Value Based Purchasing and You

Transcription

1 Value Based Purchasing and You David Gourley, RRT, MHA, FAARC Director of Clinical Services and Risk Management Millennium Respiratory Services Whippany, New Jersey

2 Value Based Purchasing and You Overview of healthcare reform initiatives Healthcare inflation and Medicare spending Pay for Performance and Value Based Purchasing (VBP) Financial Implications of VBP VBP key elements Changes for 2016 and beyond Telehealth clinical initiatives Telehealth technology advances

3 Value Based Purchasing and You Medicare Modernization Act (MMA) of 2003: Institute of Medicine (IOM) commissioned to identify and prioritize options to align performance to payment in Medicare Supported Pay for Performance (P4P) Deficit Reduction Act (DRA) of 2005: Required HHS to develop a plan to implement Value Based Purchasing (VBP) beginning in 2009

4 Value Based Purchasing and You Medicare Improvements for Patients and Providers Act (MIPPA) of 2008: Required HHS develop transition plan for VBP for physicians and other professional services

5 Value Based Purchasing and You Patient Protection and Affordable Care Act Passed Senate on December 19, 2009 (60-39) Passed House of Representatives on March 21, 2010 ( ) Signed into law on March 23, 2010 by President Obama Value based purchasing final rule released on April 29, 2011 Additional measures added to VBP in 2013

6 Value Based Purchasing and You Goals of PPACA: Increase access Increase quality of healthcare outcomes Improve patient safety Eliminate duplication/waste Enhance care coordination Reduce rate of health care inflation to sustainable levels Every American will be affected: Greater accountability for patients and providers Improving quality/reducing costs will save lives and $$$

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9 Goals for VBP Initiatives Improve clinical quality Address problems of underuse, overuse, and misuse of services Encourage patient centered care Reduce adverse events and improve patient safety Avoid unnecessary costs in the delivery of care

10 Goals for VBP Initiatives (cont.) Stimulate investments in structural components and the re-engineering of care processes system-wide Make performance results transparent to and useable by consumers Avoid creating additional disparities in health care and work to reduce existing disparities

11 Evolving Health Care Delivery System TODAY Acute treatment Cost unaware Professional prerogative Inpatient Individual professional Traditional practice Patient passivity Volume-based TOMORROW Chronic disease mgmt. Cost-of-care focus Consumer responsive Outpatient Team Evidence-based practice Activated patients Value-based

12 CMS Quality-based Payment Reform Initiatives

13 CMS Quality-based Payment Reform Initiatives

14 VBP Timeline

15 Financial implications of VBP $2.1 billion at risk in all U. S. hospitals Average U. S. hospital: Mean: approximately $500,000 Minimum: approximately $100,000 Maximum: approximately $6 million Majority of hospitals will lose money Initial actions, to be followed by additional financial impact

16 VBP Challenge Fluid scope Initially combination of clinical, outcome, and satisfaction measures 2015 HAC and Patient Safety Indicators were added 2016 CAUTI and SSI added 2017 C Difficile and MRSA added Expanding and changing terrain Bandwagon effect with other payors

17 Inclusion in VBP General acute care hospitals Critical access hospitals excluded At least 10 cases per clinical measure At least 4 measures reported At least 100 HCAHPS surveys

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20 Clinical Processes of Care Measure ID AMI 7a PN-6 SCIP-Inf 2 SCIP-Inf 3 Clinical Process Measure Description Acute Myocardial Infarction (Heart Attack) Fibrinolytic Therapy received within 30 minutes of hospital arrival Pneumonia Initial antibiotic selection for CAP in immunocompetent patient Surgical Care Improvement Project Prophylactic antibiotic selection for surgical patients Prophylactic antibiotics discontinued within 24 hours after surgery end time SCIP-Inf 9 Urinary Catheter removed on post-op day 1 or 2 SCIP-Card 2 SCIP-VTE 2 Surgery patients on a beta blocker prior to arrival rec d in perioperative period Surgery patients who rec d appropriate VTE within 24 hrs prior to 24 hrs after

21 Domain Patient Experience of Care Dimension Nursing Communication Nurse courtesy and respect Nurses listen carefully Nurse explanations are clear Doctor Communication Doctor courtesy and respect Doctors listen carefully Doctor explanations are clear Responsiveness of Staff Staff helped with bathroom needs Call bell answered timely Pain Management Pain well controlled Staff helped patient with pain Communication about Medications Staff explained new medicines Staff clearly described side effects Discharge Information Staff discussed help needed after discharge Written symptom/health information provided Hospital environment Area around room quiet at night Room and bathroom kept clean Overall Rating Rate the hospital 0-10

22 Mortality Measures Measure ID MORT 30 AMI MORT 30 HF MORT 30 PN Mortality Measures Acute Myocardial Infarction 30-day mortality rate Heart Failure 30-day mortality rate Pneumonia 30-day mortality rate the 30-day mortality measures assess deaths that occur within 30 days after admission, which, depending on the length of stay, may occur postdischarge Specifications Manual for National Hospital Inpatient Quality Measures, Version 4.0; NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE, Measure Information Form, Measure Set: CMS Mortality Measures, Set Measure ID#: MORT-30-AMI.

