Quality

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Quality and Cost Trend AnalysisPositive findings
using data from CMS/Premier P4P hospitals
Thursday, January 31, 2008 The Press Club Holeman
Lounge Washington, DC
2
Speakers

• Blair Childs, Senior Vice President of Public
  Affairs, Premier healthcare alliance
• Mark Wynn, Director of the Division of Payment
  Policy Demonstrations, Centers for Medicare and
  Medicaid Services
• Richard A. Norling, President and CEO, Premier
  healthcare alliance
• Dr. Nick Turkal, MD, President and CEO, Aurora
  Health Care (Milwaukee, WI)
• Dr. Mark D. Povroznik, PharmD, Director of
  Quality Initiatives, Chairman of Infection
  Control, United Hospital Center (Clarksburg, WV)
• Dr. Evan Benjamin, MD, FACP, Chief Quality
  Officer, Baystate Health (Springfield, MA)
  Associate Professor of Medicine, Tufts University
  School of Medicine

3
CMS Comments on the Premier Hospital Quality
Incentive Demonstration

• Mark Wynn, Ph.D.
• Director, Division of Payment
• Policy Demonstrations
• Centers for Medicare Medicaid Services
• Mark.Wynn_at_CMS.HHS.gov

4
CMS Value-Based Purchasing Demonstrations

• Premier Hospital Quality Incentive Demo
• Physician Group Practice Demonstration
• Medicare Care Management Performance
  Demonstration (small-med physician offices)
• Nursing Home Value-Based Purchasing Demonstration
  (in development)
• Home Health VBP Demonstration (in development)

5
The Premier Hospital Quality Incentive
Demonstration (HQID)

• Demonstration with 250 hospitals in Premier, Inc
  quality alliance
• Uses financial incentives to encourage hospitals
  to provide high quality inpatient care
• Tests the impact of quality incentives

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HQID Hospital Scoring

• Hospitals scored on quality measures related to
  each of 5 conditions
• Roll-up individual measures into overall score
  for each condition
• Categorized by condition to determine top
  performers
• Incentives paid separately for each condition

7
Demonstration Phase Two Policies

• Incentives if quality exceeds baseline mean
  (4.8 million)
• Pay for highest 20 attainment (3.6M)
• Pay for 20 highest improvement (3.6M)
• Hospitals paid in relation to number of Medicare
  FFS inpatients
• Total incentives 12 million

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Lessons Learned

• Value Based Purchasing can work provides focus
  on quality
• Modest dollars can have big impacts
• Sustained improvement in each year
• Demonstration provided valuable lessons on how to
  operate hospital VBP, lessons used in CMS policy
  proposal

9

• Richard A. Norling
• President and CEO
• Premier healthcare alliance

10
CMS/Premier demonstrate pay for performance
Premier is leading the first national CMS
pay-for-performance demonstration for hospitals.
More than 250 Premier hospitals participate
voluntarily.
Hypothesis
Financial Incentives and transparency improve
hospital quality performance
Findings

• Financial incentives did focus hospital executive
  attention on measuring and improving quality.
• Hospitals performance has improved continuously
  over time.

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Widely accepted clinical indicators

• Community-acquired pneumonia (CAP)
• Percentage of patients who received an
  oxygenation assessment within 24 hours prior to
  or after hospital arrival
• Initial antibiotic selection
• Initial antibiotic consistent with current
  recommendations - ICU
• Initial antibiotic consistent with current
  recommendations - Non ICU
• Blood culture collected prior to first antibiotic
  administration
• Influenza screening/vaccination
• Pneumococcal screening/vaccination
• Antibiotic timing, percentage of pneumonia
  patients who received first dose of antibiotics
  within four hours after hospital arrival
• Smoking cessation advice/counseling
• Hip and knee replacement
• 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
• Post operative hemorrhage or hematoma
• Post operative physiologic and metabolic
  derangement

• Acute myocardial infarction (AMI)
• Aspirin at arrival
• Aspirin prescribed at discharge
• ACEI for LVSD
• Smoking cessation advice/counseling
• Beta blocker prescribed at discharge
• Beta blocker at arrival
• Thrombolytic received within 30 minutes of
  hospital arrival
• PCI received within 120 minutes of hospital
  arrival
• Inpatient mortality rate
• Coronary artery bypass graft (CABG)
• Aspirin prescribed at discharge
• CABG using internal mammary artery
• 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
• Inpatient mortality rate
• Post operative hemorrhage or hematoma

