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Transcript of Barbara J. Connors, DO, MPH Chief Medical Officer, Region III The Centers for Medicare and Medicaid...
Barbara J. Connors, DO, MPH
Chief Medical Officer, Region III
The Centers for Medicare and Medicaid Services
Region III
Philadelphia Chapter ACS
CMS’ Value-Based PurchasingThe Nexus of Quality,
Coordination, & Efficiency
CMS’ Quality Improvement Roadmap
Vision: The right care for every person every time Make care:
Safe Effective Efficient Patient-centered Timely Equitable
CMS’ Quality Improvement Roadmap
Strategies Work through partnerships Measure quality and report comparative results Encourage adoption of effective health
information technology Promote innovation and the evidence base for
effective use of technology Value-Based Purchasing: Improve quality
and avoid unnecessary costs
Support for VBP
President’s Budget FYs 2006-09
Congressional Interest in P4P and Other Value-Based Purchasing Tools BIPA, MMA, DRA, TRCHA, MMSEA, MIPPA
MedPAC Reports to Congress P4P recommendations related to quality, efficiency, health
information technology, and payment reform IOM Reports
P4P recommendations in To Err Is Human and Crossing the Quality Chasm
Report, Rewarding Provider Performance: Aligning Incentives in Medicare
Private Sector Private health plans Employer coalitions
Why VBP?
Medicare Solvency and Beneficiary Impact Expenditures up from $219 billion in 2000 to a
projected $486 billion in 2009 Part A Trust Fund
Excess of expenditures over tax income in 2007 Projected to be depleted by 2019
Part B Trust Fund Expenditures increasing 11% per year over the last 6
years Medicare premiums, deductibles, and cost-sharing
are projected to consume 28% of the average beneficiaries’ Social Security check in 2010
Medicare Reimbursement Rates
Practice Variation
What Does VBP Mean to CMS?
Transforming Medicare from a passive payer to an active purchaser of higher quality, more efficient health care
Tools and initiatives for promoting better quality, while avoiding unnecessary costs
Tools: measurement, payment incentives, public reporting, conditions of participation, coverage policy, QIO program
Initiatives: pay for reporting, pay for performance, gainsharing, competitive bidding, bundled payment, coverage decisions, direct provider support
Value-Based Purchasing-What it is really about:
It is about defining/rewarding providers for the value of their
contribution to quality and efficient care that leads to better
health outcomes.
VBP: Payment Methodologies
• Pay for Reporting
• Pay for Participation
• Pay for Care Coordination
• Pay for Process
• Pay for Outcomes
VBP Programs
Physician Quality Reporting Initiative Physician Resource Use Reporting Hospital Quality Initiative: Inpatient &
Outpatient Pay for Reporting Hospital VBP Plan & Report to
Congress Hospital-Acquired Conditions & Present
on Admission Indicator Reporting
VBP
Towards Value-Based Purchasing
2007
•TRHCA
•74 measures
•Claims-based only
2008
•MMSEA
•119 measures
•Claims
•4 Measures Groups
•Registry
2009
•MIPPA
•153 measures
•Claims
•7 Measures Groups
•Registry
•EHR-testing
•eRx
2010
TBD through rule-making
Statutory Authority
• Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)– Section 131(d)
• Plan for Transition to Value-Based Purchasing Program for Physicians and Other Practitioners
• Report to Congress due May 1, 2010
Issues Paper Assumptions & Design Principles
PVBP Planning will:– Focus on performance-based payment– Accommodate different practice arrangements– Recognize the contributions of members of the health
professional team– Address multiple levels of accountability– Be at least budget neutral—across at least Medicare Parts A
and B—and will seek to identify program savings– Initially focus on traditional fee-for-service Medicare– Have short-term and longer-term timeframes, with attention
to transitions– Avoid creating additional health care disparities and work to
reduce existing disparities– Include an ongoing evaluation process
Stakeholder Input: Overarching Issues
• Affirmed goal and objectives• Advocated for new payment approaches that
cut across settings and align Part A and B payment incentives
• Agreed with the need to accommodate different practice arrangements
• Praised attention to disparities• Urged attention to operational transitions
Next Steps in Plan Development
• Receive direction from new leadership
• Design options– Physician Fee Schedule (PFS) overlay
• Performance-based PFS payments• Medical Home
– Levels of accountability beyond individuals• Groups• Accountable Care Entities
– Shared savings models– Bundled payment arrangements
• Simulations pending availability of resources
• Opportunities for stakeholder input– PFS 2010 rulemaking– Potential additional Listening Sessions
VBP and PQRI
Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
- Makes PQRI permanent; however only 2009 and 2010 incentives are funded - Increased 2009 PQRI incentive to 2% - Added new E-Prescribing incentive for
2009, an additional 2% subject to qualifying for the measure
PQRI
• PQRI reporting focuses attention on quality of care– Foundation is evidence-based measures developed by
professionals.– Reporting data for quality measurement is rewarded with
financial incentive.– Measurement enables improvements in care.– Reporting is the first step toward pay-for-performance.
