Federal Health Quality and Health

1
Federal Health Quality and Health IT Landscape
Quarterly Update To participate in the audio
portion of the webcast, please dial
800.891.3493
August 6, 2008
Prepared by
for
2
Table Of Contents

• Medicare Improvements for Patients and Providers
  Act of 2008
• IPPS Final Rule
• OPPS Proposed Rule
• Quality Measurement Update
• CMS 30-day mortality measures
• Childrens Asthma measures
• Hospital Acquired Infections (NQF)
• NQF Enhancements to Measure Policies
• NQF Measure Evaluation Criteria Change
• NQF Proposed Proprietary Methods Policy
• Hospital Rating Systems
• Appendix

3
Congress passed the Medicare Improvements for
Patients and Providers Act of 2008 on July 17,
2008

• Evidence-based Measures and Reporting
  Infrastructure
• The Act provides 10 million per year for fiscal
  years 2009 through 2012 for the Secretary of
  Health and Human Services to contract with an
  entity to deploy uniform, evidence-based
  performance measures and a reporting
  infrastructure, and specifically to set national
  performance measures priorities in all applicable
  health care settings endorse and maintain
  measures that promote health, safety, and
  efficiency and promote the development and use
  of electronic health records that support
  performance management.
• Physician Quality Reporting Initiative (PQRI)
• The Act extended the PQRI program through 2010,
  and increased bonus payments for reporting from
  1.5 to 2.0 for 2009 and 2010.
• Preventive Care
• The law grants CMS the ability to add new
  screening or preventive services to Medicare.
  Currently, it requires a special act of Congress
  to include these kinds of services. Two
  candidates for coverage are intense weight-loss
  counseling and specific genetic tests for breast
  cancer.
• E-Prescribing
• The law establishes an electronic prescribing
  initiative under which physicians will initially
  receive a slight boost in payments for using the
  technology. In 2009 and 2010, Medicare will give
  doctors an additional 2 percent bonus on top of
  their fee for "e-prescribing." In 2011 and 2012,
  the bonus will drop to 1 percent, and in 2013,
  the bonus will drop again to 0.5 percent.
• Those who dont use e-prescribing would be
  subject to fee reductions of 1 percent in 2012,
  1.5 percent in 2013 and 2 percent thereafter.
  There is a provision for hardship exemptions.

Source California Health Line http//www.californ
iahealthline.org/articles/2008/7/17/New-Medicare-L
aw-Has-Wider-Implications-Than-Payments-to-Physici
ans.aspx?topicID37 Booz Allen Analysis
4
Table Of Contents

• Medicare Improvements for Patients and Providers
  Act of 2008
• IPPS Final Rule
• OPPS Proposed Rule
• Quality Measurement Update
• CMS 30-day mortality measures
• Childrens Asthma measures
• Hospital Acquired Infections (NQF)
• NQF Enhancements to Measure Policies
• NQF Measure Evaluation Criteria Change
• NQF Proposed Proprietary Methods Policy
• Hospital Rating Systems
• Appendix

5
CMS final IPPS rule for FY 2009 expands the
scope of quality reporting as well as the number
of HACs for which CMS will withhold additional
payment

• Quality measure provisions (FY 2009 reporting
  year/FY2010 payment determination)
• Adds 13 quality measures for the RHQDAPU program
  11 will be calculated by CMS from claims data.
• Retires one topped off measure Oxygenation
  assessment for PN patients
• Updated the specifications for two measures with
  respect to timing intervals
• - AMI PCI within 120 minutes of arrival ? 90
  minutes of arrival
• - PN Initial antibiotic within 4 hours of
  arrival ? 6 hours of arrival
• Hospital acquired conditions Added three of the
  proposed nine HACs, bringing the total HACs to
  eleven conditions that as of October 1, 2009 will
  no longer qualify a case for higher reimbursement
  if the conditions were not present on admission.

Source CMS IPPS Rule http//www.cms.hhs.gov/Acut
eInpatientPPS/downloads/CMS-1390-F.pdf Booz
Allen Analysis
6
CMS will add 13 NQF-endorsed measures to the
current set of measures hospitals must report
under the RHQDAPU program for the FY 2010 payment
determination
Source CMS IPPS Rule http//www.cms.hhs.gov/Acut
eInpatientPPS/downloads/CMS-1390-F.pdf Booz
Allen Analysis
7
CMS will add 13 NQF-endorsed measures to the
current set of measures hospitals must report
under the RHQDAPU program for the FY 2010 payment
determination
Source CMS IPPS Rule http//www.cms.hhs.gov/Acut
eInpatientPPS/downloads/CMS-1390-F.pdf Booz
Allen Analysis
8
CMS elected not to implement some of the proposed
measures at this time, but indicated they will
reconsider them in future rulemaking
Source CMS IPPS Rule http//www.cms.hhs.gov/Acut
eInpatientPPS/downloads/CMS-1390-F.pdf Booz
Allen Analysis
9
CMS elected not to implement some of the proposed
measures at this time, but indicated they will
reconsider them in future rulemaking (cont.)
Source CMS IPPS Rule http//www.cms.hhs.gov/Acut
eInpatientPPS/downloads/CMS-1390-F.pdf Booz
Allen Analysis
10
CMS elected not to implement some of the proposed
measures at this time, but indicated they will
reconsider them in future rulemaking (cont.)
Source FY 2009 IPPS Rule www.cms.hhs.gov/AcuteInp
atientPPS/downloads/CMS-1390-P.prf, Booz Allen
Analysis
11
The IPPS Final Rule added three new HACs to join
those adopted in the 2008 rule

• In the FY 2008 IPPS rule, Medicare adopted the
  following HACs for which hospitals are currently
  reporting present on admission
• Foreign Object Retained After Surgery
• Air Embolism
• Blood Incompatibility
• Pressure Ulcers Stage III and IV
• The FY 2009 IPPS final rule selected additional
  conditions to which the HAC payment provision
  will apply
• Manifestations of Poor Glycemic Control
• Surgical Site Infections Certain Orthopedic
  Surgeries, Bariatric Surgery for Obesity
• Deep Vein Thrombosis (DVT)/Pulmonary Embolism
  (PE) following certain orthopedic procedures
  (e.g., knee or hip replacements)
• The HAC payment provision implications for these
  selected HACs will take effect on October 1,
  2008.

