Value Based Purchasing, Changes for ICD-10 and the Future of Medicine Robert S. Gold, MD

1. Value Based Purchasing, Changes for ICD-10 and the Future of MedicineRobert S. Gold, MD

2. The Legal Stuff Disclosure Statement I declare that I do not have a financial interest or other relationship with any manufacturer(s) of any commercial product(s).

3. Objectives • Identify where data related to healthcare comes from • State how documentation ties into quality measures and physician reimbursement as well as “Value Based Purchasing” • Describe the changes in International Classification of Disease methodology to ICD-10 and the requirements for increased accuracy and specificity of diagnoses and procedures • Define essentials of documentation that impact severity of illness and how to properly apply them • Clarify the doctor’s responsibility in the Electronic Health Record

4. Medicine Under the Microscope Morbidity Mortality Cost per patient Resource utilization Length of stay Complications Outcomes ARE YOU SAFE – avoiding harm, avoidable readmissions?

5. Manipulate provider documentation to increase Medicare reimbursement Count bullets for physician professional billing The times they are a’changin’! Historical Initiatives

6. Value-Based Purchasing Program • Beginning in FY 2013 and continuing annually, CMS will adjust hospital payments under the VBP program based on how well hospitals perform or improve their performance on a set of quality measures. The initial set of 13 measures includes three mortality measures, two AHRQ composite measures, and eight hospital-acquired condition (HAC) measures. The FY 2012 IPPS final rule (available at http://tinyurl.com/6nccdoc) includes a complete list of the 13 measures. • The FY 2013 IPPS proposed rule includes four additional proposed measures for FY 2015—one additional clinical process of care measure (i.e., statin prescribed at discharge), two additional outcomes measures (i.e., a patient safety indicator composite measure and a measure related to central line-associated bloodstream infections), and a measure pertaining to Medicare spending per beneficiary.

8. Issues of Concern • Severity of illness – conditions that make the principal diagnosis more costly – ALL diagnoses, ALL procedures • Risk of mortality – conditions that add to the likelihood that a patient will die – ALL diagnoses, ALL procedures • Patient safety – identification of risk issues that can be minimized or controlled

9. Where Does This Data Come From? • Documentation leads to identification of diagnoses and procedures • Recognition of diagnoses and procedures lead to ICD codes – THE TRUE KEY • ICD codes lead to APR-DRG assignment • APR-DRG assignment massaged to “Severity Adjustments • Severity adjusted data leads to morbidity and mortality rates

10. What Is An Index?

11. Mortality index Complication index Length of stay index Cost per patient index What Is An Index? Observed Rate of Some Thing Severity Adjusted Expected Rate of That Thing =1

12. Surgery Bundling Test Model • Disclosed May 16, 2008 • ACE (Acute Care Episode) project • Combine Part B payments with Part A • “Value Based Centers” startrd with Texas, Oklahoma, New Mexico and Colorado • Value based purchasing • 28 cardiac and 9 orthopedic inpatient surgical services • Gainsharing also permitted here • Based on severity adjusted financial outcomes

13. Florida Blue and Mayo Clinic Introduce Knee Replacement Bundled Payment Program Friday, December 14, 2012 JACKSONVILLE, Fla. — Florida Blue and Mayo Clinic jointly announce a new collaboration aimed at providing the utmost in quality care for knee replacement patients in Florida. The two Florida health care leaders are teaming up to create a bundled payment agreement specific to the treatment of knee replacement surgery. Knee replacement surgery is the most common joint replacement procedure. According to the Agency for Healthcare Research and Quality, health care professionals perform more than 600,000 knee replacements annually in the United States.

14. CMS Bundled Payment Plans September 2, 2011 Bundles physician and hospital payment into one lump sum could represent a long-term, revolutionary solution to that age-old question. Testing four new bundled payment plans, according to a Fact Sheet released August 23 Three models involve retrospective payment, one a prospective payment determined by MS-DRG Aggregate Medicare payment for the episode will be reconciled against the target price. Savings beyond the discount reflected in the target price will be paid to the participants to share among the participating providers.

