successfully competing in the health care quality marathon
TRANSCRIPT
9/8/2015
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Successfully Competing in the
Health Care Quality Marathon
Mary Ann Kliethermes, BS, PharmD Vice Chair, Professor Chicago College of Pharmacy
Midwestern University September 11, 2015
Learning Objectives
• List the organizations that are developing and selecting the quality measures that determine success toward reaching the finish line: ensuring patients are receiving high quality care at lower cost.
• List the quality measures that enable pharmacists to be a competitive runner (required provider) in the race of providing optimal patient care.
• Describe the pros and cons of measurement and explain how accurate and fair the rules are for the race.
The Rule Changes in Health Care
Volume
# of visits
Volume
Paid for a service
# of
measures
Quality incentives ACO/PCMH P4P Bundled Payments
Population
Where
are
we?
Future Past
Fee For Service Value Based Purchasing
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2015 Announcements
• Better, Smarter, Healthier (HHS)
Remainder of FFS 85% tied to quality by 2016, 90% by 2018
• Major providers, insurers plan aggressive push to new payment models
Task force
Quality or value through alternative payment models (ACO, bundled)
FFS
30 % end of 2016 50% end of 2018
http://www.hhs.gov/news/press/2015pres/01/2015126a.html http://www.modenrhealthcare.com/article/20150128/NEWS/301289934
Contracts with incentives for quality and lower cost
75% by 2020
Value Based Payment Models (VBP)
Pay for performance (65%)
Quality incentives and disincentives
ACO/PCMH
Care Coordination
Capitation, global payment, total cost of care payment (64%)
Episodes of care/bundled payment (59%)
Shared savings with only upside (46%)
Shared savings with up and down risk (29%)
http://mhsinfo.mckesson.com/rs/mckessonhealthsolutions/images/MHS-2014-Signature-Research-White-Paper.pdf
Defining Quality
The Institute of Medicine
(IOM)
the degree to which health services for
individuals or populations increase the
likelihood of desired health outcomes and are consistent with current professional knowledge
Institute of Medicine. Medicare: A Strategy for Quality Assurance. Washington, DC: National Academy Press; 1990
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Nuts and Bolts of Quality Measurement
• how resources and systems effect patient care Structure
• how the provider patient interactions and the care and services provided affect the patient
Process
• what happens to patients Outcome
Donabedian A. the quality of care. How can it be assessed? JAMA. 1988;260:1743-1748.
ECHO Model CMS
Economic
Clinical
Humanistic
Reducing per-capita costs
Better health for
populations
Better care for individuals
Measure Commandments Measures must be
meaningful
Measures must be feasible
Measures must be actionable
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Creators and Influencers of Quality
Measurement • Who is setting the course?
Government Related Organizations-
AHRQ
Agency for Healthcare Research and Quality
• National Quality Strategy
• Nation Quality Measure Clearinghouse
• Measure Developer of CHAPS surveys Consumer Assessment of Healthcare Providers surveys
• Resources: Closing the Quality Gap Series The Patient-Centered Medical Home.
Medication Adherence Interventions: Comparative Effectiveness.
Through the Quality Kaleidoscope: Reflections on the Science and Practice of Improving Health Care Quality.
Quality Domains for the National
Quality Strategy
2013 Annual Progress Report to Congress: National Strategy for Quality Improvement in Health Care http://www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm
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National Quality Strategy
http://www.qualitymeasures.ahrq.gov/browse/by-topic.aspx
Government Related Organizations:
Quality Alliances
• Hospital Compare Program • http://www.qualitynet.org • http://www.medicare.gov/hospitalcompare
Hospital Quality Alliance 2002
• Physician Quality Reporting System • http://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-Instruments/PQRS/index.html?redirect=/pqrs/
Ambulatory Quality Alliance 2004
Pharmacy Quality Alliance 2006
Long Term Quality Alliance 2010
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PQA’s Mission Statement
Improve the quality of medication management and use across health care settings with the goal of
improving patients’ health through a collaborative process to develop and implement performance measures and recognize examples of exceptional pharmacy quality.
PQA
Diverse Membership
PQA
Academic Institutions (29)
Adherence pkg org (4)
Community Pharmacy (21)
Consumer advocacy(0)
Government agencies (6)
Health IT (44)
Health Plans/PBMs (18)
Quality and Standard
Organizations (6)
Long Term Care Org. (2)
Pharma (23)
Pharmacy associations (7)
Research Institutions (4)
Trade Associations (6)
Health System alliances (3)
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Development of Measures
Measure Development Teams
Stakeholder Advisory Panels
Quality Metrics Expert Panel (QMEP) reviews/refines concepts
Specifications are drafted for high-priority measure concepts
QMEP reviews draft technical specifications and testing plan
PQA
Development of Measures
Health plan/PBM or other testing of draft technical specs
QMEP review of testing results; recommendation on endorsement
Membership vote on endorsement
Endorsed measures are reviewed and updated as necessary
PQA
CMS
Star Rating
Star Measures
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What is a Star Rating?
