Overview of Quality Reporting,
Payments and Penalties
October 9, 2012
Presenter:
Kimberly Rask, MD PhD
Medical Director
Coordinated Federal Focus on Quality
►
National Quality Strategy
►
DHHS Action Plan
►
Partnership for Patients
►
CMS Quality Improvement
Organization (QIO) program priorities
Partnership for Patients
National Campaign to Align
Priorities and Resources
Two Goals
1. Decrease by 40 percent preventable hospital-acquired
conditions (HACs) by 2013  60,000 lives saved, 1.8
million fewer injuries to patients and $20 billion in health
care costs avoided
2. Reduce 30-day hospital readmissions by 20 percent by
2013  1.6 million fewer readmissions and $15 billion in
health care costs avoided
Multiple Quality Reporting Programs Impact the Bottom Line
Program
Annual Payment Update
Data
Financial impact
Inpatient Quality
Reporting – core
measures
2%
Outpatient Quality
Reporting – core
measures
2%
Patient satisfaction,
core measures, mortality,
cost, infections
1% withhold; can lose the 1%, get
some back or even receive > 1% for
excellent performance
2 % withhold in FY 2017
Readmissions Reduction
Program
Excess readmission rate
Up to 1% in 2012-13
Up to 2% in 2013-14
Up to 3% after 2014
Preventable health care
acquired conditions
(HACs)
Claims for HACs
Value Based Purchasing
No payment unless condition
noted on admission
Three Essential Questions …
1. What “triggers” the penalty/incentive?
2. What is its “size”?
3. How is it applied?
Hospitals Paid to Report Quality Data
Program
Data
Annual Payment Update
Program
Data
Financial impact
Inpatient Quality
Reporting- core
measures
2%
Outpatient Quality
Reporting- core
Financial impact
measures
2%
Inpatient Quality
Reporting- core
measures
2%
Outpatient Quality
Reporting- core
measures
2%
Annual Payment Update
Value Based Purchasing
Patient satisfaction,
core measures,
mortality, cost,
infections
1% withhold; can lose the 1%, get
some back or even receive > 1% for
excellent performance
2 % withhold in FY 2017
Readmissions Reduction
Program
Excess readmission
rate
Up to 1% in 2012-13
Up to 2% in 2013-14
Up to 3% after 2014
Preventable health care
acquired conditions (HACs)
Claims for HACs
No payment unless condition noted
on admission
“Pay for Reporting” Programs
►
►
►
Participation is “voluntary”
Those who choose NOT to participate
will have 2% reduction in their Medicare
Annual Payment Update (APU) for the
following CMS fiscal year for each
program
Focus on timely, complete and accurate
reporting
What data is collected?
►
►
►
►
2004: Hospitals voluntarily report 10 measures; agree to
public reporting of data reported to receive incentive APU
2005-2012: New measures added yearly:
– AMI patients, congestive heart failure patients,
pneumonia patients
– Surgical patients (Surgical Care Improvement Project
or SCIP)
– Children’s asthma
2007: Added mortality rates
2008: Added patient satisfaction survey
What data is collected?
2009: Added readmission rates
► 2011: Added hospital acquired infection rates
► 2012: Composite patient safety measure
► 2013: Permutations on previous measures
─ Hospital-wide all-cause unplanned admissions
─ Hospital-level readmission rate following
elective total hip or total knee arthoplasty
─ Hospital-level complication rate following
elective total hip or total knee arthoplasty
►
Healthcare-Associated Infections (HAI)
► Data
is submitted to the CDC’s National
Healthcare Safety Network (NHSN)
–
–
–
Central-Line Associated Bloodstream
Infection (CLABSI)
Surgical Site Infection (SSI)
Catheter-Associated Urinary Tract Infection
(CAUTI)
Quality Measures Reporting
Each measure’s specific data can be collected
either retrospectively or concurrently
► The same data is submitted to The Joint
Commission and CMS – used for quality
improvement and public reporting
– Quarterly
– Hospital Compare website
– Validation
►
Quality Reporting
Pay for Performance
Program
Value Based Purchasing
Data
Program
Inpatient Quality
Reporting- core
measures
Data
Patient satisfaction,
core measures,
Financial cost,
impact
mortality,
infections
2%
Annual Payment Update
Outpatient Quality
Reporting- core
measures
2%
Value Based Purchasing
Patient satisfaction,
core measures,
mortality, cost,
infections
1% withhold; can lose the 1%, get
some back or even receive > 1% for
