Clinical Quality Payment Policies Impact to Finance and Operations

Transcription

1 Clinical Quality Payment Policies Impact to Finance and Operations Kristen Geissler, MS, PT, MBA, CPHQ Director Berkeley Research Group December 4, 2014

2 What s the Buzz? Cost Efficient VALUE Effective Quality 1

3 Concept of Value in Healthcare IHI Triple Aim Improve patient experience of care (quality & satisfaction) Improve population health Reduce per capita cost of healthcare How do you measure this? 2

4 Maze of Quality Metrics in Reimbursement AHRQ PSI PQRS OPPC HAC ACO HEDIS MU QBR HCAC IQR PPC VBP PPR RHQDAP U 3

5 Maze of Health Care Locations Rehab Home Health ACO Chronic Hosp Dialysis Hospital Psych Hospice Nursing Facility Phys Office Medical Home 4

6 Regulatory Background of Quality Indicators Sponsorship sponsored by federal or state agencies Federal: Hospital Quality Alliance Hospital Compare State: HSCRC and MHCC Hospital Performance Guide usually consistent, consensus-built standards and definitions Private/ For-profit sponsored by non-governmental agencies Healthgrades US News & World Report methodology and definitions often not consensus-built and may not be public, transparent or reproducible 5

7 Other Quality Organizations The Joint Commission non-governmental, accrediting body AHRQ (Agency for Healthcare Research and Quality) governmental, measure developer NQF (National Quality Forum) non-governmental, measure consensus builder CMS (Centers for Medicare and Medicaid Services) governmental, payer, policy creator Leapfrog Group private, report card creator Healthgrades private, report card creator 6

8 Background of Quality Indicators Types of Measures Several different types of quality measures Process Was a specific recommendation done? Evaluation of left ventricular function Outcome What happened with the patient? 30-day mortality of patients with pneumonia Much more complex, as risk adjustment must be used Patient-reported HCAHPS Patient Perception Survey Facility-reported Hospital infection rates, fall rates Concerns with hospitals using different measurement methodology & intensity of review 7

9 MARYLAND INITIATIVES 8

10 National to Maryland Quality Metric Comparison CMS Maryland (HSCRC) Value-Based Purchasing (VBP) Quality-Based Reimbursement (QBR) Hospital Readmission Reduction Program (HRRP) Readmission Payment Policy Hospital Acquired Conditions (HAC) Maryland Hospital Acquired Conditions (MHACs) (PPCs) 9

11 Maryland Quality Financial Impact Md FY16 Impact Md FY17 Impact CMS FY17 impact Core Measures 0.3% QBR HCAHPS 0.4% Mortality 0.1% AHRQ Patient Safety Indicators 0.1% 1% tbd 1.5% - 2% 2% HAI CLABSI 0.1% MHAC Read Maryland Hospital Acquired Conditions (MHAC) (65) Readmissions (all-cause) 0.3% shared savings + 0.5% potential reward 4% 4% tbd 1% 0.8% 0.8% tbd 3% Total 5.8% 6% 6% % of inpatient revenue 10

12 Maryland Waiver and Quality Because of the original waiver, Maryland was exempt from CMS IPPS quality methodologies Maryland had to develop or adopt methodologies that were the same in scope to CMS Currently, Maryland must have the same dollars at risk as CMS Specific Quality Goals: Complications Must reduce overall PPC rate 30% in 5 years Readmissions Must have all-payer readmission rate lower than the national rate in 5 years 11

13 Quality Based Reimbursement (QBR) Analogous to CMS s Value Based Purchasing (VBP) Currently in the 7 th year of the program Measures a hospital s performance: Compared to a statewide threshold and benchmark Compared to itself year-over-year 12

14 Quality Based Reimbursement (QBR) Current Measures Clinical Process Measures HCAHPS Patient Perception Inpatient All-Condition Mortality Healthcare-Associated Infections AHRQ Patient Safety Indicators Financial Impact 1% of all-payer inpatient revenue scaled Best performing hospital could receive 1% more in rates; worst performing hospital loses 1% in rates linearly scaled in between the best and the worst 13

15 Maryland Hospital Acquired Conditions (MHAC) Analogous to CMS s Hospital Acquired Conditions (HAC) program Currently in the 6 th year of the program 65 conditions/complications that occur after hospital admission Identified strictly using ICD-9 codes and present on admission indicators 14

16 Maryland Hospital Acquired Conditions (MHAC) Hospital s actual complications are measured against a severity-adjusted expected number of complications Compared to a statewide threshold and benchmark Compared to itself year-over-year Financial Impact Up to 4% of all-payer revenue 15

17 Readmission Reduction Readmissions policy is measured as Inpatient, all-payer, all-cause readmissions within 30-days of an IP admission Adjusted for planned readmissions Inter-hospital readmissions are included Risk-adjusted Financial impact Potential 0.5% reward based on year-over-year improvement only Minimum hospital improvement set at 6.76% CY 2013 vs. CY

18 IMPACT & IMPROVEMENT STRATEGIES 17

19 Actual Clinical Quality or Data Quality? Poor data quality can result in either falsely high or falsely low quality metric results Necessity to ensure data quality before clinical quality can be assessed Multiple levels of review Multiple disciplines reviewing data 18

20 Multidisciplinary Strategy for Success HIM/ Coding/ Documentation Finance Quality/PI Medical Staff 19

21 Oversight Strategic Approach Executive sponsorship Regular meetings or workgroups Information push to front-line staff Education and Awareness For all levels of staff, leadership and medical staff Repetition Analysis Where is the greatest opportunity? Review Multiple levels of review 20

22 Speaker Biography Kristen Geissler, a director with Berkeley Research Group, has over 20 years of experience in the healthcare field, both in direct patient care and administrative and consulting roles. She has expertise in various national and Maryland qualitybased reimbursement methodologies, including CMS VBP (Value Based Purchasing) and HAC (Hospital Acquired Conditions). She has also expertise in Clinical Documentation Improvement (CDI) and the role of coding and documentation in quality reporting. Prior to her consulting career, she was the Director of Quality Improvement for a health system, and she is also a licensed Physical Therapist. 21