inpatient prospective payment system fy 2013 proposed rule: comments june 18, 2012 note: printable...
TRANSCRIPT
Inpatient Prospective Payment System
FY 2013 Proposed Rule:Comments
June 18, 2012
Note: Printable slides are posted at www.premierinc.com/advisorlive
Speaker
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Danielle A. Lloyd, M.P.H.
Vice president, policy development and analysis
Premier healthcare alliance
• Released April 24 by CMS.• Published in the May 11, Federal Register• Comments due June 25, 2012• 0.9% overall average increase in operating payments• 1.9% prospective documentation and coding offset for 2009• 0.8% prospective documentation and coding offset for 2010• 2.9% restoration of retro recoupment of 2009 payments• FY 2015 payment- retires 17 and suspends data collection for 4
quality measures, plus 5 new measures • FY 2016 payment- adds 1 new measures • No section 508 wage adjustments• No Medicare Dependent Hospital Program
FY 2013 Proposed Inpatient PPS Rule
Operating Payment Update
• 2.3% net updateo + 3.0% Market Basket Update
o - 0.8% Productivity adjustment
o - 0.1% ACA-mandated reduction
o + 0.2% documentation and coding adjustmento + 2.9% restoration of FY 2012 cut to recoup 2009 payments
o - 1.9% adjustment for FY 2013 and beyond for 2009
o - 0.8% adjustment for FY 2013 and beyond for 2010
• 0.9% avg. increase in operating payments o -0.1% SCH hospital-specific amount
o -0.3% readmissions penalty
o -0.9% lower outlier payments in FY 13
o +0.1% frontier wage index floor
o -0.1% expiration of section 508 reclassification
Documentation and coding
• Comments:– CMS has overstated the documentation and coding effect and corrections
should be made in the FY 2013 final rule.
– CMS should consider our conclusion that a portion of the case-mix change estimated by CMS is actually the continuation of historical case-mix trends rather than the effect of documentation and coding changes stemming from the implementation of MS-DRGs.
– After correction for CMS’ overestimate of the extent of documentation and coding in FY2 2008 and 2009, the final rule should apply a net adjustment to the standardized amounts of 0.92 percentage points to 3.6 percentage points.
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Outliers
• Increase in threshold by $5,040, or 22%, to $27,425.
• Comments– CMS failed to estimate the change in cost to charge ratios over
time and thus established a fixed loss threshold that is substantially too high.
– CMS should recalculate the fixed loss threshold using the June HCRIS release to significantly lower the threshold and ensure CMS does not underspend on outlier payments in FY 2013.
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Low-volume Adjustment
• Criteria revert to old methodology including 25 mile and less than 200 total discharges to obtain a 25% increase in payments
• Comments:– CMS should mitigate the impact of the expiration of the enhanced
low-volume adjustment by using its authority to adjust payments up to 800 rather than 200 discharges.
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Medicare Dependent Hospitals
• Program expires 10/1/12 unless further Congressional action
• Comments– We support CMS’ proposed special process to seamlessly covert
MDHs under the expiring program to SCH status, and further urge CMS to consider how it may similarly handle the process if Congress were to retrospectively reinstate the MDH program.
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Sole Community Hospitals
• MDHs can apply by 9/1/12 to convert to SCH status instead
• Hospitals mistakenly paid SCH rates must notify CMS and status revoked subject to reopening rules
• Comments– We concur with CMS that if a hospital is knowingly incorrectly granted SCH
status it is under an obligation to report this to CMS and should be retroactively stripped of its status subject to reopening rules.
– However, if SCH status was granted by CMS due to unclear program guidance where the facility did not know a mistake had been made by CMS, the revocation should be prospective only.
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Disproportionate Share Hospital (DSH) and Indirect Medical Education (IME)
• Including labor and delivery ancillary bed days in the calculation of bed days for DSH and IME payments
• Comments– Newborn nursery costs, days, and beds are excluded because
Medicare generally doesn’t cover infant services. Medicaid does offer extensive coverage, so it is included in calculating Medicaid hospital inpatient care costs and portion of the DPP.
