Transcript materials - Michigan Health & Hospital Association

February 15, 2011
Mandatory Medicare Delivery System Reform
FFY 2013
Inpatient
Readmissions
Inpatient ValueBased Purchasing
• Implemented
• Implemented
October 1, 2012
October 1, 2012
(FFY 2013)
(FFY 2013)
• Reduces Medicare • Budget neutral;
redistributive
reimbursement by
$7 billion / 10 years within PPS system.
nationwide; $1 to
NYS.
FFY 2015
Health CareAcquired
Conditions
EHR Meaningful
Use (ARRA)
• Implemented
October 1, 2015
(FFY 2014)
• Reduced Medicare
inpatient hospital
reimbursement by
$ 1.4 billion / 10
years nationwide.
• Medicare payment
penalties assessed
against eligible
hospitals and
physicians that fail
to be meaningful
users by October 1,
2014 (FFY 2015).
Voluntary Medicare Delivery System Reform
2012
2013
Centers for Medicare
Shared Savings / ACO
and Medicaid Innovation Program
(CMMI)
• The “venture capital”
entity of ACA launched
November 2010.
• Will allocate $10 billion
over 10 years nationwide
to fund testing of
innovative care delivery
models that improve
patient care, improve
population health and
reduce costs.
• RFPs to be released
shortly.
Acute/Post-Acute
Bundling Pilot
• Implemented January 1,
• Implemented January 1,
2013.
2012.
• Budget neutral.
• $5 billion in shared
savings nationwide over
• Five-year pilots for
10 years.
episode of care (3 days
prior to inpatient stay,
• Three-year, primary care
through 30 days post
coordinating programs for
discharge).
5,000+ Medicare FFS
beneficiaries.
Value-Based Purchasing Expansion to
Other Payment Settings
Submit plans
for
Ambulatory
Surgical
Centers VBP
(Jan 1, 2011)
FY2005 2006
FY 2011
Submit plans for
SNF and Home
Health VBP
(Oct. 1,
2011/FFY 2012)
2012
Establish a CAH
and small
volume rural
hospital VBP
demonstration
Implement VBP pilot
programs for inpatient
rehabilitation, inpatient
psychiatric, LTC, cancer
hospitals, and hospice
Implement VBP
for inpatient
hospitals
2013
2015
Implement
physician VBP
modifier for
specific
physicians and
physician groups
2016
2017
Physician payment
modifier applied to all
physicians, groups
and other eligible
practitioners
VBP Provisions of the
ACA
Goal of Value-Based Purchasing
Transition acute care hospitals from P4R to P4P under Medicare
Medicare payment incentives/penalties to promote:
• Achievement of high quality care
• Improvement in care quality
Program framework outlined by Congress in ACA
Program details left to HHS Secretary/CMS
ACA Section 3001: Hospital Inpatient ValueBased Purchasing Incentive Program
Effective beginning October 1, 2012 (FFY 2013)
Applies only to PPS hospitals with the following
exclusions:
• Critical Access Hospitals
• Specialty hospitals (psychiatric, rehabilitation, children’s, cancer, LTCH)
• Hospitals cited for “immediate jeopardy”
• Hospitals not participating in the P4R program (IQR, formerly RHQDAPU)
• Hospitals with small numbers of applicable measures/cases (TBD by CMS)
Demonstration projects for CAHs and small hospitals
ACA – Funding of VBP
•Funded by Medicare IPPS payment reductions:
• 1.0% reduction in FFY 2013, increasing each year by .25% to 2.0%
for FFY 2017 and beyond
• Budget-neutral:
• each year’s pool fully distributed to hospitals in that same year
• Payment adjustments applied to base operating amount:
• excluding IME, DSH, low-volume adjustments, and outliers
Percent Carve-Out for VBP Pool
2.0
1.5
1.0
0.5
0.0
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
ACA – Required VBP Measures
Must be P4R measures - measures reported under IQR program, formerly
RHQDAPU)
FFY 2013 must include measures covering:
• AMI
• Heart failure
• Pneumonia
• Surgical infection prevention (SCIP)
• Healthcare-associated infections (HAIs)
• Patient satisfaction (HCAHPS)
Categories of measures must be weighted
Measures must be on Hospital Compare for at least one year prior to use in VBP
FFY 2014 may add efficiency measures
• Include Medicare spending per beneficiary adjusted for age, sex, race, severity, and other as
determined by the Secretary
ACA – VBP Performance Standards
Must establish VBP performance standards and a
performance period
• Performance period must:
• Be announced 60-days prior to start of the
period
• End prior to program FFY
Must recognize BOTH achievement of quality
standards and improvement in care quality
ACA – VBP Incentive Payments
Determine VBP incentive payment adjustment based on total
performance score
Apply to base operating amount (excluding IME, DSH, low-volume
adjustments, and outliers)
Inform hospitals of carve-out and VBP payment adjustment at
least 60 days prior to the start of FFY (August of each year)
Provide an appeals process
ACA – Timeline for First-Year
Implementation of VBP
Proposed Baseline Period
Oct.
