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ADVISORY

HEALTHCARE & PUBLIC SECTOR

Medicare FY 2009 IPPS Update andHealthcare Quality Mandates

11th Annual HFMA Region 11 Healthcare Symposium

January 26, 2009

Joe Sellars Carolyn ScottJoe Sellars Carolyn Scott

Director, KPMG LLP Director, KPMG LLPDirector, KPMG LLP Director, KPMG LLP

Jacksonville, FL Atlanta, GAJacksonville, FL Atlanta, GA


HEALTHCARE

KPMG LLP

Medicare FY 2009 IPPS Final RuleMedicare FY 2009 IPPS Final Rule

Joe SellarsDirector, Healthcare Advisory

HFMA Region 11 Healthcare SymposiumJanuary 26, 2009

CMS FY 2009 IPPS Final RuleSignificant MS-DRG Payment Changes

CMS FY 2009 IPPS Final RuleSignificant MS-DRG Payment Changes


MS-DRG ReclassificationsMS-DRG Reclassifications

CMS focused on making significant reforms to IPPS consistent with MedPAC recommendations made in March 2005.

Severity of Illness

Applying HSRV weights to DRGs

Three-year transition period started in FY 2007:

Adopted cost-based weights (1/3 cost-based, 2/3 charge-based)

20 new CMS-DRGs created, 32 others modified, 8 deleted; Involved 1.7 million cases in 13 different clinical areas


MS-DRG Reclassifications (continued)MS-DRG Reclassifications (continued)

Medicare Severity DRGs implemented in FY 2008:

745 MS-DRGs adopted, replacing CMS-DRGs

Continued transition to cost-based weights (2/3 cost, 1/3 charge)

List of Major Diagnostic Categories (MDC) not changed

FY 2009:

Completion of transition to 100% cost-based weights


MS-DRG Reclassifications (continued)MS-DRG Reclassifications (continued)

CMS subdivided MS-DRG 245 (AICD Lead & Generator Procedures)

Created new MS-DRG to separate implantation / replacement of leads from the implantation / replacement of pulse generators

MS-DRG 245 re-titled “AICD Generator Procedures”

New MS-DRG 265 titled “AICD Lead Procedures”

The surgical hierarchy for MDC 5 (Diseases and Disorders of the Circulatory System) was revised

MS-DRG 245 was placed above MS-DRG 265


Application of Documentation and Coding AdjustmentApplication of Documentation and Coding Adjustment

Per CMS, by increasing the number of DRGs and more fully considering severity of illness, the MS-DRGs encourage hospitals to improve their documentation and coding of patient diagnoses.

The Secretary of HHS has the authority under the Act to maintain budget neutrality by adjusting the standardized amount to eliminate the effect of changes in coding or classification that do not reflect real changes in case-mix.

Documentation and coding adjustment of -0.6 percent in FY 2008, -0.9 percent in FY 2009, consistent with P.L. 110-90 Section 7


Application of Documentation and Coding Adjustment(continued)Application of Documentation and Coding Adjustment(continued)

Documentation and coding adjustments are cumulative

The FY 2009 documentation and coding adjustment of -0.9 percent is in addition to the -0.6 percent adjustment for FY 2008, yielding a combined effect of -1.5 percent.

SCH and MDH providers may be affected in FY 2010

CMS considering applying documentation and coding adjustments to FY 2010 hospital-specific rates, including applying the FY 2008 and FY 2009 adjustment percentages in the computation of the FY 2010 adjustment percentage.

CMS FY 2009 IPPS Final RuleCharge CompressionCMS FY 2009 IPPS Final RuleCharge Compression


Charge Compression Charge Compression

Beginning in FY 2007, CMS implemented relative weights based on cost report data instead of charge information.

CMS developed cost-to-charge ratios (CCR) based on distinct hospital departments. Charges were summed by DRG for each of the 15 cost groups.

Transition to cost-based weights raised concerns about potential bias in the weights due to “charge compression”

Applying a higher percentage charge markup over costs to lower cost items and servicesApplying a lower percentage charge markup over costs to higher cost items and servicesCost-based weights would undervalue high-cost items and overvalue low-cost items if a single CCR is applied to items of widely varying costs in the same cost center


Charge Compression (continued) Charge Compression (continued)

Contract awarded to RTI in August 2006 to study effects of charge compression.

RTI found that a number of factors contribute to charge compression:

Inconsistent matching of charges in the Medicare cost report and corresponding charges in MedPAR claims for certain cost centersInconsistent reporting of costs and charges among hospitals.

Some hospitals would report costs & charges for devices and supplies in the Medical Supplies Charged to Patients cost centerOthers would report these costs and charges in their related ancillary departments such as Operating Room or Radiology

RTI’s findings demonstrated that charge compression exists in several CCRs, most notably in Medical Supplies and Equipment.



Longstanding Medicare cost reporting policy has been that hospitals must include the costs and charges of separately “chargeable medical supplies” in the Medical Supplies Charged to Patients cost center, rather than in the Operating Room, Emergency Room or other ancillary cost centers.

Transmittal 321, Change Request 5928 was issued 2/29/2008 to inform FIs/MACs of hospital associations’ initiatives to encourage hospitals to modify their cost reporting practices. It was effective March 31, 2008.

Form CMS-2552-09 is expected to establish a new Medical Implants Charged to Patients cost center to separate higher-cost implants and devices from the lower-cost supplies that will continue to be reported under Medical Supplies Charged to Patients.



Rather than use the existing criteria set forth in the proposed rule to determine what should be reported in these cost centers, CMS will use revenue codes established by the National Uniform Billing Committee (NUBC) to determine what should be reported

The use of the NUBC definitions would not require that the implantable device remain in the patient when the patient is discharged

Revenue codes to be reported in “Medical supplies” are:0270, 0271, 0272 and 0273

Revenue codes to be reported in “Implantable Devices” are:0275, 0276, 0278 and 0624

CMS has to revise the cost report (2552-09) to accomplish this change. Revisions are not expected to be available until Spring 2009.

CMS FY 2009 IPPS Final RulePreventable Hospital-Acquired Conditions (HACs) and Present on Admissions (POAs)

CMS FY 2009 IPPS Final RulePreventable Hospital-Acquired Conditions (HACs) and Present on Admissions (POAs)


Preventable Hospital-Acquired Conditions (HACs) Preventable Hospital-Acquired Conditions (HACs)

In a 1999 report titled “To Err is Human: Building a Safer Health System”, the Institute of Medicine noted the following:

Medical errors and HACs caused by medical errors are a leading cause of morbidity and mortality in the U.S.