– Keeping the Agency’s current policy maintains consistency between similarly-situated labor and delivery and healthy newborn nursery services that are not typically covered Medicare services.
– To remain consistent with this definition, CMS should continue to exclude these beds from the bed count.
– CMS needs to clarify its policy to ensure beds are not double counted for the same patient
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DSH/IME/GMETimely Filing of Medicare Advantage (MA) Claim
• Clarifying that no-pay bills for Medicare Advantage enrollees and other program enrollees must be timely filed for:– IME/Graduate Medical Education (GME) payments – Nursing and Allied Health payments– DSH payments
• Comments– While it is more time consuming to submit this type of bill, the
Premier alliance believes it is reasonable to apply the same timely filing requirements to no-pay bills as other Medicare Part A claims.
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Graduate Medical EducationNew Teaching Programs
• Extends GME FTE cap building period to 5 years• Apportions FTE based on time residents spend at each site
• Comments– Support proposal to expand to five years the period on which new
resident training programs’ permanent FTE counts are established.– CMS should include programs that are already in their three-year
cap building period as of October 1, 2012 in the policy extending the period to five years.
– Support proposal to calculate and apportion the permanent FTE count for new resident training programs where the residents train at more than one hospital.
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Graduate Medical EducationRedistribution of Residency Slots
• Requires redistributed slots to be half full by year three• Must meet 75% test for primary care/general surgeons by 3rd
year• Requires all slots to be used by 5th year, or lose them all
• Comments– CMS should remove the requirement to fill half the slots by the third
year of the program. – The 75-percent threshold should only be applied in the 5th year and
only to the slots that are filled – If not all of the slots are filled by the fifth year, CMS should at
minimum allow the hospital to retain the slots it did fill.
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• Comments– CMS should only maintain foreign objects retained after surgery,
air embolisms, blood incompatibility, and manifestations of poor glycemic control within the existing HAC payment policy.
– CMS should provide information about the conditions it expects to include in the HAC program under section 3008 of the ACA well in advance of FY 2015, and ensure that it does not overlap with the existing HAC penalty or VBP.
Hospital-acquired Conditions
• Adds new codes to Vascular Catheter-Associated Infection: – 999.32 Bloodstream infection due to central venous catheter, and– 999.33 Local infection due to central venous catheter.
• Comments– We support the addition of codes 999.32 and 999.33 in the
Vascular Catheter-Associated Infection HAC.
Hospital-acquired Conditions
• Adds Iatrogenic Pneumothorax with Venous Catheterization
• Comments– Agree with limitation to code 38.93 which reflects insertion
without the use of guidance, which is not consistent with current standard of care.
– CMS should focus on the improvement of the IQR Iatrogenic Pneumothorax measure, especially given that it is expected to be included in the VBP program in the near future, rather than adding it to the HAC payment policy.
– For these reasons, Premier suggests that the proposal to add Iatrogenic Pneumothorax to the HAC payment policy be withdrawn.
Hospital-acquired Conditions
• Adds Surgical Site Infection following Cardiac Implantable Electronic Device.
• Comments– CMS should focus on the steady expansion of the NHSN SSI
measure within the IQR with subsequent inclusion in the VBP program rather than additions to the HAC policy.
– We do not believe that this meets the threshold of “high-volume.”– We do not believe that SSI Following CIED Procedures is
reasonably preventable through the application of evidence-based guidelines at this time.
– If CMS retains this HAC, limit to diagnosis code 996.61. – Withdraw the proposal to add SSI after CIED as a HAC
Hospital-acquired Conditions
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Proposed Hospital Inpatient Quality Reporting Summary
• Removes 17, adds 4 quality measures (total of 59) for FY 15 payment – Chart-abstracted, remove one for total of (36) measures– Three (3) Mortality measures – Readmissions add 2 for total of (5)– Removes (8) AHRQ measures, for total of (2) remaining measures – Four (4) Structural measures– Removes (8) Hospital Acquired Conditions measures– New topic (1) Surgical Complication claims-based measure– New topic (1) Perinatal care– (1) Efficiency measure– (1) HCAHPS (adds 5 questions within HCAHPS composite)
• Adds 1 quality measures (total of 60) for FY 16 payment – Safe Surgery Checklist Use
Proposed Hospital Inpatient Quality ReportingComments
• We support CMS’ efforts to streamline the IQR program and align measures across programs.
