Remarks by CMS Administrator Seema Verma at the 2020 CMS Quality Conference
(As prepared for delivery – February 25, 2020)
Thank you. It hardly seems like a year since we unveiled CMS’ 16 strategic initiatives. I couldn’t be prouder or more thankful for the hard work of the CMS team, and the efforts of all of you in the audience. As we work on these initiatives, we are also quantifying and measuring our progress and have identified objectives and key results for each to hold ourselves accountable.
CMS also has three main objectives, which are:
Improve the quality and affordability of healthcare for all Americans; drive American healthcare towards payment for value, not volume; and lower the rate of growth in America’s healthcare spending.
As you can see, quality is a top tier objective. Without it, efforts to lower cost and improve access are meaningless. What good is health insurance, if the care you get is shoddy?
There is a unique role for government in ensuring quality and affordability in healthcare. Just as it sets sanitary guidelines for restaurants and regulations for airline safety, government should define essential health and safety requirements to protect consumers. Consumers should feel confident that government is doing its part to ensure that hospitals provide safe care, that nursing homes are places where we want our loved ones to reside, that laboratory tests are accurate, and that hospice care is provided with dignity.
CMS has an outsized role in quality not only because we are the nation’s largest insurer covering more than 130 million Americans, but because we set the safety and quality guidelines for every healthcare facility that receives Medicare reimbursement. We believe government is responsible for creating and preserving a level playing field for competition. That involves setting guardrails and minimum standards so patients are protected and providers can compete to provide the highest quality care possible. It involves ensuring that performance can be measured and that data is transparent so patients can make informed choices when selecting providers.
The Trump Administration has taken many actions over the past three years that demonstrate a renewed focus on quality. They include several Presidential executive orders on quality and price transparency, Advancing American Kidney Health, Strengthening Medicare. In implementing these executive orders, CMS is doing its part to advance the Trump administration’s vision for quality.
So today I want to unveil CMS’ new, reimagined quality strategy that will implement that vision. Last year, we launched a framework for ensuring safety and quality in nursing homes. This framework has shaped all of our work on nursing home quality, and in fact, was so successful that we decided to replicate it across the agency and in all our programs in 2020 and beyond.
First, we will establish clear and reasonable expectations for quality by setting government standards and quality measures… in other words, the rules of the road. Second, we will strengthen our oversight and enforcement of those standards to ensure accountability. Third, we will promote transparency, competition, and consumer choice by providing the public with the information needed to make decisions about their care; and fourth, we will work to modernize quality improvement efforts for all through advances in data analytics and technology, while prioritizing resources for those that need it most.
Allow me to take each pillar in turn.
When patients visit a healthcare provider in America, they expect a certain standard of care. Government has a solemn obligation to safeguard that confidence and security on their behalf and to prevent harm. Unfortunately, twenty years after the release of the landmark publication Too Err is Human, which shined a light on the frequency of adverse events and their consequences, we continue to see chilling instances of unacceptably poor care.
Just last year a patient received the wrong blood due to a mislabeling of blood specimens. Tragically, this resulted in the patient’s death. An investigation of the facility responsible revealed more than 100 other incidents involving problems with labeling of blood laboratory specimens.
We’ve seen a nursing home failing to lock its doors, enabling a resident with dementia to wander almost a mile away, later to be found face-down in a sewage drain with broken bones. Such instances represent dramatic, sickening failures of the system, and underscore the need for robust government action, as well as collective action from all of us to safeguard patients.
But government action should not lead to a set of overly prescriptive regulations that stand in the way of patient care, thwart innovation and drive up costs. Government must set standards that are reasonable and focused on outcomes rather than simply adding to administrative burden that takes time away from providing quality care.
In early in 2017, President Trump ordered federal agencies to cut the red tape across government agencies. Our response to the President’s directive started with a comprehensive review of our rules under our Patients over Paperwork initiative. Last September, we finalized revisions to the conditions of participation for a dozen different settings of care, including hospitals. These common-sense changes strip away onerous process rules and replace them with requirements focused on outcomes and – to the greatest extent possible – alignment across provider types for consistency and fairness.
All told, the Patients over Paperwork initiative has already saved an estimated $6.6 billion and 42 million burden hours through 2021 – time and resources that can instead be devoted to delivering high-quality care to patients.
Another example of our efforts in this area is our modification of standards for organ transplant organizations, under President Trump’s Advancing American Kidney Health Initiative. 113,000 Americans are on waitlists for lifesaving organ transplants – 20 of whom die each day. We know the nation is currently discarding nearly 20% of the kidneys made available for transplant. So we issued a historic proposal that will increase the supply of life-saving kidney transplants for people that are on these waitlists.
As part of our Patients over Paperwork initiative, we’ve also started to tackle the world of quality measurement. Now as an audience of quality professionals, we all have our favorite quality metrics….but the reality is there are too many favorites and the reporting of these metrics has been an expensive burden on the healthcare system.
