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Barbara J. Connors, DO, MPH Chief Medical Officer, Region III The Centers for Medicare and Medicaid Services Region III Philadelphia Chapter ACS CMS ’

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Presentation on theme: "Barbara J. Connors, DO, MPH Chief Medical Officer, Region III The Centers for Medicare and Medicaid Services Region III Philadelphia Chapter ACS CMS ’"— Presentation transcript:

1 Barbara J. Connors, DO, MPH Chief Medical Officer, Region III The Centers for Medicare and Medicaid Services Region III Philadelphia Chapter ACS CMS ’ Value-Based Purchasing The Nexus of Quality, Coordination, & Efficiency

2 CMS ’ Quality Improvement Roadmap  Vision: The right care for every person every time  Make care:  Safe  Effective  Efficient  Patient-centered  Timely  Equitable

3 CMS ’ Quality Improvement Roadmap Strategies  Work through partnerships  Measure quality and report comparative results  Encourage adoption of effective health information technology  Promote innovation and the evidence base for effective use of technology  Value-Based Purchasing: Improve quality and avoid unnecessary costs

4 Support for VBP  President’s Budget  FYs  Congressional Interest in P4P and Other Value- Based Purchasing Tools  BIPA, MMA, DRA, TRCHA, MMSEA, MIPPA  MedPAC Reports to Congress  P4P recommendations related to quality, efficiency, health information technology, and payment reform  IOM Reports  P4P recommendations in To Err Is Human and Crossing the Quality Chasm  Report, Rewarding Provider Performance: Aligning Incentives in Medicare  Private Sector  Private health plans  Employer coalitions

5 Why VBP?  Medicare Solvency and Beneficiary Impact  Expenditures up from $219 billion in 2000 to a projected $486 billion in 2009  Part A Trust Fund  Excess of expenditures over tax income in 2007  Projected to be depleted by 2019  Part B Trust Fund  Expenditures increasing 11% per year over the last 6 years  Medicare premiums, deductibles, and cost-sharing are projected to consume 28% of the average beneficiaries’ Social Security check in 2010

6

7 Medicare Reimbursement Rates

8 Practice Variation

9 What Does VBP Mean to CMS?  Transforming Medicare from a passive payer to an active purchaser of higher quality, more efficient health care  Tools and initiatives for promoting better quality, while avoiding unnecessary costs  Tools: measurement, payment incentives, public reporting, conditions of participation, coverage policy, QIO program  Initiatives: pay for reporting, pay for performance, gainsharing, competitive bidding, bundled payment, coverage decisions, direct provider support

10 Value-Based Purchasing- What it is really about: It is about defining/rewarding providers for the value of their contribution to quality and efficient care that leads to better health outcomes.

11 VBP: Payment Methodologies Pay for Reporting Pay for Participation Pay for Care Coordination Pay for Process Pay for Outcomes

12 VBP Programs  Physician Quality Reporting Initiative  Physician Resource Use Reporting  Hospital Quality Initiative: Inpatient & Outpatient Pay for Reporting  Hospital VBP Plan & Report to Congress  Hospital-Acquired Conditions & Present on Admission Indicator Reporting

13 VBP Towards Value-Based Purchasing 2007 TRHCA 74 measures Claims- based only 2008 MMSEA 119 measures Claims 4 Measures Groups Registry 2009 MIPPA 153 measures Claims 7 Measures Groups Registry EHR- testing eRx 2010 TBD through rule- making

14 Statutory Authority Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) –Section 131(d) Plan for Transition to Value-Based Purchasing Program for Physicians and Other Practitioners Report to Congress due May 1, 2010

15 Issues Paper Assumptions & Design Principles PVBP Planning will: –Focus on performance-based payment –Accommodate different practice arrangements –Recognize the contributions of members of the health professional team –Address multiple levels of accountability –Be at least budget neutral—across at least Medicare Parts A and B—and will seek to identify program savings –Initially focus on traditional fee-for-service Medicare –Have short-term and longer-term timeframes, with attention to transitions –Avoid creating additional health care disparities and work to reduce existing disparities –Include an ongoing evaluation process

