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Data and Healthcare: Driving Improvement
- 1. Danielle A. Lloyd, MPH Data: what’s available and how we are use it is changing March 16, 2015 Utah Health Services Research Conference
- 2. 2 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Premier, Inc. Our Mission: To improve the health of communities. MAKE HEALTHCARE SUPPLY CHAIN EFFICIENT AND EFFECTIVE DELIVER CONTINUOUS IMPROVEMENT IN COST AND QUALITY TODAY AND ENABLE SUCCESS IN NEW HEALTHCARE DELIVERY / PAYMENT MODELS INTEGRATE DATA AND KNOWLEDGE TO CREATE MEANINGFUL BUSINESS INTELLIGENCE THAT DRIVES IMPROVEMENT Uniting approximately 3,400 hospitals – 68% of U.S. community hospitals – and 110,000 alternate sites of care 74% owned by health systems $41 billion in group purchasing volume Integrating clinical, financial, operational and population data Insights into ~ 1 in every 3 U.S. hospital discharges
- 3. 3 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Collaboratives harness data for performance improvement Partnership for Patients ~450 hospitals (Premier’s HEN) • CMS Innovation Center initiative • Lower HACs (40%) and excessive readmissions (20%) by the end of 2013 • More than 7% improvement in both in first 6 months • Largest performance improvement collaborative in the U.S. • Evidence-based care, cost, patient experience, harm and readmissions • Nearly 92,000 lives and $9 billion saved in 4.5 years • Largest U.S. collaborative focused on bundled payment • Identifying, constructing, measuring, operationalizing the bundling of episode-based services across care continuum • 43 markets of Medicare data; 21 major DRG opportunities • Tethering the science of change to real-world impact • Improving quality and reducing costs in high-impact acute care and population health arenas • Building accountable care capabilities around six core structural components to improve care delivery while containing costs • Multiple systems in MSSP, Pioneer and other ACO models QUEST® collaborative ~370 hospitals Bundled payment collaborative ~95 hospitals Performance improvement research collaboratives PACT™ collaborative ~385 hospitals Leveraging technology-enabled collaborative methodology to create standard measurements, accountability and process improvements
- 4. 4 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Political Environment
- 5. 5 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. HHS Announcement
- 6. In three words, our vision for improving health delivery is about better, smarter, healthier. If we find better ways to pay providers, deliver care, and distribute information: Encourage the integration and coordination of clinical care services Improve population health Promote patient engagement through shared decision making Incentives Create transparency on cost and quality information Bring electronic health information to the point of care for meaningful use Focus Areas Description Care Delivery Information Promote value-based payment systems – Test new alternative payment models – Increase linkage of Medicaid, Medicare FFS, and other payments to value Bring proven payment models to scale HHS Announcement Better Care. Smarter Spending. Healthier People We can receive better care. We can spend our health dollars more wisely. We can have healthier communities, a healthier economy, and a healthier country. Source: CMS
- 7. Target percentage of Medicare FFS payments linked to quality and alternative payment models in 2016 and 2018 2016 All Medicare FFS (Categories 1-4) FFS linked to quality (Categories 2-4) Alternative payment models (Categories 3-4) 2018 50% 85% 30% 90% Source: CMS
- 8. Payment Taxonomy Framework Payment Taxonomy Framework Category 1: Fee for Service— No Link to Quality Category 2: Fee for Service—Link to Quality Category 3: Alternative Payment Models Built on Fee- for-Service Architecture Category 4: Population-Based Payment Description Payments are based on volume of services and not linked to quality or efficiency At least a portion of payments vary based on the quality or efficiency of health care delivery Some payment is linked to the effective management of a population or an episode of care. Payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk Payment is not directly triggered by service delivery so volume is not linked to payment. Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g. >1 yr) MedicareFFS Limited in Medicare fee- for-service Majority of Medicare payments now are linked to quality Hospital value- based purchasing Physician Value- Based Modifier Readmissions/Hosp ital Acquired Condition Reduction Program Accountable care organizations Medical homes Bundled payments Comprehensive primary care initiative Comprehensive ESRD Medicare-Medicaid Financial Alignment Initiative Fee-For-Service Model Eligible Pioneer accountable care organizations in years 3- 5 Source: CMS
- 9. 9 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Sustainable Growth Rate
- 10. SGR repeal and reform timeline 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Sunset of existing quality value penalties under PQRS, VBM, EHR 12/31/2017 Permanent repeal of SGR 0.5% update in physician payments (2014-2018) 0% update in physician base payments (2019-2023) APM participating providers exempt from MIPS; receive annual 5% bonus (2018-2023) Merit-Based Incentive Payment System (MIPS) adjustments 2018 +/-4% 2019 +/- 5% 2020 +/- 7% Track1Track2 2021 & beyond +/- 9% • CBO estimate of bipartisan, bicameral bill: @$122B/10 years • Medicare extenders will add another @$25 - 30B to cost of bill Currentlaw 2018 4% Physician Quality Reporting System Penalty 2015 -1.5% 2016 & beyond -2.0% Meaningful Use Penalty (up to %) 2015 -1.0% 2016 -2.0% 2017 -3.0% 2018 -4.0% Value-based Payment Modifier penalty (up to %) 2015 -1.0% 2016 -2.0% 2017 -4.0% (NPRM) 2019 & beyond -5.0% 2018 & beyond ???%
- 11. 11 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. 21st Century Cures
- 12. 12 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. 21ST CENTURY CURES CONSORTIUM ACT Section 2001, creates Public-private partnership to accelerate innovative cures, treatments, and preventive measures for patients. Title II – Building the Foundation for 21st Century Medicine SOFTWARE ACT Sections 2061-2063, Provides regulatory certainty for those developing apps and health information technologies. BUILDING A 21ST CENTURY DATA SHARING FRAMEWORK Sections 2081, 2082, 2085, 2086, 2087, 2088, 2091, and 2092 Establishes a data sharing framework to enable (1) patients and physicians to better identify ongoing clinical trials, (2) researchers and developers to use Medicare data for improving quality of patient care, and (3) a process for Congress to address other issues identified by the President’s Council of Advisors on Science and Technology. INTEROPERABILITY Section 2181 includes placeholder language for work toward the goal of a national interoperable health information infrastructure. NIH – FEDERAL DATA SHARING Section 2201, would require those receiving NIH grants to share their data, subject to confidentiality and trade secret protections. ACCESSING, SHARING, AND USING HEALTH DATA FOR RESEARCH PURPOSES Section 2221, would unlock the research potential of data siloed in health care facilities across the country and enable patients who want to play a more proactive role in finding better treatments or a cure for their disease to do so in a responsible manner that continues to protect their privacy.
- 13. 13 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Biomedical research working group to reduce administrative burden on researchers Section 4002, would establish a working group composed of NIH and stakeholders to provide recommendations on how to streamline the grant process for researchers. TITLE IV—ACCELERATING THE DISCOVERY, DEVELOPMENT, AND DELIVERY CYCLE TELEMEDICINE Section 4181, would advance opportunities for telemedicine and new technologies to improve the delivery of quality health care services to Medicare beneficiaries.
