# Presentation: 671221

## Office of Clinical Standards & Quality 

- Coverage &Analysis Group (CAG) Clinical Standards Group (CSG)
- Quality Measurement & Health Assessment Group (QMHAG)
- Quality Improvement Group (QIG)
- Quality Coordination Team (QCT)
- Information Systems Group (ISG)

## Coverage and Analysis Group

## National Coverage Determinations

- 	- Congress gave CMS the authority to decide if Medicare should cover (i.e., pay) certain Part A and B items, devices or services.
-  	- Most decisions about which technologies are covered are made by local contractors as they pay Part A or B claims.

## WHAT TECHNOLOGIES ARE REVIEWED?

- Technologies brought to CMS by external parties
- - Current national non-coverage policy
- - Substantial variation/disagreement among different Medicare contractors about coverage
- Technologies identified by CMS itself
- 	- Extensive literature or important new study
- Technological advance with potential major clinical or economic impact
- Concerns about major inappropriate use

## WHEN IS THERE NATIONAL COVERAGE?

- Per Congress, we may cover items, devices or services if they are “reasonable and necessary.”

## WHAT IS REASONABLE AND NECESSARY?

- Sufficient level of confidence that evidence is adequate to conclude that the item, device, or service:
- 	- improves net health outcomes
- 	- generalizable to the Medicare population
- 	- generalizable to general provider community

## Clinical Standards Group 

## WHAT DOES CSG DO?

- Develop clinical standards for providers and suppliers (e.g. CoPs/CfCs).
- Convene professional groups to discuss regulatory approach.
- Develop strategies for mandating the use of performance measures in CoPs/CfCs.
- Provide clinical analysis for proposed legislative changes.

## WHAT DOES CSG DO? continued

- Evaluate comparability of standards for deemed accrediting organizations
- Present information on new regulatory requirements to the public
- Represent CMS on Committees, Board and Round Tables

## Improving Provider Standards--Direction for the future

- Traditional (old) quality approach
- maintain status quo
- quality assurance (fix problems when they occur)
- Contemporary (new) quality approach
- Focus on stimulating continuous improvement
- Standards development--
- centered on experience of care
- require continual improvement
- use of data & quality indicators
- Requirements “outcome-oriented” rather than structural & process (where possible)

## CSG Interactions With Other CMS Components

- CMSO/Survey & Certification Group
- Regs/interpretive guidelines/enforcement of:
- Conditions of Participation (CoPs) for Providers (e.g., hospitals, nursing homes, home health agencies)
- Conditions for Coverage (CfCs) for Suppliers (e.g., end stage renal disease facilities, ambulatory surgical centers).
- Surveyor training
- Other OCSQ Components, CMM, CBC
- CMS Quality Council
- Priorities workgroup (Breakthroughs)
- Health Information Technologies workgroup
- Long Term Care workgroup

## CSG Interactions With Regional Offices

- Work closely with the 4 regional consortium Organ Procurement Organization coordinators
- Participate in CMSO/SCG monthly calls w/ ROs based on agenda
- Provide clarification/guidance on regulations to ROs as needed

## External Stakeholders

- CSG interacts with external stakeholders who are, or represent, providers and suppliers that must meet the CoPs/CfCs for Medicare & Medicaid participation.
- (e.g., American Hospital Association, American Medical Association, Association of Organ Procurement Organizations, Federation of American Hospitals, etc.)

## OCSQ Quality Interactions

## Quality Measurement & Health Assessment Group

## “McMeasures”

- Develop and maintain data collection instruments
- Work with Stakeholders to identify/ Develop quality measures to the micro-specifications level for Agency use
- Provide clinical and technical support Agency-wide regarding quality measures

## Data Collection Tools

- Maintain the content and coding of CMS data collection tools for:
- 	- Nursing Homes – Minimum Data Set
- 	- Home Health – Outcomes & Assessment    Information Set
-  	- In-patient Rehabilitation (quality section)  - Inpatient Rehabilitation Facility  - Patient Assessment Instrument

## Develop Quality Measures

- Endorse measures that can be used by not only CMS but external  parties
- 	- Efficient data collection, practical use
- 	- Reduced burden on collectors
- 		Collect once, use multiple times
- 	- Provide clear, consistent feedback to providers

## How we use measures: 

- Internally....
- CMS using all or subset of our physician measures for:
-  - Doctors office quality pilot
-  - Doctors office quality  - IT 8 SOW
-  - Medicare care management project (MCMP – MMA sect 649)
-  - Voluntary coordinated care improvement pilot (VCCIP – MMA sect 721)
-  - Physician Group Practice demonstration