A. Measurement of how well a pharmacy is performing
B. Measurement of how well a practice is performing
C. Measurement of how well a prescription plan is performing
Star Ratings CMS: Plan Evaluation
Part C Domains
1. Staying healthy – prevention
2. Managing Chronic Conditions
3. Member experience
4. Member complaints and changes in performance
5. Customer Service
Part D Domains
1. Drug plan customer service
2. Complaints, access problems and improvement
3. Member Experience
4. Drug Pricing and Patient Safety
http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/index.html?redirect=/PrescriptionDrugCovGenIn/06_PerformanceData.a
sp
Ratings displayed as 1-5 stars 1.★ = poor performance 2.★ ★ = below average performance 3.★ ★ ★ = average performance 4.★ ★ ★★ = above average performance 5.★ ★ ★★★ = excellent performance
Medicare Star Ratings
Domain : pricing & safety (6 six measures Part D)
• 1 Price accuracy and stability
• 2 Medication safety
• 3 Medication adherence
Weighting
• Process Measure x1 (e.g. price stability/ accuracy)
• Access / Patient Experience Measure x 1.5 (e.g. pharmacy hold time, members leaving the plan)
• Intermediate Outcome Measure x3
• All five Pharmacy Quality Alliance (PQA) measures
• Improvement x 5
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PQA Star Measures/Health Insurance
Marketplace *
High risk medications in the elderly
Appropriate treatment of blood pressure in persons with diabetes (to be retired)
Adherence oral diabetes medications*
Adherence to cholesterol medication (statins)*
Adherence to blood* pressure (renin-angiotensin-aldosterone inhibitors)
Medication Therapy Management Program Completion Rate for Comprehensive Medication Reviews (Part D) (weight of 1 for 2016)
Ratings for MA-PD Contracts
http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PerformanceData.html
Ratings for PDP Plans
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Importance of Ratings?
http://www.cms.gov/Medicare/Prescription-Drug-overage/PrescriptionDrugCovContra/Downloads/Announcement2012final.pdf
http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2015.pdf
Star Rating QBP
Percentage
for
2012/2013
QBP
Percentage
for 2014
QBP
Percentage
for 2015
Less than 3
stars
0% 0% 0%
3 stars 3% 3% 0%
3.5 stars 3.5% 3.5% 0%
4 stars 4% 4% 5%
4.5 stars 4% 5% 5%
5 stars 5% 5% 5%
2014 PQA Work
Workgroups ‒ Adherence
Medication synchronization measure ‒ Long-term Care
Measures related to recommendation by the consultant RPH
‒ Medication Management for integrated care teams Hypertension measure set
‒ Medication Use Safety Severe hypoglycemic events, opioid utilization
‒ Mental Health Use of multiple antipsychotic medications
‒ MTM Part D CMS CMR action plan, SNOWMED codes
2015 PQA Work
1.Hospital Admission or ED Visit for Adverse Events (e.g., bleeding events [or stroke]) Associated with Anticoagulant Medications
2.Adherence to Immuno-suppressants Post-Transplant
3.MTM-Part D: Use of Patient Satisfaction Survey following CMR completion
4.Transitions of Care: Medication Reconciliation in LTC Setting
5.Primary Medication Non-Adherence (PMN) – for health plans*
6.Hospital and/or ED Utilization Related to ADEs
7.Triple Threat: Concomitant Use of Opioids, Benzodiazepines and Muscle Relaxants
8.Gap in Therapy – Medications Used to Treat Glaucoma*
9.MTM-Part D: Specific Drug Therapy Problem (DTP) Resolution
10.Hepatitis C – Persistence and Outcomes (SVR)
Measure Development Teams ‒
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Other PQA measures used by
CMS
• Display Measures
▫ Drug-drug interactions
▫ Excessive doses of oral diabetes medications
http://www.cms.gov/PrescriptionDrugCovGenIn/06_PerformanceData.asp
Government Related Organizations:
NQF
• Build consensus on national priorities and goals for performance improvement
• Endorse consensus standards for measuring performance and publicly reporting
• Promote attainment of national goals through education and outreach
Measure Endorsement
Must be available in the public domain
Fully tested for reliability and validity
Have importance, scientific merit, feasibility, usability when compared against competing similar measures
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Government Related Organizations: Other
Institute of Medicine (IOM)
• 1970 established under the National Academy of Sciences as an independent, nonprofit organization.
• Role is to work outside government to provide unbiased and authoritative advice to decision makers and the public.
Quality Improvement Organizations (QIOs)
• Independent organizations contracted with CMS
• Purpose to improve the effectiveness, efficiency, economy and quality of services delivered to Medicare beneficiaries.
• Exists in every state.
