Optimizing Core Measure Outcomes, Value Based Purchasing & Meaningful Use

Optimizing Core Measure Outcomes, Value Based Purchasing & Meaningful Use Lou Testa Administrative Director/CFO Health Information Alliance, Inc. PHIMA Annual Meeting 2011

www.HIA-Corp.com • 800-405-8800 • Core Measure Consulting • Coding Services & CDI • Cardiac Surgery & Stroke Care Database Construction Reporting • PHC4 Compliance • PI & QI Studies • Since 1992

It all comes down to Dollars! • Core Measure Outcome Optimization • Value Based Purchasing • Meaningful Use

History • Since 2004 CMS has been collecting quality and patient experience info from acute care hospitals. • 95% of Hospitals participate and report to get the full increase each year. • Pay for reporting is ending, it’s a new era….

Where & When to Start? • January 7th 2011CMS issues the Proposed Rule for VBP; • Comments thru 03/08/11; • Hospitals are rewarded for high quality, safe care for patients; Not just reporting anymore; • The reward? Higher Payments! • Begins FY 2013 (10/01/12 Discharges)

VBP Details! • VBP Program is under the Affordable Care Act • Medicare Payments under IPPS • Affects 3000 Hospitals Nationally • Funded by a Reduction in DRG Payments for each Discharge • Lots of $ Involved!

And More Details! • Real Reductions: • 1% FY 2013 Rising to 2% by FY 2017 • For FY 2013 There Are 18 Measures: • 17 Clinical Process Measures • 1 Measure from the HCAHPS Survey

The Measures AMI & HF • AMI: • Aspirin Prescribed at Discharge • Fibrinolytic Therapy Received Within 30 mins of Hosp Arrival • Primary PCI Received w/in 90 mins of Hosp Arrival • Heart Failure: • Discharge Instructions • Evaluation of LVS Function • ACEI or ARB for LVSD

The Measures PN • PN: • Pneumococcal Vaccination • Blood Cultures in ED Prior to Initial Antibiotic Received • Adult Smoking Cessation Advice/Counseling • Initial Antibiotic Selection for CAP in Immunocompetent Patient • Influenza Vaccination

The Measures SCIP • SCIP: • Prophylactic Antibiotic Received w/in 1 hr prior to surgical incision • Prophylactic Antibiotic Selection for Surgical Patients • Prophylactic Antibiotics Discontinued w/in 24 hrs after Surgery End Time • Cardiac Surgery Patients w/ Controlled 6AM PostOP Serum Glucose • Surgery Patients on Beta Blocker Prior to Arrival that Received a Beta Blocker During the Perioperative Period • Surgery Patients w/ Recommended VTE Prophylaxis Ordered • Surgery Patients who Received Appropriate VTE Prophylaxis w/in 24 hrs prior to Surgery to 24 hrs after Surgery

Survey Measures • HCAHPS • Hospital Consumer Assessment of Providers and Systems Survey • Nurse • Doctor • Cleanliness & Quietness • Responsiveness • Pain Management • Communication about Meds • Discharge Info • Overall Rating

Calculations • Based on Performance Standards • Achievement & Improvement for Each Measure • Total Score Calculated for the hospital by combining the greater of the achievement score or improvement points for each measure finding a score for each domain. • Multiply the domain score by a proposed weight • WHAT???? Stay with me!!!!

Proposed Weights • 70% Clinical Process of Care • (The core measures we discussed, AMI, HF, PN, SCIP) • 30% Patient Experience of Care • (The HCAHPS Survey we discussed)

Add the Two! • Now this part I get! • We add the 70% weighted score for the clinical process of care And • The 30% weighted score for the patient experience of care • Eureka! We have the Total Score!

Value Based Incentive Payment • CMS proposes to convert each hospital’s total performance score into a value based incentive payment

Timing Issues • CMS will notify hospitals regarding the reduction of the base operating DRG payment $ and then add the adjustment to payments for discharges in the FY as a result of the VBP calculation not later than 60 days prior to the FY involved. • Not Much Time - Affecting our Budgets • Means we must be prepared!

Calendar • CMS “PROPOSES” to make this happen in the FY 2013 IPPS rule which will be finalized 60 days prior to FY 2013 and incorporate this into claims processing in Jan of 2013; That’s the 1% reduction • That includes discharges starting 10/01/12

Meaningful Use • Does it mean EHMR & Electronic Submission? • No More Manual Abstraction? • No more jobs? • Lets Find out….

