Remarks of CMS Acting Administrator Andy Slavitt at the CMS Quality Conference.
I want to thank everyone who is attending and participating in the CMS Quality Conference for 2015. Let me begin by thanking you for your commitment to our beneficiaries– anyone who has double-checked a patient’s chart to reconcile a medication, who has made the extra phone call to make sure a care transition happens, anyone has had the courage to call attention to a defect in their own organization’s safety and attempted to create a dialogue of improvement, anyone who has looked at the data on their performance and looked for opportunities to improve and change. Thank you. I know health care can be filled with enough distractions but thanks for all that you do to keep the patient at the center. I want to note as I begin that this conference aligns with one of the themes I’m going to touch on– by intentionally bringing together Medicare and Medicaid quality– in one place. You should take two meanings from this. First is an unequivocal statement that there cannot be two standards for quality depending on how someone is covered. And second is our commitment to aligning the rules of how Medicare, Medicaid and commercial programs work in the delivery system to improve simplicity.
I came to DC and joined the men and women of CMS a year and a half ago after a long career outside government. What drew me to Washington at this point in time from the private sector is that the health care agenda today is moving out of the “talking about it” stage into the “changing-it” and “getting-it-done” stage. Probably like you, I’ve spent too many years and too many meetings talking about the stubborn uninsured rate and talking about the broken fee for service system. About consumerism that didn’t benefit the consumer, about “what is quality?” without a commitment or the tools for quality improvement. About health IT that did nothing to improve health and wasn’t the kind of IT that made people’s job’s any easier. Health care doesn’t present big opportunities for change very often. So let’s commit to using our valuable time here to move the needle.
Over the last 50 years, from the onset of the Medicare and Medicaid program, as a country we have steadily brought health care access and security to more people. From a time when half of seniors lacked access to basic coverage, programs such as Medicare to Medicaid up through CHIP and Prescription Drug Coverage and more recently the Marketplaces, we have dramatically reduced the uninsured rate and improved people’s health. Low incomes, fixed incomes, uncertain incomes, and poor health status no longer keep people out of the care system. And we have seen generational reductions in poverty as a result.
Why Quality Matters Now
An equivalent opportunity for transformational change exists today with health care quality and can be traced to the Affordable Care Act and our commitment to better, smarter, safer, and higher quality health care system. With new patients entering the system, the mandate for quality in our nation has never been more important and the goals never more pragmatic — improve quality of life, reduce complications, manage chronic disease, and improve our ability to spend smarter in the process. But beyond the national level, every health care entity in America is faced with the reality that thanks to Congress and the Administration and the work of many of you, measuring, improving and delivering quality outcomes is a permanent part of how they will get paid.
And it’s working. Over the last few years, since the passage of the ACA, we have begun to make real progress. 95 out of 100 quality measures have increased across the country and medical inflation over the same period is at historically low levels. And we have done all of this while opening up access to care for over 16 million new people.
And later today, the Department of Health and Human Services will release a report from the Agency for Healthcare Research and Quality (AHRQ) showing a 17 percent improvement in hospital-acquired conditions from 145 per thousand discharges in 2010 to 121 in 2014. That means that from 2010 to 2014, an estimated 2.1 million fewer times a patient was harmed in America’s hospitals and an estimated 87,000 fewer patients died as a direct result of your successful improvement in quality. The major headline is that it is safer today, far safer, when your or my loved one enters the hospital than it was even four years ago. Talk about transformational.
But there’s another headline that accrues to all of us and that is the effect this quality improvement has on the sustainability of our health care system. This reduction in errors and complications has saved an estimated $20 billion in health care costs, or $5 billion annually. This is the quality dividend that will allow us to sustain the health care system– one that measures, one that takes care of people in their homes and other low cost settings, spends money more wisely through greater communication, consistency and coordination, and build a learning system to improve on the fundamentals every day. We are no longer just talking about it. We are doing it.
All of this is both a collective success and a collective work in progress. And we are just at the beginning of change. And I believe that the most important realization we can make is that what we’ve done so far is not enough and even more of the same won’t get us to the results we need.
Call to Action: Extending Quality
Much of our progress to date has come from a critical focus on fundamentals. Picking out critical areas to move the needle, focusing on areas within silos, and reinforcing progress with some basic incentives. But to move forward and continue to make progress requires more than just improvement in the fundamentals, but understanding and adjusting to a new level of fundamentals– serving a more mobile patient, a more diverse patient and through better use of information. From beginning to measure to maturing into an information industry, from improving quality events to collaborating around end to end patient experiences, from improving quality on average to improving it for everyone across the socio-economic, racial, ethnic and geographic spectrum. These new fundamentals will take more accountability, more collaboration, and more leadership across our communities. So we need to get busy.
