The Wave of the Future: Value-Based Purchasing & the Impact of Quality Reporting Within the Revenue Cycle

Transcription

1 The Wave of the Future: Value-Based Purchasing & the Impact of Quality Reporting Within the Revenue Cycle Kim Charland, BA, RHIT, CCS Senior Vice President Clinical Innovation and Publisher VBPmonitor Panacea Healthcare Solutions, Inc.

2 Disclaimer Panacea Healthcare Solutions, Inc. has prepared this seminar using official Centers for Medicare and Medicaid Services (CMS) documents and other pertinent regulatory and industry resources. It is designed to provide accurate and authoritative information on the subject matter. Every reasonable effort has been made to ensure its accuracy. Nevertheless, the ultimate responsibility for correct use of the coding system and the publication lies with the user. Panacea Healthcare Solutions, Inc., its employees, agents and staff make no representation, warranty or guarantee that this information is error-free or that the use of this material will prevent differences of opinion or disputes with payers. The company will bear no responsibility or liability for the results or consequences of the use of this material. The publication is provided as is without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose. The information presented is based on the experience and interpretation of the publisher. Though all of the information has been carefully researched and checked for accuracy and completeness, the publisher does not accept any responsibility or liability with regard to errors, omissions, misuse or misinterpretation. Current Procedural Terminology (CPT ) is copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. Copyright 2016 by Panacea Healthcare Solutions, Inc. All rights reserved. No part of this presentation may be reproduced in any form whatsoever without written permission from the publisher Published by Panacea Healthcare Solutions, Inc., 287 East Sixth Street, Suite 400, St. Paul, MN,

3 Today s Agenda Healthcare Payment Reform Environment CMS Inpatient Quality and Payment Programs Revenue Cycle and Value-Based Care Moving Forward 4

4 HEALTHCARE PAYMENT REFORM ENVIRONMENT

5 HHS Delivery System Reform Goals The Department of Health and Human Services (HHS) announced in January 2015 a new set of goals and a timeline for tying Medicare payments to quality or value through alternative payment models. Tie 30% (up from 20%) of traditional Medicare payments by the end of 2016 thru ACO s (Accountable Care Organizations) and bundled payments Tie 50% by the end of 2018 HHS also set a goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018 through programs such as Hospital Value-Based Purchasing and Hospital Readmission Reduction Programs. 6

6 HHS Delivery System Reform Goals Press, Matthew. CMS Innovation and Health Care Delivery System Reform. April Available from 7

7 Healthcare Transformation Task Force 4/12/16 Update Consortium of patients, payers, providers, and purchasers Task Force survey as of 12/31/15 41% of its provider and payer members business is value-based payment arrangements, up from 30% in 2014 Goal of 75% arrangements by

8 Healthcare Payment Transformation Source: Verisk Health (Leavitt Partners) 9

9 2016 OIG Work Plan Hospitals Quality of Care and Safety section: CMS Validation of Hospital-submitted Quality Reporting Data: We (OIG) will determine the extent to which CMS (the Centers for Medicare & Medicaid Services) validated hospital inpatient quality reporting data. Section 1886(b)(3)(B)(viii)(XI) of the Social Security Act gives CMS the authority to conduct validation of its quality reporting program. CMS uses these quality data for the hospital value-based purchasing program and the hospital acquired condition reduction program. Therefore their accuracy and completeness are important. This study will also describe the actions that CMS has taken as a result of its validation. (OEI ; expected issue date: FY 2016, ACA). 10

10 2016 OIG Work Plan Delivery System Reform section: Accountable Care Organizations: Strategies and Promising Practices: We will review ACOs (accountable care organizations) that participate in the Medicare Shared Savings Program (established by section 3022 of the Affordable Care Act). We will describe their performance on the quality measures and cost savings over the first three years of the program and describe the characteristics of those ACOs that performed well on measures and achieved savings. In addition, we will identify ACOs strategies for and challenges to achieving quality and cost savings. The Medicare Shared Savings Program is a key component of the Medicare delivery system reform initiatives and is a vehicle through which providers who work in ACOs can share in Medicare cost savings while providing high-quality care to patients. (OEI; ; expected issue date: FY 2017; ACA). 11

11 CMS INPATIENT QUALITY AND PAYMENT PROGRAMS

12 CMS Quality Measurement Programs Inpatient hospital programs: Hospital Value-Based Purchasing Program (HVBP) Hospital Readmissions Reduction Program (HRRP) Hospital-Acquired Condition Reduction Program (HAC) Hospital Inpatient Quality Program (IQR) 13

