update to federal quality programs collection of infection data

Healthcare Association of New York State www.hanys.org

Mary Therriault, R.N., M.S.Senior Director, Quality and Research Initiatives

• November 9, 2011


Objectives• Describe the current inpatient and outpatient Pay-

for-Reporting program infection indicators• Describe the CMS current Hospital- Acquired

Conditions (HAC) infection indicators• Describe the Patient Protection and Affordable Care

Act (ACA) current and future deliverables• Describe the current The Agency for Healthcare

Research and Quality (AHRQ) Infection indicators• Describe the possible future indicators

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Quality is not just one clear road anymore

Many factors will Significantly Change the Health Care Quality Landscape over the Next Several Years


Medicare Quality-Based Programs

2010 2011 2012 2013 2014 2015 2016 2017

Medicare Readmissions 1%-3% at risk(only losers)

HACs 1% at risk (only losers)

Value-Based Purchasing (VBP) 1%-2% withhold (winners/losers)

Inpatient Quality Reporting Requirement (IQR) (Pay-for-Reporting) 2.0 percentage point reduction for non-compliance

Hospital Outpatient Quality Reporting (HOQR) (Pay-for-Reporting) 2.0 percentage point reduction for non-compliance

FFY

IQR MU2015 75% 25%2016 50% 50%2017 25% 75%

** Applicable IQR/MU %

MU = Meaningful Use

ICD-10-DM

Meaningful Use **


Initial Components of the Current FederalHospital Quality Initiative (HQI)

HQI uses a multi-pronged approach to support, provide incentives, and drive systems and facilities

Section 501(b) Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003

10 quality “starter set” initiatives initially called Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) - this is now known as the Hospital Inpatient Quality Reporting Program (IQR) “Pay for Reporting”

Section 5001(a) Deficit Reduction Act (DRA) of 2005 supersedes the MMA and sets new requirements

Value-Based Purchasing (VBP) “Beginning of Pay for Performance”

Requires CMS to identify and limit payments for health care-acquired conditions (HACs)

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Current - Pay-for-Reporting Under the Hospital Inpatient Quality Reporting (IQR) Program

Implementation of Value-Based

Purchasing


Final IQR Quality Measures FFY 2014

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Final IQR Quality Measures for FFY 2015

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NYS and CMS Clinical Process Measures

84

86

88

90

92

94

96

98

100

AMI Heart Failure Pneumonia SCIP

Av

era

ge

Pe

rce

nt

Sc

ore

First Quarter 2010 - Fourth Quarter 2010Discharges

CMS Clinical Process Measures

NYS Average National Average Top 10%

Source: CMS Hospital Compare


NYS and CMS Patient Experience of Care Measures

0

10

20

30

40

50

60

70

80

90

Per

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f P

atie

nts

Rat

ing

C

ateg

ory

as

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r 10

(A

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Category of Questions

CMS HCAHPS Survey

National Average

NYS Average

First Quarter 2010 through Fourth Quarter 20010 DischargesSource: Hospital Compare


Pay-for-Reporting Under the Hospital Outpatient Quality Program Reporting (HOQR) Program

HOQR Validation begins

OPPS Proposed Measures

12

Proposed EHR Pilots (CAH’s also)


Alignment of Hospital IQR Program and EHR Incentive Program

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Current - CMS Hospital-Acquired Conditions (HAC) related to infections• Present on Admission (POA) modifiers

specify whether diagnosis codes are:– Comorbidities (i.e., potential risk

factors)– Inpatient complications

• POA modifiers are important in:– Computing rates of adverse

outcomes– Risk-adjusting performance measures

• Inaccurate coding affects:– Assessments of clinical quality– Performance-based reimbursement

• POA chart review to detect coding errors is costly, screens are used to look for coding efficiently

• The Deficit Reduction Act of 2005 (DRA) requires a quality adjustment in Medicare Diagnosis Related Group (DRG) payment for certain hospital-acquired conditions

• MD/NP/PA documentation and HIM coding

• Example: Catheter associated UTI ICD- 9- DM - 996.64

– Due to indwelling urinary catheter Use additional code: Use additional code to identify specified infections, such as: Cystitis (595.0-595.9); Sepsis (038.0-038.9)

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Additional HAC’ s Defined. . ..