## CMS Basic Requirements

- Must be scientific and clinically sound
- Evidenced based in guidelines
- Must be transparent (reproducible)
- Technical specifications and other technical documents available to public* at no charge
- Should not add burden to provider
- Should use existing data source when possible
- * www.cms.hhs.gov/quality

## Endorsement of Measures

- National Quality Forum
- Private non-profit entity to create standards for health care quality
- Working in partnership with many, including CMS, to develop consensus around what measures are ready to be called _standards_
- Final step in a long development process

**Notes:**
Might refer back to the Jencks slide - first box

## The New View......

- Broader care measures
- Continuity of care
- Self management
- Medication management
- Cross cutting care
- Priority clinical areas
- Physician level for P4P

## The New View......

- Alternate data sources
- IT driven data collection
- Patient experience of care
- Systems measures
- Presence of IT, prevention reminders, lab follow up

## Pay for Performance

## Physicians and Providers

- Issues:
- Trust or credibility in measurement
- Trust in appropriate use of measurement
- Unintended consequences or perverse incentives if not appropriate methods where needed (e.g. risk adjustment for outcomes; increase in unnecessary services)
- Availability of data at appropriate level (e.g., physician)

## Physicians and Providers

- Benefits
- Rewards superior performance and encourages overall improvement
- Aligns financial model to actual professional goals of improving the quality of health care services
- Focus on volume is diminished as focus on quality is heightened

## Issues to Consider inPaying for Performance

- Vehicles for Encouraging Quality
- Information collection
- Information dissemination
- Financial rewards
- 	(provide incentives, remove hindrances**)**

## Issues to Consider in Paying for Performance

- What to Reward
- Relative quality
- Absolute threshold
- Improvement
- How to Finance Incentives
- Across-the-board reduction to create pool
- Offsetting penalties
- Offsetting savings

## CMS Current P4P Activities

- Hospital Quality Incentive Demonstration
- Hospital 501(b) Reporting
- Physician Group Practice Demonstration
- Section 649 MCMP Demonstration
- Chronic Care Improvement Program
- Section 646 Medicare Health Care Quality Demo.
- Hospital Quality Alliance – Public Reporting

## Quality Improvement Group

## Program Mission

-       	Through QIOs and ESRD Networks, and in partnership with other stakeholders, **a*****ssist providers*** in transforming healthcare quality, and protect beneficiaries and the Trust Fund, using the following strategies:
- Performance measurement and reporting
- Systems adoption and effective use
- Process redesign
- Organizational culture change

## QIG’s ROLE 

- Monitor the financial and contractual activities of 53 QIOs and 18 ESRD Networks to ensure compliance with contract requirements.
- Manage QIO & ESRD Network procurement plan and funds control activities including the management of the Special Studies Review Panel and QIO Small-Group.

## QIG’s ROLE - continued

- Provide General Contract Oversight for all home health, nursing home and hospital improvement and case review activities.
- Included in case review activity is work associated with implementing new regulations giving appeal rights to beneficiaries (BIPA and Grijalva) whose care has been terminated.

## QIG’s ROLE – continued

- Support Quality Council Breakthrough Priorities for Nursing Home restraint reduction and Long-term care task force in P4P.
- Provides clinical and subject matter expertise and guidance for the quality improvement work for the QIO base contract in the physician office, underserved population, and physician practice pharmacy.

## 
Support the QIOs through training and tool development for change in Physician Practice based systems.

Under physician practice our focus is to improve the quality of patient care in the primary care physicians office.

- Support the QIOs through training and tool development for change in Physician Practice based systems.
- Under physician practice our focus is to improve the quality of patient care in the primary care physicians office.

- QIG’s ROLE – continued

## Our focus under Physician Practice - Underserved Populations is to improve the statewide health of the underserved Medicare population through primary care physician offices.

Under Physician Practice, we also aim to transform the delivery of prescription drugs.

- Under Physician Practice, we also aim to transform the delivery of prescription drugs.

- QIG’s ROLE – continued

## 
Oversee 18 ESRD Networks that focus on the quality of care within dialysis facilities. 

Actively developing the Fistula First Breakthrough Initiative.

- Oversee 18 ESRD Networks that focus on the quality of care within dialysis facilities.
- Actively developing the Fistula First Breakthrough Initiative.

- QIG’s ROLE – continued

## Current Status of the Quality Improvement Program

- We are entering our Third Phase of the Program
- Phase One – Case Review
- Phase Two – Measurement –Based Quality Improvement
- Phase Three – Assisting Providers to achieve transformational change.

## What Is Transformational Change?

- Change which enables providers to achieve......
- “The Right Care for Every Person Every Time.”

