Medicare Value Based Purchasing August 14, PDF Free Download

Premier is the nation s largest healthcare alliance Our mission: To improve the health of communities 2,600 member hospitals Database representing 1 in every 4 U.S. discharges Owned by 200 healthcare providers Four time winner of Ethisphere s most Ethical Companies award 83,000+ Alternate sites of care Award winning environmentally sustainable program $4.2 BILLION savings in 2011 $43 BILLION in group purchasing volume Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 2

The many flavors of Medicare value based purchasing Inpatient VBP 1% 1.25% 1.5% 1.75% 2% 30 day Readmissions 1% 2% 3% 3% 3% Hospitalacquired conditions 1% 1% 1% Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 3

Pay for Performance project Premier is leading the first national CMS pay for performance demonstration for hospitals. More than 260 Premier hospitals participate voluntarily. Hypothesis Financial incentives / transparency improve hospital quality & performance Findings Financial incentives did focus hospital executive attention on measuring and improving quality. Hospitals performance has improved continuously over time. Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 5

VBP 2013 measures and weighting 70% Weight: 12 clinical process measures in five domains Acute myocardial infarction Heart failure Pneumonia Surgery Surgical infections Clinical Process and Patient Survey Timeline for FY 2013 Payment Baseline July 1, 2009 to March 31, 2010 Performance July 1, 2011 to March 31, 2012 30% Weight: 8 patient experience measures Communication with nurses Communication with doctors Responsiveness of staff Pain management Communication about medicines Cleanliness and quietness of environment Discharge information Overall rating Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 6

VBP into the future Expands to include mortality in 2014 Expands in 2015 to include Medicare Spending per Beneficiary (A/B); AHQR Patient Safety Indicator composite measure; and Central Line Associated Blood Stream Infection measure. Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 7

Readmissions 2013 Readmissions will be measured in three categories, using three years of data (July 1, 2008 through June 30, 2011) Acute myocardial infarction Heart failure Pneumonia Aggregate payment formula for excess readmissions: [Sum of DRG payments for AMI (Excess Readmission Ratio for AMI 1)] [Sum of DRG payments for HF (Excess Readmission Ratio for HF 1)] [Sum of DRG payments for PN (Excess Readmission Ratio for PN 1)] Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 9

Readmissions into the future Expands in 2015 to include at least: Coronary Artery Bypass Graft; Chronic Obstructive Pulmonary Disease; Percutaneous Coronary Intervention; and Other vascular Conditions. CMS proposing the following additions to the Hospital Inpatient Quality Reporting program that are likely to be adopted in the penalty program in the future: 30 day Hip/Knee readmissions Hospital Wide All Cause Unplanned Readmission (HWR) Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 10

Hospital acquired conditions Top quartile hospitals penalized 1% of DRGs beginning FY 2015 ($1.4 billion over 10 years) Public reporting of HAIs Infections added to VBP (CLABSI, C.diff, MRSA, CAUTI, VAP, SSI) HHS submits report on expanding HAC policy to other providers. HHS calculates national and hospital data on HACs and shares with hospitals; publically reported on Hospital Compare Web site. Hospitals in top quartile receive 1% reduction in Medicare payments. 2010 2011 2012 2013 2014 2015 2016 2017 Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 12

Overlapping Medicare HAC policies Hospital acquired conditions (HACs) Not eligible higher payment (FY 2008 ongoing) VBP (rolling in starting FY 2013) 1% Payment Cut TBD (FY 2015) Catheter associated UTI X X? Surgical Site Infections X X? Vascular cath assoc. infections X X? Foreign object retained after surgery X? Air embolism X? Blood incompatibility X? Pressure ulcer stages III or IV X? Falls and trauma X? DVT/PE after hip/knee replacement X? Manifestations of poor glycemic control X? Ventilator associated pneumonia X? Methicillin resistant Staph. aureus (MRSA) X? Clostridium difficile (CDAD) X? Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 13

Value based Purchasing FY 2013 A larger proportion of Premier PfP hospitals will receive incentive payments greater than their contribution payments in inpatient VBP in FY 2013 Premier PfP hospitals are performing better than the nation in FY 2013 VBP measures overall Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 14

Readmissions Reduction Payment Penalty FY 2013 Approximately 75% of PfP Hospitals will be penalized for excess readmissions in FY 2013 Overall, 64% of hospitals subject to the readmissions penalty program under the IPPS will be penalized in FY 2013 Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 15

Hospital Acquired Conditions and Premier PfP Hospitals The top three drivers of the HAC rate are: Falls and Trauma CAUTI Vascular catheter associated infection Only 23% of Premier PfP Hospitals are subject to the Hospital Acquired Conditions (HACs) Payment Penalty based on performance. The 25% lowest performing hospitals (highest HAC rate) will be subject to the penalty Hospital Acquired Condition PfP IPPS Foreign object retained after surgery 2% 2% Air Embolism 0% 0% Blood incompatibility 0% 0% Pressure ulcer stages III and IV 7% 8% Falls and trauma 43% 42% Vascular catheter associated infection 21% 21% CAUTI 24% 23% Poor glycemic control 4% 4% Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 16

Strategies for aligning payment with outcomes Culture of leadership and transparency Physician coordination and buy in is key Focus on evidence based care Cuts/rewards within a hospital s control Estimate payment based on prior performance Benchmark against peers to gauge impact Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 17

Mortality improvement charter member cohort Baseline Period Reduced median o/e by 0.30 Hospitals with data for every QTR n = 135 Significant reduction in mortality within certain groups (Sepsis) Patient and family centered end of life care Improved documentation and coding Note: Box plot outliers with values greater than 3 standard deviations from the mean value removed from display. Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 19

Evidence based care (EBC) improvement charter member cohort Baseline Period Increase in median by 0.15 Hospitals with data for every QTR n = 97 Primary PCI within 90 minutes of arrival: 12.5% improvement from Year 1 to Year 4 Note: Box plot outliers with values greater than 3 standard deviations from the mean value were removed from display; results express common composite. Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 20

Patient experience improvement charter member cohort Baseline Period Increase in median by 2% Hospitals with data for every QTR n = 137 Biggest improvement in nursing communication and communication about medication scores Note: Box plot outliers with values greater than 3 standard deviations from the mean value were removed from display; trend line is based on consistent methodology Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 21

Cost improvement charter member cohort (inflation adjusted) Baseline Period Hospitals with data for every QTR n = 127 Adjusted for inflation, the median cost of a CMI adjusted discharge has been reduced by $1,359 over four years within the QUEST charter members. Note: Costs are displayed in 06/07 (baseline) constant dollars; box plot outliers with values greater than 3 standard deviations from the mean value removed from display. Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 22

Cost improvement charter member cohort 24% increase 12% increase 9% increase Baseline Period In nominal, non inflation adjusted dollars This is what is meant by bending the cost curve: While in-patient hospital costs have increased 24% since the start of the collaborative, the QUEST hospitals have increased only 9% in non inflation-adjusted terms. Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 23

VBP just a beginning step toward increasingly complex care Value based purchasing: HACs, quality, efficiency, cuts Bundled payment Shared Savings & Capitation Partnership for Patients Medical Home MOVEMENT TO INTEGRATED CARE, NEW PAYMENT MODELS & RISK High performing hospitals Most efficient supply chain Best outcomes in quality, safety Waste elimination Satisfied patients Bundled Paymen t High value episodes DRG and episode targeting Care models and gainsharing Data analytics Cost management Population management Population analytics Care management Financial modeling and management Legal Physician integration Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 26

Value Based Purchasing measures Acute Myocardial Infarction Final Regs Final Regs Final Regs Final Regs Payment Year FFY 2013 FFY 2014 FFY 2015 FFY 2016* Payment % 1% 1.25% 1.50% 1.75% Quality Measures 70% 45% 20% * Primary Performance Period 7 1 11 to 3 31 12 4 1 12 to 12 31 12 CY 2013 CY 2014 Primary Baseline Period 7 1 09 to 3 31 10 4 1 10 to 12 31 10 CY 2011 CY 2012 Fibrinolytic (thrombolytic) agent received within 30 minutes of AMI 7a hospital arrival X X X X Timing of Receipt of Primary Percutaneous Coronary AMI 8a Intervention X X X X Heart Failure (HF) HF 1 Discharge instructions X X X X Blood culture performed in the emergency department prior PN 3b to first antibiotic received in hospital X X X X PN 6 Appropriate initial antibiotic selection X X X X Prophylactic antibiotic received within 1 hour prior to surgical SCIP INF 1 incision X X X X SCIP INF 2 Prophylactic antibiotic selection for surgical patients X X X X Prophylactic antibiotics discontinued within 24 hrs. after SCIP INF 3 surgery end time (48 hrs. for cardiac surgery) X X X X Cardiac surgery patients with controlled 6AM postoperative SCIP INF 4 serum glucose X X X X Postoperative urinary catheter removal on post operative day SCIP INF 9 1 or 2 with day of surgery being day zero NEW X X Surgery Patients on a Beta Blocker prior to arrival who SCIP CV2 received a Beta Blocker during the perioperative period X X X X Surgery Patients with Recommended Venous SCIP VTE 1 Thromboembolism Prophylaxis Ordered X X Removed Surgery patients who received appropriate VTE prophylaxis SCIP VTE 2 within 24 hours pre/post surgery X X X X *Domain weights were not published, but four domain structure will be retained in FY 2016 according to final IPPS FY 2013 rule. Pneumo nia (PN) Surgical Care Improvement Project (SCIP) Source: CMS published Final Rule in Federal Register Aug 1, 2012 at http://federalregister.gov Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 28

Value Based Purchasing measures Mortality HCAHPs AHRQ PSI Final Regs Final Regs Final Regs Final Regs Payment Year FFY 2013 FFY 2014 FFY 2015 FFY 2016* Payment % 1% 1.25% 1.50% 1.75% Patients' Experience of Care Measures 30% 30% 30% * Primary Performance Period 7 1 11 to 3 31 12 4 1 12 to 12 31 12 CY 2013 CY 2014 Primary Baseline Period 7 1 09 to 3 31 10 4 1 10 to 12 31 10 CY 2011 CY 2012 Communication with Nurses X X X X Communication with Doctors X X X X Responsiveness of Hospital Staff X X X X Pain Management X X X X Communication about Medicines X X X X Hospital Cleanliness & Quietness X X X X Discharge Information X X X X Overall Rating of Hospital X X X X Outcome 0% 25% 30% * Primary Performance Period 7 1 11 to 6 30 12 10 1 12 to 6 30 13 10 1 12 to 6 30 14 Primary Baseline Period 7 1 09 to 12 31 10 10 1 10 to 6 30 11 10 1 10 to 6 30 11 Acute Myocardial Infarction (AMI) 30 day mortality rate X X X Heart Failure (HF) 30 day mortality rate X X X Pneumonia (PN) 30 day mortality rate X X X Primary Performance Period 10 15 12 to 6 30 13 10 15 12 to 6 30 14 Primary Baseline Period 10 15 10 to 6 30 11 10 15 10 to 6 30 11 Complication/patient safety for selected indicators (composite) X X Primary Performance Period 2 1 13 to 12 31 13 Primary Baseline Period 1 1 11 to 12 31 11 Infec tions Cost Efficiency Central Line Associated Bloodstream Infection X Not Proposed Efficiency 0% 0% 20% * Primary Performance Period 5 1 13 to 12 31 13 Primary Baseline Period 5 1 11 to 12 31 11 Medicare Spending per Beneficiary (3 Days prior & 30 Days Post Disc, Part A & B) *Domain weights were not published, but four domain structure will be retained in FY 2016 according to final IPPS FY 2013 rule. Source: CMS published Final Rule in Federal Register Aug 1, 2012 at http://federalregister.gov X X Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 29

Harm QUEST improvement Harm QUEST 2.0 CY2010 CY2011: 58% improved over prior year 40% achieved Premier s TPT 0.06 decrease in median Harm Composite from baseline CY2010 to CY2011 data Hospitals reaching top performance threshold increased to 40% from baseline CY2010 value of 25% (Baseline 2.0) QUEST 2.0 average scores by quarter Updated 07 23 12 n = 201 Biggest opportunities C. Difficille 3 rd or 4 th perineal lacerations Post operative respiratory failure SSI following certain orthopedic procedures SSI following bariatric surgery Note: Box plot outliers with values greater than 3 standard deviations from the mean value were removed from display. Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED

QUEST performance distribution comparison: Patient experience Baseline (1Q 2010 4Q 2010) 1Q 2011 4Q 2011 100% 90% Patient Experience Composite 100% Top Performance Threshold: 73% 90% n = 166 n = 297 Patient Experience Composite Top Performance Threshold: 73% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% This Distribution Graph shows the range of variation for the Patient Experience Composite of the QUEST membership. Each dot represents one hospital. The plotted values are based on rounded values. This Distribution Graph shows the range of variation for the Patient Experience Composite of the QUEST membership. Each dot represents one hospital. The plotted values are based on rounded values. 36% of QUEST hospitals in the top performance threshold Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 31

QUEST performance distribution comparison: Readmissions Baseline (1Q 2010 4Q 2010) 1Q 2011-4Q 2011 0.00 Readmission Rate -22-20 -18-16 -14-12 -10-8 -6-4 -2 0 2 4 6 8 10 12 14 16 18 20 22 n = 201 n = 284 Readmission Rate 0.00-30 -28-26 -24-22 -20-18 -16-14 -12-10 -8-6 -4-2 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 Top Performance Threshold: 8% Top Performance Threshold: 8% 0.10 0.10 0.20 0.20 0.30 This Distribution Graph shows the range of variation for the Readmission Rate of the QUEST members. Each dot represents one hospital. The plotted values are based on rounded values. 0.30 This Distribution Graph shows the range of variation for the Readmission Rate of the QUEST members. Each dot represents one hospital. The plotted values are based on rounded values. 29% of QUEST hospitals in the top performance threshold Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED 32

Medicare Value Based Purchasing August 14, 2012