CMS at HIMSS 2015: Day Two’s Presentations

Here are a few summaries from Day Two at HIMSS 2015.

The Intersection of Quality and Innovation at CMS

By Dr. Patrick Conway, CMS Deputy Administrator for Innovation & Quality and Chief Medical Officer

As the single largest payer for healthcare in the U.S., CMS is well positioned to study innovative healthcare payment and service delivery models that improve the experience of care, improve the health of populations, and reduce per capita healthcare costs. In this presentation, Dr. Patrick Conway, CMS Deputy Administrator for Innovation & Quality and Chief Medical Officer, discussed how CMS envisions health IT as a key component of healthcare transformation as well as the steps that the agency is taking to ensure health IT enables the delivery of high quality care.

For me, the key thing that stood out in this presentation is that CMS is taking a very comprehensive approach and is making much more progress and realizing more success than most people realize. It is very exciting to see. And, I am very confident it will drive a lot of change in healthcare over the next few years.

The CMS vision for improving healthcare delivery can be summed up in three key words: better, smarter, and healthier. They are in pursuit of finding better ways to deliver care, pay providers and distribute information. They clearly understand that it is their role and responsibility to help lead healthcare transformation, and they fully intend to do so. However, they also realize they cannot go it alone. Patients, providers, government, and business all stand to benefit if they get it right, and therefore, they view this as a shared responsibility that calls for a deeper partnership, especially with provider organizations.

As they build on their public-private partnerships, the CMS goal is to migrate healthcare from an unsustainable historical state characterized by being provider centric, fragmented and transaction based to a more sustainable and evolving future state that is characterized by being patient-centric, coordinated and value-based. The systems and policies they are focusing on to achieve this goal are value-based purchasing, accountable care organizations (ACOs), bundled payments, medical homes and transparency of quality and cost outcomes.

CMS believes healthcare delivery system reform requires a focus on the way providers are paid, how care is delivered and how information is distributed. Provider payment reform is focused on creating value-based payment system models that are sustainable and scalable. Care delivery reform is centered on encouraging the integration and coordination of clinical and support services, and patient engagement through shared accountability and improving population health. Improving information distribution relates to bringing electronic health information to the point of care for meaningful use and creating transparency for quality and cost information.

CMS has adopted a framework that categorizes provider payments into four categories: 1) fee-for-service with no link to value, 2) fee-for-service that is linked to value, 3) alternative payment models built on a fee-for-service architecture and 4) population-based payment models. This is summarized in the following table.

Category 1
FFS not linked to value
Category 2
FFS linked to value
Category 3
Alternative payment models built on FFS
Category 4
Population-based payment
  • Payments based on volume of services and not linked to quality or efficiency
  • At least a portion of payments vary based on the quality or efficiency of care delivery
  • Some payment is linked to the effective management of a population or an episode of care
  • Payments still triggered by the delivery of services, but opportunities for shared savings or 2-sided risk
  • Payment is not directly triggered by service delivery so volume is not linked to payment
  • Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g., ≥ 1 year)
Medicare FFS examples
  • Limited Medicare FFS
  • Majority of Medicare payments now are linked to quality
  • Hospital value-based purchasing
  • Physician Value Modifier program
  • Readmissions, Hospital Acquired Condition Reduction program
  • ACOs
  • Medical Homes
  • Bundled payments
  • Comprehensive PCP initiative
  • Comprehensive ESRD
  • Medicare-Medicaid Financial alignment Initiative FFS model
  • Eligible Pioneer ACO in years 3-5
  • Maryland hospitals model

In January 2015, HHS announced goals for value-based provider payments within the Medicare FFS system. These are summarized in the table below.

