Transcript CMS Update FY’14

CMS Update FY’14
Frank Briggs, Pharm.D., M.P.H.
Vice President, Quality and Patient
Safety
West Virginia University Healthcare
Objectives
• At the completion of this presentation, the
participants shall be able to:
• Describe the changes in Value Based
Purchasing (VBP)
• Explain the Hospital Acquired Condition (HAC)
penalty program
• Estimate the impact of changes in the
Inpatient Prospective Payment System (IPPS)
Outline
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Inpatient Quality Reporting (IQR)
Value Based Purchasing (VBP)
Readmission Reduction
Hospital Acquired Conditions (HAC)
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Documentation and coding effects
Disproportionate share program
Labor and delivery days
Outlier thresholds
• 2 Midnight Rule?
Inpatient Quality Reporting
• Voluntary reporting
– Required for annual payment update 2%
• Measures appear in program ~2 years before
advancing
– VBP
– HAC
– Readmissions
Inpatient Quality Reporting
• medicare.gov/hospitalcompare
Patient Survey Results
• Hospital Consumer Assessment of Healthcare
Providers and Systems
– HCAHPS
– Reported since 2007
• Uses scale from never to always (5 points)
• Top box scores – “Always”
• Report “Always”
HCAHPS Domains
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Nurse communication
Doctor communication
Responsiveness of staff
Pain control
Explanation of medications
Cleanliness
Quietness
Discharge information (recovery)
Core Measures
• Heart Attack Care
– Aspirin at discharge
– Fibrinolytic within 30 mins
– Primary PCI within 90 mins
– Statin at discharge
• Heart Failure
– Discharge instructions
– Evaluation of LVS function
– ACEI/ARB for LVSD
Core Measures
• Pneumonia Care
– Blood cultures in ED prior to antibiotic
– Appropriate antibiotic selection
• Surgical Care
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Antibiotics: timing, selection, and discontinuation
Venous thromboembolism (VTE) prevention
Beta blockers continued
Blood glucose control in cardiac surgery
Urinary catheters removal
Monitoring of body temperature
Core Measures
• Emergency Department
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Time spent in ED for admitted patients
Time spent in ED after decision to admit
Time spent in ED for patients sent home
Time before being seen by provider
Time before pain medication for broken bones
Percent of patients who leave without being seen
Percent of patients with stroke symptoms who receive
brain scan within 45 mins
• Preventive Care
– Immunizations
New Core Measures
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Immunizations
Venous Thromboembolism (VTE)
Stroke
Perinatal Care
Hospital based inpatient psychiatric services
(HBIPS)
Core Measures
• Immunizations
– Influenza
– Pneumonia
• VTE
– VTE prophylaxis
– Overlap with anticoagulation
– Heparin – platelet dose adjustments by protocol
– Discharge instructions for warfarin
– Preventable VTE
Core Measures
• Stroke
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VTE prophylaxis
Discharge on antithrombotic therapy
Anticoagulation for atrial fibrillation/flutter
Thrombolytic therapy
Antithrombotic by day 2
Discharged on Statin
Stroke education
Assessed for rehabilitation
• Perinatal Care
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Elective delivery
Cesarean sections
Antenatal steroids
Bloodstream infections
Exclusive breast feeding
Core Measures
• HBIPS
– Admission screen: violence, substance abuse,
psychological trauma, and patient strengths
– Hours of physical restraint
– Hours of seclusion
– Patients discharged on multiple antipsychotics
– Discharge plan created and transmitted to next
provider
Removals of Measures
• FY 2016
– PN: Blood cultures
– HF: discharge instructions, ACEI/ARB for LVSD
– AMI: aspirin/statin at DC
– SCIP: temperature monitoring
Readmissions Complications and
Deaths
• Readmission: 30-day all-cause
– AMI
– HF
– Pneumonia
• Death: 30-day
– AMI
– HF
– Pneumonia
New Readmissions and Death
Measures
• Readmissions
– Total Joints
– Hospital-wide
– COPD
– Stroke
– Planned readmission algorithm
• Mortalities
– COPD
– Stroke
Complications
• Agency for Healthcare Research and Quality
Measures (AHRQ)
– Patient safety indicators
• Death among surgical patients with treatable
complications
• Iatrogenic pneumothorax
• Post-op respiratory failure
• Post-op VTE
• Post-op wound dehiscence
• Accident puncture or laceration
Other Measures Reported
• Use of medical imaging
• Medicare payments
• Number of Medicare patients treated
Value Based Purchasing
• Established by Affordable Care Act
– Requires CMS to implement a Hospital VBP
program
– Rewards hospitals for quality of care provided
– Built upon IQR infrastructure
– Evaluate during performance period for
achievement or improvement on measures
– Hospital receive points on each measure reflecting
better performance
– Funding by reducing base operating DRG payment
Value Based Purchasing
• Payment reductions
– 2013: 1%
– 2014: 1.25%
– 2015: 1.5%
– 2016: 1.75%
– 2017: 2%
• Amount available for FY 14 incentive
