Jodi Frei, Northwestern Medical Center Vermont, and I co-presented at the MUSE Executive Institute on Revenue at Risk: Understanding Financial Impacts of Quality Reporting. The Executive Institute featured many amazing CXO's discussing the changing landscape of revenue cycle management and how finance, quality, and IT departments are converging on revenue cycle. Though pay for performance is the common theme, the logistics of programs including Value Based Purchasing (VBP), Inpatient Quality Reporting (IQR), Hospital Acquired Condition (HAC) Reduction Program, Readmission Reduction, MACRA, MIPS and APMs, are very different. In this session, the specifics of each Quality Program including reporting requirements, scoring methodologies, and associated incentives and penalties will be covered. In addition, tools to track performance and quantify financial risk will be shared. Reimbursement in this era of health care reform is challenging. We all seek success under this new normal in health care. Optimizing revenue capture in a quality reimbursement model requires acquisition of new knowledge and the use of new tools and strategies. Join us in the conversation; share your strategies; learn from others.

1.  
FINANCIAL IMPACTS OF QUALITY REPORTING

2. • Jodi Frei, PT, MSMIIT, Northwestern Medical Center
• William Presley, Vice President , Acmeware

3.  Background on Quality Programs
 Financial Risk Associated with Quality Programs
 Assessing Risk: State and Federal Reporting Tools
 Determining Key Areas of Focus
 Opportunities and Challenges

4. o Healthcare costs are not sustainable
o High out of pocket costs inhibit care

6. 37% of adults
forgo care due
to cost

7. 7

9. Improve Quality, Outcomes and Experience
Incentivize evidence based care through “value based
payments” and transparency of outcomes
Reduce Cost
Actively purchase value (based on health outcomes),
not passively purchasing on volume of services
Improve Population Health
Expand coverage, effectively prevent and treat chronic
disease and engage people in their own care
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/index.html

11. 11

12. CMS Has Many Quality and Reporting Programs
(991 unique measures!)
http://www.cms.gov/eHealth/downloads/eHealthU_PQRSQualityManagement101.pdf
= Public Reporting Focus for Hospitals/ CAHs/ Eligible Providers

13.  Value Based Purchasing
o 2% DRG withhold
o Reporting in the areas of:
o Reporting via Chart
Abstraction, Claims, eCQM,
NHSN, Patient Survey
o Points for performance over self or
national benchmarks

14.  Related to but separate from VBP
 25% Market Basket Update (MBU) penalty if fail to meet
requirements
o Abstracted measures
o eCQM Measures
o Patient Survey
o NHSN reporting
 75% MBU Penalty if fail to meet Meaningful Use
Requirements

15.  Hospital-Acquired Conditions (HAC)
o PSI-90, CLABSI, CAUTI, SSI, MRSA, CDI
o Reporting via Claims and Chart Abstraction
o 1% penalty (DRG) for hospitals in the top WORST performing quartile
 Hospital Readmission Reduction Program (HRRP)
o Readmit within 30 days: AMI, HF, PN, TKA/THA, COPD, CABG
o Claims based reporting
o Adjustment based on comparison to national averages; predicted
versus expected
o Up to 3% penalty (DRG) for excessive readmissions

16.  MACRA:
o Bipartisan legislation signed into law on April 16, 2015
o Repealed Sustainable Growth Rate Formula
o Rewards providers for quality versus quantity
o Combines existing quality programs into one
o Participants: Part B Eligible Clinicians
 MIPS
o Combines components of PQRS, Value Modifier, and MU into one
program
o One composite performance score, 0-100 points, determined
through 3 weighted categories
o Budget neutral program rewarding quality performance
o 2017 performance impacts 2019 payment

18.  If 25% Medicare Payments Through Advanced APM
o OR
 20% Patients seen through Advanced APM
 Receive 5% APM incentive payment
 Does not change how APMs reward value
 APM clinicians avoid MIPS reporting requirements and
payment adjustments

