Overview New Developments in Quality Based Reimbursement Recap - - PowerPoint PPT Presentation

▶
overview
SMART_READER_LITE
LIVE PREVIEW

Overview New Developments in Quality Based Reimbursement Recap - - PowerPoint PPT Presentation

Dec 05, 2022 440 likes •875 views

Quality Based Impacts to Medicare Inpatient Payments Overview New Developments in Quality Based Reimbursement Recap of programs Hospital acquired conditions Readmission reduction program Value based purchasing

slide-1
SLIDE 1

Quality Based Impacts to Medicare Inpatient Payments

slide-2
SLIDE 2

Overview

  • New Developments in Quality Based

Reimbursement

  • Recap of programs

– Hospital acquired conditions – Readmission reduction program – Value based purchasing

  • Reimbursement impacts

09/09/2014 2

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-3
SLIDE 3

New Developments in Quality Based Reimbursement

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

3

slide-4
SLIDE 4

Socioeconomic Status

  • Many comments to CMS about the lack of

socioeconomic status (SES) [or sociodemographic status (SDS)]

  • CMS has continued to push back against

comments that SES makes a significant difference risk scoring

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

4

slide-5
SLIDE 5

Socioeconomic Status

  • 2013 Medicare Hospital Quality Chartbook

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

5

2011 Data Hospital wide Risk-standardized Readmission Rate High proportion of Medicaid (>= 28%) Low proportion of Medicaid (<= 5%)

slide-6
SLIDE 6

Socioeconomic Status

  • CMS comments on SES adjustment

– “We continue to believe that the same care protocols and processes that are successful in caring for nonlow-SES patient populations may also be successful in caring for low-SES patient populations.” – “We continue to have concerns about holding hospitals to different standards for the outcomes

  • f their patients of low SES—we do not want to

mask potential disparities or minimize incentives to improve the outcomes of disadvantaged populations.”

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

6

slide-7
SLIDE 7

Socioeconomic Status

  • CMS “committed to working with NQF and
  • ther stakeholder communities to

continuously refine our measures and to address the concerns associated with SES and risk adjustment.”

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

7

slide-8
SLIDE 8

Socioeconomic Status

  • National Quality Forum (NQF) Technical

Report: “Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors”

– Released August 15, 2014 – Important because NQF initiatives drive the data collection used by CMS for quality reporting

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

8

slide-9
SLIDE 9

Socioeconomic Status

  • NQF sees measures used for

accountability programs and pay-for- performance and responds:

– “Getting the measures “right” is important given that they are being used to determine which providers to include in networks, how to determine financial rewards or penalties, where to go for healthcare services, and where to focus improvement efforts”

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

9

slide-10
SLIDE 10

Socioeconomic Status

  • Ten recommendations, important take-aways

– SES factors should be included in risk adjustment unless conceptual reason or empirical evidence to indicate such adjustment is inappropriate. – Transition period should include periods of reporting both SES adjusted and unadjusted scores – Consensus Standards Approval Committee recommended, and the NQF Board of Directors approved, a trial period that lifts restrictions against SES adjustments – Created a Disparities Committee

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

10

slide-11
SLIDE 11

Socioeconomic Status

  • From the NQF Report, traits of a sociodemographically

challenged patient:

– Poverty – Low income and/or no liquid assets – Low levels of formal education, literacy, or health literacy – Limited English proficiency – Minimal or no social support –not married, living alone, no help available for essential health-related tasks – Poor living conditions – homeless, no heat or air conditioning in home or apartment, unsanitary home environment, high risk of crime – No community resources – social support programs, public transportation, retail outlets

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

11

slide-12
SLIDE 12

Source of Performance Data

  • Medicare claims are a significant source of

data used in benchmarking

  • CMS often marries claims data from other

sources (e.g. physician office)

  • Introduces additional context to consider

when auditing HIM activity

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

12

slide-13
SLIDE 13

Hospital Acquired Conditions

  • HACs become a penalty in FFY 2015
  • Composite score from three sources of

infection tracking

– Composite Medicare safety indicators – Two types of CDC hospital acquired infection measures (Medicare and non-Medicare)

09/09/2014 13

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-14
SLIDE 14

Hospital Acquired Conditions

  • 1% reduction in payment for hospitals in

the top quartile. This is an all-or-nothing penalty.

