1. Current and New HSCRC Reporting Requirements Oscar Ibarra & Katie Eckert

2. HSCRC Update: Abstract Tape Changes to reporting requirements under the new Waiver Model New Tape Layout and Fields New timeline for reporting Issues with FY 2014 Q1 Data Quarterly Reconciliations

3. New Data Fields for FY 2014 Separate variables for each race category to accurately capture each component of the patient’s race (i.e., White and Black, or Black and Asian, etc.). Variable to capture the patient's country of origin, and Variable to capture the patient’s preferred spoken language for a health-related encounter

4. New Timeline for FY 2014

5. Challenges with FY 2014 Submissions Medicaid ID errors Preferred language Race variables left blank Variations in zip code to county mapping Reconciliations between case mix and financial data

6. Significant Changes for FY 2015 Potentially add the CMS discharge disposition for planned admissions New waiver requirements based on residency, coding zip code accurately will be essential Transition to ICD -10 –Working with MHA around testing grouper software and submission of test data to St. Paul

7. Data Workgroups Data & Infrastructure Workgroup –Will develop Data recommendations to the HSCRC for the new hospital All-Payer Model –Public meetings Kick off Feb 6 Data Workgroup –Discuss new data elements for the coming FY –Discuss data issues –Case mix liaison participation

8. Brave New World: Changes to Hospital Reporting Under the NEW Waiver 1.Changes to Traditional HSCRC Data Submissions 2.New Metrics to Monitor 3.New Platform for Reporting

9. Changes to Traditional HSCRC Data Submissions 1.Case Mix: Accelerated case mix reporting  the deadlines are changing. 2.Financials: “Enhanced” monthly financial submissions  more data elements

10. Accelerated Case Mix Reporting Final Data: –OLD: Data reported approximately 90 days after quarter-end. –NEW: Data reported approximately 60 days after quarter-end. Preliminary Data: –OLD: Quarterly data reported approximately 45 days after quarter- end –NEW: Quarter-to-Date data reported approximately 15-17 days after month-end. HSCRC Goal: Monitor tenants of waiver on a more concurrent basis.

11. Operational Implications for Hospitals 20-30% reduction in the number of days to finalize abstract data –Chart Audits –MHAC monitoring –Clinical Documentation –Curveball!: ICD-10 and additional HSCRC focus on quality metrics

12. “Enhanced” Monthly Financial Submission “Enhanced” elements –4 data points now expanded to 36 data points –IP/OP now split into In-State vs. Out-of-State –IP/OP for Medicare (Fee-For- Service vs. Non Fee-For- Service) also split into In- State vs. Out-of-State

13. Operational Implications for Hospitals New Internal Reports for Revenue and Utilization: –State data and payer data are sourced from patient account data in the patient accounting system and do not pass to traditional financial statements. –More data points from “live” patient data makes it even more important to lock down posted financials in order to avoid reconciling items. Submission : –Data Reporting 101: more data points = more room for error –OLD: Manual Submission NEW: Upload Submission?

14. Operational Implications for Hospitals Reconciling: –In-State vs. Out-of-State Split: reconcile back to traditional Experience Report data –Payer Split: Only reporting Medicare utilization. A separate reconciliation outside of the HSCRC submission is required to make sure that the “sum of the parts equals the whole” for all payers

15. Brave New World: Changes to Hospital Reporting Under the NEW Waiver 1.Changes to Traditional HSCRC Data Submissions 2.New Metrics to Monitor 3.New Platform for Reporting

16. New Metrics Rate of Change in Cost per Capita Market Share Potentially Avoidable Utilization (PAUs) –Inter/Intra Readmissions –Monthly MHAC + PPC Reporting

17. Rate of Change in Cost per Capita Two explicit “per capita” tests under the new waiver –All Payer Revenue Growth Rate Test –Medicare Savings Test

18. All Payer Revenue Limit Test What is it? –Annual growth rate in total per capita hospital charges must not exceed 3.58% for CY2014-CY2016 for Maryland residents in Maryland hospitals Why is this important to Hospitals? –HSCRC staff will need to take action to reduce hospital charges if test is in jeopardy.

19. Medicare Savings Test What is it? –Rate of growth in Medicare's per capita hospital payments must be less than the national average growth rate for Maryland residents by at least $330 million for CY2014-CY2018 Why is this important to Hospitals? –HSCRC staff will need to take action to reduce hospital charges if test is in jeopardy.

20. What Should Hospitals Monitor? Rate of Change in Charges per Capita Rate of Change in Medicare Payments per Capita Time Period: –Calendar Year –Rate Year Changes in Charges –Inpatient –Outpatient –Observation –Admit Source/Source of Arrival Changes in Population –Hospital –Primary Service Area –State

21. Calendar Year! Rate Year: July- June Calendar Year: January- December The HSCRC will be monitoring Calendar Year performance for the waiver. Consider creating additional internal reports for compliance on a calendar year basis

22. Changes in Market Share What is it? –a measurement of the population's utilization of a hospital’s services in a given geographic area over a period of time as compared to other hospitals. Why is this important to hospitals? –Global budgets will be adjusted to match utilization. –The methodology for market share adjustments hasn’t been finalized. The HSCRC has requested white papers from the Industry. Recommendation for Hospitals: –monitor market share as best you can with available data

