10th Annual Utah's Health Services Research Conference - Data: What's available and how we are use...

Danielle A. Lloyd, MPH

Data: what’s available and how we

are use it is changing

March 16, 2015

Utah Health Services

Research Conference

2PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC.

Premier, Inc.

Our Mission: To improve the health of communities.

MAKE HEALTHCARE SUPPLY CHAIN EFFICIENT AND EFFECTIVE

DELIVER CONTINUOUS IMPROVEMENT IN COST AND QUALITY TODAY AND

ENABLE SUCCESS IN NEW HEALTHCARE DELIVERY / PAYMENT MODELS

INTEGRATE DATA AND KNOWLEDGE TO CREATE MEANINGFUL

BUSINESS INTELLIGENCE THAT DRIVES IMPROVEMENT

Uniting approximately 3,400 hospitals –

68% of U.S. community hospitals – and

110,000 alternate sites of care

74% owned by health systems

$41 billion in group purchasing volume

Integrating clinical, financial, operational

and population data

Insights into ~ 1 in every 3 U.S. hospital

discharges


Collaboratives harness data for performance improvement

Partnership for Patients

~450 hospitals (Premier’s HEN)

• CMS Innovation Center initiative

• Lower HACs (40%) and excessive readmissions (20%) by the

end of 2013

• More than 7% improvement in both in first 6 months

• Largest performance improvement collaborative in the U.S.

• Evidence-based care, cost, patient experience, harm and

readmissions

• Nearly 92,000 lives and $9 billion saved in 4.5 years

• Largest U.S. collaborative focused on bundled payment

• Identifying, constructing, measuring, operationalizing the

bundling of episode-based services across care continuum

• 43 markets of Medicare data; 21 major DRG opportunities

• Tethering the science of change to real-world impact

• Improving quality and reducing costs in high-impact acute

care and population health arenas

• Building accountable care capabilities around six core

structural components to improve care delivery while

containing costs

• Multiple systems in MSSP, Pioneer and other ACO models

QUEST® collaborative

~370 hospitals

Bundled payment collaborative

~95 hospitals

Performance improvement

research collaboratives

PACT™ collaborative

~385 hospitals

Leveraging technology-enabled collaborative methodology to create standard

measurements, accountability and process improvements


Political Environment


HHS Announcement

In three words, our vision for improving health delivery is about better, smarter, healthier.

If we find better ways to pay providers, deliver care, and distribute information:

Encourage the integration and coordination of clinical care services

Improve population health

Promote patient engagement through shared decision making

Incentives

Create transparency on cost and quality information

Bring electronic health information to the point of care for meaningful use

Focus Areas Description

Care Delivery

Information

Promote value-based payment systems

– Test new alternative payment models

– Increase linkage of Medicaid, Medicare FFS, and other payments to value

Bring proven payment models to scale

HHS AnnouncementBetter Care. Smarter Spending. Healthier People

We can receive better care. We can spend our health dollars more wisely. We can have healthier communities, a healthier economy, and a healthier country.

Source: CMS

Target percentage of Medicare FFS payments linked to quality and alternative payment

models in 2016 and 2018

2016

All Medicare FFS (Categories 1-4)

FFS linked to quality (Categories 2-4)

Alternative payment models (Categories 3-4)

2018

50%

85%

30%

90%

Source: CMS

Payment Taxonomy FrameworkPayment Taxonomy Framework

Category 1:

Fee for Service—

No Link to Quality

Category 2:

Fee for Service—Link to

Quality

Category 3:

Alternative Payment Models Built on Fee-

for-Service Architecture

Category 4:

Population-Based Payment

De

scri

pti

on

Payments are

based on volume

of services and not

linked to quality or

efficiency

At least a portion of

payments vary based on

the quality or efficiency

of health care delivery

Some payment is linked to the effective

management of a population or an

episode of care. Payments still triggered by

delivery of services, but opportunities for

shared savings or 2-sided risk

Payment is not directly

triggered by service delivery

so volume is not linked to

payment. Clinicians and

organizations are paid and

responsible for the care of a

beneficiary for a long period

(e.g. >1 yr)

Med

icar

e FF

S

Limited in

Medicare fee-

for-service

Majority of

Medicare

payments

now are

linked to

quality

Hospital value-

based purchasing

Physician Value-

Based Modifier

Readmissions/Hosp

ital Acquired

Condition

Reduction Program

Accountable care organizations

Medical homes

Bundled payments

Comprehensive primary care

initiative

Comprehensive ESRD

Medicare-Medicaid Financial

Alignment Initiative Fee-For-Service

Model

Eligible Pioneer

accountable care

organizations in years 3-

5

Source: CMS


Sustainable Growth Rate

SGR repeal and reform timeline

2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024

Sunset of existing quality value

penalties under PQRS, VBM, EHR

12/31/2017

Permanent repeal of SGR

0.5% update in physician payments (2014-2018)

