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Anatomy & Physiology of CMS Pay for Performance JO ANN BROOKS PHD, RN, FAAN, FCCP SYSTEM VP SAFETY & QUALITY OCTOBER 15, 2015 12/4/2015 1
Anatomy & Physiology of CMS Pay for Performance
JO ANN BROOKS PHD, RN, FAAN, FCCP
SYSTEM VP SAFETY & QUALITY
OCTOBER 15, 2015
12/4/2015 1
Connecting the Dots….
Value Equation=
QUALITY
COST
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Hospital Inpatient Quality Reporting Program
Pay for Reporting Pay for Performance
Hospital IQR Program
Hospital Compare -
Value Based Purchasing Measures
Healthcare Reform Quality Programs
Affordable Care Act (ACA 2010)
National Quality Strategy
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Better Care
Affordable Care
Healthy People &
Communities
ACA Initiatives to Improve Care
Improve the overall quality & efficiency of health care •Hospital Value-Based Purchasing
•Hospital Readmissions Reduction Program
•Hospital-Acquired Conditions Reduction Program
• Physician Quality Reporting System
• Physician Value-Based Modifier
• Physician Compare Website
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Value Based Purchasing
Value-Based Purchasing
•Started October 1, 2012 (start of federal fiscal year 2013)
•Quality incentive program built on the Hospital Inpatient Quality Reporting (IQR) measure reporting infrastructure
•Both a bonus or penalty program depending on hospital performance
•Impacts base operating DRG payment $$$
•Budget neutral winners & losers
Terms
Measures—cannot be selected for VBP until they have been posted on Hospital Compare for one year
Domain—construct or grouping of measures
Domain weighting—each domain is weighted to calculate Total Performance Score
Total Performance Score—assessed on measures that comprise domains
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CMS VBP Program 2013
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Domains of Value
Clinical Processes
of Care
Experience Of Care
Clinical Processes Of Care
70% 30%
Results impacted Medicare Payment Starting October 1, 2012
CMS VBP Program 2014
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Domains of Value
Clinical Processes
of Care
Experience
of Care
Outcomes
45% 30% 25%
Results impacted Medicare Payment Starting October 1, 2013
CMS VBP Program 2015
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Domains of Value
Clinical
Processes
Pt
Experience
Outcomes Efficiency
MSPB
20% 30% 30% 20%
Results impacted Medicare Payment Starting October 1, 2014
CMS VBP Program 2016
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Domains of Value
Clinical
Processes
Pt
Experience
Outcomes Efficiency
MSPB
10% 25% 40% 25%
Results impact Medicare Payment Starting October 1, 2015
CMS VBP Program 2017
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Domains of Value
Clinical
Processes
Outcomes MSPB
5% 25% 25% 25%
Results impact Medicare Payment Starting October 1, 2016
Pt.
Experience
Safety
20%
VBP FY2017
In VBP FY2017 “performance period”
VBP FY2017 will close 12/31/15
Data analyzed through first 6-9 months of 2016; finalized by October 1, 2016
Penalty or reward that a hospital receives will take effect October 1, 2016 (start of federal fiscal year 2017)– why it is called VBP FY2017
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CMS VBP Program 2017
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Domains of Value
Clinical
Processes
Outcomes MSPB
5% 25% 25% 25%
Results impact Medicare Payment Starting October 1, 2016
Pt.
Experiencee
Safety
20%
Value Based Purchasing FY2017 Clinical process of care (3 measures)
◦AMI Fibrinolytic agent within 30 min arrival
◦ IMM Influenza immunization
◦PC-01 Elective delivery prior to 39 completed weeks of gestation
Value Based Purchasing FY2017
Patient Experience √ Communication with nurses
√ Communication with doctors
√ Responsiveness of hospital staff
√ Pain management
√ Communication about medicines
√ Cleanliness and quietness of environment
√ Discharge information
√ Overall rating
Value Based Purchasing FY2017
Outcomes (3 measures) ◦30 day mortality, AMI ◦30 day mortality, heart failure ◦30 day mortality, pneumonia
Value Based Purchasing FY2017 Safety
◦ AHRQ PSI-90 composite
◦ Central line asso. blood stream infection (CLABSI)
◦ Catheter asso. urinary tract infection (CAUTI)
◦ Surgical site infection (SSI) colon, abd hysterectomy
◦ C. difficile
◦ Methicillin resistant staph aureus (MRSA)
PSI-90 Composite (all rates)
PSI-08 Postop hip fracture
PSI-12 Postop PE/DVT
PSI-03 Pressure ulcer
PSI-07 Central venous CR blood stream infection
PSI-13 Postop sepsis
PSI-16 Iatrogenic pneumothorax
PSI-14 Postop wound dehiscence
PSI-15 Accidental puncture & laceration
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Value Based Purchasing FY2017 Efficiency--Medicare spending per beneficiary (MSPB) ◦For Medicare beneficiaries who are hospitalized
◦Defined as spending 3 days prior, the hospitalization & 30 days post discharge
Measures
Each domain has a baseline & performance period ◦Performance period determines achievement
◦Difference between baseline & performance period determines improvement
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FY 2017 VBP—The Clock is Ticking…
2010 2011 2012 2013 2014 2015
BASELINE
PERFORMANCE
Clinical
Process, HAI
Clinical
Process, HAI
Outcomes
Safety PSI
Outcomes
Safety PSI
Patient Exp
Patient Exp
Efficiency
Effic.