  • 30% of Medicare payments are tied to quality or value through alternative payment models (categories 3-4) by the end of 2016, and 50% by the end of 2018
  • 85% of all Medicare FFS payments are tied to quality or value (categories 2-4) by the end of 2016, and 90% by the end of 2018
  • Set internal goals for HHS
  • Invite private sector payers and Medicaid to match or exceed HHS goals
  • Consumers
  • Business/Purchasers
  • Payers
  • Providers
  • State partners (including Medicaid programs)
Next Steps
  • Testing of new models and expansion of existing models is critical to reaching incentive goals
  • Creation of the Health Care Payment Learning and Action Networks to align incentives and identify best practices

The CMS Center for Innovation has implemented several strategies to align with the private sector and states. These strategies include the following:

  • CMS is incentivizing healthcare providers through Pioneer ACO agreements that require 50% of the ACO’s business to be in value-based contracts by the end of the second program year.
  • It has convened payers in seven markets in the Comprehensive Primary Care Plan.
  • It has convened payers, providers, employers, consumers and public partners through the Health Care Payment Learning and Action Network.
  • The Partnership for Patients initiative is a public-private partnership working to improve the quality, safety and affordability of healthcare for all Americans.
  • The Bundled Payments for Care Improvement initiative is an innovative new payment model.
  • CMS is partnering with states with State Innovation Models with funds to award to states that implement models that realize comprehensive delivery system reform. An example of such a model is the Maryland All-Payer Model which is designed to test the effectiveness of an all-payer rate system for hospital payments.
  • The Transforming Clinical Practice Initiative is designed to help clinicians achieve large-scale health transformation.

Each of these strategies and their accomplishments to date were reviewed in this presentation.

The Pioneer ACOs were designed for organizations with experience in coordinated care and ACO-like contracts. Participation in Medicare ACOs is growing rapidly. 424 ACOs have been established in the Medicare Shared Savings Program (MSSP) and Pioneer ACOs covering 7.8 million beneficiaries. This includes 89 new ACOs covering 1.6 M beneficiaries assigned to the shared savings program in 2015.

In their first two performance years, Pioneer ACOs provided higher quality and lower cost care to Medicare beneficiaries. They have demonstrated improved quality outcomes including:

  • They outperformed published benchmarks for quality in 15 of 15 clinical quality measures
  • Mean quality scores for 2013 were 85.2% compared to 71.8% in 2012
  • Average quality performance scores improved for 28 of 33 (85%) quality measures

Pioneer ACOs also generated savings for the second year in a row. This included $384 M in program savings over two years and average savings per ACO of $4.2 M in the second year compared to $2.7 M in the first year.

The CMS Comprehensive Primary Care (CPC) program convenes Medicaid and commercial payers to support primary care practice transformation through enhanced, non-visit-based payments, data feedback and learning systems. Across all seven regions, CPC reduced Medicare Part A and B expenditures per beneficiary by $14 (or 2%). Reductions appear to be driven by initiative-wide impacts on hospitalizations, ED visits and unplanned 30-day readmissions.

To help achieve better care, smarter spending, and healthier people, HHS is working in concert with their partners in the private, public, and non-profit sectors to transform the nation’s health system to emphasize value over volume. HHS has set a goal of tying 30 percent of Medicare fee-for-service payments to quality or value through alternative payment models by 2016 and 50 percent by 2018. HHS has also set a goal of tying 85 percent of all Medicare fee-for-service to quality or value by 2016 and 90 percent by 2018. To support these efforts, HHS has launched the Health Care Payment Learning and Action Network to help advance the work being done across sectors to increase the adoption of value-based payments and alternative payment models.

The graphic below illustrates the targets CMS has set for the percentage of payments in ‘FFS linked to quality’ and ‘alternative payment models by 2016 and 2018. It illustrates a dramatic shift between 2011 and 2014, and an even more dramatic shift by 2018.

Physicians, nurses, hospitals, employers, patients, and their advocates, and the federal and State governments have joined together to form the Partnership for Patients. The Partnership for Patients and its over 3,700 participating hospitals are focused on making hospital care safer, more reliable, and less costly through the achievement of two goals:

  • Making Care Safer. By the end of 2014, the goal is that preventable hospital-acquired conditions would decrease by 40% compared to 2010.
  • Improving Care Transitions. By the end of 2014, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010.