0% update in physician base payments

(2019-2023)

APM participating providers exempt from MIPS; receive annual 5% bonus (2018-2023)

Merit-Based Incentive Payment System (MIPS) adjustments 2018

+/-4%

2019

+/- 5%

2020

+/- 7%

Tra

ck 1

Tra

ck 2

2021 & beyond+/- 9%

• CBO estimate of bipartisan, bicameral bill: @$122B/10 years

• Medicare extenders will add another @$25 - 30B to cost of bill

Cu

rre

nt

law 2018

4%

Physician Quality Reporting System Penalty2015

-1.5%

2016 & beyond

-2.0%

Meaningful Use Penalty (up to %)2015

-1.0%

2016

-2.0%

2017

-3.0%

2018-4.0%

Value-based Payment Modifier penalty (up to %)2015

-1.0%

2016

-2.0%

2017

-4.0% (NPRM)

2019 & beyond-5.0%

2018 & beyond

???%


21st Century Cures


21ST CENTURY CURES

CONSORTIUM ACT

Section 2001, creates Public-private

partnership to accelerate innovative

cures, treatments, and preventive

measures for patients.

Title II – Building the Foundation for 21st Century Medicine

SOFTWARE ACT

Sections 2061-2063, Provides

regulatory certainty for those

developing apps and health

information technologies.

BUILDING A 21ST CENTURY DATA

SHARING FRAMEWORK

Sections 2081, 2082, 2085, 2086, 2087,

2088, 2091, and 2092

Establishes a data sharing framework to

enable (1) patients and physicians to better

identify ongoing clinical trials, (2)

researchers and developers to use Medicare

data for improving quality of patient care,

and (3) a process for Congress to address

other issues identified by the President’s

Council of Advisors on Science and

Technology.

INTEROPERABILITY

Section 2181 includes

placeholder language for work

toward the goal of a national

interoperable health information

infrastructure.

NIH – FEDERAL DATA SHARING

Section 2201, would require those

receiving NIH grants to share their data,

subject to confidentiality and trade

secret protections.

ACCESSING, SHARING, AND USING HEALTH DATA FOR

RESEARCH PURPOSES

Section 2221, would unlock the research potential of data

siloed in health care facilities across the country and enable

patients who want to play a more proactive role in finding

better treatments or a cure for their disease to do so in a

responsible manner that continues to protect their privacy.


Biomedical research working group to reduce administrative burden

on researchers

Section 4002, would establish a working group composed of NIH and

stakeholders to provide recommendations on how to streamline the grant

process for researchers.

TITLE IV—ACCELERATING THE DISCOVERY,

DEVELOPMENT, AND DELIVERY CYCLE

TELEMEDICINE

Section 4181, would advance

opportunities for telemedicine and new

technologies to improve the delivery of

quality health care services to Medicare

beneficiaries.


Big Picture

Big Data


Measures Must Matter

Measurement should begin with the end in mind.

What are we trying to accomplish?

In Healthcare, our aim should be to deliver “value.”

• But how do you measure value?

• And value to whom: payer, purchaser, patient?

15

“All of the objectives and measures on a balanced scorecard, financial and non-financial should be derived from the organization’s vision and strategy.”

- Kaplan and Norton, The Strategy Focused Organization, 2001

Accountable Party Accountable Party Accountable Party


Big Picture- Big Data

Why do we measure?

Patient engagement and

choice

Provider Improvement

Affect Policy

• Change payment

• Signal need for technical

assistance

• Compliance/certification

What do we measure?

Process?

Outcomes

Experience

Safety

Efficiency

• What about productivity?

Coordination?

What about environment?

• Air quality for asthmatics

What about values?

• Avoid surgery

• Live to see…

• Restore functionality


New Data Sources

Electronic Health

Records

iPhones

Face book

Home monitoring


Current Challenges for Providers:

• Delivery system reform creates risks for providers and the need to

maximize HIT assets to create efficiency, patient safety, care quality.

• Meaningful use program now a penalty for providers

» MU program requires quality metrics that requires data integration

from various HIT assets.

• Current HIT assets including EHRs are proprietary

» Increased cost to unlock, build bridges, and customize data flow

Current policy landscape - Government actions:

• ONC roadmap proposal focuses on interoperability – comments due

April 3, 2015.

• Congressional action on 21st Century Cures bill and interoperability

legislative proposals currently being developed.

» Led by Rep. Burgess (R-TX), House Energy and Commerce

Committee, Senate HELP Committee holding hearings (March 17)

Policy: Interoperability of Health Information Technology


Establishment of public-private Federal HIT governance structure in

collaboration with ONC, other federal agencies and the private sector.

