Global Budget Infrastructure / Compliance with GBR / TPR

AgreementsKathy Talbot

Vice President, Rates and ReimbursementMedStar Health, Inc.

January 30, 2015

Key Takeaways• Compliance with the terms of the GBR/TPR agreements

will require regulatory teams to broaden their understanding of compliance within HSCRC policies and regulations

• Hospital teams will need to set up infrastructure to allow effective communication between operators and finance

• The infrastructure reporting requirement will require management to be able to quantify the intervention and result consequential to the investment

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The HSCRC Vision of Compliance

com·pli·ancenounconformity in fulfilling official requirements

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The HSCRC Vision of Compliance

• This presentation is not discussing compliance from the perspective of– Unit rates / Charging

Hospitals and Health Systems must aspire to achieve in their efforts to ensure that they are aware of and take steps to comply with their

GBR & TPR agreements

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The HSCRC Vision of Compliance

• The compliance requirements in the GBR / TPR agreements are broad.

• The HSCRC Staff has the authority to ask questions about hospital operations– Many new sources of reported data may

unearth questions

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The HSCRC Vision of Compliance

Compliance terms of the GBR/TPR agreements

1) Comply with various patient-centered and population-focused performance standards that have been established by the HSCRC

2) Comply with the collection and reporting of data needed to assess and monitor the performance of the GBR model

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The HSCRC Vision of Compliance

Comply with various patient-centered and population-focused performance standards that

have been established by the HSCRC

1) MHAC Program2) QBR Program3) Readmission Reduction Program4) Other existing and future quality improvement

programs (e.g. broadening of PAU definition)

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The HSCRC Vision of Compliance

Comply with the collection and reporting of data needed to assess and monitor the performance of

the GBR modelMonitoring Activities of the HSCRC for hospital under GBR: Any service discontinuations or new services Review of acquisitions and divestitures (both regulated

and unregulated) Shifts of services to related or not related hospitals or

other providers Consumer access to care

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The HSCRC Vision of ComplianceScenario: Transfer of Patients• Hospital A’s inpatient ICU is at

capacity

• Because there are no available beds, emergency department begins transferring patients to another local hospital

Potential Compliance Issues• Neighboring hospital

Inpatient ICU patient days increase significantly

• Transfers from the ED increase significantly (looks like hospital is avoiding patients)

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The HSCRC Vision of ComplianceScenario: Elimination of Lab Test• Hospital A utilization of a blood

test is excessive.

• The hospital lab director reviews their utilization patterns, discusses the utilization with physicians

• Hospital discovers excess utilization and changes care plans to reduce utilization

Potential Compliance Issues• Lab RVUs drop

significantly as reported in experience reports

• Hospital CFO is unaware of the decision made in the lab and has not seen a corresponding cost decrease

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HOSPITAL STRUCTURAL MODEL TO ACHIEVE COMPLIANCE

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Hospital structural model to achieve Compliance• Hospital teams will need to set

up infrastructure to allow effective communication between operators and finance

• MedStar has developed various mechanisms and channels of communication to manage under the GBR model

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MedStar Clinical Business Council

Membership:– Chair: Chief Medical Officer– Chief Nursing Officer– Executive Vice President

Diversified Business– Vice President, Quality and

Safety– Chief Operating Officers – Chief Financial Officer– Vice President of Rates and

Reimbursement

Chair of Subgroups:– Readmissions and other

PAU’s– Bed Status– Maryland Hospital Acquired

Condition– Clinical Documentation

Improvement– Supply Chain Management– Meaningful Use

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Report Card - Readmissions

30 Day ALL Cause Readmission (%)-Hospital Sep-14 HSCRC-PAU

30 Day ALL Cause Readmission (%)-Other Hospitals Sep-14 HSCRC-PAU

Total 30 Day ALL Cause Risk Adjusted Readmission 11.27% 12.09% Sep-14 HSCRC-SUM

Observation within 30 Days (%)-Hospital Sep-14 HSCRC-PAU

30 Day ALL Cause Readm & Obs (%)-Hospital Sep-14 HSCRC-PAU

Medicare 30 Day ALL Cause Readmission (%)-Hospital Sep-14 HSCRC-PAU

Medicare 30 Day ALL Cause Readmission (%)-Other Hospitals Sep-14 HSCRC-

PAU

Medicare Total 30 Day ALL Cause Readmission Sep-14 HSCRC-PAU

Medicare Observation within 30 days (%)-Hospital Sep-14 HSCRC-PAU

Mcr 30 Day ALL Cause Readm & Obs (%)-Hospital Sep-14 HSCRC-PAU

Impact on Revenue Incentive of up to 0.5% of inpatient revenue, if target met

Perio

d

Sour

ce

Global Budget Revenue ("GBR") and Pay for Perfomance Dashboard

Q1 Q2 Q3 Q4

SAMPLE HOSPITAL

Thr

esho

ld

Goa

l (A

)

