Value-Based Purchasing

Transcription

1 Emerging Topics in Healthcare Reform Value-Based Purchasing Janssen Pharmaceuticals, Inc.

2 Value-Based Purchasing The Patient Protection and Affordable Care Act (ACA) established the Hospital Value-Based Purchasing (VBP) Program. VBP begins to shift the payment paradigm away from volume and toward incentives to hospitals to provide high-quality care. 1 By mandating that hospitals follow established best practices, the Centers for Medicare and Medicaid Services (CMS) hopes to drive better clinical outcomes and reduce the overall cost of care for Medicare beneficiaries. 2 Financial implications On October 1, 2012, Medicare began withholding 1% of hospitals reimbursements under the new VBP Program created by the healthcare law. 4 Over time, the amount withheld gradually increases 1 meaning that the rewards and risks inherent in the application of evidence-based medicine will grow as well. Schedule for VBP withholds 1 Value-based purchasing brings pay for performance to the hospital Institutions affected by VBP Most acute-care hospitals paid through Medicare s inpatient prospective payment system are subject to VBP. 1 The program does not apply to 1 : Acute-care hospitals without the volume to meet eligibility thresholds Mental health, rehabilitation, and children s hospitals; long-term acute-care facilities; and oncology centers How VBP works In federal fiscal year (FY) 2013,* CMS began withholding 1% of the base operating diagnosis-related group (DRG) payments made to hospitals. CMS redistributes this money to hospitals in the form of incentive payments for meeting minimum performance standards. 1 A hospital s incentive payment is based on its total performance score (TPS). Hospitals that perform above the median score might earn more in incentive payments than what they give up through withholds. Hospitals scoring below the median score can lose some or all of their withholds. 1,3 Some hospitals have begun to reap the benefits of providing high-quality care. Others have been penalized for not meeting performance standards. In FY 2013, Medicare 4 : Rewarded 1557 hospitals with higher base DRGs, the biggest being a 0.83% per-beneficiary increase Reduced payments to 1427 hospitals, the strongest penalty being a 0.90% base-rate DRG reduction As the withhold grows, the potential rewards and penalties can add up How hospitals are scored In FY 2013, quality was assessed through a scoring system that examined various clinical processes of care and dimensions of a patient s experience in the hospital (as recorded in the Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS] survey). Together, these two domains (clinical process and patient experience) form the basis of a hospital s TPS. 5 * October 1, 2012 September 30, Over time, two additional domains clinical outcomes and efficiency will be added, expanding the total number of measures from 20 in FY 2013 to 26 by FY