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Dramatic and Sustained Improvement
Avg. improvement across all clinical areas for
median CQS (15 quarters) 17.3
CMS HQID Composite Quality Score
CMS Quality Score
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HQID Hospitals Started Project at National Average
HQID hospitals did not have higher quality
ratings than national hospitals overall at the
beginning of the project Composite process score
A composite of 14 measures shared in common
between HQID and the Joint Commission Comparative
for the first quarter of the project shows P4P
hospitals performing below the nation as a whole.
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Improvement Across All HQID Participants

• Quality improvement across all hospitals
• Variation in hospital performance decreased

CABG CMS Quality Score Threshold Changes by Year
AMI (heart attack) CMS HQID Quality Score
Threshold Changes by Year
Pneumonia CMS Quality Score Threshold Changes by
Year
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In Broader Comparison, HQID Hospitals Excel
National Leaders in Quality Performance
HQID hospitals have higher quality ratings than
national hospitals overall CMS process score

• HQID participants avg. 6.5 higher than
  Non-Participants
• Avg. improvement for HQID participants 7.8
• Avg. improvement for Non-participants 5.6
• New England Journal of Medicine publication by
  Lindenauer et al. (February 2007) found that
  hospitals engaged in P4P achieved quality scores
  2.6 to 4.1 percentage points above other
  hospitals due solely to the impact of P4P
  incentives.

A composite of 19 measures shared in common
between HQID and Hospital Compare shows P4P
hospitals performing above the nation as a whole
16
Premier Performance Pays Research Update
Premiers Performance Pays study demonstrated
that when evidence-based care is reliably
delivered, quality is higher and costs are lower.
The recently updated study using all payors and
three years of data(over 1.1 million patients),
confirms this result.
Study finds higher reliable care yields lower
mortality rates for heart bypass surgery patients
Study finds higher reliable care yields lower
hospital costs for patients with pneumonia
Patient Process Measure
Patient Process Measure
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Results Not Unique to Medicare Patients
Hospital Costs for Pneumonia Patients
Commercial (N9,909)
Managed Care (N32,842)
Medicaid (N14,646)
Medicaid Managed Care (N5,012)
Traditional Medicare (N149,317)
Medicare Managed Care (N12,645)
Statistical Significance Commercial (lt.05), Mgd
Care (lt.001), Medicaid (lt.001), Medicaid Mgd Care
(lt.01), Medicare (lt.001), Medicare Mgd Care
(lt.001) 
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More Patients are Reliably Receiving
Evidence-based Care
Evidence-based Care Improvements
Avg. improvement in all clinical areas (15
quarters) 52.6
Appropriate Care Score
19
Hospital Level Cost Trend Emerges Over 3 Years
Median Severity Adjusted (APR-DRG) Cost per Case
from October 2003 September 2006
Knee Replacement Patients (7,000 cases per qtr
/- 850)
AMI Patients ( 19,000 cases per qtr /- 2,500)
Pneumonia Patients (34,000 cases per qtr /-
13,000)
N of hospitals 233 /- 12
N of hospitals 191 /- 7
N of hospitals 253 /- 10
CABG Patients (8,300 cases per qtr /- 1,750)
Heart Failure Patients (27,500 cases per qtr /-
5,000)
Hip Replacement Patients (3,150 cases per qtr /-
350)
N of hospitals 250 /- 10
N of hospitals 145 /- 8
N of hospitals 130 /- 5
Statistical Significance Cost -- AMI
(plt0.01), HF (plt0.001), PN (plt0.05).
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Hospital Level Mortality Trend Emerges Over 3
Years
Median Severity Adjusted (APR-DRG) Mortality from
October 2003 September 2006
AMI Patients ( 19,000 cases per qtr /- 2,500)
Pneumonia Patients (34,000 cases per qtr /-
13,000)
N of hospitals 233 /- 12
N of hospitals 253 /- 10
CABG Patients (8,300 cases per qtr /- 1,750)
Heart Failure Patients (27,500 cases per qtr /-
5,000)
N of hospitals 130 /- 5
N of hospitals 250 /- 10
Statistical Significance Mortality -- AMI
(plt0.001), HF (plt0.001), PN (plt0.001), CABG
(plt0.01). Hip and knee replacements had
insufficient mortalities for analysis
HQID based on 3M APR-DRG severity-adjustment
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Using CareScience Risk Adjustment Method
Median Risk Adjusted Mortality from October 2003
September 2006
AMI Patients ( 19,000 cases per qtr /- 2,500)
Pneumonia Patients (34,000 cases per qtr /-
13,000)
N of hospitals 233 /- 12
N of hospitals 253 /- 10
Heart Failure Patients (27,500 cases per qtr /-
5,000)
CABG Patients (8,300 cases per qtr /- 1,750)
N of hospitals 130 /- 5
N of hospitals 250 /- 10
Statistical Significance Mortality -- AMI
(plt0.001), HF (plt0.001), PN (plt0.001), CABG
(plt0.001). Hip and knee replacements had
insufficient mortalities for analysis
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Improvement and Savings
Avg. improvement in mortality across four
clinical areas 1.87

