iHT² Health IT Summit San Francisco “Connecting the Data: Improving Outcomes and Quality with Clinical and Claims Data” There is a fundamental need in today’s healthcare system for the two largest constituents—payers and providers—to work together in alignment. Changing the thinking and actions to shift the dynamic of how payors and providers work and interact with each other is no small task. This session will address the challenges and opportunities for payors and providers to work together. Panelists will discuss examples of collaboration and lessons learned. Learning Objectives: ∙ Assess the structure of provider-payor collaborations reducing cost and improving outcomes ∙ Identify methods to combine clinical and claims data to glean insight ∙ Define clinical, economic and administrative opportunities for alignment Moderator: Jay Srini, Chief Strategist, SCS Ventures, Adjunct Faculty Assistant Professor, University of Pittsburgh, Senior Fellow and Innovation Chair, iHT² Advisory Board Member Betsy Thompson, MD, DrPH, Chief Medical Officer, Region IX, Centers for Medicare and Medicaid Services Brett Johnson, Associate Director, Medical and Regulatory Policy, California Medical Association (CMA)

1. Quick Overview of CMS Perspective
1
• CMS Strategy and Challenges
• CMS Quality Reporting Programs
- Hospital Setting
• Future Directions

2. OUR STRATEGIC GOALS

3. CMS Quality Reporting and
Performance Programs
Hospital Quality
•Medicare and Medicaid
EHR Incentive Program
•PPS-Exempt Cancer
Hospitals
•Inpatient Psychiatric
Facilities
•Inpatient Quality
Reporting
•HAC payment reduction
program
•Readmission reduction
program
•Outpatient Quality
Reporting
•Ambulatory Surgical
Centers
Physician Quality
Reporting
•Medicare and Medicaid
EHR Incentive Program
•PQRS
•eRx quality reporting
PAC and Other Setting
Quality Reporting
•Inpatient Rehabilitation
Facility
•Nursing Home Compare
Measures
•LTCH Quality Reporting
•ESRD QIP
•Hospice Quality
Reporting
•Home Health Quality
Reporting
Payment Model
Reporting
•Medicare Shared
Savings Program
•Hospital Value-based
Purchasing
•Physician
Feedback/Value-based
Modifier
“Population” Quality
Reporting
•Medicaid Adult Quality
Reporting
•CHIPRA Quality
Reporting
•Health Insurance
Exchange Quality
Reporting
•Medicare Part C
•Medicare Part D
3

4. Hospital Acquired Conditions and the
Affordable Care Act
• Public reporting of HAC rates in Hospital
Compare by 2015
• Adjustment to payments for HAC, FY 2015
– 1% decrease for high rates (risk adjusted)
– top quartile compared to national average
– finalized criteria for ranking
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5. 5
13 Clinical Process of Care Measures
8 Patient Experience of
Care Dimensions
1. AMI-7a Fibrinolytic Therapy Received within 30
Minutes of Hospital Arrival
2. AMI-8 Primary PCI Received within 90 Minutes of
Hospital Arrival
3. HF-1 Discharge Instructions
4. PN-3b Blood Cultures Performed in the ED Prior to
Initial Antibiotic Received in Hospital
5. PN-6 Initial Antibiotic Selection for CAP in
Immunocompetent Patient
6. SCIP-Inf-1 Prophylactic Antibiotic Received within
One Hour Prior to Surgical Incision
7. SCIP-Inf-2 Prophylactic Antibiotic Selection for
Surgical Patients
8. SCIP-Inf-3 Prophylactic Antibiotics Discontinued
within 24 Hours After Surgery
9. SCIP-Inf-4 Cardiac Surgery Patients with Controlled
6 a.m. Postoperative Serum Glucose
10. SCIP–Inf–9 Postoperative Urinary Catheter
Removal on Postoperative Day 1 or 2.
11. SCIP-Card-2 Surgery Patients on a Beta Blocker
Prior to Arrival That Received a Beta Blocker
During the Perioperative Period
12. SCIP-VTE-1 Surgery Patients with Recommended
Venous Thromboembolism Prophylaxis Ordered
13. SCIP-VTE-2 Surgery Patients Who Received
Appropriate Venous Thromboembolism
Prophylaxis within 24 Hours
3 Mortality Measures
1. MORT-30-AMI Acute Myocardial Infarction
(AMI) 30-day mortality rate
2. MORT-30-HF Heart Failure (HF) 30-day
mortality rate
3. MORT-30-PN Pneumonia (PN) 30-day
mortality rate
Represents a new measure for the FY 2014 Program not in the FY 2013 Program.
Domain Weights
1. Nurse Communication
2. Doctor Communication
3. Hospital Staff
Responsiveness
4. Pain Management
5. Medicine
Communication
6. Hospital Cleanliness and
Quietness
7. Discharge Information
8. Overall Hospital Rating

