Document 7834

Pay for Performance (P4P)
Value-Based Purchasing: Tying Reimbursement with
Clinical Process of Care and Patient Experience
Bringing Finance and Quality Together
Suzanne Dalton, RN, BS, EdM
Healthcare Quality Strategies, Inc.
557 Cranbury Road Suite 21 East Brunswick, NJ 08816-5419
Phone: 732-238-5570 Fax: 732-238-7766 www.hqsi.org
This material was prepared by Healthcare Quality Strategies, Inc., (HQSI), the Medicare Quality Improvement Organization for New Jersey, under contract with the Centers for Medicare &
Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-NJ-C.7.1-12-10
4/2012
Disclosure Statement
No Disclosures
2
1
Today’s Objectives
Review the Centers for Medicare & Medicaid Services’
(CMS’) process of care measures and patient experience
measure in value-based purchasing (VBP) scoring for
Fiscal Year (FY) 2013
Identify the performance period timeframe for VBP scoring
for FY 2013 and FY 2014
Discuss actions you can take to improve your VBP
performance
Clarify Central Line-Associated Bloodstream Infection
(CLABSI) Validation Process
3
HQSI – New Jersey’s QIO
When you work with HQSI, you are:
• Tapping into the largest federal network dedicated to
improving health quality at the community level
• Focusing on three critical aims to make care better for
everyone:
Better patient care
Better population health
Lower health care costs through improvement
4
2
The Alphabet Soup of Hospital Quality Data
Reporting
RHQDAPU – Reporting Hospital Quality Data for Annual
Payment Update (APU)
HIQRP – Hospital Inpatient Quality Reporting Program
HOPQDRP – Hospital Outpatient Quality Data Reporting
Program
HCAHPS – Hospital Consumer Assessment of Healthcare
Providers & Systems
VBP – Value-Based Purchasing
MSPB – Medicare Spending per Beneficiary
5
History of Hospital Quality Data Reporting
2005 - 8th Scope of
Work (SOW)
RHQDAPU
2008 – 9th SOW
RHQDAPU /
HOPQDRP
2011 and Beyond10th SOW HIQRP/
HOPQDRP/VBP
• 10 Inpatient Measures
• 27 Inpatient Measures
• 7 Outpatient Measures
• 57 Inpatient Measures
(includes HCAHPS,
Mortality, Readmission,
structural measures,
etc.)
• 22 Outpatient Measures
(13 abstracted, 2
structural, 7 claimsbased)
6
3
History of Hospital Quality Data Reporting
Payments
Hospitals not reporting receive reduced payments from
CMS during the next fiscal year
7
Value-Based Purchasing
Historic change in how Medicare pays healthcare providers
and facilities
Change from “pay for reporting” to “pay for performance”
(P4P)
• Improve clinical quality and encourage patient-centered care
• Reduce adverse events and improve patient safety
• Reduce unnecessary readmissions
• Generate better processes of care which will also result in
better financial outcomes
• Make performance results transparent to and useable by
consumers
8
4
VBP - Hospitals
Payments start with discharges beginning October 1, 2012,
for CMS FY 2013
• Baseline period 7/1/2009 – 3/31/2010
• P4P period 7/1/2011 – 3/31/2012
Payments start with discharges beginning October 1, 2013,
for CMS FY 2014
• Baseline period 4/1/2010 – 12/31/2010
• P4P period 4/1/12 – 12/31/12
9
Financial Effect on Hospitals
P4P payments will be funded for FY 2013 by reducing
Medicare DRG payments by 1% in FY 2013. Then, DRG
payments will decrease to fund the incentive payments as
follows:
• 1.25% in FY 2014
• 1.5% in FY 2015
• 1.75% in FY 2016
• 2% in FY 2017
CMS anticipates that hospitals’ P4P will range from
0.0236% to 1.817%* in FY 2013
*Source: http://www.healthindustrywashingtonwatch.com/articles/regulatory-developments/hhsdevelopments/other-cms-developments/
10
5
VBPs Roadmap Through CMS Fiscal Years
2005
2007
Hospitals
RHQDAPU
begin
begins
submitting
expanding
quality data
total
(RHQDAPU- number of
Core
measures
Measures)
Failure to
meet the
requirement
is 0.4% of
APU
2009
HIQRP
Failure to
meet the
requirement
is 2% APU
2013
2014
VBP DRG
VBP
payments
Measure
reduced by
Set
1% to
Expands
hospitals
DRG
VBP allows
payments
hospitals to
