An Update on Medicare s Value-based Purchasing and Readmissions Reduction Programs:

Transcription

1 An Update on Medicare s Value-based Purchasing and Readmissions Reduction Programs: Positioning Pharmacy as Team Leaders Steve Riddle, PharmD, BCPS, FASHP VP of Clinical Affairs, Pharmacy OneSource/Wolters Kluwer Health Affiliate Clinical Professor, UW School of Pharmacy Oct 31, 2012

2 Objectives Describe the key components of the VBP and MRRP Review alterations and adjustments made by CMS in the last year Explain the role of the pharmacist across the specific measures and examples of care services related to reforms Provide strategies for evolving a business plan from the quality and financial drivers in the ACA

3 A Tale of Healthcare Reform: Fall 2012 It s mid-august 2012 and Nancy, the CEO of Americaville Medical Center, was just presented a letter that contains the organizations performance scores for CMS Value-based Purchasing and Medicare Readmissions Reduction Program. Last she heard from the quality director they were performing at high-levels around the VBP and doing well with readmissions (one DRG just slightly higher than average rates). The news from CMS indicates that penalties for FFY13 will include $250K for VBP and $300K for excessive readmissions..or $550,000 total. After a the shock wears off, Nancy recalls that many of the low performance measures were related to medications. John, the director of pharmacy, answers his phone and CEO Nancy says We are in deep trouble! I need a plan from you in 1 week on how pharmacy can help improve our performance around quality and readmissions. Click

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5 The Patient Protection and Affordable Care Act (HR 3590): Title III - Improve the Quality & Efficiency of Care New measure added Value-Based Purchasing (VBP) Suspended Process of Care Measures (Section 3001) Patient Experience Measures HCAHPS (Section 3001) Altered Efficiency Measures (Section 3001) At Risk: 1% in FFY2013 growing annually to 2% in FFY2017 Outcomes Measures (Section 3001) Medicare Reimbursement Hospital Acquired Conditions (HAC) (Section 3008) At Risk: 1% reduction beginning FFY2015 At Risk: 1% reduction in FFY2013, increasing to 3% FFY2015 Readmission Reduction Program (Section 3025) 5

6 3 CMS Programs Accumulating Risk Over Time Program FFY13 FFY14 FFY15 FFY16 FFY17 VBP* 1% 1.25% 1.5% 1.75% 2% Readmissions 1% 2% 3% 3% 3% HAC - - 1% 1% 1% TOTAL RISK 2% 3.25% 5.5% 5.75% 6% Typical 300-bed hospital with $50 million dollar in CMS IPPS payments annually by FFY17 $3 million is potentially at risk. *VBP is budget neutral per DRA & ACA requirements

7 7 VALUE-BASED PURCHASING

8 Primary Performance Measure Sets for CMS VBP Program VBP FFY13 Process of Care Patient Experience 70% 30% 8

9 VBP Process of Care Measures (FFY13) Measure ID Measure Description Threshold/ Benchmark AMI-7a AMI-8a HF-1 PN-3b PN-6 Fibrinolytic Therapy w/in 30 Minutes of Hospital Arrival Primary PCI w/in 90 Minutes of Hospital Arrival Discharge Instructions (Composite) Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital Initial Antibiotic Selection for CAP in Immunocompetent Patient

10 VBP Process of Care Measures (FFY13) 1 Measure ID Measure Description Threshold/ Benchmark SCIP-Inf-1 Prophylactic Antibiotic Received Within 1 Hour Pre-Surgical Incision SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients SCIP-Inf-3 Prophylactic Antibiotics stopped w/in 24 hours After Surgery End Time SCIP-Inf-4 SCIP-VTE-1 SCIP-VTE-2 SCIP-Card-2 Cardiac Surgery Patients with Controlled 6AM Post-Op Serum Glucose Surgery Patients with Recommended VTE Prophylaxis Ordered Surgery Patients Who Received Appropriate VTE Prophylaxis Within 24 Hours Prior/Post Surgery Surgery Patients on a Beta Blocker Prior to Arrival That Received BB During the Perioperative Period

