Sylvia Coolidge Moore

Sylvia Coolidge Moore is an experienced hospital executive (COO) leading operations across a range of organizations from large to medium size for over 20 years. As the COO she has led organizations to adopt performance improvement and patient safety as key organizational priorities. She has guided boards, executives, management and staff through education and understanding of High Reliability No Harm Health Care, Pay For Performance Requirements and the financial rewards and penalties imposed by CMS. She has led the adoption of a High Reliability No Harm Health Care culture commitment, organizational assessment and cultural change priorities and actions. Additionally she has led organizations to significant improvement in Value Based Purchasing, HAC and Readmission Reduction parameters of the CMS Pay For Performance System. Most recently she has established a private consultancy service (FE3 Catalytics) focusing on her two passions in healthcare: High Reliability No Harm Healthcare and Patient Experience.

Here are 10 factors every provider should keep in mind as it pertains to managing care:

  1. Concurrent performance on all measures with the ability to forecast quality and financial impact, based on current performance
  2. VBP domain scores, total score, and VBP multiplier
  3. Excess readmission multiplier and monetary penalty, if any
  4. Hospital-acquired condition (HAC) multiplier and monetary penalty, if any
  5. The dollar amount of the annual 2-percent VBP reduction held back by the Centers for Medicare & Medicaid Services (CMS)
  6. The dollar amount of the annual 2-percent VBP reduction earned back
  7. The dollar amount of the VBP incentive earned annually above the 2-percent withheld
  8. Safety impact of current performance in a specific VBP measure or domain relative to baseline, CMS threshold, and CMS benchmark
  9. Financial impact of current performance in a specific VBP measure or domain
  10. The financial opportunity available through improved performance in a given VBP domain, specific measure or in HACs or readmissions

First and foremost, looking forward by forecasting your future safety and financial outcomes, rather than looking backward based on publically reported data, is essential. Furthermore, knowing both the safety and financial impact of performance and potential improvements allows you to focus on improvement investments that will deliver the greatest returns in both safety and dollars. Lastly, tracking the safety and financial impact of actual real-time improvements allows you to determine and demonstrate that the improvements are significant enough to outpace competitors.

About the Author

Sylvia Coolidge Moore is an experienced hospital executive (COO) leading operations across a range of organizations for more than 20 years. As the COO, she has led organizations to adopt performance improvement and patient safety as key organizational priorities. She has guided boards, executives, management, and staff through education and understanding of high-reliability, no-harm healthcare, pay-for-performance requirements, and the financial rewards and penalties imposed by CMS. She has led the adoption of a high-reliability, no-harm healthcare culture commitment, organizational assessment, and cultural change priorities and actions. Additionally, she has led organizations to significant improvement in value-based purchasing, HACs, and readmission reduction parameters of the CMS PFF system. Most recently she established a private consultancy service (FE3 Catalytics) focusing on her two passions in healthcare: high-reliability, no-harm healthcare and the patient experience.

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On July 9, 2015 a Centers for Medicare & Medicaid Services (CMS) press release announced a proposed “major initiative for hip and knee replacements.” And hospitals were front and center in the model!

The proposed model was detailed for comment in the July 14, 2015 Federal Register. The comment period ended Sept. 8, 2015. The proposed implementation date is January 1, 2016.

Why is CMS targeting lower extremity joint replacement (LEJR)?

In 2013 there were more than 400,000 inpatient primary LEJR procedures for Medicare recipients. The cost to Medicare was more than $7 billion for hospitalization only. Furthermore, there is significant regional variation in readmissions and complications for these procedures, resulting in average Medicare expenditure ranges from $16,500 to $33,000 across geographic areas.

Goal of Comprehensive Care for Joint Replacement (CCJR)

In the aforementioned press release, U.S. Department of Health and Human Services (HHS) Secretary Sylvia Mathews Burwell said that “this model will incentivize providing patients with the right care the first time and finding better ways to help them recover successfully.”

“Hospitals and physicians have an incentive to work together to deliver more effective and efficient care,” Burwell added, noting that CMS anticipates a $153 million saving through the CCJR model.

