Medicare  Incen+ve  and  Penal+es:  Cri+cal  Lessons  Learned  

Elizabeth  Mort,  MD,  MPH  Senior  Vice  President,  Quality  and  Safety  

Chief  Quality  Officer  Massachuse:s  General  Hospital  and    

Mass  General  h\Physicians  OrganizaAon    

Move  from  Fee  for  Service  to  Pay-­‐for-­‐Value:  authorized  in  2005  

Started  with  small  voluntary  set  of  quality  metrics  

CMS  starter  set  of  10  measures  grew  to  60  

4 Source:    Advisory  Board  Img  source:  hKp://blog.healthcarefirst.com/Portals/52995/images/HospiceDataRepor+ng.jpg  

Five  Major  CMS  Pay  for  Value  Programs    §  Inpa+ent  Quality  Repor+ng  §  Value-­‐Based  Purchasing  §  Readmissions  Reduc+on  §  Hospital  Acquired  Condi+ons  

(HAC)  Penalty  §  Meaningful  use  of  

Informa+on  Technology  (IT)  

Img  Source:    hKp://incendant.com/wp-­‐content/uploads/2014/07/002631040_Stethoscope-­‐Laying-­‐on-­‐Stacks-­‐of-­‐Hundred-­‐Dollar-­‐Bills-­‐with-­‐Narrow-­‐Depth-­‐of-­‐Field..jpg  

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Department  of  Public  Health  

CMS  and  others….  

       

The  Hospital  Pay  for  Performance  world  in  Boston  2015  

AMI-­‐7a  Fibrinoly+c  Therapy  MORT  30-­‐AMI:  Acute              Myocardial  Infarc+on    30    day  mortality  MORT  30-­‐HF:  Heart        Failure  30  day  mortality  MORT  30-­‐PN:  Pneumonia    30  day  mortality  Medicare  Spend  Per  Beneficiary    

HCAHPS–  clean  &  quiet  HCAHPS  –  Pain  mgt  HCAHPS  –  Med  comm  HCAHPS  –  overall  ra+ng  

IQI-­‐32  Mortality  AMI  w/o  transfer  cases    PSI-­‐6  Iatrogenic  Pneumothorax,  Adult    PSI-­‐7  Central  Venous  Catheter  Associated  Bloodstream  Infec+ons    PSI-­‐11  Post-­‐opera+ve  Respiratory  Failure    PSI-­‐12  Post-­‐opera+ve  PE/DVT    PSI-­‐15  Accidental  Puncture  or  Lacera+on    PSI-­‐18  OB  Trauma  -­‐  Vag  w  Instrument    PSI-­‐19  OB  Trauma  -­‐  Vag  w/o  Instrument    

VBP  (21  measures)   Commercial  (13  measures)  

MassHealth  P4P    

(14  measures)  

System    (54  measures)  

Pion

eer A

CO

(3

3 m

easu

res)

MassHealth  Readm

ission  Penalty  (1  measure)  

30-­‐day  all  cause  poten+ally  preventable  readmission  rate  

AHRQ  PSI  90  CLABSI  CAUTI  SSI  (2)  

   

                             AHRQ  PSI  90                                                                                                                        CLABSI                                                      CAUTI                                                      SSI                                

MAT-­‐1:  Intrapartum  An+bio+c        Prophylaxis  for  GBS  MAT  –  2a:  An+bio+c  Timing  MAT  -­‐2b:  An+bio+c  Selec+on  MAT  –  4:  Cesarean  Sec+on  HD-­‐2  Health  Dispari+es  

CCM  1:  Reconciled    Medica+on  List  ED  1:  Median  +me  (arrival  to  admit)  ED  2:  Median  +me  (admit  to  decision)  TOB  1:  Tob  Use  Screening  TOB  2:  Tob  Use  treatment  provided  TOB  3:  Tob  Use  treatment  provided  at  discharge  

Medicare  Readmission  Penalty    (6  measures)      AMI,  HF,  PN,  COPD,  TKA/THA,  CABG  

HCAHPS–  comm.  w.  nurses  HCAHPS  –responsiveness    of  staff  HCAHPS–  Discharge  info  HCAHPS  -­‐  Comm.  W  docs    IMM-­‐2-­‐  Influenza  Immuniza+on  

STK-­‐1  VTE  Prophylaxis  VTE-­‐1  VTE  Prophylaxis  VTE-­‐2  ICU  VTE  Prophylaxis  VTE-­‐3  An+coag  Overlap  Therapy  OP-­‐4  Aspirin  at  Arrival  OP-­‐3b  Median  Time  to  Transfer  Acute  Coronary  OP-­‐5  Median  Time  to  ECG  HCAHPS  Cleanliness  HCAHPS  Quietness  HCAHPS  Care  Transi+ons  

