1. Linking Quality To Payment 17 th Annual Rural Health Conference Timothy Burrell, MD, MBA Medical Director

2. Definition Of Quality “General excellence of standard.”

3. Definition Of Quality “General excellence of standard.”

4. Institute of Medicine “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

5. Outcomes + Knowledge =

7. Payment

8. Affordable Care Act – March 2010

9. The Centers for Medicare & Medicaid Services Changed how Medicare pays for services by rewarding/not punishing providers for delivering higher quality and value. The programs highlighted in this presentation: 1.Hospital Readmissions Reduction Program (HRRP) 2.Hospital Value-Based Purchasing Program (VBP) 3.Hospital-Acquired Condition Reduction Program

10. Advancing Medicare Value

11. What Is At Stake? Fiscal Year Readmission Reduction Program Value Based Purchasing Hospital Acquired Condition Reduct. Total 2013-1.0%-1.00%--2.00% 2014-2.0%-1.25%--3.25% 2015-3.0%-1.50%-1.0%-5.50% 2016-3.0%-1.75%-1.0%-5.75% 2017-3.0%-2.00%-1.0%-6.00%

13. What Is At Stake? Wellpoint Commercial Payments 30% of 2013 performance based 50% of 2015 performance based ??% of 2017 performance based

14. Quality / Value / Quality Government and private payors will continue exploring programs that tie value to quality. Understanding and implementing quality improvement programs will better prepare providers for the future.

15. Escalator Principle “Like an escalator, HITECH attempts to move the health system upward toward improved quality and effectiveness in health care. But the speed of ascent must be calibrated to reflect both the capacities of providers who face a multitude of real-world challenges and the maturity of the technology itself.” The “Meaningful Use” Regulation for Electronic Health Records David Blumenthal, M.D., M.P.P., and Marilyn Tavenner, R.N., M.H.A. N Engl J Med 2010; 363:501-504 August 5, 2010 DOI: 10.1056/NEJMp1006114August 5, 2010

16. UP AND DOWN

17. 1 Hospital Readmissions Reduction Program

18. Hospital Readmissions Reduction Program The historic 30-day readmission rate for Medicare beneficiaries is nearly 20%...

19. Hospital Readmissions Reduction Program The historic 30-day readmission rate for Medicare beneficiaries is nearly 20%...... at a cost of ~$20 billion/year.

20. Hospital Readmissions Reduction Program Authorized by Affordable Care Act (ACA) to begin October 1, 2012 Penalties 2013: -1% 2015: -3% Reduction applies to TOTAL Medicare payments

21. Clinical Conditions 2012 Acute Myocardial Infarction Congestive Heart Failure Pneumonia 2014 adds Chronic Obstructive Pulmonary Disease (COPD) Total Knee Arthroplasty Total Hip Arthroplasty

22. Readmission Definition Any readmission to an acute care facility within 30 days. Exceptions: Long-term Acute Care Hospital (LTACH) Inpatient Rehabilitation Facility (IRF) Observations (OBS) Other non-acute care

23. Readmission Causes P roblem - Nature of the Disease P atient - Psychosocial Factors P rovider - Gaps in Post-Discharge Management

24. Problem - Nature of the Disease Some readmissions are inevitable* Many readmissions are negotiable Most readmissions are preventable (*Don’t fight it) CMS View: DRG payments promote premature discharges

25. Patient - Psychosocial Factors Social support Access to medication Access to care Access to transportation Literacy Mental Health/Substance Abuse

26. Provider - Gaps in Post- Discharge Management Delayed outpatient follow-up Lack of medication reconciliation Poor coordination/transition of care Inattention to red flags: o Phone calls o Urgent Care/ED visits o Early medication refill requests o After-hours walk-in clinic visits

27. How Are We Doing? Many Obstacles Creativity over Technology Management over Medicine Low Tech & High Touch

28. 20%  19%  18.5%  17.5%

29. Indiana rank: #31 (2009) #43 (2014) http://datacenter.commonwealthfund.org/#ind=1/sc=1

31. 2 Hospital Value-Based Purchasing Program (VBP)

32. Value-Based Purchasing (VBP) Authorized by ACA to begin October 1, 2012 Funded by a reduction from participating hospital base-operating Diagnosis-Related Group (DRG) payments: 2013: -1% 2017: -2% The amount of funding for this program is equal to the amount generated by the payment cuts.

