David Gifford

SVP Quality & Regulatory Affairs

Congressional briefing

Washington DC

June 23rd, 2014

IMPACT ACT OF 2014

“IMPACT ACT OF 2014”

Legislation has four parts :

1. Incorporate standardized assessment

2. Public reporting of common quality measures

3. Provide quality measures to consumers when transitioning to a PAC provider

4. HHS and MedPAC to conduct several

“IMPACT ACT OF 2014” Part 1• Incorporate standardized assessment(s) (e.g. CARE tool)

into existing assessment tools across PAC providers (LTCH, IRF, SNF, & HH) and acute care hospitals for• Pressure ulcers• Functional status• Cognitive status• Special Services

• Collect data at admission and discharge• Applies also to acute care hospitals

“IMPACT ACT OF 2014” Part 2• Develop & Publicly report quality measures across

settings• Rehospitalizations & hospitalizations • Hospitalizations after discharge from PAC provider• Discharge to community• Pressure ulcers• Medication reconciliation • Incidence of major falls• Patient preferences • Efficiency measure(s): Avg Total Medicare Spend per Beneficiary• Plus any other measures Secretary wants

• Measures must be approved by National Quality Forum• Public reporting starting in Oct 2018

Using information across settings• Clinical Care• Quality Improvement • Accountability measurement

• Public reporting• Network selection• Payment (e.g. Value Based Purchasing)• Policy evaluations & decisions

Questions to ask about measures • Data source

• Is it reliable and valid?• Is consistent and comparable

• Wording of assessment• Rating scale used• Frequency of assessment

• Measure definition• Who does the measure apply to (e.g. denominator)• Who is counted in the measure (e.g. numerator)• Does the measure need to be risk adjusted?

• What are clinical and non-clinical characteristics used in risk adjustment

• Is the measure reliable and valid?

• How to compare providers based on measure results• How do you use measure results for

• Quality improvement• Network selection• Payment

ADL Questions & Ratings Vary  IRF HH SNF LTCH Hospitals

Bathing 0-7 0-6 0-4; 0-3 None NoneEating 0-7 0-5 0-4; 0-3 None NoneGrooming 0-7 0-3 0-4;0-3 None NoneDressing- Total- Upper body- Lower body

 NA0-70-7

 NA0-30-3

 0-4;0-3

NANA

None None

Transfers bed, chair 0-7 0-3 0-4;0-3 None None

Toileting- Overall- Transferring- Hygiene

  

0-70-7

  

0-40-3

 0-4;0-3

NANA

None None

Rating of questions

IRF7 = completely independent

6 = modified independence

5 = supervision (subject = 100%)

4 = minimal assistance (subject = 75% of more)

3 = moderate assistance (subject = 50% or more)

2 = max assistance (25% or more)

1= total assistance

0 activity did not occur

OASIS0 = able to bath self independently

1 = with the use of devices, is able to bath self

2 = able to bathe in shower or tub with the intermittent assistance of another person

3 = able to participate in bathing self in shower or tub but requires presence of another person

4 = unable to use the shower to tub but table to bathe self independently with or without the use of devises at the sink, in chair or on commode

5 = unable to use the shower or tub but able to participate in bathe self in bed, at the sink or in bedside chair with assistance or supervision of another person

6 = unable to participate effectively in bathing and is bathed totally by another person

Rating of questions

MDS

• IRF – average function• OASIS – typical ability• MDS – most dependent

0 = independent– no help provided

1 = supervision– oversight help only

2 = physical help limited to transfer only

3 = physical help in part of bathing activity

4 = total dependence

8 = activity did not occur

Rating Instructions

Wording of questions: Bathing

IRF-PAI: “Bathing”

OASIS: “Current ability to wash entire body safely, Excludes grooming (washing face, washing hands, and shampooing hair)”

MDS: “How resident takes full-body bath/shower, sponge bath, and transfers in /out of tub/shower (excludes washing of back and hair)”

Cognitive Function Assessment

  IRF-PIA OASIS MDS LTCH Hospitals

Memory Rate assistance

Is it ok >1x wk

Recall 3 words

None None

Orientation none yes Yr, month,

day

None None

Decision Making

Problem Solving

1-7

Ok with ADLs0,1

Decision Making

1-4

None None

Pressure Ulcer Ratings

  IRF HH SNF LTCH Hospitals

Count yes yes yes None NoneStage for worst ulcer

yes yes yes None None

Dimensions L x W L x W x D L x W x D None None

Tissue Type Yes (0-4 )

Yes(0-3)

Yes(1-4)

None None

Presence at admission

yes yes yes None None

Tissue Type ratings differ• IRF

1 = epithelial tissue2 = granulation tissue3 = slough4 = necrotic tissue

• HH0 = newly epithelialized1 = fully granulating2 = early/partial granulation3 = not healing

