1. Participation in quality initiatives 70 percent 2. Performance on clinical quality indicators 30 percent

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1 Peer Group 5 Hospital Pay-for-Performance Program April 2012 through March 2013 Program Overview Peer group 5 hospitals are small rural hospitals that provide access to care in areas where no other care is available. Many of these hospitals are classified by Medicare as Critical Access Hospitals. The Blue Cross Blue Shield of Michigan PG 5 Hospital Pay-for-Performance program gives these hospitals the opportunity to demonstrate to their communities and to the purchasers of care they are providing value by meeting expectations for access, effectiveness and quality. The program described in this document is effective April 1, 2012, through March 31, The program determines six percentage points of a PG 5 hospital s payment rate effective October 1, The Peer Group 5 P4P Advisory Group provides input to BCBSM regarding identification and use of relevant measures that promote quality, access and value in small rural hospitals. The advisory group membership includes representatives from hospitals, Michigan Health & Hospital Association and BCBSM. Peer group 5 hospitals may contact these representatives to share any comments related to the program. The representatives will present any comments received at future Advisory Group meetings for consideration. The contact information for the representatives can be found in Appendix A. The weight distribution for the quality components remained the same as last program period. The following table summarizes how the various components are weighted for this program for critical access hospitals and non-critical access hospitals: Program Components Weight Prequalifying condition (all PG 5 hospitals): 1. Culture of patient safety survey 0 percent Quality for Critical Access Hospitals: 1. Participation in quality initiatives 70 percent 2. Performance on clinical quality indicators 30 percent Quality for Non-Critical Access Hospitals: 1. Participation in quality initiatives 60 percent 2. Performance on clinical quality indicators 40 percent 1

2 Pre-qualifying Condition Hospitals must meet the following pre-qualifying condition to be eligible to participate in the P4P program: PG 5 hospitals must conduct a hospital-wide patient safety assessment survey at least once every two years. There are two eligible surveys: Hospital Survey on Patient Safety Culture (HSOPSC) Safety Assessment Questionnaire (SAQ) The survey can be assessed by a vendor, an online assessment tool, or a hospital selfassessment process. However, the assessment process must provide guidance for improvements in patient safety culture. Hospitals will be asked to submit an attestation to BCBSM verifying they have met this prequalifying condition. The form requires hospitals to provide information on the results of the patient safety assessment and activities the hospital will implement to address findings from the assessment. The form will be sent to the hospital s CEO following the end of the PG 5 P4P program period for submission by June Quality Critical Access Hospitals Critical Access Hospitals that meet the above pre-qualifying condition will earn a P4P score based on the following two components: Participation in selected quality initiatives (70 percent) Performance on clinical quality measures (30 percent) What s new in April 2012? All hospitals must participate in the MICAH Quality Network and one other quality initiative To meet the new participation requirements hospitals are given the option to report on four HCAHPS questions if they are unable to participate in any Keystone initiatives due to eligibility or administration financial constraints. Hospitals no longer earn full points just for participating in quality initiatives. Instead, they are scored on specific participation and performance measures via a performance index. Keystone ER initiative is added to the program as another option for a quality initiative. The seven ER transfers quality indicators are replaced with the CMS ER quality indicators (OP-18 and OP-20). 2

