Mandatory Elements of Healthcare Reform

1healthcare consulting

Mandatory Elements of Healthcare ReformWalter Coleman


Agenda

• Overview of ACA – Mandatory Elements of Reform– Value Based Purchasing

– Readmission Reduction Program

– Hospital Acquired Conditions

• Best practices to analyze current and previous performance

– Calculate Metrics

• Importance of Finance & Quality working together


We Are Past the “Tipping Point”


The framework situates existing and potential APMs into a series of categories.

APM Framework At-A-Glance

Source: Alternative Payment Model Framework and Progress Tracking (APM FPT) Work Group. “Alternative Payment Model (APM) Framework Final White Paper.” Health Care Payment Learning and Action Network. 12 Jan. 2016.


Work Group’s Goals for Payment Reform

Source: Alternative Payment Model Framework and Progress Tracking (APM FPT) Work Group. “Alternative Payment Model (APM) Framework Final White Paper.” Health Care Payment Learning and Action Network. 12 Jan. 2016.


Connecting the Dots— Better performance in each program

positively impacts initiatives across the continuum of care

Bundled Payments for Care Improvement Comprehensive

Care for Joint Replacement

Value Based Purchasing

Medicare Shared SavingsAccountable Care Organization

Value Based Commercial

Contracts

Value Modifier

Skilled Nursing FacilityValue Based Purchasing

Patient Centered Medical Home

BPCI

attention on outcomes+

and more+

improved patient

satisfaction

+

focus on quality

measures

+

rigorous referral

management +

improved care coordination

+

focus on comorbid condition management

+ effective utilization of technology

+

improved diagnosis coding

+

VM

PCMH

VBC

VBP

lower readmissions

+

SNF VBP

CJR

MSSPACOs


Hierarchy of Risk and Payment Models


Mandatory Elements – Reform Timeline

8Confidential – Proprietary Trade SecretDo Not Distribute


Mandatory Elements of Reform




• Outcomes = Income

• Mandatory Pay for Performance Program

– 3,500 hospitals are included in this program across the country

• Reimbursement Determine Two Ways:

– Achievement

• How we compare to National Top Decile (350 Hospitals)

– Improvement

• How we measure against ourselves

• Did we do better than a previously measured baseline period



• Percent of Medicare Reimbursement at Risk

• FY 2013 – 1.00%

• FY 2014 – 1.25%

• FY 2015 – 1.50%

• FY 2016 – 1.75%

• FY 2017 – 2.00%

• FY 2018 – 2.00%

• FY 2019 – 2.00%

• FY 20xx – refers to the Federal Fiscal Year (Oct. 1 – Sep. 30)

when DRG payments will be affected


VBP FY 2018 – New Measures

• Patient Experience

– Added Care Transition Measure

• Clinical Care

– Core Measures

• 2 Dropped Out (AMI 7-a and IMM-2)

• PC-01 (Elective Delivery Prior to 39 Weeks Moved to Safety Domain

– Mortality: AMI, HF, PN

• Safety

– PC-01 Moved to this Domain

• Efficiency

– No Change


VBP Details

• Two new measures introduced

– HCAHPS: CTM-3 for 2018 (Performance Period CY 2016)

– COPD Mortality for 2021: 36 month performance period

• Dropping two measures and dropping the subdomain and

moving the one remaining measure of PC 01 to Safety.

– AMI 7a is not widely reported and collection is “burdensome”

– IMM 2 is “topped out”

• Fully defined 2018 and partially defined through 2021

• Expansion of infection definitions to include non-ICU locations

starting with FY 2019. This includes Medical/Surgical units.

Baseline is CY 2015 and Performance Year is CY 2017


VBP FY 2018 – Patient Experience

• Communication with Nurses

• Communication with Doctors

• Responsiveness of Hospital Staff

• Pain Management

• Communication about Medicines

• Cleanliness and Quietness of Hospital

• Discharge Information

• Overall Rating of Hospital

• New Measure: Care Transition Metric – CTM-3

**For answers to count, patients must give hospitals a score of 4 or “Always”


Care Transition Metric – CTM-3

• Started in 2018 VBP (Performance Period CY 2016)

• Three questions form a composite score

– 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.

