National Strategy for Quality Improvement
(PPACA §§ 3011, 10302)
- National Strategy. Directs HHS to establish a national strategy to improve the delivery of health services, patient outcomes and population health and identify national priorities for such improvement (taking into consideration recommendations of the entity under contract with Medicare (under SSA § 1890(a)) regarding a national strategy and priorities for health care performance as well as input from other stakeholders). Directs HHS to identify national priorities for such improvement. Requires such priorities to:
- Have the greatest potential for improving outcomes, efficiency and patient-centeredness of care for all populations.
- Identify areas in the delivery of health services that have the potential for rapid improvements in quality and efficiency.
- Address gaps in quality, efficiency, comparative effectiveness information, health outcomes measures and data aggregation techniques (taking into account the limits on the use of evidence or findings from comparative effectiveness research specified under new SSA § 1182, as added by PPACA § 6301).
- Improve federal payment policy to emphasize quality and efficiency.
- Enhance the use of health care data to improve quality, efficiency, transparency and outcomes.
- Address health care provided to patients with high-cost chronic diseases.
- Improve research and dissemination of strategies and best practices to improve patient safety and reduce medical errors, preventable admissions and readmissions and health care-associated infections.
- Reduce health disparities.
- Coordination with States. Requires HHS to coordinate and consult with state Medicaid and CHIP agencies in developing and disseminating strategies, goals, models and timetables consistent with the national priorities.
- Strategic Plan. Requires national strategy to include a comprehensive strategic plan that must be updated at least annually. Requires the strategy to achieve the identified priorities that addresses at minimum:
- Coordination among agencies within HHS, including use of common quality measures, where available. Specifies that quality measures used be those identified by HHS under SSA § 1139A (child health quality measures for Medicaid and CHIP), SSA § 1139B (a new provision under this bill adding adult health quality measures under Medicaid – see PPACA § 2701) or endorsed under SSA § 1890 (the Medicare performance measurement provision noted earlier).
- Agency-specific strategic plans and annual benchmarks for each agency.
- Regular reporting by the agencies on the implementation of the strategic plan.
- Strategies to align public and private payers regarding quality and safety efforts.
- Incorporating quality improvement and measurement into the strategic plan for HIT required by the ARRA of 2009.
- Initial and Updated Strategies. Requires HHS to submit its initial recommended strategy to Congress by 1/1/11 and to submit annual updates to that strategy thereafter. Requires each update to include:
- A review of the short- and long-term goals of the national strategy and any gaps in such strategy.
- An analysis of the progress in meeting such goals and any barriers to such progress.
- Information reported under current child health quality measures for Medicaid and CHIP (under SSA § 1139A); and, after 1/1/14, the new adult health quality measures under Medicaid under new SSA § 1139B (as created by PPACA § 2701).
- Quality Internet Website. Requires HHS to create an Internet website by 1/1/11 to make public information regarding the national priorities, the agencyspecific strategic plans and other information HHS determines to be appropriate.
Interagency Working Group on Quality
Requires the President to convene an Interagency Working Group on Health Care Quality.
(PPACA § 3012)
- Goals. Sets the following goals for the Working Group:
- Collaboration, cooperating and consultation between federal departments and agencies re: developing and disseminating strategies, goals, models and timetables consistent with the national priorities developed under PPACA § 3011.
- Avoidance of duplication of quality improvement efforts and resources and a streamlined process for quality reporting and compliance requirements.
- Assessment of the alignment of quality efforts in the public and private sectors.
- Composition. Specifies that the Working Group will be composed of senior level representatives of HHS, CMS, NIH, CMC, FDA, HRSA, AHRQ, the Office of the National Coordinator for HIT, SAMSA, the Administration for Children and Families, the Departments of Commerce, Labor, Defense, Education, and Veterans Affairs, OMB, the U.S. Coast Guard, the Federal Bureau of Prisons, NHTSA, the FTC, the SSA, OPM, the Veterans Health Administration and any other federal agencies and departments with activities relating to improving health care quality and safety, as determined by the President. Specifies that HHS will chair the group, with other members serving as Vice Chair on a rotating basis.
- Report. Requires the group to make an initial report to Congress by 12/31/10 and annually thereafter, and to make this report available on a public
Development of Quality and Outcome Measures
(PPACA §§ 3013, 10303)
- Identification of Quality Measures. Requires HHS, in consultation with AHRQ and CMS, to identify, not less often than every 3 years, gaps where no quality measures exist and existing quality measures that need improvement, updating or expansion, consistent with the national strategy under PPACA § 3011, for use in federal health programs. Directs HHS to consider, in identifying such gaps:
- Any gaps identified by the entity under contract with HHS under SSA § 1890(a) and other stakeholders.
- Current child health quality measures for Medicaid and CHIP (under SSA § 1139A)
- New adult health quality measures under Medicaid under new SSA § 1139B (as created by PPACA § 2701)
- Quality Measure Development Grants
- Directs HHS to award grants, contracts or intergovernmental agreements to eligible entities to develop, improve or update such quality measures. Sets standards for entities to be eligible for such grants. Gives priority to development of measures that allow assessment of:
- Health outcomes and functional status of patients.
