Keeping Up with the Regulatory Requirements and Other Hocus Pocus. Vicky A. Mahn-DiNicola RN, MS, CPHQ Vice President and Product Manager ACS MIDAS+

Transcription

1 Keeping Up with the Regulatory Requirements and Other Hocus Pocus Vicky A. Mahn-DiNicola RN, MS, CPHQ Vice President and Product Manager ACS MIDAS+

2 Session Objectives Review Medicare s proposed strategies to transition hospitals from pay for reporting to Value based Purchasing. Discuss proposed changes in DRG coding taxonomy and the impact it will have on hospitals and performance measures Highlight new initiatives on the radar screen for Joint Commission

3 We KNOW You ve Been Busy!

4 Pay for Performance: Higher Stakes In the beginning Quality Improvement Then consumer empowerment through Public Reporting Followed by incentives for provider transparency Pay for Reporting And movement to value based purchasing Pay for PERFORMANCE Slide content borrowed from Sheila H. Roman, MD, MPH, Senior Medical Officer Quality Measurement & Health Assessment Group, Centers for Medicare & Medicaid Services

5 U.S. Department of Health and Human Services Proposes Transition from RHQDAPU to Medicare Hospital Value Based Purchasing DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 411, 412, 413, and 489 [CMS-1533-P] RIN 0938-AO70 Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates Published April Final Ruling Expected August 2007

6 Current Structure for Hospital Medicare Annual Payment Updates Hospitals receive an Annual Payment Update from Medicare based on whether they submitted performance measurement data for public reporting Hospitals must have 80% or higher agreement rates on CDAC reviews for Core Measures Last year hospitals that failed to comply with these two requirements lost only received 1.4% APU (3.4% awarded to those hospitals that met requirements).

7 Measures Required by CMS for Submission in Acute MI (8 measures) PCI within 120 minutes is being reported, not 90 Heart Failure (4 measures) Pneumonia (7 measures) Antibiotics within 4 hours is reported despite controversy Influenza being collected by not publicly reported SCIP (2 measures) HCAHPS Patient Satisfaction (27 measures) Acute MI and Pneumonia 30 day mortality Calculated by CMS for Medicare encounters only

8 What is Value Based Purchasing? VBP will link payment more directly to performance Hospitals will still be required to submit data on all measures applicable to their patient population, BUT. Hospitals will receive annual payment updates based on their performance scores for the required measures The VBP Program will reward hospitals that improve their performance, as well as those that achieve high levels of performance

9 Value Based Purchasing Scoring Plan Every measure will have a benchmark and an attainment threshold that are determined from the distribution of national hospital performance on that measure during the previous reporting period Hospitals will get 0 to 10 points for how close they get to a benchmark or an attainment threshold The proposed scoring model is specific to clinical process of care measures Benchmark and attainment thresholds not yet available for 30-day mortality measures or HCAHPS patient experience measures

10 VBP Benchmarks and Attainment Thresholds Benchmarks represent exemplary performance Calculated as the mean of the top-performing 10% of all hospitals in the previous reporting period Attainment thresholds reflect improvement Calculate as the performance of the median hospital (50 th percentile) in the previous reporting period Hospitals that perform in the current year at least as well as the mid-performing hospitals in the previous reporting period would earn points for attainment

11 VBP Points for Exceeding the Benchmark Illustration of PN Pneumococcal Vaccination 47% 87% 91% Attainment Threshold (median national value) Benchmark (mean of top 10 Percentile) Hospital s Score Hospital gets 10 points on this measure for exceeding the benchmark

12 VBP Points for Not Meeting the Attainment Threshold Illustration of PN Pneumococcal Vaccination 21% 47% 87% Hospital s Score Attainment Threshold (median national value) Benchmark (mean of top 10 Percentile) Hospital gets 0 points on this measure for not reaching the attainment threshold

13 VBP Points for mid-range performance is based on year-to-year improvement Illustration of This PN hospital Pneumococcal gets 6 points Vaccination (higher score wins; round to nearest whole number) Hospital s Score This Year 47% 70% 87% Attainment Threshold Benchmark Attainment Range Points Possible

14 VBP Points for mid-range performance is based on year-to-year improvement Illustration of PN Pneumococcal Vaccination Hospital s Score Last Year Hospital s Score This Year 21% 47% 70% 87% Attainment Threshold Benchmark Improvement Range Points Possible

15 VBP Points for mid-range performance is based on year-to-year improvement This hospital gets 7 points (higher score wins; round to nearest whole number) Hospital s Score Last Year Hospital s Score This Year 21% 47% 70% 87% Attainment Threshold Benchmark Attainment Range Improvement Range

16 Calculation of Overall VBP Score Based on all measures that count toward the financial incentive for which the hospital submitted data and for which it had a sufficient number of cases The number of measures for each hospital could vary, depending on services provided Total earned points = Sum of points earned across all reported measures Total possible points = Total number of measures reported by hospital x 10

