Understanding How Quality is Impacting Your Bottom Line in ... 2015 Swee… · Physician Quality...

2015 GAMSS Education Conference 3/31/2015

1

Understanding How Quality is Impacting Your Bottom Line

in 2015+

2015 GAMSS Education Conference,

Sherry Sweek, RHIA, CPHQ, CPMSM

Ready or Not Transparency of Performance Will Drive Improved Patient

Outcomes


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Objectives

• Identify the top three outcomes impacting value based purchasing.

• Understand the relationship between meaningful use indicators, physician quality reporting system (PQRS) and HEDIS

• Gain knowledge of outcome data available on internet and implications of that information.

• Discuss strategies to move physician performance reports and credentialing indicators from process measures to outcome measures.

Patient Protection andAffordable Care Act

• Transparency through public reporting

• Growing bundled payments around hospital episodes

• Value-Based Purchasing Program

• Readmission Reduction Program

• Hospital Acquired Condition (HAC) Reduction Program

• Value-based Payment Modifier for Physicians


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What is Driving Policy

• Health care spending continues to grow

• Large cost variations that cannot be explained

• Belief that current fee-for-service payments encourage more and not better care

• Belief that payment instead should provide incentives for better care and lower costs

Three Types of CMS Programs

• Pay for Reporting

o Provider incentives to report information, performance did not matter

• Pay for Performance

o Provider incentives to achieve targeted threshold for clinical performance. Premier & CMS pilot-most hospitals improved 15-18% each year.

• Pay for Value

o Incentives linked to both clinical quality and cost.


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Medicare Reimbursement

The Patient Protection and Affordable Care Act (H.R. 3590)

At Risk: 3%

CLABSICAUTI

SSIMRSA

C-difficile

Medicare spending per patient

Efficiency Measures(Section 3001)

Patient Experience Measures Hospital Consumer

Assessment of Healthcare Providers and Systems (HCAHPS)

(Section 3001)

At Risk: 2% in FY2017

AMI, PNE, HFSCIP/HOP

Process of Care Measures(Section 3001)

Healthcare-Associated Infections (HAI)(Section 3001)

COPD, CABG, PTCA, etc.

AMI, PNE, HF

Readmission Rates(Section 3025)

Foreign Object Postop, Air Embolism, Blood

Incompatibility, Pressure Ulcer, Falls/Trauma

CAUTI, Vascular Catheter Associated Infections, Poor

Glycemic Control At Risk: 1% reduction beginning FY2015

Hospital Acquired Conditions (HAC)

(Section 3008)

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Value-Based Purchasing (VBP)

HAC, Mortality, AHRQ PSI

Outcomes Measures(Section 3001)

#1: Value Based Purchasing

• Quality Measures selected based on evidence-based practice guidelines and posted on hospital compare for one year

• Hospitals can receive increased or decreased reimbursement based on performance from baseline performance or achieving top decile performance

• A total value based purchasing (TVBP) score is compiled and compared to national 50th percentile.

• Each year the Medicare reimbursement impact increases and measures progress from process measures to outcomes


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Value Based Purchasing (VBP)

• Comparison is for performance period to baseline (two years prior)

• Reimbursement impact is not realized until 10 months later and continues for another 12 months

• Internal VBP report card shows impact by measure for not achieving 10 points (best performance)

• Goal is to obtain at least half the points (5) on each measure to ensure performance is at national 50th percentile

• In 2016 Outcomes have the largest weighted score (40%) with HCAHPS impacting 25%

Understanding VBP

• Points: awarded on each measure for achievement (US top 10% benchmark) and improvement (baseline to performance period)

• Domains: each has a score based on points received out of possible points in Clinical Process of Care, Patient Experience, Outcomes, Patient Safety

• Domain Weighting: each domain score is multiplied by the weighting of the domain


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Hospitals Succeed by Being a Top Performer or by Improving

• Hospitals earn points for process, outcome and cost domains:

• Achievement (0-10):

Performing at the national median = 0 points

Performing at the 95%ile = 10 points

~OR~

• Improvement (0-9):

No improvement = 0 points

Degree of improvement relative to the benchmark = 1-9

VBP Domain Weighted Shift

2013 2014 2015 2016 2017

Patient Experience 30% 30% 30% 25% 25%

Clinical Process Measures 70% 45% 20% 10% 5%

Outcomes NA 25% 30% 40% 25%

Efficiency NA NA 20% 25% 25%

Safety NA NA NA NA 20%

Medicare Money at Risk 1% 1.25% 1.50% 1.75% 2%


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Value Based Purchasing Performance

FY2013 FY2014 FY2015

Average National VBP Score 55.458 46.526 41.702

Average GA VBP Score 55.696 45.374 41.508

Reimbursement at Risk 1.0% 1.25% 1.5%

VBP decreased 16.10% from 2013-2014 and 10.37% from 2014-2015

► National Quality Strategy

► Partnership for Patients

► CMS Quality Improvement Organizations (QIO) program priorities

Efficiency Measure for FY 2015:

Includes all Part A and Part B expenditures from 3 days prior to admission to 30 days post admission


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FY2017 Hospital VBP Program

#2: Hospital Acquired Condition Reduction Program

• Mandated by Affordable Care Act

• Implemented for FY2015 with hospitals with performance in the bottom 25% nationally being penalized by a 1% cut in Medicare reimbursement

• HAC composite: 35% for AHRQ PSI (mainly post-op complications) and 65% for CLABSI and CAUTI ICU infections

• Infections based on Standardized Infection Ratio (SIR) as reported to National Healthcare Safety Network (NHSN)


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HAC Program

• Measures are risk-adjusted

• Performance on each measure is compared to the national averages

• Must meet minimum volumes for a measure to be calculated but spread over 2 years

• Penalties appear to disproportionately impact larger, urban hospitals caring for disadvantaged populations

FY 2015 HAC Reduction(payment adjustments 10/14-09/15)


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HAC Current and Future

• Over 15% of hospitals received penalty in FY2015 with estimate of $330 million decrease in Medicare payments

• FY2016: PSI-25% and Infections-75%

• Infections added: Surgical Site Infections for Colon and Abdominal Hysterectomies

HAC Proposal for 2016


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#3: Readmission Reduction

• Began with FY2013 (October 2012 discharges)

• Hospitals with excessive readmissions for Heart Attack, Heart Failure, and Pneumonia will have Medicare reimbursement reduced

• Risk adjusted and it is based on a readmission to any hospital in the United States for any reason within 30 days of discharge

• Potential penalty increased each year and caps at 3% which started as of October 2014 discharges

• In 2015 COPD and Total Joints (Hips & Knees) were added

• It is a weighted score of all the readmissions so better performance on one patient population helps to off-set lower performance in another

FFY2015 National Readmissions Impact

• 77% (2,641) hospitals penalized nationally

• 39 hospital received the full 3% penalty

• 496 hospitals penalized greater than 1%

• 769 hospitals with no penalty

• Average hospital penalty in 2015 is 0.63% up from 0.38% in 2014

• Penalized hospitals will miss out on $428 million in reimbursement from Oct 14-Sep 15


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Potential Impact to Medicare Reimbursement

Program2015% at risk

2016% at risk

2017% at risk

2018% at risk

Readmission Reduction Act

3.00% 3.00% 3.00% 3.00%

Value Based Purchasing

1.50% 1.75% 2.00% 2.00%

HAC Reduction Program

1.00% 1.00% 1.00% 1.00%

Total 5.50% 5.75% 6.00% 6.00%

Healthcare in 2015


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NCQA HEDIS®

• Healthcare Effectiveness and Data Information System (HEDIS)

• Used by more than 90% of Health Plans to measure performance on care delivery

• Measures are evidence-based measures such as childhood immunization, controlled high blood pressure, flu shots, breast cancer screening

• Measures focus on preventative care and appropriate utilization of resources

• Data is reported by Managed Care Plan

2013 HEDIS Benchmarks

Measure Region4

National 50th

percentile

National Top

Quartile

Adult BMI Assessment 52 61 68

Diabetes: Blood Pressure Control <140/90 59 63 66

Diabetes: Eye Exam 45 57 60

Breast Cancer Screening 71 71 75

Flu Shots: Age 18-64 45 49 56

Childhood Immunizations for 2 year olds 84 83 86

Early Perinatal Care 93 93 95

Beta Blocker after Heart Attack 78 82 86

Region 4: GA, MS, FL, TN, AL


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Physician Quality Reporting System

• CMS quality reporting mechanism for physicians who accept Medicare Part B established in 2007

• Value-based Modifier: can receive increase, decrease or same payment based on quality of care measures

• Similar process as hospital Value Based Purchasing with top performers received additional payment and low performers receiving lower payment

• Physician compare website with clinical quality measures reported through Electronic Health Record via Meaningful Use

PQRS Requirements

• Meaningful Use clinical quality measures and PQRS measures were aligned for 2014 with most available through most EHR

• The 2014 reporting period was from Jan-Dec 2014, reporting by March 2015 deadline

• Each practice (by tax ID number) is required to report on nine (9) measures covering three (3) National Quality Domains (NQD) for every eligible provider utilizing EHR

• Non participation or not satisfactory reporting will result in a 2% payment adjustment in the calendar year 2016 for physician professional fees


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Four Distinct National Programs• Meaningful Use

• Incentives/penalties to fund installation and use of electronic health records through the American Recovery and Reinvestment Act (ARRA)

• Physician Quality Reporting System (PQRS)

• Authorized under the Tax Relief and Healthcare Act of 2006

• ePrescribing Program (eRx)

• Authorized under Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (sunsets in 2014)

• Value-based Payment Modifier (VM)

• Authorized under the Patient Protection and Affordable Care Act of 2010


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How does the VBPM work?