16 Stakeholder Input: Overarching Issues Affirmed goal and objectives Advocated for new payment approaches that cut across settings and align Part A and B payment incentives Agreed with the need to accommodate different practice arrangements Praised attention to disparities Urged attention to operational transitions

17 Next Steps in Plan Development Receive direction from new leadership Design options –Physician Fee Schedule (PFS) overlay Performance-based PFS payments Medical Home –Levels of accountability beyond individuals Groups Accountable Care Entities –Shared savings models –Bundled payment arrangements Simulations pending availability of resources Opportunities for stakeholder input –PFS 2010 rulemaking –Potential additional Listening Sessions

18 VBP and PQRI Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) - Makes PQRI permanent; however only 2009 and 2010 incentives are funded - Increased 2009 PQRI incentive to 2% - Added new E-Prescribing incentive for 2009, an additional 2% subject to qualifying for the measure

19 PQRI PQRI reporting focuses attention on quality of care –Foundation is evidence-based measures developed by professionals. –Reporting data for quality measurement is rewarded with financial incentive. –Measurement enables improvements in care. –Reporting is the first step toward pay-for-performance. Measures address various aspects of quality care –Prevention –Chronic Care Management –Acute Episode of Care Management –Procedural Related Care –Resource Utilization –Care Coordination

20 2007 PQRI Reporting Participation Statistics 109, 349 NPI/TINs – Attempted to Submit 101,138 NPI/TINs – Submitted a Quality Data Code Successfully –A feedback report is available 70,207 NPI/TINS – Satisfactorily Reported 1 or more measures –A feedback report is available 56,722 NPI/TINs – Earned Incentive –A feedback report & incentive payment are available

21 2007 PQRI Experience Report QDC Submission Attempts 12.15% Missing NPI 18.89% Incorrect HCPCS code* 13.93% Incorrect DX code* 7.24% Both incorrect HCPCS code and incorrect DX code* 4.97% All line items were QDCs only *Denominator mismatch

22 Top Ten Most Frequently Reported Measures by Clinical Topic 1.Pneumonia 2.Chest Pain 3.Perioperative Care 4.Diabetes 5.ECG for Syncope 6.Coronary Artery Disease 7.Myocardial Infarction 8.Heart Failure 9.Macular Degeneration 10.Glaucoma

23 2009 PQRI Quality Measures 153 PQRI quality measures for 2009 –Includes 101 measures from the 2008 PQRI and 52 new measures –E-prescribing measure (Measure #125) removed, as required by MIPPA as a separate incentive program –18 measures reportable only through registries –Measure specifications are available in the Measures/Codes section of the website at

24 2009 PQRI Reporting Periods 1 reporting period for claims-based reporting of individual measures: January 1, 2009 – December 31, reporting periods for reporting measures groups and registry-based reporting: –January 1, 2009 – December 31, 2009 –July 1, 2009 – December 31, 2009

25 PQRI Claims-Based Process Visit Documented in the Medical Record Encounter FormCoding & Billing Carrier/MAC NCH Analysis ContractorNational Claims History File Incentive Payment Confidential Report Critical Step N-365

26 26 Benefits of PQRI Participation Receive confidential feedback reports to support quality improvement Earn a bonus incentive payment Make an investment in the future of the practice –Prepare for higher bonus incentives over time –Prepare for pay-for-performance –Prepare for public reporting of performance results

27 MIPPA Authorized E-Prescribing Incentives Year Incentive for Successful E-Prescribers Reduction for Unsuccessful E-Prescribers % % % %-1.0% %-1.5% %

28 ARRA Authorized Incentives for Meaningful Use of EHRs YearFirst Payment Yr (Subsequent payment Yrs) Reduction in Fees for Non- Use 2011$18k ($12k, $8k, $4k, $2k) 2012$18k ($12k, $8k, $4k, $2k) 2013$15k ($12k, $8k, $4k) 2014$12k ($8k, $4k) % % %

