CV SURGERY 30 DAY RE-ADMISSION. CMS IS WATCHING YOU, AND YOU, AND ME TOO.

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1 CV SURGERY 30 DAY RE-ADMISSION. CMS IS WATCHING YOU, AND YOU, AND ME TOO. THE TEAM UTAH VALLEY HOSPITAL John Mitchell, MD January 16, 2016

2 Centers for Medicare and Medicaid Services Federally funded inpatient and outpatient insurer of healthcare. CMS: branch of Health and Human Services Insures 1/3 rd of US population (1oo million) Major influence in cost control in medicine BC/BS insures 105 million; ie, another 1/3 rd of population 36 independent companies under one Federation Includes Crossover population of age over 62 as CMS partners

3 CABG Readmission as a Measure of Quality How did we get here? 2005: Deficit Reduction Act (GW Bush) Directs Sec of Dept. of Health and Human Services publicly report quality measures including measures of hospital outcome and cost Hospital Inpatient Quality Reporting Program (IQR) 2010: Affordable Care Act. Careful out there. Also through HSS. Hospital Readmissions Reduction Program (HRRP): reduce payments to hospitals with excess readmissions. Oct 1, Hospital Value Based Purchasing Program (HVBPP) Hospital Compare Withholds / penalties

4 Public Reporting from CMS CMS has developed two outcomes measures that will be part of their public reporting program beginning 2017 for CABG, only, at this point. 30 day all-cause, Risk Standardized Mortality Rate (RSMR) 30 day all-cause, unplanned, Risk-Standardized Readmission Rate (RSRR) Population Both measures include Medicare fee for service beneficiaries age 65 + At Risk 1% withhold for outliers starting 2017, increasing 1% per year through 2019, totaling 3% by 2019 No clarity yet as to impact on MD reimbursement Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation Prepared for: Centers for Medicare and Medicaid Svcs. Revised February 1, 2014.

5 Why CABG? Impact on the Patient. CABG common operation, with high readmission rate 2014: Society of Thoracic Surgeons All CV Surgery 283,386 procedures in the US CABG 147,528 procedures in the US Jan 09-Sept 11 Medicare Fee-For-Service National rate: Median risk stratified readmit rate = 16.8%, range 12% to 23.1% 87.3% of readmits directly related to CABG 30 day mortality rate for readmitted pts = 2.8% 3 times higher than patients without readmission Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation Prepared for: Centers for Medicare and Medicaid Svcs. Revised February 1, 2014.

6 CMS identified reasons for readmission: Complications of therapy Inadequate treatment Inadequate care coordination at d/c Unexpected worsening of disease after d/c

$162,000) Part A pays 90% of charges = $90,000 So, 2014: 283,386 CV surgeries (STS 6/2015) 283,386 CVS at $90,000 = $25.5 billion (16.

7 Medicare Budget 2015: Billions of reasons. A: $203 B: $168 C: $150 D: $85 BILLIONS Part A: Inpt Hosp = 24% of $606 = $152 billion Mean Medicare CABG charge = $100,000 (range $62,398 - $162,000) Part A pays 90% of charges = $90,000 So, 2014: 283,386 CV surgeries (STS 6/2015) 283,386 CVS at $90,000 = $25.5 billion (16.7% of Medicare Part A budget in 2015) 16.8% readmit cost* of $25.5 billion = $4.3 billion CV Surgery accounts for $25.6 bill = 23% of Med A $4,300,000,000 is for readmission! *J Am Coll Cardiol Intv. 2011;4(5):

8 EVERY CABG READMISSION COSTS $87,500! Medicare Calculated Readmission Cost for 2015 Medicare CV Surgery readmission payout: $4.3 billion Based on STS 2014: CV Surgery = 283,386 procedures CABG = 143,865 procedures (50.1%) $4.3 bill / 2 = $2.1 bill payout for CABG readmits 143,836 CABG X 16.8% readmit rate = 24,164 readmits $2.1 bill / 24,164 readmits = $87,500 per readmission Index admission cost = readmission cost FACT CHECKED! Ask Lee McCann.

9 WHY CABG, you ask? You fool: MONEY

10 DATA Farming Baseline CABG Readmission and Mortality data measures Developed in 2012 by Yale New Haven Health Services Corporation-Center for Outcomes Research and Evaluation Based on Medicare FFS Database and validated through the STS CABG Registry Database Hospital Specific Report (HSR) was available for feedback Baseline data CY HSR available for 2 months Aug and Sept 2013 Reported risk adjusted annual readmission and mortality rates Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation Prepared for: Centers for Medicare and Medicaid Svcs. Revised February 1, 2014.

11 Readmission This measure will include patients aged 65 years and over admitted for a qualifying CABG procedure (without concomitant valve or other major cardiac, vascular or thoracic procedures) to a non-federal acute care hospital in the U.S. The measure does not count planned readmissions in the measure outcome, since they are generally not a signal of quality of care. Like in mortality, CMS will risk-adjust for patients comorbid conditions, as identified in both inpatient and outpatient claims for the 12 months prior to the index hospitalization, as well as those present at admission. Based on claims data, the unadjusted mean hospital readmission rate was 17.7% and ranged from 0%- 100% with a median of 16.8%.The hospital riskstandardized mean readmission rate was 16.8%, and ranged from 12.0% %. The median risk-standardized rate was 16.8%. Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation Prepared for: Centers for Medicare and Medicaid Svcs. Revised February 1, 2014.

