Value-Based Purchasing - Lake Superior Quality Innovation Network

Hospital Incentive Programs: A Basic Understanding Vicki Tang Olson; Stratis Health, Minnesota Donna Modras; MPRO, Michigan Ross Gatzke; MetaStar, Wisconsin November 10, 2015

Objectives

•

•

•

Understand the current status of Hospital ValueBased Purchasing (VBP) readmission reduction and hospital-acquired condition (HAC) programs Share tools to understand and support the Centers for Medicare & Medicaid Services (CMS) hospital incentive programs Identify tips for improvement

1

Value-Based Purchasing (VBP) Program

2

Fiscal Year (FY) 2016 Results FY2016 Value-based Purchasing Total Performance Score 60 50 40 30 20 10 0 Michigan

Minnesota State Average

Wisconsin

National Average

Source: Hospital Inpatient VIQR Outreach and Education Support Program 3

FY2018

4

FY2018 Measures Clinical Care

Experience of Care

Safety

Efficiency and Cost Reducton

30 day mortality • AMI • Heart failure (HF) • Pneumonia (PN)

Eight dimensions New! CTC – 3

Healthcare-associated Infections (HAIs) • Central line-associated bloodstream infection (CLABSI) • Catheter-associated urinary tract infection (CAUTI) • Surgical site infection (SSI) • Methicillin-resistant staphylococcus aureus (MRSA) • Clostridium difficile (CDI)

Medicare spending per beneficiary (MSPB)

Patient Safety Indicators (PSI) 90 Moved! PC-01 Early Elective Deliveries

5

FY2018 Measures Clinical Care

Patient Experience

Safety

Efficiency and Cost Reduction

25 cases

100 surveys

Three cases in one PSI 90 indicator

25 cases

One predicted infection

Two measures

Three measures

Requires scores in at least three of the four domains to receive a total performance score

6

VBP Fact Sheet

7

VBP Top 10 Activities Top 10 Activities to Support Improvement in Hospital Quality and Success in CMS VBP and Incentive Programs Value-Based Purchasing (VBP) * Readmission Reduction * Hospital-Acquired Conditions (HAC)

1. 2. 3. 4. 5.

Infection preventionist (IP)/Finance/Quality Look ahead Watch for new Inpatient Quality Reporting (IQR) measures Review claims reports Build community partnerships

8

VBP Top 10 Activities continued… Top 10 Activities to Support Improvement in Hospital Quality and Success in CMS VBP and Incentive Programs Value-Based Purchasing (VBP) * Readmission Reduction * Hospital-Acquired Conditions (HAC)

6. 7. 8. 9. 10.

Make reducing infections a priority Work on the culture of safety Root cause analysis on every defect Be action oriented Build into systems

9

Polling Question Which domain(s) is your hospital currently focusing on for the HVBP Program? Please check all that apply. • Clinical care (Mortality) • Patient safety – Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) • Safety (PSI-90 Composite, HAIs, PC-01) • Efficiency (MSPB) • Don't know or n/a

10

Key Strategies for Improvement

11

Mortality • • • • • • •

End of life care Early identification and treatment of sepsis Rapid response teams Patient safety – harm AMI – look at community capacity to stabilize HF & Pneumonia – care transitions, support Transfers from skilled nursing facilities

12

HCAHPS Overarching Strategies

Resilency

Patient Family Advisory Committees

Patient Safety Culture

Situational Awareness Empathy

13

CTM-3 3 Questions: 1. During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.

14

CTM-3 2. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. 3. When I left the hospital, I clearly understood the purpose for taking each of my medications.

15

Resources Patient-Centered Care Improvement Guide: http://bit.ly/1DCCxep A Leadership Resource for Patient and Family Engagement Strategies: http://bit.ly/1yW10Dw

16

PSI-90 Most frequent harm – accidental puncture or laceration Need to determine: • • •

Is it a documentation issue? Is it a coding issue? Is it a clinical issue?