15. Bundled Payments for Care Improvement (BPCI) Initiative On January 31, 2013, the Centers for Medicare & Medicaid Services (CMS) announced the health care organizations selected to participate in  the Bundled Payments for Care Improvement initiative, an innovative new payment model.  Under the Bundled Payments for Care Improvement initiative, organizations will enter into payment arrangements that include financial and performance accountability for episodes of care. Research has shown that bundled payments can align incentives for providers – hospitals, post-acute care providers, physicians, and other practitioners– allowing them to work closely together across all specialties and settings. http://innovation.cms.gov/initiatives/bundled-payments/index.html

16. Model 1: Retrospective Acute Care Hospital Stay Only • Under Model 1, the episode of care is defined as the inpatient stay in the acute care hospital. Medicare will pay the hospital a discounted amount based on the payment rates established under the Inpatient Prospective Payment System used in the original Medicare program. Medicare will continue to pay physicians separately for their services under the Medicare Physician Fee Schedule. Under certain circumstances, hospitals and physicians will be permitted to share gains arising from the providers’ care redesign efforts. Participation will begin as early as April, 2013 and no later than January, 2014 and will include most Medicare fee-for-service discharges for the participating hospitals.

17. Model 2: Retrospective Acute Care Hospital Stay plus Post-Acute Care • In Model 2, the episode of care will include the inpatient stay in the acute care hospital and all related services during the episode. The episode will end either 30, 60, or 90 days after hospital discharge. Participants can select up to 48 different clinical condition episodes.

18. Model 3: Retrospective Post-Acute Care Only • For Model 3, the episode of care will be triggered by an acute care hospital stay and will begin at initiation of post-acute care services with a participating skilled nursing facility, inpatient rehabilitation facility, long-term care hospital or home health agency. The post-acute care services included in the episode must begin within 30 days of discharge from the inpatient stay and will end either a minimum of 30, 60, or 90 days after the initiation of the episode. Participants can select up to 48 different clinical condition episodes.

19. Model 4: Acute Care Hospital Stay Only • Under Model 4, CMS will make a single, prospectively determined bundled payment to the hospital that would encompass all services furnished during the inpatient stay by the hospital, physicians, and other practitioners. Physicians and other practitioners will submit “no-pay” claims to Medicare and will be paid by the hospital out of the bundled payment. Related readmissions for 30 days after hospital discharge will be included in the bundled payment amount. Participants can select up to 48 different clinical condition episodes.

20. Florida Blue and Holy Cross Create Accountable Care Arrangement Jacksonville and Fort Lauderdale, Fla. – Florida Blue, Florida’s Blue Cross and Blue Shield Company, and Holy Cross Physician Partners are pleased to announce that effective January 1, 2013, Holy Cross Physician Partners will participate in the Florida Blue Accountable Care Program. “Florida Blue is excited to expand our relationship with Holy Cross surrounding this exciting new partnership,” said Dr. Jonathan Gavras, chief medical officer and senior vice president for Florida Blue. “In the age of reform, both organizations realize the importance of moving away from the fee-for-service model to one that focuses on quality outcomes that will benefit our members in South Florida.”

21. Readmissions Initiative Identify hospitals with excess readmissions for certain selected conditions beginning in FY 2013 for discharges on or after October 1, 2012. Acute myocardial infarction (i.e., heart attack) Heart failure Pneumonia Definition of readmission: “occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period from the time of discharge from the index hospitalization.” The specified time period would be 30 days. 21

22. The Hospital Readmissions Reduction Program requires a reduction to a hospital’s base operating DRG payments to account for excess readmissions of selected applicable conditions, which are acute myocardial infarction, heart failure, and pneumonia. • Goal is to lead to processes in hospital whereby all of the patient’s foreseeable needs are addresses on discharge, not only that the acute event is over and the patient is sent back to whatever environment • Coordination of care with Case Management and post hospital care facilities required