- 14. 14 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Big Picture Big Data
- 15. 15 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Measures Must Matter Measurement should begin with the end in mind. What are we trying to accomplish? In Healthcare, our aim should be to deliver “value.” • But how do you measure value? • And value to whom: payer, purchaser, patient? 15 “All of the objectives and measures on a balanced scorecard, financial and non- financial should be derived from the organization’s vision and strategy.” - Kaplan and Norton, The Strategy Focused Organization, 2001 Accountable Party Accountable Party Accountable Party
- 16. 16 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Big Picture- Big Data Why do we measure? Patient engagement and choice Provider Improvement Affect Policy • Change payment • Signal need for technical assistance • Compliance/certification What do we measure? Process? Outcomes Experience Safety Efficiency • What about productivity? Coordination? What about environment? • Air quality for asthmatics What about values? • Avoid surgery • Live to see… • Restore functionality
- 17. 17 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. New Data Sources Electronic Health Records iPhones Face book Home monitoring
- 18. 18 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Current Challenges for Providers: • Delivery system reform creates risks for providers and the need to maximize HIT assets to create efficiency, patient safety, care quality. • Meaningful use program now a penalty for providers » MU program requires quality metrics that requires data integration from various HIT assets. • Current HIT assets including EHRs are proprietary » Increased cost to unlock, build bridges, and customize data flow Current policy landscape - Government actions: • ONC roadmap proposal focuses on interoperability – comments due April 3, 2015. • Congressional action on 21st Century Cures bill and interoperability legislative proposals currently being developed. » Led by Rep. Burgess (R-TX), House Energy and Commerce Committee, Senate HELP Committee holding hearings (March 17) Policy: Interoperability of Health Information Technology
- 19. 19 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Establishment of public-private Federal HIT governance structure in collaboration with ONC, other federal agencies and the private sector. • Develop and implement a nationwide interoperability framework, business practices, and policies to achieve interoperability. Development of Standards that Promote Interoperability and Innovation. • Include: patient identifiers, terminologies, clinical data query language, security, open application program interfaces (API), and clinical decision support algorithms and others. Transparent and Public Interoperability and Cost Efficiency Measures Need to be Developed. • Transparent and public measures of interoperability should be developed in collaboration with ONC, standard setting bodies, in consultation with the private sector, and be required as part of the ONC certified technology program. • These measures should be validated and tested in terms of standards, processes, and within specific use case scenarios. • Measures should include business and implementation approaches that deliver functional interoperability outcomes and include operational processes and implementation practices. • Measures should also include assessment of cost efficiency metrics achieved through incorporation of innovative technologies. Enforcement of Standards and Measures: • ONC should be enabled to enhance its enforcement tools to ensure standards and measures compliance through its certified technology program. Policy Solutions to Achieve Interoperability and Innovation
- 20. 20 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Meaning for Patients…
- 21. 21 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Source: Office of Information Products and Data Analytics, CMS 17.0 17.5 18.0 18.5 19.0 19.5 Jan-10 Jan-11 Jan-12 Jan-13 Percent Rate CL UCL LCL All Cause, 30 Day Hospital Readmission Rate 21
- 22. 22 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. PhysicianCompare is searchable to find any US physician http://www.medicare.gov/physiciancompare/search.html
- 23. 23 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. PFS: Physician Compare Table 49: Summary of Finalized Data for Public Reporting Data Collection Year Publication Year Data Type Reporting Mechanism Finalized Proposals Regarding Quality Measures and Data for Public Reporting 2015 2016 PQRS, PQRS GPRO, EHR, and Million Hearts Web Interface, EHR, Registry, Claims Include an indicator for satisfactory reporters under PQRS, participants in the EHR Incentive Program, and EPs who satisfactorily report the individual PQRS Cardiovascular Prevention measures in support of Million Hearts. 2015 2016 PQRS GPRO & ACO GPRO Web Interface, EHR, Registry, and Administrati ve Claims All 2015 PQRS GPRO measures reported via the Web Interface, EHR, and Registry that are available for public reporting for group practices of 2 or more EPs and all measures reported by ACOs with a minimum sample size of 20 patients. 2015 2016 CAHPS for PQRS & CAHPS for ACOs CMS- Specified Certified CAHPS Vendor 2015 CAHPS for PQRS for groups of 2 or more EPs and CAHPS for ACOs for those who meet the specified sample size requirements and collect data via a CMS-specified certified CAHPS vendor. 2015 2016 PQRS Registry, EHR, or Claims All 2015 PQRS measures for individual EPs collected through a Registry, EHR, or claims. 2015 2016 QCDR data QCDR All individual-EP level 2015 QCDR data.
- 24. 24 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. CMS says that not all performance data added to Physician Compare will necessarily be included on the physician profile pages but could be downloaded • Goal: Avoid overloading consumers with information CMS had solicited comments on posting specialty society measures on Physician Compare and/or linking to specialty society websites that publish non-PQRS measures and received mixed reactions • CMS will continue to consider the issue CMS will require public disclosure of Qualified Clinical Data Registry data starting with data reported in CY 2015 • Data will be published on Physician Compare in 2016; QCDRs may choose to also publish the data on their websites in 2016 • Data will only be disclosed at the individual EP level PFS: Physician Compare, Con’t
- 25. 25 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Meaning for Providers…
- 26. 26 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. QUEST: a formula for sustaining gains Measure with defined metrics Report transparently Share best practice Execute collaboratively
- 27. 27 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Advanced analytics metrics
- 28. 28 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Sustained improvement over time Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Hospital deaths avoided 6,951 21,099 42,388 72,353 111,662 160,388 Dollars saved $683M $2.12B $4.55B $7.53B $10.12B $13.2B Patients receiving all EBC 9,427 24,091 42,878 66,531 93,934 123,956 Harms Prevented N/A N/A 3,447 7,924 13,963 21,679 Readmissions Prevented N/A N/A N/A 7,332 25,722 55,845
- 29. 29 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. QUEST hospitals outperform peers in national comparisons • Premier published peer-reviewed research in the Journal of Patient Safety • Compared the mortality performance of 600+ U.S. hospitals from 2006-2011 • Isolates the performance improvement that can only be attributed to a “QUEST effect” via several analytical methods • Results prove that QUEST hospitals have a risk-adjusted mortality rate that is up to 10% less than non-QUEST hospitals
- 30. 30 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Harm Occurrence Rate*: Premier-Identified Complications and CMS HACs 138 Premier-Defined PICs 16.02% of patients were found to experience one or more of these Harms 12 CMS-Defined HACs .19% of patients were found to experience one or more of these Harms *One patient may develop multiple complications Identifying Harm: Premier Identified Complications (PICs) provide a more comprehensive measure of harm
- 31. 31 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. $44,966,647 $26,752,409 $19,774,394 $9,470,580 $9,437,790 $8,161,730 $7,228,612 $6,909,320 $5,262,201 $4,743,643 $- $20,000,000 $40,000,000 $60,000,000 Hemorrhage/Acute Postop Anemia Acute Renal Failure Sepsis/Bacteremia Aspiration Pneumonia Embolism/Thrombus C. Diff Enteritis Encephalopathy Acute Myocardial Infarction Cerebral Infarction Gastrointestinal (GI) Ulceration & Hemorrhage Total Excess Costs QUEST or PFP focus areas Total Excess Costs Serious Complications add to the Cost of Care
- 32. 32 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Population Health
- 33. 33 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Advanced measures framework Patient-centered measures of value Aim Value = (Outcomes + Experience) Expenditures Outcomes Experience Expenditures Overall Measures Functional Health PROMIS Global-10 Others: CDC Healthy Days, VR-12, EQ-5D Health Risk IHME Risk Index1 Others: Framingham Index Overall Patient Experience Rating CAHPS: 0-10 rating Total Costs Per Capita Expenditures Utilization SubDomain Measures Functional Health Physical Health: PROMIS-PH-4 Activities of Daily Living Fall Risk++ Instrumental Activities of Daily Living Mental Health: PROMIS-MH-4 Fatigue and Pain: PROMIS Global-2 Health Risk Biometrics Lifestyle Behaviors Disease/Condition Status Hypertension: BP levels2 Diabetes: HgA1c3 Depression: PHQ-94 Heart Failure: MLHF-Q or KCCQ5 Total Knee Arthroplasty: UCLA Activity6, Knee Society Score7, or Oxford Knee Score8 Whole Person Orientation - Patient Activation HowsYourHealth, PAM-13 Access to Care PCMH CAHPS Communication with Providers PCMH CAHPS Support and Empowerment - Shared Decision-making PCMH CAHPS Coordination/Transitions PCMH CAHPS, CTM-3 Under Age 65 Expenditures: Health Partners Utilization: Health Partners Age 65 & older Expenditures: Dartmouth Atlas Utilization: Dartmouth Atlas Overuse Measures ER Visits/1000 Imaging/1000 Lab expense/1000 Drug expense/1000 End of life/last 6 months PCI non-emergency/elective rate C-section rate Unplanned readmission rate
- 34. 34 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Meaning for Policy makers…
- 35. 35 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Three National Inpatient Quality Payment Programs Inpatient VBP HRRP (Readmissions) HAC Reduction Program Last Updated February 2015
- 36. 36 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Current Reform Landscape for Hospitals Changes are Coming Fast FY refers to the federal fiscal year. For example, FY 2012 began Oct 1, 2011 and ended Sept 30, 2012. *The Multifactor Productivity Adjustment is an estimate generated by the CMS Office of the Actuary. **DCA, also known as the behavioral offset. Estimates FY 2015-FY 2017 impact of the American Taxpayer Relief Act of 2012. *** Sequestration (across the board cuts to reduce the federal budget deficit) will stay in place unless otherwise reversed by Congress.