• Measures address various aspects of quality care – Prevention– Chronic Care Management– Acute Episode of Care Management– Procedural Related Care– Resource Utilization– Care Coordination
2007 PQRI Reporting Participation Statistics
• 109, 349 NPI/TINs – Attempted to Submit• 101,138 NPI/TINs – Submitted a Quality Data
Code Successfully– A feedback report is available
• 70,207 NPI/TINS – Satisfactorily Reported 1 or more measures– A feedback report is available
• 56,722 NPI/TINs – Earned Incentive– A feedback report & incentive payment are available
2007 PQRI Experience Report
QDC Submission Attempts• 12.15% Missing NPI • 18.89% Incorrect HCPCS code* • 13.93% Incorrect DX code* • 7.24% Both incorrect HCPCS code and incorrect DX
code*• 4.97% All line items were QDCs only
*Denominator mismatch
Top Ten Most Frequently Reported Measures by Clinical Topic
1. Pneumonia 2. Chest Pain3. Perioperative Care4. Diabetes5. ECG for Syncope6. Coronary Artery Disease7. Myocardial Infarction8. Heart Failure9. Macular Degeneration10. Glaucoma
2009 PQRI Quality Measures
• 153 PQRI quality measures for 2009– Includes 101 measures from the 2008 PQRI and 52
new measures– E-prescribing measure (Measure #125) removed, as
required by MIPPA as a separate incentive program– 18 measures reportable only through registries– Measure specifications are available in the
Measures/Codes section of the website at http://www.cms.hhs.gov/pqri.
2009 PQRI Reporting Periods
• 1 reporting period for claims-based reporting of individual measures: January 1, 2009 – December 31, 2009
• 2 reporting periods for reporting measures groups and registry-based reporting:– January 1, 2009 – December 31, 2009– July 1, 2009 – December 31, 2009
PQRI Claims-Based Process
Visit Documented in the Medical Record
Encounter Form Coding & Billing
Carrier/MAC
NCH
Analysis Contractor National Claims History File
Incentive Payment
Confidential Report
CriticalStep
N-365
26
Benefits of PQRI Participation
• Receive confidential feedback reports to support quality improvement
• Earn a bonus incentive payment• Make an investment in the future of the
practice– Prepare for higher bonus incentives
over time– Prepare for pay-for-performance– Prepare for public reporting of
performance results
MIPPA AuthorizedE-Prescribing Incentives
YearIncentive for Successful
E-Prescribers
Reduction for Unsuccessful E-Prescribers
2009 2.0%
2010 2.0%
2011 1.0%
2012 1.0% -1.0%
2013 0.5% -1.5%
2014 -2.0%
ARRA Authorized Incentives for Meaningful Use of EHRs
Year First Payment Yr (Subsequent payment Yrs)
Reduction in Fees for Non-Use
2011 $18k ($12k, $8k, $4k, $2k)
2012 $18k ($12k, $8k, $4k, $2k)
2013 $15k ($12k, $8k, $4k)
2014 $12k ($8k, $4k)
2015 -1%
2016 -2%
2017 -3%
Summary of MIPPA and ARRA Authorized Incentive Programs
YearMIPPA Authorized Incentive for Successful E-Prescribers
ARRA Authorized Incentive for Meaningful Use of EHR
20092010
2% IncentiveN/A
2011 1% Incentive $18k ($12k, $8k, $4k, $2k)
2012 1% Incentive $18k ($12k, $8k, $4k, $2k)
20130.5% Incentive1.5% Reduction
$15k ($12k, $8k, $4k)
2014No Incentive
2% Reduction
$12k ($8k, $4k)
2015 N/A 1% Reduction
2016 N/A 2% Reduction
2017 N/A 3% Reduction
Premier Hospital Quality Incentive Demonstration
Surgical Care Improvement Project /Surgical Infection
Prevention (SCIP)FY 2009
SCIP-Inf-1 Prophylactic antibiotic received within 1 hour prior to surgical incision
SCIP-Inf-3 Prophylactic antibiotics discontinued within 24 hours after surgery end time
SCIP-VTE 1: prophylaxis ordered for surgical ptSCIP-VTE 2: prophylaxis within 24 hr
pre/post
SCIP (Previously SIP)
SCIP Infection 2: Prophylactic Antibiotic selection for surgical pt
SCIP Infection 4: Cardiac surgical pts with Controlled 6am post op serum glucose
