david gifford svp quality & regulatory affairs congressional briefing washington dc june 23 rd,...
TRANSCRIPT
David Gifford
SVP Quality & Regulatory Affairs
Congressional briefing
Washington DC
June 23rd, 2014
IMPACT ACT OF 2014
“IMPACT ACT OF 2014”
Legislation has four parts :
1. Incorporate standardized assessment
2. Public reporting of common quality measures
3. Provide quality measures to consumers when transitioning to a PAC provider
4. HHS and MedPAC to conduct several
“IMPACT ACT OF 2014” Part 1• Incorporate standardized assessment(s) (e.g. CARE tool)
into existing assessment tools across PAC providers (LTCH, IRF, SNF, & HH) and acute care hospitals for• Pressure ulcers• Functional status• Cognitive status• Special Services
• Collect data at admission and discharge• Applies also to acute care hospitals
“IMPACT ACT OF 2014” Part 2• Develop & Publicly report quality measures across
settings• Rehospitalizations & hospitalizations • Hospitalizations after discharge from PAC provider• Discharge to community• Pressure ulcers• Medication reconciliation • Incidence of major falls• Patient preferences • Efficiency measure(s): Avg Total Medicare Spend per Beneficiary• Plus any other measures Secretary wants
• Measures must be approved by National Quality Forum• Public reporting starting in Oct 2018
Using information across settings• Clinical Care• Quality Improvement • Accountability measurement
• Public reporting• Network selection• Payment (e.g. Value Based Purchasing)• Policy evaluations & decisions
Questions to ask about measures • Data source
• Is it reliable and valid?• Is consistent and comparable
• Wording of assessment• Rating scale used• Frequency of assessment
• Measure definition• Who does the measure apply to (e.g. denominator)• Who is counted in the measure (e.g. numerator)• Does the measure need to be risk adjusted?
• What are clinical and non-clinical characteristics used in risk adjustment
• Is the measure reliable and valid?
• How to compare providers based on measure results• How do you use measure results for
• Quality improvement• Network selection• Payment
ADL Questions & Ratings Vary IRF HH SNF LTCH Hospitals
Bathing 0-7 0-6 0-4; 0-3 None NoneEating 0-7 0-5 0-4; 0-3 None NoneGrooming 0-7 0-3 0-4;0-3 None NoneDressing- Total- Upper body- Lower body
NA0-70-7
NA0-30-3
0-4;0-3
NANA
None None
Transfers bed, chair 0-7 0-3 0-4;0-3 None None
Toileting- Overall- Transferring- Hygiene
0-70-7
0-40-3
0-4;0-3
NANA
None None
Rating of questions
IRF7 = completely independent
6 = modified independence
5 = supervision (subject = 100%)
4 = minimal assistance (subject = 75% of more)
3 = moderate assistance (subject = 50% or more)
2 = max assistance (25% or more)
1= total assistance
0 activity did not occur
OASIS0 = able to bath self independently
1 = with the use of devices, is able to bath self
2 = able to bathe in shower or tub with the intermittent assistance of another person
3 = able to participate in bathing self in shower or tub but requires presence of another person
4 = unable to use the shower to tub but table to bathe self independently with or without the use of devises at the sink, in chair or on commode
5 = unable to use the shower or tub but able to participate in bathe self in bed, at the sink or in bedside chair with assistance or supervision of another person
6 = unable to participate effectively in bathing and is bathed totally by another person
Rating of questions
MDS
• IRF – average function• OASIS – typical ability• MDS – most dependent
0 = independent– no help provided
1 = supervision– oversight help only
2 = physical help limited to transfer only
3 = physical help in part of bathing activity
4 = total dependence
8 = activity did not occur
Rating Instructions
Wording of questions: Bathing
IRF-PAI: “Bathing”
OASIS: “Current ability to wash entire body safely, Excludes grooming (washing face, washing hands, and shampooing hair)”
MDS: “How resident takes full-body bath/shower, sponge bath, and transfers in /out of tub/shower (excludes washing of back and hair)”
