CMS Announces Updates to Dialysis Facility Compare: Patient Experience Ratings Now Available

By: Kate Goodrich, M.D., Director, Center for Clinical Standards and Quality

Today, the Centers for Medicare & Medicaid Services (CMS) announced changes to the Dialysis Facility Compare (DFC) website on Medicare.gov, which provides information about thousands of Medicare-certified dialysis facilities across the country, including how well those centers deliver care to patients.

These changes are in direct response to the important feedback CMS has received from dialysis patients and their caregivers about what is most important to them in selecting their dialysis facility. CMS remains committed to seeking and incorporating input from all stakeholders, but especially patients, on an ongoing basis so that we can continually improve our Compare sites and make health care quality information more transparent and understandable for patients and their caregivers.

Since the initial release of the Dialysis Facility Compare website, patients have emphasized in their feedback to CMS that understanding how others like them view a dialysis center— in particular the cleanliness of the facility and how well the staff cares for them— is valuable information when choosing a facility. As a result, visitors to the updated Dialysis Facility Compare website will now be able to see how patients rate their experiences with dialysis facilities.

CMS collects patient experience data though the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS) Survey, which measures patients’ perspectives on the care they received at dialysis facilities. A total of six ratings on patients’ experiences with care will be reported, including three that cover specific aspects of patient experience and three overall patient ratings of the kidney doctors, the facility staff and the dialysis facilities. For each dialysis center on Dialysis Facility Compare, the site will include this patient experience information, the quality star rating, and detailed clinical quality information.

CMS is also adding two quality measures to Dialysis Facility Compare:

• The standardized infection ratio (SIR) is a ratio of the number of bloodstream infections that are observed at a facility versus the number of bloodstream infections that are predicted for that facility, based on national baseline data.
• The pediatric peritoneal dialysis Kt/V measure equals the percent of eligible pediatric peritoneal dialysis patients at the facility who had enough waste removed from their blood during dialysis.

Other major changes to the site include modifications to the methodology for calculating dialysis facility star ratings based on recommendations from a 2015 Technical Expert Panel. The updated methodology for calculating star ratings:

• Establishes a baseline to show improvement by taking into account year-to-year changes in facility performance on the quality measures compared to performance standards set in a baseline year. Star ratings will reflect if a facility improves (or declines) in performance over time.
• Limits the impact of a few very low scores by applying a statistical method called truncated z-scores to percentage measures. This ensures that star ratings are not determined by extreme outlier performance on a single measure.
• Ensures accuracy of ratings by keeping the continuity of the measures.

A final change to the DFC website relates to ratio measures:

• The Standardized Mortality Ratio, Standardized hospitalization Ratio, Standardized Transfusion Ratio, and Standardized Readmission Ratio will now be reflected as rates to display them more clearly.

These changes reflect CMS’ ongoing commitment to making sure that Dialysis Facility Compare meets the needs of individuals with kidney disease and their caregivers. This Compare website and today’s updates are part of the agency’s larger effort to make health care quality information more transparent and understandable for consumers.  As part of that effort, CMS also has other Compare websites to help in selecting providers across the continuum of care, including Home Health Compare, Hospital Compare, Nursing Home Compare, and Physician Compare.

For more information, see the fact sheet: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-10-28.html 

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CMS Awards Special Innovation Projects to Quality Innovation Network-Quality Improvement Organizations Aimed to Drive Better Care, Smarter Spending, and Healthier People

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

Kate Goodrich, MD
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 & Medicaid Services (CMS) has taken another step toward ensuring that beneficiaries receive better care, better value, and achieve better overall care, smarter spending, and healthier people by awarding 20, two-year Special Innovation Projects (SIPs) to 12 regional Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs). The SIPs offer QIN-QIOs and their partners, clinicians, schools of higher education, innovation labs, and Medicare beneficiaries and their families the opportunity to address critical health care issues important to their constituency in the areas of quality improvement that may be underutilized, but represent a significant opportunity if spread locally, regionally, or nationally. QIN-QIOs serve the Medicare population by working with Medicare beneficiaries, providers, and communities in data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality.  QIN-QIOs were eligible to submit proposals for two types of SIPs in 2016:

1. Projects addressing issues of quality occurring within the QIN-QIOs’ local service area: “Advance Local Efforts for Better Care at Lower Cost.”
2. Projects focusing on expanding the scope and national impact of quality improvement interventions that have proven success in limited areas or scope: “Interventions that are Ready for Spread and Scalability.”

