Value-Based Purchasing Program Overview. Maida Soghikian, MD Grand Rounds Scripps Green Hospital November 28, 2012

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1 Value-Based Purchasing Program Overview Maida Soghikian, MD Grand Rounds Scripps Green Hospital November 28, 2012

2 Presentation Overview Background and Introduction Inpatient Quality Reporting Program Value-Based Purchasing Program IQR and VBP Evolution and History CMS FY13 VBP Final Scores Process Measures Analysis Core Measure All or None Bundles Value-Based Purchasing Program Measures Status of FY14 VBP Performance Current data collection Addition of Outcome Measures CMS VBP in FY16 and Beyond 2

3 3 Background and Introduction

4 IQR Program Department of Health and Human Services developed Hospital Inpatient Quality Reporting (IQR) Program which requires hospitals to submit quality IQR measures. and VBP Evolution and History Conditions include: acute myocardial infarction (AMI), heart failure (HF), pneumonia (PNE), surgical care improvement project (SCIP) Indicators include: process measures and patient experience 30-day mortality and readmission rates, patient safety indicators Eligible hospitals that do not participate will receive an annual market basket update with a 2.0 percentage point reduction.

5 VBP Program: Background Congress authorized the hospital inpatient Value-Based Purchasing (VBP) Program through the Affordable Care Act. Built on the Hospital IQR measure reporting infrastructure. Uses Hospital IQR measures that have had results published on Hospital Compare* for at least one year Funded by a 1% reduction from participating hospitals base operating diagnosis-related group (DRG) payments for FY 2013, increasing to 2% by FY *

6 VBP Program: Purpose VBP Program seeks to encourage hospitals to improve the quality and safety of care for Medicare beneficiaries and all patients receive during acutecare inpatient stays by: 1) Eliminating or reducing occurrence of adverse events 2) Adopting evidence-based care standards and protocols that result in the best outcomes for the most patients 3) Improve patients experience of care 6

7 VBP Program: Domain Overview VBP Fiscal Year % Program Contribution 1.00% 1.25% 1.50% 1.75% *Six Domains: 1 Process of Care 70% 45% 20% 2 Patient Experience 30% 30% 30% 3 Outcome - 25% 30% 4 Efficiency: Medicare Spending per Beneficiary % Reclassification of Domains: National Quality Strategy* 1) Clinical Care 2) Person- and Caregiver- Centered Experience and Outcomes 3) Safety 4) Efficiency and Cost Reduction 5) Care Coordination 6) Community/ Population Health CMS Shift for Quality Measurement: Clinical Process Measures Outcomes and Efficiency Measures (not risk-adjusted) (risk-adjusted) 7

8 FY13 VBP: Performance Periods BASELINE Performance Period: July 2009 March 2010 FY13 Performance Period: July 2011 March 2012 Payment Impact Period: October 2012 September

9 National Targets *Data collection period for national baseline targets: July 2009 March

10 10 Achievement Points

11 11 Achievement Points

12 12 Improvement Points

13 13 Improvement Points

14 Final Points Each measure is worth 10 points CMS takes the higher of either the achievement or improvement points FY13 VBP: 12 process measures (120 total points) FY14 VBP: 13 process measures (130 total points) Add urinary catheter on post operative day 1 or 2 Measures with fewer than 10 reported cases are considered to have insufficient data and will not be scored for that hospital. 14

15 15 CMS FY13 VBP Final Scores

16 CMS FY13 VBP: Process of Care Clinical Process of Care Measures Heart Attack National Baseline Benchmark Achievement Threshold Baseline % Performance Period: July March 2012 Current % Green Achievement Points 1 Fibrinolytic therapy within 30 minutes 91.91% 65.48% PCI within 90 minutes % 91.86% Improvement Points Final Points Insufficient Data Insufficient Data Heart Failure 3 Discharge instructions % 90.77% 92.67% % Pneumonia 4 Blood cultures in ED before antibiotic % 96.43% 97.56% Appropriate antibiotic selection 99.58% 92.77% 93.22% 97.73% Insufficient Data 6 Prophylactic antibiotic received within one hour prior to surgical incision 99.98% 97.35% 99.00% % Prophylactic antibiotic selection for surgical patients % 97.66% 99.67% % Surgical Care Improvement Project 8 9 Prophylactic antibiotics discontinued within 24 hours after surgery end time Cardiac surgery patients with controlled 6AM postoperative serum glucose 99.68% 95.07% 94.79% 99.67% % 94.28% % 98.85% Recommended VTE prophylaxis ordered % 95.00% 98.18% % Received appropriate VTE prophylaxis within 24 hours prior - 24 hours after surgery Patients on beta blocker therapy prior to admit who received a beta blocker during perioperative period 99.85% 93.07% 96.36% % % 93.99% 96.90% 98.97% Score: 91.11% 16