• ICD-10 codes– Release re-specified existing Hospital IQR measures for comment and ensure that new
measures developed for payment determination in FY 2016 (measurement period CY 2014) and beyond are developed using the new code sets.
– Provide details on its plans to alter the quality measures within the Hospital IQR program based on ICD-10 and implement conforming changes within the VBP.
• Measure adoption in VBP– There may be situations where measures may be appropriately included in the Hospital
IQR, but not used in payment policies such as VBP. Thus, measures in the Hospital IQR should not be routinely included in payment policies such as VBP without notice and comment opportunities.
• Maintenance of technical specifications for quality measures– If CMS provides sufficient guidance and warning to hospitals and maintains the notice
and comment period for more substantial changes, we support the use of subregulatory guidance to implement minor modifications as a result of the NQF measure maintenance process.
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Removal of IQR Measures FY 2015 Payment
• Chart-abstracted propose to remove SCIP-VTE-1: Surgery patients with recommended VTE prophylaxis ordered
• Comments– Support the removal of SCIP-VTE-1 from the Hospital IQR program
as it was not recommended for continued endorsement by NQF and SCIP-VTE-2 is closer to the outcomes.
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Removal of IQR Measures FY 2015 Payment
• Propose to remove 16 claims-based measures:• 8 HACs
• Comments:– Support the removal of HACs from the Hospital IQR program that
are redundant with other measures, based on claims data.– Urges CMS to focus on risk-adjusted, rate-based measures of
HACs as part of the Hospital IQR program.
Hospital Acquired Condition Quality Measures
Air Embolism Foreign Object Retained after Surgery
Blood Incompatibility Manifestations of Glycemic Control
Catheter-Associated UTI Pressure Ulcers Stage III or IV
Falls and Trauma Vascular Catheter Associated Infections
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Removal of IQR Measures FY 2015 Payment
• AHRQ measures– IQI-11 Abdominal aortic aneurysm repair mortality rate – IQI-19 Hip Fracture Mortality Rate– IQI-91 Mortality for selected medical conditions (composite)– PSI-06 Iatrogenic Pneumothorax – PSI-14 Post-operative Wound Dehiscence– PSI-15 Accidental Puncture or Laceration – PSI-11 Post Operative Respiratory Failure – PSI-12 Post Operative PE or DVT – IQI-11 Abdominal aortic aneurysm repair mortality rate– IQI-19 Hip Fracture Mortality Rate– IQI-91 Mortality for selected medical conditions (composite)
• Comments– Support reduction of redundancy by removing 5 PSI and 3 IQI
AHRQ measures.– However, we continue to have fundamental concerns with the AHRQ
PSI composite that is also proposed for use in VBP.
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HCAHPS
• HCAHPS propose adding– Care Transition Measure which has 3 questions relating to my
healthcare needs after discharge, understanding how to manage my health, and understand the purpose of my medications
• Comments– CMS should not add the three Care transitions questions to
HCHAPS before releasing evidence supporting their validity and materiality to the Hospital IQR program.
HCAHPS
• Propose adding two questions to “About you” section – Were you admitted to this hospital through the Emergency Room– Rating of mental or emotional health
• Comments– Support collection of the ER data to make a patient-level adjustment to the
HCAHPS scores, but urge CMS to work with NUBC to collect on claim.– Agree adjustment for mental health would likely be appropriate as
depression has been linked to lower HCAHPS scores. – Do not support the collection of this question until CMS provides evidence
that the question both answers the intended question and is systematically related to scores.
