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
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
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)
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
9
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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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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