Understanding the Quality Payment Program and Opportunities for Alignment with Hospital Quality ImprovementMay 22, 2017

Candy Hanson

Sarah Brinkman

1

Objectives

• Review the basics of the Quality Payment Program (QPP)

• Identify opportunities to leverage QPP measures to support hospital quality improvement initiatives

• Understand QPP and hospital quality payment programs in the context of the Alternative Payment Model (APM) Framework

2

Alternative Payment Model Framework

3

APM Framework - Whitepaper

https://hcp-lan.org/workproducts/apm-whitepaper.pdf

4

What Are We Aiming For?

Patient Centered Care

• Quality

• Cost Effectiveness

• Patient Engagement

CMS Quality Strategy

• Better Care

• Smarter Spending

• Healthier People, Healthier Communities

Triple Aim

• Improve Patient Experience

• Improve Health of Populations

• Reduce Per Capita Cost of Health Care

5

APM Framework Principles

• Changing financial incentives is not sufficient; must empower patients as partners

• Goal of payment reform is to shift to population based payment

• Value-based incentives should reach the providers that deliver care and be intense enough to motivate investment and adoption of new approaches to delivering care

• Payment models that don’t take quality into account are not APMs

6

APM Framework At-a-Glance

7

CMS Payment Framework

8

APM Framework

9

Hospital Quality Payment

10

Value-Based Purchasing Program (VBP)

• Clinical Care

• Patient Experience

• Safety

• Efficiency

11

Readmissions Reduction Program (RRP)

30 Day Readmissions for:

• Acute Myocardial Infarction (AMI)

• Heart Failure (HF)

• Pneumonia (PN)

• Chronic Obstructive Pulmonary Disease (COPD)

• Total Hip and Total Knee Arthroplasty (THA/TKA)

• Coronary Artery Bypass Graft (CABG)

• Pneumonia (PN)

12

Hospital-Acquired Conditions Reduction Program (HAC)

• Healthcare-Associated Infections

• PSI-90

13

Quality Payment Program

14

Medicare Access and CHIP Reauthorization Act of 2015

Source: CMS Quality Payment Program – Train-The-Trainer

15

Quality Payment Program –2 Tracks for Eligible Clinicians

Merit-based Incentive Payment System

Advanced Alternative

Payment Model

Eligible for 5% *MPBPFS bonus if participating in Advanced APM through Medicare Part B

Eligible for *MPBPFS performance adjustment + high performance bonus

*Medicare Part B Physician Fee Schedule

OR

16

Replaces PQRS (Physician

Quality Reporting System)

New Category

Replaces Meaningful Use(EHR Incentive

Program)

Replaces VBM

(Value Based Modifier)

60 % 15 % 25 % 0 %

Source: CMS Quality Payment Program – Train-The-Trainer

Maximum MIPS Composite Score

100

Path 1: Merit-Based Incentive Payment System (MIPS)

17

Path 2: Advanced Alternative Payment Models (APM)

A current list of CMS and MIPS APMs is posted at QPP.CMS.GOV

2017 CMS Advanced APMs

1. Medicare Shared Savings Program (MSSP) Tracks 2, 3

2. Next Generation ACO Model

3. Comprehensive ESRD Care (CEC) (2-sided risk)

4. Oncology Care Model (OCM) (2-sided risk)

5. Comprehensive Primary Care Plus (CPC+) Model –― meets the criteria to be a Medical Home Model

Promotes quality over volume by moving away from traditional Medicare Part B Physician Fee Service

Advanced APMs  

MIPSAPMs

APMs

18

Physicians include: Doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, or optometry, and doctor of chiropractic

Physician

Nurse Practitioner

Physician Assistant

Clinical Nurse Specialist

Certified Registered Nurse Anesthetist

Voluntary Reporters

More to be added in 2019

Medicare Part B clinicians billing more than $30,000 a year AND providing care for more than 100 Medicare patients a year

Who is Exempt?Below the Low Volume Threshold in performance year

• See <100 Medicare Part B PFS patients OR• Bill <$30,000 to Medicare Part B PFS

Significantly participating in an Advanced APM• 25% of Medicare Payments paid through AAPM OR• 20% of Medicare Beneficiaries seen through AAPM

Newly enrolled in Medicare (for first year)

Non patient facing clinicians (<100 F2F visits)

MIPS Eligible Clinicians: 2017-2018

19Source: Minnesota Medical Association, Jan. 26, 2016, Janet Silversmith: Making Sense of MACRA (webinar presentation)

Medicare Incentive Payments2015-2022

20

Patient Experience

21

Consumer Assessment of Healthcare Providers & Systems

• CAHPS for MIPS vs. HCAHPS

• Episode based patient experience surveys

• Experience from the field

22

CAHPS for MIPS

1. Timely Care, Appointments & Information

2. Provider Communication

3. Provider Rating

4. Access to Specialists

5. Health Promotion & Education

6. Shared Decision Making

7. Health Status & Functional Status

8. Courteous & Helpful Staff

9. Care Coordination

10.Between-Visit Communication

11.Medication

12.Stewardship

23

HCAHPS (for VBP)