23. Patient Safety Indicators Hospital acquired preventable diagnoses Hospital falls that lead to patient damage (fractures, etc.) Mediastinitis post-CABG (36.10 – 36.19 + 519.2) Catheter-associated UTIs (996.64 + 599.0)* Vascular catheter associated infections (996.62) vs 999.31 Pressure ulcers (707.00 – 707.09) NEVER Events Object accidentally left in patient (998.4) Air embolism (999.1) Reaction from blood incompatibility (999.6)

24. Hospital Acquired Conditions (HACs) • CMS also finalized three HACs in the IPPS final rule that took effect in 2010. CMS has determined the following three conditions to be reasonably preventable through proper care: • Surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity • Certain manifestations of poor control of blood sugar levels, primarily diabetic hyperosmolarity, ketoacidosis, and hypoglycemic coma • Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures

25. 2013 HACs • Surgical Site Infection (SSI) following Cardiac Implantable Electronic Device (CIED) Procedures and Pneumothorax with Venous Catheterization, for the HAC payment provisions for FY 2013 under section 1886(d)(4)(D) of the Act. Both conditions, as reported, are currently CCs. • Iatrogenic Pneumothorax with Venous Catheterization. • Adding diagnosis codes 999.32 (Bloodstream infection due to central venous catheter) and 999.33 (Local infection due to central venous catheter) to the existing Vascular Catheter-Associated Infection HAC category for FY 2013.

26. How Do You Identify These? • There is not a unique code that identifies SSI following CIED Procedures. However, the condition can be identified as a subset of discharges with ICD–9–CM diagnosis code 996.61 (Infection and inflammatory reaction due to cardiac device, implant and graft) or 998.59 (Other postoperative infection). Our clinical advisors believe that diagnosis code 996.61 or 998.59, in combination with the associated procedure codes below, can accurately identify SSI Following CIED Procedures

27. ● 00.50 (Implantation of cardiac resynchronization pacemaker without mention of defibrillation, total system [CRT-P]); ● 00.51 (Implantation of cardiac resynchronization defibrillator, total system [CRT-D]); ● 00.52 (Implantation or replacement of transvenous lead [electrode] into left ventricular coronary venous system); ● 00.53 (Implantation or replacement of cardiac resynchronization pacemaker pulse generator only [CRT-P]); ● 00.54 (Implantation or replacement of cardiac resynchronization defibrillator pulse generator device only [CRT-D]); ● 37.80 (Insertion of permanent pacemaker, initial or replacement, type of device not specified); ● 37.81 (Initial insertion of single-chamber device, not specified as rate responsive); ● 37.82 (Initial Insertion of single-chamber device, rate responsive); ● 37.83 (Initial insertion of dual-chamber device); ● 37.85 (Replacement of any type pacemaker device with single-chamber device, not specified as rate responsive);

28. ● 37.86 (Replacement of any type of pacemaker device with single-chamber device, rate responsive); ● 37.87 (Replacement of any type pacemaker device with dual-chamber device); ● 37.94 (Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD]); ● 37.96 (Implantation of automatic cardioverter/defibrillator pulse generator only); ● 37.98 (Replacement of automatic cardioverter/defibrillator pulse generator only); ● 37.74 (Insertion or replacement of epicardial lead [electrode] into epicardium); ● 37.75 (Revision of lead [electrode]); ● 37.76 (Replacement of transvenous atrial and/or ventricular lead(s) [electrode]); ● 37.77 (Removal of lead(s) [electrode] without replacement); ● 37.79 (Revision or relocation of cardiac device pocket); and ● 37.89 (Revision or removal of pacemaker device).

29. Iatrogenic Pneumo with Central Line • There is no unique code that identifies Iatrogenic Pneumothorax with Venous Catheterization. However, Iatrogenic Pneumothorax with Venous Catheterization can be identified as a subset of discharges with ICD–9–CM diagnosis code 512.1 (Iatrogenic pneumothorax). Our clinical advisors believe that diagnosis code 512.1, in combination with the associated procedure code 38.93 (Venous catheterization NEC), can accurately identify Iatrogenic Pneumothorax with Venous Catheterization. In the FY 2013 IPPS/LTCH PPS proposed rule (77 FR 27896 through 27897), we proposed to identify Iatrogenic Pneumothorax with Venous Catheterization reported in combination with diagnosis code 512.1 (Iatrogenic pneumothorax) and procedure code 38.93 (Venous catheterization NEC).

