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CMS Update FY’14 Frank Briggs, Pharm.D., M.P.H. Vice President, Quality and Patient Safety West Virginia University Healthcare.

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Presentation on theme: "CMS Update FY’14 Frank Briggs, Pharm.D., M.P.H. Vice President, Quality and Patient Safety West Virginia University Healthcare."— Presentation transcript:

1 CMS Update FY’14 Frank Briggs, Pharm.D., M.P.H. Vice President, Quality and Patient Safety West Virginia University Healthcare

2 Objectives At the completion of this presentation, the participants shall be able to: Describe the changes in Value Based Purchasing (VBP) Explain the Hospital Acquired Condition (HAC) penalty program Estimate the impact of changes in the Inpatient Prospective Payment System (IPPS)

3 Outline Inpatient Quality Reporting (IQR) Value Based Purchasing (VBP) Readmission Reduction Hospital Acquired Conditions (HAC) Not included – Documentation and coding effects – Disproportionate share program – Labor and delivery days – Outlier thresholds 2 Midnight Rule?

4 Inpatient Quality Reporting Voluntary reporting – Required for annual payment update 2% Measures appear in program ~2 years before advancing – VBP – HAC – Readmissions

5 Inpatient Quality Reporting medicare.gov/hospitalcompare

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7 Patient Survey Results Hospital Consumer Assessment of Healthcare Providers and Systems – HCAHPS – Reported since 2007 Uses scale from never to always (5 points) Top box scores – “Always” Report “Always”

8 HCAHPS Domains Nurse communication Doctor communication Responsiveness of staff Pain control Explanation of medications Cleanliness Quietness Discharge information (recovery)

9 Core Measures Heart Attack Care – Aspirin at discharge – Fibrinolytic within 30 mins – Primary PCI within 90 mins – Statin at discharge Heart Failure – Discharge instructions – Evaluation of LVS function – ACEI/ARB for LVSD

10 Core Measures Pneumonia Care – Blood cultures in ED prior to antibiotic – Appropriate antibiotic selection Surgical Care – Antibiotics: timing, selection, and discontinuation – Venous thromboembolism (VTE) prevention – Beta blockers continued – Blood glucose control in cardiac surgery – Urinary catheters removal – Monitoring of body temperature

11 Core Measures Emergency Department – Time spent in ED for admitted patients – Time spent in ED after decision to admit – Time spent in ED for patients sent home – Time before being seen by provider – Time before pain medication for broken bones – Percent of patients who leave without being seen – Percent of patients with stroke symptoms who receive brain scan within 45 mins Preventive Care – Immunizations

12 New Core Measures Immunizations Venous Thromboembolism (VTE) Stroke Perinatal Care Hospital based inpatient psychiatric services (HBIPS)

13 Core Measures Immunizations – Influenza – Pneumonia VTE – VTE prophylaxis – Overlap with anticoagulation – Heparin – platelet dose adjustments by protocol – Discharge instructions for warfarin – Preventable VTE

14 Core Measures Stroke – VTE prophylaxis – Discharge on antithrombotic therapy – Anticoagulation for atrial fibrillation/flutter – Thrombolytic therapy – Antithrombotic by day 2 – Discharged on Statin – Stroke education – Assessed for rehabilitation Perinatal Care – Elective delivery – Cesarean sections – Antenatal steroids – Bloodstream infections – Exclusive breast feeding

15 Core Measures HBIPS – Admission screen: violence, substance abuse, psychological trauma, and patient strengths – Hours of physical restraint – Hours of seclusion – Patients discharged on multiple antipsychotics – Discharge plan created and transmitted to next provider

16 Removals of Measures FY 2016 – PN: Blood cultures – HF: discharge instructions, ACEI/ARB for LVSD – AMI: aspirin/statin at DC – SCIP: temperature monitoring

17 Readmissions Complications and Deaths Readmission: 30-day all-cause – AMI – HF – Pneumonia Death: 30-day – AMI – HF – Pneumonia

18 New Readmissions and Death Measures Readmissions – Total Joints – Hospital-wide – COPD – Stroke – Planned readmission algorithm Mortalities – COPD – Stroke

19 Complications Agency for Healthcare Research and Quality Measures (AHRQ) – Patient safety indicators Death among surgical patients with treatable complications Iatrogenic pneumothorax Post-op respiratory failure Post-op VTE Post-op wound dehiscence Accident puncture or laceration

20 Other Measures Reported Use of medical imaging Medicare payments Number of Medicare patients treated

21 Value Based Purchasing Established by Affordable Care Act – Requires CMS to implement a Hospital VBP program – Rewards hospitals for quality of care provided – Built upon IQR infrastructure – Evaluate during performance period for achievement or improvement on measures – Hospital receive points on each measure reflecting better performance – Funding by reducing base operating DRG payment

