Georgia Hospital Association FY 2014 IPPS/LTCH PPS Proposed Rule Quality Provisions 11 June 2013 ©...

Georgia Hospital Association

FY 2014 IPPS/LTCH PPS Proposed RuleQuality Provisions

11 June 2013

© 2013 American Hospital Association

IPPS/LTCH PPS Proposed Rule Summary

• Comments due on June 25, 2013

– AHA Regulatory Advisory available at www.aha.org

• Includes proposals for seven different quality reporting and payment programs

• Select headlines:

– HAC Reduction (penalty) Program - All of it

– Readmissions – Updated measures and expansion to 2 additional conditions in FY 2015

– IQR – Electronic reporting option

– VBP – new measures and measure domain realignment

2© 2013 American Hospital Association

Hospital Acquired Conditions

Beginning FY 2015, financial penalty for being in the top quartile of national HAC rates

– 1 percent reduction to Medicare payments for all discharges.

– Includes: Inpatient PPS, SCHs, and Indian Health Services

– Excludes: CAHs, LTCHs, cancer hospitals, IRFs, IPFs,

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HAC MeasuresDomain 1, Option 1: Individual PSIs

Domain 1, Option 2: Composite PSI

Domain 2: HAI Measures

Pressure ulcer (PSI 3)# * Volume of foreign object left

in the body (PSI 5) Iatrogenic Pneumothorax

rate (PSI 6)* Postoperative physiologic

and metabolic derangement rate (PSI 10)# *

Postoperative pulmonary embolism (PE) or deep vein thrombosis rate (DVT) (PSI 12)

Accidental puncture and laceration rate (PSI 15)

PSI-90 (Composite comprised of the following 8 PSIs): Pressure ulcer rate (PSI

3)# * Iatrogenic Pneumothorax

rate (PSI 6)* Central venous catheter-

related blood stream infection rate (PSI 7)# *

Postoperative hip fracture rate (PSI 8)# *

Postoperative pulmonary embolism (PE) or deep vein thrombosis rate (DVT)

(PSI 12) Postoperative sepsis rate

(PSI 13)# * Wound dehiscence rate

(PSI 14)# * Accidental puncture and

laceration rate (PSI 15)

Central Line-associated Blood Stream Infection (CLABSI) (FY 2015 onward)%

Catheter-associated Urinary Tract Infection (CAUTI) (FY 2015 onward)%

Surgical Site Infection (SSI) (FY 2016 onward):%o SSI Following Colon

Surgery o SSI Following

Abdominal Hysterectomy

Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia (FY 2017 onward) %

Clostridium difficile (FY 2017 onward)%

# = Not NQF-endorsed* = Not reviewed by the Measure Applications Partnership (MAP)%= Overlaps with finalize or proposed VBP measure


HAC: Scoring MethodologyPerformance on each measure split into quartiles….

Percentile above 75th percentile

Number of Points

Assigned for measure

1st -10th 111th – 20th 2

21st – 30th 331st – 40th 441st – 50th 551st – 60th 661st – 70th 771st – 80th 881st – 90th 9

91st – 100th 10

…with hospitals then assigned points depending on the decile of performance on each measure

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Top quartile scores then divided into deciles…


HAC Reduction Program:Assigning Points

Measure Measure Score type Scenario Points Assigned PSI-5 Frequency count Occurrence = 0

Occurrence >= 1 0 10

PSIs 3, 6, 10, 12, 15

Rate Rate >= 75th percentile Rate < 75th percentile

1-10 0

PSI 90 Weighted average of rates of component PSIs

Composite value >= 75 percentile Composite Value < 75th percentile

1-10 0

Domain 2 HAI measures

Standard Infection Ratio (SIR)

SIR >= 75th percentile SIR < 75th percentile

1-10 0


HAC Reduction Program: Areas of Concern and Analysis

• The measures– Not all are NQF-endorsed, – Not all reviewed by the MAP

• Scoring methodology– Is it sufficient to blunt the effect of rarely occurring

events?– AHA conducting an analysis to determine spread of

performance on measures, and impact to hospitals

• Double penalty (or conflicting signals about penalties)– CAUTI and CLABSI in VBP and HAC

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Hospital Readmissions Reduction Program:FY 2014 and 2015 Proposals

• FY 2014• Penalty increases to 2%, per statute• Planned readmissions algorithm incorporated into existing

measures to exclude planned readmissions• Always excludes transplant surgery, OB delivery, maintenance

chemotherapy and rehab• Possible exclusion of non-acute readmits for planned

procedures• No exclusion for readmits for acute illness or complications

• FY 2015• Penalty increases to 3%, per statute• Addition of two measures

• COPD readmissions• Total hip/Total Knee readmissions


Key HRRP problems remain…

• Measures do not exclude readmissions unrelated to the reason for initial admission in spite of the ACA statutory requirement

