Pathway for Rewarding Better Care I

Lessons Learned from the CMS/Premier Hospital Quality Incentive Demonstration Project Denise Remus, PhD, RN VP, Clinical Informatics Premier, Inc – Balancing Cost and Quality Performance ’ improvement alliance of 1,500 hospitals; owned by more than 200 notfor-profit hospitals and health systems. Core Purpose: Efficiency without Quality Unthinkable Unsustainable Quality without Efficiency To improve the health of communities. Envisioned Future: Premier hospitals and health systems will operate at costs in the lowest quartile… and at quality levels in the highest quartile. © Premier 2006 Clinical quality and financial performance are inseparable 1 Hospital Quality Incentive Demonstration (HQID) Project Overview • CMS and Premier partnership project • First national hospital Pay-for-Performance (P4P) demonstration • Tests the hypothesis that monetary incentives and market recognition can increase quality of care • 3 year project: Oct 1, 2003-Sept 30, 2006 data • 268 current participants in HQID Year One analyses – Located across the country, 38 states – Less than 100,000 population = 24%, >= 1 million population = 40% – Three critical access hospitals – Teaching = 23%, non-teaching 72.5% – Average licensed operational bedsize = 351 (range 25 to 1000) © Premier 2006 HQID Overview (cont.) • 5 clinical conditions – all defined by diagnoses and/or procedures – – – – – Acute Myocardial Infarction (AMI) Heart Failure (HF) Community Acquired Pneumonia (PN) Coronary Artery Bypass Graft (CABG) procedures Hip and Knee replacement procedures (Hip/Knee) • Hospitals must have 30 discharges in each clinical area per year to be included • 30 measures as of Sept. 1, 2005 (was 34), includes both process and outcome measures • Hospitals placed in deciles based on composite quality score (CQS) within each clinical condition – Top performers (top two deciles) 1% to 2% quality incentive each year – End of year three – penalty adjustment for hospitals who do not achieve CQS above lower thresholds (deciles 9 and 10) from year one © Premier 2006 2 Example of Payment Scenario - AMI Payment Incentive: Thresholds recalculated based on year 3 data AMI 95.79% 93.97% 1st Decile 2nd Decile 3rd Decile 4th Decile AMI + 2% 1st Decile Payment Incentive: Thresholds recalculated based on year 2 data AMI 1st Decile 2nd Decile 3rd Decile 4th Decile 5th Decile 6th Decile 7th Decile Payment Incentive 2nd Decile 3rd Decile 4th Decile 5th Decile 6th Decile 7th Decile 8th Decile 9th Decile 10th Decile + 1% Public Recognition 8th Decile 9th Decile 90.41% 5th Decile 6th Decile 7th Decile Hospital 10th Decile 85.18% 81.41% Payment Adjustment Thresholds Hospital 8th Decile 9th Decile 10th Decile 85.18% 81.41% - 1% - 2% Year One Oct 03 – Sep 04 Year Two Oct 04 – Sep 05 Year Three Oct 05 – Sep 06 Payment Adjustment - Year 3 © Premier 2006 HQID Year 1 – Final Results Released November 14, 2005 • Quality improvement across all hospitals and clinical areas • AMI alone – 235 “lives saved” • $8.85 million awarded to 123 top performers • Top performers represented large and small facilities across the country. © Premier 2006 3 Significant Improvements in CQS – Year 1 HQID Year 1: Improvement in Composite Quality Score by Clinical Area First Data Quarter to Fourth Data Quarter 95% 90.81% 90% 87.43% 84.94% 85% 84.93% 89.71% 90.14% 80% 79.17% 75% 74.19% 70% 69.37% 65% 64.58% 60% AMI 4Q03 AMI 3Q04 CABG 4Q03 CABG 3Q04 CAP 4Q03 CAP 3Q04 HF 4Q03 HF 3Q04 HK 4Q03 HK 3Q04 © Premier 2006 Range of Improvement HQID: Quality Improvement During Year 1 October 2003 to September 2004 Final Data (11/10/05) 120% 106.5% 100% 100.7% 87.43% 80% 69.37% 60% 59.10% 62.69% 64.40% 53.16% 40% 32.62% 20% 11.76% 0% AMI CQS 4Q03 AMI CQS 3Q04 CABG CQS CABG CQS 4Q03 3Q04 CAP CQS 4Q03 CAP CQS 3Q04 HF CQS 4Q03 HF CQS 3Q04 HIP CQS 4Q03 HIP CQS 3Q04 39.33% 64.58% 90.81% 84.94% 79.17% 74.19% 66.52% 70.20% 99.8% 100.1% 89.71% 92.7% 84.93% 97.3% 97.8% 100.0% 98.6% 101.3% 90.14% 18.18% Clinical Conditions: First Quarter Year 1 and Fourth Quarter Year 1 © Premier 2006 Maximum Minimum Mean 4 Improvements continue. . . CMS/Premier HQID Project Participants Composite Quality Score: Trend of Quarterly Median (5th Decile) by Clinical Focus Area October 1, 2003 - December 31, 2005 (Year 1 Final Data, Year 2 and Q4-05 Preliminary) 100% 88.9% 90.0% 93.65% 94.84% 96.07% 96.85% 96.77% Composite Quality Score 90% 89.88% 90.06% 91.5% 92.6% 93.50% 93.46% 95.07% 95.77% 95.98% 95% 78.3% 80.0% 82.51% 82.72% 84.81% 86.43% 88.54% 80% 85.14% 85.92% 85% 75% 70.00% 73.13% 70% 65% 64.10% 60% AMI CABG Pneumonia 68.11% 73.1% Heart Failure 76.2% 77.88% 81.57% 82.98% 84.38% 86.73% Clinical Focus Area Q4-03 © Premier 2006 Q1-04 Q2-04 Q3-04 Q4-04 Q1-05 Q2-05 Q3-05 Q4-05 How were improvements accomplished? Lessons from top performers. . . • “Quality” core value of institution • Priority of executive team • Physician engagement • Use improvement and prioritization methodologies • Dedicated resources • Committed “knowledge transfer” © Premier 2006 85.13% 86.87% 89.0% 90.5% 92.07% 93.98% 95.37% 95.80% 96.05% Hip and Knee 5 Example . . . • Quality indicators at core of strategic plan with active monitoring and involvement by the Board • Employees can articulate the meaning of quality in the organization • Quality is used as the business strategy to differentiate in the market, thereby driving market share and bottom line © Premier 2006 Example . . . • Metrics align executive management and medical staff • Executive leaders held accountable for assigned clinical indicators • Physician level data reviewed at medical staff meetings and information recorded in physician’s credentialing file © Premier 2006 6 Challenges and recommendations • Issues with accuracy and interpretation of measure operational definitions – National consensus measures should require developer to keep current – Expand data collected when appropriate (e.g., categorical values for reason for delay) • Delays in modifying definitions based on evidence – Continue to push for rapid alignment © Premier 2006 Challenges and recommendations (cont.) • Multiple priorities and similarities create confusion – Continue standardization of measures and simplify validation processes • Need timely feedback that incorporates comparative data – Shorten data submission and reporting cycles © Premier 2006 7 Challenges and recommendations (cont.) • Dramatic improvement achieved – still in lower deciles – Do not adopt deciles nationally, focus on achievement of thresholds and improvement – It’s not just the money – public recognition important • Optimal organizational structure – Need additional qualitative research © Premier 2006 Contact Information Denise Remus, PhD, RN Denise_Remus@Premierinc.com Additional information on HQID available at: www.cms.hhs.gov/quality/hospital and www.premierinc.com © Premier 2006 8