Value-Based Purchasing

Value-Based PurchasingPowerHour April 2012Goals of PowerHourWhat is Value Based Purchasing

Review of the FFY 2013 VBP programData SourcesData Collection TimeframesMeasuresVBP Scoring MethodologyUnresolved Issues

Review of the FFY 2014 Domains

GHA VBP Reports

QuestionsWhat is Value-Based Purchasing?Implementation is required by the Affordable Care Act of 2010

Begins October 1, 2012 (FY 2013)

Redistributes inpatient payments

Budget neutral

What is Value-Based Purchasing?Transition hospitals from P4R to P4P under MedicareMedicare payment incentives/penalties to promoteAchievement of high quality careImprovement in care qualityAdjusts Medicare IPPS payments starting Oct. 1, 2012 (FFY 2013) based on quality performance

Review of VBPWho is Subject to the Hospital VBP Program? Acute care hospitals participating in the IQR ProgramExcluded hospitals:CAHsSpecialty hospitals (psychiatric, rehabilitation, childrens, cancer, LTCH)Hospitals cited for immediate jeopardyHospitals not participating in the IQR programHospitals with small numbers of applicable measures/cases as determined by CMS

Review of VBPWhats at Stake Under VBP?Program is self-funded by hospital contributions

Contribution based on Medicare FFS payments*1.0% reduction in FFY 2013Reduction increased by 0.25% each year2.0% reduction for FFY 2017 and beyondVBP performance determines P4P amount Budget-neutralRedistributiveBest performers win, others break even or loseVBP payments are netted against contributions

Review of VBPVBPs Quality MeasuresLaw requirementsMust be measures reported under IQR programMeasures must be publicly available Hospital Compare for at least one year prior to use in VBPCMS must publish measures and national performance standards for each measure 60 days before start of the performance measurement periodMust categorize measures (domains)

CMS discretionWhat measures to include/exclude

Review of the FFY 2013 VBP programData Source:Analysis utilizes hospital quality measure database provide by CMS on Hospital Compare WebsiteWill assess hospital Quality performance using two domains:Process of Care (70%)Patient Experience (30%)

Review of the FFY 2013 VBP programData Collection Timeframes:Baseline PeriodUsed to establish performance standards and to measure performance improvementJuly 1, 2009 March 31, 2010 (9 months)Data already reported to CMSPerformance PeriodUsed to measure/calculate VBP scoresJuly 1, 2011 March 31, 2012 (9 months)Just started and will continue into Spring

Applies to both Process and HCAHPS measures

VBP DomainsFFY 2013 ProgramProposed FFY 2014 Program *Domain Measure Count Domain Weight Measure Count Domain Weight Process of Care 1270%1320% HCAHPS (Patient Experience of Care)1 (using 8 HCAHPS dimensions) 30%1 (using 8 HCAHPS dimensions) 30% Outcomes (mortality/AHRQ/HACs) N/AN/A1330% Efficiency N/AN/A120% Other TBDN/AN/AN/AN/ATotals13 (2 domains)100%28 (4 domains)100%* Only some aspects of 2014 program are finalProcess Domain Measures FFY 2013 ProgramAcute Myocardial InfarctionAMI-7aFibrinolytic Therapy Received Within 30 Minutes of Hospital ArrivalAMI-8aPrimary Percutaneous Coronary Intervention (PCI) Received Within 90 Minutes of Hospital ArrivalHeart FailureHF-1Discharge InstructionsPneumoniaPN-3bBlood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in HospitalPN-6Initial Antibiotic Selection for CAP in Immunocompetent PatientSurgeries (as measured by Surgical Care Improvement (SCIP) measures)SCIP-Card-2Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative PeriodSCIP-VTE-1Surgery Patients with Recommended Venous Thromboembolism Prophylaxis OrderedSCIP-VTE-2Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After SurgeryHealthcare-Associated Infections (as measured by SCIP measures)SCIP-Inf-1Prophylactic Antibiotic Received Within One Hour Prior to Surgical IncisionSCIP-Inf-2Prophylactic Antibiotic Selection for Surgical PatientsSCIP-Inf-3Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End TimeSCIP-Inf-4Cardiac Surgery Patients with Controlled 6 AM Postoperative Serum GlucoseHCAHPs Domain Measures FFY 2013 ProgramPatient Satisfaction SurveyHCAHPSEight 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 HospitalModifications to HCAHPS on Hospital Compare:cleanliness and quietness combinedwould you recommend this hospital?- not includedNational BenchmarksHighest achievement levelsAverage performance score for the top 10% of all hospitalsNational ThresholdsMinimum achievement levelsMedian performance score for all hospitalsEstablished from baseline period dataVary by measure:VBP National Performance Standards FFY 2013 ProgramMeasureBenchmarkThresholdAMI-7a - Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival92%65%SCIP-Inf-1 - Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision100%97%VBP Scoring MethodologyHospital performance for each measure is compared to national performance standardsPoints are awarded for:Achieving high quality goalsImproving towards high quality goalsMaximum = 10 points / measurePoints scored for each measure are used to calculate domain scoresDomain scores are weighted to calculate a Total Performance ScoreVBP Scoring FFY 2013 ProgramVBP Scoring MethodologyProgram is budget neutral. This means:All monies contributed to the VBP must be paid out within the same periodWill be funded with 1% of hospitals Medicare IPPS operating dollars for 2013Total payments into and out of the pool must be equal201320142015201620171%1.25%1.5%1.75%2.0% thereafterVBP Scoring MethodologyScoringHospitals must have sufficient data for calculating achievement points in order for an individual measures score to be included in the overall domain scoreWhen there are both achievement and improvement points for a measure, the higher of the two is taken as final points for that measure