• Develop and implement a nationwide interoperability framework, business practices, and

policies to achieve interoperability.

Development of Standards that Promote Interoperability and Innovation.

• Include: patient identifiers, terminologies, clinical data query language, security, open

application program interfaces (API), and clinical decision support algorithms and others.

Transparent and Public Interoperability and Cost Efficiency Measures Need to

be Developed.

• Transparent and public measures of interoperability should be developed in collaboration

with ONC, standard setting bodies, in consultation with the private sector, and be required

as part of the ONC certified technology program.

• These measures should be validated and tested in terms of standards, processes, and within

specific use case scenarios.

• Measures should include business and implementation approaches that deliver functional

interoperability outcomes and include operational processes and implementation practices.

• Measures should also include assessment of cost efficiency metrics achieved through

incorporation of innovative technologies.

Enforcement of Standards and Measures:

• ONC should be enabled to enhance its enforcement tools to ensure standards and measures

compliance through its certified technology program.

Policy Solutions to Achieve Interoperability and Innovation


Meaning for Patients…


Source: Office of Information Products and Data Analytics, CMS

17.0

17.5

18.0

18.5

19.0

19.5

Jan-10 Jan-11 Jan-12 Jan-13

Pe

rce

nt

Rate CL UCL LCL

All Cause, 30 Day Hospital Readmission Rate

21


PhysicianCompare is searchable to find any US physician

http://www.medicare.gov/physiciancompare/search.html

http://www.medicare.gov/physiciancompare/search.html


PFS: Physician Compare

Table 49: Summary of Finalized Data for Public Reporting

Data

Collection

Year

Publication

Year

Data Type Reporting

Mechanism

Finalized Proposals Regarding Quality Measures and Data for

Public Reporting

2015 2016 PQRS,

PQRS

GPRO, EHR,

and Million

Hearts

Web

Interface,

EHR,

Registry,

Claims

Include an indicator for satisfactory reporters under PQRS,

participants in the EHR Incentive Program, and EPs who

satisfactorily report the individual PQRS Cardiovascular

Prevention measures in support of Million Hearts.

2015 2016 PQRS

GPRO

& ACO

GPRO

Web

Interface,

EHR,

Registry,

and

Administrati

ve Claims

All 2015 PQRS GPRO measures reported via the Web Interface,

EHR, and Registry that are available for public reporting for

group practices of 2 or more EPs and all measures reported by

ACOs with a minimum sample size of 20 patients.

2015 2016 CAHPS for

PQRS &

CAHPS for

ACOs

CMS-

Specified

Certified

CAHPS

Vendor

2015 CAHPS for PQRS for groups of 2 or more EPs and CAHPS

for ACOs for those who meet the specified sample size

requirements and collect data via a CMS-specified certified

CAHPS vendor.

2015 2016 PQRS Registry,

EHR, or

Claims

All 2015 PQRS measures for individual EPs collected through

a Registry, EHR, or claims.

2015 2016 QCDR data QCDR All individual-EP level 2015 QCDR data.


CMS says that not all performance data added to

Physician Compare will necessarily be included on the

physician profile pages but could be downloaded

• Goal: Avoid overloading consumers with information

CMS had solicited comments on posting specialty society

measures on Physician Compare and/or linking to

specialty society websites that publish non-PQRS

measures and received mixed reactions

• CMS will continue to consider the issue

CMS will require public disclosure of Qualified Clinical

Data Registry data starting with data reported in CY 2015

• Data will be published on Physician Compare in 2016; QCDRs

may choose to also publish the data on their websites in 2016

• Data will only be disclosed at the individual EP level

PFS: Physician Compare, Con’t


Meaning for Providers…


QUEST: a formula for sustaining gains

Measure with defined metrics

Report transparently

Share best practice

Execute collaboratively


Advanced analytics metrics


Sustained improvement over time

Year 1 Year 2 Year 3 Year 4 Year 5 Year 6

Hospital

deaths

avoided

6,951 21,099 42,388 72,353 111,662 160,388

Dollars saved $683M $2.12B $4.55B $7.53B $10.12B $13.2B

Patients

receiving all

EBC

9,427 24,091 42,878 66,531 93,934 123,956

Harms

PreventedN/A N/A 3,447 7,924 13,963 21,679

Readmissions

PreventedN/A N/A N/A 7,332 25,722 55,845


QUEST hospitals outperform peers in national comparisons

• Premier published peer-reviewed

research in the Journal of Patient Safety

• Compared the mortality performance of

600+ U.S. hospitals from 2006-2011

• Isolates the performance improvement

that can only be attributed to a “QUEST

effect” via several analytical methods

• Results prove that QUEST hospitals

have a risk-adjusted mortality rate that is

up to 10% less than non-QUEST

hospitals


Harm Occurrence Rate*: Premier-Identified Complications and CMS HACs

138 Premier-Defined PICs16.02% of patients were found to experience one or more of these Harms

12 CMS-Defined HACs.19% of patients were found to experience one or more of these Harms

*One patient may develop multiple complications

Identifying Harm: Premier Identified Complications (PICs)

