Improving Patient Quality & Cost Outcomes:

Connecting with the Health Information Exchange/CRISP

June 1, 2011

Dianne Feeney, Associate Director

for Quality Initiatives

MARYLAND HEALTH SERVICES COST REVIEW COMMISSION

_______________________Background

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State of Maryland

• 5.65 Million people• 12% of population > age 64• 3rd highest income per capita state• 46 acute care hospitals• $13 billion in hospital revenue• 700,000 discharges per year

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Maryland Health Regulatory Agencies

Governor of Maryland

Maryland Insurance

Administration

Department of Health & Mental

Hygiene

Maryland Health Care

Commission

Health Services Cost Review Commission

Regulates CoreHealth Functions:Medicaid Program

Public HealthLicensing/Certification

Regulates: Cert. Of NeedReport Cards

Small Group Insurance

Regulates: Rates/Costs

Of Acute careHospitals

HSCRCHospital

Regulation

Law enacted in 1971; First set rates in 1974. Goals were to correct major problems.

◦ Control rapid cost growth◦ Improve access to care◦ Make the system equitable◦ Provide accountability and transparency◦ Ensure financial stability and predictability for hospitals and

patients

Key Components.◦ All Payer System◦ Waiver Test◦ Funding for Hospital Uncompensated Care◦ Charge per Case (CPC) system 5

Background: HSCRC and the All Payer System

• Quality Based Reimbursement (QBR)

• Maryland Hospital Acquired Conditions (MHAC)

• Readmission Initiatives:

– Maryland Preventable Hospital Readmissions (MHPR)– Admission-Readmission Revenue Hospital Payment

Constraint Program (ARR)

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HSCRC Quality Initiatives

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Readmission Initiatives

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Why Address Readmissions?

• Research shows hospital readmissions are sometimes indicators of poor care or missed opportunities to better coordinate care, or poor quality care in the hospital.

• For Medicare, 18% of all Medicare patients discharged from the hospital have a readmission within 30 days of discharge, accounting for $15 billion in spending nationally (Medpac 2007).

• For Maryland, the Medicare readmission is the second highest in the nation at 22%.

• Initiatives need to be put in place that reward efforts that reduce the number of readmissions and that also increase the quality of care and decrease cost.

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Readmission Incentive Programs: MHPR and ARR Initiatives

• Maryland Hospital Preventable Readmissions (MHPR) Initiative - Using the PPR methodology as the basis, the MHPR initiative provides a system of payment incentives based on the added or averted resource use resulting from a hospital’s actual number of readmissions versus a statewide target rate.

PPR Definition:

A Potentially Preventable Readmission (PPR) is a readmission that is clinically-related to the initial hospital admission that may have resulted from a deficiency in the process of care and treatment or lack of post discharge follow-up.

• Admission-Readmission Revenue (ARR) Initiative – Hospitals may volunteer for the ARR pilot to begin July 1, 2011. Hospitals under ARR will be held to a standard Charge per Episode (“CPE”) that would provide a combined revenue constraint for both initial admissions and subsequent readmissions.

– ARR provides a strong financial incentive to put in place the care coordination mechanisms/infrastructure necessary to reduce the potential for any patient to be readmitted and keep 100% of the savings associated with that outcome.

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Ensuring Accountability and Quality of Care for Bundled Payment Structures

• Patient Protection and Accountable Care Act- as providers are gradually given more responsibility and budgetary autonomy for reducing utilization, they also need to be held accountable to the public for more efficient and effective operation.

• To address unintended consequences, inject rational financial incentives through:– use of robust risk-adjustment systems and methods to account sufficiently for variations

in illness severity of patients and appropriately match payment to the required level of resource use; and

– use of outlier payments and exclusions for unusual cases.

• In order to achieve maximum improvements in the value of the care delivered over the long-term, financial incentives should be focused equally on improving quality and containing cost.

• Also monitor other utilization trends and system performance metrics over time.