3 Participation in Quality Initiatives Critical Access Hospitals must participate in the MICAH Quality Network and at least one of the following initiatives (see eligibility in Appendix B): Hospital-Associated Infection (HAI) Surgery Michigan State Action on Avoidable Rehospitalization (MI STA*AR) Keystone Emergency Room (ER) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) - Alternative to Keystone Initiatives Quality Initiatives Weights The selected two quality initiatives will be worth 35 percent each. In previous years, hospitals earned full credit for a quality initiative based entirely on active participation. Starting April 2012, a hospital s quality initiative score is determined by its performance on specific measures related to MICAH Quality Network and Keystone initiatives. These measures are referred to as the Hospital s Quality Initiative Performance Index. Performance Indexes The measures in the quality initiative performance index are developed by the MICAH Quality Network and Keystone representatives with collaboration from the PG 5 Advisory Group. Many of the measures are based on the quality of participation, such as the accuracy and timeliness of the data a hospital submits and conference call/meeting attendance. Some quality initiatives have additional performance measures based on quality outcomes, such as CAUTI Bundle Intervention implementation. The measures in each index are expected to change over time as a quality initiative matures and new improvement opportunities are identified. The index measures for each quality initiative are detailed in Appendix C. Hospital performance on the measures in each quality initiative performance index is determined by MICAH Quality Network and MHA Keystone responsible representatives. The representatives will submit hospital scores to BCBSM at the end of the measurement period. BCBSM will use the top two performance scores for the P4P program if a hospital participated in more than two initiatives. The performance index scores will be shared with hospitals prior to submission to BCBSM. Hospitals should contact the Keystone representative or Angie Emge at MICAH Quality Network if interested in obtaining performance status during the program period. HCAHPS (Alternative to Keystone Initiative) In past years, there were hospitals participating only in MICAH Quality Network since they were not eligible for either Keystone Hospital Associated Infection or Keystone Surgery initiatives. Although all hospitals are eligible in MI STA*AR and Keystone Emergency Room initiatives, BCBSM understands some hospitals have limited resources and may not be able to provide the administrative commitment necessary for these two initiatives. After discussions with the PG 5 Advisory Group and research with Michigan Center for Rural 3

4 Health, BCBSM is adding HCAHPS as an option for these hospitals. The questions required for this measure are the following: Question 3 - During this hospital stay, how often did nurses explain things in a way you could understand? Question 7 - How often did doctors explain things in a way you could understand? Question 19 - Did hospital staff talk with you about whether you would have the help you needed when you left the hospital? Question 20 - Did you get information in writing about what symptoms or health problems to look out for after you left the hospital? These questions were chosen because they are also reported as part of the MI STA*AR initiative. The hospital may use its current vendor for the HCAHPS survey. The results should be sent directly to Connie Hoveland at choveland@bcbsm.com along with the CEO attestation form due by June 1, Since HCAHPS is a new initiative for this program period, an eligible hospital selecting HCAHPS as its second quality initiative will receive 100 percent credit for reporting only. Hospitals with questions regarding eligibility in MHA Keystone initiatives or the performance indexes should contact Ron Hubble at Hospitals with questions regarding MICAH Quality Network performance index should call Angie Emge at Performance on Specific Clinical Quality Indicators The remaining 30 percent of the hospital s P4P score is earned by its performance on specific clinical quality indicators. Starting April 1, 2012 the perfect care scoring methodology for the ER transfer indicators will be replaced with the CMS Hospital Outpatient Department Quality Measures for Emergency Department. The quality indicators to be scored are listed in the table below: Indicators Weight OP 18 Median time from ED Arrival to ED Departure for Discharged ED Patients (NEW) 7.5% OP 20 Door to Diagnostic Evaluation by a Qualified Medical Personnel (NEW) 7.5% OP 4a Aspirin at arrival overall (AMI and chest pain) 7.5% OP 5a Median time to ECG overall (AMI and chest pain) 7.5% CMS has guidelines for sample size which will require additional abstracting than what was necessary for the former ER Transfer indicators. Hospitals were informed of this change during a MICAH Quality Network meeting. Hospitals will need to establish new processes to handle the increased volume. Critical access hospitals are expected to report data to Quantros (formally Core Options ) using standardized protocols. Non-Critical Access Hospitals 4

