1. Georgia Hospital Association FY 2014 IPPS/LTCH PPS Proposed Rule
Quality Provisions
11 June 2013
© 2013 American Hospital Association

2. IPPS/LTCH PPS Proposed Rule Summary
Comments due on June 25, 2013
AHA Regulatory Advisory available at
Includes proposals for seven different quality reporting and payment programs
Select headlines:
HAC Reduction (penalty) Program - All of it
Readmissions – Updated measures and expansion to 2 additional conditions in FY 2015
IQR – Electronic reporting option
VBP – new measures and measure domain realignment
© 2013 American Hospital Association 2

3. Hospital Acquired Conditions
Beginning FY 2015, financial penalty for being in the top quartile of national HAC rates
1 percent reduction to Medicare payments for all discharges.
Includes: Inpatient PPS, SCHs, and Indian Health Services
Excludes: CAHs, LTCHs, cancer hospitals, IRFs, IPFs,
© 2013 American Hospital Association 9

4. HAC Measures Domain 1, Option 1: Individual PSIs
Domain 1, Option 2: Composite PSI
Domain 2: HAI Measures
Pressure ulcer (PSI 3)# *
Volume of foreign object left in the body (PSI 5)
Iatrogenic Pneumothorax rate (PSI 6)*
Postoperative physiologic and metabolic derangement rate (PSI 10)# *
Postoperative pulmonary embolism (PE) or deep vein thrombosis rate (DVT) (PSI 12)
Accidental puncture and laceration rate (PSI 15)
PSI-90 (Composite comprised of the following 8 PSIs):
Pressure ulcer rate (PSI 3)# *
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)# *
Central Line-associated Blood Stream Infection (CLABSI) (FY 2015 onward)%
Catheter-associated Urinary Tract Infection (CAUTI) (FY 2015 onward)%
Surgical Site Infection (SSI) (FY 2016 onward):%
SSI Following Colon Surgery
SSI Following Abdominal Hysterectomy
Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia (FY 2017 onward) %
Clostridium difficile (FY 2017 onward)%
# = Not NQF-endorsed
* = Not reviewed by the Measure Applications Partnership (MAP)
%= Overlaps with finalize or proposed VBP measure
© 2013 American Hospital Association 10

5. HAC: Scoring Methodology
Performance on each measure split into quartiles….
…with hospitals then assigned points depending on the decile of performance on each measure
Percentile above 75th percentile
Number of Points Assigned for measure
1st -10th 1
11th – 20th 2
21st – 30th 3
31st – 40th 4
41st – 50th 5
51st – 60th 6
61st – 70th 7
71st – 80th 8
81st – 90th 9
91st – 100th 10
Top quartile scores then divided into deciles…
© 2013 American Hospital Association 11

6. HAC Reduction Program: Assigning Points
© 2013 American Hospital Association 8

7. HAC Reduction Program: Areas of Concern and Analysis
The measures
Not all are NQF-endorsed,
Not all reviewed by the MAP
Scoring methodology
Is it sufficient to blunt the effect of rarely occurring events?
AHA conducting an analysis to determine spread of performance on measures, and impact to hospitals
Double penalty (or conflicting signals about penalties)
CAUTI and CLABSI in VBP and HAC
© 2013 American Hospital Association 10

8. Hospital Readmissions Reduction Program: FY 2014 and 2015 Proposals
Penalty increases to 2%, per statute
Planned readmissions algorithm incorporated into existing measures to exclude planned readmissions
Always excludes transplant surgery, OB delivery, maintenance chemotherapy and rehab
Possible exclusion of non-acute readmits for planned procedures
No exclusion for readmits for acute illness or complications
FY 2015
Penalty increases to 3%, per statute
Addition of two measures
COPD readmissions
Total hip/Total Knee readmissions
© 2013 American Hospital Association 11

9. Key HRRP problems remain…
Measures do not exclude readmissions unrelated to the reason for initial admission in spite of the ACA statutory requirement
No exclusions for patients with conditions requiring frequent inpatient hospitalizations (e.g.—burns, psychosis, ESRD, substance abuse)
Poor measure reliability (i.e.—inadequate minimum case threshold to produce accurate measure results)
No adjustments for socioeconomic factors beyond hospital control
© 2013 American Hospital Association 12

