Current and New HSCRC Reporting Requirements

1. Current and New HSCRC Reporting Requirements Oscar Ibarra & Katie Eckert

2. HSCRC Update: Abstract Tape • Changes to reporting requirements under the new Waiver Model • New Tape Layout and Fields • New timeline for reporting • Issues with FY 2014 Q1 Data • Quarterly Reconciliations

3. New Data Fields for FY 2014 • Separate variables for each race category to accurately capture each component of the patient’s race (i.e., White and Black, or Black and Asian, etc.). • Variable to capture the patient's country of origin, and • Variable to capture the patient’s preferred spoken language for a health-related encounter

4. New Timeline for FY 2014

5. Challenges with FY 2014 Submissions • Medicaid ID errors • Preferred language • Race variables left blank • Variations in zip code to county mapping • Reconciliations between case mix and financial data

6. Significant Changes for FY 2015 • Potentially add the CMS discharge disposition for planned admissions • New waiver requirements based on residency, coding zip code accurately will be essential • Transition to ICD -10 • Working with MHA around testing grouper software and submission of test data to St. Paul

7. Data Workgroups • Data & Infrastructure Workgroup • Will develop Data recommendations to the HSCRC for the new hospital All-Payer Model • Public meetings • Kick off Feb 6 • Data Workgroup • Discuss new data elements for the coming FY • Discuss data issues • Case mix liaison participation

8. Brave New World: Changes to Hospital Reporting Under the NEW Waiver • Changes to Traditional HSCRC Data Submissions • New Metrics to Monitor • New Platform for Reporting

9. Changes to Traditional HSCRC Data Submissions • Case Mix: Accelerated case mix reporting the deadlines are changing. • Financials: “Enhanced” monthly financial submissions more data elements

10. Accelerated Case Mix Reporting • Final Data: • OLD: Data reported approximately 90 days after quarter-end. • NEW: Data reported approximately 60 days after quarter-end. • Preliminary Data: • OLD: Quarterly data reported approximately 45 days after quarter-end • NEW: Quarter-to-Date data reported approximately 15-17 days after month-end. • HSCRC Goal: Monitor tenants of waiver on a more concurrent basis.

11. Operational Implications for Hospitals • 20-30% reduction in the number of days to finalize abstract data • Chart Audits • MHAC monitoring • Clinical Documentation • Curveball!: ICD-10 and additional HSCRC focus on quality metrics

12. “Enhanced” Monthly Financial Submission • “Enhanced” elements • 4 data points now expanded to 36 data points • IP/OP now split into In-State vs. Out-of-State • IP/OP for Medicare (Fee-For-Service vs. Non Fee-For-Service) also split into In-State vs. Out-of-State

13. Operational Implications for Hospitals • New Internal Reports for Revenue and Utilization: • State data and payer data are sourced from patient account data in the patient accounting system and do not pass to traditional financial statements. • More data points from “live” patient data makes it even more important to lock down posted financials in order to avoid reconciling items. • Submission: • Data Reporting 101: more data points = more room for error • OLD: Manual Submission NEW: Upload Submission?

14. Operational Implications for Hospitals • Reconciling: • In-State vs. Out-of-State Split: reconcile back to traditional Experience Report data • Payer Split: Only reporting Medicare utilization. • A separate reconciliation outside of the HSCRC submission is required to make sure that the “sum of the parts equals the whole” for all payers

15. Brave New World: Changes to Hospital Reporting Under the NEW Waiver • Changes to Traditional HSCRC Data Submissions • New Metrics to Monitor • New Platform for Reporting

16. New Metrics • Rate of Change in Cost per Capita • Market Share • Potentially Avoidable Utilization (PAUs) • Inter/Intra Readmissions • Monthly MHAC + PPC Reporting

17. Rate of Change in Cost per Capita • Two explicit “per capita” tests under the new waiver • All Payer Revenue Growth Rate Test • Medicare Savings Test

18. All Payer Revenue Limit Test • What is it? • Annual growth rate in total per capita hospital charges must not exceed 3.58% for CY2014-CY2016 for Maryland residents in Maryland hospitals • Why is this important to Hospitals? • HSCRC staff will need to take action to reduce hospital charges if test is in jeopardy.

19. Medicare Savings Test • What is it? • Rate of growth in Medicare's per capita hospital payments must be less than the national average growth rate for Maryland residents by at least $330 million for CY2014-CY2018 • Why is this important to Hospitals? • HSCRC staff will need to take action to reduce hospital charges if test is in jeopardy.

20. What Should Hospitals Monitor? • Rate of Change in Charges per Capita • Rate of Change in Medicare Payments per Capita • Time Period: • Calendar Year • Rate Year • Changes in Charges • Inpatient • Outpatient • Observation • Admit Source/Source of Arrival • Changes in Population • Hospital • Primary Service Area • State

21. Calendar Year! Rate Year: July- June Calendar Year: January- December • The HSCRC will be monitoring Calendar Year performance for the waiver. • Consider creating additional internal reports for compliance on a calendar year basis

22. Changes in Market Share • What is it? • a measurement of the population's utilization of a hospital’s services in a given geographic area over a period of time as compared to other hospitals. • Why is this important to hospitals? • Global budgets will be adjusted to match utilization. • The methodology for market share adjustments hasn’t been finalized. The HSCRC has requested white papers from the Industry. • Recommendation for Hospitals: • monitor market share as best you can with available data

