Hospital Quality Program

Transcription

1 2017 Hospital Quality Program 04HQ1351 R05/16 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and incorporated as Louisiana Health Service & Indemnity Company.

2 Table of Contents (click to jump to section) Program Measures...3 Participation Condition...3 Hospital Advisory Committee (HAC)...3 Overview of Quality Blue Hospital Quality Program (HQP)... 4 The Five Aims Improve Safety Improve Outpatient Imaging Efficiency Improve Patient Experience Improve Blue Cross and Blue Shield of Louisiana Outcomes Improve Safety Culture...11 Achievement Calculation Reimbursement Methodology Additions, Deletions and Anticipated Future Measures Appendix A: Hospital Advisory Committee Members Appendix B: Hospital Contact Form...17 Appendix C: CEO Commitment to Patient Safety Attestation Appendix D: 2017 Hospital Quality Program Exhibits Appendix E: 2018 Hospital Quality Program Exhibits...20 Appendix F: Glossary

3 Program Measures The Blue Cross Hospital Quality Program (HQP) recognizes the efforts of acute care general hospitals in improving five aims: 1) safety 2) imaging efficiency 3) patient experience 4) outcomes and 5) safety culture. The program allocates achievement as shown in the table below. Aim Weight of Incentive Item 1) Improve Safety 30% 2) Improve Outpatient Imaging Efficiency 5% 3) Improve Patient Experience 20% 4) Improve Blue Cross Outcomes 25% 5) Improve Safety Culture 20% Program Participation Condition The HQP is targeted for the acute general hospital with 50 beds or more. Specialty hospitals are not included in this program. Each facility must provide a quality contact name, title, phone number and address, in addition to a staff member responsible for National Healthcare Safety Network (NHSN) data submission. This information is to be submitted on the Hospital Quality Contact Form, Appendix B. Facilities that are interested in participating in the HQP may contact their Blue Cross Network Representative or the Health and Quality contact. The program requirements/guide are available online at A meeting with the Blue Cross Quality team may be arranged to ensure that the initiatives are understood by all parties. A calculation workbook is sent at the end of the period for the facility s review. An approval or additional information to support changing the score is requested within seven days. At least one performance call will be held to ensure that the facility is aware of its progress. It is a shared responsibility of the facility and the plan to ensure that these meetings are held. System Participation Condition: For facilities that are part of a larger health system participating in the HQP, all facilities within that health system will be scored based upon the contract agreement. Hospital Advisory Committee To further select quality improvement items and set appropriate targets, the Blue Cross Hospital Advisory Committee will meet at least annually. The Hospital Advisory Committee includes members from medium and large hospitals and represents multiple disciplines. Each member serves a threeyear term, but is eligible for re-appointment for another three-year term. The principle purpose of the group is to advise Blue Cross of the strengths and issues regarding current quality and safety initiatives, appropriateness of targets that reflect performance excellence and future initiatives. Additional initiatives may be suggested as either an innovation project or direct placement of a new initiative. Conversely, the Hospital Advisory Committee may suggest retirement of initiatives. Please refer to Appendix A for a listing of Hospital Advisory Committee members. 3