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HAC Name HAC ICD 9 Codes

Definitions Cost/case

Case number

Medicare 2007

Case number POA

Medicare-for service

SPARCS (NYS) 2007

Vascular catheter associated infection

999.31 Infection due to central venous catheter (eff. 10/07)Includes: (Catheter-related bloodstream infection (CRBSI) NOS ); Infection due to: Hickman catheter, Peripherally inserted central catheter (PICC) (portacath (port-a-cath) ); Triple lumen catheter; umbilical venous catheterExcludes: infection due to: arterial catheter (996.62); catheter NOS (996.69); peripheral venous catheter (996.62); urinary catheter (996.64)

$103,027 29,536 1,292 634

Mediastinitis after CABG 519.2 Mediastinitis $299,237 69 0 0*SSI after elective TKR 81.54 Total knee replacement

Includes: Bicompartmental; Unicompartmental (hemijoint); Tricompartmental

$63,135 539 44 12*

996.66 Due to internal joint prosthesis (eff. 10/89)Use additional code: Use additional code to identify infected prosthetic joint (V43.60-V43.69)

998.59 Other postoperative infection (eff. 10/96)Includes: (Abscess intra-abdominal postoperative); Abscess stitch postoperative; Abscess subphrenic postoperative; Abscess wound postoperative; Septicemia postoperativeUse additional code: Use additional code to identify infection (continued below)


Additional HAC’ s Defined. . ..

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HAC Name HAC ICD 9 Codes

Definitions Cost/case

Case number

Medicare 2007

Case number POAMedicare-for

serviceSPARCS (NYS)

2007

99.59 Other postoperative infection (eff.10/96) Includes: (Abscess intra-abdominal Postoperative): Abscess stitchPostoperative): Abscess subphrenic ; Postoperative): Abscess wound; Postoperative: Septicemia postoperativeUse additional code: Use additional code t

SSU after elective lap gastric bypass, gastroenterostomy

44.38 Laparoscopic gastroenterostomy Includes: Bypass; (gastroduodenostomy; gastroenterostomy; gastrogastrostomy); Laparoscopic gastrojejunostomy without Gastrectomy NEC; Excludes: Gastroenterostomy, open Approach (44.39)

$180,142 208 9 1*

44.39 Other gastroenerostomyIncludes: Bypass; (gastroduodenostomy;gastroenterostomy; gastrogastrostomy);Laparoscopic gastrojejunostomy withoutGastrectomy NEC

998.59 Other postoperative infection (eff.10/96) ; Includes: (Abscess intra-abdominal; Postoperative): Abscess stitchPostoperative): Abscess subphrenic; Postoperative): Abscess wound; Postoperative: Septicemia postoperativeUse additional code: Use additional code t

SSI after elective varicose vein ligation, stripping

38.59 Ligation and stripping of varicose veins; includes: lower limb veins (Femoral; Saphenous; Popliteal; Tibial); Excludes: Ligation of varices; esophageal (42.92; gastric (44.91)

$66,355 3 0 0*

998.59 Other postoperative infection (eff.10/96) Includes: (Abscess intra-abdominal; Postoperative): Abscess stitch; Postoperative): Abscess subphrenicPostoperative): Abscess wound; Postoperative: Septicemia postoperative; Use additional code: Use additional code t

Began October 1, 2008 POA= Present on Admission Brown, Faye. ICD-9-CM Coding Handbook. Chicago, IL: Health Forum, LLC, 2007 Federal Register: Rules and Regulations. Centers for Disease Control and Prevention (CDC). Vol. 72. No. 162. 2007. 47201-7218.


Current HAC Payment Policy Example

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Adjusted Standard Rate $12,237.24

DRG Weight PaymentDRG 195 Simple pneumonia & pleurisy w/o CC/MCC 0.7095 $8,682.62

DRG 194 Simple pneumonia & pleurisy w CC 0.9976 $12,208.48

DRG 193 Simple pneumonia & pleurisy w/ MCC 1.4378 $17,594.84ICD-9 707.23 Pressure ulcer, stage III

Potential Loss ($8,912.22)


Hospital Inpatient/Outpatient Quality ReportingRequirements

• Register with QualityNet• Identify and maintain a QualityNet Security Administrator• Pledge for participation—or withdraw• Collect and report clinical process measures• Submit population and sampling size counts• Continuously collect and submit HCAHPS data• Report claims data (mortality, readmission, HAC)• Submit structural measures information—annually