13 Hospital Value Based Purchasing (HVBP) The Total Performance Score (TPS) is used as a measure to determine adjusted payment for inpatient services under the MS-DRG system. Quality performance measures in four domains of performance: Clinical Care: Process of Care and Outcomes Patient Experience Safety Efficiency The domains are measured based on a composite score from individual performance measures. CMS financial penalties and incentive payments 2016: 1.75% 2017: 2.00% 14

14 HVBP 2016 The clinical process of care score is based on the relative improvements in a hospital s demonstrated clinical process measures when compared to the measures recorded at a baseline reporting period. Not all measures have the same baseline periods. Minimum 4 measures with at least 10 cases each in both baseline and performance period 15

15 HVBP 2016 The clinical process of care score (10% 2016) is associated with the following 12 clinical process measures related to five conditions: Acute Myocardial Infarction (AMI or heart attack) AMI-7a: Fibrinolytic therapy received within 30 minutes of hospital arrival Pneumonia (PN) PN-6: Initial antibiotic selection for CAP in immunocompetent patients 16

16 HVBP 2016 Surgical Care Improvement Project (SCIP) SCIP-Card-2: Surgery patients on Beta-Blocker Therapy prior to arrival who received a Beta-Blocker during the Perioperative period SCIP-VTE-2: Surgery patients who received appropriate VTE prophylaxis 24 hours prior and to 24 hours after surgery 17

17 HVBP 2016 Healthcare-Associated Infections (HAIs) SCIP Inf 2: Prophylactic antibiotic selection for surgical patients SCIP Inf 3: Prophylactic antibiotics discontinued within 24 hours after surgery end time SCIP Inf 9: Urinary catheter removed on postop day 1 or postop day 2 Influenza Immunization (New 2016) IMM-2: Influenza immunization 18

18 HVBP 2016 The Patient Experience score (25% 2016) is based off the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) base score and consistency score HCAHPS is a national, standard survey that asks adult patients about experiences during recent hospital stays. Minimum 100 completed surveys 19

19 HVBP 2016 The patient experience of care score has a range from and indicates how well a hospital is doing on eight dimensions of the HCAHPS survey, including: HCAHPS-1: Nurse Communication HCAHPS-2: Doctor Communication HCAHPS-3: Hospital Staff Responsiveness HCAHPS-4: Pain Management HCAHPS-5: Medicine Communication HCAHPS-6: Hospital Cleanliness & Quietness HCAHPS-7: Discharge Information HCAHPS-8: Overall Hospital Rating 20

20 HVBP 2016 The outcome domain measure (40% 2016) assesses a broad set of healthcare activities that affect a patient s well-being Minimum values: 25 cases for mortality measures 3 cases for any indicator in the PSI-90 composite 1 predicted infection each in CLABSI, CAUTI and SSI Baseline and performance periods vary 21

21 HVBP 2016 Include: Mort-30-AMI: Acute Myocardial Infarction 30-day mortality rate Mort-30-HF: Heart Failure 30-day mortality rate Mort-30-PN: Pneumonia 30-day mortality rate PSI-90: AHRQ Composite patient safety / complication 22

22 HVBP 2016 Outcome domain measures continued: CLABSI: Central line-associated bloodstream infection CAUTI: Catheter-associated UTI (New 2016) SSI: Surgical site infection (colon and abdominal hysterectomy (New 2016) 23

23 HVBP 2016 The efficiency measure (25% 2016) assesses the cost of care by measuring Medicare spending per beneficiary (MSPB-1). This measure of efficiency is based on an assessment of payment for services provided to a beneficiary during a spending-per-beneficiary episode that spans from three days prior to an inpatient hospital admission through 30 days after discharge. The payments included in this measure are standardized and adjusted so that variation in geographic costs is removed, as well as variation in patient health status. Minimum 25 episodes of care 24

24 Per Beneficiary Medicare Spending Source: 2012 Medicare Chart Book 25

25 Proportion of Medicare Spending Source: 2012 Medicare Chart Book 26

26 HVBP FY 2015 HVBP FY % 30% Patient Experience of Care Efficiency 40% 25% Patient Experience of Care Efficiency 20% 20% Clinical Processes 25% Clinical Processes Clinical Outcomes 10% Clinical Outcomes 2016 Panacea Healthcare Solutions, Inc. 27

27 HVBP FY 2016 HVBP FY 2017 Patient Experience of Care Patient Experience of Care Efficiency 40% 25% 25% Efficiency Clinical Processes 20% 25% 25% 25% Processes (subdomain) Outcomes (subdomain) 10% Clinical Outcomes 5% Safety 2016 Panacea Healthcare Solutions, Inc. 28

