Medicare QIO Update

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Medicare QIO Update

• Mitzi Daffron
• Center Director, Medicare QIO Operations
• Health Care Excel

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Medicare QIOs 8th Scope of Work

• Many changes
• New settings
• New topics
• New partners
• But, the more things change, the more they remain
  the same!

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Settings

• Nursing Homes
• Home Health Agencies
• Hospitals
• Physician Practices
• Prescription Drug Plans
• Medicare Advantage Prescription Drug Plans

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Nursing Homes

• Focus on culture change
• Target setting
• Continued work on care measures
• Pressure Ulcers
• Chronic Pain
• Physical Restraints
• Depression

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Nursing Homes

• Currently working intensively with 84 nursing
  homes in Indiana
• Of the more than 500 nursing homes in Indiana,
  48 have set internal targets for pressure ulcers
  and physical restraints
• Over 50 nursing homes have collected and reported
  staff and resident surveys, as well as a baseline
  CNA turnover rate

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Home Health

• Focus on
• decreasing acute care hospitalization
• target setting
• improving the management of dyspnea
• improving immunization care processes
• culture change

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Home Health

• Twelve agencies have committed to work on
  implementation of some form of telehealth and an
  aspect of organizational culture
• Thirty-one agencies are working on two publicly
  reported outcomes, including acute care
  hospitalization, along with a measure of their
  choice
• 32 of these are working on Improvement in
  Dyspnea
• Total of 86 agencies currently working with the
  QIO on at least one measure

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Acute Care Prospective Payment System Hospitals
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Rural and/or Critical Access Hospitals (CAH)
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Physician Practice

• Support Physician Voluntary Reporting Program
  (PVRP)
• Promote improvement in preventive and
  disease-based care processes
• Recruit at least 5 of primary care practices to
  work on implementing electronic health records

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You Cant HANDLE the Paper!
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Physician Practice

• Promote physicians reporting data to clinical
  warehouse
• Assist physician practices in adopting care
  management processes
• Increase number of practices producing and using
  electronic clinical information

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Physician Practice

• Currently have 114 practices recruited that are
  planning to adopt an EHR within the next 18
  months
• PVRP has raised interest, particularly in
  hospital medical staff meetingsprogram allows
  physicians to start reporting prior to adopting
  an EHR
• Statewide activities to promote preventive care
  include a new partnership with the Area Agency on
  Aging

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Underserved Population

• Statewideimprove care for diabetes
• Statewideimprove use of preventive services
  (mammography and flu and pneumonia immunizations)
• Promote CLAS standards
• Cultural competency education

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Underserved Population

• Eight practices that serve a large underserved
  population have committed to implementing an EHR
  in the next 18 months
• Out of 50 needed, 42 providers have agreed to
  complete education through the Office of Minority
  Health Cultural Competency Program
• Key partnerships continue with the Minority
  Health Coalitions, Faith Health Initiative, and
  the Health Disparity Coalition

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Pharmacy/Part D Benefit

• Environmental scan of e-prescribing in the state
• Development and implementation of a pharmacy
  project by August 2006
• Work with Prescription Drug Plans and Medicare
  Advantage Prescription Drug Plans

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Pharmacy/Part D Benefit

• CMS-approved project in Kentucky, Indiana, and
  Ohio (in partnership) is on Improving
  Pharmaceutical Care in Long Term Care Facilities
• QIO is currently meeting with LTC pharmacies, LTC
  facilities, and prescription drug plans to
  develop a detailed project plan

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Beneficiary Protection

• Beneficiary complaints
• IOM report
• Grassley investigation

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Hospital Payment Monitoring Program

• Focused one-day stay project in Indiana
• DRGs 132, 141, 143, 182, and 183
• These 5 DRGs account for 82.3 of claims
  submitted for the 12 cardiac-mimicking DRGs
• Compliance focus area for CMS

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Pay-for-Performance
P4P is a tsunami building offshore in a sea of
stakeholder unrest, threatening those who are not
prepared. AMA 2004

• Pay-for-Performance (P4P) is here to stay
• One-sixth of the nations economy is at stake
• Providers should act now to assure they do not
  suffer from
• Reduced payment rates
• Poor public image or impaired reputation
• Reduced demand for services
• Taken from the National Committee for Quality
  Health Care

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What is Pay? What is Performance?

• Pay

• Performance

• Common performance dimensions
• Clinical quality (medical process)
• Patient outcomes
• Safety
• Satisfaction
• Cost/efficiency
• Use of IT
• Current P4P programs draw heavily on data from
  claims or administrative files to assess
  performance

Payers link some portion of a providers payments
to improvements in performance
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Focus on Common Conditions
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Private purchasers are in the lead, but Medicare
is not far behind

• Leapfrog categorizes over 90 private insurer P4P
  programs
• CMS has numerous P4P demonstrations
• State Medicaid programs are beginning P4P
  experiments
• Most P4P is regional, but national programs are
  emerging

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Questions???

• Medicare QIO Provider HelpDesk
• 1-800-300-8190
• Mitzi Daffronmdaffron_at_inqio.sdps.org