The Hospital Engagement Networks hospitals across the country are critical partners in this work. Through the Partnership for Patients, 26 State, regional, national and hospital system organizations serve as Hospital Engagement Networks. These organizations help identify solutions already working to reduce hospital-acquired conditions, and work to spread them to other hospitals and healthcare providers.

The Partnership for patients has contributed to both quality improvement and cost savings. Data shows a 17% reduction in hospital acquired conditions across measures from 2010 to 2013 resulting in 50,000 lives saved, 1.3 M patient harm events avoided and $12 B in cost savings. Many areas of harm are dropping dramatically and patient safety is clearly improving. The following graphic shows changes in some key metrics.

Leading Indicators (change from 2010 to 2013)
Ventilator associated pneumonia Early elective delivery Central line associated blood stream infections Venous thromboembolic complications Readmissions
62.4% ê 70.4% ê 12.3% ê 14.2% ê 7.3% ê

The Bundled Payments for Care Improvement initiative model targets 48 conditions with a single payment for an episode of care. It incentivizes providers to take accountability for both the cost and quality of care. There are four models.

  • Model 1 – Retrospective acute care hospital stay only.
  • Model 2 – Retrospective acute care hospital stay plus post-acute care.
  • Model 3 – Retrospective post-acute care only.
  • Model 4 – Acute care hospital stay only.

Bundled payments for care improvement is also growing rapidly. There were 102 awardees and 167 episode initiators in phase 2 as of January 2015. 85 new awardees and 373 new episode initiators entered phase 2 as of April 2015.

With the State Innovation Models, CMS is testing the ability of state governments to utilize policy and regulatory levers to accelerate healthcare transformation. Primary objectives of the program include improving the quality of care delivered, improving population health, increasing cost efficiency and expanding value-based payments. The grants have been awarded in two rounds. There were six Round 1 model test states, eleven Round 2 model test states and twenty-one Round 2 design states. Round 1 states are testing and Round 2 states are designing and implementing comprehensive reform plans.

Maryland is testing an innovative all-payer payment model and is the only all-payer hospital rate regulation system. All-payer rate setting is a price setting mechanism wherein all third parties pay the same price for services at a given hospital. This model is testing whether effective accountability for both cost and quality care be achieved within an all-payer system based upon per capita total hospital cost growth. Quality of care is being measured through readmissions, hospital acquired infections and population health. The model was initiated in January 2014 for a five-year test period. All 46 Maryland hospitals have signed agreements and began moving into all-payer global budgets in July 2014. 95% of Maryland hospital revenue will be in global budgets.

The Transforming Clinical Practice Initiative is designed to support 150,000 clinician practices over the next four years in sharing, adapting and further developing their comprehensive quality improvement strategies (e.g., improve quality, lower costs and enter alternative payment models). The initiative is one part of a strategy advanced by the Affordable Care Act to strengthen the quality of patient care and spend healthcare dollars more wisely. Two network systems will be created.

  • Practice Transformation Networks: peer-based learning networks designed to coach, mentor and assist.
  • Support and Alignment Networks: provides a system for utilizing professional association and public-private partnerships to drive improvement.