– When I left the hospital, I had a good understanding of the things I was

responsible for in managing my health.

– When I left the hospital, I clearly understood the purpose for taking

each of my medications.

• Possible answers range from ‘Strongly Disagree’ to ‘Strongly

Agree’


VBP FY 2018 – Clinical Care and Safety

Clinical Care- Outcomes

• 30 Day Mortality – AMI

• 30 Day Mortality – HF

• 30 Day Mortality – PN

Safety

• AHRQ – PSI-90

• CLABSI

• CAUTI

• SSI-Colon

• SSI-Abdominal Hyster.

• MRSA

• C. Diff

• PC-01





Outcomes – 30 Day Mortality

• Currently in 3 Performance Periods

• FY 2017 ended June 30, 2015

• FY 2020 began July 1, 2015

• 30 Day Mortality Measures

– Assess UNEXPECTED deaths: AMI, HF, and PN that occur

within 30 days after admission; which, depending on the length

of stay, may occur post-discharge….


Mortality Deaths w/in 30 Days and Outside of Facility

Total # of Patients

who Died w/in 30

Days

# of Patients who

Died w/in 30 Days

Outside of Facility

% of Patients who

Died w/in 30 Days

Outside of Facility

Facility A 209 144 68.90%

Facility B 222 128 57.66%

Facility C 117 77 65.81%

Facility D 119 65 54.62%

Facility E 206 112 54.37%

Facility F 117 67 57.26%

Facility G 277 180 64.98%

Facility H 147 71 48.30%

Facility I 52 25 48.08%

Facility J 44 25 56.82%

Facility K 127 90 70.87%

TOTAL 1,637 984 60.11%


VBP FY 2018 - Efficiency

• Medicare Spend Per Beneficiary (MSPB)

– Captures total Medicare Spending Per Beneficiary relative to a

hospital stay, bundling hospital sources (Part A) with post acute

care (Part B)

– Bundles the cost of care delivered to a beneficiary for an episode

across the continuum of care:

• 3 Days Prior

• Hospital Inpatient Stay

• 30 Days post Discharge

VBP – Shifting of Domain Weights

70%

30%

FY 2013

21

45%

25%

30%

FY 2014

20%

20%

30%

30%

FY 2015

10%

25%

40%

25%

FY 2016

5%

25%

25%20%

25%

FY 2017

25%

25%25%

25%

FY 2018

• Clinical Care • Patient Experience • Efficiency (MSPB)

• Clinical Care – Mortality (FY’17 & FY’18)

• Safety - Outcomes


VBP – FY13 Domain WeightsPerformance Period: July 1, 2011 – March 31, 2012

Reimbursement Period: October 1, 2012 – September 30, 2013

Core Measures = 70%


VBP – FY14 Domain WeightsPerformance Period: April 1, 2012 – December 31, 2012


Core Measures = 45%Outcomes = 25%


VBP – FY15 Domain WeightsPerformance Period: January 1, 2013 – December 31, 2013


HCAHPS = 30%

Outcomes = 30% MSPB = 20%

One Measure!!

