barbara j. connors, do, mph chief medical officer, region iii the centers for medicare and medicaid...

Barbara J. Connors, DO, MPH

Chief Medical Officer, Region III

The Centers for Medicare and Medicaid Services

Region III

Philadelphia Chapter ACS

CMS’ Value-Based PurchasingThe Nexus of Quality,

Coordination, & Efficiency

CMS’ Quality Improvement Roadmap

Vision: The right care for every person every time Make care:

Safe Effective Efficient Patient-centered Timely Equitable

CMS’ Quality Improvement Roadmap

Strategies Work through partnerships Measure quality and report comparative results Encourage adoption of effective health

information technology Promote innovation and the evidence base for

effective use of technology Value-Based Purchasing: Improve quality

and avoid unnecessary costs

Support for VBP

President’s Budget FYs 2006-09

Congressional Interest in P4P and Other Value-Based Purchasing Tools BIPA, MMA, DRA, TRCHA, MMSEA, MIPPA

MedPAC Reports to Congress P4P recommendations related to quality, efficiency, health

information technology, and payment reform IOM Reports

P4P recommendations in To Err Is Human and Crossing the Quality Chasm

Report, Rewarding Provider Performance: Aligning Incentives in Medicare

Private Sector Private health plans Employer coalitions

Why VBP?

Medicare Solvency and Beneficiary Impact Expenditures up from $219 billion in 2000 to a

projected $486 billion in 2009 Part A Trust Fund

Excess of expenditures over tax income in 2007 Projected to be depleted by 2019

Part B Trust Fund Expenditures increasing 11% per year over the last 6

years Medicare premiums, deductibles, and cost-sharing

are projected to consume 28% of the average beneficiaries’ Social Security check in 2010

Medicare Reimbursement Rates

Practice Variation

What Does VBP Mean to CMS?

Transforming Medicare from a passive payer to an active purchaser of higher quality, more efficient health care

Tools and initiatives for promoting better quality, while avoiding unnecessary costs

Tools: measurement, payment incentives, public reporting, conditions of participation, coverage policy, QIO program

Initiatives: pay for reporting, pay for performance, gainsharing, competitive bidding, bundled payment, coverage decisions, direct provider support

Value-Based Purchasing-What it is really about:

It is about defining/rewarding providers for the value of their

contribution to quality and efficient care that leads to better

health outcomes.

VBP: Payment Methodologies

• Pay for Reporting

• Pay for Participation

• Pay for Care Coordination

• Pay for Process

• Pay for Outcomes

VBP Programs

Physician Quality Reporting Initiative Physician Resource Use Reporting Hospital Quality Initiative: Inpatient &

Outpatient Pay for Reporting Hospital VBP Plan & Report to

Congress Hospital-Acquired Conditions & Present

on Admission Indicator Reporting

VBP

Towards Value-Based Purchasing

2007

•TRHCA

•74 measures

•Claims-based only

2008

•MMSEA

•119 measures

•Claims

•4 Measures Groups

•Registry

2009

•MIPPA

•153 measures

•Claims

•7 Measures Groups

•Registry

•EHR-testing

•eRx

2010

TBD through rule-making

Statutory Authority

• Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)– Section 131(d)

• Plan for Transition to Value-Based Purchasing Program for Physicians and Other Practitioners

• Report to Congress due May 1, 2010

Issues Paper Assumptions & Design Principles

PVBP Planning will:– Focus on performance-based payment– Accommodate different practice arrangements– Recognize the contributions of members of the health

professional team– Address multiple levels of accountability– Be at least budget neutral—across at least Medicare Parts A

and B—and will seek to identify program savings– Initially focus on traditional fee-for-service Medicare– Have short-term and longer-term timeframes, with attention

to transitions– Avoid creating additional health care disparities and work to

reduce existing disparities– Include an ongoing evaluation process

Stakeholder Input: Overarching Issues

• Affirmed goal and objectives• Advocated for new payment approaches that

cut across settings and align Part A and B payment incentives

• Agreed with the need to accommodate different practice arrangements

• Praised attention to disparities• Urged attention to operational transitions

Next Steps in Plan Development

• Receive direction from new leadership

• Design options– Physician Fee Schedule (PFS) overlay

• Performance-based PFS payments• Medical Home

– Levels of accountability beyond individuals• Groups• Accountable Care Entities

– Shared savings models– Bundled payment arrangements

• Simulations pending availability of resources

• Opportunities for stakeholder input– PFS 2010 rulemaking– Potential additional Listening Sessions

