Improving Patient Quality & Cost Outcomes:
Connecting with the Health Information
Exchange/CRISP
June 1, 2011
Dianne Feeney, Associate Director
for Quality Initiatives
MARYLAND HEALTH SERVICES COST REVIEW
COMMISSION
_______________________
Background
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State of Maryland
• 5.65 Million people
• 12% of population > age
64
• 3rd highest income per
capita state
• 46 acute care hospitals
• $13 billion in hospital
revenue
• 700,000 discharges per
year
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Maryland Health Regulatory
Agencies
.
Governor of Maryland
Maryland
Insurance
Administration
Department of
Health & Mental
Hygiene
Regulates Core
Health Functions:
Medicaid Program
Public Health
Licensing/Certification
Maryland Health
Care
Commission
Regulates:
Cert. Of Need
Report Cards
Small Group Insurance
HSCRC
Hospital
Regulation
Health Services
Cost Review
Commission
Regulates:
Rates/Costs
Of Acute care
Hospitals
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Background: HSCRC and the All Payer
System
 Law enacted in 1971; First set rates in 1974.
 Goals were to correct major problems.
◦
◦
◦
◦
◦
Control rapid cost growth
Improve access to care
Make the system equitable
Provide accountability and transparency
Ensure financial stability and predictability for hospitals and
patients
 Key Components.
◦
◦
◦
◦
All Payer System
Waiver Test
Funding for Hospital Uncompensated Care
Charge per Case (CPC) system
5
HSCRC Quality Initiatives
• Quality Based Reimbursement (QBR)
• Maryland Hospital Acquired Conditions (MHAC)
• Readmission Initiatives:
– Maryland Preventable Hospital Readmissions (MHPR)
– Admission-Readmission Revenue Hospital Payment
Constraint Program (ARR)
6
___________________________
Readmission Initiatives
7
Why Address Readmissions?
• Research shows hospital readmissions are sometimes
indicators of poor care or missed opportunities to better
coordinate care, or poor quality care in the hospital.
• For Medicare, 18% of all Medicare patients discharged from
the hospital have a readmission within 30 days of discharge,
accounting for $15 billion in spending nationally (Medpac
2007).
• For Maryland, the Medicare readmission is the second highest
in the nation at 22%.
• Initiatives need to be put in place that reward efforts that
reduce the number of readmissions and that also increase the
quality of care and decrease cost.
8
Readmission Incentive Programs:
MHPR and ARR Initiatives
•
•
Maryland Hospital Preventable Readmissions (MHPR) Initiative - Using the
PPR methodology as the basis, the MHPR initiative provides a system of
payment incentives based on the added or averted resource use resulting from a
hospital’s actual number of readmissions versus a statewide target rate.
PPR Definition:
A Potentially Preventable Readmission (PPR) is a readmission that is
clinically-related to the initial hospital admission that may have resulted from
a deficiency in the process of care and treatment or lack of post discharge
follow-up.
Admission-Readmission Revenue (ARR) Initiative – Hospitals may volunteer
for the ARR pilot to begin July 1, 2011. Hospitals under ARR will be held to a
standard Charge per Episode (“CPE”) that would provide a combined revenue
constraint for both initial admissions and subsequent readmissions.
– ARR provides a strong financial incentive to put in place the care coordination
mechanisms/infrastructure necessary to reduce the potential for any patient
to be readmitted and keep 100% of the savings associated with that outcome.
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Ensuring Accountability and Quality of
Care for Bundled Payment Structures
•
•
Patient Protection and Accountable Care Act- as providers are gradually given more
responsibility and budgetary autonomy for reducing utilization, they also need to be
held accountable to the public for more efficient and effective operation.
To address unintended consequences, inject rational financial incentives through:
–
use of robust risk-adjustment systems and methods to account sufficiently for variations
in illness severity of patients and appropriately match payment to the required level of
resource use; and
– use of outlier payments and exclusions for unusual cases.
•
•
In order to achieve maximum improvements in the value of the care delivered over
the long-term, financial incentives should be focused equally on improving quality
and containing cost.
Also monitor other utilization trends and system performance metrics over time.
