The role of nurses in new incentive-based hospital payment models

Olga Yakusheva, Ph.D.

University of Michigan

Outline

• Conceptual framework• Value-Based Purchasing (VBP) Program

– Targeted outcomes– Financial implications

• VBP-targeted outcomes, nurse sensitive outcomes

• What can be done to improve hospital performance through nursing?

Introduction

• Value and healthcare reform; role of hospitals• Center for Medicaid and Medicare Services (CMS):

– Value-Based Purchasing (VBP) program– Hospital-Acquired Conditions (HAC) reduction program– Hospital Readmissions Reduction Program

*Reimbursement tied to outcomes and costs*

• Many of the outcomes are endorsed by National Quality Forum (NQF) as nursing-sensitive

Conceptual Framework

Intersection of NDNQI indicators and CMS-targeted outcomes

=

Conceptual core of the nurses’ influence on hospital’s performance ratings under CMS’s incentive-based programs

National Database of Nursing Quality Indicators (NDNQI)

Structure ProcessNursing-sensitiveOutcomes

Targeted by

CMS

Nurse-sensitive

& targeted by CMS

Value-Based Purchasing (VBP) Program

• Incentive-based payments• Hospital VBP Performance Score:

– Process of care, – Patient Experience of Care, – Outcome and Safety, – Efficiency and Cost Reduction

Process of Care DomainFY

2014FY

2015FY

2016FY*

2017FY*

2018

Domain Weight 45% 20% 10% 10%

AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival

X X X X

AMI-8a Primary PCI Received Within 90 Minutes of Hospital Arrival

X X X

IMM-2 Influenza Immunization X X

HF-1 Discharge Instructions X X

PN-3b Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital

X X

PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient

X X X

SCIP-Inf-1 Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision

X X

Perinatal Care: Elective Delivery < 39 completed weeks of gestation

X X*

Patient Experience of Care DomainFY

2014FY

2015FY

2016FY

2017FY

2018Domain Weight 30% 30% 25% 25%

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) 8 dimensions:

Communication with NursesCommunication with Doctors

Responsiveness of Hospital Staff Pain Management

Communication About Medicines Cleanliness and Quietness of Hospital Environment

Discharge InformationOverall Rating of Hospital

X X X X X

3-Item Care Transition MeasurePatient/family preferences taken into account in post-discharge

planningPatient had good understanding of self-management after leaving

hospitalPatient had clear understanding of medications after leaving hospital

X

Patient Outcomes and Safety Domain

FY2014

FY2015

FY2016

FY2017

FY2018

Domain Weight 25% 30% 40% 40%

MORT-30-AMI

Acute Myocardial Infarction (AMI) 30-Day Mortality Rate

X X X X X

MORT-30-HF

Heart Failure (HF) 30-Day Mortality Rate

X X X X X

MORT-30-PN

Pneumonia (PN) 30-Day Mortality Rate X X X X X PSI 90 Patient safety for selected indicators

(composite) X X X X

CLABSI Central Line-Associated Blood Stream Infection

X X X X

CAUTI Catheter-Associated Urinary Tract Infection

X X X

SSI Surgical Site Infection (Colon, Abdominal Hysterectomy)

X X X

Efficiency and Cost Reduction Domain

FY2014

FY2015

FY2016

FY2017

FY2018

Domain Weight 0% 30% 25% 25%

Medicare Spending per Beneficiary X X X X

Relative VBP Domain Weights over Time

FY2014 FY2015 FY2016 FY20170%

10%20%30%40%50%60%70%80%90%

100%

Efficiency and Cost Reduc-tionOutcomes and Safety Patient ExperiencesProcesses of Care

Hospital VBP Performance Score

• Points assigned for each measure depending on:– How hospital performed on the outcome relative to

benchmark– How much hospital improved relative to benchmark

in closing the performance gap

• Hospitals that have better outcomes OR improved more from baseline score higher

(Source)

Financial implications• Hospitals’ base operating DRG Medicare

payments are reduced by 1.5%• Performance score linearly transformed to

incentive payment ranging from 0 to 2 x initial payment reduction (1.5%)

