Des Moines University - A Distinctive System of Healthcare Delivery II Lecture Notes PDF

A Distinctive System of Health Care Delivery II Presenter: Joshua Pearson, EdD, MHA, CPHQ, CHFP Lecture overview Quality and the Quintuple Aim Evidence-based practice guidelines USPSTF Quality Measure Reporting Programs NCQA/HEDIS National Quality Foru...

A Distinctive System of Health Care Delivery II Presenter: Joshua Pearson, EdD, MHA, CPHQ, CHFP Lecture overview Quality and the Quintuple Aim Evidence-based practice guidelines USPSTF Quality Measure Reporting Programs NCQA/HEDIS National Quality Forum (NQF) Healthy People 2020 Hospital Reporting Value-Based Programs and Initiatives Comprehensive Primary Care Plus (CPC+) Promoting Interoperability Medicare Shared Savings Program (MSSP) ACO REACH Model 2 Learning outcome covered in this lecture Recognize the basic measures of health status and health services. 3 Quality and the Quintuple Aim 4 Key events in the health care quality movement Year Event 1910 Ernest Codman proposes hospital standardization; Flexner report –> medical school standards 1950 Donabedian framework for patient care evaluation (structure, process, outcomes) 1951 Joint Commission on Accreditation of Hospitals founded for QA standards 1960 Japan adopts Deming management philosophy 1970 PDCA/PDSA cycles emerge 1996 Health Insurance Portability and Accountability Act (HIPAA) enacted 1999 Institute of Medicine releases To Err is Human 2000 Many changes – Six Sigma, Lean Enterprise, P4P and patient safety improvements 2001 Committee on Quality of Health Care in America released Crossing the Quality Chasm 2002 Medicare begins quality measure and reporting initiatives 2009 HITECH established (including Meaningful Use) 2010-2011 Patient Protection and Affordable Care Act; HHS National Quality Strategy Pelletier, L.R. & Beaudin, C.L. (Eds.). (2018). HQ solutions: Resource for the healthcare quality professional (4th ed.) Wolters Kluwer. 5 Evidence-based practice (EBP) EBP is a perspective built upon evidence-based medicine (EBM) to better recognize the role of all disciplines involved in the delivery of services. EBP is defined as, “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients”. EBP is further broken down into two core research areas: clinical research and health services research. Clinical research examines the impact of interventions on patient outcomes Health services research evaluates the health system at the micro and macro levels. Pelletier, L.R. & Beaudin, C.L. (Eds.). (2018). HQ solutions: Resource for the healthcare quality professional (4th ed.) Wolters Kluwer. 6 Evidence-based practice (EBP) There are many common sources which produce EBP guidelines and quality measures: Agency for Healthcare Research and Quality (AHRQ) Cochrane Specialty professional associations and societies (e.g. American Cardiology Association) The Leapfrog Group National Quality Forum (NQF) Pelletier, L.R. & Beaudin, C.L. (Eds.). (2018). HQ solutions: Resource for the healthcare quality professional (4th ed.) Wolters Kluwer. 7 Evidence-based practice (EBP) The U.S Preventive Services Task Force (USPSTF) is frequently used to support the rating of EBP. In alignment with the National Academy of Medicine, the USPSTF develops recommendations for ensuring EBP guidelines are “high quality, methodologically sound, scientifically defensible, reproducible, and unbiased” These recommendations are then published online 8 USPSTF Level of Certainty Regarding Net Benefit Level of Certainty Description The available evidence usually includes consistent results from well-designed, well- conducted studies in representative primary care populations. These studies assess the High effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies. The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by factors. As more Moderate information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion. The available evidence in insufficient to assess effects on health outcomes. Evidence is insufficient because of: The limited number or size of studies. Low Important flaws in study design or methods. See link below for other factors More information may allow estimation of effects on health outcomes. U.S. Preventive Services Task Force (n.d.). Grade definitions. 