Quality Provisions in the EPM Final Rule. Matt Baker Scott Wetzel

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1 Quality Provisions in the EPM Final Rule Matt Baker Scott Wetzel

2 Overview Quality Scoring Overview Quality Metrics in AMI and CABG EPMs Quality Metrics in SHFFT EPMs COTH Performance in these programs 2

3 Quality Scoring Overview 3

4 EPM Quality Overview Three separate EPM quality models o AMI, CABG, and Surgical hip/femur fracture treatment (SHFFT) Quality performance National Percentile o o o 30 th percentile minimum performance to receive points for each quality measure Points are awarded based on percentile Length of reporting period: AMI and CABG mortality, AMI excess days, and hip/knee complications 3 years HCAHPS 1 year Voluntary measures varies by performance year Performance + Improvement + Voluntary Points = Quality Composite Score 4

5 Improvement Scoring Measure by measure basis Points awarded up to 10% of max performance points AMI/CABG Defined as improvement over participant s own point estimate from previous year, and Improvement must be enough to place provider in top 10% of all hospitals nationally SHFFT/CJR Defined as year over year improvement of two or more deciles 5

6 Quality Metrics in AMI and CABG EPMs 6

7 AMI Quality Measure Composite Scoring Measure Weight Max Available Points Hospital AMI 30-day Mortality 50% 10 Excess Days in Acute Care After Hospitalization (EDAC) Voluntary Hybrid AMI Mortality Measure 20% 4 HCAHPS 20% 4 Total Points 100% 20 10% 2 if submitted successfully 7

8 CABG Quality Measure Composite Scoring Measure Weight Max Available Points Hospital CABG 30-day Mortality 70% 14 HCAHPS 20% 4 NEW: Voluntary STS CABG Composite Total Points 100% 20 10% 2 if submitted successfully 8

9 AMI and CABG Mortality Measures Mortality measures are calculated separately for AMI and CABG Calculates all deaths regardless of cause within a 30-day period from the date of the index admissions Both measures are NQF endorsed Measure reported on hospital compare 9

10 Excess Days in Acute Care After Hospitalization for AMI (EDAC) Actual acute days post discharge compared to expected based on degree of illness Response to increase in ED utilization and Observation Stays Not NQF Endorsed* Not yet reported on Hospital Compare; measure data release expected July 2017 *Measure has been submitted for NQF review 10

11 HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey Includes 10 questions about the hospital experience* Patients surveyed between 48 hours and 6 weeks after discharge Eligible patients include: Anyone over 18 (not just Medicare beneficiaries) Those admitted in the medical, surgical and maternity care service lines. NQF endorsed *Pain management measure not included 11

12 New Voluntary AMI Measure Hybrid measure combines standard claims based 30- day mortality with clinical data from EHR Submit five core data elements and six linking variables Age, heart rate, systolic BP, troponin, creatinine CCN, HIC#, DOB, sex, admission and discharge dates Heart rate and BP within 2 hours of admission; troponin within 24 hours Additional two points for successful submission NQF endorsed 12

13 New Voluntary STS CABG Measure STS composite was included in the EPM final rule as a voluntary measure under the CABG model The composite is based on 11 process and outcome measures. Hospitals must submit 7 of these 11 measures to receive credit: o Use of Internal Mammary Artery in Patients with Isolated CABG Surgery (NQF #0134) o Preoperative Beta Blocker in Patients with Isolated CABG Surgery (NQF #0236) o Prolonged Intubation (defined as >24hrs post surgery) (NQF #0129) o Deep Sternal Wound Infection Rate (NQF #0130) o Stroke (NQF #0131) o Postoperative Renal Failure (NQF #0114) o Surgical Re-exploration (NQF #0115) Hospitals that do not participate in the STS registry can still submit this data electronically via spreadsheet to CMS and receive credit 13

14 AMI Quality Decile-Based Points Scale Percentile AMI Mortality AMI EDAC HCAHPS 90-99th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile Not Enough Data to Report Reporting the voluntary AMI Hybrid Measure adds an additional 2 points. For each measure, 10% of hospitals will receive bonus points for improvement: 1 bonus point in AMI Mortality 0.4 bonus points in AMI EDAC 0.4 bonus points in HCAHPS The bonus points will be based on being in the best 10% of hospitals in the improvement, defined as one s own measure s point estimate relative to the hospital s score in the previous year. 14

15 AMI Quality Category and Discount Rate Composite Score Category Quality Category Eligible for Reconciliation Payment Reconciliation Payment Discount Percentage Repayment Amount Discount Percentage Year 1 (all); Year 2 (early Year 2 (w/o downside risk); early downside Year 3 & 4 (all) risk) Year 5 > 15.0 Excellent Yes 1.5% N/A 0.5% 1.5% > 6.3 and <15.0 Good Yes 2.0% N/A 1.0% 2.0% >3.8 and <6.3 Acceptable Yes 3.0% N/A 2.0% 3.0% <3.8 Below Acceptable No 3.0% N/A 2.0% 3.0% 15