The number of Americans who die each year as a result of medical errors that occur in hospitals may be as high as 98,000

Total national costs of these errors due to lost productivity, disability and health care costs were estimated at $17 billion to $29 billion



Other organizations’ findings:

In 2000, the CDC estimated that hospital-acquired infections added nearly $5 billion to U.S. health care costs every year

A 2007 study published in the March-April 2007 issue of Public Health Reports found that, in 2002, 1.7 million hospital-acquired infections were associated with 99,000 deaths

A 2007 Leapfrog Group Hospital Survey of 1,256 hospitals found that 87% of those hospitals do not follow recommendations to prevent many of the most common hospital-acquired infections



Combating HACs, including infections:

In 2005, Congress authorized CMS to adjust Medicare IPPS hospital payments to encourage the prevention of these conditions

This is part of an array of Medicare value-based purchasing (VBP) tools to promote increased quality and efficiency of care:

Measuring performance

Payment incentives

Publicly reporting performance results

Applying national and local coverage policy decisions

Enforcing conditions of participation

Providing direct support for providers through Quality Improvement Organization (QIO) activities

“CMS’ application of VBP tools… is transforming Medicare from a passive payer to an active purchaser of higher value health care services”



Combating HACs, including infections (continued):

The President’s FY 2009 budget outlines another approach for addressing serious preventable adverse events, or “never events”, including HACs:

Prohibit hospitals from billing the Medicare program for “never events” and prohibit Medicare payment for these events

Require hospitals to report occurrence of these events or receive a reduced annual update



Examples of how an MS-DRG might be paid:

Service: MS-DRG Assignment: (Operating amounts for a hospital whose wage index is equal to the national average)

(Examples below with CC/MCC indicate a single secondary diagnosis only)

Present on Admission (Status of Secondary Diagnosis)

Average Payment (Based on

50th percentile)

Principal Diagnosis: Intracranial hemorrhage or cerebral infarction (stroke) without CC/MCC – MS-DRG 066

-- $5,347.98

Principal Diagnosis: Intracranial hemorrhage or cerebral infarction (stroke) with CC – MS-DRG 065

Example Secondary Diagnosis: Dislocation of patella – open due to a fall (code 835.6 (CC))

Y $6,177.43


Example Secondary Diagnosis: Dislocation of patella – open due to a fall (code 835.6 (CC))

N $5,347.98



Examples of how an MS-DRG might be paid (continued):

Service: MS-DRG Assignment: (Operating amounts for a hospital whose wage index is equal to the national average)

(Examples below with CC/MCC indicate a single secondary diagnosis only)

Present on Admission (Status of Secondary Diagnosis)

Average Payment (Based on

50th percentile)

Principal Diagnosis: Intracranial hemorrhage or cerebral infarction (stroke) with MCC – MS-DRG 064

Example Secondary Diagnosis: Stage III pressure ulcer (code 707.23 (MCC))

Y $8,030.28


Example Secondary Diagnosis: Stage III pressure ulcer (code 707.23 (MCC))

N $5,347.98



HACs selected per FY 2009 Final Rule:Foreign Object Retained After SurgeryAir EmbolismBlood IncompatibilityStage III & IV Pressure UlcersFalls and Trauma:

FracturesDislocationsIntracranial InjuriesCrushing InjuriesBurnsElectric Shocks



HACs selected per FY 2009 Final Rule (continued)

Catheter-Associated Urinary Tract Infection (UTI)

Vascular Catheter-Associated Infection

Manifestations of Poor Glycemic Control

Surgical Site Infection – Mediastinitis after Coronary Artery Bypass Graft (CABG)



HACs selected per FY 2009 Final Rule (continued)

Surgical Site Infections Following Certain Orthopedic Procedures

Surgical Site Infection Following Bariatric Surgery for Obesity

Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) Following Certain Orthopedic Procedures


Sample Group of Five Washington State Hospitals – Preventable Hospital-Acquired Conditions (HACs) Sample Group of Five Washington State Hospitals – Preventable Hospital-Acquired Conditions (HACs)

NOTE: This slide presents a WORST-CASE scenario using the claims in the FY2007 MedPAR data. The MedPAR data does not include Present On Admission (POA) indicators. Therefore, the estimated impact is based upon the assumption that none of the HAC diagnosis codes in the MedPAR data were POA. In addition, this slide includes only those occurrences of HACs with no other qualifying CCs/MCCs present, thereby resulting in reduced payment.

Hospital-Acquired Condition Category and Impact

Hospital "A"

(LURBAN, 320 beds)

Hospital "B"

(LURBAN, 673 beds)

Hospital "C"

(OURBAN, 270 beds)

Hospital "D"

(OURBAN, 165 beds)

Hospital "E"

(LURBAN, 210 beds)

Foreign Object Retained After SurgeryNumber of Cases 0 1 0 0 0Projected FY 2009 payment before reduction $0 $13,858 $0 $0 $0Reduced FY 2009 payment due to HACs $0 $8,231 $0 $0 $0Potential payment impact $0 $5,627 $0 $0 $0

Falls and TraumaNumber of Cases 8 41 22 21 21Projected FY 2009 payment before reduction $136,573 $315,752 $289,602 $173,387 $170,911Reduced FY 2009 payment due to HACs $104,345 $268,570 $181,959 $131,018 $155,906Potential payment impact $32,228 $47,182 $107,643 $42,369 $15,005





Hospital "A"

(LURBAN, 320 beds)

Hospital "B"

(LURBAN, 673 beds)

Hospital "C"

(OURBAN, 270 beds)

Hospital "D"

(OURBAN, 165 beds)

Hospital "E"

(LURBAN, 210 beds)

Catheter-Associated Urinary Tract Infection (UTI)Number of Cases 2 5 1 2 3Projected FY 2009 payment before reduction $33,524 $30,006 $6,066 $20,523 $24,628Reduced FY 2009 payment due to HACs $25,358 $24,551 $6,066 $10,668 $17,497Potential payment impact $8,166 $5,455 $0 $9,855 $7,131

Manifestations of Poor Glycemic ControlNumber of Cases 0 0 0 2 0Projected FY 2009 payment before reduction $0 $0 $0 $10,960 $0Reduced FY 2009 payment due to HACs $0 $0 $0 $10,960 $0Potential payment impact $0 $0 $0 $0 $0