• No exclusions for patients with conditions requiring frequent inpatient hospitalizations (e.g.—burns, psychosis, ESRD, substance abuse)

• Poor measure reliability (i.e.—inadequate minimum case threshold to produce accurate measure results)

• No adjustments for socioeconomic factors beyond hospital control

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Inpatient Quality ReportingOUT• Aspirin prescribed at discharge for AMI• Statin prescribed at discharge for AMI• Angiotensin converting enzyme Inhibitors / angiotensin receptor blockers

(ACEI/ARB drugs) for left ventricular systolic dysfunction• Surgery patients with perioperative temperature management• PN-3b – Blood culture performed in the emergency department prior to first

antibiotic received in hospital• HF-1 – Discharge instructions• IMM-1 – Immunization for pneumonia (guidelines have changes)• Participation in a systematic clinical database registry for stroke care (stroke

measures render this unnecessary)

IN• 30-day risk standardized COPD readmission• 30-day risk standardized COPD mortality• 30-day risk standardized stroke readmission• 30-day risk standardized stroke mortality• AMI payment per episode of care• Expand CAUTI and CLABSI to non-ICU areas


Proposed IQR Electronic Reporting for FY 2016

• Hospitals would receive credit for both the Medicare EHR Incentive program and IQR for reporting 1 quarter’s worth of data for 16 measures common to both programs– Stroke, VTE, ED, early elective delivery

• Hospitals would have 2 different deadlines depending on whether they are in their first year of the Medicare EHR Incentive program– Hospitals in 1st year of EHR Incentive: Jun. 1, 2014– Hospitals beyond 1st year of HER Incentive: Nov. 30, 2014

• CMS strongly encourages hospital participation as a precursor to required electronic submission in the future

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IQR Electronic Reporting: Concerns

• Substantial differences between EHR-based and manual abstraction methodologies, resulting in substantial variation in performance results

• Inadequate validation of measures reported via certified EHRs

• Timing of required electronic reporting– CMS mentions required reporting may

happen as soon as CY 2015

– However, they also state they will use the results of the voluntary reporting to inform when they intend to require it.

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Inpatient Quality Reporting (IQR): Validation Process

• Timing: Quarters shifted to allow for more timely determination of annual payment update

• Selection of measures: Will validate 12 process of care, and add MRSA and C Diff to HAI validation in FY 2016

• Number of records: Will reduce the number of records validated per hospital for HAI measures

• Electronic submission of records selected for validation will be allowed

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Value-Based Purchasing (VBP)FY 2016 and FY 2017 Measure Proposals

• Three clinical process measures removed for FY 2016– AMI-8a (primary PCI within 90 minutes of hospital arrival) – dropped due to being

topped out;– PN-3b (blood cultures performed in the emergency department prior to initial

antibiotic received in hospital) – no longer NQF-endorsed– HF-1 (discharge instructions – no longer NQF-endorsed

• Three new measures added for FY 2016– IMM-2 (Influenza Vaccination for inpatients 6 months and older);– Catheter-associated urinary tract infections; and– Surgical site infections

• Two new measure for FY 2017– Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia– Clostridium difficile (C Diff).

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Proposed Domain Weighting for FY 2016 VBP Program

Measure Domain FY 2013 Final

FY 2014 Final

FY 2015 Final

FY 2016 Proposed

Process 70% 45% 20% 10%

Patient Experience 30% 30% 30% 25%

Outcomes 0% 25% 30% 40%

Efficiency 0% 0% 20% 25%

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Proposed Realignment of Domain for FY 2017 VBP Program

• CMS proposes a realignment of domains and measures within the domains to align with the National Quality Strategy priority areas

• Specific measures are remapped to the new domains

• As alternative, CMS proposes the same domains and weighting as the FY 2016 VBP program

Domain WeightSafety 15%Clinical Care: Clinical Care – Outcomes Clinical Care – Process

35% 25% 15%

Efficiency and Cost Reduction 25%Patient and Caregiver Centered Experience of Care / Care Coordination

25%

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VBP Disaster / Extraordinary Circumstances Waiver

• CMS proposes a waiver process for hospitals that have faced natural disasters or other extenuating circumstances

• CMS would have the authority to waive a hospital from the VBP program in the fiscal year during which a hospital’s performance period data is likely affected

• Hospitals would be required to submit a request within 30 days of the occurrence of the extraordinary circumstance, and simultaneously with the IQR waiver


Inpatient Psychiatric Facility Quality Reporting Program (IPFQR)

• IPFs and licensed psychiatric distinct part units reimbursed under the IPF PPS must report on quality measures to receive full annual payment update beginning in FY 2014

– FY 2014 and FY 2015 program use the HBIPS measures from the Joint Commission

• Eligible institutions. – Free-standing Psychiatric Hospitals, including government-

operated Psychiatric Hospitals – Licensed Distinct Part Psychiatric Units of acute care

hospitals and critical access hospitals


IPFQR: FY 2016 Measurement Proposals

• Not yet NQF-endorsed (NQF review underway)– SUB-1 – Alcohol Use Screening

• Percentage of patients 18 years of age and older who are screened for unhealthy alcohol use during an inpatient stay.

