Decoding Medicare Spending Per Beneficiary (MSPB) Management and Physician Opportunities Together

Transcription

1 Decoding Medicare Spending Per Beneficiary (MSPB) Management and Physician Opportunities Together Dale N. Schumacher THE TRANSFORMATION TO CONSUMER-DRIVEN HEALTHCARE

2 Decoding Medicare Spending Per Beneficiary (MSPB) Management and Physician Opportunities Together Dale N. Schumacher, MD, MPH, MEd 2

3 This presentation is based in part on an article published in the June 2015 issue of hfm: Decoding Medicare Spending Per Beneficiary, The CMS Efficiency Measure, by Dale N. Schumacher, MD, Len Felgner, Eric D. Dobkin, MD, Fern E. Nerhood, Margaret Paroski, MD, copyright 2015, The Healthcare Financial Management Association. 3

4 I. Introduction 4

5 I. Introduction It was the best of times. It was the worst of times. VBP: 1,375/3088 (45%) hospitals received no payment reduction or received an incentive (31/76=41%) MSPB: 1,255/3078 (41%) hospitals received 0 points for their Efficiency Domain in VBP (27/76=36%) HAC: 724/2576 (22%) hospitals received 1% payment reductions (11/85=13%) RRP: 2,638/3478 (76%) hospitals received payment reductions (72/91=80%) 5

6 Glossary - TMI MSPB Medicare Spending Per Beneficiary The only Efficiency measure MSPB Amount An average $ claims per episode for a hospital. Adjusted for regional differences, efficiency, and more. National average =$19,578. Standardized Claims X US National Ave. Predicted Claims Renormalized Spending Per Episode MSPB Measure A hospital's MSPB ratio: MSPB Amt. US National Median MSPB Amt. The national MSPB measure = 0.98 A close approximation of MSPB measure is: Standardized Claims Predicted Amt. Renormalized (Claims) Predicted Payment Amt. The amount generated by regression model that is price standardized, case mix adjusted, and removes regional wage variation. Predicted Amt. Renormalized The predicted payment amt. excluding extreme low cost values and outliers MSPB Achievement Threshold: 0.98, Median MSPB ratio across all hospitals MSPB Benchmark: 0.83, Mean of the lowest (best) decile MSPB ratios across all hospitals 6

7 Why Together Today? Hospitals received 2014 MSPB data in June data files: Index, Episode, Risk - Hospital Specific Report 2-year lag time: CY2015 impacts FFY2017 MSPB measure In FFY2017, VBP can impact 2% of Medicare payments to hospitals Key Questions for Management and Physicians How are MSPB and other value oriented programs impacting my hospital financially? What should we do about it? Are they a priority? Who should be on the team to improve our efficiencies and MSPB performance? 7

8 II. VBP, The Context Surrounding MSPB 8

9 VBP FY The context surrounding MSPB The Affordable Care Act of 2010 mandated MSPB ¼ of 1.75% FY 2016 Value-Based Purchasing Domain Weighting (Payment adjustment effective for discharges from October 1, 2015 to September 30, 2016) Patient Experience of Care, 25% Clinical Process of Care, 10% MSPB Efficiency, 25% Outcome, 40% 9

10 VBP FY 2017 The context surrounding MSPB The Affordable Care Act of 2010 mandated MSPB ¼ of 2% FY 2017 Value-Based Purchasing Domain Weighting (Payment adjustment effective for discharges from October 1, 2016 to September 30, 2017) Clinical Process of Care, 5% Patient Experience of Care, 25% MSPB Efficiency, 25% Clinical Care Outcome 25% AMI, HF, PN 30 day Mortality Safety 20% PSI 90, CLABSI, CAUTI, SSI, C. difficile, MRSA 10

11 Turning MSPB Measure into Efficiency Measure under VBP 4 MSPB measure scores are compared: Hospital A For Your Hospital 1. Hospital Baseline Score (MSPB Measure from the past time period) 2. Hospital Performance Score (MSPB Measure from the most recent time period) For The Nation 3. Achievement Threshold: 50 th percentile MSPB measure nationally (during baseline period) 4. Benchmark: average MSPB measure of the best performing 10% of hospitals nationally (during baseline period) 11

12 National Distribution of MSPB Measures MSPB Benchmark: 0.83 MSPB Achievement Threshold: 0.98 From CMS Hospital Specific Report 12

