Value - Based Purchasing

Value - Based Purchasing

Presented by Kyle Bain

For Kemal ErkanHCM-401 Course

Presentation Outline

Definition & Factors

Critical Quality Measures

Calculations

Incentive Percentage

Changing the Behavior

Value - Based Purchasing



Calculations




Definition A Payment Reform under which Hospitals and

other Providers are provided Bonuses based upon their performance against Quality Measures

Ranking and “Achievement Score” is based on Comparison and Improvements to a “Base-Line”

Factors (aka Domains)1. Clinical Process of Care2. “Hospital Consumer Assessment of Healthcare

Providers and Systems (HCAHPS) Survey”Changing the Behavior

Value - Based Purchasing Definition & Factors


Calculations



Critical Quality MeasuresBreakdown

“Clinical Process of Care” - 5 Specific Conditions1. Acute Myocardial Infarction2. Heart Failure3. Pneumonia4. Surgeries5. Healthcare Associated Infections

“HCAHPS Survey” (Patient Survey)

1 Year Performance Period First year based on ¾ of the fiscal year




Calculations



Calculations

CMS will Reduce Hospitals’ base Diagnosis Related Group (DRG) payments by 1% in 2013 2% in 2017 and beyond

Redistribution of about $850 Million Hospitals in the Highest Percentile receive

the Largest Incentive▪ Top 25% = Incentive▪ Bottom 25% = Penalty


Visual Factors

CQM Survey

1 Survey

Last Years Base Line

Comparison to other Hospitals

2 3 4 5

Partial Score

Final Score



Calculations



Incentive PercentageBreakdown

Incentives Top 95th = .3% to .6% Bonus Top 90th = .3% to .4% Bonus Top 75th = .1% to .3% Bonus

Middle 50th – No Bonus or Penalty

As required by law, all scores will be published on the “Hospital Compare” website Hospital’s Domain-Specific Score Hospital’s Condition Specific Score Total Performance Score


Value- Based Purchasing

Questions?


Medicare Shared Savings Program

Healthcare Reform & the Transformation of Reimbursement

Payments will be increasingly linked to performance

“Performance risk” will be increasingly transitioned to providers

Payers and consumers will become accountable; and a greater value will be placed on maintaining individual health

Accountable Care Organizations ACOs are groups of doctors, hospitals,

and other health care providers, who come together voluntarily to give coordinated high quality care to the patients they serve

When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will have the opportunity to share in the savings it achieves


The Affordable Care Act, signed by President Obama in March of 2010, requires CMS to establish a shared savings program in order to:▪ Facilitate coordination and cooperation

among providers▪ Improve quality of care▪ Reduce unnecessary costs


The Shared Savings Program is designed to improve outcomes & increase value of care by:▪ Promoting accountability for the care of

Medicare FFS beneficiaries▪ Requiring coordinated care for all services

provided under Medicare FFS▪ Encouraging investment in

infrastructure and redesigned care processes

Requirements

Form a legal structure to receive and distribute shared savings to participating providers

3-year agreement Have a minimum of 5,000 Medicare

beneficiaries Report Quality Measures

United Medical ACO Organizational Structure

Timeline

CMS will begin accepting applications for the Shared Savings Program on January 1st, 2012

First ACO agreements start on April 1st, 2012 and July 1st, 2012 First performance year will be 18 or 21

months

Quality Measures

Quality Assessments will be calculated based on 33 measures from the following 4 domains; 1. Patient Experience2. Care Coordination and Patient Safety3. Preventive Health4. Caring for at-risk populations

Payment Models

One-Sided Model Share up to 50% of any savings they

achieve compared to target spending Two-Sided Model

Share up to 60% of the savings, but will also be accountable for losses

Issues

Upfront Expenses Final rule did create the “Advanced Payment

Model” that provides upfront funds. This money would be recovered from any future shared savings achieved by the team of providers

Legal Issues Stark & Anti-Kickback

HHS estimates that ACOs could save Medicare up to $940 million in the first 4 years Far less than 1% of Medicare spending during that

time period

Shared Savings Program

Questions?

Documents

Value - Based Purchasing