23 Outcomes Measures Complications/Patient Safety for Selected Indicators PSI # 03 PSI # 06 PSI # 07 PSI # 08 PSI # 09 PSI # 10 PSI # 11 PSI # 12 PSI # 13 PSI # 14 PSI # 15 Pressure Ulcer Iatrogenic Pneumothorax Central Venous Catheter-related Bloodstream Infections Postop Hip Fracture Postop Hemorrhage or Hematoma Postop Physiologic and Metabolic Derangements Postop Respiratory Failure Postop PE or DVT Postop Sepsis Postop Wound Dehiscence Accidental Puncture or Laceration

24 Infection Measures CLABSI CAUTI SSI Colon SSI Abd. Hyster. CLABSI Measures and New Measures for 2016 Central Line Bloodstream Associated Infections Catheter-Associated Urinary Tract Infections Surgical Site Infection Colon Surgical Site Infection Abdominal Hysterectomy

25 Efficiency Measure MSPB-1 Efficiency Measure Medicare Spending Per Beneficiary As part of the VBP program, the Medicare Spending Per Beneficiary (MSPB) Measure assesses Medicare Part A and Part B payments for services provided to a Medicare beneficiary during an episode that spans from three days prior to an inpatient hospital admission through 30 days after discharge. The payments included are price-standardized and risk-adjusted. Price standardization removes sources of variation that are due to geographic payment differences. Risk adjustment accounts for variation due to patient health status. By measuring cost of care through this measure, 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.

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28 VBP Key Elements Zero sum game Withhold of baseline DRG payment across all patients Hospitals will lose reimbursement unless performance is at or above benchmarks Percentage of withhold earned back based on performance

29 Achievement vs. Improvement Achievement Points: Awarded by comparing a hospital s rates during the Performance Period with all hospitals rates from the Baseline Period Rate at or above the Benchmark: 10 points Rate less than the Achievement Threshold: 0 points Rate equal to or greater than the Achievement Threshold and less than the Benchmark: 1 10 points Improvement Points: Awarded by comparing a hospital s rates during the Performance Period to that their rates from the Baseline Period Rate at or above the Benchmark: 9 points Rate less than or equal to Baseline Period Rate: 0 points Rate between the Baseline Period Rate and the Benchmark: 0 9 points

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32 Redistribution CMS required to redistribute leftover funds Funds will be redistributed by increasing the slope of the exchange function Ultimate slope of exchange will be determined by performance across all hospitals

33 Value Based Purchasing %

34 2014 VBP Results 1,714 hospitals received higher Medicare payments 1,375 hospitals payments were reduced Maine, Nebraska, South Dakota, Utah and South Carolina fared best District of Columbia, Connecticut, New York, Wyoming and Delaware fared worst

35 Quality Measures Improvement Actions Concurrent data collection Identify patients during hospital stay Ensure clinical measures are met Physician engagement Physician champions Physician report cards Communication about measures Frequency Availability

36 HCAHPS Improvement Actions Focus for change Identify areas for improvement Identify causes of underperformance Identify specific behavior changes that staff can make that will be visible to patients Concurrent data collection and performance assessment Measure adoption rates for new behaviors Provide accountability coaching and reward Continue monitoring behavior until adopted and sustained

37 Mortality Measures Improvement Actions Continuum of care Adequate discharge planning and instructions Follow up post discharge Partner with physicians Partner with post-acute care providers Monitoring mortality data

38 Infection Measures Improvement Actions Intensive hand hygiene initiatives Compliance with CLABSI, CAUTI, and SSI best practices Focus on environmental elements Goal setting Striving for Zero

39 Medicare Spending per Beneficiary Hospital led initiatives, in collaboration with post acute care providers Home Health Hospice Outpatient Skilled Nursing Facilities Durable Medical Equipment

40 VBP Next Steps Value Based Purchasing for Physicians and Physician Groups Value Based Purchasing for Skilled Nursing Facilities Ambulatory Surgery OAS CAHPS Emergency Department EDCAHPS Hospice CAHPS

41 Telehealth

42 Telehealth What is Telehealth? Use of digital information and communication technologies Includes diagnosis, management, and education Also called e-health (electronic) or m-health (mobile) Includes basic health services, such as online support groups and health information Electronic health records E-visits

43 Telehealth Live Video Synchronous Telestroke, Tele-ICU Store and Forward Asynchronous Pre-recorded videos and digital images Remote patient monitoring Personal health data collection from person in one location transmitted to provider in different location Mobile Health Range from targeted text messages to promote healthy behavior to wide-scale alerts about disease outbreaks

44 Telehealth - Telestroke.

45 Telehealth Tele-ICU

46 Telehealth E-Visits Physician appointment online instead of in person You type in your question or problem May continue through a progression of questions Healthcare provider reviews and sends response You may receive a prescription or other recommendation Helpful for rural areas or those without easy access to transportation

47 Telehealth Personal health records Accessible to patient/next of kin anytime via Webenabled device (computer, laptop, tablet, or smartphone) Vital information (disease, medications, allergies) available immediately

48 Telehealth Personal health apps Multitude of apps have been created Allow storage of health records, upload information such as blood glucose monitor or blood pressure data and then share with provider Able to review your diagnostic results (lab, radiology, etc.

49 Telehealth Home health monitoring Devices connected to internet or video equipment allow real time face-to-face interaction with healthcare providers Wearable monitoring systems connected to monitoring center Allows early detection of problems or emergencies

50 References Center for Medicare and Medicaid Services Stratis Health Quality Improvement Initiatives Value Based Purchasing at a Glance - Fiscal AHRQ PIS composite measures Telehealth modalities

51 Questions???