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3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

Gain insights into the methodology and risk adjustment of CMS outcome indicators, including mortality and readmission rates. Learn how these indicators impact public hospital performance and financial outcomes, and the importance of clinical documentation improvement programs.

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3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

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  1. 3rd AnnualAssociation of Clinical Documentation Improvement Specialists Conference

  2. CMS Outcome IndicatorsMethodology, Risk Adjustment, & Strategy Kristen Geissler, MS, PT, CPHQ, MBA Associate Director, Navigant Consulting, Inc.

  3. Medicare’s outcome indicators • 30-day Mortality • Heart Failure • Pneumonia • Acute MI • 30-day Readmission • Heart Failure • Pneumonia • Acute MI • AHRQ PSI • PSI 4 – Death among surgical patients with treatable serious complications (also known as “failure to rescue”) • PSI 6 – Iatrogenic pneumothorax (adult) • PSI 14 – Postoperative wound dehiscence • PSI 15 – Accidental puncture or laceration • IQI 11 – Abdominal aortic aneurysm (AAA) mortality rate • IQI 19 – Hip fracture mortality rate

  4. Why understand the outcome indicator methodology? • Public hospital performance • Mortality and readmission resonate with the public • Financial impact • Currently pay-to-report • Significant readmission measure impact in health reform proposals • Clinical Documentation Improvement programs • Physician buy-in • Severity queries • Impact of present on admission

  5. A word on risk adjustment • What measures need to be risk adjusted? • Outcome measures (mortality, complications, readmissions) • Adjusts for complexity of care and severity of illness • What is the methodology? • Many different methodologies • APR-DRGTM (3M) • HealthgradesTM proprietary • CMS mortality risk adjustment • How is risk adjustment used? • Actual rate versus expected rate • i.e. sicker patients would have a higher expected rate of mortality • What’s the bottom line? • The more accurately the coding/claims data represents the severity of illness of the patient, the more accurately the risk adjustment methodology will be applied

  6. Mortality Indicators

  7. CMS mortality rate • Only for the Medicare population • 30-day mortality • Acute MI • Heart Failure • Pneumonia • Exclusions • LOS ≤ 1 day and discharged alive and not AMA • Medicare hospice program admission on first day of admission or hospice within 12 months prior to admission • Discharge AMA (new exclusion for 2009) • Multiple admissions • One admission is chosen at random for inclusion in the model

  8. CMS mortality rate • Risk adjustment • Uses information from the following Medicare claims: • Hospital inpatient • Hospital outpatient • Physician office • May not include: • Inpatient secondary conditions that are ‘not present on admission’ • Measurement model uses data from July 2005 through June 2008

  9. Risk-standardized mortality rate • Ratio of predicted to expected mortalities x national unadjusted rate: • Predicted number of 30-day mortalities (hosp-specific intercept) • Expected number of mortalities (average intercept)

  10. Mortality data on hospital compare

  11. Distribution of 30-day mortality results

  12. Mortality risk adjustment From CMS Measure Technical Specifications on www.qualitynet.org accessed 2/1/10

  13. Mortality risk adjustment From CMS Measure Technical Specifications on www.qualitynet.org accessed 2/1/10

  14. Readmission Indicators

  15. Readmission rate for select illnesses • Only for the Medicare population • 30-day readmissions for any cause • Acute MI • Heart Failure • Pneumonia • Exclusions • Admissions for patients with in-hospital death • Admissions subsequently transferred to another acute care facility • Admissions who are discharged AMA • Admissions without at least 12 months pre-discharge and 30 days post-discharge enrollment in fee-for-service Medicare • Admissions with LOS > 1 year • Same day readmissions for the same condition to the same hospital • AMI only: admissions discharged alive on same day they are admitted

  16. Readmission risk adjustment • Risk adjustment • Uses information from the following Medicare claims for the 12 months prior to admission: • Hospital inpatient • Hospital outpatient • Physician office • May not include: • Inpatient secondary conditions that are ‘not present on admission’ • Measurement model uses data from July 2005 through June 2008

  17. Risk-standardized readmission rate • Ratio of predicted to expected readmissions x national unadjusted rate: • Predicted number of 30-day readmissions (hosp-specific intercept) • Expected number of readmissions (average intercept)

  18. Readmission data on hospital compare

  19. Distribution of 30-day readmission results

  20. Readmission risk adjustment From CMS Measure Technical Specifications on www.qualitynet.org accessed 2/1/10

  21. Readmission risk adjustment From CMS Measure Technical Specifications on www.qualitynet.org accessed 2/1/10

  22. Readmission risk adjustment From CMS Measure Technical Specifications on www.qualitynet.org accessed 2/1/10

  23. A word (or two) on present on admission • Currently required for all Medicare diagnoses • May be required by your state or other payers • Currently used for CMS Hospital Acquired Conditions (HACs) • No aggregate feedback to hospitals • No widespread accuracy feedback • Still very little focus nationwide

  24. POA challenges

  25. Analysis of POA data

  26. Final thoughts • Documentation and coding will impact outcome measure risk adjustment • May be future financial impact from risk-adjusted mortality and readmission • Consider new or expanded query opportunities • All secondary conditions • Present on admission

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