– ‘‘99 percent of the amount of payment that would otherwise apply.’’

  • Reduction applies to add-on payments

such as outliers, DSH, uncompensated care, and IME

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

14

slide-15
SLIDE 15

Hospital Acquired Conditions

  • Two domains

– If volume minimums met, 1 through 10 score based on percentile of performance. – Domain 1 – AHRQ Patient Safety Indicators (PSI): 35% – Domain 2 – CDC National Healthcare Safety Network (NHSN) measures: 65%

09/09/2014 15

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-16
SLIDE 16

Hospital Acquired Conditions

  • Domain 1 – AHRQ Patient Safety

Indicators (PSI)

– PSI-90 composite measure

  • Claim extracted measure

– FFY 2015 period: July 2011 – June 2013

09/09/2014 16

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-17
SLIDE 17

Hospital Acquired Conditions

  • Domain 2 – CDC National Healthcare

Safety Network (NHSN) measures

– Standardized Infection Ratio (SIR) for each Healthcare associated infection (HAI)

  • Measure counts if SIR predicts at least 1 HAI

event.

– Chart abstracted measures – FFY 2015 period: CY 2012 & 2013 – Sample includes Medicare and non-Medicare

09/09/2014 17

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-18
SLIDE 18

Hospital Acquired Conditions

  • Domain 2 Measures

– Central line associated blood stream infection (FFY 2015) – Catheter associated urinary tract infection (FFY 2015) – Two surgical site infection (FFY 2016) – Two infectious diseases (FFY 2017)

09/09/2014 18

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-19
SLIDE 19

Hospital Acquired Conditions

  • For CDC hospital acquired infections,

sample size matters

– Score based on performance relative to predicted number of infections (risk adjusted) – For 12 month period, if only 10 infections projected, impact of a few infections:

  • 0 infections: 100th percentile (higher is better)
  • 4 infections: ~60th percentile
  • 10 infections: ~39th percentile

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

19

slide-20
SLIDE 20

Hospital Acquired Conditions

  • Data for FFY 2015 penalty is not yet

available, though providers have received hospital specific reports

  • Proxy data on Hospital Compare shows 20

NJ providers in danger of 1% penalty

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

20

slide-21
SLIDE 21

Hospital Readmission Reduction Program

  • CMS Goal: Reduce readmissions related to

costliest conditions

  • Providers with high numbers of readmissions

in targeted areas will have reduced reimbursement

– Max of 1% in FFY 2013, 2% in FFY 2014 and 3% in FFY 2015 – Risk-adjusted – Based on three-year rolling averages

09/09/2014 21

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-22
SLIDE 22

Hospital Readmission Reduction Program

  • Excess readmission ratio = Predicted

Readmission Rate / Expected Readmission Rate

  • Excess readmission ratio greater than 1

means too many readmissions per CMS metrics

  • Large excess readmission ratio does not

mean huge penalty. Penalty is proportional to excess readmissions * volume

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

22

slide-23
SLIDE 23

Hospital Readmission Reduction Program

  • Targeted areas for FFY 2015

– Heart attack (AMI) – Heart failure (HF) – Pneumonia (PN) – Total hip / knee arthroplasty (HK) (new) – Chronic obstructive pulmonary disease (COPD) (new)

09/09/2014 23

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-24
SLIDE 24

Hospital Readmission Reduction Program

  • For FFY 2017, new measure: Coronary Artery

Bypass Graft (CABG)

– Annual cost of readmissions $151 million – Isolated CABG procedures only. Patients with other cardiac procedures in same encounter are excluded. – Unlike other measures, CABG readmission methodology includes cases transferred to acute care hospital after procedure

