the chickasaw nation department of health melissa gower senior advisor, policy analyst
TRANSCRIPT
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The Chickasaw Nation Department
of Health
MELISSA GOWERSENIOR ADVISOR, POLICY ANALYST
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QUALITY REPORTING MEASURESA Tribal Story
Hospital Acquired Condition (HAC) Reduction Program
Section 3008 of the ACA establishes a financial incentive program for Inpatient Prospective Payment System (IPPS) hospitals to improve patient safety by applying a one percent payment reduction to hospitals that rank in the lowest-performing percentage of all subsection (d) hospitals with respect to the occurrence of hospital-acquired conditions (HACs) that appear during an applicable hospital stay. These HACs are a group of reasonably-preventable conditions selected by CMS that patients did not have upon admission to a hospital, but which developed during the hospital stay.
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QUALITY REPORTING MEASURESA Tribal Story
The HAC program has three measures for FY2015, which are identified in the IPPS rule:
1. Patient safety indicators (PSI 90) composite measure (eight measures), consisting of:a. Pressure Ulcerb. Latrogenic Pneumothoraxc. Central Venous Catheter-Related Bloodstream
Infectionsd. Postoperative Hip Fracturee. Postoperative Pulmonary Embolism or Deep
Venous Thrombosisf. Postoperative Sepsisg. Postoperative Wound Dehiscenceh. Accidental Puncture or Laceration
2. Central line-associated bloodstream infections (CLABSI) measure
3. Catheter-associated urinary tract infections (CAUTI) measure
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QUALITY REPORTING MEASURESA Tribal Story
Beginning in 2015, the lowest-performing 25 percent of subsection (d) hospitals will receive an one percent reduction in what would have otherwise been paid under the IPPS for all discharges.
The HAC payment penalty adjustment is applied after base diagnosis-related group (DRG) payment adjustments have been calculated for the VM and Hospital Readmission Reduction programs.
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QUALITY REPORTING MEASURESA Tribal Story
The HAC Program is comprised of two measures which are weighted to a total of 100 percent.
AHRQ Patient Safety Measures (Domain 1) is weighted at 35 percent.
HAC Infection (Domain 2) is weighted at 65 percent.
For the reporting period of Jan. 1, 2012, to Dec. 31, 2013, Chickasaw Nation Medical Center (CNMC) reported zero (0) healthcare-associated infections (HAI) for both categories of central line-associated bloodstream infection (CLASBI) and catheter-associated urinary tract infection (CAUTI).
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QUALITY REPORTING MEASURESA Tribal Story
The CDC formula that is utilized to calculate Standardized Infection Ratio (SIR) is: divide the hospital’s reported number of HAIs by a hospital’s predicted number of HAIs: A hospital’s number of predicted HAIs must be
greater than or equal to one in order to calculate a SIR.
CNMC predicted number of HAIs was below one at: CLASBI: 0.620 CAUTI: 0.927
This resulted in CNMC having insufficient data and CDC not calculating an SIR for this measure. Subsequently, this measure did not calculate into the CNMC’s Domain 2 score or Total HAC score.
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QUALITY REPORTING MEASURESA Tribal Story
Because CNMC had zero in Domain 2, Domain 1 was weighted at 100 percent, instead of 35 percent.
By removing Domain 2 from the CNMC total HAC score for FY2015, higher weighting was placed on Domain 1, thus resulting in a total hospital HAC score of greater than 7. This resulted in CMNC facility being subject to a payment reduction of one percent.
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QUALITY REPORTING MEASURESA Tribal Story
The Appeal Process:
CNMC decided since the one percent payment reduction was because of a faulty methodology, we would appeal. After researching, the following appeal process was followed.1. Appeal to CMS DTA, which forwarded to the program staff for a
response. The response was detailed with the following highlights:a. It is important and appropriate to make use of the data that
are available for each hospital, as long as the minimum thresholds for each measure are met.
b. CDC has developed a new analytic method that would have lower minimum data threshold, which if adopted, could potentially alleviate some of the concerns related to the current scoring methodology and insufficient data.
c. CMS is working with CDC to evaluate this new methodology and determine if it is appropriate for inclusion in CMS quality programs.
d. CMS does not have the authority to modify the payment adjustment.
