Optimizing Reimbursement & Quality with Pay for Performance Marisa Valdes, RN, MSN, CPHQ STEEEP Analytics, Baylor Scott & White Health AHA Leadership Forum, July 2016 Please note that the views expressed are those of the conference speakers and do not necessarily reflect the views of the American Hospital Association and Health Forum.
Baylor Scott & White Health (BSWH) BSWH is the largest not-for-profit health care system in Texas More than 900 patient care sites including 49 hospitals 5.3 million patient encounters annually More than 38,000 employees More than 6,000 affiliated physicians Scott & White Health Plan $10.5 billion in total assets $8.4 billion in total net operating revenue 2
BSWH Game Plan for the Future VISIO N 2020 Be Known as a TOP 3 Health Care System Nationally 3
Support A Full Continuum of Services Prevention and Early Detection Wellness and Community Services. Health System Partners Joint Venture Partners Integrated Health Plan and Products Care Coordination Innovative Payor Relationships Chronic Disease Management.. Full Continuum of Services Primary and Specialty Care.. Urgent Care... End - of - Life Care Long - Term Care Home Care Rehabilitation Behavioral Health Care Emergency Community Hospital Care Quaternary Hospital Care 4 4
To Err is Human: Building a Safer Health System November 30, 1999 Institute of Medicine Committee on Quality of Health Care in America announces its first report At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent. estimated to result in total costs of between $17 billion and $29 billion per year in hospitals nationwide. To Err is Human: Building a Safer Health System. Institute of Medicine, Nov. 1999. Web. <http://www.iom.edu/~/media/files/report%20files/1999/to-err-is Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf> 5
Crossing the Quality Chasm Institute of Medicine, 2011 The nation s health care delivery system has fallen far short in its ability to translate knowledge into practice and to apply new technology safely and appropriately It s overly devoted to dealing with acute, episodic care needs and lacking the multidisciplinary infrastructure required to provide the full complement of services needed by people with common chronic conditions Delivery of care often is overly complex and uncoordinated, and patient handoffs slow down care and decrease safety rather than improve it 6
IOM Six Aims for Improvement Safe Avoids injuries to patients from care that is intended to help them Timely Reduces waits and harmful delays impacting smooth delivery of care Effective Provides services based on scientific knowledge to all who could benefit & refrains from providing services to those not likely to benefit (avoids overuse & underuse) Efficient Uses resources to achieve best value by reducing waste, production, and administration costs Equitable Does not vary in quality according to personal characteristics such as gender, income, ethnicity & location Patient Centered Respectful of and responsive to individual patient preferences, needs, and values 7
The STEEEP Health Care Improvement Journey The STEEEP acronym was trademarked by BSWH to communicate the challenge of achieving its objective to provide ideal care in terms of the IOM s call for care that is safe, timely, effective, efficient, equitable, and patient-centered. STEEEP also communicates the steep challenge of ascending from current levels of care to achieving the Triple Aim (articulated by Don Berwick in 2008) of better care for individuals, better health for populations, and reduction in percapita health care costs. 8
System Alignment for STEEEP Care: Organization STEEEP Governance Council Consolidates efforts of clinical, operational, & financial leadership and ensures that all improvement efforts encompass all domains of STEEEP care. BSWH CEO / President STEEEP Governance Council (Chief Quality Officer- Chair) Clinical Service Lines: - Cardiovascular - Critical Care - ED - Gastrointestinal - Neuroscience - Oncology - Orthopedics - Transplant - Women s Health - Path & Lab Med - Radiology STEEEP Subcommittees 1. Patient Safety 2. Timeliness, Effectiveness, & Efficiency 3. Equity / Population Health 4. Patient Centeredness/Patient Experience Business Support Services: -Information Services - Compliance - Finance - Human Resources - Supply Chain New Business Development (e.g., STEEEP framework applied to new model urgent care centers) 9
Healthcare Systems Issues Run Across the Spectrum http://www.nehi.net/writable/publication_files/file/wasteland_of_ health_care_7.08.pdf 10
$900 Billion in Waste Source: Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307:1513-1516. 11
Healthcare Systems Issues 12
Alliance Achieving the Triple Aim Triple Aim Improve the patient experience of care Improve the health of the population Reduce the per capita cost of health care Better Care Better Health Better Value 13
Reimbursement Models 14
IOM Report: Best Care at a Lower Cost Institute of Medicine Report, Best Care At a Lower Cost, 2012 15