9 https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/grade-definitions USPSTF Grade Definitions Grade Definition Suggestions for Practice The USPSTF recommends this service. There is high certainty that the A Offer or provide this service. net benefit is substantial. The USPSTF recommends this service. There is high certainty that the B net benefit is moderate or there is a moderate certainty that the net Offer or provide this service. benefit is moderate to substantial. The USPSTF recommends selectively offering or providing this service Offer or provide this service for selected C to individual patients based on professional judgment and patient patients depending on individual preferences. circumstances. D The USPSTF recommends against this service. Discourage the use of this service. Read the clinical considerations section The USPSTF concludes that the current evidence is insufficient to of the USPSTF Recommendation assess the balance of benefits and harms of the service. Evidence is Statement. If the service is offered, I lacking, of poor quality, or conflicting, and the balance of benefits and patients should understand the harms cannot be determined. uncertainty about the balance of benefits and harms. U.S. Preventive Services Task Force (n.d.). Grade definitions. 10 https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/grade-definitions Quintuple Aim The Quintuple Aim serves as the primary model for developing high- quality health systems. Improving Health Equity population Originally drafted as the Triple Aim, health the model was expanded to recognize the importance Enhancing addressing burnout in the Workforce well-being the care workforce and supporting health experience equity. Reducing These five domains feed into the costs quality measure sets we’ll review throughout the lecture. Nundy, S., Cooper, L. A., & Mate, K. S. (2022). The quintuple aim for health care improvement: A new imperative to advance health equity. JAMA, 327(6), 521-522. https://doi.org/10.1001/jama.2021.25181 11 Quality Measure Reporting Programs 12 National Committee for Quality Assurance (NCQA) The National Committee for Quality Assurance (NCQA) is one of the leading entities supporting quality measure development and assessment in our health system today. NCQA supports various efforts including: Certification of the Patient-Centered Medical Home (PCMH) Health plan accreditation Development and support of Healthcare Effectiveness Data and Information Set (HEDIS) measures. HEDIS measures are primarily used for standardized performance measurement to compare/contrast quality performance between entities. 13 National Committee for Quality Assurance (NCQA) HEDIS includes more than 90 measures which cover six domains: Effectiveness of Care Access/Availability of Care Experience of Care Utilization and Risk Adjusted Utilization Health Plan Descriptive Information Measures Reported Using Electronic Clinical Data Systems For providers enrolled in value-based care contracts with health plans, oftentimes there is a requirement to report performance in these quality measures to support HEDIS reporting efforts at the health plan level. National Committee for Quality Assurance (n.d.). HEDIS measures and technical resources. https://www.ncqa.org/hedis/measures/ 14 National Committee for Quality Assurance (NCQA) Measure Category Example Measures Childhood Immunization Status Breast Cancer Screening Effectiveness of Care Cervical Cancer Screening Controlling High Blood Pressure Comprehensive Diabetes Care Adult Dental Visit Access/Availability of Care Prenatal and Postpartum Care Access to Preventive/Ambulatory Health Services Child and Adolescent Well-Care Visits Utilization Mental Health Utilization Antibiotic Utilization Hospitalization Following Discharge from a Skilled Nursing Facility Risk Adjusted Utilization Acute Hospital Utilization Emergency Department Utilization National Committee for Quality Assurance (n.d.). HEDIS measures and technical resources. https://www.ncqa.org/hedis/measures/ 15 National Quality Forum (NQF) The National Quality Forum (NQF) provides endorsement for healthcare quality measures across a wide range of categories: Cost and resource use Efficiency Outcomes Processes Structure Once a measure has been endorsed by the NQF, providers, hospitals, health systems, and government agencies can use the measure for public reporting and/or quality improvement. National Quality Forum (n.d.). Measuring performance. https://www.qualityforum.org/measuring_performance/measuring_performance.aspx 16 National Quality Forum (NQF) National Quality Forum (n.d.). Measuring performance. https://www.qualityforum.org/measuring_performance/measuring_performance.aspx 17 Healthy People 2030 The Healthy People 2030 program contains 359 measurable objectives that are centered around five guiding principles: Attain healthy, thriving lives and well-being, free of preventable disease, disability, injury and premature death. Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all. Create social, physical, and economic environments that promote attaining full potential for health and well-being for all. Promote healthy development, healthy behaviors and well-being across all life stages. Engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all. Office of Disease Prevention and Health Promotion (n.d.). Healthy People 2030 framework. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework 18 Hospital Reporting Programs Since 2002, CMS has been reporting hospital quality data through the Hospital Quality Alliance (HQA). In the many years since, hospital quality reporting has grown to become more robust and now includes over 150 measures spanning across both inpatient and outpatient reporting. The publicly-available Care Compare website allows patients to easily view hospital performance across the wide range of reported measures. Centers for Medicare & Medicaid Services (n.d.). Hospital compare. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalCompare 19 Hospital Reporting Programs Through Care Compare, CMS has aggregated hospital quality measures covering metrics such as: Process of care measures – showing whether or not the hospital gives recommended care based on guidelines, standards of care or practice parameters. Outcome measures showing the results of care. Patient experience of care measures using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Measures are typically reported with national and state average benchmarks to assist with comparison. Centers for Medicare & Medicaid Services (n.d.). Hospital compare. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalCompare 20 Hospital Reporting Programs Quality measures reported typically include: Timely & effective care Sepsis care; heart attack care; emergency department care Complications & deaths Serious complication rates; infections; death rates Unplanned hospital visits Unplanned visits by medical condition; by procedure Psychiatric unit services Substance use treatment; patient safety; follow up care Payment & value of care Medicare spending per beneficiary; value of care by health issue Centers for Medicare & Medicaid Services (n.d.). Hospital compare. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalCompare 21 Value-Based Programs and Initiatives 22 Value-Based Programs CMS is currently the largest payer of healthcare services in the United States – thus, many innovative models exist which strive to improve quality, reduce costs and improve the patient experience. A few of the programs we’ll cover include: Comprehensive Primary Care Plus (CPC+) Promoting Interoperability Medicare Shared Savings Program (MSSP) ACO REACH Model 23 Comprehensive Primary Care Plus (CPC+) CPC+ was developed as an innovative primary care medical home model which provides additional financial resources to invest in innovative solutions for supporting primary care. Payment elements included: Care Management Fees (CMFs) to support non-visit-based care. Performance-based incentive payments based on organizational performance. Payment under Medicare FFS Centers for Medicare & Medicaid Services (n.d.). Comprehensive Primary Care Plus. https://innovation.cms.gov/innovation-models/comprehensive- primary-care-plus 24 Comprehensive Primary Care Plus (CPC+) Performance measurement tends to revolve around three domains: Reporting performance on two eCQMs (currently focuses on A1c control for diabetic patients and controlling high blood pressure). Patient experience of care survey measures Claims-based utilization measures Annual evaluation reports are posted online to provide insight into organizational and program performance: https://innovation.cms.gov/innovation-models/comprehensive-primary- care-plus Centers for Medicare & Medicaid Services (n.d.). Comprehensive Primary Care Plus. https://innovation.cms.gov/innovation-models/comprehensive-primary-care-plus 25 Promoting Interoperability The Promoting Interoperability program (formerly known as Meaningful Use) encourages providers to adopt and meaningfully use EHR technology. Promoting Interoperability now lives under the larger Merit-based Incentive Payment System (MIPS) model. Measures focus on integrating technology into operations. Centers for Medicare & Medicaid Services (n.d.). 2022 Medicare Promoting Interoperability program requirements. https://www.cms.gov/regulations-guidance/promoting-interoperability/2022-medicare-promoting-interoperability-program-requirements 26 Promoting Interoperability All organizations must use a certified electronic health record technology (CEHRT) to qualify for Promoting Interoperability. Measures assess organizational performance in areas such as: Electronic prescribing Health information exchange Provider to patient exchange Public health and clinical data exchange Public health reporting includes: syndromic surveillance reporting, immunization registry reporting, electronic case reporting, and electronic reportable laboratory result reporting. Centers for Medicare & Medicaid Services (n.d.). 