29 Summary of MIPPA and ARRA Authorized Incentive Programs Year MIPPA Authorized Incentive for Successful E-Prescribers ARRA Authorized Incentive for Meaningful Use of EHR % Incentive N/A 20111% Incentive $18k ($12k, $8k, $4k, $2k) 20121% Incentive $18k ($12k, $8k, $4k, $2k) % Incentive 1.5% Reduction $15k ($12k, $8k, $4k) 2014 No Incentive 2% Reduction $12k ($8k, $4k) 2015N/A 1% Reduction 2016N/A 2% Reduction 2017N/A 3% Reduction

30 Premier Hospital Quality Incentive Demonstration

31 Surgical Care Improvement Project /Surgical Infection Prevention (SCIP) FY 2009  SCIP-Inf-1 Prophylactic antibiotic received within 1 hour prior to surgical incision  SCIP-Inf-3 Prophylactic antibiotics discontinued within 24 hours after surgery end time  SCIP-VTE 1: prophylaxis ordered for surgical pt  SCIP-VTE 2: prophylaxis within 24 hr pre/post

32 SCIP (Previously SIP)  SCIP Infection 2: Prophylactic Antibiotic selection for surgical pt  SCIP Infection 4: Cardiac surgical pts with Controlled 6am post op serum glucose  SCIP Infection 6 Surgery pts with appropriate hair removal

33 AHRQ PSIs and IQI’s Patient Safety Indicators (PSIs) Death among surgical pts with serious treatable conditions Post-op wound dehiscence Inpatient Quality Indicators (IQIs) AAA Mortality rate (with or without volume) Hip fracture mortality rate Mortality rate for selected surgical procedures Participation in a systematic database for cardiac surgery

34 ACS NSQIP –Surgeons and centers require high quality, reliable & timely data to identify opportunities for improvement and to protect themselves from data being misinterpreted to and by the public –Increasing public demand for “accountability” in healthcare –Eroding public trust in clinicians to provide safe care –Efforts by payors and purchasers to “drive” patients to centers with safer systems –Evolving move by payors to “pay for performance” –Without risk-adjusted data, surgeons and medical centers have had to use administrative (i.e., payor) data –Surgeons and medical centers find themselves profiled on the Internet

35 ASC NSQIP The ACS NSQIP involves the collection of preoperative risk factors, intraoperative variables, and postoperative outcomes by a surgical clinical nurse reviewer (SCNR) at each participating medical center DEMOGRAPHICS 9 variables SURGICAL PROFILE 9 variables PRE-OPERATIVE DATA 40 clinical variables 13 laboratory variables INTRA-OPERATIVE DATA 18 clinical variables 3 occurrence variables POST-OPERATIVE DATA 20 occurrence variables 12 laboratory variables 9 discharge variables

36 What to do with the Data Reduce postoperative mortality rates Reduce postoperative morbidity rates Reduce the median length- of-stay Leverage data for other internal and public reporting initiatives Meet CMS Surgical Care Improvement Program (SCIP) reporting requirements by collecting SCIP data through the ACS NSQIP SCIP data collection module Potentially allow for higher reimbursement in the emerging “pay for performance” environment Help to increase patient satisfaction Serve as a foundation and resource for research initiatives Help to identify possible under- billings Help to increase negotiating leverage with third-party payers and employers

37 –Inform and improve surgical rounds Regular reporting of ACS NSQIP data in conjunction with specific case discussion. Movement toward understanding and analyzing trends of occurrences v. singular events –Identify quality improvement opportunities Identification of quality improvement opportunities by Depts. of Surgery Proactive v. Reactive –Benchmark performance against peers –Re-engineer or eliminate retrospective clinical databases historically used for quality assurance or JCAHO reporting –Discuss opportunities to use data in payor negotiations, “pay for performance” –Conduct research –Review billing practices –Analyze systems of care Use the Data

