1. CMS Update FY’14 Frank Briggs, Pharm.D., M.P.H. Vice President, Quality and Patient Safety West Virginia University Healthcare

2. Objectives At the completion of this presentation, the participants shall be able to: Describe the changes in Value Based Purchasing (VBP) Explain the Hospital Acquired Condition (HAC) penalty program Estimate the impact of changes in the Inpatient Prospective Payment System (IPPS)

3. Outline Inpatient Quality Reporting (IQR) Value Based Purchasing (VBP) Readmission Reduction Hospital Acquired Conditions (HAC) Not included – Documentation and coding effects – Disproportionate share program – Labor and delivery days – Outlier thresholds 2 Midnight Rule?

4. Inpatient Quality Reporting Voluntary reporting – Required for annual payment update 2% Measures appear in program ~2 years before advancing – VBP – HAC – Readmissions

5. Inpatient Quality Reporting medicare.gov/hospitalcompare

7. Patient Survey Results Hospital Consumer Assessment of Healthcare Providers and Systems – HCAHPS – Reported since 2007 Uses scale from never to always (5 points) Top box scores – “Always” Report “Always”

8. HCAHPS Domains Nurse communication Doctor communication Responsiveness of staff Pain control Explanation of medications Cleanliness Quietness Discharge information (recovery)

9. Core Measures Heart Attack Care – Aspirin at discharge – Fibrinolytic within 30 mins – Primary PCI within 90 mins – Statin at discharge Heart Failure – Discharge instructions – Evaluation of LVS function – ACEI/ARB for LVSD

10. Core Measures Pneumonia Care – Blood cultures in ED prior to antibiotic – Appropriate antibiotic selection Surgical Care – Antibiotics: timing, selection, and discontinuation – Venous thromboembolism (VTE) prevention – Beta blockers continued – Blood glucose control in cardiac surgery – Urinary catheters removal – Monitoring of body temperature

11. Core Measures Emergency Department – Time spent in ED for admitted patients – Time spent in ED after decision to admit – Time spent in ED for patients sent home – Time before being seen by provider – Time before pain medication for broken bones – Percent of patients who leave without being seen – Percent of patients with stroke symptoms who receive brain scan within 45 mins Preventive Care – Immunizations

12. New Core Measures Immunizations Venous Thromboembolism (VTE) Stroke Perinatal Care Hospital based inpatient psychiatric services (HBIPS)

13. Core Measures Immunizations – Influenza – Pneumonia VTE – VTE prophylaxis – Overlap with anticoagulation – Heparin – platelet dose adjustments by protocol – Discharge instructions for warfarin – Preventable VTE

14. Core Measures Stroke – VTE prophylaxis – Discharge on antithrombotic therapy – Anticoagulation for atrial fibrillation/flutter – Thrombolytic therapy – Antithrombotic by day 2 – Discharged on Statin – Stroke education – Assessed for rehabilitation Perinatal Care – Elective delivery – Cesarean sections – Antenatal steroids – Bloodstream infections – Exclusive breast feeding

15. Core Measures HBIPS – Admission screen: violence, substance abuse, psychological trauma, and patient strengths – Hours of physical restraint – Hours of seclusion – Patients discharged on multiple antipsychotics – Discharge plan created and transmitted to next provider

16. Removals of Measures FY 2016 – PN: Blood cultures – HF: discharge instructions, ACEI/ARB for LVSD – AMI: aspirin/statin at DC – SCIP: temperature monitoring

17. Readmissions Complications and Deaths Readmission: 30-day all-cause – AMI – HF – Pneumonia Death: 30-day – AMI – HF – Pneumonia

18. New Readmissions and Death Measures Readmissions – Total Joints – Hospital-wide – COPD – Stroke – Planned readmission algorithm Mortalities – COPD – Stroke

19. Complications Agency for Healthcare Research and Quality Measures (AHRQ) – Patient safety indicators Death among surgical patients with treatable complications Iatrogenic pneumothorax Post-op respiratory failure Post-op VTE Post-op wound dehiscence Accident puncture or laceration

20. Other Measures Reported Use of medical imaging Medicare payments Number of Medicare patients treated

21. Value Based Purchasing Established by Affordable Care Act – Requires CMS to implement a Hospital VBP program – Rewards hospitals for quality of care provided – Built upon IQR infrastructure – Evaluate during performance period for achievement or improvement on measures – Hospital receive points on each measure reflecting better performance – Funding by reducing base operating DRG payment

22. Value Based Purchasing Payment reductions – 2013: 1% – 2014: 1.25% – 2015: 1.5% – 2016: 1.75% – 2017: 2% Amount available for FY 14 incentive payments $1.1 billion