Value-based Payment Modifier

• The modifier is based on 2014 PQRS participation

• The modifier assess both quality of care furnished and the cost of that care under the Medicare Physician Fee Schedule (PFS)

• Groups with over 100 providers can receive upward, downward or no adjustment to the Physician Fee Schedule

• Bottom 25%-1% decrease, Top 25%-1% increase

• Process CMS is implementing is very similar to hospital reporting program.


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Physician Medicare Value Modifier

How will the VBPM payment adjustments affect your organization in the future?

3) 2015 performance-based adjustments only apply to groups that chose to participate in quality tiering in 2013. 4) Non-physician eligible providers include all non-physician providers who bill Medicare under a group’s tax ID number.


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PQRS, Electronic Health Record and Meaningful Use

PQRS Domains and Measures• Domains

• Efficient Use of Resource Utilization• Clinical Effectiveness• Patient Safety• Population/Public Health• Care Coordination• Patient & Family Engagement

• Measures• 65 measures throughout the domains• Focus on preventative measures for primary care and high-

risk/high volume Medicare procedures• Examples: immunizations for children, blood pressure control,

influenza vaccination, diabetes A1c control, cervical cancer screening, functional status for knee/hip replacement


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Future of PQRSAbout the Data

• In the future, CMS will add information on participation in other quality programs to Physician Compare.

• Physician Compare will also include quality of care ratings for Group Practices. Ratings for individual physicians and other healthcare professionals will be added in the future.

• At this time, Physician Compare only includes information about whether individual physicians and other healthcare professionals participate in PQRS, not about their performance. CMS plans to post performance ratings for physicians and other healthcare professionals on the site sometime in late 2015, if technically feasible.

Provider Name


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Future of PQRS Reporting

• Similar process as hospital roll-out of reporting and incentives/penalties

• Addition of Clinical Groups Consumer Assessment of Healthcare Providers & Systems (CG-CAHPS) in 2016

• Pay for performance based on PQRS measures and patient satisfaction

• Top performers will receive additional reimbursement, bottom quartile performers will receive less reimbursement

• PQRS measures will be added, deleted, modified each year and this will require additional resources for electronic health record modifications

• More and more data will be mandated to send to government

Healthcare in 2015


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How does the consumer select care?• www.whynotthebest.org: hospitals

• Compare hospitals with national quartiles and state avg on most recent hospital compare12-month data on core measures, mortality, readmissions, HCAHPS

• www.heathgrades.com: hospitals, physicians

• (1,3,5) rating by top diagnoses and procedures

• Based on most recent 3-year Medicare data

• www.hospitalcompare.hhs.gov: hospitals

• Compare up to three hospitals on core measures, 30-day mortality and readmissions, HCAHPS showing state and US average

Doctor Web.com


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Physician Ratings-HealthGrades

• HealthGrades is a leader in online medical scores, with an estimated 7 million views monthly.

• Physician ratings consist of patient satisfaction scores and a Recognized Doctor “Honor Roll” designation.

• The satisfaction scores, are created from online survey responses that evaluate patients’ experiences with the physician and the office staff, including wait time.

• The Recognized Doctor designation: designation, a physician must meet the following criteria (never had medical license revoked, in the past 5 years, have no malpractice judgments or legal settlements and be free of state or federal disciplinary actions, and be board-certified


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Hospital Compare: Catheter Associated Urinary Tract Infections

• https://www.medicare.gov/hospitalcompare/compare.html#cmprTab=3&vwgrph=1&cmprID=110036%2C110024%2C110043&cmprDist=11.1%2C11.5%2C11.7&dist=100&loc=31411&lat=31.9134308&lng=-81.0202533


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Credentialing Process(OPPE, FPPE)

• Implement a consistent, evidence-based evaluation process for granting privileges

• Decision-makers should review a broad range of practitioner-specific data such as Morbidity and mortality data, Comparative practice patterns, Patient complaints, Adverse events

• Collect performance data on an on-going basis, analyze performance, and share results

• Follow the process when triggers identify a potential area of concern through the analysis of performance data

HospitalsOngoing ProfessionalPractice Evaluations

• OPPE – more and more complicated as performance data becomes not just an indicator of competence, but increasingly is evidence of “reimbursable” quality

• Collaborate with Quality, Patient Safety, Risk, and Infection Prevention on suitable indicators for specialty

• Move toward outcome measures with less emphasis on process measures


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Outcome Measures

• 30-Day Readmissions: Heart Attack, Pneumonia, Heart Failure, Chronic Obstructive Pulmonary Disease, Stroke

• 30-Day Mortality: Heart Attack, Pneumonia, Heart Failure, Chronic Obstructive Pulmonary Disease

• Infections: Surgical Site, Central Lines, Foley Catheters, C-diff

• HCAHPS (Patient Experience) Communication with Doctors, Discharge Information, Communication on Medications

Measures Across the ContinuumPopulation Hospital SNF Practice Health Plan

COPD 30-Day, Readmit, patient education

Breathing treatments

Medicationreconciliation, Timely follow-up appointment

Spacer for medication, appropriate medications

Patient with Foley

catheter

Catheter Associated Urinary Tract Infection, criteria for placing Foley

Maintenance of Foley, UTI

UTI, symptoms of infection

UTI visits

Stroke Timelyintervention, medication management, 30-Day Mortality

Functionalstatus and nutritional intake

Patient education, medication management

Rehab utilization, functional status


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Next Steps

• Connect with Quality, Infection Prevention, Case Management, Service Excellence to identify provider-specific data that could be utilized