23. Year IQR EHR MU VBP HAC HRRP
2016 25% MBU 50% MBU 1.75% DRG 1.0% DRG 3.00% DRG
2017 25% MBU 75% MBU 2.00% DRG 1.0% DRG 3.00% DRG
2018 25% MBU 75% MBU 2.00% DRG 1.0% DRG 3.00% DRG
2019 25% MBU 75% MBU 2.00% DRG 1.0% DRG 3.00% DRG

24. 0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
2014 2015 2016 2017 2018 2019
IQR EHR VBP HAC HRRP

25.  Medicare Hospital Value Based Purchasing (VBP) Impact
Analysis
 Provider Statistical & Reimbursement (PS&R) Report
 Inpatient Prospective Payment System (IPPS) Federal Fiscal
Year Analysis
 Readmissions Reduction Program Analysis
 Hospital Acquired Condition (HAC) Reduction Program
Analysis

26.  Physician Quality Reporting System (PQRS) Payment
Adjustment Feedback Reporting
 Annual Quality and Resource Use Report (QRUR)
 Physician Quality Reporting System (PQRS) Measures:
eCQM Benchmarks

27. 

31. Operating Payments
+ Low Volume Adjustment
+/- Readmissions Adjustment
+/- VBP Adjustment
+ Capital Payments
TOTAL REIMBURSEMENT
- HAC Reduction
+/- Other adjustments and credits
NET REIMBURSEMENT

32. $30,955,000.00

34. 

36. Table 5C. Costs per Episode, by Categories of Service, for the Medicare Spending per Beneficiary (MSPB) Measure

38. 

39.  Use of Impact reports to determine areas of focus
 Provider Cost Analysis by DRG
 Using EHR to present cost data at order entry
o Meds
o Labs
o High Risk Medications
 Qualified Clinical Data Registry (QCDR) to promote patient
engagement

40.  86% of 2010 healthcare spending was related to the top 7
leading causes of death in 2016, all chronic conditions
 Action steps to alleviate these are within the control of the
patients
 Though providers can encourage patients to make better
health care decisions, to show up to appts, to take
medications as directed, they cannot force this
 Through patient engagement, patients will take better care
of their health even when the physician isn’t looking

41.  “…in the 2016 Healthcare Management Forum, there was a
study from McGill University [on strong patient engagement]
that showed a 20% improvement in patient experience of
care, a 25% decrease in C. diff and antimicrobial-resistant
infections, and they calculated savings of $340,000 in one
year,”
• Joe Kiani, founder of the Patient Safety Movement Foundation and
chairman and CEO of Masimo

42. Patient
Engagement
Cost
$$$$$
$$

43.  Patient Engagement Measures
o Licensed tool developed by team at University of Oregon
o Some providers see this the next vital sign
o Rates patient activation as a level 1-4
1. Does not believe they have active/important role
2. Lack confidence and knowledge to take action
3. Beginning to take action
4. Maintaining behavior over time
o A proven indicator of future cost and outcomes
http://e-patients.net/archives/2011/10/the-patient-activation-measure-pam-a-framework-for-
developing-patient -engagement.html

44.  Disparate Systems
 Difficult to assess performance across settings
 Creation of Clinical Alerts
 Coding occurs post discharge
 Understanding workflow required by eCQMs
 Transition from free text and customized reporting

45.  Transformation
 Disruptive Innovation
 Mission/Vision/Values trump Personal Preference
 Provider, Staff, Patient Engagement
 Relate, Don’t Compare
o Benchmark yourself against the outside world
 Accountability and Execution
 Perseverance

46.  Jodi Frei, PT MSMIIT Northwestern Medical Center
 William Presley, Vice President Acmeware

47.  https://www.studergroup.com/resources/articles-and-
industry-updates/articles-and-whitepapers/why-patient-
engagement-matters
 http://www.commonwealthfund.org/~/media/files/publicat
ions/fund-
report/2015/jun/1821_davis_aca_and_medicare_v2.pdf