Performance Measurement Work Group 2/15/17 Meeting Emergency - PowerPoint PPT Presentation

Performance Measurement Work Group 2/15/17 Meeting

Emergency Department Performance in Maryland February 15, 2017

Statewide Trends – ED Diversion Over Time Statewide use of Yellow Alerts  ED Diversion is increasing 15.2% 16.0% in Maryland, but 14.0% 11.9% 12.0% particularly in: % of Time on Alert 9.0% 10.0% 7.9%  Region 3 (Baltimore 8.0% 6.7% 6.3% 4.9% 6.0% City/County and Central 4.1% 4.0% 4.0% 3.0% 4.0% MD) 1.0% 2.0% 0.0%  Region 5 (DC suburbs and 2013 2014 2015 2016 Year southern MD) Statewide Region 3 Region 5  Diversion remains a Yellow Alert: The ED temporarily requests that it receive absolutely no patients in need of urgent medical care. critical issue across the Yellow Alert is initiated because the ED is experiencing a temporary overwhelming overload such that priority II country, not just Maryland. and III patients may not be managed safely. Prior to diverting pediatric patients, medical consultation is advised for pediatric patient transports when EDs are on yellow alert. 3 Data Source: Md. Institute for EMS Systems (MIEMSS)

Statewide Trends – ED Wait Times Over Time OP-20: Door to Diagnostic Evaluation ED-2: Admit Decision until Admission 60 160 Median number of Minutes Median number of Minutes 140 50 120 40 100 30 80 60 20 40 10 20 0 0 Time Time Nation Statewide Nation Statewide  ED-2 – Admit Decision until Admission Some physicians concerned that “boarding” is reducing ED throughput efficiency and  increasing wait times.  OP-20 – Door to Diagnostic Evaluation This measure is most accessible to consumers and was presented in recent local news story.  4 Data Source: CMS Hospital Compare

Statewide Overview – 2016 (Yellow Alert) % of Time on Yellow Alert - 2016 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 MD Hospitals % of time on Alert Statewide % of Time on Alert 5 Data Source: MIEMSS

Statewide Overview – 2016 (Wait Times) OP-20 Door to Diagnostic Evaluation (Most ED-2 - Decision to Admit until Admission (Most Recent Data) recent Data) 400 120 350 100 Median number of Minutes Median number of Minutes 300 80 250 200 60 150 40 100 20 50 0 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 Hospitals in MD Hospitals in MD Nation Statewide Statewide Nation 6 Data Source: CMS Hospital Compare

% Change Wait Times % Change in ED-2 2016Q1 over % Change in OP-20 2016Q1 over 2014Q1 2014Q1 60.0% 120.0% 50.0% 100.0% 40.0% 80.0% 30.0% 60.0% 20.0% 40.0% 10.0% 20.0% 0.0% 0.0% -10.0% -20.0% -20.0% -40.0% -30.0% -60.0% -40.0% -80.0% Hospitals in MD State Nation Hospitals in MD State Nation 7

Additional Context for ED Throughput Measures

Ongoing Delivery System Changes beginning 2014  Expansion under ACA  Implementation of GBRs, new incentives, care coordination resources  Large EMR installations  Nurse staffing  Nursing shortages begin again  Increased use of agency nurses  Trends in Behavioral Health  Carve out of substance abuse from Medicaid MCOs  Increasing problems with substance abuse and psych patients in emergency rooms  FFY 2016 - Medicare’s two midnight rule, increasing ER observations 9

Statewide Volume Analysis An increase in volume could account for longer wait times; however, the IP/OP Volume shows a slight but steady decline. ED IP : An ED visit that resulted in an IP admission. ED OP : An ED visit that did not result in an IP admission, patient was treated in OP setting and discharged. Statewide ED IP Volume over Time 40,000 Number of Visits (by month) 30,000 20,000 10,000 - Month Statewide ED OP Volume over Time 250,000 Number of Visits (by 200,000 150,000 100,000 50,000 month) - Month 10 HSCRC Financial Data

Casemix Acuity  If there was a notable increase in the severity of illness of cases entering the ED, that could explain ED throughput challenges.  Preliminary analysis of OP ED visits suggests that there is no notable increase in difficulty of cases presenting to the Emergency Department. 11

Potential Next Steps Continue to explore root causes and respond efficiently and appropriately:  Require additional staffing level detail  Alter market shift adjustment to factor in amount of time on ED diversion  Include ED indicators as soon as possible to Quality Programs (RY2020) 12

RY 2019 Readmission Reduction Incentive (RRIP)Program

General RY 2019 RRIP Updates  Update to PPC Grouper Version 34 (ICD-10)  Proposed base period = CY 2016  Inclusion of all chronic beds  No changes to RRIP case-mix adjusted readmission measure, planned admissions, or other exclusions  RRIP Improvement and Attainment Scales  Need to set one year improvement target and scale distribution  Update attainment benchmark and scale distribution  Continue to set max reward at 1% and max penalty at 2% 14

Readmission Trends: CY 2017 Improvement Target 15

Monthly Case-Mix Adjusted Readmission Rates 2014 2013 16% 2015 2016 14% 12% 10% Case-Mix Adjusted 8% All-Payer Medicare FFS Readmissions CY13 Nov YTD 12.91% 13.71% 6% CY14 Nov YTD 12.41% 13.46% CY15 Nov YTD 12.02% 12.91% 4% CY16 Nov YTD 11.50% 12.37% CY13 - CY16 YTD % -10.92% -9.79% 2% Change All-Payer Medicare FFS 0% 16 Note: Based on final data for January 2012 – Sept. 2016, and preliminary data through December 2016.