2022 Medicare Promoting Interoperability program requirements. https://www.cms.gov/regulations-guidance/promoting-interoperability/2022-medicare-promoting-interoperability-program-requirements 27 Medicare Shared Savings Program (MSSP) The Medicare Shared Savings Program (MSSP) was developed to create shared accountability for quality, cost, and experience of care rendered to Medicare beneficiaries. Accountable Care Organizations (ACOs) are responsible for their assigned Medicare beneficiary population. Different tracks exist with differing levels of risk – those organizations willing to enter higher shared-risk arrangements have opportunities to earn larger shared savings. Centers for Medicare & Medicaid Services (n.d.). Shared Savings Program. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/about 28 Medicare Shared Savings Program (MSSP) Centers for Medicare & Medicaid Services (n.d.). Shared Savings Program. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/about 29 Medicare Shared Savings Program (MSSP) ACO performance is assessed across a variety of different measures: Cost benchmarking is used for approximating total cost per beneficiary. Coding (e.g. Hierarchical Condition Category (HCC) coding) assists with adjusting cost benchmarks. Patient satisfaction surveys are used to ensure ACOs are meeting patient needs. A variety of quality measures are used for annual reporting: Diabetes: Hemoglobin A1c (poor control) Preventive screening and follow-up for depression Controlling high blood pressure Falls risk screening Cancer screenings (colorectal, breast) Tobacco use and cessation Centers for Medicare & Medicaid Services (n.d.). Shared Savings Program. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/about 30 ACO REACH Model Building on the ACO model, the Biden-Harris Administration has redesigned the program to create the ACO REACH model. ACO REACH model differs from other ACO programs in some key measurable areas: Promotion of health equity – requirement to develop robust health equity plans to identify unserved communities and implement initiatives to measurably reduce health disparities. Similar to the CHNA requirements as implemented by the ACA Continued growth in provider-led organizations engaging in risk-based models – ACO REACH models must have at least 75% control of the ACO’s governing body held by participating providers. Protecting beneficiaries - Increased participant vetting and increased transparency Centers for Medicare & Medicaid Services (n.d.). ACO REACH. https://innovation.cms.gov/innovation-models/aco-reach 31 Looking ahead to the next lecture… The next lecture in this series will focus on recognizing the forces that are likely to shape the future of health care delivery in the 21st century. We’ll also explore some of the underlying contributing/causal factors resulting in resistance to reform. 32 Questions? Feel free to reach out! Thank you! Dr. Joshua Pearson, EdD, MHA, CPHQ, CHFP [email protected] References Centers for Medicare & Medicaid Services (n.d.). 2022 Medicare Promoting Interoperability program requirements. https://www.cms.gov/regulations-guidance/promoting-interoperability/2022-medicare-promoting-interoperability-program- requirements Centers for Medicare & Medicaid Services (n.d.). ACO REACH. https://innovation.cms.gov/innovation-models/aco-reach Centers for Medicare & Medicaid Services (n.d.). Comprehensive Primary Care Plus. https://innovation.cms.gov/innovation- models/comprehensive-primary-care-plus Centers for Medicare & Medicaid Services (n.d.). Hospital compare. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalCompare Centers for Medicare & Medicaid Services (n.d.). Shared Savings Program. https://www.cms.gov/Medicare/Medicare-Fee-for- Service-Payment/sharedsavingsprogram/about Pelletier, L.R. & Beaudin, C.L. (Eds.). (2018). HQ solutions: Resource for the healthcare quality professional (4th ed.) Wolters Kluwer. U.S. Preventive Services Task Force (n.d.). Grade definitions. https://www.uspreventiveservicestaskforce.org/uspstf/about- uspstf/methods-and-processes/grade-definitions 34 References (cont.) National Committee for Quality Assurance (n.d.). HEDIS measures and technical resources. https://www.ncqa.org/hedis/measures/ National Quality Forum (n.d.). Measuring performance. https://www.qualityforum.org/measuring_performance/measuring_performance.aspx Nundy, S., Cooper, L. A., & Mate, K. S. (2022). The quintuple aim for health care improvement: A new imperative to advance health equity. JAMA, 327(6), 521-522. https://doi.org/10.1001/jama.2021.25181 Office of Disease Prevention and Health Promotion (n.d.). Healthy People 2020 - General health status. https://www.healthypeople.gov/2020/about/foundation-health-measures/General-Health-Status Office of Disease Prevention and Health Promotion (n.d.). Healthy People 2030 framework. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework 35