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Linking Quality To Payment

Linking Quality To Payment. 17 th Annual Rural Health Conference Timothy Burrell, MD, MBA Medical Director. Definition Of Quality. “General excellence of standard.”. Definition Of Quality. “General excellence of standard.”. Institute of Medicine.

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Linking Quality To Payment

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  1. Linking Quality To Payment 17th Annual Rural Health Conference Timothy Burrell, MD, MBA Medical Director

  2. Definition Of Quality “General excellence of standard.”

  3. Definition Of Quality “General excellence of standard.”

  4. Institute of Medicine “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

  5. Outcomes + Knowledge =

  6. Outcomes + Knowledge =

  7. Payment

  8. Affordable Care Act – March 2010

  9. The Centers for Medicare & Medicaid Services Changed how Medicare pays for services by rewarding/not punishing providers for delivering higher quality and value. The programs highlighted in this presentation: • Hospital Readmissions Reduction Program (HRRP) • Hospital Value-Based Purchasing Program (VBP) • Hospital-Acquired Condition Reduction Program

  10. Advancing Medicare Value

  11. What Is At Stake?

  12. What Is At Stake? Wellpoint Commercial Payments 30% of 2013 performance based 50% of 2015 performance based ??% of 2017 performance based

  13. Quality / Value / Quality Government and private payors will continue exploring programs that tie value to quality. Understanding and implementing quality improvement programs will better prepare providers for the future.

  14. Escalator Principle “Like an escalator, HITECH attempts to move the health system upward toward improved quality and effectiveness in health care. But the speed of ascent must be calibrated to reflect both the capacities of providers who face a multitude of real-world challenges and the maturity of the technology itself.” The “Meaningful Use” Regulation for Electronic Health Records David Blumenthal, M.D., M.P.P., and Marilyn Tavenner, R.N., M.H.A. N Engl J Med 2010; 363:501-504 August 5, 2010DOI: 10.1056/NEJMp1006114

  15. UP AND DOWN

  16. 1 Hospital Readmissions Reduction Program

  17. Hospital Readmissions Reduction Program The historic 30-day readmission rate for Medicare beneficiaries is nearly 20% . . .

  18. Hospital Readmissions Reduction Program The historic 30-day readmission rate for Medicare beneficiaries is nearly 20% . . . . . . at a cost of ~$20 billion/year.

  19. Hospital Readmissions Reduction Program Authorized by Affordable Care Act (ACA) to begin October 1, 2012 Penalties 2013: -1% 2015: -3% Reduction applies to TOTAL Medicare payments

  20. Clinical Conditions 2012 • Acute Myocardial Infarction • Congestive Heart Failure • Pneumonia 2014 adds • Chronic Obstructive Pulmonary Disease (COPD) • Total Knee Arthroplasty • Total Hip Arthroplasty

  21. Readmission Definition Any readmission to an acute care facility within 30 days. Exceptions: • Long-term Acute Care Hospital (LTACH) • Inpatient Rehabilitation Facility (IRF) • Observations (OBS) • Other non-acute care

  22. Readmission Causes Problem - Nature of the Disease Patient - Psychosocial Factors Provider - Gaps in Post-Discharge Management

  23. Problem - Nature of the Disease Some readmissions are inevitable* Many readmissions are negotiable Most readmissions are preventable (*Don’t fight it) CMS View: DRG payments promote premature discharges

  24. Patient - Psychosocial Factors • Social support • Access to medication • Access to care • Access to transportation • Literacy • Mental Health/Substance Abuse

  25. Provider - Gaps in Post-Discharge Management • Delayed outpatient follow-up • Lack of medication reconciliation • Poor coordination/transition of care • Inattention to red flags: • Phone calls • Urgent Care/ED visits • Early medication refill requests • After-hours walk-in clinic visits

  26. How Are We Doing? Many Obstacles Creativity over Technology Management over Medicine Low Tech & High Touch

  27. 20%  19%  18.5%  17.5%

  28. Indiana rank: #31 (2009) #43 (2014) http://datacenter.commonwealthfund.org/#ind=1/sc=1

  29. 2 Hospital Value-Based Purchasing Program (VBP)

  30. Value-Based Purchasing (VBP) Authorized by ACA to begin October 1, 2012 Funded by a reduction from participating hospital base-operating Diagnosis-Related Group (DRG) payments: • 2013: -1% • 2017: -2% The amount of funding for this program is equal to the amount generated by the payment cuts.

  31. Value-Based Purchasing (VBP) Increasing number of measures per year 2013 – 20 Measures 2014 – 24 Measures 2015 – 26 measures

  32. Value-Based Purchasing (VBP) Fiscal Year 2014 – Three Domains • 45% –Clinical Processes of Care • 30% –Patient Experience of Care • 25% –Outcome Domain

  33. Value-Based Purchasing (VBP) In each category hospitals are scored for • Achievement • Improvement The highest score of the two is the final score for the category

  34. Clinical Processes of Care Thirteen (13) measures within well-known categories: • Acute Myocardial Infarction (AMI) • Congestive Hear Failure (CHF) • Pneumonia • Healthcare Associated Infection

  35. Eight HCAPS-based dimensions

  36. Outcome Measures • MORT-30-AMI Acute Myocardial Infarction (AMI) 30-day* mortality rate • MORT-30-HF Heart Failure (HF) 30-day* mortality rate • MORT-30-PN Pneumonia (PN) 30-day* mortality rate * Post-admission

  37. 3 Hospital-Acquired Condition (HAC) Reduction Program

  38. HAC Reduction Program Authorized by ACA to begin October 1, 2014 Requires CMS to reduce hospital payments by (1%) for hospitals that rank among the lowest-performing 25% for hospital-acquired conditions In addition to current Hospital-Acquired Conditions Program and excludes critical access hospitals

  39. HAC Reduction Program Conditions acquired while receiving care for another condition in an acute care health setting. Additional sources: Extended Care Facility Acute Rehabilitation Facility Dialysis Center Ambulatory Surgery Center

  40. Three Measures – Two Domains Domain 1 – 2014 (65%) Patient Safety Indicator #90: • Pressure Ulcer (PSI 3) • Iatrogenic Pneumothorax (PSI 6) • Central Venous Catheter-Related Blood Stream Infection (PSI 7) • Postop Hip Fracture (PSI 8) • Postop Pulm. Embolism (PE) / Deep Vein Thrombosis (DVT) (PSI 12) • Postop Sepsis (PSI 13) • Wound Dehiscence (PSI 14) • Accidental Puncture and Laceration (PSI 15)

  41. Three Measures – Two Domains Domain 2 – 2014 (35%) • Central Line-Associated Blood Stream Infection • Catheter-Associated Urinary Tract Infection

  42. Three Measures – Two Domains Domain 2 – 2014 (35%) • 2015 • Surgical Site Infection - Colon • Surgical Site Infection - Abd. Hysterectomy • 2016 • Methicillin-resistant staph aureus (MRSA) • Clostridium difficile Infection

  43. HAC Reduction Program Complements other CMS programs • Hospital-Acquired Conditions(Present on Admission) • Never Events Non-Payment • Hospital Compare Reporting

  44. CMS Program Overlap

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