- 37. 37 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Chart includes hospitals that did not meet minimum measure/data requirements Total Penalties by Percentage – FY 2015 Final Three quality programs in play: VBP, HACs, and Readmissions Greatest penalty percentage was 4.4% More than one in four hospitals experienced zero penalty or a net gain in the quality per-for-performance programs
- 38. 38 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Inpatient VBP FY 2017 Domains: Align with National Quality Strategy 25% 5% 25% 25% 20% FY 2017 Finalized Revision • Clinical Care • Process (5%) • Outcomes (25%) • Patient and Caregiver Experience • Efficiency and Cost Reduction • Safety (20%) Measure ID NQS-Based Domain AMI-7a Clinical Care – Process IMM-2 Clinical Care – Process PC-01 *NEW* Clinical Care – Process MORT-30-AMI Clinical Care – Outcomes MORT-30-HF Clinical Care – Outcomes MORT-30-PN Clinical Care – Outcomes HCAHPS Patient and Caregiver Centered Experience of Care / Care Coordination CAUTI Safety CLABSI Safety MRSA *NEW* Safety C. Diff *NEW* Safety PSI-90 Safety SSI Safety MSPB-1 Efficiency and Cost Reduction ACTIVE PERFORMANCE PERIOD
- 39. 39 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. % Winners: 52% FY 2013, 46% FY 2014, and 55% FY 2015 Average penalty: -0.21% FY 2013, -0.25% FY 2014, and -0.29% FY 2015 Average bonus: +0.23% FY 2013, +0.23% FY 2014, and +0.44% FY 2015 Relaxed domain minimums likely led to small hospital inclusion and larger relative percent penalty/bonus National Performance in VBP FY 2013 - FY 2015
- 40. 40 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Performance in Inpatient VBP by Hospital Characteristic N (3,088) FY 2013 FY 2014 FY 2015 Urban/Rural Urban 2,335 WIN NEUTRAL WIN Rural 753 NEUTRAL LOSE WIN Teaching Non-teaching 2,085 WIN NEUTRAL WIN Teaching 1,003 NEUTRAL NEUTRAL NEUTRAL Disproportionate Share Urban DSH 1,834 LOSE LOSE NEUTRAL Rural DSH 689 NEUTRAL LOSE WIN Non DSH 565 WIN WIN WIN Ownership* Voluntary 1,985 WIN NEUTRAL WIN Proprietary 711 WIN NEUTRAL WIN Government 428 LOSE LOSE WIN Urban, Teaching and DSH 527 LOSE LOSE LOSE * Data Source AHA 2013 Survey, 28 hospitals missing ownership information
- 41. 41 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. N (3,088) FY 2013 FY 2014 FY 2015 Urban Hospital Size (Beds) X-Small (less than 100) 526 WIN WIN WIN Small (100-199) 741 NEUTRAL NEUTRAL NEUTRAL Medium (200-299) 440 NEUTRAL NEUTRAL LOSE Large (300-499) 418 LOSE NEUTRAL LOSE X-Large (500 or more) 210 LOSE NEUTRAL LOSE Rural Hospital Size (Beds) X-Small (less than 50) 250 WIN NEUTRAL WIN Small (50-99) 289 LOSE LOSE WIN Medium (100-149) 118 WIN LOSE WIN Large (150-199) 48 LOSE LOSE WIN X-Large (200 or more) 48 WIN NEUTRAL WIN Performance in VBP by Hospital Size • Very small hospitals generally win under the VBP Program • Rural hospitals with 200 or more beds also generally win
- 42. 42 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Challenges
- 43. 43 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. New way of using data—whether provider or researcher DUAs and laws need to evolve • Comingling data » Clinical/EHR with claims » Combine across providers (ACO 1 with ACO 2) • Timing » Ongoing provider improvement necessitates monthly data » Quality data infrequent, inconsistent, and often late • Comprehensive data » Need more than 5% carrier file sample » Substance use data » Medicaid data for duals/VA/retiree coverage » EHR quality data • Allowances » Deidentify » Operational feed for research/research feed for operations » Commercial purpose Data Hurdles
- 44. 44 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. 42 CFR Part 2 – Confidentiality of Alcohol and Drug Abuse Patient Records
- 45. 45 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Purpose: These regulations impose restrictions upon the disclosure and use of alcohol and drug abuse patient records which are maintained in connection with the performance of any federally assisted alcohol and drug abuse program. Effect: 1) prohibits the disclosure and use of patient records unless certain circumstances exist. The regulations do not require disclosure under any circumstances. 2) not intended to direct the manner in which substantive functions such as research, treatment, and evaluation are carried out. They are intended to insure that an alcohol or drug abuse patient in a federally assisted alcohol or drug abuse program is not made more vulnerable by reason of the availability of his or her patient record than an individual who does not seek treatment. 3) a criminal penalty for violating the regulations applies 42 CFR Part 2 - CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS
- 46. 46 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Authority: 1) Section 408 of the Drug Abuse Prevention, Treatment, and Rehabilitation Act (21 U.S.C. 1175). 2) Amended by Pub. L. 98-24 to section 527 of the Public Health Service Act which is codified at 42 U.S.C. 290ee- Disclosure authorization: 1) The content of record may be disclosed in accordance with the prior written consent of the patient with respect to whom such record is maintained, but only as allowed under subsection (g) [prescribed in regulation]. 2) Without consent, the record may be disclosed: a) To medical personnel for an medical emergency. b) To qualified personnel for scientific research, management audits, financial audits, or program evaluation if patient not identified directly or indirectly in any report of work. c) If authorized by an appropriate order of a court . Statutory authority of drug abuse patient records
- 47. 47 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. “If a Pioneer ACO would like to receive data related to substance abuse, the aligned beneficiary must specifically opt-in to Substance Abuse data sharing by providing written consent to the ACO. CMS will provide Pioneer ACOs with the Substance Abuse Opt-In Form. Pioneer ACO providers/ suppliers may have a conversation about the benefits of sharing the beneficiary’s substance abuse data at the point of care. Pioneer ACOs also have the option of sending Substance Abuse Opt-In Forms via mailer. If a beneficiary inquires about data sharing, please explain that because Substance Abuse data is more sensitive, CMS will only share this information (if any even exists), if the beneficiary expressly grants written permission. This data will also help the ACO and the beneficiary’s providers with care management, care coordination, and quality improvement activities.” Substance Abuse Data Sharing
- 48. 48 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Other Limitations/Cautions “The Medicare dataset supplied to the user is a subset of the full set of Medicare data. The variables were chosen because they were deemed to be the most useful information for the ACO.” “The data does not reflect the use and expenditures for beneficiaries who have not given permission for their data to be shared with the ACO. In addition, substance abuse data must be separately approved for sharing. As a result, this data may not include 100% of the claims data for every assigned beneficiary.” CMS ACO Program Claim and Claim Line Feed (CCLF) Information Packet (IP)