CMS Moves to Value & Quality 16
CMS Moves to Value & Quality 2010 2011 2012 2013 2014 2015 2016 2017 Inpatient Quality Reporting Requirement (IQR, formerly RHQDAPU) Value-based Purchasing (VBP) Readmissions Hospital Acquired Conditions (HAC) Hospital Acquired Conditions Meaningful Use RHQDAPU = Reporting Hospital Quality Data for Acute Payment Update 17
What s at Stake? Three programs: Value Based Purchasing, Hospital Readmissions Reduction, Health care Acquired Conditions Reduction Program A total of 24 number of measures A total of $ 34.8 M in DRG payments at risk Impact on regional and national rankings/ratings Reputation 18
BSWH STEEEP Governance Council: System Governance BSWH STEEEP Governance Council Voting members: Chief Quality Officer (Chair), Chief Operations Officer, Chief Medical Officers (BSWH, North & Central), Presidents (North & Central), Chief Financial Officer, Chief Nursing Executive, Chief Nursing Officers (North & Central), Chair of Physician Groups (North & Central), President BSWACO/BSW Quality Alliance, Chief Integrated Delivery Network Officer BSWH STEEEP Governance Council Subcommittees Patient Safety Timeliness, Effectiveness, & Efficiency Equity / Population Health Patient Centeredness/ Patient Experience Aligned Entities STEEEP Measurement, Analytics, and Reporting STEEEP Care Improvement Training Clinical Service Lines 19
Goals & Goal Setting System-wide goals are aligned with the Circle of Care and Circle of Innovation -People -Quality -Service -Finance 20
How Do We Arrive at System Goals? Understand Strategic Plan Answer the question How do we measure the System s FY16 success? Involve cross-division subject-matter experts Review with the Compensation & Governance Committee of the Board Develop goals, targets, and ranges, ensure measurability, and assign weights Refine for final approval 21
Baylor Scott & White Health System Goals - QUALITY Example Hospital Goals 22
The HOW : Program Governance Align Internal Goals (when possible) with External Forces CMS Measures for VBP, Readmission Reduction, HAC Reduction Communicate Goals & Progress with Leaders Record Progress via Reporting Tools & Huddle boards on site Monitor Progress & Predict via Dashboards Value Based Purchasing Readmissions Dashboard Hospital-Acquired Conditions (HAC) Dashboard Project Losses & Gains for Budget Planning 23
The HOW : Program Governance 1. Monitor National Regulatory Policy re: P4P programs 2. Vertical & Horizontal BSWH Education & Awareness From Board Level to Bedside Caregivers Partnered with BSWH Communications to create staff level flyer series (updated semi annually) Presentations, Webinars throughout the system STEEEP Governance Council standing agenda item 3. Partnered with BSWH Government Finance Team to add financial impact estimates and build predictive modeling reports. 24
The HOW : Program Governance Combined Data Sources & Partnerships 1. Clinical Process of Care Domain Vendor supported databases with national benchmarking capabilities since 2006 2. Patient Experience of Care Domain 3. Patient Outcomes Domain 4. Press Ganey Database with national benchmarking capabilities since 2006 Inpatient Mortality Reporting on monthly basis since 2007 AHRQ Quality Indicators Software (public/free) for PSI tracking CLABSI, CAUTI, MRSA, C. Diff, SSI NHSN data reported at unit level 30 day readmission tracking for CMS sensitive conditions Efficiency Domain Partnering with Finance/Revenue Cycle, Care Coordination, and Clinical Analytics to understand and improve patterns 25
The HOW : Analytic Infrastructure Data management, analysis and reporting to support datadriven decision making at the entity, unit, physician, enterprise level Implementation and reporting of performance measurement indicators Integration of data from multiple internal sources within BSWH & state, regional, and national databases for benchmarking purposes System-wide support for standardized reporting 26
The HOW : Reporting Strategy First BSWH internal VBP monthly report prior to CMS payment implications *Centers for Medicare and Medicaid Services 27
The HOW : Reporting Strategy HOSP 1 HOSP 2 HOSP 3 HOSP 4 HOSP 5 HOSP 6 HOSP 7 HOSP 8 HOSP 9 HOSP 10 HOSP 11 Align internal reporting with external efforts HOSP 12 HOSP 13 HOSP 14 HOSP 15 HOSP 16 HOSP 17 HOSP 18 HOSP 19 AMI = Acute Myocardial Infarction; COPD= Chronic Obstructive Pulmonary Disease; HF = Heart Failure; PN = Pneumonia; TKHA= Total Knee or Hip Arthroplasty 28
The HOW : Reporting Strategy 29
The HOW : Reporting Strategy All Cause 30-Day Readmission All 30-Day All Condition All Cause Readmission Rate Example Data All 30-Day All Condition Readmission Rate By Facility Example Data Different Facilities 30
HOSP 18 HOSP 17 HOSP 16 HOSP 15 HOSP 14 HOSP 13 HOSP 12 HOSP 11 HOSP 10 HOSP 9 HOSP 8 HOSP 7 HOSP 6 HOSP 5 HOSP 4 HOSP 3 HOSP 2 HOSP 1 The HOW : Reporting Strategy HAC Reduction Dashboard HOSP 1 HOSP 2 HOSP 3 31
The HOW : Reporting Strategy Monthly VBP Prediction Workbook 32
The HOW : Analytic Strategy 33
