The American Healthcare
System The Quest for
Quality
Paul Convery, MD, MMM, FACPE
October 19, 2016
Institute of Healthcare Improvement
Triple Aim
1.
2.
3.
Improving the patient experience of care
Improving the health of populations
Reducing the per capita cost of healthcare
History of Quality Efforts in
Healthcare
Ignaz Semmelweis in Vienna in 1846
Earnest Codman at the Massachusetts General
Hospital in Boston in 1914
o Mortality and Morbidity Conferences
o Evaluation of Surgeons Competence
American College of Surgeons in 1918
o A separate and defined hospital medical staff.
The Joint Commission
The Joint Commission for the Accreditation of Hospitals
(JCAH) formed in 1951, established medical staff
requirements and hospital governance requirements
In 1965 Medicare Conditions of Participation required
The Joint Commission accreditation of hospitals
In 1987, renamed The Joint Commission for the
Accreditation of Health Care Organizations (JCAHO)
In 2007, rebranded as The Joint Commission
In 2008 The Medicare Improvement for Patients and
Providers Act gave CMS the deeming authority and
opened to other accreditation agencies
Today, The Joint Commission is a force for healthcare
quality and patient safety with both a consulting
business and an international division
National Committee for Quality
Assurance NCQA
In 1973, The Health Maintenance Organization
Act was passed (Nixon)
In 1990 the National Committee for Quality
Assurance was formed with a grant from Robert
Wood Johnson Foundation
o HEDIS (Healthcare Effectiveness Data Set) formed in 1991
o Report Cards on Health Plans, Clinicians and other Healthcare
organizations
o Consultation, measurement and reporting, publications, advocacy
HEDIS
1991 HMO Employer Data and Information Set
1993 Health Plan Employer Data and Information Set
2007 Healthcare Effectiveness Data and Information Set
NCQA Certification available
Used for Health Plan Report Cards and subsequently PPO
Report Cards and Physician Report Cards
o Data is for past year and from individual health plan administrative data
CMS requires Medicare HEDIS data for Medicare
Advantage Plans
Currently there are 75 HEDIS measurements in
effectiveness and experience of care, access, utilization,
health plan stability, and health plan education activities
and descriptive information
To Err is Human
Building a Safer Health System
Published by the Institute of Medicine in November
1999
As many as 44,000 to 98,000 people die
in American hospitals each year by
errors that could have been
prevented
Total cost (of unsafe care)between
$17 - $29 billion per year
Errors are caused by faulty systems
and processesthat lead to mistakes
This began the modern healthcare
quality movement
The Institute of Medicine (IOM) is an independent, nonprofit organization that works outside of
government to provide unbiased and authoritative advice to decision makers and the
public. Established in 1970, the IOM is the health arm of the National Academy of Sciences, which
was chartered under President Abraham Lincoln in 1863.
Why is Quality Important?
Quality and Cost
Inversely Related
2015 Milliman Medical Index
$25,000
$4,065
Out-ofPocket
$20,000
$6,408
Employee
Contribution
$15,000
$10,000
$5,000
$10,168
$12,214
$14,500
$16,771
$19,393
$22,030
$14,198
$14,198
Employer
Contribution
$0
2003
2005
2007
2009
2011
2013
2015
Measures the total cost of healthcare for a typical family of four covered by an employer-sponsored PPO plan.
15
Crossing the Quality Chasm
A New Health System for the 21st Century
Published by the Institute of Medicine in March 2001
The U.S. health care delivery system does not
provide consistent, high quality medical care to all
peopleoverly complex and uncoordinated.
Bringing state of the art care to all
Americans in every community will
require a fundamental, sweeping
redesign of the entire health system
Care that is Safe, Effective, Patient
Centered, Timely, Efficient & Equitable
Popula
t io
Health n
f
eo
nc
rie
pe
Ex are
C
Per Capita
Cost
fundamental, sweeping redesign of the entire
healthcare system
18
IOM Six Aims for Improvement
Safe avoids injuries to patients from care that is intended
to help them
Timely Reduces waits and harmful delays impacting
smooth delivery of care
Effective Provides services based on scientific knowledge
to all who could benefit and refrains from providing services
to those not likely to benefit (avoids overuse and underuse)
Efficient Uses resources to achieve best value by
reducing waste, production, and administration costs
Equitable Does not vary in quality according to personal
characteristics such as gender, income, ethnicity and
location
Patient Centered Respectful of and responsive to
individual patient preferences, needs, and values
Safe Care
Avoids injuries to patients from care that is
intended to help them.
Effective Care
Provides services based on scientific knowledge to
all who could benefit & refrains from providing
services to those not likely to benefit (avoids
overuse and underuse.)