13 MSPB Scores Achievement Points CMS compares how a hospital performed compared to national scores. 1. Achievement Points Compares your hospital (current scores) to CMS national scores (baseline period). Worse than the 50% achievement threshold = 0 points Above the benchmark = 10 points Between the threshold and the benchmark = 1 to 10 points Hospital A NOTE: For MSPB, lower scores are better 0 Points 1-10 Points 10 Points MSPB Achievement Threshold: 0.98 MSPB Benchmark: 0.83 Timeline Baseline Period 1 year time gap Performance Period From CMS Hospital Specific Report 13

14 MSPB Scores Improvement Points CMS compares how a hospital performed one period to the next. 1. Improvement Points Compares your hospital (current scores) to itself (baseline scores). Worse than baseline period = 0 points Between the threshold and the benchmark = 0 to 9 points Hospital A Hospital A 0 Points NOTE: For MSPB, lower scores are better 0-9 Points Baseline period score Current score MSPB Benchmark: 0.83 Timeline Baseline Period 1 year time gap Performance Period 14 From CMS Hospital Specific Report

15 III. MSPB Individual Beneficiary & the Measure 15

16 Medicare Spending Per Beneficiary An Episode 1 Patient Summary: Patient admitted with syncope, discharged, then re-hospitalized. There was also a skilled nursing (SNF) admission. Age Risk Adjustment Based On 90 Days Before Episode Ambulatory coding complete? Hierarchical Condition Categories and age establish patient complexity and usually add $ to the predicted payment amount. Efficient care prior to admission? 3The Episode Index hospital owns the total spend Episode Begins 3 Days Before Index Admission Claims paid for these 3 days are assigned to this episode. 4 Admission Date Index Admission Correct MS-DRG? Discharge planning prevents readmission? Discharge Date 30 Days After Discharge Efficient post-discharge management? Combined Part B Claims Paid Over Whole Episode: Up to 5 providers reported in order of claims paid amount (highest to lowest $) although only the combined $ amount is given. 1) Ambulance Company 3) Dr. Miller 5) Dr. Williams 2) Dr. Jones 4) Dr. Smith Total $6,500 5 Financial Scoreboard (All Applied to Index Hospital) Payment Inpatient (Part A) $13,000 SNF (Part A) $9,000 Physicians & Transport (Part B) $6,500 Other $200 TOTAL Claims Paid $28,700 Episode Ends Part B Claims paid consistent with patient s needs? Compared to national, standardized, claims paid model, there is $17,000 gap Predicted Payment Amount $11,700 MSPB Rate

17 MSPB: Detailed CMS Statistics A. Number of Eligible Admissions B. Average Spending per Episode C. MSPB Amount (Ave. Risk Adjusted) D. US National Median MSPB E. MSPB Measure Performance Rate (C/D) Your Hospital (example data) State U.S ,000 3,510,945 $19,500 $18,000 $19,598 $19,800 $18,500 $19,253 $19,584 $19,584 $19, From Table 3 of a simulated CMS Hospital Specific Report17

18 IV. MSPB Data Decoding and Uses at Your Hospital (Love your data) 18

19 MSPB: MDC Focus See table Page 5 Decoding MSPB Article A. MDC B. MDC Description C. MSPB Measure (Approx.) =G/H D. # of Episodes E. Total Standardized Spending F. Sum of Predicted Amount Renormalized G. Hospital Average (Standardized) Spending per Episode H. Predicted Spending per Episode Circulatory System $1,986,000 $1,960,000 $19,860 $19,

20 MDC Opportunity MSPB 30-Day Care Pathways 1 MDC-X, XXX Qualifying Episodes, MSPB Measure=X.XX Look at high-volume MDC with MSPB Measure>1.00 Which SNFs are most/least efficient? Which combinations are the most/least efficient? 3 We are the only inpatient provider XXX Episodes, MSPB=X.XX Our Hospital higher than different X Episodes, MSPB=X.XX Some leakage out Was there an inpatient event in 30 days after discharge that was not at our own hospital? NO YES Does the yes/no rate vary among our hospitals? Episodes with additional inpatient event at a different facility XX Episodes, MSPB=X.XX 6 Was our rehab facility used? Inpatient Rehab highest X Episodes, MSPB=X.XX Other Hospital highest X Episodes, MSPB=X.XX 7 Leakage out! Are there trends in case type or attending physician? Leakage in! Key MDC Major Diagnostic Category MSPB Medicare Spending Per Beneficiary SNF Skilled Nursing Facility 8 From Other Inpatient Facility - Readmission counted as part of another hospital s episode 20