Hospital "A"

(LURBAN, 320 beds)

Hospital "B"

(LURBAN, 673 beds)

Hospital "C"

(OURBAN, 270 beds)

Hospital "D"

(OURBAN, 165 beds)

Hospital "E"

(LURBAN, 210 beds)

Surgical Site Infection Following Certain Orthopedic ProceduresNumber of Cases 1 0 0 0 0Projected FY 2009 payment before reduction $30,578 $0 $0 $0 $0Reduced FY 2009 payment due to HACs $29,421 $0 $0 $0 $0Potential payment impact $1,157 $0 $0 $0 $0

Deep Vein Thrombosis and Pulmonary Embolism Following Certain Orthopedic ProceduresNumber of Cases 2 2 1 0 1Projected FY 2009 payment before reduction $58,111 $38,449 $23,698 $0 $20,264Reduced FY 2009 payment due to HACs $37,934 $29,142 $14,461 $0 $12,365Potential payment impact $20,177 $9,307 $9,237 $0 $7,899


Sample Group of Five Washington State Hospitals – Preventable Hospital-Acquired Conditions (HACs) – Occurrences of HAC DX Codes in Cases Still Qualifying for CC/MCC DRGs

Sample Group of Five Washington State Hospitals – Preventable Hospital-Acquired Conditions (HACs) – Occurrences of HAC DX Codes in Cases Still Qualifying for CC/MCC DRGs NOTE: This slide presents a WORST-CASE scenario using the claims in the FY2007 MedPAR data. The MedPAR data does not include Present On Admission (POA) indicators. The cases described on this slide (as opposed to the three previous slides) are those that still have a qualifying CC / MCC present after the HAC CC / MCC DX codes HACs have been eliminated.

Number of Occurrences by Hospital-Acquired Condition Category

Hospital "A"

(LURBAN, 320 beds)

Hospital "B"

(LURBAN, 673 beds)

Hospital "C"

(OURBAN, 270 beds)

Hospital "D"

(OURBAN, 165 beds)

Hospital "E"

(LURBAN, 210 beds)

Foreign Object Retained After Surgery 2 1 1Air EmbolismBlood IncompatibilityPressure Ulcer Stages III & IVFalls and Trauma 21 92 86 73 35Catheter-Associated Urinary Tract Infection 5 13 6 10Vascular Catheter-Associated InfectionManifestations of Poor Glycemic Control 7 10 7 13 7Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG) 1Surgical Site Infection Following Certain Orthopedic Procedures 2 1 1 1 1Surgical Site Infection Following Bariatric Surgery for ObesityDeep Vein Thrombosis and Pulmonary Embolism Following Certain Orthopedic Procedures 4 8 1 2 9


Present On Admission (POA) Indicator ReportingPresent On Admission (POA) Indicator Reporting

To identify which conditions were acquired during hospitalization for the HAC payment provision

For broader public health uses of Medicare data


Present On Admission (POA) Indicator ReportingPresent On Admission (POA) Indicator Reporting

Five POA indicators are defined in the FY 2009 Final Rule:“Y” – condition present on admission. “W” – affirms that provider has determined, based on data and clinical judgment, that it is not possible to document when onset of condition occurred. “N” – condition not present on admission“U” – insufficient medical record documentation to determine if condition was POA“1” – Signifies exemption from POA reporting. CMS established this code as a workaround to blank reporting on the electronic 4010A1. A list of exempt ICD-9-CM diagnosis codes is available in the ICD-9-CM Official Coding Guidelines.

CMS will pay CC/MCC MS-DRGs only for HACs coded with “Y” and “W” indicators. CMS plans to analyze all indicators for appropriateness of use.

CMS FY 2009 IPPS Final RuleOther Decisions and Changes – Standard Payment Rates

CMS FY 2009 IPPS Final RuleOther Decisions and Changes – Standard Payment Rates


Standard Payment RatesStandard Payment Rates

FY 2009 market basket update factors:

Full Update 3.6% (Proposed was 3%)

Reduced Update 1.6%

As required by the Medicare TMA, Abstinence Education, and QI Programs Extension Act of 2007, CMS will reduce the payment rates by another -0.9 percent for FY2009. Cumulative effect is -1.5 percent (0.06 percent in FY2008)

Hospitals must have successfully reported quality measures in FY 2008 to receive the FY 2009 full update



Fiscal Year Labor Share

Percent

Nonlabor Share

Percent

Full Update – Labor-related

Full Update Nonlabor-

related

Reduced Update Labor-related

Reduced Update

Nonlabor-related

2008

(Wage Index > 1) 69.7% 30.3% $3,478.45 $1,512.15 $3,411.10 $1,482,87

2008

(Wage Index <=1) 62% 38% $3,094.17 $1,896.43 $3,034.28 $1,859.71

2009

(Wage Index > 1) 69.7% 30.3% $3,574.50 $1,553.91 $3,505.49 $1,523.91

2009

(Wage Index <=1) 62% 38% $3,179.61 $1,948.80 $3,118.23 $1,911.17

National Adjusted Operating Standardized Amounts (excluding Puerto Rico)

S



Fiscal Year

2008 $426.14

2009 $424.17

Capital Standard Federal Payment Rate (excluding Puerto Rico)

Outlier Threshold

Fiscal Year

2008 $22,185

2009 $20,045

S


Sample Group of Five Washington State Hospitals –Operating and Capital Payment RatesSample Group of Five Washington State Hospitals –Operating and Capital Payment Rates

For FY08 vs. FY09 comparisons using 2007 MedPAR claims data

SOURCE: FY2008 and FY2009 Medicare Impact Files (from CMS website)

Provider

FY 2009 Urban / Rural Classification

FY 2008 Blended Rate (including IME

& DSH)

FY 2009 Blended Rate (including IME

& DSH)Percentage

Change

Hospital "A" - 320 beds LURBAN $8,507.35 $8,870.50 4.27%Hospital "B" - 673 beds LURBAN $6,470.76 $6,750.29 4.32%Hospital "C" - 270 beds OURBAN $6,534.15 $6,720.15 2.85%Hospital "D" - 165 beds OURBAN $5,989.97 $6,022.72 0.55%Hospital "E" - 210 beds LURBAN $5,464.71 $5,677.81 3.90%

FY 2008 FY 2009Federal Capital Rate $426.14 $424.17 (0.46%)

Provider

Impacted by Capital IME Reduction?