17 CMS FY13 VBP: Patient Experience of Care Patient Experience of Care* National Baseline Performance Period: July March 2012 Green Bench mark Achievement Threshold Floor Baseline % Current % Achievement Points Improvement Points Final Points 1 Nurses always communicated well 84.70% 75.18% 38.98% 79% 81% Doctors always communicated well 88.95% 79.42% 51.51% 83% 86% Patients always received help quickly from hospital staff 77.69% 61.82% 30.25% 63% 67% Patients' pain was always well controlled 77.90% 68.75% 34.76% 70% 75% Staff always explained about medicines before giving them to patients 70.42% 59.28% 29.27% 63% 66% Patients' rooms and bathrooms were always kept clean and quiet 77.64% 62.80% 36.88% 63% 65% Patients were definitely given information about what to do during their recovery at home Patients who gave their hospital a rating of 9 or higher on a scale of 0 to % 81.93% 50.47% 81% 85% % 66.02% 29.32% 79% 81% Consistency Points: Score: % 17 * Patient experience data is adjusted by CMS for certain patient-mix variables. These include: service line, age, response percentile, and self-reported level of education, health, and primary language.

18 Total VBP Score: State Average = 52.83% National Average = 55.46% CMS FY13 VBP: FINAL Scores* FY13 VBP Encinitas Green La Jolla Mercy FINAL VBP Scores Process 87% 91% 74% 62% Patient Experience** 42% 63% 50% 25% Total VBP Score 74% 83% 67% 51% 18 * Source: CMS Hospital Value Based Purchasing - Actual Percentage Summary Report, released 10/31/12. ** Patient experience data is adjusted by CMS for certain patient-mix variables. These include: service line, age, response percentile, and self-reported level of education, health, and primary language.

19 CMS FY13 VBP: Performance Periods and Timeline FY13 VBP Data Collection Periods: Baseline Performance: July 2009 March 2010 Current Performance: July 2011 March 2012 October 31, 2012: CMS sent hospitals the Actual Payment Percentage Summary Report January 1, 2013: Incorporate 1% reduction and value-based incentive payment simultaneously 19

20 CMS FY13 VBP: Estimated Financial Impact Measure Encinitas Green La Jolla Mercy Scripps Hospitals ACTUAL POTENTIAL* 1 FINAL VBP Scores 74% 83% 67% 51% ESTIMATED FY13 IPPS Operating Payments 1% Reduction (Pay-In Amount into VBP Pool) 1% Reduction + Value-based Incentive (Total Payment from VBP Pool) $24,110,800 $47,430,600 $47,576,100 $70,942,000 $190,059,500 $190,059,500 ($241,108) ($474,306) ($475,761) ($709,420) ($1,900,595) ($1,900,595) $325,606 $720,512 $581,702 $661,801 $2,289,621 $3,491,393 5 Net Loss/Gain $84,498 $246,206 $105,941 ($47,619) $389,026 $1,590,798 6 Total Reimbursement for FY13 IPPS Operating Payments $24,195,298 $47,676,806 $47,682,041 $70,894,381 $190,448,526 $191,650,298 *POTENTIAL reimbursement: if all sites had VBP score of 100% 20

21 CMS FY13 VBP: Example for Green Example for an FY13 Claim: 1 FINAL VBP Score Measure Measure Description Based on performance period: July March 2012 Green 83% 2 Operating Payment Claim Billed to Medicare For inpatient stay in FY13 $ % Reduction Pay-in amount into VBP pool ($1.00) 4 1% Reduction + Value-based Incentive Total payment from VBP pool $ Net Loss/Gain - $ Total Reimbursement for Claim - $

