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 Measures
Patient Experience of Care (HCAHPS)
Patient Outcomes
MHAC (Maryland Hospital-Acquired Conditions)
65 Potentially Preventable Complications
ARR Payment Methodology
Shared Savings
Readmissions

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

4. QBR MEASURES AND DOMAINS

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 Improvement 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
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
PPC Number
PPC DESCRIPTION
Number of Complications
Number of Hospitals with PPC
COST per PPC
Total PPC Cost 24
Renal Failure without Dialysis
3150 46
$9,602
$30,246,300 5
Pneumonia & Other Lung Infections
1082
$20,455
$22,132,310 35
Septicemia & Severe Infections
919 43
$22,175
$20,378,825 9
Shock
904 44
$20,538
$18,566,352 6
Aspiration Pneumonia
704 45
$14,121
$9,941,184 16
Venous Thrombosis
544 41
$17,760
$9,661,440 48
Other Complications of Medical Care
392 42
$19,703
$7,723,576 52
Inflammation & Other Complications of Devices, Implants or Grafts Except Vascular Infection
581
$12,516
$7,271,796 37
Post-Operative Infection & Deep Wound Disruption Without Procedure
467 40
$15,520
$7,247,840 7
Pulmonary Embolism
431
$16,203
$6,983,493 54
Infections due to Central Venous Catheters
150 32
$38,685
$5,802,750 31
Decubitus Ulcer
157 33
$35,691
$5,603,487
Accidental Puncture/Laceration During Invasive Procedure
772
$6,621
$5,111,412 49
Iatrogenic Pneumothrax
207 38
$7,341
$1,519,587
Post-Operative Wound Infection & Deep Wound Disruption with Procedure 60 25
$13,003
$715,165 28
In-Hospital Trauma and Fractures
100 34
$7,199
$691,104 66
Catheter-Related Urinary Tract Infection 91 26
$5,671
$487,706
Source: HSCRC Casemix Data FY 2013

10. HSCRC Progressively Increased the Revenue at Risk
State Fiscal Year
MHACs
QBR
FY 11
0.5%
FY 12 1%
FY 13 2%
FY 14
FY15
2% +1 % (improvement)
FY16
2% +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
ARR
Bundling approach
All-cause , All DRG (same hospital)
Risk adjustment using APR-DRGs
Savings to payers “off the top”
Admission-Readmission Program (ARR)
All-Cause 30-Day Readmissions and Admissions
All Payer
Most Hospitals other than TPR
Implemented in FY2012

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

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 All Payer Model
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.
Maryland’s All Payer Model
Enhance Patient Experience
Better Population Health
Lower Total Cost of Care

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