• Educate your leadership on current status of organizational performance on VBP, HAC, Readmissions and role of Medical Staff

• Participate in collaborative that may be in play beyond your four-walls

Questions & Answers

• Contact Information

Sherry L. Sweek, RHIA, CPHQ, CPMSM

Southeast Georgia Health System

2415 Parkwood Drive, Brunswick, GA 31520

[email protected], 912-466-3265

Understanding Value-Based PurchasingIn October 2012, Medicare began rewarding hospitals that provide high-quality care for their patients through the new

Hospital Value-Based Purchasing (VBP) Program. Hospitals paid under the Inpatient Prospective Payment System (IPPS) are paid for inpatient acute care services based on quality of care — not the volume of services they provide.

MeasuresThe VBP program has 24 measures for FY 2016. Measures cannot be selected for VBP until they have been adopted for the hospital Inpatient Quality Reporting Program and posted on the Hospital Compare website for one year prior to the start of the VBP performance period.

PointsEach hospital may earn two scores on each measure — one for achievement and one for improvement. The final score awarded to a hospital for each measure or dimension is the higher of these two scores.

Achievement Points: During the performance period, these are

awarded by comparing an individual hospital’s rates with the threshold, which is

the median, or 50th percentile of all hospitals’ performance during the baseline

period, and the benchmark, which is the mean of the top decile, or approxi-

mately the 95th percentile during the baseline period.*

�� Hospital rate at or above benchmark: 10 achievement points�� Hospital rate below achievement threshold: 0 achievement points�� Hospital rate equal to or greater than the achievement threshold and less

than the benchmark: 1-9 achievement points

Improvement Points: Awarded by comparing a hospital’s rates during

the performance period to that same hospital’s rates from the baseline period.

�� Hospital rate at or above benchmark: 9 improvement points�� Hospital rate at or below baseline period rate: 0 improvement points�� Hospital rate between the baseline period rate and the benchmark:

0-9 improvement points

Consistency Points: The consistency points relate only to the Patient Experience of Care domain. The purpose of these points is to reward hospitals that have scores above the national 50th percentile in ALL eight dimensions of the HCAHPS. If they do, they receive the full 20 points. If they don’t, the LOWEST dimension is compared to the range between the national 0 percentile (floor) and the 50th percentile (threshold) and awarded points proportionately. This formula is to be used for each dimension to determine the lowest dimension from the performance period:

Your hospital performance period score – floor National achievement threshold – floor

*For the Medicare Spending per Beneficiary measure, the threshold and benchmark are based on all hospitals’ rates in the performance period, rather than the baseline period.

THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. AFMC, THE MEDICARE QUALITY IMPROVEMENT ORGANIZATION FOR ARKANSAS, UNDER CONTRACT WITH THE CENTERS FOR MEDICARE & MEDICAID SERVICES CMS, AN AGENCY OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN

SERVICES. THE CONTENTS PRESENTED DO NOT NECESSARILY REFLECT CMS POLICY. QP1VBP.FY2016,39/13

Measures PointsDomainScore

DomainWeighing

Total Performance Score

IncentivePayment

This material was adapted with permission from a publication created by Stratis Health, the Medicare Quality Improvement Organization for the state of Minnesota.

SSI Points: There will be one SSI Measure score, which will be a weighted average based on predicted infections for both procedures:

(SSI Colon measure score × predicted infections) + (SSI Hysterectomy measure score × predicted infections) Predicted infections for both procedures

Domain ScoreVBP measures roll up to a domain. FY 2014 has three domains: the Clinical Process of Care domain, the Patient Experience of Care domain, and the Outcome domain. Measure scores are added and divided by the total possible points x 100 to determine the Clinical Process of Care and Outcome domain scores. Dimension scores are added together to arrive at the HCAPHS base points. Base points plus the consistency score are added together to determine the Patient Experience of Care domain score. An additional domain (Efficiency) will be added in FY 2015.

Domain WeightingThe federal rule defines how much each domain will be weighted to calculate the Total Performance Score for each fiscal year. See pie charts in attached summaries for specific percentages for each domain.

Total Performance ScoreA hospital’s performance is assessed on the measures that comprise the domains. The domains are weighted and rolled up to the Total Performance Score. For instance, in FY 2014, the Total Performance Score is computed by multiplying the Clinical Process of Care domain score by 45 percent (domain weighting), the Patient Experience of Care domain score by 30 percent (domain weighting), and the Outcome domain score by 25 percent (domain weighting), then adding those totals. The Total Performance Score is then translated into an incentive payment that makes a portion of the base DRG payment contingent on performance.

