Objectives. Medicare Spending per Beneficiary: Analyzing MSPB Data to Identify Primary Drivers

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1 Medicare Spending per Beneficiary: Analyzing MSPB Data to Identify Primary Drivers August 22, 2017 Objectives Understand the basics of the hospital specific MSPB data files and reports Review the factors that influence MSPB in the context of the MSPB timeline Learn about regional and state trends, and primary drivers of MSPB 1

2 Review of Medicare Spending per Beneficiary Measure 2 What Is MSPB? Evaluates hospital efficiency relative to the efficiency of other hospitals in terms of Medicare spending Lower scores indicate greater efficiency Hospital Value-Based Purchasing Efficiency and Cost Reduction Domain 3

3 Review MSPB Calculation 9 Available MSPB Data Calendar Year 2016 Performance Report Year 2017 Fiscal Year

4 MSPB Data Sources 11 Available Data - Hospital Compare from December 2016 (calendar year 2015 performance impacting fiscal year 2017 payment) - Hospital Specific Report May 2017 MSPB Measure - Hospital-Specific Summary Report - Beneficiary Episode File - Beneficiary Risk Score File - Index File 12

5 Table 1: MSPB Measure for Hospital 13 Table 2: Summary of Your Hospital s MSPB Performance 14

6 Table 3: Detailed Statistics of Your Hospital s MSPB Performance 15 Figure 1: National Distribution of MSPB Measure

7 Table 4: National Distribution of the MSPB Measure, by Percentile 17 Table 5: Detailed MSPB Spending Breakdowns by Claims Type 3 Days Prior to Admission During Index Admission 30 Days After Hospital Discharge Claim Type Hospital Spending per Episode Percent of Spending State Percent of Spending Nation Percent of Spending Total Pre-Index $ % 4.0% 3.4% Home Health Agency 0.0% 0.1% Hospice 0.0% 0.0% Inpatient 0.0% 0.0% Outpatient 1.5% 0.6% Skilled Nursing Facility 0.0% 0.0% Durable Medical Equipment 0.0% 0.0% Carrier 2.4% 2.6% Total During-Index 60.4% 55.2% Home Health Agency 0.0% 0 Hospice 0.0% 0 Inpatient 53.0% 47.7% Outpatient 0.0% 0.0% Skilled Nursing Facility 0.0% 0.0% Durable Medical Equipment 0.1% 0.1% Carrier 7.4% 7.4% Total Post-Index 35.6% 41.5% Home Health Agency 2.0% 3.4% Hospice 0.5% 0.6% Inpatient 10.7% 13.5% Outpatient 4.5% 3.4% Skilled Nursing Facility 13.3% 14.8% Durable Medical Equipment 0.4% 0.4% Carrier 4.2% 5.2%

8 Table 6: Detailed MPSB Spending Breakdowns by MDC MDC Major Diagnostic Category Hospital State Nation Average Average Average Average Average Average Expected Expected Expected Spending per Spending Spending per Spending per Spending per Spending per Episode per Episode Episode MDC Description Episode Episode Episode 1 Pre-MDC 54,518 53,574 54,768 52,870 2 Nervous System 20,570 22,158 21,380 21,110 3 Eye 13,856 14,643 13,590 13, Beneficiary Episode File List of episodes, one row per episode Items: Excluded reason, outliers Diagnosis of index admission (ICD-9/ICD-10) Major Diagnostic Category (MDC) Episode start and end dates Payment amounts: Total payment, Standardized payment, Predicted payment renormalized Information by Claim type Claim types: inpatient, outpatient, carrier (provider), skilled nursing, durable medical, home health, hospice Includes start date, end date, actual cost, standardized cost, top five providers (NOT separated by pre, during, post periods) 20

9 Beneficiary Risk Score File List of episodes, one row per episode Items: Medicare Severity-Diagnosis Related Group (MS-DRG) Payment amounts: Total payment, Standardized payment, Predicted payment renormalized Major Diagnostic Category (MDC) Risk equation coefficients: MS-DRG of index admission HCCs (79 categories) from claims 90 days prior to episode Ages (11 categories) Original reason for Medicare is disability End-stage renal disease (ESRD) Long-term care indicator Interaction variables (11 interaction terms) 21 Index Admission File List of hospital stays (more than one row per episode), including excluded stays Items: Episode count Index admission flag Exclusion reason (death, non-ffs, non-index) Diagnosis codes (ICD-9/ICD-10) Major Diagnostic Category (MDC) Payment amounts: Total Deductible Coinsurance Payment amount 22