22 22 Process Measures Analysis

23 Core Measures System-wide: All or None Bundle Scores 100% 80% Bundle Compliance (%) 60% 40% Heart Attack Heart Failure Pneumonia SCIP 20% 23 0% FY 03 FY 04 FY 05 FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY 12

24 Core Measures System-wide: Heart Attack Bundle Scores 100% Bundle Compliance (%) 90% 80% 70% 60% Scripps Top Decile Top Quartile Median Bottom Quartile Bottom Decile # Hospitals for percentile ranks = %

25 Core Measures System-wide: Heart Failure Bundle Scores 100% 80% Bundle Compliance (%) 60% 40% Scripps Top Decile Top Quartile Median Bottom Quartile Bottom Decile 20% # Hospitals for percentile ranks = %

26 Core Measures System-wide: Pneumonia Bundle Scores 100% 80% Bundle Compliance (%) 60% 40% 20% Scripps Top Decile Top Quartile Median Bottom Quartile Bottom Decile # Hospitals for percentile ranks = %

27 Core Measures System-wide: SCIP Bundle Scores 100% 80% Bundle Compliance (%) 60% 40% Scripps Top Decile Top Quartile Median Bottom Quartile Bottom Decile # Hospitals for percentile ranks = %

28 28 VBP Process Scores: System-wide Performance

29 VBP Process Scores: System-wide Performance Objectives 3-year Goal = 78% Systemwide (National Predicted Top Decile) Scripps Health Yearly Goals 72.5% 75.3% 76.6% 78% Baseline performance* (FY14 VBP Benchmarks) FY13 Goal (FY14 VBP Benchmarks) FY14 Goal (FY15 VBP Benchmarks) FY15 Goal (FY16 VBP Benchmarks) 29 *Based on system aggregate scores for the performance period of April to July 2012.

30 Process Scores: Site Performance National top decile for process bundle FY13 VBP 30

31 FY12 VBP Board Objective (using CMS FY13 Targets) Value-Based Purchasing Measures: Clinical Process of Care Heart Attack National Baseline Benchmark Achievement Threshold Current % 1 Fibrinolytic therapy within 30 minutes 91.9% 65.5% - 0 Current n Final Points Insufficient Data Current % Performance Period: FY12 (August July 2012) Scripps Hospitals Encinitas Green La Jolla Mercy Current n - 0 Final Points Insufficient Data Current % Current n PCI within 90 minutes 100.0% 91.9% 95.4% % % 7 Final Points Insuf f icient Data Insuf f icient Data Current % Current n - 0 Final Points Insufficient Data Current % Current n - 0 Final Points Insufficient Data 97.0% % 84 6 Heart Failure 3 Discharge instructions 100.0% 90.8% 99.3% % % % % Pneumonia Surgical Care Improvement Project 4 Blood cultures in ED before antibiotic 100.0% 96.4% 99.2% % % 8 Insuf f icient Data 100.0% % Appropriate antibiotic selection 99.6% 92.8% 99.0% % % % % Prophylactic antibiotic received within one hour 6 prior to surgical incision Prophylactic antibiotic selection for surgical 7 patients Prophylactic antibiotics discontinued within 24 8 hours after surgery end time Cardiac surgery patients with controlled 6AM 9 postoperative serum glucose 100.0% 97.4% 99.6% % % % % % 97.7% 99.5% % % % % % 95.1% 99.1% % % % % % 94.3% 96.0% Insufficient Data 99.2% % % Recommended VTE prophylaxis ordered 100.0% 95.0% 99.1% % % % % Received appropriate VTE prophylaxis within hours prior - 24 hours after surgery 99.9% 93.1% 98.5% % % % % Patients on beta blocker therapy prior to admit who 12 received a beta blocker during perioperative period 100.0% 94.0% 98.7% % % % % FY12 Score Goal 65.9% 67.0% 90.6% 67.7% 65.9% FY12-to-date Score 75.5% 87.0% 91.1% 76.4% 67.3% 31 Legend: = M aximum of either achievement or improvement points = Current performance meeting FY12 Value-Based Purchasing Goal = Current performance below FY12 Value-Based Purchasing Goal