4 Hospital Quality Program Overview Initiative Anticipated Data Timeframe Achievement Threshold** Improvement Threshold** Best of achievement/improvement awarded Maximum Weight of Incentive Central Line-Associated Bloodstream Infection (CLABSI)* January 1 - December = 6% Between and = 3% 10% improvement = 6% 5% improvement = 3% 6% Catheter-Associated Urinary Tract Infection (CAUTI)* January 1 - December = 6% Between and = 3% 10% improvement = 6% 5% improvement = 3% 6% Surgical Site Infection (SSI) Inpatient COLO/HYST January 1 - December = 6% Between and = 3% 10% improvement = 6% 5% improvement = 3% 6% Methicillin-resistant Staphylococcus Aureus Bloodstream Infections January 1 - December = 6% Between and = 3% 10% improvement = 6% 5% improvement = 3% 6% Clostridium Difficile (CDIFF) Hospital onset January 1 - December 31 = = 6% Between and = 3% 10% improvement = 6% 5% improvement = 3% 6% Outpatient Imaging Efficiency January 1 December 31 Pay for participation- data will be provided for BCBSLA members N/A 5% HCAHPS Composite Threshold applied to each measure included in the HCAHPS Composite October 1, Year 1 - September 30, Year 2 Equal to or greater than the 50th percentile for top-box response = 4% 25th 49th percentile for top-box response= 2% 10% improvement = 4% 5% improvement = 2% 20% Healthcare Worker Influenza Immunization (Acute care) October 1, Year 1 - March 31, Year 2 Equal to or >80% = 5% Equal to or >70% = 2.5% 10% improvement = 5% 5% improvement = 2.5% 5% Patient Safety Attestation January 1- December 31 Provide a copy of the hospital agreement with quality improvement organization and submit the CEO Attestation = 15% N/A 15% Risk Adjusted Mortality Index Potentially Preventable Readmissions / Potentially Preventable Complications Threshold applied to each measure included in Outcomes January 1, Year 1 - December 31, Year 2 Better than Expected = 2 points No Different than Expected = 1 point (Sum of points/3) x 25% (Maximum of 35% - additional 10% see below) N/A 25% Potential 10% transferred from Outcomes Only applied to HCAHPS Composite Maximum Total Incentive 100% *ICU, PICU and NICU only (where applicable) **Improvement earned in 2018 only for HAI 4

5 1 The Five Aims Improve Safety - 30% Quality Blue Hospital Quality Program Safety: Healthcare-Associated Infections Quality Measure Reduction in the standardized infection ratio (SIR) of laboratory-confirmed healthcare-associated infections. Summary The safety aim is composed of several measures in which data is submitted by the facility at the patient level into National Health and Safety Network (NHSN). These measures include: 1. Central line associated bloodstream infections 2. Catheter associated urinary tract infections 3. Surgical site infections: inpatient abdominal hysterectomy and inpatient colon procedures 4. Methicillin-resistant Staphylococcus aureus bloodstream infections 5. Clostridium difficile infections Data Collection All data collection is consistent with the most current NHSN guidelines. Please refer to the U.S. Centers for Disease Control and Prevention (CDC) website at Standardized Infection Ratio Calculation for Safety Measures 1-3: The Standardized Infection Ratio (SIR) is calculated by dividing the number of observed infections by the number of expected infections. The number of expected infections, in the context of statistical predictions, is calculated using rates from a standard population during a baseline time period as reported in NHSN based on the U.S. Centers for Medicare and Medicaid Services (CMS) Inpatient Quality Reporting Program. Standardized Infection Ratio Calculation for Safety Measures 4-5: The SIR is calculated by dividing the number of healthcare facility onset infections divided by the number of expected healthcare facility onset infections. The number of expected infections is calculated using rates from a standard population during a baseline time period as reported in NHSN. 5

6 Documentation Reporting through NHSN: This measure requires hospital participants to use the NHSN Patient Safety Component Protocol for reporting healthcare-associated infections. Hospital participants will join the Blue Cross and Blue Shield of Louisiana group in NHSN, and confer rights to Blue Cross to access hospital-specific data (without patient identifiers) for the NHSN Patient Safety Component. The following information is required to join the Blue Cross and Blue Shield of Louisiana group in NHSN: Group Name: BCBSLA Group ID#: Password: BCBSLAQUALITY For instructions on conferring NHSN rights, refer to JoinGroup-6_4.pdf or other current version. Reporting Requirements Performance Period: 12 months of data as indicated in Appendix D and E Report Due Date(s): Quarterly data reports will be obtained from NHSN as below: Reporting Period Due Date January - March August 15 April June November 15 July - September February 15 October - December May 15 Scoring Performance Period: Completion of Performance Period reporting according to measure requirements will earn the incentive as described in the Performance Evaluation below and agreed to by Blue Cross and the facility. Performance Evaluation: Each measure will be scored separately. Scoring of this measurement provided in table below. Receive 3% Incentive Receive 6% Incentive SIR Achievement Achieve SIR Achieve SIR SIR Improvement from 2017 Measurements *Improvement only scored in 2018 due to the re-baseline of the risk models for SIR Achieve 5% Improvement Achieve 10% Improvement If expected infections are <1, for the Performance period, observed infections will be used instead of the calculated SIR. Two Observed Infections Zero or One Observed Infections In the event that the Louisiana median is greater than for any single measure, the targets may be readjusted. 6