Change in All-Payer Case-Mix Adjusted Readmission Rates by Hospital 10% Change Calculation compares Jan-Nov CY 2013 compared to Jan-Nov CY2016 5% 0% -5% -10% Goal of 9.5% Cumulative -15% Reduction 27 Hospitals are on Track for Achieving -20% Improvement Goal Additional 11 Hospitals -25% on Track for Achieving Attainment Goal -30% -35% 17 Note: Based on final data for January 2012 – Sept. 2016, and preliminary data through December 2016.

Medicare Readmission All-Payer Model Test Waiver Test: MD Medicare Unadjusted Readmission rate must be at or below National Medicare rate by end of CY 2018 18

Maryland is reducing readmission rate but only slightly faster than the nation 18.50% 18.17% 18.00% 17.42% 17.50% 17.00% 16.61% 16.47% 16.50% 15.95% 16.29% 16.00% 15.64% 15.76% 15.50% 15.50% 15.42% 15.39% 15.29% 15.00% 14.50% 14.00% 13.50% CY2011 CY2012 CY2013 CY2014 CY 2015 CY 2016 YTD Sep National Maryland 19

Cumulative Readmission Rate Change by Month (year over year): Maryland vs Nation HSCRC Staff Currently Exploring Data Differences; need to take into account when setting target -0.21% -0.24% -0.38% -0.26% -0.23% -0.29% -0.30% -0.26% -0.28% -0.34% -0.49% -0.36% -0.32% -0.33% 0.00% -0.77% -0.85% -1.02% -0.99% -0.93% -0.92% -1.01% -0.73% -0.57% -1.00% -1.08% -1.38% -2.19% -2.22% -2.00% -2.03% -2.08% -2.61% -2.73% -2.73% -2.44% -2.34% -2.31% -2.73% -3.00% -2.77% -2.78% -3.22% -3.23% -3.00% -3.39% -3.45% -3.16% -3.27% -3.39% -3.25% -3.26% -3.18% -3.13% -3.66% -3.50% -3.49% -4.23% -4.00% -4.89% -4.71% -4.40% -4.94% -5.23% -5.15% -5.27% -5.00% -5.53% -6.00% -6.69% -7.00% -8.00% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2015 2015 2015 2015 2015 2015 2015 2015 2015 2015 2015 2015 2016 2016 2016 2016 2016 2016 2016 2016 2016 National Medicare CMMI MD Medicare HSCRC MD Medicare CMMI MD In-State 20

Mathematica Modeling of Improvement Target 21

RY 2019 Maryland Hospital Acquired Conditions (MHAC)

General RY 2019 MHAC Updates  Removal of palliative care exclusion  Update to PPC Grouper Version 34 (ICD-10)  Inclusion of all chronic beds and Holy Cross Germantown  Hospitals with only serious reportable events removed  MHAC methodology and Scaling  No changes to setting of benchmarks/thresholds or PPC scoring methodology (i.e., improvement and attainment points)  Change to single linear scale with max penalty 2%/reward 1% 23

Palliative Care (PC) Inclusion  Statewide case-mix adjusted PPC rate for RY 2017 Case-Mix Adjusted PPC FY 2014 CY 2015 % change Rates Without PC 0.97 0.73 -24% With PC 1.06 0.84 -21% Difference +4%  Statewide Revenue based on RY 2017 Final Scores Without PC With PC $ 29,256,690 $ 23,232,858 State Total -$647,766 -$663,381 Penalty -0.01% -0.01% % Inpatient $29,904,456 $23,896,239 Reward 0.34% 0.27% % Inpatient 24 See excel handout for hospital specific results

Discussion of Palliative Care  Staff are proposing commissioners vote on inclusion of palliative care cases, balancing the following issues:  Clinical concerns for palliative care patients  Serious complications could lead to palliative care  Coding changes and variation  3M recommends including discharges where palliative care is not present on admission  Starting Federal FY17 (Oct. 2016) PC dx requires POA  Currently, do majority of discharges with PC have it POA?  Consider running scores with and without PC 25

Benchmarks/Thresholds  Changes in benchmarks driven by:  Version 34  Inclusion of Palliative Care Differences in Benchmarks with and without PC by PPC (PPC Grouper Version 34) 0.40 0.30 0.20 0.10 0.00 -0.10 -0.20 -0.30 26