38 ACS NSQIP Eligible Specialties General Surgery Vascular Surgery Urology Neurosurgery Orthopedics ENT Plastic Surgery Thoracic Cardiac Gynecological surgery

39 Demonstration Projects CMS currently pays for quality through a series of Demonstration Projects Several Demonstrations are mandated through Congressional Legislation Must be budget neutral

40 VBP Demonstrations and Pilots Physician Group Practice Demonstration Medicare Care Management Performance Demonstration Medicare Medical Home Demonstration Medicare Healthcare Quality Gainsharing Demonstrations Accountable Care Episode (ACE) Demonstration

41 Demonstration Purpose Test the development and implementation of Medicare policy changes prior to legislation enacting such changes on a national basisTest the development and implementation of Medicare policy changes prior to legislation enacting such changes on a national basis –Whether it works… –What refinements… Generally look at payment, new benefit, new organization of care deliveryGenerally look at payment, new benefit, new organization of care delivery

42 Acute Care Episode (ACE) Demonstration Problems with Current System Increased number of services not necessarily correlated with better care Conflicting provider incentives –Hospitals paid per discharge –Physicians paid per service

43 Global Payment Fee-for-service Part A and Part B Services related to acute care episode only Cardiovascular and/or orthopedic procedures

44 Sites Selected Hillcrest Medical Center – Tulsa Baptist Health System – San Antonio Oklahoma Heart Hospital – Oklahoma City Lovelace Health System – Albuquerque Exempla Saint Joseph Hospital – Denver Two are cardiovascular only One is orthopedic only Two are both cardiovascular and orthopedic

45 Determination of Payment Rates Based on competitive bids from sites Compared to regular average Medicare payments to the hospitals and physicians Evaluated based upon the size of the discount Subject to annual IPPS updates

46 Gainsharing Demonstrations Authority –Deficit Reduction Act (DRA) Section 5007 –Medicare Modernization Act (MMA) Section 646 –In the absence of statutory authority, gainsharing is restricted by law Purpose –To allow hospitals to provide gainsharing payments designed to improve quality and efficiency of care to physicians Timing –3-year projects Target –Hospitals and physicians Compensation –Hospitals may share savings with physicians

47 Hospital and Physician Alignment of Incentives Medicare pays hospitals prospectively for bundles of services using DRGs Physicians generally paid per service How to align incentives to improve quality and efficiency? Encourage physician-hospital collaboration by permitting hospitals to share internal savings

48 Gainsharing Payments Incentive system must be uniform across physicians, can be reviewed and audited. Payments must be linked to quality and efficiency Gainsharing must be a transparent Must represent share of internal hospital savings and be tied to quality improvement Limited to 25% of physician fees for care of patients affected by quality improvement activity

49 Demo Comparison Design Feature DRA Section 5007MMA Section 646 Size2 hospitals Beth Israel, NY CAMC, WV Physician groups and up to 13 affiliated hospitals in limited number of geographic areas. NJ 12 and WV 1 Scope of EvaluationInpatient episodes and post- discharge window (e.g., 30 days) Inpatient episodes including pre- and post-hospital care over duration of demonstration Eligible Organizations PPS hospitals, excludes CAHsPhysician groups and affiliated hospitals, integrated delivery systems

50 Efficiency in the Quality Context  Efficiency Is One of the Institute of Medicine's Key Dimensions of Quality 1.Safety 2.Effectiveness 3.Patient-Centeredness 4.Timeliness 5.Efficiency: absence of waste, overuse, misuse, and errors 6.Equity Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21st Century, March, 2001.

51 Physician Resource Use Reports Pilot  Statutory Authority  Medicare Improvement for Patients and Providers Act of 2008, Section 131(c)  The Secretary shall establish a Physician Feedback Program under which the Secretary shall use claims data (and may use other data) to provide confidential reports to physicians (and, as determined appropriate by the Secretary, to groups of physicians) that measure the resources involved in furnishing care. The Secretary may include information on the quality of care furnished by the physician (or group of physicians) in such reports.