Incentive PaymentIn FY 2014, 1.25% of DRG payments to eligible hospitals will be withheld to provide the estimated $1.1 billion necessary for the program incentives. Following is the schedule for future withholding:

FY 2013: 1.00 %FY 2014: 1.25 %FY 2015: 1.50 %

FY 2016: 1.75 %FY 2017: 2.00 %Succeeding years: 2.00 %

Based on performance, hospitals will earn an incentive payment. The law requires the Centers for Medicare & Medicaid Services (CMS) to redistribute the estimated $1.1 billion across all participating hospitals, based on their performance scores. CMS uses a linear exchange function to distribute the available amount of value-based incentive payments to hospitals, based on hospitals’ total performance scores on the hospital VBP measures. To convert the total performance score to a value-based incentive payment factor that is applied to each discharge, there are six steps for each fiscal year:

Step 1: Estimate the hospital’s total annual base operating DRG amount. Step 2: Calculate the estimated reduction amount across all eligible hospitals. Step 3: Calculate the linear exchange function slope.Step 4: For each hospital, calculate the value-based incentive payment percentage.Step 5: Compute the net percentage change in the hospital’s base operating DRG payment.Step 6: Calculate the value-based incentive payment adjustment factor.

There is a review and correction period as well as an appeals process. This adjustment factor then is applied to the base DRG rate and affects payment for each discharge in the relevant fiscal year (October 1 – September 30).

EligibilityEligible hospitals are paid through the Inpatient Prospective Payment System, so critical access hospitals, children’s hospitals, VA hospitals, long-term care facilities, psychiatric hospitals and rehabilitation hospitals are excluded. Eligible hospitals (PPS hospitals) become ineligible if the hospital:� � Is subject to payment reduction for the IQR program� � Has been cited for deficiencies that place the health or safety of patients in immediate jeopardy� � Does not meet the minimum number of cases, measures or domains (see table titled: Case Eligibility Criteria) PPS hospitals that are ineligible do not have the initial monies withheld, nor do they receive an incentive payment.

CASE ELIGIBILITY CRITERIA

FISCAL YEAR DOMAINS

Clinical Process

of Care

Patient Experience

of CareOutcome Efficiency

FY2013

Requires scores in both

domains to receive a Total

Performance Score and be

eligible for the VBP program

Requires four or more

measures, each with at

least 10 cases

Requires at least 100 HCAHPS

surveys in the performance

period

FY2014

Requires scores in all three

domains to receive a Total

Performance Score and be

eligible for the VBP program



least 10 cases



period

30-day mortality for

AMI, HF, and PN; each

requires 10 cases minimum

To receive a domain score,

requires meeting the case

criteria on two or more 30-

day mortality measures

FY2015 and FY2016

Requires scores in at least two

of the four domains to receive

a Total Performance Score

For hospitals with at least two

domain scores, the excluded

domain weights will be

proportionately distributed to

the remaining domains



least 10 cases



period

30-day mortality for

AMI, HF, and PN; each

requires 25 cases minimum

PSI-90 requires three cases as

a minimum for any one of the

underlying indications

CLABSI requires the hospital

to have at least one predicted

infection during the

applicable period

To receive a domain score,

requires meeting the case

criteria on two of the five

measures

Medicare Spending per

Beneficiary measure

requires 25 cases

Final performance standards for the FY2016 hospital VBP programBase operating DRG payment reduction amount: 1.75%

Clinical Process of Care

BASELINE PERIOD PERFORMANCE PERIOD

Jan. 1–Dec. 31, 2012 Jan. 1–Dec. 31, 2014

MEASURE ID DESCRIPTION ACHIEVEMENT

THRESHOLD

BENCHMARK

AMI-7a Fibrinolytic therapy received within

30 minutes of hospital arrival

0.91154 1.00000

PN-6 Initial antibiotic selection for CAP in

immunocompetent patient

0.96552 1.00000

SCIP-Inf-2 Prophylactic antibiotic selection for

surgical patients

0.99074 1.00000

SCIP-Inf-3 Prophylactic antibiotics

discontinued within 24 hours after

surgery end time

0.98086 1.00000

SCIP-Inf-9 Urinary catheter removed on

postoperative day 1 or postoperative

day 2

0.97059 1.00000

SCIP-Card-2 Surgery patients on beta-blocker

therapy prior to arrival who

received a beta-blocker during the

perioperative period

0.97727 1.00000

SCIP-VTE-2 Surgery patients who

received appropriate venous

thromboembolism prophylaxis

within 24 hours prior to surgery to

24 hours after surgery

0.98225 1.00000

NEW! IMM-2 Influenza immunization 0.90607 0.98875

REMOVED!