• Avg. cost improvement per patient across all
  clinical areas
• 1,063

If all hospitals in the nation were to achieve
this improvement, the estimated cost savings
would be greater than 4.5 billion annually with
estimated 70,000 lives saved per year
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Supported by Industry Research

• Better outcomes are associated with hospitals
  where...
• The Board spends gt25 of time on quality issues
  (p 0.009)
• The Board receives a formal quality performance
  measurement report (p0.005)
• There is a high level of interaction between the
  board and the medical staff on quality strategy
  (p0.021)
• The senior executives compensation is based in
  part on QI performance (p0.008)
• The CEO is identified as the person with the
  greatest impact on QI (p0.01), especially when
  so identified by the QI executive (plt0.001).

Kroch, E. A., et al. (2006). "Hospital Boards and
Quality Dashboards." Journal of Patient Safety
2(1) 10-19. Vaughn, et al. (2006). "Engagement
of Leadership in Quality Improvement Initiatives
Executive Quality Improvement Survey Results."
Journal of Patient Safety 2(1) 2-9.
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Conclusions

• Financial incentives combined with public
  reporting of transparent data can drive
  significant improvement in quality
• Hospitals held the gains and continued to improve
• More patients are reliably receiving
  evidenced-based care
• Improved quality is associated with saving lives
  and reducing costs

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Aurora Health Care (Milwaukee, WI)
Dr. Nick Turkal, MD President and CEO Aurora
Health Care
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Aurora Health Care System Components 2008

• Private, not-for-profit integrated health care
  system
• 13 hospitals (soon to be 15)
• 23 counties, 95 communities
• 750 AMG physicians in 100 clinics
• 250 Advanced physicians
• VNA - largest in Wisconsin
• 130 retail pharmacies
• 27,500 employees
• 101,500 inpatient discharges
• 1.4 million outpatient visits
• 2.6 million ambulatory care visits

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Aurora Health Care Best Practices for Success
Auroras 1 Priority Our patients deserve and
expect the best care. We will give people better
results than they can get anywhere else by
achieving top performance in all our quality
measures. For Aurora, there is no alternative
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Aurora HQID Bingo Card
Achieve progress towards the 2007 goal of being
in the top 20 for all Medicare (CMS)
pay-for-performance measures by achieving above
median performance for each one of these
measures by year-end 2005.
Decile Performance -- 1 Top Performer 10
Bottom Performer Based on HQID Year 1 Results
(4th Q 2003 3rd Q 2004 Data)
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Aurora HQID Bingo Card
Achieve progress towards the 2007 goal of being
in the top 20 for all Medicare (CMS)
pay-for-performance measures by achieving above
median performance for each one of these measures.
Performance 1 Top Performer 10 Bottom
Performer
85 in Upper Median 58 in Top 20 Based on Oct.
2006 June 2007 Data
On track for Top Improvement Award
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CMS/Premier HQID Best Patient Care
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Aurora Health System Improving Cost and Quality
Memorial Hospital Burlington Hip and Knee
Replacement Patients
Aurora St Luke's Medical Center Quality improved
and Cost decreased in AMI Patients
West Allis Memorial Hospital Heart Failure
Patients
32

• Dr. Mark D. Povroznik, PharmD
• Director of Quality Initiatives,
• Chairman of Infection Control
• United Hospital Center (Clarksburg, WV)

