Overview of Quality Reporting, Payments and Penalties October 9, 2012 Presenter: Kimberly Rask, MD...

Overview of Quality Reporting, Payments and Penalties

October 9, 2012

Presenter:

Kimberly Rask, MD PhDMedical Director

Coordinated Federal Focus on Quality

► National Quality Strategy

► DHHS Action Plan

► Partnership for Patients

► CMS Quality Improvement Organization (QIO) program priorities

Partnership for Patients

Two Goals1. Decrease by 40 percent preventable hospital-

acquired conditions (HACs) by 2013 60,000 lives saved, 1.8 million fewer injuries to patients and $20 billion in health care costs avoided

2. Reduce 30-day hospital readmissions by 20 percent by 2013 1.6 million fewer readmissions and $15 billion in health care costs avoided

National Campaign to Align Priorities and Resources

Multiple Quality Reporting Programs Impact the Bottom Line

Program Data Financial impact

Annual Payment Update

Inpatient Quality Reporting – core measures

2%

Outpatient Quality Reporting – core measures

2%

Value Based Purchasing

Patient satisfaction, core measures, mortality, cost, infections

1% withhold; can lose the 1%, get some back or even receive > 1% for excellent performance2 % withhold in FY 2017

Readmissions Reduction Program

Excess readmission rate

Up to 1% in 2012-13Up to 2% in 2013-14Up to 3% after 2014

Preventable health care acquired conditions (HACs)

Claims for HACsNo payment unless condition noted on admission

Three Essential Questions …

1. What “triggers” the penalty/incentive?

2. What is its “size”?

3. How is it applied?

Hospitals Paid to Report Quality Data



Inpatient Quality Reporting- core measures

2%

Outpatient Quality Reporting- core measures

2%







Preventable health care acquired conditions (HACs) Claims for HACs No payment unless condition noted

on admission




2%


2%

“Pay for Reporting” Programs

► Participation is “voluntary” ► Those who choose NOT to participate

will have 2% reduction in their Medicare Annual Payment Update (APU) for the following CMS fiscal year for each program

► Focus on timely, complete and accurate reporting

What data is collected?

► 2004: Hospitals voluntarily report 10 measures; agree to public reporting of data reported to receive incentive APU

► 2005-2012: New measures added yearly:– AMI patients, congestive heart failure patients,

pneumonia patients– Surgical patients (Surgical Care Improvement

Project or SCIP)– Children’s asthma

► 2007: Added mortality rates► 2008: Added patient satisfaction survey

What data is collected?► 2009: Added readmission rates► 2011: Added hospital acquired infection

rates► 2012: Composite patient safety measure► 2013: Permutations on previous measures

─ Hospital-wide all-cause unplanned admissions

─ Hospital-level readmission rate following elective total hip or total knee arthoplasty

─ Hospital-level complication rate following elective total hip or total knee arthoplasty

Healthcare-Associated Infections (HAI)

►Data is submitted to the CDC’s National Healthcare Safety Network (NHSN) – Central-Line Associated Bloodstream

Infection (CLABSI)– Surgical Site Infection (SSI) – Catheter-Associated Urinary Tract

Infection (CAUTI)

Quality Measures Reporting

► Each measure’s specific data can be collected either retrospectively or concurrently

► The same data is submitted to The Joint Commission and CMS – used for quality improvement and public reporting – Quarterly– Hospital Compare website– Validation

Quality Reporting

Pay for Performance




2%


2%








No payment unless condition noted on admission





Value-based Purchasing

► Moving from Pay for Reporting to Pay for Performance

► Authorized under the Affordable Care Act► Funded by a 1% withhold from hospital

DRG payments► Minimum of 10 cases for process and

outcome measures over 9 month performance period

► Minimum of 100 satisfaction surveys

Hospital Total Performance

12 clinical processes of care► 2 AMI measures► 1 HF measure► 2 pneumonia measures► 7 SCIP measures• Antibiotic selection, given

within 1 hour, discontinued

• Controlled 6 a.m. glucose• Beta blocker continued• VTE prophylaxis ordered and

given

8 patient experience measures► Nurse communication► Doctor communication► Staff responsiveness► Pain management► Medication communication► Cleanliness and quiet► Discharge information► Overall hospital rating

70% 30%

How will hospitals be evaluated?

AchievementCurrent hospital

performance compared to ALL HOSPITALS baseline

rates

ImprovementCurrent hospital

performance compared to OWN BASELINE rates

►Minimum thresholds to receive any points

►Benchmarks to receive full points

No “trigger”

► Program will be budget neutral overall ► Some hospitals will not earn back

everything that they had withheld for the pool and some hospitals will earn back more than what they had withheld – 2% of hospitals projected to earn bonus

>0.5%

– 2% will lose >0.5%► Penalty or incentive applied to base

operating DRG payment for each discharge

And looking forward to the next year…

Proposed Domain Weights for Hospital VBP Program

Domain FY 2014 FY 2015

Clinical processes of care 45% 20%

Patient satisfaction 30% 30%

Outcomes (mortality, patient safety, infections)

25% 30%

Efficiency (Medicare spending per beneficiary)