• 10th Scope of Work includes reductions in Adverse Drug Events
Accreditation Organizations
National Committee for Quality Assurance (NCQA)
• Private independent non-profit health care quality oversight organization
• HEDIS - Healthcare Effectiveness Data and Information Set measures
• 90% of health plans, Medicaid and Medicare use HEDIS measures to evaluate their performance, dimensions of care and service
• PCMH Recognition
NCQA ACO HEDIS Measures
http://www.ncqa.org/Portals/0/Programs/Accreditation/Accred08/ACO/NCQA_ACO_measures_Fact_Sheet_10.18.13.pdf
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NCQA PCMH Recognition - 2014 • Patient Centered Access
▫ 24/7 access aligns with Chronic Care Management codes • Team Based Care • Population Health Management
▫ Rx medication list and list of ADEs allergies for 80% of population
▫ Identifies patient in need of immunizations and medication monitoring (Stage 2 Meaningful Use)
▫ Evidence based medicine alerts • Care management and Support
▫ Medication Management ▫ Patient self management education and tools
• Care Coordination and Care ▫ TOC
• Performance Measurement and QI ▫ 2 immunization measures ▫ 3 clinical measures ▫ Patient experience
NCQA Medication Management
components
Medication reconciliation at care transitions 50% - 80% (Stage 2 Meaningful use)
Provides information about new prescriptions 80%
Assesses patients understanding of medications 50%
Assesses patient response to medications and barriers to adherence 50%
Documents OTC, herbal and supplements 50%
Accreditation Organizations Center for Practice Accreditation (CPPA)
• Community pharmacy practice
• Specialty pharmacy practice
Joint Commission (JC)
• Hospital and Health System practice
URAC variety of accreditation programs
• Pharmacy programs
• Drug Therapy Management
• Mail Service Pharmacy
• Pharmacy Benefit Management
• Specialty Pharmacy
• Community Pharmacy
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Other Important Organizations Physicians
Consortium for Performance Improvement
(PCPI)
developed over 300 measures
50% of the PQRS and
“meaningful use”
measure sets
Institute for HealthCare
Improvement (IHI)
Authoritative reports
Education
Patient Centered
Primary Care Collaborative
(PCPCC)
mission is to innovate,
educate and advocate for an effective and efficient
health system
Institute for Clinical Systems
Improvement (ICSI)
Guidelines
Measure developer
Rules for the Race - Payers
Payers - Medicare
• ACO measures
• CAHPS
• CAHPS
• CAHPS • Five-Star Quality Rating System
http://www.cms.gov/eHealth/downloads/Webinar_eHealth_July16_QualityMeasurement.pdf
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Hospital Readmission Program (ACA)
Conditions that apply
• Acute Myocardial Infarction (AMI)
• Heart Failure (HF)
• Pneumonia (PN)
• Acute exacerbation of COPD
• Hip and Knee replacement
• CABG (2017)
Penalties
• 3% reduction in aggregate Medicare payments
• 2014 affected 2,225 hospitals for $227 million
• 2015 estimates 2638 hospitals for $428 million
ACO–33 Quality Measures
Patient Experience - 7 measures CAHPS
• Education
Care Coordination and Patient Safety - 6 measures
• Hospital readmissions
• Admissions for COPD or asthma in elderly and HF
• Med reconciliation
Preventive Health – 8 measures
• Pneumococcal and Influenza vaccination
• Obesity, Smoking
• Depression, BP
At Risk Populations – 12 measures
• DM: HgA1c, LDL, BP, ASA, smoking
• HTN: BP
• Ischemic Vascular Dx (IVD): LDL, ASA or anti-thrombotic
• HF: beta-blocker
• CAD: LDL lowering, ACE/ARB
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-Shared-Savings-Program-Quality-Measures.pdf
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/
PQRS/index.html
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Stage 2 Meaningful Use
Measure Steward Other use
Controlling BP NCQA PQRS, ACO, UDS
High risk meds in elderly NCQA PQRS
Tobacco Cessation AMA PCPI PQRS, UDS
Imaging for low back pain
NCQA
Depression Screening and plan
CMS PQRS, ACO
Complete Med list CMS PQRS
BMI and follow up CMS PQRS, ACO, UDS
Closing referral loop CMS
Functional status assessment for complex chronic conditions
CMS
Universal Data Set – HRSA
Adult weight screening (BMI) and follow up
Tobacco use and cessation
Appropriate Asthma therapy
Lipid lowering therapy for CAD
ASA for AMI, CABG, PTCA or IVD
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What are the barriers?
•
Measure Limitations
Attribution
Statistical accuracy and samples
Accounting for exceptions
Risk adjustment
Appropriate benchmarks
Potential for gaming
Gaps (i.e. cost and affordability) yet proliferation
Measuring what matters to patients
Make me better.
Do not hurt me.
Respect me
Make my care available and
affordable
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IOM Proposed Core Measures
IOM report: Vital Signs: http://iom.naionalacademies.org/Reports/2015/Vital-Signs-Core-metrics.aspx
IOM Proposed Core Measures
The quality of your work, in the long run, is the deciding factor on how much your services are valued by the world.
Orison Swett Marden
(1850 - 1924) was an American
inspirational author who wrote
on success in life and how to achieve it
