Transcript Powerpoint

Hospital P4P: The CMS/Premier
Hospital Quality Incentive
Demonstration Project
March 10, 2009
Mary B. Bergerson
Regional Quality Director
St. Helena Hospital
1
Nationwide knowledge to improve local healthcare
2,000 Hospitals gain the advantages of national scale by
uniting through the Premier healthcare alliance
2
Value-based Purchasing timeline
Institute of
Medicine
(IOM)
Report
To Err is
Human
Medicare Modernization Act
ties hospital market basket
updates to quality reporting
Hospital
Compare
launched
Premier
Hospital
Quality
Incentive
Demo
launched
1990’s
3
Grassley-Baucus
(S.1356) valuebased purchasing
legislation
introduced
2002
MedPAC
Report
supports
use of VBP
2003
2004
2005
Deficit
Reduction
Act
mandates a
Report to
Congress on
the Plan to
Implement a
Medicare
Hospital VBP
Program
CMS
Report to
Congress
on VBP
IOM
Report on
Aligning
Hospital
incentives
2006
2007
2007
Senate
Finance
Committee
Roundtable
on VBP
2008
2009
CMS/Premier
Hospital Quality Incentive Demonstration
4
•
CMS and Premier partnership project
•
First national Pay-for-Performance (P4P) demonstration
•
Tests the hypothesis that financial incentives and public recognition can
increase quality of care
•
A three-year effort launched October, 2003
•
Approximately 260 hospitals in 38 states
Rewarding delivery of widely accepted
evidence-based clinical indicators
Acute myocardial infarction (AMI)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Aspirin at arrival
Aspirin prescribed at discharge
ACEI/ARB for LVSD
Smoking cessation advice/counseling
Beta blocker prescribed at discharge
Beta blocker at arrival
Thrombolytic received within 30 minutes of hospital arrival
PCI received within 90 minutes of hospital arrival
Inpatient mortality rate
Coronary artery bypass graft (CABG)
1.
2.
3.
4.
5.
6.
7.
8.
Aspirin prescribed at discharge
CABG using internal mammary artery (Test)
Prophylactic antibiotic received within one hour prior to surgical incision
Prophylactic antibiotic selection for surgical patients
Prophylactic antibiotics discontinued within 24/48 hours after surgery end
time
Inpatient mortality rate
Post operative hemorrhage or hematoma
Post operative physiologic and metabolic derangement
Heart failure (HF)
1.
2.
3.
4.
5
Left Ventricular Systolic (LVS) assessment
Detailed discharge instructions
ACEI or ARB for LVSD
Smoking cessation advice/counseling
Pneumonia (PN)
1. Percentage of patients who received an oxygenation assessment
within 24 hours prior to or after hospital arrival
2. Initial antibiotic selection for Community Acquired Pneumonia
3. Blood culture collected prior to first antibiotic administration
4. Influenza screening/vaccination
5. Pneumococcal screening/vaccination
6. Antibiotic timing, percentage of pneumonia patients who received
first dose of antibiotics within four hours after hospital arrival
7. Smoking cessation advice/counseling
Hip and knee replacement
1. Prophylactic antibiotic received within one hour prior to surgical
incision
2. Prophylactic antibiotic selection for surgical patients
3. Prophylactic antibiotics discontinued within 24 hours after surgery
end time
4. Post operative hemorrhage or hematoma
5. Post operative physiologic and metabolic derangement
6. Readmission within 30 days to any acute care facility
Surgical
Italics = outcomes measure
Dramatic and Sustained Improvement
CMS HQID Composite Quality Score
Avg. improvement
across all 5 clinical
areas for median CQS
(19 quarters)
18.66%
Heart Failure
Hip & Knee
31.4%
13.0%
65%
98%
97.9%
98.0%
98.1%
97.4%
97.46%
98.16%
92.3%
94.11%
95.27%
85.1%
86.7%
88.7%
90.9%
91.6%
93.4%
95.2%
95.92%
96.6%
97.1%
97.8%
97.9%