5 Non-Critical Access Hospitals that meet the aforementioned pre-qualifying condition will earn a P4P score based on the following two components: Participation in selected quality initiatives (60 percent) Performance on clinical quality measures (40 percent) What s new in April 2012? Hospitals no longer earn full points just for participating in quality initiatives. Instead, they are scored on specific participation and performance measures via a performance index. Keystone ER initiative is added to the program as another option for a quality initiative. Participation Quality Initiatives Non-Critical Access Hospitals must participate in at least two of the following initiatives (see eligibility in Appendix B): Hospital-Associated Infection (HAI) Surgery Michigan State Action on Avoidable Rehospitalization (MI STA*AR) Keystone Emergency Room (ER) MICAH Quality Network Quality Initiatives Weights The selected two quality initiatives will be worth 35 percent each. In previous years, hospitals earned full credit for a quality initiative based entirely on active participation. Starting April 2012, a hospital s quality initiative score is determined by its performance on specific measures related to Keystone initiatives and MICAH Quality Network. These measures are referred to as the Hospital s Quality Initiative Performance Index. Performance Indexes The measures in the quality initiative performance index are developed by the MICAH Quality Network and Keystone representatives with collaboration from the PG 5 Advisory Group. Many of the measures are based on the quality of participation, such as the accuracy and timeliness of the data a hospital submits and conference call/meeting attendance. Some quality initiatives have additional performance measures based on quality outcomes, such as CAUTI Bundle Intervention implementation. The measures in each index are expected to change over time as a quality initiative matures and new improvement opportunities are identified. The index measures for each quality initiative are detailed in Appendix C. Hospital performance on the measures in each quality initiative performance index is determined by MHA Keystone and MICAH Quality Network responsible representatives. The representatives will submit hospital scores to BCBSM at the end of the measurement period. A hospital participating in more than one Keystone initiative will report its highest performance score to the P4P program. 5

6 The performance index scores will be shared with hospitals prior to submission to BCBSM. Hospitals should contact the Keystone representative or Angie Emge at MICAH Quality Network if they want a performance status during the program period. Hospitals with questions regarding eligibility in MHA Keystone initiatives or the performance indexes should contact Ron Hubble at Hospitals with questions regarding MICAH Quality Network performance index should call Angie Emge at Performance on Specific Clinical Quality Indicators The remaining 40 percent of the hospital s P4P score is earned by its performance on specific clinical quality indicators. Non-critical access hospitals will be scored on their performance on the following indicators: Indicators OP - 4a* Aspirin at arrival overall (AMI and chest pain) OP - 5a Median time to ECG overall (AMI and chest pain) Acute myocardial infarction*: Aspirin at arrival (AMI-1) Aspirin prescribed at discharge (AMI-2) Angiotensin converting enzyme inhibitors or angiotensin receptor blockers for LVSD (AMI-3) Beta blocker prescribed at discharge (AMI-5) Weight 6% 6% 10% Heart Failure* - Left ventricular ejection fraction less than 40 percent prescribed ACEI or ARB at discharge (HF-3) 6% Pneumonia* - Initial antibiotic selection (for non-icu patients) consistent with current recommendations (PN-6b) 6% Pneumonia* - Pneumococcal vaccine (screening or administration) prior to discharge (PN-2) 6% * A hospital will only be scored individually on an indicator if it has at least 20 cases for that indicator. A hospital with fewer than 20 cases will not be eligible for the indicator and its weight will be distributed equally among the other indicators. 6

7 Performance Thresholds Hospitals will be scored on the above quality indicators by comparing performance against thresholds. The thresholds are determined with input from hospitals and hospitals prior year s performance. BCBSM encourages the thresholds be set higher every year; however, thresholds will not be set above 95 percent. A hospital performing 95 percent or better on an indicator will receive 100 percent. The thresholds for this year will be communicated to hospitals as soon as they are available. Since the CMS outpatient ER indicators (OP-18, OP-20) are new starting April 1, 2012, hospitals will receive 100 percent for each indicator for reporting only. The tables below show the data elements needed to report on OP-18 and OP-20 and the CMS sampling requirements. To obtain data collection requirements you should contact your core measure vendor. Arrival Time Discharge Status E/M Code ED Departure Date ED Departure Time Observation Services Outpatient Encounter Date Provider Contact Date Provider Contact Time Transition Record Received ICD-9 Principal Diagnosis Code Monthly Population: Monthly Sample: Monthly Population: Monthly Sample: Monthly Population: use all 27 cases Monthly Sample: BCBSM will communicate P4P payment rates to hospitals by July 31, 2013, and the rates will become effective October 1,

