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CENTERS FOR MEDICARE & MEDICAID SERVICES

Centers for Medicare & Medicaid Services (CMS)

CMS is pursuing multiple initiatives to improve care across all settings and providers, and to improve coordination of care. As the graphic below shows, CMS quality improvement initiatives will impact multiple stakeholders and channels.

CMS Makes an Impact on Quality Across Multiple Stakeholders and Channels

CMS quality improvement initiatives impact multiple stakeholders and channels

Care Transitions May Improve Patient Safety and Quality of Care

The majority of VTEs in THR and TKR surgeries occur after hospital discharge, yet the number of patients receiving VTE prophylaxis declines after patients leave the hospital.1,2 To combat interruptions in prophylaxis that happen during care transitions, CMS has developed the Care Transitions Project.

  • The Care Transitions Project, launched in 2009 in 14 communities around the nation and scheduled to continue through summer 2011, is a CMS-sponsored pilot program that seeks to improve healthcare processes and reduce hospital readmissions by promoting seamless transitions from the hospital to home, skilled nursing facilities (SNFs), or home health care3
  • Works with state quality improvement organizations to research why hospital readmissions occur locally, and to design customized solutions
  • Ramifications of miscommunication between care providers include4:
    • Patient or caregiver confusion about the patient's condition and appropriate care
    • Lack of follow-through on referrals and inconsistent patient monitoring
    • Medication errors, overuse of narcotics, and suboptimal use of medicines
    • Increased financial impact and duplication of resource utilization
  • Medicare patient movement from acute care to other care settings such as SNFs has led to patient dissatisfaction and fragmented care5

Acute Care Episode (ACE)— the Right Care for Every Person Every Time6

CMS has also taken on the challenge of improving acute care with the Acute Care Episode (ACE) initiative.

  • The ACE Demonstration 3-year pilot program is testing the effects of bundling Medicare Part A and Part B payments by episodes of care as an alternative approach to payment for healthcare service delivery. The global payment will cover all Part A and Part B services, including physician services, as they pertain to the inpatient stay for fee-for-service beneficiaries6
  • The episodes of care will be for various cardiovascular and orthopedic procedures, and participating sites will be called value-based care centers6,7
  • Incentives will be offered to Medicare providers who demonstrate measurable clinical quality and efficiency improvements to Medicare beneficiaries7
  • A measure for VTE prophylaxis following surgery for THR and TKR surgery patients is included8
SURGICAL CARE IMPROVEMENT PROJECT (SCIP) PHYSICIAN QUALITY REPORTING SYSTEM (PQRS)

Rewarding Hospitals for Quality Compliance

  • SCIP is a Centers for Medicare & Medicaid Services (CMS)-sponsored national partnership of healthcare organizations committed to improving surgical care through the reduction of postoperative complications9
  • SCIP includes 2 VTE process outcome measures10
    • SCIP VTE 1: surgery patients with recommended VTE prophylaxis ordered
    • SCIP VTE 2: surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery or 24 hours after surgery

Rewarding Hospitals for Quality Compliance

Hip Replacement Surgery

FACT:

SCIP goal: reduce the incidence of surgical complications by 25% by 20109

  • To obtain full reimbursement from CMS, healthcare organizations must report their data for SCIP-VTE 1 and SCIP-VTE 211,12
  • The data are part of Hospital Compare, a CMS database that allows consumers to compare the quality of care provided at various health care institutions. For more information, or to compare hospitals using this database, please click http://www.hospitalcompare.hhs.gov/hospital-search.aspx.

Rewarding Providers for Quality Compliance

  • The Centers for Medicare & Medicaid Services (CMS) provide financial incentives to physicians and other eligible healthcare professionals who satisfactorily report quality data on 153 measures related to covered services provided under the Medicare Physician Fee Schedule.13,14 The Physician Quality Reporting Initiative (PQRI) is the program that was used to collect these data. In 2011, the program name was changed to Physician Quality Reporting System (PQRS)15
  • The need to provide adequate VTE prophylaxis is a measure that is included in the PQRS14
  • Documentation of appropriate VTE prophylaxis ordered, or documentation of VTE prophylaxis not ordered (for medical or other, unknown reasons) must be provided14
    • Documentation includes a written order, verbal order, or standing order/protocol or other documentation that VTE prophylaxis was given