• Falls and Trauma fractures, dislocations,
  intracranial injury, crushing injury, burn, and
  electric shock
• Catheter- Associated Urinary Tract Infection
  (UTI)
• Vascular Catheter- Associated Infection

• Surgical Site Infection-Mediastinitis After
  Coronary Artery Bypass Graft (CABG)

Indicates refinement of ICD-9 codes per
proposed rule comments received to better
identify HACs
Source CMS IPPS Rule http//www.cms.hhs.gov/Acut
eInpatientPPS/downloads/CMS-1390-F.pdf Booz
Allen Analysis
12
The final rule also identifies future potential
HACs and a decision on payment for present on
admission

• Additional measures considered, but to be
  monitored for potential future inclusion in to
  HACs includes
• Delirium
• Ventilator-Associated Pneumonia
• Staphylococcus aureus Septicemia
• Clostridium difficile-Associated Disease (CDAD)
• Methicillin-resistant Staphylococcus aureus
  (MRSA) (Caveat MRSA can cause a vascular
  catheter-associated infection (one of the HACs)
  though MRSA itself is not a HAC.
• Regarding present on admission, the final rule
  states that Medicare will only pay for those HACs
  coded with Y and W indicators. HACs coded as
  U will not be paid at this time though CMS is
  requesting information on exceptional
  circumstances.
• Y indicates that the condition was present on
  admission
• W affirms that the provider has determined
  based on data and clinical judgment that it is
  not possible to document when the onset of the
  condition occurred
• U indicates that the documentation is
  insufficient to determine if the condition was
  present at the time of admission

• Legionnaires Disease
• Iatrogenic Pneumothorax

Source CMS IPPS Rule http//www.cms.hhs.gov/Acut
eInpatientPPS/downloads/CMS-1390-F.pdf Booz
Allen Analysis
13
CMS discussed in the final rule a number of ways
they might handle HACs in the future

• Risk adjustmentCMS may explore risk adjusting
  the HACs at the subpopulation level to correct
  for risk associated with specific medical
  conditions.
• Include as part of a VBP planCMS held open the
  possibility of creating a rate-based HAC
  measurement domain as part of a future VBP plan,
  and adjusting hospital payment accordingly based
  on a hospitals rate of HACs, rather than
  withholding payment on individual cases.
• Use POA information for other purposesfor
  example, providing comparative information back
  to hospitals or reporting it publicly.
• Adopt ICD-10 as a way to provide more granularity
  in coding and to better identify HACs.
• Relationship between HACs and never
  eventscommenters cautioned that there is a
  difference between the two, since never events
  are absolutely preventable while HACs may not be.

Source CMS IPPS Rule http//www.cms.hhs.gov/Acut
eInpatientPPS/downloads/CMS-1390-F.pdf Booz
Allen Analysis
14
Table Of Contents

• Medicare Improvements for Patients and Providers
  Act of 2008
• IPPS Final Rule
• OPPS Proposed Rule
• Quality Measurement Update
• CMS 30-day mortality measures
• Childrens Asthma measures
• Hospital Acquired Infections (NQF)
• NQF Enhancements to Measure Policies
• NQF Measure Evaluation Criteria Change
• NQF Proposed Proprietary Methods Policy
• Hospital Rating Systems
• Appendix

15
CMS released the OPPS proposed rule for CY 2009

• CMS proposes to add four new quality measures
  that address efficiency.
• The rule also contains a list of 18 additional
  measures in nine measures sets which CMS is
  considering for future payment years for
  outpatient reporting, and welcomes additional
  suggestions on measures that could be harmonized
  across care settings.
• CMS proposes a methodology for validating
  outpatient data that differs from current
  practice in the inpatient setting.
• CMS once again deferred from requiring ASCs to
  report data, stating the requirement will be
  implemented in future rulemaking.
• CMS invites comment on how to apply non-payment
  for Hospital-Acquired Conditions (HACs) in the
  outpatient setting, and lists some HACs that
  could potentially be applicable to the
  outpatient hospital setting.
• Public comments are due by September 2, 2008. You
  may submit comments electronically through the
  following link http//www.regulations.gov/fdmspub
  lic/component/main?mainSubmitCommento0900006480
  68338f

Source AHA http//www.aha.org/aha_app/index.jsp?S
SO_COOKIE_ID0a2f011430e30a774ad2bbbd4090ab23ac962
4c1e655 Booz Allen Analysis
16
CMS proposes to add four new outpatient measures
that can be calculated from claims data

• CMS proposes to add four measures for imaging
  efficiency
• MRI Lumbar Spine for Low Back Pain
• Mammography Follow-up Rates
• Abdomen CTUse of Contrast Material
• ? Use of Contrast Material excluding calculi of
  the kidneys, ureter, and/or urinary tract
• ? Use of Contrast Material for diagnoses of
  calculi in the kidneys, ureter and/or urinary
  tract
• Thorax CTUse of Contrast Material
• CMS can calculate the measures from Medicare Part
  B claims data.
• For purposes of the CY 2010 payment
  determination, CMS will calculate the measures
  based on CY 2008 claims data.
• CMS has submitted the measures to NQF for
  endorsement, but they are not yet endorsed.