provide a more comprehensive measure of harm


$44,966,647

$26,752,409

$19,774,394

$9,470,580

$9,437,790

$8,161,730

$7,228,612

$6,909,320

$5,262,201

$4,743,643

$- $20,000,000 $40,000,000 $60,000,000

Hemorrhage/Acute Postop Anemia

Acute Renal Failure

Sepsis/Bacteremia

Aspiration Pneumonia

Embolism/Thrombus

C. Diff Enteritis

Encephalopathy

Acute Myocardial Infarction

Cerebral Infarction

Gastrointestinal (GI) Ulceration& Hemorrhage

Total Excess Costs

QUEST or PFP

focus areas

Total Excess Costs

Serious Complications add to the Cost of Care


Population Health


Advanced measures framework

Patient-centered measures of value

AimValue = (Outcomes + Experience)

Expenditures

Outcomes Experience Expenditures

Ove

rall

Me

asu

res

Functional Health PROMIS Global-10 Others: CDC Healthy Days, VR-12, EQ-5D

Health Risk IHME Risk Index1 Others: Framingham Index

Overall Patient Experience Rating CAHPS: 0-10 rating

Total Costs Per Capita Expenditures Utilization

Sub

Do

mai

nM

eas

ure

s

Functional Health Physical Health: PROMIS-PH-4 Activities of Daily Living Fall Risk++ Instrumental Activities of Daily Living

Mental Health: PROMIS-MH-4 Fatigue and Pain: PROMIS Global-2

Health Risk Biometrics Lifestyle Behaviors

Disease/Condition Status Hypertension: BP levels2 Diabetes: HgA1c3 Depression: PHQ-94 Heart Failure: MLHF-Q or KCCQ5 Total Knee Arthroplasty: UCLA Activity6,

Knee Society Score7, or Oxford Knee Score8

Whole Person Orientation -

Patient Activation

HowsYourHealth, PAM-13Access to Care

PCMH CAHPSCommunication with Providers

PCMH CAHPSSupport and Empowerment -

Shared Decision-making

PCMH CAHPSCoordination/Transitions

PCMH CAHPS, CTM-3

Under Age 65 Expenditures: Health Partners Utilization: Health Partners

Age 65 & older Expenditures: Dartmouth Atlas Utilization: Dartmouth Atlas

Overuse Measures ER Visits/1000 Imaging/1000 Lab expense/1000 Drug expense/1000 End of life/last 6 months PCI non-emergency/elective rate C-section rate Unplanned readmission rate


Meaning for Policy

makers…


Three National Inpatient Quality Payment Programs

Inpatient VBP

HRRP (Readmissions)

HAC Reduction Program

Last Updated February 2015


Current Reform Landscape for HospitalsChanges are Coming Fast

FY refers to the federal fiscal year. For example, FY 2012 began Oct 1, 2011 and ended Sept 30, 2012.

*The Multifactor Productivity Adjustment is an estimate generated by the CMS Office of the Actuary.

**DCA, also known as the behavioral offset. Estimates FY 2015-FY 2017 impact of the American Taxpayer Relief Act of 2012.

*** Sequestration (across the board cuts to reduce the federal budget deficit) will stay in place unless otherwise reversed by Congress.


Chart includes hospitals that did not meet minimum measure/data requirements

Total Penalties by Percentage – FY 2015 Final

Three quality programs in play: VBP, HACs, and Readmissions

Greatest penalty percentage was 4.4%

More than one in four hospitals experienced zero penalty or a net gain in

the quality per-for-performance programs


Inpatient VBP FY 2017 Domains: Align with National Quality Strategy

25%

5%

25%

25%

20%

FY 2017 Finalized Revision

• Clinical Care

• Process (5%)

• Outcomes (25%)

• Patient and Caregiver Experience

• Efficiency and Cost Reduction

• Safety (20%)