  • Presumption is that provider who is transferring the case will

be “encouraged by this measure to work closely with the institutions they transfer patients to, to provide optimal continuity of care for their patients”

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

24

slide-25
SLIDE 25

Hospital Readmission Reduction Program

  • Planned Readmission Algorithm updated

– Identifies procedures that are always considered planned (and therefore not an unplanned readmission) – Identified primary discharge diagnoses that are always planned – Procedures considered planned unless accompanied by an acute (or unplanned) primary diagnosis

  • For example, ongoing treatments such as maintenance

chemotherapy for cancer or cardiac device placement for cardiovascular disease patients are excluded from the calculation (exception: therapeutic radiation is somehow usually unplanned)

– Clinical Classification Software (CCS) used

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

25

slide-26
SLIDE 26

Hospital Readmission Reduction Program

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

26

Change to v3.0 from v2.1 did not significantly change readmission rates; however, introduction of v2.1 reduced the readmission rates by ~1% for AMI, HF, & PN in FFY 2014

slide-27
SLIDE 27

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

27

0% 10% 20% 30% 40% 50% 0.0%

  • 0.4%
  • 0.8%
  • 1.2%
  • 1.6%
  • 2.0%
  • 2.4%
  • 2.8%

Percent Distribution

Distribution of Readmission Reduction Penalties (NJ Providers)

FFY 2013 FFY 2014 FFY 2015 0% 10% 20% 30% 40% 50% 60% 0.0%

  • 0.4%
  • 0.8%
  • 1.2%
  • 1.6%
  • 2.0%
  • 2.4%
  • 2.8%

Percent Distribution

Distribution of Readmission Reduction Penalties (All US Providers)

FFY 2013 FFY 2014 FFY 2015

slide-28
SLIDE 28

Hospital Readmission Reduction Program

  • Reimbursement Impact

– Penalty is proportional to volume in risk areas – Financial impact could be small for very low volume risk areas with excessive readmissions – Medicare HMOs are taking action to deny payment for readmissions

  • Looks like QIO program, but applies different

standards

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

28

slide-29
SLIDE 29

Value Based Purchasing

  • CMS goal: Pay for value
  • Incentivize providers to meet quality

standards by tying reimbursement to performance metrics

– Achieve quality scores OR – Improve score quality

  • Performance Period (“Current” period)
  • Baseline Period (Two years prior to Performance)

09/09/2014 29

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-30
SLIDE 30

Value Based Purchasing

  • Reimbursement impact

– Revenue neutral program for CMS – All hospitals will see a reduction in the

  • perating payment, then add back based on

performance

  • 1.5% for FFY 2015
  • 1.75% in FFY 2016
  • 2.00% in FFY 2017 and beyond. CMS has no

plans to increase financial impact.

09/09/2014 30

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-31
SLIDE 31

Value Based Purchasing

FFY 2013 FFY 2014 FFY 2015 FFY 2016 Clinical Process of Care 70% 45% 20% 10% Patient Experience of Care 30% 30% 30% 25% Outcomes 25% 30% 40% Efficiency 20% 25%

CMS believes “that domains need not be given equal weight, and that over time, scoring methodologies should be weighted more towards outcomes, patient experience of care, and functional status measures (for example, measures assessing physical and mental capacity, capability, well-being and improvement).”

09/09/2014 31

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-32
SLIDE 32

Value Based Purchasing

  • Clinical process of care

– Clinical measures historically reported through the IQR program – National standard is near 100% compliance for many measures – Weight of this component is decreasing, very little separation in scores across providers

09/09/2014 32

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-33
SLIDE 33

Value Based Purchasing

  • Patient Experience of care

– 8 dimensions in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). For example,

  • Communications with Nurses, Doctors
  • Responsiveness of staff
  • Communication about medicines
  • Cleanliness & quietness

