Q&A with Dennis Wagner, Jeneen Iwugo and Dr. Paul McGann: The QIO Program in 2019

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Photo of CMS Leadership: Dennis Wagner, Jeneen Iwugo, Dr. Paul McGann
Dennis Wagner (l.), Jeneen Iwugo (m.), Dr. Paul McGann (r.), CMS

QIO News recently sat down with three leaders of the Quality Improvement and Innovation Group (QIIG) within the Centers for Medicare & Medicaid Services’ (CMS) Center for Clinical Standards and Quality (CCSQ): Dennis Wagner, director; Jeneen Iwugo, deputy director; and Dr. Paul McGann, chief medical officer for quality improvement. They shared their perspectives on the Quality Improvement Organization (QIO) Program as it prepares to enter the final year of its current five-year performance period.

Q. What were some of the QIO Program’s most significant achievements this past year?

Dr. Paul McGann: Something that sticks out to me is our announcement in June that collaborative work by Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) and Hospital Improvement Innovation Networks (HIINs) led to an estimated 350,000 fewer hospital-acquired conditions, including adverse drug events and injuries from falls, between 2014 and 2016. This resulted in approximately 8,000 fewer deaths and an estimated $2.9 billion in cost savings, according to Agency for Healthcare Research and Quality (AHRQ) data. We also have seen a lot of success in the Program’s work to increase the engagement of people with diabetes in self-managing their condition through diabetes self-management education (DSME), a part of CMS’ Everyone with Diabetes Counts (EDC) program. Another category worth mentioning, particularly because it is a vulnerable population, is the reduction in antipsychotic medication use (from 18.73 percent in August 2014 to 14.10 percent in August 2018) among residents living in long-term care facilities, thanks to the National Nursing Home Quality Improvement Campaign

Dennis Wagner: I also want to recognize the tremendous work that we’ve seen in supporting clinicians. Even with many clinicians not knowing about the brand new Merit-based Incentive Payment System (MIPS), thanks in large part to the QIO Program, we were able to hit a 91 percent participation rate in the first year of the Quality Payment Program (QPP), exceeding our goal of 90 percent. It’s also worth mentioning that an analysis done early on by the Office of the Inspector General flagged that rural providers were potentially going to have difficulty participating in the QPP. However, 94 percent of eligible rural clinicians participated in the first year, making it clear that the Program’s commitment to excellent customer service — one of CMS Administrator Seema Verma’s top priorities — has paid off. By teaming with the Transforming Clinical Practice Initiative (TCPI), the QIO Program, together with Small Underserved Rural Support (SURS) contractors, knocked it out of the park with customer satisfaction. We are in the middle of implementation of year two right now, and early data shows that clinician intent to participate” actually exceeds where we were last year at this same point in time. Congratulations to all involved!

Jeneen Iwugo: The QIN-QIOs have so many initiatives worth noting, as Paul and Dennis have mentioned, but I want to touch on the Beneficiary and Family Centered Care (BFCC)-QIO work. The two BFCC-QIOs have completed an impressive total of over 900,000 reviews and two million beneficiary calls during the current performance period. The BFCC-QIOs have responded to the positive beneficiary feedback from their immediate advocacy and patient navigation work by expanding those options and making them available to more beneficiaries. And, as a result of their responsiveness, the BFCC-QIOs have a patient and family engagement satisfaction rate of over 90 percent.

Q. What are your top priorities for the Program in 2019?

JI: My top priority for the QIO Program in 2019 is to leverage our partnerships to address the nation’s opioid crisis. While we’re not able to rewrite our contracts to add new work, we are finding efficient and strategic ways to use our current work structure for new priorities to align with major CMS and departmental priorities. For example, the Medication Management and Opioid Affinity Group and the Campaign for Meds Management both stem from ongoing work in reducing adverse drug events for opioid and other prescriptions. We’re using the tools we already have in front of us to get the momentum going and to generate improvement. One example of how this work is effecting real change is from Telligen Quality Innovation Network, which responded to the charge we made to the community by providing advanced data and analytics support to a network of over 10 hospitals to change and improve their pain management practices. The hospitals were able to achieve a 36 percent reduction in the use of opioids and a 31 percent increase in the use of alternative medications over six months. We also have several promising QIO Special Innovation Project (SIP) contracts with organizations focused on increasing naloxone dispensation and decreasing opioid-related emergency room visits, admissions and readmissions, and the number of patients on high opioid doses.