Core Measures = 20%




HCAHPS = 25%

Outcomes = 40%

MSPB = 25%

Core Measures = 10%


HCAHPS = 25%

Safety = 20%

MSPB = 25%

Clinical Care - Process = 5%

Clinical Care -

Outcomes = 25%






HCAHPS = 25%

Safety = 25%

MSPB = 25%

Clinical Care = 25%


VBP – Opportunities

HCAHPS = 25%

Safety = 25%

MSPB = 25%

Clinical Care = 25%



Readmission Reduction Program





• 9% of Current and Future Medicare Reimbursement at Risk

– 3% penalty of Medicare Reimbursement at risk each program year

– Measured Populations 30 days from DISCHARGE

• AMI, HF, PN, COPD, THA & TKA, CABG

• August 2014: CABG Added to FY 2017

• Performance Periods: 3 Year Rolling Program

– FY’16: July 1, 2011 – June 30, 2014 – 3%

– FY’17: July 1, 2012 – June 30, 2015 – 3%

– FY’18: July 1, 2013 – June 30, 2016 – 3%

– FY’19: July 1, 2014 – June 30, 2017 – 3%

– FY’20: July 1, 2015 – June 30, 2018 – 3%

Currently participating in

3 performance periods

simultaneously

Readmission Reduction Program


DHG- Healthcare RRP ApproachRRP Success

PAC

Re

adm

its



Hospital Acquired Conditions





Hospital Acquired Conditions (1% at Risk*)

• 12 Hospital Acquired Conditions Identified– Divided in to 2 Domains

• If a hospital is in the BOTTOM QUARTILE (worst

performing 25% in the country), it will be penalized

a FULL 1% of Medicare Reimbursement

• Penalties began FY’15 (October 1, 2014)

*1% After DSH, Uncompensated Care, IME, and Capital


Hospital Acquired Conditions: FY 2015

First Domain: PSIsPerformance Period: 7/1/11-6/30/13

Second Domain: CDCPerformance Period: CY 2012 & 2013

Pressure Ulcer Rate CLABSI

Iatrogenic Pneumothorax Rate CAUTI

Central Venous Catheter-Related Bloodstream Infections

Postoperative Hip Fracture

Perioperative Pulmonary Embolism and Deep Vein Thrombosis Rate

Postoperative Sepsis

Postoperative Wound Dehiscence

Accidental Puncture or Laceration


CLABSI 32.5%

CAUTI 32.5%

Pressure Ulcer 4.375%

4.375%

Postop. Sepsis

HAC Domain Weightings: FY’15

DOMAIN 1: 35% DOMAIN 2: 65%


Hospital Acquired Conditions: FY 2016First Domain: PSIs

25%Second Domain: CDC

75%




SSI Following Colon Surgery (FY 2016)

Postoperative Hip Fracture SSI Following Abdominal Hysterectomy (FY 2016)


Postoperative Sepsis




CLABSI 25%

CAUTI 25%SSI 25%


3.125%

Postop. Sepsis




Hospital Acquired Conditions: FY 2017

First Domain: PSIs15%

Second Domain: CDC85%




SSI Following Colon Surgery (FY 2016)

Postoperative Hip Fracture SSI Following Abdominal Hysterectomy (FY 2016)


Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacteremia (FY 2017)

Postoperative Sepsis Clostridium Difficile (FY 2017)




CLABSI 17%

CAUTI 17%

SSI 17%C.Diff 17%

MRSA 17%


Postop. Sepsis 1.875%





Current Dollars at Risk


Domain Weight Breakeven Reward

Medicare Spend Per Beneficiary 25% 325,000$ 576,266$

Safety 25% 325,000$ 576,266$

Patient Experience 25% 325,000$ 576,266$

Clinical Care - Outcomes 25% 325,000$ 576,266$

TOTAL 100% 1,300,000$ 2,305,065$

VBP FY 2018

VBP FY 2018 – Sample $$ at Risk

$65,000,000 Medicare Reimbursement Facility


Domain Weight At Risk Reward

FY 2016

FY 2017

FY 2018

Medicare Spend Per Beneficiary 25% 325,000$ 576,266$

Safety 25% 325,000$ 576,266$

Patient Experience 25% 325,000$ 576,266$

Clinical Care - Outcomes 25% 325,000$ 576,266$

FY 2019*

Clinical Care - Mortality & THA/TKA 25% 325,000$ 576,266$

Safety - AHRQ 3.75% 48,750$ 86,440$

FY 2020*

Clinical Care - Mortality & THA/TKA 25.00% 325,000$ 576,266$

TOTAL 1,998,750$ 3,544,038$

VBP Current Dollars At Risk (Active Performance Periods)

