1 / 76

June 23, 2008

The Hospital’s Bottom Line in an Era of Value-Based Purchasing A webinar for Philips customers that tells you what Medicare is planning and what it means for you…. June 23, 2008. The Hospital’s Bottom Line in an Era of Value-Based Purchasing. Presenters:.

jennis
Download Presentation

June 23, 2008

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. The Hospital’s Bottom Line in an Era of Value-Based Purchasing A webinar for Philips customers that tells you what Medicare is planning and what it means for you… June 23, 2008

  2. The Hospital’s Bottom Linein an Era of Value-Based Purchasing Presenters: Thomas Valuck, MD, JD, Medical Officer & Senior Adviser, Center for Medicare Management, Centers for Medicare and Medicaid Services, Washington, DC Ann Edwards, Director, Health Industries Advisory Practice, PricewaterhouseCoopers, Hartford, CT Moderator: Laurel Sweeney,Senior Director, Reimbursement and Legislative Affairs, Philips Healthcare, Andover, MA

  3. Centers for Medicare & Medicaid ServicesCMS’ Progress Toward Implementing Value-Based Purchasing Thomas B. Valuck, MD, JD Medical Officer & Senior Adviser Center for Medicare Management Procurement Sensitive

  4. Presentation Overview • CMS’ Value-Based Purchasing (VBP) Principles • CMS’ VBP Demonstrations and Pilots • CMS’ VBP Programs • Value-Driven Health Care • Horizon Scanning and Opportunities for Participation Procurement Sensitive

  5. CMS’ Quality Improvement Roadmap • Vision: The right care for every person every time • Make care: • Safe • Effective • Efficient • Patient-centered • Timely • Equitable Procurement Sensitive

  6. CMS’ Quality Improvement Roadmap • Strategies • Work through partnerships • Measure quality and report comparative results • Value-Based Purchasing: improve quality and avoid unnecessary costs • Encourage adoption of effective health information technology • Promote innovation and the evidence base for effective use of technology Procurement Sensitive

  7. What Does VBP Mean to CMS? • Transforming Medicare from a passive payer to an active purchaser of higher quality, more efficient health care • Tools and initiatives for promoting better quality, while avoiding unnecessary costs • Tools: measurement, payment incentives, public reporting, conditions of participation, coverage policy, QIO program • Initiatives: pay for reporting, pay for performance, gainsharing, competitive bidding, coverage decisions, direct provider support Procurement Sensitive

  8. Why VBP? • Improve Quality • Quality improvement opportunity • Wennberg’s Dartmouth Atlas on variation in care • McGlynn’s NEJM findings on lack of evidence-based care • IOM’s Crossing the Quality Chasm findings • Avoid Unnecessary Costs • Medicare’s various fee-for-service fee schedules and prospective payment systems are based on resource consumption and quantity of care, NOT quality or unnecessary costs avoided • Payment systems’ incentives are not aligned Procurement Sensitive

  9. Practice Variation

  10. Practice Variation

  11. Why VBP? • Medicare Solvency and Beneficiary Impact • Expenditures up from $219 billion in 2000 to a projected $486 billion in 2009 • Part A Trust Fund • Excess of expenditures over tax income in 2007 • Projected to be depleted by 2019 • Part B Trust Fund • Expenditures increasing 11% per year over the last 6 years • Medicare premiums, deductibles, and cost-sharing are projected to consume 28% of the average beneficiaries’ Social Security check in 2010 Procurement Sensitive

  12. Workers per Medicare Beneficiary Source: OACT CMS and SSA

  13. Under Current Law, Medicare Will Place An Unprecedented Strain on the Federal Budget Percentage of GDP Source: 2008 Trustees Report

  14. Support for VBP • President’s Budget • FYs 2006-09 • Congressional Interest in P4P and Other Value-Based Purchasing Tools • BIPA, MMA, DRA, TRCHA, MMSEA • MedPAC Reports to Congress • P4P recommendations related to quality, efficiency, health information technology, and payment reform • IOM Reports • P4P recommendations in To Err Is Human and Crossing the Quality Chasm • Report, Rewarding Provider Performance: Aligning Incentives in Medicare • Private Sector • Private health plans • Employer coalitions Procurement Sensitive

  15. VBP Demonstrations and Pilots • Premier Hospital Quality Incentive Demonstration • Physician Group Practice Demonstration • Medicare Care Management Performance Demonstration • Nursing Home Value-Based Purchasing Demonstration • Home Health Pay-for-Performance Demonstration • ESRD Bundled Payment Demonstration • ESRD Disease Management Demonstration Procurement Sensitive

  16. VBP Demonstrations and Pilots • Medicare Health Support Pilots • Care Management for High-Cost Beneficiaries Demonstration • Medicare Healthcare Quality Demonstration • Gainsharing Demonstrations • Accountable Care Episode (ACE) Demonstration • Better Quality Information (BQI) Pilots • Electronic Health Records (EHR) Demonstration • Medical Home Demonstration Procurement Sensitive