33. Value-Based Purchasing (VBP) Increasing number of measures per year 2013 – 20 Measures 2014 – 24 Measures 2015 – 26 measures

34. Value-Based Purchasing (VBP) Fiscal Year 2014 – Three Domains 45% – Clinical Processes of Care 30% – Patient Experience of Care 25% – Outcome Domain

35. Value-Based Purchasing (VBP) In each category hospitals are scored for Achievement Improvement The highest score of the two is the final score for the category

36. Clinical Processes of Care Thirteen (13) measures within well-known categories: Acute Myocardial Infarction (AMI) Congestive Hear Failure (CHF) Pneumonia Healthcare Associated Infection

37. Clinical Process of Care Measures 1. AMI-7a Fibrinolytic Therapy Received within 30 Min. of Hospital Arrival 2. AMI-8a Primary PCI Received within 90 Min. of Hospital Arrival 3. HF-1 Discharge Instructions 4. PN-3b Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hosp. 5. PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient 6. SCIP-Inf-1 Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision 7. SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients 8. SCIP-Inf-3 Prophylactic Antibiotic Discontinued within 24 Hrs After Surgery End Time 9. SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6 a.m. Post-op Serum Glucose 10. SCIP-Inf-9 Urinary Catheter Removed on Post-op Day 1 or Post-op Day 2 11. SCIP-Card-2 Surgery Pts on ß-Blocker Who Received a ß-Blocker Perioperatively 12. SCIP-VTE-1 Surgery Pts given Venous Thromboembolism (VTE) Prophylaxis 13. SCIP-VTE-2 Pts Who Received VTE Prophylaxes within 24 Hrs Prior/After Surgery

39. Patient Experience of Care Dimensions 1. Communication with Nurses 2. Communication with Doctors 3. Responsiveness of Hospital Staff 4. Pain Management 5. Communication about Medicines 6. Cleanliness and Quietness of Hospital Environment 7. Discharge Information 8. Overall Rating of Hospital Eight HCAPS-based dimensions

40. Outcome Measures 1.MORT-30-AMI Acute Myocardial Infarction (AMI) 30-day* mortality rate 2.MORT-30-HF Heart Failure (HF) 30-day* mortality rate 3.MORT-30-PN Pneumonia (PN) 30-day* mortality rate * Post-admission

43. 3 Hospital-Acquired Condition (HAC) Reduction Program

44. HAC Reduction Program Authorized by ACA to begin October 1, 2014 Requires CMS to reduce hospital payments by (1%) for hospitals that rank among the lowest-performing 25% for hospital-acquired conditions In addition to current Hospital-Acquired Conditions Program and excludes critical access hospitals

45. HAC Reduction Program Conditions acquired while receiving care for another condition in an acute care health setting. Additional sources: Extended Care Facility Acute Rehabilitation Facility Dialysis Center Ambulatory Surgery Center

46. Three Measures – Two Domains Domain 1 – 2014 (65%) Patient Safety Indicator #90: Pressure Ulcer (PSI 3) Iatrogenic Pneumothorax (PSI 6) Central Venous Catheter-Related Blood Stream Infection (PSI 7) Postop Hip Fracture (PSI 8) Postop Pulm. Embolism (PE) / Deep Vein Thrombosis (DVT) (PSI 12) Postop Sepsis (PSI 13) Wound Dehiscence (PSI 14) Accidental Puncture and Laceration (PSI 15)

47. Three Measures – Two Domains Domain 2 – 2014 (35%) Central Line-Associated Blood Stream Infection Catheter-Associated Urinary Tract Infection

48. Three Measures – Two Domains Domain 2 – 2014 (35%)  2015 Surgical Site Infection - Colon Surgical Site Infection - Abd. Hysterectomy  2016 Methicillin-resistant staph aureus (MRSA) Clostridium difficile Infection

49. HAC Reduction Program Complements other CMS programs  Hospital-Acquired Conditions (Present on Admission)  Never Events Non-Payment  Hospital Compare Reporting

50. CMS Program Overlap

53. You Can Do It!!!

54. Questions? Timothy Burrell, MD, MBA Medical Director Health Care Excel TBurrell@HCE.org (317) 754-5442