Going forward, the CMS Innovation Center plans to focus on implementation models, monitoring and optimizing results of strategies, evaluation and scaling of strategies, integrating innovation across CMS, and portfolio analysis and launching new models to round out their portfolio. The next generation ACO model will offer new opportunities in accountable care including more practical financial targets, greater opportunities to coordinate care and high quality standards consistent with other Medicare programs and models. The new model seeks to test how strong financial incentives for ACOs can improve outcomes and reduce expenditures for Medicare beneficiaries. The model principles include:

  • Protect Medicare FFS beneficiaries freedom of choice
  • Create a financial model with long-term sustainability
  • Use prospectively set benchmarks that reward quality, rewards both attainment and improvement of efficiency, and ultimately transitions away from updating benchmarks based on an ACO’s recent expenditures.
  • Offer benefit enhancements that directly improve patient experience and support coordinated care (e.g., telehealth)
  • Allow beneficiaries a choice in their alignment with the ACO
  • Smooth ACO cash flow and improve investment capabilities through alternative payment mechanisms (e.g., population-based payments)

Transforming Process Improvements through RTLS Data

By Sarah Kadish, Director Performance Measurement and Improvement, Dana Farber Cancer Institute, Harvard University

Real-time locating systems (RTLS) are used to automatically identify and track the location of objects or people in real time, usually within a building or other contained area. Wireless RTLS tags are attached to objects or worn by people, and in most RTLS, fixed reference points receive wireless signals from tags to determine their location. Examples of real-time locating systems include tracking automobiles through an assembly line, locating pallets of merchandise in a warehouse, or finding medical equipment in a hospital.

The data accumulated in an organization’s Real Time Locating System (RTLS) are a significant institutional asset with vast potential for widespread use. Leveraging the massive dataset requires a tiered approach to collecting, extracting, analyzing, and disseminating reports. This presentation examined one organization’s efforts to unlock this source of data to derive insights into resource utilization and drive innovations in operations.

The Dana-Farber Cancer Institute is part of the Harvard hospital system and has a singular focus on conquering cancer, with an equal commitment to patient care and research. The opening of the Yawkey Center for Cancer Care in 2011 created a unique opportunity to use technology to improve operations. The decision was made to explore RTLS to improve resource utilization, communication and management of patient visits. A method was needed to measure resource usage (e.g. exam rooms, infusion chairs, phlebotomy chairs, etc.) and to measure, monitor and communicate various patient wait times. In addition, due to the distributed clinic layout of the new building, staff would need an efficient means of knowing room availability. The new building was well wired when it was built and the goal was to ultimately achieve “chair level accuracy” (e.g., what patient is in what chair?).

Patient clinic flows and staff workflows were carefully mapped and analyzed. Patients and staff were provided radio frequency identification (RFID) enabled badges. Badges of different types were assigned to patients, family and other related people (e.g., friends). Staff badge types varied by role and responsibility (physician, nurse, therapist, manager, coordinator, assistant, etc.). Equipment badges varied depending on the type of equipment and location.

The team utilized the data warehouse and reporting team to support report creation and dissemination. The data warehouse provided the opportunity to integrate with other data sources, such as the scheduling and the chemotherapy ordering entry system.

This approach resulted in the generation of large amounts of data. Dana Farber experiences 1,000 adult patient visits daily resulting in 1.4 million rows being added daily to the tracking log and 46,000 rows added daily to the events table. Currently, 18,094,595 rows are in the events table and 188,682,147 rows are in the tracking log.

There are different levels and types of data. Live data supports clinic operations with real time information to estimate and communicate wait times to patients, to dynamically allocate exam rooms, and to track and communicate downstream delays. Periodic data is used to monitor key performance indicators and trends over time such as wait time by floor, day of week, disease center, etc. Results may drive changes in clinic schedule templates and behaviors. Ad hoc data and reports are used to answer questions related to targeted improvement areas. These could include things like improvement of wait time based on interventions, comparing actual versus scheduled durations for chemotherapy to improve accuracy and consult room utilization.

Several examples of how data was used were provided during the presentation.

  • Lab services wait time was studied. Over 400 patients per day have appointments in lab services at Dana Farber. Waiting rooms are crowded despite short wait times. The improvement team created an algorithm in the RTLS analytical system to estimate wait times. Patients were subsequently informed of the estimated wait times. As the graphs below illustrate, the majority of patients were informed once the system was in place and patient satisfaction subsequently dramatically improved.