90%
91.6%
93.2%
93.4%
94.2%
94.90%
95.38%
92%
92.4%
93.5%
93.4%
94.2%
94.85%
95.90%
98%
97.7%
97.8%
98.4%
98.5%
99.01%
99.19%
97%
97.0%
97.6%
97.5%
98.3%
98.27%
98.54%
70%
73.1%
76.1%
78.2%
81.6%
83.0%
84.38%
86.7%
88.8%
90.0%
89.9%
25.9%
75%
68.1%
Pneumonia
80%
64.0%
14.1%
85%
78.1%
80.0%
82.5%
82.7%
84.8%
86.30%
88.5%
89.3%
90.1%
91.4%
CABG
90%
70.0%
73.1%
8.9%
95%
89.6%
90.0%
91.5%
92.5%
93.5%
93.4%
95.1%
95.77%
96.0%
96.1%
96.8%
96.8%
(percentage points)
100%
85.1%
85.9%
89.4%
90.6%
93.7%
94.9%
96.2%
97.01%
96.8%
98.3%
98.4%
98.4%
AMI
Improvement
October 1, 2003 - June 30, 2008 (Years 1, 2, & 3 Final Data; Years 4 and 5 Preliminary Data)
HQID Composite Quality Score
Clinical
Area
CMS/Premier HQID Project Participants Composite Quality Score:
Trend of Quarterly Median (5th Decile) by Clinical Focus Area
60%
55%
AMI
CABG
Pneumonia
Heart Failure
Hip and Knee
SCIP
Clinical Focus Area
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4Q03
1Q04
1Q08
2Q08
2Q04
3Q04
4Q04
1Q05
2Q05
3Q05
4Q05
1Q06
2Q06
3Q06
4Q06
1Q07
2Q07
3Q07
4Q07
More Patients are
Receiving Every quality measure
Evidence-based Care Improvements
Avg. improvement from
4Q03 to 2Q08 in all
clinical areas
(19 quarters)
55.05%
CMS/Premier HQID Project Participants Appropriate Care Score:
Trend of Quarterly Median (5th Decile) by Clinical Focus Area
October 1, 2003 - June 30, 2008 (Year 1, 2, and 3 Final Data; Year 4 and 5 Preliminary)
Heart Failure
54.9%
20%
10%
86.9%
89.3%
92.9%
76.7%
84.0%
84.0%
53.6%
63.6%
72.1%
78.6%
81.3%
85.7%
85.9%
89.5%
87.1%
90.0%
86.4%
86.2%
87.0%
85.5%
87.9%
89.7%
82.6%
82.8%
87.0%
87.0%
77.1%
82.7%
87.4%
70.3%
93.5%
93.8%
94.4%
30%
27.8%
34.1%
41.2%
65.1%
40%
34.7%
43.6%
50.0%
53.8%
58.5%
62.6%
64.6%
68.0%
72.3%
75.8%
78.1%
78.3%
79.2%
82.5%
85.2%
86.0%
Pneumonia
50%
22.3%
28.0%
34.7%
39.0%
43.8%
44.3%
50.7%
53.8%
60.9%
62.8%
67.6%
66.5%
60%
45.8%
48.7%
23.7%
CABG
Hip & Knee
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(percentage points)
70%
30.0%
34.1%
AMI
Improvement
Appropriate Care Score
Clinical
Area
68.5%
77.3%
82.9%
84.2%
86.6%
91.9%
93.3%
91.7%
91.7%
93.3%
94.1%
95.5%
80%
70.7%
72.7%
75.7%
80.0%
80.9%
80.6%
85.0%
87.0%
87.8%
88.2%
89.6%
88.6%
90.0%
90.0%
92.1%
92.8%
90%
92.7%
96.0%
96.5%
100%
0%
AMI
CABG
PN
HF
Hip and Knee
SCIP
Clinical Focus Area
65.1%
4Q03
1Q04
1Q08
2Q08
2Q04
3Q04
4Q04
1Q05
2Q05
3Q05
4Q05
1Q06
2Q06
3Q06
4Q06
1Q07
2Q07
3Q07
4Q07
Substantial Improvement by Lower Performers
Percentage of Hospital Clinical Focus Groups in "Penalty Box"
Preliminary HQID Year 4 Results
Updated 2-4-09
3.0%
Percentage
2.5%
Percentage of Hospital Clinical Focus Groups in
"Penalty Box"
HQID Final Data Years 1-3
25%
2.0%
1.6%
1.4%
1.5%
1.1%
0.8%
1.0%
0.5%
20%
0.0%
Q4-06
15%
Q1-07
Q2-07
Q3-07
Yr4 Prelim
Quarter
11%
10%
8%
5%
5%
5%
3%
0%
Year 1
Base
Year 2
Q1
Year 2
Q2
Year 2
Q3
Year 2 Year 3
Q4
Q1
Quarter
2%
Year 3
Q2
1%
Year 3
Q3
Percentage of Hospital Clinical Focus Groups in "Penalty Box"
Preliminary HQID Year 5 Results
Updated 2-4-09
<1%
Year 3
Q4
5.0%
Percentage
Percentage
20%
2.4%
4.4%
4.0%
3.3%
3.0%
3.0%
2.0%
1.0%
0.0%
Q4-07
Q1-08
Q2-08
Quarter
8
Q3-08
In Broader Comparison, HQID Hospitals
Excel
National Leaders in Quality Performance
HQID hospitals have higher quality ratings than national hospitals overall
• HQID participants avg. 6.8%
higher than Non-Participants
• Avg. improvement for HQID
participants = 9.7%
• Avg. improvement for Nonparticipants = 7.4%
 New England Journal of
Medicine publication by
Lindenauer et al. (February
2007) found that hospitals
engaged in P4P achieved
quality scores 2.6 to 4.1
percentage points above
other hospitals due solely to
the impact of P4P incentives.
