1. Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

2. Understanding medicare’s quality indicators Kristen Geissler, MS, PT, MBA, CPHQ Associate Director, Navigant Consulting, Inc. May 15, 2009 Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

3. Table of contents Section 1 »Background and Measures Section 2 » Abstraction 101 Section 3 » Coding Guidelines versus HQA Spec Manual Section 4 » Concurrent Review of Quality Indicators Section 5 » Takeaways Section 6 » Questions Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

4. Section 1 Background and Measures Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

5. Sponsorship  Regulatory: – Sponsored by federal or state agencies:  Hospital Quality Alliance—Hospital Compare – Usually consistent, consensus-built standards and definitions  Private/for-profit: – Sponsored by non-governmental agencies:  HealthGrades ®  U.S. News & World Report – Methodology and definitions often not consensus-built and may not be public or reproducible Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

6. Background of quality measures in hospitals  Several different types of quality measures: – Process:  Was a specific recommendation done?  “Evaluation of left ventricular function” – Outcome:  What happened with the patient?  “30-day mortality of patients with pneumonia”  Much more complex, as risk adjustment must be used – Patient-reported:  “HCAHPS Patient Perception Survey” – Facility-reported:  Hospital infection rates, fall rates  Concerns with hospitals using different measurement methodology and intensity of review Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

7. Background of quality measures in hospitals  Two very different types of quality reporting: – “Active” data capture and transmittal:  Used for Core Measures—abstractor reviews each chart for specific data elements  Very complex data abstraction rules – “Passive” data retrieval:  Used by agencies such as HealthGrades  Used for CMS mortality measures and several new measures for FY10—readmission and AHRQ Patient Safety Indicators  Based strictly on administrative/coding data Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

8. Background of quality measures in hospitals  The Joint Commission has been requiring hospitals to collect and submit data on Core Measures since 2001  Dept HHS announced the Quality Initiative in 2001  Now called the Hospital Quality Alliance, a collaborative effort between multiple organizations, JC, CMS, AHA, NQF  Data is published on The Joint Commission’s Web site under “Quality Check” and CMS’ “Hospital Compare”  CMS-specific program related to the IPPS (Inpatient Prospective Payment System) is called Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) (pronounced ‘rackdapoo’)  Many current state and other payer efforts that publish this and other data Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

9. CMS—Value-Based Purchasing  CMS currently has a ‘pay to report’ model (RHQDAPU): – Hospitals that do not report data on the required measures will not receive 2% of the market basket update – Will change to “pay-to-perform” with VBP (Value-Based Purchasing):  Payments to achieve and exceed  Possible penalties for low performance  Possible timeline (as outlined in the November 2007 proposal to Congress) – FY2009—current RHQDAPU requirements of reporting 27 measures – FY2010—VBP: 100% based on public reporting – FY2011—VBP: 50% based on public reporting; 50% based on performance – FY2012—VBP: 100% based on performance Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

10. Publicly reported quality data Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed Organization Web site CMSwww.hospitalcompare.hhs.gov The Joint Commissionwww.qualitycheck.org HealthGrades ® www.healthgrades.com The Leapfrog Groupwww.leapfroggroup.org Local state or regional initiativesSearch the Internet

11. Documentation and quality measures  Core Measures focus on quality-of-care processes (versus outcome): – Did we assess? – Did we prescribe? – Did we administer (a medication)?  Many times, becomes more of a documentation issue Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

12. FY 2009 quality measures  Heart Attack: – AMI—1 - Aspirin at arrival – AMI—2 - Aspirin prescribed at discharge – AMI-—3 - ACE inhibitor or ARB for left ventricular systolic dysfunction – AMI—4 - Adult smoking cessation advice/counseling – AMI—5 - Beta-blocker prescribed at discharge – AMI—6 - Beta-blocker at arrival (to be retired after March 31, 2009) – AMI—7a - Fibrinolytic agent received w/in 30 minutes of hospital arrival – AMI—8a - Primary percutaneous coronary intervention (PCI) received w/in 90 minutes of hospital arrival  Heart Failure: – HF—1 - Discharge instructions – HF—2 - Left ventricular function assessment – HF—3 - ACE inhibitor or ARB for left ventricular systolic dysfunction – HF—4 - Adult smoking cessation advice/counseling Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

