Quality and Patient Safety in Healthcare: Updates and Impacts

1. CMS Update FY’14 Frank Briggs, Pharm.D., M.P.H. Vice President, Quality and Patient Safety West Virginia University Healthcare

2. Objectives • At the completion of this presentation, the participants shall be able to: • Describe the changes in Value Based Purchasing (VBP) • Explain the Hospital Acquired Condition (HAC) penalty program • Estimate the impact of changes in the Inpatient Prospective Payment System (IPPS)

3. Outline • Inpatient Quality Reporting (IQR) • Value Based Purchasing (VBP) • Readmission Reduction • Hospital Acquired Conditions (HAC) • Not included • Documentation and coding effects • Disproportionate share program • Labor and delivery days • Outlier thresholds • 2 Midnight Rule?

4. Inpatient Quality Reporting • Voluntary reporting • Required for annual payment update 2% • Measures appear in program ~2 years before advancing • VBP • HAC • Readmissions

5. Inpatient Quality Reporting • medicare.gov/hospitalcompare

7. Patient Survey Results • Hospital Consumer Assessment of Healthcare Providers and Systems • HCAHPS • Reported since 2007 • Uses scale from never to always (5 points) • Top box scores – “Always” • Report “Always”

8. HCAHPS Domains • Nurse communication • Doctor communication • Responsiveness of staff • Pain control • Explanation of medications • Cleanliness • Quietness • Discharge information (recovery)

9. Core Measures • Heart Attack Care • Aspirin at discharge • Fibrinolytic within 30 mins • Primary PCI within 90 mins • Statin at discharge • Heart Failure • Discharge instructions • Evaluation of LVS function • ACEI/ARB for LVSD

10. Core Measures • Pneumonia Care • Blood cultures in ED prior to antibiotic • Appropriate antibiotic selection • Surgical Care • Antibiotics: timing, selection, and discontinuation • Venous thromboembolism (VTE) prevention • Beta blockers continued • Blood glucose control in cardiac surgery • Urinary catheters removal • Monitoring of body temperature

11. Core Measures • Emergency Department • Time spent in ED for admitted patients • Time spent in ED after decision to admit • Time spent in ED for patients sent home • Time before being seen by provider • Time before pain medication for broken bones • Percent of patients who leave without being seen • Percent of patients with stroke symptoms who receive brain scan within 45 mins • Preventive Care • Immunizations

12. New Core Measures • Immunizations • Venous Thromboembolism (VTE) • Stroke • Perinatal Care • Hospital based inpatient psychiatric services (HBIPS)

13. Core Measures • Immunizations • Influenza • Pneumonia • VTE • VTE prophylaxis • Overlap with anticoagulation • Heparin – platelet dose adjustments by protocol • Discharge instructions for warfarin • Preventable VTE

14. Core Measures • Stroke • VTE prophylaxis • Discharge on antithrombotic therapy • Anticoagulation for atrial fibrillation/flutter • Thrombolytic therapy • Antithrombotic by day 2 • Discharged on Statin • Stroke education • Assessed for rehabilitation • Perinatal Care • Elective delivery • Cesarean sections • Antenatal steroids • Bloodstream infections • Exclusive breast feeding

15. Core Measures • HBIPS • Admission screen: violence, substance abuse, psychological trauma, and patient strengths • Hours of physical restraint • Hours of seclusion • Patients discharged on multiple antipsychotics • Discharge plan created and transmitted to next provider

16. Removals of Measures • FY 2016 • PN: Blood cultures • HF: discharge instructions, ACEI/ARB for LVSD • AMI: aspirin/statin at DC • SCIP: temperature monitoring

17. Readmissions Complications and Deaths • Readmission: 30-day all-cause • AMI • HF • Pneumonia • Death: 30-day • AMI • HF • Pneumonia

18. New Readmissions and Death Measures • Readmissions • Total Joints • Hospital-wide • COPD • Stroke • Planned readmission algorithm • Mortalities • COPD • Stroke

19. Complications • Agency for Healthcare Research and Quality Measures (AHRQ) • Patient safety indicators • Death among surgical patients with treatable complications • Iatrogenic pneumothorax • Post-op respiratory failure • Post-op VTE • Post-op wound dehiscence • Accident puncture or laceration

20. Other Measures Reported • Use of medical imaging • Medicare payments • Number of Medicare patients treated

21. Value Based Purchasing • Established by Affordable Care Act • Requires CMS to implement a Hospital VBP program • Rewards hospitals for quality of care provided • Built upon IQR infrastructure • Evaluate during performance period for achievement or improvement on measures • Hospital receive points on each measure reflecting better performance • Funding by reducing base operating DRG payment

22. Value Based Purchasing • Payment reductions • 2013: 1% • 2014: 1.25% • 2015: 1.5% • 2016: 1.75% • 2017: 2% • Amount available for FY 14 incentive payments $1.1 billion