AMI 8a PCI received within 90 minutes of hospital arrival

HF 1 Discharge instructions

PN 3b Blood culture before 1st antibiotic received in hospital

SCIP 1 Abx within 1 hour before incision or within 2 hours if vancomycin/quinolone is used

SCIP 4 Controlled 6 AM postoperative serum glucose – cardiac surgery

Patient Experience of Care


Jan. 1–Dec. 31, 2012 Jan. 1–Dec. 31, 2014

HCAHPS SURVEY DIMENSION FLOOR

ACHIEVEMENT

THRESHOLD BENCHMARK

Communication with nurses 53.99% 77.67% 86.07%

Communication with doctors 57.01% 80.40% 88.56%

Responsiveness of hospital staff 38.21% 64.71% 79.76%

Pain management 48.96% 70.18% 78.16%

Communication about medicines 34.61% 62.33% 72.77%

Hospital cleanliness and quietness 43.08% 64.95% 79.10%

Discharge information 61.36% 84.70% 90.39%

Overall rating of hospital 34.95% 69.32% 83.97%

Efficiency Measures


Jan. 1, 2012–Dec. 31, 2012 Jan. 1, 2014–Dec. 31, 2014

MEASURE

ID

DESCRIPTION ACHIEVEMENT

THRESHOLD

BENCHMARK

MSPB-1 Medicare

spending per

beneficiary

Median Medicare spending

per beneficiary ratio across

all hospitals during the

performance period

Mean of the lowest decile of

Medicare spending per beneficiary

ratios across all hospitals during the

performance period

Outcome MeasuresMORTALITY


Oct. 1, 2010–June 30, 2011 Oct. 1, 2012–June 30, 2014

MEASURE ID DESCRIPTION ACHIEVEMENT

THRESHOLD

BENCHMARK

MORT-30-AMI Acute myocardial infarction

(AMI) 30-day mortality rate

0.847472 0.862371

MORT-30-HF Heart failure (HF) 30-day

mortality rate

0.881510 0.900315

MORT-30-PN Pneumonia (PN) 30-day

mortality rate

0.882651 0.904181

Complication/Patient Safety for Selected Indicators


Oct. 15, 2010–June 30, 2011 Oct. 15, 2012–June 30, 2014

AHRQ (PSI-90) Complication/patient safety for

selected indicators (composite)

0.622879 0.451792

Healthcare Associated Infections


Jan. 1, 2012–Dec. 31, 2012* Jan. 1, 2014–Dec. 31, 2014*

Measure Threshold (†) Benchmark (†)

CLABSI Central line-associated blood

stream infection

0.465 0.000

NEW! CAUTI Catheter-associated urinary tract

infection

0.801 0.000

NEW! SSI Colon ‡ 0.668 0.000

Abdominal hysterectomy ‡ 0.752 0.000

*In proposed 2014 OPPS rule to be finalized Nov. 2013

†Standardized infection ratio

‡There will be one SSI measure score, which will be a weighted average based on predicted infections for both procedures.

Patient Experience

of Care 25%

Outcome

40%

Efficiency

25%

Clinical Process

of Care 10%

THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. AFMC, THE MEDICARE QUALITY IMPROVEMENT ORGANIZATION FOR ARKANSAS, UNDER CONTRACT WITH THE CENTERS FOR MEDICARE & MEDICAID SERVICES CMS, AN AGENCY OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. THE CONTENTS

PRESENTED DO NOT NECESSARILY REFLECT CMS POLICY. QP1VBP.FY2016,39/13

Payment adjustment effective for discharges from Oct. 1, 2015, to Sept. 30, 2016

The Lake Superior Quality Innovation Network serves Michigan, Minnesota, and Wisconsin, under the

Centers for Medicare & Medicaid Services Quality Improvement Organization Program.

Follow us on social media @LakeSuperiorQIN

Understanding the Hospital-Acquired Condition Reduction Program

Beginning in FY 2015, the Hospital-Acquired Condition (HAC) Reduction Program, mandated by the Affordable Care Act, requires the Centers for Medicare & Medicaid (CMS) to reduce hospital payments by 1 percent for hospitals that rank among the lowest-performing 25 percent with regard to HACs.

Measures The HAC program has three measures for FY 2015, which are identified in the IPPS rule:

Patient Safety Indicators PSI 90 composite measure Central Line Associated Bloodstream Infections (CLABSI) measure Catheter Associated Urinary Tract Infections (CAUTI) measure

FY 2016 Additions SSI - Colon Surgeries and Abdominal Hysterectomies

FY 2017 Additions MRSA CDI

See following tables for more information.

Measure Score Each hospital will receive 1 to 10 points for each measure based on their national percentile ranking. Points will be assigned for each measure in deciles between the score of the best performing hospital and the worst performing hospital. Note: unlike the Value Based Purchasing Program (VBP), a lower score is better, a higher score is worse.

Domain Score For domain 1, there is only one measure, so the domain score is the same as the measure score. For domain 2, 1 to 10 points will be assigned for each SIR, and then averaged to determine the domain score.

Domain Weighting Each domain is weighted to determine the Total HAC Score For FY 2016 the Domain 1 is 25% and Domain 2 is 75% of the total score.

Total HAC Reduction Score

more than one measure in a domain, the measure scores are averaged to get the domain score. Then the weighting factor for each domain is applied to get the weighted domain score. The weighted domain scores are added to get the Total HAC score. For instance, in FY 2016, the Total HAC Score is computed by multiplying the Domain 1 score by 25% (domain

Hospital-Acquired Conditions are defined as: Conditions that patients acquire while receiving treatment for another condition in an acute care health setting.