Measure ID NQS-Based Domain

AMI-7a Clinical Care – Process

IMM-2 Clinical Care – Process

PC-01 *NEW* Clinical Care – Process

MORT-30-AMI Clinical Care – Outcomes

MORT-30-HF Clinical Care – Outcomes

MORT-30-PN Clinical Care – Outcomes

HCAHPS

Patient and Caregiver Centered

Experience of Care / Care Coordination

CAUTI Safety

CLABSI Safety

MRSA *NEW* Safety

C. Diff *NEW* Safety

PSI-90 Safety

SSI Safety

MSPB-1 Efficiency and Cost Reduction

ACTIVE PERFORMANCE PERIOD


% Winners: 52% FY 2013, 46% FY 2014, and 55% FY 2015

Average penalty: -0.21% FY 2013, -0.25% FY 2014, and -0.29% FY 2015

Average bonus: +0.23% FY 2013, +0.23% FY 2014, and +0.44% FY 2015

Relaxed domain minimums likely led to small hospital inclusion and larger

relative percent penalty/bonus

National Performance in VBP FY 2013 - FY 2015


Performance in Inpatient VBP by Hospital Characteristic

N (3,088) FY 2013 FY 2014 FY 2015

Urban/Rural

Urban 2,335 WIN NEUTRAL WIN

Rural 753 NEUTRAL LOSE WIN

Teaching

Non-teaching 2,085 WIN NEUTRAL WIN

Teaching 1,003 NEUTRAL NEUTRAL NEUTRAL

Disproportionate Share Urban DSH 1,834 LOSE LOSE NEUTRAL

Rural DSH 689 NEUTRAL LOSE WIN

Non DSH 565 WIN WIN WIN

Ownership*

Voluntary 1,985 WIN NEUTRAL WIN

Proprietary 711 WIN NEUTRAL WIN

Government 428 LOSE LOSE WIN

Urban, Teaching and DSH 527 LOSE LOSE LOSE

* Data Source AHA 2013 Survey, 28 hospitals missing ownership information


N (3,088) FY 2013 FY 2014 FY 2015

Urban Hospital Size (Beds)

X-Small (less than 100) 526 WIN WIN WIN

Small (100-199) 741 NEUTRAL NEUTRAL NEUTRAL

Medium (200-299) 440 NEUTRAL NEUTRAL LOSE

Large (300-499) 418 LOSE NEUTRAL LOSE

X-Large (500 or more) 210 LOSE NEUTRAL LOSE

Rural Hospital Size (Beds)

X-Small (less than 50) 250 WIN NEUTRAL WIN

Small (50-99) 289 LOSE LOSE WIN

Medium (100-149) 118 WIN LOSE WIN

Large (150-199) 48 LOSE LOSE WIN

X-Large (200 or more) 48 WIN NEUTRAL WIN

Performance in VBP by Hospital Size

• Very small hospitals generally win under the VBP Program

• Rural hospitals with 200 or more beds also generally win


Challenges


New way of using data—whether provider or researcher

DUAs and laws need to evolve

• Comingling data

» Clinical/EHR with claims

» Combine across providers (ACO 1 with ACO 2)

• Timing

» Ongoing provider improvement necessitates monthly data

» Quality data infrequent, inconsistent, and often late

• Comprehensive data

» Need more than 5% carrier file sample

» Substance use data

» Medicaid data for duals/VA/retiree coverage

» EHR quality data

• Allowances

» Deidentify

» Operational feed for research/research feed for operations

» Commercial purpose

Data Hurdles


42 CFR Part 2 –

Confidentiality of Alcohol and

Drug Abuse Patient Records


Purpose:

These regulations impose restrictions upon the disclosure and use of

alcohol and drug abuse patient records which are maintained in

connection with the performance of any federally assisted alcohol and

drug abuse program.

Effect:

1) prohibits the disclosure and use of patient records unless certain

circumstances exist. The regulations do not require disclosure

under any circumstances.

2) not intended to direct the manner in which substantive functions

such as research, treatment, and evaluation are carried out. They

are intended to insure that an alcohol or drug abuse patient in a

federally assisted alcohol or drug abuse program is not made more

vulnerable by reason of the availability of his or her patient record

than an individual who does not seek treatment.

3) a criminal penalty for violating the regulations applies

42 CFR Part 2 - CONFIDENTIALITY OF ALCOHOL AND

DRUG ABUSE PATIENT RECORDS


Authority:

1) Section 408 of the Drug Abuse Prevention, Treatment, and

Rehabilitation Act (21 U.S.C. 1175).

2) Amended by Pub. L. 98-24 to section 527 of the Public Health

Service Act which is codified at 42 U.S.C. 290ee-

Disclosure authorization:

1) The content of record may be disclosed in accordance with the

prior written consent of the patient with respect to whom such

record is maintained, but only as allowed under subsection (g)

[prescribed in regulation].

2) Without consent, the record may be disclosed:

a) To medical personnel for an medical emergency.

b) To qualified personnel for scientific research, management

audits, financial audits, or program evaluation if patient not

identified directly or indirectly in any report of work.

c) If authorized by an appropriate order of a court .