13. FY 2009 quality measures (continued)  Pneumonia: – PN—1 - Oxygenation assessment (retired after 1/1/09) – PN—2 - Pneumococcal vaccination status – PN—3b - Blood culture performed before first antibiotic received in hospital – PN—4 - Adult smoking cessation advice/counseling – PN—5c - Initial antibiotic received w/in six hours of hospital arrival – PN—6 - Appropriate initial antibiotic selection – PN—7 - Influenza vaccination status  Surgical Care Improvement Project: – SCIP—Inf-1 - Prophylactic antibiotic received w/in one hour prior to surgical incision – SCIP—Inf-2 - Prophylactic antibiotic selection for surgical patients – SCIP—Inf-3 - Prophylactic antibiotics discontinued w/in 24 hours after surgery end time – SCIP—Inf-4 - Cardiac surgery patients w/ controlled 6AM postoperative serum glucose – SCIP—Inf-6 - Surgery patients w/ appropriate hair removal – SCIP—VTE-1 - Venous thromboembolism (VTE) prophylaxis ordered for surgery patients – SCIP—VTE-2 - VTE prophylaxis w/in 24 hours pre/post surgery Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

14. FY 2009 quality measures— (continued)  Mortality: – AMI—30-day mortality—Medicare patients – Heart failure—30-day mortality—Medicare patients – Pneumonia—30-day mortality—Medicare patients  Patient Experience: – HCAHPS patient survey Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

15. What does the public see? Hospital Compare (CMS)—Core Measures Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed www.hospitalcompare.hhs.govwww.hospitalcompare.hhs.gov – accessed 1/27/09

16. What does the public see? Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed Hospital Compare (CMS)—Mortality Measures www.hospitalcompare.hhs.govwww.hospitalcompare.hhs.gov – accessed 1/27/09

17. FY 2010—Quality measures—added  Surgical Care Improvement Project: – SCIP—Card 2 - Surgery patients on a beta-blocker prior to arrival who received a beta-blocker during the perioperative period (January 1, 2009, discharges)  Readmission Measures: – Heart failure 30-day risk standardized readmission (Medicare claims only) – AMI and PN 30-day readmission will likely be finalized for FY10 at a later date – Claims data for July 1, 2007–June 30, 2008  Nursing Sensitive Measures: – Failure to rescue—Medicare claims only – Claims data for July 1, 2007–June 30, 2008  Cardiac Surgery Measures: – Participation in a Systematic Database for Cardiac Surgery – Data collection window between July 1, 2009–August 15, 2009 Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

18. FY 2010—Quality measures (continued)  AHRQ—Patient Safety Indicators (PSI) and Inpatient Quality Indicators (IQI): – Abdominal aortic aneurysm (AAA) mortality rate (with or without volume) – Hip fracture mortality rate – Mortality for selected medical conditions (composite) – Mortality for selected surgical procedures (composite) – Complication/patient safety for selected indicators (composite) – Death among surgical patients with treatable serious complications – Iatrogenic pneumothorax, adult – Postoperative wound dehiscence – Accidental puncture or laceration – Medicare claims only (only for FY10—will change to all-payer beyond FY10) – Medicare Claims data for July 1, 2007–June 30, 2008 Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

19. A word on risk adjustment  What measures need to be risk adjusted? – Outcome measures (mortality, complications, readmissions):  Adjusts for complexity of care and severity of illness  What is the methodology? – Many different methodologies:  APR-DRGTM (3M)  HealthGradesTM proprietary  CMS mortality risk adjustment  How is risk adjustment used? – Actual rate versus expected rate:  i.e., sicker patients would have a higher expected rate of mortality  What’s the bottom line? – The more accurately the coding/claims data represents the severity of illness of the patient, the more accurately the risk-adjustment methodology will be applied Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

20. Section 2 Abstraction 101

21. Understanding the abstraction process  Abstraction process: – Cases are selected for review based on principal ICD-9 diagnosis/procedure – Entire inpatient medical record must be reviewed – Data elements (demographic and measure-related) must be abstracted for each eligible case:  Up to 35 measure-related elements per record – Data elements are entered into hospital software (a JC-accredited performance measurement program) – Software determines exclusions from a measure set or individual measure  Quality control: – Very complex set of abstraction rules issued nationally:  Updated/changed every April/October – CMS audits five random cases (across all measure sets) each quarter:  Hospitals must achieve 80% agreement – Joint Commission requires reconciliation of principal diagnosis count of measure sets each quarter Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

22. Quality review and abstraction process Abstraction on discharge Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed Software determines what records to review based on ICD-9 codes Quality abstractor reviews entire record and abstracts data Abstracted data is entered into the software system Software system transmits data to Joint Commission and to federal data clearinghouse New data abstracted may contradict with findings on concurrent review. Spec manual has very specific rules on contradicting information.