Nov.
Dec.
Jan.
Feb.
Mar.
Apr.
May
June
July
Aug.
Sept.
FFY 2009
2008
2008
2008
2009
2009
2009
2009
2009
2009
2009
2009
2009
FFY 2010
2009
2009
2009
2010
2010
2010
2010
2010
2010
2010
2010
2010
FFY 2011
2010
2010
2010
2011
2011
2011
2011
2011
2011
2011
2011
2011
FFY 2012
2011
2011
2011
2012
2012
2012
2012
2012
2012
2012
2012
2012
(reflects quality data from
Dec. 2010 Hospital
Compare release --most
recent release)
Proposed Performance Period
FFY 2013
2012
Release of Final Rule
Medicare IPPS payment
adjusted based on
hospital performance
(by law, VBP performance
standards must be published 60days prior to start of performance
period)
(will reflect quality data from
Dec. 2012 Hospital Compare
release)
CMS
Value-Based Purchasing
Proposed Rule
Proposed Quality Measures
Proposed VBP Quality Measures
• Clinical Process of Care Domain
FFY 2013
• 17 process measures
• Patient Experience of Care Domain
• HCAHPS Survey (8 HCAHPS dimensions)
• All of the above plus:
• Outcome of Care Domain
• Mortality, AHRQ measures, HACS
FFY 2014
• Possible efficiency measures
• Medicare spending per beneficiary
• Internal hospital efficiency
• Others
• Possible nursing sensitive care measures
Proposed Weighting of Measures
FFY 2013
• 30% HCAHPS
• 70 % PROCESS
• HCAHPS
FFY 2014 • PROCESS
• OUTCOME
To be
determined
Proposed FFY 2013 VBP – Process Measures
Acute Myocardial Infarction
AMI-2
Aspirin Prescribed at Discharge
AMI-7a
Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
Primary Percutaneous Coronary Intervention (PCI) Received Within 90 Minutes of Hospital
AMI-8a
Arrival
Heart Failure
HF-1
Discharge Instructions
HF-2
Evaluation of Left Ventricular Systolic (LVS) Function
HF-3
ACE Inhibitor or ARB for LVS Dysfunction
Pneumonia
PN-2
Pneumococcal Vaccination
Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received
PN-3b
in Hospital
PN-6
Initial Antibiotic Selection for CAP in Immunocompetent Patient
PN-7
Influenza Vaccination
Surgeries (as measured by Surgical Care Improvement (SCIP) measures)
Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the
SCIP-Card-2
Perioperative Period
SCIP-VTE-1
Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within
24 Hours Prior to Surgery to 24 Hours After Surgery
Healthcare-Associated Infections (as measured by SCIP measures)
SCIP-Inf-1
Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
SCIP-Inf-2
Prophylactic Antibiotic Selection for Surgical Patients
SCIP-Inf-3
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
SCIP-Inf-4
Cardiac Surgery Patients with Controlled 6 AM Postoperative Serum Glucose
SCIP-VTE-2
Measures Proposed for Exclusion from FFY
2013 VBP
Surgical Care
Improvement
(SCIP)
• Urinary catheter removal
• Temperature management
AHRQ IQI and
PSI Measures
Measures
Deemed as
“Topped Out”
• AMI: Aspirin at arrival, Beta blocker at discharge,
ACEI/ARB at discharge, Smoking cessation
• Heart Failure: Smoking cessation
• Pneumonia: Smoking cessation
• SCIP: Surgery patients with appropriate hair
removal
Proposed FFY 2013 VBP – Patient
Experience of Care Measures
Measured using the Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS) Survey
Patient Satisfaction Survey
HCAHPS
Eight Dimensions (using the most positive responses, “top box” responses
for each question used within the HCAHPS dimension):
• Communication with Nurses
• Communication with Doctors
• Responsiveness of Hospital Staff
• Pain Management
• Communication About Medicines
