Embracing our

Brave New World

Orlando Chapa, RN, MS, NE-BC

Fall 2014

Objectives

1. Describe healthcare reform and the effects on the

pediatric Registered Nurse.

2. Discuss the Registered Nurse’s role in the health care

system response to reimbursement, pay for

performance, and APRDRG changes.

3. Describe the Registered Nurse’s role in operational

changes with attention to HACs, readmissions and

meaningful use.

International Comparison of Spending on Health, 1980–2005

$-

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

United States

Germany

Canada

France

Australia

United Kingdom

0

2

4

6

8

10

12

14

16

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

United States

Germany

Canada

France

Australia

United Kingdom

* PPP=Purchasing Power Parity.

Data: OECD Health Data 2007, Version 10/2007.

Average spending on health

per capita ($US PPP*)

Total expenditures on health

as percent of GDP

61

EFFICIENCY

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 61

http://www.usdebtclock.org/

Data: Two-year averages 1999–2000, updated with 2007 Current Population Survey correction, and 2005–2006 from the

Census Bureau’s March 2000, 2001 and 2006, 2007 CPS.

WA

OR

ID

MT ND

WY

NV

CA

UT

AZ NM

KS

NE

MN

MO

WI

TX

IA

ILIN

AR

LA

AL

SC

TNNC

KY

FL

VA

OH

MI

WV

PA

NY

AK

MD

MEVT

NH

MA

RI

CT

DE

DC

HI

CO

GAMS

OK

NJ

SD

WA

OR

ID

MT ND

WY

NV

CA

UT

AZ NM

KS

NE

MN

MO

WI

TX

IA

ILIN

AR

LA

AL

SC

TNNC

KY

FL

VA

OH

MI

WV

PA

NY

AK

ME

DE

DC

HI

CO

GAMS

OK

NJ

SD

19%–22.9%

Less than 14%

14%–18.9%

23% or more

1999–2000 2005–2006

MA

RI

CT

VTNH

MD

Percent of Adults Ages 18–64 Uninsured by State

ACCESS: PARTICIPATION

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 52

7681

8884

89 89

99 97

88

97

109 106

116 115 113

130134

128

115

65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110

0

50

100

150

Fra

nce

Japan

Aus

tral

ia

Spa

in

Ital

yC

anad

aN

orw

ayN

ether

lands

Sw

eden

Gre

ece

Aus

tria

Ger

man

yFin

land

New

Zea

land

Den

mar

k

Uni

ted K

ingdo

m

Irel

and

Por

tugal

Uni

ted S

tate

s

1997/98 2002/03

Deaths per 100,000 population*

* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.

See report Appendix B for list of all conditions considered amenable to health care in the analysis.

Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality

files (Nolte and McKee 2008).

Mortality Amenable to Health Care

HEALTHY LIVES

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 4

7.2 7.0 6.9 6.8 7.0 6.8 6.8

10.3

11.1

10.2 9.9 9.99.6

10.1

5.3 5.1 5.0 4.9 4.8 4.7 4.7

0

4

8

12

1998 1999 2000 2001 2002^ 2003 2004

U.S. average Bottom 10% states Top 10% states

National Average and State Distribution International Comparison, 2004

2.8 2.83.1 3.2 3.3

4.4

5.3

6.8

Japan

Iceland

Sweden

Norway

Finland

Denmark

CanadaU.S

.

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 5

Infant Mortality Rate

Infant deaths per 1,000 live births

^ Denotes baseline year.

Data: National and state—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2003, 2004, 2005,

2006, 2007a); international comparison—OECD Health Data 2007, Version 10/2007.

HEALTHY LIVES

Healthy Life Expectancy at Age 60, 2002

2220 20 20 20 20 19 19 19 19 19 19 19 19 18 18 18 18 18 18 18 17 1718 17 17 16 17 17 16 16 16 16 16 16

1816 16 16 16 16 15 15 15 15

14

0

10

20

30

Japan

Switz

erla

nd

France

Spain

Swed

en

Aus

tral

ia

Italy

Aus

tria

Can

ada

Bel

gium

Ger

man

y

Nor

way

Icel

and

Finla

nd

Net

herla

nds

New

Zea

land

Gre

ece

Uni

ted K

ingdo

m

Uni

ted S

tate

s

Portu

gal

Irela

nd

Den

mar

k

Cze

ch R

epub

lic

Women Men

Years

Note: Indicator was not updated due to lack of data. Baseline figures are presented.