## The Quality Coordination Team

## Role:

- To administer and support CMS’ Quality Council (CQC) and its workgroups
- To document and develop CMS’ vision, goals, and strategies to improve effectiveness and efficiency of care
- To develop internal/external partnerships and teams to assist CMS in achieving strategic objectives

## Strategies:

- Work through partnerships
- Publish quality measurements and other information helpful in decision-making
- Align payment system to recognize and reward effective and efficient providers
- Promote health information technology
- Support the development and spread of new technology and innovation

## CMS Quality Council Vision

- “The right care for every person every time,”  where the “right care” corresponds to the six Institute of Medicine aims
- Safety
- Effectiveness
- Efficiency
- Patient-centeredness
- Timeliness
- Equity

## Information Systems Group

## WHAT DOES ISG DO?

- Designs, Develops and Maintains the Quality Information Systems that Support the Quality Improvement Organizations, End-Stage Renal Disease Network Programs, and Agency initiatives such as hospital public reporting.  The OCSQ IT infrastructure is also utilized by CMSO’s survey and certification program.

## QIO SYSTEMS

- Standard Data Processing System (SDPS)
- QualityNet Exchange (QNET)
- CMS Abstraction and Reporting Tool (CART)
- Clinical Data Abstraction Centers (CDAC)

## WHAT IS SDPS?

- The QIO Standard Data Processing System is an information system solution that provides a common platform for users to share applications and databases to promote efficiency and increase production.
- The overall goal is to provide an IT infrastructure to support QIO operations, promote information sharing, and to support management of information.

## WHAT IS QNET?

- QualityNet Exchange is a powerful Internet site capable of providing secure access to information, data collection and file exchange utilities.
-  Advanced Security
-  Strict user identification, digital certificates & role  based access
-  File Exchange
-  Secure distribution channel for any file
-  Safe transfer of confidential or private data
-  Advanced encryption technology is transparent to users
-  Monitors Reports (who, what, when and how often)

## WHAT IS CART?

- The CMS Abstraction and Reporting Tool is a powerful software application designed to allow hospitals, QIOs, and other organizations to abstract, edit, export, and report on quality measures.  CART may be used across data collection programs, initiatives, and settings and is available at no charge.

## WHAT IS CDAC?

- The Clinical Data Abstraction Center is a professional abstraction organization CMS has contracted with to perform clinical abstractions using CMS developed IT tools such as CART.
- Clinical information is abstracted from provider medical records and transmitted to a secure QIO Data Warehouse for calculation of rates for selected performance measures.
- Information is used to assess provider performance and make quality of care improvements

## ESRD Systems

- Project to Integrate the ESRD System (CROWN)
- Vital Information System to Improve Outcomes in Nephrology (VISION)
- Standard Information Management Systems (SIMS)
- Renal Management Information System (REMIS)

## WHAT IS SIMS?

- The Standard Information Management System that supports the business processes of the ESRD Networks
- Provides communication and data exchange links among the Networks, ESRD facilities, CMS, and other segments of the renal community to support quality improvement activities
- Provides for the collection of data to enable clinical performance measurements in meeting program goals
- Provides for overall assessment of the ESRD program and its effectiveness

## WHAT IS CROWN?

- CROWN is the automated system that brings together all of CMS’s electronic data on ESRD benefits and utilization.
- CROWN is designed to improve the data quality of ESRD information and acquire data electronically at the information source
**Primary Uses:**
- Identify ESRD Patient Population
- Calculate ESRD Coverage Periods
**Clinical Uses:**
- Monitor Providers
- Local & National Quality Improvement Projects
- Research

## WHAT IS REMIS?

- The Renal Management Information System is the central component of CROWN. It is an integrated ESRD system designed to provide for the collection and correction of information about the ESRD program, its beneficiaries and the services provided
- determines Medicare coverage periods for ESRD patients and serves as the primary mechanism to store and access patient-level information
- tracks the ESRD patient population for both Medicare and non-Medicare patients

## WHAT IS VISION?

**System designed to support electronic data entry and reporting for 4,400 dialysis facilities across the United States**
**VISION will be made mandatory in next ESRD Conditions of Coverage**

## NEW TECHNOLOGY FOR TOMORROW

**Fistula First (Breakthrough Initiative)**
- Development/maintenance Data Collection Tool
- Monthly Data load & validation
- Support Fistula First Dashboard
**Reporting Tool Project**
- Design/Development of Reporting Tool to be used by CMS and ESRD Networks
- Provides both ad hoc and standard reports
**Vista Office – EHR**
- CMS and the VHA (Veterans Health Administration) are collaborating to configure VistA, the VHA’s Electronic Health Records (EHR) technology, for use in the private physician office setting.