17 Translation of VBP Score into VBP Incentive Payment The benchmark level of performance for all possible measures submitted by the hospital is required for a hospital to obtain their full VBP incentive payment CMS can establish a minimum performance level below which a hospital would receive none of its VBP incentive An exchange rate will be set by CMS for scores between the minimum and the benchmark levels

18 VBP Exchange Rate for Determining VBP Incentive Payments - An Illustration of Concept - Hospital Hospital A Overall Performance Score (% of total points achieved) 100% Incentive Payment (% of payment earned) 100% Hospital B 58% 68% Hospital C 75% 88% Hospital D 6% 7%

19 Universe of VBP Measures VBP Measures collected by hospitals, submitted to CMS and publicly reported VBP Measures used to determine financial incentive

20 FY 2009 Candidate Process of Care Measures for VBP Financial Incentive AMI 1 Aspirin at arrival AMI 2 Aspirin at discharge AMI 3 ACI or ARB for LVSD AMI 4- Smoking cessation AMI 5 Beta blocker at discharge AMI 7a- Thrombolytics within 30 minutes AMI 8a PCI within 90 minutes HF 1 Discharge instructions HF 3 ACE or ARB for LVSD HF 4 Smoking cessation PN 2 Pneumococcal vaccination PN 3b Blood culture in ED before BC PN 4 Smoking Cessation PN 6 Appropriate antibiotic selection PN 7 Influenza vaccination SCIP 1 Antibiotics 1 hour before surgery SCIP 3 Antibiotics discontinued within 24 hours after surgery In addition, 30-day AMI and HF Mortality and HCAHPS will be required

21 Measures not recommended for inclusion in VBP Incentive Plan AMI-6 Beta blocker at arrival Clinical evidence base appears to be changing HF-2 LVEF assessment for heart failure Measure is redundant with ACEI and ARB measures PN-1 Oxygenation assessment for pneumonia Measure has topped out completely and not useful PN-5b Initial antibiotic within 4 hours of arrival Measure has produced negative unintended consequences SCIP-Inf-2 Prophylactic antibiotic selection Practice guidelines for prophylactic antibiotics have been unstable over time Hospitals are still required to collect and submit these measures

22 Proposed Redesign of Data Infrastructure to Support VBP Monthly vs. quarterly data submission Resubmission of data into the CMS warehouse Customized s to hospitals giving real time performance data to date on VBP measures CDAC reviews increased from 20 to 50 per year Allowable CDAC mismatch rate increases from 80% to 90% Increased minimum required sample size for each measure

23 Timeline for VBP Program Proposal is the begin VBP in Fiscal Year 2009 (which begins October 2008) Does not apply to critical access hospitals or to other hospital types that are not paid under the Inpatient Prospective Payment System (PPS) Expanding to hospital outpatient services by Fiscal Year 2009 Expanding to Ambulatory Surgery Centers by Fiscal Year 2010

24 FY 2008 Changes in Coding Practices Proposed by Department of Health and Human Services

25 ICD-9 Status Present or Absent on Admission Required on all Medicare claims for discharges starting October Will be used to limit Medicare reimbursement on two selected conditions not present on admission that could reasonably have been prevented through application of evidence-based guidelines and where the cost/volume burden is high. Public comment on the selection of the first two conditions is encouraged

26 Conditions being proposed for limited payment whenever they are not present on admission and move the patient into a CC or MCC DRG Catheter associated UTI Decubitus ulcers Object left in surgery Air embolism Blood incompatibility Staph aureus septicemia Ventilator associated pneumonia Vascular catheter acquired infection Clostridium difficile associated disease (CDAD) MRSA Surgical site infection Wrong surgery Falls

27 For more information on POA Indicators for Diagnosis Codes Specific instructions on how to select the correct POA indicator for a diagnosis code are included in the ICD-9-CM Official Guidelines for Coding and Reporting. These guidelines can be found at: cd9/ftpicd9.htm

28 DRG Coding Changes that will make your head spin! CMS-DRG System (Inpatient Prospective Payment System begins) MS-DRG System (Medicare Severity adjusted DRG Taxonomy begins) 1983 October 2007 (Proposed)

29 Why is this important? The current DRG structure focuses on complexity and benefits those hospitals whose patients aren t as severely ill and require more resources Payments for most severely ill patients are 36% lower than the average Medicare patient (MedPac, 2005) Medicare Severity DRG Classification System (MS-DRGs) are being proposed to improve payment accuracy for complexity and severity of cases that require additional resources Current DRG structure have separate DRGs for PCI procedures with or without stents The insertion of a stent makes the case more complex but does not mean the patient is more severely ill

