Centers for Medicare

1
Centers for Medicare Medicaid
Services Medicare Hospital Value-Based
PurchasingOverview
Midwest Business Group on Health April 11, 2007

• Susan Nedza, MD, MBA
• Special Program Office
• for
• Value-Based Purchasing

2
Overview of the Presentation

• Legislative background
• Program goals and design assumptions
• Overview of development process
• Listening Session 1 key comments by Issues Paper
  topic
• Listening Session 2 logistics

3
Legislative Background

• Deficit Reduction Act (DRA) Section 5001(b)
  authorized CMS to develop a Medicare Hospital
  Value-Based Purchasing (VBP) Report
• Based on assumption of implementation in FY 2009
  implementation will require additional statutory
  authority
• Must consider
• Measures
• Data Infrastructure and Validation
• Incentive Structure
• Public Reporting
• Must consult relevant stakeholders and consider
  experience with relevant P4P demonstrations and
  private-sector programs

3
4
VBP Program Goals

• Improve clinical quality
• Address underuse, overuse, and misuse
• Encourage patient-centered care
• Reduce adverse events and improve patient safety

4
5
VBP Program Goals

• Avoid unnecessary costs in care
• Stimulate investments in effective information
  technology and the re-engineering of systems
• Make performance results transparent to and
  useable
• Avoid creating additional disparities and work to
  reduce existing disparities

6
VBP Design Assumptions

• VBP provides CMS a key mechanism to transform
  from passive payer to active purchaser
• A specified percentage of hospital payment would
  be conditional on performance
• Would reward both improvement and attainment
• Would use both financial incentives and public
  reporting to drive quality improvement

6
7
VBP Design Assumptions

• Would build on infrastructure of the Reporting
  Hospital Quality Data for Annual Payment Update
  Program (RHQDAPU)
• Transition from and replace RHQDAPU
• Would not include additional funding

7
8
VBP Design Assumptions

• Would include measures for different purposes
• -Incentive payment
• -Public reporting
• -Measure development
• Would require submission of data on all measures
  applicable to the hospitals service mix to
  qualify for incentive payment

8
9
VBP Design Assumptions

• Would move rapidly to achieve a comprehensive
  measure set
• Expanding the measures for assessing clinical
  quality
• Including HCAHPS to assess patient-centered care
• Including efficiency measures
• Incorporating hospital outpatient measures

9
10
VBP Design Assumptions

• As recommended by the Institute of Medicine, CMS
  would perform ongoing evaluation
• Assess impact
• Monitor for unintended consequences
• Adjust design based on lessons learned

11
VBP Plan Development Process

• CMS Hospital VBP Workgroup with Subgroups to
  address
• Incentive Structure
• Measures
• Data Infrastructure and Validation
• Public Reporting
• Contractor Support
• RAND for overall Plan
• Brandeis and subcontractors for in-depth work on
  measures

11
12
CMS Subgroup Leads

• Incentive Structure
• Donald Thompson, Center for Medicare Management
• Measures
• Michael Rapp, MD Sheila Roman, MD, MPH Office
  of Clinical Standards Quality (OCSQ)
• Data Infrastructure Validation
• William Matos James Poyer, OCSQ
  
• Public Reporting
• David Miranda, PhD, Center for Beneficiary
  Choices Benedicta Abel-Steinberg, Office of
  Beneficiary Information Services

12
13
RAND Support for Workgroup

• ASPE-CMS Collaboration
• Follow-on to ASPE 2005 Physician P4P
  Environmental Scan
• Joint funding from ASPE and CMS
• Conduct Environmental Scan
• Support Workgroup and Subgroups in development of
  Issues Paper, Options Paper, and Final Report to
  Congress
• Support Listening Sessions 1 and 2
• Assemble Final Report

13
14
Support for Measures Subgroup

• Brandeis University with subcontracts to Booz
  Allen Hamilton and Boston University
• Support development and testing of performance
  assessment model
• Explore measure gaps and options for addressing
  them
• Other consultants
• Arizona QIO assists CMS in Measures Manager
  process
• Oklahoma QIO assists CMS in development
  and maintenance of hospital measures

14
15
CMS Hospital VBP Workgroup Tasks and Expected
Timeline
2006 Oct Dec 2007 Jan 17 Apr 12 June July

• Conduct Environmental Scan
• Develop Issues Paper
• Conduct Listening Session 1 for
  Stakeholder Input on Issues Paper
• Develop Hospital VBP Options Paper
• Conduct Listening Session 2 for Input on
  Hospital VBP Options Paper
• Complete Final Design
• Prepare Final Report, Including Design, Process,
  and Environmental Scan

15
16
Issues Paper Approach

• Developed by CMS Hospital VBP Workgroup with
  support from RAND and Brandeis Team
• Posted on CMS Website December 22, 2006
• Outlined key design issues for Listening Session
  1
• Stakeholder comments, both presented at Session
  and submitted in writing, have assisted CMS in
  developing Options Paper

16
17
Listening Session 1

• January 17, 2007, CMS Baltimore
• 100 in-person, 500 call-in participants
• Agenda included presentations by
• CMS senior leadership
• RAND on key findings from the Environmental Scan
• Subgroup Leads on Measures, Data Infrastructure
  and Validation, Incentive Structure, and Public
  Reporting
• Public comment on each issue area

17
18
Listening Session 1 Key Comments on Incentives

• Reward both improvement and attainment
• Improvement in performance coupled with
  exceeding a pre-determined threshold provides a
  balanced approach that will engage a broader
  array of institutions.
• Raise all boats do not pick winners and
  losers
• A tournament structure will discourage sharing
  of best practices
• Spread payments broadly to engage and incentivize
  more hospitals
• Be sensitive to potential impacts on access to
  care

18
19
Listening Session 1 Key Comments on Measures

• Emphasize outcomes and process measures
  linked to outcomes
• With appropriate risk adjustment to recognize
  differences in case mix and socioeconomic status
• Be sensitive to unintended consequences The
  fastest way to improve my score is to fire my
  complex patients.
• Use absolute thresholds specified in advance to
  enable hospitals to plan ahead

19
20
Listening Session 1 Key Comments on Measures

• Rural hospitals want to participate in a single
  VBP program
• Measures of emergency care and transfer
  particularly relevant
• Older, sicker, poorer population needs to be
  recognized
• Dont retire topped out measures
• Hospitals need positive feedback about things
  they are doing well, as well as constructive
  feedback on areas needing improvement.
• Coordination of care is a key area for measure
  development

20
21
Listening Session 1 -Key Comments on Data
Infrastructure

• Develop a process for data resubmission
• View third-party vendors as partners
• Improve the current validation process
• Use a combination of random and targeted audits
• Use less frequent but larger samples
• Strike a balance between timeliness and validity

21
22
Listening Session 1 Key Comments on Public
Reporting

• Simplify Hospital Compare for ease of use
• Composite measures are important to consumers
• Focus on composites at the condition level
• Partner with other organizations to create
  composite measures
• Adequately disclose uncertainty and variability
  in scores based on small numbers

22
23
Conduct of Listening Session 2

• Morning Session
• Performance Assessment Model presentation
• Comments and questions
• Lunch 55 minutes
• Afternoon Session
• Introduction to afternoon topics
• Measures, Data Infrastructure, and Public
  Reporting presentations
• Comments and questions for each segment
• Panel of all Subgroup Leads to listen to general
  comments and questions
• Next steps

23
24

Conduct of Listening Session 2

• Comments from in-person attendees, then call-in
  participants
• State your name and organization
• Limit remarks to 2 minutes
• Feel free to leave the room, as needed only
  formal break will be lunch

24