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