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Changes to Performance- Based Payment Programs Sule Calikoglu, Ph.D. Deputy Director of Research and Methodology.

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Presentation on theme: "Changes to Performance- Based Payment Programs Sule Calikoglu, Ph.D. Deputy Director of Research and Methodology."— Presentation transcript:

1 Changes to Performance- Based Payment Programs Sule Calikoglu, Ph.D. Deputy Director of Research and Methodology

2 Maryland Quality-Based Payment Initiatives QBR (Quality Based Reimbursement) Clinical Process of Care MeasuresClinical Process of Care Measures Patient Experience of Care (HCAHPS)Patient Experience of Care (HCAHPS) Patient OutcomesPatient Outcomes MHAC (Maryland Hospital-Acquired Conditions) 65 Potentially Preventable Complications65 Potentially Preventable ComplicationsReadmissions ARR Payment Methodology Shared Savings

3 FY 2015 Changes to QBR FY 2015 payments: Performance Period: CY 2013 Base Period: FY 2012 Eliminated appropriateness of care measurement from the QBR program Removed topped off measures from the opportunity domain Added Patient Outcome Measures: A mortality measure developed using 3M APR-DRG grouper risk of mortality (ROM) on admission


5 FY 2016 Changes to QBR Clinical Measurement and HCAHPS are aligned with CMS program –National Measure list –National Thresholds and Benchmarks –National Data Source –Performance periods (Federal Fiscal Year instead of Calendar Year) New Outcome Measures –Agency for Health Care Quality Patient Safety Indicators (10%) –Central Line Blood Stream Infections (CLABSI) (10%)

6 Maryland Hospital Acquired Conditions Initiative Implemented in July 2009 Relies on Present on Admission Indicators (POA) for secondary diagnosis PPCs are defined as harmful events (accidental laceration during a procedure) or negative outcomes (hospital acquired pneumonia) that may result from the process of care and treatment rather than from a natural progression of underlying disease.

7 FY 2015 Changes FY 2015 payments: Performance Period: CY 2013 Base Period: FY 2012 Added Improvement Scale based on comparing hospital’s performance to their own base line Raised the bar by expected MHAC values at the 85% of the state average Excluded two types of cases from counts of PPCs Hospice Palliative Care Patients (defined as cases with ICD-9 code = V66.7) Patients with more than 6 PPCs

8 MHAC Components Attainment Scale Includes 50 PPCs selected based on clinical and data quality Score is based on case-mix adjusted PPC rates weighted by the estimated resource use Revenue neutral scaling Rewards are given if a hospital performs better than 85 percent of state average. Maximum reduction is 2 % of total inpatient revenue Improvement Scale Includes 5 PPCs that are high cost, high prevalence and high priority Measures percent change from a base year for each hospital Revenue neutral scaling Rewards are given if a hospitals improves more than the current median improvement in the base year. Maximum reduction is 1 % of total inpatient revenue

9 New Improvement List for FY2016 Source: HSCRC Casemix Data FY 2013 PPC NumberPPC DESCRIPTION Number of Complications Number of Hospitals with PPCCOST per PPCTotal PPC Cost 24Renal Failure without Dialysis 315046$9,602$30,246,300 5Pneumonia & Other Lung Infections 108246$20,455$22,132,310 35Septicemia & Severe Infections 91943$22,175$20,378,825 9Shock 90444$20,538$18,566,352 6Aspiration Pneumonia 70445$14,121$9,941,184 16Venous Thrombosis 54441$17,760$9,661,440 48Other Complications of Medical Care 39242$19,703$7,723,576 52 Inflammation & Other Complications of Devices, Implants or Grafts Except Vascular Infection 58144$12,516$7,271,796 37 Post-Operative Infection & Deep Wound Disruption Without Procedure 46740$15,520$7,247,840 7Pulmonary Embolism 43143$16,203$6,983,493 54Infections due to Central Venous Catheters 15032$38,685$5,802,750 31Decubitus Ulcer 15733$35,691$5,603,487 42Accidental Puncture/Laceration During Invasive Procedure 77243$6,621$5,111,412 49Iatrogenic Pneumothrax 20738$7,341$1,519,587 38 Post-Operative Wound Infection & Deep Wound Disruption with Procedure 6025$13,003$715,165 28In-Hospital Trauma and Fractures 10034$7,199$691,104 66Catheter-Related Urinary Tract Infection 9126$5,671$487,706

10 HSCRC Progressively Increased the Revenue at Risk State Fiscal YearMHACsQBR FY 110.5% FY 121%0.5% FY 132%0.5% FY 142%0.5% FY152% +1 % (improvement)0.5% FY162% +1%1%

11 Continuous Improvement and evaluation QBR: incorporates new measures and increase their contribution to the overall score –HCAHPS, Mortality, Patient Safety Indicators MHAC: more aggressive benchmarks and evaluation of PPC selection to the program Coding audits and POA screens

12 Readmissions:Episode-Based Payment Admission-Readmission Program (ARR) All-Cause 30-Day Readmissions and AdmissionsAll-Cause 30-Day Readmissions and Admissions All PayerAll Payer Most Hospitals other than TPRMost Hospitals other than TPR Implemented in FY2012Implemented in FY2012 ARR Bundling approach All-cause, All DRG (same hospital) Risk adjustment using APR- DRGs Savings to payers “off the top”

13 Episode Development Maryland establish an episode-based payment that covers both the initial admission and any subsequent re-admission Acute Hospitalization DRG pmt Readmission 1 Readmission 2 DRG pmt Each paid separately under DRG system = Additional payment for readmissions Establish a “30 day DRG Episode” payment amount or “weight” that covers both the initial admission and ALL subsequent re- admissions within 30 days HSCRC establishes an expanded Episode Bundle $10,000$9,000$6,000 30 day “window” Broader “Scope” – multiple hospitalizations Previously….. Expanded Time Frame

14 Readmission Shared-Savings FY 2014 Rate Adjustment to achieve 0.3% savings from inpatient revenues Based on Case-mix Risk-Adjusted 30-Day Readmission Rates FY 2015: Planned readmissions are excluded Possible Changes for FY 2016 –Incorporation of across hospital readmissions –Changing the measurement methodology to align with CMS

15 Maryland’s Goals An all payer system that is accountable for the total cost of care on a per capita basis is an effective model for establishing policies and incentives to drive system progress toward achieving the three part aim of enhanced patient experience (including quality and satisfaction), better population health, and lower costs. Enhance Patient Experience Enhance Patient Experience Better Population Health Better Population Health Lower Total Cost of Care Lower Total Cost of Care Maryland’s All Payer Model

16 New Waiver and Performance-Based Payment 30% Reductions in Hospital- Acquired Conditions Readmission Target to Achieve National Rate Potentially Avoidable Utilization Other Population Health Metrics

17 Stake Holder Engagement Work Groups

18 Performance Measurement Develop State-wide Targets and Hospital Performance Measurement Potential changes to MHAC, QBR and Readmission Shared Savings Program Measuring potentially avoidable utilization, readmissions, hospital acquired conditions, ambulatory sensitive conditions Integration of cost, quality and population health and outcomes

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