Presentation on theme: "Philadelphia Chapter ACS CMS’ Value-Based Purchasing The Nexus of Quality, Coordination, & Efficiency Barbara J. Connors, DO, MPH Chief Medical Officer,"— Presentation transcript:
1Philadelphia Chapter ACS CMS’ Value-Based Purchasing The Nexus of Quality, Coordination, & EfficiencyBarbara J. Connors, DO, MPHChief Medical Officer, Region IIIThe Centers for Medicare and Medicaid ServicesRegion III
2CMS’ Quality Improvement Roadmap Vision: The right care for every person every timeMake care:SafeEffectiveEfficientPatient-centeredTimelyEquitable
3CMS’ Quality Improvement Roadmap StrategiesWork through partnershipsMeasure quality and report comparative resultsEncourage adoption of effective health information technologyPromote innovation and the evidence base for effective use of technologyValue-Based Purchasing: Improve quality and avoid unnecessary costs
4Support for VBP President’s Budget FYsCongressional Interest in P4P and Other Value-Based Purchasing ToolsBIPA, MMA, DRA, TRCHA, MMSEA, MIPPAMedPAC Reports to CongressP4P recommendations related to quality, efficiency, health information technology, and payment reformIOM ReportsP4P recommendations in To Err Is Human and Crossing the Quality ChasmReport, Rewarding Provider Performance: Aligning Incentives in MedicarePrivate SectorPrivate health plansEmployer coalitionsAvoid Unnecessary CostsMedicare’s various fee-for-service fee schedules and prospective payment systems are based on resource consumption and quantity of care, NOT quality or unnecessary costs avoidedPayment systems’ incentives are not aligned
5Why VBP? Medicare Solvency and Beneficiary Impact Expenditures up from $219 billion in 2000 to a projected $486 billion in 2009Part A Trust FundExcess of expenditures over tax income in 2007Projected to be depleted by 2019Part B Trust FundExpenditures increasing 11% per year over the last 6 yearsMedicare premiums, deductibles, and cost-sharing are projected to consume 28% of the average beneficiaries’ Social Security check in 2010
6Data from 2007Of the 47 million uninsured, 7.3 million make over 75,000 a year and 6.9 million make 50-75,000 a year.
9What Does VBP Mean to CMS? Transforming Medicare from a passive payer to an active purchaser of higher quality, more efficient health careTools and initiatives for promoting better quality, while avoiding unnecessary costsTools: measurement, payment incentives, public reporting, conditions of participation, coverage policy, QIO programInitiatives: pay for reporting, pay for performance, gainsharing, competitive bidding, bundled payment, coverage decisions, direct provider supportUse of performance measurement dataPayment incentivesPublic reportingTo encourage higher quality, more efficient care for Medicare beneficiariesMedicare Solvency and Beneficiary ImpactExpenditures up from $219 billion in 2000 to a projected $486 billion in 2009Part A Trust FundExcess of expenditures over tax income in 2007Projected to be depleted by 2019Part B Trust FundExpenditures increasing 11% per year over the last 6 yearsMedicare premiums, deductibles, and cost-sharing are projected to consume 28% of the average beneficiaries’ Social Security check in 2010
10Value-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.Medicare’s various fee-for-service fee schedules and prospective payment systems are based on resource consumption and quantity of care, NOT quality or unnecessary costs avoidedPayment systems’ incentives are not aligned
11VBP: Payment Methodologies Pay for ReportingPay for ParticipationPay for Care CoordinationPay for ProcessPay for Outcomes
12VBP Programs Physician Quality Reporting Initiative Physician Resource Use ReportingHospital Quality Initiative: Inpatient & Outpatient Pay for ReportingHospital VBP Plan & Report to CongressHospital-Acquired Conditions & Present on Admission Indicator Reporting
14Statutory AuthorityMedicare Improvements for Patients and Providers Act of 2008 (MIPPA)Section 131(d)Plan for Transition to Value-Based Purchasing Program for Physicians and Other PractitionersReport to Congress due May 1, 2010
15Issues Paper Assumptions & Design Principles PVBP Planning will:Focus on performance-based paymentAccommodate different practice arrangementsRecognize the contributions of members of the health professional teamAddress multiple levels of accountabilityBe at least budget neutral—across at least Medicare Parts A and B—and will seek to identify program savingsInitially focus on traditional fee-for-service MedicareHave short-term and longer-term timeframes, with attention to transitionsAvoid creating additional health care disparities and work to reduce existing disparitiesInclude an ongoing evaluation process
