Nash, David B.

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Medicare\u27s Roadmap

Jefferson Digital Commons

From the EditorMedicare’s RoadmapRecently, the Centers for Medicare and Medicaid Services (also known as CMS) has very publicly declared its vision regarding improving the quality of medical care in our country.  I was so intrigued by the so-called “CMS Roadmap for Quality” that I decided to devote this editorial entirely to a review of the CMS plan.1  I will first lay the groundwork for the CMS Roadmap, then outline the five major system strategies, as they call them, for improving care.  Then, we will focus on three emerging trends that have coalesced to stimulate CMS and its engagement in quality.  Finally, we will outline the five specific strategies included in this Roadmap.Since the publication of the breakthrough Institute of Medicine study, namely Crossing the Quality Chasm, CMS has decided to closely align its future vision with the key goals of the IOM, which are of course, to make health care safe, effective, efficient, patient-centered, timely, and equitable. 2  By now, most readers ought to be familiar with those six key aims as articulated by the IOM and virtually every other major healthcare policy making organization in the last five years.  CMS recognizes that it really is a “public health agency” with an opportunity to have a tremendous impact on the entire healthcare system and the care that it delivers.  CMS, in the Quality Improvement Roadmap, notes that recent developments have created in their words, “an unprecedented opportunity to substantially achieve most all of the aims of the Institute of Medicine.”  These recent developments include the following:  (1) A growing body of evidence showing that there are major opportunities to improve care with potential benefits for patients, providers, and payers.  (2) A growing complexity of medical knowledge and the number of participants, technologies, and specialties that create enormous rewards for better care and enormous challenges in continuing on the current path.  (3) Leading providers are innovating to improve systems of care and stakeholders are showing a new willingness to come together in partnerships to achieve new levels of improvement.  I certainly would concur with these important environmental observations by the leadership at CMS.What emerges then, from these unprecedented recent developments is a notion within the Roadmap called “Five System Strategies for Improving Care.”  Let me summarize those System Strategies as articulated by CMS.  They include: (1) Working through partnerships, including within CMS and with other federal and state agencies and nongovernmental partners including health professionals;(2) Publish quality measurements and information including measures directed toward both the beneficiary audience and the professional, provider, purchaser audience;(3) Pay for health care in a way that expresses our commitment to supporting providers and practitioners for doing the right thing – improving quality and avoiding unnecessary costs –rather than directing more resources to less effective care;(4) Assist practitioners and providers in taking advantage of CMS quality initiatives, and make medical care more effective and less costly, in particular, greater use of effective electronic health records; and finally,  (5) CMS wishes to become an active partner in driving the creation and use of information about the effectiveness of healthcare technologies to bring effective innovations to patients more rapidly and to help doctors and patients use the treatments we pay for more effectively.This is truly a remarkable list of so-called “system strategies” for improving care and it is worth a collective time-out to review these strategies and recognize the watershed event that is occurring by the announcement from CMS regarding the importance of these strategies.  In a word, so goes CMS, so goes America’s healthcare system!Now that we understand the unprecedented opportunities and we have articulated the system strategies for improving care, there are three other emerging trends that may provide a critical new opportunity to improve the quality of medical care.  These three emerging trends are: (1) Much better evidence on opportunities to improve quality and save money from an expanding research basis and accompanying fund of knowledge.  I would like to think that our department here at Jefferson has, in a small way, added to this body of evidence.  (2) Clear opportunities for major improvements in the way we support the health professionals who provide care that involves more treatment options and more complexity.  In translation, I believe CMS means that they recognize the power of chronic disease management and other population-based care technologies.  (3) An unprecedented new willingness of many different stakeholders to come together in partnership to achieve improvement.  I think CMS here explicitly recognizes that more people and more organizations understand that high quality care is the only kind of care we can actually afford.  Many aspects of these emerging trends have been covered in this space previously.3Let’s conclude the CMS Quality Improvement Roadmap with an overview of the five strategies they believe are essential to achieving the goal of high quality care.  Strategy one calls for working through partnerships to improve performance.  Examples of these collaborations both within and outside of the government include partnering with the Institute for Healthcare Improvement’s campaign to save 100,000 lives and partnering with the Surgical Care Improvement Partnership, a public-private group led by the American College of Surgeons.4Another key example is the partnership to implement performance measurement through stakeholder alliances such as the Hospital Quality Alliance, or HQA.  Jefferson, like most hospitals, has been an inaugural member of the HQA.  The second strategy calls for the development and application of useful measures of quality of care including outcomes and consumer experience and cost of care, and to use them collaboratively to improve quality.  I believe CMS understands how important it is to derive specific measures of hospital quality, and that these measures have emerged from some of the alliances mentioned above.  We are particularly interested in measures of ambulatory care quality and efficiency developed by the Ambulatory Care Quality Alliance (AQA).  The AQA recently endorsed a so-called starter set of 28 quality measures including several measures related to the efficiency of care.  These measure focus on preventive care and care for common chronic conditions so relevant to CMS.  The third strategy called for paying more for patient focused high quality care.  This was the focus of a previous editorial as well.5   I will not review the entire pay-for-performance field except to say that the Medicare Modernization Act of 2003 gave CMS the authority to implement additional demonstration projects that include payments focused on the quality of patient care, not simply on the services received.  A series of demonstration projects are already well underway across the country and the results of these projects will be critically important to the future of the pay-for-performance field.  The fourth strategy calls for assisting practitioners and providers in making care more effective, particularly including the use of effective electronic information health systems.  Again, our department has been in the forefront of activity in this arena, helping to create the Pennsylvania-wide summit on the electronic medical record in the summer of 2005 and then publishing these results in the American Journal of Medical Quality.6   We continue to work with the Medicare Quality Improvement Organization in our state known as Quality Insights, as they are charged in part with assisting hospitals to more effectively use health information technology in the support of quality improvement.  The fifth and final strategy calls for improving access to better treatments and evidence to use them effectively.  CMS believes that health information technology systems, improved quality measures, and value-based payments to support better decisions can only be as effective as the treatments available and the evidence on what actually works to improve patient care.  Work under this fifth strategy calls for streamlining of the somewhat arcane billing system within CMS.  In their own words, “the CMS Quality Improvement Roadmap represents a major agency wide effort to use the new Medicare law and other new opportunities to work in partnership with the rest of the healthcare system to achieve major improvements in the quality of healthcare.”  CMS views this as a shared mission and certainly we in the Department of Health Policy concur with this vision.  Now comes the hard part!  While the CMS Quality Improvement Roadmap represents a conceptual watershed event in our national discussion about measuring and improving the quality of care, operationalizing any one of the five key strategies will be a major political accomplishment.  I am confident that we are actively tracking all of these key strategiesand hopeful that we will be an effective partner with CMS moving forward.  As usual, I am interested in your views and you can reach me at my email address, which is david.nash@jefferson.edu.  References1. www.cms.gov.2. The Institute of Medicine.  Crossing the Quality Chasm:  A New Health System for the 21st Century.  Washington, D.C. 2001.3. Nash DB.  The Medicare Paradox (Editorial) Health Policy Newsletter, Sep. 2005.4. Alvarez K, Sciamanna CN. The Insitute for Healthcare Improvement’s 100,000 Lives Campaign. Health Policy Newsletter. Mar 2006.5. Nash DB.  The Value of Value-based Purchasing (Editorial) Health Policy Newsletter, Mar. 2005. 6. Clarke JL, Meris DC, Nash DB. e-Health Initiative Update: Proceedings from the e-Health Technology Summit. Am J Med Qual. 2005;20:6S-24S.

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Medicare\u27s Roadmap

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