Translating the National Quality Landscape to the Local Level GME Program Director Retreat March 29, 2013 Health Plans Employers Bridges to Excellence CMS Certification Government & Quasi-Governmental Orgs. IOM Independent Quality Orgs Providers Hospitals & Health Systems HHS CMS Nat. Qual Strat. FAH AHA IHI Star Program NCQA Individual Employers Quality measures for alternate payment arrangements (e.g., Bundled Payments) • Certification • Accreditation • HEDIS Individual Health Plans Leapfrog Pt. Prot. & Aff. Care Act AHRQ AAMC HQA QIO “Scopes of Work” Truven Health Analytics NACHRI Hosp. Comp. CHCA Independent WebBased Quality Measurement Organizations Independent subscription-based services for employers Primary Organizations Measurement Consortia Data initiatives, reports, quality standards Org. to Org. Influence Reports & Measures Top 100 Hospitals® CMS Premier • Quality Indicators • CAHPS • HCAHPS • National Guideline Clearnghse. Value-based Purchasing Pediatric Qual. Meas. Physicians NQF AMA • • • • Accreditation Certification ORYX indicators PS Sentinel Event • Nat. Consensus Stds. • Nat. Priorities Partnership • Measure Applications Partnership Hosp. Qual. Incentive Demo (HQID) JD Power TJC Distinguished Hospitals Safety Leaps • Unique performancebased incentive programs for providers • Proprietary rating systems • Unique payment/quality policies 5 million Lives 100K Lives Phys. Specialty Orgs Phys. Qual. and Report Sys. migrating to VBP Misc Provider Rating Orgs • Consumer Reports • St Louis Mag Health Grades • • • • State govt. Certification STS QIs ACC/AHA Others • Hosp. ratings • Phys. ratings US News Top U.S. Hospitals Nurses WebMD Various Care Delivery & Payment Programs • State Reporting Laws • State Payment/ Qual Policies ©2013 BJC HealthCare Center for Clinical Excellence. All rights reserved. May not reproduce without permission. American Nurses Association NDNQI & Magnet Certification Variety of provider scores Pursuing Clinical Excellence at BJC Background • The 2002 White Paper (2003 – 2007) – Systematic tracking and reporting of clinical quality results – Management accountability for clinical quality – Transparency of useful quality information 3 BJC HealthCare Clinical Indicator Performance 2002 through 2011 100% SCIP - Abx Timing SCIP - Abx Selection 90% SCIP - Abx Duration AMI - Reperfusion AMI - Aspirin at Arrival 80% AMI - Beta Blocker at Arrival AMI - Cholesterol Testing 70% AMI - Aspirin at Disch. AMI - Beta Blocker at Disch. 60% AMI - ACE/ARB at Disch. AMI - Statin at Disch. AMI - Smoking Cessation 50% CAP - Abx (6 hrs) CAP - Blood Culture 40% CAP - Abx Selection CAP - Vaccine 30% CAP - Smoking Cessation CHF - ACE/ARB at Disch. 20% CHF - LVF Assessment CHF - AFib Aspirin CHF - Disch. Instructions 10% CHF - Smoking Cessation CABG - Aspirin at Disch. 0% 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 CABG - Statin at Disch. 4 BIC 2013 Process Flow 1 Collect Metrics & Complete Preliminary Categorization 2 Screen Metrics for harm 3 Screen metrics for viability  Metrics are evaluated through a KT decision analysis, which first eliminates all metrics that are not ‘musts’ as identified through the harm, specification, and implementation evaluations  Metrics are categorized in order to 1) Create composites within key improvement areas and 2) Promote balance in evaluating metrics across key improvement areas 4 Screen metrics for ability to implement Mandatory Metrics Evaluation Criteria EBC Review? NOT Harmful? Valid? Feasible? Hospital Specific Metric Pool Drop Actionable? Attributable? No Does not meet all ‘musts’ Mandatory Metric? Drop Meets all ‘MUST’ Yes Key Quality Improvement Areas 5 Categorize Metrics Composites within key improvement areas Appropriate Care Efficiency Care Coordination Pt Safety VBP Process of Care No Track Pt Centered Outcome Set annually by Clinical Excellence Steering Committee and align to quality strategy 7 Impactful? Yes Risk Assessment Evaluation Criteria 6 Assess Impact Severe Outcomes? Reduced Care Cost? Prevalent? Usable Data? Improvable? Transparent? Financial Incentives/Penalties? 