23. Domains • Clinical process of care (core measures) • 13 measures and weighted at 45% • Patient experience (HCAHPS) • 8 domains and weighted at 30% • Outcomes • 3 mortality measures and weighted 25%

25. Evaluating Hospital Performance • Achievement points • Awarded by comparing individual hospital rate during performance period with all hospitals rates from baseline period • Rate at or above benchmark (90th%ile): 10 points • Rate less than achievement threshold (median): 0 points • Rate between achievement and benchmark: 1-10 points • Comparing current hospital performance to baseline of all hospitals

26. Evaluating Hospital Performance • Improvement points • Awarded by comparing hospitals rates during performance period to same hospitals rate from baseline period • Rate at or above benchmark: 9 points • Rate less than or equal to baseline: 0 points • Rate between baseline and benchmark: 0-9 points • Comparing against yourself over time • Fewer points than achievement

27. Proposed VBP Changes for 2015 and Beyond • 2015 (final) • Clinical process of care measures: 20% • Outcome measures: 30% • Efficiency measures(Medicare spending): 20% • HCAHPS: 30% • 2016 (proposed) • Clinical process of care measures: 10% • Outcome measures (add AHRQ PSI and infection): 40% • Efficiency measures: 25% • HCAHPS: 25%

28. VBP 2017 • Change domain and reweight • Outcomes become safety domain: 15% • AHRQ Patient Safety Indicators • Process of care becomes clinical care domain: 35% • Clinical process of care: 10% • Mortality outcomes: 25%

29. Reduction Earn back % change in DRG Value multiplier for DRG Slope for translation

30. Readmission Reduction Program • Maximum penalty increased to 2% • Projecting $175 million in fewer payments • Added planned readmission logic • Two new measures for FY 2015 • COPD and elective joint • Built upon IQR infrastructure • FY 2014 period • July 1, 2009 – June 30, 2012

31. Planned Readmission • Incorporating algorithm • AMI, HF, PN • FY 2014 • Will not count unplanned readmissions that follow planned readmissions either

32. Hospital Acquired Condition (HAC) Reduction Program • Required by Affordable Care Act • Payment adjustment for all inpatient hospital payments • ***Includes indirect medical education (IME) and disproportionate share (DSH) payments • Must apply to one quarter of all hospitals (lowest performance) • In addition to the non-payment HAC program • Reductions applied after adjusting for VBP and Readmissions reduction programs • Starts in FY 2015

33. HAC Reduction Framework Total HAC Score Worst quartile performance 1% reduction Domain 1 (35%) Domain 2 (65%) AHRQ Patient Safety Indicators NHSN Infection Pressure Ulcer Central line blood stream Iatrogenic pneumothorax Catheter associated UTI Central venous catheter infection Hip fracture 2016 Post-op VTE Surgical site infection Sepsis (Colon and abdominal hys) Wound dehiscence Accidental puncture 2017 MRSA C difficile

34. HAC Scoring (Golf) • Points assigned based on performance • Performance range for each measure divided into deciles • All hospitals receive between 1-10 points for each measure (lower is better) • Total score calculated • AHRQ score x 35% + average of 2 NHSN infections x 65% • Each year bottom 25% are penalized • Move faster than the others

35. Data Periods • Domain 1: AHRQ PSI • July 2011 – June 2013 • Domain 2: NHSN Infections • Calendar years 2012 -2013

36. Admission and Medical Review Criteria • Requires physician order for admission to inpatient status • Authenticated by attending provider • Certification • Inpatient order • Inpatient services are reasonable and necessary • Appropriately provided in accordance with 2 midnight benchmark • Reason for inpatient services • Medical record • Estimated time the beneficiary requires inpatient care • Plans for post hospital care • CAH: beneficiary reasonably expected to be discharged or transferred within 96 hours • Must be signed and dated prior to discharge • DRG payments reduced additional 0.2% to account in addition

37. 2 Midnight Benchmark • Reasonably expect patient to require inpatient hospital care for at least 2 midnights • Less than 2 midnights • Expected to be observation • May move from observation to inpatient if patient meets medical necessity and going to require hospital care for second midnight • Outpatient time does not convert to inpatient billing (no retroactive billing) • Includes time spent in hospital outpatient areas (ED and OR) • Does not begin at triage, when care starts!

38. Estimating Impact of Changes • IQR changes • Generally don’t involve payment/penalty • Voluntary, required for APU • May require additional staff and support • VBP • 1.25% withhold – earn back % = impact • Readmission reduction (2%) • HAC 1% of DRG + IME + DSH

39. Contact Information Frank Briggs, Pharm.D., M.P.H. Vice President, Quality and Patient Safety West Virginia University Healthcare Email: briggsf@wvuhealthcare.com Phone: 304.598.4057