Statutory authority of drug abuse patient records

https://www.law.cornell.edu/uscode/text/21/1175


“If a Pioneer ACO would like to receive data

related to substance abuse, the aligned

beneficiary must specifically opt-in to

Substance Abuse data sharing by providing

written consent to the ACO. CMS will provide

Pioneer ACOs with the Substance Abuse

Opt-In Form. Pioneer ACO providers/

suppliers may have a conversation about the

benefits of sharing the beneficiary’s

substance abuse data at the point of care.

Pioneer ACOs also have the option of

sending Substance Abuse Opt-In Forms via

mailer. If a beneficiary inquires about data

sharing, please explain that because

Substance Abuse data is more sensitive,

CMS will only share this information (if any

even exists), if the beneficiary expressly

grants written permission. This data will also

help the ACO and the beneficiary’s providers

with care management, care coordination,

and quality improvement activities.”

Substance Abuse Data Sharing


Other Limitations/Cautions

“The Medicare dataset supplied to the user is a subset of

the full set of Medicare data. The variables were chosen

because they were deemed to be the most useful

information for the ACO.”

“The data does not reflect the use and expenditures for

beneficiaries who have not given permission for their

data to be shared with the ACO. In addition, substance

abuse data must be separately approved for sharing. As

a result, this data may not include 100% of the claims

data for every assigned beneficiary.”

CMS ACO Program Claim and Claim Line Feed (CCLF)

Information Packet (IP)


Confidentiality of alcohol and drug abuse patient records

make it difficult for . . . health information exchange

organizations (HIEs), Accountable Care Organizations

(ACOs), and others to share records…”

• difficulty and expense of obtaining consent.

• patients are prevented from fully participating in integrated care

efforts even if they are willing to provide consent.

The current regulation presents several problems:

• Regulation has not been updated since 1987, and doesn’t

account for ACOs, EHRs etc.

• ACOs must identify every member of the ACO and any and all

ancillary providers in the network including HIEs to get consent.

Thus, patient should be given option to electronically

consent to share records with any/all in ACO network

who has a treatment relationship with the patient.

• If not, provide deidentified claims data to ACOs.

National Association of ACOs comments to SAMHSA

Danielle A. Lloyd, MPH

VP, Policy Development & Analysis

202.879.8002

[email protected]

www.premierinc.com

THANK YOU

mailto:[email protected]


APPENDIX


PQRS measures:

http://www.mdinteractive.com/files/uploaded/file/2015_PQRS_Measure

s_Groups__2014-26183.pdf

PQRS web interface measures:

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Downloads/2014_GPROWebInterface_MeasuresLi

st_NarrativeSpecs_ReleaseNotes_12132013.zip

All 2015 measures:


Instruments/PQRS/Downloads/PQRS_2015_Measure-List_111014.zip

Qualified Clinical Data Registry:


Instruments/PQRS/Qualified-Clinical-Data-Registry-Reporting.html

PQRS measure options vary based on reporting mechanism

http://www.mdinteractive.com/files/uploaded/file/2015_PQRS_Measures_Groups__2014-26183.pdf

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014_GPROWebInterface_MeasuresList_NarrativeSpecs_ReleaseNotes_12132013.zip

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/PQRS_2015_Measure-List_111014.zip

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Qualified-Clinical-Data-Registry-Reporting.html


Excess Deaths

QUEST or PFP

focus areas

Excess Deaths (Sample

N=500,000)

173

152

50

35

26

26

25

24

24

23

0 20 40 60 80 100 120 140 160 180 200

Septic Shock

Acute Renal Failure

Acute Myocardial Infarction

Cerebral Infarction

Intracranial Hemorrhage

Sepsis/Bacteremia

Pulmonary Embolism

Encephalopathy

Anoxic Brain Damage


Excess Deaths

Serious Complications Increase Risk of Mortality


13949

10497

7299

5362

4673

4366

3411

2592

2543

2467

0 2000 4000 6000 8000 10000 12000 14000 16000

Acute Renal Failure

Hemorrhage/Acute Postop Anemia

Sepsis/Bacteremia

C. Diff Enteritis


Embolism/Thrombus

Encephalopathy

Postoperative or Perioperative Infection

Cellulitis/Skin Infection

Respiratory distress of fetus or newborn

Total Excess Days

QUEST or PFP

focus areas

Total excess days

Serious Complications add to LOS


§ 2.2 Statutory authority for confidentiality of alcohol abuse patient records. The restrictions of these regulations upon the disclosure and use of alcohol abuse patient

records were initially authorized by section 333 of the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 (42 U.S.C.

4582). The section as amended was transferred by Pub. L. 98-24 to section 523 of the Public Health Service Act which is codified at 42 U.S.C. 290dd-3. The amended

statutory authority is set forth below:

§ 290dd-3.Confidentiality of patient records

(a) Disclosure authorization

Records of the identity, diagnosis, prognosis, or treatment of any patient which are maintained in connection with the performance of any program or activity relating to

alcoholism or alcohol abuse education, training, treatment, rehabilitation, or research, which is conducted, regulated, or directly or indirectly assisted by any department or

agency of the United States shall, except as provided in subsection (e) of this section, be confidential and be disclosed only for the purposes and under the circumstances

expressly authorized under subsection (b) of this section.

