Health Reform: Ready or Not, It s Here

1. Health Reform:�Ready or Not, It�s Here!� Barry M. Straube, M.D. CMS Chief Medical Officer American Health Quality Association Annual Meeting � Baltimore, MD May 4, 2010 1

3. CMS Realignment Update Donald M. Berwick, M.D., nominated as CMS Administrator Marilyn Tavenner, R.N., named: Acting CMS Administrator Principal Deputy CMS Administrator Acting Chief Operating Officer CMS Chief Medical Officer and the Director of the Office of Clinical Standards & Quality remain a direct report to the CMS Administrator and the Office of the Administrator Only 1 of 4 Career direct reports to the Administrator 3

4. CMS Realignment Update Center for Medicare (CM) Consolidates FFS Medicare, Medicare Advantage and Medicare Part D in one Center Jonathan Blum, Deputy Administrator Center for Medicaid, CHIP and Survey & (CMCSC) Certification Cindy Mann, Deputy Administrator Center for Strategic Planning (CSP) Will be Center for Medicare & Medicaid Innovation (CMI) Anthony Rodgers, Deputy Administrator 4

5. CMS Realignment Update Center for Program Integrity (CPI) Peter Budetti, M.D., Deputy Administrator Office of the Chief Operating Officer (COO) Marilyn Tavenner, R.N., Acting COO Office of e-Health Standards & Services (OESS) Office of Information Services (OIS) Office of Financial Management (OFM) Office of Operations Management (OOM) 5

6. Realignment: What�s the Significance? Emphasis on quality & value in healthcare Transition to a data and evidence-based organization Medicare program centralization Strengthening of Medicaid & CHIP, alignment with Medicare when appropriate Major initiative on reforming payment systems, healthcare delivery models Greater focus on the growing scourge of fraud and abuse Streamlining & strengthening of major operational support programs that keep the trains running 6

7. What Is OCSQ Already Doing? ARRA/HITECH Adoption of EHRs and Meaningful Use Comparative Effectiveness Research Prevention and Wellness Programs MIPPA Bundled Payment Reform in ESRD The First CMS National VBP Program ESRD Quality Incentive Program Report to Congress on Improving Medicare data on race, ethnicity and gender 7

8. What Is OCSQ Already Doing? NCDs on Preventive Services MIPPA section 101 HIV/AIDS screening tests in Medicare Expansion of smoking cessation coverage Further preventive service coverage without statute Focus on Genomics: Testing and Screening IT systems development Clinical quality measures COPs: Telehealth, Visitation rights, Standing orders, clinical scope of practice, etc. 8

9. Ensuring Quality & Value:CMS Strategies �Contemporary Quality Improvement� Transparency: Public Reporting & Data Sharing Incentives: Financial: Value-Based Purchasing, P4P, P4R, gain-sharing, etc. Non-financial Regulatory vehicles COPs & CfCs Survey & Certification, Accreditation Myriad policy decisions: Benefit categories, Fraud & Abuse, etc. National & Local Coverage Decisions Demonstrations, pilots, research 9

10. Current Quality & Value Incentive Programs Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) Hospital Out Patient Quality Data Reporting Program (HOPQDRP) Physician Quality Reporting Program (PQRI) E-prescribing Incentive Program Health Information Technology for Economic & Clinical Health Act (HITECH) Part of the American Recovery & Reinvestment Act (ARRA) of 2009 10

11. Other Quality & Value Initiatives Reports to Congress on Hospital Value-Based Purchasing (November 2007) Physician Value-Based Purchasing (draft & clearance) End-Stage Renal Disease Bundled Payment Reform: January 1, 2011 Quality Incentive Program: January 1, 2012 Pay-for-Reporting programs HHAs SNFs 11

12. 12 Open Government Directive Transparency Promotes accountability through informing citizens about what government is doing Information and data is a national asset Should be readily available and usable Executive branch departments and agencies to harness technology to put operational and decision information online and available Feedback from public should be solicited

13. 13 Open Government Directive Participation Public engagement improves decision making quality Increased opportunities for public to participate in decision making Collaboration Tools, methods and systems to partner within and external to government Individuals, non-profit organizations, businesses, etc. 120 days for CTO, OMB and GAO to develop an Open Government Directive

14. Affordable Care Act (ACA) of 2010 Patient Protection & Affordable Care Act (PPACA) Health Care & Reconciliation Act of 2010 (HCRA) Affordable Care Act of 2010 (ACA) 14

15. Affordable Care Act (ACA) of 2010 Title I: Quality, Affordable Health Care for all Americans Title II: Role of Public Programs Title III: Improving the Quality & Efficiency of Health Care Title IV: Prevention of Chronic Disease & Improving Public Health Title V: Health Care Work Force 15

16. Affordable Care Act (ACA) of 2010 Title VI: Transparency and Public Reporting Title VII: Improving Access to Innovative Medical Therapies Title VIII: Community Living Assistance Services & Support (CLASS) Act Title IX: Revenue Provisions Title X: Strengthening Quality, Affordable Health Care for All Americans (Amendments) 16