-- 20%

Penalty for Excess Readmissions




2%


2%








No payment unless condition noted on admission





Hospital Readmission Reduction Program

► Authorized under §3025 of the Affordable Care Act

► Reduces IPPS payments to hospitals for excess readmissions after October 2012

► In rule-making for 2 years

CMS Implementation

► Selected 3 conditions– Acute Myocardial Infarction (AMI)– Heart Failure (HF)– Pneumonia (PN)

► Calculated “Excess Readmission Ratios” using the National Quality Forum (NQF)-endorsed 30-day risk-standardized readmission methodology

► Set a 3-year rolling time period for measurement with a minimum of 25 discharges

► October 1, 2012 penalty determination period was July 2008 to June 2011

Excess Readmission Ratio

►The ratio comparesActual number of risk-adjusted readmissions from Hospital XX to the Expected number of risk-adjusted admissions from Hospital XX based upon the national averages for similar patients

►Ratio > 1 means more than expected

readmissions< 1 means fewer than expected

readmissions

Risk Adjustment

► The number of readmissions IS adjusted for─ Age─ Gender─ Coexisting diseases based upon 1-year review of all

inpatient and outpatient Medicare claims for that patient

► The number of readmissions is NOT adjusted for:─ Poverty level in surrounding community─ Proportion of uninsured patients─ Racial/ethnic mix of patients

“Many safety-net providers and teaching hospitals do as well or better on the measures than hospitals without substantial numbers of patients of low socio-economic status.”

Trigger and Size of Penalty

► An Excess Readmission ratio of >1 for any of the 3 measures (AMI, HF, PN) triggers penalty

► Size of penalty is intended to reflect relative cost of excess readmissions from Hospital XX─ Claims data used to calculate aggregate Medicare

payments for those 3 conditions and total Medicare payments for all cases at Hospital XX

─ Calculated over same time period as readmission ratio─ Calculate percentage of Hospital XX’s total Medicare

payments that result from excess readmissions for the 3 conditions

─ Final penalty is that raw % or 1%, whichever is smaller

Applying the Penalty

► Applied to base-DRG payment for all fee-for-service Medicare discharges during the fiscal year (FY)– Wage-adjusted DRG payment amount including

transfer adjustment plus new technology payment if applicable

– Add-on payments (IME, DSH, outlier, low volume) not reduced

► No bonus for excellent performance► For FY 2013, maximum penalty is 1%

– Impacting more than 2000 hospitals nationally– Expected to cost hospitals $280 million or 0.3% of the

total Medicare revenue to hospitals

Excess Standardized Readmission Ratio (SRR) posted on Hospital Compare

Similar but not identical to IQR readmission measure

Similarities► Same NQF-endorsed 3 risk-adjusted condition-specific

measures► Same data source► Same types of discharges and exclusions

Differences► How the measures are displayed and reported ► SRR calculated on a subset of readmissions

Impact of Reporting on Bottom Line





2%


2%







Preventable health care acquired conditions (HACs) Claims for HACs No payment unless condition noted

on admission


Preventable health care acquired conditions (HACs) Claims for HACs No payment unless condition noted on

admission

Hospital-acquired Conditions (HAC) or “Never Events”

CMS identified conditions that:

► Were high cost, high volume or both

► Result in the assignment to a DRG that has a higher payment when present as a secondary diagnosis

► “Could reasonably have

been prevented through application of evidence‑based guidelines”

Foreign Object Retained After Surgery

Air Embolism

Blood Incompatibility

Stage III and IV Pressure Ulcers

Falls and Trauma

Catheter-Associated Urinary Tract Infection (UTI)

Vascular Catheter-Associated Infection

Surgical Site Infection (SSI) Following CABG

SSI Following Bariatric Surgery for Obesity

Manifestations of Poor Glycemic Control

SSI Following Certain Orthopedic Procedures

DVT/PE Following Certain Orthopedic Procedures

HAC Reporting is Changing

► Most individual HACs have been removed from public reporting

► §3008 of Affordable Care Act requires public reporting of HACs– CMS is proposing an all-cause harm

measure with potential to “drill down” on Hospital Compare

► Studies show financial impact from current HAC nonpayment policy is negligible for most hospitals

Potential New Penalty

► §3008 of the Affordable Care Act also creates a penalty for lowest performing hospitals based upon HAC rates by 2015─ Reduction applied to hospitals in the

top quartile of hospital acquired conditions using “an appropriate” risk-adjustment methodology

─ Those hospitals will have payments reduced to 99% of amount that would otherwise apply to such discharges

Questions?

This material was prepared by Alliant GMCF, the Medicare Quality Improvement Organization for Georgia, 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 reflect CMS policy. Publication No. 10SOW-GA-IIPC-12-233

Physician Quality Reporting System (PQRS)

Program

Hospital Outpatient Quality Reporting (OQR) Program

Hospital Value-Based Purchasing (VBP) Program

Hospital Readmissions Reduction

Program

Hospital -Acquired Conditions (HAC) Program

Electronic Health Record (EHR) Incentive Program

Long-Term Care Hospitals Quality Reporting (LTCH QR) Program

Ambulatory Surgical Centers Quality Reporting (ASCQR) Program

Inpatient Rehabilitation Facility Quality Reporting (IRFQR) Program

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program

PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program

Hospice Quality Reporting (HQRP) Program

End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)

Hospital Inpatient Quality Reporting (IQR) Program

Overview of Quality Reporting, Payments and Penalties October 9, 2012 Presenter: Kimberly Rask, MD...

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