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AQA Invitational Meeting Summary

Review of CMS Quality Initiatives

Herb Kuhn, Tom Valuck, Centers for Medicare & Medicaid Services (CMS)

CMS Acting Deputy Administrator Herb Kuhn opened his remarks by noting that a lot of work needed to be done in a very short time. He announced that the agency has created a new Special Programs Office—Value-Based Purchasing—to recognize the importance of quality initiatives.

Kuhn noted three key drivers for the agency's activities:

  • Persistent deficiencies in the Nation's health care system.
  • A complaint-based, episodic payment system that penalizes quality.
  • Growing frustration with health care costs.

He said that improving quality requires CMS to use all of the tools in its tool kit, that there is a correlation between high-quality care and high-quality delivery systems, and that more efficient resource use must be encouraged. He also praised the health care community's leadership on quality improvement.

Kuhn noted that the evidence continues to mount that pay for performance is the way forward. He added that Mark McClellan had said at an earlier AQA meeting that the debate over whether to do this is over. Now the discussion is about how to do this as efficiently as possible.

Some good results from CMS pilot programs have been achieved, Kuhn continued, citing the Premier Hospital Quality Incentive Demonstration and the Physician Group Practice Demonstration, as well as the Physician Voluntary Reporting System.

Tom Valuck, director of the new Special Programs Office—Value-Based Purchasing—focused his remarks on three areas:

  • An overview of the Tax Relief and Health Care Act of 2006 and how CMS is interpreting provisions dealing with performance measures.
  • Agency efforts to include as many eligible professionals as possible in the 2007 reporting cycle.
  • Agency plans to create a more sophisticated reporting program by 2008.

Turning first to an overview of the Tax Relief and Health Care Act, Valuck said that it establishes a preliminary list of measures and a process to identify additional measures for physician quality reporting. The statute references the 66 measures named in the December 5, 2006, CMS document, 2007 Physician Voluntary Reporting Program Quality Measures. Valuck added that the statute provides for changes to the 2007 list based on a consensus process to be held in January. He said that subsequent refinements were also permitted between now and July. For 2008, the measure set must be developed through a formal rulemaking process. Valuck noted that the proposed measure set must be published in the Federal Register no later than August 15, 2007, with a final measure set issued by November 15, 2007.

Next, Valuck discussed the agency's efforts to expand the number of professionals eligible to participate in the quality reporting initiative in 2007. He noted that a number of physicians do not yet have measures that apply to their practices and that CMS is coordinating with the Physician Consortium for Performance Improvement (Consortium) to develop measures in order to have some in place by August. Valuck noted that some groups are asking CMS to add a new code or two. His agency is asking these groups to bring those requests to the Consortium instead.

Valuck noted that the agency is intent on including as many members of the medical team as possible (such as chiropractors, physician assistants, nurses and nurse practitioners, and therapists) in order to expand the scope of the initiative to eligible professionals who are not physicians.

The statute offers the opportunity for a team-based approach, according to Valuck, adding that current payment systems are splintered and that this statute may be a way to bring the medical team together around quality measures.

Valuck noted that CMS has been in discussions with the AQA Steering Committee and the Consortium on this issue. He said that, although a number of people have asked CMS to convene a forum similar to the AQA, the agency does not believe that a meeting called and hosted by CMS would meet the goal of a robust consensus process.

Valuck also noted that the Consortium has agreed that the list of 66 measures can be applied to any professional, regardless of who the instructions refer to, as long as codes are available to apply the measure to a particular practice. He added that the Consortium has agreed to consider, on a fast track, new codes where there are none.

Looking ahead to 2008, Valuck said that the agency needs to begin its work now in order to have a draft measure set ready for publication in August 2007.

Next, Valuck briefly touched on the value and benefit of registry-based reporting. He said that, although CMS would like to be able to do this in 2007, there just isn't time and the agency is exploring registry-based reporting for 2008. He noted that CMS officials have met with medical specialty societies and therapist groups that have existing registries and clinical databases. For a nationwide program, we are probably looking at some type of standardization to allow for data collection and use to populate measures and do the analysis that is contemplated under the statute.