*Performance Periods are finalized; however weightings are not and

reflect current finalized adjustments

COMPLETE

COMPLETE

VBP – Sample Total Current $$ at Risk



All Reform – Sample Current $$ at Risk


Domain On the Table

FY 2018

Value Based Purchasing 2,305,065$

Readmissions 1,950,000$

Hospital Acquired Conditions 650,000$

FY 2019

Value Based Purchasing* 662,706$


Hospital Acquired Conditions 650,000$

FY 2020

Value Based Purchasing* 576,266$


TOTAL 10,694,038$

*VBP Weightings are not finalized

All Active Mandatory Reform


SAMPL IPPS Reimbursement Letter

PPS EFFECTIVE 10/1/2014 DRG Weight 1.00

Facility CMI 1.54

OPERATING INFORMATION

Federal National Standardized Labor Rate 3,329.57

Wage Index 0.8994

Labor Rate x Wage Index 2,994.62

Federal National Standardized Non-Labor Rate 2,040.71

PPS Blended Rate 5,035.33

FY 2015 Hospital Readmissions Reduction (HRR) Adjustment Factor 0.9994 5,032.30 ($3.02) RRP Reduction

FY 2015 Value-Based Purchasing (VBP) Adjustment Factor 0.994348 5,003.86 ($28.44) VBP Reduction

($31.46) Per DRG Reduction

($31.46) x 1.54

($48.45)VBP & RRP Per

DRG Red. CMI Adj

Disproportionate Share Adjustment (Operating) (Empirically Justified Amount 25%) 0.0691 0.02 5,090.43

Disproportionate Share Adjustment (Operating) (Uncompensated Care Amount) 507.71 5,598.14

Fully Loaded Operating Rate adjusted for CMI 8,346.97

FY 2015 Hospital Acquired Condition (HAC) Adjustment Factor 0.99 8,263.50($83.47)

HAC Per DRG

CMI Adjusted

($131.92)Total Per DRG

Reduction

Penalties & Your DRG Payment



Measuring Current Performance


• System was penalized $376,003 in FY’15 VBP Program

• Must acknowledge the amount UNEARNED

• Of the programs dollars made available:

– System did not capitalize on $6,187,541

Earned Back Unearned Available $$ % Earned

System $4,925,357 $6,187,541 $11,112,898 44.32%

$0 $11,112,898

Overall Performance

VBP FY'15 TOTAL PERFORMANCE

$4,925,357Breakeven Point: $5,301,360


Earned Back Unearned Measure Value % Earned

Facility $381,643 $218,077 $599,720 63.64%

$381,643

$0 $599,720


Facility $278,896 $620,704 $899,600 31.00%

$278,896

$0 $899,600

Core Measures

HCAHPS

Breakeven Point: $232,525



Facility $539,763 $359,837 $899,600 60.00%

$539,763

$0 $899,600


Facility $59,974 $539,746 $599,720 10.00%

$59,974

$0 $599,720

Outcomes

Efficiency




Facility Bonus / (Penalty) Total Score State Average National Average National Δ

Facility A $97,593 42.03 41.81933117 41.70169535 0.325577377

Measure

Score

Amount Earned

by Measure

Amount

Unearned by

Measure

% of Measure

Earned

Core Measures

AMI-8a 6 32,712$ 21,808$ 60.00%

SCIP-Inf-1 9 49,068$ 5,452$ 90.00%

SCIP-Inf-2 7 38,164$ 16,356$ 70.00%

SCIP-Inf-3 5 27,260$ 27,260$ 50.00%

SCIP-Inf-4 9 49,068$ 5,452$ 90.00%

SCIP-Inf-9 5 27,260$ 27,260$ 50.00%

HF-1 8 43,616$ 10,904$ 80.00%

PN-3b 5 27,260$ 27,260$ 50.00%

PN-6 8 43,616$ 10,904$ 80.00%

SCIP-Card-2 3 16,356$ 38,164$ 30.00%

SCIP-VTE-2 5 27,260$ 27,260$ 50.00%

Core Measures TOTAL 381,643$ 218,077$ 63.64%

HCAHPS

Comm. w/ Nurses 2 17,994$ 71,966$ 20.00%

Comm. w/ Doctors 1 8,998$ 80,962$ 10.00%

Resp. of Hosp. Staff 2 17,994$ 71,966$ 20.00%

Pain Management 2 17,994$ 71,966$ 20.00%

Comm. Re: Medicines 1 8,998$ 80,962$ 10.00%

Clealiness & Quietness 2 17,994$ 71,966$ 20.00%

Discharge Information 3 26,990$ 62,970$ 30.00%

Overall Rating 1 8,998$ 80,962$ 10.00%

Consistency Score 17 152,933$ 26,987$ 85.00%

HCAHPS TOTAL 278,896$ 620,704$ 31.00%

Outcomes

AMI 10 179,920$ (0)$ 100.00%

HF 3 53,980$ 125,940$ 30.00%

PN 8 143,934$ 35,986$ 80.00%

AHRQ PSI-90 9 161,928$ 17,992$ 90.00%

CLABSI 0 0$ 179,920$ 0.00%

Outcomes TOTAL 539,763$ 359,837$ 60.00%

Efficiency

MSPB 1 59,974$ 539,746$ 10.00%

Efficiency TOTAL 59,974$ 539,746$

Facility TOTAL 1,260,277$ 1,738,363$ 42.03%


Perform Metric Sensitivity Analysis

FY15 ∆ FY15 ∆ FY15 ∆

Performance 1.0127 Performance 87.09% Performance 0.5783

Baseline 1.0048 -0.0078 Baseline 87.18% -0.09% Baseline 0.6457 0.0674

Threshold 0.9850 -0.0277 Threshold 88.27% -1.18% Threshold 0.6162 0.0379

Benchmark 0.8270 -0.1857 Benchmark 90.42% -3.33% Benchmark 0.4500 -0.1283

Score 0 Score 0 Score 3

Improvement Dollar Value Score Improvement Dollar Value Score Improvement Dollar Value Score

0.05 97,756$ 3 0.50% 14,663$ 1 0.05 29,327$ 5

0.10 244,390$ 6 1.50% 58,654$ 4 0.10 102,644$ 10

0.15 342,146$ 8 2.50% 102,644$ 7 0.15 102,644$ 10

0.20 488,780$ 10 3.50% 146,634$ 10 0.20 102,644$ 10

0.25 488,780$ 10 4.50% 146,634$ 10 0.25 102,644$ 10

0.30 488,780$ 10 5.50% 146,634$ 10 0.30 102,644$ 10

0.35 488,780$ 10 6.50% 146,634$ 10 0.35 102,644$ 10

0.40 488,780$ 10 7.50% 146,634$ 10 0.40 102,644$ 10

0.45 488,780$ 10 8.50% 146,634$ 10 0.45 102,644$ 10

1

Outcomes - AHRQ PSI-90

2 3

Outcomes - Mortality-PNEfficiency - Medicare Spend Per Beneficiary


RRP Penalty Breakdown

RRP Adj. Factor: 0.9787

DRG Reimb. $ 30,747,194

RRP Penalty $ 654,915

RRP Penalty Per

Penalized Read.