PC-­‐01/MAT-­‐3:  Elec+ve  delivery  prior  to  39  weeks  gesta+on  

   

CCM  2:  Transi+on  Record  CCM  3:  Timeliness  of  transi+on  record  

PCMH:  Primed  Status,  NCQA  Recogni+on  iCMP:  Pt  Survey,  Post  Disch  Bundle,  Med  admits/k,  Innova+on  Specialty:  PCP/Specialist,  Specialty  Programs,  Innova+on  Warm  Handoffs  PCC:  Reduce  readm,  complete  transfer  doc  with  Eds,  screen  for  high  risk  readm  eCSME:  Trend,    service  level    

Diabetes:  HbA1c,  LDL,  BP  CVE:  LDL  HTN:  BP    

MRSA  C.Diff  

HAC    Reduc?on    (6  m

easures)  

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At  +mes  it  feels  like  this…  

Patient

Safety

Occ. Health

Public Affairs

MESAC

PFACs

PCS Quality Program

Potential Q&S Targets

Performance, Analysis,

Improvement

Simulation Center

HIS

Quality Mgmt

Care Redesign

Pharmacy

Disparities Comm.

Exec. WalkRounds

Research

Partners Quality &

Safety

Infection Control

CMO

Affiliates

Critical Care Comm.

Pt Experience

How  do  we  manage?  Review  important  signals  and  strategic  priori3es  

Training Directors

Trainees Quality Chairs

Population Health

Patient Advocacy Analytics

Sr mangt

Quality & Safety Fellows

Ambulatory/ARMS

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Priori3ze:    Inputs  from  signals  Excellence  every  day,    IOM  pillars,    regulatory  asks,    contracts,  strategic  goals    

§     

Lead the Nation in Quality and Safety

Research  Leadership:  

Measurement  and  IT  Leadership:  

Systems  Excellence:  

Quality,  safety  and  service  excellence  every  day:  

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2015  Goals  and  Tac3cs  MGH  and  MGPO  1.  Lead  in  quality  of  care    a.  Demonstrate  measurable  improvements  in  episodic  specialty  care    b.  Improve  performance  in  managing  popula+ons  under  risk  contracts  c.  Advance  pilot  for  obtaining  guardianship  to  inpa+ents  on  medical  units  who  cannot  speak  for  themselves    d.  Reduce  observed  dispari+es  in  quality  of  care  with  focus  on  Limited  English  Proficiency      e.  Advance  pa+ent  and  family  engagement  in  Q&S  programs      

2.  Improve  pa?ent  safety    a.  Address  common  causes  of  harms  iden+fied  through  safety  repor+ng    b.  Improve  safety  in  ambulatory  care  in  focused  areas    c.  Improve  medica+on  safety  in  targeted  areas    d.  Reduce  healthcare  associated  infec+ons    e.  Implement  IPASS  and  demonstrate  improvement  in  safety  culture  scores    

 3.  Excel  on  external  surveys  and  measures    a.  Achieve  excellent  results  on  external  surveys  and  reviews  (The  Joint  Commission  Hospital  &  Lab  due  2015)    b.  Achieve  excellent  results  on  key  performance  programs  (Value  Based  Purchasing,  Readmissions,  Mass  

Health,  Meaningful  Use)      

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Assessment  of  first  10  years:  a  good  start  

§  Amazing  progress    §  CMS  listens  and  revises  

•  An+bio+cs  within  four  hours  •  HACs  sunset  •  Topped  out  measures  re+red  •  Documenta+on  based  measures  phased  out  •  Moving  from  process  measures  to  NHSN  surveillance  data  

§  Have  we  improved  care?    

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Process  measure  performance  2005-­‐2014  

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Pa+ent  experience  performance  2005-­‐2014  

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Mortality  &  readmission  performance  2005-­‐2014  

Lessons  and  New  direc+ons  

§  Reality  check  on  volume  of  metrics  §  Implementa+on  science  and  reliability  approaches  §  Revisit  structural  measures  (CPOE,  EMAR,  intensive  care  

staffing)    §  Advance  outcomes  (registries)  §  Move  away  from  measures  using  administra+ve  data  §  Par+cipa+on  in  Improvement  collabora+ve  work  §  Cross  con+nuum  care,  Popula+on  health,  innova+ons  in  

health  care  delivery,  Systems  of  care  and  affilia+ons    

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