17

Polling Question Does your organization have a review process for each component of the PSI-90, either through a concurrent review or at discharge? • Yes • No • I don’t know

18

Safety PC-01 • Implement a hard stop to review elective deliveries prior to 39 weeks

19

Medicare Spending per Beneficiary Best practice = .82 Identify priorities by looking at percent expenses in comparison to state and national for three buckets • Before admission • During admission • After discharge

20

Future Measures

• Hip/knee complications • COPD mortality

21

Measures to Watch • •

• •

Condition specific spending measures – AMI, PN, HF Episode-based cost measures – kidney/urinary tract infections (UTI), cellulitis, GI hemorrhage, hip or knee replacement/revision, lumbar spine fusion/refusion 30-day mortality for stroke, coronary artery bypass graft (CABG) Sepsis

22

Hospital Readmission Reduction (RRP) Program

23

Understanding the Readmission Reduction Program • • • • • • • • •

Affordable Care Act IPPS hospitals only Discharges 10/1/12 (FY2013) Penalty program Reduces payment for excess readmissions Adjustments to hospital based DRG As of FY2015 - 3 % maximum penalty Planned readmissions are excluded Excess Readmission Ratio (ERR) FY2016 is currently displayed in Hospital Compare

24

Definition of Readmission Readmission is an admission to an IPPS acute care hospital within 30 days of a discharge from the same or another IPPS acute care hospital

30 Days

25

Performance Period and Eligibility • Three years of discharge data − − − −

FY2013: FY2014: FY2015: FY2016:

July 1, 2008 to June 30, 2011 July 1, 2009 to June 20, 2012 July 1, 2010 to June 30, 2013 July 1, 2011 to June 30, 2014

• Minimum of 25 cases

26

Excess Readmission Ratio & Risk Adjustment A hospital’s excess readmission ratio • Measures hospital’s readmission performance • Compared to the national average

Risk adjustment • Patient demographic characteristics • Comorbidities • Patient frailty

27

Calculation of Excess Readmission Ratio (ERR) ERR: The ratio of predicted readmissions to expected readmissions Predicted readmissions • • • •

Hospital performance Hospital estimated effect on readmissions Rate per 100 discharges Divided by the number of eligible discharges

Expected readmissions • •

Number of 30-day readmissions expected Based on average hospital performance

*If a hospital performs better than an average hospital that admitted similar patients, the ratio will be less than 1.0000. If a hospital performs worse than average, the ratio will be greater than 1.0000.

28

30-Day Readmission Conditions FY2016 and Forward • • • • • • • •

AMI HF PN COPD NEW Total hip (THA) and knee (TKA) arthroplasty FY2017 Coronary Artery Bypass Graft (CABG) FY2017 Aspiration pneumonia as a principal diagnosis Sepsis as a FY2017 principalNEW with pneumonia present at admission

29

NEW

Final Rule FY2016 Extraordinary Circumstance Exception Policy • Begins October 1, 2015 • Hospital must request waiver • Provide time period for data exclusion − Example: hurricane affecting a hospital’s ability to accurately or timely submit all of its claims data − Form will be available on the QualityNet website soon

30

Extraordinary Circumstance Exception Policy continued… At a minimum, the following information will be required in order to request an exception: •Hospital CMS Certification Number (CCN) •Hospital name •Hospital CEO and any other designated personnel contact information, including name, email address, telephone number, and mailing address •Hospital’s reason for requesting an exception, including: − CMS program name (Hospital Readmissions Reduction Program) − Measure(s) and submission quarter(s) affected by the extraordinary circumstance that the hospital is seeking an exception for accompanied by the specific reasons why the exception is being sought − How the extraordinary circumstance negatively impacted performance on the measure(s) for which an exception is being sought •Evidence of the impact of the extraordinary circumstances, including but not limited to, photographs and newspaper and other media articles •Request form must be signed by the hospital’s CEO or designated non-CEO contact and submitted to CMS