16Stakeholder Input: Overarching Issues Affirmed goal and objectivesAdvocated for new payment approaches that cut across settings and align Part A and B payment incentivesAgreed with the need to accommodate different practice arrangementsPraised attention to disparitiesUrged attention to operational transitions
17Next Steps in Plan Development Receive direction from new leadershipDesign optionsPhysician Fee Schedule (PFS) overlayPerformance-based PFS paymentsMedical HomeLevels of accountability beyond individualsGroupsAccountable Care EntitiesShared savings modelsBundled payment arrangementsSimulations pending availability of resourcesOpportunities for stakeholder inputPFS 2010 rulemakingPotential additional Listening Sessions
18VBP and PQRIMedicare Improvements for Patients and Providers Act of 2008 (MIPPA) - Makes PQRI permanent; howeveronly 2009 and 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 - Additional provisions for PQRI 2010 and beyond
19PQRI 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 carePreventionChronic Care ManagementAcute Episode of Care ManagementProcedural Related CareResource UtilizationCare CoordinationAll measures developed by provider community; specialty societies and consumer groups; NQF, AQA (Alliance AAFP, ACP, AHRQ, AHIP)All have good clinical rationale, reflect good measurement science, and are evidence-basedFocus on Quality & Improvement
202007 PQRI Reporting Participation Statistics 109, 349 NPI/TINs – Attempted to Submit101,138 NPI/TINs – Submitted a Quality Data Code SuccessfullyA feedback report is available70,207 NPI/TINS – Satisfactorily Reported 1 or more measures56,722 NPI/TINs – Earned IncentiveA feedback report & incentive payment are available
212007 PQRI Experience Report QDC Submission Attempts12.15% Missing NPI18.89% 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
22Top Ten Most Frequently Reported Measures by Clinical Topic PneumoniaChest PainPerioperative CareDiabetesECG for SyncopeCoronary Artery DiseaseMyocardial InfarctionHeart FailureMacular DegenerationGlaucoma
232009 PQRI Quality Measures 153 PQRI quality measures for 2009 Includes 101 measures from the 2008 PQRI and 52 new measuresE-prescribing measure (Measure #125) removed, as required by MIPPA as a separate incentive program18 measures reportable only through registriesMeasure specifications are available in the Measures/Codes section of the website at
242009 PQRI Reporting Periods 1 reporting period for claims-based reporting of individual measures: January 1, 2009 – December 31, 20092 reporting periods for reporting measures groups and registry-based reporting:January 1, 2009 – December 31, 2009July 1, 2009 – December 31, 2009
25PQRI Claims-Based Process CriticalStepVisit Documented in the Medical RecordEncounter FormCoding & BillingN-365NCHAnalysis ContractorNational Claims History FileCarrier/MACEligible professionals document fulfillment of measure requirements in the medical record.Quality-data codes may be entered onto an encounter form.Codes associated with measure(s) are captured for the claims submission process.Claims data are submitted to Medicare claims processing contractor for processing by the National Claims History file.the PQRI code line is denied and tracked.QDC line items will be denied for payment, but are then passed through the claims processing system for PQRI analysis. EPs will receive a Remittance Advice (RA) associated with the claim which will contain the PQRI quality-data code line-item and will include a standard remark code (N365) and a message that confirms that the QDCs passed into the National Claims History (NCH) file. N365 reads: “This procedure code is not payable. It is for reporting/information purposes only.”The N365 remark code does NOT indicate whether the QDC is accurate for that claim or for the measure the EP is attempting to report.Confidential ReportIncentive Payment
26Benefits of PQRI Participation Receive confidential feedback reports to support quality improvementEarn a bonus incentive paymentMake an investment in the future of the practicePrepare for higher bonus incentives over timePrepare for pay-for-performancePrepare for public reporting of performance resultsEvery reporting provider receives report how performing compared to peers.Learn now before pay for performance with no riskBe ready in near future when full P4PPredict: Congress will add P4P if it maintains fee schedule.