Source AHA http//www.aha.org/aha_app/index.jsp?S
SO_COOKIE_ID0a2f011430e30a774ad2bbbd4090ab23ac962
4c1e655 Booz Allen Analysis
17
The proposed rule solicits comment on potential
measures for CY 2010 reporting, and specifically
seeks input on data collection/reporting
challenges for these measures
Source AHA http//www.aha.org/aha_app/index.jsp?S
SO_COOKIE_ID0a2f011430e30a774ad2bbbd4090ab23ac962
4c1e655 Booz Allen Analysis
18
The proposed rule solicits comment on potential
measures for CY 2010 reporting, and specifically
seeks input on data collection/reporting
challenges for these measures cont.
Source AHA http//www.aha.org/aha_app/index.jsp?S
SO_COOKIE_ID0a2f011430e30a774ad2bbbd4090ab23ac962
4c1e655 Booz Allen Analysis
19
The rule proposes to implement a validation
process for CY 2009 data that responds to
criticism of the methodology used for the
inpatient RHQDAPU program

• The proposed data validation methodology would
  focus on 50 patient episodes of care that had
  been successfully submitted to the OPPS Clinical
  Warehouse for the relevant reporting period.
• Hospitals would send the supporting medical
  records and a CMS contractor would independently
  re-abstract the elements from the records.
• Calculation of a hospitals validation score
  would be based on percent agreement for each
  measure, rather than for the individual data
  elements.
• 80 reliability is required to pass validation,
  with an upper bound of 95 confidence interval,
  with confidence intervals calculated in the same
  way they are for the RHQDAPU program.
• Instead of requiring the records of every
  hospital, CMS would randomly select 800 hospitals
  annually from the total hospitals reporting.
• CMS proposes an additional three methodologies
  for validation using the same approach as
  currently used for inpatient measures, targeting
  hospitals for validation based on accuracy
  concerns, or some combination of the two.

Source AHA http//www.aha.org/aha_app/index.jsp?S
SO_COOKIE_ID0a2f011430e30a774ad2bbbd4090ab23ac962
4c1e655 Booz Allen Analysis
20
The proposed rule explores the potential for
expanding the concept of hospital-acquired
conditions (HACs) to the outpatient setting

• CMS seeks comment on the applicability of
  extending the concept of hospital-acquired
  conditions to the outpatient payment system, but
  explicitly states that it is not (at this time,
  at least) proposing new Medicare policy.
• CMS is specifically concerned with (and invites
  comment) on the following
• How can reasonably preventable (one of the
  criteria used for selecting inpatient HACs) be
  defined in the hospital outpatient setting?
• Are there evidence-based guidelines relating to
  prevention of high cost/high volume conditions
  that could be used to select HACs for the
  hospital outpatient setting?
• How can the OPPS payment system that is tied to
  volume of services rather than the severity of
  illness be adjusted to accommodate non-payment
  for HACs in the outpatient setting?
• CMS mentions the following candidate measures for
  outpatient HACs
• Object left in surgery
• Air embolism
• Falls and trauma fractures, dislocations,
  intracranial injuries, crushing injuries, burns
• Blood incompatibility

Source AHA http//www.aha.org/aha_app/index.jsp?S
SO_COOKIE_ID0a2f011430e30a774ad2bbbd4090ab23ac962
4c1e655 Booz Allen Analysis
21
Table Of Contents

• Medicare Improvements for Patients and Providers
  Act of 2008
• IPPS Final Rule
• OPPS Proposed Rule
• Quality Measurement Update
• CMS 30-day mortality measures
• Childrens Asthma measures
• Hospital Acquired Infections (NQF)
• NQF Enhancements to Measure Policies
• NQF Measure Evaluation Criteria Change
• NQF Proposed Proprietary Methods Policy
• Hospital Rating Systems
• Appendix

22
CMS will publicly report risk-standardized,
30-day mortality measures for AMI, HF and PN in
the near future

• The July 2008 posting of mortality measures to
  Hospital Compare has been delayed It will be the
  second annual posting for AMI and HF mortality
  and the first public reporting for PN mortality.
• AMI and HF 30-day mortality measures now exclude
  patients with a history of using the Medicare
  hospice benefit.
• Additional information will be provided in the
  future posting, including
• Display of actual hospital 30-day mortality rates
  (not just how hospital fared compared to national
  rate)
• Case volume (AMI, HF, PN)
• A drill down for categorical information better,
  worse or same as US National rate
• Downloadable file available of all posted
  information
• All three measures will be updated annually, and
  hospital-specific reports will be distributed to
  all participating hospitals for each annual
  preview period.
• CMS is contemplating three options for displaying
  30-day mortality measures
• Decrease confidence intervals for determining
  outliers
• Use percentile distribution point estimates to
  determine outliers (as opposed to using the mean
  and confidence intervals)
• Increase the number of years used to generate
  results using current outlier methodology

Source CMS Presentation Barry Straube 6/4/2008
Quality Net http//www.qualitynet.org/dcs/ContentS
erver?cid1163010398556pagenameQnetPublic2FPage
2FQnetTier2c Page Booz Allen Analysis
23
Childrens Asthma Care Measures are anticipated
to be reported on the Hospital Compare website in
the near future

• The Joint Commission (TJC) in collaboration with
  national childrens healthcare organizations
  developed a subset of Childrens Asthma Care
  (CAC) measures. These measures include
• Use of Relievers for Inpatient Asthma, CAC- 1
  (NQF-endorsed)
• Use of Systemic Corticosteroids for Inpatient
  Asthma, CAC-2 (NQF-endorsed)
• Home Management Plan of Care Given to
  Patient/Caregiver
• The two NQF-endorsed CAC measures will be
  publicly reported on Hospital Compare beginning
  in July
• CAC-1 National Average - 100
• CAC-2 National Average - 99
• Because some hospitals did not submit the
  required release information to HQA by the
  deadline, not all hospitals reporting CAC
  measures will be represented in the July release.
  
• Additional hospitals submitting HQA pledges by
  August 15, 2008 will be displayed in September.

Source CMS Presentation Barry Straube 6/4/2008
TJC http//www.outcome.com/provider-joint-commissi
on-asthma-care.htm Booz Allen Analysis
24
The National Quality Forum has endorsed seven new
performance measures and released a framework for
reporting healthcare-associated infection, or
HAI, data

• Approximately 20 states now require healthcare
  providers to report infection-related data, and
  16 states make reports on healthcare-associated
  infection (HAI) rates available to the public.
• To date, only limited national standards for the
  public reporting of HAI data have been in use,
  making it difficult to compare or aggregate the
  reported data on regional or national levels. As
  a result, NQF has endorsed voluntary consensus
  standards related to HAIs, including a framework
  for measurement and public reporting.
• The new HAI measures join 13 others that were
  previously endorsed by the NQF. The seven new
  performance measures include
• Intravascular Catheter-Associated Bloodstream
  Infections
• ? Central line bundle compliance
• ? Surgical site infection rate
• ? Cardiac surgery patients with controlled 6 am
  postoperative serum glucose
• ? Surgery patients with appropriate hair removal
• Ventilator-Associated Pneumonia and Respiratory
  Illness
• ? Ventilator bundle
• Healthcare-Associated Infections in Pediatric
  Populations
• ? Late sepsis or meningitis in neonates
• ? Late sepsis or meningitis in very low birth
  weight neonates

Source NQF Report http//www.qualityforum.org/pub
lications/reports/hai.asp, Booz Allen Analysis
25
The National Quality Forum has endorsed seven new
performance measures and released a framework for
reporting healthcare-associated infection, or
HAI, data (cont.)

