August 13, 2013

CMS National Dry Run:Risk-Standardized Payment

Measure: Acute Myocardial Infarction

30-day Episode of Care

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• Introductions (next)

• Purpose of Dry Run and Measure

• Proposed Implementation

• Dry Run Overview

• Measure Details

• Resources

• Questions and Answers

Agenda

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• Centers for Medicare & Medicaid Services (CMS)

• Yale New Haven Health Services Corporation – Center for Outcomes Research and Evaluation (CORE)

• Mathematica Policy Research (MPR)

Introductions

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• Introductions

• Purpose of Dry Run and Measure (next)

• Proposed Implementation

• Dry Run Overview

• Measure Details

• Resources

• Questions and Answers

Agenda

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• Educate hospitals about new measures

• Provide hospitals with results and data

• Help hospitals interpret results and data

• Encourage hospitals to ask questions

Purpose of Dry Run

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• Cost: the amount incurred in providing services

• Payment: the amount paid on behalf of a Medicare patient for health care services

• Risk-standardized payment: an amount that has been modified to make payments comparable across hospitals

Defining Common Terms

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• Inpatient hospitalizations contribute to rising healthcare costs1, 2

• Payments reflect costs from Medicare’s perspective

• Variations in care patterns affect payments made by CMS

• Payments reported in conjunction with outcome quality measures, such as AMI mortality, will illuminate high-value care

1. Health Care Cost Institute, 2010; 2. Jha AK, et. al., Health Affairs, 2009

Why report a payment measure?

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• AMI is a common and expensive condition among Medicare beneficiaries

• AMI episode requires care in hospital and post-discharge

• There is substantial variation in payments • In hospital practice patterns• Post-discharge care

Why measure payment for an acute myocardial infarction (AMI) episode?

9Mean national payment is for 2008-2009 and is in 2009 dollars

• Mean national payment: $20,751

• Hospital risk-standardized payment (RSP) range:

$13,909 - $28,979

Variability in Payments

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• Making care more affordable is a priority within the National Quality Strategy (NQS) and CMS Quality Strategy

• In response to the NQS, CMS is analyzing efficiency. Currently measures exist in the following programs:• Hospital Inpatient Quality Reporting Program• Hospital Value-Based Purchasing Program• Hospital Outpatient Quality Reporting Program• Physician Value-Based Modifier Program

• Support efforts to make payments and quality more transparent to consumers and providers

Addressing Affordable Care

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• Introductions

• Purpose of Dry Run and Measure

• Proposed Implementation (next)

• Dry Run Overview

• Measure Details

• Resources

• Questions and Answers

Agenda

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• In the IPPS FY 2014 Final Rule, CMS added the AMI payment measure to the Inpatient Quality Reporting (IQR) program

• If finalized, CMS will publicly report the measure results on Hospital Compare

Proposed Implementation

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• Introductions

• Purpose of Dry Run and Measure

• Proposed Implementation

• Dry Run Overview (next)

• Measure Details

• Resources

• Questions and Answers

Agenda

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• Timeline: August 5 – September 4, 2013

• Access to Hospital-Specific Reports• QualityNet

• Results:• Hospital-Specific Report (HSR)• Measure Information and Instructions Report

• Resources:• Methodology reports, FAQs, other materials• cmsepisodepaymentmeasures@yale.edu

Dry Run Overview

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2013 Dry Run Timeline

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• Introductions

• Purpose of Dry Run and Measure

• Dry Run Overview

• Measure Details (next)

• Proposed Implementation

• Resources

• Questions and Answers

Agenda

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• Home health agency• Non-institutional providers (e.g., physicians and independent labs)• Durable medical equipment

• Inpatient• Skilled nursing facility• Outpatient• Hospice

• Hospital-level, risk-standardized payments for an AMI episode of care

• Admission to 30 days post-admission

• Includes payments for the index admission and post-discharge settings, including:

Measure Design

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• Chronic Condition Warehouse (CCW) Data• Medicare administrative claims data