8 P4P PG5 Advisory Group Contacts APPENDIX A Representatives Affiliation Phone number Address Anne Barton Herrick Medical Center anne.barton@promedica.org Rodney Nelson Mackinac Straits rnelson@mshosp.org Health System, Inc Bill Roeser Sparrow Ionia Hospital William.roeser@sparrow.org Matt Rush Hayes Green Beach Memorial Hospital mrush@hgbhealth.com Josh Salander Caro Hospital joshua@cch-mi.org Joann Urbanski Chris Wilhelm South Haven Hospital System Charlevoix Area Hospital jurbanski@sh-hs.org Ron Hubble MHA Marilyn Litka-Klein MHA Joe Stephansky MHA cwilhelm@cah.org rhubble@mha.org mklein@mha.org jstephansky@mha.org Sam Watson MHA swatson@mha.org Connie Hoveland BCBSM choveland@bcbsm.com Laurie McIntee BCBSM Lmcintee@bcbsm.com Canopy Roychoudhury BCBSM croychoudhury@bcbsm.com 8

9 Quality Initiatives - Eligibility APPENDIX B The table below provides the eligibility for the PG5 hospitals Quality Initiatives. All hospitals are eligible to participate in MICAH Quality Network, MISTA*AR and ER initiatives. The eligibility for Keystone HAI and Surgery initiatives were received from MHA Keystone December Hospitals that have an asterisk in the HCAHPS column must participate in the HCAHPS initiative unless they chose to participate in a Keystone initiative. The hospitals that were selected to report HCAHPS were chosen because they were not eligible for HAI or Surgery last year or this year. A hospital reporting the HCAHPS questions for this program period, must send the information directly to Connie Hoveland at choveland@bcbsm.com along with its attestation form and other clinical indicators. Hospital MICAH Keystone HAI Keystone Surgery MISTA*AR ER HCAHPS* Allegan General Hospital yes Yes yes yes yes * Aspirus Keweenaw Hospital yes yes yes yes yes Aspirus Ontonagon Hospital yes yes yes yes * Baraga County Memorial Hospital yes yes yes yes yes * Bell Memorial Hospital yes yes yes yes yes Borgess-Lee Memorial Hospital yes yes no yes yes * Bronson LakeView Hospital yes yes yes yes yes * Caro Community Hospital yes no yes yes yes * Charlevoix Area Hospital yes yes yes yes yes Deckerville Community Hospital yes no yes yes * Eaton Rapids Medical Center yes yes yes yes yes Grand View Hospital yes yes yes yes yes Harbor Beach Community Hospital Inc yes yes no yes yes Hayes Green Beach Memorial Hospital yes yes yes yes yes Helen Newberry Joy Hospital yes yes no yes yes Herrick Medical Center yes yes yes yes yes Hills & Dales General Hospital yes yes no yes yes * Kalkaska Memorial Health Center yes yes no yes yes Mackinac Straits Hospital yes no yes yes * Marlette Regional Hospital yes yes yes yes yes McKenzie Memorial Hospital yes yes yes yes yes * Mercy Health Partners Lakeshore * yes yes no yes yes Campus MidMichigan Medical Center- Gladwin** yes yes yes yes yes Munising Memorial Hospital yes no yes yes yes * Northstar Health Systems (f/n/a Iron * yes Yes no yes yes County Community Hospital) Paul Oliver Memorial Hospital yes No no yes yes * 9

10 Quality Initiatives Eligibility APPENDIX B Cont. Hospital MICAH Keystone HAI Keystone Surgery MISTA*AR ER HCAHPS* Scheurer Hospital yes yes yes yes yes * Schoolcraft Memorial Hospital yes yes yes yes * Sheridan Community Hospital yes no yes yes yes Sparrow Clinton Memorial Hospital yes yes yes yes yes Sparrow Ionia County Memorial yes yes Hospital yes yes yes Spectrum Health Kelsey Hospital yes No yes yes * Spectrum Health Reed City Campus yes yes yes yes yes St. Mary's of Michigan Standish Hospital yes yes yes yes yes West Shore yes Yes yes yes yes Community Hospital - Watervliet yes yes yes yes yes Huron Medical Center yes yes yes yes yes MidMichigan Medical Center- Clare yes yes yes yes yes Otsego Memorial Hospital yes yes yes yes yes Portage Health Hospital yes yes yes yes yes South Haven Community Hospital yes yes yes yes yes Three Rivers Health yes yes no yes yes * If your hospital has an asterisk in this column, you must report the HCAHPS questions unless you chose to participate in a Keystone initiative. 10

