A Short History of Healthcare in the 21st Century The Regulatory Environment, Public Reporting and Pay-for-Performance (P4P) Gene Peterson Preston Simmons Center for Clinical Excellence University of Washington Medical Center SIP #5 July 19, 2005

Goals for Today  History of the regulatory environment  History of the quality movement  What are we as a hospital reporting now?  Where is this going in the future?  Will there be individual physician profiling on the same measures?

 One role of the Health Care Leader is to manage the Environment of Care  Complex Undertaking “Regulatory Environment”, Spiegel and Kavaler, Risk management in Health Care Institutions, “Regulatory Environment”, Spiegel and Kavaler, Risk management in Health Care Institutions,

 A flavor for regulations. Who regulates the industry ( just a few examples) Federal, State and Local Federal, State and Local WAC WAC RCW RCW CMS CMS Specific regulations on how health care organizations are built Specific regulations on how health care organizations are built NFPA NFPA National Environmental Policy Act National Environmental Policy Act OSHA OSHA WISHA WISHA EPA EPA Shoreline Act Shoreline Act Department of Health Department of Health L&I L&I DSHS- Licensing Division DSHS- Licensing Division JCAHO JCAHO ADA ADA Department of Construction and Land Use Department of Construction and Land Use Etc. ………………………….. Etc. …………………………..

The good news is that we have proven structures to comply

1997- National Patient Safety Foundation

1999- To Err is Human The First Institute of Medicine Report Alerted the Public and Congress of 45,000-98,000 Deaths due to “errors” in healthcare- first real public attention to medical failures

2001- Crossing the Quality Chasm The Second IOM Report Safe Effective Patient Centered Timely Efficient Equitable

2002-JCAHO Six National Patient Safety Goals  Patient identification  Communication among caregivers  High-alert medications  Eliminate wrong-site, wrong-patient, wrong-procedure surgery  Infusion pumps  Clinical alarm systems

2002-Leapfrog Three Leaps  Computerized Physician Order Entry  ICU Care Standards  Volume Measures CABG CABG PCI PCI AAA AAA Pancreatectomy Pancreatectomy Esophagectomy Esophagectomy Neonatal Care Neonatal Care

2003- National Voluntary Hospital Reporting Initiative-CMS  Hospitals are given the chance to voluntarily report outcome data  No take always but a reporting bonus  Process measures Acute Myocardial Infarction Acute Myocardial Infarction Heart Failure Heart Failure Community Acquired Pneumonia Community Acquired Pneumonia

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 Instructs the Center for Medicare Services to contract with the Institute of Medicine of the National Academy of Sciences to:  catalogue, review, and evaluate the validity of leading health care performance measures;  catalogue and evaluate the success and utility of alternative performance incentive programs in public or private sector settings; and

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 Identify and prioritize options to implement policies that align performance with payment under the Medicare program that indicate— the performance measurement set to be used the payment policy that will reward performance the key implementation issues (such as data and information technology requirements) that must be addressed

Who is supporting this idea… An open letter in Health Affairs Co-authored by Berwick, Eddy,…support this idea. They argue that the government needs to become involved in pay-for-performance efforts:  The human and financial costs of medical care and substandard care have been exhaustively documented.  A robust inventory of measures and standards for quality improvement has been developed and continues to grow.  The strategic concept of paying for performance-a bedrock principle in most industries- has begun to emerge in health care in a variety of experiments in both private and public sectors. Health Affairs, Vol 22(6) November/December 2003, pages 7-9.

2004- Leapfrog partners with the National Quality Forum - Thirty Leaps Awareness Accountability Ability Action

2004- Leapfrog adds process and outcomes measures  Society for Thoracic Surgery (STS) for CABG  American College of Cardiologist National Cardiac Data Registry (ACC-NCDR) (Washington Data COAP)  Vermont Oxford Data Base for Neonates  Beta Blockade for AAA

2004- Institute for Healthcare Improvement Deploy Rapid Response Teams Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction Prevent Adverse Drug Events Prevent Central Line Infections Prevent Surgical Site Infections Prevent Ventilator-Associated Pneumonia

AVERAGE FOR ALL REPORTING HOSPITALS IN THE UNITED STATES 72% AVERAGE FOR ALL REPORTING HOSPITALS IN THE STATE OF WASHINGTON 72% UNIVERSITY OF WASHINGTON MEDICAL CTR 39% * Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved a 89% rate or better CMS Displays Quality Data from National Hospital Voluntary Reporting Initiative Patients with pneumonia receiving antibiotics within 4 hours

HEALTH GRADES

2005 Surgical Care Improvement Project (SCIP) Preventing Surgical Complications in four broad areas where the incidence and cost of complications are high:  Surgical site infections  Adverse cardiac events  Venous thromboembolism  Postoperative pneumonia

SCIP Steering Committee Organizations  Agency for Healthcare Research and Quality  American College of Surgeons  American Hospital Association  American Society of Anesthesiologists  Association of periOperative Registered Nurses  Centers for Disease Control and Prevention  Centers for Medicare & Medicaid Services  Department of Veterans Affairs  Institute for Healthcare Improvement  Joint Commission on Accreditation of Healthcare Organizations