– CMS should immediately conduct analyses to determine if further patient adjustments, such as acuity, are warranted and release the results to the public for comment on the appropriateness of including such adjustments
in the future.
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Proposed New Measures for FY 2015 Payment
• Adds three claims-based outcome measures
• Comments– Hip/Knee Surgical Complications
• Support inclusion in IQR program for FY 2015, but not for VBP.– Hip/Knee Readmissions
• Support inclusion in IQR program for FY 2015, but not for VBP.• CMS should use three years of data as it yields more robust and
reliable results.– Hospital-wide Readmissions
• CMS should not include the measure in IQR program.– Lack of consensus during NQF review process.– Concerns about usability given time lag and low predictive power.– Potential for unintended consequences given that it is not
sufficiently risk adjusted.
Proposed New Measures for FY 2015 Payment
• Adds one chart-based measure
• Comments– Perinatal Care measures
• Support the addition of the Perinatal Care measure to the Hospital IQR for FY 2015.
– Clarifications Regarding CLABSI and CAUTI Measures• CMS should retain the existing specifications and confine the
data collection for CLABSI and CAUTI to ICUs within acute care.
– Previously finalized measure Healthcare Personnel Influenza Vaccination• CMS should delay reporting this measure on Hospital Compare
so hospitals can gain experience with the revised measure and data collection process.
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Proposed New Measure for FY 2016 Payment
• Adds one measures for FY 2016 payment determination
• Comments– Safe surgery checklist
• We agree with CMS that it is important to align measures across settings through common measures such as a safe surgery checklist.
• Support the adoption of the safe surgery checklist in the Hospital IQR program if a particular checklist is not mandated.
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Corrections, Appeals, and ValidationComments
• Validation of HAI measures– Agree with separate HAI validation from chart-abstracted measures.– CMS should consider ways in which to reduce the resource
intensity of developing the candidate records by the hospitals.– Validators for HAI should be specifically trained in the collection of a
HAI event, and preferably have hospital experience with infection control. Moreover, CMS should ensure that inter-rater reliability is tested for this new process to ensure accuracy.
• Reduced Base Sample Size and Targeted Sampling– We support CMS’ proposal to reduce the number of hospitals
subject to random validation and establish criteria to target hospitals based on data analyses.
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Hospital Value-Based Purchasing Immediate Jeopardy
• Hospitals cited through the Medicare Survey and Certification process for deficiencies during any performance period related to that payment year that pose an “immediate jeopardy” are excluded from VBP.
• Comments– CMS should establish mutually exclusive performance periods for
each payment year for the purposes of the IJ exclusion to avoid precluding additional hospitals from participating in the VBP program than intended by Congress.
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Hospital VBPFY 2013 Payment
• FY 2013 incentive payments estimated at $956 million
• Payment adjustment to wage-adjusted DRG operating payment amount plus any applicable new tech add-on
• Does not include IME, DSH, outlier, or low volume hospital adjustments
• CMS is proposing to reprocess claims submitted prior to January 1, 2013 for FY 2013 VBP payment adjustment
• CMS will incorporate the value-based incentive payment adjustments into the claims processing system starting January 1, 2013
Hospital VBPFY 2013 Payment Process
• Comments– Base Operating Amount
• Adjustment factor applied to wage-adjusted base operating DRG payment amount (includes new tech add-on payment only, no adjustments for DSH, IME, outlier, or low volume hospitals)
– Funding pool• Support this process for routinely calculating the VBP funding pool.
– Payment Adjustments• Understand the need to delay the implementation of incentive payments
in the first year of the program due to operational concerns and supports CMS’ proposal to delay the payment reduction until the two adjustments can be implemented contemporaneously.
– Claims reprocessing• Support the reprocessing of the first quarter FY 2013 claims to account
for the VBP adjustment, but urge CMS to do so as quickly as possible to reduce the burden and cost to providers.