• The NQF report listed five principles to help
  providers and data collectors develop a framework
  for standard and regular data reporting
  including
• Metrics should be chosen that are fully specified
  and generally accepted.
• Those who collect and report data should assist
  providers in achieving a common understanding of
  their measurement roles and responsibilities.
• Evaluation of the measurement and reporting
  process- metric definition, data collection,
  analysis, and reportingshould be occurring at
  regular intervals.
• Those who report HAI rates for comparison across
  providers have the responsibility to explain to
  users the reliability of reported data and the
  uses that the achieved degree of reliability will
  support.
• Reporting programs should rely on carefully
  constructed statistical methodologies that are
  appropriate to HAI measurement.
• NQF identified eight areas for which additional
  HAI measures needed to be developed
• Case Definitions for VAP and CA UTI
• BSI Research and Measure Development
• SSI Research and Measure Development
• Incorporation of Best Practices of Urinary
  Catheter Care into the NQF-Endorsed Safe
  Practices for Better Healthcare
• CA UTI Research and Measure Development
• VAP Research and Measure Development
• Pediatric Infections
• Healthcare Disparities in HAI Rates and Management

Source NQF Report http//www.qualityforum.org/pub
lications/reports/hai.asp, Booz Allen Analysis
26
Table Of Contents

• Medicare Improvements for Patients and Providers
  Act of 2008
• IPPS Final Rule
• OPPS Proposed Rule
• Quality Measurement Update
• CMS 30-day mortality measures
• Childrens Asthma measures
• Hospital Acquired Infections (NQF)
• NQF Enhancements to Measure Policies
• NQF Measure Evaluation Criteria Change
• NQF Proposed Proprietary Methods Policy
• Hospital Rating Systems
• Appendix

27
NQF has proposed changes to their measure
evaluation criteria in an effort to clarify and
strengthen the criteria

• NQF has four measure evaluation criteria
  importance to measure and report, scientific
  acceptability of measure properties, usability
  and feasibility.
• The purpose of this review of the NQF measure
  evaluation criteria was to identify areas where
  the criteria needed clarification or
  strengthening and to recommend changes in order
  to achieve
• a stronger link to national priorities and
  higher-level performance measures
• greater measure harmonization
• greater emphasis on outcome measures
• for process measures, a tighter outcomes-process
  linkage
• The evaluation criteria are used by NQF
  committees and advisory panels to assess
  candidate measures for their suitability as
  voluntary consensus standards. The criteria
  should also be used by those who are developing
  measures as well as NQF members who vote on
  measures recommended as consensus standards. They
  also provide a structure for the measure
  submission process.
• In addition to the measure evaluation criteria,
  NQF policy has established some conditions that
  must be met before a measure is considered and
  evaluated for suitability as a voluntary
  consensus standard. These are now explicitly
  stated prior to the criteria and include that the
  measure is open source, has a measure steward
  that maintains and updates the measure, and is
  intended for both public reporting and quality
  improvement.

Source NQF http//www.qualityforum.org/pdf/projec
ts/MEC/txEvalCriteriaDraftReport2008-05-22memo.pd
f Booz Allen Analysis
28
NQF proposed revisions to its intellectual
property policy in order to balance the
proprietary interests of measure developers with
the need to eliminate barriers to measure use

• Previous policy mandated an open-source,
  no-charge policy for measure specifications,
  except in the case of regression-based risk
  adjustment methodologies that relied on frequent
  database-driven updates to the coefficients.
• Evolution of the field of performance measurement
  and the increase in complex measures and
  risk-adjustment models led to a reassessment of
  the policy.
• An NQF task force considered two policy options
  with a number of permutations and combinations.
• The task force recommended a policy with the
  following elements
• Measure descriptions and all clinical
  /demographic variables are publicly disclosed
• Database elements (e.g., beta values, standard
  errors, etc.) are disclosed to an NQF expert
  panel during endorsement and maintenance review,
  but kept confidential
• Developers can charge a reasonable fee for data
  processing/production of public reports charges
  and pricing structure will be evaluated by the
  NQF review panel
• Providers cannot be required to permit the data
  processor/vendor to use their data for other
  purposes (e.g., resale for purposes other than
  the initial measure calculation)

Source NQF http//www.qualityforum.org/pdf/projec
ts/MEC/txEvalCriteriaDraftReport2008-05-22memo.pd
f Booz Allen Analysis
29
Table Of Contents

• Medicare Improvements for Patients and Providers
  Act of 2008
• IPPS Final Rule
• OPPS Proposed Rule
• Quality Measurement Update
• CMS 30-day mortality measures
• Childrens Asthma measures
• Hospital Acquired Infections (NQF)
• NQF Enhancements to Measure Policies
• NQF Measure Evaluation Criteria Change
• NQF Proposed Proprietary Methods Policy
• Hospital Rating Systems
• Appendix

30
Consumer-oriented public reporting gained ground
in the 1990s with the arrival of several
hospital rating sites

• Public reporting of hospital ratings accelerated
  in the 1990s with several intents
• Increase transparency and information exchange
  regarding healthcare services (e.g., cost,
  coverage, access to services etc.)
• Drive consumers to receive care from high value
  providers
• Improve the quality of care through stimulating a
  more competitive provider environment
• Propel payment reform to subdue the rapid
  increase in the cost and increase value of care
  provided
• Some of the more well-known hospital programs
  that began in the 1990s and the early 2000s
  include
• US News Americas Best Hospitals
• Solucient/Thomson (formerly HCIA)
• The Joint Commission

