VALUE BASED PURCHASING & CMS Reimbursement
Value-Based Purchasing and CMS Reimbursement
Hospitals will be reimbursed not on fee-for-service, but rather a pay-for-performance (P4P), or Value-Based Purchasing (VBP)
CMS has removed 1% of each hospital’s DRG payments. Hospitals must earn the money back through the new VBP model. This amount will gradually increase to 2% by 2017.
Baseline measures were collected from July 1, 2009 – March 1, 2010. An increase from the baseline on the Initial Performance Period will reward hospitals (and a deduction will penalize)
Initial Performance Period is occurring now (July 1, 2011 – March 31st, 2012). The payments for this time period will apply to discharges occurring on or after Oct. 1, 2012.
The gap in time from the performance period to the payment period is (March 31st to Oct. 1st is used by CMS to calculate the scores.
Reimbursement is a Zero-Sum Calculation – entire cost will be funded by extracting money from the worst performers to financially reward the best facilities
Value-Based Purchasing and CMS Reimbursement
70% – 17 Quality Care Measures that are broken down into sections: Acute myocardial infarction, Heart Failure, Pneumonia, Health care-associated Infections and Surgeries.
*SCIP-VTE-1 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered.
*SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours Prior to Surgery and 24 Hours After Surgery
30% – 8 Patient Satisfaction Measures
These are part of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Some examples of the measurements:
Communication with nurses and doctors
Responsiveness of staff Pain Management Cleanliness and quietness of hospital environment-Communication with nurses and doctors
Responsiveness of staff Pain Management Cleanliness and quietness of hospital environment
For FY 2014 (data collection begins Jan.1, 2012), additional outcome measures will be added to the system. They include 8 Hospital Acquired Conditions (HAC) and 9 Agency for Healthcare Research and Quality (AHRQ) measures.
Patient satisfaction measures are posted publicly at – www.hospitalcompare.hhs.gov
The HACs are:
Foreign Object Retained After Surgery
Pressure Ulcer Stages III & IV
Falls and Trauma
Vascular Catheter-Associated Infections
Catheter-Associated Urinary Tract Infection (UTI)
Manifestations of Poor Glycemic Control
AHRQs Include Patient Safety
PSI 06-latrogenic pneumothorax adult
PSI 11-Post Operative Respiratory Failure
PSI 12-Post Operative PE or DVT
PSI 14-Post Operative Wound Dehiscence
PSI 15-Accidental puncture or laceration
IQI 11-Abdominal aortic aneurysm (AAA) repair mortality rate
IQI 19-Postoperative Hip Fracture
Complication/patient safety for selected indicators (composite)
Mortality for selected medical conditions (composite)
Here is a more detailed look at PSI 12 Post Operative Pulmonary Embolism or Deep Vein Thrombosis pulled straight from the Agency for Healthcare Research and Quality website http://www.ahrq.gov/qual/vtguide/vtguidechap4.htm
Key Metric 1: Prevalence of Appropriate Venous Thromboembolism Prophylaxis – Though Figure 3 was used earlier to understand care delivery, it can now be used to measure care delivery, as shown in Figure 4. Specifically, this diagram will assist in selecting metrics—meaningful and measurable steps the team can use to track performance over time. In most instances the most telling metric is the prevalence of appropriate prophylaxis. Not only does it have the most important causal relationship to the main clinical endpoint, hospital-acquired VTE, but it is also a sensitive indicator of how well the various care delivery steps come together.
Using the prevalence of appropriate VTE prophylaxis as one of the team’s two key metrics also offers something that can be measured regularly and reliably. Set up daily, weekly, or monthly data collection for this metric (go to Key Metric 2, below). This data flow offers a reliable way to track performance of the changed care delivery system. What makes the clinical endpoint of hospital-acquired VTE unsuitable as a lone metric for performance tracking is that events are too infrequent and are often sub-clinical or too delayed in onset for timely, useful feedback.
It should now be clear how the VTE protocol serves not just as the main ingredient for the improvement intervention but also for the measurement system that can track performance.
Key Metric 2: Incidence of Hospital-Acquired Venous Thromboembolism – The team cares most about how well the steps of care delivery come together to prevent hospital-acquired VTE, the main clinical endpoint or outcome. Clearly, the incidence of hospital-acquired VTE must be one of the team’s key metrics. A common definition for “hospital-acquired deep vein thrombosis or pulmonary embolism” would be a clot first discovered during the course of hospitalization or discovered within 30 days of a prior hospitalization.