2006-Leapfrog-Hospital Rewards Program These represent 33% of the admissions and 20 % of the spending by commercial payers Coronary artery bypass graft (CABG) Percutaneous coronary intervention (PCI) Acute myocardial infarction (AMI) Community acquired pneumonia (CAP) Deliveries/newborns

Hospital Rewards Program Quality Measures: CABG MeasureSourceWeight CABG mortalityLFG Survey34.00% CABG volumeLFG Survey12.00% Prophylactic antibiotic received within one hour prior to surgical incisision JCAHO Core Measure3.50% Prophylactic antibiotic selection for surgical patients - CABG JCAHO Core Measure3.50% Prophylactic antibiotics discontinued within 24 hours after surgery end time - CABG JCAHO Core Measure3.50% Process of Care -- 80%+ adherence to at least two: CABG using internal mammary artery Aspirin at discharge Beta-blocker within 24 hours after surgery Beta-blockers prescribed at discharge Lipid-lowering therapy prescribed at discharge Extubation within 24 hours after surgery LFG Survey18.50% Computerized physician order entry (CPOE) system LFG Survey8.33% ICU physician staffing (IPS)LFG Survey8.33% Leapfrog Quality Index (NQF Safe Practices)LFG Survey8.33%

REWARDING SUPERIOR QUALITY CARE: THE PREMIER HOSPITAL QUALITY INCENTIVE DEMONSTRATION CENTERS FOR MEDICARE & MEDICAID SERVICES FACT SHEET March 2005 Overview CMS is pursuing a vision to improve the quality of health care by expanding the information available about quality of care and through direct incentives to reward the delivery of superior quality care. Through the Premier Hospital Quality Incentive Demonstration, CMS aims to see a significant improvement in the quality of inpatient care by awarding bonus payments to hospitals for high quality in several clinical areas, and by reporting extensive quality data on the CMS web site. Quality of Care Under the demonstration, top performing hospitals will receive bonuses based on their performance on evidence-based quality measures for inpatients with: heart attack, heart failure, pneumonia, coronary artery bypass graft, and hip and knee replacements. Financial Awards CMS will identify hospitals in the demonstration with the highest clinical quality performance for each of the five clinical areas. Hospitals in the top 20% of quality for those clinical areas will be given a financial payment as a reward for the quality of their care. Hospitals in the top decile of hospitals for a given diagnosis will be provided a 2% bonus of their Medicare payments for the measured condition, while hospitals in the second decile will be paid a 1% bonus. The cost of the bonuses to Medicare will be about $7 million a year, or $21 million over three years. Improvement Over Baseline In year three, hospitals that do not achieve performance improvements above demonstration baseline will have adjusted payments. The demonstration baseline will be clinical thresholds set at the year one cut-off scores for the lower 9th and 10th decile hospitals. Hospitals will receive 1% lower DRG payment for clinical conditions that score below the 9th decile baseline level and 2% less if they score below the 10th decile baseline level.

2005-Other Reports  Washington Clinical Outcomes Assessment Project (COAP)  SCOAP  American College of Surgeons National Surgical Quality Improvement Project

UWMC Operating Plan  Through CQI produce measurable improvements in clinical care service and operating performance. CORM  2002-Lay the foundations for improving patient safety. CORM  Make measurable progress toward becoming the #1 AMC resource on patient safety by building the culture of a high reliability organization…(Increase reporting by 50% and decrease harm events in 3 areas)

UWMC Operating Plan  Achieve measurable improvements in patient safety and quality. (Six JCAHO National Safety Patient Goals, Identify and adopt an integrated quality model, Identify a balanced set of key organizational and clinical quality metrics.)  2005-Provide the safest clinical care available. Presented in a PASCO format (Increase reporting by 30%, decreased falls by 50%, reduce DVT by 50%)

2006 UWMC Operating Plan 13 of 25 Elements are Quality and safety Elements Critical Test Results Medication Reconciliation Hand Hygiene Falls With Injury AMI Heart Failure Community Acquired Pneumonia Central Line Infections Surgical Site Infections Ventilator Associated Pneumonia Venous Thromboembolism Rapid Response Teams

These are organizational performance measures. What about physician performance measures?  When will P4P role down to physicians on the surgical side?

New York Times Friday April 15, 2005

Sample Outpatient Health Outcomes/Safety Data  Women’s Health- Breast and Cervical Cancer Screening  Diabetes Care- Eye exams, HbA1c, cholesterol screening, ACE inhibitors  Use of Optimal Medications- Asthma, Otitis Media, Acute Bronchitis  Pharmacy Measures- Formulary Compliance, Generic use  Service Measures

P4P Options  Financial  Non Financial

Financial Strategies  Quality Bonuses  Compensation at Risk  Performance Fee Schedules  Quality grants  Reimbursement for Care Planning  Variable Cost Sharing for Patients

Non Financial Strategies  Performance Profiling  Publicizing Performance  Technical Assistance for Quality Improvement  Practice Sanctions  Reducing Administrative Requirements

Discussion