DW: Alignment with new and emerging priorities is a big focus for us. We have the opportunity to use our current platforms to align with emerging priorities and position ourselves for aggressive results on things like opioids. We’re also looking to generate results in areas like burden reduction and high-cost/high-impact conditions like cardiac health, diabetes and end-stage renal disease (ESRD), where we stand to make the biggest gains and have already done so. Another goal is to make it as easy as possible for providers working with us to generate improvements and outcomes in their work, so we’ve put a premium on human-centered design. Something else we are emphasizing is being smart and current on our use of data to drive improvement. This means being in direct communication with providers about using data for insights into high-risk populations and more. And finally, being timely in our communication with stakeholders about the QIO Program’s next performance period — the 12thScope of Work — is a huge priority.

PM: One more dimension to this is the Strategic Innovation Engine (SIE) projects, which are actually foreshadowing the future. We’re investing in improving the care of people with opioid dependence and misuse, with chronic kidney disease, etc.

Q. The QIO Program is entering the last year of its five-year performance period. How do you keep up the momentum in the home stretch?

JI: I use a few fitness apps to track my progress toward my personal fitness goals, and as I get closer to each new goal, these apps know it gets harder for me to succeed. In the same way these apps encourage me to continue, we are going to be doing everything we can to transparently show our Program’s quality improvement data to track where we are and map out where we need to be to reach our goals. I’m also looking forward to the 2019 CMS Quality Conference, which is always one of the most motivational events I attend each year. I’m looking forward to enjoying the three days with my quality improvement partners and am ready to leave in action with a list of commitments and reasons to take action in the next year.

PM: One of our favorite phrases at CMS is, We don’t wind down, we wind up!” We’ll be keeping that in mind and making sure to continue setting stretch, bold goals.

DW: First, we make sure we deliver on the results to which we committed. In many cases, QIOs are meeting or exceeding nearly all of their contract goals, and that’s excellent news. We are clearly setting records this contract period. If you’re an individual or organization that has met your targets, I say, Go further!” Align with what is coming and the emerging priorities. Also, we must challenge ourselves to go beyond quantitative targets. If you’ve gotten where you need to be, it means you need to go further and create space to get even better at other things — like the use of real-time data to inform and drive improvement with frontline provider partners!

Q. You mentioned the 2019 CMS Quality Conference. What are some specific things you are looking forward to at this year’s event?

DW: I always look forward to connecting personally with each other — the front line clinicians, patients, QIN- and BFCC-QIOs. I treasure and enjoy this immensely. There is a natural energy that comes from hearing best practices from people that are hitting it out of the park — the whole mindset of identifying what is working and spreading those ideas is a natural driver of success. Sharing our own learnings and successes, and hearing those of others is a huge source of energy. I use the Quality Conference to acquire and build up those individual acorns of energy,” so that I can use them in the months ahead when I inevitably encounter the natural obstacles and challenges that require commitment, action and stored up energy to transcend.

JI: We have a track record of being able to hear from a prestigious, impactful and extraordinary lineup of national leaders at the Quality Conference, and we plan to continue with that trend this year. We always aim high for plenary speakers and promise not to disappoint! 

Q. Anything else you’d like to share with QIO News readers?

PM: Quality improvement is, in a nutshell, change. When we critically examine our own performance and commit to doing better, regardless of whether it’s health care or some other metric of life, what it really means is we are committing to change. You discover over the years that change is part of what happens anyway, but 2019 gives us an opportunity to recommit to change. CMS is doing that. We’re changing our venue at the Quality Conference, changing/​aligning priorities with the new administration, etc. Because we are all quality improvers, we understand how to lead change, how to embrace change and how to get the most out of change.

DW: Quality improvement is also a system activity. Quality goes up when the system is performing well. A former CMS administrator uses the example of a car, which has a lot of parts working together. The comfort, speed, handling and cost-to-value ratio of the vehicle all add up to its quality, and we all know the difference between high- and low-quality cars. Quality improvement happens best when people are teaming within that system to make it successful. It is valuable when QIN-QIOs team up with ESRD Networks, when ESRD Networks team with external partners like the National Kidney Foundation, when Hospital Improvement Innovation Networks team with QIN-QIOs, when Practice Transformation Networks team with the American Health Quality Association (AHQA), and so on. Our partners and network work best when all of us are learning together — sharing best practices and data transparently. It does get tricky when we’re in a procurement period, and many of the same organizations are competing. We have to go through this five-year ritual that is important to guide our work and increase the value for government, but it is vital that we don’t allow the competition to stand in the way of the need for teamwork. We believe the new Network of Quality Improvement and Innovation Contractors (NQIIC) structure is a big step toward enabling both greater competition and greater teamwork. 

Going forward, all of us should expect that taxpayers and our funders will want more outcomes and more results toward ambitious goals at a lower cost. This is appropriate. The expectation is that we’re getting better and better at what we’re doing. We have a lot of room for improvement in health care, both on the cost and quality sides, so we need to challenge ourselves to do what we challenge the front-line performers to do, which is to do better, achieve higher quality, and to do it with less. And, I know that we are up to the challenge!