CMS Announces final details of Value Based Purchasing for Inpatient Acute Care

On April 29th, CMS announced the final rules of its upcoming Value Based Purchasing program for Inpatient Acute Care. This long anticipated program transitions the inpatient care provided to Medicare beneficaries from "pay for reporting" to "pay for performance".

The HHS press release itself is of little value to the healthcare quality professional. You can view it here: http://www.hhs.gov/news/press/2011pres/04/20110429a.html. However, it links to a CMS press release that contained more details. You can view it here: http://www.cms.gov/apps/media/press/factsheet.asp?Counter=3947.

Although these rules become effective with fiscal year 2013, CMS also released the list of measures for 2014 as well.

The following are excerpts from the CMS press release:


PERFORMANCE SCORING:

Performance Period: CMS has established a performance period that runs from July 1, 2011 through March 31, 2012, for the FY 2013 Hospital VBP payment determination. CMS anticipates that in future program years, if it becomes feasible, it may propose to use a full year as the performance period.

Scoring Methods: CMS will score each hospital based on achievement and improvement ranges for each applicable measure. A hospital’s score on each measure will be the higher of an achievement score in the performance period or an improvement score, which is determined by comparing the hospital’s score in the performance period with its score during a baseline period.

For scoring on achievement, hospitals will be measured based on how much their current performance differs from all other hospitals’ baseline period performance. Points will then be awarded based on the hospital’s performance compared to the threshold and benchmark scores for all hospitals. Points will only be awarded for achievement if the hospital’s performance during the performance period exceeds a minimum rate called the “threshold,” which is defined by CMS as the 50th percentile of hospital scores during the baseline period.

For scoring on improvement, hospitals will be assessed based on how much their current performance changes from their own baseline period performance. Points will then be awarded based on how much distance they cover between that baseline and the benchmark score. Points will only be awarded for improvement if the hospital’s performance improved from their performance during the baseline period.

Finally, CMS will calculate a Total Performance Score (TPS) for each hospital by combining the greater of its achievement or improvement points on each measure to determine a score for each domain, multiplying each domain score by the proposed domain weight and adding the weighted scores together. In FY 2013, the clinical process of care domain will be weighted at 70 percent and the patient experience of care domain will be weighted at 30 percent.

Incentive Payment Calculations: CMS will utilize a linear exchange function to calculate the percentage of value-based incentive payment earned by each hospital. Those hospitals that receive higher Total Performance Scores will receive higher incentive payments than those that receive lower Total Performance Scores. CMS will notify each hospital of the estimated amount of its value-based incentive payment for FY 2013 through its QualityNet account at least 60 days prior to Oct. 1, 2012. CMS will notify each hospital of the exact amount of its value-based incentive payment on Nov. 1, 2012.

FISCAL YEAR 2013 MEASURES

Clinical Process of Care Measures
AMI-7a - Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
AMI-8a - Primary PCI Received Within 90 Minutes of Hospital Arrival
HF-1 - Discharge Instructions
PN-3b - Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital
PN-6 - Initial Antibiotic Selection for CAP in Immunocompetent Patient
SCIP-Inf-1 - Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
SCIP-Inf-2 - Prophylactic Antibiotic Selection for Surgical Patients
SCIP-Inf-3 - Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
SCIP-Inf-4 - Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose
SCIP-Card-2 - Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period
SCIP-VTE-1 - Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
SCIP-VTE-2 - Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery

Patient Experience of Care Measures (HCAHPS)
· Communication with Nurses
· Communication with Doctors
· Responsiveness of Hospital Staff
· Pain Management
· Communication About Medicines
· Cleanliness and Quietness of Hospital Environment
· Discharge Information
· Overall Rating of Hospital

ADDITIONAL MEASURES FINALIZED FOR FY2014

Mortality Measures:
· Mortality-30-AMI: Acute Myocardial Infarction (AMI) 30-day Mortality Rate
· Mortality-30-HF: Heart Failure (HF) 30-day Mortality Rate
· Mortality-30-PN: Pneumonia (PN) 30-Day Mortality Rate

Hospital Acquired Condition Measures:
· Foreign Object Retained After Surgery
· Air Embolism
· Blood Incompatibility
· Pressure Ulcer Stages III & IV
· Falls and Trauma: (Includes: Fracture, Dislocation, Intracranial Injury, Crushing Injury, Burn, Electric Shock)
· Vascular Catheter-Associated Infections
· Catheter-Associated Urinary Tract Infection (UTI)
· Manifestations of Poor Glycemic Control

AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs), and Composite Measures:
· Complication/patient safety for selected indicators (composite)
· Mortality for selected medical conditions (composite)

Unadjusted "Fall and Trauma" Rates for Hospitals in Indiana

On April 6, 2011, CMS released a spreadsheet linked to its Hospital Compare website showing the frequency of the eight (8) Hospital Acquired Conditions (HAC) in hospitals participating in the Medicare Program. This data set is of Medicare beneficiaries only, is not risk adjusted for the severity of the patients, and is based on administrative data only for patients discharged between Oct 1, 2008 to June 30, 2010.

The data can be downloaded from CMS here.

The table below shows the performance of the listed Indiana hospitals for the "Fall and Trauma" measure sorted from high to low.

