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Transparency in the QIO 9 th Scope of Work: Beyond Hospital Compare

Transparency in the QIO 9 th Scope of Work: Beyond Hospital Compare

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Transparency in the QIO 9 th Scope of Work: Beyond Hospital Compare

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  1. Transparency in the QIO 9th Scope of Work: Beyond Hospital Compare Nancy Jane C. Friedley, MD Medical Director Delmarva Foundation May 9, 2008

  2. Introductions

  3. Overview Objectives: • 1) Understand the basic outline of the QIO 9th SOW • 2) Understand the various CMS comparison tools for transparency • 3) Understand the PQRI reporting system, how it works and why it is important to have physicians involved

  4. Transparency in the QIO 9th Scope of Work: Outline • Introduction to Delmarva and the QIO • Evolution of Quality Improvement and Cost Containment at the Centers for Medicare and Medicaid Services (CMS) • 1965-1986 • 1986-1999 • 1999-2008 • The Quality Improvement Organizations’ 9th Scope of Work 2008-2011 • Impetus for Change • Goals • Process • Translating Process to Outcomes • Measures • Evaluation • Transparency: Online Information about Quality and Cost • PQRI: Encouraging Physicians to Embrace Transparency

  5. Delmarva ‘Call to get a level…’

  6. Delmarva’s Impact Across the United States External Quality ReviewMedicare Quality Improvement OrganizationMaryland Patient Safety CenterMedicare Quality Improvement OrganizationExternal Quality Review (Washington, DC) Statewide Quality Assurance Program for Developmentally Disabled ExternalQuality Review for Medicaid Program Safeguard ContractWestern Integrity States Medicare+Choice Quality Assurance/Performance Improvement Project

  7. Organizational Structure of Delmarva

  8. Quality Improvement Organizations in Maryland and the District of Columbia • Delmarva Foundation for Medical Care, Inc. (DFMC) is the CMS-contracted Quality Improvement Organization (QIO) for Maryland • Delmarva Foundation of the District of Columbia (DFDC) is the CMS-contracted QIO for DC

  9. What is a QIO? • The Centers for Medicare and Medicaid Services contracts with one organization in every state, the District of Columbia, Puerto Rico, and the Virgin Islands to promote safer and more effective care in hospitals, physician practices, nursing homes, home health agencies, health plans, pharmacies, and prescription drug plans. • QIOs provide a range of services for the protection of the nation’s 42 million Medicare beneficiaries

  10. What Does the QIO Do? The primary goal of the QIO is to accelerate the diffusion of evidence-based medicine from the bookshelf to the bedside. As a community resource, the QIO serve as a national infrastructure that helps doctors, hospitals, home health agencies and nursing homes utilize best practices to improve care. CMS

  11. What Does the QIO Do? • Improves health care quality through interventions whose impact on outcomes can be measured • Provides technical support, mentoring, education and training • Works with providers to help them reach specific clinical goals • Helps providers collect and publicly report data on performance measures to prompt improvement

  12. How Has the QIO Improved Quality? • Increase use of life-saving drugs for MI patients • Make surgery safer by reducing infection rates • Improve nursing home care by ensuring limited use of restraints • Support home health care to help patients stay out of the hospital

  13. Evolution of Quality Improvement and Cost Containment at CMS 1965-1986

  14. Evolution of Quality Improvement and Cost Containment at CMS • 1965: Medicare legislation • Seniors and the disabled • 1966: HCFA (now CMS) sets standards for hospitals that wish to be reimbursed for Medicare beneficiaries’ care

  15. Evolution of Quality Improvement and Cost Containment at CMS • 1971: EMCROs (Experimental Medical Care Review Organizations) • Voluntary physician groups • Grant funded • Individual cases for Utilization Review • 1972-1982: PSROs (Professional Standards Review Organizations) • Medical Necessity • Professional Standards • Effectiveness and ‘Economics’ of Care

  16. Evolution of Quality Improvement and Cost Containment at CMS • 1982: PROs (Peer Review Organizations) • Utilization and Quality Control • Beyond local norms • More federal oversight • Funding from Medicare Trust Fund • 1983: PPS (Prospective Payment System) introduced (Maryland is waived)

  17. Evolution of Quality Improvement and Cost Containment at CMS 1984-1986 1st SOW • Era of PRO vs. Providers continues • PROs are focused on “inspecting and detecting” and sanctioning providers • 1st SOW emphasizes financial sanctions on physicians for inappropriate admissions • Prospective Payment System (PPS) using DRGs raises concerns about early discharges and readmissions

  18. Evolution of Quality Improvement and Cost Containment at CMS1986-1999

  19. Evolution of Quality Improvement and Cost Containment at CMS 1986-1993 2nd and 3rd SOW • Medicare Managed Care Organizations • Concerns arise that Medicare MCOs subject providers to financial incentives to under use services • 1986 OBRA: PROs to extend review to other settings

  20. Evolution of Quality Improvement and Cost Containment at CMS 1986-1990 PRO Problems with Providers • Punitive with no positive incentives • Adversarial • Redundancy with other programs

  21. Evolution of Quality Improvement and Cost Containment at CMS 1990 Institute of Medicine Report on PRO Program • Potentially valuable infrastructure • Improve and build on PROs • New priorities • Emphasize quality review and assurance over UR and cost control • More attention to average practice patterns than outliers • Include additional healthcare settings

  22. Evolution of Quality Improvement and Cost Containment at CMS 1990 IOM Recommendations to QIOs • Undergo ‘self-assessment’ • Demonstrate impact on quality of care for Medicare beneficiaries • Include critical provider input • Develop criteria for evaluation that is objective and well-vetted • Have access to a Technical Advisory Panel *

  23. Evolution of Quality Improvement and Cost Containment at CMS

  24. Evolution of Quality Improvement and Cost Containment at CMS Late 1980’s-early 1990s • Continuous Quality Improvement: • According to the principles of continuous quality improvement, there is no minimum acceptable level; processes can always be improved. • 1991:The Institute for Healthcare Improvement (IHI) is founded.

