The Proposed QIO 9th Statement of Work: A Content Overview

1
The Proposed QIO 9th Statement of Work A
Content Overview

• Roland A. Grieb, MD, MHSA
• Health Care Excel
• Medical Director, Indiana Medicare Quality
  Improvement Organization (QIO)
• May 1, 2008

2
Information for this presentation was taken from
the following conference materials. Centers for
Medicare Medicaid Services (CMS)  Quality
Improvement Organization (QIO) 9th Statement of
Work (SOW) Pre-Proposal Conference January 28,
2008 CMS 7500 Security Boulevard Baltimore,
Maryland
3
Objectives

• Review the background and history leading to the
  9th SOW
• Recognize the changes in the framework of
  accountability for QIOs in the 9th SOW
• Discuss the goals and themes for the 9th SOW

4
Background

• Medicare QIO program created by statute in 1982
• Focus to improve quality, safety, and efficiency
  of health care services delivered to Medicare
  beneficiaries
• Medicare contractors hired to work with health
  care providers including home health agencies,
  hospitals, nursing homes (NH), and physicians
  offices
• Goal to improve health care services by assuring
  the right care for every patient, every time

5
Background (continued)

• Improving the Medicare Quality Improvement
  Organization Program, 2006 Institute of Medicine
  (IOM) report to Congress
• Focus more on quality improvement and performance
  measurement
• Prioritize program resources so that QIOs can
  help providers who demonstrate the most need, or
  who face significant challenges delivering
  quality care
• Strengthen organizational structure and
  governance of the QIOs
• Strengthen management of the QIO Program by CMS
• Strengthen the evaluation system for the QIO
  program

6
Background (continued)

• Nursing Homes Federal Actions Needed to Improve
  Targeting and Evaluation of Quality Improvement
  Organizations, 2007 Government Accountability
  Office (GAO) report
• Increase the number of low-performing nursing
  homes that QIOs assist intensively
• Direct QIOs to focus intensive assistance on
  those quality-of-care areas in which nursing
  homes most need improvement
• Collect more complete and detailed data on the
  methods QIOs are using to assist nursing homes
  and the impact that these methods have on quality
  of care
• Identify a broader spectrum of publicly reported
  quality measures to evaluate changes in nursing
  home quality.

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9th SOW History

• Priorities of the Secretary of the Department of
  Health and Human Services (DHHS)
• Recommendations from external stakeholders
• What do QIOs do well?
• What can we measure well?
• What is important?
• What interventions are backed by evidence?
• Recommendations from the QIO community and DHHS

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9th SOW Overarching Design Principles

• More effective management
• Measurement accountability
• Relevance to CMS and DHHS
• Value-Driven Health Care (VDHC)
• Disparities Reduction
• Health Information Technology (HIT)
• Careful evaluation with attribution

9
The QIO Program Has Been Re-designed

• Framework for Accountability
• Content

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Framework for Accountability

• Clinical themes built on a business model
• Focus resources
• Allocate the most resources to the most capable
  organizations (introduce competition and reward
  good contractor behavior)
• Measure important parameters continuously during
  contract management
• Interventions linked to measurable outcomes
• Outstanding measurement system
• Standardized set of interventions, built on 8th
  SOW base
• QIOs need to link interventions to outcomes
• Continuous monitoring by CMS Central Office and
  Regional Offices

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Framework for Accountability (continued)

• Attribution carefully considered
• Well-defined measure set with continuous,
  high-quality data
• CMS chooses participants with specified criteria
• Use of matched control groups, when possible
• More ability to control for confounding variables
• Use of standardized interventions, disseminated
  with help of support contractors, linked to
  measures
• Careful management of partnerships

12
Evaluation

• Contract Evaluation
• Table of Measures
• Mid-point evaluation (18 months)
• Program Evaluation
• Independent, outside evaluation contractor
• Independent report on the QIO program is a final
  deliverable (2011)
• Attribution of success to QIO interventions

13
Our Shared Goal

• To help providers accomplish the following
  objectives
• Prevent illness
• Decrease harm to patients
• Reduce waste in health care

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9th SOW Content4 Themes

• Prevention
• Patient Safety
• Care Transitions/Patient Pathways
• Beneficiary Protection

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9th SOW Content4 5 Themes

• Prevention
• Patient Safety
• Care Transitions/Patient Pathways
• Beneficiary Protection
• Evaluation

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9th SOW Levels of Understanding

• 4 Themes ( Evaluation)
• 10 Components
• 44 Final Measures
• 59 Total Measures
• 15 18-month and 44 28-month (Final) Measures
• 200 to 300 Detailed Measures
• Schedule of Deliverables

