Transcript Readmission Analysis Experience

PfP Quality Metrics:
Readmissions, Value-Based
Purchasing and Beyond
Presented to ASHNHA
Alaska Partnership for Patients Advisory
Group
February 4, 2015
Gloria Kupferman
Agenda
• Readmissions
– Calculation methods
• 3M compared to Medicare (CMS)
– Sample reporting tool
• Medicare Value-Based Purchasing
• Maintaining PfP momentum with data
collection and reporting
Readmissions
What is a Readmission?
• A readmission is a return hospitalization to an
acute care hospital that follows a prior admission
from an acute care hospital within the specified
readmission time interval
– The time interval can vary depending upon the
purpose of the review
• Many methodologies exist to identify and
quantify readmissions
Methodologies
• 3M™ Potentially Preventable Readmissions
– Some States’ Medicaid Penalties
• CMS Hospital Readmissions Reduction Program
– Hospital-Level 30-Day Risk-Standardized
Readmission Measures for specific conditions
• AMI, HF, PNEU, COPD, THA/TKA, CABG
• Readmissions in the BPCI and ACO Initiatives
• Others developed by QIOs, health departments,
etc.
3M™ PPR Methodology
3M™ PPR Methodology
• Index admissions and readmissions for
conditions that are not considered preventable
are globally excluded
– e.g. major or metastatic malignancies, multiple
trauma and burns, etc.
• Some admissions are considered non-events
and are considered at risk admissions
– e.g. same day transfer to an acute care hospital for
non-acute care, etc.
Observed PPR Rate
Expected PPR Rate
Observed to Expected Ratio
Overview of the Current CMS Methodology
• All-cause readmissions
• Current focus areas
–
–
–
–
–
–
Heart Failure (HF) patients
Heart Attack (AMI) patients
Pneumonia (PN) patients
Chronic Obstructive Pulmonary Disease (COPD)
Total hip and knee replacements (THA/TKA)
CABG in FFY 2017
• What hospitals are included?
– All acute care PPS hospitals
– CAHs are exempt
– Hospital must have 25 discharges within a disease category over
the 3 year reporting period
Inclusions
• Medicare Fee-for-Service patients, at least 65
years of age, with a principal diagnosis of AMI,
HF, or PN
• 12 full months of enrollment in parts A and B
FFS prior to the index admission
• FFS Medicare Part A at the time of the index
admission
• One full month of enrollment in Parts A and B
FFS post discharge
Exclusions
•
•
•
•
•
•
•
Incomplete Medicare enrollment data
Under age 65
Length of stay greater than one year
Discharged against medical advice
In hospital deaths
Transfers out
Same day readmissions for the same condition
to the same hospital
• Disease category specific exclusions
• Some recognition of planned readmissions
Risk Adjustment Methodology
• Developed by a team of clinical and statistical
experts from Yale and Harvard universities
• Each disease category has an individual risk
adjustment model
– Adjust for variables that are clinically relevant and
have strong relationships with the outcome
• Demographics, disease severity indicators, indicators of
frailty
• Example for HF: age, sex, history of CABG, cancer, diabetes,
asthma, COPD, pneumonia, renal failure, etc.
Risk Standardized Readmission Rate (RSRR)
• RSRR=
Predicted
Rate
Expected
Rate
 National
Unadjuste
d Rate
• Predicted Rate (similar to observed rate)
– the number of readmissions within 30 days predicted on
the basis of the hospital's performance with its observed
case mix
• Expected Rate
– the number of readmissions expected on the basis of the
nation’s performance (US average hospital performance)
with that hospital’s case mix.
Predicted to Expected Ratio
• P/E less than 1 =
– Lower than expected readmission rate
– Better quality, no penalty
• P/E greater than 1=
– Higher than expected readmission rate
– Lower quality, subject to penalty
Live Tour
• Readmissions Diagnostic Tool
17
Takeaways
• You can’t evaluate and address issues without data
• You need an analytic tool that can identify and track
readmissions
• Let the CMO, Dept. Chairs, Nurse Leads. . .