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Hospital VBPReview and Correction Process
• Proposing process for claims-based measure rates– Confidential report with calculations and a discharge-level file– 30 day review period to notify CMS of suspected errors in calculation– No corrections or additions to the claims data
• TPSs and Condition-Specific and Domain- Specific Scores – 30 day review and notify CMS of any calculation errors– Prerequisite to being able to submit an appeal
• Comments– We support CMS’ proposal for review of VBP rates and scores.– We support TPS report, and 30 day preview period; and submission
of a correction be a prerequisite to appeal the score. – Appropriate to use the corrections process to reconsider whether a
hospital is eligible to participate in the VBP program for a year.
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Hospital VBPFY 2015 Proposed Measures
• Determined SCIP-Inf-10: Surgery Patients with Perioperative Temperature Management now topped out
• Removing SCIP-VTE-1 from FY 2014 VBP because of similarity to SCIP-VTE-2
• Adding 1 clinical process of care measure – AMI-10: Statin Prescribed at Discharge
• Retaining all 8 HCAHPS for patient experience• Adding 2 outcomes measures – PSI-90, the AHQR PSI
composite measure and the CLABSI: Central Line-Associated Blood Stream Infection measure
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Hospital VBPFY 2015 Proposed Measures
• Comments– Agree with the removal of SCIP-VTE-1 from the Hospital IQR program,
and thus agrees to its removal from VBP.– Agree that SCIP-Inf-10 should not be included in VBP.– Support the assumption that a measure will continue as part of VBP unless
proposed for removal through rulemaking.– AMI-10 and CLABSI
• Support the addition of the AMI-10 and CLABSI measures to VBP, if the truncated baseline and performance periods are only for FY 2015.
– AHRQ• CMS should not use the PSI composite measures in VBP.• At minimum, CMS should push off the use of AHRQ composite
measure until FY 2016 when longer baseline and performance periods can be utilized.
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Hospital VBPFY 2015 Proposed Measures
• Comments– Efficiency
• Develop efficiency measure that is limited to factors within the hospital’s control and sufficiently risk adjusted.
• Do not include a full Parts A and B per beneficiary spending measure in VBP at this time given lack of testing and available data.
• If CMS chooses to include measure, it should wait until FY 2016 so that longer baseline and performance periods can be used.
– Baseline and performance periods in FY 2015• We continue to be concerned about a truncated baseline and
performance period in FY 2015 and the possible unintended consequences.
• CMS should continue proposing performance periods and standards within rulemaking to ensure public input until a more stable pattern is established within the VBP program.
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Hospital VBPFY 2015 Proposed Measures
• Comments– Domain weights in FY 2015
• Patient experience of care domain within VBP should not exceed 20 percent and that CMS should conduct further research to improve the population adjustment methodology of the survey.
• If CMS were to nevertheless include this measure as the sole measure within an efficiency domain, it should not be weighted more than 5 percent.
• Premier proposes the following alternative weighting scheme for calculation of the total performance score for FY 2015:
– Clinical process of care weight of 65 percent, – HCAHPS weight of 20 percent, – Outcome weight of 15 percent, and – Efficiency weight of 0 percent.
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Hospital VBPFY 2016 Proposed Measures and Domains
• Retains all the mortality measures finalized for FY 2014 and PSI-90 measure
• Not proposing to adopt CLABSI measure for FY 2016, but may do so in future rulemaking
• Will allow for longer performance period and collect more data, proposing start of performance period Oct 1, 2012
• Six domains for FY 2016: – Clinical Care; – Person- and Caregiver-Centered Experience and Outcomes;– Safety; – Efficiency and Cost Reduction; – Care Coordination; and – Community/Population Health
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Hospital VBPFY 2016 Proposed Measures, Domains and Timelines
• Comments– Measures and Domains for FY 2016
• We are unsure why CMS specifically noted that it is not proposing the CLABSI measure for FY 2016, but urge CMS to retain this measure and to confine it to ICUs only.
• Do not support the use of the AHRQ PSI composite as it is currently specified.
• Support the alignment of domains with National Quality Strategy, but believe premature to do so.
• Do not think we have enough information to make informed comments on the weighting of these domains yet.