Less detail
More detail
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9th SOW Component Level

• Prevention (3)
• Core
• Chronic Kidney Disease (CKD)
• Focused disparities
• Patient Safety (6)
• Pressure Ulcers
• Physical Restraints
• SCIP (Surgical Care Improvement Project)
• MRSA (Methicillin Resistant Staphylococcus
  Aureus)
• Drug Safety
• Nursing Homes in need of quality improvement (QI)
  assistance
• Care Transitions (1)
• Beneficiary Protection (1)

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Prevention Theme

• Emphasize evidence-based and cost-effective care
• Interventions to prevent and/or slow disease
  progression
• Focus on early testing, effective, and timely
  interventions
• Three areas of focus
• Core Measures
• CKD
• Disparities

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Core Prevention

• Goal is to use Electronic Health Records (EHRs)
  to report and improve the following
• Colorectal Cancer (CRC) Screening
• Mammography Screening
• Influenza Vaccination
• Pneumococcal Vaccination
• Target will be clinical offices with EHR
  capability

20
Disparities Reduction

• Emphasize preventive care for population with
  diabetes
• Based on evidence collected in research trials
  and a special study in the 8th SOWEvery
  Diabetic Counts
• Will be awarded to a subset of QIOs, based on
  population and need

21
Disparities in the Prevention Theme

• Cross-cutting across the theme
• Collect data on all measures for race, ethnicity,
  and zip code
• Analytic report on disparities findings and its
  impact

22
CKD

• Optional competitive task awarded to a subset of
  QIOs
• CKD goals
• Timely testing to reduce rate of kidney failure
  due to diabetes
• Slow progression of kidney disease in
  hypertensive persons with diabetes
• Angiotensin Converting Enzyme (ACE) inhibitor
• Angiotensin Receptor Blocking (ARB) agent
• Arteriovenous fistula (AVF) placement and
  maturation, where medically appropriate, for
  individuals starting hemodialysis

23
9th SOW Measure Level

• Prevention (10 measures)
• Core
• Mammography screening
• CRC screening
• Influenza vaccination
• Pneumococcal pneumonia vaccination
• Focused disparities Diabetes
• A1C rates
• Lipid examination rates
• Eye exam rates

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9th SOW Measure Level (continued)

• CKD
• Screening for nephropathy
• ACE/ARB therapy to prevent progression
• AV fistula rate (new dialysis patients)

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Patient Safety

• Freeing patients from the risk of harm, injury,
  or loss resulting from their interaction with the
  health care delivery system
• Components of Patient Safety
• Pressure UlcersNursing Homes and Hospitals
• Physical RestraintsNursing Homes
• SCIPHospitals
• MRSAHospitals
• Drug SafetyPhysician Offices, Nursing Homes,
  Home Health, Hospitals
• Nursing Homes in need of assistance with quality
  improvement (QI) efforts

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Components

• Pressure UlcersHospitals
• 20 of pressure ulcers identified in nursing home
  residents originate outside the nursing home
  (acute care hospitals)
• Cross-setting efforts are needed to reduce
  incidence of pressure ulcers
• Hospital-acquired conditions/present on admission
  requirements
• Mean length of stay is 13.14 days compared to
  4.83 days
• SCIP
• Two new measures added for the 9th SOW
• SCIP Cardiac 2Perioperative beta blocker
• SCIP Infection 7Colorectal surgery patients with
  post-operative normothermia

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Components (continued)

• MRSA
• 94,000Annual life-threatening infections
• 19,000Annual deaths
• 250Deaths per day
• Drug safety measures
• Drug-drug interactions
• Potentially inappropriate medications
• Physical Restraints
• Reduce use of physical restraints in nursing
  homes to improve the quality of care for
  beneficiaries in these facilities

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Components (continued)

• Nursing Homes in need of assistance with QI
  efforts
• Based on evaluation, in conjunction with CMS
  Survey and Certification
• QIOs will perform a root cause analysis to
  identify factors leading to suboptimal
  performance
• Action plan will be implemented involving QI
  efforts
• Improvement in quality measures (Pressure ulcers
  (PrU) and physical restraints)
• Nursing home satisfaction with QIO technical
  assistance

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9th SOW Measure Level

• Patient safety (14 measures)
• MRSA 1 (infection rate)
• MRSA 2 (transmission rate)
• PrU 1 (high risk, NH)
• PrU 2 (hospital, acquired)
• Physical restraints (NH)
• SCIP Infection 1,2,3,4,6,7
• SCIP Venous thromboembolism (VTE) 1,2
• SCIP Cardiac 2