– Play with it
– Formally analyze
– Provide feedback
– Share with MD/RN and other key clinicians
• Use for focus groups. . . What goes well and where are
the opportunities
Medicare Value-Based Purchasing
Value-Based Purchasing Overview
• Mandated by the ACA
• The only Medicare quality program that actually
rewards good performance
• Funded by Medicare payment carve-outs
• Complex scoring methodology looks at quality
metrics in several “domains”
• Scores reflect performance compared to national
standards and individual improvement
• Domains, metrics and standards change annually
General VBP Program Trends
• Continuously evolving program
– Program rules established well in advance
– Increasing program exposure
– Increasing weight towards Outcomes & Efficiency Measures
0%
2013
2014
2015
2016
25%
2017
1.75%
Program Contribution Amount
25%
25%
20%
10%
10%
20%
20%
25%
30%
30%
5%
45%
40%
25%
20%
50%
2.00%
40%
30%
60%
70%
Domain Weight
70%
30%
80%
25%
90%
30%
100%
1.50%
1.25%
1.00%
0.75%
0.50%
0.25%
0.00%
2013
2014
2015
2016
2017
FFY 2015 VBP Program Overview
• 1.5% program contribution
• Outcomes domain measure expansion
– PSI-90 Safety Indicator Composite
– CLABSI Standardized Infection Ratio
• New Efficiency Domain
– SPP_1 (Medicare Spending Per Beneficiary)
• Overlap with FFY 2015 HAC Reduction Program
– PSI-90 Composite
– CLABSI
Process Domain
30%
20%
20%
Patient Experience Domain
Patient Outcomes Domain
30%
Efficiency Domain
FFY 2015 VBP Program Overview
• First Year of Proportional Reweighting
– Impacts program eligibility
Unweighted Domain
Score
Original Domain
Weight
Proportionally
Reweighted Domain
Weight *
Process Domain
63.33%
20.00%
28.57%
Patient Experience Domain
96.00%
30.00%
42.86%
Patient Outcomes Domain
Not Eligible
30.00%
Not Elgible
90.00%
20.00%
28.57%
Efficiency Domain
Process Domain
29%
43%
29%
Patient Experience Domain
Patient Outcomes Domain
Efficiency Domain
Hospital Counts
Scored on 2 Domains
92
2.9%
Scored on 3 Domains
420
13.1%
Scored on 4 Domains
2683
84.0%
Total Number of Insiders*
3195
100.0%
*Based on 4Q2013 DataGen Estimate
Tracking VBP Performance
FFY 2013 Program ACTUAL Performance
Measure and Domain Score Comparison
Hospital
Performance
VBP Measure Score
Process of Care
Program Eligibility
AMI-7a
N/A
N/A
AMI-8a
N/A
N/A
Patient Experience of Care
FFY 2015 Program ESTIMATED Performance
Hospital Performance
Eligible
VBP Measure Score
Projected to be Eligible
N/A
N/A
N/A
N/A
100.0%
10
gggggggggg
88.0%
6
gggggg
10
gggggggggg
98.0%
6
gggggg
100.0%
10
gggggggggg
HF-1
100.0%
10
gggggggggg
PN-3b
100.0%
10
gggggggggg
100.0%
10
gggggggggg
PN-6
98.3%
8
gggggggg
100.0%
10
gggggggggg
100.0%
10
gggggggggg
SCIP-Inf-1
100.0%
10
99.4%
7
ggggggg
100.0%
10
gggggggggg
SCIP-Inf-2
99.4%
8
100.0%
10
gggggggggg
100.0%
10
gggggggggg
SCIP-Inf-3
100.0%
10
98.7%
6
gggggg
100.0%
10
gggggggggg
SCIP-Inf-4
N/A
N/A
N/A
N/A
gggggggggg
gggggggg
gggggggggg
Measure Not Evaluated for VBP 2013
100.0%
100.0%
10
gggggggggg
SCIP-Card-2
97.6%
8
gggggggg
100.0%
10
gggggggggg
SCIP-VTE-1
96.5%
6
gggggg
100.0%
10
gggggggggg
SCIP-VTE-2
96.5%
7
ggggggg
100.0%
10
gggggggggg
SCIP-Inf-9
85.6%
3
ggg
1
Communication with Doctors
1
g
0
2
gg
3
ggg
Responsiveness of Hospital Staff
Pain Management
Not Provided By
CMS
N/A
N/A
98.0%
6
gggggg
97.0%
5
ggggg
Measure Not Evaluated for VBP 2015
100.0%
gggggggggg
10
93.6%
Communication with Nurses
Not Provided By
CMS
g
83.0%
77.0%
1
79.0%
0
1
g
62.0%
0
1
g
69.0%
0
g
6
gggggg
3
ggg
64.0%
3
ggg
Cleanliness and Quietness of Hospital Environment
3
ggg
3
ggg
67.5%
3
ggg
Discharge Information
10
gggggggggg
7
ggggggg
88.0%
7
ggggggg
Overall Rating of Hospital
3
ggg
0
70.0%
2
gg
HCAHPS Consistency Score
20
Communication about Medicines
gggggggggggggggggggg
19
ggggggggggggggggggg
Not Applicable
51.0%
Unweighted Domain Score
MORT-30-AMI
Patient Outcomes
VBP Measure Score
Eligible
Unweighted Domain Score
Efficiency
FFY 2014 Program ACTUAL Performance
Hospital
Performance
MORT-30-HF
Domain Not Evaluated
for VBP 2013
MORT-30-PN
PSI-90
85.0%
2
85.8%
0
89.1%
7
gg
ggggggg
N/A
N/A
86.0%
0
87.6%
0
0.760
0
N/A
N/A
0.0%
30.0%
Unweighted Domain Score
SPP_1
35.0%
35.0%
Measure Not Evaluated for VBP 2014
HAI_1
ggggggggg
19
Domain Not Evaluated for VBP 2013
Domain Not Evaluated for VBP 2014
0.81
gggggggggg
10
100.0%
Unweighted Domain Score
Reweighting factor
FFY 2013 ACTUAL Program Performance
TPS and Payment Impact Comparison
FFY 2014 ACTUAL Program Performance
1
FFY 2015 ESTIMATED Program Performance
Unweighted
Domain
X
Domain
Weight
=
Weighted
Score
Unweighted
Domain
X
Domain
Weight
=
Weighted
Score
Unweighted
Domain Score
X
Domain
Weight
=
Weighted
Score
Process of Care Domain
85.6%
X
70.0%
=
59.9%
93.6%
X
45.0%
=
42.1%
83.0%
X
20.0%
=
16.6%
Patient Experience of Care Domain
51.0%
X
30.0%
=
15.3%
35.0%
X
30.0%
=
10.5%
35.0%
X
30.0%
=
10.5%
30.0%
X
25.0%
=
7.5%
0.0%
X
30.0%
=
0.0%
100.0%
X
20.0%
=
20.0%
Patient Outcomes Domain
Efficiency Domain
Total Performance Score (TPS)
Not Applicable
75.2%
Not Applicable
60.1%
47.1%
PfP Data Collection and Reporting
Maintain Momentum
• Sample data collection / reporting tool
• Sample summary workbook
Questions?
Gloria Kupferman
Vice President, DataGen
[email protected]
518-431-7968