– Baseline and performance period in FY 2016• Support 24-month long performance periods for both AHRQ and
mortality measures, and believes CMS should not incorporate these measures until such time frames can be achieved.
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Readmissions Payment Adjustment
• Readmission Reduction Program hospital-specific payment adjustment factor will be applied to inpatient claims will begin on Oct 1, 2012
• Adjustment factor applied to wage-adjusted base operating DRG payment amount (includes new tech add-on payment only, no adjustments for DSH, IME, outlier, or low volume hospitals)
• Payment to MDH/SCH will exclude the difference between hospital-specific cost-based rates and national wage-adjusted rates for these hospitals
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Readmissions Payment Adjustment
• Comments– Exclusions
• CMS does not make sufficient exclusions within measures.• CMS should actively and quickly work with the National Uniform Billing
Committee to enable CMS, and other payors, to track planned readmissions through claims and alter the measure specifications to exclude additional cases for which the hospital should not be penalized under this policy.
– Risk Adjustment• We continue to urge the agency to incorporate additional characteristics, such
as socio-economic status, into its patient-adjustment methodology, both to comply with the law and to avoid penalizing the very providers who are trying to eliminate disparities in health care.
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Readmissions Payment Adjustment
• Comments– Base operating amount
• Support CMS’ proposal exclude IME, DSH, outliers, low-volume adjustment, additional payments made due to status as a sole community hospital, and include new technology add-on payments.
– Alternative Approaches for Adjustment• Strongly recommend CMS calculate the payment penalty based
on a blended rate for dual-eligibles and non-dual-eligibles.• If not CMS should stratify hospitals based on dual-eligibles
served for the Readmission Reduction Program.
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Danielle Lloyd, M.P.H.
Vice president, policy development & analysis
Premier healthcare alliance
Questions?
Appendix
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Capital Payment Update
• 0.7% net update o + 1.3% Capital Input Price Index
o - 0.8% document and coding adjustment
o +0.2% outlier
• - 0.2% average decrease in capital payments
Wage Index
• Section 508- expired wage adjustments March 31, 2012
• Frontier Floor- applies 1.0 floor in MT, ND, SD, WY
• Imputed Floor- new methodology for floor calculation for all-urban states to benefit Rhode Island
• Report to Congress- summarizes the Acumen-prepared report released in April recommending hospital-specific wage indices based on commuting-based wage index
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New Technology Add-on Payments
• FY 2013 continued technologies:– AutoLitt™ laser for brain tumor removal
• FY 2013 new applications:– Voraxaze® treats toxic methotrexate concentrations as a
result of renal impairment – DIFCID™ tablets treat Clostridium Difficile-associated
disease– Zilver® PTX® Drug Eluting Stent treats peripheral artery
disease of the above-the-knee femoropopliteal arteries – Zenith® Fenestrated Abdominal Aortic Aneurysm
Endovascular Graft
New Technology Add-on PaymentsComments
• Premier recommends CMS consider Voraxaze® as a new technology in its consideration for granting new technology add-on status.
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Hospital VBPCorrections, Appeals, and ValidationComments
• Appeals process– We support CMS’ proposal for the appeals process and the ability
of hospitals to submit an appeal for a CMS rejected data correction request. We note that CMS identified a list of specific items that can be appealed, however stated that appeals on other matters could be submitted after the correction process ends.
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Hospital VBPFY 2015 Proposed Measures
• The first measures in new domain: Efficiency
• Suppressed for FY 2014 payment
• Medicare Parts A and B spending per beneficiary between 3 days prior to inpatient admission and 30 days post-hospital discharge– Adjusted using age and severity of illness
• Calculating the ratio:
Hospital’s Medicare spending per beneficiary
National Median Medicare spending per beneficiary
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Hospital VBP FY 2016 Proposed Quality Domains
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Proposed 2016 Domain Measures Mapping to DomainDomain Weight
Clinical Care • All VBP Clinical Process of Care Measures except HF-1: Discharge Instructions
• Mortality Measures
TBD
Person- and Caregiver-Centered Experience
and Outcomes
• HCAHPS TBD
Safety • AHRQ PSI 90 • CLABSI
TBD
Efficiency and Cost Reduction
• Medicare spending per beneficiary TBD
Care Coordination • HF-1 Discharge Instructions TBD
Community Population Health
None TBD
Copyright © 2012 Premier, Inc. All rights reserved.