Cognitive Function Assessment
IRF-PIA OASIS MDS LTCH Hospitals
Memory Rate assistance
Is it ok >1x wk
Recall 3 words
None None
Orientation none yes Yr, month,
day
None None
Decision Making
Problem Solving
1-7
Ok with ADLs0,1
Decision Making
1-4
None None
Pressure Ulcer Ratings
IRF HH SNF LTCH Hospitals
Count yes yes yes None NoneStage for worst ulcer
yes yes yes None None
Dimensions L x W L x W x D L x W x D None None
Tissue Type Yes (0-4 )
Yes(0-3)
Yes(1-4)
None None
Presence at admission
yes yes yes None None
Tissue Type ratings differ• IRF
1 = epithelial tissue2 = granulation tissue3 = slough4 = necrotic tissue
• HH0 = newly epithelialized1 = fully granulating2 = early/partial granulation3 = not healing
• SNF1 = epithelial tissue2 = granulation tissue3 = slough4 = necrotic tissue
SAMPLE SIZE
Focus on all cause all disease• National Quality Forum & CMS require minimum number
of patients in each measure (e.g. minimum denominator size) which is usually 25-30• Implications for measures that are not all cause or disease specific
16
# of Facilities vs # of Part A Admissions
2009 2010 2011
Number of
Facilities
% of
Total
Number of
Facilities
% of
Total
Number of
Facilities% of
Total
TOTAL 15,453 15,449 15,395
Low volume (≤ 100 stays/ year)
6,766 44%
6,744 44%
7,773 50%
Moderate volume (101-200 stays/ year)
4,678 30%
4,591 30%
4,449 29%
High volume (201-300 stays/ year)
2,061 13%
2,103 14%
1,784 12%
Very high volume (>300 stays/ year)
1,948 13%
2,011 13%
1,389 9%
17
# Part A admissions for Top 15 Hospital DRGs by Facility annual volume of Part A admissions
Low Vol
(<100/yr)Mod Vol
(100-200/yr)High Vol
(200-300/yr)Very High Vol
>300/yr
DRG CategoriesSNF stays
2009% of All
SNF StaysSNF stays
2009% of All
SNF StaysSNF stays
2009% of All
SNF StaysSNF stays
2009% of All
SNF Stays
TOTAL 451,119 2,230,389 637,920 2,230,389 437,273 2,230,389 704,077 2,230,389
1. Orthopedic surgery on lower extremity 55,309 2.5% 81,156 3.6% 65,495 2.9% 135,074 6.1%
2. Respiratory 67,714 3.0% 83,695 3.8% 50,532 2.3% 67,725 3.0%
3. Cardiac surgery 9,884 0.4% 15,817 0.7% 12,679 0.6% 25,233 1.1%
4. Cardiac medical management 37,728 1.7% 54,067 2.4% 35,906 1.6% 54,766 2.5%
5. GI hospitalizations (surgical and medical) 31,422 1.4% 44,580 2.0% 30,825 1.4% 48,380 2.2%
6. Renal failure 11,820 0.5% 17,963 0.8% 11,627 0.5% 16,826 0.8%
7. Amputations 3,704 0.2% 5,228 0.2% 3,346 0.2% 4,973 0.2%
8. Spinal surgery 2,663 0.1% 4,258 0.2% 3,880 0.2% 8,484 0.4%
9. Other major musculoskeletal surgery 4,916 0.2% 8,181 0.4% 6,811 0.3% 13,105 0.6%
10. Other musculoskeletal medical mgmt 23,126 1.0% 34,940 1.6% 25,768 1.2% 44,136 2.0%
11. Multiple significant trauma 1,242 0.1% 1,797 0.1% 1,226 0.1% 1,977 0.1%
12. Infections & parasitic dis. (plus sepsis) 52,428 2.4% 74,247 3.3% 47,122 2.1% 64,947 2.9%
13. Psychiatric 6,146 0.3% 7,509 0.3% 4,233 0.2% 5,298 0.2%
14. Stroke and related conditions 18,863 0.8% 26,840 1.2% 17,522 0.8% 25,819 1.2%
15. Other 124,154 5.6% 177,642 8.0% 120,301 5.4% 187,334 8.4%
Average volume Medicare Admissions per SNF for #1 Admitted diagnosis
Low Vol
(<100/yr)Mod Vol
(100-200/yr)High Vol
(200-300/yr)Very High Vol
>300/yr
# of SNFs (%) 7,773 (50%) 4,449 (29%) 1,784 (12%) 1,389 (9%)
DRG CategoriesSNF stays
2009% of All
SNF StaysSNF stays
2009% of All
SNF StaysSNF stays
2009% of All
SNF StaysSNF stays
2009% of All
SNF Stays
TOTAL 451,119 2,230,389 637,920 2,230,389 437,273 2,230,389 704,077 2,230,389
1. Orthopedic surgery on lower extremity 55,309 2.5% 81,156 3.6% 65,495 2.9% 135,074 6.1%
Avg # of Medicare Admissions per year 7.1 18.2 36.7 96.6
RISK ADJUSTMENT
Change in Decile Rank from Actual to Risk Adjusted SNF Rehospitalization
Change in decile rank between Actual vs Risk adjusted rate # SNFs
% of Total
No data 2619 18.59-8 1 0.01-7 2 0.01-5 5 0.04-4 51 0.36-3 218 1.55-2 693 4.92-1 1818 12.900 4272 30.321 2717 19.282 1126 7.993 401 2.854 116 0.825 33 0.236 15 0.117 4 0.038 1 0.01