52 Physician Resource Use Measurement  Goals  Construct resource use measures that are meaningful, actionable, and fair  Provide confidential reports of resource use to individual/groups of physicians  Compare actual use to expected resource use  Link resource use to measures of quality and patient experiences of care

53 Statutory Authority MIPPA Section 131(c) MIPPA Options:  Resource use can be measured on an episode or per capita basis, or both  Resource use can be measured with claims or through other data sources  Focus can be on selected physicians by: specialty, conditions treated, geography, high cost outliers, minimum # of cases  CMS can make adjustments to resource use measures to render them comparable across physicians  Resource use measures can apply to individual physicians or physician groups

54 Prepare claims data, including Standardize unit prices Group claims into episodes of care; Sum costs of all claims in an episode Risk-adjust the cost of each episode Attribute each episode and associated episode cost to one or more physicians Calculate physician’s average cost for all attributed episodes Compare physician’s average cost to peer group benchmark (including drill downs) Produce, test, and distribute RURs Creating Resource Use Reports

55 Hospital VBP  Deficit Reduction Act (DRA) Section 5001(b) authorized CMS to develop a Medicare Hospital VBP Plan  IPPS hospitals  FY 2009 start date  Must consider  Measures  Data infrastructure and validation  Incentive structure  Public reporting  Must consult stakeholders and consider experience with relevant demonstrations and private-sector programs

56 Value-Based Purchasing and Hospital-Acquired Conditions The Hospital-Acquired Conditions provision is a step toward Medicare VBP for hospitals Strong public support for CMS to pay less for conditions that are acquired during a hospital stay Considerable national press coverage of HAC has prompted dialogue of how to further eliminate healthcare-associated infections and conditions

57 Statutory Authority: DRA Section 5001(c)  Beginning October 1, 2007, hospitals were required to submit data on their claims for payment indicating whether diagnoses were present on admission (POA)  Beginning October 1, 2008, CMS cannot assign a case to a higher DRG based on the occurrence of one of the selected conditions, if that condition was acquired during the hospitalization  This provision does not apply to Critical Access Hospitals, Rehabilitation Hospitals, Psychiatric Hospitals, or any other facility not paid under the Medicare Hospital IPPS

58 Statutory Selection Criteria CMS must select conditions that are 1.High cost, high volume, or both 2.Assigned to a higher paying DRG when present as a secondary diagnosis 3.Reasonably preventable through the application of evidence-based guidelines

59 Present on Admission Present on admission (POA) is defined as present at the time the order for inpatient admission occurs –Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA POA indicator is assigned to –Principal diagnosis –Secondary diagnoses –External cause of injury codes (Medicare requires reporting only if E-code is reported as an additional diagnosis)

60 POA Indicator Reporting Options CodeReason for Code Y Diagnosis was present at time of inpatient admission. N Diagnosis was not present at time of inpatient admission. U Documentation insufficient to determine if condition was present at the time of inpatient admission. W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission. 1 Unreported/Not used. Exempt from POA reporting. This code is equivalent code of a blank on the UB-04; however, it was determined that blanks are undesirable when submitting this data via the 4010A.

61 “ A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.”

62 Selected HACs for Implementation 1.Foreign object retained after surgery 2.Air embolism 3.Blood incompatibility 4.Pressure ulcers –Stages III & IV 5.Falls –Fracture –Dislocation –Intracranial injury –Crushing injury –Burn –Electric shock

63 Selected HACs for Implementation 6.Manifestations of poor glycemic control –Hypoglycemic coma –Diabetic ketoacidosis –Nonketotic hyperosmolar coma –Secondary diabetes with ketoacidosis –Secondary diabetes with hyperosmolarity 7.Catheter-associated urinary tract infection 8.Vascular catheter-associated infection 9.Deep vein thrombosis (DVT)/pulmonary embolism (PE) –Total knee replacement –Hip replacement

