CMS’ Hospital Readmission Reduction Program: What does it mean for your hospital?
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CMS’ Hospital Readmission Reduction Program: What does it mean for your hospital?
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CMS’ Hospital Readmission Reduction Program: What does it mean for your hospital?
- 1. CMS’ Hospital Readmission Reduction Program: What does it mean for your hospital? Alabama Hospital Association Meeting February 1, 2013 Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 0
- 2. Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 1
- 3. It’s All About Money • Medicare annual spend – 2010: $525B – 2020: $922B • Medicaid annual spend – 2010: $401B ($271B federal/$130B state) – 2020: $908B ($561B federal/$347B state) • Total annual spend – 2010: $2.64 trillion; 17.6% of GDP; $8,327 per capita – 2020: $4.64 trillion; 19.8 % of GDP; $13,708 per capita Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 2
- 4. How We Got Into This Mess • Providers incentivized by fee-for-service reimbursement – Sick care v. health care – We don’t know what works, so we do it all • Over-regulation in a futile attempt to prevent over-utilization and control costs • Health care as piece work • Data blind Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 3
- 5. Evolution of Reimbursement Bundled Payments Fee for Service Shared Savings Visitor Symptomatic Acute Needs Services & Supplies Unit Based No Financial Risk Patient Episode Most Common Conditions Packaged Treatments Efficiency Based Partial Financial Risk Prepared for Alabama Hospital Association Meeting Partial Capitation Global Payment Person Overall Health Community Health Characteristics Manage Well Being Outcome Based Full Financial Risk February 1, 2013 Page 4
- 6. Two Intertwined Goals Goals Make better health insurance coverage more available and affordable for legal residents Prepared for Alabama Hospital Association Meeting Reform the health care delivery and payment system to provide better care in a more cost-efficient manner February 1, 2013 Page 5
- 7. The Future is Now • Pay for volume • No quality measured Fee For Service Value- Based Payment • Quality per click • Process improvement THEN NOW FUTURE Prepared for Alabama Hospital Association Meeting • Quality outcomes of episodes • Whole system improvement Care Coordination February 1, 2013 Page 6
- 8. The Real Change Drivers Data is king; HIT/HIE non-negotiable Quality will be quantifiable Payment will be based on quantified quality Demand for quantified quality will drive clinical integration Successful integration will require high degrees of trust among providers The building blocks of trust are common purpose and agreed-upon ground rules Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 7
- 9. Link Payment to Quality Readmission reduction program Physician value-based purchasing Physician quality incentives Prepared for Alabama Hospital Association Meeting Hospital value-based purchasing February 1, 2013 Page 8
- 10. Readmission Reduction Program • The Affordable Care Act established the basis for the Hospital Readmissions Program. – CMS reduced payments to IPPS hospitals with excess readmissions beginning October 1, 2012 – 30 Day Readmission Measures: • Acute Myocardial Infarction (AMI) • Heart Failure (HF) • Pneumonia (PN) Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 9
- 11. Readmission Reduction Program • Readmission reductions are based on three years worth of data – FY 2013 provider adjustment is based on readmission data collected from July 1, 2008 through June 30, 2011 – Minimum 25 cases to calculate readmission rate – CMS expects the readmission reduction program to be base on a rolling three years of readmissions data – Providers have a 30-day preview period to review their readmission rates – CMS posts readmission measures results on Hospital Compare http://www.medicare.gov/hospitalcompare/ Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 10
- 12. Readmission Reduction Adjustments • Maximum excessive readmission adjustments are applied to a provider’s Medicare base rate: – FY 2013 - 1% reduction – FY 2014 - 2% reduction – FY 2015 - 3% reduction • Readmission results are public information, therefore, hospitals face negative community response for excessive readmission rates Source: Readmission Adjustment factors are based on excess readmission ratios from the performance period of July 1, 2008 to June 30, 2011, as finalized in the FY 2013 IPPS/LTCH PPS Final Rule. Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 11
- 13. Readmission Reduction Adjustments What does it mean for Alabama hospitals? ($3,903,338) Source: Readmission Adjustment factors are based on excess readmission ratios from the performance period of July 1, 2008 to June 30, 2011, as finalized in the FY 2013 IPPS/LTCH PPS Final Rule. Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 12
- 14. Quality Counts… But can you prove it? 1. AMI-2 Aspirin Prescribed at Discharge 2. AMI-7 a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival 3. AMI-8a Primary PCI Received Within 90 Minutes Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 13 of Hospital Arrival 4. HF-1 Discharge Instructions 5. HF-2 Evaluation of LVS Function 6. HF-3 ACEI or ARB for LVSD 7. PN-2 Pneumococcal Vaccination 8. PN-3b Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital 9. PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient 10. PN-7 Influenza Vaccination 11. SCIP-Inf-1 Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision 12. SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients 13. SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time 14. SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose 15. SCIP-Card-2 Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period 16. SCIP-VTE-2 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered 17. SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hrs After Surgery Clinical Process of Care Measures 70% HCAHPS 30% Source: CMS Special Open Door Forum: VBP 2/10/2011
- 15. HCAHPS Composite Scores – Communication with doctors – Communication with nurses – Pain management – Cleanliness and quietness of hospital environment – Responsiveness of hospital staff – Communication about medicine – Discharge information – Overall rating of hospital Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 14
- 16. Press Ganey Performance Insights 2012 “While the association between performance HCAHPS and readmission is clear, it’s not causal. Improving HCAHPS performance will not by itself lower readmission rates. Rather, the organizational culture, management and systems that enable a hospital to perform well on HCAHPS will also facilitate better performance on readmissions and other outcomes.” Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 15
- 17. Readmission Reduction Goal Patients CAPABLE of managing their own care Communication Alignment Partners Access Barriers Learning Evaluation Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 16
- 18. Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 17
- 19. FFS Payment for Transitional Care Management • New Medicare payment for post-discharge transitional care management • Key elements – Contact within 2 days of discharge – Face-to-face visit within 7 (or 14) days – Non-face-to-face care management services over 30-day period Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 18
- 20. Transitional Care Management What does it mean to Alabama hospitals? + $23,675,699 Source: Estimated reimbursement is based on the assumption that CMS expects 92% of TCM codes will be billed as non-facility. 2013 Fee schedule amounts are derived from the MAC website. Medicare discharges source 2011 MEDPAR. Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 19
- 21. Questions? Prepared for Alabama Hospital Association Meeting February 1, 2013 Page 20
- 22. Contact Information Thank you for allowing us to share our thoughts and expertise with you. Denise Hall, RN, BSN Principal dhall@pyapc.com Pershing Yoakley & Associates, P.C. (800) 270-9629 www.pyapc.com Prepared for Alabama Hospital Association Meeting Kristen Lilly, MHA, RHIA, CPHQ Manager klilly@pyapc.com February 1, 2013 Page 21