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SCIP Measures

• Infection
• 1Prophylactic antibiotic received within one
  hour prior to surgical incision
• 2Prophylactic antibiotic selection for surgical
  patients
• 3Prophylactic antibiotics discontinued within 24
  hours after surgery end time
• 4Cardiac surgery patients with controlled 6 A.M.
  postoperative serum glucose
• 6Surgery patients with appropriate hair removal
• 7Colorectal surgery patients with immediate
  postoperative normothermia

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SCIP Measures (continued)

• VTE
• 1Surgery patients with recommended venous
  thromboembolism prophylaxis ordered
• 2Surgery patients who received appropriate
  venous thromboembolism prophylaxis within 24
  hours prior to surgery to 24 hours after surgery
• Cardiac
• 2Surgery patients on beta blocker therapy prior
  to admission who received a beta blocker during
  the perioperative period

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Care Transitions/ Patient Pathways

• The QIO work under the Care Transitions (Patient
  Pathways) Theme aims to measurably improve the
  quality of care for Medicare beneficiaries who
  transition among care settings, through a
  comprehensive community effort. These efforts
  aim to reduce readmissions following
  hospitalization and to yield sustainable and
  replicable strategies to achieve high-value
  health care for sick and disabled Medicare
  beneficiaries.

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Interventions

• Aim of QIO work under Care Transitions Theme
• Improve Medicare beneficiary transitions from
  hospitals to other care settings through a
  comprehensive community effort
• Three general strategies of intervention
• Hospital and community system-wide
• Interventions that target specific diseases or
  conditions
• Interventions that target specific reasons for
  readmission

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Continuity Assessment Record and Evaluation (CARE)

• Develop a uniform assessment instrument to
  measure and compare Medicare beneficiaries
  health and functional status across settings,
  over time
• Develop and test the instruments usefulness in a
  three-year demonstration starting in 2008
• Uniform assessment instrument
• Standardized data collection vehicle
• Internet-based, interoperable
• Rapid communication of critical information

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9th SOW Measure Level

• Care Transitions (10 measures)
• Four types of re-hospitalization rates
• Two patient assessments of hospital discharge
  performance using the Hospital Consumer
  Assessment of Healthcare Providers and Systems
  (H-CAHPS)
• One physician visit post discharge, before
  re-admission (within 30 days)
• Two measures with CARE instrument
• One measure of adoption of interventions

36
Beneficiary Protection

• Statutorily Mandated Case Review Activities
• Are the items and/or services reasonable and
  medically necessary
• Do the quality of services meet professionally
  recognized standards of care
• Are services being provided in the appropriate
  and most economical setting

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Mandatory Review Activities

• Utilization review
• Quality of care review
• Review of beneficiary appeals of certain provider
  notices (Grijalva, Benefits Improvement and
  Protection Act of 2000 (BIPA), Weichardt)
• Review of potential Emergency Medical Treatment
  Labor Act (EMTALA) cases

38
Other Case Review Activities

• Quality Improvement Activities (QIAs)
• Alternative Dispute Resolution (ADR)
• Sanction activities
• Collaboration with CMS contractors
• Transparency through reporting
• Quality data reporting
• Communication

39
9th SOW Measure Level

• Beneficiary Protection (four measures)
• Timely completion of case reviews
• Beneficiary satisfaction with complaint process
• Completion of satisfaction survey
• Percent of QIA completion, based upon confirmed
  quality of care complaints and concerns

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Ways to Think of the 9th SOW

• Levels
• 4 Themes to 59 Measures, and beyond
• Topic-oriented, not setting oriented
• Cross-cutting themes (HIT, disparities, and VDHC)
• Outcomes oriented (44 Final Measures)
• Patient-centered
• 245,000 more patients screened for CKD
• 40,000 fewer pressure ulcers
• 20,000 more adult immunizations provided
• What will change? (Old work compared to new work)
• What will not be automatic? (National compared to
  sub-national tasks)

41
Old Work Compared to New WorkTheme by Theme

• Prevention
• Mammography
• Influenza vaccination
• Pneumococcal pneumonia vaccination
• Colorectal cancer screening
• CKD
• Focused disparities reduction

42
Old Work Compared to New WorkTheme by Theme
(continued)

• Patient Safety
• Pressure ulcers (New hospital setting)
• Physical restraints
• SCIP
• Drug safety
• Focused MRSA work

43
Old Work Compared to New WorkTheme by Theme
(continued)

• Care Transitions (entire program)
• Beneficiary Protection
• Increasing linkage of case review to quality of
  care
• Emphasis on improved efficiency in the case
  review process