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• Private, not-for-profit
• 375 licensed beds
• 140 active medical staff
• 1,800 active employees
• 1,375 FTE's
• 150 volunteers

• 14,994 annual admissions
• 176 million annual operating budget
• 25 million annual uncompensated care

Merged with West Virginia University Hospitals in
1997 to form the West Virginia United Health
System
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Transition from Bottom to Top Performance
United Hospital Center Clarksburg, WV
CONSISTENT TOP PERFORMER

• Top performer in two areas in Year 2
• Top performer in three areas in Year 3
• Tracking to be top performer in four areas in
  Year 4

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Historical Perspective
D ata
R ich
I nformation
P oor
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Revised Processes

• Nurtures house-wide collaboration
• Provides consistency, uniformity and clear
  expectations
• Reduces amount of duplicate efforts by multiple
  departments
• Collective reasoning and prioritization
• Builds in accountability and ownership of P.I.
  activities
• Assigned to champion and tied into quarterly
  goals and objectives

37
Annual PI Planning

• Premier Clinical Advisor Data Analysis
• LOS, Mortality, Complications, and Readmission
  Outliers
• UHC performance vs Expected vs Peer Groups
• External comparisons
• HQA, AHRQ, Health Grades
• Proposed Future focus
• IHI, JCAHO, Sg2 health care intelligence, HPPS
• Opportunity for multi-disciplinary feedback
• What did we miss?
• Early Buy-in by department leaders

38
Leadership Support of Data Analysis

• Positive culture BOD, Med Staff, C-Suite
• Bold system level aims
• Negative trends assigned to a hospital champion
• Corrective Action Plans Developed, Implemented,
  and Reported back to the P.A. Subcommittee
• Moving away from a Reactive focus to structured
  Proactive plan
• United Hospital Centers culture for excellence
  was featured by the Institute for Healthcare
  Improvement during the 2007 Fall Harvest Tour

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Closing the Loop
Quality Improvement
Annual PI Planning
Implementation Oversight
Department Level Review Approval
Medical Staff Review Approval
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Expanded approach to quality
UHCs 2007 Performance Improvement Plan

• Quality
• National Quality Indicators!
• 5 Million Lives Campaign
• Maintain Sepsis Mortality lt Peer
• Critical care protocol for tight glycemic control
• Readmission rate evaluation
• JCAHO Stroke indicators
• Implement Medical Staff Grand-rounds system
• Continued Medical record automation

• Patient Safety
• Reduce Central Line infection rate to lt3.7
• Reduce Ventilator-associated Pneumonia to 6.0
  (ICU) and 4.2 (CCU)
• Develop a unified DVT risk assessment / protocol
• Best practices to minimize Clostridium difficile
  infections
• Minimizing Cardio-toxicity associated with Local
  Anesthetic use

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Highlight of Success Stories
Acute Myocardial Infarction (AMI)

• Moved from 71 compliance with PCI within 120
  minutes to 100 compliance within 90
  minutes
• Mortality reduction by nearly 55

• Sustained 100 performance for the HQID
  measures

• Improved D2B times (2007 average 62 minutes)

UHC is Part of a WV State PCI Demonstration
Project
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Highlight of Success Stories (contd)

• Ventilator-Associated Pneumonia (VAP)
• Reduced VAP rates
• Reduced CCU VAP rate from 23.8 to zero for 9
  months
• Reduced ICU VAP rate from 21.0 to zero for 12
  months
• Congestive Heart Failure (CHF)
• Sustained 100 performance for the HQID measure
• Hip and Knee Replacement Surgery
• Documented improved Quality and decreased Cost

43
Improvements in Quality and Outcomes
Quality improved and Cost decreased in Hip and
Knee Replacement Patients
Quality improved and Mortality Rate decreased in
Heart Failure Patients
44

• Dr. Evan Benjamin, MD, FACP
• Chief Quality Officer
• Baystate Health (Springfield, MA)
• Associate Professor of Medicine
• Tufts University School of Medicine

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NEJM Study From Division of Healthcare Quality,
Baystate Medical Center
B. Heart Failure
A. Acute Myocardial Infarction
Lindenauer P et al. N Engl J Med 2007356486-496
D. Composite of 10 Measures
C. Pneumonia