payments $1.1 billion
Domains
• Clinical process of care (core measures)
– 13 measures and weighted at 45%
• Patient experience (HCAHPS)
– 8 domains and weighted at 30%
• Outcomes
– 3 mortality measures and weighted 25%
Evaluating Hospital Performance
• Achievement points
– Awarded by comparing individual hospital rate
during performance period with all hospitals rates
from baseline period
• Rate at or above benchmark (90th%ile): 10 points
• Rate less than achievement threshold (median): 0
points
• Rate between achievement and benchmark: 1-10
points
– Comparing current hospital performance to
baseline of all hospitals
Evaluating Hospital Performance
• Improvement points
– Awarded by comparing hospitals rates during
performance period to same hospitals rate from
baseline period
• Rate at or above benchmark: 9 points
• Rate less than or equal to baseline: 0 points
• Rate between baseline and benchmark: 0-9 points
– Comparing against yourself over time
– Fewer points than achievement
Proposed VBP Changes for 2015 and
Beyond
• 2015 (final)
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Clinical process of care measures: 20%
Outcome measures: 30%
Efficiency measures(Medicare spending): 20%
HCAHPS: 30%
• 2016 (proposed)
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Clinical process of care measures: 10%
Outcome measures (add AHRQ PSI and infection): 40%
Efficiency measures: 25%
HCAHPS: 25%
VBP 2017
• Change domain and reweight
– Outcomes become safety domain: 15%
• AHRQ Patient Safety Indicators
– Process of care becomes clinical care domain: 35%
• Clinical process of care: 10%
• Mortality outcomes: 25%
Reduction
Earn back
% change in
DRG
Value
multiplier for
DRG
Slope for
translation
Readmission Reduction Program
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Maximum penalty increased to 2%
Projecting $175 million in fewer payments
Added planned readmission logic
Two new measures for FY 2015
– COPD and elective joint
– Built upon IQR infrastructure
• FY 2014 period
– July 1, 2009 – June 30, 2012
Planned Readmission
• Incorporating algorithm
– AMI, HF, PN
– FY 2014
– Will not count unplanned readmissions that follow
planned readmissions either
Hospital Acquired Condition (HAC)
Reduction Program
• Required by Affordable Care Act
– Payment adjustment for all inpatient hospital
payments
– ***Includes indirect medical education (IME) and
disproportionate share (DSH) payments
– Must apply to one quarter of all hospitals (lowest
performance)
– In addition to the non-payment HAC program
– Reductions applied after adjusting for VBP and
Readmissions reduction programs
• Starts in FY 2015
HAC Reduction Framework
Total HAC Score
Worst quartile performance
1% reduction
Domain 1 (35%)
Domain 2 (65%)
AHRQ Patient Safety Indicators
NHSN Infection
Pressure Ulcer
Iatrogenic pneumothorax
Central venous catheter infection
Hip fracture
Post-op VTE
Sepsis
Wound dehiscence
Accidental puncture
Central line blood stream
Catheter associated UTI
2016
Surgical site infection
(Colon and abdominal hys)
2017
MRSA
C difficile
HAC Scoring (Golf)
• Points assigned based on performance
• Performance range for each measure divided into
deciles
• All hospitals receive between 1-10 points for each
measure (lower is better)
• Total score calculated
– AHRQ score x 35% + average of 2 NHSN infections x
65%
• Each year bottom 25% are penalized
– Move faster than the others
Data Periods
• Domain 1: AHRQ PSI
– July 2011 – June 2013
• Domain 2: NHSN Infections
– Calendar years 2012 -2013
Admission and Medical Review Criteria
• Requires physician order for admission to inpatient status
– Authenticated by attending provider
• Certification
– Inpatient order
• Inpatient services are reasonable and necessary
• Appropriately provided in accordance with 2 midnight benchmark
– Reason for inpatient services
• Medical record
– Estimated time the beneficiary requires inpatient care
– Plans for post hospital care
– CAH: beneficiary reasonably expected to be discharged or transferred
within 96 hours
– Must be signed and dated prior to discharge
• DRG payments reduced additional 0.2% to account in addition
2 Midnight Benchmark
• Reasonably expect patient to require inpatient hospital
care for at least 2 midnights
• Less than 2 midnights
– Expected to be observation
• May move from observation to inpatient if patient
meets medical necessity and going to require hospital
care for second midnight
– Outpatient time does not convert to inpatient billing (no
retroactive billing)
• Includes time spent in hospital outpatient areas (ED
and OR)
– Does not begin at triage, when care starts!
Estimating Impact of Changes
• IQR changes
– Generally don’t involve payment/penalty
– Voluntary, required for APU
– May require additional staff and support
• VBP
– 1.25% withhold – earn back % = impact
• Readmission reduction (2%)
• HAC 1% of DRG + IME + DSH
Contact Information
Frank Briggs, Pharm.D., M.P.H.
Vice President, Quality and Patient Safety
West Virginia University Healthcare
Email: [email protected]
Phone: 304.598.4057