27MIPPA Authorized E-Prescribing Incentives YearIncentive for Successful E-PrescribersReduction for Unsuccessful E-Prescribers20092.0%201020111.0%2012-1.0%20130.5%-1.5%2014-2.0%Medicare Improvement for Patients and Providers Act of 2008 (MIPPA)Eligible professionals who are not successfully using electronic prescribing by 2012 will be penalized 1% of their covered Medicare Part B charges.Limitation applies as for incentivesFee reduction is prospective, providers will have to electronically prescribe by a date to be determined to be sure their fees are not reduced in 2012.This date will not be before 2010.Hardship exemption
28ARRA Authorized Incentives for Meaningful Use of EHRs YearFirst Payment Yr (Subsequent payment Yrs)Reduction in Fees for Non-Use2011$18k ($12k, $8k, $4k, $2k)20122013$15k ($12k, $8k, $4k)2014$12k ($8k, $4k)2015-1%2016-2%2017-3%75% incentive max paymentsPhysicians in rural health professional shortage areas who adopt/use EHRs are eligible to receive a 10%increase on the incentive payment amounts described above.Physicians who report using an EHR system that is also capable of e-prescribing will no longer beeligible for the e-prescribing bonuses established by MIPPA; they will be eligible for HIT incentives only to avoid “double-dipping.”e-prescribing penalties sunset after 2014, so that no physician will be subject to penalties for failing to both e-prescribe anduse an EHR.Incentives under the Medicaid program are also available for physicians, hospitals, federally-qualified healthcenters, rural health clinics, and other providers; however, physicians cannot take advantage of the incentivepayment programs under both the Medicare and Medicaid programs.In the event that the Secretary of HHS finds that the proportion of health care providers who are meaningfulusers of EHRs is less than 75%, the Secretary is authorized to increase penalties beginning in 2018, but penaltiescannot exceed -5%.
29Summary of MIPPA and ARRA Authorized Incentive Programs YearMIPPA Authorized Incentive for Successful E-PrescribersARRA Authorized Incentive for Meaningful Use of EHR200920102% IncentiveN/A20111% Incentive$18k ($12k, $8k, $4k, $2k)201220130.5% Incentive1.5% Reduction$15k ($12k, $8k, $4k)2014No Incentive2% Reduction$12k ($8k, $4k)20151% Reduction201620173% ReductionPhysicians in rural health professional shortage areas who adopt/use EHRs are eligible to receive a 10%increase on the incentive payment amounts described above.Physicians who report using an EHR system that is also capable of e-prescribing will no longer beeligible for the e-prescribing bonuses established by MIPPA; they will be eligible for HIT incentives only to avoid “double-dipping.”Also, e-prescribing penalties sunset after 2014, so that no physician will be subject to penalties for failing to both e-prescribe anduse an EHR.Incentives under the Medicaid program are also available for physicians, hospitals, federally-qualified healthcenters, rural health clinics, and other providers; however, physicians cannot take advantage of the incentivepayment programs under both the Medicare and Medicaid programs.In the event that the Secretary of HHS finds that the proportion of health care providers who are meaningfulusers of EHRs is less than 75%, the Secretary is authorized to increase penalties beginning in 2018, but penaltiescannot exceed -5%.
31Surgical Care Improvement Project /Surgical Infection Prevention (SCIP) FY 2009 SCIP-Inf-1 Prophylactic antibiotic received within 1 hour prior to surgical incisionSCIP-Inf-3 Prophylactic antibiotics discontinued within 24 hours after surgery end timeSCIP-VTE 1: prophylaxis ordered forsurgical ptSCIP-VTE 2: prophylaxis within 24 hr pre/postProcess measures
32SCIP (Previously SIP)SCIP Infection 2: Prophylactic Antibiotic selection for surgical ptSCIP Infection 4: Cardiac surgical pts with Controlled 6am post op serum glucoseSCIP Infection 6 Surgery pts with appropriate hair removalHCAHPS
33AHRQ PSIs and IQI’s Patient Safety Indicators (PSIs) Death among surgical pts with serious treatable conditionsPost-op wound dehiscenceInpatient Quality Indicators (IQIs)AAA Mortality rate (with or without volume)Hip fracture mortality rateMortality rate for selected surgical proceduresParticipation in a systematic database for cardiac surgeryIatrogenic pneumothoraxAccidental puncture or laceration
34ACS NSQIPSurgeons 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 publicIncreasing public demand for “accountability” in healthcareEroding public trust in clinicians to provide safe careEfforts by payors and purchasers to “drive” patients to centers with safer systemsEvolving move by payors to “pay for performance”Without risk-adjusted data, surgeons and medical centers have had to use administrative (i.e., payor) dataSurgeons and medical centers find themselves profiled on the InternetPrivate Sector Demand Market drivers are creating a demand in private sector medical centers