11 Measures Under Consideration for VBP (pertinent to pharmacy) AMI patients with statins at discharge Stroke measures (8 measure set) VTE measures (6 measure set) C dif SIR CAUTI rate

12 Patient Experience of Care Measures 8 Measure Domains HCAHPS Hospital Consumer Assessment of Healthcare Providers & Systems Measure ID Measure Domain Communication with doctors Communication with nurses Responsiveness of hospital staff HCAHPS (Composite) Quietness of environment Cleanliness of environment Pain management Communication about medicines Discharge information 1

13 HCAHPS Question Sample PAIN How often was your pain well controlled? How often did the hospital staff do everything they could to help you with your pain? MEDICATIONS During this hospital stay, were you given any medicine that you had not taken before? How often did the hospital staff tell you what your medication was for? How often did the hospital staff describe possible side effects in a way you could understand? POST-DISCHARGE CARE Did you receive information in writing about what symptoms or health problems to look out for? Did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital? Did you get information in writing about what symptoms or health problems to look out for after you left the hospital? At least 8 of 27 questions could be impacted by Pharmacy 1

14 Evaluating Patient Experience Measures Measure Domain Floor Threshold Benchmark Pain management Communication about medicines Hospital cleanliness & quietness Responsiveness of hospital staff Communication with nurses Communication with doctors Discharge information Overall Hospital Rating Note: Much lower scores much bigger gaps. May be place where efforts can have the most impact!

15 New HCAHPS Questions in new HCAHPS survey items that were made available for voluntary use in July 2012 and will become part of the HCAHPS Survey beginning with January 2013 discharges. When I left the hospital, I clearly understood the purpose for taking each of my medications. Strongly disagree Disagree Agree Strongly agree I was not given any medication when I left the hospital

16 VBP Initiation Timeline The race has begun! FFY13 Program July 2009 March 2010 July 2011 March 2012 Initial Data Report on Performance Oct 2012 Baseline Period Improvement Period Performance Period VBP Reimbursement Begins

17 Primary Performance Measure Sets for CMS VBP Program VBP FFY13 Process of Care Patient Experience 70% 30% Original VBP FFY14 Process of Patient Care Experience Outcomes Efficiency 20% Actual VBP FFY14 Process of Care 30% 30% 20% Patient Experience Outcomes 45% 30% 25%

18 VBP Initiation Timeline FFY14 Program Process of Care Patient Experience Outcomes 45% 30% 25% July 2011 April 2012 July 2012 Dec 2012 Mortality/Outcomes Performance Period Process of Care & Patient Experience Performance Period

19 VBP Outcomes Measure (FFY14): Proposed vs Final Sole Measures for FFY14 Measure Measure Description 30-Day* Mortality AMI Heart Failure Pneumonia Manifestations of poor glycemic control (DKA) ON HOLD TILL FURTHER Falls and Trauma Hospital Acquired Conditions CA-UTI RULING Vascular-associated catheter infection Foreign object retained post-op Air embolism Pressure ulcers (stage III & IV) AHRQ Measures: Quality & Safety Indicators *Post-admission Blood incompatibility Delayed till FFY15 2 Composite indicators representing 10 measures Example: Post-Op PE or DVT, Post-surg Septicemia 19

20 VBP Efficiency Measure (FFY14) Measure* Measure Description Expenditures per Hospital Patient (per MC beneficiary) Total expenditures per unique admission or EPISODE OF CARE (3 days prior to admission/ends 30-days post-discharge) Delayed till FFY15 Measure goal is to drive smooth transitions in care with a focus on: Decreasing redundancy in care (ie, lab test, procedures) Reduction in unnecessary high-cost, low-value services (ie, nonevidence based care and medications) Baseline period = 9 months of hospital discharges, from May 15, 2010 to February 14, 2011 Performance period = 9 months of hospital discharges from May 15, 2013 to February 14,

