Experiences of the
CMS/Premier Hospital
Quality Incentive
Demonstration Project
Denise Remus, PhD, RN
VP, Clinical Informatics
Premier, Inc – Balancing Cost and Quality
Performance
’
improvement alliance of
1,500 hospitals; owned
by more than 200 notfor-profit hospitals and
health systems.
Core Purpose:
Efficiency without
Quality
Unthinkable
Quality without
Efficiency
Unsustainable
To improve the health of
communities.
Envisioned Future:
Premier hospitals and health
systems will operate at costs in the
lowest quartile… and at quality
levels in the highest quartile.
Clinical quality and financial
performance are inseparable
© Premier 2006
1
Hospital Quality Incentive Demonstration (HQID)
Project Overview
• CMS and Premier partnership project
• First national hospital Pay-forPerformance (P4P) demonstration
• Tests the hypothesis that monetary
incentives and market recognition can
increase quality of care
• 3 year project: Oct 1, 2003-Sept 30, 2006
data
• 268 current participants in HQID Year One
analyses
© Premier 2006
HQID Overview (cont.)
• 5 clinical conditions – all defined by diagnoses
and/or procedures
–
–
–
–
–
Acute Myocardial Infarction (AMI)
Heart Failure (HF)
Community Acquired Pneumonia (PN)
Coronary Artery Bypass Graft (CABG) procedures
Hip and Knee replacement procedures (Hip/Knee)
• Hospitals must have 30 discharges in each clinical
area per year to be included
• 30 measures as of Sept. 1, 2005 (was 34),
includes both process and outcome measures
• Hospitals placed in deciles based on composite
quality score (CQS) within each clinical condition
© Premier 2006
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Example of Payment Scenario - AMI
AMI
AMI
+ 2%
1st Decile
95.79%
1st Decile
93.97%
2nd Decile
Payment
Incentive
Payment
Incentive:
Thresholds
recalculated
based on year
2 data
AMI
1st Decile
Payment
Incentive:
Thresholds
recalculated
based on
year 3 data
2nd Decile
3rd Decile
2nd Decile
4th Decile
3rd Decile
5th Decile
4th Decile
6th Decile
7th Decile
+ 1%
5th Decile
6th Decile
9th Decile
Public
Recognition
7th Decile
10th Decile
3rd Decile
4th Decile
90.41%
5th Decile
8th Decile
8th Decile
Hospital
9th Decile
6th Decile
7th Decile
10th Decile
Hospital
85.18%
8th Decile
85.18%
81.41%
9th Decile
81.41%
10th Decile
Payment
Adjustment
Thresholds
- 1%
- 2%
Year One
Year Two
Oct 03 – Sep 04
Oct 04 – Sep 05
Year Three
Oct 05 – Sep 06
Payment
Adjustment - Year 3
© Premier 2006
HQID Year 1 – Final Results
Released November 14, 2005
• Quality
improvement across
all hospitals and
clinical areas
• AMI alone – 235
“lives saved”
• $8.85 million
awarded to 123 top
performers
• Top performers
represented large
and small facilities
across the country.
© Premier 2006
3
Significant Improvements in CQS – Year 1
HQID Year 1: Improvement in Composite Quality Score by Clinical Area
First Data Quarter to Fourth Data Quarter
95%
90.81%
90.14%
89.71%
90%
87.43%
84.93%
84.94%
85%
79.17%
80%
74.19%
75%
69.37%
70%
64.58%
65%
60%
AMI 4Q03
AMI 3Q04
CABG 4Q03 CABG 3Q04
CAP 4Q03
CAP 3Q04
HF 4Q03
HF 3Q04
HK 4Q03
HK 3Q04
© Premier 2006
Improvements continue. . .
CMS/Premier HQID Project Participants Composite Quality Score:
Trend of Quarterly Median (5th Decile) by Clinical Focus Area
October 1, 2003 - December 31, 2005 (Year 1 Final Data, Year 2 and Q4-05 Preliminary)
70%
85.13%
86.87%
89.0%
90.5%
92.07%
93.98%
95.37%
95.80%
96.05%
81.57%
82.98%
84.38%
86.73%
68.11%
70.00%
73.13%
75%
76.2%
77.88%
80%
73.1%
85.14%
85.92%
85%
78.3%
80.0%
82.51%
82.72%
84.81%
86.43%
88.54%
90%
89.88%
90.06%
91.5%
92.6%
93.50%
93.46%
95.07%
95.77%
95.98%
65%
64.10%
Composite Quality Score
95%
88.9%
90.0%
93.65%
94.84%
96.07%
96.85%
96.77%
100%
60%
AMI
CABG
Pneumonia
Heart Failure
Hip and Knee
Clinical Focus Area
Q4-03
Q1-04
Q2-04
Q3-04
Q4-04
Q1-05
Q2-05
Q3-05
Q4-05
© Premier 2006
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A Business Case for Quality
• Traditionally in healthcare the
relationship between cost and quality
has not been consistently demonstrated.