excellent performance
2 % withhold in FY 2017
Readmissions Reduction
Program
Excess readmission
rate
Up to 1% in 2012-13
Up to 2% in 2013-14
Up to 3% after 2014
Preventable health care
acquired conditions (HACs)
No payment unless condition noted
on admission
Financial impact
1% withhold; can lose the 1%, get
some back or even receive > 1% for
excellent performance
2 % withhold in FY 2017
Value-based Purchasing
Moving from Pay for Reporting to Pay for
Performance
► Authorized under the Affordable Care Act
► Funded by a 1% withhold from hospital
DRG payments
► Minimum of 10 cases for process and outcome
measures over 9 month performance period
► Minimum of 100 satisfaction surveys
►
Hospital Total Performance
70%
12 clinical processes of care
►
►
►
►
2 AMI measures
1 HF measure
2 pneumonia measures
7 SCIP measures
• Antibiotic selection, given within
1 hour, discontinued
• Controlled 6 a.m. glucose
• Beta blocker continued
• VTE prophylaxis ordered and given
30%
8 patient experience measures
►
Nurse communication
►
Doctor communication
►
Staff responsiveness
►
Pain management
►
Medication communication
►
Cleanliness and quiet
►
Discharge information
►
Overall hospital rating
How will hospitals be evaluated?
Achievement
Improvement
Current hospital performance
compared to ALL HOSPITALS
baseline rates
Current hospital
performance compared to
OWN BASELINE rates
► Minimum
thresholds to receive any points
► Benchmarks to receive full points
No “trigger”
Program will be budget neutral overall
► Some hospitals will not earn back everything
that they had withheld for the pool and some
hospitals will earn back more than what they
had withheld
►
►
–
2% of hospitals projected to earn bonus >0.5%
–
2% will lose >0.5%
Penalty or incentive applied to base operating
DRG payment for each discharge
And looking forward to the next year…
Proposed Domain Weights for Hospital VBP Program
Domain
FY 2014
FY 2015
Clinical processes of care
45%
20%
Patient satisfaction
30%
30%
Outcomes (mortality, patient safety, infections)
25%
30%
Efficiency (Medicare spending per beneficiary)
--
20%
Penalty for Excess Readmissions
Program
Data
Readmissions Reduction
Program
Excess readmission
rate
Program
Data
Financial impact
Financial impact
Inpatient Quality
Reporting- core
measures
2%
Outpatient Quality
Reporting- core
measures
2%
Annual Payment Update
Value Based Purchasing
Patient satisfaction,
core measures,
mortality, cost,
infections
1% withhold; can lose the 1%, get
some back or even receive > 1% for
excellent performance
2 % withhold in FY 2017
Readmissions Reduction
Program
Excess readmission
rate
Up to 1% in 2012-13
Up to 2% in 2013-14
Up to 3% after 2014
Preventable health care
acquired conditions (HACs)
No payment unless condition noted
on admission
Up to 1% in 2012-13
Up to 2% in 2013-14
Up to 3% after 2014
Hospital Readmission Reduction Program
►
►
►
Authorized under §3025 of the
Affordable Care Act
Reduces IPPS payments to hospitals for
excess readmissions after October 2012
In rule-making for 2 years
CMS Implementation
►
Selected 3 conditions
–
–
–
►
►
►
Acute Myocardial Infarction (AMI)
Heart Failure (HF)
Pneumonia (PN)
Calculated “Excess Readmission Ratios” using the
National Quality Forum (NQF)-endorsed 30-day
risk-standardized readmission methodology
Set a 3-year rolling time period for measurement
with a minimum of 25 discharges
October 1, 2012 penalty determination period
was July 2008 to June 2011
Excess Readmission Ratio
► The
ratio compares
Actual number of risk-adjusted readmissions from
Hospital XX to the Expected number of risk-adjusted
admissions from Hospital XX based upon the national
averages for similar patients
► Ratio
> 1 means more than expected readmissions
< 1 means fewer than expected readmissions
Risk Adjustment
►
►
The number of readmissions IS adjusted for
─ Age
─ Gender
─ Coexisting diseases based upon 1-year review of all
inpatient and outpatient Medicare claims for that patient
The number of readmissions is NOT adjusted for:
─ Poverty level in surrounding community
─ Proportion of uninsured patients
─ Racial/ethnic mix of patients
“Many safety-net providers and teaching hospitals do as well or
better on the measures than hospitals without substantial
numbers of patients of low socio-economic status.”