21 Estimating Impact of VBP: A Moving Target Total Annual CMS Reimbursement = $100,000,000 $1,000,000 $1,042,400 $42,400 $792,700 $207,300 2

22 VBP Linear Payment Model P A Y E M E N T % SCORE 2

23 VBP Impact Based on Total Performance Scores (TPS) Losers Winners VBP must be budget neutral... $850m at risk! Payment Modifier For 55% of hospitals, reimbursement/penalty will be 0.25% of withheld payment 24

24 2 Welcome to Value-based Purchasing

25 2 READMISSIONS REDUCTION PROGRAM

26 Medicare Readmissions Reduction Program Targeted MS-DRGs and Timelines Reduces Medicare inpatient payments for hospitals with higher than expected risk-adjusted 30-day readmission rates for certain conditions. FFY12 1% FFY13 2% FFY14 3% Year 1: FFY2012 Heart failure Myocardial infarction Pneumonia Year 3: FFY2014 COPD CABG PTCA & vascular procedures Year 4: FFY2015 Expand to other conditions 28

27 The Fiscal Impact of Readmissions: CMS Readmissions Reduction Program DRG Penalty Calculations HF AMI PNE # of Patients Treated with MS-DRGs Number of Readmissions Risk-Adjusted Readmit Rate 28.5% 22.5% 19.8% US 30-Day Readmission Rate 24.7% 19.7% 18.5% Predicted/Expected Ratio P/E Ratio Total Medicare DRG Operating Payments $1,500,000 $775,000 $2,150,00 Excess Payment Amount $231,000 $110,000 $151,000 Total Excess Payment ($ at risk) $492,000 Total Medicare DRG Payments Max Capped Penalty Rate Amount at Risk $60,000,000 1% (FFY12) $600,000 $60,000,000 2% (FFY13) $1,200,000 60,000,000 3% (FFY14) $1,800,000 Penalty for Future DRG Admits FFY13 $492,000 / $600,000 = 0.82% 29

28 Impact of HRRP in Year One 3400 Hospitals 34.5% None 65.5% Penalized 25.2% with <0.3% penalty FFY13 1% Penalty = $280m 18.4% with 0.3-6% penalty 7.7% with % penalty 14.2% with full 1% penalty

29 Not Just CMS in the P4P Game WellPoint (May 2011) Will halt annual payment increases to 1,500 hospitals if they fail to meet care quality criteria. Reimbursement increases for hospitals in 14 states that serve WellPoint's Blue Cross Blue Shield plans will be tied to a 51-indicator test. Outcomes = 55% Patient safety = 35% Patient satisfaction = 10% WellPoint Goal: decelerate inpatient care spending 3-5 percentage points annually over time 3

30 Handling Healthcare Reform Are you ready for the ride? 3

31 Consider the Value Proposition for Pharmacy Establish the gaps in care. Which services would be most valuable in closing these gaps at your organization? Which of these can pharmacists truly impact that will improve care or reduce readmissions at your institution? What are the care delivery model options for this service? Sustainability: What are the diverse sources of value that will support the service (ie, % reduction in readmissions, new revenue, improvements in quality)?

32 Example: Pharmacy Opportunities around Process of Care Measures Measure ID AMI-8a HF-1 PN-3b PN-6 Measure Description Primary PCI w/in 90 Minutes of Hospital Arrival Discharge Instructions (Composite) Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital Current Performance Initial Antibiotic Selection for CAP in Immunocompetent Patient Threshold/ Benchmark / / / / Gap Small Pharm Impact??? High Process Example: Find your current performance Evaluate the perceived gap (High, Medium, Low) Evaluate potential for pharmacy to impact gap (High, Medium, Low) Prioritize opportunities and investigate those with highest scores in Gap and Pharm Impact categories. 3