10 Polling Question How is your hospital using the information from the MSPB Data Files (Excel)? A. I ve never heard of it before now B. Our team has reviewed it, but didn t know how to make use of the data C. Our team actively analyzes the data provided (if so please share more details in chat) 23 Regional Analysis 24

11 Most Recent Public Data - Regional Performance 25 Hospital-Specific Report Data from Table 3 Michigan Minnesota Wisconsin National Total Spending per Episode 19, , , , MSPB Amount 19, , , , National Median MSPB Amount 20, , , , MSPB Measure Number of eligible admissions 214,604 54,875 84,713 5,389,267 26

12 State MSPB Performance 2015 and Episode Actual Spending 28

13 MSPB Percent Episode Spending by Claim Regional and National 29 MSPB Percent Episode Spending by Claim Type

14 MSPB Episode Spending by Claim Type EPISODE START CLAIM START CLAIM END 90 Days Prior 3 Days Prior Index Admission 30 Days Post ADMISSION DISCHARGE EPISODE END 32

15 Most Frequent DRGs - Regional DRG Code Diagnosis Related Group (DRG) Title Regional Regional Count Percent State Ranking MI MN WI 470 Major Joint Replacement Or Reattachment Of Lower Extremity w/o MCC 24, % Septicemia Or Severe Sepsis w/o MV 96+ Hours w/ MCC 16, % Heart Failure & Shock w/ MCC 9, % Esophagitis, Gastroent & Misc Digest Disorders w/o MCC 6, % Heart Failure & Shock w/ CC 6, % Septicemia Or Severe Sepsis w/o MV 96+ Hours w/o MCC 6, % Pulmonary Edema & Respiratory Failure 5, % Renal Failure w/ CC 5, % Chronic Obstructive Pulmonary Disease w/ MCC 5, % Kidney & Urinary Tract Infections w/o MCC 5, % Most Frequent DRGs State Specific State DRG Code Diagnosis Related Group (DRG) Title State Count State Percent State Ranking MI 378 G.I. Hemorrhage W Cc 3, % 10 MN 885 Psychoses 1, % 3 MN 193 Simple Pneumonia & Pleurisy W Mcc % 9 MN 483 Major Joint/Limb Reattachment Procedure Of Upper Extremities % 10 WI 378 G.I. Hemorrhage W Cc 1, % 8 WI 193 Simple Pneumonia & Pleurisy W Mcc 1, % 10 34

16 Most Costly DRGs per Group - Regional DRG Code 470 Diagnosis Related Group (DRG) Title Total Cost Count Major Joint Replacement Or Reattachment Of Lower Extremity w/o MCC Median Per Episode $544,785, ,914 $19, Septicemia Or Severe Sepsis w/o MV 96+ Hours w/ MCC $410,742, ,541 $19, Heart Failure & Shock w/ MCC $201,538, ,246 $16, Infectious & Parasitic Diseases w/ O.R. Procedure w/ MCC $158,968, ,662 $51, Spinal Fusion Except Cervical w/o MCC $ 139,534, ,561 $35, Hip & Femur Procedures Except Major Joint w/ CC $112,479, ,286 $33, Intracranial Hemorrhage Or Cerebral Infarction w/ CC or TPA In 24 Hrs $105,574, ,389 $20, Pulmonary Edema & Respiratory Failure $105,557, ,919 $13, Heart Failure & Shock w/ CC $99,906, ,159 $11, Simple Pneumonia & Pleurisy w/ MCC $97,495, ,008 $14, Most Costly DRGs per Episode - Regional DRG Code Diagnosis Related Group (DRG) Title Mean Cost per Episode Count 1 Heart Transplant or Implant of Heart Assist System W Mcc $244, Ecmo Or Trach W Mv 96+ Hrs Or Pdx Exc Face, Mouth & Neck W Maj O.R. Extensive Burns Or Full Thickness Burns W Mv 96+ Hrs W Skin Graft $192, $187, Heart Transplant or Implant of Heart Assist System W/O Mcc $147, Trach W Mv 96+ Hrs Or Pdx Exc Face, Mouth & Neck W/O Maj O.R. $146, Other Heart Assist System Implant $124, Liver Transplant w Mcc or Intestinal Transplant $121, Intracranial Vascular Procedures W Pdx Hemorrhage W Mcc $119, Intracranial Hemorrhage or Cerebral Infarction $111, Lung Transplant $102,