- 49. 49 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Confidentiality of alcohol and drug abuse patient records make it difficult for . . . health information exchange organizations (HIEs), Accountable Care Organizations (ACOs), and others to share records…” • difficulty and expense of obtaining consent. • patients are prevented from fully participating in integrated care efforts even if they are willing to provide consent. The current regulation presents several problems: • Regulation has not been updated since 1987, and doesn’t account for ACOs, EHRs etc. • ACOs must identify every member of the ACO and any and all ancillary providers in the network including HIEs to get consent. Thus, patient should be given option to electronically consent to share records with any/all in ACO network who has a treatment relationship with the patient. • If not, provide deidentified claims data to ACOs. National Association of ACOs comments to SAMHSA
- 50. Danielle A. Lloyd, MPH VP, Policy Development & Analysis 202.879.8002 Danielle_Lloyd@premierinc.com www.premierinc.com THANK YOU
- 51. 51 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. APPENDIX
- 52. 52 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. PQRS measures: http://www.mdinteractive.com/files/uploaded/file/2015_PQRS_Measure s_Groups__2014-26183.pdf PQRS web interface measures: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/Downloads/2014_GPROWebInterface_MeasuresLi st_NarrativeSpecs_ReleaseNotes_12132013.zip All 2015 measures: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/Downloads/PQRS_2015_Measure-List_111014.zip Qualified Clinical Data Registry: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/Qualified-Clinical-Data-Registry-Reporting.html PQRS measure options vary based on reporting mechanism
- 53. 53 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Excess Deaths QUEST or PFP focus areas Excess Deaths (Sample N=500,000) 173 152 50 35 26 26 25 24 24 23 0 20 40 60 80 100 120 140 160 180 200 Septic Shock Acute Renal Failure Acute Myocardial Infarction Cerebral Infarction Intracranial Hemorrhage Sepsis/Bacteremia Pulmonary Embolism Encephalopathy Anoxic Brain Damage Aspiration Pneumonia Excess Deaths Serious Complications Increase Risk of Mortality
- 54. 54 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. 13949 10497 7299 5362 4673 4366 3411 2592 2543 2467 0 2000 4000 6000 8000 10000 12000 14000 16000 Acute Renal Failure Hemorrhage/Acute Postop Anemia Sepsis/Bacteremia C. Diff Enteritis Aspiration Pneumonia Embolism/Thrombus Encephalopathy Postoperative or Perioperative Infection Cellulitis/Skin Infection Respiratory distress of fetus or newborn Total Excess Days QUEST or PFP focus areas Total excess days Serious Complications add to LOS
- 55. 55 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. § 2.2 Statutory authority for confidentiality of alcohol abuse patient records. The restrictions of these regulations upon the disclosure and use of alcohol abuse patient records were initially authorized by section 333 of the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 (42 U.S.C. 4582). The section as amended was transferred by Pub. L. 98-24 to section 523 of the Public Health Service Act which is codified at 42 U.S.C. 290dd-3. The amended statutory authority is set forth below: § 290dd-3.Confidentiality of patient records (a) Disclosure authorization Records of the identity, diagnosis, prognosis, or treatment of any patient which are maintained in connection with the performance of any program or activity relating to alcoholism or alcohol abuse education, training, treatment, rehabilitation, or research, which is conducted, regulated, or directly or indirectly assisted by any department or agency of the United States shall, except as provided in subsection (e) of this section, be confidential and be disclosed only for the purposes and under the circumstances expressly authorized under subsection (b) of this section. (b) Purposes and circumstances of disclosure affecting consenting patient and patient regardless of consent (1) The content of any record referred to in subsection (a) of this section may be disclosed in accordance with the prior written consent of the patient with respect to whom such record is maintained, but only to such extent, under such circumstances, and for such purposes as may be allowed under regulations prescribed pursuant to subsection (g) of this section. (2) Whether or not the patient, with respect to whom any given record referred to in subsection (a) of this section is maintained, gives his written consent, the content of such record may be disclosed as follows: (A) To medical personnel to the extent necessary to meet a bona fide medical emergency. (B) To qualified personnel for the purpose of conducting scientific research, management audits, financial audits, or program evaluation, but such personnel may not identify, directly or indirectly, any individual patient in any report of such research, audit, or evaluation, or otherwise disclose patient identities in any manner. (C) If authorized by an appropriate order of a court of competent jurisdiction granted after application showing good cause therefor. In assessing good cause the court shall weigh the public interest and the need for disclosure against the injury to the patient, to the physician-patient relationship, and to the treatment services. Upon the granting of such order, the court, in determining the extent to which any disclosure of all or any part of any record is necessary, shall impose appropriate safeguards against unauthorized disclosure. (c) Prohibition against use of record in making criminal charges or investigation of patient Except as authorized by a court order granted under subsection (b)(2)(C) of this section, no record referred to in subsection (a) of this section may be used to initiate or substantiate any criminal charges against a patient or to conduct any investigation of a patient. (d) Continuing prohibition against disclosure irrespective of status as patient The prohibitions of this section continue to apply to records concerning any individual who has been a patient, irrespective of whether or when he ceases to be a patient. (e) Armed Forces and Veterans' Administration; interchange of record of suspected child abuse and neglect to State or local authorities The prohibitions of this section do not apply to any interchange of records— (1) within the Armed Forces or within those components of the Veterans' Administration furnishing health care to veterans, or (2) between such components and the Armed Forces. The prohibitions of this section do not apply to the reporting under State law of incidents of suspected child abuse and neglect to the appropriate State or local authorities. (f) Penalty for first and subsequent offenses Any person who violates any provision of this section or any regulation issued pursuant to this section shall be fined not more than $500 in the case of a first offense, and not more than $5,000 in the case of each subsequent offense. (g) Regulations of Secretary; definitions, safeguards, and procedures, including procedures and criteria for issuance and scope of orders Except as provided in subsection (h) of this section, the Secretary shall prescribe regulations to carry out the purposes of this section. These regulations may contain such definitions, and may provide for such safeguards and procedures, including procedures and criteria for the issuance and scope of orders under subsection(b)(2)(C) of this section, as in the judgment of the Secretary are necessary or proper to effectuate the purposes of this section, to prevent circumvention or evasion thereof, or to facilitate compliance therewith. (Subsection (h) was superseded by section 111(c)(4) ofPub. L. 94-581. The responsibility of the Administrator of Veterans' Affairs to write regulations to provide for confidentiality of alcohol abuse patient records under Title 38 was moved from 42 U.S.C. 4582 to 38 U.S.C. 4134.) Statutory authority for confidentiality of alcohol abuse patient records.