  • RTLS data was used to dynamically assign clinic rooms. Dynamically assigning rooms required a decision-support tool to prioritize patients into exam rooms. RTLS data was used to create a computer simulation model to assess the feasibility of doing this. Once feasibility was established, a tool was created using RTLS data that shows current status of patients in queue, sorts the results, and color-codes the results based on logic. When the system was put into use, it resulted in more efficient use of rooms, improved productivity and higher patient satisfaction. During peak periods, when rooms are most constrained, they were able to decrease wait time by over 5 minutes.
  • A leadership dashboard was created to allow leadership to assess clinic efficiency and observe trends by building floor as illustrated in the graph below.
  • A report was created to assess appointment duration versus the amount of time scheduled. Accurate appointment durations ensure appropriate staffing ratios to the daily caseload and maximizes scarce resources. Median observed appointment durations were statistically different than the suggested duration. This revealed areas for quality improvement initiatives. Further investigations are ongoing to elucidate factors that cause variation in appointment duration.

Going forward the team plans to dynamically map the flow of patients, people and supplies to further improve operational performance.

Driving Health IT ROI with Data Analytics

By Ken Congdon, Editor in Chief, Health IT Outcomes

With the launch of HITECH, it was predicted that health IT would result in $100 B in healthcare savings annually and dramatically improve patient outcomes. After investing billions in programs to promote health IT adoption, there is little demonstrated ROI to date. The Wall Street Journal has claimed that HIT savings are all hype. Members of Senate are calling for major overhaul to Meaningful use program. A 2013 study from the University of Michigan School of Public Health shows that only 27% of health providers show positive ROI on EHR investment and the average physician lost $43,000 over 5 years.

This raises the question of whether the health IT initiative is failing. The answer to this question is “no,” but to believe that one has to understand where the ROI will come from in the nation’s investment in health IT. Implementing an EHR is a necessary first step to creating electronic infrastructure. Digitizing medical information captures and makes data available for information management. Thus, an EHR provides the foundation for an ROI by providing necessary data for analytics and improvement. Ultimately, the ROI will come from value production (e.g., higher quality, less harm, less waste and lower costs) and effective population health management (PHM).

This presentation highlighted three key elements to PHM.

  • Information-Powered Clinical Decision Making.
    • Use data to drive improvement and deliver information-powered effective care to patients in real time
    • Use integrated data from all necessary source systems to provide reliable and timely data to decision-makers
    • Integrated data and effective information sharing and transparency
  • A primary care-based care model
    • Creation of patient-centered medical homes (PCMH)
    • Build multi-disciplinary clinical teams to incorporate care managers, RNs, PAs, etc.
  • Patient engagement and community integration
    • Build connections across the care continuum in all care venues (e.g. hospitals, group practices, clinics, long-term care, home health, social services, mental health, etc.)
    • Overcome non-clinical barriers to maximize outcomes (e.g. financial, social, etc.)

The presentation highlighted the following benefits of PHM:

  • Alerts providers to patient population trends (e.g. super-utilizers, at-risk patients, no shows, etc.)
  • Gives providers the information necessary for action/intervention
  • Helps providers influence patient behavioral change
  • Improved patient outcomes
  • Improved patient satisfaction and experience
  • Reduced financial strain on the healthcare system
    • Adherence to standard evidence-based best practice care plans and pathways eliminating inappropriate variation
    • Reduced hospital readmissions, ED and office visits
    • Less waste
    • Lower costs

The presenter argued that the ultimate end game would be predictive analytics and personalized care. Predictive analytics is the process of learning from historical data to make predictions about the future. In healthcare, well-designed algorithms will be able to improve the odds that a certain treatment will result in a favorable outcome for a specific patient (based on condition, demographic, socioeconomic, and even genetic profile). This will enable highly tailored personalized care plans that will improve long-term health outcomes and population health.

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