CMS is prepared to be a partner in this change. We are committed to listening and learning what works and what doesn’t and to being transparent, clear, and consistent in our priorities. I hold a not so distant memory of when I worked outside the government trying to decipher what sometimes felt like opaque and unpredictable policies and regulations. You shouldn’t have to comb through regulations to piece together what we are saying. And so one of my commitments is speaking to you straight about our agenda and equally straight about our expectations.
Our priority is clear– to drive a delivery system that provides better care, with a smarter payment system that keeps people healthier.
This means specifically that by 2018 we will reach a tipping point in our payments, with over 50% of Medicare FFS payments rewarding for quality and value and aligning Medicare Advantage and Medicaid to do the same. This commitment from us should help galvanize your organizations in the right direction. Change often boils down to practical decisions on where to invest and we aim to make the case that investment in a quality program and population health will carry a greater return than another expensive MRI machine or a 100 new beds in the hospital. And our commitment extends beyond how we pay to data, tools and sharing best practices as we commit to providing leadership in data transparency and in technical support.
Payment policy is not our goal. Until we produce better care more affordably, we will not have succeeded. I know of one hospital in Michigan. It’s an urban hospital who participated in our Value-based purchasing program which rewards for improvements in quality. Their first year in they received a payment reduction. It was discouraging let alone a threat to their viability. The next year, they focused on their clinical process and fully implemented an EMR and that next year, they improved their quality score by 32 points. The incentive alone wasn’t enough, but combining the tools of technology and a different payment structure helped the leadership provide better care and get rewarded for it. This is why we just committed to a $650 million-plus investment to 140,000 physicians to support them as their aim to transform their practices to get paid for quality.
Let me call out three specific areas that we will believe will be at the heart of making continued progress: defining quality around the emerging needs of today’s patient, ensuring quality is equitably delivered to a people with a diverse set of needs, and turning healthcare into an information industry that supports the patient and those who serve them.
The New Mobile Patient
First is meeting the needs of the new and more mobile patient and their family. For us this means refreshing our understanding of who our customer, the patient, is. At CMS, there are 140 million different beneficiaries and consumers who rely on CMS’s programs every day. It’s the Medicare patient leaving the hospital with five prescriptions to fill and two appointments to book, the young marketplace customer who will have coverage for the first time and finally be able to have his wife’s chronic fatigue treated, the daughter who has made the difficult decision to finally put her mother in a nursing home and wants the best quality, the Medicaid patient waiting for her kidney transplant and managing to make it to dialysis for most appointments, the cancer patient who has decided he wants to be treated at home in more comfort. It’s the family with a child with severe disabilities on Medicaid that requires 24 hour care and is watching every dollar and interviewing every home care worker. These are a diverse group of people with a diverse set of health care needs, affordability concerns and each has their own definition of quality. This is a consumer who is more mobile and more demanding than ever before and is used to information, choices, and quality improving at a rapid pace in other parts of their life.
For all the quality improvement we’ve achieved to date, for progress to continue it must be felt by these millions of Americans and their families the way they experience care and the way they think about quality. In a larger variety of care settings, with a broader array of care providers, with more transitions and opportunities for dropped balls and miscommunication, and for millions of people without historic relationships with the health care system, other than perhaps at an ER. Understanding and wrapping your quality practices around this new mobile patient and their needs is critical. Until the consumer feels the improvement in quality we haven’t succeeded.
The second critical quality focus I want to talk about is in the area of health equity. We can’t just improve the average quality levels. We need to improve quality for everyone, but we also need to close the gap between those at the top and those at the bottom, starting with where we are falling behind the most. Including, and in particular, individuals with lower incomes, people with disabilities, racial and ethnic minorities, and those living in rural communities. We don’t need a lot of data to tell us we have a problem here but we do need to actively measure and increase visibility here. And we all understand that many barriers to care aren’t clinical, their social, economic and the practical things in people’s lives that don’t match up to the way we built our delivery system. If patients are customers, we need to change our service model rather than expecting people to come to us.