VBP and PQRI

Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)

- Makes PQRI permanent; however only 2009 and 2010 incentives are funded - Increased 2009 PQRI incentive to 2% - Added new E-Prescribing incentive for

2009, an additional 2% subject to qualifying for the measure

PQRI

• PQRI reporting focuses attention on quality of care– Foundation is evidence-based measures developed by

professionals.– Reporting data for quality measurement is rewarded with

financial incentive.– Measurement enables improvements in care.– Reporting is the first step toward pay-for-performance.

• Measures address various aspects of quality care – Prevention– Chronic Care Management– Acute Episode of Care Management– Procedural Related Care– Resource Utilization– Care Coordination

2007 PQRI Reporting Participation Statistics

• 109, 349 NPI/TINs – Attempted to Submit• 101,138 NPI/TINs – Submitted a Quality Data

Code Successfully– A feedback report is available

• 70,207 NPI/TINS – Satisfactorily Reported 1 or more measures– A feedback report is available

• 56,722 NPI/TINs – Earned Incentive– A feedback report & incentive payment are available

2007 PQRI Experience Report

QDC Submission Attempts• 12.15% Missing NPI • 18.89% Incorrect HCPCS code* • 13.93% Incorrect DX code* • 7.24% Both incorrect HCPCS code and incorrect DX

code*• 4.97% All line items were QDCs only

*Denominator mismatch

Top Ten Most Frequently Reported Measures by Clinical Topic

1. Pneumonia 2. Chest Pain3. Perioperative Care4. Diabetes5. ECG for Syncope6. Coronary Artery Disease7. Myocardial Infarction8. Heart Failure9. Macular Degeneration10. Glaucoma

2009 PQRI Quality Measures

• 153 PQRI quality measures for 2009– Includes 101 measures from the 2008 PQRI and 52

new measures– E-prescribing measure (Measure #125) removed, as

required by MIPPA as a separate incentive program– 18 measures reportable only through registries– Measure specifications are available in the

Measures/Codes section of the website at http://www.cms.hhs.gov/pqri.

http://www.cms.hhs.gov/pqri

2009 PQRI Reporting Periods

• 1 reporting period for claims-based reporting of individual measures: January 1, 2009 – December 31, 2009

• 2 reporting periods for reporting measures groups and registry-based reporting:– January 1, 2009 – December 31, 2009– July 1, 2009 – December 31, 2009

PQRI Claims-Based Process

Visit Documented in the Medical Record

Encounter Form Coding & Billing

Carrier/MAC

NCH

Analysis Contractor National Claims History File

Incentive Payment

Confidential Report

CriticalStep

N-365

26

Benefits of PQRI Participation

• Receive confidential feedback reports to support quality improvement

• Earn a bonus incentive payment• Make an investment in the future of the

practice– Prepare for higher bonus incentives

over time– Prepare for pay-for-performance– Prepare for public reporting of

performance results

MIPPA AuthorizedE-Prescribing Incentives

YearIncentive for Successful

E-Prescribers

Reduction for Unsuccessful E-Prescribers

2009 2.0%

2010 2.0%

2011 1.0%

2012 1.0% -1.0%

2013 0.5% -1.5%

2014 -2.0%

ARRA Authorized Incentives for Meaningful Use of EHRs

Year First Payment Yr (Subsequent payment Yrs)

Reduction in Fees for Non-Use

2011 $18k ($12k, $8k, $4k, $2k)

2012 $18k ($12k, $8k, $4k, $2k)

2013 $15k ($12k, $8k, $4k)

2014 $12k ($8k, $4k)

2015 -1%

2016 -2%

2017 -3%

Summary of MIPPA and ARRA Authorized Incentive Programs

YearMIPPA Authorized Incentive for Successful E-Prescribers

ARRA Authorized Incentive for Meaningful Use of EHR

20092010

2% IncentiveN/A

2011 1% Incentive $18k ($12k, $8k, $4k, $2k)