Data: The World Health Report 2003 (WHO 2003, Annex Table 4).

Developed by the World Health Organization, healthy life expectancy is based on

life expectancy adjusted for time spent in poor health due to disease and/or injury

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 6

HEALTHY LIVES

Meaningful Use Staged Approach

Methodist Mansfield

These signs are

posted outside every

elevator.

When asked why,

one RN responded

“because the families

were asking so often”

Hospital Acquired Conditions

To Be Addressed

1. Injuries from Falls

2. VAP – Ventilator Associated Pneumonia

3. CAUTI – Catheter Associated Urinary Tract Infections

4. CLABSI – Catheter Line Associated Blood Stream Infections

5. PU – Pressure Ulcers

6. VTE – Venous Thromboembolism

7. ADE – Adverse Drug Events

8. Preventable Readmissions

9. SSI – Surgical Site Infections

10. SSE – Serious Safety Events

(CMS, n.d.; Scott, 2007)

Ohio Clinical Collaborative

Arkansas Children’s Hospital

Children’s Hospital Los Angeles

Lucile Packard Children’s Hospital at

Stanford

Rady Children’s Hospital

Children’s Hospital Colorado

Nemours A.I. duPont Hospital for Children

Children’s Healthcare of Atlanta

Riley Children’s Hospital

Children’s Mercy Hospitals and Clinics

Boston Children’s Hospital

Helen DeVos Children’s Hospital

University of Michigan C.S. Mott Children’s

Hospital

Children's Hospitals and Clinics of

Minnesota

St. Louis Children's Hospital

Steven and Alexandra Cohen Children's

Medical Center

Wake Forest Baptist Health Brenner

Children’s Hospital

Akron Children’s Hospital

Cincinnati Children's Hospital and Medical

Center

Cleveland Clinic Children’s Hospital

Dayton Children's Hospital

Mercy Children's Hospital

Nationwide Children's Hospital

Rainbow Babies & Children's Hospital

ProMedica Toledo Children's Hospital

Children's Hospital of Philadelphia

Children's Hospital of Pittsburgh

Children's Hospital at Vanderbilt

Cook Children's

Dell Children's Medical Center of Central

Texas

Texas Children's Hospital

Primary Children's Medical Center

Seattle Children's Hospital

Children's National Medical Center

Children's Hospital Wisconsin

HCAHPS

Hospital Consumer Assessment of Healthcare

Providers and Systems. CMS and AHRQ

developed standardized instrument to measure

patient perceptions of care.

Aggregate data is reported/posted quarterly

Measurement reports only “top box” data

ACA established plan to transition providers to a

3 tiered HCAHPS pay-for-performance.

www.medicare.gov/hospitalcompare

APR –DRG

September 1, 2013, Inpatient Traditional

Medicaid will go from paying claims on a Cost

Basis to an APR-DRG rate

Diagnosis-related group (DRG) is a system to

classify hospital cases into one of 350 groups.

Uses Severity of Illness (SOI) and Risk of

Mortality (ROM) subclasses

Kaiser Foundation, n.d.

APR DRG Classification

MDC Major Diagnostic Category

Base APR DRG

Four Severity of Illness Subclasses

1. Minor

2. Moderate

3. Major

4. Extreme

Four Risk of Mortality Subclasses

1. Minor

2. Moderate

3. Major

4. Extreme

Why does coding & documentation

become more important

SDA * relative weight = reimbursement

APR-DRG 003 Bone Marrow Transplant

003-01 relative weight 9.0159

003-02 relative weight 13.1525

003-03 relative weight 19.6157

003-04 relative weight 34.4865

• 01= $11,000*9.0159= $99,174.90

• 02= $11,000*13.1525= $144,677.50

• 03= $11,000* 19.6157= $215,772.70

• 04= $11,000* 34.4865=$379,351.50

(Sibley, T., 2013)

What is the difference between Cost

Based Model and APR DRG?