The Meaningful Measures initiative I launched in 2017 introduced a framework which sought to focus measurements on outcomes, reduce burden on clinicians, and align measures across all our programs.
We started with a multi-stakeholder process to get input, the response was tremendous. It helped shape our effort to eliminate dozens of unnecessary, or topped out measures. Our efforts have eliminated 18 percent of all measures for a projected savings of $128 million and 3.3 million burden hours through 2020.
The Meaningful Measures framework also informed our overhaul of the Merit Based Incentive Program or MIPs. Instead of hundreds of measures across multiple categories, we are establishing MIPS Value Pathways for which physicians will be able to pick sets of measures that clearly relate to their specialty or the type of patients they see. Most importantly, measures under MVP will be developed with the help of physician specialty societies, so they will be meaningful to physicians.
We are now embarking on the launch of Meaningful Measurement 2.0. It will go far beyond the mere elimination of measures and point us toward a future in which quality is only measured electronically. Imagine a world in which clinicians don’t have to lift a finger – where quality measures can be seamlessly transmitted from their EHRs. This data might then be combined with other data on claims, inspections, or surveys. In an era of artificial intelligence, this might mean more easily identifying providers delivering high quality care and those that need interventions. In this world, we would be able to identify quality problems before patients are harmed and intervene accordingly. That’s the vision of Meaningful Measures 2.0.
We are also working to more fully incorporate the voices of patients in measure development. I know we have patients and families in the audience today. We want to measure what matters to you.
Much of this progress will be made by leveraging technology through the Fast Healthcare Interoperability Resources (FHIR) based standards for exchanging clinical information through Application Programming Interfaces (API). FHIR allows clinicians to submit quality information through digital sources once for many uses. This will pave the way for stakeholders to submit data to a centralized submission system. The receiving system can then perform the measure calculations and exchange data and results with several applicable quality programs, removing the burden from the submitter to submit data multiple times. You will hear more about our Meaningful Measurement 2.0 framework in the next several months.
With the basic rules of the road in place, we can now move to enforcing them. That brings us to our next pillar, Strengthening Oversight and Enhancing Enforcement. And allow me to say upfront: this is not business as usual.
Medicare’s basic safety and quality standards are useless without robust enforcement. CMS has broad enforcement tools at our disposal, starting with our relationship with state survey agencies and Accrediting Organizations. We don’t directly inspect the 5,000 hospitals and 15,000 nursing homes that participate in Medicare. We partner with states and Accrediting Organizations to conduct inspections on our behalf. As part of this process, we want to make sure that every provider is held to the same standard, no matter who inspects them. Unfortunately, this has not always been the case.
For example, one of CMS’ key enforcement tools is Civil Money Penalties, or CMPs. These penalties can be levied on nursing homes in cases of serious noncompliance that endanger patients. According to our own data, we saw that CMPs were being levied at a level eight times greater in some parts of the country than in others. Even accounting for geographic differences in quality of care, this variation was one that called for an explanation.
CMS has a network of 10 regional offices across the country, and while they all operate under the same set of rules, we saw opportunities for better coordination, communication and alignment. So, last year, we reintegrated our regional offices with the central office to ensure our policies are consistently applied across the nation. We are now using the same tools, conducting reviews in a more systematic and objective manner, and using data analytic tools to evaluate their performance. We are also submitting cases with significant issues to a committee of CMS staff from across the nation to ensure that enforcement decisions fair and consistent.
Just as our regional offices underwent a complete overhaul so must our relationship with states and accrediting organizations acting on behalf of CMS.
We have improved oversight of State Survey Agencies by clearly communicating our expectations to them – and to the nursing homes they inspect – so they have no question about how we measure performance. For example, we have seen inconsistency related to how state survey agencies perform their role. Last year, we revised the program used to assess SSA’s performance, known as the State Performance Standards System. These revisions include new and better applications of data to monitor performance and ensure states are protecting residents from harm consistently across the country. Moving forward, we’re looking at ways to set clearer timelines for SSAs, so they know the expectations for arriving onsite to investigate allegations of abuse and neglect, and if necessary, refer to law enforcement for additional support.
We’re also looking at ways to enhance our oversight of accrediting organizations. In recent years, we’ve identified inconsistencies in the way accrediting organizations inspect providers. Some even use standards that differ from our own, which is simply not acceptable. Receiving CMS’ authorization to inspect and deem healthcare providers compliant with Medicare’s quality standards is nothing short of assuming a sacred public trust responsibility. But an increasing amount of evidence indicates that accrediting organizations are not living up to that high bar.