31

Final Rule FY2017 Expansion of the cohort for the pneumonia readmission measure begins with the FY 2017 Program •Finalized a modified version of the expanded cohort from what was proposed that includes the addition of more pneumonia diagnoses, as follows: − Patients with a principal discharge diagnosis of pneumonia − Patients with a principal discharge diagnosis of aspiration pneumonia − Patients with a principal discharge diagnosis of sepsis, with a secondary diagnosis of pneumonia present on admission − Patients with respiratory failure or coded as having severe sepsis •Developed in response to changing trends in hospital coding practices for pneumonia and to address potential bias related to variations in coding practices •Provides a more complete picture of a hospital’s performance on readmissions with respect to its pneumonia patients and allows for better comparison of performance across hospitals

32

Readmission Measures in the Hospital Readmissions Reduction Program

33

Polling Question Which measure(s) is your hospital focusing on for the Readmission Reduction Program? Please check all that apply. • • • • • •

AMI HF PN COPD THA/TKA Don't know or n/a

34

Michigan Condition Volume Readmissions Reduction Program Patient Volume for Conditions at Risk in Michigan FY2016 (96 Hospitals) 50000

47418

45000 38587

Patient Volume

40000 35000

30128

30729

HIP-KNEE Arthroplasty Cases

Pneumonia Cases

30000 25000

20719

20000 15000 10000 5000 0 Acute Myocardial Infarction Cases

Chronic Obstructive Pulmonary Disease Cases

Heart Failure Cases

Source: http://cms.gov/Medicare/MedicareFee-for-ServicePayment/AcuteInpatientPPS/Readmissions35 Reduction-Program.html/

Minnesota Condition Volume Readmissions Reduction Program Patient Volume for Conditions at Risk in Minnesota FY2016 (50 Hospitals) 12000 9690

Patient Volume

10000 8000 6673

6818

Pneumonia Cases


6000 4742

4744

Acute Myocardial Infarction Cases


4000 2000 0 Heart Failure Cases

Source: http://cms.gov/Medicare/Medicare-Fee-forService36 Payment/AcuteInpatientPPS/Readmission s-Reduction-Program.html/

Wisconsin Condition Volume Readmissions Reduction Program Patient Volume for Conditions at Risk in Wisconsin FY2016 (66 Hospitals) 20000 17628

18000

Patient Volume

16000

14137

14000

12774

12000

10566

10000 8000

7601

6000 4000 2000 0 Acute Myocardial Infarction Cases



Pneumonia Cases

Heart Failure Cases

Source: http://cms.gov/Medicare/MedicareFee-for-ServicePayment/AcuteInpatientPPS/Readmissions37 Reduction-Program.html/

Michigan Hospitals with Excess Readmissions Readmissions Reduction Program Number & Percent of Michigan Hospitals with Excess Readm for a Condition FY2016 (96 Hospitals) 50

47.92%

45 40 35

37.50%

38.54%

46

33

36

60.00% 50.00%

34.38%

30 25

41.67%

40.00%

40

37

30.00%

20 20.00%

15 10

10.00%

5 0

0.00% AMI

HF

COPD

Number of MI Hospitals with Excess Readmissions

HIP-KNEE

PN

Percent of MI Hospitals with Excess Readmissions

Source: http://cms.gov/Medicare/Medicare-Feefor-ServicePayment/AcuteInpatientPPS/Readmissions38 Reduction-Program.html/

Minnesota Hospitals with Excess Readmissions Readmissions Reduction Program Number & Percent of Minnesota Hospitals with Excess Readm for a Condition FY2016 (50 Hospitals) 30

60.00% 48.00%

25

50.00%

42.00% 38.00%

20 30.00% 15 10

16.00%

5

8

19

24

40.00%

21 30.00%

15

20.00% 10.00%

0

0.00% AMI

HF

HIP-KNEE


COPD

PN


Source: http://cms.gov/Medicare/Medicare-Feefor-ServicePayment/AcuteInpatientPPS/Readmissions39 Reduction-Program.html/

Wisconsin Hospitals with Excess Readmissions Readmissions Reduction Program Number & Percent of Wisconsin Hospitals with Excess Readm for a Condition FY2016 (66 Hospitals) 30

