Hospital-Acquired Condition (HAC) Reduction Program for FY 2015 Implementation of the Hospital-Acquired Condition (HAC) Reduction Program for FY 2015 Jeanne Dufresne This material was prepared by Masspro, the Medicare Quality Improvement Organization for Massachusetts, 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 represent CMS policy. 10-ma-ptcare-14-274-hac-reduction-ppt-Jan14

To Educate Participants of the Following: OBJECTIVES To Educate Participants of the Following: CMS’ Implementation of the Hospital Acquired Condition Reduction Program The Three Measures Involved in the FY 2015 HAC Program The Two Domains that Performance will be based on The Possible Payment Reduction based on Performance

HAC REDUCTION PROGRAM General Framework for the Implementation of the HAC Reduction Program for FY 2015 Relevant Definitions Applicable to the Program Payment Adjustment under the Program Measure Selection and Conditions for the Program Scoring Methodology Performance Scoring Process for making Hospital-Specific Performance Information available to the Public, Including the Opportunity for a Hospital to Review the Information and Submit Corrections FY 2014 IPPS/LTCH PPS proposed rule (78 FR 27622 through 27636)

(Current) Hospital Acquired Condition Program HAC REDUCTION PROGRAM (Current) Hospital Acquired Condition Program VS. (New) Hospital-Acquired Condition Reduction Program

CURRENT HAC PROGRAM Part of the Deficit Reduction Act of 2005

What is a Hospital Acquired Condition? Hospital Acquired Conditions or HACs are Conditions that Patients Acquire while Receiving Treatment for Another Condition in an Acute Care Health Setting. HACs also include Hospital Acquired Infections (HAIs) such as Surgical Site Infections, as well as Conditions such as Foreign Objects Retained after Surgery “Tens of thousands of lives are forever changed each year as a result of healthcare errors. There is a critical need to enhance health system capacity, so that all patients will receive care that is safe and effective.” - NQF President and CEO Janet Corrigan (2008)

A Present on Admission (POA) value of N or U A HAC REQUIRES: A Qualifying Diagnosis Code as One of the First Eight Secondary Diagnoses (i.e., diagnoses 2 through 9; not 10 or beyond) AND A Present on Admission (POA) value of N or U N = Diagnosis was not present at time of inpatient admission. U = Documentation insufficient to determine if the condition was present at the time of inpatient admission. HAC reporting counts all HACs Regardless of the effect on DRG assignment

Hospital-Acquired Conditions (Present on Admission Indicator) Hospital Acquired Condition Program Hospital-Acquired Conditions (Present on Admission Indicator)

2005 Section 5001(c) of Deficit Reduction Act of 2005 requires the Secretary of the Department of Health and Human Services (DHHS) to identify Hospital-Acquired Conditions (HACs) that: Are High Cost or High Volume or Both Result in the Assignment of a Case to a Diagnosis-Related Group (DRG) that has a Higher Payment when Present as a Secondary Diagnosis Could Reasonably have been Prevented through the Application of Evidence-Based Guidelines Since October 1, 2007, hospitals have been required to submit information on Medicare claims specifying whether diagnoses were Present on Admission (POA). Data Source: Quality Net

2008 Starting with October 1, 2008 Discharges, the Centers for Medicare & Medicaid Services (CMS) selected 10 Categories of Conditions for a HAC Payment Provision. Hospitals no longer received additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present. Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule

2009 Initiatives to reduce HACs continued in 2009 when The National Coverage Determinations (NCDs) for the Medicare Program was developed to eliminate ‘‘never events”. These ‘‘never events’’ stemmed from a 2002 report conducted by the NQF that listed 27 adverse events, listed as serious reportable events, that were both serious and largely preventable. Under these NCDs, Medicare does not cover a particular surgical or other invasive procedure to treat a particular medical condition when a practitioner erroneously performs: A different procedure altogether The correct procedure but on the wrong body part The correct procedure but on the wrong patient