10
Maryland PPR Impact in 2007 for a
15 Day Readmission Time Interval
• 472,380 admissions were candidates for having a
subsequent potentially preventable readmission
• 31,873 admissions were followed by one or more PPRs
• PPR rate is the percent of candidate admissions that were
followed by one or more PPRs
– PPR Rate 6.75 = 31,873 / 472,380
• 38,840 admissions were indentified as PPRs
• PPRs account for $430.4 (5.3%) million in charges and
199,582 hospital bed days
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Maryland PPR Impact in 2007 for a
30 Day Readmission Time Interval
• 452,863 admissions were candidates for having a
subsequent potentially preventable readmission
• 44,417 admissions were followed by one or more PPRs
• PPR rate is the percent of candidate admissions that were
followed by one or more PPRs
– PPR Rate 9.81 = 44,417 / 452,863
• 59,599 admissions were indentified as PPRs
• PPRs account for $656.9 million (8%) in charges and
303,865 hospital bed days
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____________________________
Focus: Unique Patient Identifier
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Maryland Statewide Health Information
Exchange- CRISP
•Chesapeake Regional Information System for our Patients (CRISP)
•Designated Health Information Exchange (HIE) by the Office of the
National for Health Information Technology
•a 501(c)(3) corporation with a mandate to electronically connect all
healthcare providers in the state.
•CRISP’s infrastructure uses a hybrid-federated model that is supported
by two technology vendors. Axolotl Corporation, an Ingenix company,
provides the core infrastructure and Initiate Systems, an IBM company,
provides the master patient index (MPI) technology.
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Proposed New Data Fields
Field Name
Name, First
HSCRC
Current Requirement
No
HSCRC
New Requirement
Yes
Name, Middle Initial
No
Yes*
Name, Last
No
Yes
Date of Birth
Yes
Yes
Gender
Yes
Yes
Street Address
No
Yes
City
No
Yes
State
No
Yes
Zip code
Yes
Yes
Social Security Number
No
Yes*
Medical Record Number (MRN)
Yes
Yes
Date of Admission
Yes
Yes
Date of Discharge
Yes
Yes
Yes*- Required Only if data provided by patient
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Matching CRISP and HSCRC Data for
Readmission Analysis
Using the patient information submitted by the hospital, CRISP will create a master patient
index (MPI) for each unique patient using a probabilistic matching algorithm.
CRISP will be required to provide reports to the HSCRC at the patient level which will include
at least the following fields:
•Enterprise MPI Number
•Hospital/Facility ID
•Medical Record Number
•Date of Admission
•Date of Discharge
The exact list of fields that will be required to match the report from CRISP to HSCRC’s data
set will be determined based on the analysis of a pilot data set. HSCRC may require CRISP
to use an HSCRC algorithm to generate a supplemental HSCRC ID for the purposes of
matching against other hospital reported data.
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Anticipated Timeline for Regulation
Promulgation
4/15 - Commission Meeting: Final Staff Policy
Recommendation presented and approved
•6/17 - Regulation for Proposed Action posted in Maryland
Register with Comment Period through August 1
•8/3 - Commission Meeting Regulation Ripe for Final Action
•12/1 - Regulation Becomes Effective
HOSPITALS ESTABLISH CONNECTIVITY WITH CRISP
•June through November
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_______________________
Appendix: Readmission Data
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Maryland Rates of PPRs
PPR Rate
15 Day Readmission Time Interval
Across Hospital Readmissions
30 Day Readmission Time Interval
Across Hospital Readmissions
2006
6.74
2007
6.74
2006
9.89
2007
9.81
PPR rates consistent between two years
19
8,000
120,000
100%
7,000
6,000
100,000
5,000
80,000
66%
4,000
60,000
3,000
38%
40,000
2,000
20,000
Number of PPRs Per Day
Cumulative Number of PPRs
140,000
1,000
0
0
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
Readmission Time Inteval (Days)
Cumulative Number of PPRs