FY 2008 Capital Rate (including

GAF, IME & DSH)


GAF, IME & DSH)

Percentage Change

Hospital "A" YES $642.96 $576.58 (10.32%)Hospital "B" YES $512.55 $507.26 (1.03%)Hospital "C" YES $493.13 $482.55 (2.15%)Hospital "D" NO $485.73 $483.72 (0.41%)Hospital "E" NO $479.42 $481.12 0.35%


Sample Group of Five Washington State Hospitals –Outlier Payment FactorsSample Group of Five Washington State Hospitals –Outlier Payment Factors



FY 2008 FY 2009Outlier Fixed Loss Threshold $22,185 $20,045 (9.65%)

Provider

FY 2008 Hospital Specific

Operating Cost-to-Charge Ratio

FY 2009 Hospital Specific

Operating Cost-to-Charge Ratio

Percentage Change

Hospital "A" 0.4670 0.4780 2.36%Hospital "B" 0.3060 0.3030 (0.98%)Hospital "C" 0.4170 0.3810 (8.63%)Hospital "D" 0.3290 0.2870 (12.77%)Hospital "E" 0.5140 0.4960 (3.50%)

Provider

FY 2008 Hospital Specific Capital Cost-to-Charge

Ratio

FY 2009 Hospital Specific Capital Cost-to-Charge

RatioPercentage

Change

Hospital "A" 0.0410 0.0380 (7.32%)Hospital "B" 0.0300 0.0290 (3.33%)Hospital "C" 0.0290 0.0290 0.00%Hospital "D" 0.0300 0.0210 (30.00%)Hospital "E" 0.0660 0.0520 (21.21%)


Summary of FY2008 vs. FY2009 ImpactTotal Payment and DRG Amount OnlySummary of FY2008 vs. FY2009 ImpactTotal Payment and DRG Amount Only

Provider

FY 2007 MedPAR

DischargesFY 2008 Total

PaymentFY 2009 Total

Payment Gain (Loss)Percentage

Change

Hospital "A" 4,934 $95,883,253 $99,260,733 $3,377,480 3.52%Hospital "B" 8,685 $96,110,341 $99,769,305 $3,658,964 3.81%Hospital "C" 4,803 $65,167,718 $66,332,109 $1,164,391 1.79%Hospital "D" 5,468 $50,532,607 $50,425,851 ($106,756) (0.21%)Hospital "E" 3,638 $31,767,303 $33,010,077 $1,242,774 3.91%

ProviderFY 2008 DRG

AmountFY 2009 DRG

Amount Gain (Loss)Percentage

Change

Hospital "A" $81,803,102 $85,442,258 $3,639,156 4.45%Hospital "B" $83,205,415 $87,082,544 $3,877,129 4.66%Hospital "C" $58,578,953 $60,387,339 $1,808,386 3.09%Hospital "D" $44,506,176 $45,243,112 $736,936 1.66%Hospital "E" $27,503,143 $29,025,319 $1,522,176 5.53%


Summary of FY2008 vs. FY2009 ImpactCapital and Outlier PaymentsSummary of FY2008 vs. FY2009 ImpactCapital and Outlier Payments

Provider

FY 2008 Capital

Payment

FY 2009 Capital


Change

Hospital "A" $6,182,526 $5,553,776 ($628,750) (10.17%)Hospital "B" $6,590,395 $6,543,640 ($46,755) (0.71%)Hospital "C" $4,421,360 $4,336,077 ($85,283) (1.93%)Hospital "D" $3,609,050 $3,633,525 $24,475 0.68%Hospital "E" $2,413,022 $2,459,482 $46,460 1.93%

Provider

FY 2008 Outlier

Payment

FY 2009 Outlier


Change

Hospital "A" $7,897,625 $8,264,699 $367,074 4.65%Hospital "B" $6,314,531 $6,143,121 ($171,410) (2.71%)Hospital "C" $2,167,405 $1,608,693 ($558,712) (25.78%)Hospital "D" $2,417,381 $1,549,214 ($868,167) (35.91%)Hospital "E" $1,851,138 $1,525,276 ($325,862) (17.60%)

CMS FY 2009 IPPS Final RuleOther Decisions and Changes – Phase-out of Capital IME

CMS FY 2009 IPPS Final RuleOther Decisions and Changes – Phase-out of Capital IME


Phase-out of the Capital Teaching (IME) AdjustmentPhase-out of the Capital Teaching (IME) Adjustment

CMS has indicated that the statutory history of the Capital IPPS suggests that the system in the aggregate should not provide for continuous, large positive margins

CMS concluded that the record of relatively high, persistent positive margins for teaching hospitals under Capital IPPS indicated that the teaching adjustment is unnecessary

CMS also believes that abrupt changes in payment policy should be mitigated and that time should be provided to hospitals to adjust to changes in Medicare payments


Phase-out of the Capital Teaching (IME) AdjustmentPhase-out of the Capital Teaching (IME) Adjustment

With the FY 2008 IPPS final rule with comment period, CMS adopted a policy to phase out the capital teaching adjustment over a three-year period:

The adjustment was maintained for FY 2008

For FY 2009, the formula for the adjustment was revised so that teaching adjustments will be reduced by half

For FY 2010 and after, hospitals will no longer receive a teaching adjustment under Capital IPPS

Requires subscripting column 1 of Worksheet L Part I to separate DRG payments and Capital IME factors into before 10/1 and on/after 10/1 portions


Sample Group of Three Washington State Teaching Hospitals – Capital Payment RatesSample Group of Three Washington State Teaching Hospitals – Capital Payment Rates



FY 2008 FY 2009Federal Capital Rate $426.14 $424.17 (0.46%)

Provider


GAF, IME & DSH)


GAF, IME & DSH)

Percentage Change

Hospital "A" - 320 beds $642.96 $576.58 (10.32%)Hospital "B" - 673 beds $512.55 $507.26 (1.03%)Hospital "C" - 270 beds $493.13 $482.55 (2.15%)

ProviderFY 2008 Capital

IME FactorFY 2009 Capital

IME FactorPercentage

Change

Hospital "A" 0.30084 0.15042 (50.00%)Hospital "B" 0.03954 0.02059 (47.93%)Hospital "C" 0.03074 0.01457 (52.60%)


