Outcome Measures and Value Based Purchasing (Text Version)

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On September 14, 2009, Michael Rapp made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (10 MB).

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Slide 1

 

Outcome Measures and Value Based Purchasing

AHRQ 2009 Annual Conference

Michael T. Rapp, MD, JD, FACEP
Director, Quality Measurement and Health Assessment Group
Office of Clinical Standards & Quality .Centers for Medicare & Medicaid Services

 

Slide 2

 

Overview

• Value Based Purchasing
• Current CMS VBP implementation
• Outcome measures in use by CMS
• Review considerations in use of outcome measures in VBP
• CMS 30 day mortality measures
• CMS 30 day re-admission measures

 

Slide 3

 

What VBP Means to CMS

• Transforming Medicare from a passive payer to an active purchaser of higher quality, more efficient health care
• Tools and initiatives for promoting better quality, while avoiding unnecessary costs
  • Tools: measurement, payment incentives, public reporting, conditions of participation, coverage policy, QIO program
  • Initiatives: pay for reporting, pay for performance, gainsharing, competitive bidding, coverage decisions, direct provider support
• Current program authority to pay differentially for better quality
  • ESRD VBP authorized in MIPAA

 

Slide 4

 

Support for VBP

• President's Budget
  • FYs 2006-09
• Congressional Interest in P4P and Other Value-Based
• Purchasing Tools
  • BIPA, MMA, DRA, TRHCA, MMSEA
• MedPAC Reports to Congress
  • P4P recommendations related to quality, efficiency, health information technology, and payment reform
• IOM Reports
  • P4P recommendations in To Err Is Human and Crossing the Quality Chasm Report, Rewarding Provider Performance: Aligning Incentives in Medicare
• Private Sector
  • Private health plans
  • Employer coalitions

 

Slide 5

 

VBP Demos and Pilots

• Premier Hospital Quality Incentive Demonstration
• Physician Group Practice Demonstration
• Medicare Care Management Performance Demonstration
• Nursing Home Value-Based Purchasing Demonstration
• Home Health Pay-for-Performance Demonstration
• ESRD Bundled Payment Demonstration
• ESRD Disease Management Demonstration
• Medicare Health Support Pilots
• Care Management for High-Cost Beneficiaries Demonstration
• Medicare Healthcare Quality Demonstration
• Gainsharing Demonstrations
• Electronic Health Records (EHR) Demonstration
• Medical Home Demonstration

 

Slide 6

 

VBP Initiatives

• Hospital Pay for Reporting: Inpatient & Outpatient
• • RHQDAPU & HOP QDRP
• Hospital VBP Plan & Report to Congress
• Hospital-Acquired Conditions & Present on Admission Indicator
• Physician Quality Reporting Initiative
• Physician Resource Use Confidential Reports
• Home Health Care Pay for Reporting
• Ambulatory Surgical Centers Pay for Reporting
• ESRD Pay for Performance

 

Slide 7

 

Measures for VBP

• Various measure types used
• Various pros and cons to each
  • Process
  • • Most available but may become "topped out"
    • Focus on specific but limited set of processes that impact outcomes
  • Outcome
  • • Less available but broader in scope, less subject to become "topped out"
  • Experience of Care
  • • May relate to processes or outcomes
  • Structural

 

Slide 8

 

Outcomes Measures in Use by CMS

• Measure Summary:�74 total current CMS outcome measures in use (approximately)
  • 28 Inpatient (including QIO)
  • 8 Physician
  • 12 Home Health
  • 14 Nursing Home
  • 4 ESRD
  • 8 Medicare Advantage

 

Slide 9

 

Hospital Inpatient Outcome Measures:
Mortality, Complications, Readmissions (RHQDAPU & QIO)

