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Philadelphia Chapter ACS CMS’ Value-Based Purchasing The Nexus of Quality, Coordination, & Efficiency Barbara J. Connors, DO, MPH Chief Medical Officer,

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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:

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

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 Avoid Unnecessary Costs 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 avoided Payment systems’ incentives are not aligned

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 Data from 2007 Of the 47 million uninsured, 7.3 million make over 75,000 a year and 6.9 million make 50-75,000 a year.

7 Medicare Reimbursement Rates

8 Practice Variation 8

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 Use of performance measurement data Payment incentives Public reporting To encourage higher quality, more efficient care for Medicare beneficiaries 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

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. 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 avoided Payment systems’ incentives are not aligned

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 Towards Value-Based Purchasing
VBP 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 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

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 All 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-based Focus on Quality & Improvement

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 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
Pneumonia Chest Pain Perioperative Care Diabetes ECG for Syncope Coronary Artery Disease Myocardial Infarction Heart Failure Macular Degeneration 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, 2009 2 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
Critical Step Visit Documented in the Medical Record Encounter Form Coding & Billing N-365 NCH Analysis Contractor National Claims History File Carrier/MAC Eligible 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 Report Incentive Payment

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 Every reporting provider receives report how performing compared to peers. Learn now before pay for performance with no risk Be ready in near future when full P4P Predict: Congress will add P4P if it maintains fee schedule.

27 MIPPA Authorized E-Prescribing Incentives
Year Incentive for Successful E-Prescribers Reduction for Unsuccessful E-Prescribers 2009 2.0% 2010 2011 1.0% 2012 -1.0% 2013 0.5% -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 incentives Fee 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

28 ARRA Authorized Incentives for Meaningful Use of EHRs
Year First Payment Yr (Subsequent payment Yrs) Reduction in Fees for Non-Use 2011 $18k ($12k, $8k, $4k, $2k) 2012 2013 $15k ($12k, $8k, $4k) 2014 $12k ($8k, $4k) 2015 -1% 2016 -2% 2017 -3% 75% incentive max payments Physicians 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 be eligible 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 and use an EHR. Incentives under the Medicaid program are also available for physicians, hospitals, federally-qualified health centers, rural health clinics, and other providers; however, physicians cannot take advantage of the incentive payment 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 meaningful users of EHRs is less than 75%, the Secretary is authorized to increase penalties beginning in 2018, but penalties cannot exceed -5%.

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 2009 2010 2% Incentive N/A 2011 1% Incentive $18k ($12k, $8k, $4k, $2k) 2012 2013 0.5% Incentive 1.5% Reduction $15k ($12k, $8k, $4k) 2014 No Incentive 2% Reduction $12k ($8k, $4k) 2015 1% Reduction 2016 2017 3% Reduction Physicians 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 be eligible 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 and use an EHR. Incentives under the Medicaid program are also available for physicians, hospitals, federally-qualified health centers, rural health clinics, and other providers; however, physicians cannot take advantage of the incentive payment 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 meaningful users of EHRs is less than 75%, the Secretary is authorized to increase penalties beginning in 2018, but penalties cannot exceed -5%.

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 Process measures

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 HCAHPS

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 Iatrogenic pneumothorax Accidental puncture or laceration

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 Private Sector Demand Market drivers are creating a demand in private sector medical centers

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 40 clinical variables 13 laboratory variables PRE-OPERATIVE DATA The 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 costs ASC-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) Ratios ASC NSQIP had developed a data collection tool to capture the SCIP process measures to meet the CMS reporting requirements 18 clinical variables 3 occurrence variables INTRA-OPERATIVE DATA 20 occurrence variables 12 laboratory variables 9 discharge variables POST-OPERATIVE DATA

36 What to do with the Data 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 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

37 Use 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 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

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

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 Demonstration Origins Congressional Mandate Administration/CMS Initiative

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 basis Whether it works… What refinements… Generally look at payment, new benefit, new organization of care delivery 41

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 Developed by RTI, CMS’s implementation contractor Currently 22 measures

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 Background: CABG global payment demonstrations used shared savings from hospitals to doctors in 1980s, incentives were helpful NJ Hospital Association proposed a gainsharing demonstration Demo started in 2004 Injunction against demo due to lack of statutory authority to waive gainsharing restrictions

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 No payments for referrals SAFEGUARDS: Savings available for gainsharing derived from quality improvement initiatives Hospital oversight committee to monitor quality and operations Incentive payments limited to physicians who contribute to quality efforts Ongoing CMS monitoring of projects Quality measurement and tracking Independent evaluator will draft reports to Congress Issues will include: Quality Internal cost savings Medicare payments/savings Reasonable and fair payments to physicians Any needed changes to policy or design Beneficiary satisfaction Physician practice patterns

49 Demo Comparison Design Feature DRA Section 5007 MMA Section 646 Size
2 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 Evaluation Inpatient 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 CAHs Physician 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 Safety Effectiveness Patient-Centeredness Timeliness Efficiency: absence of waste, overuse, misuse, and errors 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 52

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 Creating Resource Use Reports
1 Prepare claims data, including Standardize unit prices 2 Group claims into episodes of care; Sum costs of all claims in an episode 3 Risk-adjust the cost of each episode 4 Attribute each episode and associated episode cost to one or more physicians 5 Calculate physician’s average cost for all attributed episodes 6 Compare physician’s average cost to peer group benchmark (including drill downs) 7 Produce, test, and distribute RURs 54

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 Inpatient hospital prospective payment system. The IOM estimated in 1999 that as many as 98,000 Americans die each year as a result of medical errors Total national costs of these errors estimated at $17-29 billion To 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 annually A 2007 study found that, in 2002, 1.7 million hospital-acquired infections were associated with 99,000 deaths Klevens et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, Public Health Reports. March-April Volume 122.