30. When Do You Code a Pneumo? • If an x-ray finding that leads to insertion of a chest tube (tube thoracostomy), it’s valid • If an x-ray finding that leads to insertion of a catheter to aspirate the air, it’s valid • If it’s an x-ray finding that is not treated, it’s NOT valid – it will not meet UHDDS criteria as a valid secondary diagnosis • If it was put in at another hospital or on the ambulance or during an outpatient encounter, it was POA

31. Line Insertion

32. Apical Cap

33. Midline shift to left Edge of right lung

34. What Defines a HAC? Hospital-Acquired Conditions • Section 5001(c) of the DRA required the Secretary to identify, by October 1, 2007, at least two conditions that: 1. Are high cost or high volume or both, 2. Result in the assignment of a case to an MS-DRG that has a higher payment when present as a secondary diagnosis, and 3. Could reasonably have been prevented through the application of evidence-based guidelines.

35. How Did They Do?

37. Total Impact Savings: 19,512,422

38. Participation and Success in Reporting of Core Measures • Acute MI • Heart failure • Pneumonia • Postoperative wound infections • Venous thromboembolism • Stroke • Asthma in children’s hospitals

39. Goals of Implementation – Prove You Are Value Based • Low incidence of HACs • Reasonable occurrence of PSIs • Lower than average Readmissions for Pneumonia, Heart Failure, AMI • Cooperation with quality initiatives • Decent responses to a new questionnaire on discharge

40. New Survey-Based Measure Item ● During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left. __ Strongly disagree __ Disagree __ Agree __ Strongly agree ● When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. __ Strongly disagree __ Disagree __ Agree __ Strongly agree ● When I left the hospital, I clearly understood the purpose for taking each of my medications. __ Strongly disagree __ Disagree __ Agree __ Strongly agree __ I was not given any medication when I left the hospital

41. How Does This Affect Me? • Physician quality profiles (M&M) • Physician utilization profiles (efficiency of treating patients) • Physician E&M levels now • Physician E&M levels in the future including P4P • Interference of daily smooth work flow by needs of Utilization Review • HOW I LOOK TO THE WORLD

42. Documentation’s Effect on E&M Coding and Physician Income • The sicker your patient is… • The higher the complexity of medical decision making… • Justifying an appropriately higher level of E&M • The less your documentation leads to sick ICD codes, the less you get • An attempt to make counting bullets obsolete

43. Effect on Quality of Care • Identifying a condition with the proper words permits retrieval of risk adjusted mortality data • Identifying a condition by your thoughts permits other who follow to know what you’re thinking (links, pathogenesis, etc.) • Identifying a condition specifically permits quality indicators to be extracted retrospectively

44. HCC RAs - Here Since 2004 • Hierarchical condition category risk adjustment – the more complex the disease, the higher the risk, the higher your reimbursement • Billing only vanilla codes reaps least rewards • 250.00 is diabetes type 2, not stated as uncontrolled – is this ALL of your patients? • 428.0 is CHF with no additional risk – is this ALL of your patients?

45. The More Complex the Diabetic, the Higher the Payments

46. Risk Adjusted Capitation

47. Change in the Entire System ICD-9 ICD-10

48. Don’t Wait Till Tomorrow for ICD-10

49. Notable Changes ICD-9 has maximum of 5 digits with rare alphanumeric codes (V-, E-) limiting breakdown for specificity or addition of categories; ICD-10 has three to seven alphanumeric places ICD-9: 14,000 codes; ICD-10: 73,000 codes ICD-9 has no specificity as to which side of the body (e.g., percent burn on right or left arm or leg, side of paralysis after stroke)

50. Example - Specificity Category 1–3 Etiology, anatomic site, severity, other detail 4–6 Extension 7 S52: Fracture of forearm S52.5: Fracture of lower end of radius S52.52: Torus fracture of lower end of radius S52.521: Torus fracture of lower end of right radius S52.521A: Torus fracture of lower end of right radius, initial encounter for closed fracture