Patient Centered Care
Respectful of and responsive to individual patient
preferences, needs, and values.
Timely Care
Reduces waits and harmful delays impacting the
smooth delivery of care.
Efficient Care
Uses resources to achieve best value by reducing
waste, production, and administrative cost.
Equitable Care
Does not vary in quality according to personal
characteristics such as gender, income, ethnicity &
location.
Institute of Medicine Definitions
Quality the degree to which health services for
individuals and populations increase the
likelihood of desired health outcomes and are
consistent with current professional knowledge.
Efficiency in an efficient health care
system, resources are used to get the
best value for the money spent. The
opposite of efficiency is waste, the use
of resources without the benefit to
the patients.
Institute of Medicine
Recommendation
Thatthe department of Health and Human
Services create an environment that fosters and
rewards improvement by:
Creating an infrastructure to support evidence
based practice
Facilitating the use of information
technology
Aligning payment incentives and
Preparing the workforce to better serve
patients in a world of expanding
knowledge and rapid change
Value Based Purchasing as alternative
to Fee for Service
This is a Major Transformational Shift
Fee For Service
FFS = Volume x
Price
Pay For Value
V = Quality / Payment
This is Transformational
This is a Transaction
Government / CMS Efforts to
Improve Quality in Healthcare
Core Measures began in 2001, hospital quality metrics
in CHF, MI, PN, SCIP, readmission rates, mortality rates
and satisfaction surveys (HCAHPS)
o Available at Medicare.gov/HospitalCompare
Physician Quality Reporting System (PQRS) 2011
o Hospital Compare Data and PQRS are the Basis for Value Base Purchasing in
Medicare
Medicare and Medicaid EHR Incentive Programs
o Part of ARRA 2009
o Incentive payments to hospitals and physicians; Stage 1, 2, 3 Meaningful Use
Accountable Care Organization (PPACA) 2010
o Align Incentives to change models of payment
o Move towards Value Based Purchasing
o Achieve coordination across continuum of care
Partial History of Reform
Federal Regulatory
Reporting
Inpatient Prospective
Payment
System (IPPS)
Measures
Part of Deficit Reduction Act of 2005
Initial Rules Released August 2007
Hospital Acquired Conditions Payment Penalties - PPACA 2010
Hospital Readmission Reduction Program
Readmission Rates initially posted on Hospital Compare in
2009 (2005-2008 data)
20% Medicare pts readmit in 30 days ($17.4 b/yr) NEJM
April 2009
Provision of PPACA 2010
Meaningful Use Clinical Quality Measures
Part of ARRA Bill / HITECH Act 2009
Final Medicare & Medicaid EHR Incentive Program Rule 7/13/10
Hospital Value Based Purchasing Program Measures
CMS Original Proposal to Congress 11/07
Payment Proposals within ARRA Bill
CMS Hospital Value Based
Purchasing
CMS Bulletin March 2013; updated January 2016
FY 2013
(Oct 12)
FY 2014
70%
45%
20%
10%
5%
Patient
Experience
(HCAHPS)
30%
30%
30%
25%
25%
Outcomes
NA
25%
30%
40%
25%
Efficiency
NA
NA
20%
25%
25%
Domain
Clinical Care
Processes
FY 2015
FY 2016
FY 2017
Patient Safety
Penalty / Reward
20%
1.0%
1.25%
1.50%
1.75%
30 Day Post-discharge mortality for AMI, HF, PN + Composite PSI bundle (2015) + CLABSI (2015) + CAUTI + SSI (2016)
Medicare Spending per Beneficiary ( includes Parts A & B from 3 days PTA to 30 days post-discharge)
PSI 90 Composite + CLABS, CAUTI, SSI(colon)/AbdomHysterectomy, C. dif, MRSA
includes elective delivery prior to 39 weeks gestation
2.0%
Core Measures (Clinical Care
Process) Have Evolved
AMI
1 PCI within 90 minutes - GONE
aspirin at discharge - GONE
statin at discharge - GONE
HF
LVS functional level - GONE
ACEI / ARB at discharge - GONE
discharge instructions - GONE
CAP
BC in ED pre-Abx - GONE
initial Abx in IC patient - RETAINED
33
Impact of Value Based Purchasing
(Hospitals)
Reporting of Hospital Quality
2%
Value Based Purchasing
2%
Readmission Rate Penalty
3%
Hospital Acquired Conditions
1%
Meaningful Use
5%
(incentive moves to penalty that reaches 5% in 2018)
This level of data collection, process improvement
and organization will require scale, resources and
capability.