2012 1% Incentive $18k ($12k, $8k, $4k, $2k)

20130.5% Incentive1.5% Reduction

$15k ($12k, $8k, $4k)

2014No Incentive

2% Reduction

$12k ($8k, $4k)

2015 N/A 1% Reduction



Premier Hospital Quality Incentive Demonstration

Surgical Care Improvement Project /Surgical Infection

Prevention (SCIP)FY 2009

SCIP-Inf-1 Prophylactic antibiotic received within 1 hour prior to surgical incision

SCIP-Inf-3 Prophylactic antibiotics discontinued within 24 hours after surgery end time

SCIP-VTE 1: prophylaxis ordered for surgical ptSCIP-VTE 2: prophylaxis within 24 hr

pre/post

SCIP (Previously SIP)

SCIP Infection 2: Prophylactic Antibiotic selection for surgical pt

SCIP Infection 4: Cardiac surgical pts with Controlled 6am post op serum glucose

SCIP Infection 6 Surgery pts with appropriate hair removal

AHRQ PSIs and IQI’s

Patient Safety Indicators (PSIs)• Death among surgical pts with serious treatable

conditions• Post-op wound dehiscence

Inpatient Quality Indicators (IQIs)• AAA Mortality rate (with or without volume)• Hip fracture mortality rate• Mortality rate for selected surgical procedures• Participation in a systematic database for cardiac

surgery

ACS NSQIP

– Surgeons and centers require high quality, reliable & timely data to identify opportunities for improvement and to protect themselves from data being misinterpreted to and by the public

– Increasing public demand for “accountability” in healthcare– Eroding public trust in clinicians to provide safe care– Efforts by payors and purchasers to “drive” patients to

centers with safer systems – Evolving move by payors to “pay for performance”– Without risk-adjusted data, surgeons and medical centers

have had to use administrative (i.e., payor) data– Surgeons and medical centers find themselves profiled on

the Internet

ASC NSQIP

• The ACS NSQIP involves the collection of preoperative risk factors, intraoperative variables, and postoperative outcomes by a surgical clinical nurse reviewer (SCNR) at each participating medical center

DEMOGRAPHICS 9 variables

SURGICAL PROFILE 9 variables

PRE-OPERATIVE DATA 40 clinical variables13 laboratory variables

INTRA-OPERATIVE DATA18 clinical variables 3 occurrence variables

POST-OPERATIVE DATA20 occurrence variables12 laboratory variables 9 discharge variables

What to do with the Data

• Reduce postoperative mortality rates

• Reduce postoperative morbidity rates

• Reduce the median length-of-stay

• Leverage data for other internal and public reporting initiatives

• Meet CMS Surgical Care Improvement Program (SCIP) reporting requirements by collecting SCIP data through the ACS NSQIP SCIP data collection module

• Potentially allow for higher reimbursement in the emerging “pay for performance” environment

• Help to increase patient satisfaction

• Serve as a foundation and resource for research initiatives

• Help to identify possible under-billings

• Help to increase negotiating leverage with third-party payers and employers

– Inform and improve surgical rounds• Regular reporting of ACS NSQIP data in conjunction with

specific case discussion. Movement toward understanding and analyzing trends of occurrences v. singular events

– Identify quality improvement opportunities• Identification of quality improvement opportunities by Depts. of

Surgery Proactive v. Reactive

– Benchmark performance against peers– Re-engineer or eliminate retrospective clinical databases

historically used for quality assurance or JCAHO reporting– Discuss opportunities to use data in payor negotiations, “pay

for performance”– Conduct research– Review billing practices– Analyze systems of care

Use the Data

ACS NSQIP Eligible Specialties

General SurgeryVascular Surgery UrologyNeurosurgeryOrthopedicsENTPlastic SurgeryThoracicCardiacGynecological surgery

Demonstration Projects

• CMS currently pays for quality through a series of Demonstration Projects

• Several Demonstrations are mandated through Congressional Legislation

• Must be budget neutral

VBP Demonstrations and Pilots

• Physician Group Practice Demonstration• Medicare Care Management Performance

Demonstration• Medicare Medical Home Demonstration• Medicare Healthcare Quality • Gainsharing Demonstrations• Accountable Care Episode (ACE)