17 EPISODE START CLAIM START CLAIM END 90 Days Prior 3 Days Prior Index Admission 30 Days Post ADMISSION DISCHARGE EPISODE END 37 Hierarchical Condition Categories 70 indicators derived from the beneficiary s claims during the period 90 days prior to the start of the episode MSPB model also accounts for interactions between HCCs and/or enrollment status. Presence of certain comorbidities increase costs in a greater way than predicted by the HCC indicators alone 38

18 Most Costly HCCs Regional HCC HCC Title # of Episodes % of Episodes Median Cost Contribution HCC81 Acute Myocardial Infarction 2, % $3, HCC111 Aspiration and Specified Bacterial Pneumonias 4, % $3, HCC67 Quadriplegia, Other Extensive Paralysis 8, % $2, HCC78 Respiratory Arrest 6, % $2, HCC82 Unstable Angina and Other Acute Ischemic Heart Disease % $2, HCC45 Disorders of Immunity 3, % $2, HCC174 Cerebral Palsy 3, % $2, HCC70 Muscular Dystrophy 1, % $2, HCC7 Metastatic Cancer and Acute Leukemia 9, % $2, HCC19 Diabetes without Complication 11, % $2, Most Frequent HCCs Regional HCC HCC Title Number of Episodes % of Episodes Median Cost Contribution HCC92 Specified Heart Arrhythmias 74, % $ HCC131 Renal Failure 71, % $ HCC101 Cerebral Palsy and Other Paralytic Syndromes 70, % $ HCC17 Diabetes with Acute Complications 68, % $ HCC119 Proliferative Diabetic Retinopathy and Vitreous Hemorrhage 59, % $ HCC18 Diabetes with Chronic Complications 43, % $ HCC68 Paraplegia 28, % $1, HCC21 Protein-Calorie Malnutrition 27, % $1, HCC157 Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone 25, % $1, HCC44 Severe Hematological Disorders 21, % $

19 EPISODE START CLAIM START CLAIM END 90 Days Prior 3 Days Prior Index Admission 30 Days Post ADMISSION DISCHARGE EPISODE END 41 MSPB Spending by Claims Type Post Index Michigan Percent of Spending Minnesota Percent of Spending Wisconsin Percent of Spending Nation Percent of Spending Total Pre-Index 3.2% 4.0% 3.6% 3.4% Total During-Index 55.6% 60.4% 58.6% 55.2% Total Post-Index 41.1% 35.6% 37.8% 41.5% Post-Index Home Health 3.5% 2.0% 2.3% 3.4% Post-Index Hospice 0.6% 0.5% 0.7% 0.6% Post-Index Inpatient 12.8% 10.7% 11.0% 13.5% Post-Index Outpatient 3.5% 4.5% 4.5% 3.4% Post-Index SNF 14.8% 13.3% 14.7% 14.8% Post-Index DME 0.4% 0.4% 0.4% 0.4% Post-Index Carrier 5.5% 4.2% 4.1% 5.2% Length of Index Stay (days) N/A Total Spending per Episode $19, $19, $19, $20, MSPB Measure

20 Next Steps 43 Other Possibilities Dig in further to HCCs and impact of co-morbidities Readmissions vs. Index Cost Post Acute Care vs. Index Cost Most costly DRGs analyzed by pre, during, and post index Analyze DRGs looking at ICD-10 codes Link data to EHR to assess severity 44

21 Lessons Learned Impact of care post-index discharge Balance costs for index with costs for post-index care Ambulatory care documentation There is more analysis to be done 45 Questions? Sarah Brinkman, MBA, MA, CPHQ Erik Zabel, PhD, MPH, Epidemiologist

22 This material was prepared by Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-D