Summary of FY2008 vs. FY2009 ImpactCapital and Capital IME PaymentsSummary of FY2008 vs. FY2009 ImpactCapital and Capital IME Payments

Provider

FY 2008 Capital

Payment

FY 2009 Capital


Change

Hospital "A" $6,182,526 $5,553,776 ($628,750) (10.17%)Hospital "B" $6,590,395 $6,543,640 ($46,755) (0.71%)Hospital "C" $4,421,360 $4,336,077 ($85,283) (1.93%)

Provider

FY 2008 Capital IME

Payment

FY 2009 Capital IME


Change

Hospital "A" $1,345,461 $677,608 ($667,853) (49.64%)Hospital "B" $236,663 $124,183 ($112,480) (47.53%)Hospital "C" $122,026 $57,350 ($64,676) (53.00%)

Joseph W. SellarsJoseph W. Sellars

KPMG LLPKPMG LLP

904-350-1234904-350-1234

[email protected]

The information contained herein is of a general nature and is not intended to address the circumstances of any particular individual or entity. Although we endeavor to provide accurate and timely information, there can be no guarantee that such information is accurate as of the date it is received or that it will continue to be accurate in the future. No one should act on such information without appropriate professional advice after a thorough examination of the particular situation.

©2008 KPMG LLP, a U.S. limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International, a Swiss cooperative. All rights reserved.

mailto:[email protected]


HEALTHCARE

KPMG LLP

Healthcare Quality Mandates – From the Healthcare Quality Mandates – From the CMS IPPS Final Rule and BeyondCMS IPPS Final Rule and Beyond

Carolyn Scott, RN, M.Ed., MHADirector, Healthcare Advisory

HFMA Region 11 Healthcare SymposiumJanuary 26, 2009


Presentation OutlinePresentation OutlinePresentation OutlinePresentation Outline

Hospital Quality Reporting – Core Measures and Beyond

The next big focus: Hospital Readmissions

Medicare’s Value Based Purchase Program – Update

A Hot Topic in Healthcare Quality: Organization-wide Throughput

Physician Quality Reporting

Leadership’s Role and Accountability for Healthcare Quality


Healthcare QualityHealthcare QualityHealthcare QualityHealthcare Quality

How is it defined?

To what extent do hospital leaders recognize that reimbursement is now tied to healthcare quality?

Do you know the difference between hospital acquired conditions and “never events”?

Who has responsibility for a hospital’s quality and safety?

How accurate is your organization’s quality information?

What regulatory activities impacting healthcare quality reporting and performance are on the horizon?

What are hospital leaders’ responsibilities regarding healthcare quality at your organization?

Hospital Quality Reporting –Core Measures and BeyondHospital Quality Reporting –Core Measures and Beyond


Progression in the Number of Quality Measures Progression in the Number of Quality Measures for Reporting/Payment Updatefor Reporting/Payment UpdateProgression in the Number of Quality Measures Progression in the Number of Quality Measures for Reporting/Payment Updatefor Reporting/Payment Update

FY 2005 - 2006 – 10 measures

FY 2007 – 21 measures



FY 2010 – 44 measures (so far)

FY 2011 – ??? – expect another increase in the

number of measures to be reported


Quality Reporting for 2008Quality Reporting for 2008

To avoid the 2% reduction in the payment update, hospitals had to submit quality data for 27 different metrics – all from 2007 plus 6 new ones

New Metrics for 2008HCAHPS Survey ResultsSurgical Care Improvement Project (“SCIP”)

VTE prophylaxis orderedVTE prophylaxis given within 24 hours of surgeryAppropriate antibiotic selection for surgery patients

30-Day Mortality ResultsAMI PatientsHeart Failure Patients


AMI Performance (January 2007 – December 2007) AMI Performance (January 2007 – December 2007) AMI Performance (January 2007 – December 2007) AMI Performance (January 2007 – December 2007)

IndicatorTop 10%Hospitals

NationalAverage

ASA @ Arrival 100% 94%

ASA @ Discharge 100% 91%

ACEI/ARB for LVSD 100% 88%

Smoking Cessation Advice/Counseling

100% 92%

BBlocker @ Discharge 100% 92%

BBlocker @ Arrival 100% 89%

Fibrinolytics w/in 30 minutes 100% 40%

PCI w/in 90 minutes 92% 67%

Source: www.hospitalcompare.hhs.gov


Heart Failure Performance (January 2007 – December 2007)Heart Failure Performance (January 2007 – December 2007)Heart Failure Performance (January 2007 – December 2007)Heart Failure Performance (January 2007 – December 2007)

Source: www.hospitalcompare.hhs.gov.


NationalAverage

Discharge Instructions 97% 69%

LVS Assessment 100% 87%


Smkg Cessation Advice/Counseling

100% 89%


Pneumonia Performance (January 2007 – December 2007)Pneumonia Performance (January 2007 – December 2007)Pneumonia Performance (January 2007 – December 2007)Pneumonia Performance (January 2007 – December 2007)


NationalAverage

O2 Assessment 100% 99%

Pneumococcal Scrng/Immun. 95% 78%

ED BCult Before 1st Antibiotic 100% 90%

Smkg Cessation Advice/Counseling 100% 85%

Antibiotic within 6 hours** 100% 93%

Appropriate Initial Antibiotic 97% 87%

Influenza Screening/Immun. 99% 75%

Source:www.hospitalcompare.hhs.gov ** denotes measure in effect commencing with 4/1/07 discharges


Surgical Care Improvement Performance Surgical Care Improvement Performance (October 2006 – September 2007)(October 2006 – September 2007)Surgical Care Improvement Performance Surgical Care Improvement Performance (October 2006 – September 2007)(October 2006 – September 2007)

Indicator

Top 10% Hospitals

National Average

Antibiotic Start within 1 Hour of Surgical Incision 97% 84%

Appropriate Antibiotic Selection for Surgery Type 99% 91%

Patients who received treatment for blood clots within 24 hours before or after surgery for selected surgery types

95% 77%

Patients whose doctors ordered treatment to prevent blood clots for selected surgeries 97% 80%

Antibiotics Discontinued within 24 Hours after Surgery End (48 Hours for Cardiac Surgery)

97% 82%


30 Day Mortality Results30 Day Mortality Results30 Day Mortality Results30 Day Mortality Results

How do hospitals in your state perform?