7 NHSN reports can be run by the facility to mimic the reports Blue Cross runs in order for the facility to monitor on a frequent basis. Refer to AnalysisBasics-PSC.pdf for guidance. All Reports found in CMS Reports>Acute Care Hospitals (Hospital IQR)>CDC Defined Output> SSI: SIR Complex 30 Day SSI Data for CMS IPPS CLABSI: SIR CLAB Data for CMS IPPS (ICU, NICU, PICU only) CAUTI: SIR CAUTI Data for CMS IPPS (ICU, PICU only) MRSA: SIR MRSA Blood FacwideIN LabID Data for CMS IPPS CDIFF: SIR CDI FacwideIN LabID Data for CMS IPPS (Hospital Onset) References: Improve Outpatient Imaging Efficiency - 5% Quality Blue Hospital Quality Program Outpatient Imaging Efficiency: Outpatient Imaging Efficiency Quality Measure Facility will use Outpatient Imaging Efficiency rates for improvement efforts to reduce unnecessary imaging. These measures are pay for participation, and defined as Outpatient Imaging Efficiency (OIE) measure sets. Summary The Hospital Outpatient Quality Reporting (OQR) Program is a U.S. Centers for Medicare and Medicaid Services (CMS) initiative to pay for quality data for outpatient hospital services. The Hospital OQR program was mandated by the Tax Relief and Health Care Act of 2006, which requires hospitals to submit data on measures of the quality of care furnished by hospitals in outpatient settings. This program also allows for publication of these measures and financial incentives. Data Collection The data elements in this measure include numerator and denominator values defined in the CMS Specifications Manual for National Hospital Outpatient Quality Measures. No data submission is required by the facility. The CMS specifications will be applied to Blue Cross claims. Blue Cross calculates this measurement at least annually and it is provided to the facility. This measure is pay for participation. This data may be shared in future transparency efforts. Reporting Frequency No data submission is required by the facility. Blue Cross calculates this measurement at least annually. 7

8 3 Improve Patient Experience - 20% Quality Blue Hospital Quality Program Patient Experience: Hospital Consumer Assessment of Healthcare Providers and Systems Composite Quality Measure Increase in the top-box responses for selected Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questions. Data Collection All data collection is consistent with the most current HCAHPS guidelines. Please refer to the HCAHPS website at Blue Cross will obtain data from Hospital Compare. Documentation The data elements in this measure include patient responses to selected HCAHPS measures. The top-box score indicates how often patients selected the most positive response category when asked about their hospital experiences. The higher a hospital s top-box score, the higher it ranks among participating hospitals. The five areas of focus for this initiative are: Communication with Nurses Communication with Doctors Responsiveness of Hospital Staff Communication about Medicines Discharge Information Report Frequency Data will be obtained from Hospital Compare for the Performance Evaluation for each facility in July each year for the data results from October through September as indicated in Appendix D and E. If data is not refreshed in July, the most recently available data will be utilized for scoring purposes. Data Collection Performance Period: Participation in the HCAHPS Measures Composite initiative will earn the achievement as described in the Performance Evaluation and agreed to by Blue Cross and facility. 8

9 Performance Evaluation Each measure will be scored separately. Scoring of this measurement provided below: The national HCAHPS percentiles for the top-box results will be used as indicated below for each measure: Scores < the bottom 25th percentile 0% Scores between the 25th and 49th percentile 2% Scores 50th percentile 4% OR The prior year s scores are compared to the Performance Period scores. Improvement points are earned as below for each measure, if the Performance Period rates meet or exceed improvement as calculated below: (1-Prior Year s Rate) x Prior Year s Rate 4% earned (1-Prior Year s Rate) x Prior Year s Rate 2% earned The sum of all measures or their improvement as described above is equal to the percent earned for this initiative. Reference: 4 Improve Blue Cross and Blue Shield of Louisiana Outcomes - 25% Quality Blue Hospital Quality Program Blue Cross and Blue Shield of Louisiana Outcomes: Risk Adjusted Mortality, Potentially Preventable Complications and Potentially Preventable Readmissions Quality Measure This section is divided into three major initiatives: 1. Potentially Preventable Complications (PPC); 2. Potentially Preventable Readmissions (PPR); 3. Risk Adjusted Mortality. The data used for these measures is collected and calculated by Blue Cross. There is no data submission requirement from the facility. 9