23. Readmissions What is it? –Reduce the Medicare readmissions rate to the national level in 5 years (CY2014-CY2018)

24. Readmissions Why is this important to Hospitals? –ALL Readmissions (no distinction between intra and inter) –Maryland’s focus up until now for reporting purposes has been intra-hospital readmissions –Value-based annual financial adjustment

25. Readmissions: What Should Hospitals Monitor? Time Period: CY vs. RY Intra vs. Inter Medicare vs. All Payers Benchmarks: State vs. Nation vs. Peers Service Line

26. Raising the Bar: Quality-based Reimbursement (“QBR”) and Maryland Hospital Acquired Conditions (“MHAC”) What is it? –QBR and MHAC are Maryland’s versions of CMS’ Value Based Purchasing (VBP) and Hospital Acquired Conditions (HAC) programs. –Quality-based policy tools

27. Why is this important to hospitals? New waiver Reduce Potentially Preventable Complications (a.k.a MHACs) by 30% in five years (CY2014-CY2015) Workgroups will be modifying MHAC policy to align with the new waiver requirements Scaling: MHAC and QBR scaling will be even more relevant under GBR because it’s one of the few variable update factors for hospitals More Financial Risk: FY2016 QBR: 0.5%  1.0% base approved hospital inpatient revenues

28. Potentially Avoidable Utilization (PAUs) What are PAUs? –30- Day Readmissions/Rehospitalizations (includes ER) –Preventable Admissions (Admissions for ambulatory sensitive conditions) (based on AHRQ Prevention Quality Indicators) –ER visits than can be treated in other settings –Maryland Hospital Acquired Conditions (MHAC) a.k.a Potentially Preventable Complications

29. Potentially Avoidable Utilization (PAUs) Why are they important? –Cost & Quality: Crosses the 3 major tenants of waiver (cost per capita, readmissions, quality) –Financial Performance: In a GBR world if you can reduce inappropriate volumes, you can reduce excess cost and therefore improve operating margins (or reinvest).

30. Brave New World: Changes to Hospital Reporting Under the NEW Waiver 1.Changes to Traditional HSCRC Data Submissions 2.New Metrics to Monitor 3.New Platform for Reporting

31. CRISP: NEW Platform for Hospital Analytics Chesapeake Regional Information System for our Patients or (“CRISP”) Maryland’s state designated health information exchange (“HIE”). Not-for-profit organization charged with electronically connecting healthcare providers across the region.

32. CRISP: NEW Platform for Hospital Analytics CRISP receives real-time encounter messages (called “ADTs”) which carry facility, medical record number, visit IDs, and other important information about visit. Unique Aspects of ADTs: –Enable population-health analysis (unduplicated users across hospitals) –Real –Time data flows –Street address, enabling more granular level of geographic analysis Linked ADT and HSCRC Abstract Data enable more analysis –Inpatient matching rate: 99.98% –Outpatient matching rate: 99.86%

33. CRISP’s Data Model Potential Linkage: All- Payer Claims Database

34. CRISP’s Unique Reporting Capabilities Unique patient ID assigned to each individual across hospitals Real-time ADT with geo-code Real-time ADT reconciles to HSCRC tapes Coordination of logic with HSCRC reimbursement policies

35. CRISP’s Data Utility Tape Data reconciled to CRISP’s unique patient ID supports: –New Policies: Data is a shared resource to support policymakers, payers, and providers respond to new policy direction. –Population Health: CRISP data can support care coordination activities/analytics for population- based models (TPR/GBR). POTENTIAL

36. Overview of CRISP Reports CRISP has developed the capability to generate reports through a combination of CRISP data and HSCRC tape data. Initial ideas have focused on: 36 Readmission analysis reports (HSCRC or CMS methodology)   Monthly reports with patient drill downs   Year-to-year and monthly   By hospital, zip, region, county, HEZ   By diagnosis or disposition Market share analysis   Clinical service line utilization by hospital PSA   By majority of inpatient visits, total visits, etc.   By diagnosis and charges Analysis of Potentially Avoidable Volume   Visits with ambulatory sensitive conditions   Readmission   Market share shifts Uncompensated Care/ACA Impact   Using CRISP EID to link insurance status and UCC use across time periods

37. High utilization analysis  By # of visits, LOS, date, overlap, etc.  By census tract or neighborhood  By diagnosis, disposition, or charges Hospital Utilization by diagnosis, disposition, charges using HSCRC data  County reports (patients, discharges, readmits by diagnosis) Patient attribution analysis  Based on prior visits  Identify exclusive patients and % of visit allocation by patient  By census tract or neighborhood  By diagnosis and charges Episode of Care analysis  All subsequent hospital visits after discharge  By diagnosis or disposition  By census tract or neighborhood MORE…

38. Stay Tuned…. Hospitals are being asked to produce: –MORE data –MORE accurately –FASTER Lots of rapid changes happening for hospital reporting

39. Questions?

40. Contact Information Oscar Ibarra Chief, Information Management and Program Administration HSCRC Oscar.Ibarra@maryland.gov Katie Eckert, CPA Director, Budget & Reimbursement Bon Secours Baltimore Health System katie_eckert@bshsi.org