35ASC NSQIPThe 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 centerDEMOGRAPHICS9 variablesSURGICAL PROFILE9 variables40 clinical variables13 laboratory variablesPRE-OPERATIVE DATAThe ACS NSQIP is an outcomes-based, data-driven, risk-adjusted surgical quality improvement program, which empowers surgeons and medical centers to report reliably their outcomes and potentially improve care and lower costsASC-NSQIP collects data on 133 variables including pre-op risk factors, intra-operative variables and 30 day postoperative morbidity and mortality outcomes (in and out-pt surgical procedures)res) (O/E) RatiosASC NSQIP had developed a data collection tool to capture the SCIP process measures to meet the CMS reporting requirements18 clinical variables3 occurrence variablesINTRA-OPERATIVE DATA20 occurrence variables12 laboratory variables9 discharge variablesPOST-OPERATIVE DATA
36What to do with the DataPotentially allow for higher reimbursement in the emerging “pay for performance” environmentHelp to increase patient satisfactionServe as a foundation and resource for research initiativesHelp to identify possible under-billingsHelp to increase negotiating leverage with third-party payers and employersReduce postoperative mortality ratesReduce postoperative morbidity ratesReduce the median length-of-stayLeverage data for other internal and public reporting initiativesMeet CMS Surgical Care Improvement Program (SCIP) reporting requirements by collecting SCIP data through the ACS NSQIP SCIP data collection module
37Use the Data 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 eventsIdentify quality improvement opportunitiesIdentification of quality improvement opportunities by Depts. of SurgeryProactive v. ReactiveBenchmark performance against peersRe-engineer or eliminate retrospective clinical databases historically used for quality assurance or JCAHO reportingDiscuss opportunities to use data in payor negotiations, “pay for performance”Conduct researchReview billing practicesAnalyze systems of care
38ACS NSQIP Eligible Specialties General SurgeryVascular SurgeryUrologyNeurosurgeryOrthopedicsENTPlastic SurgeryThoracicCardiacGynecological surgery#1. The VA NSQIP can be applied to the Private Sector (PS).#2. Implementing the NSQIP was associated with a significant reduction in 30 day morbidity in the PS.
39Demonstration Projects CMS currently pays for quality through a series of Demonstration ProjectsSeveral Demonstrations are mandated through Congressional LegislationMust be budget neutralDemonstration OriginsCongressional MandateAdministration/CMS Initiative
40VBP Demonstrations and Pilots Physician Group Practice DemonstrationMedicare Care Management Performance DemonstrationMedicare Medical Home DemonstrationMedicare Healthcare QualityGainsharing DemonstrationsAccountable Care Episode (ACE) Demonstration
41Demonstration Purpose Test the development and implementation of Medicare policy changes prior to legislation enacting such changes on a national basisWhether it works…What refinements…Generally look at payment, new benefit, new organization of care delivery41
42Acute Care Episode (ACE) Demonstration Problems with Current SystemIncreased number of services not necessarily correlated with better careConflicting provider incentivesHospitals paid per dischargePhysicians paid per service
43Global Payment Fee-for-service Part A and Part B Services related to acute care episode onlyCardiovascular and/or orthopedic procedures
44Sites Selected Hillcrest Medical Center – Tulsa Baptist Health System – San AntonioOklahoma Heart Hospital – Oklahoma CityLovelace Health System – AlbuquerqueExempla Saint Joseph Hospital – DenverTwo are cardiovascular onlyOne is orthopedic onlyTwo are both cardiovascular and orthopedicDeveloped by RTI, CMS’s implementation contractorCurrently 22 measures
45Determination of Payment Rates Based on competitive bids from sitesCompared to regular average Medicare payments to the hospitals and physiciansEvaluated based upon the size of the discountSubject to annual IPPS updates
46Gainsharing Demonstrations AuthorityDeficit Reduction Act (DRA) Section 5007Medicare Modernization Act (MMA) Section 646In the absence of statutory authority, gainsharing is restricted by lawPurposeTo allow hospitals to provide gainsharing payments designed to improve quality and efficiency of care to physiciansTiming3-year projectsTargetHospitals and physiciansCompensationHospitals may share savings with physiciansBackground: CABG global payment demonstrations used shared savings from hospitals to doctors in 1980s, incentives were helpfulNJ Hospital Association proposed a gainsharing demonstrationDemo started in 2004Injunction against demo due to lack of statutory authority to waive gainsharing restrictions