64 Selected HACs for Implementation 10. Surgical site infection –Mediastinitis after coronary artery bypass graft (CABG) –Certain orthopedic procedures Spine Neck Shoulder Elbow –Bariatric surgery for obesity Laprascopic gastric bypass Gastroenterostomy Laparoscopic gastric restrictive surgery

65 Selected HAC Medicare Data (FY 2007) CC/MCC (ICD-9-CM Codes) Selected Evidence ‑ Bas ed Guidelines Vascular Catheter- Associated Infection ● 29,536 cases ● $103,027/hospital stay (CC)Available at the Web site: idod/dhqp/gl_intravas cular.html Surgical Site Infection- Mediastinitis after Coronary Artery Bypass Graft (CABG) ● 69 cases ● $299,237/hospital stay (MCC) And one of the following procedure codes: 36.10–36.19 Available at the Web site: idod/dhqp/gl_surgical site.html

66 Selected HAC Medicare Data (FY 2007) CC/MCC (ICD-9-CM Codes) Selected Evidence ‑ Bas ed Guidelines Catheter- Associated Urinary Tract Infection (UTI) ● 12,185 cases ● $44,043/hospital stay (CC) Also excludes the following from acting as a CC/MCC: (CC) (CC) (MCC) (MCC) (CC) (CC) (CC) (CC) (CC) (CC) idod/dhqp/gl_cathetea ssoc.html

67 Selected HACMedicare Data (FY 2007) CC/MCC (ICD-9-CM Codes) Selected Evidence ‑ Bas ed Guidelines Stage III & IV Pressure Ulcers ● 257,412 cases ● $43,180/hospital stay (MCC) (MCC) NQF Serious Reportable Adverse Event h.gov/books/bv.fcgi?ri d=hstat2.chapter Falls and Trauma: - Fractures - Dislocations - Intracranial Injuries - Crushing Injuries - Burns ● 193,566 cases ● $33,894/hospital stay CC/MCC codes within these ranges: NQF Serious Reportable Adverse Event ual/nqfpract.htm

68 Selected HAC Medicare Data (FY 2007) CC/MCC (ICD-9-CM Codes) Selected Evidence ‑ Bas ed Guidelines Foreign Object Retained After Surgery ● 750 cases ● $63,631/hospital stay (CC) (CC) NQF Serious Reportable Adverse Event ual/nqfpract.htm Air Embolism● 57 cases ● $71,636/hospital stay (MCC)NQF Serious Reportable Adverse Event ual/nqfpract.htm Blood Incompatibility ● 24 cases ● $50,455/hospital stay (CC)NQF Serious Reportable Adverse Event ual/nqfpract.htm

69 Candidate HACs Fiscal Year 2009 Inpatient Prospective Payment System (IPPS) final rule pdfhttp://edocket.access.gpo.gov/2008/pdf/E pdf (page 39)

70 Candidate HACs 1.Surgical site infection following device procedures 2.Failure to rescue 3.Death or disability associated with drugs, devices, or biologics 4.Dehydration 5.Malnutrition

71 Candidate HACs 6. Water-borne pathogens 7.Surgical site infections following procedures – orthopedic and other 8.Ventilator-associated pneumonia 9.Clostridium difficile-associated disease

72 HAC Candidate Medicare Data (FY 2007) CC/MCC (ICD-9-CM Codes) Selected Evidence-Based Guidelines Surgical Site Infections Following Elective Procedures: - Total Knee Replacement - Laparoscopic Gastric Bypass and Gastroenter- ostomy - Ligation and Stripping of Varicose Veins Total Knee Replacement ● 539 cases ● $63,135/hospital stay Laparoscopic Gastric Bypass and Gastroenterostomy ● 208 cases ● $180,142/hospital stay Ligation and Stripping of Varicose Veins ● 3 cases ● $66,355/hospital stay Total Knee Replacement (81.54): (CC) and (CC) Laparoscopic Gastric Bypass (44.38) and Gastroenter- ostomy (44.39): (CC) Varicose Veins (38.5): (CC) /ncidod/dhqp/gl_su rgicalsite.html /ncidod/dhqp/gl isolation.html

