HAC REDUCTION PROGRAM

Implementation of the Hospital-Acquired Condition (HAC) Reduction

Program for FY 2015

Jeanne Dufresne

This material was prepared by Masspro, the Medicare Quality Improvement Organization for Massachusetts, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily represent CMS policy. 10-ma-ptcare-14-274-hac-reduction-ppt-Jan14

To Educate Participants of the Following:I. CMS’ Implementation of the Hospital Acquired Condition

Reduction ProgramII. The Three Measures Involved in the FY 2015 HAC ProgramIII. The Two Domains that Performance will be based onIV. The Possible Payment Reduction based on Performance

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OBJECTIVES

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General Framework for the Implementation of the HAC Reduction Program for FY 2015

a) Relevant Definitions Applicable to the Program

b) Payment Adjustment under the Program

c) Measure Selection and Conditions for the Program

d) Scoring Methodology

e) Performance Scoring

f) Process for making Hospital-Specific Performance Information available to the Public,

Including the Opportunity for a Hospital to Review the Information and Submit

Corrections

FY 2014 IPPS/LTCH PPS proposed rule (78 FR 27622 through 27636)

HAC REDUCTION PROGRAM

(New) Hospital-Acquired Condition Reduction Program

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(Current) Hospital Acquired Condition Program

VS.

HAC REDUCTION PROGRAM

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CURRENT HAC PROGRAM

Part of the Deficit Reduction Act of 2005

What is a Hospital Acquired Condition?

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Hospital Acquired Conditions or HACs are Conditions that Patients Acquire while Receiving Treatment for Another Condition in an Acute Care Health Setting.

HACs also include Hospital Acquired Infections (HAIs) such as Surgical Site Infections, as well as Conditions such as Foreign Objects Retained after Surgery

“Tens of thousands of lives are forever changed each year as a result of healthcare errors. There is a critical need to enhance health system capacity, so that all patients will receive care

that is safe and effective.” - NQF President and CEO Janet Corrigan (2008)

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A Qualifying Diagnosis Code as One of the First Eight Secondary Diagnoses(i.e., diagnoses 2 through 9; not 10 or beyond)

AND

A Present on Admission (POA) value of N or U

N = Diagnosis was not present at time of inpatient admission. U = Documentation insufficient to determine if the condition was present at the time of inpatient admission.

HAC reporting counts all HACs Regardless of the effect on DRG assignment

A HAC REQUIRES:

Hospital-Acquired Conditions (Present on Admission Indicator)

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Hospital Acquired Condition Program

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Section 5001(c) of Deficit Reduction Act of 2005 requires the Secretary of the Department of Health and Human Services (DHHS) to identify Hospital-Acquired Conditions (HACs) that:

- Are High Cost or High Volume or Both

- Result in the Assignment of a Case to a Diagnosis-Related Group (DRG) that has a Higher Payment when Present as a Secondary Diagnosis

- Could Reasonably have been Prevented through the Application of Evidence-Based Guidelines

Data Source: Quality Net

2005

Since October 1, 2007, hospitals have been required to submit information on Medicare claims specifying whether diagnoses were Present on Admission (POA).

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2008Starting with October 1, 2008 Discharges, the Centers for Medicare & Medicaid Services (CMS) selected 10 Categories of Conditions for a HAC Payment Provision.

Hospitals no longer received additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present.

Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule

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Initiatives to reduce HACs continued in 2009 when The National Coverage Determinations (NCDs) for the Medicare Program was developed to eliminate ‘‘never events”.

These ‘‘never events’’ stemmed from a 2002 report conducted by the NQF that listed 27adverse events, listed as serious reportable events, that were both serious and largely preventable. Under these NCDs, Medicare does not cover a particular surgical or other invasive procedure to treat a particular medical condition when a practitioner erroneously performs:

(1) A different procedure altogether

(2) The correct procedure but on the wrong body part

(3) The correct procedure but on the wrong patient

2009

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In the FY 2011 Final Rule for the FY 2012 Payment Determination, CMS Adopted 8 Claims-Based HAC Measures for the Hospital Inpatient Quality Reporting (IQR) Program, Based on 8 of the 10 Conditions Applicable Under the HAC Payment Provisions:

I. Air EmbolismII. Blood IncompatibilityIII. Catheter-Associated Urinary Tract Infection (UTI)IV. Falls and Trauma (Includes Fracture Dislocation, Intracranial Injury, Crushing

Injury, Burn, Electric Shock)V. Foreign Object Retained After SurgeryVI. Manifestations of Poor Glycemic ControlVII. Pressure Ulcer Stages III or IVVIII. Vascular Catheter Associated Infections

2011

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As announced in the IPPS FY 2012 Final Rule, CMS used eight of these 10 HACs for the Hospital Inpatient Quality Reporting (IQR) Program. CMS has been publicly reporting on these eight HAC measures successfully on the Hospital Compare Web site since September 2010.