47Hospital and Physician Alignment of Incentives Medicare pays hospitals prospectively for bundles of services using DRGsPhysicians generally paid per serviceHow to align incentives to improve quality and efficiency?Encourage physician-hospital collaboration by permitting hospitals to share internal savings
48Gainsharing PaymentsIncentive system must be uniform across physicians, can be reviewed and audited.Payments must be linked to quality and efficiencyGainsharing must be a transparentMust represent share of internal hospital savings and be tied to quality improvementLimited to 25% of physician fees for care of patients affected by quality improvement activityNo payments for referralsSAFEGUARDS: Savings available for gainsharing derived from quality improvement initiativesHospital oversight committee to monitor quality and operationsIncentive payments limited to physicians who contribute to quality effortsOngoing CMS monitoring of projectsQuality measurement and trackingIndependent evaluator will draft reports to CongressIssues will include:QualityInternal cost savingsMedicare payments/savingsReasonable and fair payments to physiciansAny needed changes to policy or designBeneficiary satisfactionPhysician practice patterns
49Demo Comparison Design Feature DRA Section 5007 MMA Section 646 Size 2 hospitalsBeth Israel, NYCAMC, WVPhysician groups and up to 13 affiliated hospitals in limited number of geographic areas.NJ 12 and WV 1Scope of EvaluationInpatient episodes and post-discharge window (e.g., 30 days)Inpatient episodes including pre- and post-hospital care over duration of demonstrationEligible OrganizationsPPS hospitals, excludes CAHsPhysician groups and affiliated hospitals, integrated delivery systems
50Efficiency in the Quality Context Efficiency Is One of the Institute of Medicine's Key Dimensions of QualitySafetyEffectivenessPatient-CenterednessTimelinessEfficiency: absence of waste, overuse, misuse, and errorsEquityInstitute of Medicine: Crossing the Quality Chasm:A New Health System for the 21st Century, March, 2001.
51Physician Resource Use Reports Pilot Statutory AuthorityMedicare 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.
52Physician Resource Use Measurement GoalsConstruct resource use measures that are meaningful, actionable, and fairProvide confidential reports of resource use to individual/groups of physiciansCompare actual use to expected resource useLink resource use to measures of quality and patient experiences of care52
53Statutory Authority MIPPA Section 131(c) MIPPA Options:Resource use can be measured on an episode or per capita basis, or bothResource use can be measured with claims or through other data sourcesFocus can be on selected physicians by: specialty, conditions treated, geography, high cost outliers, minimum # of casesCMS can make adjustments to resource use measures to render them comparable across physiciansResource use measures can apply to individual physicians or physician groups
54Creating Resource Use Reports 1Prepare claims data, includingStandardize unit prices2Group claims into episodes of care;Sum costs of all claims in an episode3Risk-adjust the cost of each episode4Attribute each episode and associated episode cost to one or more physicians5Calculate physician’s average cost for all attributed episodes6Compare physician’s average cost to peer group benchmark (including drill downs)7Produce, test, and distribute RURs54
55Hospital VBPDeficit Reduction Act (DRA) Section 5001(b) authorized CMS to develop a Medicare Hospital VBP PlanIPPS hospitalsFY 2009 start dateMust considerMeasuresData infrastructure and validationIncentive structurePublic reportingMust consult stakeholders and consider experience with relevant demonstrations and private-sector programsInpatient hospital prospective payment system.The IOM estimated in 1999 that as many as 98,000 Americans die each year as a result of medical errorsTotal national costs of these errors estimated at $17-29 billionTo Err is Human: Building a Safer Health System, November 1999.In 2000, CDC estimated that hospital-acquired infections add nearly $5 billion to U.S. health care costs annuallyA 2007 study found that, in 2002, 1.7 million hospital-acquired infections were associated with 99,000 deathsKlevens et al. Estimating Health Care-Associated Infections andDeaths in U.S. Hospitals, Public Health Reports. March-AprilVolume 122.
