Oscar Ibarra & Katie Eckert

• Changes to reporting requirements under the new Waiver Model
• New Tape Layout and Fields
• New timeline for reporting
• Issues with FY 2014 Q1 Data
• Quarterly Reconciliations

• Separate variables for each race category to accurately capture each component of the patient’s race (i.e., White and Black, or Black and Asian, etc.).
• Variable to capture the patient's country of origin, and
• Variable to capture the patient’s preferred spoken language for a health-related encounter

Month-Ending Data
January and February 2014
Updated January, February and March 2014
April 2014
Q3 Final (Jan – Mar 2014)
Updated April and May 2014
Updated April, May and June 2014
Q4 Final (Apr – Jun 2014)
Due Date
March 17 th*
April 15 th
May 15 th
May 30 th
June 16 th
July 15 th
August 29 th

• Medicaid ID errors
• Preferred language
• Race variables left blank
• Variations in zip code to county mapping
• Reconciliations between case mix and financial data

• Potentially add the CMS discharge disposition for planned admissions
• New waiver requirements based on residency, coding zip code accurately will be essential
• Transition to ICD -10
– Working with MHA around testing grouper software and submission of test data to St. Paul

• Data & Infrastructure Workgroup
– Will develop Data recommendations to the
HSCRC for the new hospital All-Payer Model
– Public meetings
• Kick off Feb 6
• Data Workgroup
– Discuss new data elements for the coming FY
– Discuss data issues
– Case mix liaison participation

Brave New World: Changes to Hospital
Reporting Under the NEW Waiver
1. Changes to Traditional HSCRC Data Submissions
2. New Metrics to Monitor
3. New Platform for Reporting

Changes to Traditional HSCRC Data
Submissions
1. Case Mix: Accelerated case mix reporting  the deadlines are changing.
2. Financials : “Enhanced” monthly financial submissions  more data elements

• Final Data:
– OLD: Data reported approximately 90 days after quarter-end.
– NEW: Data reported approximately 60 days after quarter-end.
• Preliminary Data:
– OLD: Quarterly data reported approximately 45 days after quarterend
– NEW: Quarter-to-Date data reported approximately 15-17 days after month-end.
• HSCRC Goal: Monitor tenants of waiver on a more concurrent basis.

• 20-30% reduction in the number of days to finalize abstract data
– Chart Audits
– MHAC monitoring
– Clinical Documentation
– Curveball!: ICD-10 and additional HSCRC focus on quality metrics

“Enhanced” Monthly Financial Submission
• “Enhanced” elements
– 4 data points now expanded to 36 data points
– IP/OP now split into In-State vs. Out-of-State
– IP/OP for Medicare (Fee-For-
Service vs. Non Fee-For-
Service) also split into In-
State vs. Out-of-State

• New Internal Reports for Revenue and Utilization:
– State data and payer data are sourced from patient account data in the patient accounting system and do not pass to traditional financial statements.
– More data points from “live” patient data makes it even more important to lock down posted financials in order to avoid reconciling items.
• Submission
:
– Data Reporting 101: more data points = more room for error
– OLD: Manual Submission NEW : Upload Submission?

• Reconciling:
– In-State vs. Out-of-State Split : reconcile back to traditional Experience
Report data
– Payer Split: Only reporting Medicare utilization.
• A separate reconciliation outside of the HSCRC submission is required to make sure that the “sum of the parts equals the whole” for all payers

Brave New World: Changes to Hospital
Reporting Under the NEW Waiver
1. Changes to Traditional HSCRC Data Submissions
2. New Metrics to Monitor
3. New Platform for Reporting

• Rate of Change in Cost per Capita
• Market Share
• Potentially Avoidable Utilization (PAUs)
– Inter/Intra Readmissions
– Monthly MHAC + PPC Reporting

• Two explicit “per capita” tests under the new waiver
– All Payer Revenue Growth Rate Test
– Medicare Savings Test

• What is it?
– Annual growth rate in total per capita hospital charges must not exceed 3.58% for CY2014-CY2016 for
Maryland residents in Maryland hospitals
• Why is this important to Hospitals?
– HSCRC staff will need to take action to reduce hospital charges if test is in jeopardy.

• What is it?
– Rate of growth in Medicare's per capita hospital payments must be less than the national average growth rate for Maryland residents by at least $330 million for
CY2014-CY2018
• Why is this important to Hospitals?
– HSCRC staff will need to take action to reduce hospital charges if test is in jeopardy.

• Rate of Change in Charges per Capita
Hosptial Gross Charges
# of People in Defined Population
• Rate of Change in Medicare
Payments per Capita
Medicare Payments to Hosptial
# of Medicare Beneficiaries in Defined Population
• Time Period:
– Calendar Year
– Rate Year
• Changes in Charges
– Inpatient
– Outpatient
– Observation
– Admit Source/Source of
Arrival
• Changes in Population
– Hospital
– Primary Service Area
– State

Rate Year: July- June
Calendar Year: January- December
• The HSCRC will be monitoring Calendar Year performance for the waiver.
• Consider creating additional internal reports for compliance on a calendar year basis

• What is it?
– a measurement of the population's utilization of a hospital’s services in a given geographic area over a period of time as compared to other hospitals.
• Why is this important to hospitals?
– Global budgets will be adjusted to match utilization.
– The methodology for market share adjustments hasn’t been finalized. The HSCRC has requested white papers from the
Industry.
• Recommendation for Hospitals:
– monitor market share as best you can with available data