SCIP Infection 6 Surgery pts with appropriate hair removal
AHRQ PSIs and IQI’s
Patient Safety Indicators (PSIs)• Death among surgical pts with serious treatable
conditions• Post-op wound dehiscence
Inpatient Quality Indicators (IQIs)• AAA Mortality rate (with or without volume)• Hip fracture mortality rate• Mortality rate for selected surgical procedures• Participation in a systematic database for cardiac
surgery
ACS NSQIP
– Surgeons and centers require high quality, reliable & timely data to identify opportunities for improvement and to protect themselves from data being misinterpreted to and by the public
– Increasing public demand for “accountability” in healthcare– Eroding public trust in clinicians to provide safe care– Efforts by payors and purchasers to “drive” patients to
centers with safer systems – Evolving move by payors to “pay for performance”– Without risk-adjusted data, surgeons and medical centers
have had to use administrative (i.e., payor) data– Surgeons and medical centers find themselves profiled on
the Internet
ASC NSQIP
• The ACS NSQIP involves the collection of preoperative risk factors, intraoperative variables, and postoperative outcomes by a surgical clinical nurse reviewer (SCNR) at each participating medical center
DEMOGRAPHICS 9 variables
SURGICAL PROFILE 9 variables
PRE-OPERATIVE DATA 40 clinical variables13 laboratory variables
INTRA-OPERATIVE DATA18 clinical variables 3 occurrence variables
POST-OPERATIVE DATA20 occurrence variables12 laboratory variables 9 discharge variables
What to do with the Data
• Reduce postoperative mortality rates
• Reduce postoperative morbidity rates
• Reduce the median length-of-stay
• Leverage data for other internal and public reporting initiatives
• Meet CMS Surgical Care Improvement Program (SCIP) reporting requirements by collecting SCIP data through the ACS NSQIP SCIP data collection module
• Potentially allow for higher reimbursement in the emerging “pay for performance” environment
• Help to increase patient satisfaction
• Serve as a foundation and resource for research initiatives
• Help to identify possible under-billings
• Help to increase negotiating leverage with third-party payers and employers
– Inform and improve surgical rounds• Regular reporting of ACS NSQIP data in conjunction with
specific case discussion. Movement toward understanding and analyzing trends of occurrences v. singular events
– Identify quality improvement opportunities• Identification of quality improvement opportunities by Depts. of
Surgery Proactive v. Reactive
– Benchmark performance against peers– Re-engineer or eliminate retrospective clinical databases
historically used for quality assurance or JCAHO reporting– Discuss opportunities to use data in payor negotiations, “pay
for performance”– Conduct research– Review billing practices– Analyze systems of care
Use the Data
ACS NSQIP Eligible Specialties
General SurgeryVascular Surgery UrologyNeurosurgeryOrthopedicsENTPlastic SurgeryThoracicCardiacGynecological surgery
Demonstration Projects
• CMS currently pays for quality through a series of Demonstration Projects
• Several Demonstrations are mandated through Congressional Legislation
• Must be budget neutral
VBP Demonstrations and Pilots
• Physician Group Practice Demonstration• Medicare Care Management Performance
Demonstration• Medicare Medical Home Demonstration• Medicare Healthcare Quality • Gainsharing Demonstrations• Accountable Care Episode (ACE)
Demonstration
Demonstration Purpose
• Test the development and implementation Test the development and implementation of Medicare policy changes prior to of Medicare policy changes prior to legislation enacting such changes on a legislation enacting such changes on a national basisnational basis– Whether it works…Whether it works…– What refinements…What refinements…
