1. PfP Quality Metrics: Readmissions, Value-Based Purchasing and Beyond
Presented to ASHNHA
Alaska Partnership for Patients Advisory Group
February 4, 2015
Gloria Kupferman

2. Medicare Value-Based Purchasing
Agenda
Readmissions
Calculation methods
3M compared to Medicare (CMS)
Sample reporting tool
Medicare Value-Based Purchasing
Maintaining PfP momentum with data collection and reporting

3. Readmissions

4. Many methodologies exist to identify and quantify readmissions
What is a Readmission?
A readmission is a return hospitalization to an acute care hospital that follows a prior admission from an acute care hospital within the specified readmission time interval
The time interval can vary depending upon the purpose of the review
Many methodologies exist to identify and quantify readmissions

5. Methodologies 3M™ Potentially Preventable Readmissions
Some States’ Medicaid Penalties
CMS Hospital Readmissions Reduction Program
Hospital-Level 30-Day Risk-Standardized Readmission Measures for specific conditions
AMI, HF, PNEU, COPD, THA/TKA, CABG
Readmissions in the BPCI and ACO Initiatives
Others developed by QIOs, health departments, etc.

6. 3M™ PPR Methodology

7. 3M™ PPR Methodology
Index admissions and readmissions for conditions that are not considered preventable are globally excluded
e.g. major or metastatic malignancies, multiple trauma and burns, etc.
Some admissions are considered non-events and are considered at risk admissions
e.g. same day transfer to an acute care hospital for non-acute care, etc.

8. Observed PPR Rate

9. Expected PPR Rate

10. Observed to Expected Ratio

11. Overview of the Current CMS Methodology
All-cause readmissions
Current focus areas
Heart Failure (HF) patients
Heart Attack (AMI) patients
Pneumonia (PN) patients
Chronic Obstructive Pulmonary Disease (COPD)
Total hip and knee replacements (THA/TKA)
CABG in FFY 2017
What hospitals are included?
All acute care PPS hospitals
CAHs are exempt
Hospital must have 25 discharges within a disease category over the 3 year reporting period

12. FFS Medicare Part A at the time of the index admission
Inclusions
Medicare Fee-for-Service patients, at least 65 years of age, with a principal diagnosis of AMI, HF, or PN
12 full months of enrollment in parts A and B FFS prior to the index admission
FFS Medicare Part A at the time of the index admission
One full month of enrollment in Parts A and B FFS post discharge
Patients are identified by their principal diagnosis not DRG. CMS has released a set of ICD-9s that define each of the three disease areas.
June 2010 release on hospital compare has additional changes, highlight later.

13. Incomplete Medicare enrollment data Under age 65
Exclusions
Incomplete Medicare enrollment data
Under age 65
Length of stay greater than one year
Discharged against medical advice
In hospital deaths
Transfers out
Same day readmissions for the same condition to the same hospital
Disease category specific exclusions
Some recognition of planned readmissions
AMI – exclusions for planned readmissions: exclude readmissions with PCI or CABG that follow and index AMI admission, except those that are not consistent with planned (HF, AMI, unstable angina, arrhythmia, cardiac arrest, etc)
AMI – same day discharges
MD fixes Admissions that: (1) had a principal diagnosis code indicating psychiatric care (2) occurred within one day of an index discharge; and (3) had a discharge disposition of “65” (Discharged/ Transferred to a psychiatric hospital or psychiatric distinct unit of a hospital)
Readmission with a principal diagnosis beginning with “V57” (rehab)

14. Risk Adjustment Methodology
Developed by a team of clinical and statistical experts from Yale and Harvard universities
Each disease category has an individual risk adjustment model
Adjust for variables that are clinically relevant and have strong relationships with the outcome
Demographics, disease severity indicators, indicators of frailty
Example for HF: age, sex, history of CABG, cancer, diabetes, asthma, COPD, pneumonia, renal failure, etc.
Only comorbidities that convey info about the patient at the time of index and 12 months prior and not complications that arise during the course of hospitalization are included.
Models do not adjust for admit source/discharge disposition bc these factors are associated with the structure of the health care system not the patiebnts clinical risk factors.
Do not adjust for SES bc association between ses and health outcomes can be due in pt to quality of health care. Risk adjusting for ses would imply that hospitals w/ more low SES pts are held to a different standard.
HF:

15. Risk Standardized Readmission Rate (RSRR)
Predicted Rate (similar to observed rate)
the number of readmissions within 30 days predicted on the basis of the hospital's performance with its observed case mix
Expected Rate
the number of readmissions expected on the basis of the nation’s performance (US average hospital performance) with that hospital’s case mix.
Analogous to the observed to expected ratio = but allows for a comparison of a particular hospital’s performance give its case-mix to an average hospital’s performance with the same case mix.

16. Predicted to Expected Ratio
P/E less than 1 =
Lower than expected readmission rate
Better quality, no penalty
P/E greater than 1=
Higher than expected readmission rate
Lower quality, subject to penalty

17. Live Tour
Readmissions Diagnostic Tool

18. Takeaways You can’t evaluate and address issues without data
You need an analytic tool that can identify and track readmissions
Let the CMO, Dept. Chairs, Nurse Leads. . .
Play with it
Formally analyze
Provide feedback
Share with MD/RN and other key clinicians
Use for focus groups. . . What goes well and where are the opportunities

19. Medicare Value-Based Purchasing

20. Value-Based Purchasing Overview
Mandated by the ACA
The only Medicare quality program that actually rewards good performance
Funded by Medicare payment carve-outs
Complex scoring methodology looks at quality metrics in several “domains”
Scores reflect performance compared to national standards and individual improvement
Domains, metrics and standards change annually

21. General VBP Program Trends
Continuously evolving program
Program rules established well in advance
Increasing program exposure
Increasing weight towards Outcomes & Efficiency Measures

22. FFY 2015 VBP Program Overview
1.5% program contribution
Outcomes domain measure expansion
PSI-90 Safety Indicator Composite
CLABSI Standardized Infection Ratio
New Efficiency Domain
SPP_1 (Medicare Spending Per Beneficiary)
Overlap with FFY 2015 HAC Reduction Program
PSI-90 Composite
CLABSI

23. FFY 2015 VBP Program Overview
First Year of Proportional Reweighting
Impacts program eligibility

24. Tracking VBP Performance

25. PfP Data Collection and Reporting

26. Maintain Momentum
Sample data collection / reporting tool
Sample summary workbook

27. Vice President, DataGen
Questions?
Gloria Kupferman
Vice President, DataGen