Thursday, 17 December 2015 05:41

Less Than Meets the Eye

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Many years ago actress Tallulah Bankhead sat in on a session of the Algonquin Round Table, a regular gathering of brilliant wits and intellectuals in the bar of a venerable New York City hotel. After listening to the repartee for an hour or so, she turned to a friend and said, “there is less here than meets the eye.”

The same can be said of the just-issued Centers for Medicare & Medicaid Services (CMS) Quality Strategy for 2016. The Strategy’s aim is to help move U.S. healthcare far down the road toward a health system that “delivers improved care, spends healthcare dollars more wisely, and … makes our communities healthier,” In the words of the agency. It advances a set of goals that, if achieved, would certainly help greatly in creating such a system. But the goals lack the boldness, specificity, and accountability necessary for the effective, quality strategy U.S. healthcare needs.

When CMS was still called the Health Care Financing Administration (full disclosure: I worked there then), its mission was simply to manage Medicare and the federal aspects of Medicaid. But over the years, and especially during the era of electronic health record (EHR) incentives and the Patient Protection and Affordable Care Act, the agency has experienced massive legislative and regulatory scope creep. The agency now can state, apparently without fear of contradiction, that driving quality across the entire system is a CMS “core function.” And its Quality Strategy for 2016 lays out six goals to help do just that:

  • Goal 1: Make care safer by reducing harm caused in the delivery of care. CMS plans to do this by supporting a culture of safety, eliminating inappropriate and unnecessary care, and reducing rates of hospital-acquired conditions (HACs).
  • Goal 2: Strengthen persons and their families as partners in their care. The aim will be to engage individuals and their families fully in the design, delivery, and evaluation of care.
  • Goal 3: Promote effective communication and coordination of care. This strategy extends CMS’s already extensive efforts in this area. The document provides 21 examples of initiatives it has launched focusing on this, mostly involving financial incentives that promote care management across the continuum of care (e.g. reducing admission and readmission rates).
  • Goal 4: Promote effective prevention and treatment of chronic disease by increasing the appropriate use of screening and prevention services, strengthening interventions to prevent heart attacks and strokes, and improving quality of care for people with multiple chronic conditions.
  • Goal 5: Work with communities to promote best practices of healthy living. CMS intends to build partnerships with and among local healthcare providers, public health professionals, social service organizations, and HCBS providers to support the delivery of community-based programs and services such as exercise classes, self-management, lead abatement, food assistance, and other activities beyond clinical care delivery.
  • Goal 6: Make care affordable by reducing medical errors, improving care coordination, investing in health IT, improving the transparency of cost and quality data, paying providers based on the quality and efficiency of care delivered, developing and promulgating guidelines and quality standards, improving team management of complex patients, and increasing administrative efficiency.

This is a solid, expansive set of goals that take aim at many of the tasks that the volume-to-value shift entails for CMS. But a strategy must do more than simply state goals; it must explain how the goals are to be carried out and how we can tell whether and when they have been accomplished. Let’s zero in on one of the goals and see how well it does this.

Goal 6, “make care affordable,” begins with a recitation of what CMS is already doing to reduce growth in spending, including the Medicare Shared Savings Program, the Hospital Value-Based Purchasing Program, and, taking effect in 2019, the new Medicare Incentive Payment System (MIPS) and Alternative Payment Models (APMs) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation. The Strategy then describes its plans to contain costs in broad strokes, specifically by establishing common cost measures, improving data systems through health information exchanges, making actionable cost and utilization available to providers, making costs and quality more transparent to consumers and providers, managing the QIO Learning and Action Network to drive how providers are paid, care is delivered, and information is distributed; and “implementing national quality improvement programs and initiatives to systematically spread known best practices to reduce costs and improve care.”

These Goal 6 activities are coalesced in two objectives, each of which has a set of “desired outcomes:”

1.   Develop and implement systems that reward value over volume. The desired outcomes are that new payment models are tested for their health impacts, that new outcome and experience metrics are used to determine payments, that incentives link payment to outcomes, that provider administrative burden is reduced, that access to quality primary and team-based care is expanded, and that costs go down and quality goes up in all settings of care.

2.   Use cost analysis data to inform payment policies. The desired outcomes are that cost data is routinely reviewed by line of service and region to determine practice patterns and identify outliers, that the system’s analytic capacity is improved, and that quality and cost data drive program integrity and fraud investigations.

And that’s it for Goal 6. What strikes you about it? For me, four things are true of this goal – and of the goals as a whole (you can either trust me on the latter, or better, read the document on the CMS website and see for yourself).

  • Nothing here is likely to upset any stakeholders. This is not surprising, since the strategy was developed through an iterative, collaborative process involving all stakeholders. But it means that the document comes up short as a strategy, because truly reforming the U.S. healthcare system will certainly be disruptive, producing winners and losers. A goal regarding making care affordable should explicitly address the steps that will achieve a true shift from volume to value, and it should address the impact on stakeholders. Goal 6 doesn’t. It promises to test new payment models and to pay providers “based on the quality and efficiency of their services,” but both testing and financial rewards can easily be put into place in the future as an adjunct rather than a replacement for fee-for-service (as is being done now with the Accountable Care Organization program and its variations). Even current CMS initiatives that really do advance the shift, like bundled payments, must have been considered too controversial; they aren’t discussed in Goal 6. The only mention of bundled payments in the Strategy is a two-word dot point in Goal 3.
  • Nothing here exceeds CMS’s current legislative and regulatory authorities. This is very wise and probably mandatory, but a fatal weakness for a goal about containing costs. As noted above, true healthcare cost containment will require bold, disruptive shifts in the roles of providers and payors that are beyond CMS’s current ability to mandate.
  • Key words aren’t precisely defined. For example, what does “affordable” actually mean for individuals, families, employees, and governments? Without defining that term for each stakeholder, it’s unlikely that there will ever be public consensus on whether the goal has been achieved.
  • There are no metrics, timelines, or milestones that commit CMS to do any specific thing by any specific time. Even high-level strategies should have objectives and outcomes that are SMART – specific, measurable, achievable, relevant, and time-related. You will find no objectives or desired outcomes in Goal 6 (or elsewhere in the Strategy) with those characteristics. Consider the second objective in Goal 6: “Use cost analysis data to inform payment policies.” There is no discussion of when that might happen or even how we might determine objectively whether or when it has been achieved. The desired outcomes are expressed in subjective terms: cost data are “routinely” reviewed, analytic capacity is “improved,” and quality and cost data “inform” fraud and program integrity activities.

To sum up: As a checklist containing a lot of what the agency needs to do to play its part in achieving the triple aim, the CMS Quality Strategy for 2016 is commendable. But it needs bolder goals and concrete and measurable objectives, outcomes, and timelines. Without them, as was once memorably said of a certain West Coast city, “there’s no ‘there’ there.”

About the Author

Philip Nathanson is the president of Nathanson Consulting LLC. Phil has held quality leadership positions at CMS, Aetna, and NCQA. His consulting clients include hospital systems, health information management (HIM) firms, and biotech companies. His articles on quality and healthcare management have appeared in Becker’s Hospital Review, H&HN Online, Topics in Healthcare Financing, and other journals.

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Philip Nathanson is the President of Nathanson Consulting LLC.  Phil has held quality leadership positions at CMS, Aetna, and NCQA. His consulting clients include hospital systems, HIM firms and biotech companies. His articles on quality and healthcare management have appeared in Becker’s Hospital Review, H&HN Online, Topics in Healthcare Financing and other journals.