• Generally look at payment, new benefit, Generally look at payment, new benefit, new organization of care deliverynew organization of care delivery
Acute Care Episode (ACE) Acute Care Episode (ACE) DemonstrationDemonstration
Problems with Current System
• Increased number of services not necessarily correlated with better care
• Conflicting provider incentives– Hospitals paid per discharge– Physicians paid per service
Global Payment
• Fee-for-service
• Part A and Part B
• Services related to acute care episode only
• Cardiovascular and/or orthopedic procedures
Sites Selected
• Hillcrest Medical Center – Tulsa• Baptist Health System – San Antonio• Oklahoma Heart Hospital – Oklahoma City• Lovelace Health System – Albuquerque• Exempla Saint Joseph Hospital – Denver
• Two are cardiovascular only• One is orthopedic only• Two are both cardiovascular and orthopedic
Determination of Payment Rates
• Based on competitive bids from sites• Compared to regular average
Medicare payments to the hospitals and physicians
• Evaluated based upon the size of the discount
• Subject to annual IPPS updates
Gainsharing Demonstrations
• Authority– Deficit Reduction Act (DRA) Section 5007– Medicare Modernization Act (MMA) Section 646– In the absence of statutory authority, gainsharing is
restricted by law• Purpose
– To allow hospitals to provide gainsharing payments designed to improve quality and efficiency of care to physicians
• Timing– 3-year projects
• Target– Hospitals and physicians
• Compensation– Hospitals may share savings with physicians
Hospital and Physician Alignment of Incentives
• Medicare pays hospitals prospectively for bundles of services using DRGs
• Physicians generally paid per service
• How to align incentives to improve quality and efficiency?
• Encourage physician-hospital collaboration by permitting hospitals to share internal savings
Gainsharing Payments
• Incentive system must be uniform across physicians, can be reviewed and audited.
• Payments must be linked to quality and efficiency
• Gainsharing must be a transparent • Must represent share of internal hospital
savings and be tied to quality improvement• Limited to 25% of physician fees for care of
patients affected by quality improvement activity
Demo Comparison
Design Feature DRA Section 5007 MMA Section 646
Size 2 hospitals
Beth Israel, NY
CAMC, WV
Physician groups and up to 13 affiliated hospitals in limited number of geographic areas. NJ 12 and WV 1
Scope of Evaluation Inpatient episodes and post-discharge window (e.g., 30 days)
Inpatient episodes including pre- and post-hospital care over duration of demonstration
Eligible Organizations
PPS hospitals, excludes CAHs Physician groups and affiliated hospitals, integrated delivery systems
Efficiency in the Quality Context
Efficiency Is One of the Institute of Medicine's Key Dimensions of Quality
1. Safety
2. Effectiveness
3. Patient-Centeredness
4. Timeliness
5. Efficiency: absence of waste, overuse, misuse, and errors
6. Equity
• Institute of Medicine: Crossing the Quality Chasm:
A New Health System for the 21st Century, March, 2001.
Physician Resource Use ReportsPilot
Statutory Authority
Medicare Improvement for Patients and Providers Act of 2008, Section 131(c) The Secretary shall establish a Physician
Feedback Program under which the Secretary shall use claims data (and may use other data) to provide confidential reports to physicians (and, as determined appropriate by the Secretary, to groups of physicians) that measure the resources involved in furnishing care. The Secretary may include information on the quality of care furnished by the physician (or group of physicians) in such reports.