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Maryland PPR Impact in 2007 for a 15 Day Readmission Time Interval

• 472,380 admissions were candidates for having a subsequent potentially preventable readmission

• 31,873 admissions were followed by one or more PPRs• PPR rate is the percent of candidate admissions that were

followed by one or more PPRs– PPR Rate 6.75 = 31,873 / 472,380

• 38,840 admissions were indentified as PPRs• PPRs account for $430.4 (5.3%) million in charges and

199,582 hospital bed days

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Maryland PPR Impact in 2007 for a30 Day Readmission Time Interval

• 452,863 admissions were candidates for having a subsequent potentially preventable readmission

• 44,417 admissions were followed by one or more PPRs• PPR rate is the percent of candidate admissions that were

followed by one or more PPRs– PPR Rate 9.81 = 44,417 / 452,863

• 59,599 admissions were indentified as PPRs• PPRs account for $656.9 million (8%) in charges and

303,865 hospital bed days

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Focus: Unique Patient Identifier

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Maryland Statewide Health Information Exchange- CRISP

•Chesapeake Regional Information System for our Patients (CRISP)

•Designated Health Information Exchange (HIE) by the Office of the National for Health Information Technology

•a 501(c)(3) corporation with a mandate to electronically connect all healthcare providers in the state.

•CRISP’s infrastructure uses a hybrid-federated model that is supported by two technology vendors. Axolotl Corporation, an Ingenix company, provides the core infrastructure and Initiate Systems, an IBM company, provides the master patient index (MPI) technology.

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Proposed New Data Fields

Field NameHSCRC Current Requirement

HSCRC New Requirement

Name, First No Yes

Name, Middle Initial No Yes*

Name, Last No Yes

Date of Birth Yes Yes

Gender Yes Yes

Street Address No Yes

City No Yes

State No Yes

Zip code Yes Yes

Social Security Number No Yes*

Medical Record Number (MRN) Yes Yes

Date of Admission Yes Yes

Date of Discharge Yes Yes

Yes*- Required Only if data provided by patient

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Matching CRISP and HSCRC Data for Readmission Analysis

Using the patient information submitted by the hospital, CRISP will create a master patient index (MPI) for each unique patient using a probabilistic matching algorithm. CRISP will be required to provide reports to the HSCRC at the patient level which will include at least the following fields:

•Enterprise MPI Number•Hospital/Facility ID•Medical Record Number•Date of Admission•Date of Discharge

The exact list of fields that will be required to match the report from CRISP to HSCRC’s data set will be determined based on the analysis of a pilot data set. HSCRC may require CRISP to use an HSCRC algorithm to generate a supplemental HSCRC ID for the purposes of matching against other hospital reported data.

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Anticipated Timeline for Regulation Promulgation 4/15 - Commission Meeting: Final Staff Policy Recommendation presented and approved

•6/17 -  Regulation for Proposed Action posted in Maryland Register with Comment Period through August 1

•8/3 - Commission Meeting Regulation Ripe for Final Action

•12/1 - Regulation Becomes Effective

HOSPITALS ESTABLISH CONNECTIVITY WITH CRISP•June through November

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Appendix: Readmission Data

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PPR Rate

2006 6.74

2007 6.74

2006 9.89

2007 9.81

30 Day Readmission Time IntervalAcross Hospital Readmissions

15 Day Readmission Time IntervalAcross Hospital Readmissions

PPR rates consistent between two years

Maryland Rates of PPRs

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0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30

Readmission Time Inteval (Days)

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PR

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ay

Cumulative Number of PPRs Number of PPRs Per Day

38%

66%

100%

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Top 15 PPRs represents 42% of charges on PPRs for a 30 day readmission time window