10 Summary Potentially Preventable Complications (PPC) are harmful events or negative outcomes that develop after hospitalization. They may occur from processes of care and treatment rather than natural progression of the disease. PPCs are identified first by conditions not present on admission and then by determining whether those conditions were potentially preventable given the reason for admit, procedures performed and underlying medical conditions. The two most recent calendar years risk adjusted observed versus expected PPC rates are used to compare the hospital s performance. This metric is aimed at reducing the incidence of complications. Potentially Preventable Readmission (PPR) is a readmission or return hospitalization within 15 days from the initial admission, which is clinically related. PPRs are calculated from the number of chains, or sequences of one or more readmissions. A PPR must meet the following criteria: the readmission was clinically associated with the prior discharge and the readmission could have been prevented through any of the following: adequate care in the initial hospitalization, adequate discharge planning or discharge follow up, and coordination between healthcare settings. The two most recent calendar years' risk adjusted observed versus expected PPR rates are used to compare the hospital s performance. This metric is aimed at reducing the incidence of readmissions. Risk Adjusted Mortality: Risk Adjusted Mortality takes into account the severity of each patient s illness as well as the likelihood of dying based on several things including the principle diagnosis, principle procedure age, sex, discharge status, secondary diagnoses, etc. based on the All Patient Refined (APR) Diagnosis Related Groups (DRG) in which the patient is included. The two most recent calendar years' risk-adjusted observed versus expected inpatient mortality are used to compare the hospital s performance. This initiative is aimed at rewarding hospitals with low mortality rates as compared to the expected mortality rate. Data Collection No data submission is required by the facility. Blue Cross calculates this measurement annually by pulling information from an internal database, 3M. Report Frequency: Data will be obtained from 3M for the Performance Evaluation for each facility in June each year for the data results, as indicated in Appendix D and E. Scoring Performance Evaluation: Risk Adjusted Mortality, Potentially Preventable Complications and Potentially Preventable Readmissions: The risk adjusted rates for the above measures will be obtained from 3M for the previous two calendar years. The data will be statistically tested using a 95% confidence interval. Based upon these results, points will be earned as below: Actual rate is Better than the expected rate 2 points Actual rate is No Different than the expected rate 1 point Actual rate is Worse than the expected rate 0 points 10

11 The sum of points for each of the three measures is divided by three. This result is multiplied by the aim weight: 25%. The facility can earn a max of 35%, 25% applied to the Outcomes Aim, 10% applied only to the HCAHPS Composite Score in the Patient Experience Aim. Hospital Scorecards will be distributed no less than once per year in order for participating facilities to observe their performance. Example: Hospital A Risk Adjusted Mortality: No Different than expected = 1 point Potentially Preventable Complications: Better than expected = 2 points Potentially Preventable Readmissions: Worse than expected = 0 points Sum of all points: 3/3 = 1 Multiply by 25%: 1 x 0.25 = 25% 25% is applied to the Outcomes Aim. No extra points are awarded. References: Providers with a 3M account may also use the following reference: 5 Improve Safety Culture- 20% Quality Blue Hospital Quality Program Safety Culture: Healthcare Worker Influenza Immunization Quality Measure Increase in the percent of healthcare workers immunized against the influenza virus each season. Summary Influenza (the flu) can be a serious disease that can lead to hospitalization and sometimes even death. Anyone can get very sick from the flu, including people who are otherwise healthy. Overall, the number of healthcare workers who reported having had an influenza vaccination increased in the flu season as compared to the season. The coverage rate for healthcare workers was estimated at 72% for the season as compared to 66.9% in the season. Coverage was highest among healthcare workers working in occupational settings with vaccination requirements, 96.5% and physicians 92.3%. Healthy People 2020 includes an initiative to increase the percentage of healthcare worker influenza vaccination rates to 90%. In addition, the inclusion of the influenza vaccination coverage among healthcare personnel in both the Hospital Inpatient Quality Reporting (IQR) and Outpatient Quality Reporting (OQR) programs promotes further alignment with national priorities. Data Collection All data collection is consistent with the most current NHSN guidelines. Please refer to the CDC website at 11