Demonstration

Demonstration Purpose

• Test the development and implementation Test the development and implementation of Medicare policy changes prior to of Medicare policy changes prior to legislation enacting such changes on a legislation enacting such changes on a national basisnational basis– Whether it works…Whether it works…– What refinements…What refinements…

• Generally look at payment, new benefit, Generally look at payment, new benefit, new organization of care deliverynew organization of care delivery

Acute Care Episode (ACE) Acute Care Episode (ACE) DemonstrationDemonstration

Problems with Current System

• Increased number of services not necessarily correlated with better care

• Conflicting provider incentives– Hospitals paid per discharge– Physicians paid per service

Global Payment

• Fee-for-service

• Part A and Part B

• Services related to acute care episode only

• Cardiovascular and/or orthopedic procedures

Sites Selected

• Hillcrest Medical Center – Tulsa• Baptist Health System – San Antonio• Oklahoma Heart Hospital – Oklahoma City• Lovelace Health System – Albuquerque• Exempla Saint Joseph Hospital – Denver

• Two are cardiovascular only• One is orthopedic only• Two are both cardiovascular and orthopedic

Determination of Payment Rates

• Based on competitive bids from sites• Compared to regular average

Medicare payments to the hospitals and physicians

• Evaluated based upon the size of the discount

• Subject to annual IPPS updates

Gainsharing Demonstrations

• Authority– Deficit Reduction Act (DRA) Section 5007– Medicare Modernization Act (MMA) Section 646– In the absence of statutory authority, gainsharing is

restricted by law• Purpose

– To allow hospitals to provide gainsharing payments designed to improve quality and efficiency of care to physicians

• Timing– 3-year projects

• Target– Hospitals and physicians

• Compensation– Hospitals may share savings with physicians

Hospital and Physician Alignment of Incentives

• Medicare pays hospitals prospectively for bundles of services using DRGs

• Physicians generally paid per service

• How to align incentives to improve quality and efficiency?

• Encourage physician-hospital collaboration by permitting hospitals to share internal savings

Gainsharing Payments

• Incentive system must be uniform across physicians, can be reviewed and audited.

• Payments must be linked to quality and efficiency

• Gainsharing must be a transparent • Must represent share of internal hospital

savings and be tied to quality improvement• Limited to 25% of physician fees for care of

patients affected by quality improvement activity

Demo Comparison

Design Feature DRA Section 5007 MMA Section 646

Size 2 hospitals

Beth Israel, NY

CAMC, WV

Physician groups and up to 13 affiliated hospitals in limited number of geographic areas. NJ 12 and WV 1

Scope of Evaluation Inpatient episodes and post-discharge window (e.g., 30 days)

Inpatient episodes including pre- and post-hospital care over duration of demonstration

Eligible Organizations

PPS hospitals, excludes CAHs Physician groups and affiliated hospitals, integrated delivery systems

Efficiency in the Quality Context

Efficiency Is One of the Institute of Medicine's Key Dimensions of Quality

1. Safety

2. Effectiveness

3. Patient-Centeredness

4. Timeliness

5. Efficiency: absence of waste, overuse, misuse, and errors

6. Equity

• Institute of Medicine: Crossing the Quality Chasm:

A New Health System for the 21st Century, March, 2001.

Physician Resource Use ReportsPilot

Statutory Authority

Medicare Improvement for Patients and Providers Act of 2008, Section 131(c) The Secretary shall establish a Physician

Feedback Program under which the Secretary shall use claims data (and may use other data) to provide confidential reports to physicians (and, as determined appropriate by the Secretary, to groups of physicians) that measure the resources involved in furnishing care. The Secretary may include information on the quality of care furnished by the physician (or group of physicians) in such reports.