17. Quality, Affordable Health Care Bars insurance company discrimination by pre-existing condition, health status, gender Creates health insurance exchanges Tax credits and cost-sharing assistance to low income Americans Invests in Community Health Centers Annual review of new plans with unjustified premium increases 17

18. Public Programs Expands Medicaid coverage to non-elderly with incomes < 133% of FPL Federal government pays 100% of costs first three years of coverage, decreasing 2017-2020, then 90% Extends CHIP funding 2 years to 2015 Increases payments to Medicaid providers 18

19. Improving Medicare Hospital Value-Based Purchasing Program (Section 3001) Start FY2013 Quality Measures Outcome: AMI, CHF, Pneumonia SCIP HAIs HCAHPS Efficiency measures Public reporting on Hospital Compare website VBP demonstrations for CAHs and small hospitals 19

20. Improving Medicare Improvements to PQRI (Section 3002) PQRI extended to 2014 with bonus payments: 2011: 1.0% 2012-2014: 0.5% Reductions in fee schedule for failure to report: 2015: 1.5% 2016 and beyond: 2.0% Maintenance of Certification (MOC) Program inclusion Integration of PQRI and EHR reporting 20

21. Improving Medicare Improvements to Physician Feedback Program (Section 3003) Confidential resource use reports based on claims data to physicians May include linked quality data Episode groupers by 2012 Risk adjustment: Socioeconomic, geographic, race & ethnicity, health status, etc. Public availability of methodology Coordination with VBP programs 21

22. Improving Medicare Quality reporting for LTCHs, Inpatient Rehabilitation Hospitals, Hospices (Section 3004) Quality measures development with required reporting Reduction of payment methodology by 2.0% for failure to report starting 2014 Quality reporting for PPS-exempt cancer hospitals (Section 3005): Starts 2014 VBP program for SNFs, HHAs, ASCs (Section 3006) Report to Congress by January 1, 2011 22

23. Improving Medicare VBP modifier under PFS (Section 3007) Quality compared to costs Budget neutrality specified Rulemaking during 2013, implementation 2015 Payment adjustment for conditions acquired in hospitals (Section 3008) 1% payment reduction for HACs starting 2015 Risk adjustment required Public reporting required Study with RTC by 1/1/2012 on extending to other providers 23

24. Improving Medicare National Strategy for Quality Improvement in Health Care (Section 3011, with amendment 399HH) National priority setting & strategic plan by 1/1/2011 Priority requirements Improve outcomes, efficiency, patient-centeredness for all populations Identify areas with potential for most rapid improvement Address gaps in quality, efficiency and comparative effectiveness Enhances data use for quality, efficiency, transparency, outcomes High-cost chronic diseases, preventable admissions & readmissions, patient safety, medical error reduction, HAIs, health disparities, others as determined by Secretary Website with priorities, agency plans, updates 24

25. Improving Medicare Inter-Agency Work Group on Health Care Quality (Section 3012) Quality Measurement Development (Section 3013) Outcomes, Efficiency Quality Measurement by Consensus-Based Endorsement Body (Section 3014) Multi-stakeholder group input Dissemination by Secretary Data Collection & Public Reporting (Section 3015 with multiple amendments) Clear public plan for data collection and public reporting developed 2010-2014 25

26. Improving Medicare Establishes a CMS Innovations Center by 2011 Develop patient-centered payment models Encourage evidence-based, coordinated care for Medicare, Medicaid, CHIP Rapid piloting/testing of new payment programs Medicare Shared Savings Program (ACOs) National Pilot Program on Payment Bundling Independence at Home Demonstration Hospital Readmissions Reduction Program Community-Based Care Transitions Program Extension of Gainsharing Demonstration 26

27. Improving Medicare Improving beneficiary access by payment increases or extensions Rural protections Improving payment accuracy Reduces overpayments to Medicare Advantage health plans and strengthens MA benefit and contracting frameworks Fills Medicare prescription drug �donut hole� 2010: $250 rebate 2011: 50% manufacturer�s discount on brand names 2012-2020: Phase-in filling of donut hole 27

28. Improving Medicare Extends Medicare Trust Fund solvency by 9 years to 2026 Trauma Centers creation Women�s Health provisions Coordinated care for chronic conditions Increased payments to primary care physicians in shortage areas 5 year, 10% bonus for PCPs and general surgeons Medicaid rates 100% of adjusted Medicare rates in 2013 and 2014 28

29. Preventing Chronic Disease & Improving Public Health Eliminates cost-sharing for preventive services Improves education on prevention and public health Mandates a national prevention and public health strategy Outcomes focused Controlling costs National Prevention, Health Promotion and Public Health Council Community Preventive Services Task Force Increased community access to preventive services School-based settings, etc. Oral healthcare services promotion Annual wellness visits with preventive services without copayment 29