• Leapfrog
• HealthGrades
• WebMD

Source Booz Allen Analysis
31
Hospital Compare was launched in 2004 as a
consumer-oriented website that provides
information on how well hospitals provide
recommended care to their patients

• Hospital Compare was launched in 2004 through CMS
  along with the Hospital Quality Alliance (HQA) to
  make it easier for the consumer to make informed
  healthcare decisions, and to support efforts to
  improve quality in U.S. hospitals.
• Hospital Compare publicly reports hospital
  performance in a consistent, unified manner to
  ensure the availability of credible information
  about the care delivered in the nations
  hospitals. The information reported includes
• Process of Care includes measures of AMI, HF or
  PN, or patients having surgery
• Hospital Outcome of Care includes the 30-day Risk
  Adjusted Death (Mortality) Rates for patients
  with Medicare who were admitted to the hospital
  for AMI and HF
• Survey of Patients Hospital Experiences, using
  data collected from the Hospital Consumer
  Assessment of Healthcare Providers and Systems
  (HCAHPS) Survey
• Medicare inpatient hospital payment information
  and the number of Medicare patients treated
  (volume) for certain illnesses or diagnoses

Source Hospital Compare www.hospitalcompare.hhs.g
ov QualityNet http//www.qualitynet.org/dcs/Conte
ntServer?cid1121785350618pagenameQnetPublic/Pag
e/QnetTier2cPage Booz Allen Analysis
32
Despite Hospital Compares launch, the
pre-existing sites have flourished and new sites
have entered the market
Consumer Reports
Data Advantage

• Launched 2008
• Description A web tool based on the Dartmouth
  Atlas of Health Care data on end-of-life care of
  patients with severe chronic illnesses
• Scope of Services 2,857 hospitals nationwide are
  scored on a 100-point scale based on how they
  aggressively they treat patients with nine
  serious conditions in the last two years of life
• Outputs A tool
  that compares
  hospitals on the
  aggressiveness
  of their treatment

• Launched 2008
• Description A web-based value index
• Scope of Services Measures the relative value of
  care provided by U.S. hospitals includes more
  than 1,500 general acute-care hospitals in
  Americas 100 largest cities, serving
  approximately 180 million consumers
• Outputs Free comparisons of hospitals by
  metropolitan area (in-depth reports cost 795) a
  list of national best kept secrets-
  lesser-known hospitals that offer high value in
  their markets a
  
  list of the 100
  highest-value
  hospitals
  nationally

Source Consumer Reports www.consumersreports.org
Data Advantage http//www.data-advantage.com
Booz Allen Analysis
33
These new ratings sites provide the consumer with
different ways of evaluating hospital care

• Consumer Reports reliance on the Dartmouth Atlas
  data introduces to the consumer the idea that
  quality can mean fewer interventions,
  especially in the last months of life
• Hospitals are rated as providing conservative
  care (fewer days in the hospital and ICU and
  fewer doctor visits overall, with emphasis on
  primary care) versus aggressive care (more days
  in the hospital and ICU and more doctor visits
  overall, with emphasis on specialty care)
• The point is made over and over that aggressive
  care is not necessarily tied to better outcomes
• The Data Advantage Hospital Value Index
  attempts to define value based on
• Quality (45) uses the National Hospital Quality
  Measures, key patient safety measures (as
  defined by AHRQ), Joint Commission accreditation
  and inclusion in the Leapfrog Survey
• Affordability and efficiency (45) uses list
  prices for outpatient services and
  severity-adjusted Medicare cost report
  information
• Patient satisfaction (10) HCAHPS data
• Hospitals also receive a ranking based on their
  reputation in the local market

...but it is too soon to determine whether these
new sites are part of a trend toward more
sophisticated analysis
Source Consumer Reports www.consumersreports.org
Data Advantage http//www.data-advantage.com
http//www.hospitalvalueindex.com/showpdf.aspx?fil
epressdocs/abstract.pdf Booz Allen Analysis
34
What is certain is that while hospital ratings
sites have potential to change the way consumers
chose their care, few are using them in their
health care decision-making

• Rating web sites may still be a long way from
  becoming an integral part of the healthcare
  process
• While 22 percent of respondents to a recent poll
  by the California HealthCare Foundation reported
  looking at physician rating sites in 2007, only
  about 2 of patients have actually changed
  physicians based on information from an online
  rating.
• According to the Kaiser Family Foundations 2006
  Update on Consumers Views of Patient Safety and
  Quality Information just over a third (36) of
  the public says that in the past year they have
  seen information comparing the quality of
  different health plans, hospitals, or doctors.
• 20 of those polled in Kaiser Family Foundations
  study who have seen quality information say they
  used the information to make a decision about
  care, with most using the data to select a health
  plan. Only 10 reported using the information to
  make a health care decision about a hospital.
• The most active users of these sites may be
  providers themselves, who use them as a new tool
  for managing and improving patient care
• The work of Judy Hibbard and others continues to
  show that public reporting of quality information
  encourages hospitals to initiate quality
  improvement activities
• Stories are beginning to emerge about providers
  who use the online ratings to negotiate discounts
  in their malpractice fees one Cincinnati ENT
  practice, for example, used ratings to obtain a
  3 discount

Source KFF http//www.kff.org/kaiserpolls/upload/
7560.pdf Health Leaders Media http//www.healthle
adersmedia.com/content/214175/topic/WS_HLM2_PHY/Tu
rning-Online-Physician-Ratings-into-Lemonade.html
JH Hibbard, What Can we Say about the Impact of
Public reporting? Annals of Internal Medicine
2008 148 160-61 Booz Allen Analysis
35
Implications for consumers who utilize hospital
rating programs Confusion!

