Value Based Purchasing and You

(1)

Value Based Purchasing and You

David Gourley, RRT, MHA, FAARC

Director of Clinical Services and Risk Management Millennium Respiratory Services

(2)

Value Based Purchasing and You



Overview of healthcare reform initiatives



Healthcare inflation and Medicare spending



Pay for Performance and Value Based Purchasing (VBP)



Financial Implications of VBP



VBP key elements



Changes for 2016 and beyond



Telehealth clinical initiatives

(3)



Medicare Modernization Act (MMA) of 2003:

 _{Institute of Medicine (IOM) commissioned to “identify and}

prioritize options to align performance to payment in Medicare”

 Supported “Pay for Performance” (P4P)



_{Deficit Reduction Act (DRA) of 2005:}

 Required HHS to develop a plan to implement Value Based Purchasing (VBP) beginning in 2009

(4)



Medicare Improvements for Patients and Providers

Act (MIPPA) of 2008:

 Required HHS develop transition plan for VBP for physicians and other professional services

(5)



Patient Protection and Affordable Care Act

 _{Passed Senate on December 19, 2009 (60-39)}

 Passed House of Representatives on March 21, 2010 (219-216)

 Signed into law on March 23, 2010 by President Obama

 Value based purchasing final rule released on April 29, 2011

 Additional measures added to VBP in 2013

(6)



Goals of PPACA:

 _{Increase access}

 Increase quality of healthcare outcomes

 _{Improve patient safety}

 Eliminate duplication/waste

 Enhance care coordination

 Reduce rate of health care inflation to sustainable levels



Every American will be affected:

 _{Greater accountability for patients and providers}

 Improving quality/reducing costs will save lives and $$$

(7)

(8)

(9)



Improve clinical quality



Address problems of underuse, overuse, and misuse

of services



Encourage patient centered care



Reduce adverse events and improve patient safety



Avoid unnecessary costs in the delivery of care

(10)



Stimulate investments in structural components and

the re-engineering of care processes system-wide



Make performance results transparent to and useable

by consumers



Avoid creating additional disparities in health care and

work to reduce existing disparities

(11)

(12)

CMS Quality-based

(13)

CMS Quality-based

(14)

(15)



$2.1 billion at risk in all U. S. hospitals



Average U. S. hospital:

 Mean: approximately $500,000

 Minimum: approximately $100,000

 _{Maximum: approximately $6 million}



Majority of hospitals will lose money



Initial actions, to be followed by additional financial

impact

(16)



Fluid scope

 _{Initially – combination of clinical, outcome, and}

satisfaction measures

 2015 –HAC and Patient Safety Indicators were added

 2016 – CAUTI and SSI added

 2017 – C Difficile and MRSA added

 Expanding and changing terrain



Bandwagon effect with other payors

(17)



General acute care hospitals

 _{Critical access hospitals excluded}



At least 10 cases per clinical measure



At least 4 measures reported



At least 100 HCAHPS surveys

(18)

(19)

(20)

Clinical Processes of Care

Measure ID Clinical Process Measure Description Acute Myocardial Infarction (Heart Attack)

AMI – 7a Fibrinolytic Therapy received within 30 minutes of hospital arrival

Pneumonia

PN-6 Initial antibiotic selection for CAP in immunocompetent patient

Surgical Care Improvement Project

SCIP-Inf 2 Prophylactic antibiotic selection for surgical patients

SCIP-Inf 3 Prophylactic antibiotics discontinued within 24 hours after surgery end time SCIP-Inf 9 Urinary Catheter removed on post-op day 1 or 2

SCIP-Card 2 Surgery patients on a beta blocker prior to arrival rec’d in perioperative period

(21)

Domain Patient Experience of Care Dimension

Nursing Communication Nurse courtesy and respect Nurses listen carefully

Nurse explanations are clear

Doctor Communication Doctor courtesy and respect Doctors listen carefully

Doctor explanations are clear

Responsiveness of Staff Staff helped with bathroom needs Call bell answered timely

Pain Management Pain well controlled

Staff helped patient with pain

Communication about Medications Staff explained new medicines

Staff clearly described side effects

Discharge Information Staff discussed help needed after discharge Written symptom/health information provided

Hospital environment Area around room quiet at night Room and bathroom kept clean

(22)

Measure ID Mortality Measures

MORT 30 AMI Acute Myocardial Infarction 30-day mortality rate MORT 30 HF Heart Failure 30-day mortality rate

MORT 30 PN Pneumonia 30-day mortality rate

“…the 30-day mortality measures assess deaths that occur within 30 days after admission, which, depending on the length of stay, may occur post-discharge…”

Specifications Manual for National Hospital Inpatient Quality Measures, Version 4.0; NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE, Measure Information Form, Measure Set: CMS Mortality Measures, Set Measure ID#: MORT-30-AMI.