33 Example: Pharmacy Opportunities around Process of Care Measures Measure ID SCIP-Inf-1 SCIP-Inf-2 SCIP-Inf-3 SCIP-Inf-4 SCIP-VTE-1 SCIP-VTE-2 SCIP-Card-2 Measure Description Prophylactic Antibiotic Received Within 1 Hour Pre-Surg Incision Prophylactic Antibiotic Selection for Surgical Patients Prophylactic Antibiotics DC d w/in 24 hr After Surgery End Time Current Performance Cardiac Surg Pts with Controlled 6AM Post-Op Serum Glucose 0.89 Surgery Patients with Recommended VTE Prophylaxis Ordered Surgery Patients Who Received Appropriate VTE Prophylaxis Within 24 Hours Prior/Post Surgery Surgery Patients on a Beta Blocker Prior to Arrival That Received BB During the Perioperative Period 0.91 Threshold/ Benchmark / / / / / / / 1.0 Gap High High Pharm Impact??? Med?? High 3

34 3 Examples of Pharmacy Activities to Address Care Reform

35 Pharmacist Role in SCIP: Compliance across infection prevention and VTE Work with surgeons/or staff to develop standardized post-op orders by procedure type Antibiotic selection/duration DVT prophylaxis Standardize start time of LMWH Screening/intervention program for unit-based care Places reminder stickers on antibiotics regarding appropriate timing for administration and discontinuation Surveillance by pharmacy on 6am post-op glucose Beta-blocker use: Med list info review (captured pre- or post-admit) Pharmacist ensures order in place or documentation for no resumption 3

36 Pneumonia Quality Improvement: ED Example Automated Dispensing Cabinet Alert Step 1: ER nurse selects one of the following antibiotics: Ceftriaxone, Doxycycline, Moxifloxacin, or Ampicillin/sulbactam Step 3: A response must be selected Step 2: Question Appears 38

37 HCAHPS and Pain Stewardship: Fairview Health Services Pharmacy Pain set as an institutional priority Pain stewardship pharmacist role created Daily report for all patients on oral long acting opioids, fentanyl and methadone Current med profile checked for consistency with patient history Interventions Opioid review note documented by the pain medication stewardship pharmacist Plan for transition to oral, weaning of acute pain medications, and continuity of care is developed Marker of success to date Numerous physician consults 40

38 HCAHPS and Meducation : Improving Patient Education 4 Assist in development of patient education process improvements Implement use of teach-back tool Early identification of learners PharmD-lead education of nursing around medication instruction (ie, scripting, common MRPs, adherence) Develop medication education information High quality info Appropriate for varying levels of knowledge and different languages and learning styles Patient risk stratification system: pharmacy intervenes on high-risk/high-need patients Medication indicators Certain meds (high-risk, high complexity) # of meds/doses Patient indicators Adherence issues Learning barriers or impairments

39 Amplatz Hospital HCAHPS/TOC Improvements Created Medication Teaching Pharmacist Position (1 FTE in Discharge Pharmacy) Reviews all discharge medication orders Compares the med lists Resolves any MRPs Teaching Process Brings medications to the teaching appointment Creates a MedActionPlan for complex regimens Conducts medication teaching for the patient/family Focus on new meds/dose changes Documents teaching activities and interventions Provides a follow up call to the patient/family after discharge Trains/supervises pharmacy students participating in the service 4

40 Amplatz Medication Teaching Metrics Process Measures: % patients taught/offered teaching at discharge % patients with discharge med rec completed by pharmacist Time spent teaching/preparing for teaching/reconciling meds Fairview Discharge Pharmacy prescription capture rate Patient Care Measures: Type/# of interventions made by PharmD Readmission rates Patient Satisfaction Measures: NRC Picker survey results specific med teaching questions Follow up call satisfaction question 4

41 Developing Your Services for Readmissions Reduction Provide Value Improve Quality &/or Decrease Care Costs Readmissions Med-related problems & costs EBM Use HCAHPS Improvement Increase Revenue Discharge Rx Services PharmD Billable Visits Increasing referrals Ensure Efficiency Risk Stratification of Patients Optimize Team-based Care Full engagement of stakeholders Pharmacy-facilitated services use of pharm techs, residents, students Make Use of Technology Telepharmacy Virtual visits Scale Development Increase capacity of hospital or clinic

