CMS & Healthcare Stakeholders: Opportunities for Collaboration

Barry M. Straube, M.D.Chief Medical Officer

Centers for Medicare & Medicaid Services, Region IXLA Collaborative Meeting

December 3, 2004

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Federal Stakeholders in the U.S. Healthcare System

• Department of Health & Human Services

• Veterans Affairs• Department of Defense• Department of Labor• Federal Bureau of

Prisons• United States Coast

Guard• Office Personnel

Management

• Federal Trade Commission

• Office of Management & Budget

• Department of Commerce• National Highway

Transportation & Safety Administration

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Department of Health & Human Services:Agencies

• Secretary of HHS• Administration for Children

and Families• Administration on Aging• Agency for Healthcare

Research & Quality• Agency for Toxic

Substances & Disease Registry

• Centers for Disease Control

• Centers for Medicare & Medicaid Services (CMS)

• Food & Drug Administration

• Health Resources & Services Administration

• Indian Health Service• National Institute of Health• Program Support Center• Substance Abuse &

Mental Health Services Administration

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Centers for Medicare & Medicaid Services (CMS)

• Health benefits for over 76 million Americans– Medicare– Medicaid– State Children's Health Insurance Program

(SCHIP)

• Spends over $450 billion annually for health care services in CMS programs

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Centers for Medicare & Medicaid Services (CMS)

• Healthcare Benefits Administration– Establish payment methodology for providers– Conduct research on financing, treatment &

management– Assure that contractors & state agencies run

CMS programs correctly– Identify fraud & abuse, take appropriate action

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Centers for Medicare & Medicaid Services (CMS)

• Beneficiary-Focused Activities– Benefits and health education– Advocacy: Appeals, Grievances, patient rights– Assuring access and continuity of care– Preventive services– Healthcare data for choice– Promoting partnerships of patients and

providers to provide patient-centered care

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Centers for Medicare & Medicaid Services (CMS)

• Quality-Focused Activities– Laboratory Testing (CLIA)– Survey & Certification of Health Care Facilities

(Hospitals, LTC, SNF, HHA, etc.)– End-Stage Renal Disease Networks– Organ Procurement Organizations– Quality Improvement Organizations– Quality Improvement Systems in Managed

Care (QISMC)– Multiple Demonstration Projects

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CMS 2005 Priorities

• Implementation of the Medicare Modernization Act

• Quality, quality, quality…….• Ongoing reimbursement reform

– Pay-for-Performance (P4P)

• Health Information Technology promotion• Prevention• Contractor reform• A host of other issues…….

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CMS Quality Initiatives

• Nursing Homes

• Home Health

• Hospitals

• Doctor Offices

• End Stage Renal Disease Facilities

• More initiatives to come…..

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Medicare Modernization Act: Disease Management Projects

• Medicare Health Care Quality Demonstration Programs (Section 646)– 5 year project expanding current physician

group practice demonstration

• Consumer Directed Chronic Outpatient Services (Section 648a)– 3 demonstration projects aimed at improving

the quality of care for Medicare patients with chronic conditions

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Medicare Modernization Act: Disease Management Projects

• Care Management Performance Demonstration (Section 649)– 3 year P4P pilot– Adoption and use of health information

technology• Voluntary Chronic Care Improvement Program

under traditional fee-for-service (Section 721)– 3 year contracts with chronic care improvement

organizations for randomized clinical trials– Guide beneficiaries with chronic disease to

disease management programs

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Medicare Modernization Act: Chronic Disease Sections

• Chronically Ill Medicare Beneficiary Research, Data, Demonstration Strategy (Section 723)– Within 6 months of enactment, Secretary must

develop a plan to improve quality of care and reduce cost to chronically ill Medicare beneficiaries

– Integrate existing datasets, identify new data needs and methodology to address them, plan for new data warehouse, develop research agenda

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CMS Region IX Quality Forum

• CMS RO IX• QIOs• Associations

– Physician– Hospital– Health Plan – Medical group– SNF, hospice, etc.

• Employer groups• Pay-for-Performance

initiatives

• NFP health foundations• Individual

– Health Plans– Medical Groups– Hospital chains– SNFs, other providers

• Private-sector health companies

• Academic institutions• Growing list of others

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CMS Region IX Quality ForumQuality Forum Mission• We strive to make healthcare better, safer, and

more cost-effective for residents within the region.

