MHCC UPDATE: THE

MISSION CONTINUES

Presented by Ben Steffen

to the

Maryland Health Care Financial Management Association

October 12, 2013

Realign MHCC Centers with Commissioners’

Priorities

� Assume leadership roles in areas of Health Care Reform

� Align health planning and the Certificate of Need program with incentives in health care reform and Maryland’s evolving health care system

� Diffuse health information technology to support clinical decision-making and delivery system reforms

� Expand quality reporting and align with other quality efforts of public and private partners.

� Focus on cost and system efficiencies

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THE MARYLAND HEALTH CARE COMMISSION

EXECUTIVE DIRECTION

Center for

Analysis &

Information

Services

Center for

Health

Information &

Innovative Care

Delivery

Center for

Quality

Measurement &

Reporting

Center for Health

Care Facilities

Planning &

Development

APCD expansion as a tool for:

• Measuring practitioner

performance

• Increasing price transparency

• Monitoring population

health

• Accelerate EHR

adoption

• Expand advanced

primary care

initiatives

• Continue to integrate

quality domains in

hospital reimbursement

• Expand Hospital

Performance Guide

• Streamline CON

• Align health planning with

‘new waiver’ & ACA

• Modernize oversight of

specialized services

Center for Quality Measurement &

Reporting

Continue to integrate quality domains in

hospital reimbursement

Expand Hospital Performance Guide

Hospital Performance Evaluation System

A data collection and management system established for:

� Monitoring and publicly reporting on hospital performance and

quality

� Supporting our all-payer hospital rate setting system and its quality

programs that focus on patient health outcomes and cost savings

� Aligning with CMS hospital quality programs to demonstrate

Maryland’s ability to meet or exceed federal requirements

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Hospital Performance Evaluation System –

Components

� Web-based Quality Measures Data Center (QMDC)

� Process of Care measures

� Patient experience measures

� Outcome Measures (30-day Readmission; 30-day mortality)

� Common Medical Conditions (DRGs)/Maternity & Newborn

� Data validation

� Healthcare Associated Infections Initiative

� Healthcare Worker Influenza Vaccination

� Use of CDC NHSN Surveillance System

� Surgical Site Infections

� Central Line Associated Bloodstream Infections

� Public Reporting on Hospital Guide -- New Website Planned in 2014

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Hospital Performance Evaluation System –

Enhancements

� Joint MHCC/HSCRC Policy on Expanded Data Collection

� January 2014 Full Implementation

� Outpatient Measures – Claims Based & Chart Abstracted

� New HAI measures (CAUTI, MRSA, Colon, SSIs added)

� Use of CDC HCW Flu Vaccination Module for national comparison

� New Vendor for Quality Measures Data Center

� Advanta Government Services, LLC

� Focus on System Redesign

� Enhanced Data Infrastructure to support HSCRC QBR/Waiver Test

� Enhanced Communication with Hospitals

� Price Transparency Initiative

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Hospital Performance Evaluation System

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Comparison of 2010-11 through 2012-13 Hospital HCW Vaccination Rates

Statewide Stats 2010-11 2011-12 2012-13

Vaccination Rate 81.4% 87.8% 96.4%

Number of Hospitals at or Above 85% 21 31 39

Number of Hospitals with Mandatory

Vaccination Policy 15 25 37

Number of Employees Vaccinated 79,504 89,206 99,724

Number of Employees 97,639 101,565 103,436

Average Declination Rate 15.2% 10.5% 4.5%

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Hospital Performance: Central Line Associated

Blood Stream Infections (CLABSI)

Performance Measure FY2010 FY2011 FY2012 Difference

All ICU CLABSIs 472 296 206 Improvement (56.36% reduction)

Adult/Pediatric Intensive Care Units

CLABSIs 424 262 166 Improvement (60.85% reduction)

Hospitals with 0 Infections 6 12 20 Improvement

Hospitals Better than National Experience 0 4 8 Improvement

Hospitals Same as National Experience 37 39 36

Hospitals Worse than National Experience 8 2 1 Improvement

Maryland Standardized Infection Ratio (SIR)* 1.35 0.85 0.57 Improvement

Maryland Performance (using SIR) Worse Better Better

Maryland Adult/Ped ICU Central Line Days 163,757 157,706 149,736

Neonatal Intensive Care Units (NICUs)

Hospitals with NICUs 15 16 16

CLABSIs (total) 48 34 40 Improvement (16.67% reduction)

Hospitals with 0 Infections 4 3 4 No Change

Hospitals Better than National Experience 1 2 1 No Change

Hospitals Same as National Experience 14 14 14 No Change

Hospitals Worse than National Experience 0 0 1 Decline

Maryland NICU Central Line Days 27,299 26,817 25,926

* The Standardized Infection Ratio (SIR) is a summary measure used to compare the infection rate of one group of patients to that of a standard population.

