Understanding HSCRC Quality Programs and Methodology Updates

Understanding HSCRC Quality Programs and Methodology Updates Kristen Geissler, MS, PT, CPHQ, MBA Managing Director Beth Greskovich - Director Berkeley Research Group August 19, 2016

Maryland Waiver and Quality Because of the original waiver, Maryland was exempt from CMS hospitalbased quality programs Maryland had to develop or adopt methodologies that were the same (or broader) in scope to CMS Maryland must have the same (or more) dollars at risk as CMS New 5-year waiver began 2014 All Maryland hospitals now under a Global Budget Revenue (GBR) system 1

Quality-Specific Waiver Goals Maryland Statewide 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 2

Quality Programs CMS vs Maryland CMS Maryland (HSCRC) Value-Based Purchasing (VBP) Quality-Based Reimbursement (QBR) Hospital Readmission Reduction Program (HRRP) Hospital Acquired Conditions (HAC) Readmission Reduction Incentive Program (RRIP) Maryland Hospital Acquired Conditions (MHACs) (PPCs) 3

Maryland versus National Quality Financial Impact CMS (Inpt Medicare revenue) VBP Maryland (Inpt all-payer revenue) QBR 2% variable 2% 1% HAC MHAC 1% 0 3% 1% HRRP RRIP 3% 0 2% 1% Total Total 6% variable 7%, but capped at 3.5% 3% 4

Maryland versus National Quality Financial Impact CMS (Inpt Medicare revenue) VBP Maryland (Inpt all-payer revenue) QBR 2% variable 2% 1% HAC MHAC 1% 0 3% 1% HRRP RRIP 3% 0 2% 1% 6% Total variable 7%, but capped at 3.5% Total 3% 5

Quality Based Reimbursement QBR 7

QBR Components and Weighting 9

QBR Components Over Time FY 2016: 1% Penalty / 1% Reward (Scaled around median) HCAHPS Clinical Process Clinical Outcomes Mortality PSI-90 CLABSI FY 2017: 2% Penalty / 1% Reward (Predetermined Scale) HCAHPS Clinical Process Clinical Outcomes Mortality Patient Safety PSI-90 CLABSI CAUTI SSI FY 2018: 2% Penalty / 1% Reward (Predetermined Scale) HCAHPS + CTM Clinical Outcomes Mortality Patient Safety PC-01 CLABSI CAUTI SSI C-diff MRSA 10

QBR Measurement Periods for RY2018 Impact Measures Distribution Base Period Perf Period HCAHPS 50% CY14 Oct 15 - Sep 16 Mortality 15% FY15 CY16 PC-01 CY14 Oct 15 - Sep 16 CLABSI CY14 Oct 15 - Sep 16 CAUTI CY14 Oct 15 - Sep 16 SSI (colon; abd hyst) 35% CY14 Oct 15 - Sep 16 Cdiff CY14 Oct 15 - Sep 16 MRSA Bacteremia CY14 Oct 15 - Sep 16 PSI-90* (suspended) FY15 CY16 11

QBR Acronyms CLABSI Central line associated blood stream infection CAUTI Catheter associated urinary tract infection SSI Surgical site infection C diff Clostridium difficile MRSA Methicillin resistant staphylococcus aureus PSI-90 Patient safety indicator composite PC-01 Perinatal care Elective deliveries < 39 weeks 12

QBR Financial Impact Up to 1% reward Up to 2% penalty Predetermined scale Not revenue neutral 13

QBR Outcomes Domain - Mortality Maryland-unique metric In-hospital, all-condition (~38 APR DRGs) mortality Measurement period: January December 2016 Risk adjustments: Age Gender Admitting APR ROM (risk of mortality 1-4) Transfers in from another hospital 14

FY18 Updates Process measure IMM-2 (Influenza Immunization) removed and new process measure PC-01 (Elective deliveries at 37-38 weeks) added PC-01 sits in Safety Domain rather than a separate Process Domain New Healthcare Associated Infections (HAIs) added to Safety Domain MRSA Infection C Difficile Infection New scored item bundle in HCAHPS 3 questions on Care Transition 15

Maryland Hospital Acquired Conditions MHAC 16

MHAC and PPC Highlights PPC Potentially Preventable Complication (3M) MHAC Maryland Hospital Acquired Condition Current measurement period = CY2016, which impacts FY2018 payment Applies to inpatients only Coded/documented data only Different from CMS (Medicare) HACs (Hospital Acquired Conditions) Most PPCs/MHACs can affect any patient population PPC/MHAC is the complication, not the reason for admission 17

