3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

1. 3rd AnnualAssociation of Clinical Documentation Improvement Specialists Conference

2. CMS Outcome IndicatorsMethodology, Risk Adjustment, & Strategy Kristen Geissler, MS, PT, CPHQ, MBA Associate Director, Navigant Consulting, Inc.

3. Medicare’s outcome indicators • 30-day Mortality • Heart Failure • Pneumonia • Acute MI • 30-day Readmission • Heart Failure • Pneumonia • Acute MI • AHRQ PSI • PSI 4 – Death among surgical patients with treatable serious complications (also known as “failure to rescue”) • PSI 6 – Iatrogenic pneumothorax (adult) • PSI 14 – Postoperative wound dehiscence • PSI 15 – Accidental puncture or laceration • IQI 11 – Abdominal aortic aneurysm (AAA) mortality rate • IQI 19 – Hip fracture mortality rate

4. Why understand the outcome indicator methodology? • Public hospital performance • Mortality and readmission resonate with the public • Financial impact • Currently pay-to-report • Significant readmission measure impact in health reform proposals • Clinical Documentation Improvement programs • Physician buy-in • Severity queries • Impact of present on admission

5. A word on risk adjustment • What measures need to be risk adjusted? • Outcome measures (mortality, complications, readmissions) • Adjusts for complexity of care and severity of illness • What is the methodology? • Many different methodologies • APR-DRGTM (3M) • HealthgradesTM proprietary • CMS mortality risk adjustment • How is risk adjustment used? • Actual rate versus expected rate • i.e. sicker patients would have a higher expected rate of mortality • What’s the bottom line? • The more accurately the coding/claims data represents the severity of illness of the patient, the more accurately the risk adjustment methodology will be applied

6. Mortality Indicators

7. CMS mortality rate • Only for the Medicare population • 30-day mortality • Acute MI • Heart Failure • Pneumonia • Exclusions • LOS ≤ 1 day and discharged alive and not AMA • Medicare hospice program admission on first day of admission or hospice within 12 months prior to admission • Discharge AMA (new exclusion for 2009) • Multiple admissions • One admission is chosen at random for inclusion in the model

8. CMS mortality rate • Risk adjustment • Uses information from the following Medicare claims: • Hospital inpatient • Hospital outpatient • Physician office • May not include: • Inpatient secondary conditions that are ‘not present on admission’ • Measurement model uses data from July 2005 through June 2008

9. Risk-standardized mortality rate • Ratio of predicted to expected mortalities x national unadjusted rate: • Predicted number of 30-day mortalities (hosp-specific intercept) • Expected number of mortalities (average intercept)

10. Mortality data on hospital compare

11. Distribution of 30-day mortality results

12. Mortality risk adjustment From CMS Measure Technical Specifications on www.qualitynet.org accessed 2/1/10

13. Mortality risk adjustment From CMS Measure Technical Specifications on www.qualitynet.org accessed 2/1/10

14. Readmission Indicators

15. Readmission rate for select illnesses • Only for the Medicare population • 30-day readmissions for any cause • Acute MI • Heart Failure • Pneumonia • Exclusions • Admissions for patients with in-hospital death • Admissions subsequently transferred to another acute care facility • Admissions who are discharged AMA • Admissions without at least 12 months pre-discharge and 30 days post-discharge enrollment in fee-for-service Medicare • Admissions with LOS > 1 year • Same day readmissions for the same condition to the same hospital • AMI only: admissions discharged alive on same day they are admitted

16. Readmission risk adjustment • Risk adjustment • Uses information from the following Medicare claims for the 12 months prior to admission: • Hospital inpatient • Hospital outpatient • Physician office • May not include: • Inpatient secondary conditions that are ‘not present on admission’ • Measurement model uses data from July 2005 through June 2008

17. Risk-standardized readmission rate • Ratio of predicted to expected readmissions x national unadjusted rate: • Predicted number of 30-day readmissions (hosp-specific intercept) • Expected number of readmissions (average intercept)

18. Readmission data on hospital compare

19. Distribution of 30-day readmission results

20. Readmission risk adjustment From CMS Measure Technical Specifications on www.qualitynet.org accessed 2/1/10

21. Readmission risk adjustment From CMS Measure Technical Specifications on www.qualitynet.org accessed 2/1/10

22. Readmission risk adjustment From CMS Measure Technical Specifications on www.qualitynet.org accessed 2/1/10

23. A word (or two) on present on admission • Currently required for all Medicare diagnoses • May be required by your state or other payers • Currently used for CMS Hospital Acquired Conditions (HACs) • No aggregate feedback to hospitals • No widespread accuracy feedback • Still very little focus nationwide

24. POA challenges

25. Analysis of POA data

26. Final thoughts • Documentation and coding will impact outcome measure risk adjustment • May be future financial impact from risk-adjusted mortality and readmission • Consider new or expanded query opportunities • All secondary conditions • Present on admission