• Early analyses focused on cost and
quality at the hospital level.
• In the HQID, the composite quality score
is compared to hospital cost within each
clinical group.
© Premier 2006
Hospital cost – quality relationship
Community Acquired Pneumonia: Composite Quality Score & Cost Comparison
HQID Project Participants
October 1, 2004 - June 30, 2005 (First 3 Quarters Year 2, Preliminary Data)
December 15, 2005
N of Hospitals = 254 (discharge > 22)
Average Cost, $7.14
100%
95%
1st Decile, 90.07%
2nd Decile, 88.31%
85%
80%
8th Decile, 77.70%
Bottom Decile, 74.55%
75%
Composite Quality Score
90%
70%
65%
60%
$18
$16
$14
$12
$10
$8
$6
$4
$2
Wage and Severity Adjusted Cost
(In Thousands of $'s, Cost Based Only on Patients in APR-DRG's 137, 139, 720)
© Premier 2006
5
Refocused on Reliable Care
Modified analyses to look at patient level
– examined exposure to “reliable care”
Reliable defined as:
The consistent execution of evidencebased care processes
or
The right care to the right patient at the
right time in the right place
© Premier 2006
“Performance Pays” Study
• Over 75,000 Patients Studied in High-volume
Clinical Focus Areas (Medicare patients only)
– Medical: Pneumonia
– Surgical: Heart Bypass Surgery
• Evidence-based Care Processes Studied
– Quality measures (process) from CMS/Premier P4P
demonstration
– Industry-supported, uncomplicated measures
• Cost and Outcome Elements Studied
– Total hospital cost for patient
– Patient readmission and complications
– Patient length of stay in hospital
– Mortalities
© Premier 2006
6
Reliable Care Costs Less (PN)
Pneumonia - Average Total Cost (Hospital) Per Discharge by Patient Process Measure Category
HQID Year One (Oct 03 to Sept 04)
N = 59,116
$12,000
$11,000
$10,298
$10,000
$9,158
$9,000
$8,412
$8,000
$7,000
$6,000
Low (0% to 49%)
Medium (50% to 74%)
High (75% to 100%)
© Premier 2006
Reliable Care Reduces Length of Stay (PN)
Pneumonia - Average Length of Stay by Patient Process Measure Category
HQID Year One (Oct 03 to Sept 04)
N = 59,129
9
7.8
8
7.0
7
6.5
6
5
4
Low (0% to 49%)
Medium (50% to 74%)
High (75% to 100%)
© Premier 2006
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Reliable Care Reduces Readmissions (PN)
Pneumonia - Percent of Patients Readmitted by Patient Process Measure Category
HQID Year One (Oct 03 to Sept 04)
N = 54,699
17%
15.7%
15%
14.6%
13.8%
13%
11%
Low (0% to 49%)
Medium (50% to 74%)
High (75% to 100%)
© Premier 2006
Reliable Care Reduces Complications (PN)
Pneumonia - Percent of Patients With Complications by Patient Process Measure Category
HQID Year One (Oct 03 to Sept 04)
N = 59,129
6%
5%
4.5%
4.0%
4%
3.4%
3%
2%
Low (0% to 49%)
Medium (50% to 74%)
High (75% to 100%)
© Premier 2006
8
Reliable Care Reduces Mortality (CABG)
CABG - Mortality Rate by Patient Process Measure Category
HQID Year One (Oct 03 to Sept 04)
N = 18,095
12%
11.0%
10%
8%
6.2%
6%
4%
1.6%
2%
0%
Low (0% to 49%)
Medium (50% to 74%)
High (75% to 100%)
© Premier 2006
Composite Quality Score Compared to Appropriate
Care Score
CABG Composite Quality Score, Composite Process Score and Perfect Process Score
HQID Participants, Yr 2 YTD (October 2004 through June 2005)
100%
Reliable,
equitable care
80%
60%
40%
Unreliability in
delivery system
20%
0%
Perfect Process Score
Composite Process Score
Composite Quality Score
© Premier 2006
9
Challenges and recommendations
• Aligning financial incentives and recognition
with quality can drive improvement.
– Need to examine challenges of sustaining
quality and challenge of expanding
measurement
– Need better understanding of
organizational culture
• Deciles are not recommended for national
adoption.
– Focus should be on achievement and
improvement.
© Premier 2006
Challenges and recommendations (cont.)
• Accuracy and interpretation of measure
operational definitions
– National consensus measures should
require developer to keep current
– Expand data collected when appropriate
(e.g., categorical values for reason for
delay)
– Need to push for rapid alignment of
definitions with changes in evidence
– Need to simplify validation processes
© Premier 2006
10
Contact Information
Denise Remus, PhD, RN
Denise_Remus@Premierinc.com
Additional information on HQID available at:
www.cms.hhs.gov/quality/hospital and
www.premierinc.com
© Premier 2006
11