HOSPITAL ACQUIRED CONDITIONS AND FEDERAL PAY FOR PERFORMANCE

Eric Schulz, MBA

June 25, 2013

Key Learnings for Today

• The Medicare Pay for Performance Program is complex and will become even more complex

• There is significant financial risk for PPS hospitals in Oregon and across the US

• Quality Directors and Managers must think in two time periods, payment and performance

• The Hospital Acquired Conditions portion of the program will feel both familiar and unfamiliar

COMPLEXITY

First…take a deep breath

While you will observe that there are lots of measures to that will go into Medicare Pay for Performance. There is nothing new to report.

Your hospital is already providing CMS everything they need to run this program.

1.00 Percent Readmissions

1.00 Percent Value Based Purchasing

Process Measures

Patient Satisfaction

Pneumonia Readmissions

Heart Failure Readmissions

Heart Attack Readmissions

FFY 2013 Medicare Pay for Performance Program

• First year of the program • At Risk – 2% of Medicare Revenue • Measures - 3 domains and 24 individual measures

2.00 Percent Readmissions

1.25 Percent Value Based Purchasing

Process Measures

Patient Satisfaction

Pneumonia Readmissions

Heart Failure Readmissions

Heart Attack Readmissions

PN, CHF, AMI

Mortality

FFY 2014 Medicare Pay for Performance Program

• Addition of Mortality Measures to Value Based Purchasing • At Risk – 3.25% of Medicare Revenue • Measures - 4 domains and 27 individual measures

3.00 Percent Readmissions

1.50 Percent Value Based Purchasing

1.00 Percent Hospital Acquired

Conditions

Process Measures

Patient Satisfaction

Pneumonia Readmissions

Heart Failure Readmissions

Heart Attack Readmissions

PN, CHF, AMI TKA, THA Mortality

PSI 90

MSBP Total Knee Readmissions

Total Hip Readmissions

AHRQ PSIs 3, 5, 6, 10,

12, &15 NHSN CAUTI

NHSN CLABSI

FFY 2015 Medicare Pay for Performance Program

• Value-Based Purchasing becomes very complex • Hospital Acquired Conditions Program begins • At Risk – 5.5% of Medicare Revenue • Measures - 8 domains and 40 individual measures

AECOPD Readmissions

3.00 Percent Readmissions

1.75 Percent Value Based Purchasing

1.00 Percent Hospital Acquired

Conditions

CA

UTI

C

LAB

SI

SSI C

olo

n

SSI H

yste

rect

om

y

FFY 2016 Medicare Pay for Performance Program

• Hospital Acquired Conditions Program gets more complex • At Risk – 5.75% of Medicare Revenue • Measures – 8 domains and 42 individual measures

Heart Failure Readmissions

PN, CHF, AMI TKA, THA Mortality

PSI 90

MSBP Total Knee Readmissions

AECOPD Readmissions

Process Measures

Patient Satisfaction

Pneumonia Readmissions

Heart Attack Readmissions

Total Hip Readmissions

AHRQ PSIs 3, 5, 6, 10,

12, &15

FINANCIAL RISK

What’s at risk?