Patient with APR-DRG 661.3 Coagulation & platelet disorder

Total Charges of $877,411

Under cost based model we were paid rates which were 39% of billed charges in FY 12 totaling $342,190

Under the APR-DRG payment we will receive for APR-DRG 661.3

SDA * relative weight

$11,000 * 4.1452= $45,597

A unfavorable difference of $293,593

(Sibley, T., 2013)

Patient with APR-DRG 661.1 Coagulation & platelet disorder

Total Charges of $18,661

Under cost based model we were paid TEFRA rates which were 39% of billed charges in FY 12 totaling $7,278

Under the APR-DRG payment we will receive for APR-DRG 661.1

SDA * relative weight

$11,000 * 1.0026= $11,029

A favorable difference of $3,751

Example of Payment differences

(Sibley, T., 2013)

Patient with APR-DRG 020-4, Craniotomy for Trauma

Total Charges of $437,506

Under cost based model we were paid TEFRA rates which were 39% of billed charges in FY 12 totaling $170,627

Under the APR-DRG payment we will receive for APR-DRG 020-4

SDA * relative weight

$11,000 * 10.7124 = $117,836

A unfavorable difference of $52,791

Example of Payment differences

(Sibley, T., 2013)

References

Centers for Medicare and Medicaid Services [CMS]. (n.d.) Retrieved

from http://www.cms.gov/

HCAHPS (n.d.) Retrieved from www.hcahpsonline.org

Health IT.gov (n.d.). Retrieved from http://www.healthit.gov/

Kaiser Family Foundation (n.d.). Retrieved from http://kff.org/

Meadows, T. (2013). NEC presentation: Information Services

Overview. Cook Children’s Health Care System.

Scott, D. R. (2009) The direct medical costs of HAI in US hospitals.

CDC. Retrieved from

http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf

Sibley, T. (2013) APR-DRG 101. [PowerPoint slides]. Retrieved from:

Cook Children’s Health Care System.

Questions?

Possible inclusion

Davis, K., Schoen, C., & Stremikis, K.

(2010). Mirror, mirror on the wall: How the

performance of the US. health care system

compares internationally, 2010 update. The

Commonwealth Fund Report, Retrieved

from http://www.commonwealthfund.org/Pu

blications/Fund-Reports/2010/Jun/Mirror-

Mirror-Update.aspx?page=all

Medical, Medication, and Lab Errors, Among Sicker Adults

3432

1921

22

2628

30

0

10

20

30

40

GER NETH UK NZ CAN AUS

International Comparison

AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom.

Data: 2005 and 2007 Commonwealth Fund International Health Policy Survey.

EXHIBIT 16

2005 2007

United States

QUALITY: SAFE CARE

Percent reporting medical mistake, medication error, or lab error in past two years

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 30

Waiting Time to See Doctor When Sick or Need Medical Attention,

Among Sicker Adults

47 46

7469

6358 57

32

0

25

50

75

100

NZ NETH GER AUS UK CAN

International Comparison

AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom.

Data: 2005 and 2007 Commonwealth Fund International Health Policy Survey.

EXHIBIT 16

2005 2007

United States

QUALITY: PATIENT-CENTERED, TIMELY CARE

Percent of adults who could get an appointment on the same or next day

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 41

58

12

2125 26

37

0

25

50

75

NETH UK CAN GER NZ AUS US

69

18

24

32 30

52

38 7

1822 21

25

NETH UK CAN GER AUS NZ US

Below average income Above average income

51

* Did not get medical care because of cost of doctor’s visit, skipped medical test, treatment, or follow-up because of cost, or did

not fill Rx or skipped doses because of cost.

AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom; US=United States.

Data: 2007 Commonwealth Fund International Health Policy Survey.

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 51

Access Problems Because of Costs, By Income, 2007

Percent of adults who had any of three access problems* in past year because of costs

ACCESS: PARTICIPATION

Physicians’ Use of Electronic Medical Records

17

28

9892

89

79

42

23

0

25

50

75

100

NETH NZ UK AUS GER CAN

International Comparison

AUS=Australia; CAN=Canada; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom.

Data: 2001 and 2006 Commonwealth Fund International Health Policy Survey of Physicians.

EFFICIENCY

Percent of primary care physicians using electronic medical records

2001 2006

United States

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 73