Hospital name	Rate (per 1,000 discharges)	Number of eligible discharges (Denominator)	Number of HACs (Numerator)	National HAC rate (per 1,000 discharges)
UNITY MEDICAL AND SURGICAL HOSPITAL	7.634	131	1	0.564
RIVERVIEW HOSPITAL	2.428	3707	9	0.564
THE HEART HOSPITAL AT DEACONESS GATEWAY LLC	1.878	1065	2	0.564
SAINT CATHERINE REGIONAL HOSPITAL	1.641	1219	2	0.564
FAYETTE REGIONAL HEALTH SYSTEM	1.553	1932	3	0.564
REID HOSPITAL & HEALTH CARE SERVICES	1.257	9549	12	0.564
FRANCISCAN PHYSICIANS HOSPITAL LLC	1.233	811	1	0.564
MEMORIAL HOSPITAL OF SOUTH BEND	1.205	9955	12	0.564
ST. CLARE MEDICAL CENTER	1.179	1697	2	0.564
WITHAM HEALTH SERVICES	1.174	1704	2	0.564
KOSCIUSKO COMMUNITY HOSPITAL	1.084	2767	3	0.564
PARKVIEW HUNTINGTON HOSPITAL	1.065	939	1	0.564
INDIANA UNIVERSITY HEALTH ARNETT HOSPITAL	1.02	4904	5	0.564
MARION GENERAL HOSPITAL	0.962	4158	4	0.564
HENRY COUNTY MEMORIAL HOSPITAL	0.957	3134	3	0.564
BLUFFTON REGIONAL MEDICAL CENTER	0.944	2118	2	0.564
CLARK MEMORIAL HOSPITAL	0.932	8581	8	0.564
INDIANA UNIVERSITY HEALTH NORTH HOSPITAL	0.906	3313	3	0.564
COMMUNITY HOSPITAL NORTH	0.9	6664	6	0.564
ST. FRANCIS HOSPITAL - BEECH GROVE	0.853	9377	8	0.564
THE ORTHOPAEDIC HOSPITAL	0.788	1269	1	0.564
ST. VINCENT CARMEL HOSPITAL, INC.	0.767	2609	2	0.564
ST. MARGARET MERCY - DYER	0.725	5515	4	0.564
WESTVIEW HOSPITAL	0.7	1429	1	0.564
INDIANA UNIVERSITY HEALTH WEST HOSPITAL	0.689	4352	3	0.564
ELKHART GENERAL HOSPITAL	0.676	8879	6	0.564
GOOD SAMARITAN HOSPITAL	0.641	6241	4	0.564
DEARBORN COUNTY HOSPITAL	0.617	3239	2	0.564
DUPONT HOSPITAL LLC	0.603	1658	1	0.564
BALL MEMORIAL HOSPITAL INC	0.591	11840	7	0.564
METHODIST HOSPITALS, INC	0.588	13602	8	0.564
ST. CATHERINE HOSPITAL, INC	0.576	5211	3	0.564
INDIANA ORTHOPAEDIC HOSPITAL LLC	0.565	1770	1	0.564
COMMUNITY HOSPITAL	0.557	16165	9	0.564
COMMUNITY HOSPITAL SOUTH, INC.	0.549	5468	3	0.564
SAINT ANTHONY MEDICAL CENTER	0.545	9179	5	0.564
SAINT JOSEPH REGIONAL MEDICAL CENTER - SOUTH BEND	0.541	11100	6	0.564
LUTHERAN HOSPITAL OF INDIANA	0.535	13088	7	0.564
INDIANA HEART HOSPITAL, THE	0.528	3791	2	0.564
ST. MARY'S MEDICAL CENTER OF EVANSVILLE INC	0.514	11672	6	0.564
GOSHEN GENERAL HOSPITAL	0.489	4088	2	0.564
PORTER HOSPITAL, LLC, VALPARAISO HOSP CAMPUS	0.481	10389	5	0.564
PARKVIEW HOSPITAL	0.465	10748	5	0.564
MAJOR HOSPITAL	0.457	2189	1	0.564
BLOOMINGTON HOSPITAL	0.445	8981	4	0.564
ST. FRANCIS HOSPITAL - MOORESVILLE	0.435	2299	1	0.564
DEACONESS HOSPITAL INC	0.422	18959	8	0.564
SCHNECK MEDICAL CENTER	0.421	2378	1	0.564
JOHNSON MEMORIAL HOSPITAL	0.421	2378	1	0.564
TERRE HAUTE REGIONAL HOSPITAL	0.411	4861	2	0.564
MEMORIAL HOSPITAL AND HEALTH CARE CENTER	0.385	5190	2	0.564
UNION HOSPITAL INC	0.383	13057	5	0.564
ST. JOSEPH HOSPITAL	0.381	2626	1	0.564
FLOYD MEMORIAL HOSPITAL AND HEALTH SERVICES	0.375	10678	4	0.564
WILLIAM N WISHARD MEMORIAL HOSPITAL	0.368	5431	2	0.564
ST. VINCENT HOSPITALS AND HEALTH SERVICES	0.358	19569	7	0.564
CLARIAN HEALTH PARTNERS, INCORPORATED	0.321	28027	9	0.564
ST. FRANCIS HOSPITAL - INDIANAPOLIS	0.313	6388	2	0.564
COLUMBUS REGIONAL HOSPITAL	0.296	6766	2	0.564
THE KING'S DAUGHTERS' HOSPITAL AND HEALTH SERVICES	0.28	3574	1	0.564
ST. ELIZABETH EAST	0.244	4090	1	0.564
COMMUNITY HOSPITAL EAST	0.244	8195	2	0.564
LA PORTE HOSPITAL AND HEALTH SERVICES	0.235	4263	1	0.564
ST. MARGARET MERCY HEALTHCARE CENTERS - HAMMOND	0.228	8754	2	0.564
ST. MARY MEDICAL CENTER, INC.	0.224	8912	2	0.564
ST. ELIZABETH CENTRAL	0.219	4558	1	0.564
COMMUNITY HOSPITAL OF ANDERSON AND MADISON COUNTY	0.179	5601	1	0.564
SAINT JOHN'S HEALTH SYSTEM	0.169	5918	1	0.564
SAINT ANTHONY MEMORIAL HEALTH CENTER	0	5335	0	0.564
KENTUCKIANA MEDICAL CENTER LLC	0	619	0	0.564
MEMORIAL HOSPITAL	0	1480	0	0.564
HENDRICKS REGIONAL HEALTH	0	3423	0	0.564
DAVIESS COMMUNITY HOSPITAL	0	1727	0	0.564
HOWARD REGIONAL HEALTH SYSTEM	0	4148	0	0.564
PHYSICIANS' MEDICAL CENTER LLC	0	180	0	0.564
SURGICAL HOSPITAL OF MUNSTER	0	31	0	0.564
ST. JOSEPH HOSPITAL & HEALTH CENTER, INC	0	3856	0	0.564
PINNACLE HOSPITAL	0	542	0	0.564
HANCOCK REGIONAL HOSPITAL	0	2989	0	0.564
MONROE HOSPITAL	0	1335	0	0.564
ST. VINCENT HEART CENTER OF INDIANA, LLC	0	5756	0	0.564
WOMEN'S HOSPITAL, THE	0	114	0	0.564
PARKVIEW WHITLEY HOSPITAL	0	807	0	0.564
STARKE MEMORIAL HOSPITAL	0	785	0	0.564
PARKVIEW NOBLE HOSPITAL	0	1175	0	0.564
SAINT JOSEPH REGIONAL MEDICAL CENTER - PLYMOUTH	0	1773	0	0.564
DEKALB MEMORIAL HOSPITAL INC	0	1100	0	0.564
MORGAN HOSPITAL AND MEDICAL CENTER	0	1472	0	0.564
ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH LLC	0	1039	0	0.564