- Management and coordination of care across episodes of care and care transitions across the continuum of providers, settings and health plans.
- Experience, quality and use of information provided to and used by patients and caregivers to inform decision-making about treatment options.
- Meaningful use of HIT.
- Safety, effectiveness, patient-centeredness, appropriateness and timeliness of care.
- Efficiency of care.
- Equity of health services and health disparities.
- Patient experience and satisfaction.
- Use of innovative strategies and methodologies identified under new PHSA § 933 (as added by PPACA § 3501).
- Other areas determined appropriate by HHS.
- Quality measures developed by grantees must address the gaps identified by HHS, support other measures required to reported under the SSA, and: 1) to the extent practicable, be able to be collected using HIT; 2) be free of charge to users of such measures; and 3) be publicly available on an Internet website.
- Requires HHS to ensure that grants or contracts are coordinated with those awarded under SSA §§ 1139A and 1139B.
- Quality Measures under CMS. Amends SSA § 1890A (added by the bill) to direct CMS, in consultation with AHRQ, to develop quality measures for use under the Social Security Act. Requires that at least half of the $375 million appropriated for this provision ($75 million for each of FYs 2010-2014) be spent on this subsection.
- “Quality Measure.” Defines this term as a standard for measuring the performance and improvement of population health or of health plans, providers and other clinicians in the delivery of health care services.
- Outcomes Measure Development. Requires HHS to develop and update (not less than every 3 years) provider-level outcome measures for physicians, hospitals and other providers determined appropriate by HHS. Requires such measures to include outcome measures for 1) acute and chronic diseases, including, as feasible, the 5 most prevalent and resource-intensive acute and chronic medical conditions; and 2) primary and preventive care, including, as feasible, measures for care of distinct patient populations.
- Goals. Such measures are intended to address issues regarding risk adjustment, accountability and sample size; include the full scope of services in a cycle of care; and include multiple dimensions.
- Timing. Requires HHS to develop at least 10 measures for acute and chronic disease by 24 months after enactment and at least 10 measures for primary and preventive care by 36 months after enactment.
- Hospital-Acquired Conditions. Requires HHS, to the extent practicable, to publicly report on measures for hospital-acquired conditions currently used by CMS for adjusting hospital payments.
Quality and Efficiency Measures
(PPACA §§ 3014, 10304)
- New Duties for Consensus-Based Entity. Gives new duties to the consensus-based entity under contract with Medicare (under SSA § 1890(a)) to make recommendations on a national strategy and priorities for health care performance and endorse measures for standardized health care performance. These new duties include:
- Identifying Gaps in Quality and Efficiency Measures. Requires the consensus-based entity to provide a report identifying gaps in endorsed quality and efficiency measures and areas in which evidence is insufficient to support endorsement of quality/efficiency measures and where targeted research may address such gaps.
- Selection of Quality and Efficiency Measures. Requires the entity to convene a multi-stakeholder group to provide input on the selection of quality and efficiency measures endorsed by the entity as well as measures used or proposed to be used by HHS and on national priorities for performance improvement developed under PPACA § 3011. Establishes transparency requirements for the multi-stakeholder group. Requires the consensusbased entity to report the input of the group to HHS annually, beginning 2/1/12, and HHS to determine to use recommended quality and efficiency measures only after taking into account this input. Requires HHS, no later than 12/1 of each year (starting with 12/1/11), to make the list of quality and efficiency measures under consideration by HHS available to the public.
- Impact Assessment. Requires HHS to assess the quality impact of the use of endorsed measures no later than 3/1/12 and at least once every 3 years thereafter, and make such assessment available to the public.
- Dissemination. Requires HHS to establish a process for disseminating endorsed quality and efficiency measures.
- Periodic Review of Measures. Requires HHS to periodically (no less than once every 3 years) review the quality measures in use and determine whether to continue using them or to phase them out.
- Funding. Provides for the transfer from the Medicare trust funds to CMS of $20 million for each of FYs 2010-2014.
Data Collection and Reporting
(PPACA §§ 3015, 10305)
- Data Collection and Analysis
- Requires HHS to collect data on quality and resource use measures from information systems used to support health care delivery to implement the public reporting of performance information.
- Permits HHS to award grants to entities that enable summary data that can be integrated and compared across multiple sources. Eligible entities must:
- Be: 1) a multi-stakeholder group that coordinates the development of methods and implementation plans for consistent reporting of summary quality and cost information; 2) an entity capable of submitting summary data for particular populations; or 3) a federal Indian Health Service program.
- Promote the use of systems that provide data to improve and coordinate patient care.
- Support the provision of timely, consistent quality and resource use information to health care providers, and other groups, with an opportunity for providers to correct inaccurate measures.
- Agree to report measures on quality and resource use to the public.
- Match funds with $1 for each $5 of federal funds provided under the grant.