• The hospital rating differences in scope, data
  inputs, and methodologies often produce
  incongruent ratings that may contradict the
  intention to promote transparency. The rating
  systems use different sources of data, cover
  different dimensions, and use different
  methodologies to arrive at high quality or top
  hospitals.
• Example A large tertiary care hospital in a
  major metropolitan area with a well-respected
  cardiovascular program.
• Solucient did rate the hospital's cardiovascular
  program among the top 100 nationally
• U.S. News ranked the cardiovascular program in
  the top 15 in the country
• This hospital did win a HealthGrades Excellence
  AwardTM for cardiac care and coronary
  intervention, but not cardiac surgery in 2008
• The hospital was a top hospital for 1 AMI
  measure but not any of the other medical or
  surgical measures relating to cardiovascular care
  on Hospital Compare
• Consumer Reports tool ranks the hospital at 87,
  with 0 being conservative care and 100 being
  aggressive care
• Data Advantages Hospital Value Index did not
  include this hospital as a best in value
  hospital (in the top quartile) for its service
  area

Source HealthGrades http//www.healthgrades.com
/consumer/ US News and World Report
http//www.usnews.com/directories/hospitals/index_
html/specialtyIHQCARD/ Hospital Value Index
http//www.hospitalvalueindex.com/Default.aspx
Booz Allen Analysis
36
Implications for policy makers HQA has requested
that the Hospital Compare site become more
effective

• The HQA issued a letter in April to CMS
  advocating for changes in how information is
  shared on Hospital Compare to improve its appeal
  and usability for consumers
• Use consumer testing to revamp data displays,
  including use of symbols, colors, and other
  graphical cues
• Address concerns about cognitive difficulties and
  navigation
• Develop condition- and treatment-specific
  composite measures
• Improve the value of the mortality information
  through such means as pairing it with process
  measures, volume measures, and (if possible)
  other outcomes measures, and establishing more
  than three categories of performance
• CMS is aware of these concerns and is already
  working towards some of these goals.

Source FAH http//www.americashospitals.com/issue
s/comment_letters/2008/Ltr_CMS_ModifyingInfoHospCo
mp4-16-08FINAL.pdfBooz Allen Analysis
37
Implications for hospitals

• The ratings systems are not going away, so
  explore creative use of them.
• Some consumers ARE looking at these sites, and it
  is likely that more will follow suit, as the
  Kaiser poll below illustrates. Be prepared to
  respond to consumer questions

about the data and indices being used (e.g.,
about the Dartmouth Atlas data utilized by
Consumer Reports).
Source KFF http//www.kff.org/kaiserpolls/upload/
7560.pdf Booz Allen Analysis
38
Appendix

• NQF Initial HAI Measures
• NQF Additional Endorsed Measures
• NQF Evaluation Criteria Change Recommendations
• NQF National Priorities Partnership Priorities
  and Goals
• NQF Outpatient Imaging Efficiency Measures
  submitted by CMS
• Hospital Rating Systems Additional Information

39
Previously endorsed national voluntary consensus
standards for the reporting of healthcare-associat
ed infection data
NQF INITIAL HAI MEASURES

• Catheter-Associated Urinary Tract Infections
• Catheter-associated urinary tract infection rate
  for intensive care unit patients
• Ventilator-Associated Pneumonia and Respiratory
  Illness
• Rate of ventilator-associated pneumonia
• Clinician-Level Perioperative Care
• Timing of prophylactic antibiotics, ordering
  physician
• Timing of prophylactic antibiotics, administering
  physician
• Selection of prophylactic antibiotic, first- and
  second-generation cephalosporin
• Discontinuation of prophylactic antibiotics,
  non-cardiac procedures
• Discontinuation of prophylactic antibiotics,
  cardiac procedures

• Intravascular Catheter-Associated Bloodstream
  Infections
• Central line-associated bloodstream infections
• Surgical Site Infections
• Prophylactic antibiotic received within one hour
  prior to surgical incision
• Prophylactic antibiotic selection for surgical
  patients
• Prophylactic antibiotics discontinued within 24
  hours after surgery end time (48 hours for
  coronary artery bypass graft CABG and other
  cardiac surgery)
• Deep sternal wound infection rates for CABG
• Postoperative sepsis

Source NQF HAI Report http//www.qualityforum.org
/pdf/reports/HAI20Report.pdf, Booz Allen Analysis
40
On May 15, 2008 National Quality Forum endorsed
consensus standards for quality of hospital care
NQF ADDITIONAL ENDORSED MEASURES

• Length of Stay/Readmission
• Risk-adjusted average length of inpatient
  hospital stay
• Overall inpatient hospital average length of stay
  (ALOS) and ALOS by DRG service category
• All-cause readmission index
• 30-day all-cause risk standardized readmission
  rate following heart failure hospitalization
• Severity-standardized average length of
  stay-routine care
• Severity-standardized average length of
  stay-special care
• Severity-standardized average length of
  stay-deliveries

• Patient Safety, Adult
• Accidental puncture or laceration
• Death in low mortality DRGs
• Iatrogenic pneumothorax
• Death among surgical inpatients with serious,
  treatable complications
• Bilateral cardiac catheterization rate
• Blood cultures performed within 24 hours prior to
  or 24 hours after hospital arrival for patients
  who were transferred or admitted to ICU within 24
  hours of hospital arrival
• Congestive heart failure mortality
• Hip fracture mortality rate
• Transfusion reaction, age 18 years and older 

Source NQF http//www.qualityforum.org/news/relea
ses/051508-endorsed-measures.asp Booz Allen
Analysis
41
On May 15, 2008 National Quality Forum endorsed
consensus standards for quality of hospital care
(cont.)
NQF ADDITIONAL ENDORSED MEASURES

• Surgery and Anesthesia
• Abdominal aortic aneurysm volume
• Abdominal aortic aneurysm repair mortality rate
• Esophageal resection mortality rate
• Esophageal resection volume
• Incidental appendectomy in the elderly rate
• Pancreatic resection mortality rate
• Pancreatic resection volume
• Post operative wound dehiscence, age under 18
  years
• Post operative wound dehiscence, 18 years and
  older
• Foreign body left after procedure, age under 18
  years
• Foreign body left in during procedure, 18 years
  and older
• Failure to Rescue In-hospital Mortality
• Failure to Rescue 30-day mortality