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Center for Health Information &

Innovative Care Delivery

Accelerate EHR adoption

Expand advanced primary care initiatives

An HIICD Goal – Serve as a Resource to Hospitals

� Information regarding electronic health records (EHRs), health information exchange (HIE), and telemedicine

� Health IT implementation strategy development support and evaluation

� Convener of CIOs and Chief Medical Informatics Officers

� Link to community-based ambulatory practices

� Shed light on best practices through reporting

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Specific results on HIT adoption

� Since 2008, the health IT adoption rate has increased roughly 25 percent

� Maryland hospitals exceed national adoption rates for 8 out of 10

technologies assessed

� Hospitals continue to take advantage of the federal incentives for the

adoption and MU of health IT

� As of 2012, approximately 83 percent of hospitals had received an

incentive payment, totaling approximately $67.9M

� Approximately 54 percent of hospitals have attested to MU

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How do Maryland and US Hospitals Compare on

Adoption Rates?

US Maryland

Adopted Basic EHR 44% 83%

Computerized physician order entry (CPOE) 72 85

Implemented Clinical Decision Support 87 67

Established E-prescribing 61 22

Adopted electronic medication administration

record (eMAR),

60 91

Adopted Barcode Medication Administration

(BCMA)

27 78

Number of hospitals with patient portals (in

place/planning)

- 14/27

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� ACA and ‘new waiver’ envision closer integration between hospital and community care

� Practices organized around PCMH programs are best equipped to keep patients out of the hospital and to manage patients’ transition back into the community

� 5 large commercial carriers, Medicaid, some self-funded employers

� Practice transformation agent – Maryland Learning Collaborative

� About one quarter million “attributed” patients

� MHCC expects that PCMH practices will adopt HIE services such as the Encounter Notification system (ENS)

� External Evaluation – lower cost, improved quality, increased satisfaction, reduction in disparities

Advanced Primary Care Initiatives – Multipayer PCMH

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Center for Health Care Facilities

Planning & Development

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Streamline CON Processes

Align health planning with requirements of ‘new

waiver’ and health care reform

Modernize approach to oversight of specialized

services

Current HFPD Priority Activity –

Planning and CON

Streamline project review processes

� Implement new approaches for completeness review and

analysis of regulations

� More interaction with prospective applicants prior to

submission of CON

� MHCC will monitor application review times and

uncontested review standards (90 days for

uncontested/150 days for contested matters)

� Overhaul procedural regulations – govern how MHCC

reviews applications

� Look for streamlining opportunities in SHP updates –

recognize new roles for planning post 2014

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Current HFPD Priority Activity –

State Health Plan Updates

State Health Plan Chapters will be updated consistent with MHCC’s statutory requirements

� Acute Inpatient Rehabilitation Services (2013)

� Hospice Services (2013)

� Acute Care Hospital Services (2013-14)

� Cardiac Surgery and PCI Services (Major revision underway -2014 completion)

� Organ Transplant Services (Need projections updated in October 2011- full overhaul in 2013-14)

� Freestanding Medical Facilities (Coming in 2014/2015)

� Acute Psychiatric Hospital Services (initiate in 2014)

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Current HFPD Priority –

Oversight of Cardiac Services

� Cardiac Surgery with Full Spectrum PCI services at 10 Hospitals

� PCI services without cardiac surgery backup at 13 hospitals

� Primary (Emergency) PCI Waiver Program at 13 Hospitals without on-

site cardiac surgery

� Elective PCI at 8 Hospitals without on-site cardiac surgery (all are

primary PCI waiver hospitals)

� C-PORT-E (Elective) PCI Research Waiver Program C-PORT-E research

study was completed in 2012

� MHCC and hospitals agree that PCI should be defined as a regulated

service (eliminate need for waiver programs)

� Transition to a mode of regulation requiring ongoing performance

evaluation and compliance with minimum standards

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Overview of Draft Regulations

� MHCC will place greater emphasis on the quality of programs, in addition to

enforcing volume standards

� For cardiac surgery, the data registry of the Society of Thoracic Surgeons (STS)

will be used for performance evaluation and monitoring

� For PCI programs, the data registries of the National Cardiovascular Data

Registry of the American College of Cardiology will be used

� Physicians performing primary PCI must meet the ACCF/AHA/SCAI competency

criteria, which is currently an average of 50 PCI cases over a 24 month period.