- 56. 56 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. FY 2015 Quality Program Measurement Periods Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 VBP FY 2015 Domains Weight Patient Experience (8 measures + consistency) 30% Clinical Process (12 measures) 20% Outcomes 30% 3 mortality measures (HF, AMI, PN) 1 CLABSI measure 1 AHRQ PSI measure Efficiency (1 measure) 20% * Period starts May 1, ** Period starts Oct 15, *** Period starts Feb 1 Hospital Readmissions Reduction Program FY 2015 Payment (AMI, HF, PN, COPD, Hip/Knee) Hospital Acquired Conditions Penalty (program starts FY 2015) Domain 1 (FY 2015 PSI-90 only) Domain 2 (FY 2015 CLABSI, CAUTI) Performance Baseline Performance Performance Period Performance Period Baseline Performance*** Baseline** Performance** Baseline* Performance* ACA Quality Provisions for Medicare Inpatient Hospital Payment FY 2015 CY 2010 CY 2011 CY 2012 Baseline CY 2013 Performance Period Performance Baseline FY 2015 payment penalty hit Oct 1, 2014
- 57. 57 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. A percent of inpatient base operating payments are at risk based on quality and efficiency metric performance A budget neutral policy, where hospitals must fail to meet targets for bonuses to be generated for others Rewards for achievement or improvement Quality measures from Hospital Compare measure set • 20 measures (12 process/8 HCAHPS dimensions) in FY 2013, • Adds 3 outcome measures (3 mortality) in FY 2014, • Adds 2 outcome measures and 1 efficiency measure in FY 2015, • Removes 5 process and adds 1 process, 2 outcome measures in FY 2016, and • Removes 6 process and adds 1 process, 2 “safety” measures in FY 2017 Inpatient Quality Reporting measures are “on deck” for VBP. AdvisorLive on March 27, 2014 – Premier Alliance Community Inpatient Value-Based Purchasing (VBP) FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 1% 1.25% 1.5% 1.75% 2%
- 58. 58 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. 30% 20%30% 20% 25% 10% 40% 25% FY 2016 Performance Period Complete! 30% 45% 25% FY 2015 30% 70% VBP: movement toward outcomes and efficiency Clinical process Patient experience Outcomes Efficiency FY 2013 FY 2014 Hospitals’ VBP payment will increasingly be based on their performance on outcomes/efficiency
- 59. 59 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Inpatient VBP FY 2017 Domains: Align with National Quality Strategy 25% 5% 25% 25% 20% FY 2017 Finalized Revision • Clinical Care • Process (5%) • Outcomes (25%) • Patient and Caregiver Experience • Efficiency and Cost Reduction • Safety (20%) Measure ID NQS-Based Domain AMI-7a Clinical Care – Process IMM-2 Clinical Care – Process PC-01 *NEW* Clinical Care – Process MORT-30-AMI Clinical Care – Outcomes MORT-30-HF Clinical Care – Outcomes MORT-30-PN Clinical Care – Outcomes HCAHPS Patient and Caregiver Centered Experience of Care / Care Coordination CAUTI Safety CLABSI Safety MRSA *NEW* Safety C. Diff *NEW* Safety PSI-90 Safety SSI Safety MSPB-1 Efficiency and Cost Reduction ACTIVE PERFORMANCE PERIOD
- 60. 60 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. National Performance: FY 2015 Inpatient Value-Based Purchasing (VBP) Program 55% of IPPS hospitals eligible for VBP are “winners” in FY 2015 Average penalty in FY 2015 -0.29%, average bonus +0.44% 45 hospitals received bonus of +1.5% or greater Only 11% of all IPPS hospitals were exempt from the FY 2015 VBP program, down from 22% in FY 2014
- 61. 61 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. About 4 out of every 5 IPPS hospitals were penalized for excess readmissions in FY 2015 (greater proportion than FYs 2013 & 2014). Slightly over 1 percent of IPPS hospitals eligible for the readmissions program received the maximum 3% penalty (8 percent received max penalty in FY 2013, less than 1 percent received max in FY 2014) Analysis based on final readmissions payment penalty adjustment factors released in October 2014. National Performance: FY 2015 Hospital Readmission Reduction Program (HRRP) National Average = 0.995
- 62. 62 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC.
- 63. 63 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC.
- 64. 64 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. Part D Data
- 65. 65 PROPRIETARY & CONFIDENTIAL – © 2015 PREMIER, INC. “The Part D data file will only include records for assigned beneficiaries who are enrolled in a Prescription Drug Plan (PDP). Many beneficiaries have Part D prescription drug coverage through an employer-sponsored retiree drug plan. Part D data does not include prescription data for these beneficiaries due to differences in the data that are required to be submitted by a PDP and a retiree drug plan. Furthermore, Part D data only reflect expenditures for filled prescriptions.” *Medicare Shared Savings Participants report drug paid amount frequently missing in data. CMS ACO Program Claim and Claim Line Feed (CCLF) Information Packet (IP)
Notas del editor
- A quick intro to Premier, for those of you who may be rusty. We are an alliance of about 3,400 hospitals – that’s about 68% of US community hospitals – coming together with a mission of improving the health of communities by transforming healthcare. And we are about doing that from the inside out. [Stats on right…] We have three strategic objectives… So our strategy addresses a risky paradox – it is about surviving what’s left of FFS in a reform environment and do all the cost cutting linked to that, while investing in a pop health future with no blueprint. And your forum here today is about ENVISIONING THE FUTURE. So my hope is to share some of the experiences and lessons learned within our alliance – so that you all can thread those through your discussions today. Let’s first set some context for this discussion – and maybe some good context for your day as well.
- Who we are What we do (focus on collab) How we gather and use data Some of the obstacles we hace encountered
- In three words, our vision for improving health delivery is about better, smarter, healthier. If we find better ways to deliver care, pay providers, and distribute information, we can receive better care, spend our dollars more wisely, and have healthier communities, a healthier economy, and a healthier country. We understand that it’s our role and responsibility to lead … and we will. What we won’t do – and can’t do – is go it alone. Patients, physicians, government, and business all stand to benefit if we get this right, and this shared purpose calls out for deeper partnership. So we will continue to work across sectors and across the aisle for the goals we share: better care, smarter spending, and healthier people.
