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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
Maine
Utah
Nebras
kaIlli
nois
Indiana
Missouri
South Caro
lina
Texa
s
Michiga
n
New Je
rsey
Colorado
Montana
Pennsyl
vania
U.S. Ave
rage
Georgi
a
Tenness
ee
Oregon
Arkansas
Hawaii
Californ
ia
Arizona
Alaska
Oklahoma
Nevad
a
Distric
t of C
olumbia
Wyo
ming0%
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
[email protected](317) 754-5442
