Affordable Care Act (ACA) Quality Initiatives

1. Affordable Care Act (ACA) Quality Initiatives League of Women Voters January 28, 2013 David Evelyn MD, MPH Vice President for Medical Affairs Cayuga Medical Center at Ithaca

2. Linking ClinicalAnd Financial InformationFor Medicare

3. Quality Measures in the ACA • ACA requires the establishment of a • federal “pre-rulemaking process” for • the selection of quality and efficiency • measures for specific qualifying • programs within the Department of • Health and Human Services (HHS) • • Measure Applications Partnership • (MAP) is a public-private partnership • that reviews performance measures • for potential use in federal public • reporting and performance-based • payment programs, while working to • align public programs with measures • being used in the private sector. • – Source: • http://www.qualityforum.org/Setting_Priorities/ • 1. Ambulatory Surgical Center Quality Reporting • 2. CMS Nursing Home Quality Initiative and Nursing • Home Compare Measures • 3. e-Rx Incentive Program • 4. End Stage Renal Disease Quality Improvement • 5. Home Health Quality Reporting • 6. Hospice Quality Reporting • 7. Hospital Inpatient Quality Reporting • 8. Hospital Outpatient Quality Reporting • 9. Hospital Value-Based Purchasing • 10. Inpatient Psychiatric Facility Quality Reporting • 11. Inpatient Rehabilitation Facility Quality • Reporting • 12. Long-term Care Hospital Quality Reporting • 13. Medicare and Medicaid EHR Incentive Program • for Eligible Professionals • 14. Medicare and Medicaid EHR Incentive Program • for Hospitals and CAHs • 15. Medicare Shared Savings Program • 16. Measures Physician Quality Reporting System • 17. Prospective Payment System (PPS) Exempt

4. Initial Components of FederalHospital Quality Initiatives (HQI) Section 501(b) Medicare Modernization Drug, Improvement and Modernization Act (MMA) of 2003 – 10 quality “starter set” initiative called Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) “Pay for Reporting” Section 5001(a) Deficit Reduction Act (DRA) of 2005 supersedes MMA and sets new requirements • – Value-Based Purchasing (VBP) “Pay for Performance” • – Requires CMS to identify and limit payments for health care-associated conditions (HACs)

5. Accountable Care Act Quality and Financial Links for Hospitals Value Based Purchasing (VBP) Hospital Readmissions Hospital Acquired Conditions (HAC’s)

6. ACA Mandatory Medicare Delivery System Reform Federal Fiscal Year 2013 Federal Fiscal Year 2015 • Inpatient Value-Based Purchasing • • Implemented October 2012 Federal Fiscal Year 2013 • • Budget neutral; redistributive within payment system • Inpatient Readmissions • • Implemented October 2012 • • Reduces Medicare reimbursement by $7 billion / 10 years nationwide. • Health Care Acquired Conditions • • Implemented October 2014 (FFY 2015) • • Reduced Medicare inpatient hospital reimbursement by • $ 1.4 billion / 10 years nationwide

7. Value Based Purchasing Measures of Process13 measures - some examples Acute Myocardial Infarction • Heart attack victims given PCI in 90 min Heart Failure • Discharge instructions given to patient Pneumonia • Blood cultures before antibiotics & correct antibiotics Healthcare Associated Infection • Correct surgical antibiotic timing Surgical Care Improvement • Blood clot prophylaxis New in 2014 • Urinary catheter removed within 24-48 hours

8. Value Based Purchasing Patient Experience of Care8 measures • HospitalConsumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) Examples • • Communication with Nurses • • Communication with Doctors • • Responsiveness of Hospital Staff • • Pain Management • • Communication about Medicines • • Hospital Cleanliness & Quietness • • Discharge Information • • Overall Rating of Hospital

9. Outcome Measures New in 2014 — 30-day Mortality Rates for: • Pneumonia • Heart Failure • Heart Attack

10. What’s at Stake Under VBP? • • Program is self-funded by hospital “contribution” • • Contribution based on Medicare Fee for Service payment* • - 1.0% reduction in Fiscal Year 2013 • - Reduction increased by 0.25% each year • - 2.0% reduction for Fiscal Year 2017 and beyond • • Budget-neutral • - Redistributive • - Best performers win, others break even or lose • - VBP payments are netted against contributions • • VBP performance determines adjustment factor • – Applied to the Inpatient rate • – Adjustment factor of < 1.0 means a decrease in Inpatient payments • – Adjustment factor of > 1.0 means an increase in Inpatient payments

11. What’s at Stake Under Hospital Readmissions? • Mandated by the ACA to begin FFY 2013 • • Hospital can either maintain full payment levels or be subject to a • hospital-specific payment penalty : • – 1.0% in FFY 2013 • – 2.0% in FFY 2014 • – 3.0% in FFY 2015 and subsequent years • – Not budget neutral • • Three-Year Aggregate Period • – Readmissions rates are calculated using 3-years of claims data • • FFY 2013 readmission rates used July 1, 2008 through June 30, 2011 • • Readmission Adjustment Factor • – Applied to the “inpatient PPS base operating DRG payment amount”

12. Concerns about readmissions • NYS Readmissions ranking: • 48th of 50 • Diagnosis of AMI, HF, PN for 2013 • All-cause readmissions • Observed-to-Expected greater then 1 = higher than expected readmission rate • Readmissions often dependent on community/patient resources

13. What’s at Stake Under Hospital Acquired Conditions? • Implementation beginning October 2014 (FFY 2015) • Medicare hospitals that fall in the bottom 25th quartile will receive a 1% penalty • Establishment of a risk adjustment methodology is yet to be determined • Public reporting for each hospital with an opportunity for review of the data

14. Concerns about Hospital Acquired Conditions • ACA does not specify which HAC’s will be used • ACA does not specify how cases will be risk adjusted • ACA does not specify how rates will be calculated

15. What’s coming up in the future? 2015 • – 59 measures • – New: • • 5 Hospital Consumer Assessment of Healthcare Providers and • Systems (HCAHPS) survey items • • 1 claims-based surgical complication measure • • 1 Chart abstracted perinatal care measure • • 2 Claims based readmission measures • • Hip/Knee 30 –Day All-Cause Risk Standardized Mortality • • 30 –Day Hospital Wide All-Cause Unplanned Readmission Rate 2016 • – 60 measures • – New: Safe Surgery Checklist Use (Structural Measure)

16. Information Further information about how all local hospitals are doing is available at the Medicare website at: www.medicare.gov/hospitalcompare/