Www.qualityforum.org Performance Measurement & Reporting: Future Directions Janet Corrigan, PhD, MBA President and CEO National Quality Forum

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Performance Measurement & Reporting:

Future Directions

Janet Corrigan, PhD, MBAPresident and CEONational Quality Forum


National Quality Forum Mission

• Improve the quality of American healthcare by setting national priorities and goals for performance improvement

• Endorse national consensus standards for measuring and publicly reporting on performance

• Promote the attainment of national goals through education and outreach programs

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This Presentation at a Glance

• Key Components of Health Reform Aimed at Improving Quality and Affordability of Health Care

• National Quality Enterprise: Key Functions

• Role of the National Quality Forum

3


Health Reform Legislation

• Patient Protection & Affordability of Care Act (ACA) of 2010– Rapid expansion of public reporting– Alignment of payment with value– Development of accountable care organizations

• American Recovery and Reinvestment Act (ARRA) of 2009 – $32 billion to rapidly “wire” American

healthcare

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ACA Transparency Provisions

• Broad Plan for Public Reporting – Requires a clear federal plan to make performance information widely

available. • Hospitals and Ambulatory Surgery Centers

– Expands Hospital Compare; includes information on the Value Based Purchasing (VBP) program; report on health care acquired admissions, hospital readmissions, and hospital charge data.

• Physicians– Requires development of Physician Compare website by January 2011. – Annually, physician ownership or investments in hospitals and

manufacturers (by September 2013) will be published. • Nursing Homes, Skilled Nursing Facilities, LTC Facilities

– New information will be added to Nursing Home Compare by March 2011. Nursing home ownership by March 2012.

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Public Reporting

In 2009 more than half of Americans used the Internet to look up health information

Source: CDC. National Center for Health Statistics http://www.cdc.gov/nchs/data/hestat/healthinfo2009/healthinfo2009.pdf

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ACA Payment Reforms

• Physician Payment – Provides 5-year, 10% bonus for primary care and general surgeons in

health professional shortage areas beginning in 2011 based on reporting of quality measures.

– Medicaid primary care rates will be 100% of adjusted Medicare rates for 2013 and 2014.

– Secretary establishes a payment modifier that provides for differential payment to physicians based on quality of care compared to cost. Must be budget neutral and program starts in 2013.

• Hospital Payment– Reduces payments for “excess” readmissions in selected conditions

starting in FY 2013. – Establishes a hospital VBP program to start in FY 2013. – Reduces payment for hospitals in top quartile of national health care

acquired conditions rate by 1% starting in 2015.• Expansion of Value-based Purchasing

– VBP pilots for long-term care; rehabilitation facilities; PPS-except cancer hospitals; and hospice to be implemented by 2016.

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ACA Payment Reforms (cont’d.)

• CMS Innovation Center– Establishes an Innovation Center with the capacity to implement

innovations program-wide that require review and assessment by the Office of the Actuary.

– Center must be established by 2011.

• Piloting of New Programs – Authorizes a multitude of payment redesign programs to be rapidly

tested and, as proven, expanded. – Bundled Payments, Shared Decision-Making, etc.

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ARRA & ACA Delivery System Reform

• Build technological infrastructure necessary to improve quality and reduce costs– $30B in Medicare and Medicaid incentive payments linked

to “meaningful use” of EHRS

• Promote integration of personal health care and population health – Community health teams

• Encourage development of clinically integrated health systems – Medical Homes/ Health Care Homes– Accountable Care Organizations

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Accountable Care Organizations

• Patient-focused orientation– Follows the natural trajectory of care over time

• Directed at value – Quality, costs, and patient preferences

• Emphasizes care coordination– Care transitions and hand-offs

• Promotes shared accountability– Individual, team, system

• Addresses shared decision making– Attention to patient preferences

• Supports fundamental payment reform – Bundled payment for the episode of care

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Quality Enterprise Functions:Contributions of NQF

Establish National Priorities

• National Priorities Partnership

• Top 20 conditions

Identify Measure Gaps

• Agenda for Measure Development and Endorsement

Measure Development

Endorse Measures, Practices, and SREs

• Over 600 measures covering all settings, including Safe Practices and SREs

Build Data Platforms

• Health Information Technology Expert Panel

Publicly Report Results

• Guidance for performance reporting on safety

• MAPs & Dashboard

Align Payment and Other Incentives

• Analysis of measurement implications of various payment reform models

Improve Performance

• Webinars• Measures database

Evaluate

• Measure use evaluation

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Why Set National Priorities?

