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: cmsmspbmeasure@acumenllc.com 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