reduced
earn this
by 1.25%
money back
HIQRP
through P4P
continues
HIQRP
continues
Failure to
meet the
reporting
requirement is
2% APU
2017
VBP
continues
DRG
payments
reduced
by 2%
HIQRP
continues
11
VBP – Scoring Process of Care Measures
(FY 2013 and 2014)
Acute Myocardial Infarction (AMI):
• AMI-7a: Fibrinolytic Therapy Received Within 30 Minutes of
Hospital Arrival
• AMI-8a: Primary PCI Received Within 90 Minutes of Hospital
Arrival
Suggested processes for improvement:
– Transmission of ECGs from ambulance to ED/cath lab
– Interventional cardiologist on call
– Comprehensive fibrinolytic administration “kit” in the ED
12
6
VBP – Scoring Process of Care Measures
(FY 2013 and 2014)
Heart Failure (HF):
• HF-1: Discharge Instructions
Suggested processes for improvement
– “One source of truth” medication reconciliation record
– Physician documentation of medications the patient is to take after
discharge
– Written list of medications given to patient/caregiver
13
VBP – Scoring Process of Care Measures
(FY 2013 and 2014) continued
Pneumonia (PN):
• PN-3b: Blood Cultures Performed in the Emergency
Department Prior to Initial Antibiotic Received in Hospital
• PN-6: Initial Antibiotic Selection for Community-Acquired
Pneumonia (CAP) in Immunocompetent Patient
Suggested processes for improvement
– Clarification that Blood Cultures do not have to be performed
– Physician preprinted pathways/order sets for CAP
– Stock recommended antibiotics in the ED
» Review every six months (changes in Specification Manual)
14
7
VBP – Scoring Process of Care Measures
(FY 2013 and 2014) continued
Surgical Care Improvement Project (SCIP)
• SCIP-Inf-1: Prophylactic Antibiotic (ABX) 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 (48 hours if cardiac surgery)
Suggested processes for improvement
– Preprinted physician order sets(update every 6 months)
– Designate responsibility for recommended ABX preoperatively to
anesthesiologist/anesthetist
– Automatic ABX post-op
15
VBP – Scoring Process of Care Measures
(FY 2013 and 2014) continued
Surgical Care Improvement Project (SCIP) continued
• SCIP-Inf-4: Cardiac Surgery Patients with Controlled 6AM
Postoperative Serum Glucose
• SCIP-Card-2: Surgery Patients on a Beta Blocker Prior to
Arrival That Received a Beta Blocker During the Perioperative
Period
Suggested processes for improvement
– Medical staff approved glucose control protocol
– Designate responsibility for beta blocker administration
– Preprinted pre-operative and post-operative physician order sets
16
8
VBP – Scoring Process of Care Measures
(FY 2013 and 2014) continued
Surgical Care Improvement Project (SCIP) continued
• 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 to 24 Hours After Surgery
Suggested processes for improvement
– Medical staff approved VTE prophylaxis protocols/preprinted physician
order sets by type of surgical procedure
– Improved documentation of mechanical VTE prophylaxis initiation
17
HCAHPS
Short-term, acute care hospitals
• Excludes pediatric, psychiatric, and specialty hospitals
Eligible patients
• Adult
• Medical, surgical, or maternity care
• Overnight stay or longer
• Alive at discharge
• Excludes hospice discharge, prisoner, foreign address, “nopublicity” patients, and patients discharged to nursing homes
and skilled nursing facilities
9
Objectives of HCAHPS
Standardized survey for meaningful comparisons across
hospitals for public reporting
Increased hospital accountability and incentives for quality
improvement
Enhanced public accountability
VBP Scoring - HCAHPS
One composite score from “eight dimensions”
• Nurse Communication
• Doctor Communication
• Cleanliness and Quietness
• Responsiveness of Hospital Staff
• Pain Management
• Communication about Medications
• Discharge Information
• Overall Rating
Note: A dimension is an aggregate measure
20
10
Improvement in HCAHPS Measures
(March 2008 to March 2009)
Significant improvement in 8 of 9 measures (p<0.01).