12 Inclusion/Exclusion Criteria Extensive: leave it at that for now (111 pages) Risk adjusted: both measures adjust for differences in hospital s patient case mix Will be reported as risk adjusted data point, and confidence intervals Intent: to compare hospitals doing sicker patients to those serving healthier patients Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation Prepared for: Centers for Medicare and Medicaid Svcs. Revised February 1, 2014.

13 Medicare.gov/Hospital Compare Not just volume. Linking quality to payment. AFFORDABLE CARE ACT: MARCH, 2010 Hospital Readmissions Reduction Plan: authorizes CMS to reduce payments to hospitals with excess readmissions (began Oct 1, 2012) Hospital Value Based Purchasing Plan: Pay for performance Performance measured against all hospitals, or Performance improvement from a prior baseline

14 Rolling quarterly time span July 1, 2011 to June 30, 2014 Readmission after CABG: UVH Risk adj d; age 65+; volume noted Black Tick: National rate (14.9%) Caret: facility adjusted rate (14.5%) Yellow: facility 95% CI of risk Green: better than Nat l Av (left) Red: worse than Nat l Av (right)

15 Allows comparison of up to 3 facilities This is the public view of the Hospital Specific Report (HSR) generated by Yale/Hew Haven study.

16 May compare hospitals across the Nation, by zip Code. No data when caseload too small. Allows comparison of Death Rate as well.

17 In Comparison: Ann Thorac Surg 2014;98:` (Oct)

18 Readmission After Cardiac Surgery Observational study, prospective, up to 65 days after operation, first operation only 10 hospitals in US and Canada Feb 1 to Sept 30, patients All cause readmission data examined

19 Demographics

20 CABG Same as National Average Readmit rates by procedure

21 Cause of readmit < 30 days Arrhythmia Infection: pneumonia, wound, UTI Volume overload

22 Cause of readmit > 30 days Volume overload Infection: pneumonia, wound, UTI ACS Arrhythmia: A fib, V tach

23 Soooooo Each of our four Heart Programs are well within CMS standards for CABG 30 day readmission at or below 14.9% Cardiac Surgery readmissions generate exorbitant cost $4.3 BILLION Nationally. Feds have caught on, and are penalizing. Av readmit costs $87,500, nearly = index surgery. Consider the consequence of eventual Medicare withhold for readmission. Readmit rate reduction by even 1 patient will be IMPORTANT!

AIM STATEMENT Reduce the 30-day all cause readmission rate for heart surgery

Report specifically on isolated CABG, isolated AVR, and all heart surgery patients.

2% (all cases) with an average readmission of 21.5 patients/year.

24 AIM STATEMENT Reduce the 30-day all cause readmission rate for heart surgery patients at UVRMC. Report specifically on isolated CABG, isolated AVR, and all heart surgery patients. The readmission rate was 10.2% (all cases) with an average readmission of 21.5 patients/year. The entry goal is to reduce the readmission rate by 5% (1 patient), the target goal is to reduce the readmission rate by 10% (2 patients), and the stretch goal is to reduce the readmission rate by 15% (3 patients).

25 QUE II: Reduce the 30-day all cause readmission rate for heart surgery Team effort, shared accountability, improved communication. Surgeon responsible. Multi-disciplinary: Patient and family, Primary MD, Cardiology, Ph II Rehab, Pharm, Dietary, Discharge Tool (100%) Patient Ownership: Surgeon Aggressive use of Outpatient Clinic 23 hour Observation when necessary: Does NOT Count. Focused Pre Operative and Hospitalization Protocol changes Begin / establish medication reconciliation Begin/establish discharge planning and needs Home, Home Health, SNF, Rehab, LTAC Pre op teaching: MAWDS. Aggressive diuresis when tolerable

26 QUE II: Reduce the 30-day all cause readmission rate for heart surgery Post Discharge Discharge Tool: 100%, no exceptions, no weekends, no holidays, no excuses. Phone call within 24 hours of discharge: Nursing floor. No exceptions. Follow up visit within 7 days: Clinical RN Wellness Center (Kelly Smith RN) Pharmacy attends Wellness Center Rounds on Wednesdays, 2 hours. Every Med Rec reviewed. CT Surgery f/u at 2 weeks (changed from 6 weeks) Follow Heart Failure Protocol (MAWDS) in all discharged surgery patients, regardless of EF Caution discontinuing diuretics at time of discharge; ie, DO NOT. Surgeon responsible to evaluate EVERY possible readmit: ER, SNF, LTAC, Rehab, Out Pt Clinic referral. Surgeon makes admit determination: who, when, why. PS: This is painful. EVERY readmit gets presented to Team Meeting as an M&M. Goal to determine why, prevent.

