AQA Second Invitational Meeting Summary

CMS Perspective

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

Mark McClellan said that the progress of the three workgroups to date has been quite impressive, and he thanked all the organizers for moving the process forward. The November meeting was an important step for moving forward on identifying and implementing ambulatory care measures, he said, and now the workgroups are looking at specific issues to be addressed and resolved. This progress is a reflection of the groups' leadership and of the need for more relevant, available information, he said.

McClellan emphasized his strong support for the broad goal of developing quality measures and encouraging better performance around measures that reflect true improvements in the health care system. He noted a surge in interest around hospital and nursing facility measures. Interest in pay for performance is at an unprecedented level. To achieve pay for performance, we must have strong performance measures.

We are all interested in having this group's collaboration lead to some timely and concrete recommendations that can have a key impact on the debate about how best to achieve a quality health care system, said McClellan. He added that the collaboration was also critical to moving forward collectively on the development of standardized measures.

McClellan noted that the clinical areas toward which the workgroup on performance measurement was working were, together, a very strong starter set of conditions. He added that it was also important to move forward on quality and to empower consumers to get the best care at the lowest cost. And we hope this becomes a tool to meet quality improvement goals this year.

These measures, he said, complement the prevention quality indicators that are also going through the National Quality Forum (NQF) process. If we're delivering better care in ambulatory settings, then we should have fewer hospital admissions. This is an important outcome to look at, said McClellan, who added that it was also important to link the starter set to the hospital measures.

McClellan thanked the workgroup on performance measurement for its efforts, and said that he hoped to see a starter set soon. Stressing that the work has just begun, he said it was important to work proactively to develop a consensus set of measures that addresses efficiency in conjunction with other aspects of quality improvement. A starter set, he said, would make it much easier for other activities (including testing data aggregation methods and aligning financial incentives with quality measures) to move forward in a consensus manner.

The CMS Administrator made clear that he was not talking about cost containment alone. Indeed, he said, there was a tremendous potential for improving care in a way that achieves higher quality at a lower cost. But we must move quickly, or attention will turn back to policies that lower costs alone (rather than lowering them as part of a comprehensive quality improvement strategy).

"I am very concerned that we tend to pay more in Medicare when doctors do a worse job," said McClellan. "We need to keep working to change that—and we need to do it right now, before people feel there is no choice but to go to more drastic cost-containment measures."

McClellan also thanked the other two workgroups. He noted that they are tackling very complicated issues. The data needed to monitor measures are quite sensitive, he said, and often difficult to get. CMS supports responsible use of data that also protects confidentiality and the security of underlying patient information.

We've learned a lot from the Hospital Quality Alliance, said McClellan. Interest in pay for performance is a critical stimulus to these efforts. He pointed out that Medicare now pays everyone equally, regardless of performance, efficiency, or quality. There is growing evidence that pay-for-performance systems can be implemented and can achieve better results at lower costs, all of which suggests that it is possible to support the overall sustainability of the Medicare program while providing quality care at lower cost.

Next, McClellan provided a brief update on several Medicare pilot projects. He said that CMS had selected provider participants last month for the care improvement program for chronic care, and stressed that the entities selected would be paid only if they achieve measurable quality improvements in the region, improvements in patients' satisfaction with care (and providers' satisfaction), and lower costs. Each program includes an element of health information technology and has built-in incentives.

CMS will also be moving forward soon with a 3-year medical practice pilot program, said McClellan, and a Medicare demonstration, aimed at small practices, under which physicians will be given incentives to put in place health information technology. There is also a Section 646 demonstration aimed at achieving area-level improvements in care. We will see broad external input on incentives and delivery methods, said McClellan. He stressed that CMS is very focused on the importance of stakeholder involvement in this process, noting that quality improvement will not be possible unless all the stakeholders in the area are involved.

In concluding his remarks, McClellan reiterated that the opportunities exist right now, this year, to improve the quality of the health care system. We cannot succeed in this effort unless we work together to provide an environment for the delivery of care that provides better quality at a lower cost.

Discussion

Following Mark McClellan's remarks, Agency for Healthcare Research and Quality (AHRQ) Director Carolyn Clancy thanked the CMS Administrator for reminding everyone that measurement is a means to an end—quality of care.

In the discussion that followed, McClellan was asked whether he had any advice on models for data aggregation. In response, McClellan stressed that it is very important that the public does not think there's "a big black box with all the information on all patients treated in this country," and that it is important to find ways to overcome patient confidentiality concerns. He noted that CMS has separated patient identifiers from the actual data that will be used to construct performance measures. I know there is a lot of concern about provider information, he said, but my real concern is patient information.

Looking ahead, McClellan said his bigger hope is that it will be possible to use electronic data systems and good statistical methods in such a way as to avoid aggregating patient data information at all. He noted that prior to joining the U.S. Government, he had worked on an international data project. It turned out, he said, that they didn't really need to aggregate the data at the patient level. Generally, he said, we're interested in summary statistics based on patient data—not the information itself.

McClellan added that his longer term vision was to be able to query a hospital or a physician, and have its local computer system run the statistical analysis and send the results. We can then pull them together, he said, without ever having to look at the patient data ourselves.

Those in the employer community expect that there will be no patient-level data, said one participant. Can you explain the difference between that approach and what you are contemplating? In response, McClellan said that he didn't think there was a significant difference. The key is for the public to understand that their individual data have a role to play, but that the data will be aggregated. As a result, he said, all quality measures must be based on aggregated data.

One participant asked about the status of pay for performance within the Medicaid program. McClellan stressed that Medicaid is a key part of the overall quality improvement process. We've already started, he said, to help provide better-aligned incentives (such as using prescription drugs more effectively) to keep overall costs down. The challenge is to construct data that are valid for performance measures.

There is a lot of buy-in for using the NQF process, said one participant. He expressed concern that the stakeholders at the table could develop a core set of measures and deliver them to the health care system only to have the NQF system alter them. This would render our consensus moot, he said. In response, McClellan said he believed that the NQF process is very helpful, and can be seen as an opportunity to achieve public buy-in on performance measures that will actually be used. I view these as truly complementary activities, he said, with the NQF able to provide overall validity. The key, stressed McClellan, is to identify how to get quality measures validated quickly and effectively and in use in a real-world practice.

Wrapping up the discussion, Carolyn Clancy thanked Mark McClellan for his remarks and reiterated that there is an incredible urgency to move forward now. We need to bring our efforts together as expeditiously as possible, she said, in a way that is credible and can be implemented by physicians.

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