0%

1%

2%

3%

4%

5%

6%

7%

FFY 2013 FFY 2014 FFY 2015 FFY 2016 FFY 2017

Greater than $50M at risk for Oregon hospitals in FFY 2017

PAYMENT & MEASUREMENT

Different Payment and Measurement Periods Require Abstract Thinking

Measurement Period for FFY 2015

Payment Period for FFY 2013

HOSPITAL ACQUIRED CONDITION PROGRAM

FFY2014 IPPS Proposed Rule

PSI – 3 Pressure Ulcer

Rate 8.3%

PSI – 6 Iatrogenic

Pneumothorax Rate 8.3%

PSI – 12 Postoperative PE/DVT Rate

8.3%

NHSN CLABSI 25%

PSI – 5 Foreign Object

Left in Body 8.3%

PSI – 10 Postoperative

Metabolic Derangement

Rate 8.3%

PSI – 15 Accidental Puncture &

Laceration Rate 8.3%

NHSN CAUTI 25%

FFY 2015 Hospital Acquired Conditions Program

PSI – 3 Pressure Ulcer

Rate 8.3%

PSI – 6 Iatrogenic

Pneumothorax Rate 8.3%

PSI – 12 Postoperative PE/DVT Rate

8.3%

NHSN CLABSI 25%

PSI – 5 Foreign Object

Left in Body 8.3%

PSI – 10 Postoperative

Metabolic Derangement

Rate 8.3%

PSI – 15 Accidental Puncture &

Laceration Rate 8.3%

NHSN CAUTI 25%

FFY 2015 Hospital Acquired Conditions Program

July 1, 2011 June 30, 2013 AHRQ Measures

CDC/NHSN January 2011 December 2013

PSI – 3 Pressure Ulcer

Rate 8.3%

PSI – 6 Iatrogenic

Pneumothorax Rate 8.3%

PSI – 12 Postoperative PE/DVT Rate

8.3%

NHSN CLABSI 12.5%

NHSN SSI Colon Surgery 12.5%

PSI – 5 Volume of

Foreign Object Left in Body

8.3%

PSI – 10 Postoperative

Metabolic Derangement

Rate 8.3%

PSI – 15 Accidental Puncture &

Laceration Rate 8.3%

NHSN CAUTI 12.5%

NHSN SSI Abdominal

Hysterectomy 12.5%

FFY 2016 Hospital Acquired Conditions Program

PSI – 3 Pressure Ulcer

Rate 8.3%

PSI – 6 Iatrogenic

Pneumothorax Rate 8.3%

PSI – 12 Postoperative PE/DVT Rate

8.3%

NHSN CLABSI 12.5%

NHSN SSI Colon Surgery 12.5%

PSI – 5 Volume of

Foreign Object Left in Body

8.3%

PSI – 10 Postoperative

Metabolic Derangement

Rate 8.3%

PSI – 15 Accidental Puncture &

Laceration Rate 8.3%

NHSN CAUTI 12.5%

NHSN SSI Abdominal

Hysterectomy 12.5%

FFY 2016 Hospital Acquired Conditions Program

July 1, 2012 June 30, 2014 AHRQ Measures

CDC/NHSN January 2012 December 2014 Not Yet Specified

HOW WILL MY HOSPITAL BE ASSESSED?

FFY2014 IPPS Proposed Rule

Basic Scoring Rubric for HAC Program

No Points Assessed 1 2 3 4 5 6 7 8 9 10 Points Assessed

Best 75% of Hospitals Worst 25% of Hospitals

PSI – 5 (Foreign Object Left in Body)

• ≥ 1 occurrence in measurement period = 10 points assessed

or

• 0 occurrences in the measurement period = 0 points assessed

5 Points

5 Points

FFY 2015 Hospital Acquired Conditions Program

Weighted 50% Weighted 50%

AHRQ PSIs NHSN Measures

5 Points

10 Points

5 Points

5 Points

5 Points

5 Points

For this example let’s assume that this hospital is the median of the worst quartile for every measure and that they had at least one

foreign object left in body during the 24 month period.

Total FFY 2015 HAC Scoring Rubric Measure Points Assessed

PSI – 3 5

PSI - 5 10

PSI – 6 5

PSI – 10 5

PSI – 12 5

PSI – 15 5

PSI TOTAL 35 Points

CAUTI Standard Infection Rate 5

CLABSI Standard Infection Rate 5

NHSN TOTAL 10 Points

Weighted Points (50% PSI + 50% NHSN) 17.5 PSI Points + 5 NHSN Points

HAC TOTAL 22.5 Total HAC Points

Determining the Penalty

No Penalty 1% Penalty

Best 75% of Hospitals Worst 25% of Hospitals

22.5 Points

HAC Program Summary

• 25% of IPPS hospitals in the US will be assessed a 1% penalty on their FFY2015 and beyond Medicare revenues based on HACs

• The penalty will be assessed based on 6 AHRQ PSIs and 2 NHSN Measures in FFY2015

• The measurement period for the FFY2015 penalty has already occurred

• Hospitals should focus their efforts toward the FFY2016 program

Key Learnings for Today

• The Medicare Pay for Performance Program is complex and will become even more complex

• There is significant financial risk for PPS hospitals in Oregon and across the US

• Quality Directors and Managers must think in two time periods, payment and performance

• The Hospital Acquired Conditions portion of the program will feel both familiar and unfamiliar

We are here to help.

OAHHS Quality Team Apprise Health Insights

Oregon Association of Hospitals & Health Systems

Education Performance Improvement Partnership for Patients

Data & Analytics Benchmarking Financial Impact

You are already ahead of the game!

• Being here

• Learning

• Sharing Best Practices

• Benchmarking

. You may not know exactly where the path leads,

but you have the tools to find your way

Thank You

Eric Schulz Director of Business Development

Apprise Health Insights 503-686-0915

eric.schulz@apprisehealthinsights.com