Physician Resource Use Measurement

Goals

Construct resource use measures that are meaningful, actionable, and fair

Provide confidential reports of resource use to individual/groups of physicians

Compare actual use to expected resource use

Link resource use to measures of quality and patient experiences of care

Statutory AuthorityMIPPA Section 131(c)

MIPPA Options: Resource use can be measured on an episode or per capita

basis, or both

Resource use can be measured with claims or through other data sources

Focus can be on selected physicians by: specialty, conditions treated, geography, high cost outliers, minimum # of cases

CMS can make adjustments to resource use measures to render them comparable across physicians

Resource use measures can apply to individual physicians or physician groups

Prepare claims data, includingStandardize unit prices

Group claims into episodes of care;Sum costs of all claims in an episode

Risk-adjust the cost of each episode

Attribute each episode and associated episode cost to one or more physicians

Calculate physician’s average cost for all attributed episodes

Compare physician’s average cost to peer group benchmark (including drill downs)

Produce, test, and distribute RURs

1

2

3

4

5

6

7

Creating Resource Use Reports

Hospital VBP

Deficit Reduction Act (DRA) Section 5001(b) authorized CMS to develop a Medicare Hospital VBP Plan IPPS hospitals FY 2009 start date Must consider

Measures Data infrastructure and validation Incentive structure Public reporting

Must consult stakeholders and consider experience with relevant demonstrations and private-sector programs

Value-Based Purchasing and Hospital-Acquired Conditions

• The Hospital-Acquired Conditions provision is a step toward Medicare VBP for hospitals

• Strong public support for CMS to pay less for conditions that are acquired during a hospital stay

• Considerable national press coverage of HAC has prompted dialogue of how to further eliminate healthcare-associated infections and conditions

Statutory Authority: DRA Section 5001(c)

Beginning October 1, 2007, hospitals were required to submit data on their claims for payment indicating whether diagnoses were present on admission (POA)

Beginning October 1, 2008, CMS cannot assign a case to a higher DRG based on the occurrence of one of the selected conditions, if that condition was acquired during the hospitalization

This provision does not apply to Critical Access Hospitals, Rehabilitation Hospitals, Psychiatric Hospitals, or any other facility not paid under the Medicare Hospital IPPS

Statutory Selection Criteria

CMS must select conditions that are

1. High cost, high volume, or both

2. Assigned to a higher paying DRG when present as a secondary diagnosis

3. Reasonably preventable through the application of evidence-based guidelines

Present on Admission

Present on admission (POA) is defined as present at the time the order for inpatient admission occurs– Conditions that develop during an outpatient encounter,

including emergency department, observation, or outpatient surgery, are considered POA

POA indicator is assigned to – Principal diagnosis– Secondary diagnoses – External cause of injury codes (Medicare requires

reporting only if E-code is reported as an additional diagnosis)

POA Indicator Reporting Options

Code Reason for Code

Y Diagnosis was present at time of inpatient admission.

N Diagnosis was not present at time of inpatient admission.

U Documentation insufficient to determine if condition waspresent at the time of inpatient admission.

W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission.

1 Unreported/Not used. Exempt from POA reporting. This code is equivalent code of a blank on the UB-04; however, it was determined that blanks are undesirable when submitting this data via the 4010A.

“ A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.”

Selected HACs for Implementation

1. Foreign object retained after surgery2. Air embolism3. Blood incompatibility4. Pressure ulcers

– Stages III & IV

5. Falls– Fracture– Dislocation– Intracranial injury– Crushing injury– Burn– Electric shock


6. Manifestations of poor glycemic control– Hypoglycemic coma– Diabetic ketoacidosis– Nonketotic hyperosmolar coma– Secondary diabetes with ketoacidosis– Secondary diabetes with hyperosmolarity

7. Catheter-associated urinary tract infection

8. Vascular catheter-associated infection

9. Deep vein thrombosis (DVT)/pulmonary embolism (PE)– Total knee replacement– Hip replacement


10. Surgical site infection– Mediastinitis after coronary artery bypass graft (CABG)– Certain orthopedic procedures

• Spine

• Neck

• Shoulder

• Elbow

– Bariatric surgery for obesity• Laprascopic gastric bypass

• Gastroenterostomy

• Laparoscopic gastric restrictive surgery

Selected HAC

Medicare Data(FY 2007)

CC/MCC (ICD-9-CM

Codes)

