Paul Moore, DPh Senior Health Policy Advisor Department of Health and Human Services

1. Southeast CAH ConferenceSavannah, GAJune 17-19, 2013What does the future hold for Critical Access Hospitals? Paul Moore, DPh Senior Health Policy Advisor Department of Health and Human Services Health Resources and Services Administration Office of Rural Health Policy

2. One thing is for certain… CHANGE Changes are coming, under auspices of reform or otherwise…

3. The Changing Landscape • Inpatient payment to PPS hospitals became effective October 1, 2012…will be developed for outpatient payment • Value based purchasing • Value based modifiers for physician payment • Bundled payments

4. The Changing Landscape • Expansion of Medicaid enrollment • Expansion of enrollment in the individual and small group marketplace. • Managed care organizations • Accountable care organizations • Prevention and population health • Community well-being

5. The Changing Landscape • Payment per event will moderate • Tolerance for services of questionable use will diminish • Health Systems will form and spread • Multiple payers moving in similar directions

6. The Point…. Critical Access Hospitals can’t expect current / historic approaches to delivering and financing care to respond to this shift in the way care will be provided and paid for.

7. Your Role? …To lead your Board and staff to understand and implement the changes required in the context of the changing landscape… …and what is desirable for your rural community. How do you pull that off?

8. Define the Goal(s) • Preserve rural health system design flexibility in order to provide local access to meet the needs of your community in a sustainable way. • Strive for a healthy community through developing needed services. • Prepare to survive the transition from Volume- to Value-based payment.

9. Expect to see… Expansion and transformation of primary care… • PCMH as organizing framework • Greater use of all primary care professionals in most efficient manner possible • Use health information to manage and coordinate care: records, registries • Collaboration to integrate services

10. Expect to see… Evolution in health care work force… • More community paramedicine • Increased use of community health workers • Optimal use of all professionals, (which requires rethinking delivery and payment models – has implications for regulatory policy including conditions of participation)

11. Expect to see… Increased leveraging of technology… • providing clinical services through local providers linked by tele-health to providers in other places: e-Emergency, e-ICU, e-Psychiatry, e-Pharmacy, etc… • …Providing services directly to patients where they live.

12. Expect to see… More emphasis on measuring and reporting Quality and Performance; • More effort to deliver value in measurable ways that can be basis for payment • Increasing use of results to promote sustainability.

13. Why does measuring clinical performance matter? We tend to measure what we value… We tend to improve what we measure.

14. “High performer” characteristics: Quality: Not just a department… the highest organizational priority Data: Real time collection, fix problems as they occur, not just for inspection Culture: The norm is 100% success, failures trigger investigation Observations

15. “Low performer” characteristics: Quality: “Here we go again …” Data: Batched collection, periodic review Culture: Failures are expected… and accepted. Observations

16. So… what shall we measure? 42% of all 2009 IP CAH claims that were submitted to Medicare were for pneumonia. * * Source: Ted Fraser, MS , Dir. Of Evaluation and Planning CIMRO of Nebraska

17. Pneumonia and Heart Failure Process of Care Measures Percent Pneumonia Patients: • Whose Initial Blood Culture Was Performed Prior to the Administration of the First Hospital Dose of Antibiotics • Given the Most Appropriate Initial Antibiotic(s) Percent Heart Failure Patients: • Given Discharge Instructions • Given an Evaluation of Left Ventricular Systolic Function • Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)

18. So… what shall we measure? 60-70% of CAH revenue is usually derived from the Out-Patient department….. * Source: Ted Fraser, MS , Dir. Of Evaluation and Planning CIMRO of Nebraska

19. Out-Patient Measures • OP-1 Median Time to Fibrinolysis • OP-2 Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival • OP-3 Median Time to Transfer to Another Facility for Acute Coronary Intervention • OP-4 Aspirin at Arrival • OP-5 Median Time to ECG • OP-6 Timing of Antibiotic Prophylaxis (Prophylactic Antibiotic Initiated Within One Hour Prior to Surgical Incision) • OP-7 Prophylactic Antibiotic Selection for Surgical Patients

20. So… what shall we measure? Many cases which present through our emergency departments are transferred for more definitive care…. * Source: Ted Fraser, MS , Dir. Of Evaluation and Planning CIMRO of Nebraska

21. ED Patient Transfer Communication* • Pre-Transfer Communication Information (0-2) • Patient Identification (0-6) • Vital Signs (0-6) • Medication-Related Information (0-3) • Physician or Practitioner Generated Information (0-2) • Nurse Generated Information (0-6) • Procedures and Tests (0-2) * NFQ Endorsed

22. Why does measuring clinical performance matter? We tend to measure what we value… We tend to improve what we measure.

23. Why else could measuring clinical performance matter? Possible future link to payment? Shared Savings Programs?

24. Who knows? But what we do know…. CHANGE “Survival of the most adaptable”Darwin Value Based Purchasing for CAHs?

25. 70% clinical process measures 30% HCAHPS 10 point scales Scored twice – Attainment & Improvement Keep higher score Revenue neutral (winners & losers) Value Based PurchasingHow it works…

26. The “no brainer” for CAHs…. HCAHPS Accounts for 30% Value Based Purchasing

27. So… What else can we expect to see? Ans: A decreased tolerance for error and harm…

28. 2010Department of Health and Human ServicesOFFICE OF INSPECTOR GENERAL “One of every seven Medicare beneficiaries who is hospitalized is harmed… …Added at least $4.4 billion a year to costs… …Contributed to the deaths of about 180,000 patients a year… …44 percent… preventable.”

29. 2010Department of Health and Human ServicesOFFICE OF INSPECTOR GENERAL “The most frequent problems…. …were those related to medication… “the study highlighted the importance of improving procedures to prevent medication errors…”

30. Partnership for Patients

31. Pharmacist Order Entry or Verification of Medication Orders within 24 hours

32. MBQIP(AN OVERVIEW)http://www.hrsa.gov/ruralhealth/about/video/index.htmlOrwww.Youtube.com [MBQIP]

33. Phase 1(Since Sept. 2011)Reporting PNE & HF data…Finding and using value…(best practices / best methods)

34. Phase 2(Since Sept. 2012)Out-Patient MeasuresHCAHPS(Benchmarking IP Measures)

35. Phase 3 (Starting Sept. 2013) ED Transfer Communication Measure & Pharmacist Order Entry or Verification of Medication Orders within 24 hours

36. Leveraging Resources and Relationships….Measuring and Reporting data…Finding and using value…(best practices / best methods) MBQIP is about….

37. MBQIP… …is about making a difference!

38. But that requires leadership…

39. One final thought… … regarding your leadership in this changing environment. Thank you for your courage to stand in the “lonely place”.

40. Thank you. Paul Moore, DPh Federal Office of Rural Health Policy 5600 Fishers Lane Rockville, MD  20857 Tel: 301-443-1271  Fax:  301-443-2803 pmoore2@hrsa.gov http://ruralhealth.hrsa.gov