National Quality Strategy Webinar

National Quality Strategy Webinar

National Quality Strategy Webinar Using Payment to Improve Health and Health Care Quality February 4, 2015 Housekeeping Submit technical questions via chat If you lose your Internet connection, reconnect using the link emailed to you If you lose your phone connection, re-dial the phone number to re-join ReadyTalk support: 800-843-9166 Closed captioning: http:// www.captionedtext.com/cli ent/event.aspx?CustomerI D=1159&EventID=614886 91 2 Agenda Welcome Ann Gordon, Facilitator Presentation of the NQS Levers Nancy Wilson, Executive Lead

National Quality Strategy Buying Value Gerry Shea, Director Blue Cross Blue Shield of Massachusetts Alternative Quality Contract Dana Gelb Safran, Senior Vice President for Performance Measurement and Quality Facilitated Discussion Presenters Question and Answer 3 The National Quality Strategy: Using Payment to Improve Health and Health Care Quality Nancy Wilson, B.S.N., M.D., M.P.H. 4 Background on the National Quality Strategy Established by the Affordable Care Act to improve the delivery of health care services, patient health outcomes, and population health The Strategy was first published in 2011 and serves as a nationwide effort to improve health and health care across America

The Strategy was iteratively designed by public and private stakeholders, and provides an opportunity to align quality measures and quality improvement activities 5 The IHI Triple Aim and NQS Three Aims Improving the patient experience of care (including quality and satisfaction) Improving the health of populations Better Care: Improve overall quality by making health care more patient-centered, reliable, accessible, and safe Reducing the per capita cost of health care

Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government 6 Six National Quality Strategy Priorities 7 Nine National Quality Strategy Levers Measurement and Feedback Payment Public Reporting

Learning and Technical Assistance Health Information Technology Certification, Accreditation, and Regulation Innovation and Diffusion Better Care. Healthy People/Healthy Communities. Affordable Care. Consumer Incentives and Benefit Designs Workforce Development 8 Payment Reward and incentivize providers to deliver high-quality, person-centered care

Better Care. Healthy People/Healthy Communities. Affordable Care. 9 Switching from Volume Buying to Value Buying THE Quality Challenge for Private Purchasers Gerry Shea, Buying Value Director NQS Webinar, February 4, 2015 Value-Based Purchasing is a Key Design Element in the ACA Starts with Framework for Major Improvement The National Quality Strategy Requires Standardized Measures of Quality Adds major Investment Quality Improvement The Partnership for Patients, CMMI, etc. Ties Medicare Payments to Quality Performance Overtime Calls for Alignment of Private and Public Purchasing 11 Value Purchasing Is The Primary Way Private Purchasers Support Quality Improvement Switching to value purchasing is the MOST important step purchasers can take to better care, better health, and lower costs But today, only 40 percent of private purchasing is tied to quality metrics most of it modest, first generation programs

Private purchasers typically pay healthcare bills without knowing whether the care was great, mediocre, or downright dangerous 12 To Be Successful, Value Purchasing Requires Good Measures & Alignment Measures of quality must be accurate and reliable Measures must be aligned across public and private purchasers and payers To change from volume-purchasing to value purchasing, private purchasers need core measure sets that are virtually plug and play Poor alignment of measures overwhelms everyone and impedes progress on quality 13 Medicare Hospital Value Payments 2011-2017 Policy 2011 2012 2013 2014

2015 2016 2017 Hospital Inpatient Quality Reporting Program /a -2.0% -2.0% -2.0% -2.0% -1.0% -1.0% -1.0% Meaningful Use + Incentive Payments /b - .5%

1.7% 1.7% 1.3% 1.4% -1.0% -2.0% -3.0% -.02% -.02% -.02% -.02% -.02% -.02% -.02% -1.0% -1.0%

-1.0% Hospital Acquired Conditions (Current) /c Hospital Acquired Conditions (ACA) /d Readmissions /e Hospital Value-Based Purchasing /f + - -1.0% -2.0% -3.0% -3.0% -3.0% 1.0% - 1.0% 1.25% - 1.25%

