The Nexus of Quality and Finance

The Nexus of Quality and Finance Kristen Geissler Pat Ercolano March 4, 2014

Transition from Volume to Value: IHI Triple Aim IHI Triple Aim Improve patient experience of care (quality & satisfaction) Improve population health Reduce per capita cost of healthcare Efficient Effective 1

Quality Programs CMS vs Md CMS Value Based Purchasing (VBP) Maryland (HSCRC) Quality Based Reimbursement (QBR) Hospital Readmission Reduction Program (HRRP) Hospital Acquired Conditions (HAC) Admission Readmission Revenue (ARR) Maryland Hospital Acquired Conditions (MHACs) (PPCs) 2

Increasing Financial Impact of Quality Metrics Maryland (HSCRC) National (CMS) Core Measures Core Measures HCAHPS HCAHPS QBR Mortality AHRQ Patient Safety Indicators 1% VBP Mortality AHRQ Patient Safety Indicators 1.75% HAI CLABSI HAI CLABSI, CAUTI, SSI MHAC Maryland Hospital Acquired Conditions (MHAC) (65) 3% HAC AHRQ Patient Safety Indicators HAI CLABSI, CAUTI 1% PAU Readmissions (all cause)? HRRP Readmissions (5 diagnoses) 3% Total >4% Total 5.75% 3

Maryland Waiver Quality Goals Readmissions Must reduce Medicare all cause interhospital 30 day readmissions to below the national rate in 5 years Complications Must decrease all payer complications (all 65 MHACs) by 30% over 5 years Other Improve HCAHPS scores Targets for improvement in AHRQ Patient Safety Indicators Improve Core Measures Targets for potentially avoidable utilization Ambulatory health measures Population health measures 4

Update on Current HSCRC Quality Programs Quality Based Reimbursement (QBR) Increase to 1% at risk Additions to Outcomes component AHRQ Patient Safety Indicator Composite Central Line Blood Stream Infections (CLABSI) as measured by CDC Maryland Hospital Acquired Conditions (MHAC) Readmissions 5

Quality and Finance Can either Quality or Finance drive success on their own? No! Goals are now aligning Quality may become the main driver of revenue in the future Must be able to speak the same language and collaborate in order to drive improvement Transition from volume to value drives the imperative 6

Data Quality versus Clinical Quality Documentation and submitted data must reflect what actually happened with the patient in the hospital no more and no less Incomplete/unclear documentation and data may result in poor performance scores and may not reflect real clinical quality 7

Strategies To Drive Desired Performance Engagement of the Clinicians Audience: Senior Leaders * include Board members Finance Data Mining Quality Front-line Staff Physicians Education 8

Understanding The Data Provider ID Hospital At Risk Inpatient Revenue % of At Risk Revenue FY14 Q1 Rank 210003 $86,216,208.64-0.71% 20 210063 $141,054,330.90-0.93% 21 210043 $138,183,651.84-0.99% 22 210044 $124,525,558.76-1.06% 23 210013 $48,081,697.24-1.12% 24 210038 $61,806,850.39-1.20% 25 210049 $91,421,174.59-1.21% 26 210012 $263,262,289.55-1.23% 27 210010 $18,193,289.42-1.30% 28 210015 $181,058,680.88-1.32% 29 210016 $100,100,783.31-1.34% 30 210024 $157,855,048.45-1.35% 31 210033 $91,102,402.85-1.37% 32 What does this mean to your audience? 210037 $60,486,039.59-1.38% 33 210005 $122,868,024.67-1.38% 34 210011 $150,833,120.57-1.41% 35 210023 $195,732,144.80-1.48% 36 210057 $146,094,676.17-1.66% 37 210039 $44,430,727.61-1.70% 38 210045 $3,175,647.56-1.93% 39 210028 $45,555,934.33-2.07% 40 210034 $79,165,838.45-2.36% 41 210035 $47,411,626.63-2.44% 42 210017 $12,473,010.20-2.85% 43 210030 $19,451,338.74-2.89% 44 210056 $104,250,966.99-3.11% 45 210061 $24,460,163.46-3.65% 46 9

MHAC Education Hospital Below Expected 10

Data Mining Who s the Audience? HSCRC Methodology Finance Weighted By Charges Quality Total # of Complications Clinician HSCRC Methodology Severity adjusted Weighted By Charges Dollars at Risk Pro Forma Estimates Rate Impact Observed over Expected Total # Complications Trending Data Process Failures Concurrent Surveillance Coded vs Clinical Data Observed over Expected Patient Level Drill Down Weighted By Charges Trending Data 11

