Changes to PerformanceBased Payment Programs
Sule Calikoglu, Ph.D.
Deputy Director of Research and
Methodology
Maryland Quality-Based Payment
Initiatives
QBR
(Quality Based
Reimbursement)
• Clinical Process of
Care Measures
• Patient Experience
of Care (HCAHPS)
• Patient Outcomes
MHAC
(Maryland Hospital-Acquired
Conditions)
• 65 Potentially
Preventable
Complications
Readmissions
ARR Payment
Methodology
Shared Savings
FY 2015 Changes to QBR
• FY 2015 payments:
Performance Period: CY 2013
Base Period: FY 2012
• Eliminated appropriateness of care measurement
from the QBR program
• Removed topped off measures from the opportunity
domain
• Added Patient Outcome Measures: A mortality
measure developed using 3M APR-DRG grouper
risk of mortality (ROM) on admission
QBR MEASURES AND DOMAINS
FY 2014
FY 2015
30%
70%
10%
40%
50%
Clinical
Patient Experience
Outcome
FY 2016
30
%
30
%
40
%
FY 2016 Changes to QBR
• Clinical Measurement and HCAHPS are aligned
with CMS program
–
–
–
–
National Measure list
National Thresholds and Benchmarks
National Data Source
Performance periods (Federal Fiscal Year instead of
Calendar Year)
• New Outcome Measures
– Agency for Health Care Quality Patient Safety Indicators
(10%)
– Central Line Blood Stream Infections (CLABSI) (10%)
Maryland Hospital Acquired Conditions Initiative
• Implemented in July 2009
• Relies on Present on Admission Indicators
(POA) for secondary diagnosis
• PPCs are defined as harmful events
(accidental laceration during a procedure) or
negative outcomes (hospital acquired
pneumonia) that may result from the process
of care and treatment rather than from a
natural progression of underlying disease.
FY 2015 Changes
• FY 2015 payments:
Performance Period: CY 2013
Base Period: FY 2012
• Added Improvement Scale based on comparing
hospital’s performance to their own base line
• Raised the bar by expected MHAC values at the
85% of the state average
• Excluded two types of cases from counts of PPCs
• Hospice Palliative Care Patients (defined as cases with ICD-9
code = V66.7)
• Patients with more than 6 PPCs
MHAC Components
Attainment Scale
Improvement Scale
• Includes 50 PPCs selected
based on clinical and data
quality
• Score is based on case-mix
adjusted PPC rates weighted
by the estimated resource use
• Revenue neutral scaling
• Rewards are given if a hospital
performs better than 85
percent of state average.
• Maximum reduction is 2 % of
total inpatient revenue
• Includes 5 PPCs that are high
cost, high prevalence and high
priority
• Measures percent change from
a base year for each hospital
• Revenue neutral scaling
• Rewards are given if a
hospitals improves more than
the current median
improvement in the base year.
• Maximum reduction is 1 % of
total inpatient revenue
New Improvement List for FY2016
PPC
Number
PPC DESCRIPTION
24Renal Failure without Dialysis
5Pneumonia & Other Lung Infections
35Septicemia & Severe Infections
9Shock
6Aspiration Pneumonia
16Venous Thrombosis
48Other Complications of Medical Care
Inflammation & Other Complications of Devices, Implants
52 or Grafts Except Vascular Infection
Post-Operative Infection & Deep Wound Disruption Without
37 Procedure
7Pulmonary Embolism
54Infections due to Central Venous Catheters
31Decubitus Ulcer
42Accidental Puncture/Laceration During Invasive Procedure
49Iatrogenic Pneumothrax
Post-Operative Wound Infection & Deep Wound Disruption
38 with Procedure
28In-Hospital Trauma and Fractures
66Catheter-Related Urinary Tract Infection
Number of
Number of
Hospitals with
Complications PPC
COST per PPC Total PPC Cost
3150
46
$9,602
$30,246,300
1082
46
$20,455
$22,132,310
919
43
$22,175
$20,378,825
904
44
$20,538
$18,566,352
704
45
$14,121
$9,941,184
544
41
$17,760
$9,661,440
392
42
$19,703
$7,723,576
581
44
$12,516
$7,271,796
467
431
150
157
772
207
40
43
32
33
43
38
$15,520
$16,203
$38,685
$35,691
$6,621
$7,341
$7,247,840
$6,983,493
$5,802,750
$5,603,487
$5,111,412
$1,519,587
60
100
91
25
34
26
$13,003
$7,199
$5,671
$715,165
$691,104
$487,706
Source: HSCRC Casemix Data FY 2013
HSCRC Progressively Increased
the Revenue at Risk
State Fiscal Year
MHACs
QBR
FY 11
0.5%
0.5%
FY 12
1%
0.5%
FY 13
2%
0.5%
FY 14
2%
0.5%
FY15
2% +1 % (improvement)
0.5%
FY16
2% +1%
1%
Continuous Improvement and
evaluation
• QBR: incorporates new measures and increase their
contribution to the overall score
– HCAHPS, Mortality, Patient Safety Indicators
• MHAC: more aggressive benchmarks and evaluation of
PPC selection to the program
• Coding audits and POA screens
Readmissions:Episode-Based Payment
Admission-Readmission
Program (ARR)
• All-Cause 30-Day
Readmissions and
Admissions
• All Payer
• Most Hospitals other than
TPR
• Implemented in FY2012
ARR
Bundling
approach
All-cause ,
All DRG
(same
hospital)
Risk
adjustment
using APRDRGs
Savings to
payers “off
the top”
Episode Development
• Maryland establish an episode-based payment that covers both the
initial admission and any subsequent re-admission HSCRC establishes
Previously…..
Acute Hospitalization
DRG pmt
$10,000
Expanded Time Frame
30 day “window”
Readmission 1
DRG pmt
$9,000
an expanded Episode
Bundle
Readmission 2
DRG pmt
$6,000
Each paid separately under DRG system =
Additional payment for readmissions
Broader “Scope” – multiple hospitalizations
Establish a “30
day DRG
Episode”
payment amount
or “weight” that
covers both the
initial admission
and ALL
subsequent readmissions
within 30 days
Readmission Shared-Savings
• FY 2014 Rate Adjustment to achieve 0.3%
savings from inpatient revenues
• Based on Case-mix Risk-Adjusted 30-Day
Readmission Rates
• FY 2015: Planned readmissions are
excluded
• Possible Changes for FY 2016
– Incorporation of across hospital readmissions
– Changing the measurement methodology to
align with CMS
Maryland’s Goals
An all payer system that is accountable for the total cost of care on
a per capita basis is an effective model for establishing policies and
incentives to drive system progress toward achieving the three part
aim of enhanced patient experience (including quality and
satisfaction), better population health, and lower costs.
Maryland’s
All Payer
Model
• Enhance Patient Experience
• Better Population Health
• Lower Total Cost of
Care
New Waiver and Performance-Based
Payment
30%
Reductions
in HospitalAcquired
Conditions
Readmission
Target to
Achieve
National
Rate
Potentially
Avoidable
Utilization
Other
Population
Health
Metrics
Stake Holder Engagement Work Groups
Performance Measurement
• Develop State-wide Targets and Hospital
Performance Measurement
• Potential changes to MHAC, QBR and
Readmission Shared Savings Program
• Measuring potentially avoidable utilization,
readmissions, hospital acquired conditions,
ambulatory sensitive conditions
• Integration of cost, quality and population
health and outcomes