• Cleanliness and Quietness of Hospital Environment
• Discharge Information
• Overall Rating of Hospital
Modifications to HCAHPS on Hospital Compare:
•“cleanliness and quietness” – combined
•“would you recommend this hospital?”- not included
Proposed FFY 2014 VBP - Outcomes Measures
Mortality Measures
Mort-30-AMI
AMI 30-day mortality (Medicare patients)
Mort-30-HF
HF 30-day mortality (Medicare patients)
Mort-30-PN
PN 30-day mortality (Medicare)
AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs), and Composite Measures
PSI-06
Iatrogenic pneumothorax, adult
PSI-11
Post Operative Respiratory Failure
PSI-12
Post Operative PE or DVT
PSI-14
Postoperative wound dehiscence
PSI-15
Accidental puncture or laceration
IQI-11
Abdominal aortic aneurysm (AAA) repair mortality rate (with or without volume)
IQI-19
Hip fracture mortality rate
Complication/patient safety for selected indicators (composite)
Mortality for selected medical conditions (composite)
Hospital Acquired Condition (HAC) Measures
HACs
• Foreign Object Retained After Surgery
• Air Embolism
• Blood Incompatibility
• Pressure Ulcer Stages III & IV
• Falls and Trauma: (includes fracture, dislocation, intracranial injury, crushing injury, burn,
electric
shock)
• Vascular Catheter-Associated Infections
• Catheter-Associated Urinary Tract Infection (UTI)
• Manifestations of Poor Glycemic Control
Possible Measures for Future Program Years
Nursing
Sensitive Care
Measures
• CMS indicates they will consider including
nursing sensitive care measures in FFY 2014 or
thereafter
• CMS requests comments
Efficiency
Measures
• ACA allows use of efficiency measures in FFY
2014 or thereafter
• Must include Medicare spending per beneficiary
adjusted for age, sex, race, severity, and other
factors as determined by the Secretary
• CMS requests comments
• CMS is also considering measures of hospital
internal efficiency
• CMS requests comments
Proposed Process for Adding Measures to
VBP Program
CMS has the authority to add measures
within parameters
• Measures are to be selected from those reported under the IQR program
• Measures must be published on Hospital Compare for at least one year prior to
the start of the performance period
• CMS must provide notice to the industry of measures at least 60 days prior to
the start of the performance period
• Readmissions cannot be included in VBP (separate program under ACA)
CMS proposes a “sub-regulatory process” to
expedite inclusion of new measures
• Once a measure has been published for a year, it could be included in VBP
without need for official notification in the Federal Register
CMS has the authority to retire measures
• CMS proposes to retire “topped out” measures
CMS
Value-Based Purchasing
Proposed Rule
Proposed Scoring Methodology
Proposed Timeframes for FFY 2013 VBP
Performance
Period
Baseline
Period
• July 1, 2011 to March 31, 2012
• A hospital’s performance in this period will determine its
score
• First year of the program will have a shortened, 9-month
performance period
• Future years will reflect at least a full year (12 months)
• July 1, 2009 to March 31, 2010
• National data will determine standards for achievement
scores
• Hospital data will determine improvement when compared
to performance period
• Same nine months to avoid any seasonality issues
23
Proposed Standards for
Process Domain
Achievement
Threshold minimum score to
receive achievement
points on a measure
• National median score in the base