2011 In the FY 2011 Final Rule for the FY 2012 Payment Determination, CMS Adopted 8 Claims-Based HAC Measures for the Hospital Inpatient Quality Reporting (IQR) Program, Based on 8 of the 10 Conditions Applicable Under the HAC Payment Provisions: Air Embolism Blood Incompatibility Catheter-Associated Urinary Tract Infection (UTI) Falls and Trauma (Includes Fracture Dislocation, Intracranial Injury, Crushing Injury, Burn, Electric Shock) Foreign Object Retained After Surgery Manifestations of Poor Glycemic Control Pressure Ulcer Stages III or IV Vascular Catheter Associated Infections

2012 As announced in the IPPS FY 2012 Final Rule, CMS used eight of these 10 HACs for the Hospital Inpatient Quality Reporting (IQR) Program. CMS has been publicly reporting on these eight HAC measures successfully on the Hospital Compare Web site since September 2010.

2013 PUBLIC REPORTING We are finalizing our proposal to remove 8 HAC measures, 3 AHRQ Inpatient Quality Indicator (IQI) measures, and 5 AHRQ Patient Safety Indicator (PSI) measures from the Hospital IQR Program measure set. We seek to reduce redundancy among the measures in the program. 2 of the 8 HAC measures address HAIs which are addressed by other measures currently in the Hospital IQR Program. These 2 HAI measures are the NQF endorsed CAUTI and CLABSI measures collected via the CDC’s NHSN system. An additional 3 of the 8 HAC measures address similar topics (pressure ulcers, air embolism, and manifestations of poor glycemic control) to patient safety indicators that are included in the NQF-endorsed AHRQ PSI composite that is also included in the Hospital IQR Program CMS does not intend to provide or publicly report new calculations of these individual HACs as part of the Hospital IQR Program after 2012. Federal Register /Vol. 77, No. 170 / Friday, August 31, 2012 /Rules and Regulations 53507

Hospital Acquired Condition Program Continues to be part of the Inpatient Prospective Payment System (IPPS) Payment Adjustment Taken out of the Inpatient Quality Reporting Program No Longer Reported on Hospital Compare

Starting with October 1, 2014 Discharges Hospital-Acquired Condition (HAC) Reduction Program FY 2015 Starting with October 1, 2014 Discharges

Hospital-Acquired Condition (HAC) Reduction Program FY 2015 The New Hospital-Acquired Condition (HAC) Reduction Program IS IN ADDTION TO The Current Hospital-Acquired Conditions Program

Understanding the Hospital-Acquired Condition Reduction Program Starting with October 1, 2014 Discharges, and affecting FY 2015 Payment Adjustment, CMS will Implement The Hospital-Acquired Condition (HAC) Reduction Program Mandated by the Affordable Care Act This Requires the Centers for Medicare and Medicaid (CMS) to Reduce Hospital Payments by 1% for Hospitals That Rank Among the Lowest-Performing 25 Percent with Regard to Hospital Acquired Conditions CMS Final Rule: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2014-IPPS-Final-Rule-Home-Page-Items/FY-2014-IPPS-Final-Rule-CMS-1599-F-Regulations.html?DLPage=1&DLSort=0&DLSortDir=ascending

MEASURES Patient Safety Indicators PSI 90 Composite Measure Central Line Associated Bloodstream Infections (CLABSI) Measure Catheter Associated Urinary Tract Infections (CAUTI) Measure The HAC Program has 3 Measures and 2 Domains for FY 2015, Identified in the IPPS Rule

DOMAIN 1 Domain 1 will include the Agency for Health Care Research and Quality (AHRQ) Composite PSI #90 Pressure Ulcer Rate (PSI 3) Iatrogenic Pneumothorax Rate (PSI 6) Central Venous Catheter-Related Blood Stream Infection Rate (PSI 7) Postoperative Hip Fracture Rate (PSI 8) Postoperative Pulmonary Embolism (PE) or Deep Vein Thrombosis Rate (DVT) (PSI 12) Postoperative Sepsis Rate (PSI 13) Wound Dehiscence Rate (PSI 14) Accidental Puncture and Laceration Rate (PSI 15)

Domain 2 Will Consist of Two Healthcare-Associated Infection Measures Central Line-Associated Blood Stream Infection Catheter-Associated Urinary Tract Infection