2012

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2013 PUBLIC REPORTING

CMS does not intend to provide or publicly report new calculations of these individual HACs as part of the Hospital

IQR Program after 2012.

We are finalizing our proposal to remove 8 HAC measures, 3 AHRQ Inpatient Quality Indicator (IQI) measures, and 5 AHRQ Patient Safety Indicator (PSI) measures from the Hospital IQR Program measure set.

We seek to reduce redundancy among the measures in the program. 2 of the 8 HAC measures address HAIs which are addressed by other measures currently in the Hospital IQR Program. These 2 HAI measures are the NQF endorsed CAUTI and CLABSI measures collected via the CDC’s NHSN system.

An additional 3 of the 8 HAC measures address similar topics (pressure ulcers, air embolism, and manifestations of poor glycemic control) to patient safety indicators that are included in the NQF-endorsed AHRQ PSI composite that is also included in the Hospital IQR Program

Federal Register /Vol. 77, No. 170 / Friday, August 31, 2012 /Rules and Regulations 53507

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Continues to be part of the Inpatient Prospective Payment

System (IPPS)

Payment Adjustment

Taken out of the Inpatient Quality Reporting Program

No Longer Reported on Hospital Compare

Hospital Acquired Condition Program

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Hospital-Acquired Condition (HAC) Reduction Program FY 2015

Starting with October 1, 2014 Discharges

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Hospital-Acquired Condition (HAC) Reduction Program FY 2015

The New Hospital-Acquired Condition (HAC) Reduction Program

IS IN ADDTION TO

The Current Hospital-Acquired Conditions Program

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CMS Final Rule:http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2014-IPPS-Final-Rule-Home-Page-Items/FY-2014-IPPS-Final-Rule-CMS-1599-F-Regulations.html?DLPage=1&DLSort=0&DLSortDir=ascending

Understanding the Hospital-Acquired Condition Reduction Program

Starting with October 1, 2014 Discharges, and affecting FY 2015 Payment Adjustment,

CMS will Implement The Hospital-Acquired Condition (HAC) Reduction Program

Mandated by the Affordable Care Act

This Requires the Centers for Medicare and Medicaid (CMS) to Reduce Hospital

Payments by 1% for Hospitals That Rank Among the Lowest-Performing 25 Percent

with Regard to Hospital Acquired Conditions

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Patient Safety IndicatorsPSI 90 Composite Measure

Central Line Associated Bloodstream Infections (CLABSI)

Measure

Catheter Associated Urinary Tract Infections (CAUTI) Measure

MEASURES

The HAC Program has 3 Measures and 2 Domains for FY 2015, Identified in the IPPS Rule

DOMAIN 1

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Domain 1 will include the Agency for Health

Care Research and

Quality (AHRQ)

Composite PSI #90

•Pressure Ulcer Rate (PSI 3)•Iatrogenic Pneumothorax Rate

(PSI 6)•Central Venous Catheter-

Related Blood Stream Infection Rate (PSI 7)

•Postoperative Hip Fracture Rate (PSI 8)

•Postoperative Pulmonary Embolism (PE) or Deep Vein Thrombosis Rate (DVT) (PSI 12)

•Postoperative Sepsis Rate (PSI 13)

•Wound Dehiscence Rate (PSI 14)

•Accidental Puncture and Laceration Rate (PSI 15)

DOMAIN 2

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Domain 2 Will Consist

of Two Healthcare-Associated Infection Measures

•Central Line-Associated Blood Stream Infection

•Catheter-Associated Urinary Tract Infection

DOMAIN WEIGHTING

Domain 1PSI-90 Composite Measure

Weighted at 35%

Domain 2CAUTI and CLABSI Measures

Weighted at 65%25% of Worst Performing Hospitals Receive a 1% Reduction

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35%

65%

Total Hac Score

Domain 1 Domain 2

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Points will be assigned according to a hospital’s performance on the three measures:(Domain 1)