- $170B bill, expect to pay for $70B- debating 2-5 year SCHIP reauthorization ($20B-25B) Care/caid Extenders for 2 years ($25B) An extension of ‘two midnights’ RAC audit moratorium, before it expires on March 31; The Premier-supported readmissions bill introduced this week by Reps. Jim Renacci (R-OH) and Eliot Engel (D-NY), the Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015 (H.R. 1343) (more on that below). Rep. Renacci has conveyed to leadership and the Ways and Means Committee his desire to have it included in the legislative package. The Protecting the Integrity of Medicare Act (PIMA) of 2015 (H.R. 1021); and The Notice of Observation Treatment and Implication for Care Eligibility Act or the NOTICE Act (H.R. 876). SGR repeal & annual updates 0.5% increase in physician payments for 4 yrs; Freeze through 2023 – NOTE, Senate Finance Committee has 0% instead Beyond 2023: physicians in advanced payment models (APMs) receive 2% annual updates, all others receive 1% Time to develop quality measures & clinical improvement activities Value-Based Performance (VBP) Payment Program 2017, payments adjusted for physicians’ performance in prior period 2017: Consolidate PQRS, VBM & EHR MU into VBP 4% tied to performance in 2017; 6% in 2018; 8% in 2019; 10% in 2020 & beyond. Secretary can increase funding pool in 2021 and beyond to no more than 12% Maximum upside and downside adjustment equal to funding pool % (e.g. +/- 4% in 2017) Professionals will be measured on: Quality Resource use Clinical practice improvement activities EHR MU Encouraging provider participation in APMs APM participating providers exempt from VBP; receive annual 5% (2017-2022) Significant share of revenues must be from APM with 2-sided risk and quality measurement Reimbursed according to payment arrangements of model
- NIH Federal data sharing: LIMITATION.—Subsection (a) does not authorize 5 the Director of NIH to require the sharing of— 6 ‘‘(1) any individually identifiable information 7 with respect to a human subject participating in the 8 research; or 9 ‘‘(2) any trade secret or commercial or financial 10 information that is privileged or confidential.’’. Data sharing framework: Not later than 90 days after 25 the date of enactment of this Act, the Secretary of Health and Human Services shall convene a meeting of stakeholders (including patients, researchers, physicians, industry representatives, health information technology providers, and the Food and Drug Administration) to provide advice to the Secretary on enhancements to the clinical trial registry data bank under section 402(j) of the Public Health Service Act (including enhancements to usability, functionality, and search capability) that are necessary to implement paragraph (7) of section 10 402(j) of such Act, as added by subsection (a). The Secretary, acting through the Commissioner of Food and Drugs and the Director of the National Institutes of Health, shall enter into a collaborative agreement, to be known as the Clinical Trial Data System Agreement, with one or more eligible entities to implement a system to make de-identified clinical trial data from qualified clinical trials available for purposes of conducting further research. Software Act: Not later than 24 months after the date of enactment of this section, the Secretary shall promulgate final regulations to establish standards, policies, and procedures for—‘‘(A) classifying medical software; ‘‘(B) standards for the development of medical software; ‘‘(C) standards for the validation and verification of medical software; ‘‘(D) review of medical software; ‘‘(E) modifications to medical software; ‘‘(F) manufacturing of medical software; ‘‘(G) quality systems for medical software; ‘‘(H) labeling requirements for medical software; and ‘‘(I) postmarketing requirements for reporting networks and the reporting of adverse 18 events. Interoperability: Placeholder section to allow for greater interoperability (no language in the discussion draft) Using health data for research: The Secretary shall allow the use and disclosure of protected health information by a covered entity for research purposes, including studies whose purpose is to obtain generalizable knowledge, to be treated as the use and disclosure of such information for health care operations described in subparagraph (1) of the definition of health care operations in section 164.501 of title 45, Code of Federal Regulations (or any successor regulations).
- Biomedical research working group: The Director of the National Institutes of Health shall serve as the Chairperson of such working. The Biomedical Research Working Group shall (1) review literature and reports on— (A) administrative burdens of researchers funded by the National Institutes of Health; (B) improving replicability of research funded by the National Institutes of Health; (2) provide recommendations to the Director of the National Institutes of Health to—(A) reduce such administrative burdens, including with respect to the extent to which (and how) the grant proposal submission and 24 progress report requirements of the National Institutes of Health should be restructured, streamlined, and simplified; and (B) improve replicability of research funded by the National Institutes of Health; (3) evaluate and provide recommendations on the extent to which it is required for Congress to provide any statutory authority to implement any recommendation proposed pursuant to paragraph (2); and (4) prepare a plan, including timeframes, for implementing recommendations proposed pursuant to paragraph (2) for which congressional action is 13 not required. Telemedicine: Beginning not later than 4 years after the date of the enactment of this section, the Secretary shall implement a methodology to provide for coverage and payment for a telehealth service (or episodes of such services). The Secretary may waive any provision of such section that applies a limitation on what qualifies as an originating site, any geographic limitation, or any limitation on the type of health care provider who may furnish such services.
- At Premier, we think that measurement should begin with the end in mind – what is it that we are trying to accomplish As a company, we start with a strategy – which is something that is relatively fixed. From there we understand what goals we need to achieve and what key initiatives will drive that goal. Once we understand the goals and the processes we intend to use to achieve them, the measures follow. Something obvious to achieving success and worth stating, is that each goal and each initiative has an owner – that is someone who is unambiguously accountable for success or failure. Let’s contrast this to healthcare. Do we nation know what it is we want to achieve? Do we determine the processes that are likely to get us there? Do we agree on who is accountable? If not, why do we measure? One of our Premier information products is a solution for organizations who need to monitor physician performance as a part of the Joint Commission OPPE requirement. [ongoing physician performance evaluation]. And it is helpful at looking at such things as mortality rates, readmission rates, complications, etc. It is amazing to me how many times physicians can look at this data and say, “Oh, that’s not my patient.” It’s an interesting paradox; three, four and five physicians, maybe more, will see the patient, and submit a bill, but no one seems to be responsible for the patient as a whole. Another thing that might not be obvious is that to be successful, you don’t need a whole lot of measures. Just because something is easy to measure does not mean it is useful to measure. When the Medicare Shared Savings model first came out, it proposed something in excess of 60 measures of quality. Premier had proposed a much smaller set, and after push-back from the provider community, CMS pared the list down to 33.
- In hospital parking lot Walking distance to major academic medical center Across the street from fire station with paramedics Yet, no access– are we measuring what really matters? Distance to doctor might mean a bit, but are they accepting patients with your insurance? Are we honoring patient values (use the term broadly) – Want to ride a bike 100 miles again Not measuring taste of food or parking- but can have an effect if can’t get back into car.
- This is the power of hospitals coming together to collaborate. We measure and compare results. We use data to find and target improvement opportunities. We test simple ideas, see if they work and spread them across providers….building bridges of knowledge and improvement across the nation. Through QUEST, hospitals transparently share their data, creating consistent measures for top performance - measures that we make publicly available so that anyone can replicate them and use them to assess their own performance. They also share their experiences and knowledge. And they work together to rethink status quo ways of doing things. Having 350 hospitals working together leads to breakthroughs that are implemented quickly, broadly and consistently. It scales the best ideas and ensures we don’t have pockets of excellence, but system-wide excellence. And it provides ongoing monitoring to ensure any progress we find gets locked in and made permanent. And this is how QUEST hospitals are collectively achieving big, system-wide improvements. To give you a better understanding of exactly how QUEST hospitals are making these improvements, I’d now like to turn it over to Dr. Knych from Adventist Health System – one of the largest health systems in QUEST.
- We can include the new QUEST reports – this may be too detailed.
