The Business Case for Quality: A CMS Perspective

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The Business Case for Quality A CMS Perspective

• at the Institute for Quality in Laboratory
  Medicine, April 29, 2005

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Vision

• The right care for every patient every time

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What is the right care?

• Safe
• Effective
• Efficient
• Patient-centered
• Timely
• Equitable
• -- Crossing the Quality Chasm
• 
  The Institute of Medicine

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Pursuing Perfection in MedicareHospital and
Office Care (all states, 24 measures)
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Scope

• This vision is transformational, not incremental
• To serve Medicare and Medicaid we must transform
  the entire healthcare system.
• Transforming the system requires, in turn,
  transforming CMS, which is often a part of the
  problem as well as a part of the solution.

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Transformational strategies

• Work through partnerships
• Publish quality measurements
• Pay-for-performance/quality
• Promote health information technology
• Create and use evidence about effectiveness

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Work through partnerships

• Includes coordination
• within CMS
• across Federal agencies
• between governmental and nongovernmental partners.

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Publish quality measurements

• Audiences are both professionals, providers, and
  purchasers and the beneficiary audience.
• We must drive out secrecy

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Pay-for-performance/quality

• Includes paying for
• prevention
• disease management
• patient-centered care.

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Promote health information technology

• Includes
• standards development and promotion
• systems development
• encouraging implementation
• payment for HIT results

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Create and use evidence about effectiveness

• CMS becomes part of post-marketing surveillance
• When effectiveness is not absolutely clear,
  coverage may be conditional on registering data
• At the same time coverage decisions become faster

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The Toolkit
LEAD
ESTABLISH ENFORCE REQUIRE-MENTS
SUPPORT STANDARD METHODS
REWARD DESIRED PERFORMANCE
PROMOTE PARTNER- SHIPS
PROVIDE TECHNICAL ASSISTANCE
STRUCTURE COVERAGE AND PAYMENTS
PROVIDE PUBLIC INFORMATION
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The Management Framework
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MANAGE PROCESS IN PARTNERSHIP WITH
STAKEHOLDERS
ESTABLISH ENFORCE STANDARDS
STRUCTURE COVERAGE AND PAYMENTS TO
IMPROVE CARE
SUPPORT STANDARD METHODS
GIVE CONSUMERS INFOR-MATION AND ASSISTANCE TO
MAKE CHOICES
PROMOTE OR CREATE COLLABORA-TIONS
AND PARTNER-SHIPS
GIVE PLANS, DOCTORS PROVIDERS
TECHNICAL ASSISTANCE
REWARD DESIRED PERFORM-ANCE
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What is the Business Case?

• CMS believes that we can only keep Medicare and
  Medicaid solvent by focusing on effective care
  and eliminating ineffective care. Thus, for us,
  quality is a survival strategy.

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Hypothesis on Cost and Quality

• 90 percent of the benefits of quality
  improvement will come from free or cost-saving
  changes.

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How can this be?

• Most of the best-studied treatments with the best
  evidence that they are effective are also
  relatively inexpensive.
• The current payment system encourages procedures
  so strongly that a net increase in their use is
  rarely needed even when current use is not
  totally appropriate.

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Does Better Care Save Money?

• Waste and rework are expensive.
• In general, better outcomes reduce downstream
  costs, although these savings often accrue to the
  insurer rather than the provider.