I. PSI-90 Composite(Domain 2)

II. CLABSIIII. CAUTI

• The performance range for each of the measures will be divided into 10 Deciles• All hospitals will receive between 1 and 10 points for each measure based on National Percentile Ranking• Points will be Assigned for each Measure in Deciles between the Score of the Best Performing Hospital and

the Worst Performing HospitalHigher Score = Worse Performance

HAC MEASURE SCORING

Percentile Points1st-10th 111th-20th 221st-30th 331st-40th 441st-50th 551st-60th 661st-70th 771st-80th 881-90th 991st-100th 10

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Domain 1 (PSI-90)(1 to 10) Points Assigned to the Domain Score since it is Considered One Composite Measure

Domain 2 (HAIs) CLABSI & CAUTI(1 to 10) Points will be Assigned for Each SIR and Averaged to Determine the Domain Score

Summing The Two Weighted Domain Scores will Determine the Total HAC Score

TOTAL HAC REDUCTION SCORE

The Total HAC Score will be used to Determine the Top Quartile of Affected Hospitals

If a Hospitals Result is within the Worse Performing Quartile for Domain 1, CMS will Assign 1 to 10 Points to the Hospital for this Composite Measure

If a Hospitals Result is not within the Worse Performing Quartile for Domain 1, CMS will Assign Zero Points to the Hospital for this Composite Measure

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Performance is Assessed on the Measures within Each DomainEach Measure is ScoredMore than One Measure in a Domain – Measure Scores are Averaged to get the Domain ScoreThe Sum of the Weighted Domain Scores = Total HAC Score

The Total HAC Score is Ranked with other Hospitals to Identify the Lowest-Performing 25%

TOTAL HAC REDUCTION SCORE

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A Hospital’s Total HAC Score is Calculated by:

TOTAL HAC SCORE

Domain 1 (PSI-90) 35%

Domain 2 (avg of measures) CLABSI

& CAUTI 65%

Multiplying the (Domain 1) score by 35% and the average of the two (Domain 2) scores by 65%Summing the two weighted domain scores to determine the Total HAC Score

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Calculation of the SIR

CASE ELIGIBILITY

Case Eligibility Domain 1 - AHRQ Patient Safety Indicators DOMAIN 2 - CDC NHSN MEASURES Total HAC Score3 or More Eligible Discharges for at Least 1

Component Indicator >1 Predicted HAI Event

Not Enough Cases to Calculate a SIR Measure Score No Measure Score 100% Domain 1Not Enough Eligible Discharges in Claims Data No Measure Score Measure Score 100% Domain 2Not Enough Eligible Discharges in Claims or Enough Cases to Calculate a SIR No Measure Score No Measure Score No Calculation

Non-Submission of Data Domain 1 Domain 2 Total HAC ScoreHospital Has an ICU Waiver Measure Score Data is not Required 100% Domain 1Hospital Does Not Have an ICU Waiver but has no Submitted Data Measure Score 10 Points 100% Domain 1

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CMS Believes using 2 years of data for both domains would balance the needs of the program and allow for sufficient time to process the claims data and calculate the measures to meetthe program implementation timeline.

Applicable Time Period

For FY 2015 (Domain 1) AHRQ Measures:24-Month Period

July 1, 2011 through June 30, 2013

For FY 2015 (Domain 2) CDC Measures:24-Month Period

Calendar Years 2012 and 2013

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PAYMENT ADJUSTMENTS

*Indirect Medical Education (IME) (Teaching hospitals)Disproportionate Share (DSH) payments

Reductions for Applicable Hospitals under the HAC Reduction Program will be applied after Payment Adjustments are made for the Value-Based Purchasing (VBP) and the Hospital Readmissions Reductions Programs

Institutions that are penalized will see their total payments reduced, including add-ons *(IME and DSH). This is different from the Readmissions and VBP Programs, where the penalty only applies to base DRG payments

Although the measures exist in more than one program, the measures are used and calculated for very distinct purposes.

CMS believes that it is useful for hospitals to be able to distinguish the effect of each program, so that they can focus their resources for improvement.

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PAYMENT ADJUSTMENTS The Hospital VBP Program is an Incentive Program that Redistributes

Reductions made to the Base Operating DRG Payment Amount, based on Certain Performance Measures.

The HAC Reduction Program is a Penalty Program that Reduces Payments to Hospitals for Excess HACs to Increase Patient Safety

in Hospitals.

The HAC Reduction Program and the Hospital VBP Program are Separate Hospital Reporting Programs with Different Purposes

and Policy Goals.