10. Inpatient Quality Reporting
OUT
Aspirin prescribed at discharge for AMI
Statin prescribed at discharge for AMI
Angiotensin converting enzyme Inhibitors / angiotensin receptor blockers (ACEI/ARB drugs) for left ventricular systolic dysfunction
Surgery patients with perioperative temperature management
PN-3b – Blood culture performed in the emergency department prior to first antibiotic received in hospital
HF-1 – Discharge instructions
IMM-1 – Immunization for pneumonia (guidelines have changes)
Participation in a systematic clinical database registry for stroke care (stroke measures render this unnecessary) IN
30-day risk standardized COPD readmission
30-day risk standardized COPD mortality
30-day risk standardized stroke readmission
30-day risk standardized stroke mortality
AMI payment per episode of care
Expand CAUTI and CLABSI to non-ICU areas
This slide provides a list of the major IQR measurement changes for FY The “new” performance measures are for reporting in 2014, and will affect FY 2016 inpatient payment.
CMS removes 8 measures. CMS cycles measures out of the program because they have “topped out,” lost NQF endorsement, or better measures become available.
CMS adds 5 new measures, which are based on claims data (so hospitals do not need to abstract it). Some concerns include the following:
Stroke mortality, stroke readmission and AMI payment per episode of care are not NQF-endorsed.
Stroke mortality rates are not adjusted for stroke severity, leading to reporting inaccuracies
AMI payment per episode is being proposed as a hospital measure, but the measure includes payments for a variety of services—physician, long-term care hospitals, SNFs, etc—that hospitals do not always control.
In addition, CMS proposes to expand its CAUTI (urinary track) and CLABSI (blood stream) measures to areas beyond the ICU. These measures are likely to require additional effort for hospitals to collect and report.
© 2013 American Hospital Association 16

11. Proposed IQR Electronic Reporting for FY 2016
Hospitals would receive credit for both the Medicare EHR Incentive program and IQR for reporting 1 quarter’s worth of data for 16 measures common to both programs
Stroke, VTE, ED, early elective delivery
Hospitals would have 2 different deadlines depending on whether they are in their first year of the Medicare EHR Incentive program
Hospitals in 1st year of EHR Incentive: Jun. 1, 2014
Hospitals beyond 1st year of HER Incentive: Nov. 30, 2014
CMS strongly encourages hospital participation as a precursor to required electronic submission in the future
© 2013 American Hospital Association 14

12. IQR Electronic Reporting: Concerns
Substantial differences between EHR-based and manual abstraction methodologies, resulting in substantial variation in performance results
Inadequate validation of measures reported via certified EHRs
Timing of required electronic reporting
CMS mentions required reporting may happen as soon as CY 2015
However, they also state they will use the results of the voluntary reporting to inform when they intend to require it.
© 2013 American Hospital Association 15

13. Inpatient Quality Reporting (IQR): Validation Process
Timing: Quarters shifted to allow for more timely determination of annual payment update
Selection of measures: Will validate 12 process of care, and add MRSA and C Diff to HAI validation in FY 2016
Number of records: Will reduce the number of records validated per hospital for HAI measures
Electronic submission of records selected for validation will be allowed
© 2013 American Hospital Association 18

14. Value-Based Purchasing (VBP) FY 2016 and FY 2017 Measure Proposals
Three clinical process measures removed for FY 2016
AMI-8a (primary PCI within 90 minutes of hospital arrival) – dropped due to being topped out;
PN-3b (blood cultures performed in the emergency department prior to initial antibiotic received in hospital) – no longer NQF-endorsed
HF-1 (discharge instructions – no longer NQF-endorsed
Three new measures added for FY 2016
IMM-2 (Influenza Vaccination for inpatients 6 months and older);
Catheter-associated urinary tract infections; and
Surgical site infections
Two new measure for FY 2017
Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
Clostridium difficile (C Diff).
© 2013 American Hospital Association 19

15. Proposed Domain Weighting for FY 2016 VBP Program
Measure Domain
FY 2013 Final
FY 2014 Final
FY 2015 Final
FY 2016 Proposed
Process
70%
45%
20%
10%
Patient Experience
30%
25%
Outcomes 0%
40%
Efficiency
© 2013 American Hospital Association 20

16. Proposed Realignment of Domain for FY 2017 VBP Program
Weight
Safety
15%
Clinical Care:
Clinical Care – Outcomes
Clinical Care – Process
35%
25%
Efficiency and Cost Reduction
Patient and Caregiver Centered Experience of Care / Care Coordination
CMS proposes a realignment of domains and measures within the domains to align with the National Quality Strategy priority areas
Specific measures are remapped to the new domains
As alternative, CMS proposes the same domains and weighting as the FY 2016 VBP program
© 2013 American Hospital Association 21

17. VBP Disaster / Extraordinary Circumstances Waiver
CMS proposes a waiver process for hospitals that have faced natural disasters or other extenuating circumstances
CMS would have the authority to waive a hospital from the VBP program in the fiscal year during which a hospital’s performance period data is likely affected
Hospitals would be required to submit a request within 30 days of the occurrence of the extraordinary circumstance, and simultaneously with the IQR waiver
© 2013 American Hospital Association 22

18. Inpatient Psychiatric Facility Quality Reporting Program (IPFQR)
IPFs and licensed psychiatric distinct part units reimbursed under the IPF PPS must report on quality measures to receive full annual payment update beginning in FY 2014
FY 2014 and FY 2015 program use the HBIPS measures from the Joint Commission
Eligible institutions.
Free-standing Psychiatric Hospitals, including government-operated Psychiatric Hospitals
Licensed Distinct Part Psychiatric Units of acute care hospitals and critical access hospitals
© 2013 American Hospital Association 23