Primary goal – improve coordination of patient care

Within the hospital settingAt the time of discharge

Next big area of focus for coordination of care: Hospital Readmissions


HCAHPS SurveyHCAHPS SurveyHCAHPS SurveyHCAHPS Survey

Components

Nurse communication

Physician communication

Responsiveness of hospital staff

Pain management

Communication about medications

Discharge information

Overall rating of hospital (0 – 10)

Likelihood to recommend hospital (Definitely no – Definitely yes)

Overall Goal: Continually improve quality of care


HCAHPS Performance Results HCAHPS Performance Results HCAHPS Performance Results HCAHPS Performance Results

Indicator US Average

Nurse Communication 74%

Physician Communication 80%

Responsiveness of Hospital Staff 63%

Pain Management 68%

Communication about Medications 59%

Cleanliness of Room/Bathroom 70%

Quietness at Night 56%

Discharge Information 80%

Overall Rating (0-10) 6.4

Likelihood to Recommend 68%


HCAHPS Oversight Process - Background, Implications, HCAHPS Oversight Process - Background, Implications, and Future Activitiesand Future ActivitiesHCAHPS Oversight Process - Background, Implications, HCAHPS Oversight Process - Background, Implications, and Future Activitiesand Future Activities

Hospitals and survey vendors must participate in quality oversight process conducted by the HCAHPS project team (source: FY 2008 IPPS Final Rule)

Commencing in July 2007, CMS asked hospitals and survey vendors to correct any problems that were identified and to provide for review documentation of corrections

HCAPHS project staff reviews and discusses findings with hospitals and survey vendors

Quality Assurance Plans

Survey Management Procedures

Sampling and Data Collection Protocols

Data Preparation and Submission Procedures

If the HCAHPS project team finds that the hospital has not made the corrections, “CMS may determine that the hospital is not submitting HCAHPS data that meet the requirements for the RHQDAPU program”

No significant change in oversight process planned for FY 2009 or 2010


Quality Reporting for 2009Quality Reporting for 2009Quality Reporting for 2009Quality Reporting for 2009

To avoid the 2% reduction in the payment update, hospitals must submit quality data for at least 30 different metrics – all from 2008 plus three new ones

New Metrics for 2009

Surgical Care Improvement Project (“SCIP”) Cardiac surgery patients with controlled 6am glucose24 hours post surgery Surgery patients with appropriate hair removal

30 Day Mortality Results – Pneumonia Patients

Outpatient Measures (Heart Attack and Surgical Measures Released November 1, 2007 and new Imaging Measures in the Final OPPS Proposed Rule)


Hospital Quality Measures in the 2009 OPPS Final Hospital Quality Measures in the 2009 OPPS Final RuleRuleHospital Quality Measures in the 2009 OPPS Final Hospital Quality Measures in the 2009 OPPS Final RuleRule

For hospitals to receive the full OPPS payment updated for CY 2010, hospitals must submit quality data on the following for services rendered in the outpatient setting

OP 1 – Median Time to Fibrinolysis

OP 2 – Fibrinolytics Received within 30 Minutes of Arrival

OP 3 – Median Time to Transfer to Another Facility for Acute Coronary Intervention

OP 4 – Aspirin at Arrival

OP 5 – Median Time to Electrocardiogram (ECG)

OP 6 - Timing of Antibiotic Prophylaxis

OP 7 – Prophylactic Antibiotics for Surgical Patients

OP 8 – MRI Lumbar Spine for Low Back Pain

OP 9 – Mammography Follow-up Rates

OP 10 – Abdomen CT – Use of Contrast Material

OP 11 – Thorax CT – Use of Contrast Material


Quality Reporting for 2010Quality Reporting for 2010Quality Reporting for 2010Quality Reporting for 2010

To avoid the 2% reduction in the payment update, hospitals must submit/allow CMS to report quality data for at least 42 different metrics

New Metrics for 2010

Surgical Care Improvement Project - 1 measure (Beta Blocker)

Readmissions – 1 measure (Heart Failure)

AHRQ Patient Safety Indicators, Inpatient Quality Measures and Composite Measure – 9 measures

Nursing Sensitive – 1 measure (Failure to Rescue)

Cardiac Surgery – 1 measure (Database Participation)

One measure from 2009 will be retired and not reported by hospitals for 2010 (PN measure – Oxygenation Assessment)

Items in yellow are measures for which data will be collected from Medicare claims


Quality Reporting for 2011 and BeyondQuality Reporting for 2011 and Beyond

Additional measures being considered

Those that were proposed for 2010 but didn’t make the final list

COPD Measures

Complications of Vascular Surgery

Timeliness of Emergency Care

Additional Surgical Care Improvement Project measures

HACs/Complications

Cancer Care

Length of Stay coupled with Global Readmissions Measures

More Glycemic Control Measures

Specific focus of future measures

Surgical care

Patient outcomes

Patient safety

Efficiency


CMS Perspective –Reducing the Data CMS Perspective –Reducing the Data Collection BurdenCollection BurdenCMS Perspective –Reducing the Data CMS Perspective –Reducing the Data Collection BurdenCollection Burden

Staggering the data collection start dates

Allowing the data to come from other sources (e.g., registries)

CMS collecting some of the data from Medicare claims

Some proposed relief for hospitals that have less than five

cases of a specific condition in a quarter (e.g., AMI, HF)

Hospital ReadmissionsHospital Readmissions


Making the Case: Readmission StatisticsMaking the Case: Readmission StatisticsMaking the Case: Readmission StatisticsMaking the Case: Readmission Statistics

Medicare spends $15 billion each year on

readmissions

Approximately 18% of Medicare patients discharged from hospitals are readmitted within 30 days

80% of Medicare spending for readmissions is potentially avoidable

Source: Medicare Payment Advisory Commission: Report to Congress: Promoting Greater Efficiency in Medicare. June 2007, Chapter 5, page 103.