– Participation in a Systematic Database for Cardiac Surgery – Participation in a Systematic Clinical Database Registry for Stroke Care – Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care– Participation in a Systematic Clinical Database Registry for Surgical Care – Participation in a Systematic Clinical Database Registry for Outpatient Laboratory Results

• Pass clinical process measures Validation• Submit Data Accuracy and Completeness Acknowledgement (DACA) —annually• Display data on Hospital Compare Web Site


Hospital IPPS/OPPS Quarterly Process


Centers for Medicare and Medicaid ServicesAcute Inpatient Measures (55)

(72 IPPS Measures by 2015)Acute Outpatient Measures (33)Electronic Health Measures (15)

Clinical Process Measures All Payer

AMI - five measuresHF - four measuresPN – two measuresSCIP - ten measures

Claims-Based DataMedicare FFS

30-day mortality rate AMI, HF, PN

30-day readmission rate AMI, HF, PN

Global Flu /Pneumonia ImmunizationInpatient and Outpatient

All Payer

Emergency DepartmentsAll Payer

ED throughput Inpatient and Outpatient

Hospital-Acquired ConditionsMedicare FFS

(Eight conditions)

Healthcare-Acquired InfectionsAll Payer(CLABSI )

(Surgical Site Infections)

Meaningful UseAll Payer

Electronic Health Record16 ‘Core’ functions5 ‘Menu’ functions

Stage 1 - Quality15 clinical measures

Stroke, VTE, ED

Stroke - eight measuresVTE - six measures

All Payer

OutpatientAll PayerAMI - five measures

Surgery - two measures

ED Diabetic

measuresImaging

AHRQ

Medicare FFSIQI - two measures PSI - five measuresAHRQ composite:

PSI/mortality


IPPS Provider Participation Report


Timeframes for FFY 2013 VBP

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FFY 2013 VBPProcess Domain Measures

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FFY 2013 VBP Process Domain, cont’d

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FFY 2013 VBP Patient Experience of Care Domain

Modifications to HCAHPS on Hospital Compare:• Cleanliness and quietness combined• “Would you recommend this hospital?” not included

Measured using the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS)

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Weighting of Domains

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Final Efficiency Measure

Inpatient Stay

Pre-op lab work

Dr. Visit

Three Days Prior:

Dr. Visit

ED Visit

Rehab

Thirty Days Post: (Final IPPS Rule)

Dr. Visit

Dr. Visit

One Episode

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New York VBP ImpactFFY 2013 Final Rule

Note: CAHs, Cancer hospitals and others that do not meet the minimum data requirements are excluded.

Source: CMS Hospital Compare Database – 4Q 2010 (April 1, 2009 – March 31, 2010) and 1Q 2011 (Oct 1, 2009 – Sept 30, 2010) releases. CMS’ final VBP rule published in the May 6, 2011, Federal Register.

Winners LosersTotal

Impact ($)Count Impact ($) Count Impact ($)

New York City 13 1,528,000 30 (5,368,000) (3,841,000)

Western New York 1 18,000 15 (1,363,000) (1,345,000)

Rochester Regional 8 569,000 6 (227,000) 342,000

Iroquois – Central 5 227,000 18 (1,458,000) (1,231,000)

Iroquois – Northeastern 3 168,000 13 (953,000) (785,000)

Nassau-Suffolk 15 2,290,000 7 (847,000) 1,442,000

Northern Metropolitan 6 597,000 17 (1,456,000) (859,000)

Statewide 51 5,396,000 106 (11,673,000) (6,276,000)


Submit plans for

Ambulatory Surgical

Centers VBP (Jan 1, 2011)

Submit plans for SNF and Home

Health VBP (Oct. 1,

2011/FFY 2012)

Implement physician VBP

modifier for specific

physicians and physician groups

Implement VBP for inpatient

hospitals

2006FY

Establish a CAH and small

volume rural hospital VBP

demonstration

2011 2012 2013 2015 2016 2017

Implement VBP pilot programs for inpatient rehabilitation, inpatient

psychiatric, LTC, cancer hospitals, and hospice

Physician payment modifier applied to all

physicians, groups and other eligible

practitioners

Value-Based Purchasing Expansion to Other Payment Settings

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Medicare Readmission Reduction Program

34


Applicable Conditions FFY 2013

35


Medicare Readmission Measures

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Index Readmission

Jan 1 Jan 15 Jan 25 Feb 10

Does not count

Index

Example of a Medicare Readmission

Discharged: Admitted:Admitted:Admitted:

Primary dx=HF

Primary dx=broken hip

Primary dx= CAD

Primary dx= PN

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Medicare Readmission: Future Expansion

Initial Set FFY 2013 - FFY2014

• Heart Attack• Heart Failure• Pneumonia

Payment Penalty Cap - 1% Payment Penalty Cap - 3%

Expanded Set FFY 2015

• Under Consideration:• COPD• CABG• PTCA• Other Vascular

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HAC-Related Medicare Policies

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CMS did not adopt a new HAC condition Contrast-Induced Acute Kidney Injury41


CMS Public Website HAC Measures

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ACA HAC Future Payment Policy

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ACA Mandatory Medicare Delivery System Reform

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Voluntary Medicare Delivery System Reform


The Agency for Healthcare Research and Quality (AHRQ)

and the Infection Indicators Pay for Reporting


Value-Based Purchasing and AHRQ

• POA coding is also used in the specifications for the component indicators for the AHRQ Patient Safety composite measure CMS will be adopted for the Hospital VBP program for FY 2014

• This composite measure consists of 8 component indicators, including – PSI-3 (Pressure ulcer) – PSI-6 (Iatrogenic Pneumothorax)– PSI-7 (Central venous catheter-related bloodstream infections)– PSI-8 (Postoperative hip fracture),– PSI-12 (Postoperative pulmonary embolism or deep vein thrombosis)– PSI-13 (Postoperative sepsis)– PSI-14 (Postoperative wound dehiscence)– PSI-15 (Accidental Puncture or Laceration)

• CMS is using the POA information on the final adjudicated claim submitted by the Hospital

• This data is subject to the same scrutiny as other information on Medicare claims

– Reference: Medicare Program; Hospital Inpatient Value-Based Purchasing Program, April 29, 2011

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AHRQ Claims Data Quality Measures

• The AHRQ Quality Indicators are based on diagnosis and procedures billed

• Administrative data are primarily used for billing, but also for other business and financial planning purposes

• There is a basic tension between using the data for reimbursement and for defining quality indicators– Submitting bills quickly versus coding from a complete

record– Maximizing the coding of complications and

comorbidities versus only coding diagnoses “out of the norm”


AHRQ Measures Displayed on Hospital Compare

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Reference: Pollock August 25, 2010 Presentation

Healthcare Association of New York State www.hanys.orgReference: Pollock August 25, 2010 Presentation


IPPS Infection Quality IQR Potential Future Measures

• Potentially using the CDC NHSN –Ventilator Associated Pneumonia

(VAP)–Multi-drug-resistant organism (MDRO)

infection–Clostridium Difficile Associated Disease

(CDAD)54


CDC NHSN Data Collection of Infections. . ..the Future

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Reference: http://www.cdc.gov/nhsn/CDA_eSurveillance.html


NYS Hospitals that share a Medicare Number (CCN)

• IPPS hospitals will sign NHSN consent agreement (Hospitals with no ICU will have to attest to that on the consent form)– Hospitals will be indentified by CMS Certification Number

(CCN) • (Not NYS PFI number or NHSN facility number)

• NHSN will forward the CLABSI Standardized Infection Rate (SIR) rate to CMS as one rate for the group of hospitals

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Operational Plans for Hospital Compare

• CDC will do quarterly NHSN calculation of hospital specific CLABSI SIR rates

• CDC will send CLABSI data by CCN number to CMS and that will ensure ‘pay for reporting’ yearly marketbasket payment

• Publicly Reported: First Quarter 2011 CLABSI will post to Hospital Compare in December 2011

• 2010 NHSN convened a Steering Committee Work Group (NYS DOH and HANYS are participating)

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CDC NHSN Standardized Infection Rate (SIR)

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Reference: http://www.cdc.gov/hai/pdfs/stateplans/SIR_05_25_2010.pdf


Public Perceptions and Infections

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Selected References• http://www.cdc.gov/ncidod/dhqp/pdf/guideli

nes/BSI_tagged.pdf• http://www.cdc.gov/nhsn/• http://www.qualitynet.org/• http://www.safepatientproject.org/topic/hos

pital_acquired_infections/• http://www.health.state.ny.us/statistics/facilit

ies/hospital/hospital_acquired_infections/

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Healthcare Association of New York State www.hanys.org62


CONTACT INFORMATION:

Mary Therriault, R.N. [email protected]

(518) 431-7757

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update to federal quality programs collection of infection data

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