23. Quality indicator challenges  No certification or competency criteria for quality indicator abstractors  Very complex abstraction rules: – Specification manual made of many different sections – Rare to find a single-source answer to a question  Limitations on documentation clarifications that can be added to the record after discharge  Some quality indicator definitions/guidelines contradict coding guidelines  If incorrect principal diagnosis/working DRG is applied during admission, incorrect Core Measure Set may be applied: – Pneumonia versus Heart Failure  Even if record is reviewed concurrently, entire record must be reviewed on discharge  Many ‘precedents’ must be understood in order to determine whether measure was met or not – ACEI/ARB for left ventricular systolic dysfunction:  How does HQA define ‘left ventricular systolic dysfunction’ Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

24. Abstraction resources  Specification Manual – www.qualitynet.org—go to “Hospital Inpatient” tab, and then “Specification Manual” or http://qualitynet.org/dcs/ContentServer?cid=1141662756099&pagename=QnetP ublic%2FPage%2FQnetTier2&c=Page www.qualitynet.org Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

25. Abstraction resources  Specification Manual: – Pick appropriate discharge time period Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

26. Abstraction resources  Specification Manual: – Different sections of the manual Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

27. Abstraction resources  Specification Manual: – Qnet Quest—FAQs Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

28. Section 3 Coding guidelines versus HQA Spec Manual

29. From the physician’s perspective …  Some examples of the many things we ask of our providers:  Joint Commission standards: – Critical lab values – Verbal orders – Clinical indications for diagnostic tests  AHA/CMS/OIG inpatient coding guidelines for reimbursement: – Acuity/specificity – Spelling out up/down arrows – Linking diagnoses to cause  Hospital Quality Alliance: – Contraindications to medications – Timing of antibiotics – Discontinuation of antibiotics  CMS Professional Fee coding guidelines for reimbursement: – Order for the consultation – Complexity of care Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

30. Examples of conflicts between quality indicators and coding guidelines Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed  Quality indicator rules 1. Left ventricular function may be derived directly from an echo report (does not have to be redocumented by the treating physician) 2. Patient’s smoking status and evidence of smoking cessation education may be derived from nursing notes  Coding rules 1. Left ventricular function must be documented by a treating physician in order to be coded 2. Patient’s smoking status must be documented by a physician to be coded

31. Quality versus coding  Examples of documentation that may be provided by someone other than a treating physician in Quality Indicators:  Nursing: – Medication administration or prescription on discharge – Medication allergies – Participation in clinical trials – Smoking history & evidence of smoking cessation education – Discharge instructions – Vaccination status – Blood culture collection  Non-Treating Physician: – EF from echo report – ST-segment elevation from ECG report – Chest x-ray results – Culture results from pathology report Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

32. From the physician’s perspective  Collaborate with quality and accreditation staff on physician education  Ensure multiple points of review for new medical record forms or reminder sheets: – Does it meet the needs of many different stakeholders? – Does it contradict any of the stakeholder’s guidelines?  Encourage physician advisors to collaborate with one another  Physicians and other providers need to hear one message Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

33. Section 4 Concurrent Review of Quality Indicators

34. Quality indicator concurrent review models  Possible models:  Target review population (i.e., just Medicare) OR all payers  All quality indicators OR targeted selection of indicators  All CDS’ review for quality indicators OR specialty CDS reviews for quality indicators Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed Concurrent reviewer reviews record based on some trigger criteria (admitting dx, CM report, etc.) Based on ‘presumed’ final diagnosis, chart is reviewed for quality indicators Reviewer may query physician for specific quality indicator criteria Reviewer may or may not document findings on worksheet or in software. Patient discharged.

35. Pros/cons of CDS’ performing quality indicator concurrent review  Opportunities:  Decreases number of reviewers interfacing with physicians  Many top query opportunities are also core measure sets (HF, PN, AMI)  Appropriate identification of principal diagnosis before discharge  Challenges:  Increased material to learn  Contradicting rules  Continued competence will require updates every six months  May be disconnect in target population (i.e., Medicare versus all payers) Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

36. Section 5 Takeaways

37. What can you do Monday morning?  Look at your quality scores online.  Introduce yourself to the quality abstractors.  Set up education session or lunch & learn with the quality team.  Find out what tools the quality team uses to help physicians with documentation: – Checklists – Reminder stickers – Preprinted progress notes – Order sets  Meet with your physician advisor and discuss opportunities.  COLLABORATE! Copyright © NCI 2009 Confidential and proprietary, shall not be transferred or distributed

38. Section 6 Questions