1. Communication with Nurses

2. Communication with Doctors

3. Responsiveness of Staff

4. Communication about Medications

5. Cleanliness and Quietness

6. Discharge Information

7. Care Transitions

8. Overall Rating

24

Making the Link

• Consistent use of educational materials and methods

• Use of patient portal

• Follow-up post discharge and care coordination

• Medication reconciliation

• Environment

• Courteous staff

• Patient comments

25

Antibiotic Stewardship and Healthcare-Associated Infections

26

CMS Proposed Rule for Hospitals

• https://federalregister.gov/a/2016-13925

• Federal Register Vol. 81 No. 116

• Released June 16, 2016

• Applicable to hospitals and critical access hospitals

• §482.42

• Would require establishment of an antibiotic stewardship program

27

Why Antibiotic Stewardship

• Antibiotic resistance infections

• Optimize treatment of infections

• Reduce adverse events associated with antibiotic use

• Reduce hospital rates of CDI and antibiotic resistance

• 35% of adult and 70% of pediatric C. difficile infections are community associated

28

Antibiotic Stewardship MIPS Quality Measures

• Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)

• Adult Sinusitis: Appropriate choice of Antibiotic: Amoxicillin, with or without clavulanate prescribed for patients with Acute Bacterial Sinusitis (Appropriate Use)

• Appropriate Testing for Children with Pharyngitis

• Appropriate Treatment for Children with Upper Respiratory Infection

• Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

29

Antibiotic Stewardship MIPS Improvement Activities

• Implementation of Antibiotic Stewardship Program

• Implementation of Medication Management Practice Improvements

• Use Evidence-Based Decision Aids to Support Shared Decision-Making

30

Care Coordination and Readmissions

31

Care Coordination MIPS Quality Measures

• Adult Kidney Disease: Referral to Hospice

• Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions

• Biopsy follow-up

• Cardiac Rehabilitation Patient Referral from an Outpatient Setting

• Closing the Referral Loop: Receipt of Specialist Report

• Dementia: Caregiver Education and Support

• Maternity Care: Post-Partum Follow-Up and Care Coordination

• Melanoma: Coordination of Care

32

Care Coordination MIPS Improvement Activities

• Implementation of use of specialist reports back to referring clinician or group to close referral loop

• Implementation of improvements that contribute to more timely communication of test results

• Implementation of additional activity as a result of TA for improving care coordination

• TCPI participation

• CMS partner in Patients Hospital Engagement Network

• Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination

• Regular training in care coordination

33

Care Coordination MIPS Improvement Activities

• Implementation of documentation improvements for practice/process improvements

• Implementation of practices/processes for developing regular individual care plans

• Care transition documentation practice improvements

• Care transition standard operational improvements

• Care coordination agreements that promote improvements in patient tracking across settings

• Practice improvements for bilateral exchange of patient information

• Practice improvements that engage community resources to support patient health goals

34

Population Management and Readmissions

35

Population Management and Readmissions MIPS Quality Measures

• All-cause Hospital Readmission

• Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation

• Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

• Persistence of Beta-Blocker Treatment After a Heart Attack

• Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation

36

Population ManagementMIPS Improvement Activities

• Participation in systematic anticoagulation program

• Anticoagulant management improvements

• RHC, HIS, or FQHC quality improvement activities

• Glycemic management services

• Engagement of community for health status improvement

• Use of toolsets or other resources to close healthcare disparities across communities

• Use of QCDR for feedback reports that incorporate population health

• Participation in CMMI models such as Million Hearts Campaign

• Participation in population health research

37

Population ManagementMIPS Improvement Activities cont.

• Use of QCDR data for quality improvement such as comparative analysis reports across patient populations

• Regular review practices in place on targeted patient population needs

• Population empanelment

• Chronic care and preventative care management for empaneled patients

• Implementation of methodologies for improvements in longitudinal care management for high risk patients

• Implementation of episodic care management practice improvements

• Implementation of medication management practice improvements

38

Moving Towards Population Health

39

Visual that depicts a population of patients surrounded by settings of care (hospital, clinic, nursing home, home health, pharmacy, etc.)

CLINIC

40

Questions?

Candy Hanson, BSN, PHN, LHIT-HP

Program Manager

chanson@stratishealth.org

Sarah Brinkman, MBA, MA, CPHQ

Program Manager

sbrinkman@stratishealth.org

www.lsqin.org

This material was prepared by Lake Superior QualityInnovation Network, under contract with the Centers forMedicare & Medicaid Services (CMS), an agency of theU.S. Department of Health and Human Services. Thematerials do not necessarily reflect CMS policy.11SOW-D1-17-83 051917