ACOs are here! ...but will it be everywhere?

Details of the long awaited CMS ACO proposed rules were released on March 31, 2011 and posted in the April 7, 2011 edition of the Federal Register.

The Federal Register entry can be found here.

The Centers for Medicare and Medicaid Services also simultaneously posted fact sheets and other resources about the proposed ACOs rules:

• Summary of Proposed Rules.
• Summary of the 65 ACO Performance Measures
• Other Federal Agencies Addressing the Legal Issues of ACO Participation
• The Press Release Announcing the ACO Rules
• CMS Fact Sheet about what Providers Need to Know of ACOs

No doubt there will be significant commentary provided by healthcare organizations throughout the country over the next few months. The comment period closes on June 6, 2011. ACO final rules go into effect January 1, 2012.

Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care

Last week the Institute for Healthcare Improvement (IHI) released a white paper describing current frameworks of providing patient centric care. Within the document is also an assessment of primary and secondary drivers as well as descriptions of practices at exemplar organizations.

This IHI white paper can be download here.

The following are excerpts from IHI's document description:

In response to growing interest from the hospital community in better understanding and improving the experience of patients and their families during hospitalization, the Institute for Healthcare Improvement (IHI) conducted an in-depth review of the research, studied exemplar organizations, and interviewed experts in the field. Our aim was to identify the primary and secondary drivers of exceptional patient and family inpatient hospital experience (defined as care that is patient centered, safe, effective, timely, efficient, and equitable), as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey’s “willingness to recommend” the hospital.


The project identified five primary drivers of exceptional patient and family inpatient hospital experience of care: leadership; staff hearts and minds; respectful partnership; reliable care; and evidence-based care.

Ambulatory Surgery Centers (ASCs) & Healthcare Reform

With the upcoming health care reform changes, ASCs can prove to be valuable in containing costs for all. See ASC Campaign for Advancing Surgical Care site for information on their initiatives:

http://advancingsurgicalcare.com/index.cfm/asc-policy/initiatives/

FAQ on ACOs

Discussions of Accountable Care Organizations (ACOs) are sure to dominate the minds of hospital and health plan administrators in the next few months/years. The establishment of these entities will likely impact the work and expectations of health care quality professionals. Kaiser Health News recently posted an ACO FAQ list. You can find it here.