1.5% - 1.5% 1.75% - 1.75% 2.0% - 2.0% Notes: Percentages reflect approximate maximum potential impact to an individual hospital. The values in the column labeled 2017 remain constant thereafter. a. Non-reporting hospitals lose 2% of their annual market basket update through 2014, then lose of that update from 2015 onwards. The actual percentage will vary depending on the market basket update each year (-1% is illustrative). b. Incentive payments approximate CMS Office of the Actuary estimates in the high adoption scenario. Payment reductions represent reduction to annual market basket update by , , and in 2015, 2016, and 2017, respectively for hospitals that have not qualified as meaningful users. The actual percentage will vary depending on the market basket update each year (-1%, -2%, and -3% are illustrative). c. HACs reported through claims do not qualify DRG payment for severity adjustment. d. Requires a 1% cut to those hospitals who rank in the top quartile of occurrences of HACs. e. Hospitals that do not meet individualized hospital-specific readmissions benchmark face potential cut to up to a percentage ceiling . f. Percentage of base-DRG payment subject to meeting quality measure requirements. Policy must be budget neutral, so potential for highachieving hospitals to earn bonuses depending on the number of non-achieving hospitals. The Buying Value Project Buying Value is an Robert Wood Johnson Foundation-funded initiative of private health care purchasersemployers, leading business health organizations, and union health funds that was launched in 2012. Mission Private purchasers contribute to better health and lower health costs by buying on value rather than on volume. Objective Enable widespread adoption of value purchasing in the private sector through alignment of measures among private purchasers and with

federal and state public programs Strategy Measure Alignment Campaign Public and private purchasers, health plans, providers, and care delivery systems commit to core measure sets developed through multi-stakeholder consensus processes nationally, and at the regional or state level. Help for States/Other Stakeholders in Creating Aligned Measure Sets Online Measure Selection Tool and hands-on help. 15 Buying Value Work On Accelerating Value Purchasing in Private Sector Website www.buyingvalue.org (2012) Basic info on valuepurchasing Primer, Legal Memo on Anti-Trust Issues Starter Core Measure Set (March 2013) National purchasers, consumers, CMS & payers (health plans) Study of 48 Measure Sets in Use at State Level (2013) Only 20% of measures used by more than one program; 25% of shared measures modified in some way; 39% of measures either non-standard or homegrown Model for Consensus Core Measure Sets A multi-stakeholder, twotier (national and regional or state) process for consensus core measure sets Online Measure Selection Tool (9/2014; Updated 1/2015) web-based spreadsheet linked to measure databases that enables those creating measure sets to view in one place a multitude of important decision factors 16 2013 Buying Value Research Found Little Alignment Across Measure Sets

Shared; Shared; Shared;20.04% 20.04% 20.04% Not shared; 79.96% Not Not shared; shared; 79.96% 79.96% Number of distinct measures shared by multiple measure sets n = 509 Programs have very few measures in common or sharing across the measure sets Of the 1367 measures, 509 were distinct measures Only 20% of these distinct measures were used by more

than one program * By shared, we mean that the programs have measures in common with one another, and not that programs are working together 17 How Often are Shared Measures Actually Shared? Not that often 16-30 sets; 19; 3.73% 6-10 sets; 21; 4.13% 11-15 sets; 14; 2.75% 3-5 sets; 20; 3.93% 2 sets; 28; 5.50% measures not shared; 407; 79.96% Most measures are not shared Only 19 measures were shared by at least 1/3 (16+) of the measure sets 18 How Did We Get Into this Mess? Everyone supports the idea of alignment, but

strong forces pull in the opposite direction Poor measure alignment reflects the failure of national organizations to make it a priority Little or no help to Regional, State & Local Entities Build It (better measures) and They Will Come remains the dominant paradigm Alignment needs to become a priority equal to development of better measures 19 Buying Value Model for Consensus Core Measure Sets Spring, 2014 Recommendations by large multi-stakeholder group (See Resources at www.buyingvalue.org) Features two tiers of consensus measure sets National Core Set(s) of most commonly used, effective measures for major clinical conditions Regional/State Core Set(s) of supplementary (not replacement) measures to meet local needs and test innovative measures Testing model awaits overdue reports from IOM Committee & AHIP project 20 Buying Value Assistance for Those Creating/Revising Measure Sets