(23)

Complications/Patient Safety for Selected Indicators

PSI # 03 Pressure Ulcer

PSI # 06 Iatrogenic Pneumothorax

PSI # 07 Central Venous Catheter-related Bloodstream Infections PSI # 08 Postop Hip Fracture

PSI # 09 Postop Hemorrhage or Hematoma

PSI # 10 Postop Physiologic and Metabolic Derangements PSI # 11 Postop Respiratory Failure

PSI # 12 Postop PE or DVT PSI # 13 Postop Sepsis

PSI # 14 Postop Wound Dehiscence

PSI # 15 Accidental Puncture or Laceration

(24)

CLABSI Measures and New Measures for 2016

CLABSI Central Line Bloodstream Associated Infections CAUTI Catheter-Associated Urinary Tract Infections SSI – Colon Surgical Site Infection – Colon

SSI – Abd. Hyster. Surgical Site Infection – Abdominal Hysterectomy

(25)

Efficiency Measure

MSPB-1 Medicare Spending Per Beneficiary

Efficiency Measure

As part of the VBP program, the Medicare Spending Per Beneficiary (MSPB)

Measure assesses Medicare Part A and Part B payments for services provided to a Medicare beneficiary during an episode that spans from three days prior to an

inpatient hospital admission through 30 days after discharge. The payments included are price-standardized and risk-adjusted. Price standardization removes sources of variation that are due to geographic payment differences. Risk adjustment accounts for variation due to patient health status.

By measuring cost of care through this measure, CMS hopes to increase the

(26)

(27)

(28)



Zero sum game



Withhold of baseline DRG payment across all patients



Hospitals will lose reimbursement unless

performance is at or above benchmarks



Percentage of withhold earned back based on

performance

(29)



Achievement Points: Awarded by comparing a hospital’s rates

during the Performance Period with all hospitals’ rates from

the Baseline Period

 Rate at or above the Benchmark: 10 points

 Rate less than the Achievement Threshold: 0 points

 Rate equal to or greater than the Achievement

 Threshold and less than the Benchmark: 1–10 points



Improvement Points: Awarded by comparing a hospital’s rates

during the Performance Period to that their rates from the

Baseline Period

 Rate at or above the Benchmark: 9 points

 Rate less than or equal to Baseline Period Rate: 0 points

 Rate between the Baseline Period Rate and the Benchmark: 0–9 points

(30)

(31)

(32)



CMS required to redistribute leftover funds



Funds will be redistributed by increasing the slope of

the exchange function



Ultimate slope of exchange will be determined by

performance across all hospitals

(33)

(34)



1,714 hospitals received higher Medicare payments



1,375 hospitals payments were reduced



Maine, Nebraska, South Dakota, Utah and South

Carolina fared best



District of Columbia, Connecticut, New York,

Wyoming and Delaware fared worst

(35)



Concurrent data collection

 Identify patients during hospital stay

 Ensure clinical measures are met



Physician engagement

 Physician champions

 _{Physician report cards}



Communication about measures

 Frequency

 Availability

Quality Measures

(36)



Focus for change

 _{Identify areas for improvement}

 Identify causes of underperformance

 Identify specific behavior changes that staff can make that will be visible to patients



Concurrent data collection and performance assessment

 Measure adoption rates for new behaviors

 Provide accountability – coaching and reward

 Continue monitoring behavior until adopted and sustained

HCAHPS

(37)



Continuum of care

 _{Adequate discharge planning and instructions}  Follow up post discharge

 Partner with physicians

 Partner with post-acute care providers



Monitoring mortality data

(38)



Intensive hand hygiene initiatives



Compliance with CLABSI, CAUTI, and SSI best

practices



Focus on environmental elements



Goal setting – Striving for Zero

(39)



Hospital led initiatives, in collaboration with post

acute care providers

 Home Health

 Hospice

 Outpatient

 Skilled Nursing Facilities

 Durable Medical Equipment

(40)



Value Based Purchasing for Physicians and Physician

Groups



Value Based Purchasing for Skilled Nursing Facilities



Ambulatory Surgery OAS CAHPS



Emergency Department EDCAHPS



Hospice CAHPS

(41)

(42)



What is “Telehealth”?

 _{Use of digital information and communication}

technologies

 Includes diagnosis, management, and education

 Also called “e-health” (electronic) or “m-health” (mobile)

 Includes basic health services, such as online support groups and health information

 Electronic health records

 _E-visits

(43)



Live Video – Synchronous

 _{Telestroke, Tele-ICU}



Store and Forward – Asynchronous

 Pre-recorded videos and digital images



Remote patient monitoring

 Personal health data collection from person in one location transmitted to provider in different location



Mobile Health

 Range from targeted text messages to promote healthy behavior to wide-scale alerts about disease outbreaks

(44)

Telehealth - Telestroke

(45)

(46)



E-Visits

 _{Physician appointment online instead of in person}  You type in your question or problem

 _{May continue through a progression of questions}  Healthcare provider reviews and sends response

 You may receive a prescription or other recommendation

 Helpful for rural areas or those without easy access to transportation

(47)



Personal health records

 _{Accessible to patient/next of kin anytime via}

Web-enabled device (computer, laptop, tablet, or smartphone)

 Vital information (disease, medications, allergies) available immediately

(48)



Personal health apps

 _{Multitude of apps have been created}

 Allow storage of health records, upload information such as blood glucose monitor or blood pressure data and then share with provider