8 BIC Candidate 5 BIC 2013 System Metric Selection Number of Metrics Collect Metrics Conduct Initial Screening Assess for Must Criteria Appropriate Care 810 77 56 5 Efficiency 46 13 12 2 Patient Safety 173 51 33 7 VBP Process of Care 16 21 21 12 Care Coordination 35 10 7 1 Pt Centered Outcomes 86 10 1 0 1166 182 130 27 Composite Total Metrics Passing Initial Screen Candidate Measures • 1166 metrics • 107 total measure stewards • 10 stewards contribute 2/3 of all metrics • • • • • 182 metrics 19 measure stewards 104 mandatory 24 existing BIC metrics 92 existing tracked metrics “Must” Metrics • • • • • 130 metrics 13 measure stewards 104 mandatory 22 existing BIC metrics 79 existing tracked metrics Assess Impact & Select Metrics Final Best-in-Class Metrics • 27 metrics • 23 mandatory metrics 6 Pursuing Clinical Excellence at BJC Background • The 2002 White Paper (2003 – 2007) – Systematic tracking and reporting of clinical quality results – Management accountability for clinical quality – Transparency of useful quality information • The 2012 White Paper (2008 – 2012) – Eliminate defects in care that lead to patient harm – Establish a framework through which BJC can help its patients and the communities it serves achieve the best possible outcomes. • The 2017 White Paper (2013-2017) – Organize for Patient-Centered Outcomes – Create a culture of patient safety and clinical excellence – Enhance our capacity for innovation 7 Value-Based Purchasing Overview What is Value-Based Purchasing (VBP)? • Part of the Patient Protection and Affordable Care Act of 2010 – Final rule April 29, 2011 • Designed to reward hospitals with higher quality care • Based on existing Inpatient Quality Reporting program • Funded by trimming CMS base operating DRG payments – – – – – FY 2013: 1% FY 2014: 1.25% FY 2015: 1.5% FY 2016: 1.75% FY 2017: 2% • Not a cost savings measure; money given back to some hospitals based on performance 9 VBP Measures • Process of Care – 13 CMS core measures covering AMI, CHF, pneumonia, and surgical care • Patient Experience – 8 domains derived from the HCAHPS survey • Outcomes (new for FY2014) – 30 day mortality for AMI, CHF, and pneumonia • Efficiency (? FY2015) – Medicare spending per beneficiary 10 VBP Timelines VBP 2013 measures end 3/31/2012 VBP 2014 measures have varied time periods 2009 Q3 2010 Q4 Q1 Q2 2011 Q3 Q4 Q1 Q2 2012 Q3 Q4 Q1 Q2 2013 Q3 Q4 Q1 Process of Care and HCAHPS FY 2013 Baseline Baseline FY 2013 Performance Performance FY 2014 Baseline Baseline FY 2014 Performance Performance Outcomes (30 Day Mortality) FY 2014 Baseline FY 2014 Performance Baseline Performance 11 VBP Score Weights Hospitals receive a single Total Performance Score (TPS) 2013 2014 25% 30% 70% 45% 30% Process of Care HCAHPS Outcomes (mortality) 12 VBP Payments • • Total dollars given back depend on total dollars withheld Payback % made on linear scale based on TPS VBP Payout Model (max payback %) 2.0 % 1.5 % 1.28 % 1.0 % 0.5 % 0 25 50 TPS 75 71 AMH 100 Break even TPS Low (1.5% ) 67 Medium (1.8%)* 56 High (2%) 50 Very High (2.35%) 43 *CMS projects 1.8% maximum payback 13 BJC – VBP Scores FY 2013 Hospital AMH BHC BJH BJSP BJWC CH MBMC PHC PWHC Clinical 73.33 57.27 46.36 72.00 62.22 72.73 76.36 55.56 71.11 HCAHPS 47.00 53.00 27.00 42.00 36.00 36.00 23.00 46.00 40.00 TPS 65.43 55.99 40.55 63.00 54.36 61.71 60.35 52.69 61.78 Est. net gain/ Payback % (loss) $ 1.20 44.8K 1.03 19.9K 0.75 (453K) 1.16 32.6K 1.00 0 1.13 67.2K 1.11 94.4K 0.97 (3.3K) 1.14 7.5K 14 BJC – VBP Estimated Scores FY 2014 (as of Oct 2012) Hospital Clinical AMH BHC BJH BJSP BJWC CH MBMC PHC PWHC 82.00 61.67 53.33 58.18 71.11 60.83 74.17 74.00 75.00 Low. est. net Mod. est. net HCAHPS Outcomes* TPS** gain/(loss) $ gain/(loss) $ 82.00 45.00 45.00 46.00 50.00 49.00 32.00 44.00 63.00 86.67 100 100 66.67 100 100 100 100 100 83.17 66.25 62.50 56.65 72.00 67.08 67.98 71.50 77.65 66K (6.2K) (151K) (42K) 9.7K 4.2K 22K 10K 13K 132K 193K 302K 5.5K 36K 144K 253K 40K 32K * based on projections from in-system mortality; there is a margin of error that is hard to estimate ** break-even is projected at 67 for low payment estimate and 56 for moderate estimate 15 Best in Class 2013 16 Best In Class Changes: Adult Hospitals 2011 2012 40 incented measures 4 Appropriate Care Composites + 36 other measures 5 incented 2013 6 incented measures (composites) measures (composites) 24 component 27 component measures measures 12 new to BIC 7 new to BIC measures measures 31 Hospital Specific Measures 17 BIC 2013 Scorecard Example Color Key (corresponds to performance level achieved) Maximum Appropriate Care Care Coordination Efficiency Patient Safety Value-based Purchasing (VBP) Clinical Process of Care Hospital Specific Measures Target Threshold Minimum Below Minimum Rolling 6 Rolling 3 Threshold Minimum (07/12 - 12/12) (10/12 - 12/12) Points Weighted Weighted Value Points * Maximum Target 47.50 99% 0.2% 47.50 37.50 97% 1.4% 37.50 27.50 95% 2.6% 27.50 17.50 