Hospitals Are the Overall Accountable Party and at Financial Risk

Key Points:

  1. Five-year payment model demonstration
  2.  Payment for an episode of care:
    • Episode begins with a hospital admission and ends 90 days post-discharge (MS-DRG 469 or 470)
    • Includes both Part A and part B services
  3. Required participation by all hospitals in 75 MSAs (except hospitals currently participating in Bundled Payments for Care Improvement (BPCI) initiative for LEJR episodes)
  4. Applies to all Medicare fee-for-service beneficiaries

Target Pricing and Payment

Pricing:

  1. Medicare establishes hospital-specific episode prices (target prices) for MS-DRG 469 and 470 each year for five performance years. Hospitals receive notice of target prices prior to the start of each performance year.
  2. Target prices are based on three years of historical payment data. Years Nos. 1 and 2 will use historical CCJR episodes between the start of 2012 and the end of 2014. Years Nos. 3 and 4 will use historical episodes from the start of 2014 through the end of 2016.
  3. Target prices begin with a 2-percent reduction from historical episode spending in years 1 through 5 of model.
  4. Target prices blend together hospital-specific and regional historical CCJR episode payments. The blend transitions from primarily hospital-specific to completely regional historical episode spending over the course of the five performance years.
  5. Target price includes inpatient hospital services, including readmissions, physician services, inpatient psych facility (IPF) services, LTCH, IRF, SNF, HHA, hospital outpatient, independent outpatient therapy, clinical lab, DME, Part B drugs, and hospice.

Payment: Retroactive Bundled payment model

  1. All providers and suppliers for the episode are paid under the existing Medicare payment system throughout the performance year.
  2. At the end of each performance year, the actual episode spending is compared to target LEJR episode spending.
    • If target LEJR spending is below the Medicare target and all three quality thresholds are met, the hospital is eligible for a positive reconciliation payment up to a specified cap.
    • If LEJR episode spending exceeds target price, hospital is required to make repayment up to a specified limit. The repayment component of the model is phased in during the second year.

 

Quality Measure Requirements

Three required quality measures include:

  1. Hospital-level risk-standardized complication rate (RSCR)
  2. Hospital-level, 30-day, all-cause, risk-standardized readmission rate. (RSRR)
  3. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey (HCAHPS linear mean roll-up score, or HLMR). HLMR is based on 11 publically reported HCAHPS measures.

Other Considerations Relative to Quality

  1. Voluntary reporting of patient-reported functional outcome measures provides slightly higher target prices by reducing the taget price discount noted above from 2 percent to 1.7 percent. This provides an opportunity for additional reconciliation payment amounts.
  2. Performance-level threshold requirements on quality measures relative to the national distribution of measure results for all participating hospitals increase over the five performance years (at or above the 30th percentile of all participating hospitals in years Nos. 1-3 and at or above the 40th percentile in years Nos. 4 and 5.)

Flexibilities Offered to Facilitate Cost-Effective, Timely, Convenient, Accessible Care

  1. Waiver of three-day inpatient stay prior to SNF admission
  2. Payment for in-home physician telemedicine visits
  3. Payment for physician-directed post-discharge visits in the home anytime during the episode (maximum nine visits)
  4. Hospital may enter into financial arrangements with collaborating providers and suppliers, including gain-sharing

Things to Think About

All providers within the 75 MSAs who provide care to patients who undergo primary elective LEJR are thrust into a bundled episode of care. However, the hospitals are ultimately at financial risk for meeting or beating the episode of care target price. The hospital will have to drive the improvements in quality, transitions of care, evidence-based decision-making, and efficiency (overall Medicare spending per episode per beneficiary). Working relationships and collaboration with all providers in the episode continuum will have to become significantly more collaborative, well-coordinated, and interdependent. New financial arrangements with other episode care providers likely will be desirable in order to incentivize collaboration, coordination, and efficiency. Don’t forget that the annual target price is based on regional performance and quality performance requirements, with your performance gauged by your national percentile rank. If other hospitals in your region and nationally are outperforming you, you’ll be at significant risk. As others get more efficient and improve quality outcomes, the bar will be raised for all.

About the Author

Sylvia Coolidge Moore is an experienced hospital executive leading operations across a range of organizations for over 20 years. As the chief operating officer, she has led organizations to adopt performance improvement and patient safety as key organizational priorities. She has guided boards, executives, management, and staff through education and understanding of high-reliability, no-harm healthcare; pay-for-performance requirements; and the financial rewards and penalties imposed by CMS. She has led the adoption of a high-reliability, no-harm healthcare culture commitment, organizational assessment, and cultural change priorities and actions. Additionally, she has led organizations to significant improvement in value-based purchasing, HAC and readmission reduction parameters of the CMS pay-for-performance system. Most recently she has established a private consultancy service (FE3 Catalytics) focusing on her two passions in healthcare: high-reliability, no-harm healthcare and patient experience.

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s coolidgeThe evidence is readily available. Guidelines exist. Bundles are proven and published. Toolkits are yours for the taking.