Physician Resource Use Measurement
Goals
Construct resource use measures that are meaningful, actionable, and fair
Provide confidential reports of resource use to individual/groups of physicians
Compare actual use to expected resource use
Link resource use to measures of quality and patient experiences of care
Statutory AuthorityMIPPA Section 131(c)
MIPPA Options: Resource use can be measured on an episode or per capita
basis, or both
Resource use can be measured with claims or through other data sources
Focus can be on selected physicians by: specialty, conditions treated, geography, high cost outliers, minimum # of cases
CMS can make adjustments to resource use measures to render them comparable across physicians
Resource use measures can apply to individual physicians or physician groups
Prepare claims data, includingStandardize unit prices
Group claims into episodes of care;Sum costs of all claims in an episode
Risk-adjust the cost of each episode
Attribute each episode and associated episode cost to one or more physicians
Calculate physician’s average cost for all attributed episodes
Compare physician’s average cost to peer group benchmark (including drill downs)
Produce, test, and distribute RURs
1
2
3
4
5
6
7
Creating Resource Use Reports
Hospital VBP
Deficit Reduction Act (DRA) Section 5001(b) authorized CMS to develop a Medicare Hospital VBP Plan IPPS hospitals FY 2009 start date Must consider
Measures Data infrastructure and validation Incentive structure Public reporting
Must consult stakeholders and consider experience with relevant demonstrations and private-sector programs
Value-Based Purchasing and Hospital-Acquired Conditions
• The Hospital-Acquired Conditions provision is a step toward Medicare VBP for hospitals
• Strong public support for CMS to pay less for conditions that are acquired during a hospital stay
• Considerable national press coverage of HAC has prompted dialogue of how to further eliminate healthcare-associated infections and conditions
Statutory Authority: DRA Section 5001(c)
Beginning October 1, 2007, hospitals were required to submit data on their claims for payment indicating whether diagnoses were present on admission (POA)
Beginning October 1, 2008, CMS cannot assign a case to a higher DRG based on the occurrence of one of the selected conditions, if that condition was acquired during the hospitalization
This provision does not apply to Critical Access Hospitals, Rehabilitation Hospitals, Psychiatric Hospitals, or any other facility not paid under the Medicare Hospital IPPS
Statutory Selection Criteria
CMS must select conditions that are
1. High cost, high volume, or both
2. Assigned to a higher paying DRG when present as a secondary diagnosis
3. Reasonably preventable through the application of evidence-based guidelines
Present on Admission
Present on admission (POA) is defined as present at the time the order for inpatient admission occurs– Conditions that develop during an outpatient encounter,
including emergency department, observation, or outpatient surgery, are considered POA
POA indicator is assigned to – Principal diagnosis– Secondary diagnoses – External cause of injury codes (Medicare requires
reporting only if E-code is reported as an additional diagnosis)
POA Indicator Reporting Options
Code Reason for Code
Y Diagnosis was present at time of inpatient admission.
N Diagnosis was not present at time of inpatient admission.
U Documentation insufficient to determine if condition waspresent at the time of inpatient admission.
W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission.
1 Unreported/Not used. Exempt from POA reporting. This code is equivalent code of a blank on the UB-04; however, it was determined that blanks are undesirable when submitting this data via the 4010A.
“ A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.”
Selected HACs for Implementation
1. Foreign object retained after surgery2. Air embolism3. Blood incompatibility4. Pressure ulcers