40.00% 31.82%

36.36%

35.00%

25

30.00%

25.76% 20

21.21%

24.24%

24 25.00%

21 15

10

14

16

20.00%

17

15.00% 10.00%

5

5.00%

0

0.00% HF

AMI

COPD


PN

HIP-KNEE


Source: http://cms.gov/Medicare/Medicare-Fee-forServicePayment/AcuteInpatientPPS/Readmissions40 Reduction-Program.html/

Readmission Reduction Fact Sheet

41

Improvement Opportunities

• Review excess readmissions in Readmission Reduction Report received in July 2015 • Implement major readmission strategies/tools

42

Resources on Reducing Hospital Readmissions General Program Information: https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetT ier2&cid=1228772412458 HRRP General Inquiries - HRRP Measure Methodology Inquiries: [email protected] [email protected] More Program and Payment Adjustment Information: http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/ReadmissionsReduction-Program.html/ Readmission Measures: https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetT ier3&cid=1219069855273 Initiatives to Reduce Readmissions: https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetT ier4&cid=1228766331358

43

Resources continued…. •

• • • •

Partnership for Patients: https://partnershipforpatients.cms.gov/p4p_resources/tsppreventablereadmissions/toolpreventablereadmissions.html Improving Quality of Care Through Care Coordination: http://www.medscape.org/viewarticle/841260_slide CMS website: http://go.cms.gov/1DHPeF1 QualityNet: http://bit.ly/1DHPjbK RARE website: http://www.rarereadmissions.org/

44

Hospital-Acquired Condition (HAC) Program

45

FY2016 • • • •

•

Second year of HAC program Third incentive CMS program implemented after VBP and Readmission Reduction program Measures are inpatient quality reporting measures and overlap with VBP program measures Set up similar to VBP program with measure scores, domain scores, domain weighting, and total score Penalty program – no gains

46

FY2016

47

HAC Calculations Domains

Domain 1

Measure results

PSI-90 Composite

CLABSI standardized infection ratio (SIR)

Domain 2 CAUTI SIR

SSI - Colon/Ab. Hysterectomy

Percentile ranking

Compared to other U.S. hospitals




Measure score

Decile #

Decile #

Decile #

Decile #

Domain score

Measure score CLABSI measure score + CAUTI = domain score score + SSI score 2

HAC score

Domain 1 score x .25 (25 percent) + Domain 2 score x .75 (75 percent)

HAC penalty

Top 25 percent of all U.S. PPS hospital HAC scores (Higher is worse) in FY2016 HAC score>6.75 had 1 percent penalty

48

Polling Question Which domain(s) is your hospital currently focusing on for the HAC Reduction Program? Please check all that apply. • • • • •

PSI-90 composite CLABSI CAUTI SSI/Colon hysterectomy Don't know or n/a

49

Penalty

• •

•

VBP and RRP penalties taken first HAC penalty applied after other program adjustments are made – outliers, disproportionate share hospital (DSH), uncompensated care, and indirect medical education (IME) Discharges Oct. 1, 2015 – Sept. 30, 2016

50

FY2016 Results FY2016 Hospital-Acquired Condition (HAC) Program Michigan PPS Hospitals Total HAC Score 10 9 8 7 6 5 4 3 2 1 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 87 89 91 93 95 MI Hospital HAC

Source: July 2014 HAC Hospital Specific Report 51

FY2016 Results FY2016 Hospital-Acquired Condition (HAC) Program Minnesota PPS Hospitals Total HAC Score 10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 MN Hospital HAC Score


FY2016 Results FY2016 Hospital-Acquired Condition (HAC) Program Wisconsin PPS Hospitals Total HAC Score 10 9 8 7 6 5 4 3 2 1 0 1

3

5

7

9

11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65


Public Reporting Reporting on Hospital Compare • • • • •

HAC scores will be reported beginning December 2015 PSI 90 Composite measure score CLABSI, CAUTI, and SSI measure scores Domain 1 and Domain 2 scores Total HAC Score

54

FY2017 Added to Domain 2 • MRSA, Clostridium difficile (CDI) −

• •

Domain weighting changes

PSI-90 measure decreases from 25 percent to 15 percent National Healthcare Safety Network (NHSN) measures increase from 75 percent to 85 percent