Financial Perspective MHAC Financial Weight Performance CYTD December 2014 PRELIM Resource Use PPC Code PPC Description Financial Weight Actual PPCs Expected PPCs PPC Variance Over/(Under) Expected ($) 9 Shock $19,321 66.0 115.9 (49.9) (963,785) 35 Septicemia & Severe Infections $18,853 50.0 75.5 (25.5) (481,034) 65 Urinary Tract Infection $14,313 130.0 161.2 (31.2) (446,255) 6 Aspiration Pneumonia $16,628 20.0 42.4 (22.4) (372,999) 14 Ventricular Fibrillation/Cardiac Arrest $20,204 58.0 74.6 (16.6) (335,254) 10 Congestive Heart Failure $6,375 4.0 46.5 (42.5) (271,024) 5 Pneumonia & Other Lung Infections $20,888 80.0 92.4 (12.4) (258,310) 17 Major Gastrointestinal Complications without Transfusion or Significant Bleeding $15,508 12.0 28.1 (16.1) (248,969) 19 Major Liver Complications $21,822 7.0 17.0 (10.0) (218,366) 47 Encephalopathy $11,772 3.0 20.9 (17.9) (210,491) 31 Decubitus Ulcer $32,815 7.0 13.0 (6.0) (196,540) 1 Stroke & Intracranial Hemorrhage $13,527 29.0 42.0 (13.0) (176,278) 52 Inflammation & Other Complications of Devices, Implants or Grafts except Vascular Infection $11,290 33.0 45.8 (12.8) (144,291) 48 Other Complications of Medical Care $18,559 20.0 26.2 (6.2) (115,605) 27 Post-Hemorrhagic & Other Acute Anemia with Transfusion $6,618 34.0 51.5 (17.5) (115,585) Pro Forma Estimate CYTD Dec 2013 CYTD Sept Final CYTD Sept Final Prelim Attainment Improvement Hospital Total @2% Inp Rev @1% Inp Rev Hosptial 1 ($3,474,554) ($3,314,932) ($159,623) Hosptial 2 (168,285) 6,070 (174,355) Hosptial 3 (2,350,110) (2,390,692) 40,582 Hosptial 4 (161,451) 1,045 (162,496) Hosptial 5 301,818 92,504 209,315 Hosptial 6 43,682 14,395 29,286 Hosptial 7 76,463 23,208 53,256 Hosptial 8 (2,095,773) 48,933 (2,144,706) Hosptial 9 (311,855) 11,730 (323,584) Hosptial 10 50,994 28,801 22,193 Hosptial 11 79,287 36,799 42,488 Hosptial 12 71,932 32,913 39,019 Hosptial 13 61,288 46,211 15,077 Hosptial 14 102,614 88,679 13,935 Hosptial 15 75,976 73,290 2,686 Hosptial 16 (30,648) 20,911 (51,559) Hosptial 17 256,285 116,871 139,413 Hosptial 18 (93,941) 42,886 (136,827) 12

Quality Perspective MHAC Trending Analysis Observed-to-Expected Improvement PPCs 11.6% O/E Ratio Reduction Hospital Actual Expected Target Hospital 1 425 468.3 0.91 1.01 Hospital 2 182 255.5 0.71 1.00 Hospital 3 64 61.0 1.05 1.25 Hospital 4 43 85.7 0.50 0.61 Hospital 5 11 23.9 0.46 0.43 Hospital 6 9 26.3 0.34 1.07 Hospital 7 40 44.2 0.91 0.74 Hospital 8 30 46.0 0.65 1.05 Hospital 9 122 143.8 0.85 1.04 Hospital 10 53 88.5 0.60 0.73 Hospital 11 161 216.8 0.74 1.25 Hospital-to-Hospital Comparison PPC Code PPC Financial Weight Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7 Hospital 8 Hospital 9 Hospital 10 Hospital 11 % of Hospitals Over Expected 39 Reopening Surgical Site $16,986 8.8 1.9 0.4 1.4 0.3 0.0 0.5 0.9 0.3 0.8 3.6 73% 10 Congestive Heart Failure $6,375 42.3 3.5 17.4 11.5 4.8 2.2 4.5 3.1 1.5 6.5 9.1 64% 8 Other Pulmonary Complic $9,405 109.6 0.4 14.8 0.4 0.6 0.3 0.0 0.7 0.8 2.6 3.4 55% 66 Catheter Related Urinary $11,718 0.5 1.7 1.9 1.2 1.4 0.3 0.4 0.2 1.8 0.3 1.1 55% 3 Acute Pulmonary Edema a $9,808 24.6 16.9 7.6 7.4 22.7 0.6 3.2 1.8 6.3 6.0 6.6 45% 4 Acute Pulmonary Edema a $32,783 59.4 3.1 17.7 1.1 3.0 2.2 0.4 2.7 2.4 4.0 13.7 45% 13 Other Cardiac Complicatio $5,664 3.7 0.7 1.6 0.4 0.1 0.3 0.8 0.4 0.5 0.5 1.5 45% 20 Other Gastrointestinal Co $14,443 0.1 1.7 2.8 0.7 0.6 0.6 1.1 0.3 0.4 0.5 3.8 45% 40 Post Operative Hemorrha $9,819 8.9 0.5 1.4 0.6 0.3 1.0 2.5 0.6 1.7 5.1 8.5 45% 47 Encephalopathy $11,772 17.9 2.3 6.4 3.7 0.3 0.1 0.3 0.0 1.1 1.1 10.9 45% 13