9,396$

AMI COPD HF PN THA / TKA

RRP Penalty 85,953$ 263,139$ 96,016$ 88,508$ 121,300$

% of Penalty 13.1% 40.2% 14.7% 13.5% 18.5%

Pen. Patients 9.1 28.0 10.2 9.4 12.9

% of RRP Pats. 6.8% 35.3% 30.4% 22.2% 5.3%


Penalized RRP Patients Breakdown

MeasureNumber of Eligible

Discharges at

Your Hospital

Number of

Readmissions at

Your Hospital

# of Penalized

Patients

Per Year

Improvement

Penalized Patients

as % of

Readmissions

Penalized Patients

as % of Total

AMI 134 33 9.1 3.0 27.7% 6.8%

COPD 699 172 28.0 9.3 16.3% 4.0%

HF 567 148 10.2 3.4 6.9% 1.8%

PN 530 108 9.4 3.1 8.7% 1.8%

THA/TKA 238 26 12.9 4.3 49.7% 5.4%

TOTAL 2,168 487 69.7 TOTAL 14.3% 3.2%

Per YEAR 723 162 23.2 Per YEAR 4.8% 1.1%


Readmissions by Measure – Last 3 Years

9

15

9

5956 57

74

42

3236

30

42

12 11

3

2010 - 2011 2011 - 2012 2012 - 2013

AMI COPD HF PN THA / TKA


FY’16 RRP – 2010-2011 Performance Dropped

2010 - 2011 2011 - 2012 2012 - 2013

July 2 1

August 1

September 1 2

October 1

November 1 1 1

December 2 1

January 1 1

February 3 1

March 2 1

April 1 3 2

May 1

June 1 2

9 15 9

AMI Readmissions

2010 - 2011 2011 - 2012 2012 - 2013

July 5 4 3

August 4 4 2

September 2 8 3

October 3 4 2

November 9 5 7

December 6 6 7

January 9 7 8

February 6 7 7

March 4 1 3

April 6 3 7

May 3 3 4

June 2 4 4

59 56 57

COPD Reamissions

2010 - 2011 2011 - 2012 2012 - 2013

July 8 2 2

August 5 4 1

September 5 3 2

October 7 2 3

November 8 2 1

December 6 4 5

January 2 5 5

February 8 3 3

March 8 3 4

April 9 6 3

May 6 5 1

June 2 3 2

74 42 32

HF Readmissions

2010 - 2011 2011 - 2012 2012 - 2013

July 0 4 3

August 1 1 4

September 7 4 2

October 4 4 5

November 3 3 3

December 0 3 2

January 5 2 4

February 3 3 4

March 3 1 7

April 1 0 1

May 2 3 4

June 7 2 3

36 30 42

PN Readmissions

2010 - 2011 2011 - 2012 2012 - 2013

July 2 3 0

August 2 1 1

September 2 1 0

October 1 0 0

November 0 0 0

December 1 1 0

January 1 0 0

February 1 2 1

March 1 0 1

April 0 0 0

May 1 1 0

June 0 2 0

12 11 3

THA / TKA Readmissions


2010 - 2011 2011 - 2012 2012 - 2013

July 2 1

August 1

September 1 2

October 1

November 1 1 1

December 2 1

January 1 1

February 3 1

March 2 1

April 1 3 2

May 1

June 1 2

9 15 9

AMI Readmissions

2010 - 2011 2011 - 2012 2012 - 2013

July 5 4 3

August 4 4 2

September 2 8 3

October 3 4 2

November 9 5 7

December 6 6 7

January 9 7 8

February 6 7 7

March 4 1 3

April 6 3 7

May 3 3 4

June 2 4 4

59 56 57

COPD Reamissions

2010 - 2011 2011 - 2012 2012 - 2013

July 8 2 2

August 5 4 1

September 5 3 2

October 7 2 3

November 8 2 1

December 6 4 5

January 2 5 5

February 8 3 3

March 8 3 4

April 9 6 3

May 6 5 1

June 2 3 2

74 42 32

HF Readmissions

2010 - 2011 2011 - 2012 2012 - 2013

July 0 4 3

August 1 1 4

September 7 4 2

October 4 4 5

November 3 3 3

December 0 3 2

January 5 2 4

February 3 3 4

March 3 1 7

April 1 0 1

May 2 3 4

June 7 2 3

36 30 42

PN Readmissions

2010 - 2011 2011 - 2012 2012 - 2013

July 2 3 0

August 2 1 1

September 2 1 0

October 1 0 0

November 0 0 0

December 1 1 0

January 1 0 0

February 1 2 1

March 1 0 1

April 0 0 0

May 1 1 0

June 0 2 0

12 11 3

THA / TKA Readmissions

FY’16 RRP – 2010-2011 Performance Dropped

56


Length of Inpatient Stay and Readmissions Trends

Avg. LOS Readmission 6.52

Avg. LOS Non Read. 5.08

1.44

AMI Readmission Rate