Value Based Purchasing
(Physicians)
Physician Quality Reporting System
2% until 2018
MACRA and MIPS
(2015)
o MIPS includes begins 2019
PQRS adjustments to
Value Based Modifier payments
EHR Meaningful Use budget neutral
Unless 25% related to alternate payment
mechanisms (ACO, Bundles, PCMH, etc.)
What is MACRA?
The Medicare Access and CHIP Reauthorization Act (2015)
What Does MACRA Do?
Repeals the Sustainable Growth Rate Formula
Changes the way Medicare rewards clinicians for
Value over Volume
Combines multiple quality programs thru MIPS
or
Provides bonus payments for participation in
eligible Alternative Payment Models [APMs]
36
MIPS Changes How Medicare
Links Performance to Payment
Currently There are Three Medicare Quality & Value programs for Physicians
PQRS Physician
Quality Reporting
System
Value-Based
Payment
Modifier
MU Medicare
EHR Incentive
Program
MIPS
Merit-based Incentive Payment System
37
Annual MIPS Adjustments
+ 7%
+ 4% + 5%
Program is:
+ 9%
-budget neutral
- 4%
- 5%
- 7%
- 9%
2019
2020
2021
2022
onward
-provider composite
score may result in
positive, neutral,
negative change in
Medicare part B
base rate
38
Alternative Payment Models
APMs are new Medicare payment options to
incentivize quality and value [ MACRA authorized ]
CMS Innovation Center model
MSSP [Medicare Shared Savings Program]
Health Care Quality Demonstration program
Demonstration authorized under federal law
39
MACRA Timeline
2015 and earlier
FFS
2016
Physicians must move quickly toward one of the two
tracks. Performance Year 1 starts January 1, 2017 for FY 2019
payment
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026 and
later
0.75%
Fee Schedule
Updates
APMs
.5%
.5%
.5%
.5% 0% 0% 0% 0% 0% 0%
0.25%
MIPS
Quality
MIPS
Resource Use
Practice Improvement Activitiess
Meaningful Use of Certified EHRs
PQRS, Value Modifier, EHR Incentives
Certain
APMs
Qualifying APM
Participant
9%
4%
5%
7%
MIPS Maximum Bonus or Penalty (+/-)
5% Incentive Payment
Medicare Payment Threshold
Excluded from MIPS
Source: Centers for Medicare & Medicaid Services :
www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ValueBased-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html
Excluded from MIPS
MIPS and APMS begin operating
National Physician Reported Survey
$15.4 billion per year on reporting quality metrics
15.1 hours per week for staff and physician
Average cost of $40,069 per physician per year
CMS Payment Change
Medicares Commitment to Quality Based Payment Systems Sylvia Burwell 2015
Percentage of Payments
linked to quality programs
All Medicare
Payments
80%
85%
20%
30%
Current
Quality Based Programs
Hospital VBP
Hospital Readmissions
Hospital Acquired Conditions
ESRD
Quality Incentive
Value Based Modifier
Percent of
payments linked
to alternate
programs
90%
50%
By 2016
By 2018
Alternative Payment Programs
Pioneer ACOs
Medicare Shared Savings Programs
Bundled Payments
Comprehensive PCP Initiative
PCMH
Comprehensive ESRD
Oncology Care Model
Medicare Medicaid Financial Alignment
In 2015 Three DFW ACOs Saved
Medicare $50 million
Savings for
Medicare
Incentives Paid to
ACO
Number of
Beneficiaries
UTSW ACO
$29.9 m
$14.2 m
67,672
MHS ACO
$18.7 m
$8.3 m
14,229
ACO North TX
$4.7 m
$2.2 m
5,698
Genesis ACO
$1.9 m
12,700
($4.8 m)
64,308
($8 m)
(21,597)
ACO
BSW ACO (BQO)
USMD ACO
In 2015, 392 Medicare
Shared Savings ACOs
saved $429m; $200m came
from Texas ACOs.
Bundled Payment
Medicare Shared Savings Program ACOs
Pioneer ACOs
Insurance Benefits News
Private Sector Efforts
Most major health insurers have embraced a
version of Value Based Purchasing (P4P) and
efforts to coordinate care of providers (Case
Rates, Capitation, ACOs, etc.) 40% of
commercial in-network payments are value
(quality) oriented. Catalyst for Payment Reform 2014
Transparency - Multiple web sites provide health
care quality data, including most large health
systems
Commercial Payment Change
In January 2015, the Health Care
Transformation Task Force
announced that they intended to
shift 75% of their respective
business to a value based
payment model by 2020.
46
CMS and AHIP to Align Quality
Metrics
CMS and Americas Health Insurance Plans released 7
core sets of quality measures created to reduce
complexity, decrease cost burden, and ensure highquality care. (Feb 2016)
The core measures released are in the following 7
sets:
o Accountable care organizations, patient-centered medical homes, and
primary care
o Cardiology
o Gastroenterology
o HIV and hepatitis C
o Oncology
o Obstetrics and gynecology
o Orthopedics.