Hospital VBP FY 2016 Proposed Time Periods
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Measure Baseline Period Performance Period
Mortality Measures
October 1, 2010 – June 30, 2011 October 1, 2012 – June 30, 2014
AHRQ PSI 90 October 1, 2010 – June 30, 2011 October 1, 2012 – June 30, 2014
All other measures
TBD TBD
Copyright © 2012 Premier, Inc. All rights reserved.
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Hospital VBP FY 2016 Proposed Time Periods
Domain Weight Baseline Period Performance Period
Clinical Care• Mortality
Measures
TBD October 1, 2010 – June 30, 2011 October 1, 2012 – June 30, 2014
Person- and Caregiver-Centered Experience and Outcomes
TBD TBD TBD
Safety• AHRQ PSI
TBD October 1, 2010 – June 30, 2011 October 1, 2012 – June 30, 2014
Efficiency and Cost Reduction
TBD TBD TBD
Care Coordination
TBD TBD TBD
Community Population Health
TBD TBD TBD
Copyright © 2012 Premier, Inc. All rights reserved.
Hospital VBPFY 2015 Proposed Minimums
• 25-case minimum for outcomes domain mortality measures (change from 10-case minimums for FY 2014)
• AHRQ PSI composite measure – three cases for any of the underlying indicators
• CLABSI measure – 1 predicted infection during applicable period
• Minimum of 2 measures in outcomes domain to calculate a score
• 25-case minimum for Medicare Spending per Beneficiary
• Case minimums for Clinical Process of Care and Patient Experience stay the same as FY 2014
• Hospitals with sufficient data in at least 2 domains will receive a total performance score (TPS)
• The TPS will be reweighted proportionately to ensure the TPS is still scored out of 100 points
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Readmissions Applicable Hospitals
• All hospitals paid under the IPPS are subject to the readmission payment reduction. Applicable hospitals DO NOT include:– Children’s, Cancer, LTCHs, IRFs, IPFs, CAHs, hospitals located in
Puerto Rico
• CMS is establishing criteria for evaluation of an annual report to determine whether Maryland can be exempted
• MDHs and SCHs, as well as Indian Health Services hospitals, are considered applicable hospitals
• Admission and readmission only counted if they occur in applicable hospitals, so IPPS readmission rates may differ slightly to what is posted on Hospital Compare.
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Readmissions Adjustment Calculation
• Aggregate payments for excess readmissions = [Sum of DRG payments for AMI * (Excess Readmission Ratio for AMI – 1)] + [Sum of DRG payments for HF * (Excess Readmission Ratio for HF – 1)] + [Sum of DRG payments for PN * (Excess Readmission Ratio for PN – 1)]
• Aggregate payments for all discharges = sum of DRG payments for all discharges
• Ratio = 1-(Aggregate payments for excess readmissions/Aggregate payments for all discharges)
• Readmissions Adjustment Factor for FY 2013 is the greater of the ratio or 0.99 (floor adjustment factor for FY 2013).
The most DRG base operating payment can be reduced on a claim due to the Readmission Adjustment Factor in FY 2013 is 1 percent.
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Readmissions Report Review Process
• Excess readmission ratios used for the program will be made available during the rulemaking cycle
• Confidential reports and discharge-level information to applicable hospitals will be delivered to QualityNet accounts by June 20, 2012
• Hospitals get 30 days to review and submit corrections
• Discharge level information will allow hospitals to review excess readmissions ratio calculations and facilitate quality improvement efforts
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ASC Quality Reporting Program
• Ambulatory Surgical Center Quality Reporting Program– CMS should develop a validation process for the QDC data ASCs
will submit as a part of the quality reporting program.
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Questions?