27 UVH All CV Surgery Caseload and Readmits by Year. 10.2% Inpatient readmits in green Baseline readmits = 43 patients, 22 / year, at 10.2% Goals: Entry: reduce 1 pt, 5% reduction Target: reduce 2 pts, 10% reduction Stretch: reduce 3 pts, 15% reduction

28 Average days to readmission Causes? Volume overload suspected! CHF, Atrial fib, Concentrate post op visits to prevent readmission 7 day RN visit 2 wk surgeon visit vs 6 wk Continue diuretics

Phone call to patient within 72 hours of discharge Follow up visit with patient within 7 days Caution discontinuing

29 Readmission Summit Engage our discharge facilities We wish to manage readmissions in partnership with our transfer and receiving facilities. You, then, become a critical member of the Heart Surgery Team! Phone call to patient within 72 hours of discharge Follow up visit with patient within 7 days Caution discontinuing diuretics at time of discharge Direct surgeon involvement in every encounter related to a discharged patient. CALL US FIRST One call, that s all.

30 MEDICATION ACTIVITY WEIGHT DIET SYMPTOMS

31 Methods STS database, 4 CV sites, trended 2013/14/Jan-Jun 15 Implemented Readmission Reduction Protocol at UVH and applied to all 4 facilities Jul 1, 2015 through Nov 30, 2015 STS Data incomplete for Dec 2015 Examined: Medicare only, and All Payer Isolated CABG, Isolated MV, Isolated AV CABG/AVR, CABG/MVR Other Total CV Surgery cases Examined: All Payer Readmission Diagnosis

32 Results: All Surgeries, All Payers All facilities have readmit rates < 10%, well below National rates of 14-25% Each facility had marginal readmit reduction in late 2015, including UVH Cannot attribute UVH reduction to Readmission Protocol Limited patient volume in Study Group.

33 Results: Isolated CABG, All Payers All facilities have readmit rates at / or below Nat l 8.3%-21.1%* (all payers) UVH rate decreased from 13% to 9% (31%) in Study Group. Thus, is result attributable? But, Dixie and MKD had substantial rate drop while not on Study. J Am Coll Cardiol Intv. 2011;4(5):

34 Results: All Surgeries, Medicare Payer Only All facilities perform well in Medicare population, for all surgeries Nat l rate 14-25%. No specific CMS range No rate reduction in Study Grp at UVH But three other facilities demonstrate rate red, without protocol.

35 Results: Isolated CABG, Medicare Payer Only Specific group CMS targeted with Rate Reduction Protocol All facilities in range, per HospitalCompare Rate Reduction Protocol had no impact at UVH in Study Group

36 All Cause Readmission, All facilities, All operations Related and non-related readmissions?? Definition. CHF, Arrhythmia, Pneumonia High rate of readmission Volume overload? PE is more common Wound infection low! Compared to reference study

37 Summary Readmissions are expensive. Cost to Medicare $4.3 bill per annum. $87,500 per readmit, nearly equal to index operation CMS and all payers will expect reduction: incentivize success, penalize failure. It begins 2017 for hospitals; provider risk will follow. All facilities well with in readmission range targeted by CMS Targeted Readmission Reduction Protocol may be beneficial. Will benefit the patient, case by case. Comprehensive protocol changes. Surgeon MUST own the goal. Multi-disciplinary Team approach: providers, facilities, MAWDS

38 Current Project Summary Met Stretch Goal reduction of 20% reduction, from 10.2% in baseline to 8.1% in study phase, for All CV Cases, All Payers only Significance not met: comparison facilities had rate reductions in study phase off protocol as well. All other focused surgery / payer groups are too small at 5 months of test data.

39 Current Project Summary Study revealed significant 30 day patient status variability between sites, with high rate of data exclusion in one facility Uniformity of database completion based on STS definition Arrhythmia, Pneumonia, CHF account for high readmit rate. Manage volume overload aggressively. Management of Readmission Reduction requires Team approach, significant surgeon direction, and Flea Level EngAgement (FLEA) Future: Power the study through 2016!

40 Summary And you think the scrutiny is bad now, in 2018, this presentation will be by surgeon NAME. We will own this. Go Seahawks!

41 11.9% 1.7%

48 QUE II: Reduce the 30-day all cause readmission rate for heart surgery Results Our 5-month trial period (July 01,2015 to November 30, 2015) has a readmission rate of 8.1% which is actually 20.5% below the readmission rate of 10.2%. We exceeded the stretch goal (wahoo!). Our total number of readmissions during the 5-month trial period was 5 patients, or one patient per month. If we extrapolate that out for 12 months, we project 12 readmissions for a 12-month period, which also exceeds our stretch goal because we are going from an average of 21.5 readmissions to 12.

49 QUE II Result

Medicare P4P -- Medicare Quality Reporting, Incentive and Penalty Programs

Medicare P4P -- Medicare Quality Reporting, Incentive and Penalty Programs Presenter: Daniel J. Hettich King & Spalding; Washington, DC dhettich@kslaw.com 1 I. Introduction Evolution of Medicare as a Purchaser