Ambulatory Care Quality Alliance: Invitational Meeting

Keynote Remarks

Mark McClellan, Centers for Medicare & Medicaid Services (CMS)

Mark McClellan opened his remarks with an observation that there was great enthusiasm and sense of purpose behind the work that the Ambulatory Care Quality Alliance (AQA) had achieved in the past year and the activities currently underway. He noted that collaborative efforts are never easy, but added that with commitment tremendous progress is possible. McClellan thanked all the attendees for their work and their commitment to improving health care quality, singling out for thanks Carolyn Clancy, the AQA steering committee, and the workgroup chairs.

We passed a milestone in 2005 in the way that Congress and the public think about the work we are doing, said McClellan. He noted that people are now looking at how to provide better quality and not just debating whether it should be done. As a result, he said, we are at a point where Congress is asking us to promote a discussion of what a pay-for-performance system under Medicare would look like. McClellan stressed that the effort is and must remain collaborative. He said he was very pleased that the AQA includes people involved in primary care, internal medicine, and a range of specialties.

Everyone here recognizes an opportunity to make fundamental changes in health care, continued McClellan. He stressed that Congress was interested in the AQA's work. We need to get to a long-term, stable payment system, to avoid complications, and to avoid unnecessary costs, he said.

Congress wants to see more quality measures to help improve the health care system, added McClellan. In fiscal year 2007, he said, hospitals and home health agencies will receive a full market update if they hit quality measures. Those that don't will receive less than a full update. McClellan noted that the Medicare Modernization Act also includes some important provisions to push payment reforms that support better payment systems and reduced costs.

Turning to the topic of pilot projects, McClellan said Medicare gain-sharing would receive funding in the coming year. He also said that there would be six demonstration sites in the coming year designed to show how to raise the quality and efficiency of care.

McClellan noted that the Medicare Modernization Act calls for a demonstration program for post acute care payment. The idea, he explained, is to move to a system where a beneficiary receives one comprehensive assessment when he or she is transferred from acute care and when discharged. We ought to pay increasingly for what works best, he stressed, and pay in such a way that we provide the flexibility to get a patient into the right place of care.

Next, McClellan touched on the progress of the systems design reviews. He said that despite a lack of action on the issue from lawmakers, there was strong congressional interest on the quality agenda and that he expected Congress to revisit the issue soon. He added that Medicare Payment Advisory Commission (MedPAC) has been asked to submit a report to Congress on ways to report system design activities, and that CMS had been asked to comment on improvements that would lead to a better payment system.

McClellan also noted that there had been a number of questions from medical systems and physician groups about how a new payment system might work. He said that CMS was forging ahead in order to implement a system as soon as Congress approves a new payment system. We expect to trigger higher payments within a couple of business days of the law's passage, said McClellan, and we will try to make payment changes retroactive to the beginning of the year. He added that his agency has been working with the Office of the Inspector General to make sure there would be no burden on physicians in collecting a differential copayment rate from those who don't have supplemental insurance, and said that CMS intended to reopen reenrollment for physicians to participate in Medicare.

Regarding the Deficit Reduction Act, McClellan reiterated that there was a strong recognition in Congress of the need to build on quality-related activities—and to move within the current year to support and pay for it. Here we can make a strong case for making quality measures, he said.

Next, McClellan thanked the medical community for its engagement and support. It is not enough for physicians to be on sidelines for effective changes to occur, he said. Physicians and other health care professionals must lead the way. McClellan also thanked participants for providing meaningful feedback on the physicians' voluntary reporting program. As a result of that feedback, the number of measures is down to 16 from 36, he said, and is starting in a way that is more manageable for physicians participating in voluntary programs. He added that CMS would continue to seek consensus on these quality measures.

As we put quality measures into practice, continued McClellan, pilots and demonstration programs will be essential steps for using quality measures and paying on that basis. It is critical for AQA to work with CMS to move the demonstration programs forward to shape the future of payment reforms in a way that works for health professionals, he said.

Congress is interested in paying for reporting, said McClellan, and we are looking for physician leadership and AQA leadership when Congress builds on existing efforts.

McClellan noted that CMS is implementing performance measures from the American Medical Association in the demonstrations mandated by Sections 646 and 649 of the Medicare Modernization Act. He pointed out that the hospital pilot has achieved significant results, and that CMS was implementing other, similar demonstration programs involving family medicine and surgical specialty groups.

McClellan added that he was encouraged by forthcoming AQA pilot programs. These will yield important lessons for reporting by physician practices and build a foundation for future, large-scale programs, he said. He added that Phase I was scheduled to be launched in the spring, and he said it would provide real-time data to inform policy makers and Congress on next steps.

Regarding the regional health information exchange programs, McClellan said the Indiana program and others like it provide useful information about how to use data effectively (particularly electronic data). While many physicians don't have electronic medical records in place now, he added, we want to work with them so they will.

Next, McClellan thanked the AQA for developing efficiency measures. He noted that one subgroup was looking for three sub-measure grouper projects and said that CMS had evaluated the three predominant episode products for use with the Medicare population. That report will be out in late spring, he said.