• Patient Safety, Pediatrics
• Accidental puncture or laceration
• Decubitus ulcer
• Iatrogenic pneumothorax in nonneonates
• Transfusion reaction, age under 18 years 
• Pediatrics
• PICU severity-adjusted length of stay
• PICU unplanned readmission rate
• Review of unplanned PICU readmissions
• Home management plan of care document given to
  patient/caregiver
• Pediatric heart surgery mortality
• Pediatric heart surgery volume
• PICU pain assessment on admission
• PICU periodic pain assessment
• PICU standardized mortality ratio

Source NQF http//www.qualityforum.org/news/relea
ses/051508-endorsed-measures.asp Booz Allen
Analysis
42
On May 15, 2008 National Quality Forum endorsed
consensus standards for quality of hospital care
(cont.)
NQF ADDITIONAL ENDORSED MEASURES

• Venous Thromboembolism
• VTE prophylaxis
• Intensive Care Unit (ICU) VTE Prophylaxis
• VTE Patients with Anticoagulation Overlap Therapy
• VTE Patients Unfractionated Heparin
  (UFH)Dosages/Platelet Count Monitoring by
  Protocol (or Nomogram)
• VTE Discharge Instructions
• Incidence of Potentially Preventable VTE

Source NQF http//www.qualityforum.org/news/relea
ses/051508-endorsed-measures.asp Booz Allen
Analysis
43
NQF Measure Evaluation Criteria
NQF MEASURE EVALUATION CRITERIA
44
NQF Measure Evaluation Criteria (cont.)
NQF MEASURE EVALUATION CRITERIA
45
NQF Measure Evaluation Criteria (cont.)
NQF MEASURE EVALUATION CRITERIA
46
NQF Measure Evaluation Criteria (cont.)
NQF MEASURE EVALUATION CRITERIA
47
NQF Measure Evaluation Criteria (cont.)
NQF MEASURE EVALUATION CRITERIA
48
NQF Measure Evaluation Criteria (cont.)
NQF MEASURE EVALUATION CRITERIA
49
NQF Measure Evaluation Criteria (cont.)
NQF MEASURE EVALUATION CRITERIA
50
NQF is currently soliciting feedback on the NQF
National Priorities Partnerships Priorities and
Goals
NQF NATIONAL PRIORITIES PARTNERSHIP PRIORITIES
AND GOALS

• The National Quality Forum (NQF) convened the
  National Priorities Partnership (NPP) with the
  goal of setting national priorities and goals to
  achieve real healthcare reform in the next five
  years. 
• The Partners focused only on achievable goals
  that would, if implemented broadly, reduce harm,
  improve patient-centered care, eliminate
  healthcare disparities, and remove waste from the
  system.
• The priorities and goals agreed to by the
  Partnership reflect the input of NQF members
  through a survey, which identified several areas
  NQF members felt were critical
  healthcare-associated infections, end-of-life
  care, care coordination, and medication
  reconciliation. All of these areas are included
  in the NPP recommended priorities.
• Feedback on the priorities is currently requested
  with comments due by July 30th, 2008.

Source NQF http//www.qualityforum.org/about/NPP/
feedback/index.asp Booz Allen Analysis
51
NQF Proposed Priorities and Goals
NQF NATIONAL PRIORITIES PARTNERSHIP PRIORITIES
AND GOALS

• Patient and Family Engagement
• Priority Statement Engage patients and their
  families in managing their health and making
  decisions about their care
• Goal 1 By 2012, all providers will routinely
  solicit and publicly report on their patients
  perspectives of care.
• Goal 2 By 2012, all providers will work
  collaboratively with their patients to assist
  them in making informed decisions about treatment
  options consistent with their values and
  preferences.
• Population Health
• Priority Statement Improve Health of the US
  Population
• Goal 1 By 2016, 90 of the population will be up
  to date on all high-priority age- and
  gender-appropriate evidence-based clinical
  preventive services.
• Goal 2 By 2016, 90 of the population will
  receive recommended evidence-based interventions
  to improve targeted healthy lifestyle behaviors.
• Goal 3 By 2016, all communities will demonstrate
  a 10 improvement in their community index of
  health.
• Goal 4 By 2020, 25 of Americans will have all
  recommended high priority healthy lifestyle
  behaviors under control.

Source NQF http//www.qualityforum.org/about/NPP/
feedback/index.asp Booz Allen Analysis
52
NQF Proposed Priorities and Goals (cont.)
NQF NATIONAL PRIORITIES PARTNERSHIP PRIORITIES
AND GOALS

• Safety
• Priority Statement Improve the safety of the US
  Health Care System
• Goal 1 By 2014, all providers will drive all
  preventable healthcare-associated infections
  (HAI) to zero.
• Goal 2 By 2014, all providers will drive the
  incidence of preventable NQF Serious Reportable
  Events (SRE) to zero.
• Goal 3 By 2014, all hospitals will reduce
  preventable and premature mortality rates to
  best-in-class.
• Goal 4 By 2014, all hospitals and their
  community partners will reduce 30-day mortality
  rates following hospitalization for select
  conditions to best-in-class.
• Palliative Care
• Priority Statement Guarantee appropriate and
  compassionate care for patients with
  life-limiting illnesses
• Goal 1 By 2010, all providers will identify,
  document, and effectively treat physical symptoms
  (e.g. pain, shortness of breath, constipation,
  others) at levels acceptable to patients with a
  life-limiting illness.
• Goal 2 By 2011, all providers will effectively
  address the psychosocial and spiritual needs of
  patients with life-limiting illnesses and their
  families according to their preferences.
• Goal 3 By 2012, all eligible patients will
  receive high quality palliative care and hospice
  services.