11 Quality Initiatives - Performance Indexes APPENDIX C MHA Keystone: Hospital Associated Infections Measure Weight Measure Description #1 30 Data Collection* Points earned 90% of data returned 30 75% 89% 25 50% 74% 15 Less than 50% 0 #2 30 Participation in conference calls ** All conferences calls 30 At least 75% of the conference calls 25 At least 50% conference calls 15 Less than half conference calls 0 #3 40 CAUTI Bundle Intervention implementation *Frequency of Reporting: Initial phase (baseline to post intervention 1) weekly Post intervention phase quarterly Fully implemented 40 Partially implemented 25 Not begun 0 ** Hospitals can earn credit for participation by listening to MHA Keystone s recorded line within 1 month of the initial conference call; however, hospitals must participate live in at least 3 calls to earn full points for the category. 11

12 Quality Initiatives - Performance Indexes APPENDIX C Cont. Measure Weight Measure Description #1 30 Data Collection* MHA Keystone: Surgery Points earned 90% or more of data returned 30 75% 89% 25 50% 74% 15 Less than 50% 0 #2 30 Participation in conference calls** At least one meeting and all (usually 12) conferences calls 30 At Least one meeting and at least 75% of the conference calls 25 At least one meeting and at least 50% conference calls 15 No meetings and less than 50% conference calls 0 #3 40 Intervention implementation Fully implemented 40 Partially implemented 25 Not begun 0 *Data collection activities include monthly briefing, debriefing, and mislabeled specimens. ** Hospitals can earn credit for participation by listening to MHA Keystone s recorded line within 1 month of the initial conference call; however, hospitals must participate live in at least 3 calls to earn full points for the category. 12

13 Quality Initiatives - Performance Indexes APPENDIX C Cont. MHA Keystone: Emergency Room Measure Weight Measure Description #1 30 Data Collection* Points earned 90% of data returned 30 60% 89% 15 Less than 60% 0 #2 30 Participation in workshops and conference calls** At least one workshop and all conference calls 30 At least one workshop and at least 75% of 25 conference calls At least 50% of conference calls 15 No conference calls 0 #3 40 Severe Sepsis Screening Program implementation Fully implemented 40 Partially implemented 25 Not begun 0 *Data collection activities include Monthly Team Check up Tool & ER Operational Data (see Keystone: ER Data Definitions) ** Hospitals can earn credit for participation by listening to MHA Keystone s recorded line within 1 month of the initial conference call; however, hospitals must participate live in at least 3 calls to earn full points for the category. 13

14 Quality Initiatives - Performance Indexes APPENDIX C Cont. Measure Weight Measure Description #1 30 Data Collection* Michigan STA*AR Points earned 90% or more of data returned 30 60% 89% 15 Less than 60% 0 #2 30 Participation in workshops and conference calls* At least one workshop and 90% conference calls 30 At least one workshop and at least 75% of conference calls 25 At least 50% of conference calls 15 Less than 50% of conference calls 0 #3 40 Community Cross Continuum Team Development and Implementation Fully implemented (Representation across the 40 continuum of care, regular meetings) Partially implemented (e.g., invited participants but no 25 meetings) Not begun 0 *Data collection activities include review of at least 10 readmission cases per year and monthly reporting of 30 day all cause readmission rates and HCAHPS scores for Questions 3, 7, 19 & 20. ** Hospitals can earn credit for participation by listening to MHA Keystone s recorded line within 1 month of the initial conference call; however, hospitals must participate live in at least 3 calls to earn full points for the category. Measure Weight Measure Description MICAH Quality Network Points earned #1 100 Participation in meetings All four (in person or teleconference) 100 Three or two meetings 75 One Meeting 25 Did not attend any meeting 0 sendnormalbcbsm 14