This FAQ provides thoughts to the following questions:

• What is an accountable care organization?
• When will ACOs begin operating?
• Why did Congress include ACOs in the law?
• How would ACOs be paid?
• How will an ACO be different for patients?
• Who's in charge — hospitals, doctors or insurers?
• If I don't like HMOs, why should I consider an ACO?
• What can go wrong?
• Are there any possible legal concerns?

CMS Proposes Value Based Purchasing Program Rules for Hospital Inpatient

On Friday, CMS announced its highly anticipated proposed rules for its new hospital value based purchasing program. The pdf of the proposed rules can be found here: http://www.ofr.gov/OFRUpload/OFRData/2011-00454_PI.pdf
(Note: this link will not likely become live until 1/13/2011).

Although these are "new" proposed rules, there are really no surprises in terms of payment methodology. The amount "at risk" due to poor performance is probably lower than what was initially expected (ie: 1-2% rather than 4-5%).


The following are excerpts from the CMS press release and fact sheet that may be of interest:

• Under the program, hospitals that perform well on quality measures relating both to clinical process of care and to patient experience of care, or those making improvements in their performance on those measures, would receive higher payments.
• The financial incentives would be funded by a reduction in the base operating DRG payments for each discharge, which under the statute will be 1% in FY 2013, rising to 2% by FY 2017.
• CMS will accept comments on the hospital value-based purchasing Program proposed rule until March 8, 2010, and will respond to them in a final rule to be issued next year.
• For the FY 2013 hospital value-based purchasing program, CMS proposes to use 17 clinical process of care measures as well as 8 measures from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that document patients’ experience of care.
• CMS also proposes to adopt three mortality outcome measures, eight Hospital Acquired Condition (HAC) measures, and nine Agency for Healthcare Research and Quality (AHRQ) measures for the FY 2014 Hospital VBP program.
• Proposed Performance Period: As required by the Affordable Care Act, CMS is proposing a performance period that ends prior to the beginning of FY 2013, specifically from July 1, 2011 through March 31, 2012, for the FY 2013 hospital value-based purchasing payment determination. CMS anticipates that in future fiscal years, the Agency may propose to use a full year as the performance period. In addition, CMS is proposing to use an 18-month performance period for the three proposed mortality measures for the FY 2014 Hospital VBP payment determination, and expects to propose a performance period for the eight HAC and nine AHRQ measures in future rulemaking.
• Proposed Scoring Methods: CMS proposes to score each hospital on relative achievement and improvement ranges for each applicable measure. A hospital’s performance on each quality measure would be evaluated based on the higher of an achievement score in the performance period or an improvement score, which is determined by comparing the hospital’s score in the performance period with its score during a baseline period of performance. For each of the proposed clinical process and patient experience of care measures that apply to a hospital for FY 2013, CMS proposes that a hospital would earn 0-10 points for achievement based on where its performance for the measure fell within an achievement range, which is a scale between an achievement threshold and a benchmark. With regard to the improvement score, CMS proposes that a hospital would earn 0-9 points based on how much its performance on the measure during the performance period improved from its performance on the measure during the baseline period. Finally, CMS would calculate a Total Performance Score (TPS) for each hospital by combining its scores on all of the measures within each domain, multiplying its performance score on each domain by the proposed weight for the domain, and adding the weighted scores for the domains.
• Proposed Incentive Payment Calculations:  CMS proposes to translate each hospital’s TPS into a value-based incentive payment using a linear exchange function.  The linear exchange function provides the same marginal incentives to both lower- and higher-performing hospitals.
• CMS proposes to notify each hospital of the estimated amount of its value-based incentive payment for FY 2013 through its QualityNet account at least 60 days prior to Oct. 1, 2012.  CMS proposes to notify each hospital of the exact amount of its value-based incentive payment on or about Nov. 1, 2012.
• CMS will accept public comments on the proposed rule through March 8, 2010  CMS will review all comments and respond to them in a final Hospital VBP rule scheduled to be released some time in 2011.

PROPOSED QUALITY MEASURES FY2013   
AMI-2: Aspirin Prescribed at Discharge
AMI-7a: Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
AMI-8a: Primary PCI Received Within 90 Minutes of Hospital Arrival
 
HF-1: Discharge Instructions
HF-2: Evaluation of LVS Function
HF-3: ACEI or ARB for LVSD

PN-2: Pneumococcal Vaccination
PN-3b: Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital
PN-6: Initial Antibiotic Selection for CAP in Immunocompetent Patient
PN-7: Influenza Vaccination 
SCIP-Inf-1: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
SCIP-Inf-2: Prophylactic Antibiotic Selection for Surgical Patients
SCIP-Inf-3: Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
SCIP-Inf-4: Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose
SCIP-Card-2: Surgery Pts. on a Beta Blocker Prior to Arrival... 
SCIP-VTE-1: Surgery Pts. with Recommended Venous Thromboembolism Prophylaxis Ordered
SCIP-VTE-2: Surgery Pts. Who Received Appropriate Venous Thromboembolism Prophylaxis...
 