period
• Zero points if below threshold
Achievement
Benchmark -
• Average score for hospitals in the
top decile in base period
performance to receive
maximum points for a • 10 points if at benchmark or above
measure
Improvement
Range
• Based on comparison to hospital’s
own performance in base period
• 0 to 9 points
24
Example of Process Domain Scoring
Hospital score in performance period:
Hospital score in base period:
0.70
0.21
From CMS Proposed Rule
25
National - Baseline Period
Hospital - Baseline Period
Hospital - Performance Period
Final Points
Sample
Hospital
VBP
Process
Domain
Score
Calculation
Indicator
Benchmark
Surgery Patients Who Were Kept
on Their Beta Blockers Before and
100.0%
After Surgery
Surgery Patients Given Preventative
Antibiotic(s) Within One Hour
99.4%
Before Surgery
Surgery Patients Given the
Appropriate Preventative
100.0%
Antibiotic(s) for Surgery
Surgery Patients Whose
Preventative Antibiotic(s) Were
98.9%
Stopped Within 24 Hours After
Surgery
Heart Surgery Patients Whose
Blood Sugar Was Kept Under Good
98.9%
Control
Surgery Patients Whose Doctors
Ordered Treatments to Prevent
99.4%
Blood Clots for Certain Types of
Surgeries
Surgery Patients Given Treatment
to Prevent Blood Clots within 24
98.9%
Hours Before or After Selected
Surgeries
Heart Attack Patients Given Aspirin
100.0%
at Discharge
Heart Attack Patients Given
Fibrinolytic Medication Within 30
85.3%
Minutes of Arrival
Heart Attack Patients Given PCI
99.3%
Within 90 Minutes of Arrival
Performance
Achievement
Points
Improvement
Points
(Higher of
Achievement or
Improvement)
142
93%
2
0
2
97%
361
98%
7
4
7
386
96%
364
94%
0
0
0
92.0%
362
93%
339
96%
6
5
6
92.0%
1
0%
0
Insufficient Data
Not Computed
Not Computed
Not Computed
93.0%
398
94%
282
97%
6
5
6
91.0%
397
94%
280
97%
7
6
7
98.0%
87
100%
91
95%
0
0
0
67.0%
2
50%
0
Insufficient Data
Not Computed
Not Computed
Not Computed
85.0%
4
50%
7
43%
Not Computed
Not Computed
Not Computed
Achievement
Threshold
Case Count
Performance
Case Count
92.0%
39
97%
95.0%
383
98.0%
Pneumonia Patients Assessed and
Given Pneumococcal Vaccination
99.7%
92.0%
314
92%
299
90%
0
0
0
Pneumonia Patients Whose Initial
Emergency Room Blood Culture
Was Performed Prior to the
Administration of the First Hospital
Dose of Antibiotics
99.6%
95.0%
258
96%
243
99%
8
8
8
Pneumonia Patients Given the
Most Appropriate Initial Antibiotic(s)
98.4%
91.0%
168
92%
159
94%
4
3
4
99.7%
91.0%
212
95%
210
84%
0
0
0
99.7%
86.0%
303
90%
290
91%
4
1
4
Heart Failure Patients Given ACE
Inhibitor or ARB for Left Ventricular
Systolic Dysfunction (LVSD)
100.0%
94.0%
77
87%
98
84%
0
0
0
Heart Failure Patients Given an
Evaluation of Left Ventricular
Systolic (LVS) Function
100.0%
98.0%
386
96%
367
96%
0
0
0
Pneumonia Patients Assessed and
Given Influenza Vaccination
Heart Failure Patients Given
Discharge Instructions
Overall Domain Score (Sum of Final Points Earned / Maximum Possible Points)
31%
Sample Hospital VBP Process Score
Calculation
National - Baseline Period
Hospital - Baseline Period
Hospital - Performance Period
Final Points
Indicator
Benchmark
Surgery Patients Who Were Kept
on Their Beta Blockers Before and
100.0%
After Surgery
Surgery Patients Given Preventative
Antibiotic(s) Within One Hour
99.4%
Before Surgery
Surgery Patients Given the
Appropriate Preventative
100.0%
Antibiotic(s) for Surgery
Surgery Patients Whose
Preventative Antibiotic(s) Were
98.9%
Stopped Within 24 Hours After