Commenting on his agency's strategic goals for 2006, McClellan said that CMS would continue to emphasize these in order to improve health care in the United States. These goals also need to be reflected in the way that we pay providers, he said. McClellan noted that CMS was hoping to get useful stakeholder input (including from AQA) into pay for performance and other options.

Thanks to physician groups, McClellan added, AQA has done a lot of work developing primary care measures. He added that it was important now to move beyond the starter set. He outlined key areas in which CMS wanted to work with AQA. These include:

• Continuing to develop and adopt measures of quality in a comprehensive way and to work toward measures that will encompass a broader range of specialties.
• Developing measures important to other populations. As one example, McClellan cited post-acute care, which accounts for significant Medicare spending growth. He said CMS wants to work with physicians as the agency develops post acute care demonstration projects, and that he wanted to see a measure for care for frail populations.
• Making improvements on measures already in use. McClellan cited the need for quick progress on the practicality of data reporting to go hand-in-hand with performance measurement. He also stressed the need to test and improve physician feedback, stressing that if the system doesn't work for physicians then it won't achieve widespread adoption.
• Continuing educational efforts.

McClellan urged AQA participants to keep the congressional timetable in mind and make real progress in these four areas by Fall 2006. Congress will revisit physician payments and Medicare payments this fall, he said.

Finally, McClellan said that CMS is counting on AQA participants in 2006 to get the message out to physicians about the progress being made and the opportunities to take advantage of pilot programs. This is the right time, with specialty society leadership and momentum on quality, he said, for AQA to move its efforts forward. McClellan committed CMS to providing the resources needed to enable physicians to do what they do best. There is no doubt, he concluded, that we can achieve goals in 2006 and that AQA will be instrumental in making that happen.

Discussion

The question-and-answer period began with a concern raised about the impact of budget cuts on Medicaid and the State Children's Health Insurance Program (SCHIP). It's hard not to feel cynical about quality measures for children, the participant said, when the cuts are so draconian. In response, McClellan said he was convinced that the statute gives CMS the authority to continue SCHIP benefits and said he was committed to keeping it in place for everyone in the Medicaid program. McClellan added that CMS would try to implement these programs in such a way as to make sure there were no problems in accessing care. He added that he had received some new ideas about a new waiver that would make it possible to increase coverage outside the traditional Medicaid population.

McClellan also remarked that Medicaid lagged behind in the way long-term care for the disabled was structured. He said that long-term case wasn't just about nursing home care, but that in fact many disabled people receive care in community settings. He said the Deficit Reduction Act includes the most important provisions since the Americans with Disabilities Act was passed to get people the long-term care they prefer. It's time to move away from an institutional bias in Medicaid care, he said.

One participant noted that CMS had created “an unprecedented work pattern where CMS stands shoulder-to-shoulder with workgroups so we meet your challenge.” This means, she stressed, that CMS needs to commit to the effort and really get involved so that physician groups, employers, and consumers can achieve the vision that you have laid out.

In response, McClellan acknowledged that it was easy to talk about the big picture and much harder to implement it at the patient level. He reiterated that his staff would give substantial time and effort to help AQA in its work. He also stressed his hope to expand pilots and demonstrations, which he said were useful ways to test pay-for-performance and other initiatives in development. Our goal is to turn our vision into practical, real improvements that physicians see as beneficial, he said.

One participant thanked CMS for its work on quality measures, particularly in relationship to the Hospital Quality Alliance (HQA). This is a really big step from a consumer point of view, he said. In response, McClellan noted that the hospital quality survey had problems, but succeeded because the kind of collaboration existed that exists through AQA.

Finally, a participant asked McClellan to share his observations on the recent Institute of Medicine (IOM) report on improving performance. In response, McClellan noted that much of the report focused on the role of Congress—but said that his view was that much could be done without a congressional mandate. It's easier to get the legislation we want if we make progress now, he said.

Remarks

Carolyn Clancy, Agency for Healthcare Research and Quality (AHRQ)

Carolyn Clancy opened her remarks by saying that a great deal of progress has been made in the past 15 months, and that the leadership of many organizations has given considerable time to AQA's efforts. She also noted the continued and growing engagement of physician organizations.

Dr. Clancy pointed out that a lot of the work happens between AQA meetings. The performance measurement group, she said, has evaluated measures developed by the National Committee for Quality Assurance (NCQA) and is taking a crack at developing efficiency measures. Another workgroup is tackling the very important issue of data aggregation. She noted that the Hospital Quality Alliance had a leg up because it had an infrastructure in place for reporting to Joint Committee on Accreditation of Healthcare Organizations (JCAHO); a counterpart does not yet exist for most ambulatory care settings.

Next, Clancy cited the recently released National Healthcare Quality Report (NHQR) that found a 9.2-percent increase in improvement on measures reported by hospitals. Outside the hospital arena, however, there isn't that consistency. Clancy noted that 60 percent of physicians practice in units of five or fewer—and that capturing their data has been a challenge. She added, however, that pilots slated to be launched in the spring should start to make this a reality.

AQA's efforts strive to be transparent and uniform, concluded Clancy, and we are committed to harmonizing requirements and to ensuring that private employers and health care organizations are all using the same set of measures.

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