Organizations in the National
Quality Quest
National Quality Forum (NQF)
o Established in 1999
o Public/private partnership to establish consensus on quality goals/metrics
o Stakeholders from across healthcare including physicians, hospitals, insurers,
suppliers, communities
o Identifies quality metrics to submit to CMS and others for use in programs
Agency for Healthcare Research and Quality (AHRQ)
o Established in 1989 as the Agency for Health Care Policy and Research
o Government agency in HHS
o Charged with research to improve health care quality, access, safety and
effectiveness (developing clinical guidelines was dropped in 1999)
Patient Centered Outcomes Research Institute (PCORI)
o Established by PPACA of 2010
o Established to fund and disseminate research concerning best evidence to
help patients and providers make optimal decisions about healthcare choices;
to understand prevention, treatment, and care options available and the
scientific evidence behind them
Healthcare Systems
Most are moving towards more vertical and
horizontal integration.economic incentive or to
improve coordination and efficiencies of care?
Physicians are also aggregating in large groups,
both specialty and multispecialty, both regional
and national
Wide spread uptake of implementation and use of
Electronic Medical Records (without clear ROI to date)
Quality Process Improvement Strategies are more
wide spread in healthcare today in response to
Value Based Purchasing
History of Performance
Improvement in Healthcare
1950 Deming in Japanese Automobile Industry
(CQI)
1990 CQI introduced to Healthcare; Curing Health
Care, Berwick et al
1990 Motorola introduced Six Sigma
1991 The Institute for Healthcare Improvement
(IHI)
1999- Baldrige Performance Excellence Program
added a healthcare category (20 winners to date)
2000 LEAN Manufacturing began in the USA (TPS)
Today - CQI (Deming), LEAN, and Six Sigma are all
used in healthcare organizations across the country
Moving from Process Improvement to
Outcomes
The Donabedian Model
Avedis Donabedian (1919-
2000)
1966 Evaluating the Quality of Medical Care
Structure - the context of care
o 1950 to 1999 facilities, training, provider qualifications, organizations,
departments, etc. (The Joint Commission Certification, prior to 2000)
Process the transactions of care
o 1999 to current times how care is delivered, process improvement,
evidence based care, standardization, order sets, guidelines and
pathways (e.g. beta blocker use in AMI)
Outcomes the results of care
o The future the results for the community and for the patients,
function, access, results, mortality ( the health status of the
community or the post operative mortality rate for CABG)
Healthcare Systems Strategy to
Reach the Triple Aim
Leadership Commitment to Quality and a new Model
of Care..Population Health
Framework and Vision to Guide Organizational
Strategy
Investments in Quality Improvement
and Leadership Training for All
Large Scale Data Collection,
Analysis and Reporting
Alignment with Physicians,
both Employed and with the
Medical Staff
Integrated Healthcare Association
Medical Group Report Card
(California: 150 participating physician organizations; Health Affairs Blog, March 9, 2016)
MEDICAL CITY DALLAS HOSPITAL
7777 FOREST LANE
DALLAS, TX 75230
(972) 566-6222
Overall rating :
3 out of 5 stars
UT SOUTHWESTERN UNIVERSITY HOSPIT
BAYLOR UNIVERSITY MEDICAL CENTER
AL ST
3500 GASTON AVE
PAUL
DALLAS, TX 75246
6201 HARRY HINES BLVD
(214) 820-0111
DALLAS, TX 75390
Overall rating :
(214) 633-5555
4 out of 5 stars
Overall rating :
3 out of 5 stars
Hospitals Struggle
With EHRs For Quality
Reporting, AHA Says
MD Anderson points to Epic
implementation for 77% drop in
adjusted income
We Are Seeing Improvements
Hospital Rating
Annual and Cumulative Effect of HAC
Decrease 2011-1014
17%
50,357
$11.9b
$7.9b
34,530
9%
12,300
7%
3,527
2%
$3.1b
$0.9b
An estimated
1.3 million
fewer harm
events were
experienced by
patients (in our
hospitals) from
2010 to 2013
2011
2012
2013
2014
AHRQ National Scorecard Estimates from Medicare Patient Safety Monitoring System; announced by HHS 2014
HACs include Adverse Drug Events, CAUTI, Central Line Bloodstream Infections, Falls, OB Adverse Events, Pressure Ulcers,
SSI, VAP, Post Op VTE, others
This represents an 8% drop
over five years, in 49 out of 50
states. Since 2010, that is
565,000 fewer readmissions.
CMS
Triple Aim