- Plus we know our approach is working. Here is just a sample of what we have been able to accomplish And because we have some real skeptics on our advisory committee, we wanted to make sure that these results were not simply due to selection bias. So our research built econometric models to include hospitals effects as well as secular trends and were able to show there was still some factor, we call it a “quest effect” that was active in the QUEST hospitals but not in the others. SCRIPTING QUEST collaborative members are achieving impressive results. If we look at what has taken place in the QUEST cohort, we see an impressive story. Data for the 1st 4 and a half years of the collaborative show that QUEST participants: Prevented an inpatient death 91,840 times Note this is not the same as 91,840 lives saved: the death could have occurred in another setting one patient can have his/her death prevented several times (every time they are admitted) but represents only one unique life. Reduced healthcare spending by nearly 9.13 billion, and Provided approximately 80,128 additional patients with all appropriate, evidence-based care for the clinical conditions assessed throughout the entire time period (subset of EBC measures!). All QUEST measures and standards of top performance are publicly available, on our Web site, and can be adopted by any hospital nationwide. METHODOLOGY NOTES These results are based upon all QUEST members that joined in 2011 and are cumulative. The data source for mortality and EBC was the PAD (not all QUEST members are represented) and the data source for cost is the OperationsAdvisor database (missing data dropped some QUEST hospitals from being included) Deaths Avoided Based on mortality rates and case counts for all QUEST hospitals in our cohort with mortality data in CY 2011. Cumulative results are shown in the table Calculated by comparing changes in observed to expected mortality rates between baseline and each year following, up through the end of Q2 2012 Baseline for each hospital was dependent on when that hospital joined QUEST Data vintage factors applied as they are for our cohort mortality trend analyses All-cause inpatient mortality, no exclusions For reference, equation used: Deaths avoided = cases in current year x ((observed mortality baseline rate – observed mortality rate in the current year)-(expected mortality baseline rate – expected mortality baseline rate in current year)) This was repeated for each year of the QUEST performance period Results were summed across years Dollars Saved Based on cost per discharge and case counts for all QUEST hospitals in our cohort with cost data in CY 2011 Cumulative results are shown Calculated by comparing changes in average ADJUSTED (adjusted for inflation using Bureau of Labor and Statistics inflation estimates of inpatient hospital services) between the baseline period and each year following, up through the end of Q2 2012 Baseline for each hospital was dependent on when that hospital joined QUEST For reference, equation used: Total cost savings per year = (Average Cost per Discharge in current year – Average cost per discharge in baseline) multiplied by total discharges in the current year This was repeated for each year of the QUEST performance period Results were summed across years EBC Improved Based on EBC cases and total case counts for all QUEST hospitals in our cohort with EBC data in CY 2011 Cumulative results are shown EBC measures are limited to those present across the entire 4.5 years of the QUEST performance period (dropped measures and new measures NOT included) Calculated by comparing changes in the rate of EBC performance between the baseline period and each year following, up through the end of Q2 2012 Baseline for each hospital was dependent on when that hospital joined QUEST For reference, equation used: Total EBC improvement per year = Patients receiving EBC in current year – (rate of patients receiving EBC in baseline X total patients eligible for EBC in current year) This was repeated for each year of the QUEST performance period Results were summed across years Extrapolation figures If all hospitals could achieve these results: Mortality – deaths avoided over 4.5 years = 91,840 (QUEST) * 10.4 (national/QUEST disch) = 950,000 deaths avoided over 4.5 years. Note that about 750,000 die in hospital each year. EBC – additional patients getting EBC over 4.5 years = 80,128 (QUEST) * 13.5 (national/QUEST disch) = over 1 million additional patients getting EBC nationally over 4.5 years. Only using the ratio of acute-care discharges, which is 3.8 million for QUEST and 39 million nationally; so the ratio is 39/3.8 = 10.2. Multiplying by $9.13 billion gives $93 billion saved over 4.5 years.
- There has been growing interest in the use of performance improvement programs, like QUEST, to rapidly achieve positive change. However, evidence on the effectiveness of these types of collaboratives has been mixed due to their highly variable nature. So, it is essential to begin to understand if and which types of collaborative methodologies are effective. So, we took a look at it, comparing the inpatient mortality rates of our QUEST members to a set of Premier hospitals not participating in the program. Results from this research were published online ahead of print in the Journal of Patient Safety. We were able to demonstrate what we call a “QUEST effect” via several multivariate analyses, meaning we set out to isolate as many variables as possible to account for the fact that this study was not randomized since it is based off of a group of volunteer hospitals. We took into account, for instance, hospital characteristics, severity of patient illness and background, and secular trends to see if we could find evidence that QUEST hospitals perform better than non-QUEST hospitals. The different models used in the study (which adjust for standard, fixed and random effects), determined that QUEST had an impact on hospital mortality rates, with participating hospitals performing as much as 10% better than non-QUEST hospitals. In addition, the non-QUEST hospitals studied were comparable Premier hospitals with similar characteristics that had access to the same quality and safety tools as QUEST participants. In other words, we believe the improvements we found can be attributed to the focused interventions and collaborative improvement framework we provide through QUEST. We believe these findings provide further evidence that transparent peer-to-peer collaboration and data sharing, coupled with a holistic framework to facilitate change, is impacting hospitals outcomes, and specifically reducing mortality.
- QUEST informed us that better, broader measures of harm were needed. We found them. We drew from analytic experience with coded hospital discharge abstract summaries, including present on admission flag, to devise an algorithm to identify a broad set of harm indicators. We call these the Premier Identified Complications (PICs). They include 138 measures of patient harm (inclusive of the CMS hospital acquired conditions). They are much broader and will occur commonly enough to allow us to adequately measure them and identify opportunity areas for improvement. As can be seen in the graphic, in the approximately 11 million patients used for this analysis we found that about 16% of them had at least one Premier Identified Complications, whereas if we just used the CMS defined HACs we were only able to detect less than 1% of patients. With a broader set of complication/harm measures we feel like we will be able to adequately identify signals of variation from what would be expected. This will allow us to better measure harm and point our collaborative members toward real opportunities for improvement.
- PIC impact on Cost of Care: Lastly, using that sample of 500,000 patients in our database, we evaluated the marginal effect of PICs on cost of care. We found that, in sum , there were more than $471 million in excess costs attributable to the newly identified complications. As this graph illustrates, there was at least $28 million of that associated with infections alone (there was even more not shown in this graph). Here again we see the major costs associated with harm that is occurring in the hospital setting. QUEST sprints Collaboratives related to this graph: Sepsis-Bacteremia: Sepsis Collaborative, Early ID of Sepsis Sprint, Inpatient Surgical Mortality Collaborative Embolism / Thrombus: SCIP VTE 2 Sprint (offered 2x) C. Diff Enteritis: C. Diff Sprint Acute Myocardial Infarction: Readmissions Collaborative There will be sprints in PFP this year in the following compatible topics: CAUTI (catheter assoc. urinary tract infection), CLBSI (central line associated blood stream infection), VAP (ventilator associated pneumonia-) all can lead to sepsis/ bacteremia SSI (surgical site infection) VTE (venous thromboembolism)
- Of course we all share the big picture goal of creating healthier patients and healthier communities So premier is finding some innovative ways of measuring population health as I’ll show you on the next slide.
- In 2012 we published in the Health Affairs Blog, (need to put the citation on slide) a framework for advanced measurement that was the result of an ASD sponsored in Wash DC that included a broad group of stakeholders including NQF, AHRQ, IHI, Dartmouth and others. We began with the premise that our Aim was to measure Value. We defined that at the time as Outcomes + Experience over expenditures. Later Gene Nelson from Dartmouth, who was quite instrumental in putting this framework together, commented that the math should really be Outcomes * Experience / Expenditure, so that all three parameters are on equal footing, which is what we intended. One of the things we discovered, which is not on this slide, is that the high level “big dot” measures you need for comparing value, are not the same as the operational measures one needs to track and trend on a daily basis to make sure that the big dots are achieved. This is an important point, because we see in healthcare today a trend to in a sense, micro-manage the provider by measuring processes and sub processes. We don’t need to do this if we have a clear idea of what we are trying to achieve and we are willing to hold people accountable for results. Being overly prescriptive in our measurement stifles innovation. Let providers figure out how to get there – let’s just agree on the “big dots” we are trying to achieve. Another thing we discovered was that outcomes and experiences most relevant to the patient and to the purchaser were things that only the patient could report. Thus you see a lot of patient reported outcomes on this slide. And we recognized that there might be specific sub domains one would want to look at, in addition to the overall measures. When we looked at Expenditures – we defined these broadly as the total cost to the purchaser + the cost to the consumer. We also felt that there needed to be explicit measures of overuse because generating waste is the opposite of creating value. Finally, something that may not be obvious from the chart. Just as most businesses do, we rely on a set of “leading measures” and “lagging” measures. A leading measure may be someone’s Health Risk, whereas the lagging measure may be the number of healthy days. In healthcare we tend to talk about “process measures” and “outcome measures” as if the two were unrelated. But aren’t some of these “process measures” really “leading measures.” If we know someone has gotten all the evidence based AMI care that is appropriate for example, doesn’t serve in a sense as a “leading measure” of AMI mortality. Aren’t both really important.
