft plan include:

• Many commenters expressed support for the strategic approach of the Quality Measure Development Plan.
• Responses favored CMS’ intent to engage clinicians, medical societies, and other stakeholders more broadly in measure identification, selection, and development processes for MIPS and APMs.
• Professional associations representing diverse clinical practice areas identified current measurement gaps and proposed priorities for measure development that are directly applicable to their specialties.
• Consumer advocates urged CMS to partner with patients, families, and caregivers and recommended a model for engaging them in measure development.
• Many commenters approved of the approach envisioned by the National Testing Collaborative and the National Quality Forum (NQF) Incubator to promote early engagement of stakeholders in measure development and testing.
• Both organizations and individuals contributed insights into the integral roles of their clinical professions or practices in the U.S. health care delivery system.

Taking these comments and suggestions into consideration, CMS finalized the Quality Measure Development Plan to include:

• Identification of known measurement and performance gaps and prioritization of approaches to close those gaps by developing, adopting, and refining quality measures, including measures in each of the six quality domains:
  • Clinical care
  • Safety
  • Care coordination
  • Patient and caregiver experience
  • Population health and prevention
  • Affordable care

• CMS actions to promote and improve alignment of measures, including the Core Quality Measures Collaborative, a work group convened by America’s Health Insurance Plans (AHIP). On February 16, 2016, CMS and the Collaborative announced the selection of seven core measure sets that will support multi-payer and cross-setting quality improvement and reporting across our nation’s health care systems.
• Partnering with frontline clinicians and professional societies as a key consideration to reduce the administrative burden of quality measurement and ensure its relevance to clinical practices.
• Partnering with patients and caregivers as a key consideration for having the voice of the patient, family, and/or caregiver incorporated throughout measure development.
• Increased focus and coordination with federal agencies and other stakeholders to lessen duplication of effort and promote person-centered health care.

The MACRA law provides the opportunity to further progress the Medicare program and our national health care system toward paying for value rather than volume.  However, the successful implementation of the Quality Payment Program established by MACRA requires a partnership with patients, their families, frontline clinicians, and professional organizations to develop measures that are meaningful, applicable, and useful across payers and health care settings. We thank all who contributed comments and dialogue to the draft CMS Quality Measure Development Plan, and we look forward to partnering with you on these exciting efforts related to our quality payment programs.