42 Team-based Comprehensive TOC Service Admission Inpt Stay Discharge Post- Discharge Home / Community Pt Pt Pt Pt VNS RN PharmD RxT RN Pharm D DC Meds RX MD PharmacoTx Clinic # Patients: Mod-High Risk for readmission Intervention: Risk strat, med rec/med hx, education, DC med service, Pharmacotx Clinic* Providers: PharmD, PharmTech, RN, MD, MSW, Case Mgmt Timing: within 5 days of discharge Key Communication: MD Referrals to PCTx clinic, Referrals to VNS, MD engagement for MRPs #Pharmacotherapy Clinic CMR Med Rec MRP identified Adherence Access Sacred Heart Medical Center, Spokane, WA Quality of Transitional Care Program 2012

43 Team-based Service Sacred Heart Medical Center Program Pilot Value Primary Outcomes 30-Day Reduction in Post- Discharge Acute Care Use 30% RR Reduction 9% RR Reduction Medication-related Results INPATIENT 61% improved accuracy in med history (3365 changes) Frequency change = 1100 (33%) Dose change = 1045 (31.1%) OUTPATIENT Errors of omission = 379 Unnecessary meds DC d = 278 Med dose or frequency change = 267 MRP corrected rated as severe= 61 Sacred Heart Medical Center, Spokane, WA Quality of Transitional Care Program 2012

44 SHMC Service Sustainability Program Value Risk stratified patients Team-based focus (nursing-pharmacy-md cooperative effort) Maximized use of pharmacy technicians Focused care on (billable) post-discharge services Improvements for key medication-related problems Unexpected Barriers Increase in discharge prescription intake (13%) Low, volume and low-cost agents = weak revenue stream Increased in visiting nurse service referrals (27%) Not owned by hosp.not direct revenue source Value of readmissions reduction Administration/finance not supportive of program

45 4 Considerations for Readmissions Efforts Medication Errors Discovered by pharmacists on Day 2 Post-Dsch Call (N=197) Participants with at least 1 medication problem 65% Failure to Take Medication No. (%) Patient did not think he/she needed med 19 (15%) Patient did not fill Rx due to cost 21 (17%) Patient did not pick up Rx from pharmacy 14 (11%) Patient did not get Rx on discharge from hospital 15 (12%) Patient self-discontinued due to side effects 14 (11%) Patient did not fill because of insurance issues 10 (8%) Pharmacy Interventions Project Red* Citation: A Reengineered Hospital Discharge Program to Decrease Rehospitalization. Ann Intern Med. 2009;150: Result Successfully contacted patients (average 2 attempts) 62% Completed medication review 53% Median total pharmacist time per participant 26 min

46 Resources for Readmissions Efforts What are resource needs for med rec and care intervention? 300-bed hospital average census of 250.LOS of 3 days = 25 discharges/day If 30% of patients are determined to be high-risk, then 8 patients per day would need post-discharge call within hours. Time for intervention Simple Intervention: 20 min per call Complex Intervention: 40 min per call Time per week = hours/week Resourcing Incorporate into current service? Use residents? Students? Allocate new staffing = FTE or $75,000- $150,000 (pay/benefits)

47 Leveraging and Limits of HRRP Step 1: CMS published hospital readmission penalty percentages in August Your hospital will know what the penalty $ amount is for FFY13 Step 2. Use the Medicare readmissions formulas to determine how current readmission rates for 3 targeted DRGs will impact reimbursement.

48 Estimating the Value of Your Service Step 3 Estimate the relative improvement in readmission rates based on the literature, your pilot, etc and apply it to the formula. Estimated value of services. Compare to resource costs.