• Current state of performance measurement is a cacophony of well-meaning but uncoordinated signals

• National priorities help align strategies and efforts of multiple groups around common goals for improvement

• Drive fundamental change in the delivery system

• New link to ACA: – Secretary to establish and implement a

national strategy to improve care delivery, health outcomes and population health

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National Priorities Partnership

32 multi-stakeholder organizations:• Consumers• Purchasers/Employers• Health Professionals/Providers• Health Plans• Accreditation/Certification Groups• Quality Alliances• Suppliers/Industry• Community/Regional Collaboratives• Public Sector: CMS, AHRQ, CDC, NIH, NGA

Co-Chairs: Donald Berwick Institute for Healthcare Improvement Margaret O'Kane National Committee for Quality Assurance

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Criteria for Selecting the Priorities

© National Priorities Partnership

RemoveWaste

EradicateDisparities

EliminateHarm

Reduce Disease Burden

High Impact Areas

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National Priorities

• Population health - Key preventive services - Healthy lifestyle behaviors

• Safety – Hospital-level mortality rates– Serious adverse events – Healthcare-Acquired

Infections

• Care Coordination – Medication reconciliation– Preventable hospital

readmissions– Preventable emergency

department visits

• Patient/family engagement – Informed decision-making– Patient experience of care– Patient self-management

• Palliative Care:– Relief of physical symptoms– Help with psychological, social

and spiritual needs– Communication regarding

treatment options, prognosis– Access to palliative care services

• Overuse– 9 major areas


Potential Areas of Overuse

• Inappropriate medication use• Unnecessary laboratory testing• Unwarranted diagnostic procedures• Unnecessary maternity care interventions• Unnecessary consultations• Potentially harmful preventive services

(USPSTF “D” list) • Preventable hospitalization and ED visits• Inappropriate non-palliative care at end-of-life

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Drivers of Change

Performance Measurement

Payment

Accreditation &

Certification

COLLABORATIVE, ACTION-ORIENTED STRATEGIES

Applied Research

Infrastructure

(Information Technology

& Workforce

Public Reporting

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Measure Development










Improve Performance


Evaluate


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ACA: Measure Development

• AHRQ and CMS to conduct triennial assessment to identify measures gaps

• Consider gaps identified by NQF, pediatric program, and Medicaid

• Priority to health outcomes, functional status, coordination of care, shared decision-making, MU, safety, patient experience, efficiency and disparities

• $75M for measure development (not yet appropriated)

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Measure Development & Endorsement Agenda

Measure Development & Endorsement

Agenda

National Priorities

LeadingMedicare Conditions

Child and Family Health

HITMeaningful

Use

Population Health

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Prioritized Medicare Conditions• Major depression• CHF• IHD• Diabetes• Stroke/TIA• Alzheimer’s dx• Breast CA• COPD• AMI• Colorectal CA

• Hip/pelvic fracture• Chronic renal dx• Prostate CA• Rheumatoid &

osteoarthritis• Atrial fibrillation• Lung CA• Cataract• Osteoporosis• Glaucoma• Endometrial CA

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Measure Development










Improve Performance


Evaluate


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NTTAA

National Technology and Transfer Advancement of Act of 1995 (NTTAA)

Defines the five key attributes of a “voluntary consensus standards-setting body” (i.e., openness, balance of interest, due process, consensus, and an appeals process)

Obligates federal government to adopt voluntary consensus standards (when the government is adopting standards)

Encourages federal government to participate in setting voluntary consensus standards

NTTAA

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Measurement & Improvement Paths

NQF, 2002


NQF Consensus Development Process

• Call for nominations for steering committee and technical panels

• Call for measures • Measure evaluation• Member and public comment• NQF member voting • Consensus Standards Approval

Committee (CSAC) • Board of Directors endorsement• Appeals

Consensus Development Process Steps

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NQF Evaluation Criteria

• Importance to measure and report • What is the level of evidence for the measures? • Is there an opportunity for improvement?• Relation to a priority area or high impact area of care?

• Scientific acceptability of the measurement properties • What is the reliability and validity of the measure?

• Usability • Can the intended audiences understand and use the

results for decision-making?• Feasibility

• Can the measure be implemented without undue burden, capture with electronic data/EHRs?

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Types of Quality Measures

• Process• Outcome• Structure/management• Access• Efficiency/cost• Use of services (used as proxy for outcome,

cost)• Patient experience of care• Composite (two or more measures

combined into a single score)

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• Drive toward higher performance • Shift toward composite measures • Measure disparities in all we do• Harmonize measures across sites and

providers• Promote shared accountability &

measurement across patient-focused episodes of care: – Outcome measures– Appropriateness measures – Cost/resource use measures coupled with

quality measures, including overuse

Quality Measurement in Evolution

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Patient-Focused Episodes of Care Model

Population at RiskEvaluation & Initial Management

Rehabilitation & Follow-up Care

Clinical episode begins

Appropriate Times Throughout Episode

- Determination of key patient attributes for risk adjustment

- Assessment of informed patient preferences and the degree of alignment of care processes with these preferences

- Assessment of symptom, functional, and emotional status

PHASE 1

PHASE 2

PHASE 3

End of Episode

- Risk-adjusted health outcomes (i.e. mortality & functional status)

- Risk-adjusted total cost of care

Time

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Episodes Model Measurement Domains