• Mortality (Medical Conditions)
  • 30 day mortality AMI, HF, PNE, (CMS) *
  • Selected Medical Conditions (AHRQ) *
• Mortality (Surgical Conditions/Procedures)
  • AAA, Hip Fractures (AHRQ) *
  • Selected Surgical Conditions (AHRQ) *
  • Death of surgical patients with treatable serious complications*
  • Complication/patient safety for selected indicators *
• Complications (Medical and Surgical)
  • Post op wound dehiscence in abdominal-pelvic surgery *
  • Accidental puncture or laceration *
  • Iatrogenic pneumothorax *
  • MRSA Infection Rate; Transmission Rate (CMS-QIO)
  • Hospital Acquired Pressure Ulcers (CMS-QIO)
• Readmission (Medical Conditions)
  • AMI, HF, PNE (CMS) *
  • All patient Readmission Rate (CMS-QIO)
• Intermediate Outcome
  • Cardiac Surgery Patient Controlled 6 AM Glucose
• [* = RHQDAPU Hospital Pay for Reportin Program]

 

Slide 10

 

Premier Hospital Quality Incentive Demonstration (HQID)

• The Premier HQID recognizes and provides financial rewards to hospitals that demonstrate high quality performance in a number of areas of acute care.
• The demonstration rewards participating top performing hospitals by increasing their payment for Medicare patients.
• Clinical conditions and procedures
  • Heart attack
  • Heart failure
  • Pneumonia
  • Coronary artery bypass graft
  • Hip and knee replacements

 

Slide 11

 

Hospital Outcome Measures—Premier Demonstration

• Current
  • Inpatient Mortality Rate AMI, CABG, HF
  • Post-op Hemorrhage or Hematoma
    • Hip/Knee Replacement
  • Physiologic and Metabolic Derangement
    • Hip/Knee Replacement
• Expansion
  • Test further outcome measures
    • AHRQ PSI's
    • AHRQ Inpatient Mortality (IQI)
    • CMS 30 day readmission and mortality measures AMI, HF, PNE

 

Slide 12

 

Outcome Measures—Hospital VPP Plan

• Report to Congress
• Included process, experience of care
• Method for including 30 day mortality measures in scoring developed subsequently

 

Slide 13

 

Hospital Acquired Conditions: Background

• The Deficit Reduction Act (DRA) of 2005 requires the Secretary to identify conditions that are:
  • (a) high cost or high volume or both
  • (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and
  • (c) could reasonably have been prevented through the application of evidence-based guidelines
• Beginning October 1, 2008, Medicare no longer paid hospitals at a higher rate for the increased costs of care that result when a patient is harmed by one of the listed conditions if it was hospital-acquired.
• Medicare continues to assign a discharge to a higher paying MS�DRG if the selected condition is present on admission (POA).
• The POA indicator reporting requirement and the HAC payment provision apply to IPPS hospitals only.

 

Slide 14

 

Hospital Acquired Conditions

• Foreign Object Retained After Surgery
• Air Embolism
• Blood Incompatibility
• Stage III and IV Pressure Ulcers
• Falls and Trauma
  • Fractures
  • Dislocations
  • Intracranial Injuries
  • Crushing Injuries
  • Burns
  • Electric Shock

 

Slide 15

 

Hospital Acquired Conditions

• Manifestations of Poor Glycemic Control
  • Diabetic Ketoacidosis
  • Nonketotic Hyperosmolar Coma
  • Hypoglycemic Coma
  • Secondary Diabetes with Ketoacidosis
  • Secondary Diabetes with Hyperosmolarity
• Catheter-Associated Urinary Tract Infection (UTI)
• Vascular Catheter-Associated Infection

 

Slide 16

 

Hospital Acquired Conditions

• Surgical Site Infection Following:
  • Coronary Artery Bypass Graft (CABG)—Mediastinitis
  • Bariatric Surgery
    • Laparoscopic Gastric Bypass
    • Gastroenterostomy
    • Laparoscopic Gastric Restrictive Surgery
  • Orthopedic Procedures
    • Spine
    • Neck
    • Shoulder
    • Elbow
• Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
  • Total Knee Replacement
  • Hip Replacement

 

Slide 17

 

Hospital Acquired Conditions: Projected Costs savings

• Savings estimates for the next 5 fiscal years are shown below:

Year	Savings (in millions)
FY 2009	$21
FY 2010	21
FY 2011	21
FY 2012	22
FY 2013	22