• Effective incentive range (-1.5% to +1.5%), or 3%– FY2015: reduction - 1.5%, range - 3%– FY2016: reduction - 1.75%, range - 3.5%– FY2017: reduction - 2%, range - 4%

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97

-1.50%

-1.00%

-0.50%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

VBP Payment Adjustment

VBP Payment adjustments

010

020

030

0N

um

ber

of H

osp

itals

-1 0 1 2VBP_payment_2015

Distribution of VBP payment adjustments, FY2015

Intersection of NDNQI and VBP

• Four NDNQI nurse-sensitive outcomes intersect with VBP-targeted outcomes:– Central-Line Associated Blood Stream

Infections (CLABSI)– Catheter-Associated Urinary Tract Infections

(CAUTI)– Pressure Ulcer (PU) prevalence– Ventilator-Associated Pneumonia (VAP)

CLABSINDNQI VBP Program

CLABSI Central Line-Associated Blood Stream Infection Rates

FY 2015: 6% (direct measure, Outcome and Patient Safety Domain) + 0.55% (indirect as part of PSI 90, Outcome and Patient Safety Domain) = 6.55% of total VBP Performance Score

FY 2016: 5.71% (direct measure, Outcome and Patient Safety Domain) + 0.52% (indirect as part of PSI 90, Outcome and Patient Safety Domain) = 6.23% of total VBP Performance Score

CAUTINDNQI VBP Program

CAUTI Catheter-Associated Urinary Tract Infection Rates

FY 2015: 6% (direct measure, Outcome and Patient Safety Domain) of total VBP Performance Score FY 2016: 5.71% (direct measure, Outcome and Patient Safety Domain) of total VBP Performance Score

PU prevalenceNDNQI VBP Program

Pressure Ulcer Incidence Rates from Electronic Health Records

FY 2015: 0.55% (indirect as part of PSI 90, the Outcome and Patient Safety Domain) of total VBP Performance Score

FY 2016: 0.52% (indirect as part of PSI 90, the Outcome and Patient Safety Domain) of total VBP Performance Score

VAP rateNDNQI indicator VBP Program

Ventilator-Associated Pneumonia Rates Related to the outcome measures of “30-day pneumonia

mortality rate” (Outcome and Patient Safety Domain) accounting for 6% of total VBP Performance Score in FY 2015 and 5.71% of total VBP Performance Score in FY 2016

What outcomes should be targeted by nurses?

• CAUTI/ CLABSI together account for over 12% of the hospital’s performance score – primary focus

• PU prevalence, VAP are also important

Where are we now?

• HAC-prevention bundles =>– Up to 41% CLABSI – 6-14% CAUTI– Up to 40% VAP

• However, adoption and adherence are low:– CLABSI 87-97% adoption, 37-71% adherence – CAUTI 27-68% adoption, 6-27% adherence– VAP 69-91% adoption, 45-55% adherence

• Improving adoption and adherence is key

What can we do to improve?• Educating all physician and nursing staff on evidence-

based practices• Empowering nurses to ensure compliance with check lists• Providing feedback on infection rates at the nursing unit

level• Shared ownership of infection rates between infection

prevention specialists and nurses• Physician and nurse champions to facilitate nurse

interceptions of checklist breach

(Source)

Importance of nursing structure

• Structure: – staffing, skill mix, education =>

• Improved outcomes of 30-day mortality, pressure ulcers, readmissions, lower costs of care

– work environment (collaboration between physicians and nurses, opportunities to participate in hospital- and unit-level decisions, and continuing education opportunities)

• Reduced mortality, readmissions, lower costs, lower failure to rescue

Conclusion

Structure:- staffing, skill mix,

and education- Improved nurse

work environment

Process: - increased

adoption/ adherence with HAC prevention bundles

Nursing-sensitiveOutcomes

Targeted by

CMS

CLABSICAUTI

PU VAP

National Database of Nursing Quality Indicators (NDNQI)

Formula for SuccessHigh-value provider of patient care

=

Focuses on outcomes-specific evidence-based nursing interventions +

Invests in training and education of nurses +

Committed to a positive nurse work environment