- Three pay for performance federal quality programs – inpatient quality reporting (IQR) is pay for report only Although these programs appear completely separate, there are direct and indirect measure crossovers: All harm measures in Inpatient VBP overlap with measures in HAC Reduction Readmissions and complications (harm measures) contribute to Medicare spending per beneficiary performance
- Updated September 2014 – Reflects Final IPPS FY 2015 rule policies. Other adjustments for FY 2014 (Oct 2013) are Admission and Medical Review Criteria Reduction (only included for FY 2014 payments, not into perpetuity) Sequestration was effectively 1% cut to payments in FY 2013 (Oct 2012) because it was only for 6 months of the fiscal year DCA will be 0.8% in FY 2014, 1.6% in FY 2015, 2.4% in FY 2016, and 3.6% in FY 2017.
- Prepared by Marla Kugel, February 2015 Based on IPPS final rule FY 2015 data, quality data released December 2014. N = 3376 hospitals, Maryland and Puerto Rico hospitals excluded from analysis (N = 100). Some hospitals with no penalty didn’t qualify for quality programs due to not meeting data minimum requirements (i.e. small hospitals)
- Slide updated by Marla Kugel January 2015 Shows final weight changes for FY 2017
- Prepared by Marla Kugel, February 2015 Biggest take away: “VBP program changed measures and domains considerably between FY 2013 and FY 2015. This as well as hospital performance contributed to shifts in winners/losers over time. By FY 2015 there are more extremes in winners and losers. Relaxing the minimum domains from 3 to 2 allowed for more hospitals to be included in the program (more small hospitals in that had previously dropped out). The percent win/loss looks inflated, but likely this is because of increase of small hospitals now included in the program.” Ranges on X-axis should be interpreted as, “Values between 0.991 and 0.992, including 0.991”. 519 hospitals were exempt from VBP in FY 2013, 778 were exempt in FY 2014, and only 388 in FY 2015. 100 of these are MD or PR hospitals. The rest were exempt because they didn’t meet the minimum data requirements. Percentages shown instead of counts to control for differences in hospital counts between VBP program in FY 2013, FY 2014, and FY 2015.
- Slide updated February 2015 by Marla Kugel Descriptive only – not necessarily statistically significant difference Only includes hospitals eligible for the VBP program based on minimum data requirements, IPPS hospital, not in MD or Puerto Rico Some types of hospitals are consistent winners or losers under VBP, but some switch as the program changes Rural hospitals lost under FY 2014 program but won under FY 2015 program Urban, Teaching, and DSH hospitals consistently lose DSH status did not determine win/loss under FY 2015 program Determined by FY 2013, FY 2014 and FY 2015 average payment adjustment factors (neutral defined as between 1.000 and 0.9997)
- Slide updated February 2015 by Marla Kugel Descriptive only – not necessarily statistically significant difference Only includes hospitals eligible for the VBP program based on minimum data requirements, IPPS hospital, not in MD or Puerto Rico Small hospitals and rural hospitals win under FY 2015 VBP Medicare spending per beneficiary may push rural hospitals to win – efficiency or just lack of post-acute care resources? Determined by FY 2013, FY 2014, and FY 2015 average payment adjustment factors (neutral defined as between 1.000 and 0.9997)
- (g) Regulations; interagency consultations; definitions, safeguards, and procedures, including procedures and criteria for issuance and scope of orders Except as provided in subsection (h) of this section, the Secretary, after consultation with the Administrator of Veterans' Affairs and the heads of other Federal departments and agencies substantially affected thereby, shall prescribe regulations to carry out the purposes of this section. These regulations may contain such definitions, and may provide for such safeguards and procedures, including procedures and criteria for the issuance and scope of orders under subsection (b)(2)(C) of this section, as in the judgment of the Secretary are necessary or proper to effectuate the purposes of this section, to prevent circumvention or evasion thereof, or to facilitate compliance therewith. (Subsection (h) was superseded by section 111(c)(3) ofPub. L. 94-581. The responsibility of the Administrator of Veterans' Affairs to write regulations to provide for confidentiality of drug abuse patient records under Title 38 was moved from 21 U.S.C. 1175 to 38 U.S.C. 4134.)
- Effect of PICs on Mortality: We looked at a sample of 500,000 patients in our database, and for each PIC we evaluated the marginal effect it had on mortality. We found that, in sum, there were more than 2,500 excess deaths attributable to the newly identified complications. As this graph illustrates, there were nearly 200 of that 2500 associated with sepsis alone. This study confirmed our earlier assessments that sepsis should be a focus area for reducing mortality. [**Note: 200 # listed above is sum of Sepsis/Bacteremia (26)and Septic Shock (173)]** There were QUEST sprints/collaboratives related to this graph: Septic Shock / Sepsis-Bacteremia: Sepsis Collaborative, Early ID of Sepsis Sprint, Inpatient Surgical Mortality Collaborative Acute Myocardial Infarction: Readmissions Collaborative There will also be sprints in PFP this year in the following compatible topics- CAUTI (catheter assoc. urinary tract infection), CLBSI (central line associated blood stream infection), VAP (ventilator associated pneumonia-) all can lead to sepsis/ bacteremia SSI (surgical site infection) VTE (venous thromboembolism)
- PIC effect on LOS: Again, we looked at a sample of 500,000 patients in our database. For each PIC we evaluated each PICs contribution to LOS in our sample. We found that in sum there were more than 199,000 excess days of stay attributable to the newly identified complications. As this graph illustrates, there were nearly 20,000 of the 199,000 associated with infection alone. [**Note: 20,000 number listed above includes Sepsis/Bacteremia, C.Diff, post-operative or perioperative infection, and cellulitis/ skin infection**] There were QUEST sprints/collaboratives related to this graph as well: Sepsis-Bacteremia: Sepsis Collaborative, Early ID of Sepsis Sprint, Inpatient Surgical Mortality Collaborative C. Diff Enteritis: C. Diff Sprint Embolism / Thrombus: SCIP VTE 2 Sprint (offered 2x) There will be sprints in PFP this year in the following compatible topics: CAUTI (catheter assoc. urinary tract infection), CLBSI (central line associated blood stream infection), VAP (ventilator associated pneumonia-) all can lead to sepsis/ bacteremia SSI (surgical site infection) VTE (venous thromboembolism)
- Slide created by Marla Kugel
- Slide updated by Marla Kugel, IPPS FY 2015 final rule Hospital IQR percentage stays 2.0% until 2015, when it will drop to 0.725%, or one-fourth reduction of the market basket update
- Slide updated by Marla Kugel, January 2015 Performance periods for FY 2016 ended December 2014
- Slide updated by Marla Kugel January 2015 Shows final weight changes for FY 2017. New domain structure – outcomes measures (maroon-colored sections) split between “Safety” domain and “Clinical Care” domain.
- Slide updated February 2015 by Marla Kugel All IPPS hospitals N = 3,476 100 hospitals exempt because they are located in MD or PR 288 hospitals exempt because they didn’t meet minimum measure data requirements N = 3,088 eligible hospitals in VBP FY 2015 program Biggest changes in FY 2015 VBP Introduction of Medicare spending per beneficiary domain (20% of score) Relaxation of required domains for total score (down from 3 to 2)
- Created by Marla Kugel on Oct 2, 2014 based on data released with IPPS FY 2015 final rule MD and PR hospitals excluded – exempt from readmissions program