(b) Purposes and circumstances of disclosure affecting consenting patient and patient regardless of consent

(1) The content of any record referred to in subsection (a) of this section may be disclosed in accordance with the prior written consent of the patient with respect to whom

such record is maintained, but only to such extent, under such circumstances, and for such purposes as may be allowed under regulations prescribed pursuant to

subsection (g) of this section.

(2) Whether or not the patient, with respect to whom any given record referred to in subsection (a) of this section is maintained, gives his written consent, the content of

such record may be disclosed as follows:

(A) To medical personnel to the extent necessary to meet a bona fide medical emergency.

(B) To qualified personnel for the purpose of conducting scientific research, management audits, financial audits, or program evaluation, but such personnel may not

identify, directly or indirectly, any individual patient in any report of such research, audit, or evaluation, or otherwise disclose patient identities in any manner.

(C) If authorized by an appropriate order of a court of competent jurisdiction granted after application showing good cause therefor. In assessing good cause the court shall

weigh the public interest and the need for disclosure against the injury to the patient, to the physician-patient relationship, and to the treatment services. Upon the granting

of such order, the court, in determining the extent to which any disclosure of all or any part of any record is necessary, shall impose appropriate safeguards against

unauthorized disclosure.

(c) Prohibition against use of record in making criminal charges or investigation of patient

Except as authorized by a court order granted under subsection (b)(2)(C) of this section, no record referred to in subsection (a) of this section may be used to initiate or

substantiate any criminal charges against a patient or to conduct any investigation of a patient.

(d) Continuing prohibition against disclosure irrespective of status as patient

The prohibitions of this section continue to apply to records concerning any individual who has been a patient, irrespective of whether or when he ceases to be a patient.

(e) Armed Forces and Veterans' Administration; interchange of record of suspected child abuse and neglect to State or local authorities

The prohibitions of this section do not apply to any interchange of records—

(1) within the Armed Forces or within those components of the Veterans' Administration furnishing health care to veterans, or

(2) between such components and the Armed Forces.

The prohibitions of this section do not apply to the reporting under State law of incidents of suspected child abuse and neglect to the appropriate State or local authorities.

(f) Penalty for first and subsequent offenses

Any person who violates any provision of this section or any regulation issued pursuant to this section shall be fined not more than $500 in the case of a first offense, and

not more than $5,000 in the case of each subsequent offense.

(g) Regulations of Secretary; definitions, safeguards, and procedures, including procedures and criteria for issuance and scope of orders

Except as provided in subsection (h) of this section, the Secretary shall prescribe regulations to carry out the purposes of this section. These regulations may contain such

definitions, and may provide for such safeguards and procedures, including procedures and criteria for the issuance and scope of orders under subsection(b)(2)(C) of this

section, as in the judgment of the Secretary are necessary or proper to effectuate the purposes of this section, to prevent circumvention or evasion thereof, or to facilitate

compliance therewith.

(Subsection (h) was superseded by section 111(c)(4) ofPub. L. 94-581. The responsibility of the Administrator of Veterans' Affairs to write regulations to provide for

confidentiality of alcohol abuse patient records under Title 38 was moved from 42 U.S.C. 4582 to 38 U.S.C. 4134.)

Statutory authority for confidentiality of alcohol abuse

patient records.


https://www.law.cornell.edu/uscode/text/42/290dd-3




FY 2015 Quality Program Measurement Periods

Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

VBP FY 2015 Domains Weight

Patient Experience (8 measures + consistency) 30%

Clinical Process (12 measures) 20%

Outcomes 30%

3 mortality measures (HF, AMI, PN)

1 CLABSI measure

1 AHRQ PSI measure

Efficiency (1 measure) 20%

* Period s tarts May 1, ** Period s tarts Oct 15, *** Period s tarts Feb 1

Hospital Readmissions Reduction Program

FY 2015 Payment (AMI, HF, PN, COPD, Hip/Knee)

Hospital Acquired Conditions Penalty (program starts FY 2015)

Domain 1 (FY 2015 PSI-90 only)

Domain 2 (FY 2015 CLABSI, CAUTI)