Points/Scoring
Each hospital receives two scores on each measure ◦Achievement Points
◦ Improvement Points
◦The final score for a measure is the higher of the two
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The Process
Measures Points Domain
Score
Domain
Weighting TPS $$$
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Hospital VBP Program--Basics
Funded by a reduction from participating hospitals’ Diagnosis-Related Group (DRG) payments for each year of program
Amount of money at risk:
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2013 2014 2015 2016 2017 2018
1.0% 1.25% 1.50% 1.75% 2.0% 2.0%
How the Program Works
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FY2017 2.00%
AT RISK
Results of VBP
Overview of VBP Scoring Methodology
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
VB
P P
aym
en
t P
erc
en
tage
Total Performance Score
Break Even Point
Changes in VBP FY2018
Remove two Process Measures ◦ Influenza immunization
◦ Fibrinolytic therapy within 30 min for AMI
Move perinatal care measure to Safety Domain and delete Process Domain
Patient Experience Domain ◦ Add 3 item Care Transition Measures
FY2018 4 domains equally weighted—outcome, safety, patient experience, efficiency
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CMS VBP Program 2018
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Domains
Outcomes MSPB
25% 25% 25%
Results impact Medicare Payment Starting October 1, 2017
Safety
25%
Pt
Experience
Changes in VBP FY2019 and Beyond
FY2019 Start new process of reporting HAI data
FY2019 Include CAUTI and CLABSI in non-ICU areas
FY2021 New measure of hospital 30day all cause risk standardized mortality--COPD
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Hospital Readmission Reduction Program
Hospital Readmission Reduction Program
ACA—plan to save $8 billion dollars over 10 yrs.
Started with 3 diagnoses/conditions ◦ Acute myocardial infarction
◦ Heart failure
◦ Pneumonia
Penalty up to: ◦ 1% 2013
◦ 2% 2014
◦ 3% 2015 and beyond
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Hospital Readmission Reduction Program 2017
All cause readmission ◦ AMI ◦ HF ◦ PN ◦ COPD ◦ Elective Hip Arthroplasty ◦ Elective Knee Arthroplasty ◦ CABG (2017)
Three year rolling period July 2012-June 2015
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Hospital Readmission Reduction Program
Three year rolling period
FY2019
FY2020
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7/2012 2013 2014 6/2015 FY2017
7/2013 2014 2015 6/2016 FY2018
7/2014 2015 2016 6/2017
7/2015 2016 2017 6/2018
2016 Regulations
Expand measure cohort for pneumonia Include discharge diagnosis:
◦aspiration pneumonia ◦sepsis who also have a secondary diagnosis of pneumonia on admission
◦Will increase number of pts
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Hospital Acquired Conditions Program
Hospital Acquired Conditions Program
Is a penalty program
ACA – plan to save $3.2B over 10 years
Hospitals in the top quartile for HACs get 1% penalty (all Medicare dollars)
In first year of program 2015, 54% of academic health centers received a penalty
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Hospital Acquired Conditions 2017
DOMAIN 1 PSI 90 15%
PSI-08 Postop hip fracture
PSI-12 Postop PE/DVT
PSI-03 Pressure ulcer
PSI-07 Central venous CR blood stream infection
PSI-13 Postop sepsis
PSI-16 Iatrogenic pneumothorax
PSI-14 Postop wound dehiscence
PSI-15 Accidental puncture & laceration
July 2013 to June 2015
DOMAIN 2 HAI 85%
CLABSI
CAUTI
SSI Colon, abdominal hysterectomy
C. difficile
Meth resistant staph aureus
Jan 2014 to December 2015
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Domain Weighting (%) for HACs
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Percent of Base DRG Payments at Risk
Potential to Have
6% at Risk By 2017
FED FISCAL YEAR VBP READMISSIONS HAC* TOTAL
2013 1.00% 1.00% 2.00%
2014 1.25% 2.00% 3.25%
2015 1.50% 3.00% 1.00% 5.50%
2016 1.75% 3.00% 1.00% 5.75%
2017 2.00% 3.00% 1.00% 6.00%
*HAC is more than DRG base payment
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