6. Hospital Readmissions Reduction
Program
• FY 2014, Based on readmissions for AMI, HF and Pneumonia
– Algorithm introduced to account for planned readmissions
• In FY2015, adding 3 conditions
– Acute exacerbation of chronic obstructive pulmonary disease
– Elective total hip arthroplasty
– Total knee arthroplasty
• Applies to hospital’s base DRG payments for Medicare discharges
starting October 1, 2012
– FY 2014 no more than 2% reduction
– FY 2015 no more than 3% reduction
– Calculation methodology finalized in rule-making
6

7. partnershipforpatients.cms.gov
40%
G O A L S :
20%
Reduction in Preventable Hospital-
Acquired Conditions
1.8 Million Fewer Injuries | 60,000 Lives Saved
Reduction in 30-Day Readmissions
1.6 Million Patients Recover without Readmission
$35 Billion Dollars Saved
Status:
• Over 3700 hospitals have signed the pledge
• Hospital readmission rates down from 18.9% to 17.7% in first year
(unpublished data)

8. Results Being Seen Nationally
• Cost trends are down
• Outcomes are improving
• Adverse events are falling

9. Medicare Per Capita Spending Growth at Historic Lows
Source: CMS Office of the Actuary
9.24%
5.99%
4.63%
7.64%
7.16%
*27.59%
1.98%
4.91%
4.15%
1.36%
2.25%
1.13%
0.35%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
11%
12%
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Medicare Per Capita Growth Medical CPI Growth
*Medicare Part D prescription drug
benefit implementation, Jan 2006

10. Medicare FFS 30-Day All-Cause Readmission Rate,
January 2010-May 2013 (all hospitals)

11. Reducing Early Elective Deliveries Nationally
Improvement from Baseline
Source: August 2013 HEN Submissions. Baseline and Current time periods vary by HEN.

12. 0
0.5
1
1.5
2
2.5 41 %
Reduction
1.133
CLABSIsper1,000centrallinedays
Quarters of participation by hospital cohorts, 2009–2012
Over 1,000
ICUs achieved
an average
41% decline in
CLABSI over 6
quarters (18
months), from
1.915 to 1.133
CLABSI per
1,000 central
line days.
National Bloodstream Infection Rate

13. Physician-Based Strategies
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• CMS’ Physician “Toolbox”
− Physician Quality Reporting System (PQRS)
− ePrescribing Program
− EHR Incentive Program
− Value Based Payment Modifier (VM)
− Accountable Care Organizations
− Comprehensive Primary Care initiative
• Progress and Next Steps
• Questions and Comments

14. CMS Innovations Portfolio:
Testing New Models to Improve Quality
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1414

15. Marketplace

16. Delivery system and payment transformation
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PUBLIC
SECTOR
Future State –
People-Centered
Outcomes Driven
Sustainable
Coordinated Care
New Payment Systems
(and many more)
 Value-based purchasing
 ACOs, Shared Savings
 Episode-based payments
 Medical Homes and care mgmt.
 Data Transparency
Current State –
Producer-Centered
Volume Driven
Unsustainable
Fragmented Care
FFS Payment Systems
PRIVATE
SECTOR

17. San Francisco Regional Office
Centers for Medicare & Medicaid Services
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Betsy L. Thompson, MD, DrPH
Regional Chief Medical Officer
415-744-3631
Betsy. Thompson@cms.hhs.gov