Online Measure Selection Tool at www.buyingvalue.org Six Steps, from defining program goals and audiences, to picking measure selection criteria, to choosing existing measure sets for comparison purposes, to creating draft list of measures Single spreadsheet that is pre-populated with ten major federal measure sets, NQF data, and some state measure sets 21 A webinar on use of the tool and the 2015 updates to it is scheduled for Tuesday, February 24, at 2 pm EST., at https://mhca.webex.com/mhca/onstage/g.php?MTID=e3c3898c421f973fe0df6dbe5194770be For audio only, call 650-479-3207 and use access code 665 533 484. 22 Success Story: Federal Agencies Agree to Cut Measures in 7 Areas from 567 to 35! Number of Measures in Harmonized Measure Set Obesity 0 Topic Area 138 7

Hospital Acquired Conditions Hypertension 86 5 HIV/AIDS Smoking Cessation 76 5 Perinatal Depression Number of Measures Reviewed 105 9 48 3

63 4 51 2 20 40 60 80 100 Better Care. Healthy People/Healthy Communities. Affordable Care. 120 140 160 23 For More Information Gerry Shea Director, Buying Value [email protected]

24 The Alternative Quality Contract (AQC): Improving Quality While Slowing Spending Growth Dana Gelb Safran, ScD Senior Vice President, Performance Measurement and Improvement Blue Cross Blue Shield of Massachusetts Presented to: National Quality Strategy Priority in Action 4 February 2015 The Alternative Quality Contract: Twin goals of improving quality and slowing spending growth In 2007, leaders at BCBSMA challenged the company to develop a new contract model that would improve quality and outcomes while significantly slowing the rate of growth in health care spending. 18% 15.9% 16% The Massachusetts health reform law (2006) caused a bright light to shine on the issue of unrelenting double-digit increases in health care spending growth (Health Care Reform II).

13.8% 14% 13.3% 13.1% 12.1% 12.8% 12.5% 12% 10.8% 10.7% 2008 2009 10% 8.2% 8% 6% 4% 2% 0%

2000 -2% 2001 2002 BCBSMA Medical Trend 2003 2004 2005 Workers' Earnings 2006 2007 General Economic Growth Sources: BCBSMA, Bureau of Labor Statistics. Blue Cross Blue Shield of Massachusetts 26 The Alternative Quality Contract Global Budget

Population-based budget covers full care continuum Health status adjusted Based on historical claims Shared risk (2-sided) Trend targets set at baseline for multi-year Quality Incentives Ambulatory and hospital Significant earning potential Nationally accepted measures Continuum of performance targets for each measure (good to great) Blue Cross Blue Shield of Massachusetts Long-Term Contract 5-year agreement Sustained partnership Supports ongoing investment and commitment to improvement 27 Results Under The AQC: Improvement of the 2009 Cohort of AQC Groups from 2007-2012

Pediatric Care Adult Chronic Care Optimal Care 100 83.1 84.0 79.6 80.4 81.1 79.2 80.3 77.7 86.0 86.7 80.8 81.0 88.2

68.1 89.9 69.5 Adult Health Outcomes 91.3 91.6 92.2 92.1 69.7 70.7 71.6 71.7 72.2 65.6 61.5 59.8

74.0 68.3 62.1 61.2 61.4 61.9 62.2 61.9 50 = 2007 2012 BCBSMA HEDIS National Average 2007 2012 BCBSMA

HEDIS National Average 2007 2012 BCBSMA HEDIS National Average These graphs show that the AQC has accelerated progress toward optimal care since it began in 2009. The first two scores are based on the delivery of evidence-based care to adults with chronic illness and to children, including appropriate tests, services, and preventive care. The third score reflects the extent to which providers helped adults with serious chronic illness achieve optimal clinical outcomes. Linking provider payment to outcome measures has been one of the AQCs pioneering achievements. Blue Cross Blue Shield of Massachusetts 28 AQC Results: Formal Evaluation Findings Source: Song Z, et al. Changes in Health Care Spending and Quality 4 Years into Global Payment. The New England Journal of Medicine. 2014. Blue Cross Blue Shield of Massachusetts 29 Total Cost Results AQC Total Cost Increases (FFS + incentives) The Harvard evaluation