• 100% of patients with a primary discharge diagnosis of AMI

• Why use CCW?• Can follow patients across multiple care settings using a

unique patient identifier

Data Source

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• Non-federal short-term acute care hospitals• Critical access hospitals (CAH) are included

• Dry run includes patients: • Discharged in 2008-2009 • ≥65 years of age• Principal discharge diagnosis of AMI (defined by

ICD-9 codes 410.xx, excluding 410.x2)• Randomly select one index admission per patient

for patients with multiple admissions

Inclusion Criteria

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Enrolled in hospice within one year prior to or on date of index admission (0.83%)

Incomplete administrative data in the 30 days following the index admission (if alive) (1.25%)

Same- or next-day discharge and patient did not die or get transferred (4.80%)

Transfers into the hospital (6.95%)

Inconsistent or unknown vital status (0.01%)

Unreliable data (0.05%)

Discharges against medical advice (AMA) (0.38%)

Admissions within 30 days of a prior index admission (0.02%)

Transfers to federal hospitals (0.04%)

Initial Index Cohort 2008-2009 Calendar Year Data Set

N=367,850

Randomly select one hospitalization per patient

N=351,013Hospitalizations not selected (4.6%)

Final Index Cohort 2008-2009 Calendar Year Dataset

N=350,930

Total Discharges 2008-2009 Calendar Year Data Set

N=422,842

Missing DRG or DRG weight (0.07%)

Exclusion criteria

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• Payments for both admissions and post-discharge care are combined to calculate total payment

• Total payment assigned to the initial admitting hospital

Transferred Patients

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• Payments made for care that begins during measurement period but ends after measurement period are prorated

Prorating Payments

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• Includes payments from admission to 30 days post-admission

• Incorporates claims from across all care settings

• Removes or averages payment adjustments unrelated to care• Geography (wage index, cost of living)• Policy adjustments (IME, DSH, etc.)

Payment Calculation

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• Goal is to assess payments influenced by clinical decisions

• Payment adjustments such as wage index are unrelated to clinical decisions/practice patterns of care

• Using actual payments would not allow for a fair comparison across hospitals

Removing Payment Adjustments

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• To isolate differences in payments that reflect practice patterns, the measure estimates payments by:

• Stripping: • Removing geographic adjustments• Removing policy adjustments

• Standardizing: • Average payments across geographic areas

when geographic differences cannot be removed

Removing Payment Adjustments: Stripping/Standardizing

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• Accounts for differences in patient characteristics and comorbidities across hospitals

• Includes:• Secondary diagnosis codes from index admission

(except for potential complications of care)• All diagnosis codes from previous year from:

• acute inpatient hospital stays• hospital outpatient care• physician, radiology, and laboratory services

Risk Adjustment

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• Calculating risk-standardized payment (RSP)

Risk-Standardized Payments

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• Categories of measure results:• Less than U.S. average national payment

• No different than U.S. average national payment

• Greater than U.S. average national payment

• Number of cases too small (<25 cases)

• Final RSP reported with interval estimate

Categorizing Hospital Results

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Risk-Standardized Payment ($)

U.S. National Average Payment($20,751)

Less than national payment

Example Hospital 1$16,560 ($14,600, $18,735)

Example Hospital 2$20,110 ($17,900, $22,140)

Greater than national payment

Example Hospital 3$23,450 ($21,490, $25,000)

No different than national payment

14,000 16,000 18,000 20,000 22,000 24,000 26,000

Categorizing Hospital Performance

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• Introductions

• Purpose of Dry Run and Measure

• Proposed Implementation

• Dry Run Overview

• Measure Details

• Resources (next)

• Questions and Answers

Agenda

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• http://www.QualityNet.org

Resources

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• Email Q&A period

August 5 – September 4, 2013

cmsepisodepaymentmeasures@yale.edu

Note: Please do NOT email or attach to emails any patient identifiable information

Questions & Comments

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Questions?