3 A Closer Look at VBP Selection of measures In FY 2013, VBP focused on 20 measures 5 : 12 clinical procedures with well-defined best practices proven to maximize clinical outcomes and 8 measures that gauged patients satisfaction with their treatment experience. The 12 clinical measures have been endorsed by the National Quality Forum, an organization representing healthcare providers, consumer groups, professional associations, purchasers, federal agencies, and research and quality organizations. 6,7 Hospitals are familiar with these measures, as they are among those in CMS s Hospital Inpatient Quality Reporting Program 8 The 8 satisfaction measures are among those in HCAHPS, the first national standardized survey of patients perspectives of care. CMS administers HCAHPS randomly to Medicare patients within 6 weeks of their hospital stay. Results are publicly reported, the intent being to motivate hospitals to improve quality of care 9 How measures are weighted In FY 2013, the 12 clinical procedures accounted for 70% of a hospital s score. 5 As measures and domains are added to VBP, however, the emphasis on clinical process declines. The HCAHPS survey consistently accounts for 30% of a hospital s TPS each year making HCAHPS an increasingly important factor in a hospital s VBP reimbursement. Domain weighting by fiscal year 5 A hospital s score on any given measure depends on whether it beats the threshold or the benchmark or falls below the threshold Threshold refers to the 50th percentile of hospital performance on this measure. Benchmark refers to the 95th percentile performance level. Several HCAHPS questions focus on communication and are intended to ensure that patients understand their medication regimens and discharge instructions. Clinical process of care Patient experience of care (HCAHPS) Outcomes Efficiency A hospital s performance period precedes the fiscal years in which incentive payments are made. A hospital s FY 2013 incentive payment, for instance, was based on its performance on FY 2013 measures in 2011 and A hospital s performance on VBP quality measures during calendar year 2013 will factor into its FY 2015 incentive payment. Adapted from Stratis Health Value-Based Purchasing 4 Fact Sheet, published under contract with CMS. 5 FY 2015 performance measures 5 Measure Threshold Benchmark Clinical Process of Care (Performance period: January 1 December 31, 2013) AMI patients given fibrinolytic medication within 30 minutes of arrival 80.00% 100% AMI patients given PCI within 90 minutes of arrival 95.34% 100% HF patients given discharge instructions 92.09% 100% Pneumonia patients whose initial ER blood culture preceded first hospital antibiotic dose 94.11% 100% Initial antibiotic selection for CAP in immunocompetent patient 97.78% 100% Prophylactic antibiotic received within 1 hour before surgical incision 97.17% 100% Prophylactic antibiotic selection for surgical patients consistent with recommendation 98.63% 100% Prophylactic antibiotics discontinued within 24 hours after surgery (cardiac surgery, 48 hours) 98.63% 100% Cardiac surgery patients with controlled 6:00 am postoperative serum glucose 97.49% 100% Urinary catheter removed postoperative Day 1 or % 99.76% Surgery patients on a beta blocker before arrival who received a beta blocker during the perioperative period Surgery patients who received appropriate VTE prophylaxis within 24 hours prior to or after surgery Patient Experience of Care (Performance period: January 1 December 31, 2013) 95.91% 100% 94.89% 99.99% Communication with nurses 76.56% 85.70% Communication with doctors 79.88% 88.79% How well caregivers explained patients medications 60.89% 71.85% How well caregivers explained discharge information 83.54% 89.72% Responsiveness of hospital staff 63.17% 79.06% How well caregivers managed patients pain 69.46% 78.17% Cleanliness and quietness 64.07% 78.90% Overall satisfaction with hospital 67.96% 83.44% Outcomes Measures (Performance period: October 1, 2012 June 30, 2013) 30-day mortality, AMI 84.78% 86.23% 30-day mortality, HF 88.15% 90.03% 30-day mortality, pneumonia 88.26% 90.41% AHRQ patient safety indicator composite a 45.17% 62.28% Central line associated blood stream infection b 43.70% 0.00% Efficiency (Performance period: May 1 December 31, 2013) Medicare spending per beneficiary a Measure period October 15, 2012 June 30, b Measure period February 1, 2013 December 31, Median spending across all hospitals Mean of lowest decile of spending across all hospitals Abbreviations: AMI = acute myocardial infarction; AHRQ = Agency for Healthcare Research and Quality; CAP = community-acquired pneumonia; ER = emergency room; HF = heart failure; PCI = percutaneous coronary interventions; VTE = venous thromboembolism.

