Learning Objectives. Medicare P4P Programs. How to Interpret Medicare s Hospital Pay for Performance Reports

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1 1 How to Interpret Medicare s Hospital Pay for Performance Reports Richard D. Pinson, MD, FACP, CCS Principal Pinson & Tang, LLC Houston, TX Learning Objectives At the completion of this educational activity, the learner will be able to: Identify the components of the three Medicare Hospital Payfor Performance Reports Explain the difference between claims based and abstraction measures Explain the point system for grading hospital performance Interpret the results of the Pay for Performance Reports 2 Medicare P4P Programs Hospital Value Based Purchasing (HVBP) Hospital Readmissions Reduction Program (HRRP) HAC Reduction Program (HACRP) All 3 programs include claims based measures that are risk adjusted based on severity of illness. 3 1

2 4 CMS Measure Methodology Claims based Derived from programmed data analysis of Medicare claims Based on codes submitted CDI has significant impact Abstraction Clinical review of selected medical record samples by quality department or infection control Based on specific objective findings recorded in the record and CDC criteria (including POA status), not physician documentation CDI has no impact CMS Abstraction: CAUTI Reference: CDC Device Associated Module UTI, Jan 2016, pg Hospital Value Based Purchasing Hospital payments withheld 2% Repay best performing hospitals based on quality ranking 0% to 4% back Best 50% get more than 2% back 6 2

3 7 Hospital Value Based Purchasing Weight Domain/Components 25% Outcomes 30 day all cause mortality: AMI, CHF, PNA 5% Process of Care Fibrinolytic < 30 min for AMI, flu vaccination, elective delivery < 39 weeks 20% Safety CLABSI, CAUTI, SSI (2), C. diff, MRSA bacteremia, PSI 90 25% Patient Experience of Care National Healthcare Survey of all inpatients collected and reported by quality department 25% Cost Reduction MSPB all Part A+B all providers from 3 days pre admit thru 30 days post DC Hospital Value Based Purchasing: Summary Report Higher score = Better performance Survey Max possible 4.0% Max possible +2.0% = Possible range = Outcomes/Process of Care Higher rate (ratio) = Better care = Higher score 9 3

4 10 Safety Lower rate = Better performance = Higher score Patient Experience of Care Higher rate = Better performance = Higher score 11 Efficiency: Medicare Spending Per Beneficiary (MSPB) Lower MSPB measure ratio = Lower cost = Higher score 12 4

5 13 Hospital Readmission Reduction Penalty for high readmission rates Up to 3% All cause 30 day readmission rate for: Acute MI Heart failure Pneumonia COPD CABG THA/TKA Risk adjusted based on comorbid conditions Hospital Readmission Reduction Penalty = 1.91% Higher ratio = Higher readmission rate > = Graduated increasing penalty (up to 3%) f = d/e 14 HAC Reduction Penalty for high HAC rates 1% For 25% of the lowest performing hospitals Domain 1: Claims based PSI 90 (15%) Domain 2: Abstracted (85%) CAUTI, CLABSI, SSI, MRSA, C. diff Risk adjusted based on comorbid conditions Measure Weight Accidental Punct/Laceration 44% Peri op DVT or PE 34% Iatrogenic Pneumothorax 8% Post op Sepsis 6% Central Ven Cath Bld Strm Inf 4% Pressure Ulcer 3, 4, Unstageable 3% Post op Wound Dehiscence 2% Post op Hip Fracture 0.2% 15 5

6 16 HAC Reduction Higher score = Worse performance Worst 25% = 1% penalty Worst possible score High score HAC Reduction Higher score = Worse performance 17 Audience Exercises: Medicare P4P Reports 18 6

7 19 Polling Exercise #1 Value Based Purchasing: Overall What is the hospital s net percent gain or loss in base operating DRG revenue for VBP? % % % % 20 Exercise #2 Value Based Purchasing: Mortality x 21 7

8 22 Polling Exercise #2 Value Based Purchasing: Mortality 2. In how many mortality measures did the hospital performance period rate meet the national benchmark rate? a) 0 measures b) 1 measure c) 2 measures d) 3 measures 3. How many measure score points does a hospital receive if it reaches the national benchmark rate? a) 0 points b) 5 points c) 10 points Exercise #3 Hospital Readmissions Reduction Program x Note: No CABG measure for this hospital = < 10 cases 23 Polling Exercise #3 Hospital Readmissions Reduction Program 4. In how many measures did the hospital readmission rate exceed the expected rate? a) 0 measures b) 1 measure c) 4 measures d) 5 measures 5. Will the hospital receive an HRRP penalty? a) Yes b) No 6. What is the maximum possible penalty under HRRP? a) 1% b) 2% c) 3% 24 8

9 25 Thank you. Questions? In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 9

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