12 Documentation Reporting through NHSN: This measure requires hospital participants to use the NHSN Healthcare Personnel Component. Only data for the acute care facility will be used in scoring. Employees, Licensed Independent Practitioners and Adult Student/Volunteers will be included in the numerator and denominator. In order to submit Healthcare Worker data, there are additional steps required for participation in the NHSN. Please see the NHSN website, gov/nhsn/cms-welcome. html, for complete details regarding NHSN training, enrollment and Agreement to Participate and Consent form. Direct questions regarding NHSN training, enrollment and submission can be sent to Hospital participants will join the Blue Cross Blue Shield of Louisiana group in NHSN, and confer rights to Blue Cross and Blue Shield of Louisiana to access hospital-specific data (without personnel identifiers) for the NHSN Healthcare Personnel Component. The following information is required to join the Blue Cross and Blue Shield of Louisiana group in NHSN: Group Name: BCBSLA Group ID#: Password: BCBSLAQUALITY Reporting Requirements Report Period(s) Performance Period: Six months of data, as indicated in Appendix D and E, will be submitted to Blue Cross by June of each year. Report Due Date: All Healthcare Worker Influenza Immunization data is due June 15 of each year. If CMS extends the due date, the most recently available data will be utilized for scoring purposes. Scoring Performance Period: Completion of the Performance Period reporting according to measure requirements will earn the achievement as described in the Performance Evaluation and agreed to by Blue Cross and the facility. Performance Evaluation: Scoring of this measurement provided below: Achieve 80% OR improve by 10% from prior year s rate = 5% earned Achieve 70% OR improve by 5% from prior year s rate = 2.5% earned Improvement Methodology: The prior year s scores are compared to the Performance Period scores. Improvement points are awarded as below for each measure, if the Performance Period rates meet or exceed improvement as calculated below: (1-Prior Year s Rate) x Prior Year s Rate = 5% earned (1-Prior Year s Rate) x Prior Year s Rate = 2.5% earned References:

13 Quality Blue Hospital Quality Program Safety Culture: Commitment to Patient Safety Standards Quality Measure The CEO will attest to and provide appropriate documentation of commitment to patient safety through either the use of a patient safety evaluation system and implementation of a person-centered hospital discharge process or implementation of initiatives to improve patient outcomes via participation in an improvement organization. Summary Develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. Focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. Reporting Requirements Submit attestation, Appendix C and required documentation listed on Appendix C on or before January 1 of each year to earn the achievement described below. Scoring Performance Period: Completion of the Performance Period reporting according to measure requirements will earn the achievement as described in the Performance Evaluation and agreed to by Blue Cross and the facility. Performance Evaluation: Scoring of this measurement provided below: Submit CEO attestation AND required documentation = 15% earned Safety Culture Initiatives Measure Weight Domain Percent Healthcare Worker Influenza Immunization 5% Commitment to Patient Safety Attestation and Participation 15% 20% 13

14 Achievement Calculation For final scoring, the Safety, Patient Experience, Imaging Efficiency and Safety Culture domains performance values are equal to the percentage earned. The Outcomes performance values are summed, divided by three and then multiplied by the maximum weight value to obtain the final item weight achievement. The cumulative sum of all measures final item weight is multiplied by the negotiated rate for the final achievement earned. An example for evaluating total performance is given below in Table 1. Table 1: Example of Performance Scoring for a Hospital Domain Initiative Maximum Weight (Example) Performance Achieved (Example) Final Item Weight (Example) Safety Central Line-Associated Bloodstream Infection (CLABSI) 6% 3% 3% Safety Catheter-Associated Urinary Tract Infection (CAUTI) 6% 0% 0% Safety Surgical Site Infection (SSI) 6% 6% 6% Safety Methicillin-resistant Staphylococcus Aureus Bloodstream Infections (MRSA) 6% 6% 6% Safety Clostridium Difficile (CDIFF) 6% 6% 6% Imaging Efficiency Outpatient Imaging Efficiency Data Sharing 5% 5% 5% Patient Experience HCAHPS Composite 20% 20% 20% Safety Culture Healthcare Worker Influenza Immunization 5% 5% 5% Safety Culture Commitment to Patient Safety Standards Attestation 15% 15% 15% BCBSLA Outcomes Risk Adjusted Mortality Index Potentially Preventable Readmissions Potentially Preventable Complications 25% 66.7% 16.7% Total Possible Incentive 100% Total Earned Incentive 82.7% 14