documented that AQC is reducing medical spending, but accounts also want to see reductions in total spending By Year-3, BCBSMA met its goal of cutting trend in half (2 years ahead of plan) By Year-4, BCBSMA total cost trend was below state general economic growth benchmark (<3.6%) Blue Cross Blue Shield of Massachusetts 30 Components of the AQC Support Model Our four-pronged support model is designed to help provider groups succeed in the AQC. Data and Actionable Reports Consultative Support Best Practice Sharing and Collaboration

Training and Educational Programming Blue Cross Blue Shield of Massachusetts 31 Account View: Illustration FFS Costs Member Based Charges $700 Costs FFSFFS Costs $700 $600 $600 $500 $600 the incentives payments to $400 $500 providers are billed as Member Based Charges - the AQC will have

$300 $400 higher MBC than traditional contract types $200 Global budget create the AQC createscontracts incentives for $300 providers deliver more incentives fortoproviders to deliver $100 effi cent, high quality care care - $200 more efficient, high quality lowering

FFS trend lowering FFS trend $0 $100 $500 the AQC creates incentives for $400 providers to deliver more effi cent, high quality care $300 lowering FFS trend $200 $100 $0 Year 1 $700 $700 Total Costs Year 2 Year 3

AQC Business businessasasusual usual AQC budget contracts Global the incentives payments to providers are billed as Member Global budget contracts will Based - the AQC will have have Charges higher incentive payments higher MBC than traditiotypes nal than traditional contract contract types

$0 Year 4 Year 5 Year 1 Year 2 Year 3 Year 4 Year 5 Total Costs Total Cost Total Cost $600 Incentive Payments for Member Based Charges business as usualPerformance

$700 $500 $600 $400 $500 However, on a total cost basis, $400 global budgetoncontracts deliver on the however, a total cost basis, the goal of providing high quality AQC delivers on its goal of $300 care at more affordable trends delivering

high quality care at $300 $200 $100 $200 $0 Year 1 Year 2 $100 Year 3 more affordable trends Year 4 While the charges associated with incentive payments rose relative to however, on a total cost basis, the traditional contracts, the overall AQC delivers on its goal of delivering high quality care at medical

trend declined significantly more affordable trends Year 5 $0 Blue Cross Blue Shield of Massachusetts 32 Summary and Priority Issues Ahead Summary Payment reform gives rise to significant delivery system reform Priority Issues Ahead Expanding payment reform to include PPO presents unique challenges Rapid and substantial performance improvements are possible in the context of: Meaningful financial incentives

Rigorously validated measures & methods Ongoing and timely data sharing and engagement Committed leadership Continued evolution of performance measures to fill priority gaps and significant market share are advantageous For national payers, remote provider relationships pose engagement challenges; member-facing incentives (benefit design) an attractive lever Blue Cross Blue Shield of Massachusetts Focus on outcomes, including patient reported outcomes (functional status, well being) Continued evolution of the delivery system: For payment reform, deep provider relationships Gaining strong employer buy-in & support will be important; and this means models must offer value from day-1

Evolving the role of hospitals in the delivery system Building deeper engagement of specialists Bringing incentives (financial & non-financial) to front lines Advancing innovations in virtual care Payment incentives to front line clinicians need continued attention 33 For More Information [email protected] Blue Cross Blue Shield of Massachusetts 34 Facilitated Discussion 35 How to Find More Tools and Resources http://www.ahrq.gov/workingforquality/ http://www.ahrq.gov/workingforquality www.buyingvalue.org

www.bluecrossma.com 36 Questions and Answers Presenters 37 Questions and Answers For users of the audio broadcast, submit questions via chat For those who dialed into the meeting, dial 14 to enter the question queue 38 Thanks for attending todays event The presentation archive will be available on www.ahrq.gov/workingforquality within two weeks For questions or high resolution lever icons, please email [email protected] For the new NQS Stakeholder Toolkit, visit: http://

www.ahrq.gov/workingforquality/nqs/nqstoolkit.pdf 39

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