Source NQF http//www.qualityforum.org/about/NPP/
feedback/index.asp Booz Allen Analysis
53
NQF Proposed Priorities and Goals (cont.)
NQF NATIONAL PRIORITIES PARTNERSHIP PRIORITIES
AND GOALS

• Care Coordination
• Priority Statement Ensure patients receive
  well-coordinated care across all providers,
  settings, and levels of care
• Goal 1 By 2012, all providers will accurately
  and completely reconcile medications across the
  continuum of care (i.e. admission, transfer
  within and between care providers, discharge, and
  outpatient appointments) and ensure communication
  with the next provider of services.
• Goal 2 By 2012, all inpatient and outpatient
  providers will assess the patients perspective
  of the coordination of their care using a
  validated care coordination survey tool.
• Goal 3 By 2012, all providers will reduce 30-day
  all-cause readmission rates resulting from poorly
  coordinated care to best-in-class.
• Goal 4 By 2012, all providers will reduce
  preventable emergency department (i.e. those that
  could be avoided with timely access to primary
  care) visits resulting from poorly coordinated
  care by 50.

Source NQF http//www.qualityforum.org/about/NPP/
feedback/index.asp Booz Allen Analysis
54
NQF Proposed Priorities and Goals (cont.)
NQF NATIONAL PRIORITIES PARTNERSHIP PRIORITIES
AND GOALS

• Patient-focused Care
• Priority Statement Guarantee high value care
  across acute and chronic episodes
• Goal 1 By 2016, all patients will receive
  high-value care over the course of their acute or
  chronic illness.
• Overuse
• Priority Statement Eliminate waste while
  ensuring the delivery of appropriate care
• Goal 1 By 2012, reduce wasteful and
  inappropriate care for the top ten targeted areas
  by 50.

Source NQF http//www.qualityforum.org/about/NPP/
feedback/index.asp Booz Allen Analysis
55
As of June 2008, CMS had submitted four measures
for NQF consideration for outpatient imagining
efficiency
NQF OUTPATIENT IMAGING EFFICIENCY MEASURES
SUBMITTED BY CMS
Source NQF http//www.qualityforum.org/pdf/projec
ts/imaging/tblSubmittedMeasures5-16-08_short20tab
le.pdf Booz Allen Analysis
56
Consumers have a wealth of different sites they
can consult for ratings
HOSPITAL REPORTING SYSTEMS ADDITIONAL INFORMATION
Source Booz Allen Analysis
57
Consumers have a wealth of different sites they
can consult for ratings (cont.)
HOSPITAL REPORTING SYSTEMS ADDITIONAL INFORMATION
Source Booz Allen Analysis
58
YourCity.MD is the first to reach healthcare
consumers and providers in the top 300 U.S.
markets with its city specific domain names with
the .MD extension.
HOSPITAL REPORTING SYSTEMS ADDITIONAL INFORMATION

• Started 2007

• Website http//www.yourcity.md

• Name YourCity.md
• Description YourCity.MD is a digital media
  company with a reach to the top 300 U.S. markets
  with a city specific domain names with the .MD
  extension.
• Scope of Services Information on specific
  medical conditions and access to shared
  strategies, local or national online support
  groups and education e.g., newsletters, regarding
  specific conditions or medical concerns
• Inputs The site relies completely on consumer
  entry and feedback. Feedback is requested in the
  following categories (on a scale from 1-10)
  Cleanliness, Doctor Timeliness, Explanation of
  Diagnosis, Time Spent With Patient, Knowledge of
  Patient History, Put Your Best Interest First,
  Prevention Education, Office Follow-up,
  Effectiveness of Treatment, Helpful Staff, and
  Would Recommend.
• Output(s) Site displays local providers by
  specialty, last name, travel distance, gender,
  hospital affiliation, insurance plan and language
  spoken - along with information on how a specific
  physician or provider has been rated, helping in
  the decision-making process

Source YourCity.md http//www.yourcity.md/include
s/11012007_citylaunch.pdf Booz Allen Analysis
59
Consumer Reports has launched a broad effort to
expand its involvement in health care with their
recently launched hospital rating service
HOSPITAL REPORTING SYSTEMS ADDITIONAL INFORMATION

• Website http//www.consumerreports.org

• Started 2008

• Name Consumer Reports
• Description Consumer Reports aims to provide
  consumers answer to their questions and create a
  forum to share unbiased, accurate, evidence-based
  information to make appropriate healthcare
  choices.
• Scope of Services 2,857 hospitals nationwide are
  scored on a 100-point scale based on how they
  treat patients with nine serious conditions in
  the last two years of life.
• Inputs Based on the 2008 Dartmouth Atlas of
  Health Care, which used Medicare data on the
  treatment given to elderly patients in the last
  two years of their lives. The intensity of care
  is measured by days spent in the hospital and
  number of physician visits in addition, an
  average out-of-pocket cost for physician visits
  is provided.
• Output(s) Consumers will be able to see a graph
  showing how intensely each hospital tends to
  treat patients, on a scale from zero for the most
  conservative to 100 for the most aggressive.
  Will also include a dollar figure that reflects
  an average out-of-pocket cost for doctor visits
  during the last two years of life for the nine
  conditions.

Source Consumer Reports www.consumerreports.org
PBN http//www.pbn.com/stories/32456.html Booz
Allen Analysis
60
The Data Advantage Hospital Value Index is a new
comprehensive index to measure the relative value
of care that hospitals provide to patients
HOSPITAL REPORTING SYSTEMS ADDITIONAL INFORMATION

• Website http//www.hospitalvalueindex.com

• Started 2008

• Name Hospital Value Index
• Description Hospital Value Index provides a
  scorecard ranking U.S. hospitals on the relative
  value of care they provide their communities.
• Scope of Services Measures the relative value of
  care that hospitals provide to patients of more
  than 1,500 general acute-care hospitals in
  America's 100 largest cities, serving 180
  million consumers.
• Inputs Several data sources were used to measure
  hospitals on each of the four metrics, including
  CMS, National Research Healthcare Market Guide,
  The Joint Commission, The Leapfrog Group,
  Medicare Hospital Outpatient Prospective Payment
  Systems (OPPS) and Medicare Severity - Diagnosis
  Related Groups MS-DRGs.
• Output(s) Site displays an all-encompassing
  hospital score and compares the value of
  hospitals. Where the quality of care between
  hospitals is relatively equal, the site will
  identify the hospital that is more affordable.
  Where the price between hospitals is the same,
  the Hospital Value Index will reveal the one
  with better quality.

Source Hospital Value Index http//www.hospitalva
lueindex.com/about.aspx Booz Allen Analysis