Cloudy with a Chance of Readmissions Penalties...Cloudy with a Chance of Readmissions Penalties Lynn...
Transcript of Cloudy with a Chance of Readmissions Penalties...Cloudy with a Chance of Readmissions Penalties Lynn...
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Cloudy with a Chance of Readmissions Penalties Lynn Smith, Clinical Excellence Executive, Midas+ Solutions
Alycia R James, VP Care Performance Transformation Group, Midas+ Solutions
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Objectives • Be able to describe the CMS readmission
reduction program penalty calculation • Be able to explain the analytics and insights
available to predict performance and target areas of opportunity for improvement
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Readmissions! Readmissions!
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Shifting From Volume to Value • Historically
readmissions were a revenue stream
• DRG-based payment caused intense focus on decreasing LOS with no provisions for readmissions
• “Frequent Flyers” common
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• Hospitals struggle to make the shift – Not lack of intent/will – Like trying to turn a big ship quickly
• No longer responsible for JUST care within their four walls
• “Out of our control” no longer adequate
*Affordable Care Act (3/20/10) instigates MAJOR paradigm shift
*Section 3052 of Affordable Care Act established the Hospital Readmissions Reduction Program
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Multiple TOP Priorities With Bottom-line Impact
• Value-Based Purchasing (VBP) • Hospital Readmissions Reduction Program
(HRRP) • Hospital Acquired Complications Reduction
Program (HACRP)
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Payment Adjustment Hierarchy Payment reductions are made in a hierarchical order: 1. Value Based Purchasing 2. Hospital Readmissions
Reduction Program 3. Hospital Acquired
Complications Reduction Program
HOWEVER: • VBP and HRRP payment
adjustments are made independently of each other.
• Each applied to the base operating DRG payment amount.
• HAC adjustments are made after VBP and HRRP
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Plethora of Published Data – 906,000 results on Google search
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Excessive Readmission Ratios Values > 1.0 = Financial Penalties
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Your Hospital ERR Other Hospitals
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Hospital Readmission Reduction Program Penalties Forecasted to Impact More
Hospitals in Future
• Acute Myocardia Infarction
• Pneumonia
• Heart Failure
• Total Hip and Knee
• COPD
• CABG
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Excess Readmission Ratio’s > 1
in ANY one of the clinical cohorts
results in financial penalties
Excess Readmission Ratio = Predicted /Expected
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A Primer on Predicted and Expected
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Predicted FY 2016
Excess Readmission Ratio = Predicted /Expected
=
Your patient’s risk factors for FY 2016 Part A & B Claims
(July 1, 2010 – June 30, 2014) x
Risk Coefficients
(July 1, 2011 – June 30, 2014)
+
Your hospital
provider Intercept
(July 1, 2011 - June 30, 2014)
Expected FY 2016 = +
Average hospital provider intercept for all Section(d) Hospitals in US
(July 1, 2011 – June 30, 2014)
Your patient’s risk factors for FY 2016 Part A & B Claims
(July 1, 2010 – June 30, 2014)
x
Risk Coefficients
(July 1, 2011-June 30, 2014)
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Midas+ Xerox
Hospital Readmission Penalty Forecaster
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Hospital Readmission Penalty Forecaster Service explained
• Delivered via presentation with quarterly updates • Generated by Midas+ proprietary methodology • Executive-level analysis insights
– System-level rollups forecasts – Individual hospital view by cohort – Cohort detail – Cohort trend – Non-same hospital readmissions trend
• Cohort detail at patient-level files delivered
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How It Works • Utilizes advanced analytics, machine
learning technology, and clinical executive insight
• Informs you of your anticipated readmission penalties up to two years before your hospital-specific reports
• Help you focus improvement resources most effectively
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Midas+ Predictive Analytics Creates a Proactive Response Strategy……
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Risk Factors Risk Coefficients
Midas+ Clients see their results
CMS Hospital Specific Reports
Adjusted Payments
Begin
July 2012 to June 2015
July 2011 to June 2015
October 2016 TODAY! August
2016
Midas+ Hospitals can
prioritize and intervene high risk populations to impact
financial penalties two years before they apply!
FY 17 Risk Factors and Risk Coefficients
calculated from Medicare Part A & B Claims July 1, 2011 – Dec 31, 2013
+ Midas+ Data Jan 1, 2014, to date
+ Midas+ Predictive Analytics
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Understanding Your Tipping Point
• Which populations are at greatest risk?
• How many readmissions are too many?
