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Mandatory Medicare Delivery System Reform Inpatient Readmissions Implemented October 1, 2012 (FFY 2013) Reduces Medicare reimbursement by $7 billion / 10 years nationwide; $1 to NYS. Inpatient Value-Based Purchasing Budget neutral; redistributive within PPS system. Health Care- Acquired Conditions Implemented October 1, 2015 (FFY 2014) Reduced Medicare inpatient hospital reimbursement by $ 1.4 billion / 10 years nationwide. EHR Meaningful Use (ARRA) Medicare payment penalties assessed against eligible hospitals and physicians that fail to be meaningful users by October 1, 2014 (FFY 2015). FFY 2013 FFY 2015
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Medicare Hospital Value-Based Purchasing Proposed Rule Reports
and Analysis
February 15, 2011 Mandatory Medicare Delivery System Reform
Inpatient Readmissions Implemented October 1, 2012 (FFY 2013)
Reduces Medicare reimbursement by $7 billion / 10 years nationwide;
$1 to NYS. Inpatient Value-Based Purchasing Budget neutral;
redistributive within PPS system. Health Care- Acquired Conditions
Implemented October 1, 2015 (FFY 2014) Reduced Medicare inpatient
hospital reimbursement by $ 1.4 billion / 10 years nationwide. EHR
Meaningful Use (ARRA) Medicare payment penalties assessed against
eligible hospitals and physicians that fail to be meaningful users
by October 1, 2014 (FFY 2015). FFY 2013 FFY 2015 Voluntary Medicare
Delivery System Reform
2012 2013 Centers for Medicare and Medicaid Innovation (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. Shared
Savings / ACO Program Implemented January 1, 2012. $5 billion in
shared savings nationwide over 10 years. Three-year, primary care
coordinating programs for 5,000+ Medicare FFS beneficiaries.
Acute/Post-Acute Bundling Pilot Implemented January 1, 2013. Budget
neutral. Five-year pilots for episode of care (3 days prior to
inpatient stay, through 30 days post discharge). Value-Based
Purchasing Expansion to Other Payment Settings
Implement VBP pilot programs for inpatient rehabilitation,
inpatient psychiatric, LTC, cancer hospitals, and hospice Implement
VBP for inpatient hospitals Submit plans for Ambulatory Surgical
Centers VBP (Jan 1, 2011) Submit plans for SNF and Home Health VBP
(Oct. 1, 2011/FFY 2012) FY 2011 2006 2012 2013 2015 2016 2017 2005
FY Text above the bar- Expansion and Escalation- continue to see
new measures added quickly- Outpt and CAHs likely in future- these
measures will likely be derivative of inpatient measures (e.g.-
heart failure pt in ER not admitted- ASA and ACE) CMS is
transitioning from a pay for reporting to a pay for performance
strategy. It has selected 17 initial measures, from the current
list of hospital quality reporting measures that may be used in a
value based purchasing, or pay for performance, program. Not on
here : Metrics will grow rapidly to include efficiency,
coordination, patient safety, outcomes, emergency care efficiency,
nurse-sensitive and disease-specific measures, structural measures
as well as outpatient measures. CMS focus on leadership- hospital
self assessment tool NYS hospitals welcome to volunteer to pilot
test over summer Move to text beneath the bar,CMS is implementing
its physician quality reporting program.This is currently a
voluntary program that provides a modest incentive for clinicians
in outpatient settings to report on a series of quality
measures.Some of these measures overlap with those included in the
hospital reporting program, and thus offer an opportunity for
aligning physician and hospital interests.IF the MD program follows
the model used for other entities, we expect it will ultimately
become mandatory and include a public reporting component. This
slide represents when CMS quality reporting will impact
payment.Associated data collection begins with cases at least one
year prior. EG. Hospitals are now collecting 27 measures, payment
will be impacted in 08. CMS is developing a hospital
self-assessment tool with the University of Iowa to assess the
actions of hospital executives and Board leadership in promoting
quality and patient safety and linking the results with CMS quality
data. HANYS has been invited to pilot test the instrument and
provide input throughout the process. CMS is developing a more
intense interest in this area and there is some discussion that CMS
may fold this concept into pay for performance or 9th Scope of Work
activities. No decisions have been made in this regard. Implement
physician VBP modifier for specific physicians and physician groups
Physician payment modifier applied to all physicians, groups and
other eligible practitioners Establish a CAH and small volume rural
hospital VBP demonstration 4 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 Value-Based
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, childrens,
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 years 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 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 (reflects quality data from Dec Hospital
Compare release --most recent release) Oct. Nov. Dec. Jan. Feb.
Mar. Apr. May June July Aug. Sept. FFY 2009 2008 2009 FFY 2010 2010
FFY 2011 2011 FFY 2012 2012 FFY 2013 Proposed Performance Period
(will reflect quality data from Dec Hospital Compare release)
Release of Final Rule (by law, VBP performance standards must be
published 60-days prior to start of performance period) Medicare
IPPS payment adjusted based on hospital performance CMS Value-Based
Purchasing Proposed Rule Proposed Quality Measures Proposed VBP
Quality Measures
FFY 2013 Clinical Process of Care Domain 17 process measures
Patient Experience of Care Domain HCAHPS Survey (8 HCAHPS
dimensions) FFY 2014 All of the above plus: Outcome of Care Domain
Mortality, AHRQ measures, HACS 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 FFY 2014 HCAHPS PROCESS OUTCOME
SCORE VBP 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 AMI-8a Primary Percutaneous Coronary Intervention (PCI)
Received Within 90 Minutes of Hospital 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 PN-3b Blood Cultures
Performed in the Emergency Department Prior to Initial Antibiotic
Received 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) SCIP-Card-2
Surgery Patients on a Beta Blocker Prior to Arrival That Received a
Beta Blocker During the Perioperative Period 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 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 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 caremeasures 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 is also
considering measures of hospital internal efficiency 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 July 1, 2011 to March 31, 2012 A hospitals
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) Baseline
Period 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 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 - performance to receive
maximum points for a measure Average score for hospitals in the top
decile in base period 10 points if at benchmark or above
Improvement Range Based on comparison to hospitals own performance
in base period 0 to 9 points Example of Process Domain
Scoring
Hospital score in performance period: Hospital score in base
period: From CMS Proposed Rule Sample Hospital VBP Process Domain
Score Calculation Sample Hospital VBP Process Score Calculation
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 - performance
to receive maximum points for a measure 95th percentile ranking of
scores in the base period 10 points if at benchmark or above
Improvement Range Based on comparison to hospitals own performance
in base period 0 to 9 points Example of Patient Satisfaction Domain
Scoring
Hospital score in performance period: 64th percentile Hospital
score in base period: nd percentile From CMS Proposed Rule HCAHPS
Consistency Points
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 HCAHPS Consistency Examples Sample Hospital
VBP HCAHPS Calculation Sample Hospital VBP HCAHPS Calculation
Exclusions Critical access hospitals
Specialty hospitals (psychiatric, rehabilitation, childrens,
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 Calculation of VBP
Score
Determine points for each measure Higher of achievement or
improvement Combine each measures points into domain scores Sum of
points earned divided by total possible points for domain Combine
domain scores Weight clinical process by 70% Weight patient
experience by 30% Determine VBP distribution 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 CMS
Proposed Payout Function
Linear function distributes fundsacross 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 Issues for Comments HCAHPS Domain Process
Domain Subregulatory Process
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 your
State Association or:
Contact Information: Contact your State Association or: Gloria
Kupferman (518) Kevin Krawiecki (518)