Clinician Perspective MHAC Service Line Clinical Program Actual PPCs Expected PPCs PPC Variance Resource Use Over/(Under) Expected ($) Medicine- Pulmonary MPU 58.0 24.4 33.6 724,715 Emergency Surgery- Emergency Surgery ESC 85.0 78.4 6.6 362,679 Surgery- Vascular Surgery SVA 170.0 118.0 52.0 885,079 Cancer Center- Bone Marrow CBM 0.0 1.0 (1.0) (14,188) Cancer Center- Medical Oncology CCO 3.0 1.8 1.2 19,208 Medicine- (MED 2) General Internal CHR 57.0 54.4 2.6 68,378 Childrens Services- Neonatal PPI 4.0 1.8 2.2 65,495 Otorhinolaryngology- Otorhinolaryngology SEN 28.0 24.6 3.4 138,145 Childrens Services- Peds Cardiology PCA 0.0 0.2 (0.2) (3,555) Oral/Maxillofacial Surgery- Oral/Maxillofacial Surgery DOM 54.0 35.4 18.6 415,921 Research Case Studies 14

Management of Performance Continuous Communication Concurrent Review Identification & Resolution Discharge Coding 3M Encoder Retrospective Review 1. Identification & Resolution 2. Trending Documentation Opportunities Clinical Opportunities Flag Supporting Documentation Documentation POA of N Clinical Trends Medical Quality Committee Recommend Standard of Care Peer Review Referral 15

Management of Performance Engage Physician Champions 16

Data Mining Readmissions Who s the Audience? Finance Quality Clinician ARR/TPR Methodology # of Readmissions RA Severity of Illness Medicare vs Other Payors Cost of Care Adjustments Pro Forma Estimates Observed over Expected By Diagnosis Source of Admission Strategy Compliance Comparative Data Observed over Expected By Service Line By Provider Patient Level Drill Down Risk Analysis By Diagnosis 17

Financial Perspective Readmission 18

AdmSource FY14 Quality Perspective Readmission Source of Admission 61 Admitted from Nursing Home 50 Admitted from Long Term Care facility MONTH RA IA+OA+TA RA DAYS RA RATE RA LOS 7 2012 19 29 151 65.5% 7.95 8 2012 13 32 102 40.6% 7.85 9 2012 17 28 111 60.7% 6.53 10 2012 19 43 169 44.2% 8.89 11 2012 19 30 117 63.3% 6.16 12 2012 13 39 66 33.3% 5.08 1 2013 16 32 108 50.0% 6.75 2 2013 20 29 171 69.0% 8.55 3 2013 19 42 148 45.2% 7.79 4 2013 17 26 140 65.4% 8.24 5 2013 24 33 182 72.7% 7.58 6 2013 22 32 181 68.8% 8.23 7 2013 18 31 132 58.1% 7.33 8 2013 19 28 116 67.9% 6.11 9 2013 16 26 141 61.5% 8.81 10 2013 15 38 133 39.5% 8.87 11 2013 20 28 128 71.4% 6.40 12 2013 22 35 216 62.9% 9.82 1 2014 16 31 118 51.6% 7.38 2 2014 3 2014 4 2014 5 2014 6 2014 FY13 218 395 1,646 55.2% 7.55 FYTD14 126 217 984 58.1% 7.81 Trending Analysis 19

