Quality….. The True Sustainable Strategy To Ensure Viability L. Keith Granger Chair – AlaHA Quality Task Force October 3, 2017

Federal quality measurement and transparency 2005 Hospital Compare is launched 2012 Value-based purchasing 2013 Readmission penalties 2015 Penalty for being in top poorest performing quartile of HACs 2015 Meaningful Use Penalties began About 9% of Medicare payments at risk Add that this is not just Medicare payments: Mention insurers negotiations based on quality Medicaid instituting quality measures

Hospital Compare Website Value Based Purchasing (VBP) Readmissions Reduction Program (RRP) Hospital Acquired Conditions (HAC) Comprehensive Care for Joint Replacement (CJR) Episode Payment Model (EPM)

9/27/17 CMS announced it will not update the overall hospital quality star rating in October.

IS IT PAY FOR PERFORMANCE OR PENALTY FOR FAILURE TO PERFORM ???

Do you really have a TEAM? Quality Clinical (nursing and ancillaries) Medical Staff Finance Risk, IP, Wound Care, etc. Case Management Others

Impact Areas Reputation Clinical Efficiency/Outcomes Financial Security

VBP --- Started with a bang In the first year of CMS’s value-based purchasing program, Alabama hospitals ranked number one in quality performance and quality improvement. As a result, Alabama’s hospitals received the second largest bonus payment, $1.9M, of any state – 113 percent of pool Estimates for FY2018 Alabama rank – 40! Alabama estimated to lose $2.1 million ($12 million in worst case scenario on this single program) In the first year of value-based purchasing, Alabama scored well on the improvement points. Now that we’ve made great improvements, the outcomes or achievement points are more important, and that’s where Alabama is not doing so well.

Domain weights over time

Alabama VBP Trends Statewide Performance Percentage (remove Payback)

Domain Weighting for FY2018 VBP Patient Experience of Care—25% Clinical Care—25% Safety of Care—25% Efficiency and Cost Reduction: 25%

FFY 2018 (Based on FFY 2017 Performance) Alabama Hospitals IN-PLAY LOSS PROJECTED VBP (2% of Payment) (38 Hospitals Penalized) $30,374,200 $2,124,900 Readmission (3% of Base) (70 Hospitals Penalized) $46,375,251 $12,642,000 HAC Penalty (1%) (14 Hospitals Penalized) $18,784,487 $1,820,300 TOTAL $95,533,968 $15,587,200

No specific reimbursement tied to Star Rating…… but …… Hospital Compare Update 2nd Quarter 2017 Overall Star Rating: 1-5 Stars Q2 2016 thru Q4 2016 HCAHPS Star Rating Q1 2015 thru Q2 2017 HCAHPS Star Rating Breakdown by Measure No specific reimbursement tied to Star Rating…… but ……

Safety of Care Measures 6 Hospital Acquired Infection HAI Measures Q2 2014 thru Q2 2017 for data that is complete Patient Safety PSI-90 Q3 2013 thru Q2 2016 (* PSI not updated due to AHQA software issues) Process Measures: IMM-2, AMI-7a, PC-01 For 2018 IMM-2 and AMI-7a will be removed along with process domain. PC-01 will go to safety domain.

Safety of Care Measures CLABSI (ICU & Select Wards – HAI-1) CLABSI (ICU Only – HAI-1a) CAUTI (ICU & Select Wards – HAI-2) CAUTI (ICU Only – HAI-2a) SSI (Colon – HAI-3) SSI (Abdominal Hysterectomy – HAI-4) MRSA (HAI-5) C-Diff (HAI-6) Patient Safety Indication Composite (PSI-90)

VBP – Patient Outcomes Composite taken from 2 SSI categories. Clinical Care Process Measures Patients assessed and given Influenza vaccination (IMM-2) Fibrolytic Therapy within 30 minutes of hospital arrival (AMI-7a) Elective Delivery Prior to 39 Weeks (PC-01)

Patient Experience of Care Q2 2014 – Q2 2017 10 measures (technically become 9 measures): Patient Experience (CJR & EPM) – Q3 2015 thru Q2 2017 Not the same as VBP CJR and EPM use linear mean score for each and use all “Would you recommend” scores. Communication with Nurses Communication with Physicians Responsiveness of Hospital Staff Pain Management Communication about Medication Patient Rooms and Bathrooms Kept Clean Quietness Around Patient Rooms Discharge Information Overall Rating of Hospital 3 Item Care Transition Measure (CTM-3) Combined on VBP

Outcome of Care Measures 5 Mortality and 1 Complications Rate measures Q4 2014 – Q2 2017 (where complete data is available) The 6 Patient Outcomes: AMI - 30 day mortality (MORT-30-AMI) HF - 30 day mortality (MORT-30-HF) PN - 30 day mortality (MORT-30-PN) COPD - 30 day mortality (MORT-30-COPD) CABG - 30 day mortality (MORT-30-CABG) Risk Standardized Complications Rate (RSCR) Following elective primary Total Hip (THA) and Total Knee Arthroplasty (TKA) *Q2 2016 – Pneumonia Readmission expanded to include aspiration pneumonia and patient with sepsis and secondary diagnosis of pneumonia (therefore previous periods are not comparable)

Readmission Measures Readmission Measure – 6 measures Q4 2014 – Q2 2017 AMI 30 day readmissions rate HF 30 day readmissions rate PN 30 day readmissions rate COPD 30 day readmissions rate CABG 30 day readmissions rate RSCR Risk Standardized Complications Rate following Total Hip and Total Knee – 30 day readmissions rate *Q2 2016 – Pneumonia Readmission expanded to include aspiration pneumonia and patient with sepsis and secondary diagnosis of pneumonia (therefore previous periods are not comparable)

Efficiency Measure Medicare Spending per Beneficiary Q4 2013 through Q3 2016

AL Lowest Scoring Areas for Action Measure Rank Hip/Knee Complications 47th HCAHPS – Patient Information for Recovery at Home 36th HCAHPS – Patient Understanding Their Care Leaving Hospital 40th MRSA 42nd AMI – Mortality (30 day) 48th CABG – Mortality (30 day) 46th Pneumonia – Mortality (30 day) 45th PSI 4 – Deaths Serious Treatable Complications After Surgery 49th SSI Abdominal Hysterectomy 30th Readmissions – HIP/KNEE 50th Readmissions – AMI 41st

AlaHA Contacts Rosemary Blackmon Margaret Borders Wesley Ashmore

Do you really have a TEAM? Quality Clinical (nursing and ancillaries) Medical Staff Finance Risk, IP, Wound Care, etc. Case Management Others

Questions?