 

Slide 18

 

National Coverage Determination—Hospitals and Physicians

• No coverage for
  • Surgery on wrong body part
  • Surgery on wrong patient
  • Wrong surgery on a patient
• Not reasonable and necessary

 

Slide 19

 

Physician Outcome Measures (PQRI)

• Intermediate Outcomes
  • Diabetes: HbA1C, LDL, BP Control
• Mortality
  • None
• Complications
  • Medical Conditions
    • None
  • Surgical Conditions
    • CABG
      • Deep Sternal Wound Infection; Stroke/CVA; Post Op Renal Insufficiency; Prolonged Intubation; Surgical Re-exploration

 

Slide 20

 

Physician Outcome Measures
(Physician Group Practice Demonstration)

• Intermediate Outcome Measures
  • Diabetes HbA1c, Blood Pressure, and LDL control

 

Slide 21

 

Physician Outcome Measures
(Physician VBP Plan)

• Report to Congress required in MIPPA
• Due May, 2010
• Outcome measures under consideration

 

Slide 22

 

Home Health Outcome Measures

• Management of Care
  • Acute Care Hospitalization
  • Emergent Care (risk adjusted)
  • Discharge to Community
• Improvement in functional status
  • Ambulation /locomotion
  • Bathing
  • Bed transferring
  • Dyspnea
• Medication Management
  • Management of Oral Medication
• Pain
  • Improvement in pain interfering with activity
• Surgical Wounds
  • Improvement in status of surgical wounds
• Complications
  • Emergency Care for Wound Infections, Deteriorating Wound Status
• Incontinence
  • Improvement in Urinary Incontinence

 

Slide 23

 

Nursing Home Outcome Measures (Long Stay)

• Pressure Sores
  • High risk patients
  • Low risk patients
• Functional Status
  • Improvement in Daily Activities independence
  • Most of time in Bed or Chair
  • Ability to move about in and around Room worse
  • Weight loss
• Pain
  • Moderate to Severe Pain
• Incontinence
  • Catheter inserted and left in bladder
  • Loss of control of bowels or bladder
• Urinary Tract Infection
  • Percentage with UTI
• Mental Health
  • Percentage more anxious or depressed

 

Slide 24

 

Nursing Home (short stay)

• Percentage with Delirium
• Percentage with Moderate to Severe Pain
• Percentage with pressure sores

 

Slide 25

 

ESRD

• Patient Survival
• Hematocrit/Hemoglobin Control for ESA therapy
• Hematocrit below minimum level

 

Slide 26

 

Medicare Advantage

• Diabetes
  • Blood Pressure Control (2)
  • HbA1c Good Control; Poor Control
  • LDL Control
• Hypertension
  • Blood Pressure Control
• Improving Mental Health
• Improving Physical Health

 

Slide 27

 

Outcome Measure:
Data Considerations

• Claims
  • Routinely collected secondary data source
  • CMS 30 day Mortality
  • CMS 30 Day Readmission
  • AHRQ measures
• Lab Data
  • Helpful for risk adjustment but not readily available for Medicare
• Chart Abstraction
  • Burdensome but benefit of primary source and complete data
• Registries
  • Data collection over time supports outcome measures
  • Can accommodate multiple data source types
• Electronic Health Record
  • Future financial incentives for both physicians and hospitals to use
  • Reporting clinical quality measures required element of "meaningful use"
  • Primary source data
  • Clinical data supports risk adjustment

 

Slide 28

 

CMS Hospital 30 day Mortality Measures

• Claims-based
  • Risk standardized 30-day all-cause mortality and readmission measures for AMI, HF and Pneumonia
  • NQF endorsed and implemented for RHQDAPU program
• Registry-based
  • PCI 30-day all-cause risk standardized mortality for STEMI/shock and non-STEMI/non-shock patients
  • Risk standardized 30-Day All-Cause Mortality and/or Complications for Lower Extremity Bypass
  • NQF endorsed

 

Slide 29

 