73 HAC Candidate Medicare Data (FY 2007) CC/MCC (ICD-9-CM Codes) Selected Evidence- Based Guidelines Legionnaires’ Disease ● 351 cases ● $86,014/hospital stay (MCC)http://www.cdc.gov /ncidod/dbmd/dise aseinfo/legionellos is_g.htm la.org/ Iatrogenic Pneumothorax ● 22,665 cases ● $75,089/hospital stay (CC)http://www.ncbi.nl m.nih.gov/pubmed / Delirium● 480 cases ● $23,290/hospital stay (CC)http://www.ahrq.go v/clinic/ptsafety/ch ap28.htm

74 HAC Candidate Medicare Data (FY 2007) CC/MCC (ICD-9-CM Codes) Selected Evidence- Based Guidelines Glycemic Control: - Diabetic Ketoacidosis - Nonketotic Hyperosmolar Coma - Diabetic coma - Hypoglycemic Coma Diabetic Ketoacidosis ● 11,469 cases ● $42,974/hospital stay Nonketotic Hyperosmolar Coma ● 3,248 cases ● $35,215/hospital stay Diabetic Coma ● 1,131 cases ● $45,989/hospital stay Hypoglycemic Coma ● 212 cases ● $36,581/hospital stay Diabetic Ketoacidosis: – (CC) Nonketotic Hyperosmola Coma: – (CC) Diabetic coma: (CC) Hypoglycemic Coma: (CC) NQF Serious Reportable Adverse Events address hypoglycemia es.org/uedocume nts/InpatientDMG lycemicControlPo sitionStmt REV.pdf

75 HAC Candidate Medicare Data (FY 2007) CC/MCC (ICD-9-CM Codes) Selected Evidence- Based Guidelines Ventilator- Associated Pneumonia (VAP) ● 30,867 cases ● $135,795/hospital stay (CC) Must also include ventilator codes: – al.com/cpgs/ html Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) ● 149,010 cases ● $50,937/hospital stay – (CC) (MCC) (MCC) urnal.org/cgi/reprin t/126/3_suppl/172 S s.org/topic.cfm?top ic=A00219

76 HAC Candidate Medicare Data (FY 2007) CC/MCC (ICD-9-CM Codes) Selected Evidence- Based Guidelines Staphylococcus Aureus Septicemia ● 27,737 cases ● $84,976/hospital stay (MCC) (MCC) (MCC) (CC) (CC) /ncidod/dhqp/gl_is olation.html /ncidod/dhqp/gl_int ravascular.html Clostridium Difficile Associated Disease (CDAD) ● 96,336 cases ● $59,153/hospital stay (CC)http://www.cdc.gov /ncidod/dhqp/gl_is olation.html /ncidod/dhqp/id_C diffFAQ_HCP.html #9

77 Proposed 2010 IPPS Rule Data/ _PI.pdf

78 Guidelines for Preventing HACs Where are guidelines developed –Professional organizations, Task Forces, Government agencies, academic institutions What are they –Recommendations for interventions based scientific evidence or expert opinion Who develops and uses them –Scientists, clinicians –Policy makers, consumers

79 Future Considerations Risk adjustment –Individual and population level Rates of HACs for VBP –Appropriate for some HACs Uses of POA information –Public reporting Adoption of ICD-10 –Example: 125 codes capturing size, depth, and location of pressure ulcer Expansion of the IPPS HAC payment provision to other settings –Discussion in the IRF, OPPS/ASC, SNF, LTCH regulations

80 Never Events Wrong surgery performed on a patient Surgery performed on wrong body part Surgery performed on the wrong patient

81 Resources Available Physician Quality Reporting Initiative: https://www.cms.hhs.gov/pqri CMS Quality Initiatives – General Information: 12/9/08 Issues Paper: Development of a Plan to Transition to a Medicare Value-Based Purchasing Program for Physician and Other Professional Services Hospital Quality Reporting: Demonstrations:

82 THANK YOU! Questions?


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