ONC Stage 1 EHR • Ability for hospitals to demonstrate via attestation that they may electronically calculate numerators and denominators and generate reports on 15 defined clinical quality measures; • These must be completed via an EHR system or Module that has been certified by the ONC;

What are the 15 Measures? • ED Measures (12 total) • Stroke Measures (7 total) • VTE Measures (6 total) • Note the VTE Measures are in addition to what we normally collect for SCIP now

Important Note: • These e-measures are NOT a substitute for the chart abstracted measures required by CMS currently (Core Measures).

Compliance w/ HITECH ACT • Acute Care Organizations must prepare to include quality measure submissions into the overall EHR/MU strategy. • Quality Measures are one of the MU Core Objectives and need specific attention because they overlap with incentive payments from CMS and other payers.

How will MU Work? • Most Hospitals will have a software vendor who is certified. • Data will come from the hospital’s EHMR to a specific file format for their software vendor. • The software will import that data and analyze it. • Now comes the “HUMAN PART” • Wait, I thought it was all Electronic?

We still need people? • YES! We are not out of jobs yet! • The electronic data must be validated, it’s the old gibberish in gibberish out… • Reports must be run after data validation to assess outcomes • Comparatives must be analyzed and improvements implemented

Finish Line • The attestation is submitted to CMS • In 2012 Compliance will be fully electronic to CMS

What do I need to know Right now? • Per the 03/31/11 for RHQDAPU 1.1 Release Notes – Get Started on planning for Participation in a Systematic Database for: • Cardiac Surgery • Stroke Care • Nursing Sensitive Care • CMS Spec Manual for 04/01/11 Discharges several changes to PN 6 & 6b; If you collect Stroke there are medication table changes.

3M / SCIP Issue • Major Importance! • Incorrect Sequencing of principal Procedures • No Impact to the DRG; but definitely Cores - SCIPs • Effected Hysterectomies and Bowel Procedures, but may not be limited to just those procedures; • 3M issued a Patch, but it was too late for Q4; • Q4 SCIPs will not be considered in the APU calculations by CMS for 2012; • You could still have an issue depending how current you are and when you loaded the patch;

3M SCIP – Cover your Bases • If your facility began abstracting Q1 SCIPs PRIOR to loading the 3M patch you may need to re-abstract the Q1 SCIPs. • AHA advises you to suspend SCIP abstraction if this is the case and do an analysis, especially if you Sample SCIP. • CMS will continue to assess this issue into the fall of 2011 and issue further guidance on how this may or may not affect BOTH the current Pay for Reporting and the new Value Based Purchasing Program.

Hot off the Press! • As of 04/15/11 (Pres Due) • Health and Human Services Secretary Kathleen Sebelius said the agency is dedicating 1 Billion $ to 2 programs to reduce 40% of preventable Hospital injuries and 20% of re-admissions. • The goal – improve care and lower costs. • The CDC estimates the US spends 45 Billion in extra care due to HAI. • They say its not the hospital workforce at fault, it’s the hospital workforce is trapped by bad systems. • Honeywell, a large employer is signed on already to pay hospitals higher reimbursement if they provide high quality care under this program. • The party isn’t over folks! Its just begun…..

Summary • Many Changes – Cores, VBP, MU • So Much Detail! • Validating Outliers is so important no matter where they come from • Interrator Testing of “Mets” so important again, no matter where they come from • Educate about www.qualitynet.org

Keep it Simple • Explain the measurea in Plain English • Explain why it was not met in Plain English • Disseminate the info in an easy to read format such as EXCEL

Communicate with Your QIO • They are here to help and a wealth of information.

Physicians & PI • Work with the PI Director • Identify a Physician Champion for Each Core Measure

Final Thought – Avoid This • Avoid “gaming the system”, don’t cave into changing any data based on PI or Physician Response to your Outlier Reports unless you have read the specifications manual and seen the documentation in the record.

Thank You! Lou Testa Administrative Director/CFO Health Information Alliance, Inc. 800 405-8800 Lou.Testa@HIA-Corp.com www.HIA-Corp.com

Optimizing Core Measure Outcomes, Value Based Purchasing & Meaningful Use