• SNF1 = epithelial tissue2 = granulation tissue3 = slough4 = necrotic tissue

SAMPLE SIZE

Focus on all cause all disease• National Quality Forum & CMS require minimum number

of patients in each measure (e.g. minimum denominator size) which is usually 25-30• Implications for measures that are not all cause or disease specific

16

# of Facilities vs # of Part A Admissions

2009 2010 2011

Number of

Facilities

% of

Total

Number of

Facilities

% of

Total

Number of

Facilities% of

Total

TOTAL 15,453 15,449 15,395

Low volume (≤ 100 stays/ year)

6,766 44%

6,744 44%

7,773 50%

Moderate volume (101-200 stays/ year)

4,678 30%

4,591 30%

4,449 29%

High volume (201-300 stays/ year)

2,061 13%

2,103 14%

1,784 12%

Very high volume (>300 stays/ year)

1,948 13%

2,011 13%

1,389 9%

17

# Part A admissions for Top 15 Hospital DRGs by Facility annual volume of Part A admissions

 Low Vol

(<100/yr)Mod Vol

(100-200/yr)High Vol

(200-300/yr)Very High Vol

>300/yr

DRG CategoriesSNF stays

2009% of All

SNF StaysSNF stays

2009% of All

SNF StaysSNF stays

2009% of All

SNF StaysSNF stays

2009% of All

SNF Stays

TOTAL 451,119 2,230,389 637,920 2,230,389 437,273 2,230,389 704,077 2,230,389

1. Orthopedic surgery on lower extremity 55,309 2.5% 81,156 3.6% 65,495 2.9% 135,074 6.1%

2. Respiratory 67,714 3.0% 83,695 3.8% 50,532 2.3% 67,725 3.0%

3. Cardiac surgery 9,884 0.4% 15,817 0.7% 12,679 0.6% 25,233 1.1%

4. Cardiac medical management 37,728 1.7% 54,067 2.4% 35,906 1.6% 54,766 2.5%

5. GI hospitalizations (surgical and medical) 31,422 1.4% 44,580 2.0% 30,825 1.4% 48,380 2.2%

6. Renal failure 11,820 0.5% 17,963 0.8% 11,627 0.5% 16,826 0.8%

7. Amputations 3,704 0.2% 5,228 0.2% 3,346 0.2% 4,973 0.2%

8. Spinal surgery 2,663 0.1% 4,258 0.2% 3,880 0.2% 8,484 0.4%

9. Other major musculoskeletal surgery 4,916 0.2% 8,181 0.4% 6,811 0.3% 13,105 0.6%

10. Other musculoskeletal medical mgmt 23,126 1.0% 34,940 1.6% 25,768 1.2% 44,136 2.0%

11. Multiple significant trauma 1,242 0.1% 1,797 0.1% 1,226 0.1% 1,977 0.1%

12. Infections & parasitic dis. (plus sepsis) 52,428 2.4% 74,247 3.3% 47,122 2.1% 64,947 2.9%

13. Psychiatric 6,146 0.3% 7,509 0.3% 4,233 0.2% 5,298 0.2%

14. Stroke and related conditions 18,863 0.8% 26,840 1.2% 17,522 0.8% 25,819 1.2%

15. Other 124,154 5.6% 177,642 8.0% 120,301 5.4% 187,334 8.4%

Average volume Medicare Admissions per SNF for #1 Admitted diagnosis

 Low Vol

(<100/yr)Mod Vol

(100-200/yr)High Vol

(200-300/yr)Very High Vol

>300/yr

# of SNFs (%) 7,773 (50%) 4,449 (29%) 1,784 (12%) 1,389 (9%)

DRG CategoriesSNF stays

2009% of All

SNF StaysSNF stays

2009% of All

SNF StaysSNF stays

2009% of All

SNF StaysSNF stays

2009% of All

SNF Stays

TOTAL 451,119 2,230,389 637,920 2,230,389 437,273 2,230,389 704,077 2,230,389

1. Orthopedic surgery on lower extremity 55,309 2.5% 81,156 3.6% 65,495 2.9% 135,074 6.1%

Avg # of Medicare Admissions per year 7.1 18.2 36.7 96.6

RISK ADJUSTMENT

Change in Decile Rank from Actual to Risk Adjusted SNF Rehospitalization

Change in decile rank between Actual vs Risk adjusted rate # SNFs

% of Total

No data  2619 18.59-8 1 0.01-7 2 0.01-5 5 0.04-4 51 0.36-3 218 1.55-2 693 4.92-1 1818 12.900 4272 30.321 2717 19.282 1126 7.993 401 2.854 116 0.825 33 0.236 15 0.117 4 0.038 1 0.01