CY

201

3

CY 2014 (To Date)

Quarterly Compliance

Rea

dmiss

ions

0.5%

Rev

enue

at-R

isk ($

5.7M

)

8.16% 8.98% 8.61%

10.42% 11.10% 10.59%

10.33%

1.45% 1.31% 1.29% 1.45%

8.16%

10.90% 10.72% 10.33%

14.32% 15.63% 14.88% 14.32%

10.42%

2.17% 1.92% 2.11% 2.17%

1.87% 1.77% 1.81% 1.87%

16.19% 17.40% 16.69% 16.19%

0.50% 0.50% 0.50% 0.50%

3.27% 2.95% 3.12% 3.27%

17.59% 18.58% 18.00% 17.59%

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Report Card – Efficiency

Admissions 6,461 6,461 Sep-14 CorpObservation 1,684 1,684 Sep-14 CorpTotal Cases 8,145 8,145 Sep-14 Corp% Change

Less: PAUs (767) Sep-14 HSCRC-PAU

% ChangeAdjusted Cases 8,145 7,378 % Change50% of ChangeMarket Share GBR Service Area 53.40% Sep-14 Mkt

Point Change

Out of State Revenue % 0.20% 0.28% Nov-14 HSCRC-SUBMIT

Transfer Cases 65 Sep-14 HSCRC-PAU

Case-Mix

Medicare Revenue Growth Nov-14 HSCRC-SUBMIT

Total Revenue Growth Nov-14 HSCRC-SUBMIT

Revenue Growth per Case Nov-14 HSCRC-SUBMIT

Revenue per EIPAs Nov-14 HSCRC-SUBMIT

Revenue per ECMAD TBDCosts per EIPDs TBDCosts per ECMAD TBD

1,991 2,084 2,114 676 702 736

Mar

ket S

hare

50%

of C

hang

e

Good/Bad

5,945 1,870

8,059 2,546 2,693 2,820 -1.06%

1.11%

(599) (199) (207) (193)

-21.90%

GBR Agreement-85%

53.00% 52.00% 53.60% 53.40%

7,460 2,347 2,486 2,627

-0.75%

0.56%

Effi

cien

cy

Futu

re U

pdat

e

-3.27% 8.24% -12.96%

-0.79% -1.31% 0.14% 3.59%

61 25 10 26

0.78% -10.76%

0.25% 6.59% -8.82% 5.54% -3.02%

-0.12% 12.96% -12.15% 4.99% -7.99%

-0.13% 12.96% -12.16% 5.00% -7.98%

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INFRASTRUCTURE REPORTING

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Infrastructure Reporting

• A key compliance requirement of the GBR agreements is the requirement to report on infrastructure spending and results– Qualifying investments include

new programs or technologies directly related to GBR incentives

– Important for reporting successes to CMMI

– Due 90 days after the end of Fiscal Year 2015

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Infrastructure ReportingTypes of Expenses to Report Patient Centered Investments

e.g. case management, programs to support patient decision making

Provider / Care Team Investments e.g. Infrastructure to set up pay-for-performance or shared

savings models

Health Information Technology Investments e.g. predictive models for identifying and stratifying patients

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Infrastructure ReportingExamples of Types of Expenses Not Qualifying

Billable services Investments to improve coding or documentation Fraud prevention activities Any expenses for marketing purposes

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Infrastructure Reporting

The challenge of quantifying results relates to two types of investments

Tangible Investments – e.g. Hiring of a case manager / nurse navigator

Intangible Investments – e.g data extraction, predictive models, activities which support collaboration

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Infrastructure Reporting

• Challenge: Explaining the utilization impact of infrastructure investments– Hard to track how a strategy impacted volume

• Unless you isolate a cohort of patients– Volume compared over time will not likely

include the same patient– No access to patient data outside of hospital /

health system

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Challenge:• If Hospital A decides

to invest in opening an urgent care center, do they receive credit for the utilization impacts at Hospital B?

Hospital B

Hospital A

Opening of Hospital A’s Urgent Care

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Key Takeaways• Compliance with the terms of the GBR/TPR agreements

will require regulatory teams to broaden their understanding of compliance with HSCRC policies and regulations

• Hospital teams will need to set up infrastructure to allow effective communication between operators and finance

• The infrastructure reporting requirement will require management to be able to quantify the intervention and result consequential to the investment

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Be nice to your Rates Department!

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QUESTIONS?

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