– Stages III & IV
5. Falls– Fracture– Dislocation– Intracranial injury– Crushing injury– Burn– Electric shock
Selected HACs for Implementation
6. Manifestations of poor glycemic control– Hypoglycemic coma– Diabetic ketoacidosis– Nonketotic hyperosmolar coma– Secondary diabetes with ketoacidosis– Secondary diabetes with hyperosmolarity
7. Catheter-associated urinary tract infection
8. Vascular catheter-associated infection
9. Deep vein thrombosis (DVT)/pulmonary embolism (PE)– Total knee replacement– Hip replacement
Selected HACs for Implementation
10. Surgical site infection– Mediastinitis after coronary artery bypass graft (CABG)– Certain orthopedic procedures
• Spine
• Neck
• Shoulder
• Elbow
– Bariatric surgery for obesity• Laprascopic gastric bypass
• Gastroenterostomy
• Laparoscopic gastric restrictive surgery
Selected HAC
Medicare Data(FY 2007)
CC/MCC (ICD-9-CM
Codes)
Selected Evidence‑Based Guidelines
Vascular Catheter-Associated Infection
● 29,536 cases
● $103,027/hospital stay
999.31 (CC) Available at the Web
site:
http://www.cdc.gov/nc
idod/dhqp/gl_intravas
cular.html
Surgical Site
Infection-
Mediastinitis
after Coronary
Artery Bypass
Graft (CABG)
● 69 cases
● $299,237/hospital stay
519.2 (MCC)
And one of the
following
procedure
codes:
36.10–36.19
Available at the Web site:
http://www.cdc.gov/nc
idod/dhqp/gl_surgical
site.html
Selected HAC
Medicare Data(FY 2007)
CC/MCC (ICD-9-CM
Codes)
Selected Evidence‑Based Guidelines
Catheter- Associated Urinary Tract Infection (UTI)
● 12,185 cases
● $44,043/hospital stay
996.64 (CC)Also excludes
the following from acting as a CC/MCC:
112.2 (CC)590.10 (CC)
590.11 (MCC)590.2 (MCC)
590.3 (CC)590.80 (CC)590.81 (CC)595.0 (CC)597.0 (CC)599.0 (CC)
http://www.cdc.gov/ncidod/dhqp/gl_catheteassoc.html
Selected HAC Medicare Data(FY 2007)
CC/MCC (ICD-9-CM
Codes)
Selected Evidence‑Based Guidelines
Stage III & IV Pressure Ulcers
● 257,412 cases
● $43,180/hospital stay
707.23 (MCC)707.24 (MCC)
NQF Serious Reportable Adverse
Eventhttp://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.4409
Falls and
Trauma:
- Fractures
- Dislocations
- Intracranial Injuries
- Crushing Injuries
- Burns
● 193,566 cases
● $33,894/hospital stay
CC/MCC codes
within these
ranges:
800-829
830-839
850-854
925-929
940-949
991-994
NQF Serious Reportable Adverse
Eventhttp://www.ahrq.gov/qual/nqfpract.htm
Selected HAC
Medicare Data(FY 2007)
CC/MCC (ICD-9-CM
Codes)
Selected Evidence‑Based Guidelines
Foreign Object Retained After Surgery
● 750 cases● $63,631/hospital
stay
998.4 (CC)998.7 (CC)
NQF Serious Reportable Adverse
Eventhttp://www.ahrq.gov/qual/nqfpract.htm
Air Embolism ● 57 cases● $71,636/hospital
stay
999.1 (MCC) NQF Serious Reportable Adverse
Eventhttp://www.ahrq.gov/qual/nqfpract.htm
Blood Incompatibility
● 24 cases● $50,455/hospital
stay
999.6 (CC) NQF Serious Reportable Adverse
Eventhttp://www.ahrq.gov/qual/nqfpract.htm
Candidate HACs
• Fiscal Year 2009 Inpatient Prospective Payment System (IPPS) final rule
http://edocket.access.gpo.gov/2008/pdf/E8-17914.pdf
(page 39)
Candidate HACs
1. Surgical site infection following device procedures
2. Failure to rescue
3. Death or disability associated with drugs, devices, or biologics
4. Dehydration
5. Malnutrition
Candidate HACs
6. Water-borne pathogens
7. Surgical site infections following procedures – orthopedic and other
8. Ventilator-associated pneumonia
9. Clostridium difficile-associated disease
HAC Candidate
Medicare Data(FY 2007)
CC/MCC(ICD-9-CM
Codes)
Selected Evidence-Based
Guidelines
Surgical Site Infections Following Elective Procedures: - Total Knee
Replacement - Laparoscopic Gastric Bypass and Gastroenter-
ostomy - Ligation and Stripping of Varicose Veins
Total Knee Replacement● 539 cases● $63,135/hospital
stayLaparoscopicGastric Bypass and Gastroenterostomy● 208 cases● $180,142/hospital
stayLigation and Stripping of Varicose Veins● 3 cases● $66,355/hospital
stay
Total Knee Replacement (81.54):
996.66 (CC) and