90% 5.5% 17.50 45.00 100% 2.8% 41.43 50.00 100% 2.5% 38.57 1.5 2 0 1.5 25.0% 5.0% 10.0% 30.0% 0.375 0.100 0.000 0.450 99% 97% 95% 90% 99% 100% 2 20.0% 0.400 46.50 36.50 26.50 16.50 40.00 36.67 1.5 10.0% 0.150 Weighted Total Score Total Composites 1.48 6 *Weights reflect the underlying effort needed to drive improvement on the composite measure, as well as how actionable the components of the composite are. 18 BIC 2013 Scorecard Component Measures Appropriate Care Composite • Hospital Outpatient - Emergency Department: – Median time to ECG (CMS OP-5)* • Immunization: – Influenza vaccination (CMS IMM-2) – Pneumococcal vaccination (CMS IMM-1) • Stroke: – Discharged on statin medication (TJC STK-6)* • Venous Thromboembolism (VTE): – Appropriate VTE Prophylaxis received by the day after hospital arrival (BJC PHT) Blue indicates mandatory measure * Indicates new to BIC for 2013 19 BIC 2013 Scorecard Component Measures Care Coordination Composite • Stroke: – Assessed for rehabilitation (STK-10)* Blue indicates mandatory measure * Indicates new to BIC for 2013 20 BIC 2013 Scorecard Component Measures Efficiency Composite • Hospital Outpatient - Imaging Efficiency: – Abdomen CT use of contrast material (CMS OP-10) – Thorax CT use of contrast material (CMS OP-11) Blue indicates mandatory measure * Indicates new to BIC for 2013 21 BIC 2013 Scorecard Component Measures Patient Safety Composite • Healthcare-associated Infections (HAI): – Catheter-associated urinary tract infection (CAUTI) (NHSN) – Central line-associated bloodstream infection (CLABSI) (NHSN) – Standardized infection ratio for colon surgery surgical site infection (NHSN)* – Standardized infection ratio for hysterectomy surgical site infection (NHSN)* • Medication Safety: – Hypoglycemia event rate per 1,000 at risk patient days (BJC PHT) • Preventable Harm: – Falls with injury per 1,000 patient days (excludes gero-psych units) (BJC PHT)* – Pressure ulcer incidence (BJC PHT)* Blue indicates mandatory measure * Indicates new to BIC for 2013 22 BIC 2013 Scorecard Component Measures VBP Clinical Process of Care Composite • Acute Myocardial Infarction: – Primary PCI received within 90 minutes of hospital arrival (CMS AMI-8a) • Community-acquired Pneumonia: – Blood cultures performed in the emergency department prior to initial antibiotic received in hospital (CMS PN-3b) – Initial antibiotic selection for CAP in immunocompetent patient (CMS PN-6) • Congestive Heart Failure: – Discharge instructions (CMS HF-1) Blue indicates mandatory measure * Indicates new to BIC for 2013 23 BIC 2013 Scorecard Component Measures VBP Clinical Process of Care Composite cont. • Surgical Care Improvement Project: – Prophylactic antibiotic received within one hour prior to surgical incision (CMS SCIP-Inf 1a) – Prophylactic antibiotic selection for surgical patients (CMS SCIP-Inf 2a) – Prophylactic antibiotics discontinued within 24 hours after surgery end time (CMS SCIP-Inf 3a) – Cardiac surgery patients with controlled 6 A.M. postoperative blood glucose (CMS SCIP-Inf 4) – Urinary catheter removed on postoperative day 1 (POD 1) or postoperative day 2 (POD 2) with day of surgery being day zero (CMS SCIP-Inf 9) – Surgery patients on beta-blocker therapy prior to arrival who received a betablocker during the perioperative period (CMS SCIP-CARD-2) – Surgery patients with recommended venous thromboembolism prophylaxis ordered (CMS SCIP-VTE 1) – Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery (CMS SCIP-VTE 2) Blue indicates mandatory measure * Indicates new to BIC for 2013 24 Hospital Specific Metric Selection • Each hospital has three hospital specific metrics (HSMs) for BIC 2013 • CCE reviewed individual hospital performance of the Appropriate Care measures that were moved to Tracked – Measure performance ≤ 95% = Hospitals must use as HSM • If the originally proposed metrics did not provide enough improvement opportunity or did not have adequate measurement specifications, hospitals were directed to select new HSMs. 25 BIC Composite Scoring • For VBP Processes of Care, Care Coordination, and Efficiency, the composite is the total achievements over the total opportunities. Max, target, etc. goals are set based on the composite score. • For Appropriate Care, Patient Safety, and Hospital Specific Measures, the component measures vary in type. Therefore targets are set for each individual measure based on a 50 point scale. The composite score is the average of the component scores. 26 Official 2012 UHC Q & A Scorecard 29 30 Discussion