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MHA-Member Roundtable BreakfastNovember 6, 2015
Herb B. KuhnPresident and CEOMissouri Hospital AssociationP.O. Box 60Jefferson City, MO 65102573/893-3700, ext. [email protected]
Agenda
Transparency Initiative Opioids Medicaid
Medicaid Reform Managed Care Principles
Transparency Initiative
3
Transparency Initiative Milestones
Agreement to participate Education Website development Data
Two modifications
4
Price Data Inpatient
100 most prevalent statewide DRGs for FY2014 Minimum, maximum and median charges are
calculated with the lowest and highest 10 percent outliers removed at the hospital and aggregate level
Outpatient Emergency department services will be
grouped in the five facility levels. Note: Emergency department admissions will not show in the ED category.
Outpatient data omitted — 45 procedural codes based on Clinical Classification System
5
Risk-Adjustment Options for Readmissions
6
Problem Statement Risk-adjustment for age, gender and
comorbidities to address variation in acuity is accepted methodology and practice.
Despite national discussion, no consensus on which variables and how to adjust for social determinants that influence quality of care outcomes, e.g. readmissions. The Hospital Readmission Reduction
Program penalizes hospitals for readmissions, but does not adjust for social determinants. 7
Exploratory research and perspective published National Quality Forum
Technical report June 2014 Testing 2015-2017
Congress S. 688 & H.R. 1343 - Establishing beneficiary equity in the Hospital
Readmission Program Act of 2015. Would require CMS to adjust for SDS.
Centers for Medicare & Medicaid Services 2015 Rand report to CMS, CMS call letter and S. 2104 - A bill to amend
title XVIII of the Social Security Act to provide relief to Medicare Advantage plans with a significant number of dually-eligible or low-income subsidy beneficiaries and to prevent the termination of two star plans.
SDS National Discussion
8
Opportunity
Decrease variation of reported readmission rates among hospitals based on socio-demographic status for the transparency initiative on the consumer website.
Encourage and advance the national policy discussion.
Test and promote a better methodology, consistent with current research.
9
Methodological Comparison: Impact DistributionCMS/Yale Method and CMS/Yale With SDS-Enrichment for All MO Hospitals
Hospitals w/ Increased
Risk-Adjusted
Rate
Hospitals w/
Decreased Risk-
Adjusted Rate
Moving from Under to
Over Expected Rate (SDS SRR >1)
Moving from Over to Under
Expected Rate (SDS SRR <1)
No change in Over to Under 1
AMI 53.7% 46.3% 19.6% 5.3% 75.1%
Heart Failure 52.3% 47.7% 16.2% 11.7% 72.1%
Pneumonia 55.2% 44.8% 18.1% 9.5% 72.4%
COPD 48.7% 51.3% 16.5% 8.7% 74.8%
Total Knee & Hip
52.5% 47.5% 20.0% 15.0% 65.0%
Hospital-wide 57.7% 42.3% 26.8% 4.1% 69.1%
10
Methodological Comparison Calibration and reduction in variance (CHF
example)
Decile
1
Decile
2
Decile
3
Decile
4
Decile
5
Decile
6
Decile
7
Decile
8
Decile
9
Decile
10
00.20.40.60.8
11.21.4
0%
5%
10%
15%
20%
25%
30%
SDS-Enriched HF
SDS Enriched SRR SDS Observed
Decile
1
Decile
2
Decile
3
Decile
4
Decile
5
Decile
6
Decile
7
Decile
8
Decile
9
Decile
10
00.20.40.60.8
11.21.4
0%
5%
10%
15%
20%
25%
CMS HF
CMS SRR CMS Observed
0.85 0.9 0.95 1 1.05 1.1 1.150.50.60.70.80.9
11.11.21.31.41.5
Scatter Plot
No DifferenceBoth Significant (95%)
SDS SRR
CM
S S
RR
Estimated Risk Estimated Risk
Reduction in Variance: Shrinkage Plot
CMS SRR SDS SRR0.6
0.7
0.8
0.9
1
1.1
1.2
1.3
1.4
1.5
11
Evaluation Process Internal review of MHA staff External reviewers
David Nerenz, Ph.D., Henry Ford Health System Katherine Baicker, Ph.D., Harvard economist Bruce Hall, M.D., Ph.D., BJC and Washington
University District council meetings Strategic Quality Advisory Committee
recommendation Today — MHA Board of Trustees decision November-December — member feedback
12
Cons Ahead of CMS and NQF “Masking disparities” No national consensus yet
on which variables are most appropriate
Rigor of national research still in process
Public messaging
Balancing RiskPros Reduced statistical
variation among hospitals for population characteristics
Current HIDI model promising
“Essential for fair comparison”
Aligns with MHA advocacy and policy agenda
Additive information for the NQF pilot
Advances national policy discussion
Opportunity to introduce other SDS-related quality outcomes
Public messaging
13
Response Themes General agreement
Continues to fulfill the commitment to transparency
More accurate and fair reflection of patient population and performance of health care organizations
Identifies margin for improvement Opportunity to advance policy discussion Opportunity for focused, continued investment
in quality initiatives Hesitation
Hide poor performance or disparities Appearance we are manipulating the numbers Ahead of CMS
14
Next StepsNovember 10
Webinar with membership
November 16
Comparison data available for participating hospitals to review
TBA Ongoing message and website development
TBA Actions only taken if board approves SDS adjustment• Briefing for national stakeholders
AHA FAH AAMC America's Essential Hospitals NQF
• Briefing for state-based stakeholders• Advanced briefing for selected trade press and
national media
15
Opioid Overuse in Missouri
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Opioid Misuse and Abuse Nationally, an alarming
increase of opioid-related Prescriptions Consumption Chronic, non-medical use Abuse Hospitalizations Death
Missouri hospital utilization White, males under age 30 Rural – Northeast and
Southeast St. Louis metropolitan area Report generated dozens of
news stories across the state17
Rate of Hospital Inpatient and Emergency Department Visits and Cumulative Percent Change in Missouri, 2005 - 2014
2005 2006 2007 2008 2009 2010 2011 2012 2013 20140
50
100
150
200
250
300
350
400
450
-20%
0%
20%
40%
60%
80%
100%
120%
140%
187.3
424.0
137%
Rate Per 100,000 Cumulative Percent Change
Source: HIDI HealthStats October 2015. Alarming Trends in Hospital Utilization for Opioid Overuse in Missouri
18
2005-2014 ZIP Code Hot Spots for Opioid Overuse-Related Hospital Visits
19
Missouri Efforts
Absence of a prescription drug monitoring program
Absence of a registry system Missouri DHSS Prescription Overdose Drug
Workgroup Proposed state legislation
20
Partners
Chief Medical Officers affinity groupMissouri State Medical AssociationMissouri Association of Osteopathic
Physicians & Surgeons Missouri Academy of Family Physicians Missouri College of Emergency Physicians
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Refuse requests to provide prescriptions for refills “lost” or destroyed”
Avoid prescribing long-acting or controlled-release opioids
Consider abuse-deterrent forms of opioids
Encourage policies allowing Naloxone dispensing
Emergency Room Protocols: Suggested Recommendations
Comprehensive pain assessment
Evidence-based diagnosis
Non-narcotic treatment of non-traumatic tooth pain
Communication between emergency room and primary care physicians
Prescriptions limited to 72 hours
22
Announcement and Dissemination
Member calls – November 17, 18, 19 Webinar for clinical staff – December 1 Joint association press release – early
December
23
Medicaid Reform
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Previous Board Discussion of New Directions for Medicaid Advocacy
Rebranding campaign Legislative topics
Ensuring stable financing Incremental expansion of coverage Imposing personal responsibility
requirements Support delivery system reform Exploring new waiver opportunities and
other reforms
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Managed Care Principles
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2015 Legislative Action on Medicaid Managed Care
Expansion of Medicaid managed care program Limited to children and low-income
parents outside the “I-70 corridor” Removed all FRA funding from expansion Delay to June 2016 Any willing provider standard for
practitioners Task force to develop strategy Will require rebidding of all managed
care vendor contracts 27
Updates on Medicaid Managed Care
“Task Force for Examining Statewide Medicaid Delivery Models” held initial meeting in October
Dwindling prospects to have a statewide managed care contract in place by June 2016
MHA responded to state “Request for Information” on design of statewide system
Action by Medicaid Oversight Committee Insurer conversations on common
interests in promoting alternatives to traditional HMOs
28
Category of Eligibility
Percent of Medicaid Hospital
Payments (FY 15)
Percent of Payments in
Managed Care for Category
Parents 7.3% 39.3%Children 23.1% 41.8%Pregnant Women 5.5% 25.8%
Elderly 4.8% 0.0%Disabled 58.6% 0.0%Blind 0.3% 0.0%Other 0.4% 0.0%
100.0%29
Medicaid Managed Care Policy Development
September board review of: Concerns about Medicaid managed care expansion
Ways to resolve those concerns through legislation or executive branch actions
• These issues also were discussed in the Fall round of non-metropolitan District Council meetings.
• Staff has incorporated these issues into a set of proposed principles to guide MHA’s advocacy.
30
Medicaid Managed Care Principles
Provider interactions Funding issues State budget issues Accountability measures Provider-sponsored care models
31
Thank YouQuestions?
32