VBP Scoring MethodologyA hospitals Total Performance Score (TPS) will be calculated:Calculating Overall Domain Score (all domains): For each domain, the overall domain score will be the sum of the final points earned for the domain divided by the maximum possible points for all useable measures in the domainDomain Weighting and Calculating a TPS: 2013: Process Measures 70% Patient Outcomes 30%VBP Scoring MethodologyCMS has established the following formulas to calculate VBP points:

Process Score Calculation FFY 2013 VBP Program

HCAHPS Score Calculations FFY 2013 Program

Concerns with Process and HCAHPS MeasuresProcess measuresThe full range of Achievement is not possibleMinimum case size is 10Small hospitals may fall in and out of the program from year to yearCMS exclusion method for topped out measuresHCAHPS measuresBias based on region, hospital size and typeWeight is too highResulting scores are not evenly distributed, skewed lowValue Based Purchasing 2014New Measures/Domains for the FFY 2014 VBP ProgramFFY 2013 ProgramProposed FFY 2014 Program *Domain Measure Count Domain Weight Measure Count Domain Weight Process of Care 1270%1320% HCAHPS (Patient Experience of Care)1 (using 8 HCAHPS dimensions) 30%1 (using 8 HCAHPS dimensions) 30% Outcomes (mortality/AHRQ/HACs) N/AN/A1330% Efficiency N/AN/A120% Other TBDN/AN/AN/AN/ATotals13 (2 domains)100%28 (4 domains)100%* Only some aspects of 2014 program are finalOutcomes Domain Measures FFY 2014 ProgramMortality MeasuresMort-30-AMIAMI 30-day mortality (Medicare patients)Mort-30-HFHF 30-day mortality (Medicare patients)Mort-30-PNPN 30-day mortality (Medicare patients)AHRQ Composite MeasuresAHRQComplication/patient safety for selected indicators (composite)AHRQMortality for selected medical conditions (composite)HAC MeasuresHACs 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 Control25Proposed Efficiency Domain Measures FFY 2014Medicare Spending per BeneficiaryACA requires use of efficiency measures in FFY 2014 or thereafterMust include total Part A and Part B spending per beneficiaryMust include Medicare spending per beneficiary adjusted for age, sex, race, severity, and other factors as determined by the SecretaryCMS is also considering measures of hospital internal efficiencyConcerns with Proposed Efficiency MeasureDoes proposal satisfy ACA mandate for a measure of spending per beneficiary?Holds hospitals accountable for all providers practice patternsShould consider future IOM report and proposal for Medicare bundling demonstrationsMethodology cannot be replicatedNo-one can check/audit CMS calculationsIndustry does not have access to the dataData Collection Timeframes FFY 2014 ProgramProcess of Care and Patient Experience of Care Domains *Baseline Period: April 1, 2010 through December 31, 2010 (9-months)Performance Period: April 1, 2012 through December 31, 2012 (9-months)

Outcomes Domain Mortality MeasuresBaseline Period: July 1, 2009 through June 30, 2010 (12-months)Performance Period: July 1, 2011 through June 30, 2012 (12-months)

Outcomes Domain AHRQ composite and HAC Measures *Baseline Period: March 3, 2010 through September 30, 2010 (7-months)Performance Period: March 3, 2012 through September 30, 2012 (7-months)

Efficiency Domain *Baseline Period: May 15, 2010 through 90 days prior to February 14, 2011 (9-months)Performance Period: May 15, 2012 through February 14, 2013 (9-months)* ProposedGHA ReportsGHA ReportsGHA reports are based off of HANYs VBP reports

Finding your GHA ReportGo to www.gha.orgClick on Quality and HealthClick on Hospital DataClick on the click here buttonYou will need your GHA log-in and passwordOnly PRC (Peer Review Contacts) can view the reports and CEOs

Questions?