Performance

Baseline Performance

Performance Period

Performance Period

Baseline Performance***

Baseline** Performance**

Baseline* Performance*

ACA Quality Provisions for Medicare Inpatient Hospital

Payment FY 2015

CY 2010 CY 2011 CY 2012

Baseline

CY 2013

Performance Period

Performance

Baseline

FY 2015 payment penalty hit Oct 1, 2014


A percent of inpatient base operating payments are at risk based on

quality and efficiency metric performance

A budget neutral policy, where hospitals must fail to meet targets for

bonuses to be generated for others

Rewards for achievement or improvement

Quality measures from Hospital Compare measure set

• 20 measures (12 process/8 HCAHPS dimensions) in FY 2013,

• Adds 3 outcome measures (3 mortality) in FY 2014,

• Adds 2 outcome measures and 1 efficiency measure in FY 2015,

• Removes 5 process and adds 1 process, 2 outcome measures in FY 2016, and

• Removes 6 process and adds 1 process, 2 “safety” measures in FY 2017

Inpatient Quality Reporting measures are “on deck” for VBP.

AdvisorLive on March 27, 2014 – Premier Alliance Community

Inpatient Value-Based Purchasing (VBP)

FY 2013

FY 2014

FY 2015

FY 2016

FY 2017

1% 1.25% 1.5% 1.75% 2%

https://premierconnect.premierinc.com/wps/myportal/mypremier/!ut/p/b0/TY5Na8MwDIZ_TY6pHcdOnULZYZDR2y5lc26OrWyG2A7-CPTfzxntVhBI7yMkHjSiTzQ6uZkvmYx3cilZrAGsgVAr7xyonceTLH0zyUCsmlaiDzSiMWUH2ueERAoZdqK8tdmZdLtmo5FgnBDM9FRzAk1NGe_rHmZc93JWjeooBj3tZ9GH5IOGgATe85qnxaj_txGW4gH6ksBe3l-vYUHiO6U1nipc4SfNw13dOHUoLhV-0sYRwmYUFJi8JX-728tj2KXPwzC8NS0_dgRaSjmnbD5yBprOvMekk5SyX6c1ItFgjB_-s4FFF6YzaJkArdby9l4_Nm50Gg!!/


30%

20%30%

20% 25%

10%

40%

25%

FY 2016

Performance Period

Complete!

30%

45%

25%

FY 2015

30%

70%

VBP: movement toward outcomes and efficiency

Clinical process Patient experience Outcomes Efficiency

FY 2013 FY 2014

Hospitals’ VBP payment will increasingly be based

on their performance on outcomes/efficiency


Inpatient VBP FY 2017 Domains: Align with National Quality Strategy

25%

5%

25%

25%

20%

FY 2017 Finalized Revision

• Clinical Care

• Process (5%)

• Outcomes (25%)

• Patient and Caregiver Experience

• Efficiency and Cost Reduction

• Safety (20%)

Measure ID NQS-Based Domain

AMI-7a Clinical Care – Process

IMM-2 Clinical Care – Process

PC-01 *NEW* Clinical Care – Process

MORT-30-AMI Clinical Care – Outcomes

MORT-30-HF Clinical Care – Outcomes

MORT-30-PN Clinical Care – Outcomes

HCAHPS

Patient and Caregiver Centered

Experience of Care / Care Coordination

CAUTI Safety

CLABSI Safety

MRSA *NEW* Safety

C. Diff *NEW* Safety

PSI-90 Safety

SSI Safety

MSPB-1 Efficiency and Cost Reduction

ACTIVE PERFORMANCE PERIOD


National Performance:

FY 2015 Inpatient Value-Based Purchasing (VBP) Program

55% of IPPS hospitals eligible for VBP are “winners” in FY 2015

Average penalty in FY 2015 -0.29%, average bonus +0.44%

45 hospitals received bonus of +1.5% or greater

Only 11% of all IPPS hospitals were exempt from the FY 2015 VBP

program, down from 22% in FY 2014


About 4 out of every 5 IPPS hospitals were penalized for excess

readmissions in FY 2015 (greater proportion than FYs 2013 & 2014).

Slightly over 1 percent of IPPS hospitals eligible for the readmissions

program received the maximum 3% penalty (8 percent received max penalty

in FY 2013, less than 1 percent received max in FY 2014)

Analysis based on final readmissions payment penalty adjustment factors

released in October 2014.

National Performance:

FY 2015 Hospital Readmission Reduction Program (HRRP)

National Average = 0.995




Part D Data


“The Part D data file will only include records for assigned

beneficiaries who are enrolled in a Prescription Drug Plan

(PDP). Many beneficiaries have Part D prescription drug

coverage through an employer-sponsored retiree drug

plan. Part D data does not include prescription data for

these beneficiaries due to differences in the data that are

required to be submitted by a PDP and a retiree drug plan.

Furthermore, Part D data only reflect expenditures for filled

prescriptions.”

*Medicare Shared Savings Participants report drug paid

amount frequently missing in data.

CMS ACO Program Claim and Claim Line Feed (CCLF)

Information Packet (IP)

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