HCAHPS: Communication with Nurses
HCAHPS: Communication with Doctors
HCAHPS: Responsiveness of Hospital Staff
HCAHPS: Pain Management
HACHPS: Communication About Medicines
HACHPS: Cleanliness and Quietness of Hospital Environment
HACHPS: Discharge Information
HACHPS: Overall Rating of Hospital

PROPOSED ADDITIONAL QUALITY MEASURES FOR FISCAL YEAR 2014

Mortality-30-AMI: Acute Myocardial Infarction (AMI) 30-day Mortality Rate
Mortality-30-HF: Heart Failure (HF) 30-day Mortality Rate
Mortality-30-PN: Pneumonia (PN) 30-Day Mortality Rate

Foreign Object Retained After Surgery
Air Embolism
Blood Incompatibility
Pressure Ulcer Stages III & IV
Falls and Trauma: (Includes: Fracture, Dislocation, Intracranial Injury, Crushing Injury, Burn, Electric Shock)
Vascular Catheter-Associated Infections
Catheter-Associated Urinary Tract Infection (UTI)
Manifestations of Poor Glycemic Control

PSI 06 – Iatrogenic pneumothorax, adult
PSI 11 – Post Operative Respiratory Failure
PSI 12 – Post Operative PE or DVT
PSI 14 – Post Operative would dehiscence
PSI 15 – Accidental puncture or laceration
IQI 11 – Abdominal aortic aneurysm (AAA) repair mortality rate (with or without volume)
IQI 19 – Hip fracture mortality rate

Complication/patient safety for selected indicators (composite)
Mortality for selected medical conditions (composite)

Be a Baldrige Examiner in 2011

Baldrige Examiners contribute to the process of determining each year's Baldrige Award recipients. Last year, 1/3 of all examiners were from the healthcare industry.

Why is the Baldrige Criteria for performance excellence so important to healthcare? Rulon Stacy, the CEO for Pouder Valley Health Systems says that "...as soon as you become a Baldrige organization, it will cost you less to run your business, and your outcomes will be better."

Organizations will a Baldrige Examiner on staff will have a unique resource that will give them insight on how to best align themselves to the Baldrige criteria to improve their performance.

Applications for next year's Baldrige Board of Examiners are being accepted until January 13, 2011.

You can learn more about the Baldrige Criteria here: http://www.nist.gov/baldrige/
You can learn more about the examiner application process here: http://www.nist.gov/baldrige/examiners/index.cfm

Berwick Testifies to the Senate Finance Committee

On November 17th, Donald Berwick testified before the Senate Finance Committee. As you can imagine, there was a lot of political tension surrounding this event.

The video of the entire senate hearing is here: http://finance.senate.gov/hearings/watch/?id=280ebc81-5056-a032-5254-1010c1e9b945

Berwick's prepared statement can be found here: http://finance.senate.gov/imo/media/doc/FINAL%20Donald%20Berwick%20Testimony%2011.15.101.pdf

Bacus' prepared opening statement can be found here: http://finance.senate.gov/imo/media/doc/11172010%20Baucus%20Hearing%20Statement%20Regarding%20New%20Patient%20Protections%20to%20Strengthen%20Medicare%20and%20Medicaid1.pdf

Grassley's prepared opening statement can be found here: http://finance.senate.gov/imo/media/doc/health%20care%2011-17-10%20hearing%20with%20Dr.pdf

Kaiser Health News, a program of the Kaiser Family Foundation, consolidated a resource page about Dr. Donald Berwick. It contains both what he has said as well as what others have said about him (and what he said). It can be found here: http://www.kaiserhealthnews.org/Stories/2010/June/30/Donald-Berwick-Resource-Guide.aspx

RAC for Medicaid?

The following is a press release from CMS (Nov 5, 2010) announcing some of the details for the implementation of Medicaid RAC. Items of interest to quality professionals are in red.

MEDICAID RECOVERY AUDIT CONTRACTORS RULE ANNOUNCED TO HELP REDUCE IMPROPER PAYMENTS
CMS ANNOUNCES EDUCATION EFFORT TO SUPPORT PROGRAM

The Centers for Medicare & Medicaid Services (CMS) today proposed new rules to help states reduce improper payments for Medicaid health care claims through the use of Medicaid Recovery Audit Contractors (RACs) as part of the Affordable Care Act’s larger strategy to crack down on waste, fraud and abuse in the health care system. Medicaid RACs are contractors, working for States, that will audit payments made to health care providers to identify Medicaid payments that may have been underpaid or overpaid, and recover overpayments or correct underpayments, similar to the RAC program in Medicare.

“Reducing improper payments is a key goal of the Administration, and the tools provided by the Affordable Care Act will help us achieve that goal,” said CMS Administrator Donald Berwick, M.D. “We are using many of the lessons that we learned from the Medicare RAC program in the development and implementation of the Medicaid RACs, including a far-reaching education effort for health care providers and State managers.”

Under the Affordable Care Act, States must establish Medicaid RAC programs by submitting state plan amendments to CMS by December 31, 2010. The law allows CMS to provide extensions or exceptions to States, if necessary, and details regarding these processes are included in the proposed regulation. In addition, the proposed regulation issued by CMS today outlines the requirements that states must meet and the Federal contribution CMS will provide to assist in funding the state RAC programs.