DOMAIN WEIGHTING Domain 1 PSI-90 Composite Measure Weighted at 35% CAUTI and CLABSI Measures Weighted at 65% 25% of Worst Performing Hospitals Receive a 1% Reduction

Higher Score = Worse Performance HAC MEASURE SCORING Points will be assigned according to a hospital’s performance on the three measures: (Domain 1) PSI-90 Composite (Domain 2) CLABSI CAUTI The performance range for each of the measures will be divided into 10 Deciles All hospitals will receive between 1 and 10 points for each measure based on National Percentile Ranking Points will be Assigned for each Measure in Deciles between the Score of the Best Performing Hospital and the Worst Performing Hospital Higher Score = Worse Performance

TOTAL HAC REDUCTION SCORE Domain 1 (PSI-90) (1 to 10) Points Assigned to the Domain Score since it is Considered One Composite Measure Domain 2 (HAIs) CLABSI & CAUTI (1 to 10) Points will be Assigned for Each SIR and Averaged to Determine the Domain Score Summing The Two Weighted Domain Scores will Determine the Total HAC Score The Total HAC Score will be used to Determine the Top Quartile of Affected Hospitals If a Hospitals Result is within the Worse Performing Quartile for Domain 1, CMS will Assign 1 to 10 Points to the Hospital for this Composite Measure If a Hospitals Result is not within the Worse Performing Quartile for Domain 1, CMS will Assign Zero Points to the Hospital for this Composite Measure

TOTAL HAC REDUCTION SCORE Performance is Assessed on the Measures within Each Domain Each Measure is Scored More than One Measure in a Domain – Measure Scores are Averaged to get the Domain Score The Sum of the Weighted Domain Scores = Total HAC Score The Total HAC Score is Ranked with other Hospitals to Identify the Lowest-Performing 25%

Domain 2 (avg of measures) CLABSI & CAUTI TOTAL HAC SCORE Domain 1 (PSI-90) 35% Domain 2 (avg of measures) CLABSI & CAUTI 65% A Hospital’s Total HAC Score is Calculated by: Multiplying the (Domain 1) score by 35% and the average of the two (Domain 2) scores by 65% Summing the two weighted domain scores to determine the Total HAC Score

CASE ELIGIBILITY Calculation of the SIR

Applicable Time Period CMS Believes using 2 years of data for both domains would balance the needs of the program and allow for sufficient time to process the claims data and calculate the measures to meet the program implementation timeline. For FY 2015 (Domain 1) AHRQ Measures: 24-Month Period July 1, 2011 through June 30, 2013 For FY 2015 (Domain 2) CDC Measures: 24-Month Period Calendar Years 2012 and 2013

PAYMENT ADJUSTMENTS Reductions for Applicable Hospitals under the HAC Reduction Program will be applied after Payment Adjustments are made for the Value-Based Purchasing (VBP) and the Hospital Readmissions Reductions Programs Institutions that are penalized will see their total payments reduced, including add-ons *(IME and DSH). This is different from the Readmissions and VBP Programs, where the penalty only applies to base DRG payments Although the measures exist in more than one program, the measures are used and calculated for very distinct purposes. CMS believes that it is useful for hospitals to be able to distinguish the effect of each program, so that they can focus their resources for improvement. *Indirect Medical Education (IME) (Teaching hospitals) Disproportionate Share (DSH) payments

PAYMENT ADJUSTMENTS The Hospital VBP Program is an Incentive Program that Redistributes Reductions made to the Base Operating DRG Payment Amount, based on Certain Performance Measures. The HAC Reduction Program is a Penalty Program that Reduces Payments to Hospitals for Excess HACs to Increase Patient Safety in Hospitals. The HAC Reduction Program and the Hospital VBP Program are Separate Hospital Reporting Programs with Different Purposes and Policy Goals.