Top 15 Reasons for PPRs - 2007

APR DRG

Number of Admissions

Identified as a PPR

Total Charges for

PPRs

Number of Admissions Identified as

a PPR

Total Charges for

PPRs

720 SEPTICEMIA & DISSEMINATED INFECTIONS 1,945 $36,578,709 3,041 $57,464,024194 HEART FAILURE 2,929 $28,621,634 4,712 $45,489,197140 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 1,338 $11,695,437 2,317 $19,740,461130 RESPIRATORY SYSTEM DIAG W VENTILATOR SUPPORT 96+ HOURS 247 $13,131,776 352 $19,531,963460 RENAL FAILURE 993 $10,852,746 1,568 $17,288,207133 PULMONARY EDEMA & RESPIRATORY FAILURE 755 $11,477,824 1,145 $17,236,788721 POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS 904 $9,858,735 1,241 $13,552,588139 OTHER PNEUMONIA 878 $8,208,719 1,376 $12,538,408711 POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROC 298 $8,652,870 441 $11,882,757137 MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS 599 $7,545,054 855 $11,476,928753 BIPOLAR DISORDERS 883 $7,083,904 1,365 $10,923,940750 SCHIZOPHRENIA 678 $6,867,837 1,085 $10,247,78145 CVA & PRECEREBRAL OCCLUSION W INFARCT 550 $6,946,806 796 $9,976,474

248 MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS 562 $5,873,658 890 $9,544,644890 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 231 $6,893,043 335 $9,451,503

15 Day Window 30 Day Window

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Top 15 represents 35% of all initial admissions followed by PPRs

APR DRG

Initial Admissions Followed by

PPRs

Percent of Initial

AdmissionsPPR Rate

Initial Admissions Followed by

PPRs

Percent of Initial

AdmissionsPPR Rate

194 HEART FAILURE 1,838 5.77% 12.03% 2,567 5.78% 18.80%140 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 1,178 3.70% 10.02% 1,693 3.81% 15.67%720 SEPTICEMIA & DISSEMINATED INFECTIONS 1,024 3.21% 10.14% 1,321 2.97% 14.31%139 OTHER PNEUMONIA 765 2.40% 6.55% 1,078 2.43% 9.61%175 PERCUTANEOUS CARDIOVASCULAR PROCEDURES W/O AMI 737 2.31% 8.02% 1,063 2.39% 11.81%753 BIPOLAR DISORDERS 634 1.99% 7.53% 918 2.07% 11.56%460 RENAL FAILURE 683 2.14% 9.85% 896 2.02% 14.01%463 KIDNEY & URINARY TRACT INFECTIONS 606 1.90% 7.60% 836 1.88% 11.11%201 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS 604 1.90% 6.93% 830 1.87% 9.95%173 OTHER VASCULAR PROCEDURES 489 1.53% 10.38% 752 1.69% 16.61%198 ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS 542 1.70% 5.93% 752 1.69% 8.68%751 MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES 512 1.61% 6.87% 732 1.65% 10.29%383 CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS 505 1.58% 4.73% 724 1.63% 7.01%221 MAJOR SMALL & LARGE BOWEL PROCEDURES 529 1.66% 10.36% 718 1.62% 14.14%750 SCHIZOPHRENIA 506 1.59% 9.16% 709 1.60% 13.85%

30 Day Window15 Day Window

Top 15 Initial Admissions followed by one or more PPR - 2007

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Top Five PPR Reasons for an Initial Admission of Heart Failure - 2007

APR DRG

Number of Admissions

Identified as a PPR

Total Charges for

PPRs

Number of Admissions Identified as

a PPR

Total Charges for

PPRs

194 HEART FAILURE 962 $9,109,280 1,557 $14,239,684

460 RENAL FAILURE 104 $1,335,969 150 $1,969,758

720 SEPTICEMIA & DISSEMINATED INFECTIONS 97 $1,627,948 135 $2,535,465

140 RESPIRATORY SYSTEM DIAG W VENTILATOR SUPPORT 96+ HOURS 84 $691,335 134 $1,164,383

133 PULMONARY EDEMA & RESPIRATORY FAILURE 80 $1,044,021 113 $1,523,105

All Other PPRs 1,602 $14,813,081 2,623 $24,056,802

Total PPRs for Initial Admission of Heart Failure 2,929 $28,621,634 4,712 $45,489,197

15 Day Window 30 Day Window

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Length of Stay and Charges for Initial Admissions Followed by a PPR within a 30 Day Readmission Time Interval - 2007

Number of Admissions CMI

Average Length of

StayAverage Charge

3.75 $10,834

3.58 $10,337 CMI Adjusted

5.47 $14,930

4.16 $11,368 CMI Adjusted

At Risk Followed by PPRs(Initial Admission)

44,417 1.3133

408,446 1.0481At Risk Not Followed by PPRs(Other Admission)

Patients readmitted had a longer LOS than those not readmitted.