Surgery
Heart Surgery Patients Whose
Blood Sugar Was Kept Under Good
98.9%
Control
Surgery Patients Whose Doctors
Ordered Treatments to Prevent
99.4%
Blood Clots for Certain Types of
Surgeries
Surgery Patients Given Treatment
to Prevent Blood Clots within 24
98.9%
Hours Before or After Selected
Surgeries
Heart Attack Patients Given Aspirin
100.0%
Performance
Achievement
Points
Improvement
Points
(Higher of
Achievement or
Improvement)
142
93%
2
0
2
97%
361
98%
7
4
7
386
96%
364
94%
0
0
0
92.0%
362
93%
339
96%
6
5
6
92.0%
1
0%
0
Insufficient Data
Not Computed
Not Computed
Not Computed
93.0%
398
94%
282
97%
6
5
6
91.0%
397
94%
280
97%
7
6
7
98.0%
87
100%
91
95%
0
0
0
Achievement
Threshold
Case Count
Performance
Case Count
92.0%
39
97%
95.0%
383
98.0%
Proposed Standards for
Patient Satisfaction Domain
Achievement
Threshold minimum score to
receive achievement
points on a measure
• 50th percentile ranking of scores in
the base period
• Zero points if below threshold
Achievement
Benchmark -
• 95th percentile ranking of scores in
the base period
performance to receive
maximum points for a • 10 points if at benchmark or above
measure
Improvement
Range
• Based on comparison to hospital’s
own performance in base period
• 0 to 9 points
28
Example of Patient Satisfaction Domain
Scoring
Hospital score in performance period: 64th percentile
Hospital score in base period:
42nd percentile
From CMS Proposed Rule
29
HCAHPS Consistency Points
Consistency –
an incentive for
hospitals to perform
well on all dimensions
• 20 points if all eight HCAHPS
dimensions are at or above the 50th
percentile
• If any HCAHPS score is below the 50th
percentile, the single lowest percentile
determines the points
• 0 points if the lowest percentile is 0
30
HCAHPS Consistency Examples
Hospital A Hospital B Hospital C Hospital D
HCAPHS Measure
Dimension 1
Dimension 2
Dimension 3
Dimension 4
Dimension 5
Dimension 6
Dimension 7
Dimension 8
0th
50th
20th
43th
64th
38th
72th
35th
70th
42th
10th
53th
29th
46th
80th
56th
61th
52th
70th
38th
25th
39th
53th
49th
60th
90th
80th
70th
62th
73th
55th
81th
Consistency Points
0
4
10
20
Sample Hospital VBP HCAHPS Calculation
National - Baseline Period
Hospital - Baseline Period
Hospital - Performance Period
Final Points
Indicator
Benchmark
Percentile
Achievement
Threshold
Percentile
Percentile
Performance
Percentile
Performance
Nurses always communicated well
95th
50th
28th
70%
30th
72%
0
0
0
Doctors always communicated well
95th
50th
53rd
79%
34th
77%
0
0
0
Patients always received help
quickly from hospital staff
95th
50th
11th
50%
19th
55%
0
0
0
Patients' pain was always well
controlled
95th
50th
38th
66%
39th
67%
0
0
0
Staff always explained about
medicines before giving them to
patients
95th
50th
17th
52%
24th
55%
0
0
0
Patients' rooms and bathrooms
were always kept clean and quiet
95th
50th
28th
57%
20th
57%
0
0
0
Patients were definitely given
information about what to do during
their recovery at home
95th
50th
57th
81%
66th
83%
4
2
4
Patients who gave their hospital a
rating of 9 or higher on a scale of 0
to 10
95th
50th
4th
46%
5th
51%
0
0
0
Minimum Percentile for
Consistency Points
Achievement Improvement
Points
Points
5th
Overall Domain Score (Sum of Final Points Earned / 100)
(Higher of
Achievement or
Improvement)
2
6%
Patients' pain was always well
controlled
95th
50th
38th
66%
39th
67%
0
0
0
Staff always explained about
medicines before giving them to
patients
95th
50th
17th