Highest Tier PPCs CY 2016 All Other PPCs Weighted at 50% PPC # PPC Name 3 Acute Pulmonary Edema and Respiratory Failure without Ventilation 4 Acute Pulmonary Edema and Respiratory Failure with Ventilation 5 Pneumonia & Other Lung Infections 6 Aspiration Pneumonia 7 Pulmonary Embolism 9 Shock 14 Ventricular Fibrillation/Cardiac Arrest 16 Venous Thrombosis 21 Clostridium Difficile Colitis 27 Post-Hemorrhagic & Other Acute Anemia with Transfusion 35 Septicemia & Severe Infections 37 Post-Operative Infection & Deep Wound Disruption Without Procedure 38 Post-Operative Wound Infection & Deep Wound Disruption with Procedure 40 Post-Operative Hemorrhage & Hematoma without Hemorrhage Control Procedure or I&D Proc 41 Post-Operative Hemorrhage & Hematoma with Hemorrhage Control Procedure or I&D Proc 42 Accidental Puncture/Laceration During Invasive Procedure 49 Iatrogenic Pneumothorax 54 Infections due to Central Venous Catheters 65 Urinary Tract Infection without Catheter 66 Catheter-Related Urinary Tract Infection 18

MHAC Measurement Basis of measurement is an Observed to Expected (O/E Ratio) PPCs must be below expected to score any attainment points Each PPC evaluated for: Achievement 0-10 Hospital O/E Ratio compared to a statewide benchmark Improvement 0-9 Hospital O/E ratio compared to itself year over year The higher score of achievement or improvement wins 19

Expected Value Calculation Each PPC has an expected number of occurrences Calculated number based on the statewide average in the base year and adjusted for the hospital s volume and mix of cases in the performance year APR DRG (TKR) Severity of Illness (SOI) Statewide Rate of PPC 7 PE in Base Period (FY2014) Hospital A Volume CY2015 Hospital A Expected Amount of PPC 7 in CY2015 302 1 0.32% 75 0.24 302 2 0.55% 85 0.46 302 3 1.83% 55 1 302 4 0.00% 5 0 1.7 20

Statewide MHAC Improvement Goals Waiver Goal: Reduce statewide overall MHACs by 30% CY2018 compared to CY2013 2014 8% goal 2015 7% goal 2016 6% goal Statewide reduction to-date: CY14: 26% CY15: 24% CY16 YTD: 14% 21

MHAC Financial Impact Statewide Improvement Target Met Up to 1% reward Up to 1% penalty Statewide Improvement Target NOT Met No reward Up to 3% penalty Predetermined scale Not revenue neutral 22

FY18 Updates Move from 3 tiers to 2 tiers (100%, 50%) Five PPCs placed on monitor-only list New combination PPCs Updated expected values and benchmarks New benchmark calculation to ensure inclusion of 25% of population Statewide improvement target at 6% 23

Readmissions Reduction Incentive Program RRIP 24

Readmission Highlights CMMI agreement requires MD to have a lower readmission rate than the nation by the end of the demonstration period, CY 2018 Drives the improvement target in RRIP Current measurement period = CY2016, which impacts FY2018 payment Applies to inpatients only Different from CMS (Medicare) HRRP which measures AMI, HF, PN, COPD, TKR/THR, and CABG and penalizes hospitals for excess readmissions More similar to HWR (Hospital Wide Readmissions) which is pay to report only 26

RRIP Methodology Readmission policy is measured as Inpatient, all-payer, all-cause readmissions within 30 days of an inpatient admission Adjusted for planned readmissions Inter-hospital readmissions are included Risk-adjusted using Discharge APR SOI (severity of illness) Adjusted for out-of-state readmissions CY2016 measurement period looks at both attainment and improvement Must improve at least 9.5% comparing CY2016 risk adjusted readmission rate to the CY2013 (base period) risk adjusted readmission rate Must attain better than 11.85% risk adjusted readmission rate + out of state adjustor Pre-set scale for financial impact Better of attainment or improvement scaling will win 27

Readmission Measurement Basis of measurement is an Observed to Expected (O/E Ratio) Risk Adjusted Rate = Hospital O/E x Statewide Average RA Rate Improvement = CY 2016 Risk Adjusted Rate change from CY 2013 Risk Adjusted Rate, compare to the target of 9.5% improvement Attainment = CY 2016 Risk Adjusted Rate x Medicare Out of State Adjustor, compare to the target of 11.85% Attainment and Improvement have their own separate payment scales, Penalties or Rewards are calculated based on the difference from the target Hospital result is the better of Attainment $ or Improvement $ HSCRC files available on the CRISP CRS portal FY18 Readmission Reduction Program Comparison CY16-04 created 2016-07- 28.xls HSCRC provided a calculator file 28

