Introduction to Medicare, Masspro, and the 8th SOW

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Introduction to Medicare, Masspro, and the 8th SOW

• Hospital Liaison Meeting
• February, 2007

This material was prepared by Masspro, the
Medicare Quality Improvement Organization for
Massachusetts, under contract with the Centers
for Medicare Medicaid Services (CMS), an agency
of the U.S. Department of Health and Human
Services. The contents presented do not
necessarily represent CMS policy.
8sow-ma-hosp-07-63 Intro-feb
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Background

• Timeline
• 1965 SSA establishes Medicare and Medicaid
• 1977 HCFA created
• 1982 Peer Review Act
• 2001 HCFA renamed CMS
• 2002 Quality Initiatives launched
• 2003 Section 501(b) Medicare Prescription
  Drug, Improvement and Modernization Act

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Overview

• Medicare
• Medicare is the national health insurance program
  for
• - People age 65 or older
• - Some people under the age of 65 with
  disabilities
• - People with end-stage renal disease
• Medicare currently provides coverage for
  approximately
• 40 million Americans

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Overview

• Quality Improvement Organizations
• Quality Improvement Organizations (QIOs) are
  charged
• with improving the effectiveness, efficiency,
  economy,
• and quality of services delivered to Medicare
• beneficiaries by
• - Protecting beneficiaries and the Trust Fund
• - Improving the quality of care received by
  Medicare
• beneficiaries

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8th SOW

• Protecting Beneficiaries
• QIOs are responsible for expeditiously addressing
  individual beneficiary issues
• - Medicare Helpline
• - Beneficiary complaints
• - Beneficiary appeals
• - EMTALA review
• Beneficiary satisfaction with process and outcome
  measured

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8th SOW

• Protecting the Trust Fund
• QIOs are responsible for ensuring proper
  inpatient fee-for-service payments (HPMP)
• - Reasonable and medically necessary
• - Provided efficiently / most appropriate
  setting
• - Consistent with medical information supplied
• - Demonstrate coding validity of information
  supplied
• - Correctly billed

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8th SOW

• Improving Quality of Care
• QIOs are responsible for assisting providers in
  developing the capacity for and achieving
  excellence in care
• - Measuring and reporting data
• - Redesigning care processes
• - Adopting health information technology
• - Transforming organizational culture

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8th SOW

• Improving Quality of Care
• Assist Nursing Homes in developing the capacity
  for and achieving excellence in care
• - Improving clinical measures
• - Implementing STAR (Setting Targets Achieving
  Results)
• - Utilizing STAR, an interactive website
• - Measuring the nursing home experience and
• reducing workforce turnover

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8th SOW

• Improving Quality of Care
• Assist Home Health Agencies in developing the
  capacity for and achieving excellence in care
• - Improving clinical measures
• - Incorporating immunization assessment
• - Implementing and/or utilizing telehealth
• - Implementing a survey tool that measures
• organizational culture change

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8th SOW

• Improving Quality of Care
• Assist Hospitals in developing the capacity for
  and achieving excellence in care
• - Improving clinical measures
• - Implementing surgical care improvement (SCIP)
• - Utilizing CPOE, barcoding, or telehealth
• - Improving safety culture (CAHs)

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8th SOW

• Improving Quality of Care
• Assist Physician Practices in developing the
  capacity for and achieving excellence in care
• - Improving claims based clinical measures
• - Adopting a care management process
• - Utilizing an electronic health record (EHR)
• - Completing cultural competency education

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8th SOW

• The right care for every person, every time

13
8th SOW

• Contact Information
• Beneficiary Issues Cheryl Lehane
• HPMP Jo-Ann Peranelli
• Nursing Home Helen Magliozzi
• Home Health Helen Magliozzi
• Hospital Jim Liljestrand
• Physician Practices Joe Holtschlag
• Firstinitiallastname_at_maqio.sdps.org

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Hospital Activities

• While quality care is provided at the patient
  level,
• it is usually measured at the hospital level
• ______________________________________________
• Case identification
• Record abstraction
• Data submission
• Validation process
• Appeal process
• Preview Report

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Hospital Activities

• Case identification
• Record abstraction
• Data submission
• ____________________________________________
• Does your list of identified cases agree with
  what
• the finance system is billing for?
• Do you perform intra and inter rater reliability?
• Are you using QIO Clinical Warehouse Feedback
  reports?

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Hospital Activities

• Validation Process
• ____________________________________________
• Expect a CDAC medical record request for every
  quarter
• you summit 6 or more cases
• If the record is not received within 30 days, the
  case is
• considered to have failed validation
• Review all measures that fail for internal and
  external
• improvement, even if overall gt 80

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Hospital Activities

• Appeal Process
• ____________________________________________
• Validation results are posted on Mondays
• A score of gt 80 is required to pass
• All mismatches can be appealed if hospital score
  lt 80, but the appeal must be completed with 10
  business days of posting

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Hospital Activities

• Preview Reports
• ____________________________________________
• Reflects data from 3rd Qtr 05 through 2nd Qtr
  06
• Contact Masspro if you think there is a
  publication error before February 15, 2007
• Data will be refreshed on Hospital Compare in
  March 2007

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Masspro Activities

• QIOs are responsible for assisting providers in
• developing the capacity for and achieving
  excellence in care
• ___________________________________________
• Listservs
• WebEx teleconferences
• Regional meetings / collaboratives
• Telephonic assistance
• On-site consultations

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Masspro Activities

• Listservs
• ____________________________________________
• Liaison
• Hospmeasures
• Surgical Infection Prevention (SIP)
• HCAHPS

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CMS Activities

• CMS provides online access to tools, articles,
  and links to resources about how to measure and
  report performance, redesign care processes,
  adopt health information technology, and
  transform organizational culture
• ____________________________________________
• Quality Net Exchange
• MedQIC

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CMS Activities

• Quality Net Exchange
• ____________________________________________
• Reports (Submission / Validation / Preview)
• Specification Manual and QUEST
• CMS Abstraction and Reporting Tool (CART)
• File Exchange and Data Upload
• Auto-Notification Lists

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CMS Activities

• MedQIC
• ____________________________________________

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