In concluding his remarks, Valuck reiterated that the statute offers an opportunity to:

  1. Move the quality agenda forward.
  2. Include a team approach to measure development.
  3. Standardize registry-based reporting.


Opening the discussion, one participant noted that the AQA has approved a number of measures provisionally—with the understanding that they still have to be vetted through the National Quality Forum (NQF) process. He asked what happens, from a payment standpoint, if a measure doesn't make it through the NQF process. Another participant asked how CMS would address the fact that not all measures are created equal, with some addressing basic competence and others addressing high performance.

Valuck responded that CMS expected to wait for NQF final approval before reacting but that, regarding the quality of various measures, it was important to start somewhere. He added that, although we don't know what the perfect measure is, at the same time, it is important to recognize the need to evaluate ongoing efforts and look at unintended consequences. He stressed that it is equally important to raise the stakes and "take it up a notch" each year to get closer to the ideal design—we need to get started, evaluate for problems and unintended consequences along the way, and work toward the ideal.

Another participant asked about specialties that don't yet have any measures. Do we rush to use something that hasn't gone through the consensus process, or do we wait until 2008? In response, Valuck stressed that the statute requires that measures be developed using a consensus process. He added that CMS is assessing strategies for broadening a measure's applicability. Valuck also noted that measures are reported based on Current Procedural Terminology codes and diagnoses, so there may be a situation in which a measure thought of on a condition basis may be used.

Next, Valuck stressed that physicians or other eligible professionals will select the measures that are valid for their practices and on which they want to report (but that they must report on at least three measures for the entire reporting period). The issue will become whether or not the physician or other eligible professional has a big enough pool to get over the cap to be eligible for a bonus.

For his part, Kuhn stressed the importance of the consensus process and observed that there is currently more collaboration among stakeholders than ever before. The process must move forward to create a roadmap to include more and more eligible professionals. No one must be left behind.

Later in the meeting, Carolyn Clancy said that the July 1 deadline had created an unprecedented workload and deadlines for performance measurement groups and physician organizations. As a result, some organizations that have done great work have not yet had their measures reviewed by the AQA. She indicated that those measures would be taken up by the Performance Measurement Workgroup during its next conference call.

One participant asked about the impact of quality reporting initiatives on Medicaid reimbursement. In response, Kuhn said that the agency's focus right now is on the Medicare program and that the impact on Medicaid would be taken up later. Valuck added that the agency also hopes to study the activities of those States that have been early adopters of pay for performance.

Another participant asked about the impact of registries on patient confidentiality. In response, Valuck said that existing registries take a number of different formats and that, for a national system to be useful, a standardized format for data collection is needed. Carolyn Clancy added that AHRQ is about to release a guide to patient registries. In direct response to a request from CMS, the guide includes an entire chapter that focuses on confidentiality.

A participant asked about how the voluntary reporting initiative and data registries will relate to value exchanges. In response, Valuck acknowledged that it was too early to say how the various pieces of the quality system will interrelate. He added, however, that the idea is to have more centralization and integration.

One participant stated that he would not participate in either the Physician Voluntary Reporting Program or his own professional association's registry because of concerns that the data would be reported publicly. Has CMS been given authority to promulgate rules on public reporting?

Valuck answered that the statute doesn't address the issue and that CMS currently has no plans for public reporting. At the same time, he discussed the value of public reporting, saying that CMS believes having good quality and cost information about every provider type available to the public is the right direction to go. As a result, he said that he would anticipate that CMS will eventually be able to report physician quality and cost-of-care data.

Kuhn reiterated that the public wants reporting, stating that it would be remiss not to say that this is an expectation of the community at large and something we as an agency and the entire stakeholder community need to address. Reporting is inevitable. The question is how to do it.

Finally, one participant raised the issue of keeping the patient in the forefront, maintaining that physicians must do what's best for their patients and must be sure they don't leave the patient behind in their zeal to report on a measure.

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