The Chickasaw Nation Department of Health MELISSA GOWER SENIOR ADVISOR, POLICY ANALYST Good afternoon, I am Melissa Gower, Senior Advisor, Policy Analyst with the Chickasaw Nation in Oklahoma. I also serve as the TTAG Alternate for Oklahoma Area and Chair & Co-Chair several TTAG and MMPC committees. You have heard a great overview of the new payment reforms and the fact that they do affect Indian Country and our tribal facilities. Now I want to share with you a specific tribal story about the effect one of the payment reforms has had on the Chickasaw Nation, the Hospital Acquired Conditions. Now is the time to begin studying and learning about all these new changes and how they can affect your health facility.

QUALITY REPORTING MEASURES A Tribal Story Hospital Acquired Condition (HAC) Reduction Program Section 3008 of the ACA establishes a financial incentive program for Inpatient Prospective Payment System (IPPS) hospitals to improve patient safety by applying a one percent payment reduction to hospitals that rank in the lowest-performing percentage of all subsection (d) hospitals with respect to the occurrence of hospital-acquired conditions (HACs) that appear during an applicable hospital stay. These HACs are a group of reasonably-preventable conditions selected by CMS that patients did not have upon admission to a hospital, but which developed during the hospital stay. Hospital Acquired Condition (HAC) Reduction Program The HAC program is in Section 3008 of the ACA and establishes a financial incentive program for Inpatient Prospective Payment System (IPPS) hospitals to improve patient safety by applying a one percent payment reduction to hospitals that rank in the lowest-performing percentage of all subsection (d) hospitals with respect to the occurrence of hospital-acquired conditions (HACs) that appear during an applicable hospital stay. These HACs are a group of reasonably-preventable conditions selected by CMS that patients did not have upon admission to a hospital, but which developed during the hospital stay.

QUALITY REPORTING MEASURES A Tribal Story The HAC program has three measures for FY2015, which are identified in the IPPS rule: Patient safety indicators (PSI 90) composite measure (eight measures), consisting of: Pressure Ulcer Latrogenic Pneumothorax Central Venous Catheter-Related Bloodstream Infections Postoperative Hip Fracture Postoperative Pulmonary Embolism or Deep Venous Thrombosis Postoperative Sepsis Postoperative Wound Dehiscence Accidental Puncture or Laceration Central line-associated bloodstream infections (CLABSI) measure Catheter-associated urinary tract infections (CAUTI) measure The HAC program has three measures: Patient safety indicators composite measure. There are 8 of them which you can see below: Pressure Ulcer Latrogenic Pneumothorax Central Venous Catheter-Related Bloodstream Infections Postoperative Hip Fracture Postoperative Pulmonary Embolism or Deep Venous Thrombosis Postoperative Sepsis Postoperative Wound Dehiscence Accidental Puncture or Laceration Central line-associated bloodstream infections (CLABSI) measure Catheter-associated urinary tract infections (CAUTI) measure

QUALITY REPORTING MEASURES A Tribal Story Beginning in 2015, the lowest-performing 25 percent of subsection (d) hospitals will receive an one percent reduction in what would have otherwise been paid under the IPPS for all discharges. The HAC payment penalty adjustment is applied after base diagnosis-related group (DRG) payment adjustments have been calculated for the VM and Hospital Readmission Reduction programs. Beginning in 2015, the lowest-performing 25% of hospitals will receive a 1% reduction in what would have otherwise been paid under the IPPS for all discharges. The HAC payment penalty adjustment is applied after DRG payment adjustments have been calculated for the Value Based Model and Hospital Readmission Reduction programs.

QUALITY REPORTING MEASURES A Tribal Story The HAC Program is comprised of two measures which are weighted to a total of 100 percent. AHRQ Patient Safety Measures (Domain 1) is weighted at 35 percent. HAC Infection (Domain 2) is weighted at 65 percent. For the reporting period of Jan. 1, 2012, to Dec. 31, 2013, Chickasaw Nation Medical Center (CNMC) reported zero (0) healthcare-associated infections (HAI) for both categories of central line-associated bloodstream infection (CLASBI) and catheter-associated urinary tract infection (CAUTI). The HAC Program is comprised of two measures which are weighted to equal a 100%: 1. AHRQ Patient Safety Measures (Domain 1) is weighted at 35% 2. HAC Infection (Domain 2) is weighted at 65% For the reporting period of Jan. 1, 2012, to Dec. 31, 2013, Chickasaw Nation Medical Center reported zero healthcare-associated infections for both categories of central line-associated bloodstream infection and catheter-associated urinary tract infection.