The Lake Superior Quality Innovation Network serves Michigan, Minnesota, and Wisconsin, under the Centers for Medicare & Medicaid Services Quality Improvement Organization Program.


weighting) and the Domain 2 score by 75% (domain weighting), then adding those values to get the Total HAC score. The Total HAC Score is then ranked with other hospitals to identify the lowest-performing 25 percent that will be penalized.

Payment Penalty HAC payment penalty adjustment would occur after base DRG payment adjustments have been calculated and made for the VBP and Readmission Reduction programs. Payment adjustment would impact hospitals that rank among the lowest-performing 25 percent with regard to HACs. They would receive 99% of the amount of payment that would otherwise apply to discharges. This includes the base DRG and add-on payments of outliers, disproportionate share hospital (DSH), uncompensated care, and indirect medical education (IME).

Eligibility This program does not affect long-inpatient psychiatric facilities, or critical access hospitals. Claims for all Medicare FFS beneficiaries discharged during this period would be included.

Improvement Resources: Collaborative Healthcare-Associated Infection Network (CHAIN) The Collaborative Healthcare-Associated

Infection Network (CHAIN) develops and helps carry out effective approaches for reducing and preventing healthcare-associated infections in Minnesota.

Healthcare-Associated Infections (HAI) Road Map The Road Map to a Comprehensive Healthcare-Associated Infection (HAI) Prevention Program provides evidence-based recommendations and standards for Minnesota hospitals to develop comprehensive HAI prevention programs.

AHRQ PSI 90 Composite Measure Patient Safety for Selected Indicators

Other Ongoing HAC programs: CMS Hospital-Acquired Conditions present on admission reporting For discharges occurring on or after October 1,

2008, hospitals will not receive additional payment for cases in which one of the listed conditions was not present on admission.

Guidance related to payment policies adopted by the Medicare program. for selected hospital-

Hospital Compare HAC reporting (scroll down to see HAC measures)

For more information

If you have questions regarding the HAC Reductions Program, contact Stratis Health Program Manager, Vicki Olson, RN, MS, 952-853-8554, [email protected]

Case Eligibility Domain 1 - AHRQ Patient Safety Indicators3 or more eligible discharges for at

least 1 component indicator

Domain 2 - CDC NHSN Measures>1 predicted HAI event

Total HAC

Score

Not enough cases to calculate a SIR Measure score No measure score 100% Domain 1

Not enough eligible discharges in claims data No measure score Measure score 100% Domain 2

Not enough eligible discharges in claims or enough cases to calculate a SIR

No measure score No measure score No calculation

Non-submission of Data Domain 1 Domain 2 TotalHAC

Score

Hospital has an ICU waiver Measure score Data is not required 100% Domain 1

Hospital does not have an ICU waiver, but has no submitted data

Measure score 10 points 100% Domain 1



DOMAIN 1

Performance PeriodJuly 1, 2011 June 30, 2013

AHRQ* PSI 90 Measure Score 1-10

PSI 3 Pressure ulcer rate

PSI 6 Iatrogenic pneumothorax rate

PSI 7 Central venous catheter-related blood stream infection rate

PSI 8 Postoperative hip fracture rate

PSI 12 Postoperative pulmonary embolism (PE) or deep vein thrombosis rate (DVT)

PSI 13 Postoperative sepsis rate

PSI 14 Wound dehiscence rate

PSI 15 Accidental puncture and laceration rate

DOMAIN 2

Performance PeriodJanuary 1, 2012 December 31,

2013

CDC NHSN* Measures Average Score 1-10

CLABSI SIR rate 1-10

CAUTI SIR rate 1-10

FY 2015 HAC Reduction ProgramDomain Weighting and Measures(Payment adjustment effective for discharges

from October 1, 2014 September 30, 2015)

*Centers for Disease Control and Prevention National Healthcare Safety Network

*The Agency for Healthcare Research and Quality

Domain 1 (AHRQ Patient Safety Indicators)

35%

Domain 2 (CDC NHSN Measures)

65%



This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-D1-14-13 112614

FY 2016 HAC Reduction ProgramDomain Weighting and Measures(Payment adjustment effective for discharges

from October 1, 2015 September 30, 2016) DOMAIN 1

Performance PeriodJuly 1, 2012 June 30, 2014

AHRQ* PSI 90 Measure Score 1-10

PSI 3 Pressure ulcer rate

PSI 6 Iatrogenic pneumothorax rate

PSI 7 Central venous catheter-related blood stream infection rate

PSI 8 Postoperative hip fracture rate

PSI 12 Postoperative pulmonary embolism (PE) or deep vein thrombosis rate (DVT)

PSI 13 Postoperative sepsis rate

PSI 14 Wound dehiscence rate

PSI 15 Accidental puncture and laceration rate

DOMAIN 2

Performance PeriodJanuary 1, 2013 December 31, 2014

CDC NHSN* Measures Average Score 1-10

CLABSI SIR rate 1-10

CAUTI SIR rate 1-10

SSI ColonSSI Abdominal Hysterectomy

1-10

DOMAIN 2

Future Measures for FY2017

MRSA

CDI

Domain 1 (AHRQ Patient

Safety Indicators)

25%

Domain 2 (CDC NHSN Measures)

75%

*Centers for Disease Control and Prevention National Healthcare Safety Network

*The Agency for Healthcare Research and Quality

will be a weighted average based on predicted infections for both procedures.