15 Reimbursement Methodology The cumulative sum of the quality achievement will result in a rate reduction and recoupment if less than 100% of quality is achieved. All increases are tied to quality results and paid as though 100% of the quality will be earned. If the facility earns less than 100% of quality, Blue Cross will adjust the next scheduled rate increase according to the quality achievement met by the facility in the most recent quality measurement year. Please see program guide for measure specifications. Quality achievement is performance based, with the exception of Imaging Efficiency. Example: 2017 Health and Quality Program (HQP) Reimbursement Timeframe: Performance Period (Healthcare-Associated Data Collection Year Blue Cross collects data Year Contract Signed Contract Fiscal Year (Adjustments made to the Infections Data Year) entered from NHSN, Hospital Compare and our Internal Vendor) prepaid percentage are based off of the quality achievement score using the performance period data) / / Additions, Deletions and Anticipated Future Measures Additions This version of the HQP has been modified to include the measures below: Outpatient Imaging Efficiency Safety Culture Attestation from CEO Deletions The following measures were deleted from the previous program: Process Measures Composite Potential Future Measures Sepsis measure #

16 APPENDIX A Hospital Advisory Committee Name Title Represents Roland Waguespack, MD Chief Medical Officer Gulf South Quality Network Sandra Kemmerly, MD Medical Director of Quality and Patient Safety Ochsner Health System Kenneth Alexander Louisiana Hospital Association Quality Louisiana Hospital Association Leslie Kelt, MT Infection Prevention St. Tammany Parish Hospital Pamela Booker Chief Nursing Officer Lifepoint Claire Rebouche Patient Safety Officer Willis-Knighton Health System Steve Horner Vice President of Clinical Analytics Hospital Corporation of America Christi Pierce VP of Quality and Safety Franciscan Missionaries of Our Lady Health System Wanda Hughes Director of Quality Baton Rouge General Erica Washington Epidemiologist Office of Public Health Debra Rushing Executive Director eqhealth Systems Joan Stokes Assistant Vice President Quality Lafayette General Health System 16

17 APPENDIX B Blue Cross and Blue Shield of Louisiana Hospital Quality Program Contact Form Signature of Facility Representative: Name: Date: Signature: Facility Name: Point of Contact for Each Facility/Quality Initiative and Backup Contact: Contact #1 Name: Title: Address: Phone: Contact #2 Name: Title: Address: Phone: Contact #3 Name: Title: Address: Phone: Contact #4 Name: Title: Address: Phone: 17

18 APPENDIX C: Hospital Quality Program Commitment to Patient Safety Attestation for Plan Years Beginning On or After January 1, Attest that the hospital uses a patient safety evaluation system as defined in 42 CFR 3.20 (meaning the collection, management, or analysis of information for reporting to or by a Patient Safety Organization (PSO)); and implements a mechanism for comprehensive person-centered hospital discharge to improve care coordination and health care quality for each patient, which we evidence by providing our CMS Certification Number (CCN): CCN: OR 2. Attest that the hospital implements an evidence-based initiative to improve health care quality through the collection, management and analysis of patient safety events that reduces all cause preventable harm, prevents hospital readmission or improves care coordination, via at least one of the following: Patient Safety Organization as listed by the Secretary (please provide current participation agreement) Health Engagement Network (please provide current participation agreement) Quality Improvement Organization (please provide current participation agreement) Evidence based patient safety initiative consistent with the National Quality Strategy and existing public and private patient safety programs (please provide current participation agreement) I certify that this attestation is true and accurate to the best of my knowledge and belief. CEO Signature: Date: Printed name and title: Facility Name: Signatory Business Address: Signatory Business Phone number: Signatory address: 18

