Linking Quality To Payment 17 th Annual Rural Health Conference Timothy Burrell, MD, MBA Medical...

Linking Quality To Payment

17th Annual Rural Health ConferenceTimothy Burrell, MD, MBA

Medical Director

Definition Of Quality

“General excellence of standard.”

Definition Of Quality

“General excellence of standard.”

Institute of Medicine

“The degree to which health services for individuals and populations increase the

likelihood of desired health outcomes and are consistent with current professional

knowledge.”

Outcomes + Knowledge =

Outcomes + Knowledge =

Payment

Affordable Care Act – March 2010

The Centers for Medicare & Medicaid Services

Changed how Medicare pays for services by rewarding/not punishing providers for delivering higher quality and value.

The programs highlighted in this presentation:

1. Hospital Readmissions Reduction Program (HRRP)

2. Hospital Value-Based Purchasing Program (VBP)

3. Hospital-Acquired Condition Reduction Program

Advancing Medicare Value

What Is At Stake?

Fiscal Year

Readmission Reduction Program

Value Based Purchasing

Hospital Acquired Condition Reduct. Total

2013 -1.0% -1.00% - -2.00%

2014 -2.0% -1.25% - -3.25%

2015 -3.0% -1.50% -1.0% -5.50%

2016 -3.0% -1.75% -1.0% -5.75%

2017 -3.0% -2.00% -1.0% -6.00%

What Is At Stake?

Wellpoint Commercial Payments

30% of 2013 performance based

50% of 2015 performance based

??% of 2017 performance based

Quality / Value / Quality

Government and private payors will continue exploring programs that tie value to quality.

Understanding and implementing quality improvement programs will better prepare providers for the future.

Escalator Principle

“Like an escalator, HITECH attempts to move the health system upward toward improved quality and effectiveness in health care. But the speed of ascent must be calibrated to reflect both the capacities of providers who face a multitude of real-world challenges and the maturity of the technology itself.”The “Meaningful Use” Regulation for Electronic Health Records

David Blumenthal, M.D., M.P.P., and Marilyn Tavenner, R.N., M.H.A.

N Engl J Med 2010; 363:501-504 August 5, 2010 DOI: 10.1056/NEJMp1006114

UP AND DOWN

1

Hospital Readmissions

Reduction Program

Hospital Readmissions Reduction Program

The historic 30-day readmission rate for Medicare beneficiaries is nearly 20% . . .

Hospital Readmissions Reduction Program

The historic 30-day readmission rate for Medicare beneficiaries is nearly 20% . . .

. . . at a cost of ~$20 billion/year.

Hospital Readmissions Reduction Program

Authorized by Affordable Care Act (ACA) to begin October 1, 2012

Penalties2013: -1%

2015: -3%

Reduction applies to TOTAL Medicare payments

Clinical Conditions

2012• Acute Myocardial Infarction• Congestive Heart Failure• Pneumonia

2014 adds• Chronic Obstructive Pulmonary Disease (COPD)• Total Knee Arthroplasty• Total Hip Arthroplasty

Readmission Definition

Any readmission to an acute care facility within 30 days.

Exceptions:• Long-term Acute Care Hospital (LTACH)• Inpatient Rehabilitation Facility (IRF)• Observations (OBS)• Other non-acute care

Readmission Causes

Problem - Nature of the Disease

Patient - Psychosocial Factors

Provider - Gaps in Post-Discharge Management

Problem - Nature of the Disease

Some readmissions are inevitable*

Many readmissions are negotiable

Most readmissions are preventable(*Don’t fight it)

CMS View:

DRG payments promote premature discharges

Patient - Psychosocial Factors

• Social support• Access to medication• Access to care• Access to transportation• Literacy• Mental Health/Substance Abuse

Provider - Gaps in Post-Discharge Management

• Delayed outpatient follow-up• Lack of medication reconciliation• Poor coordination/transition of care• Inattention to red flags:

o Phone callsoUrgent Care/ED visitso Early medication refill requestso After-hours walk-in clinic visits

How Are We Doing?

Many Obstacles

Creativity over

TechnologyManagement

over Medicine

Low Tech & High Touch

20%

19%

18.5%

17.5%

Indiana rank: #31 (2009) #43 (2014) http://datacenter.commonwealthfund.org/#ind=1/sc=1

2

Hospital Value-Based

Purchasing Program

(VBP)

Value-Based Purchasing (VBP)

Authorized by ACA to begin October 1, 2012

Funded by a reduction from participating hospital base-operating Diagnosis-Related Group (DRG) payments:• 2013: -1%• 2017: -2%

The amount of funding for this program is equal to the amount generated by the payment cuts.