The Lake Superior Quality Innovation Network serves Michigan, Minnesota, and Wisconsin, under the

Centers for Medicare & Medicaid Services Quality Improvement Organization Program.


UNDERSTANDING THE

HOSPITAL READMISSIONS REDUCTION PROGRAM The Hospital Readmissions Reduction Program, mandated by the Affordable Care Act, requires the Centers for Medicare & Medicaid (CMS) to reduce payments to IPPS hospitals with excess readmissions. The first penalty affecting payment was for discharges beginning October 1, 2012. Unlike the Value-based Purchasing (VBP) program, this is a penalty program and a hospital cannot get additional monies, only lose money as result of their performance. What is similar to the VBP program is that the penalty for the Readmission Reductions Program affects the base DRG for discharges. It also applies to the federal fiscal year, which starts October 1 and goes through September 30 of the following year. The penalties increase every year up to a maximum of 3% reached in FY2015.

Readmissions Measures FY2013 & FY2014 (added algorithm to exclude planned admissions)

30 day Readmissions Acute Myocardial Infarction (AMI), 30 day Readmissions Heart Failure (HF) 30 day Readmissions Pneumonia (PN);

FY 2015 Additions 30 day Readmissions chronic obstructive pulmonary disease (COPD) 30 day Readmissions elective total hip arthroplasty (THA) and total knee arthroplasty (TKA)

FY 2016 No Additions FY 2017 Additions

30 day Readmissions coronary artery bypass graft (CABG) surgery

These same measures are used for the inpatient quality reporting (IQR) program. However, because they are applied to a different set of hospitals, the results might vary slightly from the rates.

Eligibility/Performance Period Three years of discharge data

FY2013 July 1, 2008 to June 30, 2011 FY2014 July 1, 2009 to June 30, 2012 FY2015 July 1, 2010 to June 30, 2013 FY2016 July 1, 2011 to June 30, 2014

Minimum of 25 cases

Readmission is defined as an admission to an IPPS acute care hospital within 30 days of a discharge from the same or another IPPS acute care hospital.

November 2014



Calculation of Excess Readmissions Ratios

condition. The calculation uses the risk adjustment methodology endorsed by the National Quality Forum (NQF) for the readmissions measures to calculate the excess readmission ratios, which includes adjustment for factors that are clinically relevant including patient demographic characteristics, comorbidities, and patient frailty.

The Excess Readmission Ratio is calculated as the ratio of predicted readmissions to expected readmissions.

Predicted admissions is the number of 30-day readmission predicted for your hospital on the basis of your hospireadmissions. This is presented as a rate per 100 discharges by dividing by the number of eligible discharges.

Expected readmissions is the number of 30-day readmissions expected for your hospital on the basis

If a hospital performs better than an average hospital that admitted similar patients, the ratio will be less than 1.0000. If a hospital performs worse than average, the ratio will be greater than 1.0000.

Payment - Readmissions Adjustment Factor The Excess Readmission ratios for each condition are multiplied times the sum of base operating DRG payments for that condition; then added together. This aggregate payment for excess readmissions is divided by the aggregate payments for all discharges, then subtracted from 1 to get the Readmissions Adjustment Factor.

If the Readmissions Adjustment Factor is 1.000, there is no payment reduction. Any number between .9999 and .9700 would trigger a payment reduction. The maximum penalties identified per year are:

FY2013 1% FY2014 2% FY2015 3% Future years 3%

actor

Step 1 Go to the CMS website The Readmissions Adjustment Factor for your hospital is found in the CMS Readmissions Reduction program website: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

Step 2 Find the Zip file in the downloads Once on thProgram Supplemental Data File (Final Rule and Correction Notice) [ZIP, 8 MG].



This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-XX-YY-## MMDDYY

Step 3 Open the Excel spreadsheet 015 Final Rule Readmissions PUF- Oct

conditions as well as the excess readmission ratios for all US hospitals. This file is organized by hospital CCN (CMS Certification Number) so you will either need to have that information or access it from the link identified in the resource section.

Public Reporting The results of the Readmissions Reduction Program will be posted on Hospital Compare. The following information will be publically reported:

Number of eligible discharges Readmission rate Confidence intervals

Resources RARE Campaign link http://www.rarereadmissions.org/

QualityNet Readmission resources http://www.qualitynet.org/dcs/ContentServer?cid=1219069855273&pagename=QnetPublic%2FPage%2FQnetTier3&c=Page

Hospital CCN numbers https://data.medicare.gov/Hospital-Compare/Hospital-General-Information/v287-28n3

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