  25. Evolution of Quality Improvement and Cost Containment at CMS 1992 Jencks and Wilensky • Recommended a dramatic course change from retrospective review that identified a few poor performers to prospective improvement in quality of care for all providers • Health Care Quality Improvement Initiative • Focus on practice patterns and care outcomes at the institutional and national levels • Develop practice guidelines • Initiate Cooperative Cardiovascular Project for AMI

  26. Evolution of Quality Improvement and Cost Containment at CMS 1993-1996 PRO 4th SOW PROs Evolve • National quality improvement projects on Heart Failure and Diabetes • Emphasis shifts to collaboration between governments, providers, and consumers • Data collection methods improve

  27. Evolution of Quality Improvement and Cost Containment at CMS 1996-1999 PRO 5th SOW • National Health Care Quality Improvement Projects (HCQIP) • HCFA-directed for statewide impact • Local needs assessments • Measurable indicators • Beneficiary protection and complaints

  28. Evolution of Quality Improvement and Cost Containment at CMS

  29. Evolution of Quality Improvement and Cost Containment at CMSCommunications

  30. Evolution of Quality Improvement and Cost Containment at CMS 1999-2008

  31. Evolution of Quality Improvement and Cost Containment at CMS 1999-2002 PRO 6th SOW • National HCQIP • Specific disease topics • AMI, CHF, Pneumonia, Stroke, DM, Breast Cancer • Local projects • Expand beyond acute care • New projects for managed care • Beneficiary Protection (payment error)

  32. Evolution of Quality Improvement and Cost Containment at CMS 2002-2005 7th SOW: ‘PRO’ becomes ‘QIO’ • Specific topics with standardized indications for each setting • NH, HH, Hospital (AMI, HF, Pneumonia, Surgical infections), Physician office (DM, Cancer, Immunization) • Projects for underserved and rural populations • Projects for Medicare managed care • Information and Communication • Hospital-generated performance data • QIO Data Warehouse

  33. Evolution of Quality Improvement and Cost Containment at CMS 2005-2008 QIO 8th SOW • Developing capacity for and achieving excellence • Tasks still divided by setting of care • Physician office expanded to include underserved, Part D, and HIT • Beneficiary Protection continues

  34. Quality Improvement and Cost Containment at CMS?

  35. Evolution of Quality Improvement and Cost Containment at CMS 2008-2011 QIO 9th SOW Based on all that went before and more…

  36. Impetus for Change

  37. Impetus for Change • Improving the Medicare Quality Improvement Organization Program, 2006 Institute of Medicine (IOM) report to Congress • Focus more on quality improvement and performance measurement • Prioritize program resources so that QIO can help providers who demonstrate the most need, or who face significant challenges delivering quality care • Strengthen organizational structure and governance of the QIO • Strengthen management of the QIO program by CMS • Strengthen the evaluation system for the QIO program

  38. Impetus for ChangeNursing Home Report • Nursing Homes: Federal Actions Needed to Improve Targeting and Evaluation of Quality Improvement Organizations, 2007Government Accountability Office (GAO) report • Increase the number of low-performing nursing homes that QIO assists intensively • Direct QIO to focus intensive assistance on those quality-of-care areas in which nursing homes most need improvement • Collect more complete and detailed data on the methods QIO are using to assist nursing homes and the impact that these methods have on quality of care • Identify a broader spectrum of publicly reported quality measures to evaluate changes in nursing home quality.

  39. Result: Transparency • December 2007: CMS publishes its first ever nationwide list of poor-performing nursing homes. • Poor-performers display what CMS calls a "yo-yo" compliance history of providing consistently poor care, while instituting just enough improvement to pass their next survey. • These128 out of 16,000 nationwidenursing homes are subject to double inspections by state health officials and risk losing their eligibility to receive Medicare or Medicaid reimbursements.

  40. QIO 9th SOW: Overview

  41. QIO 9th SOW: Overview • Traditional perspectives of care from the hospital, nursing home, home health, physician office are removed. • Quality Improvement in the QIO 9th SOW revolves around the patient not the health care setting or provider. • Quality Improvement must occur across the continuum of care.

  42. QIO 9th SOW: Overview • Levels • 4 Themes, 10 Components, to 59 Measures, and beyond • Topic-oriented, not setting oriented • Cross-cutting themes (HIT, disparities, and VDHC) • Outcomes oriented • Patient-centered • 245,000 more patients screened for CKD • 40,000 fewer pressure ulcers • 20,000 more adult immunizations provided

  43. QIO 9th SOW: Overview • National • Sub-national • Special Projects

  44. QIO 9th SOW: Goals 6 Aims 10 Rules 4 Priorities 4 Design Principles 3 Objectives

  45. QIO 9th SOW: GoalsCMS’ Six Aims for Redesign of Healthcare Services • Safe • Timely • Effective • Efficient • Equitable • Patient-centered