22 Value Based Purchasing Payment reductions – 2013: 1% – 2014: 1.25% – 2015: 1.5% – 2016: 1.75% – 2017: 2% Amount available for FY 14 incentive payments $1.1 billion

23 Domains Clinical process of care (core measures) – 13 measures and weighted at 45% Patient experience (HCAHPS) – 8 domains and weighted at 30% Outcomes – 3 mortality measures and weighted 25%

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25 Evaluating Hospital Performance Achievement points – Awarded by comparing individual hospital rate during performance period with all hospitals rates from baseline period Rate at or above benchmark (90 th %ile): 10 points Rate less than achievement threshold (median): 0 points Rate between achievement and benchmark: 1-10 points – Comparing current hospital performance to baseline of all hospitals

26 Evaluating Hospital Performance Improvement points – Awarded by comparing hospitals rates during performance period to same hospitals rate from baseline period Rate at or above benchmark: 9 points Rate less than or equal to baseline: 0 points Rate between baseline and benchmark: 0-9 points – Comparing against yourself over time – Fewer points than achievement

27 Proposed VBP Changes for 2015 and Beyond 2015 (final) – Clinical process of care measures: 20% – Outcome measures: 30% – Efficiency measures(Medicare spending): 20% – HCAHPS: 30% 2016 (proposed) – Clinical process of care measures: 10% – Outcome measures (add AHRQ PSI and infection): 40% – Efficiency measures: 25% – HCAHPS: 25%

28 VBP 2017 Change domain and reweight – Outcomes become safety domain: 15% AHRQ Patient Safety Indicators – Process of care becomes clinical care domain: 35% Clinical process of care: 10% Mortality outcomes: 25%

29 ReductionEarn back% change in DRG Value multiplier for DRG Slope for translation

30 Readmission Reduction Program Maximum penalty increased to 2% Projecting $175 million in fewer payments Added planned readmission logic Two new measures for FY 2015 – COPD and elective joint – Built upon IQR infrastructure FY 2014 period – July 1, 2009 – June 30, 2012

31 Planned Readmission Incorporating algorithm – AMI, HF, PN – FY 2014 – Will not count unplanned readmissions that follow planned readmissions either

32 Hospital Acquired Condition (HAC) Reduction Program Required by Affordable Care Act – Payment adjustment for all inpatient hospital payments – ***Includes indirect medical education (IME) and disproportionate share (DSH) payments – Must apply to one quarter of all hospitals (lowest performance) – In addition to the non-payment HAC program – Reductions applied after adjusting for VBP and Readmissions reduction programs Starts in FY 2015

33 HAC Reduction Framework Total HAC Score Worst quartile performance 1% reduction Domain 1 (35%)Domain 2 (65%) AHRQ Patient Safety IndicatorsNHSN Infection Pressure UlcerCentral line blood stream Iatrogenic pneumothoraxCatheter associated UTI Central venous catheter infection Hip fracture2016 Post-op VTESurgical site infection Sepsis (Colon and abdominal hys) Wound dehiscence Accidental puncture2017 MRSA C difficile

34 HAC Scoring (Golf) Points assigned based on performance Performance range for each measure divided into deciles All hospitals receive between 1-10 points for each measure (lower is better) Total score calculated – AHRQ score x 35% + average of 2 NHSN infections x 65% Each year bottom 25% are penalized – Move faster than the others

35 Data Periods Domain 1: AHRQ PSI – July 2011 – June 2013 Domain 2: NHSN Infections – Calendar years

36 Admission and Medical Review Criteria Requires physician order for admission to inpatient status – Authenticated by attending provider Certification – Inpatient order Inpatient services are reasonable and necessary Appropriately provided in accordance with 2 midnight benchmark – Reason for inpatient services Medical record – Estimated time the beneficiary requires inpatient care – Plans for post hospital care – CAH: beneficiary reasonably expected to be discharged or transferred within 96 hours – Must be signed and dated prior to discharge DRG payments reduced additional 0.2% to account in addition

37 2 Midnight Benchmark Reasonably expect patient to require inpatient hospital care for at least 2 midnights Less than 2 midnights – Expected to be observation May move from observation to inpatient if patient meets medical necessity and going to require hospital care for second midnight – Outpatient time does not convert to inpatient billing (no retroactive billing) Includes time spent in hospital outpatient areas (ED and OR) – Does not begin at triage, when care starts!

38 Estimating Impact of Changes IQR changes – Generally don’t involve payment/penalty – Voluntary, required for APU – May require additional staff and support VBP – 1.25% withhold – earn back % = impact Readmission reduction (2%) HAC 1% of DRG + IME + DSH

39 Contact Information Frank Briggs, Pharm.D., M.P.H. Vice President, Quality and Patient Safety West Virginia University Healthcare Phone:


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