CMS PerspectivesCMS PerspectivesCMS PerspectivesCMS Perspectives

Readmissions may reflect poor quality of care

Readmissions may affect beneficiaries’ quality of life

Not all readmissions are avoidable

Hospitals should share accountability for readmission rates

Readmission rates could be lower through the application of evidence-based practices

Application of incentives may serve to reduce readmissions, resulting in

Higher quality of care

Reduction in unnecessary costs


Comments Received on Use of Incentives to Reduce Comments Received on Use of Incentives to Reduce Avoidable ReadmissionsAvoidable ReadmissionsComments Received on Use of Incentives to Reduce Comments Received on Use of Incentives to Reduce Avoidable ReadmissionsAvoidable Readmissions

Approaches to applying incentives to reduce avoidable readmissions

Direct adjustment to hospital DRG payments (similar to HACs)

Adjustments to hospital DRG payments through a performance-based payment methodology (similar to VBP)

Public reporting of readmission rates

Measures of readmissions

Accountability

Medicare’s Value Based Purchasing (VBP) Program – UpdateMedicare’s Value Based Purchasing (VBP) Program – Update


Medicare’s VBP ProgramMedicare’s VBP ProgramMedicare’s VBP ProgramMedicare’s VBP Program

Premise of VBP: CMS will no longer be a transactional purchaser of healthcare services; it is moving to being an active purchaser of quality healthcare services

Authorized as part of the Deficit Reduction Act of 2005

Links payment with quality, rather than for just the deliveryof service

Replaces the current hospital quality reporting system

Encompasses both public reporting and financial incentives to drive improvements in clinical quality, patient centeredness, and efficiency

Commences in fiscal year 2009 – will require additional legislation


Goals of Medicare’s VBP ProgramGoals of Medicare’s VBP ProgramGoals of Medicare’s VBP ProgramGoals of Medicare’s VBP Program

Improve clinical quality

Address problems of overuse, underuse, and misuse of services

Encourage patient-centered care

Reduce adverse events and improve patient safety

Avoid unnecessary costs in the delivery of care

Stimulate investments in structural components and thereengineering of care system-wide

Make performance results transparent to and useable by consumers

Avoid new/reduce existing disparities in healthcare


Other VBP Details – Currently in DevelopmentOther VBP Details – Currently in DevelopmentOther VBP Details – Currently in DevelopmentOther VBP Details – Currently in Development

Payments at Two Levels

Top decile performers

Overall improvement

Potential reduction in DRG payment – 2–5 percent – with opportunity to “earn back” based on performance on the quality metrics

VBP Implementation

Phased Approach

FY 2009 – Payment based 100 percent on reporting

FY 2010 – Payment based 50 percent on reporting and 50 percent on performance

FY 2011 – Payment based 100 percent on performance

Additional Impacts on HospitalsData submission time reduced from 135 days to 60 days after quarter-endIncreased validation efforts by CMS


VBP Candidate Measures for 2009VBP Candidate Measures for 2009VBP Candidate Measures for 2009VBP Candidate Measures for 2009

Clinical quality measures

Outcomes measures

30-day AMI mortality

30-day Heart Failure mortality

HCAHPS Survey results

Yet to be determined outpatient measures (good source – those in the 2008 OPPS Final Rule)

Note: Measures noted in blue on the following pages are initial candidate measures in the VBP Program


AMI Performance (January 2007 – December 2007) AMI Performance (January 2007 – December 2007) AMI Performance (January 2007 – December 2007) AMI Performance (January 2007 – December 2007)


NationalAverage

ASA @ Arrival 100% 94%

ASA @ Discharge 100% 91%


Smoking Cessation Advice/Counseling

100% 92%

BBlocker @ Discharge 100% 92%

BBlocker @ Arrival 100% 89%

Fibrinolytics w/in 30 minutes 100% 40%

PCI w/in 90 minutes 92% 67%

Source: www.hospitalcompare.hhs.gov


Heart Failure Performance (January 2007 – December 2007)Heart Failure Performance (January 2007 – December 2007)Heart Failure Performance (January 2007 – December 2007)Heart Failure Performance (January 2007 – December 2007)

Source: www.hospitalcompare.hhs.gov.


NationalAverage

Discharge Instructions 97% 69%

LVS Assessment 100% 87%


Smkg Cessation Advice/Counseling

100% 89%


Pneumonia Performance (January 2007 – December 2007)Pneumonia Performance (January 2007 – December 2007)Pneumonia Performance (January 2007 – December 2007)Pneumonia Performance (January 2007 – December 2007)


NationalAverage

O2 Assessment 100% 99%

Pneumococcal Scrng/Immun. 97% 78%

ED BCult Before 1st Antibiotic 100% 90%

Smkg Cessation Advice/Counseling 100% 85%

Antibiotic within 6 hours** 100% 93%

Appropriate Initial Antibiotic 97% 87%

Influenza Screening/Immun. 99% 75%

Source:www.hospitalcompare.hhs.gov ** denotes measure in effect commencing with 4/1/07 discharges


Surgical Care Improvement Performance Surgical Care Improvement Performance (January 2007 – December 2007)(January 2007 – December 2007)Surgical Care Improvement Performance Surgical Care Improvement Performance (January 2007 – December 2007)(January 2007 – December 2007)

Indicator

Top 10% Hospitals

National Average

Antibiotic Start within 1 Hour of Surgical Incision 97% 84%

Appropriate Antibiotic Selection for Surgery Type 99% 91%

Patients who received treatment for blood clots within 24 hours before or after surgery for selected surgery types

95% 77%

Patients whose doctors ordered treatment to prevent blood clots for selected surgeries 97% 80%

Antibiotics Discontinued within 24 Hours after Surgery End (48 Hours for Cardiac Surgery)

97% 82%


30 Day Mortality Results30 Day Mortality Results30 Day Mortality Results30 Day Mortality Results

AMI

Heart Failure

Pneumonia


HCAHPS Performance Results HCAHPS Performance Results HCAHPS Performance Results HCAHPS Performance Results

Indicator US Average

Nurse Communication 74%

Physician Communication 80%

Responsiveness of Hospital Staff 63%

Pain Management 68%

Communication about Medications 59%

Cleanliness of Room/Bathroom 70%

Quietness at Night 56%

Discharge Information 80%

Overall Rating (0-10) 6.4

Likelihood to Recommend 68%


VBP Measures for Fiscal Years 2010 and BeyondVBP Measures for Fiscal Years 2010 and Beyond

FY 2010–FY2011

Efficiency measures

Outcomes measures

Emergency care measures

Care coordination measures

Patient safety measures

Structural measures

FY 2012 and Beyond

Areas where performance gaps are identified

New measures currently in development


VBP TestingVBP TestingVBP TestingVBP Testing

Workgroup is currently testing the VBP Plan

Information to be gained from the VBP testingPerformance scores by domain

Total performance scores

Financial impacts

Comments noted in the Final RuleMost objected to publicly posting test information at the hospital level

Most believed test results should be provided to the hospital at the hospital level