30 New MS- DRG Classification System is based on detailed identification of complications and co-morbidities Historic definition of a CC is any secondary diagnosis that would cause an increase in length of stay by at least 1 day in at least 75 percent of the patients (currently there are 115 DRGs split based on presence or absence of a CC In the current CMS-DRG system, nearly 80% of acute inpatient admissions currently have a DRG with a CC because of the shift of care to outpatient services and lower levels of care, thus the current CC system is no longer sensitive

31 Development of New MS-DRG System All 3,326 ICD-9 diagnoses that could possibly place a patient in a DRG with complications or co-morbidities category were reviewed List of complications and co-morbidities for DRG assignment was decreased to 2,583, thus reducing the percentage of patients in a DRG with cc category from 78% to 41% Chronic disease without acute manifestations are excluded from a DRG with CC

32 Differentiating Chronic Disease in the new MS-DRG system Acute Heart Failure , Acute systolic heart failure , Acute systolic and diastolic heart failure , Acute on chronic systolic heart failure , Acute diastolic heart failure , Acute on chronic diastolic heart failure Chronic Heart Failure 428.0, Congestive heart failure not otherwise specified 428.1, Left heart failure , Systolic heart failure not otherwise specified , Chronic systolic heart failure , Chronic diastolic heart failure , Systolic and diastolic heart failure 428.9, Heart failure not otherwise specified

33 Categorization of Severity Levels Three severity levels proposed MCC Major complications and co-morbidities CC Complications and co-morbidities Non-CC Non complications and co-morbidities Adding the new MCC subgroup greatly enhances CMS s ability to identify and reimburse hospitals for treating patients with high levels of severity. The MCC subgroup contains patients with average charges almost twice as large as for those in the CC group ($44,219 compared to $24,115).

34 Example of Severity Levels in CHF Codes , Acute systolic heart failure , Acute systolic & diastolic heart failure , Acute on chronic systolic heart failure , Acute diastolic heart failure , Acute on chronic diastolic heart failure 428.1, Left heart failure CC , Systolic heart failure NOS CC , Chronic systolic heart failure CC , Chronic diastolic heart failure CC , Systolic & diastolic heart failure CC 428.0, Congestive heart failure NOS Non-CC 428.9, Heart failure NOS Non-CC MCC CC Non-CC

35 Proposed MS-DRGs for Heart Failure 291 Heart failure & shock w MCC 292 Heart failure & shock w CC 293 Heart failure & shock w/o CC/MCC No more DRG 127 After October 07

36 Transition will challenge Report Writers! DRG 127 DRG 291 DRG 292 DRG 293 September 2007 October 2007

37 Same Codes Different Meaning New MS-DRG Codes 533 Fractures of femur w MCC 534 Fractures of femur w/o MCC Old CMS-DRG Codes 533 Extracranial vascular procedures with CC 534 Extracranial vascuclar procedures w/o CC

38 Proposed MS-DRG System Current CMS DRGs 538 Elimination of CC subgroups -114 Elimination of MCC subgroups -7 Elimination of CC Complexity subgroups -5 Elimination of age 0-17 subgroups -43 Consolidation due to similar volume or resources -34 New DRGs +1 Revised base DRG 311 Newborn, maternity and error DRG 24 Base DRGs for severity subdivision 335 Total proposed MS-DRGs 745

39 Dividing Proposed MS-DRGs on the Basis of the CCs and MCCs DRGs with no subgroups (all subgroups combined) DRGs with two severity subgroups -With MCC - Without MCC (CC + non-cc combined) DRGs with two severity subgroups - With CC/MCC (CC + MCC combined) - Without CC/MCC (non-cc ) DRGs with three severity subgroups -MCC -CC - Non-CC Total proposed MS-DRGs (includes 24 MDC 14 and error DRGS)

40 More DRG Coding Changes in your future! CMS-DRG System (Inpatient Prospective Payment System begins) MS-DRG System (Medicare Severity adjusted DRG Taxonomy begins) Next Generation Severity Adjusted DRG Taxonomy 1983 October 2007 (Proposed)???

41 Additional Severity Adjusted DRG Systems Currently Being Reviewed by RAND Corporation for Future Use 3M/Health Information Systems (HIS) CMS DRGs modified for AP-DRG Logic (CMS+AP-DRGs) Consolidated Severity-Adjusted DRGs (CS DRGs) Health Systems Consultants (HSC) Refined DRGs (HSC-DRGs) HSS/Ingenix All-Payer Severity DRGs with Medicare modifications (MM- APS-DRGs) Solucient Solucient Refined DRGs (Sol-DRGs) Final report due from Rand September 1, 2007 but it will be awhile before one is implemented!