VTE Measure14,16

VTE Measure

Hip Replacement Surgery

FACT:

In 2011, healthcare professionals who successfully report quality-measures data are eligible to earn an incentive equal to 1% of estimated allowed charges for covered services.15,17


References:

  1. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133(suppl 6):381S-453S. doi:10.1378/chest.08-0656.
  2. Warwick D, Friedman RJ, Agnelli G, et al. Insufficient duration of venous thromboembolism prophylaxis after total hip or knee replacement when compared with the time course of thromboembolic events: findings from the Global Orthopaedic Registry. J Bone Joint Surg Br. 2007;89-B(6):799-807.
  3. Medicare announces sites for pilot program to improve quality as patients move across care settings [press release]. Centers for Medicare & Medicaid Web site. http://www.cms.gov/apps/media/press/release.asp?Counter=3439. Published April 13, 2009. Accessed May 11, 2011.
  4. Improving transitions of care—the Vision of the National Transitions of Care Coalition. Little Rock, AK: National Transitions of Care Coalition; May 2008. http://www.ntocc.org/Portals/0/PolicyPaper.pdf. Published May 2008. Accessed May 11, 2011.
  5. QIO 9th statement of work executive summary series: Medicare QIOs and care transitions. http://www.ahqa.org/pub/uploads/CMS_SoW9_Summary_Care_Transitions_0807.pdf. Accessed May 11, 2011.
  6. Acute care episode demonstration. Centers for Medicare & Medicaid Services Web site. http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/ACEFactSheet.pdf. Accessed May 11, 2011.
  7. CMS announces demonstration to encourage greater collaboration and improve quality using bundled hospital payments [press release]. Centers for Medicare & Medicaid Services Web site. http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3109. Published May 16, 2008. Accessed May 11, 2011.
  8. Technical specifications for proposed ACE demonstration quality measures requested in the acute care demonstration application. Centers for Medicare & Medicaid Services Web site. http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/ACETechSpecAQM.pdf. Accessed May 11, 2011.
  9. Premier—a supporting partnership organization of the Surgical Care Improvement Project (SCIP). Premier Inc Web site. http://www.premierinc.com/safety/topics/scip/. Accessed May 11, 2011.
  10. Hospital Quality Alliance (HQA) 2004-2007 measure build-out table. Centers for Medicare & Medicaid Services Web site. http://www.cms.gov/HospitalQualityInits/downloads/HospitalHQA2004_2007200512.pdf. Accessed May 11, 2011.
  11. Quality measures for reporting in fiscal year 2009 for 2010 update. Centers for Medicare & Medicaid Services. http://www.cms.hhs.gov/apps/media/press/factsheet.asp. Accessed February 2, 2011.
  12. Federal Register. U.S. Department of Health and Human Services. Centers for Medicare & Medicaid Services. http://edocket.access.gpo.gov/2008/pdf/E8-26213.pdf. Published November 19, 2008. Accessed February 2, 2011.
  13. What's new for the 2009 Physician Quality Reporting Initiative (PQRI). Centers for Medicare & Medicaid Services Web site. http://www.cms.hhs.gov/PQRI/downloads/PQRIWhatsNew2009Final.pdf. Published January 2009. Accessed February 16, 2011.
  14. The 2009 Physician Quality Reporting Initiative (PQRI). Centers for Medicare & Medicaid Services Web site. http://www.cms.gov/MLNProducts/downloads/2009-PQRI-Booklet.pdf. Published January 2010. Accessed May 11, 2011.
  15. Physician quality reporting system formerly known as the physician quality reporting initiative. Centers for Medicare & Medicaid Services Web site. https://www.cms.gov/PQRI/01_Overview.asp. Updated February 11, 2011. Accessed February 12, 2011.
  16. American Medical Association and National Committee for Quality Assurance. Physician quality reporting system 2011 measure 23.http://www.acr.org/SecondaryMainMenuCategories/quality_safety/p4p/FeaturedCategories/P4PInitiatives/pqri/FeaturedCategories/PQRI-Tools/Interventional/Measure-23.aspx. Published January 11, 2011. Accessed May 11, 2011.
  17. Physician quality reporting initiative: analysis and payment. Centers for Medicare & Medicaid Services. http://www.cms.gov/PQRI/25_AnalysisAndPayment.asp. Accessed February 16, 2011.