The HOW : Analytic Strategy 34
The HOW : Analytic Strategy 35
The HOW : Analytic Strategy 36
The HOW : Analytic Strategy 37
The HOW : Analytic Strategy 38
The HOW : Analytic Strategy 39
The HOW : Analytic Strategy 40
The HOW : Analytic Strategy 41
The HOW : Analytic Strategy 42
The HOW : Analytic Strategy 43
VBP Slope of Linear Exchange Function 44
The HOW : Improvements at the Sites Value Based Purchasing: Benchmarking against the 95th 75th percentiles nationally Reviewing every fall out Partnering with clinicians to implement improvements Documentation improvements and real time abstraction 45
The HOW : Improvements at the Sites Readmissions Reduction Program: Created system task force to drive change and governance Real time analytics and risk based predictive modeling Care paths by condition to ensure best practices and global care Developing continuum of care for HF patients Comprehensive care coordination team 46
The HOW : Improvements at the Sites Healthcare Acquired Conditions Program Patient Safety Task Force for PSI improvement Documentation and coding secondary reviews Physician review of questionable events Real time reporting Infection prevention and control (adapting surveillance) Senior leader weekly report of numerator cases with action plan 47
You have to be willing (or forced) to redesign
Redesign Implications we need to reorganize care around achieving value for patients- and that we have to do it in more thoughtful and strategic ways. If we are really trying to improve health outcomes for patients, we first need to define all the activities that are likely to enhance health for specific segments of the population-that is, to map out what organizational strategies call value chain analyses. Sayer C, Lee TH. N Engl J Med 2014;371:1273-1276. 49
Closing Thoughts Improving quality is a key priority of our P4P journey Setting goals and measuring progress is critical to reducing readmissions, infections, undesirable events, and improving P4P related metrics A strong analytic infrastructure is vital, requires resources, and takes time to mature Tools and dashboards are complementary to support goal attainment Communication between leadership, medical staff, and front line staff is the key to success Targeted improvement activities aligned with goals are essential 50
Closing Thoughts Installation [of any new system or approach] is hard, and mainly technical Implementation is really hard, and mainly organizational Transition (lasting change) is incredibly hard, and purely human Transformation is a state of profound new personal and enterprise behavior Marc Overage MD PhD, Regenstrief Institute, Inc: A Healthcare Laboratory and a Community of Scholars 51
Questions? 52
Appendix 53
Value Based Purchasing: Program Overview Enacted by the Affordable Care Act (2010) Rewards hospitals for better value, patient outcomes, and efficiency, instead of just volume of services Uses quality measures reported through the Hospital Inpatient Quality Reporting (IQR) program, (core measures), results from the inpatient HCAHPS survey, claims based measures (mortality, patient safety, MSPB) Allows hospitals to receive value based incentive payments if they meet certain standards during a defined performance period Funded by a reduction from participating hospitals base operating diagnosis-related group (DRG) payments Medicare spending per beneficiary is a key measure part of the efficiency domain 54
How Much is at Risk? Value-based purchasing is one of several CMS quality-based payment initiatives expected to put more than 7% of payment at risk by 2017. Value- based purchasing accounts for 2% of base DRG payments. 55
Value Based Purchasing Evolution 56
Changes in FFY17 2% of base DRG payments at risk 57
HAC Reduction Program (Old) Hospital Acquired Condition Program Hospitals no longer receiving additional payment when one of the selected conditions was not present on admission Eight of the 10 conditions adopted for public reporting (tied to APU) in 2011. Reporting on hospital compare modified to remove redundancy in 2013. VS. (New) Hospital Acquired Condition Reduction Program Reduces hospital payments by 1% to the hospitals in the worst ranking quartile PSI 90 (composite of 8 PSI s), CAUTI and CLABSI (SIR), and HAI s added in FY16 & FY17 58
HAC Reduction Program Measures 59
HAC Payment Years & Performance Periods 60
References Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307:1513-1516. Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999. Institute of Medicine. Crossing the Quality Chasm. Washington, DC: National Academy Press; 2001. Institute of Medicine. Best Care At a Lower Cost. Washington, DC: National Academy Press; 2012. Sayer C, Lee TH. Time after time health policy implications of a threegeneration case study. N Engl J Med. 2014;371:1273-1276. The Network for Excellence in Innovation. The Wasteland of Health Care. July 2008. Marc Overage MD PhD, Regenstrief Institute, Inc: A Healthcare Laboratory and a Community of Scholars 61