32 Green s Performance: CMS FY13 vs. FY14 Targets Value-Based Purchasing Measures: Clinical Process of Care Heart Attack CMS FY13 VBP National Baseline Benchmark Achievement Threshold Performance Period: FY12 (August July 2012) Current % 1 Fibrinolytic therapy within 30 minutes 91.91% 65.48% PCI within 90 minutes % 91.86% % 7 Current n Final Points Benchmark Achievement Threshold Current % Current n Insufficient Data 96.30% 80.66% - 0 Insufficient Data % 93.44% - 0 Heart Failure 3 Discharge instructions % 90.77% % % 92.66% % Green CMS FY14 VBP National Baseline Performance Period: FY13 (August 2012) Green Final Points Insufficient Data Insufficient Data 32 Pneumonia Surgical Care Improvement Project 4 Blood cultures in ED before antibiotic % 96.43% % 8 Insufficient Data % 97.30% Appropriate antibiotic selection 99.58% 92.77% 98.18% % 94.46% % Prophylactic antibiotic received within one hour prior to surgical incision 99.98% 97.35% 99.75% % 98.07% 96.88% Prophylactic antibiotic selection for surgical patients % 97.66% % % 98.13% % Prophylactic antibiotics discontinued within 24 8 hours after surgery end time Cardiac surgery patients with controlled 6AM 9 postoperative serum glucose Postoperative urinary catheter removal on post 10 operative day 1 or day % 95.07% 99.00% % 96.63% 96.88% % 94.28% 99.19% % 96.34% % 8 10 n/a n/a n/a n/a n/a 99.89% 92.86% % Recommended VTE prophylaxis ordered % 95.00% % % 95.65% % 8 10 Received appropriate VTE prophylaxis within hours prior - 24 hours after surgery Patients on beta blocker therapy prior to admit who 13 received a beta blocker during perioperative period 99.85% 93.07% % % 94.62% % % 93.99% 99.28% % 94.92% % FY12 Score GOAL 90.6% FY13 Score GOAL 91.00% FY12 Score ACTUAL 91.1% FY13 Score ACTUAL 81.00% Insufficient Data

33 Green s Performance: Indicator Drilldown SCIP Antibiotic within 1 hour Green s score: 9 (99.8%) 0 (96.9% = 1 OFI*) Site performance National performance Gap between top decile and median scores decreases and the VBP achievement range narrows FY13: 97.4% - 100% FY14: 98.1% - 100% 33 *OFI = Opportunity for improvement

34 FY 2014 Baseline and Performance Periods

35 CMS FY14 VBP Performance: Update for Green Heart Attack ACTUAL Performance Period: Apr 2012 Dec 2012 CURRENT Performance Period: Apr 2012 Sep 2012 Benchmark Achievement Threshold 1 Fibrinolytic therapy within 30 minutes 96.30% 80.66% PCI within 90 minutes % 93.44% % 5 Heart Failure 3 Discharge instructions % 92.66% % Pneumonia Value-Based Purchasing Measures: Clinical Process of Care National Baseline Performance Period: FY13 (Apr Sep 2012) 4 Blood cultures in ED before antibiotic % 97.30% % 1 Current % Green 5 Appropriate antibiotic selection % 94.46% % Prophylactic antibiotic received within one hour prior to surgical incision % 98.07% 99.04% Prophylactic antibiotic selection for surgical patients % 98.13% % Prophylactic antibiotics discontinued within 24 hours after surgery end time 99.96% 96.63% 98.04% Current n Final Points Insufficient Data Insufficient Data Insufficient Data Surgical Care Improvement Project 35 9 Cardiac surgery patients with controlled 6AM postoperative serum glucose % 96.34% % Postoperative urinary catheter removal on post operative day 1 or day % 92.86% % Recommended VTE prophylaxis ordered % 95.65% % Received appropriate VTE prophylaxis within 24 hours prior - 24 hours after surgery % 94.62% % Patients on beta blocker therapy prior to admit who received a beta blocker during perioperative period 99.83% 94.92% % Score: 89.00%