Readmission Sample Calculations RY 2018 RRIP Scaling Calculation Sheet Purpose: Hospitals can use this sheet to enter in current or projected readmission rates to estimate revenue adjustments for RY 2018. User entered values CY13 YTD CY16 Casemix Casemix Adjusted Adjusted Readmission Readmission Rate Rate CY2013 Base period O/E x CY2013 statewide average readmission Rate Out of State Ratio (see CY15 tab for estimate) * Improvement Target Improvement Scaling Percent Change in Case Mix Adjusted Rate Over/Under Improvement Target FY 18 Improvement scaling RY 2018 Scaling Points RY18 Targets and Benchmarks Improvement Target: CY 13 - CY16 Change -9.50% Attainment Benchmark: CY 2016 Readmission Rate 11.85% Improvement Payment Scale Attainment Payment Scale All-Payer Readmission Rate Change CY13-CY16 Worksheet calculated values Attainment Scaling Attainment Benchmark CY16 Casemix Adjusted Rate with Out of State Adjustment RRIP % Inpatient Revenue Payment Adjustment Over/Under Attainment Benchmark All Payer Readmission Rate CY16 FY 18 Attainment scaling *Final calculations will use CY 2016 ratios of total Medicare / In state Readmission Rates; CY 2015 ratios can be used as estimates (see CY15 Out of State Ratio Tab). RRIP % Inpatient Revenue Payment Adjustment Lower 1.00% Lower 1.00% -20.00% 1.00% 10.61% 1.00% -18.00% 0.81% 10.85% 0.81% -15.00% 0.52% 11.20% 0.52% -10.00% 0.05% 11.79% 0.05% -9.50% 0.00% 11.85% 0.00% -9.00% -0.05% 11.91% -0.05% 5.00% -1.49% 13.57% -1.49% 9.00% -1.90% 14.05% -1.90% 10.00% -2.00% 14.16% -2.00% Higher -2.00% Higher -2.00% Final Adjustment FY18 Better of Attainment/Impro vement 10.60% 9.51% 1.04-9.50% -10.28% -0.78% 0.07% 11.85% 9.89% -16.54% 1.00% 1.00% CY2016 Perf period O/E x CY2013 statewide average readmission Rate 29

RRIP Financial Impact Up to 1% reward Up to 2% penalty Better of attainment or improvement Predetermined scale Not revenue neutral 30

FY18 Updates Payment based on attainment or improvement, also retro to FY 2017 impact Updates related to exclusions Transfers now include 0 and 1 day Intervals Oncology discharges based on APR DRG list CMS Planned admission algorithm v4.0 + all deliveries + Rehab Discharges 31

Potentially Avoidable Utilization PAU 32

Potentially Avoidable Utilization (PAU) Shared Savings Overview PAU is volume that can be potentially avoided through strategies such as care management across the healthcare continuum. HSCRC uses this as a tool to adjust the global budget, not as a quality payfor-performance metric Readmissions Measured at the readmitting hospital Includes inpatients and observation > 23 hours Prevention Quality Indicators (PQI) Medically-necessary, chronic conditions, identified by principal diagnosis Includes inpatients and observation > 23 hours Measured as charges associated with readmissions and PQI as a percent of total charges (inpatient + outpatient) 33

AHRQ Prevention Quality Indicators (PQI) Diabetes short-term complications Diabetes long-term complications Diabetes lower-extremity amputation Uncontrolled diabetes Bacterial pneumonia COPD/Asthma in older adults Asthma in younger adults Hypertension Heart failure Dehydration Urinary tract infection Angina without procedure Perforated appendix Patients with an admission source of long term care, nursing facility, or another hospital are excluded from PQIs 34

PAU Measure and Impact Inpatient Observation ER Visits Policy Impact Readmissions At Readmitting Hospital Initial admission and 30 day Readmission Initial admission and 30 day Readmission Not applicable Rate Year 2017 Population Adjustment for Annual Update PQIs Based on PDX Based on PDX Not applicable PPCs Not applicable Not applicable Not applicable Market Shift Adjustment Shared Savings Data Period : Calendar 2015 HSCRC files available on the CRISP Portal PAU Summary CY16-01 to CY16-04_rev 07-11-2016.xls File now includes All Payor, Medicare and Medicaid Summaries 35

FY 2017 Shared Savings For FY 2017 HSCRC has expanded the basis from readmissions to readmissions and PQI Syncing up the definition with the market shift adjustment Increased the annual reduction from 0.2% to 0.65% 1.25% is the cumulative (multi-year) reduction 0.65% is the net one year reduction Hospital PAU % x statewide reduction amount of 11.43% For hospitals with higher socio economic burden, reduction is capped PAU Sample PAU % CY2015 Statewide Reduction PAU Adjustment Reverse Prior Year FY2017 Net Adjustment 11.29% (11.43%) (1.29%) 0.60% (0.69%) 36

Speaker Biographies Kristen Geissler has over 20 years of experience in healthcare, both in direct patient care and administrative and consulting roles. She has expertise in various quality-based reimbursement methodologies and has a detailed understanding of providers auditing and submission requirements related to the various required and voluntary national quality reporting policies. She also has expertise in clinical documentation improvement and the role of coding and documentation in quality reporting. Before her consulting career, Ms. Geissler was the director of Quality Improvement at a Maryland hospital, and she is also a licensed physical therapist. Beth Greskovich has over 25 years of experience in healthcare, both in administrative and consulting roles. She has expertise in various quality-based reimbursement methodologies. She also has expertise in HSCRC compliance and reimbursement methodology. Over the course of her career, Ms. Greskovich was the director of Financial Planning at three Maryland hospitals. Most recently, Ms. Greskovich has developed data and reporting techniques to monitor and support population health initiatives. 37