PROD LINE IA PROD LINE Clinician Perspective Readmission Service Line Orthopedic/Musculoskeletal Orthopedic/Musculoskeletal MONTH RA IA+OA+TA RA DAYS RA RATE RA LOS 7 2012 7 123 35 5.7% 5.00 8 2012 16 113 89 14.2% 5.56 9 2012 10 112 80 8.9% 8.00 10 2012 14 109 103 12.8% 7.36 11 2012 15 113 93 13.3% 6.20 12 2012 7 99 48 7.1% 6.86 1 2013 7 133 71 5.3% 10.14 2 2013 17 120 109 14.2% 6.41 3 2013 10 114 81 8.8% 8.10 4 2013 12 103 56 11.7% 4.67 5 2013 12 122 74 9.8% 6.17 6 2013 5 106 28 4.7% 5.60 7 2013 8 103 52 7.8% 6.50 8 2013 9 125 37 7.2% 4.11 9 2013 13 95 76 13.7% 5.85 10 2013 14 108 87 13.0% 6.21 11 2013 14 126 79 11.1% 5.64 12 2013 10 110 66 9.1% 6.60 1 2014 9 132 64 6.8% 7.11 2 2014 3 2014 4 2014 5 2014 6 2014 DRG IA DRG Diagnosis 720 SEPTICEMIA & DISSEMINATED INFECTIONS 720 SEPTICEMIA & DISSEMINATED INFECTIONS MONTH RA IA+OA+TA RA DAYS RA RATE RA LOS 7 2012 6 40 92 15.0% 15.33 8 2012 2 35 25 5.7% 12.50 9 2012 6 29 48 20.7% 8.00 10 2012 4 32 50 12.5% 12.50 11 2012 3 29 18 10.3% 6.00 12 2012 14 35 103 40.0% 7.36 1 2013 9 34 43 26.5% 4.78 2 2013 3 44 16 6.8% 5.33 3 2013 47 0.0% 4 2013 8 56 101 14.3% 12.63 5 2013 11 35 88 31.4% 8.00 6 2013 6 45 34 13.3% 5.67 7 2013 5 37 35 13.5% 7.00 8 2013 3 43 9 7.0% 3.00 9 2013 9 40 58 22.5% 6.44 10 2013 2 52 15 3.8% 7.50 11 2013 5 41 35 12.2% 7.00 12 2013 7 48 71 14.6% 10.14 1 2014 9 47 87 19.1% 9.67 2 2014 3 2014 4 2014 5 2014 6 2014 Readmission Encounters Readmit by Attending MD Nonelective readmits only Acute All Inpatient Admissions From 4/2013 to 6/2013 for readmits within 30 days. Attending Provider for Index Total Readmission Rate Doctor 1 69 18.1% Doctor 2 51 18.0% Doctor 3 49 21.1% Doctor 4 46 17.7% Doctor 5 41 19.8% Doctor 6 36 14.4% Doctor 7 34 17.3% Doctor 8 33 27.3% Doctor 9 33 20.2% Doctor 10 32 12.4% FY13 132 1,367 867 9.7% 6.57 FYTD14 77 799 461 9.6% 5.99 FY13 72 461 618 15.6% 8.58 FYTD14 40 308 310 13.0% 7.75 20

Management of Performance Best Practice Research Reports Finance Quality Reports Gap Analysis Case Clinicians Management Action Plan Development Reports 21

Kristen Geissler, MS, PT, MBA, CPHQ Kristen Geissler 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 quality based reimbursement methodologies, including VBP (Value Based Purchasing) and MHAC (Maryland Hospital Acquired Conditions), and has a detailed understanding of providers auditing and submission requirements related to the various required and voluntary national quality reporting policies. She has assisted the Maryland Hospital Association, its members, and the Health Services Cost Review Commission (HSCRC) of Maryland, during the implementation of Maryland s quality based reimbursement policies related to clinical process measures, hospital acquired conditions, and preventable readmissions. 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 large urban health system, and she is also a licensed Physical Therapist. 22

Pat Ercolano, RN, MBA Pat Ercolano has been in healthcare for more than 30 years with direct clinical care experience as well as healthcare administration. Her practice spans the fields of emergency and occupational health management, leadership development, and performance improvement to advance patient quality and safety outcomes in hospitals. She is the Corporate Vice President of Quality Management for the University of Maryland Medical System a multi hospital system with academic, community and specialty services across the State of Maryland. In her role she has developed a strong partnership between Quality and Finance to align quality outcomes and cost of care information shared by hospital management and clinical teams to drive improved clinical performance and positive quality based reimbursements. Pat is a registered nurse and received her MBA from Loyola University. 23