� PCI programs that offer primary and non-primary PCI services shall perform 200

cases annually

� PCI programs that offer primary only shall perform at least 49 cases annually (34

for rural programs)

� Continue to use process and outcome measures and align with ACC-NCDR and STS

to the extent possible

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Overview of Draft Regulations(continued)

� Hospitals required to conduct external (5%) and internal review (10%) of

both PCI and cardiac surgery cases

� Revised cardiac services planning regions

� Revised methodologies for projecting demand for cardiac surgery and for

PCI services

� Closure built off nationally recognized guidelines…

� Cardiac surgery programs with a one star composite rating for CABG

surgery using the rating scale developed by STS-ACSD for 4 consecutive

six-month reporting periods or cardiac surgery case volume of less

than 100 cases for 2 consecutive years.

� PCI programs that failed to meet standards would not receive

Certificates of Ongoing performance

� Standards for closure of cardiac and PCI programs will include an

opportunity to address deficiencies identified before program closure is

ordered by the Commission.

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Overview of Draft Regulations(continued)

� Criteria and standards for allowing the addition of new programs

� Preferences for primary PCI programs that wish to add elective PCI

� MHCC will consider impact on the financial viability of existing

programs when evaluating new primary PCI, elective PCI, or cardiac

surgery programs.

� No interested parties permitted in new PCI program reviews

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Center for Analysis & Information

Services

APCD expansion as a tool for …

Monitoring population health

Increasing price transparency

Measuring practitioner performance

Expand the All Payer Claims Data Base (APCD)

� All commercial carriers are required to submit under State law

� CMS shares Medicare data under a federal data use agreement

� Historical uses….

� Legislatively required analyses,

� MHCC programs (medical home), and

� Commission-originated studies

� Future of the APCD

� Source of information for state-administered reinsurance program

� Foundation of a practitioner performance measurement system

� Source for measuring spending per capita (enhanced waiver)

� Monitoring the impact of health reforms on population health

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Content Changes Driven by New

Information Needs

� Complete information on enrollee utilization/spending

� Self-insured employer plans

� Enrollees who change carriers

� Information on plan benefit design – copayments, coinsurance and deductible levels

� Information for plans sold in the Health Benefit Exchange.

� Qualified Health Plans

� Qualified Dental Plans

� Inclusion of Medicaid data

� Accelerate collection of information on utilization/spending.

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New information needs require regulatory

and technology changes

� Expands the universe of data submitters

� Pharmacy benefit and behavioral health administrators (“carved out” services)

� Stand-alone third party administrators

� Carriers (including dental plans) selling in the Exchange

� Adds 3 new report files

� Plan benefit design;

� Non-claims-based payments to providers;

� Dental claims (carriers in HBE)

� Requires submitters to obtain Master Patient Index (MPI) for enrollees

� CRISP will supply MPI to submitters, submitters will append MPI to

eligibility files on the APCD

� MPI will be unique to resident

� Potential to link with hospital discharge and outpatient records

� Quarterly submissions of data files – accelerate timeliness of data

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New Initiatives 27

� Make APCD information available for examining population health –develop a resident summary file

� Mirrors Medicare beneficiary level cost and utilization file

� Demographics of the patient/resident

� Summarized information on spending by broad service ‘buckets’

� Resident summary file starts with privately insured, would also include Medicare and eventually Medicaid

� Further Price Transparency (CCIIO will provide some funding)

� MHCC and MIA will work together to use APCD for MIA’s rate review processes

� MHCC will accelerate data collection to align data with information reported by

carriers in rate applications

� MHCC and MIA will work together to build analytic tools that will enable APCD used in

dynamic rate review environment

New Initiatives 28

� Practitioner performance measurement

� Planning underway as part of State Innovation Grant activities

� Measurement system will be based on APCD data provided by private carriers, Medicaid, and Medicare

� Use of Medicare claims for measurement will require MHCC to obtain authorization from CMS as a Qualified Entity

� Initial program likely will focus on NQF-recognized quality metrics

� System will have an initial testing period in which data will be released to practices only

You must retain faith that you will prevail in the end, regardless of the difficulties.

AND at the same time…

You must confront the most brutal facts of your current reality, whatever they might be.

Practical Next Steps Stockdale Paradox

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