Projects that “Advance Local Efforts for Better Care at Lower Cost” include:

• Great Plains QIN will work with 25 home health agencies in Kansas, Nebraska, North Dakota, and South Dakota to develop and test educational interventions to prevent and manage common infections observed in home health such as respiratory, urinary tract and wound infections.
• Health Services Advisory Group will be building capacity for telepsychiatry services in the Virgin Islands of St. Croix, St. John, and St. Thomas to address the lack of psychiatric specialty services available.
• TMF Quality Innovation Network will be working with 80 physician practices in Arkansas, Missouri, Oklahoma, and Texas to increase primary care physician knowledge of treatment for depression and alcohol use disorder through knowledge transfer from specialists to primary care physicians.

Topic areas for “Interventions that are Ready for Spread and Scalability” were identified through consultation with the Strategic Innovation Engine (SIE). The Strategic Innovation Engine (SIE) is a new endeavor that will advance CMS’ six quality goals by rapidly moving innovative, evidence-based quality practices from research to implementation throughout the QIN-QIO program and be made available to the greater health care community. The SIE will serve as an instrument in furthering the science of improvement to better inform quality improvement efforts in the future for QIOs and others that draws upon the literature, healthcare quality data, and experts and practitioners in the field to ensure safe, effective practices are available for use by providers seeking to improve quality and reduce costs.

These high leverage topic areas include streamlining patient flow in health care settings; working with health plans and care coordination providers on approaches to post-acute care that results in enhanced care management; increasing value, patient affordability, and appropriate use of specialty drugs by applying evidenced based criteria to prescribing practices; addressing acute pain management in sickle cell patients; and utilizing big data analytics to reduce preventable harm in health care. Examples of funded projects for “Interventions that are Ready for Spread and Scalability” include:

• Alliant Quality, utilizing the breakthrough collaborative model, will work with 30 emergency departments in Georgia and North Carolina to improve the triage, treatment, and quality of care received by patients with sickle cell disease who present to the emergency room in vaso-occlusive crisis (VOC). It is expected that interventions will result in appropriate and timely pain management and improved patient experience.
• Atlantic Quality Innovation Network, working in New York (Orange, Putnam, and Dutchess Counties) with physician offices, pharmacies, hospitals, nursing homes and county health departments, seeks to modify and standardize prescribing practices for managing anticoagulants during the periprocedural period to reduce anticoagulant adverse drug events in all patients, including Medicare Fee-for-Service beneficiaries. Interventions include the operationalization of a mobile/web-based application for clinical decision support in hospital/ambulatory surgery settings and optimization of patient education using health information technology.
• Qualis Health, working in Washington and Idaho, seeks to improve the quality, safety, and reliability of the care transition process by focusing on a comprehensive assessment of the social determinants impacting beneficiaries’ transitions from the hospital to the home and creating robust linkages to community social service providers for high-risk beneficiaries to improve care coordination and reduce avoidable medical care utilization.

CMS sought proposals with scientific rigor, a strong analytic framework and a reasonable, proposed intervention based on the supporting evidence. CMS looked for evidence of QIN-QIO partnerships at the community, regional and national levels, and inclusion of patients and families in each project as well as direct links to the CMS Quality Strategy goals.

A complete list of 2016 SIP awardees is located on the QIO Program website.