Most supported public reporting of test results at an aggregate level (e.g., State or National)

A Hot Topic in Healthcare Quality: Organization-Wide ThroughputA Hot Topic in Healthcare Quality: Organization-Wide Throughput


Making the Connection between Organization-wide Making the Connection between Organization-wide Throughput and Healthcare QualityThroughput and Healthcare QualityMaking the Connection between Organization-wide Making the Connection between Organization-wide Throughput and Healthcare QualityThroughput and Healthcare Quality

Joint Commission

New for 2008 – hospital-specific tracer on patient flow

Rationale: Patient safety

Treatment delays, medical errors, and unsafe practices “thrive” during times of patient congestion and can lead to sentinel events

Focus: Organization-Wide

Areas First Impacted: ED, OR, ICU

Accountability: Hospital Leadership


Making the Connection between Organization-wide Making the Connection between Organization-wide Throughput and Healthcare Quality Throughput and Healthcare Quality (cont’d.)(cont’d.)

Making the Connection between Organization-wide Making the Connection between Organization-wide Throughput and Healthcare Quality Throughput and Healthcare Quality (cont’d.)(cont’d.)

National Quality Forum (NQF)

National Voluntary Consensus Standards for Emergency Care – Phase 2

NQF is formally considering measures that address pressing quality issues such as patient wait-time, overcrowding, boarding, and diversions (source:www.qualityforum.org)

Other “efficiency-related” projects and measures in development

CMS – VBP

Emergency care and “efficiency” are program domains and will have specific measures


Making the Connection between Organization-Wide Making the Connection between Organization-Wide Throughput and Healthcare Quality Throughput and Healthcare Quality (cont’d.)(cont’d.)

Making the Connection between Organization-Wide Making the Connection between Organization-Wide Throughput and Healthcare Quality Throughput and Healthcare Quality (cont’d.)(cont’d.)

Media

“Tucson Emergency Rooms in Life and Death Crunch” (source: Arizona Daily Star, March 16, 2008)

39 year-old man dies after waiting in a crowed ED waiting room for 8 hours

Consumers

HCHAPS Survey Results

Likelihood to recommend hospital

Overall rating of hospital

Word of Mouth

Physician Quality Reporting InitiativePhysician Quality Reporting Initiative


Overview of PQRI – 2007Overview of PQRI – 2007

CMS given the authority to establish this initiative via the Tax Relief and Healthcare Act of 2006

“Eligible professionals” had the potential for receiving a bonus, which could be up to 1.5 percent of the total allowed charges for services paid pursuant to the Medicare Physician Fee Schedule

Lump sum bonus to be paid to eligible professionals during mid-2008

Reporting was for activity from July 1 – December 31, 2007

Reporting was all “claims based”

74 metrics included in the metric set – professionals submit information only on those metrics that apply to his/her practice

Reporting for at least 80% of the cases that apply to the appropriate metrics


Results from 2007Results from 2007

More than 70,000 NPI/TINs submitted quality data for one measure (more than 109,000 attempted to submit data)

56,722 NPI/TINs received an incentive payment

Average payment per individual - $630

Average payment per group - $4,713

Total payment amount - $36 million

Providers in all 50 states plus D.C., Puerto Rico, Virgin Islands, and Guam participated in the program

Florida (over $3 million) and Illinois (over $2 million) received the highest incentive payments

Feedback reports regarding performance became available around the same time as the incentive payments were made

(Source: QUADAX, Inc. Newsletter, August 2008)


PQRI for 2008 PQRI for 2008

Legislative authority given through the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA), which was enacted on December 29, 2007

Program Timeframe: January 1 – December 31, 2008

No significant change in the bonus payment percentage from 2007 (1.5%)

119 measures included in the metric set – all process measures except 2 (EHRs and E-prescribing)

New aspect for the program – reporting can be claims or registry based (32 registries already approved)


PQRI for 2009 and Beyond PQRI for 2009 and Beyond

Starting in 2009, the PQRI incentive payment increases to 2%

Expands the list of “eligible providers” to include audiologists

New and additional incentives for E-prescribing starting in 2009 (2%)

This incentive will decline over 2011 and 2012Plan for the future: Penalties for not E-prescribing

Additional information regarding the 2009 PQRI program will be included in the 2009 Medicare Physician Fee Schedule


Corporate Responsibility and Healthcare QualityCorporate Responsibility and Healthcare Quality

Quality oversight is part of the Board’s fiduciary duty

Increased focus on accuracy of quality reporting dataCore Measure data to CMSPQRI data to CMSSentinel Event information to Joint Commission

Increased attention on “provision of care that is so deficient it amounts to no care at all”

Remedies availableCivil money penaltiesCriminal finesExclusion from federal health care programs (Medicare and Medicaid)

(Source: Corporate Responsibility and Health Care Quality: A Resource for Healthcare Boards of Directors, United States Department Health and Human Services Office of Inspector General and American Health Lawyers Association. www.oig.hhs.gov.)


Recent Regulatory Actions Related to Healthcare QualityRecent Regulatory Actions Related to Healthcare Quality

“Hospital Fined in Wrong Site Surgery” (source: Rhode Island News, November 27, 1907)

Hospital fined $50,000 after third wrong site neurosurgery

“California Hospitals Fined for Not Ensuring Patient Safety” (source: Modern Healthcare’s Daily Dose, August 18, 2008)

18 hospitals fined $25,000 per violation

“Yale-New Haven Fined $8,000 for Violations” (source: New Haven Register, October 2, 2008)

State Health Department issues fine and Consent Agreement based on safety and quality issues

“State Reprimands Miriam Hospital for Wrong Site Surgery” (Source: Rhode Island News, October 8, 2008)

Hospital enters into a Consent Agreement with the Rhode Island Department of Health regarding surgical quality deficiencies

Carolyn Scott, RN, M.Ed., MHACarolyn Scott, RN, M.Ed., MHA

KPMG LLPKPMG LLP

817-800-6504817-800-6504

[email protected]

The information contained herein is of a general nature and is not intended to address the circumstances of any particular individual or entity. Although we endeavor to provide accurate and timely information, there can be no guarantee that such information is accurate as of the date it is received or that it will continue to be accurate in the future. No one should act on such information without appropriate professional advice after a thorough examination of the particular situation.

©2008 KPMG LLP, a U.S. limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International, a Swiss cooperative. All rights reserved.

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