1.33

COPD Readmission Rate



0.87

HF Readmission Rate



1.17

PN Readmission Rate



1.04

THA/TKA Readmission Rate


COPD Readmissions by Discharge Destination

10%11%

68%

0%0%

0%

11%

% of Penalized Readmissions

Facility that Provides Custodial or Supportive Care

Home Health

Home or Self Care (Routine Discharge)

Hospice - Home

Long Term Care Hospital

Psychiatric Hospital or Unit

SNF

5%16%

67%

0%

0% 1%

11%

% of Total Readmissions

Facility that Provides Custodial or Supportive Care

Home Health

Home or Self Care (Routine Discharge)

Hospice - Home

Long Term Care Hospital

Psychiatric Hospital or Unit

SNF


Skilled Nursing Facility (SNF) Analysis

0

50

100

150

200

250

300

350

Facility A Facility B Facility C Facility D Facility E Facility F Facility G Facility H Facility I Facility J Facility K Facility L

819

6

36

310

35

4 7 5

104

6

27

55

30

104

14

8

83

19 9

223

5

Readmitted Pateints Not Readmitted Patients

Note: *21 SNF’s with only 1 Patient*


How the Scoring Worked

Scenario: what it could have looked like to score under a 6.75



FY 2016 Final Rules


Expansion of Efficiency Measure

• Re-proposed expansion for future years

• Related metrics already in Hospital IQR

– AMI Payment, HF Payment, PN Payment

• Proposed 3 of original 4 related metrics already in Hospital

IQR for FY 2019 VBP

– Kidney/UTI, Cellulitis, & Gastrointestinal Hemorrhage


COPD Mortality

• COPD is the 3rd leading cause of death in the US and is one of

the top 20 conditions contributing to Medicare costs.

• Adopting within IQR so will be on Hospital Compare for 1 year

prior to the start of the performance period as required.

• Added to the 2021 Clinical Care Domain

• Performance period will be 7/1/16-6/30/19 and Baseline period

will 7/1/11-6/30/14 (same as other diagnoses for 2021

mortality)


VBP – Other Possible Metrics to Follow

• Emergency Department Care

• Preventative Care

– Pneumonia Vaccine

• Children’s Asthma Care

• Stroke Care

– Blood Clot Prevention Care

– Preventative Care


FY ‘19 New Measure

• Added THA/TKA for 30 month performance period.

– January 1, 2015-June 30, 2017

– Baseline of July 1, 2010-June 30, 2013

• Risk standardized measure for complications after Total

Hips and Knees surgeries for up to 90 days post surgery

– One of eight complications: AMI, pneumonia, sepsis, SSI, PE, death,

mechanical complication or periprosthetic joint infection/wound

infection.

– Each has a defined time frame

– Each is a ‘Yes’ or ‘No

– Risk adjusted for patient age, sex and comorbidities


Readmissions

• Readmission Reduction Program

– Final refinement to PN measure expansion

• Includes principle discharge of aspiration pneumonia

• Previously only viral or bacterial pneumonia

• Did not include originally proposed respiratory failure

– Two year study underway to determine if socio-

demographics alter performance and results to be reported

before Congress

– FY 2017 max penalty set at 3%


Readmissions – Proposed Future Measures

• Percutaneous Coronary Intervention (PCI)

• Stroke


HAC Summary

• Potential addition of three metrics to PSI-90 composite through the NQF

review process:

– Perioperative hemorrhage rate, Perioperative physiologic metabolic

derangement rate and Post-operative respiratory failure rates. Would engage in

additional rule-making if so.