36 CMS FY14 VBP How Will Hospitals Be Evaluated? Total Performance Score

37 About the same as our last VBP report so far Patient Experience

38 Outcome: Current Performance OUTCOME MEASURES 30-day Mortality Rate (displayed as survival rate) Heart Attack Heart Failure Pneumonia AHRQ PSI-90 Composite for selected indicators (n = # outcomes) 2014 National Baseline Benchmark Achievement Threshold 2015 National Baseline Benchmark Achievement Threshold not included National Baseline Benchmark Achievement Threshold 86.73% 84.77% 86.24% 84.75% 86.24% 84.75% 90.42% 88.61% 90.03% 88.15% 90.03% 88.15% 90.21% 88.18% 90.42% 88.27% 90.42% 88.27% 0.62 Performance 86.4% (N) 91.2% (N) 89.9% (N) 0.89 (W) Green Data Collection Period Jul Jun 2011 PSI-90 Measures: Publicly Reported PSI-90 Measures: NOT Publicly Reported PSI 6: Iatrogenic pneumothorax PSI 12: Postoperative VTE PSI 14: Postoperative wound dehiscence 0.42 (N) 5.88 (N) 0.41 (N) PSI 15: Accidental Puncture or Laceration Part of PSI-90 Part of PSI-90 Part of PSI (W) PSI 3: Pressure Ulcer Composite Composite Composite 0.01 PSI 7: Central Venous Catheter-Related Bloodstream Infections PSI 8: Postoperative Hip Fracture 0.06 PSI 13: Postoperative Sepsis Jul Jun 2011 Central line-associated blood stream infection (shown as a Standardized Infection Ratio) not included not included 1.35 (W) Jul Mar B = Better than U.S. National Rate N = No different than U.S. National Rate W = Worse than U.S. National Rate

39 39 VBP in FY16 and Beyond

40 VBP Program: Domain Overview VBP Fiscal Year % Program Contribution 1.00% 1.25% 1.50% 1.75% *Six Domains: 1 Process of Care 70% 45% 20% 2 Patient Experience 30% 30% 30% 3 Outcome - 25% 30% 4 Efficiency: Medicare Spending per Beneficiary % Reclassification of Domains: National Quality Strategy* 1) Clinical Care 2) Person- and Caregiver- Centered Experience and Outcomes 3) Safety 4) Efficiency and Cost Reduction 5) Care Coordination 6) Community/ Population Health CMS Shift for Quality Measurement: Clinical Process Measures Outcomes and Efficiency Measures (not risk-adjusted) (risk-adjusted) 40

41 VBP FY16: Example of Reclassification Heart Attack PROPOSED FY 2015 Measures PROPOSED FY 2015 Domain PROPOSED FY 2016 Domain Clinical Care Heart Failure - Discharge instructions Pneumonia Surgical Care Improvement Project HCAHPS Questions 30-day Mortality - Heart Attack, Heart Failure, Pneumonia PSI-90 Composite - Patient safety for selected indicators Central line-associated blood stream infection Medicare spending per beneficiary Clinical Process of Care Patient Experience of Care Outcome Efficiency Care Coordination Clinical Care Clinical Care Person- and Caregiver- Centered Experience and Outcomes Clinical Care Safety Safety Efficiency and Cost Reduction 41

42 SUMMARY The CMS VBP is how Medicare is paying us from here on out The top performers make money the poor performers have money taken away SGH is performing well but did not receive full opportunity payment Even 1 OFI impacts our final score The bar keeps increasing as the nation improves and as the measures evolve

