Transcript Policy and the Caregiver

Maryland Hospitals’
Payment Policy
Environment
About Me
From This....
To This:
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Why is Volume-Based Payment a
Problem?
• Incentivizes volume in an expensive setting
• Incentivizes creation of service lines which may not be necessary
• De-emphasizes care coordination and working with post-acute
and primary care partners
• Promotes cost-shifting among payers
 May incentivize hospitals to seek out certain groups of
patients
• Less coordination and money available for charity care
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How Should a System Work?
Triple Aim
Population Health
Experience of
Care
Per Capita Costs
-Institute for Healthcare Improvement, 2007
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Changing Incentives
Global Budgets
•
“The GBR model assures hospitals that adopt it that they will receive an agreedon amount of revenue each year—i.e., the Hospital’s “Approved Regulated
Revenue” (Approved Regulated Revenue) under the GBR system-- regardless of
the number of Maryland residents they treat and the amount of services they
deliver provided that they meet their obligations to serve the health care needs of
their communities in an efficient, high quality manner on an ongoing basis.”
» Health Services Cost Review Commission
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Different Incentives
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Financial Targets
Financial Targets in Waiver
•
3.58% annual, all-payer per capita growth limit
Cumulative All-Payer
8.00%
7.29%
6.00%
4.13%
4.00%
3.58%
2.00%
0.00%
1.47%
Year One
Cumulative
All-Payer Growth
Per Capita Costs
Target
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Financial Targets
Financial Targets in Waiver
•
$330M in cumulative Medicare hospital savings
Spending Trends in Dollars
$186.4
$200.0
$180.0
$160.0
$140.0
$120.0
$116.6
$100.0
$69.9
$80.0
$60.0
$40.0
$20.0
$-
2014
2015 YTD Oct
Cumulative
Total
Per Capita Costs
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Financial Targets
Financial Targets in Waiver
•
Maryland’s Medicare per beneficiary total cost growth rate cannot
exceed the national average by more than 1 percentage point
Per Capita Costs
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Quality Targets
Preventable Complication Reductions
Maryland will achieve an annual aggregate reduction of 6.89% in the 65
Potentially Preventable Complications (PPCs) over five years for a
cumulative reduction of 30%
Readmission Reductions
Maryland will reduce its aggregate Medicare 30-day unadjusted all-cause,
all-site hospital readmission rate in Maryland to the national rate
Other Quality Program Not in Waiver...QBR
The state must ensure that the aggregate percentage of regulated revenue
at risk for quality programs…is equal to or greater than the aggregate…at
risk under national Medicare quality programs
Experience of
Care
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How Are We Doing - Readmits
Maryland Readmissions Rates versus Nation, Medicare Unadjusted
19%
Readmissions Reductions, 2011-2015
Maryland: 11.8 percent
Nation: 5.5 percent
18%
17%
16%
15%
2011
2012
2013
Nation
Source: CMS
2014
July 2015
Maryland
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How Are We Doing – PPCs
Potentially Preventable Complications, Q1 2014 – Q3 2015
7,000
37.2% Decline
6,130
6,000
5,000
3,850
4,000
3,000
2,000
Q1-2014
Q2-2014
Q3-2014
Q4-2014
Q1-2015
Q2-2015
Q3-2015
Source: HSCRC monthly inpatient case-mix data with 3M PPCs, final data
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MD Hospitals Have More at Risk
•
For Maryland, penalties affect all inpatient revenue under global budgets
•
For hospitals in the rest of the nation, penalties only affect Medicare inpatient revenue
Example Maryland Hospital With $100M in Annual Revenue*
Example National Hospital With $100M in Annual Revenue*
$60M in Inpatient Revenue
$60M in Inpatient Revenue
$24M (40% of Inpatient Revenue) from Medicare
$14M (~60% of Medicare inpatient Revenue) from base MS-DRG
2016
Program
MHAC
Readmits
QBR
Total Without PAU
•
•
2016
% at Risk
Dollar Value
4%
$2.4M
1.36%
Program
% at Risk
Dollar Value
HAC
1%
$0.14M
$0.8M
Readmits
3%
$0.42M
1%
$0.6M
VBP
1.75%
$0.25M
6.36%
$3.8M
Total
5.75%
$0.81M
When the dollar value of potential penalties is considered against total annual revenue, the
Maryland hospital in this example would have 3.8% at risk versus 0.8% for the hospital located
elsewhere in the nation
There is a cap in place, so in actuality, no hospital would reach 6.36% in penalties
*Revenues are hypothetical and roughly based on known proportions of inpatient revenue, Medicare
inpatient revenue and base MS-DRG revenue relative to total hospital revenue
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PPC Issues
• Where’s the floor?
• Data accuracy
• Do PPCs accurately capture quality?
• Collaboration is needed to ensure
there is definitional agreement
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How to Reduce?
What Staff Are Doing About PPCs
Interventions Targeting Respiratory Failure
• Reduced postoperative ventilator times for post cardiac surgery patients with the goal of
extubation within 6 hours after the procedure
• Implemented new staff training regarding best practices for chest physiotherapy, patient
positioning, surgical preparation, patient change in status tracking through documentation,
oral hygiene, and activity promotion
Interventions Targeting Heart Failure
• Created a heart failure task force to participate in daily rounding and perform medications
reviews with patients and discuss compliance
Interventions Targeting Decubitus Ulcers
• Revised the H& P section of ED documentation to include an Integumentary Assessment
section
• Utilized screen savers with a q 2hr turning reminder
•
Instituted a turning campaign with a turning schedule and clock in each room
Interventions Targeting CHF
 Created a heart failure task force to participate in daily rounding and perform medications
reviews with patients and discuss compliance
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Readmissions
Readmissions Count More in
Maryland!
Medicare Readmissions Program
(Everyone Else)
Maryland
Medicare Readmissions Only, Some
Payers have Programs
Medicare Only for Waiver, but All-Payer
for Yearly Payment Program
Only Certain Conditions for Index Admit
All Cause
Penalties Only on Medicare Revenue,
Some Payers have Programs
Penalties on All Revenue
Risk Adjusted
Not Risk Adjusted for Waiver, but Risk
Adjusted for Payment Program
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Readmission Issues
• Risk adjustment?
• Competing incentives?
• Who will be readmitted?
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Working With Partners
A key to readmission reductions is working closely with other
partners
The percentage of Home Health
episodes in MD that come straight
from an acute-care hospital is much
higher than the national average
(50% versus 22%)
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Other Quality Efforts
Someone will be
watching you wash
your hands!
Improving Sepsis Survival
Collaborative
93%
91%
90%
89%
July
June
May
April
March
February
January
2015
December
November
88%
2014
Compliance Rate
92%
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Incentives Beyond Payment
Hospitals are subject to public scrutiny through public
reporting
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What We Need
•
•
•
•
•
Team Players
Adaptable
Smart
Able to Anticipate
Understand the Bigger Picture
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Opportunities for the Future?
Examples of change
Patients
Partnerships
Population health
Bedside prescription
delivery
Close collaboration
with SNFs
Wellness initiatives
Health “coaches”
Transport to primary
care appointments
Predictive data analytics
In-home postdischarge visits
Physician
Mental health &
education/partnerships substance abuse clinics
Nurse hotlines
Sharing of data
Mobile health clinics
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