Quality Provisions in the EPM Proposed Rule Matt Baker Scott Wetzel
Overview Quality Scoring Overview Quality Metrics in AMI and CABG EPMs Quality Metrics in SHFFT EPMs COTH Performance in these programs
Quality Scoring Overview
Overview EPMs Quality Three separate EPM quality models o AMI, CABG, and Surgical hip/femur fracture treatment (SHFFT) Quality performance National Percentile o o o 30 th percentile minimum performance to receive points for each quality measure Points are awarded based on percentile Length of reporting period: AMI and CABG mortality, AMI excess days, and hip/knee complications 3 years HCAHPS 1 year Voluntary measures varies by performance year Performance + Improvement + Voluntary Points = Quality Composite Score
Improvement Scoring Measure by measure basis Points awarded up to 10% of max performance points AMI/CABG Defined as improvement over participant s own point estimate from previous year SHFFT/CJR Defined as year over year improvement of two or more deciles
Quality Metrics in AMI and CABG EPMs
AMI Quality Measure Composite Scoring Measure Weight Max Available Points Hospital AMI 30-day Mortality 50% 10 Excess Days in Acute Care After Hospitalization (EDAC) 20% 4 Voluntary Hybrid AMI Mortality 10% 2 if submitted successfully HCAHPS 20% 4
CABG Quality Measure Composite Scoring Measure Weight Max Available Points Hospital CABG 30-day Mortality 75% 15 HCAHPS 25% 5
AMI and CABG Mortality Calculated separately for AMI and CABG Calculates all deaths regardless of cause within a 30-day period from the date of the index admissions NQF endorsed Measure reported on hospital compare
Excess Days in Acute Care After Hospitalization for AMI (EDAC) Actual acute days post discharge compared to expected based on degree of illness Response to increase in ED utilization and Observation Stays Not NQF Endorsed* Not Reported on Hospital Compare *Measure has been submitted for NQF review
HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey Includes 10 questions about the hospital experience* Patients surveyed between 48 hours and 6 weeks after discharge Patients included: All adult inpatients Not limited to Medicare beneficiaries includes patients admitted in the medical, surgical and maternity care service lines. *pain management measure not included
New Voluntary AMI Measure Hybrid measure combines standard claims based 30- day mortality with clinical data from EHR Submit five core data elements and six linking variables Age, heart rate, systolic BP, troponin, creatinine CCN, HIC#, DOB, sex, admission and discharge dates Heart rate and BP within 2 hours of admission; troponin within 24 hours Additional two points for successful submission
Proposed AMI Quality Decile-Based Points Scale Percentile AMI Mortality AMI EDAC HCAHPS 90-99th Percentile 10.00 4.0 4.0 80-89th Percentile 9.25 3.7 3.7 70-79th Percentile 8.50 3.4 3.4 60-69th Percentile 7.75 3.1 3.1 50-59th Percentile 7.00 2.8 2.8 40-49th Percentile 6.25 2.5 2.5 30-39th Percentile 5.50 2.2 2.2 20-29th Percentile 0 0 0 10-19th Percentile 0 0 0 0-9th Percentile 0 0 0 Not Enough Data to Report 7.00 2.8 2.8 Reporting the voluntary AMI Hybrid Measure adds an additional 2 points. For each measure, 10% of hospitals will receive bonus points for improvement: 1 bonus point in AMI Mortality 0.4 bonus points in AMI EDAC 0.4 bonus points in HCAHPS The bonus points will be based on being in the best 10% of hospitals in the improvement, defined as one s own measure s point estimate relative to the hospital s score in the previous year.
Proposed AMI Quality Category and Discount Rate Composite Score Category Quality Category Eligible for Reconciliation Payment Reconciliation Payment Discount Percentage Repayment Amount Discount Percentage Year 1 Years 2 & 3 Years 4 & 5 > 14.8 Excellent Yes 1.5% N/A 0.5% 1.5% > 6.9 and <14.8 Good Yes 2.0% N/A 1.0% 2.0% >3.6 and <6.9 Acceptable Yes 3.0% N/A 2.0% 3.0% <3.6 Below Acceptable No 3.0% N/A 2.0% 3.0%
Proposed CABG Quality Decile-Based Points Scale Percentile CABG Mortality HCAHPS 90-99th Percentile 15.00 5.00 80-89th Percentile 13.68 4.63 70-79th Percentile 12.75 4.25 60-69th Percentile 11.63 3.88 50-59th Percentile 10.50 3.50 40-49th Percentile 9.38 3.13 30-39th Percentile 8.25 2.75 20-29th Percentile 0 0 10-19th Percentile 0 0 0-9th Percentile 0 0 Not Enough Data to Report 10.50 3.50 For each measure, 10% of hospitals will receive bonus points for improvement: 1.5 bonus points in CABG Mortality 0.5 bonus points in HCAHPS The bonus points will be based on being in the best 10% of hospitals in the improvement, defined as one s own measure s point estimate relative to the hospital s score in the previous year.
Proposed CABG Quality Category and Discount Rate Composite Score Category Quality Category Eligible for Reconciliation Payment Reconciliation Payment Discount Percentage Repayment Amount Discount Percentage Year 1 Years 2 & 3 Years 4 & 5 > 17.5 Excellent Yes 1.5% N/A 0.5% 1.5% > 4.8 and <17.5 Good Yes 2.0% N/A 1.0% 2.0% >2.8 and <4.8 Acceptable Yes 3.0% N/A 2.0% 3.0% <2.8 Below Acceptable No 3.0% N/A 2.0% 3.0%
Quality Metrics in CJR and SHFFT
SHFFT* Quality Measure Composite Scoring Measure Weight Max Available Points Hip/Knee Complications 50% 10 HCAHPS 40% 8 THA/TKA Voluntary PRO *Same scoring as CJR 10% 2 if submitted successfully
Hip/knee Complications Hospital-level Risk Standardized Complication Rate (RSCR) following elective primary THA and/or TKA Denominator: Patients with a qualifying* elective primary THA/TKA procedure, enrolled in Medicare fee-for-service, aged 65 or over Excludes: patients with more than two THA/TKA procedure codes during the index admission; discharged against medical advice; transferred from another acute care facility for the THA/TKA Numerator: patients with any of the following acute myocardial infarction pneumonia, or sepsis/septicemia within 7 days of admission surgical site bleeding, pulmonary embolism or death within 30 days of admission or mechanical complications, periprosthetic joint infection, or wound infection within 90 days of admission *For details on which procedures quality, see CMS s Measure Specification: https://www.cms.gov/medicare/quality-initiatives-patient-assessment- Instruments/HospitalQualityInits/Downloads/Hip-and-Knee-Arthroplasty- Complications-Updates.zip
CJR and SHFFT Quality Decile-Based Points Scale Percentile THA/TKA Complications Points HCAHPS Points 90-99th Percentile 10 8 80-89th Percentile 9.25 7.4 70-79th Percentile 8.5 6.8 60-69th Percentile 7.75 6.2 50-59th Percentile 7 5.6 40-49th Percentile 6.25 5 30-39th Percentile 5.5 4.4 20-29th Percentile 0 0 10-19th Percentile 0 0 0-9th Percentile 0 0 Not Enough Data to 7 5.6 Report THA/TKA PRO and limited risk variable data reporting earns 2 points for reporting, 0 points otherwise Hospitals can receive bonus points in a category for improvement by moving up relative to the previous year s measures: 1 bonus point in THA/TKA Complications 0.8 bonus points in HCAHPS In order to receive these bonus points, hospitals must improve by two decile groups for CJR, and SHFFT.
CJR and SHFFT Quality Category and Discount Rate Composite Score Category Quality Category Eligible for Reconciliation Payment Reconciliation Payment Discount Percentage Repayment Amount Discount Percentage Year 1 Years 2 & 3 Years 4 & 5 > 15.0 Excellent Yes 1.5% N/A 0.5% 1.5% > 6.9 and <15.0 Good Yes 2.0% N/A 1.0% 2.0% >5.0 and <6.9 Acceptable Yes 3.0% N/A 2.0% 3.0% <5.0 Below Acceptable No 3.0% N/A 2.0% 3.0%
Example SHFFT Hospital Step 1 Convert Your Rate to Percentile Ranking THA/TKA Complications Rate HCAHPS Linear Mean Score Your Rate 2.7 86.4 National Percentile 80-89th Percentile 60-69th Percentile Step 2 Convert Your Percentile Ranking to Points Percentile THA/TKA Complications Points HCAHPS Points 90-99th Percentile 10 8 80-89th Percentile 9.25 7.4 70-79th Percentile 8.5 6.8 60-69th Percentile 7.75 6.2 50-59th Percentile 7 5.6 40-49th Percentile 6.25 5 30-39th Percentile 5.5 4.4 20-29th Percentile 0 0 10-19th Percentile 0 0 0-9th Percentile 0 0 Not Enough Data to Report 7 5.6
Example SHFFT Hospital Step 3 Sum Total Points Total Points = THA/TKA Complications Points + HCAHPS Points + THA/TKA PRO Points Total Points = 9.25 + 6.2 + 0 = 15.45 Step 4 Assign to a Category Based on Total Points Composite Score Category Quality Category Eligible for Reconciliation Payment Reconciliation Payment Discount Percentage Repayment Amount Discount Percentage Year 1 Years 2 & 3 Years 4 & 5 > 15.0 Excellent Yes 1.5% N/A 0.5% 1.5% > 6.9 and <15.0 Good Yes 2.0% N/A 1.0% 2.0% >5.0 and <6.9 Acceptable Yes 3.0% N/A 2.0% 3.0% <5.0 Below Acceptable No 3.0% N/A 2.0% 3.0%
Performance Periods: AMI, CABG, SHFFT
Performance Periods: CABG, AMI, SHFFT Bundles Performance period charts courtesy of HPA
Performance Periods: CABG, AMI, SHFFT Bundles, Cont. Voluntary measure performance periods
COTH Performance on AMI, CABG, and SHFFT Quality Metrics
COTH Performance on AMI Mortality Decile Distribution 30% 25% 20% 15% 10% 5% 0% 1 2 3 4 5 6 7 8 9 10 NA Decile COTH All Hospitals Source: July 2016 Release of Hospital Compare. Reporting period: July 2012 June 2015. Based on hospitals that are located in a MSA eligible for cardiac bundled payments. Includes hospitals live with AMI episodes in BPCI.
COTH Performance on AMI Readmissions Decile Distribution 30% 25% 20% 15% 10% 5% 0% 1 2 3 4 5 6 7 8 9 10 NA Decile COTH All Hospitals Source: July 2016 Release of Hospital Compare. Reporting period: July 2012 June 2015. Based on hospitals that are located in a MSA eligible for cardiac bundled payments. Includes hospitals live with AMI episodes in BPCI.
COTH Performance on CABG Mortality Decile Distribution 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 1 2 3 4 5 6 7 8 9 10 NA Decile COTH All Hospitals Source: July 2016 Release of Hospital Compare. Reporting period: July 2012 June 2015. Based on hospitals that are located in a MSA eligible for cardiac bundled payments. Includes hospitals live with CABG episodes in BPCI.
COTH Performance on HCAHPS Decile Distribution 30% 25% 20% 15% 10% 5% 0% 1 2 3 4 5 6 7 8 9 10 NA Decile COTH All Hospitals Source: July 2016 Release of Hospital Compare. Reporting period: October 2014 September 2015. Based on hospitals that are located in a MSA eligible for cardiac bundled payments.
COTH Overall Performance on AMI and CABG Quality Measures Projected AMI Quality Rating Percent of COTH Members Percent of All Hospitals CABG Quality Rating Percent of COTH Members Percent of All Hospitals Quality Rating n=130 N=1,591 n=130 N=1,591 Below Acceptable 17% 10% 5% 5% Acceptable 11% 12% 7% 6% Good 54% 66% 68% 83% Excellent 18% 11% 20% 5%
COTH Performance on THA/TKA Complications Decile Distribution 30% 25% 20% 15% 10% 5% 0% 1 2 3 4 5 6 7 8 9 10 NA Decile COTH All Hospitals Source: July 2016 Release of Hospital Compare. Reporting period: April 2012 March 2015. Based on hospitals that are in a MSA eligible for CJR. Includes hospitals live with major joint replacement episodes in BPCI.
COTH Performance on HCAHPS Decile Distribution 30% 25% 20% 15% 10% 5% 0% 1 2 3 4 5 6 7 8 9 10 NA Decile COTH All Hospitals Source: July 2016 Release of Hospital Compare. Reporting period: October 2014 September 2015. Based on hospitals that are in a MSA eligible for CJR. Includes hospitals live with major joint replacement episodes in BPCI.
COTH Overall Performance on SHFFT and CJR Quality Measures Projected Percent of COTH Members Percent of All Hospitals Quality Rating n=74 n=779 Below Acceptable 15% 8% Acceptable 11% 13% Good 66% 66% Excellent 8% 13% Although COTH overall distribution in overall quality ratings are lower than other hospitals, only 15% of hospitals are projected to receive 0 points overall in CJR
Notes For more information on measure methodology, see: CMMI's Measure Descriptions QualityNet website HCAHPS description
Contact Matthew Baker, Research Analyst mbaker@aamc.org Scott Wetzel, Senior Specialist, Quality Reporting swetzel@aamc.org Jessica Walradt, Senior Payment Reform Specialist jwalradt@aamc.org