We are committed to innovation and are excited to study the results produced by these SIPs and to identify ways in which to incorporate them throughout the QIO Program based upon their results. The SIPs create an exciting opportunity for providers, professional organizations, innovation labs, and others to innovate and impact health care quality in the Medicare program at local, regional and national levels through the QIO Program.

Medicare’s investment in primary care shows progress

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

Today, the Centers for Medicare & Medicaid Services (CMS) announced the Comprehensive Primary Care (CPC) initiative’s second round of shared savings results, with nearly all practices (95 percent) meeting quality of care requirements and four out of seven regions sharing in savings with CMS. These results reflect the work of 481 practices that served over 376,000 Medicare beneficiaries and more than 2.7 million patients overall in 2015.

As the largest test of advanced primary care in U.S. history, CPC demonstrates the potential of primary care clinicians redesigning their practices to deliver better care to their patients, and provides clinicians support to innovate and deliver care in ways that better meet their patients’ needs and preferences.

During 2015, its second shared savings performance year, CPC generated a total of $57.7 million gross savings in Part A and Part B expenditures. These savings are essentially equivalent to the $58 million paid in care management fees to the practices. Four of the seven regions participating in CPC – the states of Arkansas, Colorado, and Oregon, and the Greater Tulsa region in Oklahoma – realized net savings (after accounting for the care management fees paid) and will share in those savings with CMS. Although three of the CPC regions had net losses, the savings generated in the other four regions covered those losses, such that care management fees across CPC were offset by reduced spending on Medicare Part A and Part B services. Further, more than half of participating CPC practices will receive a share of over $13 million in earned shared savings.

In addition to the gross Medicare savings, CPC practices showed positive quality, with lower than expected hospital admission and readmission rates, and favorable performance on patient experience measures. CPC practices’ performance on electronic Clinical Quality Measures (eCQMs) also exceeded national benchmarks, particularly on preventive health measures.

This is the first year CMS has included eCQM performance in Medicare shared savings determinations for CPC. eCQM reporting covering the entire practice population at the practice site level is critical to using health information technology as a tool to support care delivery transformation. eCQM data are recorded in the electronic health record in the routine course of clinical care, allowing practices to engage in real time quality improvement efforts that drive population health. As we move to a health care system that rewards value over volume, CPC practices are at the forefront of using eCQMs for quality improvement, measurement, and reporting.

Quality highlights from the 2015 shared savings performance year include:

• 97 percent of CPC practices successfully reported 9 eCQMs. For ten out of the eleven eCQMs in the CPC measure set, the majority of CPC practices who reported surpassed the median national performance.
• Nearly all (99 percent) practices reported higher levels of colorectal cancer screening and influenza immunization compared to national benchmarks. Additionally, 100 percent of practices who reported on screening for clinical depression surpassed national benchmarks.
• Compared to 2014, most regions maintained or improved their scores on hospital readmissions and admissions for chronic obstructive pulmonary disorder and congestive heart failure.
• Patients rated the care they receive from their CPC practitioners highly, particularly on how well practitioners supported them in taking care of their own health and the attention they paid to care from other providers.

The positive performance is a testament to the efforts CPC practices have made to provide truly “comprehensive primary care.”

CPC is a multi-payer partnership launched by the Center for Medicare and Medicaid Innovation (Innovation Center) in October 2012 to advance primary care by paying clinicians to deliver accessible, comprehensive, and coordinated care in seven regions across the country. CPC supports advanced primary care as the foundation of our health system. In addition to attending to patients’ acute, chronic, and preventive health care needs, primary care practices act as the quarterback of each patient’s health care team. CPC practices help patients navigate their care, communicate with specialists and hospitals, and ensure that patients with complex social and medical needs do not “fall through the cracks” of the health care system.

These results build on the first shared savings performance year in 2014. Gross savings nearly doubled from the first performance year to the second and practices in four regions were eligible to receive shared savings, compared to one region in 2014. Primary care transformation takes time, and it is especially encouraging that CPC practices maintained such positive quality of care results while also seeing gross Medicare savings in the 2015 performance year.