  17. Premier Hospital Quality Incentive Demonstration

  18. VBP Programs • Hospital Quality Initiative: Inpatient & Outpatient • Hospital VBP Plan & Report to Congress • Hospital-Acquired Conditions & Present on Admission Indicator • Physician Voluntary Reporting Program • Physician Quality Reporting Initiative • Physician Resource Use • Home Health Care Pay for Reporting • Medicaid Procurement Sensitive

  19. VBP Initiatives Hospital-Acquired Conditions and Present on Admission Indicator Reporting Procurement Sensitive

  20. The HAC Problem • The IOM estimated in 1999 that as many as 98,000 Americans die each year as a result of medical errors • Total national costs of these errors estimated at $17-29 billion IOM: To Err is Human: Building a Safer Health System, November 1999. Available at: http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf. Procurement Sensitive

  21. The HAC Problem • In 2000, CDC estimated that hospital-acquired infections add nearly $5 billion to U.S. health care costs annually Centers for Disease Control and Prevention: Press Release, March 2000. Available at: http://www.cdc.gov/od/oc/media/pressrel/r2k0306b.htm. • A 2007 study found that, in 2002, 1.7 million hospital-acquired infections were associated with 99,000 deaths Klevens et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports. March-April 2007. Volume 122. Procurement Sensitive

  22. The HAC Problem • A 2007 Leapfrog Group survey of 1,256 hospitals found that 87% of those hospitals do not consistently follow recommendations to prevent many of the most common hospital-acquired infections 2007 Leapfrog Group Hospital Survey. The Leapfrog Group 2007. Available at: http://www.leapfroggroup.org/media/file/Leapfrog_hospital_acquired_ infections_release.pdf Procurement Sensitive

  23. Statutory Authority: DRA Section 5001(c) • Beginning October 1, 2007, IPPS hospitals were required to submit data on their claims for payment indicating whether diagnoses were present on admission (POA) • Beginning October 1, 2008, CMS cannot assign a case to a higher DRG based on the occurrence of one of the selected conditions, if that condition was acquired during the hospitalization Procurement Sensitive

  24. Statutory Selection Criteria • CMS must select conditions that are: • High cost, high volume, or both • Assigned to a higher paying DRG when present as a secondary diagnosis • Reasonably preventable through the application of evidence-based guidelines Procurement Sensitive

  25. HACs Selected During IPPS FY 2008 Rulemaking • Foreign object retained after surgery • Air embolism • Blood incompatibility • Catheter-associated urinary tract infection • Vascular catheter-associated infection • Surgical site infection – mediastinitis after CABG • Pressure ulcers • Falls – specific trauma codes Procurement Sensitive

  26. Candidate HACs • Surgical site infections following specific elective procedures • Staphylococcus aureus septicemia • Clostridium difficile-associated disease (CDAD) • Ventilator-associated pneumonia (VAP) • Deep vein thrombosis (DVT) / pulmonary embolism (PE) • Legionnaires’ Disease • Iatrogenic pneumothorax • Delirium • Extreme glycemic aberrancies Procurement Sensitive

  27. Methicillin-Resistant Staph. aureus (MRSA) • Directly addressed, as MRSA could be the cause of any of the selected infectious conditions • Presence of MRSA as a colonizing bacterium does not constitute an HAC • Presence of MRSA is not a CC or MCC Procurement Sensitive

  28. POA Indicator General Requirements • Present on admission is defined as present at the time the order for inpatient admission occurs • Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered present on admission • Phased implementation Procurement Sensitive

  29. POA Indicator General Requirements • POA indicator is assigned to • Principal diagnosis • Secondary diagnoses • External cause of injury codes (Medicare requires reporting only if E-code is reported as an additional diagnosis) Procurement Sensitive

  30. POA Indicator Reporting Options

  31. POA Indicator ReportingIPPS FY 2009 Proposed Rule • POA indicator • CMS is proposing to pay the CC/MCC for HACs that are coded as “Y” & “W” • CMS is proposing to NOT pay the CC/MCC for HACs that are coded “N” & “U” Procurement Sensitive

  32. POA Indicator Reporting Requires Accurate Documentation “ A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.” ICD-9-CM Official Guidelines for Coding and Reporting Procurement Sensitive

  33. HAC & POAEnhancement & Future Issues • CMS seeks public comment on enhancements to the HAC payment provision in the IPPS FY 2008 proposed rule • Risk adjustment • Rates of HACs for VBP • Uses of POA information • Adoption of ICD-10 • Expansion of the IPPS HAC payment provision to other settings • Relationship to NQF’s Serious Reportable Adverse Events Procurement Sensitive