Medicaid RACs will be paid by the States on a contingency basis to review Medicaid provider claims, identify and recover overpayments made for services provided under Medicaid State plans and Medicaid waivers. The proposed regulation allows States the discretion to determine whether to pay their Medicaid RACs on a contingency basis or under some other fee structure for identifying underpayments.

CMS is encouraging interested parties to comment on the proposals included in the regulation. These include the payment methodology for identifying overpayments and underpayments as well as the recovery of overpayments and correction of underpayments, and the requirement that RACs report fraud or criminal activity whenever they have reasonable grounds to believe such activity has occurred.

Under the regulation, as proposed, a State may use its current administrative appeals process or may modify its process for Medicaid RAC-related appeals. All fees paid to the Medicaid RACs must come from amounts recovered after all available appeals have been exhausted.

Because CMS has proposed to require States to implement their programs in a timely manner, CMS is providing educational programs to help States understand both the Medicare and Medicaid RAC programs. On October 1, 2010, CMS released a State Medicaid Director letter which provided initial guidance to the States regarding the RAC program. CMS issued an educational DVD entitled “Medicaid RACs: Are You Ready?” targeted to State Medicaid and Program Integrity Directors and held a webinar for states offering RAC procurement tips. Additionally, on November 4, 2010, CMS hosted an educational forum describing Lessons Learned from CMS’s experience with Medicare RACs.

A copy of the regulation may be viewed at the Federal Register’s website, http://www.ofr.gov/inspection.aspx. For Additional information on the Affordable Care Act can be accessed at, http://www.healthcare.gov/.

Indiana Performs Well on HCAHPS

The following is a table of how States performed on the HCAHPS overall rating question from Jan 09 to Dec 09. The table is sorted from high to low based on the percentage of patients responding with a rating of 9 or 10 on this 10 point scale.

As you can see, the average of Indiana hospitals ranks 7th of all states for this question.

% State
73 SD
72 KS
72 LA
72 IA
71 NE
71 ME
71 IN
70 VT
70 ID
70 NH
70 WI
69 CO
69 UT
69 MN
69 NC
68 AL
68 MI
68 OK
68 KY
68 TX
68 SC
67 MO
67 MS
67 MA
67 OH
67 OR
67 TN
66 WA
66 AZ
66 AR
66 GA
65 CT
64 AK
64 WV
64 VA
64 PA
64 IL
64 RI
63 WY
63 MT
63 CA
62 DE
62 NV
62 ND
62 FL
61 MD
61 NM
60 NJ
59 HI
58 NY
58 DC

Indiana Hospitals HCAHPS Performance

The following is a table of the performance of Indiana hospitals (Jan 09 to Dec 09) on the HCAHPS overall rating question. The table is sorted from high to low based on the percentage of patients providing a response of 9 or 10 on this 10 point scale.