28 HVBP FY 2017 HVBP FY % 25% Patient Experience of Care Efficiency 25% 25% Patient Experience of Care Efficiency 25% 5% 25% Processes (subdomain) Outcomes (subdomain) Safety 25% 25% Safety Clinical Care (Outcomes & Process) 2016 Panacea Healthcare Solutions, Inc. 29

29 Hospital Readmissions Reduction Program (HRRP) An admission to an IPPS acute care hospital within 30 days of a discharge from the same or another acute care hospital Financial Penalty Program: Maximum 3% from base DRG for all Medicare discharges Readmission Measures: Acute Myocardial Infarction (AMI) Heart Failure (HF) Pneumonia (PN) Chronic Obstructive Pulmonary Disease (COPD) Total Hip or Knee Arthroplasty CABG Planned readmissions excluded 30

30 Medicare Readmissions by Number of Chronic Conditions Source: 2012 Medicare Chart Book 31

31 Hospital Acquired Conditions (HAC) Conditions (preventable) that patients acquire while receiving treatment for another condition in an acute care setting Lowest performing 25% of hospitals are penalized, 1% of base DRG payment HAC Domain 1: AHRQ Patient Safety Indicators (PSI 90 Composite) HAC Domain 2: CDC National Healthcare Safety Measures 32

32 % of Total HAC Score Fiscal Year Domain 1 AHRQ PSI 90 Domain 2 CDC HAIs % 65% % 75% % 85% % 85% 33

33 Hospital Acquired Conditions 2016 HAC Domain 1: PSI 90 Composite Pressure ulcer rate Iatrogenic pneumothorax Central venous catheter related blood stream infection Post-op hip fracture Post-op pulmonary embolism or deep vein thrombosis rate Post-op sepsis rate Would dehiscence rate Accidental puncture and laceration rate 34

34 Hospital Acquired Conditions 2016 HAC Domain 2: CDC National Healthcare Safety Measures CLABSI rate CAUTI rate Surgical site infection colon and abdominal hysterectomy rates MRSA rate (New 2017) C-Difficile (New 2017) 35

35 CMS Reimbursement Impact VBP Program Hospital Value Based Purchasing Hospital Readmissions Reduction Program Hospital Acquired Conditions 1% 1.25% 1.5% 1.75% 1.75% 1% 2% 3% 3% 3% 1% 1% 1% Total 2% 3.25% 5.5% 5.75% 5.75% 36

36 Hospital Inpatient Quality Program (IQR) The Hospital IQR Program is intended to equip consumers with quality of care information to make more informed decisions about healthcare options. It is also intended to encourage hospitals and clinicians to improve the quality of inpatient care provided to all patients. The hospital quality of care information gathered through the program is available to consumers on the Hospital Compare website. The Hospital IQR Program requires Medicare subsection (d) hospitals to submit data for specific quality measures for health conditions common among people with Medicare that typically result in hospitalization. 37

37 Other CMS Quality Initiatives PPS-Exempt Cancer Hospital Quality Reporting Program (PCHQR) Inpatient Psychiatric Facility Quality Reporting Program (IPFQR) Hospital Outpatient Reporting Program (OQR) Physician Quality Reporting System (PQRS) MACRA Replacing Ambulatory Surgery Center Quality Reporting (ASCQR) 38

38 CMS Quality Initiatives Inpatient Rehabilitation facility Quality Reporting Program (IRF QRP) Long-term Care Hospital Quality Reporting Program (LTCHQR) Home Health Quality Reporting Program (HH QRP) Hospice Quality Reporting Program End-Stage Renal Disease Quality Initiative 39

39 Alternative Payment Models (APMs) Pay for Performance Initiatives Healthcare providers are only compensated if they meet certain metrics for quality and efficiency. Creating quality benchmark metrics ties reimbursement directly to quality of care. Bundled Payments / Episode of Care Payment Reimbursed for specific episodes of care such as an inpatient hospital stay. This healthcare payment model encourages efficiency and quality of care because there is only a set amount of money to pay for the entire episode of care. 40

40 Alternative Payment Models (APMs) Shared Savings Program (CMS and Commercial) Upside - provide incentives for providers with respect to specific patient populations. A percentage of any net savings realized is given to the provider. Must move to a downside model after 3 years Downside - Includes both the gain share potential of an upside model, but also the downside risk of sharing the excess costs of healthcare delivery between provider and payer. Because providers are taking on greater risk with this model, the upside opportunity potential is larger in most cases than in an all-upside program. 41