QUALITY REPORTING MEASURES A Tribal Story The CDC formula that is utilized to calculate Standardized Infection Ratio (SIR) is: divide the hospital’s reported number of HAIs by a hospital’s predicted number of HAIs: A hospital’s number of predicted HAIs must be greater than or equal to one in order to calculate a SIR. CNMC predicted number of HAIs was below one at: CLASBI: 0.620 CAUTI: 0.927 This resulted in CNMC having insufficient data and CDC not calculating an SIR for this measure. Subsequently, this measure did not calculate into the CNMC’s Domain 2 score or Total HAC score. CDC developed the formula that is utilized to calculate Standardized Infection Ratio and is calculated by dividing the hospital’s reported number of hospital acquired infections by a hospital’s predicted number of hospital acquired infections, which must be greater than or equal to one in order to calculate a standardized infection ratio. CNMC’s predicted number of hospital acquired infections was below one at: CLASBI: 0.620 CAUTI: 0.927 This resulted in CNMC having insufficient data and CDC not calculating an standardized infection ratio for this measure. Subsequently, this measure did not calculate into the CNMC’s Domain 2 score or total hospital acquired condition score.

QUALITY REPORTING MEASURES A Tribal Story Because CNMC had zero in Domain 2, Domain 1 was weighted at 100 percent, instead of 35 percent. By removing Domain 2 from the CNMC total HAC score for FY2015, higher weighting was placed on Domain 1, thus resulting in a total hospital HAC score of greater than 7. This resulted in CMNC facility being subject to a payment reduction of one percent. Because CNMC did not have any hospital acquired infections, nor had a predicted rate of 1 or more, it resulted in us having zero in Domain 2, which would be weighted at 65%. When this happens, they do not consider Domain 2, but instead weigh Domain 1 at 100%, instead of the intended 35%. By removing Domain 2 from the CNMC total hospital acquired conditions score for FY2015, and placing a weighting of 100% on Domain 1, it resulted in a total hospital acquired condition score of greater than 7, which means that CMNC will be subject to a payment reduction of 1%.

QUALITY REPORTING MEASURES A Tribal Story The Appeal Process: CNMC decided since the one percent payment reduction was because of a faulty methodology, we would appeal. After researching, the following appeal process was followed. Appeal to CMS DTA, which forwarded to the program staff for a response. The response was detailed with the following highlights: It is important and appropriate to make use of the data that are available for each hospital, as long as the minimum thresholds for each measure are met. CDC has developed a new analytic method that would have lower minimum data threshold, which if adopted, could potentially alleviate some of the concerns related to the current scoring methodology and insufficient data. CMS is working with CDC to evaluate this new methodology and determine if it is appropriate for inclusion in CMS quality programs. CMS does not have the authority to modify the payment adjustment. Because the payment reduction was really because of a faulty methodology and this doesn’t seem fair or logical, we decided to appeal the payment reduction. I wanted to go over the appeal process as it was not clearly laid out anywhere that I could find. After researching, the following appeal process was followed. Appealed to CMS Division of Tribal Affairs via email, which was forwarded to the program staff for a response. The response was detailed with the following highlights: It is important and appropriate to make use of the data that is available for each hospital, as long as the minimum thresholds for each measure are met. CDC has developed a new analytic method that would have lower minimum data threshold, which if adopted, could potentially alleviate some of the concerns related to the current scoring methodology and insufficient data. CMS is working with CDC to evaluate this new methodology and determine if it is appropriate for inclusion in CMS quality programs. CMS does not have the authority to modify the payment adjustment.

QUALITY REPORTING MEASURES A Tribal Story The Appeal Process: Appeal letter to CMS Acting Administrator. The response was detailed with the following highlights: CDC has set a threshold predicted number of infections of at least one CDC can’t at this time, calculate a SIR for that measure, regardless of the number of actual infections Recognition of the impact to facilities with this reporting scenario and are working with CDC to evaluate the future potential to lower the threshold below one CDC has developed an alternative to the SIR calculation method, called the adjusted ranking metric (ARM) which would take into account, among other variables, hospitals that have low numbers of central line and/or catheter days Committed to considering other ways of improving the program Can’t make a change to the payment reduction Appeal letter to DHHS Secretary Burwell with no response as of this date. An appeal letter was sent to the CMS Acting Administrator from our Secretary of Health. The response was detailed with the following highlights: CDC has set a threshold predicted number of infections of at least one CDC can’t at this time, calculate a Standardized Infection Ratio for that measure, regardless of the number of actual infections (even though ours was zero) Recognition of the impact to facilities with this reporting scenario and are working with CDC to evaluate the future potential to lower the threshold below one CDC has developed an alternative calculation method, called the adjusted ranking metric (ARM) which would take into account, among other variables, hospitals that have low numbers of infections Committed to considering other ways of improving the program Can’t make a change to the payment reduction An appeal letter was sent to DHHS Secretary Burwell from Governor of our Nation with no response as of this date.