Exception was Doctor Communication (p=0.25)
Magnitude of improvement was relatively uniform across
items
Total improvement did not vary significantly by hospital size,
region, or ownership
(Improvement in HCAHPS Scores over the First Two Years of Public Reporting [See Elliott et
al.,“Hospital survey shows improvements in patient experience.” Health Affairs 2010
Nov;29(11):2061-7] http://www.hcahpsonline.org/trainingmaterials.aspx)
Observations on Most Improved Measures
Improvement seen in concrete, actionable domains
• E.g., Quietness and Discharge Information
These items may have been early targets of quality improvement
efforts
Improvement also seen in more diffuse domains
• E.g., Nurse Communication and Staff Responsiveness
May reflect staffing changes
(Improvement in HCAHPS Scores over the First Two Years of Public Reporting [See Elliott et
al., “Hospital survey shows improvements in patient experience.”Health Affairs 2010
Nov;29(11):2061-7] http://www.hcahpsonline.org/trainingmaterials.aspx)
11
Observations on Least Improved Measures
Less improvement seen in overall patient impressions (e.g.,
Would Recommend the Hospital). This domain not included
in VBP
• Improving overall patient impressions may take more time
• May consider reputational factors
Previous research suggests that performance on physician-
related measures (e.g., Doctor Communication) can be
difficult to change
(Improvement in HCAHPS Scores over the First Two Years of Public Reporting [See Elliott et
al., “Hospital survey shows improvements in patient experience.”Health Affairs 2010
Nov;29(11):2061-7] http://www.hcahpsonline.org/trainingmaterials.aspx)
Improvements May Continue and Even Accelerate
in the Future
Incentives for improvement could become even stronger
with VBP
Hospitals now have access to comparative information on
HCAHPS performance
Hospitals have had more time for QI projects
(Improvement in HCAHPS Scores over the First Two Years of Public Reporting [See Elliott et
al.,“Hospital survey shows improvements in patient experience.”Health Affairs 2010
Nov;29(11):2061-7] http://www.hcahpsonline.org/trainingmaterials.aspx)
12
Nurse Communication
Listen carefully to you
Treat you with courtesy/respect
Explain things understandably
Introduction of all caregivers entering patient
room
Use patient name, not room number, “honey”,
Suggested
Interventions
“sweetie”
Consistent rounding
Educate staff on listening tools to help listen
more effectively
Strengthen unit teamwork
Doctor Communication
Listen carefully to you
Treat you with courtesy/respect
Explain things understandably
Introduction of physicians, residents, PAs having
patient contact
Suggested
Interventions
Use patient name, not room number, “honey”,
“sweetie”
Allow patient/caregiver to ask questions
Tell patient what you plan to do during this visit
13
Cleanliness And Quietness
Room and bathroom kept clean
Quiet around room at night
Develop responses to patient concerns regarding
noise, especially at night
Suggested
Interventions
Involve environmental services front line staff in
understanding HCAHPS scoring for hospital
payment
Provide “hot line” for reporting unclean room
Responsiveness of Hospital Staff
Receive help going to the bathroom as soon as it was
wanted
Get help as soon as it was wanted—call light
Develop responses for those answering call
Suggested
Interventions
lights
Patient use phones for calling nurse caring for
them
14
Pain Management
Did hospital staff do everything they could to help you with
your pain?