– SUB-4—Alcohol and Drug Use: Assessing Status after discharge

• Assesses whether discharged patients are contacted between 7 and 30 days after hospital discharge to collect information about their alcohol or drug use

• FUH – Follow up after Hospitalization for Mental Illness (NQF-endorsed)– Assesses the percentage of discharges for patients

hospitalized for mental health disorders who subsequently had outpatient treatment

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PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) – FY 2015 and 2016 Proposals

• Submit quality measures for FY 2014 and beyond

• Compliance is tied to 2 percent of the annual update

• One new measure for FY 2015– Surgical Site Infection

• 13 new measures for FY 2016– Six SCIP measures– Six clinical process / oncology care measures– HCAHPS survey

• Disaster / extenuating circumstances waiver modeled on IQR waiver process


Long-Term Care Hospital Quality Reporting (LTCHQR)

• Submit quality measures for FY 2014 and beyond

• Compliance is tied to 2 percent of the annual update

Measure FY 2014 FY 2015 FY 2016 FY 2017 FY 2018

Central-Line Associated Blood Stream Infection (CLABSI)

X X X X X

Catheter-Associated Urinary Tract Infection (CAUTI)

X X X X X

Percent of nursing home residents with pressure ulcers that are new or worsened

X X X X X

Percent of nursing home residents who were assessed and appropriately given the seasonal influenza vaccine

-- -- X X X

Influenza vaccination coverage among healthcare personnel

-- -- X X X

Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia

P P

Clostridium difficile (C Diff) P PUnplanned all-cause, all condition readmissions to LTCHs and acute care hospitals

P P

Percent of residents experiencing one or more falls with major injury (Long stay)

P

X = Previously Finalized

P = Proposed


LTCHQR Proposals – Areas of Concern

• Proposed measures not ready to use in LTCHs– The measures proposed for FY 2017 and FY 2018

received a “support direction” vote from the MAP• MRSA and C Diff are NQF-endorsed but not fully

tested in LTCHs• Falls measure received NQF endorsement based

on specifications and testing for nursing homes, not LTCHs

• Proposed readmissions measure modeled on hospitalwide all-cause, all-condition readmissions measure in the IQR, carrying with it all of the same problems


LTCHQR Proposals – Measure Updates

• Healthcare personnel flu vaccination measure: reporting periods changed so that they reflect a full flu season– FY 2016: Oct. 1, 2014 – Mar. 31, 2015 (due May 15,

2016)– FY 2017: Oct. 1, 2015 – Mar. 31, 2016 (due May 15,

2016)

• Patient flu vaccination measure– Change in reporting timelines for FY 2016 and FY 2017

to reflect the implementation of LTCH CARE Tool (see the Regulatory Advisory)

– Public reporting to reflect flu season time periods, though data collection must take place for all specified periods


Proposed Readmission measure

• Why readmissions?– CMS estimates readmissions to LTCHs and IPPS hospitals

within 30 days of discharge is 26%

• What measure is CMS proposing? (See Measure Specifications)

– Returns within 30 days of LTCH discharge from the community or another care setting of lesser intensity (i.e.—SNFs, home health, Inpatient Rehab) to acute-care hospitals or LTCHs.

– Based on “all cause, all condition” because of variability in types of patients treated in LTCHs

• Small ‘N’ of patient types means unstable measure

– Uses 2 year time-period of data from inpatient claims and Medicare eligibility files


http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/LTCH-Quality-Reporting/Downloads/LTCH-Readmissions-Measure-Specifications.pdf

Proposed Readmission measure (2)

• Patients included– Age: 18 years and older– Discharged alive from LTCHs– Had 12 months of Medicare Part A FFS coverage and 30

days post discharge– Had IPPS hospital stay within the 30 days prior to LTCH stay

• Exclusions– Transfers from LTCH to another LTCH or IPPS hospital– “Planned readmissions” within 30 days

• Exclusions for labor/delivery, cancer treatment, transplant already in IPPS measure

• LTCH measure includes several additional planned procedures (e.g.—amputations, select colorectal procedures, removal of feeding/tracheostomy tubes)


LTCHQR ProposalsHousekeeping items

• Proposing a reconsideration process for annual payment update determination (modeled on the IQR)

• Proposing a disaster / extraordinary circumstances waiver process (modeled on the IQR)

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Georgia Hospital Association FY 2014 IPPS/LTCH PPS Proposed Rule Quality Provisions 11 June 2013 ©...

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