Quality Forum Vision• Pursue high-quality, safe, accessible and

affordable health services for residents in the region

• Enhance collaboration and communication among all stakeholders

• Detect problems & engage in problem solving• Seek out the best healthcare practices to drive

innovation and quality in all aspects of healthcare

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CMS Region IX Quality Forum

Quality Forum Goals• Select projects that affect broad group of

healthcare providers• Address evolving health system needs to

prepare healthcare for the future– Public health– Evolving information infrastructure needs

• Develop 2-3 project plans by May 2005 • Focus on and promote California as the

initial pilot location

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Quality Forum Initial Project List

1.Collect and Share Physician Performance Data

2.Create Personalized Beneficiary Health Information Communication

3.Alleviate Emergency Department Overcrowding

4.Develop Public Physician and Physician Practice Information Website

5.Expand Use of e-ICUs

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Quality Forum Initial Project List

6. Expand Use of Telemedicine – Target Rural Populations

7. Promote Fistula First Initiative

8. Support California Adult Immunization Coalition

9. Focus on End-of-Life / Palliative Care

10.Assist Physicians Entering into EHR Capabilities

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Quality Forum Project Selection

• Physician Level Performance Measurement – Data Use for Beneficiary Healthcare

Improvement

• Emergency Department Overcrowding

• Workgroups established

• Synopsis of progress to date

• Additional function of identifying problems that CMS and stakeholders need to address

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Physician Level Performance Measurement

• Choose measures and validate– Database issues: Medicare FFS is essential

• Phase I: Voluntary & confidential physician quality improvement

• Phase II: Credentialing, proprietary QI, other proprietary uses

• Phase III: Public reporting, P4P, etc.

• Complementary beneficiary education

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E.D. Overcrowding

• One in three U.S. hospital E.D.s are routinely on diversion

• 34% of hospitals in U.S. report operating over capacity– 28% report at capacity

• For large, urban hospitals 61% operating over capacity– 30% operating at capacity

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E.D. Overcrowding

• E.D. visits have increased from 90 million in 1992 to 110 million in 2002– 23% increase

• Over same timeframe number of hospital E.D.s have decreased by 15%– 10% decrease in California

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E.D. Overcrowding

• CMA 2001 Study– E.D.s under-reimbursed by all payers,

particularly Medi-Cal– Ranks of uninsured continue to grow– Medi-Cal patients accounted for 40% of all

E.D. visits in 1998-1999• 53% for CA E.D.s with largest E.D. losses

– 80% of E.D. visits of Medi-Cal & uninsured did not require an E.D. setting

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E.D. Overcrowding

• Factors leading to overcrowding– More patients– Fewer E.D.s– Inappropriate use of E.D.s by patients– Decreased access to physician offices and

other sites– EMTALA restrictions– Downsized E.D. and hospital staffs and facilities– Throughput problems– Fewer discharge setting options

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E.D. Overcrowding Goals

• Obtain more data• Reduce frequent users and inappropriate use

of E.D.s– Frequent user grants and initiatives– FQHC, CHC, RHC options– Specialized centers: Alcohol, substance abuse,

wound care, etc.

• Address barriers to receiving care outside E.D.s– PCP and managed care focus

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E.D. Overcrowding Goals

• Identify & address EMTALA, regulatory & accreditation components

• Identify and address “throughput” problems

• Tackle discharge barriers• Address quality measurement and

payment issues– P4P overlap– CMS E.D. quality metric development

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Select Other Region IX Priorities

• Access to and continuity of care• Fraud & Abuse (Program Integrity) Increase• Ethnic & Racial Health Disparities, cultural

competence, health literacy• Rural health issues• Health Information Technology Initiatives• Pay-for-Performance (P4P) initiative

collaboration• Employer retirement coverage subsidies

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Contact Information

Barry M. Straube, M.D.Chief Medical OfficerCenters for Medicare & Medicaid ServicesRegion IX75 Hawthorne Street, Suite 408San Francisco, CA 94105

Email: bstraube@cms.hhs.govPhone: (415) 744-3503