55

FY2017 Domain 1

FY 2017 HAC Reduction Program Domain Weighting and Measures (Payment adjustment

Performance Period

effective for discharges from Oct. 1, 2016-Sept. 30, 2017)

Domain 1

July 1, 2013-June 30 2015 AHRQ* PSI 90 Measure

(AHRQ Patient Safety Indicators) 15%

Domain 2 (CDC NHSN Measures) 85%

Score 1-10

PSI 3 Pressure ulcer rate PSI 6 Latrogenic pneumothorax rate PSI 7 Central venous catheter-related blood stream infection rate PSI 8 Postoperative hip fracture rate PSI 12 Postoperative pulmonary emobolism or deep vein thrombosis rate PSI 13 Postoperative sepsis rate PSI 14 Wound dehiscence rate PSI 15 Accidental puncture and laceration rate

Domain 2

CDC NHSN*Measures CLABSI SIR Rate CAUTI SIR Rate SSI Colon Abdominal Hysterectomy MRSA CDI

Performance Period January 1, 2014-December 31, 2015 Average Score 1-10 1-10 1-10 1-10 1-10 1-10

56

FY2018 Finalized expansion of patient population for CAUTI and CLABSI measures • Expands to include patients in select non-intensive care units (pediatric & adult medical wards, surgical wards, and med/surgical wards locations) •

Changes the relative contribution of each measure within Domain 2 and the domain weighting of the total HAC score, which could impact the mix of hospitals receiving the HAC penalty

57

FY2016 IPPS Final Rule • • • •

$373 million in penalties for FY2015 Not adding or removing categories of HACs for FY2016 CMS considering adding untreated malnutrition, including disease-related malnutrition, as an HAC category Will continue to monitor contemporary evidencebased guidelines and previously considered HACs to determine future rule-making

58

FY2016 IPPS Final Rule • •

Extraordinary circumstance exemption policy finalized Beginning in FY2017, hospitals not submitting data for Domain 2 measures (without a waiver) will receive a maximum score of 10 for that measure

59

Possible Future Changes in Rule-making Agency for Healthcare Research and Quality (AHRQ) is still considering the addition of three additional measures for the composite: • PSI #9 Perioperative Hemorrhage or Hematoma Rate • PSI #10 Postoperative Physiologic and Metabolic Derangement Rate • PSI #11 Postoperative Respiratory Failure Rate CMS believes this change to be significant and will propose the change in the rule-making process prior to requiring reporting of the revised measure

60

Possible Future Changes in Rule-making Align the conditions measured between the: HAC Reduction Program & Hospital-Acquired Conditions Present on Admissions Indicator Program (HAC-POA)

61

HAC Fact Sheet

62

Polling Question Have you performed root cause analysis on any of your hospital's incentive programs (VBP, HAC, or RRP) data? • Yes • No

63

HAC Resources http://www.cdc.gov/nhsn/cms/index.html http://www.qualityindicators.ahrq.gov

64

Join Your State Collaborative for Care Transitions & HAI We offer a Care Transitions and HAI collaborative in each state. If you are interested in joining a collaborative please contact the following: MI: Kristie Mimms [email protected] or 248-465-1370 MN: Vicki Olson [email protected] or 952-853-8554 WI: Ross Gatzke [email protected] or 608-441-8292

65

IQR Resources www.qualityreportingcenter.com • Quick Support Reference Card − Provides support information related to the Inpatient Quality Reporting Program − Resources/Education » Resources/Tools » Hospital IQR Resources

66

Additional Resources QualityNet Helpdesk •

Secure Portal access issues, data submission issues, and password resets − −

Phone: 866-288-8912 [email protected]

67

Questions? Vicki Tang Olson, Program Manager, Stratis Health 952-853-8554 [email protected] Donna Modras, Project Coordinator, MPRO 248-465-7407 [email protected] Ross Gatzke, Project Specialist, MetaStar 608-441-8292 [email protected]

Follow us online @LakeSuperiorQIN

68

This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-D1-15-64 110415