52%
24th
55%
0
0
0
Patients' rooms and bathrooms
were always kept clean and quiet
95th
50th
28th
57%
20th
57%
0
0
0
Patients were definitely given
information about what to do during
their recovery at home
95th
50th
57th
81%
66th
83%
4
2
4
Patients who gave their hospital a
rating of 9 or higher on a scale of 0
to 10
95th
50th
4th
46%
5th
51%
0
0
0
Sample Hospital VBP HCAHPS Calculation
Minimum Percentile for
Consistency Points
5th
Overall Domain Score (Sum of Final Points Earned / 100)
2
6%
Exclusions
Critical access hospitals
Specialty hospitals (psychiatric, rehabilitation, children’s,
cancer, long-term care)
Hospitals with small numbers of applicable measures
• Fewer than 4 useable Process measures or
• Fewer than 100 HCAHPS survey responses
Hospitals cited for “immediate jeopardy”
Hospitals not participating in the Pay-for-Reporting
program
Hospitals in Maryland and Puerto Rico
34
Calculation of VBP Score
Determine
points for each
measure
• Higher of
achievement or
improvement
Combine each
measure’s
points into
domain scores
• Sum of points
earned divided by
total possible
points for domain
Combine
domain scores
Determine VBP
distribution
• Weight clinical
process by 70%
• Weight patient
experience by
30%
• based on
Exchange
Function
Points for
• Each of the 17
process measures
that apply to the
hospital
• Each of the 8
HCAHPS
measures plus
consistency
Scores for
• Clinical process
of care domain
• Patient
experience of
care domain
Total
Performance
Score
Percent of
contribution
(through rate
reduction) that
will be
returned as a
VBP
distribution
35
CMS’ Proposed Payout Function
Linear function distributes funds across
hospitals based on total VBP scores
Not all hospitals will earn back everything
they contribute to the pool
Some hospitals will earn back more than they
contribute to the pool
Break-even score is approximately 42.63%
All VBP pool dollars must be expended
Sample Hospital VBP Payment Incentive
Calculation
Sample Hospital
Process Domain Score:
31%
HCAHPS Domain Score:
6%
Overall VBP Score (70%
Process, 30% HCAHPS):
24%
Payment Percentage:
56%
FFY 2013
FFY 2014
FFY 2015
FFY 2016
FFY 2017
1% Carve-Out
1.25% Carve-Out
1.5% Carve-Out
1.75% Carve-Out
2% Carve-Out
$147,000
$184,000
$221,000
$258,000
$294,000
Estimated Payment from VBP Pool
$82,075
$102,733
$123,391
$144,050
$164,150
Dollars Left in the VBP Pool for
Redistribution
($64,925)
($81,267)
($97,609)
($113,950)
($129,850)
Dollars Contributed to VBP
Linear Payment Scenario
260%
240%
220%
200%
Payment Percentage
180%
160%
140%
120%
100%
80%
60%
40%
20%
0%
0%
10%
20%
30%
40%
50%
60%
70%
Score
Payment Conversion Linear Function
Sample Hospital
80%
90%
100%
Issues for Comments
HCAHPS Domain
• Weight for this domain is too high given that the survey is subjective
• Why the conversion to percentiles?
• Why consistency points and why only for HCAHPS?
Process Domain
• Some measures have extremely high performance standards
Subregulatory Process
• This is not adequate notification
2014 Measures
• Should exclude HACS
• Require adequate risk-adjust for outcome measures
• Mortality measures are very tightly arrayed
Efficiency measures
• Do not implement in FFY 2014
• Postpone pending development of equitable adjustments for patient
demographics, socioeconomic factors, etc.
Contact Information:
Contact your State Association or:
Gloria Kupferman
[email protected]
(518) 431-7968
Kevin Krawiecki
[email protected]
(518) 431-7710