42 Implications for MIDAS+ Users if legislation passes Longitudinal data for DRG based indicators will not be available in MIDAS+, CPMS and DataVision DRG based indicators will have to be redefined in MIDAS+ SmarTrack, ReporTrack, CPMS and DataVision DataVision metrics will have more precision All hospitals will have to update their DRG dictionary in MIDAS+ by October MIDAS+ is currently developing a strategy to address this issue and minimize client effort in transitioning to this new taxonomy.

43 How to Post a Comment to Proposed Regulatory Changes The proposed rule can be downloaded at Go to CMS Home > Medicare > Acute Inpatient PPS > IPPS Regulations and Notices Look for this document: CMS-1533-P In commenting, please refer to file code CMS-1533-P Submit electronic comments on specific issues in this regulation to Click on the link Submit electronic comments on CMS regulations with an open comment period. (Attachments should be in Microsoft Word, WordPerfect, or Excel) All comments must be received by 5PM on June 12, 2007

44 Who to contact at CMS with questions Sheila Blackstock, (410) , Quality Data for Annual Payment Update Issues Thomas Valuck, (410) , Hospital Value-Based Purchasing Issues

45 Joint Commission: What s Coming Next? Anonymous Patient Level Data will be transmitted to Joint Commission in October 2007 for April 2007 discharges. Hospitals will be required to submit FOUR Core Measure topics beginning with January 2008 discharges. No increase for non-core measure submission requirements

46 New Core Measure Requirements - January Hospitals Able to Identify 4 Core Measure populations 3 Core Measure populations 2 Core Measure populations 1 Core Measure populations No core Measure populations Core Measure Sets Required 4 Core Measure Sets 3 Core Measure Sets 2 Core Measure Sets 1 Core Measure Sets No Core Measure Sets Non-Core Measures Required None 3 Non-Core Measures 6 Non-Core Measures 9 Non Core Measures 9 Non-Core Measures

47 Requirements for SCIP Currently Required SCIP Infection 1 and 3 SCIP Infection 2 (but not reported) SCIP VTE 1 and 2 Required in January 2008 (possible requirement for Q if NQF approves earlier) SCIP Infection 4 (Controlled post-op glucose in cardiac patients) SCIP Infection 6 (Hair Removal) SCIP Infection 7 (Normothermia in colon surgery patients) To Be Determined There is a question if SCIP-Card-2 will survive (Surgery Patients on Beta Blockers who received beta blockers during perioperative period)

48 Children s Asthma Care Begins for discharges April 2007 Use of relievers Use of systemic corticosteroids Home management plan of care document given to patient/caregiver Optional for all acute care hospitals unless you are currently sending non-core ORYX measures and pediatrics is one of your populations MIDAS+ users must sign up for Children s Asthma Care by August 8 th if they wish to participate Can participate as a MIDAS+ report only participant and not submit data to Joint Commission Must have a minimum of 30 MIDAS+ clients collecting CAC data before comparative reports are available

49 Critical Care Measure Set Implementation Date January Head of Bed Elevation Stress Ulcer Disease Prophylaxis Venous Thromboembolism Prophylaxis Ventilator Weaning Central-Line Associated Blood Stream Infection Urinary catheter Associated Urinary Tract Infections (includes adults and pediatrics) Ventilator Associated Pneumonia (includes adults, pediatrics, NICU)

50 Additional Measure Sets Under Development VTE Measures VTE-1 VTE Risk Assessment/Prophylaxis within 24 hours of admission VTE-2 VTE Risk Assessment/Prohylaxis within 24 hours after transfer to ICU VTE-3 Documentation of Inferior Vena Cava Filtration Indication VTE-4 VTE Patients with overlap of anticoagulation therapy VTE-5 VTE Patients receiving unfractionated heparin with platelet count monitoring VTE-6 VTE patients receiving unfractionated heparin with heparin mangement by nomogram/protocol VTE-7 VTE patients given written instructions on bleeding symptoms, diet, follow up, GCS, Medications, next lab appointment, signs and symptoms of complication VTE-8 Incidence of potentially preventable hospital acquired VTE Going to NQF for potential endorsement October 2007 Some measures may change or be eliminated in final set

51 Nursing Sensitive Care Measure Set Death among surgical inpatients with treatable serious complications (Failure to Rescue) Pressure Ulcer Prevalence Patient Falls Falls with injury Restraint Prevalence (vest and limb) Ventilator-Associated Pneumonia Smoking Cessations for Acute MI Smoking Cessation for Heart Failure Smoking Cessation Counseling for Pneumonia Skill Mix Nursing Care Hours per Patient Day Practice Environment Scale Nursing Work Index Voluntary Turnover

52 Project Timeline for Nursing Sensitive Care Measures April - May 07 Recruit & Identify test sites July 07 to June 08 Data Collection July to Nov 08 Analysis of Project findings January June 07 Build data collection tools January March 08 Reliability Assessment December 08 Recommendations for implementation

53 Closing Remarks and Questions