44
Matching the Scope to Resources Available

• National Implementation
• Sub-national Implementation
• CKD
• Focused Disparities
• Care Transitions Theme
• Special Projects

45
National Compared to Sub-national

• First, consider the new work
• Care Coordination Sub-national
• CKD Sub-national
• Pressure Ulcer Work (in hospitals) National
• Focused MRSA Work National

46
National Compared to Sub-national (continued)

• Review of old work
• Cancer Screening and Adult Immunization
  National
• Focused Disparity Reduction Sub-national
• Patient Safety Work National
• Beneficiary Protection Work National

47
Special Initiative/Project Funding

• Projects essential to the following goals
• Advance quality improvement and beneficiary
  protection work with a focus on implementation
  in the 10th SOW
• Advance 9th SOW efforts
• Management objectives
• CMS will more aggressively prioritize and manage
  special projects and results (higher efficiency)
• Track and maintain project results and evaluation
• Obtain results in time for 10th SOW
  Implementation (minimum one year in advance)
• Link all projects to overall measurement strategy

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Sample of 9th SOW Proposed Special Projects

• Use of EHR to improve access and quality of care
  for minority health
• Use of electronic prescribing technology to
  eliminate Adverse Drug Events (ADEs), reduce
  polypharmacy, and increase rate of generic
  medication prescription
• Preventive and chronic care quality improvement
  initiatives in Medicare Advantage Programs

49
Cross-Cutting Priorities in 9th SOW

• Reducing Health Care Disparities
• Promoting use of HIT
• Value-Driven Health Care

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The CMS Strategy to Reduce Health Care Disparities

• Data
• Find affected individuals
• Providers
• Sensitize providers (continued work from the 8th
  SOW)
• Interventions
• Use proven interventions, develop effective
  partnerships, and help CMS programs be responsive
  to need
• Messaging
• Get the message out

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HIT

• Potential benefits of broad use of HIT
• Improve health care quality
• Prevent medical errors
• Reduce health care costs
• Increase administrative efficiencies
• Decrease paperwork
• Expand access to affordable care
• Improve tracking of chronic disease management
• http//www.hhs.gov/healthit/

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Value-Driven Health Care

• Four Cornerstones
• Interoperable HIT
• Measure and publish quality information
• Measure and publish price information
• Promote quality and efficiency of care (e.g.,
  Value-Based Purchasing)
• http//www.hhs.gov/valuedriven/

53
Support for QIOs before and during the 9th
SOWQuality Improvement Organization Support
Contractors (QIOSC)
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QIOSC-like Entities Currently in Preparation

• Core Functions
• 1. Beneficiary Protection
• 2. Patient Safety
• 3. Prevention
• a. Core
• b. Disparities
• c. CKD
• 4. Care Transitions

• Cross-Cutting Functions
• Reducing Health Care Disparities
• Promoting use of HIT
• Instilling the values of Value-Driven Health Care
• Program Communications

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Whats in it for Beneficiaries?

• 245,000 more patients screened for CKD
• 39,616 fewer pressure ulcers in NH
• 3,687 fewer pressure ulcers in hospitals
• 23,610 fewer physical restraints in NH
• 7,875 fewer antibiotic-resistant infections
• 14,252 lives saved from postoperative
  complications in hospitals

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Summary

• 9th SOW now planned
• Measurement system (final and interim), support
  system structure, list of possible special
  studies
• Evaluation strategy has been worked out in
  advance with quantitative targets and some
  control groups
• Higher degree of competition has been introduced
  (sub-national deployment)
• Monitoring now has greater transparency and
  involves both DHHS and Office of Management and
  Budget (OMB) regularly through contract

57
Summary (continued)

• Interventions are linked to measures
• Independent outside evaluation contractor will be
  engaged from the beginning
• Final independent program evaluation report at
  end of contract
• New management strategies will be applied to
  continuous contract oversight, encouraging high
  performance throughout the contract period
• New contract responsive to all external
  stakeholders

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Our goals are to prevent illness, decrease harm
to patients, and reduce waste in health care
59

• QUESTIONS?
• Roland A. Grieb, MD, MHSArgrieb_at_inqio.sdps.org
  [phone] Extension 221
• This material was prepared by Health Care Excel,
  the Medicare Quality Improvement Organization
  (QIO) for Indiana, under contract with the
  Centers for Medicare Medicaid Services (CMS),
  an agency of the US Department of Health and
  Human Services. The contents presented do not
  necessarily reflect CMS policy.
  8SOW-IN-GENE-08-17 03/14/2008