4 VBP and Anticoagulation Therapy Relevant measures Several VBP measures are of particular relevance for patients who will require anticoagulation therapy while in the hospital and after discharge. A hospital s performance on these measures will influence its TPS and its incentive payment. Relevant process-of-care measure: Received VTE prophylaxis within 24 hours prior to or after surgery This measure tells how often patients having certain types of surgery received treatment to prevent blood clots in the period from 24 hours before surgery to 24 hours after surgery. 10 Relevant experience of care (HCAHPS) measures: Communication with nurses Communication with doctors Communication about medication Discharge instructions These measures focus on how well patients understood their care and instructions for continuing their care after discharge from the hospital. 10 Role of modern anticoagulation therapy For patients undergoing total hip replacement or total knee replacement, American College of Chest Physicians (ACCP) guidelines recommend initiation of VTE prophylaxis 12 or more hours prior to surgery and continuing postsurgical thrombotic prophylaxis for a minimum of 10 to 14 days. 11 The ACCP recommends that healthcare professionals involved in the management of anticoagulant therapy employ a comprehensive, systematic approach that includes 11 : Patient education Ongoing follow-up and monitoring Clear, effective communication with patients This means that a patient s preferences and ability to follow a therapeutic protocol should be factored into VTE prevention strategies. Some patients, for instance, may place a value on avoiding the inconvenience of daily injections. 11 Adherence factors may include frequency of dosing or patients ability to understand a complicated regimen that includes the need for monitoring. Novel oral anticoagulants offer potential ease-of-use benefits over warfarin and the ability to tailor therapy to patients needs. 12 Postsurgical patient adherence with anticoagulation therapy is vital because adherence is an important factor in both VTE prevention and a hospital s HCAHPS scores. Successful transitions of care from the hospital to rehabilitation or the home can reduce the potential for readmission. 13 Let Janssen Partner With You Your Janssen representative can offer support tools to help hospital staff, case managers, and postacute providers provide high-quality care, ensure smooth transitions across care settings, and help patients understand their self-care to improve outcomes. Ask your representative for: Resources for case managers: Information on managing transitions of care and helping patients stay adherent to therapy Postoperative follow-up care brochures Resources for hospital discharge planners: Discharge planning checklist Fact sheets on VTE prevention and postdischarge risk prevention Resources for postacute providers: Flow chart on managing VTE risk Resources for patients: Materials explaining postoperative follow-up and care Patient self-care is an important part of ensuring positive outcomes. Sometimes, patients need help understanding their medications, managing side effects, and sticking to a medication regimen. CarePath by Janssen can help patients by providing: Product information Medication reminders Access and reimbursement assistance programs Means for providing feedback to physicians Tips on recovery and rehabilitation Visit JanssenCareCoordination.com and CarePathbyJanssen.com for more information 6 7

5 References 1. Centers for Medicare and Medicaid Services. Frequently Asked Questions Hospital Value-Based Purchasing Program. Downloads/FY-2013-Program-Frequently-Asked-Questions-about-Hospital-VBP pdf. Updated March 9, Accessed January 15, Department of Health and Human Services. Administration Implements Affordable Care Act Provision to Improve Care, Lower Costs. Published April 29, Updated May 7, Accessed January 15, Rau J. Are Medicare s new quality incentives large enough to change hospital behavior? Kaiser Health News website. Published September 4, Updated September 5, Accessed January 15, Rau J. Medicare discloses hospitals bonuses, penalties based on quality. Kaiser Health News website. Published December 20, Accessed January 15, Stratis Health. Is Your Hospital Ready for Value-Based Purchasing? Stratis Health website. documents/vbp_factsheet.pdf. Accessed January 15, Department of Health and Human Services. Administration Implements New Health Reform Provision to Improve Care Quality, Lower Costs. Published April 29, Accessed January 15, Hospital Consumer Assessment of Healthcare Providers and Systems. HCAHPS Fact Sheet. Hospital Care Quality Information from the Consumer Perspective website. Sheet%20May% pdf. Published May Accessed January 15, Centers for Medicare and Medicaid Services. CMS Issues Final Rule for First Year of Hospital Value-Based Purchasing Program. Published April 29, Accessed February 15, Centers for Medicare and Medicaid Services. HCAHPS: Patients Perspectives of Care Survey. Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html. Updated May 14, Accessed January 15, Department of Health and Human Services. Hospital Value-Based Purchasing: Measure Explanations. Published April 29, Accessed January 15, Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schünemann HJ; for the American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 suppl):7s 47S. 12. Eikelboom JW, Weitz JI. New anticoagulants. Circulation. 2010;121: Jack BW, Chetty VK, Anthony D, et al. A re-engineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3): Janssen Pharmaceuticals, Inc May 2013 K02X13106A Janssen Pharmaceuticals, Inc.