  34. Relationship of HACs to NQF’s “Never Events” • In 2002, NQF created a list of 27 Serious Reportable Adverse Events, which was expanded to 28 events in 2006 • Of the HACs selected during IPPS FY 2008 rulemaking, 7 are on NQF’s list • Of the HACs candidates under consideration during IPPS FY 2009 rulemaking, 1 overlaps with NQF’s events Procurement Sensitive

  35. Relationship of HACs to NQF’s “Never Events” • NQF’s selection criteria for Serious Reportable Adverse Events • Unambiguous: clearly identifiable and measurable • Usually preventable: recognizing that some events are not always avoidable • Serious: resulting in death or loss of a body part, disability, or more transient loss of a body function • Indicative of a problem in a health care facility’s safety systems • Important for public credibility or public accountability Procurement Sensitive

  36. Combating Never Events • HAC payment provision • Conditions of Participation • VBP Plan—measurement, financial incentives, and public reporting • Coverage policy • Quality Improvement Organization (QIO) 8th and 9th Scopes of Work • The President’s FY 2009 Budget proposal • Prohibit hospitals from billing Medicare for never events • Require hospitals to report occurrence of these events or receive a reduced annual payment update Procurement Sensitive

  37. Opportunities for HAC & POA Involvement • IPPS Rulemaking • IPPS FY 2009 proposed rule on display April 14, 2008 • 60 day comment period ended on June 13, 2008 • IPPS FY 2009 final rule released in August 2008 • Updates to the CMS HAC & POA website: www.cms.hhs.gov/HospitalAcqCond/ • Hospital Open Door Forums • Hospital Listserv Messages Procurement Sensitive

  38. VBP Programs Hospital Value-Based Purchasing Procurement Sensitive

  39. Hospital Quality Initiative • MMA Section 501(b) • Payment differential of 0.4% for reporting (hospital pay for reporting) • FYs 2005-07 • Starter set of 10 measures • High participation rate (>98%) for small incentive • Public reporting through CMS’ Hospital Compare website Procurement Sensitive

  40. Hospital Quality Initiative • DRA Section 5001(a) • Payment differential of 2% for reporting (hospital P4R) • FYs 2007- “subsequent years” • Expanded measure set, based on IOM’s December 2005 Performance Measures Report • Expanded measures publicly reported through CMS’ Hospital Compare website • DRA Section 5001(b) • Report for hospital VBP beginning with FY 2009 • Report must consider: quality and cost measure development and refinement, data infrastructure, payment methodology, and public reporting Procurement Sensitive

  41. Hospital VBP Workgroup Tasks & Timeline 2006 Oct Dec 2007 Jan 17 Apr 12 May June • Environmental Scan • Issues Paper • Listening Session #1 for Stakeholder Input on Issues Paper • Options Paper • Listening Session #2 for Input on Hospital VBP Options Paper • Final Design • Final Report, Including Design, Process, and Environmental Scan • Report Submitted to Congress Nov 21

  42. Performance Model Overview • Hospitals submit data for all VBP measures that apply • CMS determines each hospital’s performance score on each measure: higher of 0 - 10 points on attainment or improvement • For each hospital, CMS aggregates scores across all measures within a domain (e.g., clinical process-of-care measures, HCAHPS) • CMS weights and combines each hospital’s domain scores to determine the hospital’s Total Performance Score • CMS translates each hospital’s Total Performance Score into an incentive payment using an exchange function Procurement Sensitive

  43. .47 .87 Benchmark Attainment Threshold 4 7 1 2 3 6 5 8 9 Attainment Range Earning Clinical Process of Care Points: Example Measure: PN Pneumococcal Vaccination Hospital I Attainment Range Score Score baseline • .21 .70 performance • • • • • • • • • • • • • • • • • • • 9 2 3 4 5 6 7 8 1 Improvement Range Hospital I Earns: 6 points for attainment 7 points for improvement Hospital I Score: maximum of attainment or improvement = 7 points on this measure

  44. Calculation of Clinical Process of Care Performance Score • Total Earned Points = • Sum of points earned across all reported measures • Total Possible Points = • Number of measures reported by hospital x 10 • Clinical Process of Care Performance Score = • Total Earned Points / Total Possible Points x 100 Procurement Sensitive

  45. Earning HCAHPS Points: Example Dimension: Doctor Communication 50thBaseline Percentile 95thBaseline Percentile Attainment Threshold Benchmark Attainment Range Score Hospital I Score • 42nd baseline 63rd • performance 1 2 3 4 5 6 7 8 9 10 Attainment Range 1 2 3 4 5 6 7 8 9 Improvement Range Hospital I Earns: 3 points for attainment 4 points for improvement Hospital I Score: maximum of attainment or improvement = 4 points on this measure

More Related