The experience in CPC has contributed to our continued efforts to support primary care going forward in the Innovation Center’s Comprehensive Primary Care Plus (CPC+), which will begin on January 1, 2017 and for which we recently announced the 14 selected regions and are currently reviewing practice applications. CMS anticipates that CPC+ could meet the criteria to qualify as an Advanced Alternative Payment Model (Advanced APM) under the recently finalized Quality Payment Program rule, which implements the Medicare Access and CHIP Reauthorization Act of 2015. A robust primary care system is essential to achieve better care, smarter spending, and healthier people. For this reason, CMS is committed to supporting primary care clinicians to deliver the best, most comprehensive primary care possible for their patients.

Tackling Tough Issues Together: The CMS Rural Health Council Solution Summit

By Cara James, Director of CMS Office of Minority Health and John Hammarlund, Regional Administrator 

In 1909, President Theodore Roosevelt’s Country Life Commission issued a report finding that in rural populations, “the physicians are further apart and are called in later in cases of sickness, and in some districts, medical attendance is relatively more expensive.” We have made progress in closing some of the access gap in recent years. Since the Affordable Care Act was signed into law by President Obama in 2010, uninsured rates in rural America have dropped by nearly 40 percent with corresponding improvements in access to care. Nevertheless, rural Americans are more likely to live in states that have not expanded Medicaid, more likely to live in areas with fewer physicians per capita, and more likely to have difficulty accessing timely emergency care.

To address these issues, earlier this year CMS established the CMS Rural Health Council. Made up of experts from across the agency, the Rural Health Council has been thinking about three strategic areas – first, ways to improve access to care for all Americans in rural settings; second, ways to support the unique economics of providing health care in rural America; and third, making sure the health care innovation agenda appropriately fits rural health care markets.

Supported by the Council, CMS has undertaken a number of efforts to reach out to stakeholders to hear about ways to improve access to services for rural Americans. CMS has rural health coordinators at each of our Regional Offices, who meet monthly with the Health Resources and Services Administration (HRSA) to discuss emerging issues. During the Rural Health Open Door Forums, CMS engages with stakeholders to provide current information on CMS programs, answer questions, and learn about emerging rural health issues.

Through our rural health coordinators and the Rural Health Council, CMS has conducted nearly two dozen listening engagements nationwide on key rural health issues, such as telemedicine, hospice, and hospital support. We’ve heard directly from physicians and hospitals who are treating their patients while juggling the unique challenges of rural health care.

In recent years, CMS reformed Medicare regulations that were identified as obsolete or excessively burdensome on hospitals and rural health care providers, which will save providers nearly $660 million annually and $3.2 billion over five years.

Going forward, we’re continuing to embed a rural focus into new programs. For example, with the proposed new Quality Payment Program, we’re making a special effort to reach clinicians in rural areas. Through technical assistance and other activities, we’ll help them transition to the proposed Quality Payment Program’s new approach for paying clinicians for the value and quality of care they provide.

We hope that all of our ongoing efforts, including the work of the CMS Rural Health Council, will give us a better understanding of how our policies and programs affect rural communities.

But we can’t address the challenges of rural communities alone. That’s why we recently announced we will be conducting the CMS Rural Health Solutions Summit on October 19, 2016, at CMS headquarters in Baltimore, Maryland. The CMS Rural Health Council will be bringing in stakeholders from all sectors of the health care industry as we engage in in-depth discussions about ways to improve access to care in rural America and support local innovation in care delivery. We’re excited to bring together national, state, and local leaders to discuss innovative strategies for improving rural care, access, and cost. This discussion will help us work together towards rural health policy and implementation that drives high-value, high-quality health care. If you’d like to join our conversation on October 19, please register at https://register.mitre.org/CMS_Rural_Health_Solutions_Summit/index.html