Update to Federal Quality Programs Collection of Infection Data

1. Update to Federal Quality Programs Collection of Infection Data Mary Therriault, R.N., M.S. Senior Director, Quality and Research Initiatives • November 9, 2011

2. Objectives • Describe the current inpatient and outpatient Pay-for-Reporting program infection indicators • Describe the CMS current Hospital- Acquired Conditions (HAC) infection indicators • Describe the Patient Protection and Affordable Care Act (ACA) current and future deliverables • Describe the current The Agency for Healthcare Research and Quality (AHRQ) Infection indicators • Describe the possible future indicators

3. Quality is not just one clear road anymore Many factors will Significantly Change the Health Care Quality Landscape over the Next Several Years

4. Medicare Quality-Based Programs 2010 2011 2012 2013 2014 2015 2016 2017 Inpatient Quality Reporting Requirement (IQR) (Pay-for-Reporting) 2.0 percentage point reduction for non-compliance FFY Hospital Outpatient Quality Reporting (HOQR) (Pay-for-Reporting) 2.0 percentage point reduction for non-compliance Value-Based Purchasing (VBP) 1%-2% withhold (winners/losers) ICD-10-DM Medicare Readmissions 1%-3% at risk (only losers) HACs 1% at risk (only losers) Meaningful Use **

5. CMS Current - “Pay-for-Reporting. . . . .

6. HQI uses a multi-pronged approach to support, provide incentives, and drive systems and facilities Section 501(b) Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 10 quality “starter set” initiatives initially called Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) - this is now known as the Hospital Inpatient Quality Reporting Program (IQR) “Pay for Reporting” Section 5001(a) Deficit Reduction Act (DRA) of 2005 supersedes the MMA and sets new requirements Value-Based Purchasing (VBP) “Beginning of Pay for Performance” Requires CMS to identify and limit payments for health care-acquired conditions (HACs) Initial Components of the Current FederalHospital Quality Initiative (HQI)

7. Current - Pay-for-Reporting Under the Hospital Inpatient Quality Reporting (IQR) Program Implementation of Value-Based Purchasing

8. Final IQR Quality Measures FFY 2014

9. Final IQR Quality Measures for FFY 2015

10. NYS and CMS Clinical Process Measures Source: CMS Hospital Compare

11. NYS and CMS Patient Experience of Care Measures Source: Hospital Compare First Quarter 2010 through Fourth Quarter 20010 Discharges

12. Pay-for-Reporting Under the Hospital Outpatient Quality Program Reporting (HOQR) Program OPPS Proposed Measures Proposed EHR Pilots (CAH’s also) HOQR Validation begins

13. Alignment of Hospital IQR Program and EHR Incentive Program

14. Review of Current CMS Hospital - Acquired conditions (HAC)

15. Current - CMS Hospital-Acquired Conditions (HAC) related to infections • Present on Admission (POA) modifiers specify whether diagnosis codes are: • Comorbidities (i.e., potential risk factors) • Inpatient complications • POA modifiers are important in: • Computing rates of adverse outcomes • Risk-adjusting performance measures • Inaccurate coding affects: • Assessments of clinical quality • Performance-based reimbursement • POA chart review to detect coding errors is costly, screens are used to look for coding efficiently • The Deficit Reduction Act of 2005 (DRA) requires a quality adjustment in Medicare Diagnosis Related Group (DRG) payment for certain hospital-acquired conditions • MD/NP/PA documentation and HIM coding • Example: Catheter associated UTI ICD- 9- DM - 996.64 • Due to indwelling urinary catheter Use additional code: Use additional code to identify specified infections, such as: Cystitis (595.0-595.9); Sepsis (038.0-038.9)

16. Additional HAC’ s Defined. . ..

17. Additional HAC’ s Defined. . ..

18. Current HAC Payment Policy Example

19. Inpatient and Outpatient Prospective Payment System Update

20. Hospital Inpatient/Outpatient Quality Reporting Requirements • Register with QualityNet • Identify and maintain a QualityNet Security Administrator • Pledge for participation—or withdraw • Collect and report clinical process measures • Submit population and sampling size counts • Continuously collect and submit HCAHPS data • Report claims data (mortality, readmission, HAC) • Submit structural measures information—annually • Participation in a Systematic Database for Cardiac Surgery • Participation in a Systematic Clinical Database Registry for Stroke Care • Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care • Participation in a Systematic Clinical Database Registry for Surgical Care • Participation in a Systematic Clinical Database Registry for Outpatient Laboratory Results • Pass clinical process measures Validation • Submit Data Accuracy and Completeness Acknowledgement (DACA) —annually • Display data on Hospital Compare Web Site