23. Domains Clinical process of care (core measures) – 13 measures and weighted at 45% Patient experience (HCAHPS) – 8 domains and weighted at 30% Outcomes – 3 mortality measures and weighted 25%

25. Evaluating Hospital Performance Achievement points – Awarded by comparing individual hospital rate during performance period with all hospitals rates from baseline period Rate at or above benchmark (90 th %ile): 10 points Rate less than achievement threshold (median): 0 points Rate between achievement and benchmark: 1-10 points – Comparing current hospital performance to baseline of all hospitals

26. Evaluating Hospital Performance Improvement points – Awarded by comparing hospitals rates during performance period to same hospitals rate from baseline period Rate at or above benchmark: 9 points Rate less than or equal to baseline: 0 points Rate between baseline and benchmark: 0-9 points – Comparing against yourself over time – Fewer points than achievement

27. Proposed VBP Changes for 2015 and Beyond 2015 (final) – Clinical process of care measures: 20% – Outcome measures: 30% – Efficiency measures(Medicare spending): 20% – HCAHPS: 30% 2016 (proposed) – Clinical process of care measures: 10% – Outcome measures (add AHRQ PSI and infection): 40% – Efficiency measures: 25% – HCAHPS: 25%

28. VBP 2017 Change domain and reweight – Outcomes become safety domain: 15% AHRQ Patient Safety Indicators – Process of care becomes clinical care domain: 35% Clinical process of care: 10% Mortality outcomes: 25%

29. ReductionEarn back% change in DRG Value multiplier for DRG Slope for translation

30. Readmission Reduction Program Maximum penalty increased to 2% Projecting $175 million in fewer payments Added planned readmission logic Two new measures for FY 2015 – COPD and elective joint – Built upon IQR infrastructure FY 2014 period – July 1, 2009 – June 30, 2012

31. Planned Readmission Incorporating algorithm – AMI, HF, PN – FY 2014 – Will not count unplanned readmissions that follow planned readmissions either

32. Hospital Acquired Condition (HAC) Reduction Program Required by Affordable Care Act – Payment adjustment for all inpatient hospital payments – ***Includes indirect medical education (IME) and disproportionate share (DSH) payments – Must apply to one quarter of all hospitals (lowest performance) – In addition to the non-payment HAC program – Reductions applied after adjusting for VBP and Readmissions reduction programs Starts in FY 2015

33. HAC Reduction Framework Total HAC Score Worst quartile performance 1% reduction Domain 1 (35%)Domain 2 (65%) AHRQ Patient Safety IndicatorsNHSN Infection Pressure UlcerCentral line blood stream Iatrogenic pneumothoraxCatheter associated UTI Central venous catheter infection Hip fracture2016 Post-op VTESurgical site infection Sepsis (Colon and abdominal hys) Wound dehiscence Accidental puncture2017 MRSA C difficile

34. HAC Scoring (Golf) Points assigned based on performance Performance range for each measure divided into deciles All hospitals receive between 1-10 points for each measure (lower is better) Total score calculated – AHRQ score x 35% + average of 2 NHSN infections x 65% Each year bottom 25% are penalized – Move faster than the others

35. Data Periods Domain 1: AHRQ PSI – July 2011 – June 2013 Domain 2: NHSN Infections – Calendar years 2012 -2013

36. Admission and Medical Review Criteria Requires physician order for admission to inpatient status – Authenticated by attending provider Certification – Inpatient order Inpatient services are reasonable and necessary Appropriately provided in accordance with 2 midnight benchmark – Reason for inpatient services Medical record – Estimated time the beneficiary requires inpatient care – Plans for post hospital care – CAH: beneficiary reasonably expected to be discharged or transferred within 96 hours – Must be signed and dated prior to discharge DRG payments reduced additional 0.2% to account in addition

37. 2 Midnight Benchmark Reasonably expect patient to require inpatient hospital care for at least 2 midnights Less than 2 midnights – Expected to be observation May move from observation to inpatient if patient meets medical necessity and going to require hospital care for second midnight – Outpatient time does not convert to inpatient billing (no retroactive billing) Includes time spent in hospital outpatient areas (ED and OR) – Does not begin at triage, when care starts!

38. Estimating Impact of Changes IQR changes – Generally don’t involve payment/penalty – Voluntary, required for APU – May require additional staff and support VBP – 1.25% withhold – earn back % = impact Readmission reduction (2%) HAC 1% of DRG + IME + DSH

39. Contact Information Frank Briggs, Pharm.D., M.P.H. Vice President, Quality and Patient Safety West Virginia University Healthcare Email: briggsf@wvuhealthcare.combriggsf@wvuhealthcare.com Phone: 304.598.4057