Across Medicare and Medicaid, we have consistently high expectations for quality. We are excited about the recent launch of our CMS Equity plan. And we at CMS are publicly and visibly focused on ensuring proper incentives for those in the communities who make investments in dual-eligible and higher risk patients. We have research and are accepting comments now on these areas for Medicare Advantage. And, through SIM grants, Delivery System Reform waivers, and other activities, we are working to make quality delivery an equivalent expectation for beneficiaries on Medicaid. More broadly, health equity goals are a critical component of new CMS requirements in many things we do– including in the new QIO SOW and as part of MACRA.
The focus on health equity is particularly important with the advent of new alternative payment models. To be very clear, cherry-picking or redlining one’s way to a quality bonus will not work. I am asking every health plan, hospital and physician practice to ensure your contract language, training materials, data and practices work to achieve health equity. There are only a few things that will rate a call from me to a CEO. This is one of them.
Third, for continued progress to be possible, health care must become an information industry. Someone asked me what the opposite of an information industry is recently. I think it’s an industry of educated guesses. CMS has begun this journey– beginning with how we release data and we are extending it further. We now release over 200 new and updated data files on everything from geographic variation in Medicare, to chronic disease patterns to utilization and prescribing patterns and quality data on hospitals, nursing homes, home health agencies, physicians, and dialysis facilities. And, we are making the creation of usable information part of doing business with the Federal government. We are requiring commercial plans that do business in the marketplace and in Medicare to make data that is valuable to providers or patients available in machine readable form. We have led the development of a federated data infrastructure on health plans. We are building and investing in a Medicaid data infrastructure. We will use every opportunity to plant the seeds that permanently change data availability and create a usable information pipeline for researchers and software developers. And we now provide data to providers on their populations’ claims experience in near real time as we get the data from our claims system. How we provide data to enable change is of equal importance to CMS as how we pay for care. That’s a big departure as we partner with consumers and the care provider community– we are not just a payer, we are an information partner.
At this point it’s not technology, but business practices which hold us back. Earlier this year, I visited a safety net clinic in Chicago with a great electronic medical record and analytics capability. They enjoy some of the highest quality results in the country. Only the physicians can’t follow patients who see specialists outside the clinic or who need inpatient care. Information must be able to move from point A to point B along with the patient. We continue to hear stories of those who intentionally block information from moving outside of their own systems. Very soon, all EMRs have be required to have open APIs so that innovators can build applications and safely and securely connect to the data in an EMR. In the meantime, if you experience any practice that blocks information from moving, send an email about it to NOINFORMATIONBLOCKING@CMS.HHS.GOV. Information blocking is not acceptable to patients or to us. People don’t experience care in silos and their data can’t live in silos.
But none of this matters unless the data helps care providers deliver patients better care. In addition to making data available and portable, we must make it usable by integrating it with the needs of providers. Some care providers in alternative payment models tell me that some health plans often don’t provide them access to their data or if data is provided it is through individual reports or portals that don’t integrate with data on the rest of a providers practice. Payers need to support providers in improving the entirety of their practice or we can’t expect success. I was recently in Denver and met with a QIO, several physicians and their major health plans. One primary care doctor told me what happened when the health plans and Medicare all decided to provide them data on their practice through one single mechanism. Physicians in his office are finally able to use it and integrate it into their practices.
Delivering usable information must be part of our larger commitment to the health care system– to simplify. We believe the most valuable commodity physicians and other care providers have is their time– time we would like them to productively spend with the patients on their panels and away from paperwork or systems that don’t help them. CMS has a lot of work to do here. We are making it a priority to reduce paperwork, align our quality measures, and roll back regulations that have outlived their usefulness. We are making reforms to Medicare regulations that were identified as unnecessary, obsolete, or excessively burdensome on hospitals and other health care providers. To date, in fact, we have saved nearly $660 million annually, and $3.2 billion over five years. We have more work to do here. This is just the beginning.
Committing to quality is also committing to constantly changing. To reach the next level, we will need to both continue what we’re doing and do more to integrate around the mobile consumer, focus especially on the needs of the most difficult to treat individuals so we don’t leave them behind and support an infrastructure which provides more usable information to everyone.
This is the most exciting time to be in health care. Your work is not only integral to charting the course to improving life for Jesse Soriano and the patients he assists, but to building a system that can be around to serve his six children, his seven grandchildren and even his two great-grandchildren. The next step requires your innovation, your capabilities, your focus on quality and your willingness and ability to measure and be accountable like never before. Enjoy the rest of the conference. We look forward to continuing our collaborative work, to listening and learning and supporting the urgent and critical progress ahead.
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