41 Alternative Payment Models (APMs) Accountable Care Organizations (ACO s) Are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program. 42

42 Alternative Payment Models (APMs) Patient Centered Medical Homes (PCMH) Patient treatment is coordinated through the primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand. The objective is to have a centralized setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient s family. 43

43 THE REVENUE CYCLE AND VALUE BASED CARE

44 Quality Team C-Suite Finance Medical Staff IT Nursing Quality Case Management CDI/HIM 45

45 Preparing for Value-Based Payment Selecting Which Alternative Payment Models to Participate In Contract Management Purchasing Strategic Pricing Revenue Cycle Processes 46

46 Revenue Management Cycle (RMC) Systems Systems set for fee for service, not payment and value Various payment models to track Various payers Tracking costs and quality throughout the year Ability to make adjustments for improvement throughout the year Often there are multiple RCM systems that separately support providers 47

47 Scheduling and Patient Access Identifying Patients in Value-Based Programs Accurate Patient Registration Price Quotes / Cost Estimation Point of Service Collection Financial Counseling 48

48 It s All About the Data Demographic Clinical (documentation and coding) Financial Focus on data that is required to manage incentive programs, shared savings and risk contracts Focus on your most expensive patients (chronic disease, in and out of hospital) 49

49 Service Level Managing costs at service and department level Tracking costs across the continuum of care, constantly analyzing performance and making adjustments 50

50 Chargemaster Multiple Chargemaster Strategies Fee-For-Service / Line-Item Bundled Payments Procedure-Based Episodes (30 / 90 days) Chronic / Preventative Care 51

51 Chargemaster Further Defined By: Site Payer / Plan Physician Other.. 52

52 Chargemaster Maintenance Evaluate, Adjust, and Maintain: Department / Service-Line Charge Strategies Strategic Pricing For Acute Inpatient / Outpatient Hospital Physician Post-Acute Care 53

53 Charge Capture Department Level Processes Who? Training Charge Reconciliation / Verification Pre-Billing Edits Post-Billing Rejections / Denials 54

54 Claims Processing Verification of Data Pre-Billing Edits Post-Billing Rejections / Denials Reconciliation 55

55 MOVING FORWARD

56 Value-Based Revenue Cycle Team Managed Care Patient Access Patient Financial Services Financial Reporting Receivables Management 57

57 Value-Based Revenue Cycle Team Integrate: C-Suite IT Clinical Finance / Billing 58

58 Questions We Ask Our Clients How does your hospital compare? What does your medical record documentation support? What does your quality data show? What are your processes for collecting and reporting quality data? What IT support do you have? How are you addressing costs and charges? How are you are negotiating contracts? 59

59 What Should You Focus On? Assess inefficient areas of the hospital Ensure cross organizational governance IT involvement is critical Investment in comprehensive data collection and reporting systems Patient satisfaction Sharing of quality scores (ongoing) 60

60 What Should You Focus On? Review of all reporting and audit mechanisms to assess for duplication of efforts and conflicting messages Focused review of cases with quality issues by an external auditor Development of multidisciplinary task force to develop workflow and shared processes with single point reference for providers 61

61 What Should You Focus On? Use of quality tracking tool Determine problem quality issues and develop a focused corrective action plan Education for entire multidisciplinary team Reports 62

62 What Should You Focus On? Accurate Clinical Documentation Impacts: Documentation / CDI Coding Severity of Illness (SOI) Mortality Patient Safety Indicators (PSI) Present on Admission (POA) / Hospital Acquired Conditions (HAC) Core Measures Outcome measures Readmissions Length of Stay (LOS) Patient Costs Case Mix Index (CMI) And more 63

63 Tools for Today Data Tools Cost Accounting Systems Contract Management Systems Process Improvement Software Enterprise Master Person Index Enterprise Master Provider Index Scheduling Systems that Incorporate Referral Management 64

64 Tools for Today Case Management Systems Population Health Management Systems Productivity Management Systems Health Information Exchanges Patient Portals Social Medial Tools Consumer Marketing 65

65 New Revenue Cycle Management External - Becoming Patient Focused Financial / Cost Concerns Experience Face-to-Face Contact Phone Technology Care Management 66

66 New Revenue Cycle Management Internal - Efficient claims processing Ongoing financial visibility into financial performance Ability to reconcile various value-based payment models for Accurate payment (upfront and annual bonuses) Track costs Track outcomes 67

67 Contact the Presenter Kim Charland, BA, RHIT, CCS Senior Vice President Clinical Innovation and Publisher of VBPmonitor Panacea Healthcare Solutions, Inc , Ext

68 Questions? 69

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