49 5 Tools and Resources

50 Service Proposal: Pharmacy-driven Readmissions Reduction Pilot Background: Risks around Readmissions ocms new hospital readmissions reduction program will penalize facilities with higher than adjusted readmission rates. At WRX Medical Center our current readmissions overall rates are 22.3% with higher rates for targeted conditions. Based on expected performance, WRX could incur penalties estimated at $500,000 for FFY12 Medicare payments. ofurthermore, internal quality data reviews indicates that in 50% of readmissions included some component of medication as a complicating factor. In 20% of readmissions, an adverse drug event (ADE) was the primary cause. opublished studies indicate that pharmacist interventions of medication management focused on high-risk patients can decrease ADE occurrence and resolve discrepancies with accompanying reductions in readmissions. Description of Service: 6-month pilot ointroduction of a medication-related problem (MRP) risk assessment screening tool for use by nursing and pharmacy in our medical and cardiac step-down units (2 units). The tool will stratify patients into high vs moderate-to-low risks. oa pharmacist will conduct investigation into all high-risk patients and provide, as appropriate, medication reconciliation, optimize medication regimens and eliminate unnecessary medications. Patients will receive education on proper management of high-risk medications with specific instructions on home monitoring.

51 Service Proposal: Pharmacy-driven Readmissions Reduction Pilot Financial overview: oit is estimated that the MRP Pharmacist working 8 hours (day shift, M-F) will be able to manage 8-10 patients per day. For the pilot, the pharmacy can reallocate 0.4 current FTE to support the project. Support would require an additional 0.6 FTE for 6 months, which equates to approximately $42,000 ($84,000 annually). Benefits: oquality and Safety: 80% decrease in medication discrepancies and related downstream events 50% reduction in ADE events (based on literature) oregulatory Compliance Readmissions: A 50% reduction in the current ADE rate could translate to a 10% relative reduction in current readmissions (2% absolute reduction) or a new rate of 20%. HCAHPS: Current HCAHPS scores around medication teaching and discharge planning at WRX MC are in the lower quartile. MRP project is expected to increase scores notably in the target population. ofinancial It s estimated that 60% of the total readmissions for HF, AMI and pneumonia at WRX MC are related to patients discharged from the 2 MRP pilot care units. A 2% absolute reduction in readmissions for these patients would translate to savings of $150,000. ROI opilot = 78% return ooverall is breakeven when considering readmissions penalties. Other benefits?

52 IHI Readmission Risk Assessment Tool

53 Medication Discrepancy Tool

54 Project BOOST Tools Better Outcomes for Older Adults through Safe Transitions

55 Health Care Reform VBP, Readmissions - Reference Sites HHS Final Rule on Value-based Purchasing ohttp:// CMS Info on VBP Program and Other General Info ohttps:// CMS VBP Process of Care Measures and HCAHPS Measures ohttps:// ohttps:// HR 3590 Patient Protection and Affordable Care Act Readmissions Reduction Program (Section 3025 ) ohttp:// Hospital Compares Website owww.hospitalcompare.hhs.gov Hospital Value Index: Rankings for over 4,500 hospitals

56 Readmissions Information Sources IHI (STAAR Initiative) ohttp:// oidablerehospitalizationsstaar.htm IHI Transforming Care at the Bedside (TCAB) ohttp:// eatthebedside.htm CMS ocommunity-based Care Transitions Program (CCTP) care_transitions.pdf

57 Readmissions Information Sources Care Transitions Project oinformation and tools, including the Med Discrepancy Tool ohttp:// Project Boost orobust info site with tools, etc on care transitions ohttp:// Project RED ohttp:// National Priorities Partnership o7 key targets, including Continuity of Care ohttp://

58 Readmissions Programs to Explore Google for guidance IHI STAAR Initiative and Transforming Care at the Bedside Program Colorado/Kaiser Care Transitions Project CMS Community Care Transitions Program Hospitals in Pursuit of Excellent (HPOE) / AHA 5 Million Lives Campaign / IHI Speak Up / TJC National Priorities Partnership Project Boost, Project RED 6

59 Resources on Readmissions IHI (STAAR Initiative) IHI Transforming Care at the Bedsite (TCAB) x CMS Affordable Care Act: Readmission payment reform Community Care Transitions Program (CCTP) Patients/CCTP/index.html?itemID=CMS Care Transitions Project Project Boost cfm Project RED National Priorities Partnership

60 Questions and Discussion