21 MSPB: Physician Profiles MS-DRG 470 Operating Physician (PB1) = Dr. A., n=28, MSPB = 1.08 Operating Physicians (PB1) = All Others, n=56, MSPB % 100% 80% 11% 90% 80% 27% 57% 70% 63% 60% 40% 20% 43% 96% 89% No Yes 60% 50% 40% 30% 20% 38% 75% 73% No Yes 10% 25% 0% 4% 0% Rehab SNF HH Rehab SNF HH 21

22 Additional MSPB Opportunities Hospital Compare Public Reporting Hospital Compare Public Reporting Stars 2016 MSPB (SPP Spending Per Patient) Payment 30 day (MSPB-1) AMI, HF, PN, THA/TKA, Kidney UTI, Spine Fusions, Cellulitis, GI Hemorrhage No MSPB in 75 measures MSPB Trends Comprehensive Care for Joint Replacement (CCJR) Public Use Files (PUF) Physician Payments 90 days not 30, but MSPB useful Example to Follow Value Modifier includes MSPB 22

23 Medicare Payments by County PUF 2013 Using Claims Paid (MSPB Methodology) County Total $ 1 E & M 2 HCC 3 Readmission Rate 4 Tuscaloosa 10,106 1, Jefferson 9, Etowah 11, Franklin (Ohio) 9, Standardized and risk adjusted per capita 2 Evaluation and Management Standardized 3 Hierarchical Condition Categories 4 All Cause Medicare 23

24 Making MSPB Interoperable with HAC & QualityAdvisor 1 HAC File 2 MSPB File 3 Quality Advisor HIC HIC MRN DVT/PE PDGNS_CD PSI Trigger Diagnoses or Procedures Std_Pmt_ All_Clm Pred_Amt Renormal MSPB Measure (Approx.) $ 44,659 $ 26, $ 49,257 $ 28, $ 84,115 $ 56, $ 74,037 $ 61, $ 47,538 $ 35, $ 68,780 $ 53,

25 V. MSPB Working with Physicians 25

26 V. MSPB Working with Physicians Education Necessary but insufficient Data Necessary but insufficient Part B might be an exception Comparative Performance Necessary Incentives Can help MSPB and Value Modifier. MACRA (Medicare Access and CHIP Reauthorization Act 2015), Initiates Merit-Based Incentive Payment System (MIPS) with MSPB like measures. Performance 2017, Payment Resource use 30%

27 What Cost Measures Will Be Used to Calculate the 2018 Physician Value Modifier? Total per capita costs measure (Parts A & B) Total per capita costs for beneficiaries 4 chronic conditions (COPD, HF, CAD, and DM) Medicare Spending Per Beneficiary (MSPB) measure (3 days before and 30 days after an inpatient hospitalization) 27

28 Physician Involvement MSPB The MSPB data from 2012, 2013, and 2014 provide multiple opportunities to work with physicians, particularly: Validating Part B claims for specific physicians in specific case mix groups. Studying patients who leak out of the system (MSPB 30 Day Care Pathways - Panels 5, 6 and 7). Comparing use of home health and SNF for comparable patients. Are there SNF patients that should be Rehab? Understanding the impact of HACs on MSPB results. Physician involvement is highly dependent on existing institutional cultures, roles, responsibilities, and experiences with bundled or episode care. Understanding the impact MSPB will have on the physicians 2016 VM. 28

29 VI. MSPB In Context A Multi-Year Resource & Process Improvement Opportunity 29

30 QUALITY FATIGUE Oh no, not another. 30

31 Mobilizing Your Expertise and Investing in your Future To make best use of MSPB (and other) data, establish a performance improvement team Physician or nurse champion with authority for quality improvement Finance representative who understands the flow of Medicare fee-for-service claims data and continuum claims and costs Analyst to interface MSPB data with the hospital s clinical, financial databases, and VBP, RRP, and HAC data Clinician with patient transition responsibilities Coordinate with other performance improvement projects and information systems data governance The team leader should have in-depth understanding of analytic issues and clear reporting lines to both the physician leaders and senior financial managers 31

32 Your Hospital 2017 Performance Period Ends 2015 VBP 2% Process 5% Pt Experience Care 25% Safety 20% -PSI HAI Outcomes - 30 Day Mortality 25% 6-30 MSPB - Efficiency 25% RRP 3% 6-30 HAC 1% Domain Domain

33 Thank You! Good Luck! Have Happy Interoperable Data!

34 Questions 34