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QUALITY REPORTING MEASURESA Tribal Story
The Appeal Process:
2. Appeal letter to CMS Acting Administrator. The response was detailed with the following highlights:a. CDC has set a threshold predicted number of infections of at
least oneb. CDC can’t at this time, calculate a SIR for that measure,
regardless of the number of actual infectionsc. Recognition of the impact to facilities with this reporting
scenario and are working with CDC to evaluate the future potential to lower the threshold below one
d. CDC has developed an alternative to the SIR calculation method, called the adjusted ranking metric (ARM) which would take into account, among other variables, hospitals that have low numbers of central line and/or catheter days
e. Committed to considering other ways of improving the program
f. Can’t make a change to the payment reduction3. Appeal letter to DHHS Secretary Burwell with no response as of
this date.
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MMPC Payment Reform Workgroup
The Medicare, Medicaid and Health Reform Policy Committee developed a Payment Reform Workgroup in 2015.
Issue Summary: CMS is implementing a series of payment reform programs,
including the Electronic Health Records (EHR) Incentive Program, the Physician Quality Reporting System (PQRS) and the Value-Based Payment Modifier (VBM).
Some of these programs previously provided incentives for participation, but are now transitioning into penalty phases in which Medicare reimbursements are reduced for failure to comply.
Some programs, such as the Hospital Acquired Conditions (HAC) Program, impose penalties based on formulas that can be detrimental to small tribal providers.
Additionally, many of the quality reporting programs do not include measures that tribes already must report.
Beginning in 2018, the EHR Incentive Program, PQRS and VBM will be folded into a new program, the Merit-Based Incentive Payment System (MIPS) for Medicare Part B payments, presenting opportunities to engage with CMS about reforming some of the incentive program regulations.
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MMPC Payment Reform Workgroup
Strategies and Actions: MMPC Payment Reform Workgroup has been
formed and will continue meeting to work on these topics/issues.
A CMS/IHS inter-agency workgroup should be established to address how the payment reform programs impact Indian Country.
The MMPC and tribes should work to engage CMS on the MIPS regulations that will be issued to ensure measures that tribes already use are included in the required quality measures.
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MMPC Payment Reform Workgroup
A successful workgroup meeting was held on Aug. 27, 2015, with the following agenda items:
1. Medicare Quality Reporting Payment & Penalties Chart – Workgroup decided to distribute the chart to Indian Country
2. Training on Payment Reforms: IHS Training Plan – PQRS Trainings Training gaps and needs – information from Area Health Boards Technical Assistance gaps and needs – information from Area
Health Boards
3. Reporting Methods Strategy: Exempt Indian health from GPRA reporting Use GPRA measures instead of the Medicare and Medicaid clinical
quality measures Merit-Based Incentive Payment System (MIPS) for Medicare Part B
payments - 2018 IHS and tribes align their quality assurance with the Medicare and
Medicaid approaches Other
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MMPC Payment Reform Workgroup
4. To assist in developing a policy strategy, the TSGAC requested IHS conduct an analysis and comparison of the GPRA and Clinical Quality Management approaches to include: Timelines for each (are they the same or different?) Type of data collection (What types of data are being
collected? Are they the same or different?) Cost of data collection (What is the cost, to include
equipment and software and human resources, of GPRA data collection system wide? How does that compare to the estimated cost of collecting data under Clinical Quality Management approaches that are in regulation or proposed regulations? What is the cost of doing both, versus one or another?)
How many self-governance tribes are reporting GPRA data, and how many are not?
If interested in the workgroup, please contact Devin Delrow, NIHB.
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MMPC Payment Reform Workgroup
THANK YOU!!!