16 CABG Quality Decile-Based Points Scale Percentile CABG Mortality HCAHPS 90-99th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile 0 0 Not Enough Data to Report For each measure, 10% of hospitals will receive bonus points for improvement: 1.4 bonus points in CABG Mortality 0.4 bonus points in HCAHPS The bonus points will be based on being in the best 10% of hospitals in the improvement, defined as one s own measure s point estimate relative to the hospital s score in the previous year. 16

17 CABG Quality Category and Discount Rate Composite Score Category Quality Category Eligible for Reconciliation Payment Reconciliation Payment Discount Percentage Repayment Amount Discount Percentage Year 1 Years 2 & 3 Years 4 & 5 > 16.2 Excellent Yes 1.5% N/A 0.5% 1.5% >3.4 and <16.2 Good Yes 2.0% N/A 1.0% 2.0% >2.2 and <3.4 Acceptable Yes 3.0% N/A 2.0% 3.0% <=2.2 Below Acceptable No 3.0% N/A 2.0% 3.0% 17

18 Quality Metrics in CJR and SHFFT 18

19 SHFFT* Quality Measure Composite Scoring Measure Weight Max Available Points Hip/Knee Complications 50% 10 HCAHPS 40% 8 THA/TKA Voluntary PRO *Same scoring as CJR 10% 2 if submitted successfully 19

20 Hip/Knee Complications Hospital-level Risk Standardized Complication Rate (RSCR) following elective primary THA and/or TKA Denominator: Patients with a qualifying* elective primary THA/TKA procedure, enrolled in Medicare fee-for-service, aged 65 or over Excludes: patients with more than two THA/TKA procedure codes during the index admission; discharged against medical advice; transferred from another acute care facility for the THA/TKA Numerator: patients with any of the following acute myocardial infarction pneumonia, or sepsis/septicemia within 7 days of admission surgical site bleeding, pulmonary embolism or death within 30 days of admission or mechanical complications, periprosthetic joint infection, or wound infection within 90 days of admission *For details on which procedures quality, see CMS s Measure Specification: Instruments/HospitalQualityInits/Downloads/Hip-and-Knee-Arthroplasty- Complications-Updates.zip 20

21 HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey Includes 10 questions about the hospital experience* Patients surveyed between 48 hours and 6 weeks after discharge Eligible patients include: Anyone over 18 (not just Medicare beneficiaries) Those admitted in the medical, surgical and maternity care service lines. NQF endorsed *Pain management measure not included 21

22 Voluntary Patient Reported Outcome (PRO) Measure THA/TKA PRO measure is still being developed CMS notes that PROs will be assessed separately for THA and TKA procedures; results, however, may be combined into a single measure Voluntary data will not be publicly reported Reporting/Submission of Data Year 1: Pre-operative data elements on THA/TKA cases performed during 10 month period (September June 2017). Must submit data for 60% of patients or 75 procedures Year 2: Post-operative data for cases performed during 10 month period cited above; pre-operative data for 12 month period (July 2017 June 2018). Must submit data for 70% of patients or 100 procedures Years 3-5: Pre-operative and post-operative data for full 12 month periods. Must submit data for 80% of patients or 200 procedures SHFFT model participants that are also participating in the CJR model do not need to submit data twice 22

23 SHFFT Quality Points Scale and Discount Rate Percentile THA/TKA Complications HCAHPS 90-99th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile 0 0 Not Enough Data to Report

24 SHFFT Quality Points Scale and Discount Rate, Continued Composite Score Category Quality Category Eligible for Reconciliation Payment Reconciliation Payment Discount Percentage Repayment Amount Discount Percentage Year 1 (all); Year 2 (w/o early downside risk) Year 2 (early downside risk); Year 3 & 4 (all) Year 5 > 15.0 Excellent Yes 1.5% N/A 0.5% 1.5% > 6.9 and <15.0 Good Yes 2.0% N/A 1.0% 2.0% >5.0 and <6.9 Acceptable Yes 3.0% N/A 2.0% 3.0% <5.0 Below Acceptable No 3.0% N/A 2.0% 3.0% 24

25 Example: SHFFT Hospital Scoring Step 1 Convert Your Rate to Percentile Ranking THA/TKA Complications Rate HCAHPS Linear Mean Score Your Rate National Percentile 80-89th Percentile 60-69th Percentile Step 2 Convert Your Percentile Ranking to Points Percentile THA/TKA Complications Points HCAHPS Points 90-99th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile 0 0 Not Enough Data to Report

26 Example: SHFFT Hospital Scoring, Cont. Step 3 Sum Total Points Total Points = THA/TKA Complications Points + HCAHPS Points + THA/TKA PRO Points Total Points = = Step 4 Assign to a Category Based on Total Points Composite Score Category Quality Category Eligible for Reconciliation Payment Reconciliation Payment Discount Percentage Repayment Amount Discount Percentage Year 1 (all); Year 2 (w/o early downside risk) Year 2 (early downside risk); Year 3 & 4 (all) Year 5 > 15.0 Excellent Yes 1.5% N/A 0.5% 1.5% > 6.9 and <15.0 Good Yes 2.0% N/A 1.0% 2.0% >5.0 and <6.9 Acceptable Yes 3.0% N/A 2.0% 3.0% <5.0 Below Acceptable No 3.0% N/A 2.0% 3.0% 26