Trigger and Size of Penalty
An Excess Readmission ratio of >1 for any of
the 3 measures (AMI, HF, PN) triggers penalty
► Size of penalty is intended to reflect relative
cost of excess readmissions from Hospital XX
►
─
─
─
─
Claims data used to calculate aggregate Medicare
payments for those 3 conditions and total Medicare
payments for all cases at Hospital XX
Calculated over same time period as readmission ratio
Calculate percentage of Hospital XX’s total Medicare
payments that result from excess readmissions for the 3
conditions
Final penalty is that raw % or 1%, whichever is smaller
Applying the Penalty
►
Applied to base-DRG payment for all fee-for-service
Medicare discharges during the fiscal year (FY)
–
–
►
►
Wage-adjusted DRG payment amount including transfer
adjustment plus new technology payment if applicable
Add-on payments (IME, DSH, outlier, low volume) not
reduced
No bonus for excellent performance
For FY 2013, maximum penalty is 1%
– Impacting more than 2000 hospitals nationally
– Expected to cost hospitals $280 million or 0.3% of the
total Medicare revenue to hospitals
Excess Standardized Readmission Ratio (SRR)
posted on Hospital Compare
Similar but not identical to IQR readmission measure
Similarities
► Same NQF-endorsed 3 risk-adjusted condition-specific
measures
► Same data source
► Same types of discharges and exclusions
Differences
► How the measures are displayed and reported
► SRR calculated on a subset of readmissions
Impact of Reporting on Bottom Line
Program
Program
Data
Data
Preventable health care
Program
Data
acquired
conditions (HACs)
Financial impact
Claims Financial
for HACs
impact
Inpatient Quality
Reporting- core
measures
2%
Outpatient Quality
Reporting- core
measures
2%
Annual Payment Update
Value Based Purchasing
Patient satisfaction,
core measures,
mortality, cost,
infections
1% withhold; can lose the 1%, get
some back or even receive > 1% for
excellent performance
2 % withhold in FY 2017
Readmissions Reduction
Program
Excess readmission
rate
Up to 1% in 2012-13
Up to 2% in 2013-14
Up to 3% after 2014
Preventable health care
acquired conditions (HACs)
Claims for HACs
No payment unless condition noted
on admission
Financial impact
No payment unless condition noted on
admission
Hospital-acquired Conditions (HAC) or
“Never Events”
CMS identified conditions that:
►
►
►
Were high cost, high volume or
both
Result in the assignment to a
DRG that has a higher
payment when present as a
secondary diagnosis
“Could reasonably have been
prevented through application
of evidence-based guidelines”
Foreign Object Retained After Surgery
Air Embolism
Blood Incompatibility
Stage III and IV Pressure Ulcers
Falls and Trauma
Catheter-Associated Urinary Tract Infection (UTI)
Vascular Catheter-Associated Infection
Surgical Site Infection (SSI) Following CABG
SSI Following Bariatric Surgery for Obesity
Manifestations of Poor Glycemic Control
SSI Following Certain Orthopedic Procedures
DVT/PE Following Certain Orthopedic Procedures
HAC Reporting is Changing
►
►
Most individual HACs have been removed
from public reporting
§3008 of Affordable Care Act requires
public reporting of HACs
–
►
CMS is proposing an all-cause harm measure
with potential to “drill down” on Hospital
Compare
Studies show financial impact from current
HAC nonpayment policy is negligible for most
hospitals
Potential New Penalty
► §3008
of the Affordable Care Act also
creates a penalty for lowest performing
hospitals based upon HAC rates by 2015
─
─
Reduction applied to hospitals in the top
quartile of hospital acquired conditions using
“an appropriate” risk-adjustment methodology
Those hospitals will have payments reduced to
99% of amount that would otherwise apply to
such discharges
Questions?
Hospital Inpatient Quality Reporting (IQR) Program
Hospital -Acquired Conditions (HAC) Program
Inpatient Rehabilitation Facility Quality Reporting (IRFQR) Program
Ambulatory Surgical Centers Quality Reporting (ASCQR) Program
Hospital Value-Based Purchasing (VBP) Program
This material was prepared by Alliant GMCF, the Medicare Quality Improvement Organization for Georgia, under contract with the Centers for Medicare & Medicaid
Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No.
10SOW-GA-IIPC-12-233