CMS 30 day Mortality and Readmission

• Endorsed by National Quality Forum and adopted by Hospital Quality Alliance
• Complies with American Heart Association and American College of Cardiology standards for outcomes models
  • Well-defined patient cohort
  • Clinically coherent model risk-adjustment
  • Use of an appropriate outcome
  • Standardized period of follow-up: 30-day
• Currently publicly reported on Hospital Compare
• Developed by Yale/Harvard team of clinical and statistical experts

 

Slide 30

 

Standardized Period of follow-up

• All patients followed for 30 days from discharge
• 30-days Strikes a Balance
  • Allow enough time for hospitals to have impact on outcome
  • Take into account discharge practice variation
  • Consistent for mortality and readmission measures

 

Slide 31

 

Risk Adjustment

• Risk adjustment takes into account patient case mix and hospital-specific effect
• Hospital rates are calculated based on 3 years of hospitalizations
• Risk factors based on index admission and the prior year from inpatient, outpatient, and physician claims
• Models estimated on administrative data, validated by models based on chart data

 

Slide 32

 

Interval Estimates

• Risk Standardized Rate—point estimate
• Interval estimates (IEs) are used to determine if mortality or readmission is different from national rate with high-degree of certainty
• 95% IEs is used to specify lower and upper IEs

 

Slide 33

 

Distribution of Hospital Mortality

Images: Two graphs showing risk-standarized mortality rates (%) for AMI and HF.
AMI shows a spike of about 650 hospitals at about 17%.
HF shows a spike of about 610 hospitals at about 12%.

 

Slide 34

 

Performance Categories

Image: Chart showing the placement of hospitals compared to the national rate in several performance categories.

• Hospital A (200 cases)—less than the national rate—"Better"
• Hospital B (100 cases)—at the national rate—"No different"
• Hospital C (150 cases)— above the national rate—"Worse"
• Hospital D (20 cases)—at the national rate—"Number cases too small (fewer than 25)"

 

Slide 35

 

Distribution of AMI Mortality by HRR

Acute Myocardial Infarction 30-Day Risk-Standardized Mortality Rate (RSMR)
Weighted Average By Hospital Referral Region (HRR)

Image: Map of the United States showing the distribution of AMI mortality by HRR.

 

Slide 36

 

Distribution of HF Mortality by HRR

Heart Failure 30-Day Risk-Standardized Mortality Rate (RSMR)
Weighted Average By Hospital Referral Region (HRR)

Image: Map of the United States showing the distribution of HF mortality by HRR.

 

Slide 37

 

Distribution of Hospital Readmission

Images: Two graphs showing risk-standarized readmission rates (%) for AMI and HF.
AMI shows a spike of about 960 hospitals at about 20%.
HF shows a spike of about 610 hospitals at about 24%.

 

Slide 38

 

Distribution of AMI Readmission by HRR

Acute Myocardial Infarction 30-Day Risk-Standardized Readmission Rate (RSMR)
Weighted Average By Hospital Referral Region (HRR)

Image: Map of the United States showing the distribution of AMI readmission by HRR.

 

Slide 39

 

Distribution of HF Readmission by HRR

Heart Failure 30-Day Risk-Standardized Readmission Rate (RSMR)
Weighted Average By Hospital Referral Region (HRR)

Image: Map of the United States showing the distribution of HF readmission by HRR.

 

Slide 40

 

2009 National Results
(7/05-6/08 discharges): Readmission

• Average 30-day hospital readmission rates are high (AMI 19.9, HF 24.5, PN 18.2)
• There is high variation
• The goal is not zero; all hospitals have room to improve

 

Slide 41

 

CMS' ultimate goal is to shift the curve

Image: Graph showing a spike in the readmission rate being moved from the high side to the low side.

 

Slide 42

 

Conclusion

• Active work to develop VBP programs that include outcome measures
• Greatest numbers of outcome measures in inpatient hospital and other provider settings
• Fewer physician outcome measures
• Outcome measures
  • Broader reach than process measures
  • Meaningful to consumers
  • Present issues such as risk adjustment and sufficient numbers and how best to incorporate into VBP scoring