998.59 (CC)Laparoscopic Gastric Bypass (44.38)and Gastroenter-ostomy (44.39):
998.59 (CC)Varicose Veins(38.5):
998.59 (CC)
http://www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html
http://www.cdc.gov/ncidod/dhqp/glisolation.html
HAC Candidate
Medicare Data(FY 2007)
CC/MCC(ICD-9-CM
Codes)
Selected Evidence-
Based Guidelines
Legionnaires’ Disease
● 351 cases
● $86,014/hospital stay
482.84 (MCC) http://www.cdc.gov/ncidod/dbmd/diseaseinfo/legionellosis_g.htm
http://www.legionella.org/
Iatrogenic Pneumothorax
● 22,665 cases
● $75,089/hospital stay
512.1 (CC) http://www.ncbi.nlm.nih.gov/pubmed/1485006
Delirium ● 480 cases
● $23,290/hospital stay
293.1 (CC) http://www.ahrq.gov/clinic/ptsafety/chap28.htm
HAC Candidate
Medicare Data(FY 2007)
CC/MCC(ICD-9-CM
Codes)
Selected Evidence-
Based Guidelines
Glycemic
Control:
- Diabetic
Ketoacidosis
- Nonketotic
Hyperosmolar
Coma
- Diabetic coma
- Hypoglycemic
Coma
Diabetic
Ketoacidosis
● 11,469 cases
● $42,974/hospital stay
Nonketotic
Hyperosmolar Coma
● 3,248 cases
● $35,215/hospital stay
Diabetic Coma
● 1,131 cases
● $45,989/hospital stay
Hypoglycemic Coma
● 212 cases
● $36,581/hospital stay
DiabeticKetoacidosis:
250.10–250.13 (CC)
Nonketotic HyperosmolaComa:
250.20–250.23 (CC)
Diabetic coma:250.3 -250.33
(CC)Hypoglycemic Coma:
251.0 (CC)
NQF Serious
Reportable
Adverse Events
address
hypoglycemia
http://www.diabet
es.org/uedocume
nts/InpatientDMG
lycemicControlPo
sitionStmt02.01.0
6.REV.pdf
HAC Candidate
Medicare Data(FY 2007)
CC/MCC(ICD-9-CM
Codes)
Selected Evidence-
Based Guidelines
Ventilator-Associated Pneumonia (VAP)
● 30,867 cases
● $135,795/hospital stay
997.31 (CC)
Must also include
ventilator codes:
96.70 – 96.72
http://www.rcjournal.com/cpgs/09.03.0869.html
Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
● 149,010 cases
● $50,937/hospital stay
453.40 – 453.42(CC)
415.11 (MCC) 415.19 (MCC)
http://www.chestjournal.org/cgi/reprint/126/3_suppl/172S
http://orthoinfo.aaos.org/topic.cfm?topic=A00219
HAC Candidate
Medicare Data(FY 2007)
CC/MCC(ICD-9-CM
Codes)
Selected Evidence-
Based Guidelines
Staphylococcus AureusSepticemia
● 27,737 cases
● $84,976/hospital stay
038.11(MCC)995.91 (MCC)995.92 (MCC)
998.59 (CC)999.3 (CC)
http://www.cdc.gov/ncidod/dhqp/gl_isolation.html
http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html
Clostridium Difficile Associated Disease (CDAD)
● 96,336 cases
● $59,153/hospital stay
008.45 (CC) http://www.cdc.gov/ncidod/dhqp/gl_isolation.html
http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html#9
Proposed 2010 IPPS Rule
http://federalregister.gov/OFRUpload/OFRData/2009-10458_PI.pdf
Guidelines for Preventing HACs
• Where are guidelines developed– Professional organizations, Task Forces,
Government agencies, academic institutions
• What are they– Recommendations for interventions based
scientific evidence or expert opinion
• Who develops and uses them– Scientists, clinicians– Policy makers, consumers
Future Considerations
• Risk adjustment– Individual and population level
• Rates of HACs for VBP– Appropriate for some HACs
• Uses of POA information– Public reporting
• Adoption of ICD-10– Example: 125 codes capturing size, depth, and location of
pressure ulcer • Expansion of the IPPS HAC payment provision to
other settings– Discussion in the IRF, OPPS/ASC, SNF, LTCH
regulations
Never Events
• Wrong surgery performed on a patient
• Surgery performed on wrong body part
• Surgery performed on the wrong patient
http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=223
Resources Available
Physician Quality Reporting Initiative:https://www.cms.hhs.gov/pqri
CMS Quality Initiatives – General Information:http://www.cms.hhs.gov/QualityInitiativesGenInfo/
12/9/08 Issues Paper: Development of a Plan to Transition to a Medicare Value-Based Purchasing Program for Physician and Other Professional Services
http://www.cms.hhs.gov/center/physician.asp
Hospital Quality Reporting:www.hospitalcompare.hhs.gov
Demonstrations:http://www.cms.hhs.gov/DemoProjectsEvalRpts/