MMPC Payment Reform Workgroup The Medicare, Medicaid and Health Reform Policy Committee developed a Payment Reform Workgroup in 2015. Issue Summary: CMS is implementing a series of payment reform programs, including the Electronic Health Records (EHR) Incentive Program, the Physician Quality Reporting System (PQRS) and the Value-Based Payment Modifier (VBM). Some of these programs previously provided incentives for participation, but are now transitioning into penalty phases in which Medicare reimbursements are reduced for failure to comply. Some programs, such as the Hospital Acquired Conditions (HAC) Program, impose penalties based on formulas that can be detrimental to small tribal providers. Additionally, many of the quality reporting programs do not include measures that tribes already must report. Beginning in 2018, the EHR Incentive Program, PQRS and VBM will be folded into a new program, the Merit-Based Incentive Payment System (MIPS) for Medicare Part B payments, presenting opportunities to engage with CMS about reforming some of the incentive program regulations. Now, I want to shift to a new workgroup that has been developed by the Medicare, Medicaid and Health Reform Policy Committee called Payment Reform, to work on all the new payment reforms and their effect on Indian Healthcare facilities. The workgroup’s purpose is to review and understand the new CMS payment reform programs, including the Electronic Health Records Incentive Program, the Physician Quality Reporting System, and the Value-Based Payment Modifier, which were discussed in more detail by both Akilah and Michael. As they stated some of these programs previously provided incentives for participation, but are now transitioning into penalty phases in which Medicare reimbursements are reduced for failure to comply. As I have discussed, some programs such as the Hospital Acquired Conditions Program, impose penalties based on formulas that can be detrimental to tribal providers. Additionally, many of the quality reporting programs do not include measures that tribes already must report.

MMPC Payment Reform Workgroup Strategies and Actions: MMPC Payment Reform Workgroup has been formed and will continue meeting to work on these topics/issues. A CMS/IHS inter-agency workgroup should be established to address how the payment reform programs impact Indian Country. The MMPC and tribes should work to engage CMS on the MIPS regulations that will be issued to ensure measures that tribes already use are included in the required quality measures. The Payment Reform Workgroup was formed in Spring of this year and meets once a month, via conference call. We are hopeful that CMS and IHS will continue to engage and develop a more formal inter-agency workgroup to address how the payment reform programs impact Indian Country so we can have a voice on the front end of these reforms. The MMPC, and in particular the workgroup, and tribes will work to engage CMS on the Merit Based Incentive Payment System regulations that will be issued to ensure measures that tribes already use are included in the required quality measures.

MMPC Payment Reform Workgroup A successful workgroup meeting was held on Aug. 27, 2015, with the following agenda items: Medicare Quality Reporting Payment & Penalties Chart – Workgroup decided to distribute the chart to Indian Country Training on Payment Reforms: IHS Training Plan – PQRS Trainings Training gaps and needs – information from Area Health Boards Technical Assistance gaps and needs – information from Area Health Boards 3. Reporting Methods Strategy: Exempt Indian health from GPRA reporting Use GPRA measures instead of the Medicare and Medicaid clinical quality measures Merit-Based Incentive Payment System (MIPS) for Medicare Part B payments - 2018 IHS and tribes align their quality assurance with the Medicare and Medicaid approaches Other On Aug. 27, we had our third meeting. It was very successful. We discussed the following agenda items: Medicare Quality Reporting Payment & Penalties Chart – Workgroup decided to distribute the chart to Indian Country through NIHB and TSGAC websites – Akilah went over this chart earlier this morning. Training on Payment Reforms: IHS Training Plan – PQRS Trainings Indian Country Training and Technical Assistance gaps and needs – NIHB will gather information through the Area Health Boards 3. Reporting Methods Strategy: Various strategies were discussed, a few are: -Do we want an exemption for Indian health from GPRA reporting that we are doing today and utilize the new payment reform reporting tools? -Do we want to use GPRA measures that we are currently reporting on instead of the Medicare and Medicaid clinical quality measures? -Utilize the reporting tool for Merit-Based Incentive Payment System for Medicare Part B payments in 2018. -Do we want IHS and tribes to align their quality assurance with the Medicare and Medicaid approaches?

MMPC Payment Reform Workgroup To assist in developing a policy strategy, the TSGAC requested IHS conduct an analysis and comparison of the GPRA and Clinical Quality Management approaches to include: Timelines for each (are they the same or different?) Type of data collection (What types of data are being collected? Are they the same or different?) Cost of data collection (What is the cost, to include equipment and software and human resources, of GPRA data collection system wide? How does that compare to the estimated cost of collecting data under Clinical Quality Management approaches that are in regulation or proposed regulations? What is the cost of doing both, versus one or another?) How many self-governance tribes are reporting GPRA data, and how many are not? If interested in the workgroup, please contact Devin Delrow, NIHB. To assist in developing a policy strategy, the TSGAC requested IHS to conduct an analysis and comparison of the GPRA and Clinical Quality Management approaches to include: Timelines for each (are they the same or different?) Type of data collection (What types of data are being collected? Are they the same or different?) Cost of data collection (What is the cost, to include equipment and software and human resources, of GPRA data collection system wide? How does that compare to the estimated cost of collecting data under Clinical Quality Management approaches that are in regulation or proposed regulations? What is the cost of doing both, versus one or another?) How many self-governance tribes are reporting GPRA data, and how many are not? If you are interested in participating in this workgroup we would love to have you and would encourage you to please contact Devin Delrow, NIHB and ask to be put on the Payment Reform Workgroup Mailing List at ddelrow@nihb.org.

MMPC Payment Reform Workgroup THANK YOU!!! Thank you very much for listening to my tribal story and for your consideration to become involved in the Payment Reform Workgroup.