Number of PPRs Per Day
20
Top 15 Reasons for PPRs - 2007
APR
DRG
720
194
140
130
460
133
721
139
711
137
753
750
45
248
890
SEPTICEMIA & DISSEMINATED INFECTIONS
HEART FAILURE
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
RESPIRATORY SYSTEM DIAG W VENTILATOR SUPPORT 96+ HOURS
RENAL FAILURE
PULMONARY EDEMA & RESPIRATORY FAILURE
POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS
OTHER PNEUMONIA
POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROC
MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS
BIPOLAR DISORDERS
SCHIZOPHRENIA
CVA & PRECEREBRAL OCCLUSION W INFARCT
MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS
Number of
Number of
Total
Admissions
Total
Admissions
Identified Charges for Identified as Charges for
PPRs
a PPR
PPRs
as a PPR
30 Day Window
15 Day Window
3,041 $57,464,024
1,945 $36,578,709
4,712 $45,489,197
2,929 $28,621,634
2,317 $19,740,461
1,338 $11,695,437
352 $19,531,963
247 $13,131,776
1,568 $17,288,207
993 $10,852,746
1,145 $17,236,788
755 $11,477,824
1,241 $13,552,588
904 $9,858,735
1,376 $12,538,408
878 $8,208,719
441 $11,882,757
298 $8,652,870
855 $11,476,928
599 $7,545,054
1,365 $10,923,940
883 $7,083,904
1,085 $10,247,781
678 $6,867,837
796 $9,976,474
550 $6,946,806
890 $9,544,644
562 $5,873,658
335 $9,451,503
231 $6,893,043
Top 15 PPRs represents 42% of charges on PPRs
for a 30 day readmission time window
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Top 15 Initial Admissions followed by
one or more PPR - 2007
APR
DRG
194
140
720
139
175
753
460
463
201
173
198
751
383
221
750
HEART FAILURE
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
SEPTICEMIA & DISSEMINATED INFECTIONS
OTHER PNEUMONIA
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W/O AMI
BIPOLAR DISORDERS
RENAL FAILURE
KIDNEY & URINARY TRACT INFECTIONS
CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS
OTHER VASCULAR PROCEDURES
ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS
MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES
CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS
MAJOR SMALL & LARGE BOWEL PROCEDURES
SCHIZOPHRENIA
Initial
Admissions Percent of
Initial
Followed by
Admissions
PPRs
15 Day Window
5.77%
1,838
3.70%
1,178
3.21%
1,024
2.40%
765
2.31%
737
1.99%
634
2.14%
683
1.90%
606
1.90%
604
1.53%
489
1.70%
542
1.61%
512
1.58%
505
1.66%
529
1.59%
506
PPR
Rate
12.03%
10.02%
10.14%
6.55%
8.02%
7.53%
9.85%
7.60%
6.93%
10.38%
5.93%
6.87%
4.73%
10.36%
9.16%
Initial
Admissions Percent of
Initial
Followed by
Admissions
PPRs
30 Day Window
5.78%
2,567
3.81%
1,693
2.97%
1,321
2.43%
1,078
2.39%
1,063
2.07%
918
2.02%
896
1.88%
836
1.87%
830
1.69%
752
1.69%
752
1.65%
732
1.63%
724
1.62%
718
1.60%
709
PPR
Rate
18.80%
15.67%
14.31%
9.61%
11.81%
11.56%
14.01%
11.11%
9.95%
16.61%
8.68%
10.29%
7.01%
14.14%
13.85%
Top 15 represents 35% of all initial admissions followed by PPRs
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Top Five PPR Reasons for an Initial
Admission of Heart Failure - 2007
Number of
Number of
Admissions
Total
Admissions
Total
Identified Charges for Identified as Charges for
as a PPR
PPRs
a PPR
PPRs
APR
DRG
15 Day Window
30 Day Window
194 HEART FAILURE
962
$9,109,280
1,557 $14,239,684
460 RENAL FAILURE
104
$1,335,969
150
$1,969,758
720 SEPTICEMIA & DISSEMINATED INFECTIONS
97
$1,627,948
135
$2,535,465
140 RESPIRATORY SYSTEM DIAG W VENTILATOR SUPPORT 96+ HOURS
84
$691,335
134
$1,164,383
133 PULMONARY EDEMA & RESPIRATORY FAILURE
80
$1,044,021
113
$1,523,105
All Other PPRs
1,602 $14,813,081
2,623 $24,056,802
Total PPRs for Initial Admission of Heart Failure
2,929 $28,621,634
4,712 $45,489,197
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Length of Stay and Charges for Initial
Admissions Followed by a PPR within a
30 Day Readmission Time Interval - 2007
Number of
Admissions
At Risk Not Followed by PPRs
(Other Admission)
At Risk Followed by PPRs
(Initial Admission)
408,446
44,417
CMI
Average
Length of Average
Stay
Charge
3.75
$10,834
3.58
$10,337 CMI Adjusted
5.47
$14,930
4.16
$11,368 CMI Adjusted
1.0481
1.3133
Patients readmitted had a longer LOS than
those not readmitted.
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