A composite of 19 measures shared in common between HQID and Hospital
Compare shows P4P hospitals performing above the nation as a whole
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• Established in 1878, St. Helena serves
a five county region and 200,000
residents in largely rural northern CA
• 158 inpatient beds treating 75,000
inpatient & outpatient visits annually
• Medical staff of 125 with 920 total employees
• 63% revenue from Medicare and Medicaid
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Continuous Improvement in Composite Quality
Scores
Continuous improvement from Year 1 to Year 5 Year to Date (YTD) HQID data for
the Composite Quality Score (CQS), a combination of clinical quality measures
and outcome measures.
St Helena Hospital
Trend of Quarterly HQID Composite Quality Scores by Clinical Focus Area
October 1, 2003 - June 30, 2008 (Year 1-3 Final Data; Year 4 & 5 Preliminary Data)
▲ = HQID Top 20% Threshold Value; ● = HQID Median
100%
95%
90%
Composite Quality Score
85%
80%
75%
70%
65%
60%
55%
50%
AMI
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Heart Failure
Pneumonia
CABG
Hip/Knee
Consistent Top Performer
• Top Performer in Heart Failure for Years 1 and 2
• Top Performer in AMI in Years 2 and 3
– Tracking for Top Performer in Years 4 and 5
• Top Performer in Hip/Knee Replacement for Year 3
– Tracking for Top Performer in Year 4
• Tracking Top Performer in CABG for Year 5
• Significant improvement in Pneumonia
– 65% in Year 1 to 94% Year 4
– Tracking for Top Improver Award in Years 4 and 5
• Tracking to receive Attainment Award for all clinical areas
in Year 4 and all except Hip/Knee Replacement for Year 5
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More Patients are Reliably Receiving Evidencedbased Care
The appropriate care score (ACS), also referred to as “perfect process or “all or
nothing” to designate when a patient receives all possible care measures within a
clinical area, showed improvement across time.
St Helena Hospital
Trend of Quarterly HQID Appropriate Care Scores by Clinical Focus Area
October 1, 2003 - June 30, 2008 (Year 1-3 Final Data; Year 4 & 5 Preliminary Data)
▲ = HQID Top 20% Threshold Value; ● = HQID Median
100%
90%
80%
Appropriate Care Score
70%
60%
50%
40%
30%
20%
10%
0%
AMI
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Heart Failure
Pneumonia
CABG
Hip/Knee
Performing Above the National Average
A composite of 19 process measures shared between HQID and Hospital Compare
shows St. Helena Hospital performing above the nation as a whole.
St. Helena Hospital Compared to National Group Trend
Hospital Compare Data
19 Process Measures Aggregated to Overall Composite Process Score
National Average
State Average
St Helena Hospital
82%
85.1%
94.7%
89.1%
89.7%
90.3%
93.0%
88.1%
87.5%
86.7%
84.0%
84%
83.0%
86%
88.3%
88%
86.4%
91.7%
90.6%
90%
92.5%
92%
94.2%
94%
85.9%
Composite Process Score (Mean Value, Percent)
96%
80%
78%
76%
July 05-June 06
Oct 05-Sept 06*
Jan 06-Dec 06
Apr 06-Mar 07
July 06-June 07
Oct 06-Sept 07
Comparison of HQID Participation and Non-Premier Status
*Beginning w ith Oct 05-Sept 06 the inf luenza vaccination measure became unsuppressed and the number of process measures increased f rom 18 to 19
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Improvement and Savings
Avg. cost improvement
across all clinical areas
Avg. improvement in mortality
across four clinical areas
$1,063
1.87%
Clinical Area
Improvement
AMI
$1,599
CABG
$1,579
Pneumonia
Heart Failure
$811
$1,181
Hip Replacement
$744
Knee Replacement
$463
Clinical Area
Improvement
AMI
2.27%
CABG
0.95%
Pneumonia
2.39%
Heart Failure
1.86%
If all hospitals in the nation were to achieve this
improvement, the estimated cost savings would be greater than
$4.5 billion annually with estimated 70,000 lives saved per year
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Findings: Mortality, Complications, Length of
Stay and Costs all go down for Heart Attack (AMI)
Median Cost per Case over 3 years (AMI)
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Conclusions
1. Creates a performance improvement engine
• Public reporting
• Financial incentives
2. Aligns incentives within hospitals
3. Re-aligns payment incentives in Medicare
• From rewarding more procedures to rewarding quality procedures
4. Improved quality is associated with saving lives and
reducing costs
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Policy Recommendations
1. Create a positive incentive to improve performance.
– All unallocated funds must be used to reward top performers and improvers
– There must be an annual actuarial assessment to identify savings, which should be
used to fund a bonus pool
– Phase in so that hospitals can realistically achieve the benchmarks
2. Align physician and hospital interests.
– Assure alignment between physician and hospital measures
– Hospitals should be able to share money from the bonus pool with their physicians
3. Set benchmarks based on real world evidence from the CMS/Premier
HQID project.
4. VBP should be irrevocably tied to public reporting.
– The Hospital Compare Web site must be more user friendly
– Hospital Compare should include reporting of the hospital’s performance in
delivering all recommended quality measures for each clinical condition
– All new measures should be tested and publicly reported use in a VBP program
5. Government should direct attention and resources to lower performing
hospitals
– QIOs should be directed to focus attention on non-performing hospitals
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