Rate Year 2020 Quality Programs June 19, 2018
Covered in this Presentation Introduction Maryland All-Payer Model Performance Based Payment Programs Overview Rate Year 2020 Approved Program Updates: MHAC Program QBR Program RRIP Program RY 2019 PAU Savings RY 2020 (Expected) Maximum Guardrail under Maryland Hospital Performance-Based Programs CRISP Reports to Track Hospital Progress HSCRC Resources Q and A 2
Webinar Housekeeping
Maryland All-Payer Model Overview
Unique New Model: Maryland’s All -Payer Model Maryland is implementing an All-Payer Model for hospital payment Approved by Center for Medicare & Medicaid Services (CMS) effective January 1, 2014 for 5 years Modernizes Maryland’s Medicare waiver and unique all -payer hospital rate system Old Waiver New Model Per inpatient All-payer, per capita, admission hospital total hospital payment payment & quality Key provisions of the new Model: Hospital per capita revenue growth ceiling of 3.58% per year, with savings of at least $330 million to Medicare over 5 years Patient and population centered-measures to promote care improvement Payment transformation to global and population based for hospital services Proposal covering all health spending, to include at least Medicare patients, presented at the end of Year 3 for 2019 and beyond 5
Stakeholder Input Structure Maryland Dept HSCRC Commissioners MHCC of Health & Staff Advisory Council Consumer Standing Advisory Committee HSCRC Functions/Activities Partnership Activities Payment Performance Total Cost Multi-Agency & Stakeholder Models Measurement of Care Work Groups Primary Ad Hoc Sub- Duals Care Care group (e.g., Delivery Council CAEM, PAU) 6
HSCRC Performance-based Payment Programs Overview
HSCRC Performance Measurement Workgroup Comprises broad stakeholder group of hospital, payer, quality measurement, e-health quality, academic, consumer, and government agency experts and representatives Meets monthly with in-person and virtual participation Meetings are public and materials are publicly available Reviews and recommends annual updates to the performance-based payment programs Considers and recommends strategic direction for the overall performance measurement system Focus on high-need patients and chronic condition management Build care coordination performance measures Broaden focus to patient-centered population health Align to the extent possible with CMS Star Rating approach Incorporate new measures as available, such as Emergency Department, Outpatient, measures etc. 8
Guiding Principles For HSCRC Performance- Based Payment Programs Program must improve care for all patients, regardless of payer Program incentives should support achievement of all payer model targets Program should prioritize high volume, high cost, opportunity for improvement and areas of national focus Predetermined performance targets and financial impact Hospital ability to track progress Encourage cooperation and sharing of best practices Consider all settings of care 9
Performance Based Payment Programs: Maryland and CMS National Maryland Maryland Quality Readmission Potentially Hospital Based Reduction Avoidable Acquired Reimburse- Incentive Utilization Conditions ment Program (PAU) Savings (MHAC) (RRIP) (QBR) CMS National Value Based Hospital Readmissions Hospital Acquired Reduction Program Purchasing Condition Reduction 10
RY 2020 Quality Program Timelines Rate Year (Maryland Q3-16 Q4-16 Q1-17 Q2-17 Q3-17 Q4-17 Q1-18 Q2-18 Q3-18 Q4-18 Q1-19 Q2-19 Q3-19 Q4-19 Q1-20 Q2-20 Q3-20 Q4-20 Fiscal Year) Calendar Year Q1-16 Q2-16 Q3-16 Q4-16 Q1-17 Q2-17 Q3-17 Q4-17 Q1-18 Q2-18 Q3-18 Q4-18 Q1-19 Q2-19 Q3-19 Q4-19 Q1-20 Q2-20 Quality Programs that Impact Rate Year 2020 MHAC Base Period Rate Year Impacted by (Proposed) MHAC: Better MHAC Results of Attainment MHAC Better of or Attainment or Improvement Improvement Performance (Proposed) Hospital Compare Base Rate Year Impacted by Period* QBR Results Hospital Compare Performance Period* QBR Maryland Mortality Base Period QBR Maryland Mortality Performance Period RRIP Base Period Rate Year Impacted (Proposed) by RRIP RRIP Incentive RRIP Performance Period (Proposed) PAU Savings Performance Rate Year Impacted by PAU Savings Period PAU Savings 11
Rate Year (RY) 2020 Quality Program Updates
RY 2020 Maryland Hospital Acquired Conditions (MHAC) Program
