CMS Update FY’14

Frank Briggs, Pharm.D., M.P.H.Vice President, Quality and Patient

SafetyWest Virginia University Healthcare

Objectives

• At the completion of this presentation, the participants shall be able to:

• Describe the changes in Value Based Purchasing (VBP)

• Explain the Hospital Acquired Condition (HAC) penalty program

• Estimate the impact of changes in the Inpatient Prospective Payment System (IPPS)

Outline• Inpatient Quality Reporting (IQR)• Value Based Purchasing (VBP)• Readmission Reduction• Hospital Acquired Conditions (HAC)

• Not included– Documentation and coding effects– Disproportionate share program– Labor and delivery days– Outlier thresholds

• 2 Midnight Rule?

Inpatient Quality Reporting

• Voluntary reporting– Required for annual payment update 2%

• Measures appear in program ~2 years before advancing– VBP– HAC– Readmissions

Inpatient Quality Reporting

• medicare.gov/hospitalcompare

Patient Survey Results

• Hospital Consumer Assessment of Healthcare Providers and Systems– HCAHPS– Reported since 2007

• Uses scale from never to always (5 points)• Top box scores – “Always”• Report “Always”

HCAHPS Domains

• Nurse communication• Doctor communication• Responsiveness of staff• Pain control • Explanation of medications• Cleanliness• Quietness• Discharge information (recovery)

Core Measures

• Heart Attack Care– Aspirin at discharge– Fibrinolytic within 30 mins– Primary PCI within 90 mins– Statin at discharge

• Heart Failure– Discharge instructions– Evaluation of LVS function– ACEI/ARB for LVSD

Core Measures

• Pneumonia Care– Blood cultures in ED prior to antibiotic– Appropriate antibiotic selection

• Surgical Care– Antibiotics: timing, selection, and discontinuation– Venous thromboembolism (VTE) prevention– Beta blockers continued– Blood glucose control in cardiac surgery– Urinary catheters removal– Monitoring of body temperature

Core Measures• Emergency Department– Time spent in ED for admitted patients– Time spent in ED after decision to admit– Time spent in ED for patients sent home– Time before being seen by provider– Time before pain medication for broken bones– Percent of patients who leave without being seen– Percent of patients with stroke symptoms who

receive brain scan within 45 mins• Preventive Care– Immunizations

New Core Measures

• Immunizations• Venous Thromboembolism (VTE)• Stroke• Perinatal Care• Hospital based inpatient psychiatric services

(HBIPS)

Core Measures

• Immunizations– Influenza– Pneumonia

• VTE– VTE prophylaxis– Overlap with anticoagulation– Heparin – platelet dose adjustments by protocol– Discharge instructions for warfarin– Preventable VTE

Core Measures• Stroke

– VTE prophylaxis– Discharge on antithrombotic therapy– Anticoagulation for atrial fibrillation/flutter– Thrombolytic therapy– Antithrombotic by day 2– Discharged on Statin– Stroke education– Assessed for rehabilitation

• Perinatal Care– Elective delivery– Cesarean sections– Antenatal steroids– Bloodstream infections– Exclusive breast feeding

Core Measures

• HBIPS– Admission screen: violence, substance abuse,

psychological trauma, and patient strengths – Hours of physical restraint– Hours of seclusion– Patients discharged on multiple antipsychotics – Discharge plan created and transmitted to next

provider

Removals of Measures

• FY 2016– PN: Blood cultures– HF: discharge instructions, ACEI/ARB for LVSD– AMI: aspirin/statin at DC– SCIP: temperature monitoring

Readmissions Complications and Deaths

• Readmission: 30-day all-cause– AMI– HF– Pneumonia

• Death: 30-day– AMI – HF– Pneumonia

New Readmissions and Death Measures

• Readmissions– Total Joints – Hospital-wide – COPD– Stroke– Planned readmission algorithm

• Mortalities– COPD– Stroke

Complications

• Agency for Healthcare Research and Quality Measures (AHRQ)– Patient safety indicators• Death among surgical patients with treatable

complications• Iatrogenic pneumothorax• Post-op respiratory failure• Post-op VTE• Post-op wound dehiscence • Accident puncture or laceration