Pain well controlled during your stay
Patient use phones for calling nurse caring for
Suggested
Interventions
them
Have all staff inquire about level of pain when
interacting with the patient
Communication About Medications
Before giving a new medication, staff should:
• Explain what the new medicine is
• Describe possible side effects in a way the patient can
understand
Maintain accurate Medication Reconciliation
documentation
Use both generic and brand names on discharge
Suggested
Interventions
form to avoid any confusion with home meds
Staff should understand it is crucial to take the
time to be sure patients can answer “always” to
the medication questions on HCAHPS
Involve pharmacists in multidisciplinary patient
rounds and discussion
15
Discharge Information
Receive information in writing about symptoms to look for at
home
Talk about help the patient would need in the home
Post-discharge phone call
Suggested
Interventions
Involve all caregivers in the home
Recognize health literacy
Use Teach-back method to ascertain knowledge
Overall Rating
Patients rank hospital stay on a scale of 0 – 10
Evaluate scores on an on-going basis to develop
strategies to improve areas of weakness
Suggested
Interventions
– Involve discharge patients in focus groups
Use best practices for onboarding front line
employees on the importance of patient
experience scores
16
VBP Scoring – The Basics
Process of Care Measures Score (Q3 2011 – Q1 2012) will
be the greater of the following scores
• Achievement Score
• Improvement Score
HCAHPS will be the greater of the Achievement/
Improvement Scores + Consistency Score
33
VBP Scoring – The Basics continued
Process of Care Measures (70%)
+
=
HCAHPS Score (30%)
Total Performance Score, which
determines your P4P payment
34
17
VBP Worksheet
Let’s review a simulated hospital report
35
VBP FY 2014
Mortality Outcome Measures
Acute Myocardial Infarction (AMI) 30-Day Mortality Rate
Performance Standard Achievable threshold - 84.8082%
• Heart Failure (HF) 30-Day Mortality Rate
Performance Standard Achievable threshold - 88.6109%
• Pneumonia (PN) 30-Day Mortality Rate
Performance Standard Achievable threshold - 88.1795%
– Suggested processes for improvement
Chart review of last admission to identify opportunities for
improvement
36
18
Readmission Payment (Not VBP)
FY 2013 Medicare DRG payments for all discharges will be
reduced based on avoidable readmissions for three
conditions (up to 1% total Medicare payment)
• Acute Myocardial Infarction, Pneumonia, and Heart Failure
– Suggested processes for improvement
Chart review of last admission to identify opportunities for
improvement: e.g. appropriate discharge planning, discharge
instructions to patient, patient/caregiver engagement, follow-up
appointment with physician within 10 days of discharge
37
Readmission Payment (Not VBP) continued
FY 2015
Medicare will increase the number of conditions that result
in reduced payments for avoidable readmissions
• Chronic Obstructive Pulmonary Disease (COPD)
• Bypass Surgery (CABG)
• Coronary Angioplasty
• Vascular procedures are likely
38
19
Medicare Spending Per Beneficiary (MSPB)
Measure
By measuring cost of care through MSPB, CMS hopes to
increase the transparency of care for consumers and
recognize hospitals that are involved in the provision of
high-quality care at lower cost to Medicare.
MSPB assesses Medicare Part A and Part B payments for
services provided to a Medicare beneficiary during a
spending-per-beneficiary episode
• from three days prior to an inpatient hospital admission
through 30 days after discharge.
Payments are price-standardized and risk-adjusted to
remove sources of variation not directly related to hospitals'
decisions to utilize care.