Many providers research and publish evidence-based practice guidelines and care bundles that have been proven to improve outcomes when utilized collectively and reliably. Many also make use of toolkits and checklists to reduce the prevalence of hospital-acquired conditions (HACs), readmissions, and issues associated with negative results on value-based purchasing (VBP) process and outcome measures.

The U.S. Department of Health and Human Services (HHS), through the federal Agency for Healthcare Research and Quality (AHRQ), publishes a variety of resources that are free and available to all. Thousands of guidelines are available through their National Guideline Clearinghouse. AHRQ’s Healthcare Associated Infections Program provides tools and resources to prevent CLABSI, CAUTI, SSI, C-difficile, and MRSA. Additionally, they provide guides for reducing readmissions, preventing falls, and preventing pressure ulcers.

Likewise, the Institute for Healthcare Improvement (IHI) provides extensive resources relative to the science of improvement as well as care bundles for CLABSI, VAP, sepsis, and other conditions. It also publishes how-to guides for preventing surgical site infections for knee and hip arthroplasty and addressing VAP, CLABSI, harm from high-risk medications, and adverse obstetrical events.

The JCAHO Center for Transforming Healthcare has a mission to transform healthcare into a highly reliable industry. To that end, it has launched improvement projects providing strategies for improving outcomes through hands-off communication and preventing VTE, falls, SSIs, sepsis mortality, C-difficile, and avoidable heart failure admissions. It also provides Targeted Solution ToolsR  (TSTR) to assist organizations with improvement.

The Centers for Medicare & Medicaid Services (CMS), through its Partnership For Patients, also makes HAC reduction resources available. The American Hospital Association, through its Healthcare Research and Education Trust (HRET) and Hospitals in Pursuit of Patient Safety, provides checklists to improve patient safety when it comes to matters ranging from adverse drug events to HAIs, pressure ulcers, and venous thromboembolisms.

There is no shortage of knowledge and proven practice resources readily available to all organizations. With all of these resources, though, why are hospitals struggling to be top performers relative to VBP, HACs, and readmissions? The answer to the question lies not in available knowledge but in the age-old problems of organizational vision, culture, change management, process improvement, communication, focus, measurement, execution, and leadership. These are the difficult challenges that make knowledge and proven practice necessary but not sufficient. Top performers do not have secret evidence or guidelines or toolkits or checklists. What they have is an organizational vision and an active commitment to positive performance in patient safety, supported by readily available clinical knowledge and proven practice, focus, change management/process improvement skills, caregiver and organizational communication skills, measurement, and daily positive leadership.

About the Author

Sylvia Coolidge Moore is an experienced hospital executive (COO) leading operations across a range of organizations of varying sizes for over 20 years. As a COO she has led organizations to adopt performance improvement and patient safety as key organizational priorities. She has guided boards, executives, management, and staff through education and understanding of high-reliability, no-harm healthcare, pay-for-performance requirements, and the financial rewards and penalties imposed by CMS. She has led the adoption of a high-reliability, no-harm healthcare culture commitment, organizational assessment, and cultural change priorities and actions. Additionally, she has led organizations to significant improvement in value-based purchasing, HAC, and readmission reduction parameters of the CMS regulations. Most recently she established a private consultancy service (FE3 Catalytics) focusing on her two passions in healthcare: high-reliability, no-harm healthcare and patient experience.

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Tuesday, 07 April 2015 20:11

Revenue Meets Quality: It’s Complicated

s coolidgeRevenue and quality have both been key components of every healthcare institution's success for as long as they have existed. However, they historically have been independent, parallel success factors. Revenue was concrete, the easy one to measure, while quality was more elusive and difficult to measure.

Quality began to gain prominence about 10 years ago with the IHI 100,000 Lives Campaign and the subsequent 5 Million Lives Campaign. Several of the initiatives to reduce harm and deaths from those campaigns are still with us today in the Centers for Medicare & Medicaid Services (CMS) elements of performance within the pay-for-performance (P4P) program.

The more direct relationship between quality and revenue grew out of the Patient Protection and Affordable Care Act, which mandates reduced payments to hospitals based on negative performance across three quality programs bundled into the CMS P4P program. Since 2012, revenue and quality are no longer on separate yet distantly related tracks. Now, revenue is becoming dependent on quality, and by 2020 it is likely that this dependence will be increased dramatically. In January the U.S. Department of Health and Human Services (HHS) secretary announced "measureable goals and a timeline to move the Medicare program and the healthcare system at large toward paying providers based on quality rather than the quantity of care they give patients."