56Value-Based Purchasing and Hospital-Acquired Conditions The Hospital-Acquired Conditions provision is a step toward Medicare VBP for hospitalsStrong public support for CMS to pay less for conditions that are acquired during a hospital stayConsiderable national press coverage of HAC has prompted dialogue of how to further eliminate healthcare-associated infections and conditions
57Statutory 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 hospitalizationThis provision does not apply to Critical Access Hospitals, Rehabilitation Hospitals, Psychiatric Hospitals, or any other facility not paid under the Medicare Hospital IPPS
58Statutory Selection Criteria CMS must select conditions that areHigh cost, high volume, or bothAssigned to a higher paying DRG when present as a secondary diagnosisReasonably preventable through the application of evidence-based guidelinesCondition must trigger higher paymentComplications, including infections, can be designated complicating conditions (CCs) or major complicating conditions (MCCs)MS-DRGs may split into three different levels of severity, based on complications (no CC or MCC, CC, or MCC)The presence of a CC or MCC condition as a secondary diagnosis on a claim generates higher payment
59Present on AdmissionPresent on admission (POA) is defined as present at the time the order for inpatient admission occursConditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POAPOA indicator is assigned toPrincipal diagnosisSecondary diagnosesExternal cause of injury codes (Medicare requires reporting only if E-code is reported as an additional diagnosis)
60POA Indicator Reporting Options CodeReason for CodeYDiagnosis was present at time of inpatient admission.NDiagnosis was not present at time of inpatient admission.UDocumentation insufficient to determine if condition waspresent at the time of inpatient admission.WClinically undetermined. Provider unable to clinicallydetermine whether the condition was present at the timeof inpatient admission.1Unreported/Not used. Exempt from POA reporting. This codeis equivalent code of a blank on the UB-04; however, it wasdetermined that blanks are undesirable when submitting thisdata via the 4010A.POA Indicator Options and DefinitionsPOA indicatorCMS pays the CC/MCC for HACs that are coded as “Y” & “W”CMS does NOT pay the CC/MCC for HACs that are coded “N” & “U”
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.”
62Selected HACs for Implementation Foreign object retained after surgeryAir embolismBlood incompatibilityPressure ulcersStages III & IVFallsFractureDislocationIntracranial injuryCrushing injuryBurnElectric shockThe CMS and Centers for Disease Control and Prevention (CDC) internal Workgroup selected the HACsInformal comments from stakeholdersCMS/CDC sponsored Listening SessionDecember 17, 2007 & December 18, 2008Ad hoc meetings with stakeholders
63Selected HACs for Implementation 6. Manifestations of poor glycemic controlHypoglycemic comaDiabetic ketoacidosisNonketotic hyperosmolar comaSecondary diabetes with ketoacidosisSecondary diabetes with hyperosmolarity7. Catheter-associated urinary tract infection8. Vascular catheter-associated infection9. Deep vein thrombosis (DVT)/pulmonary embolism (PE)Total knee replacementHip replacement
64Selected HACs for Implementation 10. Surgical site infectionMediastinitis after coronary artery bypass graft (CABG)Certain orthopedic proceduresSpineNeckShoulderElbowBariatric surgery for obesityLaprascopic gastric bypassGastroenterostomyLaparoscopic gastric restrictive surgery
65Selected Evidence‑Based Guidelines Selected HACMedicare Data(FY 2007)CC/MCC(ICD-9-CMCodes)Selected Evidence‑Based GuidelinesVascularCatheter-AssociatedInfection● 29,536 cases● $103,027/hospital stay(CC)Available at the Website:idod/dhqp/gl_intravascular.htmlSurgical SiteInfection-Mediastinitisafter CoronaryArtery BypassGraft (CABG)● 69 cases● $299,237/hospital stay519.2 (MCC)And one of thefollowingprocedurecodes:36.10–36.19Available at the Web site:idod/dhqp/gl_surgicalsite.html
78Guidelines for Preventing HACs Where are guidelines developedProfessional organizations, Task Forces, Government agencies, academic institutionsWhat are theyRecommendations for interventions based scientific evidence or expert opinionWho develops and uses themScientists, cliniciansPolicy makers, consumersCriteria for selection of NQF never eventsUnambiguous: clearly identifiable and measurable;Usually preventable: recognizing that some events are not always avoidable;Serious: resulting in death or loss of a body part, disability, or more transient loss of a body function;Indicative of a problem in a health care facility’s safety systems;Important for public credibility or public accountability
79Future Considerations Risk adjustmentIndividual and population levelRates of HACs for VBPAppropriate for some HACsUses of POA informationPublic reportingAdoption of ICD-10Example: 125 codes capturing size, depth, and location of pressure ulcerExpansion of the IPPS HAC payment provision to other settingsDiscussion in the IRF, OPPS/ASC, SNF, LTCH regulationsICD-10:Reimbursement – cannot always pay claims fairlyQuality – difficult to evaluate medical processes and outcomes
80Never Events Wrong surgery performed on a patient Surgery performed on wrong body partSurgery performed on the wrong patientJanuary 15, 2009
81Resources Available Physician Quality Reporting Initiative: https://www.cms.hhs.gov/pqriCMS 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 ServicesHospital Quality Reporting:Demonstrations: