CMS Overview

Chris Vanni MSQA Regional Director Quality/PI Franciscan Alliance

Objectives

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Overview of CMS Review Pay for Performance

Initiatives

Understand the Outpatient Quality

Data Reporting System’s (OPPS) Core Measures

Examine the implications of

“failure to meet”

Discuss strategies for meeting OP-16

CMS Common Acronyms

CMS

• Center for Medicaid and Medicare Services

HCAHPS

• Hospital Consumer Assessment of Healthcare Providers and Systems

HOP

• Hospital Outpatient • This includes the ED.

QDRP

• Quality Data Reporting Program

OPPS

• Outpatient Prospective Payment System

• Defines the fees CMS will pay for outpatient services

ASC

• Ambulatory Surgical Center

A Word about Final Rule… Final Rule CMS 1525FC

Defines Quality Measures and the timing over the next 3 years

Describes the reasoning and process in creating the core measures (including Comments and Responses)

Defines “failure to meet” reduction in payment update

The Emergency Department: Front Door to Pay-for-Performance

…based upon hospital's performance under the Patient Protection and Affordable Care Act’s rules and

reimbursement provisions…

ED will have a huge impact

There exists an opportunity to influence both patient perceptions

of care and clinical quality in the ED

Beginning 10/12 (FY2013) Hospitals will sink or swim based upon

performance

30%

70% HCAHPS

Core Measures

The HCAHPS Measures (30%)

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30%

HCAHPS

Core Measures

Does HCAHPS apply? YES!

• it’s true that CMS pay-for-performance measures only HCAHPS scores from In-patients

• Healthcare leaders do not always understand that there is a strong correlation between ED performance and overall hospital performance

-Studer Group

Relationship: HCAHPS “Overall” and ED Percentile Rankings

It works both ways: Hospitals whose EDs are ranked highly by patients on patient satisfaction surveys also perform well on inpatient HCAHPS surveys. Likewise, hospitals whose EDs are rated poorly by patients tend to perform poorly on HCAHPS. -Studer Group

The CMS Core Measures (70%)

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70% HCAHPS

Core Measures

What are CMS Quality Measures?

A measurement of how well a Healthcare System gives good care that leads to good outcomes

Measures are based upon scientific evidence that sums up defined standards of care

Information gathered from measures data helps the Healthcare System to understand their own

performance

Background and Purpose of Quality Data Reporting Program

• Program began November 1, 2007

• Under this program, hospitals report data for services on the quality of hospital outpatient care using standardized measures of care to receive the full annual update to their OPPS payment rate.

What is the focus for selecting new Quality Measures?

• Conditions that result in the greatest mortality and morbidity in the Medicare population

• Conditions that are high volume and high cost for the Medicare program

• Conditions for which wide cost and treatment variations have been reported, despite established clinical guidelines

Who does it affect?

Performance Data is collected and reported on ALL Outpatients Medicare,

private pay, HMO, “self pay” services

However; if the hospital does not meet the core measures, the penalty affects

Medicare reimbursement only.

In the future, other Insurance carriers will line up to enforce similar core

measures.

Hospitals Excluded from OPPS Payment and therefore Quality Data Reporting

Hospitals can opt-out of the Quality Measurement program – but they automatically forfeit the 2%

Critical Access Hospitals (<25 IP

beds)

Medicare provider Hospitals located

outside the US

Indian Health Service Hospitals

Most Maryland Hospitals (because

they have a different payment system)

Current CMS HOP QDRP Measures

OP-1: Median Time to Fibrinolysis

OP-2: Fibrinolytic Therapy Received Within 30 Minutes

OP-3: Median Time to Transfer to Another Facility for Acute Coronary Intervention

OP-4: Aspirin at Arrival

OP-5: Median Time to ECG

OP-6: Timing of Antibiotic Prophylaxis

OP-7: Prophylactic Antibiotic Selection for Surgical Patients

OP-8: MRI Lumbar Spine for Low Back Pain

OP-9: Mammography Follow-up Rates

OP-10: Abdomen CT – Use of Contrast Material

OP-11: Thorax CT – Use of Contrast Material

Measured in 2010, affected payment for 2011

CMS HOP QDRP Measures – for 2012 payment determination

OP-12: The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into their Qualified/Certified EHR System as Discrete Searchable Data

OP-13: Cardiac Imaging for Preoperative Risk Assessment for Non Cardiac Low Risk Surgery

OP-14: Simultaneous Use of Brain Computed Tomography (CT) & Sinus Computed Tomography (CT)

OP-15: Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache

Collected data in 2011 that will impact 2012 payment

CMS HOP QDRP Measures – for 2013 payment determination

OP-16: Troponin Results for Emergency Department acute myocardial infarction

(AMI) patients or chest pain patients (with Probable Cardiac Chest Pain)

Received Within 60 minutes of Arrival

OP-17: Tracking Clinical Results between Visits

OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients

OP-19: Transition Record with Specified Elements Received by Discharged Patients

OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional

OP-21: ED- Median Time to Pain Management for Long Bone Fracture

OP-22: ED- Patient Left Before Being Seen

OP-23: ED- Head CT Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke

who Received Head CT Scan Interpretation Within 45 minutes of Arrival

Data collection began January 1, 2012 for payment in 2013

In fiscal year 2011, If FA fails to meet the

measures or does not report, the hospital will

see a 2% penalty for CMS Outpatient

(Medicare) payment rates for ALL OPPS

claims.

Failure to meet guidelines will result in a 2%

penalty across the board, not just for

the core measures that they did not

meet.

Franciscan Alliance (FA) Notes

Data: Original source: S:\Groups\RegDecisionSup\Site ADS P&L Historical Info\"Facility"\2011\YTD Dec 2011 •Sort characteristics -Financial Class Code: MC - Account Balance: 0 - Insurance Name: Medicare Part A & B

• Calculation: sum total value of column: FINAL Net Revenue

Potential Loss of 2% for CMS Outpatient Payments

based on 2011 historical data

238.5

131.9

190.08

560.48

0

100

200

300

400

500

600

SAMC SAMHC SMM Total

Values in Thousands of Dollars ($)

Data Submission

Data is submitted quarterly

Transmission via QualityNet is the only CMS-approved method for submission.

Submission for OP-16, OP-18-21 and OP-23 will begin in August 2012 with data collection beginning with January 1, 2012 discharges

Validation CMS will

randomly select 450 hospitals to submit up to 12

records per quarter for one

year.

50 additional hospitals will be “targeted” based on poor performance

For full OPPS payment

update, hospitals

must obtain at least a 75

percent validation

score.

OP-16 Update

OP-16: Troponin Results for Emergency Department acute myocardial infarction (AMI) patients or chest pain patients (with Probable Cardiac Chest Pain) Received Within 60 minutes of Arrival • According to the CMS final ruling for 2012 payments (CMS

1525-FC), the target population of this measure is ED patients with a diagnosis of AMI, and Angina, Acute Coronary Syndrome, or Chest Pain patients presumed to be cardiac in nature and have been prescribed a Troponin test and are:

• Discharged/transferred to a short-term general hospital

for inpatient care (Code 2) • Discharged/transferred to a federal health care facility

(Code 43)

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How will you meet OP-16?

• Streamline current process Dedicated labeling, transport, processing for Chest Pain Patients

• Implement Point of Care Cardiac Testing

…on a personal note

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Enter CPC

Troponin TAT

Current: <60 minutes

Enter POCT Troponin and other cardiac markers

POCT: 15 minutes (five

markers) Traditional Lab

Services: 60 minutes (troponin)

Cardiac Markers

Fast results achieved in 15 minutes vs 60

minutes

“Rule out” conditions that

will lead to quicker

disposition of patient either

to IP units or to home.

Quick discharges lead to less ED wait

times

Speedy interventions

Speedy Interventions=Efficiencies

Saving Lives Less heart damage Reduced LOS

Better patient outcomes

Better patient throughput/bed

utilization

Happy Patients/Families

Happy Doctors/Hospital

Staff Cost containment

Additional Resources

www.cms.gov

www.qualitynet.org

www.hospitalcompare.hhs.gov

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Questions?