30. Health Care Workforce Funds shortages in primary care areas Invests in National Health Service Corps scholarship and loan repayment programs Incentives for primary care providers to practice in rural and physician shortage areas Education grants and subsidies Focus on workforce diversity promotion Educational best practices and centers of excellence GME funding provisions 30

31. Transparency & Public Reporting Broad Plan for Public Reporting Make performance information widely available Hospitals and Ambulatory Surgery Centers Expands Hospital Compare Information on the Value Based Purchasing (VBP) program Mandates reporting on health care acquired infections, hospital readmissions, and hospital charge data Physicians Physician Compare website by January 2011. Physician ownership or investments in hospitals, ASCs, other provider sites and manufacturers (by September 2013) 31

32. Transparency & Public Reporting SNFs, LTCFs Expansion of Nursing Home Compare by March 2011 Nursing home ownership by March 2012 Multiple efforts directed at fraud & abuse Stricter enforcement requirements Private, non-profit entity to identify priorities in patient-centered outcomes research Nationwide background checks Dementia and abuse training Elder justice activities Sense of the Senate regarding medical malpractice 32

33. Access to Innovative Services Biologic Price competition provisions Establishes regulatory pathway for FDA approval of biosimilar versions of previously licensed biologics Expands scope of current 340B drug discount program to expand access to medicines at lower cost Children and Underserved Communities 33

34. Community Living Assistance Services & Support (CLASS) Lifetime cash benefit for people with severe disabilities to allow them to remain in their homes and communities Voluntary, self-funded insurance program provided through the workplace Premiums through payroll deductions Worker participation voluntary CBO rates this program as actuarially sound 34

35. Revenue Provisions Deficit reduction over 10-20 years Tightens current health tax incentives Increases penalties or reduces caps on HSA premature distributions, FSAs, etc. Excise tax on indoor tanning services Collects industry fees Insurance companies that sell high-cost plans (2018) Modest excise taxes Slightly increases Medicare HI for individuals and couples $200K/$250K Taxable base expanded to include net investment income 35

36. How Does QIO Program Fit In? 9th and 10th SOW have focused on key Administration and Health Reform priorities Prevention Patient Safety Care Transitions Beneficiary Issues: Access, Quality of Care, etc. But with a fixed apportionment, QIO Program is limited in �units� of quality improvement Success at 9th SOW Metrics will hopefully justify more funding, more units in 10th SOW 36

37. How Does QIO Program Fit In? Conceptual proposal of a model going forward: Core SOW focused on high priority themes/tasks Some degree of directing resources towards those providers/beneficiaries with greatest need We now have better metrics, evidence-based interventions, unit cost estimates, accountability, and even attribution for the core SOW �Shell� of aligned collaborative efforts around the core Mississippi Health First as a paradigm Funding outside the QIO apportionment? Leverage resources of other federal agencies, others? Rapid cycle interventions? 37

38. How Does QIO Program Fit In? QIO Program has attracted attention to align and/or integrate with healthcare reform Funding sources? Appropriations QIO apportionment ? Other sources Healthcare reform related tasks Part of the core SOW? Outside core SOW? Hybrid/combination of above? Subject to same metric accountability? 38

39. How Does QIO Program Fit In? ACA, HITECH, MIPPA Topics: Good Fit with QIOs? QIOs role with FQHCs/CHCs should be considered Technical assistance for VBP Programs Quality/efficiency measurement, analysis, root cause analysis Interpretation of feedback reports and how to respond Evidence-Based interventions Culture change of organizations Collaborative, rapid cycle change models Providing part of the operational framework to implement the National Priority strategies for Healthcare Improvement 39

40. How Does the QIO Program Fit In? Similar role as part of the operational framework for implementation of a National Data collection and reporting plan For the content of both plans, the QIO Program could potentially play a role Technical assistance for Innovation Demonstrations Technical assistance for chronic care coordination, women�s health, trauma, healthcare acquired infections, etc. 40

41. How Does the QIO Program Fit In? Potential key role in national prevention and public health strategic plan Need to consider role in public reporting, particularly Educating beneficiaries in using information/data Improving usefulness of Compare websites Possible role in Program Integrity Might be a reverse step to PRO regulatory atmosphere, however Could consider a PI beneficiary focus 41

42. How Does the QIO Program Fit In? CLASS Act Focus on community and home services could rejuvenate QIO efforts in: Post-acute care settings Home health Other, new approaches? EHR adoption, meaningful use, CQMs Health Disparities Telehealth Enormous vacuum in patient-centered quality improvement which will hinge on Redesign of Beneficiary Protection Alignment of Medicare, Medicaid, CHIP quality & value initiatives Finally, additional A-19 process legislative changes in progress are needed to fulfill the QIO Program potential 42

43. 43 Contact Information Barry M. Straube, M.D. CMS Chief Medical Officer, & Director, Office of Clinical Standards & Quality Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD 21244 Email: Barry.Straube@cms.hhs.gov Phone: (410) 786-6841