19 APPENDIX D 2017 HQP Exhibit The cumulative sum of the quality achievement will result in a rate reduction and recoupment if less than 100% of quality is achieved. All increases are tied to quality results and paid as though 100% of the quality will be earned. If the facility earns less than 100% of quality, Blue Cross will adjust the next scheduled rate increase according to the quality achievement met by the facility in the most recent quality measurement year. Please see program guide for measure specifications. Measure Timeframe Quality Threshold Quality Weight CLABSI 1/1/ /31/2016 CAUTI 1/1/ /31/2016 SSI 1/1/ /31/2016 MRSA 1/1/ /31/2016 CDIFF 1/1/ /31/2016 HCW Flu* 10/1/2016-3/31/2017 SIR % SIR % SIR % SIR % SIR % SIR % SIR % SIR % SIR % SIR % 80% or greater 5% 70%-79% 2.5% Outpatient Efficiency HCAHPS* (applicable to each of the 5 measures) Safety Attestation Outcomes applicable to each of the 3 measures NA 10/1/2015-9/30/2016 Submit at signing 1/1/ /31/2016 Pay for participation 5% 50th percentile for top-box results 4% Between 26th and 49th percentile for 2% top-box results Submitted with required documentation 15% No Different than Expected 1 pt Sum of points Better than Expected 2 pts x 25% Worse than Expected 0 pts Bonus NA Applies only to HCAHPS 10% maximum Total Quality Achievement Earned 100% max potential Quality Achievement x Increase = Increase Earned Quality Achievement Not Earned x Increase = Reduction for future increases *Measures applicable to improvement thresholds as below: 10% improvement from previous timeframe = max threshold weight 5% improvement from previous timeframe = mid threshold weight 19

20 APPENDIX E 2018 HQP Exhibit The cumulative sum of the quality achievement will result in a rate reduction and recoupment if less than 100% of quality is achieved. All increases are tied to quality results and paid as though 100% of the quality will be earned. If the facility earns less than 100% of quality, Blue Cross will adjust the next scheduled rate increase according to the quality achievement met by the facility in the most recent quality measurement year. Please see program guide for measure specifications. Measure Timeframe Quality Threshold Quality Weight CLABSI* 1/1/ /31/2017 CAUTI* 1/1/ /31/2017 SSI* 1/1/ /31/2017 MRSA* 1/1/ /31/2017 CDIFF* 1/1/ /31/2017 HCW Flu* 10/1/2017-3/31/2018 SIR % SIR % SIR % SIR % SIR % SIR % SIR % SIR % SIR % SIR % 80% or greater 5% 2.5% Outpatient Efficiency HCAHPS* (applicable to each of the 5 measures) Safety Attestation Outcomes applicable to each of the 3 measures NA 10/1/2016 9/30/2018 Submit at signing 1/1/ /31/2017 Pay for participation 5% 50th percentile for top-box results 4% Between 26th and 49th percentile for 2% top-box results Submitted with required documentation 15% No Different than Expected 1 pt Sum of points Better than Expected 2 pts x 25% Worse than Expected 0 pts Bonus NA Applies only to HCAHPS 10% maximum Total Quality Achievement Earned 100% max potential Quality Achievement x Increase = Increase Earned Quality Achievement Not Earned x Increase = Reduction for future increases *Measures applicable to improvement thresholds as below: 10% improvement from previous timeframe = max threshold weight 5% improvement from previous timeframe = mid threshold weight 20

21 APPENDIX F GLOSSARY OF ACRONYMS BCBSLA Blue Cross and Blue Shield of Louisiana CAUTI Catheter Associated Urinary Tract Infection CLABSI Central Line Associated Bloodstream Infection CMS Centers for Medicare and Medicaid Services HAI Healthcare-Associated Infections HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems HPAC Hospital Advisory Committee HQP Hospital Quality Program ICD International Classification of Diseases NHSN National Healthcare Safety Network OQR Outpatient Quality Reporting Program PPC Potentially Preventable Complication PPR Potentially Preventable Readmission RAMI Risk Adjusted Mortality Index SSI Surgical Site Infection TJC The Joint Commission If you have questions about Blue Cross and Blue Shield of Louisiana s Hospital Quality Program, please us at QualityBlue@bcbsla.com 21