Other Measures Reported

• Use of medical imaging• Medicare payments• Number of Medicare patients treated

Value Based Purchasing

• Established by Affordable Care Act– Requires CMS to implement a Hospital VBP

program– Rewards hospitals for quality of care provided– Built upon IQR infrastructure – Evaluate during performance period for

achievement or improvement on measures– Hospital receive points on each measure reflecting

better performance– Funding by reducing base operating DRG payment

Value Based Purchasing

• Payment reductions– 2013: 1%– 2014: 1.25%– 2015: 1.5%– 2016: 1.75%– 2017: 2%

• Amount available for FY 14 incentive payments $1.1 billion

Domains

• Clinical process of care (core measures)– 13 measures and weighted at 45%

• Patient experience (HCAHPS)– 8 domains and weighted at 30%

• Outcomes– 3 mortality measures and weighted 25%

Evaluating Hospital Performance

• Achievement points– Awarded by comparing individual hospital rate

during performance period with all hospitals rates from baseline period• Rate at or above benchmark (90th%ile): 10 points• Rate less than achievement threshold (median): 0

points• Rate between achievement and benchmark: 1-10

points– Comparing current hospital performance to

baseline of all hospitals

Evaluating Hospital Performance

• Improvement points– Awarded by comparing hospitals rates during

performance period to same hospitals rate from baseline period• Rate at or above benchmark: 9 points• Rate less than or equal to baseline: 0 points• Rate between baseline and benchmark: 0-9 points

– Comparing against yourself over time– Fewer points than achievement

Proposed VBP Changes for 2015 and Beyond

• 2015 (final)– Clinical process of care measures: 20%– Outcome measures: 30%– Efficiency measures(Medicare spending): 20%– HCAHPS: 30%

• 2016 (proposed)– Clinical process of care measures: 10%– Outcome measures (add AHRQ PSI and infection): 40%– Efficiency measures: 25%– HCAHPS: 25%

VBP 2017

• Change domain and reweight – Outcomes become safety domain: 15%• AHRQ Patient Safety Indicators

– Process of care becomes clinical care domain: 35%• Clinical process of care: 10%• Mortality outcomes: 25%

Reduction Earn back % change in DRG

Value multiplier for DRG

Slope for translation

Readmission Reduction Program

• Maximum penalty increased to 2%• Projecting $175 million in fewer payments• Added planned readmission logic• Two new measures for FY 2015– COPD and elective joint– Built upon IQR infrastructure

• FY 2014 period– July 1, 2009 – June 30, 2012

Planned Readmission

• Incorporating algorithm – AMI, HF, PN– FY 2014– Will not count unplanned readmissions that follow

planned readmissions either

Hospital Acquired Condition (HAC) Reduction Program

• Required by Affordable Care Act– Payment adjustment for all inpatient hospital

payments– ***Includes indirect medical education (IME) and

disproportionate share (DSH) payments– Must apply to one quarter of all hospitals (lowest

performance)– In addition to the non-payment HAC program– Reductions applied after adjusting for VBP and

Readmissions reduction programs• Starts in FY 2015

HAC Reduction FrameworkTotal HAC Score

Worst quartile performance1% reduction

Domain 1 (35%) Domain 2 (65%)AHRQ Patient Safety Indicators NHSN InfectionPressure Ulcer Central line blood streamIatrogenic pneumothorax Catheter associated UTICentral venous catheter infectionHip fracture 2016Post-op VTE Surgical site infectionSepsis (Colon and abdominal hys)Wound dehiscenceAccidental puncture 2017

MRSAC difficile

HAC Scoring (Golf)• Points assigned based on performance• Performance range for each measure divided into

deciles• All hospitals receive between 1-10 points for

each measure (lower is better)• Total score calculated – AHRQ score x 35% + average of 2 NHSN infections x

65%• Each year bottom 25% are penalized – Move faster than the others

Data Periods

• Domain 1: AHRQ PSI– July 2011 – June 2013

• Domain 2: NHSN Infections– Calendar years 2012 -2013

Admission and Medical Review Criteria

• Requires physician order for admission to inpatient status– Authenticated by attending provider

• Certification – Inpatient order

• Inpatient services are reasonable and necessary • Appropriately provided in accordance with 2 midnight benchmark

– Reason for inpatient services• Medical record

– Estimated time the beneficiary requires inpatient care– Plans for post hospital care– CAH: beneficiary reasonably expected to be discharged or transferred

within 96 hours– Must be signed and dated prior to discharge

• DRG payments reduced additional 0.2% to account in addition

2 Midnight Benchmark• Reasonably expect patient to require inpatient hospital

care for at least 2 midnights• Less than 2 midnights– Expected to be observation

• May move from observation to inpatient if patient meets medical necessity and going to require hospital care for second midnight– Outpatient time does not convert to inpatient billing (no

retroactive billing)• Includes time spent in hospital outpatient areas (ED

and OR)– Does not begin at triage, when care starts!

Estimating Impact of Changes

• IQR changes– Generally don’t involve payment/penalty– Voluntary, required for APU – May require additional staff and support

• VBP– 1.25% withhold – earn back % = impact

• Readmission reduction (2%)• HAC 1% of DRG + IME + DSH

Contact Information

Frank Briggs, Pharm.D., M.P.H.Vice President, Quality and Patient Safety

West Virginia University Healthcare

Email: briggsf@wvuhealthcare.comPhone: 304.598.4057