NHLBI Workshop
Data Needs for Cardiovascular Events, Management, and Outcomes
Centers for Medicare & Medicaid Services (CMS) - Dr. Marcel Salive
Outline of Talk
- Medicare Claims
- The bills submitted by hospitals (Part A) and physicians (Part
B) to CMS for reimbursement
- Medicare Coverage Process
- Ability to link to data collection
- Quality Improvement
- Expansion of public reporting
- Implementation of pay-for-performance
Medicare is the national health insurance program for:
- People age 65 or older
- Some people under age 65 with disabilities
- People with End-Stage Renal Disease
- 34.9 million covered lives in 2004
Three General Categories of Available Data
- Category 1: Medicare Eligibility & Enrollment Data
- Category 2: Medicare Claims Data
- Category 3: Medicaid Overview Data
The first category includes Medicare beneficiary eligibility and enrollment data. The second
category of data includes the Medicare data associated with fee-for-service
claims. The third category of data includes Medicaid eligibility, utilization,
and demographics data.
(Category 1) The Medicare Eligibility and Enrollment category contains
person-level entitlement information for Medicare beneficiaries. Each
time a claim for services rendered is received for adjudication and payment,
beneficiary entitlement status is verified using this information. The
Enrollment Database (EDB) is the designated CMS repository of enrollment
and entitlement data for persons who are or have ever been enrolled in
Medicare.
(Category 2) Medicare claims data constitutes the second category. Processing
claims for Medicare health insurance benefits is fundamental to the operation
of the Medicare program. CMS ensures that payments are made for services
that are medically appropriate, covered, and rendered to eligible beneficiaries
by qualified providers. The detailed claims records provide a unique source
of information on health care utilization and costs. From these records,
analytic files are created to support program and policy development and
evaluation, as well as health care analyses and research. The National
Claims History (NCH) is the CMS designated repository for all claims and
utilization data.
Data from both categories contributes to the beneficiary demographics
information that is maintained in the Enrollment Database (EDB), including:
name; temporary residence, & mailing addresses; FIPS state & county
codes; SSA state & county codes; date of birth; sex; representative
payee; and program service center.
(Category 3) The third category contains data that originates in the
State Medicaid Claims Processing systems. The types of data found in this
category include eligibility data, claims data, other encounter and utilization
information, and provider data.
Advantages of Using Medicare Claims for Surveillance
- Routinely collected
- Virtually the entire population of patients and providers
- Large numbers
- Tied to reimbursement, so is complete
- Fraud if not accurate
- Unique identifiers allow episodes of care to be linked for complete
follow-up
Part A (Hospital) Claims
- Unique patient and hospital ID
- Dates of admission and discharge
- Admitting diagnosis and acuity
- Procedures performed (ICD-9-CM)
- Medical diagnoses (ICD-9-CM)
- Discharge status
- Discharge destination
Part B (Physician) Claims
- Unique patient and physician ID
- Surgical and diagnostic procedures (CPT)
- Date of service
- Diagnosis for which service performed
Medicare Coverage
- Section 1862(a)(1)(A) of the Social Security Act
- Coverage and payment limited to items and services
- Found "reasonable and necessary"
- For treatment of illness or injury...
Steps to Medicare Coverage Determination and Payment
- Outside of CMS:
- Congress determines benefit categories
- FDA approves drugs/devices for market
- Within CMS:
What standards are used in an NCD
- Evidence of improved health outcomes
- Appropriate for Medicare population
- Could be replicated in provider community
Medicare ICD expanded coverage
- Effective 1/05
- Based on the results of SCD-HeFT trial
- Linked to submission of data to national ICD database
- Can answer residual questions regarding safety & effectiveness
in certain groups of patients & providers
- Initial hypotheses included in Decision Memo
ICD Implant Data Form
- One page printed form
- Data elements include:
- Demographics
- Patient history & clinical characteristics
- Medications
- Provider information
- Clinical indications
- Complications
CMS Vision of Quality: "The right care for every person every time,"
where the "right care" corresponds to the 6 Institute of Medicine aims
- Safety
- Effectiveness
- Efficiency
- Patient-centeredness
- Timeliness
- Equity
CMS Strategies For Promoting The Quality Council Vision
- Standards setting, regulation, enforcement
- Public reporting
- Payment policy including pay-for-performance
- Technical assistance
Upcoming work to Support This Vision?
- Launch the third phase of the QIO Program - promote the Quality Council
vision through infrastructure for public reporting and p4p and the provision
of assistance
- Lay foundation for evidence-based improvement in drug safety/quality
- Lay foundation for evidence-based improvement in efficiency of resource
use
Quality Measures
- Measures do not stay constant due to changes in care
- Measure refinement and development of new measures is needed
- Abstraction, electronic, and survey tools must be modified to support
data collection
- CMS will develop and implement data validation processes
- Maintenance and upgrades to IT infrastructure necessary to support
data collection, validation, and reporting.
Assistance Tools and Methodology
- Tools/methodologies needed to help providers seeking improvement
on new performance measures
- CMS needs to refine the tools and methods we are implementing
- New tools to support work on new measures
- Refined tools for work on measures that have not shown substantial
improvement
Single Measure Set, Multiple Uses...
- CMS using all or subset of measures for:
- Doctors office
- Medicare care management project
- Voluntary coordinated care improvement pilot
- Physician Group Practice demonstration
- External interest in common measure set...
- Physician specialty boards
- Health plans
- Purchasers
- Consumers
CMS Measurement Framework
- Build from previous work
- Use existing, accepted concepts or measures
- Align with other measures
- Public comments/forums
CMS Basic Requirements
- Must be scientific and clinical sound
- Evidenced based in guidelines
- Must be transparent (reproducible)
- Should not add burden to provider
- Should use existing data source when possible
Types of Measures
- Process: Blood pressure checked? Flu shot given?
- Outcomes: Mortality, morbidity, HgbA1c control
- Structure: Staffing levels, IT infiltration
Measure Alignment*
- AMA, NCQA and CMS worked to create a single set of measures for coronary
artery disease (CAD), congestive heart failure (CHF), hypertension (HTN),
diabetes mellitus (DM), and prevention
- JCAHO & CMS have aligned the reported hospital measures
* Alignment at the micro-specification level
Measure Development
- Identify existing relevant measures
- If none found or revisions required....
- Extensive input from expert clinicians
- Draft technical specifications & training manuals
- Build data collection tool if none exists
- Support warehouse construction, record layouts
- Multiple rounds of testing and refinement
- Validity testing (do I get the information I expected?)
- Reliability testing (does someone else get the same answer?)
- Send for endorsement
Risk Adjustment: Address risk adjustment and other data adjustment needs
- Inclusions and exclusions into the numerators and denominators
- Variety of other techniques available to adjust the data
- Result: measures calculated so that one has an 'apples to apples'
comparison
- May not always need to be risk adjusted
Endorsement of Measures: National Quality Forum
- Private non-profit entity to create standards for health care quality
- Working in partnership with many, including CMS, to develop consensus
around what measures are ready to be called standards
- Final step in a long development process
Contact Information
Websites: www.cms.hhs.gov/coverage
1-800-MEDICARE
www.medicare.gov
Marcel Salive, MD, MPH
410/786-0297
Marcel.Salive@cms.hhs.gov
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