27 Performance Periods: AMI, CABG, SHFFT 27

28 Performance Periods: AMI Required: Voluntary: 28 Performance period charts courtesy of HPA

29 Performance Periods: CABG Required: Voluntary: 29 Performance period charts courtesy of HPA

30 Performance Periods: SHFFT Required: Voluntary: 30 Performance period charts courtesy of HPA

31 COTH Performance on AMI, CABG, and SHFFT Quality Metrics 31

32 Projected Measure Cutoffs to Calculate Percentile Ranking Percentile Cutoff AMI Mortality Point Estimate CABG Mortality Point Estimate THA/TKA Complications Estimate 90 th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile To determine your estimated percentile, compare your point estimate for these three measures to the point estimates in the chart. Your institution s point estimate for these measures can be found in the AAMC Hospital Compare Benchmark Report (distributed in April, July, October, and December). Lower point estimates are better. 32 Source: AAMC analysis of the December 2016 Release of Hospital Compare. Reporting periods: July 2012 June 2015 for mortality measures and April 2012 March 2015 for hip/knee complications rates. Point estimates are based on rankings of all hospitals reporting on Hospital Compare. The reporting periods in this analysis is a projection, using lagged performance periods relative to the performance periods that CMS will use in Year 1 of the program to calculate your quality points.

33 COTH Performance on AMI Mortality Decile Distribution 30% 25% 20% 15% 10% 5% 0% NA Decile COTH All Hospitals 33 Source: December 2016 Release of Hospital Compare. Reporting period: July 2012 June Based on hospitals that are located in a MSA eligible for AMI/CABG bundled payments. Includes hospitals live with AMI/CABG episodes in BPCI.

34 COTH Performance on AMI Readmissions Decile Distribution 30% 25% 20% 15% 10% 5% 0% NA Decile COTH All Hospitals 34 Source: December 2016 Release of Hospital Compare. Reporting period: July 2012 June Based on hospitals that are located in a MSA eligible for AMI/CABG bundled payments. Includes hospitals live with AMI/CABG episodes in BPCI.

35 COTH Performance on CABG Mortality Decile Distribution 30% 25% 20% 15% 10% 5% 0% NA Decile COTH All Hospitals 35 Source: December 2016 Release of Hospital Compare. Reporting period: July 2012 June Based on hospitals that are located in a MSA eligible for AMI/CABG bundled payments. Includes hospitals live with AMI/CABG episodes in BPCI.

36 COTH Performance on HCAHPS Decile Distribution 30% 25% 20% 15% 10% 5% 0% NA Decile COTH All Hospitals 36 Source: December 2016 Release of Hospital Compare. Reporting period: April 2015 March Based on hospitals that are located in a MSA eligible for AMI/CABG bundled payments. Includes hospitals live with AMI/CABG episodes in BPCI.

37 COTH Overall Performance on AMI and CABG Quality Measures AMI Quality Rating Percent of COTH Members Percent of All Hospitals CABG Quality Rating Percent of COTH Members Percent of All Hospitals Quality Rating n=66 N=718 n=66 N=718 Below Acceptable 20% 11% 6% 4% Acceptable 11% 8% 6% 5% Good 59% 70% 73% 86% Excellent 11% 11% 15% 4% 37

38 COTH Performance on THA/TKA Complications Decile Distribution 30% 25% 20% 15% 10% 5% 0% NA Decile COTH All Hospitals 38 Source: December 2016 Release of Hospital Compare. Reporting period: April 2012 March Based on hospitals that are in a MSA eligible for SHFFT. Includes hospitals live with major joint replacement episodes in BPCI.

39 COTH Performance on HCAHPS Decile Distribution 30% 25% 20% 15% 10% 5% 0% NA Decile COTH All Hospitals 39 Source: December 2016 Release of Hospital Compare. Reporting period: April 2015 March Based on hospitals that are in a MSA eligible for SHFFT. Includes hospitals live with major joint replacement episodes in BPCI.

40 COTH Overall Performance on SHFFT Quality Measures Projected Percent of COTH Members Percent of All Hospitals Quality Rating n=90 n=844 Below Acceptable 19% 10% Acceptable 11% 14% Good 66% 66% Excellent 4% 10% Although COTH overall distribution in overall quality ratings are lower than other hospitals, only 15% of hospitals are projected to receive 0 points overall in CJR 40

41 Notes For more information on measure methodology, see: CMMI's Measure Descriptions QualityNet website HCAHPS description 41

42 Contact Matthew Baker, Research Analyst Scott Wetzel, Senior Specialist, Quality Reporting Jessica Walradt, Lead Payment Reform Specialist 42

43 43

Quality Provisions in the EPM Proposed Rule. Matt Baker Scott Wetzel

Quality Provisions in the EPM Proposed Rule Matt Baker Scott Wetzel Overview Quality Scoring Overview Quality Metrics in AMI and CABG EPMs Quality Metrics in SHFFT EPMs COTH Performance in these programs