The recent spate of serious deficiencies at large hospitals – rising to the level of patient harm and sometimes even death – that accrediting organizations had deemed compliant with Medicare’s standards is deeply concerning to CMS. Our concerns are only heightened by the growing trend of accrediting organizations providing fee-based consulting services to the same organizations they accredit – a glaring conflict of interest. It’s worth noting that we don’t allow these kinds of relationships in other parts of CMS, like QIOs in Medicare or external reviews in Medicaid. We have already put out an RFI to seek comment from stakeholders to ascertain the scope of the issue. You’ll see more from us on this issue in the near future.
The government’s obligation to develop and enforce essential standards for safety and quality is a critical one, but it’s only the start of the story. Those essential standards represent the groundwork for a safe, fair, and competitive market, which empowers patients to make decisions for themselves… Which brings me to the third pillar of promoting transparency to foster competition and consumer choice.
Last June, President Trump released an executive order on Price and Quality Transparency. The purpose of this order was to empower patients to choose the healthcare that is best for them. To make fully informed decisions about their healthcare, patients must know the price and quality of a good or service in advance.
Price transparency often makes the headlines, but quality transparency is equally indispensable. If we fail to equip patients with accurate and understandable data about the quality of their healthcare providers, we have a market in name only. Patients may choose a higher-priced provider under the faulty assumption that they are providing high quality care. In short, patients will be unable to make good decisions about value.
CMS is doing its part to promote transparency. We are making more quality data available through an API format, so innovators in the field can also use the data and help make it useful for patients. We are also improving CMS’ “Compare” tools, our most important means of publicizing quality of care information for patients. Later this year, we will launch a new tool that houses them all under one roof – giving patients a consistent look and feel. Patients will be able to go to one source for quality data on different types of providers. If you stop by CMS’ booth, or one of our breakout sessions on Wednesday afternoon, you can even test out a prototype and share your feedback.
These improvements will build on major actions we took this past year across our programs. For instance: the decision to place a loved one in a nursing home is a wrenching one. In the past, prospective residents could access information about nursing homes cited for abuse, but only by clicking through multiple screens. In short, you had to know where and how to look. Last year, we added a new alert icon to our Nursing Home Compare website that identifies providers cited for significant cases of abuse or neglect.
In the individual market, we required all exchanges to publicly report 2019 quality rating information on their websites to help consumers compare and shop for qualified health plans. Likewise, we’re proposing additional improvements to the Star Ratings program for MA Plans. The agency is proposing to increase the impact that patient experience and access measures have on a plan’s star rating, as we recognize that one of the best indicators of a plan’s quality is how enrollees feel about their coverage experience.
And in Medicaid, we released a new Scorecard to increase public transparency about the programs’ administration and outcomes. For CMS, quality transparency is a full-spectrum, system wide endeavor spanning all our programs.
Last, but certainly not least, is revamping our approach to quality improvement activities at CMS. Traditional quality improvement activities have been effective in important ways: such as a nearly 9% reduction in readmissions to hospitals, a 32% decrease in catheter-associated urinary tract infections, a 25% decrease in central line associated blood stream infections, and a significant reduction in the rates of other areas of harm such as surgical site infections. Most of you in this room contributed to these results; thank you for your hard work.
While these efforts have helped to move the needle, a more fundamental and transformational change is called for. Estimates persist of thousands of errors still occurring in this country each year. In many cases, we continue to pay for substandard care.
Quality improvement should be top of mind for every healthcare provider in the country, from the largest regional health conglomerate to the smallest solo physician practice in a rural town. But while quality expectations are always the same, the resources needed to achieve them are not. The larger systems are more likely to have all the necessary resources at its disposal to commit to the kinds of internal process and personnel – and even cultural – changes necessary to improve quality. But that small-town doctor’s office may be the only source of primary care for miles, and may not have the means to make the same changes.
As many of you are aware, we have made some changes in the QIO program this year. The work of QIOs is important, and going forward, we want to focus their expertise on providers that need it most.
The new QIO goals will focus on increasing patient safety, chronic disease management, quality of care transitions, nursing home quality, and certain behavioral health areas. Going forward, the work of QIOs will be targeted to low performing providers in rural areas, who serve vulnerable populations.
At the same time, it’s time for larger health systems to continue to double down on quality improvement by their own making investments in quality, independent of government funded assistance.
At every turn, the Trump Administration is seeking to empower patients to be better consumers. For too long, when navigating the healthcare system, patients have been buffeted by winds outside their own control: they have lacked understandable and accessible information on price and quality; they have not been adequately protected against lapses in quality; and they have had their choices curtailed by a system that doesn’t give them the means to reward high quality by voting with their feet. We are committed to reversing that paradigm, to setting and enforcing standards for quality that are focused on outcomes, rather than processes – and after that leaving quality in the hands of consumers and providers to work out between themselves.
So in closing, thank you for coming. We have an exciting few days planned. You’ll hear from our top leadership about our 16 strategic initiatives, with which the Trump Administration is charting a path toward higher quality and lower cost care for all Americans. Thank you.
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