Critical Access Hospital Quality Current Performance and the Development of Relevant Measures Ira Moscovice, PhD Mayo Professor & Head Division of Health Policy & Management School of Public Health, University of Minnesota Small & Rural Hospital Conference Charlotte, NC November 10, 2015
Overview Current political context for CAHs Recent FMT Quality Projects A look at quality data for CAHs nationwide CAH quality performance: NC & SC NQF quality measurement efforts
CAHs Under Siege Numerous proposed changes to CAH program: End CAH program entirely (CBO, 2011) Eliminate enhanced payments for CAHs (MedPAC, 2012) Remove necessary provider permanent exemption from CAH distance requirement (OIG, 2013) Prohibit CAH designation for facilities that are less than 10 miles from the nearest hospital (OMB, 2014) Redirect cost-based reimbursement to preserving access to emergency care (MedPAC, 2015)
Effects of Proposals Reduced number of hospitals eligible for CAH program Hospitals losing CAH status forced back on PPS reimbursement, reducing Medicare revenue Reduced access to care for rural populations
Political Context Signs point to cost-based reimbursement going away CAHs need to prepare for Value-Based Purchasing ACOs will want to contract with highperforming CAHs
Recent Related FMT Quality Projects How a minimum-distance requirement for CAHs may impact care quality How Value-Based Purchasing may impact rural hospitals
Minimum Distance Impact We compared hospitals that could lose CAH status due to a minimum distance requirement in terms of: Organizational characteristics Quality and financial performance Estimated potential financial consequences of reversion to PPS for these CAHs
Examining CAH Performance Every CAH in nation assigned to one of three categories based on distance to next hospital: Less than 15 miles ( nearest distance ) Between 15-35 miles ( middle distance ) More than 35 miles ( farthest distance ) Compared quality in terms of Hospital Compare reporting rates and performance Used financial distress model to compare financial implications
National Results: Quality For 19 inpatient and outpatient Hospital Compare quality measures: Nearest-distance (<15 miles) group was significantly more likely than the other two groups of CAHs to report data for 12 measures Nearest-distance group performed significantly better than the middle-distance group for 13 quality measures, and significantly better than the farthest-distance group for 11 measures
National Results: Finance A 20% reduction in Medicare reimbursements would result in a savings of about $308 million, based on 2011 financial data This is 0.056% of the total 2011 Medicare expenditures of $549.1 billion (CMS data). Put another way: the total savings of this proposal would be equivalent to about 4.9 hours of Medicare s annual spending.
National Results: Finance In 2011, 62% of nearest-distance CAHs had a positive operating margin, compared to 53% of middle-distance and 49% of farthest-distance CAHs. Nationwide, 71.6% of all US hospitals had a positive operating margin in 2011. CAH status removal would dramatically affect these hospitals financial stability.
Conclusions Compared to CAHs located farther away, hospitals that could lose CAH status because of a minimum distance requirement: Have a higher volume of patients Are more financially stable Are more likely to publicly-report quality data Perform better on quality measures
Conclusions Distance from another hospital is a narrow criterion to determine a hospital s fate. Other factors to consider: clinical expertise, availability of key services, use of technology Loss of CAH status and cost-based reimbursement could affect many CAHs, with: Substantial financial consequences Possible CAH closures, affecting community at large Reduced access to care & overall care quality
Conclusions None of the proposals to change the CAH program recognize the potential harm on the rural health system and access to care for rural residents. Even with close proximity to another hospital, many CAHs could be considered safety-net facilities if they provide certain services, have a large proportion of Medicaid patients, etc.
Value-Based Purchasing CMS historically paid hospitals based on volume rather than performance; ACA authorized efforts to realign financial incentives to provide high quality care The Value-Based Purchasing program raises or lowers Medicare payment rates for hospitals based on how they score on a range of quality measures Both programs apply to Prospective Payment System (PPS) hospitals; Critical Access Hospitals are exempt Relevant to CAHs insofar as it is on the horizon
VBP Program Overview Maximum VBP bonuses and penalties increased from 1% of Medicare payments in FY 2013 to 2% in FY 2017 VBP bonuses and penalties are based on achievement (relative to other hospitals) or improvement (over hospital s own baseline performance), whichever is higher
VBP Scoring Domains and Weighting by Payment Fiscal Year FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 Clinical Care: Process 70% 45% 20% 10% 5% - Patient Experience of Care 30% 30% 30% 25% 25% 25% Clinical Care: Outcome - 25% 30% 40% 25% 25% Efficiency - - 20% 25% 25% 25% Safety - - - - 20% 25%
Rural PPS Hospitals Receiving a Bonus or Penalty FY 2014- FY 2015 Bonus Penalty US (666) 46% 52% FY 2014 NC (31) 65% 35% SC (11) 27% 73% US (748) 66% 33% FY 2015 NC (32) 69% 31% SC (13) 69% 31%
FY 2015 VBP Results Among rural and urban hospitals, probability of VBP penalty significantly more likely for hospitals that have: Larger size Public ownership Higher proportions of Medicare and Medicaid inpatient days Locations in counties with lower median family income, higher uninsured rates, and fewer primary care physicians per 1,000 county residents
Discussion / Implications Which hospitals are more likely to receive VBP penalties? Hospital characteristics: non-accredited, non-system affiliated, public ownership, lower licensed nurse staffing per inpatient day, higher proportions of Medicare and Medicaid inpatient days County characteristics: higher uninsured rates, lower primary care physician supply, lower household income and education level
Discussion / Implications How much control do hospitals have over these factors? Which factors are responsible for ruralurban differences in the likelihood of receiving VBP penalties or bonuses over time? Changing metrics or changing performance?
Discussion/Implications Amount of penalties may not seem large, but Hospitals may be incurring penalties under multiple programs: Readmissions, VBP, Hospital-Acquired Condition, EHR Meaningful Use Penalties occurring in context of overall precarious financial condition of many rural hospitals Average Medicare acute inpatient margin for a rural PPS hospital was -2.6% in 2012 56 rural hospitals have closed since 2010
CAH Quality: The Big Picture CAHs reporting quality data: 86.4% reported at least one inpatient measure to Hospital Compare (Q2/13-Q1/14) 54.0% reported at least one outpatient measure to Hospital Compare (Q2/13-Q1/14) 59.0% reported HCAHPS results (2013) CAH performance varies by measure
North Carolina CAHs Lower reporting rates: inpatient & outpatient Hospital Compare measures, HCAHPS State reporting rank (of 45 Flex states): #35 State performance rank: #5 Overall state rank: #19 Performance: compared to all other CAHs nationally, NC s reporting CAHs have Significantly better scores on 14 Hospital Compare measures Significantly worse scores on 8 measures No significant differences on 18 measures Insufficient data to compare 8 measures
South Carolina CAHs Higher reporting on inpatient Hospital Compare measures, lower reporting on outpatient measures, similar reporting for HCAHPS State reporting rank (of 45 Flex states): #27 State performance rank: #41 Overall state rank: #39 Performance: compared to all other CAHs nationally, SC s reporting CAHs have Significantly better scores on 0 Hospital Compare measures Significantly worse scores on 7 measures No significant differences on 13 measures Insufficient data to compare 28 measures
CAH Quality Reporting Data, 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 74% Q2 2013 Q1 2014 100% 86% 44% 20% NC (n=23) SC (n=5) All CAHs in US (n=1,338) 54% 48% 59% Inpatient Outpatient HCAHPS 59% Benchmarks Top 25% Inpatient 98% Outpatient 77% HCAHPS 80% Top 10% Inpatient 100% Outpatient 95% HCAHPS 93%
Q2/13 - Q1/14 Data for Measures Required for MBQIP All CAHs NC CAHs SC CAHs OP-27: Flu Vaccinations, Healthcare Personnel 86% 95% 81% IMM-2: Flu Immunizations 90% 94% 91% OP-20: Door to Diagnostic Eval. 18 min. 34 min. 28 min. OP-21: Median Time, Bone Fracture Pain Mgmt. 44 min. 58 min. 76 min. OP-22: Patient Left w/o Being Seen 1% 2% 1% Significantly Better than all CAHs Nationally (p<.05) Significantly Worse than all CAHs Nationally (p<.05)
Q2/13 - Q1/14 Data for Measures Required for MBQIP All CAHs NC CAHs SC CAHs OP-1: Median Time to Fibrinolysis 28 min. insuf. data insuf. data OP-2: Fibrinolytic w/in 30 mins. 49% insuf. data insuf. data OP-3: Median Time to Transfer, Acute Coronary 53 min. 75 min. insuf. data OP-5: Median Time to ECG 7 min. 10 min. 8 min. Significantly Better than all CAHs Nationally (p<.05) Significantly Worse than all CAHs Nationally (p<.05)
National Quality Forum Rural Health Project Goal: to provide performance measurement guidance to rural, low volume providers Key issues for rural provider measurement Geographic isolation Small practice size Setting / patient population heterogeneity Low case-volume
Overarching Recommendation of NQF Rural Health Committee Make participation in CMS quality improvement programs mandatory for all rural providers Utilize a phased approach for full participation across program types A lack of data denies rural residents the ability to choose providers based on performance and may suggest that rural providers cannot provide high-quality care
Supporting Recommendations of NQF Committee Development of Rural-Relevant Measures Fund development of rural-relevant measures Develop and/or modify measures to address low case volume explicitly Consider rural-relevant sociodemographic factors in risk adjustment Ensure that the components of composite measures are appropriate for rural, low-volume providers
Supporting Recommendations of NQF Committee Alignment of Measurement Efforts for Rural Providers Use across HHS programs and multiple health care settings Collect data only once Align technical assistance
Supporting Recommendations of NQF Committee Measure Selection Use guiding principles for selecting quality measures that are relevant for rural providers Use a core set of measures, along with a menu of optional measures for rural providers Consider measures that are used in patient-centered medical home (PCMH) models Create a Measure Application Partnership (MAP) workgroup to advise CMS on the selection of ruralrelevant measures
Guiding Principles for Selecting Quality Measures Address the low case-volume challenge Facilitate fair comparisons for rural providers Address areas of high risk for patients Support local access to care Address actionable activities for rural providers Are evidence-based Address opportunities for improvement
Guiding Principles for Selecting Quality Measures (cont.) Suitable for use in internal quality improvement efforts Require feasibility for data collection by rural providers Exclude measures that have unintended consequences for rural patients Suitable for use in particular programs Align with other programs Support the triple aim
Supporting Recommendations of NQF Committee Pay-for-Performance Considerations Create payment programs that include incentive payments, but not penalties Base rewards upon achievement or improvement Encourage voluntary groupings of rural providers for payment incentive purposes Fund additional work to consider how peer groups for rural providers should be defined and used for comparison purposes
Additional Recommendations of NQF Committee Relax requirements for use of vendors in administering CAHPS surveys and/or offer alternative data collection mechanisms (e.g., similar to CART tool for hospitals) Facilitate quicker and broader access to performance scores and to Medicare data Facilitate inclusion of CMS data into all-payer databases
The Bottom Line We are approaching a tipping point It is still unclear how rural providers and populations will be affected by health care reform. It is clear that the successful implementation of health care reform requires reliable and valid quality measurement. The challenge is to ensure that quality measurement is relevant for rural providers and populations (particularly in low-volume environments).
Thank You! Ira Moscovice, PhD mosco001@umn.edu Michelle Casey, MS mcasey@umn.edu flexmonitoring.org rhrc.umn.edu This work was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under cooperative agreement # U27RH01080. The information, conclusions and opinions expressed in this presentation are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.