Quality Reporting: Why IT Matters

September 25, 2012

Presenter:Kimberly Rask, MD PhDMedical Director

Driving Improvement► CMS contracts with QIOs

to improve health and health care for Medicare beneficiaries

► Largest federal network dedicated to improving health quality at the community level

► QIOs based in all 50 states

BETTER CARE

AFFORDABLE CARE

BETTER HEALTH FOR POPULATIONS

Joint Letter of Cooperation

It’s not just about the numbers

2011 Senior Softball World Championships in Phoenix, Arizona

5 for 5 in playoff game► 2 doubles ► and a triple!

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

Hospitals Paid to Report Quality Data

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 HACs No payment unless condition noted

on admission

Program Data Financial impact

Annual Payment Update

Inpatient Quality Reporting- core measures

2%

Outpatient Quality Reporting- core measures

2%

“Pay for Reporting” ProgramsParticipation is “voluntary” and hospitals are not required to participate.

► Those who choose NOT to participate will receive a reduction of 2 percent for each program in their Medicare Annual Payment Update for the following CMS fiscal year (FY)

What data is collected?► 2004: Hospitals voluntarily report 10 measures and agree to

have the data reported publicly to receive an incentive payment (Annual Payment Update)

► 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► 2009: Added readmission rates► 2011: Added hospital acquired infection rates► 2012: Composite patient safety measure► 2013: Elective deliveries

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

Processes of Care

Mortality Rates

Patient Satisfaction

Emergency Department (ED) Measures

Measure Set ID# Performance Measure Name

ED - 1a Median Time from ED Arrival to ED Departure for Admitted ED Patients – Overall Rate

ED - 1b Median Time from ED Arrival to ED Departure for Admitted ED Patients – Reporting Measure

ED - 1c Median Time from ED Arrival to ED Departure for Admitted ED Patients – Observation Patients

ED - 1d Median Time from ED Arrival to ED Departure for Admitted ED Patients – Psychiatric/Mental Health Patients

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)

Pay for Performance

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)

No payment unless condition noted on admission

Program Data Financial impact

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

Value-based Purchasing► Moving from Pay for Reporting to Pay for

Performance► Authorized under the Affordable Care Act► Funded by a 1 percent 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 threshold rates to receive any points

► Benchmark rates to receive full points

Incentive or Penalty?► 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 – Projected that 2 percent of hospitals will earn

bonus of more than 0.5 percent – While 2 percent will lose more than 0.5

percent► 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

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)

No payment unless condition noted on admission

Program Data Financial impact

Readmissions Reduction Program

Excess readmission rate

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

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

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

Excess Readmission Ratio► The ratio compares

Actual 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

Applying the Penalty

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

► Not revenue neutral, no bonus for excellent performance

► For FY 2013, maximum penalty is 1 percent– Impacting more than 2000 hospitals nationally– Expected to cost hospitals $280 million or 0.3

percent of the total Medicare revenue to hospitals► Excess Standardized Readmission Ratio (SRR) will

be public

Impact of Reporting on Bottom Line

Program Data Financial impact

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 HACs No payment unless condition noted

on admission

Program Data Financial impact

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 Definition Changing► Most individual HACs have been removed from public

reporting► Section 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► Section 3008 creates payment reduction 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 percent of the amount that would otherwise apply to such discharges

IT Capabilities are Critical!► Managing and organizing a growing

body of clinical quality information (data)– Coordination with HITECH– Evaluating measures with electronic

specifications– Anticipate EHR direct reporting by FY 2015

► From documentation to usable information – forms/screens that allow queries

► Real-time data capabilities

It’s not just about “the numbers”► You can impact

patient outcomes► Patients hold us

accountable and “the numbers” are critical to document good work!

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-12-226