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 High cost, high volume, or both Assigned to a higher paying DRG when present as a secondary diagnosis Reasonably preventable through the application of evidence-based guidelines Condition must trigger higher payment Complications, 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

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
Code Reason 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. POA Indicator Options and Definitions POA indicator CMS 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.”

62 Selected HACs for Implementation
Foreign object retained after surgery Air embolism Blood incompatibility Pressure ulcers Stages III & IV Falls Fracture Dislocation Intracranial injury Crushing injury Burn Electric shock The CMS and Centers for Disease Control and Prevention (CDC) internal Workgroup selected the HACs Informal comments from stakeholders CMS/CDC sponsored Listening Session December 17, 2007 & December 18, 2008 Ad hoc meetings with stakeholders

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 Evidence‑Based Guidelines
Selected HAC Medicare Data (FY 2007) CC/MCC (ICD-9-CM Codes) Selected Evidence‑Based 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 519.2 (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 Evidence‑Based Guidelines
Selected HAC Medicare Data (FY 2007) CC/MCC (ICD-9-CM Codes) Selected Evidence‑Based 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: 112.2 (CC) (CC) (MCC) 590.2 (MCC) 590.3 (CC) (CC) (CC) 595.0 (CC) 597.0 (CC) 599.0 (CC) idod/dhqp/gl_cathetea ssoc.html

67 Selected Evidence‑Based Guidelines
Selected HAC Medicare Data (FY 2007) CC/MCC (ICD-9-CM Codes) Selected Evidence‑Based 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.440 9 Falls and Trauma: - Fractures - Dislocations - Intracranial Injuries - Crushing Injuries - Burns ● 193,566 cases ● $33,894/hospital stay CC/MCC codes within these ranges: ual/nqfpract.htm

68 Selected Evidence‑Based Guidelines
Selected HAC Medicare Data (FY 2007) CC/MCC (ICD-9-CM Codes) Selected Evidence‑Based Guidelines Foreign Object Retained After Surgery ● 750 cases ● $63,631/hospital stay 998.4 (CC) 998.7 (CC) NQF Serious Reportable Adverse Event ual/nqfpract.htm Air Embolism ● 57 cases ● $71,636/hospital stay 999.1 (MCC) Blood Incompatibility ● 24 cases ● $50,455/hospital stay 999.6 (CC)

69 Candidate HACs Fiscal Year 2009 Inpatient Prospective Payment System (IPPS) final rule (page 39)

70 Candidate HACs Surgical site infection following device procedures
Failure to rescue Death or disability associated with drugs, devices, or biologics Dehydration Malnutrition

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

72 Evidence-Based Guidelines
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 Varicose Veins ● 3 cases ● $66,355/hospital stay (81.54): (CC) and (CC) Gastric Bypass (44.38) Gastroenter- ostomy (44.39): (38.5): /ncidod/dhqp/gl_su rgicalsite.html /ncidod/dhqp/gl isolation.html

73 Evidence-Based Guidelines
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) /ncidod/dbmd/dise aseinfo/legionellos is_g.htm la.org/ Iatrogenic Pneumothorax ● 22,665 cases ● $75,089/hospital stay 512.1 (CC) m.nih.gov/pubmed / Delirium ● 480 cases ● $23,290/hospital stay 293.1 (CC) v/clinic/ptsafety/ch ap28.htm

74 Evidence-Based Guidelines
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 Diabetic ● 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 Ketoacidosis: 250.10– (CC) Hyperosmola Coma: 250.20– (CC) Diabetic coma: (CC) Hypoglycemic 251.0 (CC) NQF Serious Reportable Adverse Events address hypoglycemia es.org/uedocume nts/InpatientDMG lycemicControlPo sitionStmt 6.REV.pdf

75 Evidence-Based Guidelines
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: 96.70 – 96.72 al.com/cpgs/09.03. 0869.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 Evidence-Based Guidelines
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 038.11(MCC) (MCC) (MCC) (CC) 999.3 (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) /ncidod/dhqp/id_C diffFAQ_HCP.html #9

77 Proposed 2010 IPPS Rule

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 Criteria for selection of NQF never events Unambiguous: 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

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 ICD-10:Reimbursement – cannot always pay claims fairly Quality – difficult to evaluate medical processes and outcomes

80 Never Events Wrong surgery performed on a patient
Surgery performed on wrong body part Surgery performed on the wrong patient January 15, 2009

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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