21. Hospital IPPS/OPPS Quarterly Process

22. Healthcare-Acquired Infections All Payer (CLABSI ) (Surgical Site Infections) Clinical Process Measures All Payer AMI - five measures HF - four measures PN – two measures SCIP - ten measures Stroke - eight measures VTE - six measures All Payer Emergency Departments All Payer ED throughput Inpatient and Outpatient Centers for Medicare and Medicaid Services Acute Inpatient Measures (55) (72 IPPS Measures by 2015) Acute Outpatient Measures (33) Electronic Health Measures (15) • Global Flu / • Pneumonia Immunization • Inpatient and Outpatient • All Payer Outpatient All Payer AMI - five measures Surgery - two measures ED Diabetic measures Imaging Meaningful Use All Payer Electronic Health Record 16 ‘Core’ functions 5 ‘Menu’ functions Stage 1 - Quality 15 clinical measures Stroke, VTE, ED AHRQ Medicare FFS IQI - two measures PSI - five measures AHRQ composite: PSI/mortality Claims-Based Data Medicare FFS 30-day mortality rate AMI, HF, PN 30-day readmission rate AMI, HF, PN Hospital-Acquired Conditions Medicare FFS (Eight conditions)

23. IPPS Provider Participation Report

24. The future of HAC in “Health Care Reform” . . .The Patient Protection and Affordable Care Act (ACA)

25. Timeframes for FFY 2013 VBP

26. FFY 2013 VBPProcess Domain Measures

27. FFY 2013 VBP Process Domain, cont’d

28. FFY 2013 VBP Patient Experience of Care Domain Measured using the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) • Modifications to HCAHPS on Hospital Compare: • Cleanliness and quietness combined • “Would you recommend this hospital?” not included

29. Weighting of Domains

30. Final Efficiency Measure Three Days Prior: One Episode Pre-op lab work Thirty Days Post: (Final IPPS Rule) Inpatient Stay Dr. Visit Dr. Visit Dr. Visit Dr. Visit Rehab ED Visit

31. New York StateImpactsof the VBP Final Rule for FFY 2013

32. New York VBP ImpactFFY 2013 Final Rule Note: CAHs, Cancer hospitals and others that do not meet the minimum data requirements are excluded. Source: CMS Hospital Compare Database – 4Q 2010 (April 1, 2009 – March 31, 2010) and 1Q 2011 (Oct 1, 2009 – Sept 30, 2010) releases. CMS’ final VBP rule published in the May 6, 2011, Federal Register.

33. Value-Based Purchasing Expansion to Other Payment Settings Implement VBP pilot programs for inpatient rehabilitation, inpatient psychiatric, LTC, cancer hospitals, and hospice Implement VBP for inpatient hospitals Submit plans for Ambulatory Surgical Centers VBP (Jan 1, 2011) Submit plans for SNF and Home Health VBP (Oct. 1, 2011/FFY 2012) 2011 2006 2012 2013 2015 2016 2017 FY Implement physician VBP modifier for specific physicians and physician groups Physician payment modifier applied to all physicians, groups and other eligible practitioners Establish a CAH and small volume rural hospital VBP demonstration

34. Medicare Readmission Reduction Program

35. Applicable Conditions FFY 2013

36. Medicare Readmission Measures

37. Example of a Medicare Readmission Primary dx=HF Primary dx=broken hip Primary dx= CAD Primary dx= PN Admitted: Admitted: Admitted: Discharged: Jan 1 Feb 10 Jan 15 Jan 25 Does not count Index Index Readmission

39. Medicare Readmission: Future Expansion Initial Set FFY 2013 - FFY2014 • Heart Attack • Heart Failure • Pneumonia Payment Penalty Cap - 1% Payment Penalty Cap - 3% Expanded Set FFY 2015 • Under Consideration: • COPD • CABG • PTCA • Other Vascular

40. HAC-Related Medicare Policies

41. CMS did not adopt a new HAC condition Contrast-Induced Acute Kidney Injury

42. CMS Public Website HAC Measures

43. ACA HAC Future Payment Policy

44. ACA Mandatory Medicare Delivery System Reform

45. Voluntary Medicare Delivery System Reform

46. The Agency for Healthcare Research and Quality (AHRQ) and the Infection Indicators Pay for Reporting

47. Value-Based Purchasing and AHRQ • POA coding is also used in the specifications for the component indicators for the AHRQ Patient Safety composite measure CMS will be adopted for the Hospital VBP program for FY 2014 • This composite measure consists of 8 component indicators, including • PSI-3 (Pressure ulcer) • PSI-6 (Iatrogenic Pneumothorax) • PSI-7 (Central venous catheter-related bloodstream infections) • PSI-8 (Postoperative hip fracture), • PSI-12 (Postoperative pulmonary embolism or deep vein thrombosis) • PSI-13 (Postoperative sepsis) • PSI-14 (Postoperative wound dehiscence) • PSI-15 (Accidental Puncture or Laceration) • CMS is using the POA information on the final adjudicated claim submitted by the Hospital • This data is subject to the same scrutiny as other information on Medicare claims  • Reference: Medicare Program; Hospital Inpatient Value-Based Purchasing Program, April 29, 2011

48. AHRQ Claims Data Quality Measures • The AHRQ Quality Indicators are based on diagnosis and procedures billed • Administrative data are primarily used for billing, but also for other business and financial planning purposes • There is a basic tension between using the data for reimbursement and for defining quality indicators • Submitting bills quickly versus coding from a complete record • Maximizing the coding of complications and comorbidities versus only coding diagnoses “out of the norm”

49. AHRQ Measures Displayed on Hospital Compare

50. Using the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) to meet the new CMS Inpatient Prospective Payment System (IPPS) Quality IQR Reporting Requirement