Changes to Performance-Based Payment Programs

1. Changes to Performance-Based Payment Programs Sule Calikoglu, Ph.D. Deputy Director of Research and Methodology

2. Maryland Quality-Based Payment Initiatives

3. FY 2015 Changes to QBR • FY 2015 payments: Performance Period: CY 2013 Base Period: FY 2012 • Eliminated appropriateness of care measurement from the QBR program • Removed topped off measures from the opportunity domain • Added Patient Outcome Measures: A mortality measure developed using 3M APR-DRG grouper risk of mortality (ROM) on admission

4. QBR MEASURES AND DOMAINS

5. FY 2016 Changes to QBR • Clinical Measurement and HCAHPS are aligned with CMS program • National Measure list • National Thresholds and Benchmarks • National Data Source • Performance periods (Federal Fiscal Year instead of Calendar Year) • New Outcome Measures • Agency for Health Care Quality Patient Safety Indicators (10%) • Central Line Blood Stream Infections (CLABSI) (10%)

6. Maryland Hospital Acquired Conditions Initiative • Implemented in July 2009 • Relies on Present on Admission Indicators (POA) for secondary diagnosis • PPCs are defined as harmful events (accidental laceration during a procedure) or negative outcomes (hospital acquired pneumonia) that may result from the process of care and treatment rather than from a natural progression of underlying disease.

7. FY 2015 Changes • FY 2015 payments: Performance Period: CY 2013 Base Period: FY 2012 • Added Improvement Scale based on comparing hospital’s performance to their own base line • Raised the bar by expected MHAC values at the 85% of the state average • Excluded two types of cases from counts of PPCs • Hospice Palliative Care Patients (defined as cases with ICD-9 code = V66.7) • Patients with more than 6 PPCs

8. MHAC Components Attainment Scale Improvement Scale Includes 5 PPCs that are high cost, high prevalence and high priority Measures percent change from a base year for each hospital Revenue neutral scaling Rewards are given if a hospitals improves more than the current median improvement in the base year. Maximum reduction is 1 % of total inpatient revenue • Includes 50 PPCs selected based on clinical and data quality • Score is based on case-mix adjusted PPC rates weighted by the estimated resource use • Revenue neutral scaling • Rewards are given if a hospital performs better than 85 percent of state average. • Maximum reduction is 2 % of total inpatient revenue

9. New Improvement List for FY2016 Source: HSCRC Casemix Data FY 2013

10. HSCRC Progressively Increased the Revenue at Risk

11. Continuous Improvement and evaluation • QBR: incorporates new measures and increase their contribution to the overall score • HCAHPS, Mortality, Patient Safety Indicators • MHAC: more aggressive benchmarks and evaluation of PPC selection to the program • Coding audits and POA screens

12. Readmissions:Episode-Based Payment

13. Episode Development HSCRC establishes an expanded Episode Bundle Previously….. Expanded Time Frame • Maryland establish an episode-based payment that covers both the initial admission and any subsequent re-admission 30 day “window” Acute Hospitalization Readmission 1 Readmission 2 Establish a “30 day DRG Episode” payment amount or “weight” that covers both the initial admission and ALL subsequent re-admissions within 30 days DRG pmt DRG pmt DRG pmt $10,000 $9,000 $6,000 Each paid separately under DRG system = Additional payment for readmissions Broader “Scope” – multiple hospitalizations

14. Readmission Shared-Savings • FY 2014 Rate Adjustment to achieve 0.3% savings from inpatient revenues • Based on Case-mix Risk-Adjusted 30-Day Readmission Rates • FY 2015: Planned readmissions are excluded • Possible Changes for FY 2016 • Incorporation of across hospital readmissions • Changing the measurement methodology to align with CMS

15. Maryland’s Goals An all payer system that is accountable for the total cost of care on a per capita basis is an effective model for establishing policies and incentives to drive system progress toward achieving the three part aim of enhanced patient experience (including quality and satisfaction), better population health, and lower costs. Maryland’s All Payer Model • Enhance Patient Experience • Better Population Health • Lower Total Cost of Care

16. New Waiver and Performance-Based Payment

17. Stake Holder Engagement Work Groups

18. Performance Measurement • Develop State-wide Targets and Hospital Performance Measurement • Potential changes to MHAC, QBR and Readmission Shared Savings Program • Measuring potentially avoidable utilization, readmissions, hospital acquired conditions, ambulatory sensitive conditions • Integration of cost, quality and population health and outcomes