Value-Based Purchasing (VBP)

Increasing number of measures per year

2013 – 20 Measures

2014 – 24 Measures

2015 – 26 measures

Value-Based Purchasing (VBP)

Fiscal Year 2014 – Three Domains• 45% – Clinical Processes of Care

• 30% – Patient Experience of Care

• 25% – Outcome Domain

Value-Based Purchasing (VBP)

In each category hospitals are scored for

• Achievement

• Improvement

The highest score of the two is the final score for the category

Clinical Processes of Care

Thirteen (13) measures within well-known

categories:• Acute Myocardial Infarction (AMI)

• Congestive Hear Failure (CHF)

• Pneumonia

• Healthcare Associated Infection

Clinical Process of Care Measures1. AMI-7a Fibrinolytic Therapy Received within 30 Min. of Hospital Arrival

2. AMI-8a Primary PCI Received within 90 Min. of Hospital Arrival

3. HF-1 Discharge Instructions

4. PN-3b Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hosp.

5. PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient

6. SCIP-Inf-1 Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision

7. SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients

8. SCIP-Inf-3 Prophylactic Antibiotic Discontinued within 24 Hrs After Surgery End Time

9. SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6 a.m. Post-op Serum Glucose

10. SCIP-Inf-9 Urinary Catheter Removed on Post-op Day 1 or Post-op Day 2

11. SCIP-Card-2 Surgery Pts on ß-Blocker Who Received a ß-Blocker Perioperatively

12. SCIP-VTE-1 Surgery Pts given Venous Thromboembolism (VTE) Prophylaxis

13. SCIP-VTE-2 Pts Who Received VTE Prophylaxes within 24 Hrs Prior/After Surgery

Patient Experience of Care Dimensions1. Communication with Nurses

2. Communication with Doctors

3. Responsiveness of Hospital Staff4. Pain Management

5. Communication about Medicines

6. Cleanliness and Quietness of Hospital Environment

7. Discharge Information

8. Overall Rating of Hospital

Eight HCAPS-based dimensions

Outcome Measures

1. MORT-30-AMI Acute Myocardial Infarction (AMI) 30-day* mortality rate

2. MORT-30-HF Heart Failure (HF) 30-day* mortality rate

3. MORT-30-PN Pneumonia (PN) 30-day* mortality rate

* Post-admission

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New Je

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Arkansas

Hawaii

Californ

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Alaska

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10%

20%

30%

40%

50%

60%

70%

80%

90%

2014 Hospital Value Based Purchasing Bonus

1,231 Gain – 1,451 Lose

3

Hospital-Acquired

Condition (HAC)

Reduction Program

HAC Reduction Program

Authorized by ACA to begin October 1, 2014

Requires CMS to reduce hospital payments by (1%) for hospitals that rank among the lowest-performing 25% for hospital-acquired conditions

In addition to current Hospital-Acquired Conditions Program and excludes critical access hospitals

HAC Reduction Program

Conditions acquired while receiving care for another condition in an acute care health setting.

Additional sources:Extended Care FacilityAcute Rehabilitation FacilityDialysis CenterAmbulatory Surgery Center

Three Measures – Two Domains

Domain 1 – 2014 (65%)

Patient Safety Indicator #90:• Pressure Ulcer (PSI 3) • Iatrogenic Pneumothorax (PSI 6) • Central Venous Catheter-Related Blood Stream Infection (PSI 7) • Postop Hip Fracture (PSI 8) • Postop Pulm. Embolism (PE) / Deep Vein Thrombosis (DVT) (PSI 12) • Postop Sepsis (PSI 13) • Wound Dehiscence (PSI 14)• Accidental Puncture and Laceration (PSI 15)

Three Measures – Two Domains

Domain 2 – 2014 (35%)

• Central Line-Associated Blood Stream Infection

• Catheter-Associated Urinary Tract Infection

Three Measures – Two Domains

Domain 2 – 2014 (35%) 2015

• Surgical Site Infection - Colon• Surgical Site Infection - Abd. Hysterectomy

2016• Methicillin-resistant staph aureus (MRSA)• Clostridium difficile Infection

HAC Reduction Program

Complements other CMS programs

Hospital-Acquired Conditions(Present on Admission)

Never Events Non-Payment

Hospital Compare Reporting

CMS Program Overlap

You Can Do It!!!

Questions?

Timothy Burrell, MD, MBAMedical Director

Health Care Excel

TBurrell@HCE.org(317) 754-5442