• Patient-level outcomes (better health)– Morbidity and mortality– Avoidance of complications (e.g., HAIs)– Functional status– Health-related quality of life– Patient experience of care

• Processes of care (better care)– Technical – Care coordination and transitions – Alignment with patients’ preferences; shared

decision-making

• Cost and resource use (overuse, waste, misuse)– Total cost of care across the episode– Indirect costs

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Patient-Focused Episodes of Care Model

• Patient-focused orientation– Follows the natural trajectory of care over time

• Directed at value – Quality, costs, and patient preferences

• Emphasizes care coordination– Care transitions and hand-offs

• Promotes shared accountability– Individual, team, system

• Addresses shared decision making– Attention to patient preferences

• Supports fundamental payment reform – Bundled payment for the episode of care

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Integrated Performance Measurement Framework

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Population at RiskEvaluation & Initial Management

Follow-up Care

Clinical Episode Begins

PHASE 1

PHASE 2

PHASE 3

End of Episode ~ Risk-Adjusted Health Outcomes and Total Cost of Care

Time

Patient & Family Engagement

Safety

Care Coordination

Overuse Palliative CarePopulation Health


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Not everything that counts can be counted, and not everything

that can be counted counts.

Albert Einstein








Measure Development










Improve Performance


Evaluate


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Comprehensive Data Needed to Generate Performance Information

Data Integration

Patients

Pay for

Perform

anceConsumer

Activation

Hospitals/Institutions

EHRs

Laboratories

Pharmacies

Medical Claims

Registries

Quality

Impro

vement

Care Evaluation

Data Aggregation

RWJF Aligning Forces for Quality35


Linkage of HIT and Measurement

Data Source

s

•Capture the right data

•Calculate the performance measure

•Provide real-time information to the clinician with decision support

•Publicly report for secondary uses: accountability, payment, public health, and comparative effectiveness

Data Sources

Performance Measures

EHRs and HIT tools

E-Infra structure

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Performance measurement600 + Measures

Dozens of stewards

Health IT Advisory CommitteeTranslate (QDS)

Harmonize measure standardsand HIT standards

Health ITVendors

Standard Development Orgs

Interfacing Measurement and Health IT

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Shared Data Elements: “Sweet Spot”

Clinical Guidelines

Decision Support

Quality Measures

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QDS Data Element

39


QDS Data Flow

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Shared Supply Chain

01110100 01101000 01100001 01101100 00100000

01010010 01101111 01110011 01100101 01101110

01000100 01100001 01101110 01101110 01111001

Guideline

diabetes aspirin

hemoglobin

lumpectomy smoker EKG

QDS data element repository

QM

CDS CDS rule

repository

QM specification repository

CDSmap map

EHR

01101001 01110011 00100000 01100011 01101111 01101111 01101100 00100001

quality report

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Measure Development










Improve Performance


Evaluate


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Applications of Performance Information

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NQF and RAND Project: Measurement Implications of Payment Reform Models

• Performance-based payment incentives as a driver of change– Pay for performance– Episode-based payment– Population-based payment

Increasing aggregation of services into a unit of payment

Payment for service Payment for event or condition

Payment for care of a population

Fee-for-service

Augmented fee-for-service

(e.g., P4P)

Bundled payment (single

provider)

Bundled payment (multiple

providers)

Partial capitation

Full capitation

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Payment Reform Models

1. Global Payment

2. ACO Shared Savings

3. Medical Home

4. Bundled (Episode) Payment

6. Payment for Coordination

5. Hospital-Physician Gainsharing

7. Hospital P4P

8. Readmissions

10. Physician P4P

11. Shared Decision Making

Performance goals addressed by payment Narrowly-definedBroadly-defined

Degree of provider aggregation Less aggregatedMore aggregated

Type of payment Fee-for-servicePopulation-based

9. Hospital-acquired conditions

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NQF and RAND Project: Measurement Implications of Payment Reform Models• Measurement analysis for selected

payment reform models– Assessment of measure needs

• Proposed measure sets– Analysis of methodological issues raised by

application of measures• Attribution• Risk adjustment• Benchmarking • Data source• Small numbers

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Measure Development










Improve Performance


Evaluate


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Searchable Database of Endorsed Measures

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Measure Use Evaluation Getting Underway

• To assess the use of performance measures for driving system change:– Public reporting– Payment incentives– Accreditation and certification– Quality improvement

• To inform measure development, endorsement, and implementation

• Independent contractor

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Take Home Messages

• Entering a period of extraordinary challenges and opportunities

• Two critical drivers–- public reporting and payment alignment

• Early investment in HIT is critical

• Delivery system reform is essential to succeed– Integration of personal and population health to address

behavioral change– Clinical integration to manage patient-focused episodes

and maximize value

50


Thank You

Documents

Www.qualityforum.org Performance Measurement & Reporting: Future Directions Janet Corrigan, PhD, MBA President and CEO National Quality Forum