09/09/2014 33

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-34
SLIDE 34

Value Based Purchasing

  • Outcomes Measures

– FFY 2014: Three 30-Day mortality measurements: AMI, HF & PN – FFY 2015: Add AHRQ Patient Safety Indicators (PSI) composite and CDC Central Line Associated Blood Stream Infections (CLABSI) – FFY 2016: Add CDC catheter associated urinary tract infections (CAUTI) and Surgical Site Infection (SSI) for Colon and Abdominal Hysterectomy

09/09/2014 34

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-35
SLIDE 35

Value Based Purchasing

  • Efficiency Domain

– Only one measure: Medicare Spending per Beneficiary – Begins FFY 2015

09/09/2014 35

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-36
SLIDE 36

Value Based Purchasing

  • Medicare Spending per Beneficiary

– Three periods: Three days prior to admission, the inpatient encounter, and 30 days after discharge – Standardized payment that removes IME, DSH, and any wage related factors – Includes all spending, physicians, hospital readmissions, DME, and most importantly, post-acute care providers

09/09/2014 36

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-37
SLIDE 37

Value Based Purchasing

  • Medicare Spending per Beneficiary

– Spending per episode is risk adjusted across 95 risk factors – Expected spending for an average episode based on nationwide data for each DRG – Expected spending then adjusted + / - for each risk factor

09/09/2014 37

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-38
SLIDE 38

Value Based Purchasing

New Jersey U.S. Average Spending per Episode

$20,918 $19,578

MSPB Amount (Avg. Risk-Adjusted Spending)

$21,011 $19,239

U.S. National Median MSPB Amount

$19,546 $19,546

Average MSPB Measure

1.07 0.98

09/09/2014 38

CBIZ KA Consulting Services, LLC for NJ HFMA

Medicare Spending per Beneficiary – Comparative Benchmarks Note: Medicare Spending refers to funds spent by Medicare to treat patients having an index admission in a hospital setting. This does NOT refer to provider’s cost to treat the patient.

slide-39
SLIDE 39

Value Based Purchasing

Spending by segment and provider type MSPB – 2013 Data New Jersey Nation

Average Spending per Episode Percent of Spending per Episode Average Spending per Episode Percent of Spending per Episode

3 Days Prior to Admission $607 2.9% $627 3.2% Inpatient Admission $10,271 49.1% $10,533 53.8% Inpatient Hospital $8,451 40.4% $9,006 46.0% Carrier (Professionals) $1,799 8.6% $1,508 7.7% Others $21 0.1% $20 0.1% 30 Days Post Discharge $10,062 48.1% $8,419 43.0% Home Health Agency $628 3.0% $764 3.9% Hospice $84 0.4% $117 0.6% Inpatient Hospital* $2,678 12.8% $2,604 13.3% Outpatient $648 3.1% $666 3.4% Skilled Nursing Facility $4,393 21.0% $3,093 15.8% DME $105 0.5% $98 0.5% Carrier (Professionals) $1,506 7.2% $1,077 5.5% Total $20,918 $19,578 *Includes LTACH, IRF, IPF

39 09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

slide-40
SLIDE 40

Value Based Purchasing

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

40

2 4 6 8 10 12 14 16 18 20 50 100 150 200 250 300 350 400 450 500 Number of Providers (NJ Only) Number of Providers (All US)

Distribution of VBP Net Impacts (FFY 2014)

All US NJ Only

slide-41
SLIDE 41

Value Based Purchasing

  • Realignment of Measures

09/09/2014

CBIZ KA Consulting Services, LLC for NJ HFMA

41

FFY 2017 Measures Safety 20%

CAUTI, CLABSI, C. difficile, MRSA, PSI-90, SSI (All were in Outcomes Measure)

Clinical Care – Outcomes 25%

Mortality (AMI, HF, PN)

Clinical Care – Processes 5%

AMI-7a, IMM-2, PC-01

Efficiency and cost reduction 25% MSPB Patient experience 25% HCAHPS

slide-42
SLIDE 42

Thank You

  • Questions?
  • Contact information

– Brian Herdman

  • bherdman@cbiz.com
  • (609) 918-0990 x131

09/09/2014 42

CBIZ KA Consulting Services, LLC for NJ HFMA