43 43 Appendix

44 FY12 vs FY13 VBP Board Objective for Green Heart Attack Value-Based Purchasing Measures: Clinical Process of Care CMS FY13 VBP Targets National Baseline Benchmark Achievement Threshold Performance Period: FY12 (August July 2012) Green Current % 1 Fibrinolytic therapy within 30 minutes 91.91% 65.48% PCI within 90 minutes % 91.86% % 7 Current n Final Points CMS FY14 VBP Targets National Baseline Benchmark Achievement Threshold Performance Period: FY13 (August - September 2012) Green Current % Current n Insufficient Data 96.30% 80.66% - 0 Insufficient Data % 93.44% % 2 Heart Failure 3 Discharge instructions % 90.77% % % 92.66% % Final Points Insufficient Data Insufficient Data Pneumonia Surgical Care Improvement Project 44 4 Blood cultures in ED before antibiotic % 96.43% % 8 Insufficient Data % 97.30% Appropriate antibiotic selection 99.58% 92.77% 98.18% % 94.46% % Prophylactic antibiotic received within one hour prior to surgical incision 99.98% 97.35% 99.75% % 98.07% 98.65% Prophylactic antibiotic selection for surgical patients % 97.66% % % 98.13% % Prophylactic antibiotics discontinued within 24 hours 8 after surgery end time Cardiac surgery patients with controlled 6AM 9 postoperative serum glucose Postoperative urinary catheter removal on post 10 operative day 1 or day % 95.07% 99.00% % 96.63% 98.65% % 94.28% 99.19% % 96.34% % n/a n/a n/a n/a n/a 99.89% 92.86% % Recommended VTE prophylaxis ordered % 95.00% % % 95.65% % Received appropriate VTE prophylaxis within 24 hours 12 prior - 24 hours after surgery Patients on beta blocker therapy prior to admit who 13 received a beta blocker during perioperative period 99.85% 93.07% % % 94.62% % % 93.99% 99.28% % 94.92% % FY12 Score GOAL 90.6% FY13 Score GOAL 91.0% FY12 Score ACTUAL 91.1% FY13 Score ACTUAL 89.0% Insufficient Data

45 VBP Board Objective: Indicator Drilldown for Green SCIP Antibiotic within 1 hour Green s score: 9 (99.75%) 3 (98.65% = 1 OFI*) Site performance National performance Gap between top decile and median scores decreases and the VBP achievement range narrows FY13: 97.35% - 100% FY14: 98.07% - 100% 45 *OFI = Opportunity for improvement

46 VBP Program: Performance Periods Overview VBP Fiscal Year 2013 VBP 2014 VBP 2015 VBP % Program Contribution 1.00% 1.25% 1.50% weight 70% 45% 20% Process of Care All except AMI-10 Jul 1, Mar 31, 2012 Apr 1, Dec 31, 2012 Jan 1, Dec 31, 2013 Patient Experience of Care Outcome Efficiency Only AMI Apr 1, Dec 31, 2013 weight 30% 30% 30% HCAHPS Jul 1, Mar 31, 2012 Apr 1, Dec 31, 2012 Jan 1, Dec 31, 2013 weight 0% 25% 30% Mortality - Jul 1, Jun 30, 2012 Oct 1, Jun 30, 2013 AHRQ - - Oct 15, Jun 30, 2013 CLABSI - - Jan 26, Dec 31, 2013 weight 0% 0% 20% MSPB - - May 1, Dec 31,

47 Efficiency: Medicare Spending per Beneficiary Medicare Spending per Beneficiary (MSPB): CMS claims based efficiency measure Evaluates cost to Medicare of services performed by hospitals and other healthcare providers during an MSPB episode Start Date = 3 days prior to an inpatient index admission End Date = 30 days post-hospital discharge MSPB Amount = Risk-adjusted Spending for All Episodes # Episodes 47 MSPB Measure = Hospital s Average MSPB Amount National Median MSPB Amount

48 Efficiency: Measure Methodology 48 Price-standardization Removes sources of variation that are due to geographic payment differences Variables: wage index, geographic practice cost differences, disproportionate share hospital (DSH) payments for the poor and uninsured population Risk-adjustment Accounts for variation due to patient health status Variables: age and severity of illness

49 Efficiency: Site Performance Performance Period: May 2011 December 2011 # Eligible Admissions Cost per case (Risk-adjusted) VBP Performance Standards Achievement Threshold Scripps Performance Benchmark Encinitas Green La Jolla Mercy - - 1,062 1,413 1,686 3,034 $18,307 $14,495 $18,666 $17,112 $17,931 $19,312 MSPB Score Median 0.99 Mean of Top Decile * Source: CMS Hospital-Specific Report, released September

50 Efficiency: National Percentile Categories Green 0.93 La Jolla 0.98 Mercy 1.05 Encinitas 1.02 Top 5% Top 10% Top 25% Median Bottom 25% Bottom 10% Bottom 5% MSPB Scores

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