Confidential Reports and Public Reporting Prior to FY 2015 and each subsequent fiscal year, delivery of confidential reports to applicable hospitals with respect to HACs during the applicable period are required. Reports to be Delivered in Hospitals’ Secure QualityNet Accounts Information will be made available to the public regarding HACs for each applicable hospital. Hospitals have the opportunity to review, and submit corrections with respect to the HACs prior to such information being made public. Once corrected, the HAC information be posted on the Hospital Compare Web site on the Internet in an easily understandable format.

Confidential Reports and Public Reporting The information in the confidential reports and accompanying confidential discharge-level information would be calculated using the claims information CMS has available approximately 90 days after the last discharge date in the applicable period, which is when CMS would create the data extract for the calculations. The discharge-level information accompanying the Domain 1 PSI measure rates would include: Risk Factors for the Discharges that Factor into the Calculation of these Measures Dates of Admission and Discharge Discharge Characteristics Exclusions The intent in providing this information is two fold: To facilitate hospitals’ verification of the Domain 1 PSI measure calculations provided during the review and correction period based upon the information available at the time the data extract was created To facilitate hospitals’ quality improvement efforts with respect to the PSI measures. The review and correction process for claims-based measures in Domain 1 would not include submitting additional corrections related to the underlying claims data used to calculate the measures for Domain 1, or adding new claims to the data extract used to calculate the measures used in Domain 1. This is because it is necessary to take a static “snapshot” of the claims in order to perform the calculations. For purposes of this program, calculation of the measures in Domain 1 using a static snapshot (data extract) taken at the conclusion of the 90-day period following the last date of discharge used in the applicable period.

FUTURE CHANGES HAC Domains and Measures Domain 1 AHRQ PSI-90 Composite Weighted 35% Domain 2 CDC Measures Weighted 65% FY 2015   PSI-90 CLABSI & CAUTI Additional Measures Affecting Domain 2 Only FY 2016 Surgical Site Infection (Colon Surgery and Abdominal Hysterectomy) FY 2017 MRSA C Diff CMS notes that the Hospital IQR Program is finalizing expanded collection for the non-ICU population (78 FR 27628). CMS intends to propose use of these data for the HAC Reduction Program in the future.

NOTE CMS is unable to combine: Hospital IQR Program Hospital VBP Program HAC Reduction Program Hospital Readmissions Reduction Program Into one aggregate payment adjustment, because by law, they affect different portions of the Medicare payment made to hospitals under the IPPS. The Hospital IQR Program adjustment is made to the Annual Percentage Update (APU) The Hospital VBP and Hospital Readmissions Reduction Programs’ adjustments are made to the base operating DRG payment amount. The HAC adjustment is a percentage reduction to the amount otherwise payable under the IPPS

NOTE CMS will consider hosting educational provider calls to further explain the scoring methodology for the program, and will design the confidential reports in a manner that provides step-by-step explanations of the scoring. Data for the PSI-90 measure and the CAUTI and CLABSI measures are currently publicly available on the Hospital Compare Web site. CMS will be making updated information available to the public on the individual indicators in PSI-90 in an upcoming release on the Hospital Compare Web site. CMS is using the risk-adjustment factors listed in specifications for the AHRQ and CDC Measures selected for this program. The PSI Measures are Risk-Adjusted and Reliability-Adjusted. Specifically, Risk Factors such as the Patient’s Age, Gender, Comorbidities, and Complications would be considered in the Calculation of the Measure Rates so that Hospitals Serving a Large Proportion of Sicker Patients would not be Unfairly Penalized.

RESOURCES Hospital-Acquired Conditions (Present on Admission Indicator) New Hospital-Acquired Condition (HAC) Reduction Program FY 2015 Final Rule www.cms.gov Quality Net www.qualitynet.org Hospital-Acquired Conditions (HACs) Agency for Healthcare Research and Quality (AHRQ) Indicators http://qualityindicators.ahrq.gov National Quality Forum (NQF) www.qualityforum.org Serious Reportable Events  Publication (Oct 2008) http://www.qualityforum.org/Publications/2008/10/Serious_Reportable_Events.aspx For Questions Regarding the HAC Reduction Program, contact the Masspro, Quality Data Reporting Advisor, Jeanne Dufresne 781.419.2759 jdufresne@maqio.sdps.org