% Hospital and City
94 SURGICAL HOSPITAL OF MUNSTER of MUNSTER
89 INDIANA ORTHOPAEDIC HOSPITAL LLC of INDIANAPOLIS
87 ST VINCENT HEART CENTER OF INDIANA LLC of INDIANAPOLIS
87 WOMEN'S HOSPITAL THE of NEWBURGH
86 PHYSICIANS' MEDICAL CENTER LLC of NEW ALBANY
85 INDIANA HEART HOSPITAL THE of INDIANAPOLIS
82 HENDRICKS REGIONAL HEALTH of DANVILLE
80 CLARIAN NORTH MEDICAL CENTER of CARMEL
80 ST VINCENT CARMEL HOSPITAL INC of CARMEL
80 PARKVIEW LAGRANGE HOSPITAL of LAGRANGE
79 ST FRANCIS HOSPITAL MOORESVILLE of MOORESVILLE
79 SCHNECK MEDICAL CENTER of SEYMOUR
78 GOOD SAMARITAN HOSPITAL of VINCENNES
78 DEKALB MEMORIAL HOSPITAL INC of AUBURN
78 PARKVIEW WHITLEY HOSPITAL of COLUMBIA CITY
78 TIPTON HOSPITAL of TIPTON
78 PARKVIEW NOBLE HOSPITAL of KENDALLVILLE
78 DUPONT HOSPITAL LLC of FORT WAYNE
77 COMMUNITY HOSPITAL of MUNSTER
77 ST MARY'S MEDICAL CENTER OF EVANSVILLE INC of EVANSVILLE
77 MEMORIAL HOSPITAL AND HEALTH CARE CENTER of JASPER
77 MARGARET MARY COMMUNITY HOSPITAL INC of BATESVILLE
77 ST VINCENT FRANKFORT HOSPITAL INC of FRANKFORT
76 FRANCISCAN PHYSICIANS HOSPITAL LLC of MUNSTER
76 ST VINCENT DUNN HOSPITAL INC of BEDFORD
76 WITHAM HEALTH SERVICES of LEBANON
76 PARKVIEW HUNTINGTON HOSPITAL of HUNTINGTON
75 SAINT JOSEPH'S REGIONAL MEDICAL CENTER - PLYMOUTH of PLYMOUTH
75 THE ORTHOPAEDIC HOSPITAL OF LUTHERAN HEALTH NETWOR of FT WAYNE
75 ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH LLC of FORT WAYNE
75 MEMORIAL HOSPITAL OF SOUTH BEND of SOUTH BEND
75 MONROE HOSPITAL of BLOOMINGTON
75 CLARIAN WEST MEDICAL CENTER of AVON
74 LUTHERAN HOSPITAL OF INDIANA of FORT WAYNE
74 BLUFFTON REGIONAL MEDICAL CENTER of BLUFFTON
74 COMMUNITY HOSPITAL OF ANDERSON AND MADISON COUNTY of ANDERSON
74 CLARK MEMORIAL HOSPITAL of JEFFERSONVILLE
74 ST VINCENT WILLIAMSPORT HOSPITAL INC of WILLIAMSPORT
74 GOSHEN GENERAL HOSPITAL of GOSHEN
74 ST VINCENT HOSPITAL & HEALTH SERVICES of INDIANAPOLIS
74 PARKVIEW HOSPITAL of FORT WAYNE
74 FLOYD MEMORIAL HOSPITAL AND HEALTH SERVICES of NEW ALBANY
73 JAY COUNTY HOSPITAL of PORTLAND
73 MAJOR HOSPITAL of SHELBYVILLE
73 ST MARY MEDICAL CENTER INC of HOBART
73 BEDFORD REGIONAL MEDICAL CENTER of BEDFORD
73 RIVERVIEW HOSPITAL of NOBLESVILLE
73 ST FRANCIS HOSPITAL AND HEALTH CENTERS-INDIANAPOLI of INDIANAPOLIS
73 ST VINCENT MERCY HOSPITAL of ELWOOD
73 ST JOSEPH HOSPITAL & HEALTH CENTER INC of KOKOMO
72 SAINT JOSEPH REGIONAL MEDICAL CENTER of MISHAWAKA
72 HARRISON COUNTY HOSPITAL of CORYDON
72 CLARIAN-ARNETT HEALTH SYSTEM INC of LAFAYETTE
72 WABASH COUNTY HOSPITAL of WABASH
71 CAMERON MEMORIAL COMMUNITY HOSPITAL INC of ANGOLA
71 GIBSON GENERAL HOSPITAL of PRINCETON
71 HANCOCK REGIONAL HOSPITAL of GREENFIELD
70 REID HOSPITAL & HEALTH CARE SERVICES of RICHMOND
70 FAYETTE REGIONAL HEALTH SYSTEM of CONNERSVILLE
70 TERRE HAUTE REGIONAL HOSPITAL of TERRE HAUTE
70 COLUMBUS REGIONAL HOSPITAL of COLUMBUS
70 SAINT JOHN'S HEALTH SYSTEM of ANDERSON
70 HENRY COUNTY MEMORIAL HOSPITAL of NEW CASTLE
70 ST VINCENT JENNINGS HOSPITAL INC of NORTH VERNON
69 COMMUNITY HOSPITAL NORTH of INDIANAPOLIS
69 SULLIVAN COUNTY COMMUNITY HOSPITAL of SULLIVAN
69 ST CATHERINE HOSPITAL INC of EAST CHICAGO
69 SAINT ANTHONY of CROWN POINT
69 MARION GENERAL HOSPITAL of MARION
68 ST ANTHONY MEMORIAL HEALTH CENTERS of MICHIGAN CITY
68 UNION HOSPITAL CLINTON of CLINTON
68 DEACONESS HOSPITAL INC of EVANSVILLE
68 ST ELIZABETH CENTRAL of LAFAYETTE
68 LAPORTE HOSPITAL AND HEALTH SERVICES of LA PORTE
68 JOHNSON MEMORIAL HOSPITAL of FRANKLIN
68 DAVIESS COMMUNITY HOSPITAL of WASHINGTON
68 KING'S DAUGHTERS' HOSPITAL AND HEALTH SERVICESTHE of MADISON
68 WILLIAM N WISHARD MEMORIAL HOSPITAL of INDIANAPOLIS
67 ST FRANCIS HOSPITAL AND HEALTH CENTERS of BEECH GROVE
67 WESTVIEW HOSPITAL of INDIANAPOLIS
67 BLOOMINGTON HOSPITAL of BLOOMINGTON
67 DECATUR COUNTY MEMORIAL HOSPITAL of GREENSBURG
67 BALL MEMORIAL HOSPITAL INC of MUNCIE
67 ST VINCENT CLAY HOSPITAL INC of BRAZIL
66 SCOTT COUNTY MEMORIAL HOSPITAL AKA SCOTT MEMORIAL of SCOTTSBURG
66 ELKHART GENERAL HOSPITAL of ELKHART
66 UNION HOSPITAL INC of TERRE HAUTE
66 ST JOSEPH HOSPITAL of FORT WAYNE
66 HOWARD REGIONAL HEALTH SYSTEM of KOKOMO
65 COMMUNITY HOSPITAL SOUTH of INDIANAPOLIS
64 DEARBORN COUNTY HOSPITAL of LAWRENCEBURG
64 MEMORIAL HOSPITAL of LOGANSPORT
63 ST VINCENT RANDOLPH HOSPITAL INC of WINCHESTER
63 CLARIAN HEALTH PARTNERS INC D/B/A METHODIST IU RIL of INDIANAPOLIS
62 KOSCIUSKO COMMUNITY HOSPITAL of WARSAW
61 ST MARGARET MERCY HEALTHCARE CENTERS of DYER
61 STARKE MEMORIAL HOSPITAL of KNOX
60 DUKES MEMORIAL HOSPITAL of PERU
60 ST ELIZABETH EAST of LAFAYETTE
59 COMMUNITY HOSPITAL EAST of INDIANAPOLIS
57 MORGAN HOSPITAL AND MEDICAL CENTER of MARTINSVILLE
55 ST CLARE MEDICAL CENTER of CRAWFORDSVILLE
55 PORTER VALPARAISO HOSPITAL of VALPARAISO
55 ST MARGARET MERCY HEALTHCARE CENTERS of HAMMOND
48 SAINT CATHERINE REGIONAL HOSPITAL of CHARLESTOWN
41 METHODIST HOSPITALS INC of GARY