Selected Evidence‑Based Guidelines

Vascular Catheter-Associated Infection

● 29,536 cases

● $103,027/hospital stay

999.31 (CC) Available at the Web

site:

http://www.cdc.gov/nc

idod/dhqp/gl_intravas

cular.html

Surgical Site

Infection-

Mediastinitis

after Coronary

Artery Bypass

Graft (CABG)

● 69 cases


519.2 (MCC)

And one of the

following

procedure

codes:

36.10–36.19

Available at the Web site:

http://www.cdc.gov/nc

idod/dhqp/gl_surgical

site.html

Selected HAC


CC/MCC (ICD-9-CM

Codes)


Catheter- Associated Urinary Tract Infection (UTI)

● 12,185 cases


996.64 (CC)Also excludes

the following from acting as a CC/MCC:

112.2 (CC)590.10 (CC)

590.11 (MCC)590.2 (MCC)

590.3 (CC)590.80 (CC)590.81 (CC)595.0 (CC)597.0 (CC)599.0 (CC)

http://www.cdc.gov/ncidod/dhqp/gl_catheteassoc.html

Selected HAC Medicare Data(FY 2007)

CC/MCC (ICD-9-CM

Codes)


Stage III & IV Pressure Ulcers

● 257,412 cases


707.23 (MCC)707.24 (MCC)

NQF Serious Reportable Adverse

Eventhttp://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.4409

Falls and

Trauma:

- Fractures

- Dislocations

- Intracranial Injuries

- Crushing Injuries

- Burns

● 193,566 cases


CC/MCC codes

within these

ranges:

800-829

830-839

850-854

925-929

940-949

991-994


Eventhttp://www.ahrq.gov/qual/nqfpract.htm

Selected HAC


CC/MCC (ICD-9-CM

Codes)


Foreign Object Retained After Surgery

● 750 cases● $63,631/hospital

stay

998.4 (CC)998.7 (CC)



Air Embolism ● 57 cases● $71,636/hospital

stay

999.1 (MCC) NQF Serious Reportable Adverse


Blood Incompatibility

● 24 cases● $50,455/hospital

stay

999.6 (CC) NQF Serious Reportable Adverse


http://www.ahrq.gov/qual/nqfpract.htm






Candidate HACs

• Fiscal Year 2009 Inpatient Prospective Payment System (IPPS) final rule

http://edocket.access.gpo.gov/2008/pdf/E8-17914.pdf

(page 39)



Candidate HACs

1. Surgical site infection following device procedures

2. Failure to rescue

3. Death or disability associated with drugs, devices, or biologics

4. Dehydration

5. Malnutrition

Candidate HACs

6. Water-borne pathogens

7. Surgical site infections following procedures – orthopedic and other

8. Ventilator-associated pneumonia

9. Clostridium difficile-associated disease

HAC Candidate


CC/MCC(ICD-9-CM

Codes)

Selected Evidence-Based

Guidelines

Surgical Site Infections Following Elective Procedures: - Total Knee

Replacement - Laparoscopic Gastric Bypass and Gastroenter-

ostomy - Ligation and Stripping of Varicose Veins

Total Knee Replacement● 539 cases● $63,135/hospital

stayLaparoscopicGastric Bypass and Gastroenterostomy● 208 cases● $180,142/hospital

stayLigation and Stripping of Varicose Veins● 3 cases● $66,355/hospital

stay

Total Knee Replacement (81.54):

996.66 (CC) and

998.59 (CC)Laparoscopic Gastric Bypass (44.38)and Gastroenter-ostomy (44.39):

998.59 (CC)Varicose Veins(38.5):

998.59 (CC)

http://www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html

http://www.cdc.gov/ncidod/dhqp/glisolation.html






http://www.cdc.gov/ncidod/dhqp/gl_isolation.html




HAC Candidate


CC/MCC(ICD-9-CM

Codes)

Selected Evidence-

Based Guidelines

Legionnaires’ Disease

● 351 cases


482.84 (MCC) http://www.cdc.gov/ncidod/dbmd/diseaseinfo/legionellosis_g.htm

http://www.legionella.org/

Iatrogenic Pneumothorax

● 22,665 cases


512.1 (CC) http://www.ncbi.nlm.nih.gov/pubmed/1485006

Delirium ● 480 cases


293.1 (CC) http://www.ahrq.gov/clinic/ptsafety/chap28.htm

HAC Candidate


CC/MCC(ICD-9-CM

Codes)