23. Readmissions • What is it? • Reduce the Medicare readmissions rate to the national level in 5 years (CY2014-CY2018)

24. Readmissions • Why is this important to Hospitals? • ALL Readmissions (no distinction between intra and inter) • Maryland’s focus up until now for reporting purposes has been intra-hospital readmissions • Value-based annual financial adjustment

25. Readmissions: What Should Hospitals Monitor? • Time Period: CY vs. RY • Intra vs. Inter • Medicare vs. All Payers • Benchmarks: State vs. Nation vs. Peers • Service Line

26. Raising the Bar: Quality-based Reimbursement (“QBR”) and Maryland Hospital Acquired Conditions (“MHAC”) • What is it? • QBR and MHAC are Maryland’s versions of CMS’ Value Based Purchasing (VBP) and Hospital Acquired Conditions (HAC) programs. • Quality-based policy tools

27. Why is this important to hospitals? • New waiver • Reduce Potentially Preventable Complications (a.k.a MHACs) by 30% in five years (CY2014-CY2015) • Workgroups will be modifying MHAC policy to align with the new waiver requirements • Scaling: • MHAC and QBR scaling will be even more relevant under GBR because it’s one of the few variable update factors for hospitals • More Financial Risk: FY2016 QBR: 0.5%  1.0% base approved hospital inpatient revenues

28. Potentially Avoidable Utilization (PAUs) • What are PAUs? • 30- Day Readmissions/Rehospitalizations (includes ER) • Preventable Admissions (Admissions for ambulatory sensitive conditions) (based on AHRQ Prevention Quality Indicators) • ER visits than can be treated in other settings • Maryland Hospital Acquired Conditions (MHAC) a.k.a Potentially Preventable Complications

29. Potentially Avoidable Utilization (PAUs) • Why are they important? • Cost & Quality: Crosses the 3 major tenants of waiver (cost per capita, readmissions, quality) • Financial Performance: In a GBR world if you can reduce inappropriate volumes, you can reduce excess cost and therefore improve operating margins (or reinvest).

30. Brave New World: Changes to Hospital Reporting Under the NEW Waiver • Changes to Traditional HSCRC Data Submissions • New Metrics to Monitor • New Platform for Reporting

31. CRISP: NEW Platform for Hospital Analytics • Chesapeake Regional Information System for our Patients or (“CRISP”) • Maryland’s state designated health information exchange (“HIE”). • Not-for-profit organization charged with electronically connecting healthcare providers across the region.

32. CRISP: NEW Platform for Hospital Analytics • CRISP receives real-time encounter messages (called “ADTs”) which carry facility, medical record number, visit IDs, and other important information about visit. • Unique Aspects of ADTs: • Enable population-health analysis (unduplicated users across hospitals) • Real –Time data flows • Street address, enabling more granular level of geographic analysis • Linked ADT and HSCRC Abstract Data enable more analysis • Inpatient matching rate: 99.98% • Outpatient matching rate: 99.86%

33. CRISP’s Data Model Potential Linkage: All-Payer Claims Database

34. CRISP’s Unique Reporting Capabilities • Unique patient ID assigned to each individual across hospitals • Real-time ADT with geo-code • Real-time ADT reconciles to HSCRC tapes • Coordination of logic with HSCRC reimbursement policies

35. CRISP’s Data Utility • Tape Data reconciled to CRISP’s unique patient ID supports: • New Policies: Data is a shared resource to support policymakers, payers, and providers respond to new policy direction. • Population Health: CRISP data can support care coordination activities/analytics for population-based models (TPR/GBR). POTENTIAL

36. Overview of CRISP Reports CRISP has developed the capability to generate reports through a combination of CRISP data and HSCRC tape data. Initial ideas have focused on: • Readmission analysis reports (HSCRC or CMS methodology) • Monthly reports with patient drill downs • Year-to-year and monthly • By hospital, zip, region, county, HEZ • By diagnosis or disposition • Market share analysis • Clinical service line utilization by hospital PSA • By majority of inpatient visits, total visits, etc. • By diagnosis and charges • Analysis of Potentially Avoidable Volume • Visits with ambulatory sensitive conditions • Readmission • Market share shifts • Uncompensated Care/ACA Impact • Using CRISP EID to link insurance status and UCC use across time periods

37. MORE… High utilization analysis • By # of visits, LOS, date, overlap, etc. • By census tract or neighborhood • By diagnosis, disposition, or charges Hospital Utilization by diagnosis, disposition, charges using HSCRC data • County reports (patients, discharges, readmits by diagnosis) Patient attribution analysis • Based on prior visits • Identify exclusive patients and % of visit allocation by patient • By census tract or neighborhood • By diagnosis and charges Episode of Care analysis • All subsequent hospital visits after discharge • By diagnosis or disposition • By census tract or neighborhood

38. Stay Tuned…. • Hospitals are being asked to produce: • MORE data • MORE accurately • FASTER • Lots of rapid changes happening for hospital reporting

39. Questions?

40. Contact Information Oscar Ibarra Chief, Information Management and Program Administration HSCRC Oscar.Ibarra@maryland.gov Katie Eckert, CPA Director, Budget & Reimbursement Bon Secours Baltimore Health System katie_eckert@bshsi.org