Note that the following hospitals were tagged as "Survey results are not available for this reporting period".

WHITE COUNTY MEMORIAL HOSPITAL
UNITY MEDICAL AND SURGICAL HOSPITAL
THE HEART HOSPITAL AT DEACONESS GATEWAY LLC
ST MARY'S WARRICK HOSPITAL INC
PUTNAM COUNTY HOSPITAL
PINNACLE HOSPITAL
PERRY COUNTY MEMORIAL HOSPITAL
KENTUCKIANA MEDICAL CENTER LLC
JASPER COUNTY HOSPITAL
GREENE COUNTY GENERAL HOSPITAL
COMMUNITY HOSPITAL OF BREMEN INC
ADAMS MEMORIAL HOSPITAL

The "Gift"

This is not exactly "Healthcare Quality", but it is well worth the 3 minutes. It keeps our work in perspective.



(If you don't see the video embedded above, it is being blocked.)

National Health Care Quality Strategy and Plan

The Secretary of the Department of Health and Human Services recently put out a call for public input on a national strategy for healthcare quality. You can see the document here.

The proposed framework of the national strategy centers around three principles: 1) Better Care; 2) Affordable Care; 3) Healthy People/Healthy Communities.

The specific questions that the HHS Secretary is asking the public are:

Question 1: Are the proposed Principles for the National Strategy appropriate? What is missing or how could the principles be better guides for the Framework, Priorities and Goals?

Question 2: Is the proposed Framework for the National Strategy sound and easily understood? Does the Framework set the right initial direction for the National Health Care Quality Strategy and Plan? How can it be improved?

Question 3: Using the legislative criteria for establishing national priorities, what national priorities do you think should be addressed in the initial National Health Care Quality Strategy and Plan in each of the following areas. Better Care: Person-centered care that works for patients and providers. Better care should expressly address the quality, safety, access, and reliability of how care is delivered and how patients rate their experience in receiving such care; Affordable Care: Care that reins in unsustainable costs for families, government, and the private sector to make it more affordable; and Healthy People/Healthy Communities: The promotion of health and wellness at all levels.

Question 4: What aspirational goals should be set for the next 5 years, and to what extent should achievable goals be identified for a shorter timeframe?

Question 5: Are there existing, well-established, and widely used measures that can be used or adapted to assess progress towards these goals? What measures would best guide public and private sector action, as well as support assessing the nation’s progress to meeting the goals in the National Quality Strategy?

Question 6: The success of the National Health Care Quality Strategy and Plan is, in large part, dependent on the ability of diverse stakeholders across both the public and private sectors to work together. Do you have recommendations on how key entities, sectors, or stakeholders can best be engaged to drive progress based on the National Health Care Quality Strategy and Plan?

Question 7: Given the role that States can play in organizing health care delivery for vulnerable populations, do the Principles and Framework address the needs and issues of these populations?

Question 8: Are there priorities and goals that should be considered to specifically address State needs?

Question 9: What measures or measure sets should be considered to reflect States’ activities, priorities, and concerns?

Question 10: What are some key recommendations on how to engage with States and ensure continued alignment with the National Quality Strategy?

The deadline for public submission is October 15, 2010 at 5pm. The HHS has created a convenient website for feedback submission at: http://www.hhs.gov/news/reports/quality/nhcqsap.html

Rounding to Influence

A former boss of mine introduced me to the concept of "Management by Walking Around". I've seen many leaders fully endorse using this concept with highly variable results. Maybe there's something more than just being visible?

The Sept/Oct 2010 edition of Healthcare Executive published an article from Dr. James Reinertsen about rounding to influence staff behavior and adoption of best practices. The Institute for Healthcare Improvement has made available the reprint here.

The following is an excerpt of the article:

Rounding to Influence
Rounding to influence is one element of an evidence-based bundle of leadership methods used in highly reliable organizations. Rounding to influence is not quite the same thing as leadership safety walkrounds, in which leaders go to hospital units and visit with staff to send a signal that they care about the hospital’s improvement agenda, want to gain better awareness of safety issues and want to build relationships with frontline staff. While these are all desirable outcomes, they don’t drive the successful execution of specific safety or infection control practices. Rounding to influence is much more focused. It’s not just about leaders being seen—it’s about what leaders are seen doing and asking.