19. IPFQR: FY 2016 Measurement Proposals
Not yet NQF-endorsed (NQF review underway)
SUB-1 – Alcohol Use Screening
Percentage of patients 18 years of age and older who are screened for unhealthy alcohol use during an inpatient stay.
SUB-4—Alcohol and Drug Use: Assessing Status after discharge
Assesses whether discharged patients are contacted between 7 and 30 days after hospital discharge to collect information about their alcohol or drug use
FUH – Follow up after Hospitalization for Mental Illness (NQF-endorsed)
Assesses the percentage of discharges for patients hospitalized for mental health disorders who subsequently had outpatient treatment
© 2013 American Hospital Association 24

20. PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) – FY 2015 and 2016 Proposals
Submit quality measures for FY 2014 and beyond
Compliance is tied to 2 percent of the annual update
One new measure for FY 2015
Surgical Site Infection
13 new measures for FY 2016
Six SCIP measures
Six clinical process / oncology care measures
HCAHPS survey
Disaster / extenuating circumstances waiver modeled on IQR waiver process
© 2013 American Hospital Association 25

21. Long-Term Care Hospital Quality Reporting (LTCHQR)
Submit quality measures for FY 2014 and beyond
Compliance is tied to 2 percent of the annual update
Measure
FY 2014
FY 2015
FY 2016
FY 2017
FY 2018
Central-Line Associated Blood Stream Infection (CLABSI) X
Catheter-Associated Urinary Tract Infection (CAUTI)
Percent of nursing home residents with pressure ulcers that are new or worsened
Percent of nursing home residents who were assessed and appropriately given the seasonal influenza vaccine --
Influenza vaccination coverage among healthcare personnel
Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia P
Clostridium difficile (C Diff)
Unplanned all-cause, all condition readmissions to LTCHs and acute care hospitals
Percent of residents experiencing one or more falls with major injury (Long stay)
X = Previously Finalized
P = Proposed
For those at the last round of RPBS we went over the basics of the VPB program and CMS’ proposed rule.
Starts in 2013 with 1 percent of payments set aside for VBP.
Only IPPS hospitals and doesn’t affect special payments. 26
© 2013 American Hospital Association

22. LTCHQR Proposals – Areas of Concern
Proposed measures not ready to use in LTCHs
The measures proposed for FY 2017 and FY 2018 received a “support direction” vote from the MAP
MRSA and C Diff are NQF-endorsed but not fully tested in LTCHs
Falls measure received NQF endorsement based on specifications and testing for nursing homes, not LTCHs
Proposed readmissions measure modeled on hospitalwide all-cause, all-condition readmissions measure in the IQR, carrying with it all of the same problems
© 2013 American Hospital Association 27

23. LTCHQR Proposals – Measure Updates
Healthcare personnel flu vaccination measure: reporting periods changed so that they reflect a full flu season
FY 2016: Oct. 1, 2014 – Mar. 31, 2015 (due May 15, 2016)
FY 2017: Oct. 1, 2015 – Mar. 31, 2016 (due May 15, 2016)
Patient flu vaccination measure
Change in reporting timelines for FY 2016 and FY 2017 to reflect the implementation of LTCH CARE Tool (see the Regulatory Advisory)
Public reporting to reflect flu season time periods, though data collection must take place for all specified periods
© 2013 American Hospital Association

24. Proposed Readmission measure
Why readmissions?
CMS estimates readmissions to LTCHs and IPPS hospitals within 30 days of discharge is 26%
What measure is CMS proposing? (See Measure Specifications)
Returns within 30 days of LTCH discharge from the community or another care setting of lesser intensity (i.e.—SNFs, home health, Inpatient Rehab) to acute-care hospitals or LTCHs.
Based on “all cause, all condition” because of variability in types of patients treated in LTCHs
Small ‘N’ of patient types means unstable measure
Uses 2 year time-period of data from inpatient claims and Medicare eligibility files
© 2013 American Hospital Association 27

25. Proposed Readmission measure (2)
Patients included
Age: 18 years and older
Discharged alive from LTCHs
Had 12 months of Medicare Part A FFS coverage and 30 days post discharge
Had IPPS hospital stay within the 30 days prior to LTCH stay
Exclusions
Transfers from LTCH to another LTCH or IPPS hospital
“Planned readmissions” within 30 days
Exclusions for labor/delivery, cancer treatment, transplant already in IPPS measure
LTCH measure includes several additional planned procedures (e.g.—amputations, select colorectal procedures, removal of feeding/tracheostomy tubes)
© 2013 American Hospital Association 27

26. LTCHQR Proposals Housekeeping items
Proposing a reconsideration process for annual payment update determination (modeled on the IQR)
Proposing a disaster / extraordinary circumstances waiver process (modeled on the IQR)
© 2013 American Hospital Association 28