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Readmission Penalty Forecaster Uses Medicare Part A & B Claims Data • Includes risk Factors and risk coefficients
Also includes Midas+ data from January 2014 through latest harvested quarter
RPF measures available to Readmission Penalty Forecaster clients only; delivered as a service including quarterly presentations and executive level insights
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Unique Features
• Combines CMS Claims data with YOUR data (DV quarterly harvest) to identify patient level
• Provides visibility and predictive adjustment for “Non-Same” readmissions
• Defines how many readmissions are EXCESS causing penalties
• Calculates Expected Probability of Readmission to each INDEX case
16% 7%
33% 29%
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Process • Contract Signed
• Financial Line Item data received
• Your Hospital Model developed/Data Generated by Advanced Analytics
• Data to Care Performance Transformation – Insights
• Presentation of YOUR results via web ex • Follow up with delivery of patient level (by cohort)
files
FY 18 Predictions available – Newest CMS data anticipated in August, 2-4 weeks to forecast
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Financial Info Needed for Forecaster • Medicare Fee-for-Service In-Patient Volume
• FFS Part A inpatient Medicare claims as principal payer • May include Medicare Part A FFS as secondary is secondary paid • May include Medicare Part A FFS enrolled in state-buy-in program • Must NOT include Medicare Advantage or HMO
• CASE MIX for Medicare Fee for Service inpatient volume • Relative weights for DRGS that have been adjusted for transfer • Only Medicare populations previously defined
• TOTAL REVENUE for Medicare FFS Inpatient volume • By fiscal year 2012, 2013, 2014
• BASE Operating DRG VALUE for 3 years • DRG Weights x [(labor share x wage index)+(non-labor share x cost of living
adjustment)]+New technology if applicable • DO NOT include adjustments for graduate medical education, disproportionate
share, high-cost outliers or Value-Based Purchasing • Does NOT include adjustments or add-on payments for Medicaid payments to
Disproportionate Share Hospitals (DSH)
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System-level Forecast
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Individual Hospital View
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Cohort Detail
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Cohort Trend
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Patient-level Files
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SAME but Different DataVision Readmission Penalty Forecaster
DATA Hospital’s ADT/DAB All Patients with Medicare as payer
Primary: CMS Claims Secondary: Hospital’s Midas+ data CMS Claims – Medicare as principal/secondary
FACILITY Readmissions ONLY to same facility
Readmissions to same facility with adjustment for “non-same” Identification of “non-same” via Claims data
PRIMARY FOCUS
Patient care management at your facility
Predicting excess readmissions & associated penalties at the cohort & system level
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Good Enough Today May Not Be Good Enough Tomorrow
“Even if you’re on the right track, you’ll get run over if you just sit there.”
Will Rogers
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I’ve Got the Data – Now What?
• Financial planning (budget) – Reality (What is fluid/what is static?)
• Performance Improvement – Focus on “teaching” cases – Root Causation
• Expected Probability • Readmission to “Non-Same” hospitals • Discharge Disposition
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Midas+ Findings • Much variation in Expected Probability of
Readmission by Cohort – Highest doesn’t always translate to most readmissions
• CABG and TH/TK typically highest cost/case
• Being discharged to a SNF or home with Home Health no guarantee
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Importance of Documentation • Accurate & complete
documentation of patient’s clinical condition is of utmost importance
• “Not uncommonly, a measured risk-adjusted readmission rate is artificially high either because the conditions defining the cohort and/or the comorbidities defining the severity of the expected readmission rate were not documented by the provider or were not coded by the facility as to be reported, or both…” – https://www.nationalreadmissionp
revention.com/documents/snf-penalties-announced.pdf
LOST in TRANSLATION?
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Client Findings - Forecaster
• “Non-same” readmit trends
• The amount of excess readmissions only has to be 1 (in 1 cohort) to initiate penalty
• Post acute care providers importance
• The “EXPECTED” is consistently lower for FY 17 than FY 16 (window tightening) – Above average in FY 16 is not a guarantee for
FY 17 … moving target
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Quick Wins • Systems
– Communicate, communicate, communicate – “Non-same” readmissions
• What cohort is “almost” there? Minor issues
• Trends of decreasing Relative Weight/increasing provider intercepts – What Changed? Who Changed?
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Long-range Improvement Strategies • Systems
– Transparency – ID Best Practices • Community Collaboration with Post Acute
Care providers • Cohorts with major opportunity
– Process evaluation / root causation – Care Transitions
• Talk to your patients
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• There is no “one size fits all” to reduce readmissions
• Hospitals must deploy and support multiple strategies
• IMPORTANT – consistently monitor results • Reliable data is CRITICAL • The time for action is NOW – don’t delay
Summary
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Guidance in the Storm • Readmission Penalty Forecaster • Midas+ Care Performance
– Additional Hands on Deck – Impartial Root Causation – Best Practices – Collaboration – DV Data
• Process Control
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Thanks for attending. Are there any questions?
Lynn Smith, Clinical Excellence Executive, Midas+ Solutions
Alycia R James, VP Care Performance Transformation Group, Midas+ Solutions