MHAC Program Uses Potentially Preventable Complication (PPCs) measures developed by 3M Health Information Systems. PPCs are post-admission (in-hospital) complications that may result from hospital care and treatment, rather underlying disease progression Examples: Accidental puncture/laceration during an invasive procedure or hospital acquired pneumonia Relies on Present on Admission (POA) Indicators Links hospital payment to hospital performance by comparing the observed number of PPCs to the expected number of PPCs. 14
Rate Year 2020 Base Period = FY 2017 (July 2016-June 2017) Used for normative values for case-mix adjustment Performance Period = CY2018 3M APR-DRG and PPC Grouper Version 35 15
MHAC Methodology 16
Overview of MHAC Methodology Potentially Preventable Case-Mix Adjustment Hospital MHAC Score & Complication Measures and Standardized Scores Revenue Adjustments PPC scores (0-10 points) calculated RY 2020: Restrict to diagnosis and Hospital MHAC Score is Sum of using observed to expected ratios. PPC pairings where >80% of Earned Points / Possible Points with complications occurred in base. Tier Weights Applied Expected calculated by applying statewide average PPC rates by Scores Range from 0-100%, with APR-DRG-SOI to hospitals case- revenue neutral zone 45-55% Tier 1 mix (i.e., indirect standardization). 100% Weight Max Penalty 2% & Reward +1% 16 PPCs Threshold: State Median (O/E=1) Tier 2 Abbreviated Financial MHAC Score Benchmark: T op performing 50% Weight Preset Scale Adjustment 28 PPCs hospitals w/ 25% discharges Max Penalty 0% -2.00% Attainment Points: Global Exclusions: 10% -1.56% Threshold 20% -1.11% Palliative care • Benchmark 30% -0.67% • Discharges >6 PPCs 0 2 4 6 8 40% -0.22% Improvement Points: 10 • Apr-DRG SOI cells with less Penalty/Reward Hist. Perf 45-55% 0.00% Cut Point than 30 at-risk discharges Benchmark (Range) Hospital PPC Exclusions: 60% 0.11% 0 2 4 6 8 10 70% 0.33% • <10 at-risk discharges Final Points are Better of 80% 0.56% • <1 expected PPC Improvement or Attainment 90% 0.78% Max Reward 100% 1.00% 17
Performance Metric Hospital performance is measured using the Observed (O) / Expected (E) ratio for each PPC. Lower number = Better performance Expected number of PPCs for each hospital are calculated using the base period statewide PPC rates by APR-DRG and severity of illness (SOI). See Appendix B of RY2020 MHAC Memo for details on how to calculate expected numbers Normative values for calculating expected numbers are included in MHAC Excel workbook. 18
Adjustments to PPC Measurement Adjustments are done to improve measurement fairness and stability. Exclusions: Palliative care cases Cases with more than 6 PPCs For each hospital, PPCs will be excluded if during the base period: The number of cases at-risk is less than 10 List of hospital specific The number of expected cases is less than 1 excluded PPCs is included in MHAC Excel workbook. NEW RY 2020: Restrict P4P program to the diagnosis-complication pairings where at least 80% of complications occurred during the base period Increase the number of at-risk cases required per APR-DRG SOI statewide from 2 to 31 These changes were to address concerns regarding “zero norms” 19
Example 80% Restriction APR-DRG-PPC Groupings: Each combination of APR-DRG (328 in total) and clinically eligible PPC included in payment program (44 PPC/PPC combos in total). Sorted by Observed % of T otal Cumulative APR-DRG PPC Counts (highest to lowest) Observed PPCs Percent 720 14 45 23% 23% 181 39 36 18% 41% 540 59 25 13% 53% 194 14 22 11% 64% 720 1 21 11% 75% 230 42 11 6% 80% 230 9 11 6% 86% 540 60 9 5% 90% 560 59 9 5% 95% 166 8 6 3% 98% 190 52 3 2% 99% 201 6 2 1% 100% Observed PPCs across all groupings 200 20
RY 2020 PPCs Total 41 individual PPCs and three PPC combos included in payment program 9 PPCs included in Three Combo PPCs New combo for RY 2020: Infection Combo (PPC 34 Moderate Infections, 54 Infections due to Central Venous Catheters, 66 Catheter Associated Urinary Tract Infection) Hospitals scored on up to 44 PPC/PPC combos Seven PPCs (2, 15, 20, 29, 33, 36, 21) with lower reliability moved to a monitoring-only status and will not be scored for payment purposes. The MHAC Excel workbook contains data on individual PPCs and PPC combos. Monitoring reports for all clinically valid PPCs are under development. 21
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