• Finalization of time periods for FY 2017: Domain 1= 24 month period

ending 6/30/15 and Domain 2= CY 2014 and 2015. Weights are: Domain

1=15% and Domain 2= 85%

• Narrative on scoring if data is not reported and a waiver is not obtained- a

score of ‘10’ will be assigned.

• PROPOSED Refinements in measurements for CLABSI and CAUTI to

include Non-ICU locations starting in 2018 (CY 2015 and 2016

performance periods).

• Exception policy/waiver for hospitals that experience disasters or other

extraordinary circumstances.


Moving Forward with 67 MSAs; 8 MSAs

removed• Estimated 720 impacted CJR regional hospitals in 67 MSAs

• IPPS hospitals in the selected MSAs are required to participate in CJR.

• MSAs selected in 33 states.

• Only exceptions are:• BPCI Phase 2 LEJR

hospitals• Non-IPPS hospitals

• Maryland hospitals

Removed MSAMandated MSA

Moving Forward with 67 MSAs; 8 MSAs removed


Optimizing CJR – Requires New Areas of

Understanding

$0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000

Hospital Physician HHA SNF IRF

≈60% of spendingis outside of hospital

PAC Setting vitally important to manage- Discharge status- Picking PAC partners

Readmission often is over 2x the “spend” of non-readmitted patient

Ex. Target Price = $24kDRG 470, Spending by Setting

Readmit.

MACRA - MIPS or APM?

Medicare Access & CHIP Reauthorization (MACRA)

• MACRA:

– Ended the Sustainable Growth Rate (SGR) formula for determining Medicare Part B payments for health care providers’ services

– Establishes a new framework for rewarding health care providers for giving better care not more just more care (MIPS and APM)

– Sunsets existing programs – PQRS, VM, MU, eRX

– Provides consistent physician fee schedule increases (0.5% from 2015 through 2019)

– Establishes a technical advisory committee for assessing Physician Focused Payment Model (PFPM) proposals

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https://www.cms.gov/medicare/medicare-fee-for-service-payment/sustainablegratesconfact/downloads/sgr2015p.pdf

Quality Payment Program: MIPS or APM?Starting in 2019, all medical practices will fall into one of two categories under the Quality Payment Program established MACRA:

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MEASURE CATEGORIES

YEAR 1 (2019)

YEAR 2 (2020)

YEAR 3 (2021)

Quality (aka PQRS)

50% 45% 30%

Cost -Resource Use (aka VM)

10% 15% 30%

Advancing Care Information (aka MU)

25% 25% 25%

Clinical Practice Improvement Activities (CPIA)

15% 15% 15%

*THRESHOLDS2019 to

20202021 to

20222023 +

% of Payments 25% 50% 75%

% Patients 20% 35% 50%

No downside risk on Physician Fee Schedule if a significant portion of Medicare Revenue flows through an Advanced APM (Qualified Participant = QP):

Portion of practice Medicare Revenue at risk at the Tax Identification Number or individual level based on performance in these categories:

Proposed Models:• Comprehensive Primary Care Plus (CPC+)• MSSP Tracks 2 & 3• Next Generation ACO• Oncology Care Model Two-Sided Risk Arrangement

(OCM - available 2018)• Comprehensive ESRD Care (CEC) Model

* Awaiting final rule and partially qualifying APM status is available

Merit Incentive Based Program (MIPS) Advanced Alternative Payment Models (QP)

HHS may revise weights

Starting in 2021 - can include non Medicare Revenue/Patients


Thank You!

Contact Information:

Walter Coleman

[email protected]

(804) 474-1248

mailto:[email protected]

Documents

Mandatory Elements of Healthcare Reform