- Public Reporting. Requires HHS to make available to the public, through standardized Internet websites, performance information summarizing data on quality measures. Such information shall include information on clinical conditions and, where appropriate, shall be provider-specific and disaggregated and specific enough to meet the needs of patients with different conditions.
- Requires information to be tailored to the different needs of providers, practitioners, patients, consumers, researchers, and other stakeholders.
- Requires HHS to consult with the consensus-based entity under SSA § 1890(a) and other entities as appropriate to determine the type of information that is useful to stakeholders and the format that will best facilitate use of the reports. Requires the entity to convene a multi-stakeholder group to provide input on the design and format of the website.
- Funding. Appropriates funds as necessary for FYs 2010 through 2014.
Clinical Practice Guidelines
Amends MIPPA § 304(b) (which requires HHS to contract with the Institute of Medicine to study and report on the best methods for developing clinical practice guidelines) to use the results of that study to identify existing and new clinical practice guidelines developed using such best methods. (PPACA § 10303(c))
- Availability of Medicare Data for Performance Measurement. Starting 1/1/2012, HHS may give (for a fee) standardized extracts of Medicare claims data for specified geographic areas to qualified public and private entities to evaluate provider performance. (PPACA § 10332)
- “Physician Compare” Website. No later than 1/1/2011, HHS will develop a website on Medicare physicians participating in the PQRI program, and by 1/1/13, implement a plan to publicly report information on physician performance. To the extent practicable, HHS will include data reflecting care to all patients seen by physicians, and appropriately attribute care when multiple providers are involved in caring for a patient. Report to Congress due 1/1/15. (PPACA § 10331)
- Better Diabetes Care. HHS and CDC will issue biennial national and (if possible) state diabetes report cards showing aggregate health outcomes (PPACA § 10407).
- Facilitating Shared Decision-Making. Establishes standards and certification of patient-decision aids for “preference sensitive care” – where clinical evidence does not clearly support one treatment option – and grants for their implementation. (PPACA § 3506)
- Rx Drug Benefit and Risk Information. FDA determines whether to add standardized summaries of benefits and risks to Rx drug labels. (PPACA § 3507)
- Improving Women’s Health. Establishes an Office of Women’s Health and a National Women’s Health Information Center to facilitate sharing information regarding health promotion, preventive services, research advances and education in appropriate use of health care services. (PPACA § 3509)
- Young Women’s Breast Cancer. CDC conducts national education campaign to increase awareness of breast health issues. (PPACA § 10413)
Comparative Effectiveness Research
Comparative Effectiveness Research (CER). Establishes a private, nonprofit Patient-Centered Outcomes Research Institute to identify national priorities for research and carry out research projects to evaluate and compare health outcomes and clinical effectiveness, risks and benefits of 2 or more medical treatments/services/items. Governed by a Board consisting of AHRQ and NIH Directors and 19 members (appointed by the Comptroller General) representing consumers, providers, payers, drug/device makers, researchers and federal and state health programs. Funded by the Patient-Centered Outcomes Research Trust Fund that collects $1 multiplied by the number of lives covered under each health insurance policy or self-insured health plan, and Medicare Part A and B in FY 2013, and $2 (growing at the rate of per capita growth in health expenditures) in 2014-19. (PPACA §§ 6301, 10602)
- Limits. Places conditions on HHS uses of CER, including that HHS may not deny coverage of items/services under Medicare solely on the basis of CER, or use CER that values older, disabled or terminally ill lives lower than younger, non-disabled or not terminally ill lives. The Institute may not establish cost-effectiveness based on dollars-per-quality adjusted life year or similar measures.
- Office of Communication and Knowledge Transfer within AHRQ. Creates tools to broadly disseminate CER findings to providers, patients, payers and policy makers. (PPACA § 6301)
Other Quality Improvement
- Center of Excellence for Depression. HHS awards grants to educational or research institutions to establish national centers of excellence for depression to develop and carry out innovative treatments. (PPACA § 10410)
- Programs for Congenital Heart Disease. CDC establishes a National Congenital Heart Disease Surveillance System, made available to public and researchers. (PPACA § 10411)
- Clinical Education Demonstration. HHS matching grants (5:1) to institutions of higher education to develop curricula integrating quality improvement and patient safety in the education of health professionals. (PPACA § 3508)
- Patient Navigator Program. Extends existing Navigator program indefinitely, and requires that entities receiving grants to provide patient navigator services meet minimum core proficiencies. (PPACA § 3510)
- Public Access Defibrillation Programs. Adds requirements that current program be administered by an organization with expertise in pediatric education/medicine, electrophysiology and sudden death. Extends authorization of appropriations through 2014. (PPACA § 10412)
- Key National Indicators. Establishes a Commission on Key National Indicators that will work with the National Academy of Sciences to determine how best to establish a key national indicator system for the U.S. (PPACA § 5605)
Nursing Home Transparency
Improving Transparency of Information. New disclosure requirements regarding the ownership of a facility and accountability requirements for SNFs and a new compliance and ethics program to prevent/detect violations and promote quality. (PPACA §§ 6101, 6102)