Source: QualityNet
Medicare Spending Per Beneficiary (MSPB)
Measure continued
For questions regarding the information or
calculations in the MSPB Hospital-Specific Reports,
contact Acumen at the following e-mail address:
[email protected]
Source: QualityNet
20
VBP Fiscal Years ahead
Number of Measures Will Continue to Expand
Hospital-Acquired
Conditions (HAC)
Healthcare-Acquired
Infections (HAI)
Nursing Sensitive
Measures
Medicare Spending
per Beneficiary
Financial Impact for Hospitals
In FY 2013 Potential Hospital Liability
• HIQRP Payment Model (2% APU)
• VBP Payment Model (1% DRG reduction)
• Readmission Penalty (up to 1% total Medicare payment)
42
21
History of Physician Quality Data Reporting
Physician Offices
2007
Physician Offices
2012 10th SOW
Physician Offices
- Near Future
Physician Offices
2017
• EHR deployment
begins
• Voluntary Physician
Quality Reporting
Systems (PQRS)
• 1.5% incentive
payment of their
total estimated
allowed charges for
Medicare Part B
Physician Fee
Schedule
• Voluntary PQRS
Expands
• 0.5% incentive
payment of their
total estimated
allowed charges for
Medicare Part B
Physician Fee
Schedule
• PQRS continues to
expand
• 2015: 1.5% penalty
for failure to report
PQRS (2% in 2016)
• VBP starts in 2015
• VBP for all
physicians by 2017
43
The Future
Roadmap is clear
• P4P is here
Will expand across all providers of care (SNF, LTCH, HHA,
physician offices, etc)
Information Technology – Meaningful use – Best Practice
Validation of data
44
22
CLABSI Validation
45
HIP Validation Chart Submission
HIP Validation Chart Submission
Maximum three charts for each project for a total of 12
charts
New additions beginning with January 1, 2012 discharges
• ED and Immunizations
Number of charts increases by six (new total is 18)
• New CLABSI validation – three additional charts
Beginning validation Q3 2011, the time to submit validation
charts to CDAC decreases to 30 days
46
23
CLABSI Validation for FY 2014
For FY 2014 payment based on validation Q4 2011 – Q3 2012:
Hospitals will be selected May – June 2012
Annual Payment Update (APU) will only use Q1, Q2, Q3
2012 for CLABSI
47
CLABSI Candidate CLABSI Case-Finding
Methodology
Basic Criteria for CLABSI Case
ICU patient
Positive blood culture result (one or more)
Presence of a central venous catheter in the patient at the
time of, or within 48 hours before, onset of the infection
48
24
CLABSI Responsibility: Validation Support
Contractor (TBD)
Two-step selection process
Step one – Identify candidate events
• List sent to CMS by sample hospitals
ICU
Bloodstream infection (positive blood culture results)
– A likely pathogen found at least once
– Common skin commensal found in two or more positive blood cultures
drawn on separate occasions
Central Venous Catheter
Step two – Randomly select up to three candidate events
49
CLABSI Responsibility: Validation Support
Contractor (TBD) continued
If no CLABSIs are identified:
Three additional charts will be reassigned to the other
topics
50
25
CLABSI Responsibilities: Hospital
Hospital
Maintain a hospital contact
Give information and updates to HQSI
Contact must be an active My QualityNet user
Use IPledge to complete updates
51
CLABSI Responsibilities: Hospital continued
Provide list of positive blood cultures for ICU patients with
CVC to CMS Validation Support Contractor
Submit list quarterly, prior to actual clinical submission
deadlines, beginning with Q1 2012 discharges
Clinical
Submission Deadlines
List Due
Dates
August 15
August 1
November 15
November 1
February 15
February 1
May 15
May 1
Send CDAC copies of requested charts within 30 days
52
26
CLABSI Responsibility: CDAC
CLABSI Records Abstraction
CDAC requests copies of records from hospitals
Abstracts copy of hospital charts
• On a weekly basis, sends CLABSI abstraction data to
Validation Support Contractor
• On a weekly basis, sends normal validation results to the
warehouse
CLABSI Scoring: Validation Support Contractor
Scoring CLABSI Records
Produces agreement statistics – compares CLABSI
indicator file from CDC and CLABSI abstraction data from
CDAC
• When mismatch occurs, collaborates with CDC to adjudicate
54
27
CLABSI Scoring
CMS contractor validation coordinator compares CDAC’s
CLABSI infection status to the hospital’s event data
reported to NHSN for the quarter
For each medical record reviewed, a match occurs only if
the CMS contractor validation coordinator determines
agreement between the CMS contractor’s determination of
infection status and the infection status reported to NHSN
Possible 1/1 match for each record
• Mismatch would be scored 0/1
55
CLABSI Validation
Hospital Receives Overall Validation Decision
Score ≥75% of combined CLABSI and non-CLABSI
measures passes validation
Score <75% combined CLABSI and non-CLABSI measures
fails
• Hospital accepts outcome or appeals
If appeal, send appeal to HQSI who will review for all topics
except CLABSI
– If appeal is CLABSI, HQSI will forward to CLABSI Validation Support
Contractor
56
28
CLABSI Validation Appeal
Appeal response determined by Validation Support Contractor
and CDC:
Collaborate to adjudicate appeal
Send post appeal validation results to warehouse
57
QUESTIONS
29
`