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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	
  hPhysicians	
  OrganizaAon	
  
	
  
Move	
  from	
  Fee	
  for	
  Service	
  to	
  Pay-­‐for-­‐Value:	
  
authorized	
  in	
  2005	
  
Started	
  with	
  small	
  voluntary	
  set	
  of	
  quality	
  metrics	
  
CMS	
  starter	
  set	
  of	
  10	
  measures	
  grew	
  to	
  60	
  
4Source:	
  	
  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	
  
6
Department	
  of	
  Public	
  Health	
  
CMS	
  and	
  others….	
  
 
	
  
	
  
	
  
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)	
  
PioneerACO
(33measures)
MassHealth	
  Readmission	
  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	
  measures)	
  
8
At	
  +mes	
  it	
  feels	
  like	
  this…	
  
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:	
  
10
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)	
  	
  
	
  
11
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?	
  
	
  
12
13
Process	
  measure	
  performance	
  2005-­‐2014	
  
14
Pa+ent	
  experience	
  performance	
  2005-­‐2014	
  
15
Mortality	
  &	
  readmission	
  performance	
  2005-­‐2014	
  
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	
  	
  
16

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Medicare Incentive and Penalties: Critical Lessons Learned (Elizabeth Mort)

  • 1. 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  hPhysicians  OrganizaAon    
  • 2. Move  from  Fee  for  Service  to  Pay-­‐for-­‐Value:   authorized  in  2005  
  • 3. Started  with  small  voluntary  set  of  quality  metrics  
  • 4. CMS  starter  set  of  10  measures  grew  to  60   4Source:    Advisory  Board   Img  source:  hKp://blog.healthcarefirst.com/Portals/52995/images/HospiceDataRepor+ng.jpg  
  • 5. 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  
  • 6. 6 Department  of  Public  Health   CMS  and  others….  
  • 7.         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)   PioneerACO (33measures) MassHealth  Readmission  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  measures)  
  • 8. 8 At  +mes  it  feels  like  this…  
  • 9. 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
  • 10. 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:   10
  • 11. 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)       11
  • 12. 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?     12
  • 13. 13 Process  measure  performance  2005-­‐2014  
  • 15. 15 Mortality  &  readmission  performance  2005-­‐2014  
  • 16. 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     16