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Prior to FY 2015 and each subsequent fiscal year, delivery of confidential reports to applicable hospitals with respect to HACs during the applicable period are required.

Reports to be Delivered in Hospitals’ Secure QualityNet Accounts

Information will be made available to the public regarding HACs for each applicablehospital. Hospitals have the opportunity to review, and submit corrections with respect to the HACs prior to such information being made public.

Once corrected, the HAC information be posted on the Hospital Compare Web site on the Internet in an easily understandable format.

Confidential Reports and Public Reporting

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The information in the confidential reports and accompanying confidential discharge-level information would be calculated using the claims information CMS has available approximately 90 days after the last discharge date in the applicable period, which is when CMS would create the data extract for the calculations. The discharge-level information accompanying the Domain 1 PSI measure rates would include:

Risk Factors for the Discharges that Factor into the Calculation of these MeasuresDates of Admission and DischargeDischarge CharacteristicsExclusions

The intent in providing this information is two fold: (1) To facilitate hospitals’ verification of the Domain 1 PSI measure calculations provided during the review and

correction period based upon the information available at the time the data extract was created(2) To facilitate hospitals’ quality improvement efforts with respect to the PSI measures.

The review and correction process for claims-based measures in Domain 1 would not include submitting additional corrections related to the underlying claims data used to calculate the measures for Domain 1, or adding new claims to the data extract used to calculate the measures used in Domain 1. This is because it is necessary to take a static “snapshot” of the claims in order to perform the calculations. For purposes of this program, calculation of the measures in Domain 1 using a static snapshot (data extract) taken at the conclusion of the 90-day period following the last date of discharge used in the applicable period.

Confidential Reports and Public Reporting

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CMS notes that the Hospital IQR Program isfinalizing expanded collection for the non-ICU

population (78 FR 27628). CMS intends topropose use of these data for the HAC

Reduction Program in the future.

FUTURE CHANGESHAC Domains and Measures

Domain 1AHRQ PSI-90 Composite

Weighted 35%

Domain 2CDC MeasuresWeighted 65%

FY 2015

PSI-90 CLABSI & CAUTI

Additional Measures Affecting Domain 2 Only

FY 2016 Surgical Site Infection (Colon Surgery and Abdominal

Hysterectomy)

FY 2017

MRSA C Diff

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NOTE

CMS is unable to combine:

i. Hospital IQR Programii. Hospital VBP Programiii. HAC Reduction Programiv. Hospital Readmissions Reduction Program

Into one aggregate payment adjustment, because by law, they affect different portions of the Medicare payment made to hospitals under the IPPS.

The Hospital IQR Program adjustment is made to the Annual Percentage Update (APU)

The Hospital VBP and Hospital Readmissions Reduction Programs’ adjustments are made to the base operating DRG payment amount.

The HAC adjustment is a percentage reduction to the amount otherwise payable under the IPPS

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CMS will consider hosting educational provider calls to further explain the scoring methodology for the program, and will design the confidential reports in a

manner that provides step-by-step explanations of the scoring.

Data for the PSI-90 measure and the CAUTI and CLABSI measures are currently publicly available on the Hospital Compare Web site. CMS will be making updated information available to the public on the

individual indicators in PSI-90 in an upcoming release on the Hospital Compare Web site.

NOTE

CMS is using the risk-adjustment factors listed in specifications for the AHRQ and CDC Measures selected for this program.

The PSI Measures are Risk-Adjusted and Reliability-Adjusted.

Specifically, Risk Factors such as the Patient’s Age, Gender, Comorbidities, and Complications would be considered in the Calculation of the Measure Rates so that Hospitals Serving a Large Proportion of

Sicker Patients would not be Unfairly Penalized.

RESOURCES

Hospital-Acquired Conditions (Present on Admission Indicator) New Hospital-Acquired Condition (HAC) Reduction ProgramFY 2015 Final Rulewww.cms.gov

Quality Netwww.qualitynet.orgHospital-Acquired Conditions (HACs)

Agency for Healthcare Research and Quality (AHRQ) Indicatorshttp://qualityindicators.ahrq.gov

National Quality Forum (NQF)www.qualityforum.org

Serious Reportable Events Publication (Oct 2008)http://www.qualityforum.org/Publications/2008/10/Serious_Reportable_Events.aspx

For Questions Regarding the HAC Reduction Program, contact the Masspro, Quality Data Reporting Advisor,Jeanne Dufresne 781.419.2759jdufresne@maqio.sdps.org

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