18,00%
16,00%
14,00%
12,00%
10,00%
8,00%
6,00%
4,00%
2,00%
0,00%
• What is it?
– Reduce the Medicare readmissions rate to the national level in 5 years (CY2014-CY2018)
Relative Readmission Rates
MD to Nation

• Why is this important to Hospitals?
– ALL Readmissions (no distinction between intra and inter)
– Maryland’s focus up until now for reporting purposes has been intra-hospital readmissions
– Value-based annual financial adjustment

Readmissions: What Should Hospitals Monitor?
• Time Period: CY vs. RY
• Intra vs. Inter
• Medicare vs. All Payers
• Benchmarks: State vs.
Nation vs. Peers
• Service Line

Raising the Bar: Qualitybased Reimbursement (“QBR”) and Maryland Hospital Acquired Conditions (“MHAC”)
• What is it?
– QBR and MHAC are Maryland’s versions of CMS’ Value Based
Purchasing (VBP) and Hospital Acquired Conditions (HAC) programs.
– Quality-based policy tools

• New waiver
• Reduce Potentially Preventable Complications (a.k.a MHACs) by
30% in five years (CY2014-CY2015)
• Workgroups will be modifying MHAC policy to align with the new waiver requirements
• Scaling:
• MHAC and QBR scaling will be even more relevant under GBR because it’s one of the few variable update factors for hospitals
• More Financial Risk: FY2016 QBR: 0.5%  1.0% base approved hospital inpatient revenues

Potentially Avoidable Utilization (PAUs)
• What are PAUs?
– 30- Day Readmissions/Rehospitalizations (includes ER)
– Preventable Admissions (Admissions for ambulatory sensitive conditions) (based on AHRQ Prevention Quality Indicators)
– ER visits than can be treated in other settings
– Maryland Hospital Acquired Conditions (MHAC) a.k.a
Potentially Preventable Complications

Potentially Avoidable Utilization (PAUs)
• Why are they important?
– Cost & Quality : Crosses the 3 major tenants of waiver (cost per capita, readmissions, quality)
– Financial Performance : In a GBR world if you can reduce inappropriate volumes, you can reduce excess cost and therefore improve operating margins (or reinvest).

Brave New World: Changes to Hospital
Reporting Under the NEW Waiver
1. Changes to Traditional HSCRC Data Submissions
2. New Metrics to Monitor
3. New Platform for Reporting

CRISP: NEW Platform for Hospital Analytics
• C hesapeake R egional I nformation S ystem for our
P atients or (“CRISP”)
• Maryland’s state designated health information exchange (“HIE”).
• Not-for-profit organization charged with electronically connecting healthcare providers across the region.

CRISP: NEW Platform for Hospital Analytics
• CRISP receives real-time encounter messages (called “ADTs”) which carry facility, medical record number, visit IDs, and other important information about visit.
• Unique Aspects of ADTs:
– Enable population-health analysis (unduplicated users across hospitals)
– Real –Time data flows
– Street address, enabling more granular level of geographic analysis
• Linked ADT and HSCRC Abstract Data enable more analysis
– Inpatient matching rate: 99.98%
– Outpatient matching rate: 99.86%

Potential Linkage : All-
Payer Claims Database

• Unique patient ID assigned to each individual across hospitals
• Real-time ADT with geo-code
• Real-time ADT reconciles to HSCRC tapes
• Coordination of logic with HSCRC reimbursement policies

• Tape Data reconciled to CRISP’s unique patient ID supports: POTENTIAL
– New Policies: Data is a shared resource to support policymakers, payers, and providers respond to new policy direction.
–
Population Health : CRISP data can support care coordination activities/analytics for populationbased models ( TPR/GBR).

Overview of CRISP Reports
CRISP has developed the capability to generate reports through a combination of
CRISP data and HSCRC tape data. Initial ideas have focused on:
Readmission analysis reports (HSCRC or CMS methodology)
 Monthly reports with patient drill downs
 Year-to-year and monthly

By hospital, zip, region, county, HEZ

By diagnosis or disposition
Market share analysis
 Clinical service line utilization by hospital PSA

By majority of inpatient visits, total visits, etc.

By diagnosis and charges
Analysis of Potentially Avoidable Volume
 Visits with ambulatory sensitive conditions

Readmission

Market share shifts
Uncompensated Care/ACA Impact
 Using CRISP EID to link insurance status and UCC use across time periods
36

High utilization analysis

By # of visits, LOS, date, overlap, etc.
 By census tract or neighborhood
 By diagnosis, disposition, or charges
Hospital Utilization by diagnosis, disposition, charges using HSCRC data

County reports (patients, discharges, readmits by diagnosis)
Patient attribution analysis
 Based on prior visits

Identify exclusive patients and % of visit allocation by patient
 By census tract or neighborhood

By diagnosis and charges
Episode of Care analysis
 All subsequent hospital visits after discharge

By diagnosis or disposition
 By census tract or neighborhood

• Hospitals are being asked to produce:
– MORE data
– MORE accurately
– FASTER
• Lots of rapid changes happening for hospital reporting

Oscar Ibarra
Chief, Information Management and Program
Administration
HSCRC
Oscar.Ibarra@maryland.gov
Katie Eckert, CPA
Director, Budget & Reimbursement
Bon Secours Baltimore Health System katie_eckert@bshsi.org