Never, almost never, and often enough: Hospital Acquired Conditions

1
Never, almost never, and often enough Hospital
Acquired Conditions

• NASMD 2008
• Foster Gesten, MD
• Medical Director
• Office of Health Insurance Programs
• New York State Department of Health

2
Background

• CMS program (hospital acquired conditions or
  HACs)
• National Quality Forum list of serious adverse
  events (SAEs)
• Private insurer interest
• Adverse event reporting system
• NYPORTS
• 3M Potentially Preventable Complications (PPCs)
• Present on admission (POA) requirement for
  inpatient discharge database

3
Goals for New York Medicaid

• No payment for avoidable complications/errors
• Medically unnecessary care
• Provide incentive for investment in system
  changes leading to improved quality and safety
• Reward hospitals with better performance

4
Approach

• Begin discussion with stakeholders using CMS and
  NQF lists
• View the process as iterative
• Improve the validity of administrative data
• Create a practical system for identification and
  claim adjustment
• POA for all.even if current events not
  relevant
• Same program for FFS and Managed Care

5
Our starter set 14

• Three (3) CMS conditions (and 11 NQF)
• Retention of foreign object
• Incompatible blood transfusion
• Intravascular air embolism
• Use POA and DRG approach, per CMS
• No payment for cost or day outliers that might
  result from payment adjustment

6
NQF Events

• Wrong body part
• Wrong patient
• Wrong procedure
• Medication error
• Failure to identify/treat hyperbilirubinemia
• Contaminated device/drug/biologics
• Malfunctioning device
• Electric shock
• Wrong gas
• Burn
• Disability due to restraints/bedrails

7
Why these?

• Clinician concern about ability to prevent HACs
  on CMS list
• Risk adjustment (lack thereof)
• Start with a manageable number of events
• Serious and with some frequency
• Combination of hospital acquired conditions and
  serious adverse events

8
Process

• POA edit starting in September
• 3 HACs edit starting October
• 11 SAEs
• Workgroup with industry, finance, and systems
• Make use of modified NYPORTS definitions, where
  available
• Develop rate codes for claim to identify that
  an event happened
• Pended claim and manual review by UR agent to
  determine appropriate claim
• Anticipate being able to implement in next 2-3
  months

9
Next Steps

• Audit of POA accuracy
• Administrative review for consistency and logic
• Chart review
• Integration of POA and event review into
  retrospective UR, DRG validation reviews
• Including outlier payments
• What else should be on the list?
• Central line associated infections
• Potentially Preventable Complications and
  Readmissions

10
PPCs and PPRs

• A method for identifying inpatient complications
  using administrative data
• Assess risk of developing complications based on
  admitting diagnosis and illness severity
• Observed vs. expected rates
• Relies on
• Correct coding
• POA
• APR-DRG
• Exclusions
• Complication inevitable consequence of admitting
  diagnosis
• Trauma, metastatic malignancy, cardiac arrest,
  newborns

11
Future

• Evaluate implementation
• National codes
• Standardization of events across payers
• Explore translation of PPC and PPR into payment
  adjustment
• Coherence Integrate HACs, SAEs, and PPCs/PPRs