Selected Evidence-

Based Guidelines

Glycemic

Control:

- Diabetic

Ketoacidosis

- Nonketotic

Hyperosmolar

Coma

- Diabetic coma

- Hypoglycemic

Coma

Diabetic

Ketoacidosis

● 11,469 cases


Nonketotic

Hyperosmolar Coma

● 3,248 cases


Diabetic Coma

● 1,131 cases


Hypoglycemic Coma

● 212 cases


DiabeticKetoacidosis:

250.10–250.13 (CC)

Nonketotic HyperosmolaComa:

250.20–250.23 (CC)

Diabetic coma:250.3 -250.33

(CC)Hypoglycemic Coma:

251.0 (CC)

NQF Serious

Reportable

Adverse Events

address

hypoglycemia

http://www.diabet

es.org/uedocume

nts/InpatientDMG

lycemicControlPo

sitionStmt02.01.0

6.REV.pdf

HAC Candidate


CC/MCC(ICD-9-CM

Codes)

Selected Evidence-

Based Guidelines

Ventilator-Associated Pneumonia (VAP)

● 30,867 cases


997.31 (CC)

Must also include

ventilator codes:

96.70 – 96.72

http://www.rcjournal.com/cpgs/09.03.0869.html

Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)

● 149,010 cases


453.40 – 453.42(CC)

415.11 (MCC) 415.19 (MCC)

http://www.chestjournal.org/cgi/reprint/126/3_suppl/172S

http://orthoinfo.aaos.org/topic.cfm?topic=A00219

HAC Candidate


CC/MCC(ICD-9-CM

Codes)

Selected Evidence-

Based Guidelines

Staphylococcus AureusSepticemia

● 27,737 cases


038.11(MCC)995.91 (MCC)995.92 (MCC)

998.59 (CC)999.3 (CC)


http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html

Clostridium Difficile Associated Disease (CDAD)

● 96,336 cases


008.45 (CC) http://www.cdc.gov/ncidod/dhqp/gl_isolation.html

http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html#9

Proposed 2010 IPPS Rule

http://federalregister.gov/OFRUpload/OFRData/2009-10458_PI.pdf

Guidelines for Preventing HACs

• Where are guidelines developed– Professional organizations, Task Forces,

Government agencies, academic institutions

• What are they– Recommendations for interventions based

scientific evidence or expert opinion

• Who develops and uses them– Scientists, clinicians– Policy makers, consumers

Future Considerations

• Risk adjustment– Individual and population level

• Rates of HACs for VBP– Appropriate for some HACs

• Uses of POA information– Public reporting

• Adoption of ICD-10– Example: 125 codes capturing size, depth, and location of

pressure ulcer • Expansion of the IPPS HAC payment provision to

other settings– Discussion in the IRF, OPPS/ASC, SNF, LTCH

regulations

Never Events

• Wrong surgery performed on a patient

• Surgery performed on wrong body part

• Surgery performed on the wrong patient

http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=223




Resources Available

Physician Quality Reporting Initiative:https://www.cms.hhs.gov/pqri

CMS Quality Initiatives – General Information:http://www.cms.hhs.gov/QualityInitiativesGenInfo/

12/9/08 Issues Paper: Development of a Plan to Transition to a Medicare Value-Based Purchasing Program for Physician and Other Professional Services

http://www.cms.hhs.gov/center/physician.asp

Hospital Quality Reporting:www.hospitalcompare.hhs.gov

Demonstrations:http://www.cms.hhs.gov/DemoProjectsEvalRpts/

[email protected]

https://www.cms.hhs.gov/pqri

http://www.cms.hhs.gov/QualityInitiativesGenInfo/

http://www.cms.hhs.gov/center/physician.asp

http://www.hospitalcompare.hhs.gov/

http://www.cms.hhs.gov/DemoProjectsEvalRpts/

http://www.cms.hhs.gov/DemoProjectsEvalRpts/

THANK YOU!

Questions?

[email protected]

barbara j. connors, do, mph chief medical officer, region iii the centers for medicare and medicaid...

Documents

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