VALUE BASED PERFORMANCE: UNDERSTAND YOUR
SCORECARD AND BOOST YOUR REIMBURSEMENT
MARCH 06, 2013
INTRODUCTIONS
ROBIN KISH
Vice President
+1 813.220.6868
robin.kish@marsh.com
SUZANNE HOLBACH
Vice President
+1 865.274.9729
suzanne.holbach@marsh.com
DONNA JENNINGS
Senior Vice President
+1 404.539.8018
donna.jennings@marsh.com
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AGENDA
• VBP and Its Impact
• Healthcheck-2014 and Beyond
• Risk & Finance: Impact Points
• Unhealthy Hospitals (Collateral Risks)
• “Healthy Hospital Solutions”
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VBP AND ITS IMPACT
VBP AND ITS IMPACT
WHAT IS VBP?
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VBP AND ITS IMPACT
WHAT IS VBP?
Incentive for quality outcomes and efficiency:
• Required by the Affordable Care Act.
• Quality incentive program built on the Hospital Inpatient Quality Reporting
(IQR) measure reporting infrastructure.
• Next step in promoting higher quality care for Medicare; pays for care that
rewards better value and patient outcomes, instead of just volume of
services.
• Funded by a 1% reduction from participating hospitals’ base operating
diagnosis-related group (DRG) payments for FY 2013, increasing to 2%
by FY 2017.
• Uses measures that have been specified under the Hospital IQR Program
and results published on Hospital Compare for at least one year.
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VBP AND ITS IMPACT
WHAT IS VBP?
Incentive for quality outcomes and efficiency:
• The VBP program design includes:
– Measuring Quality Performance and Patient Experience
- Total Performance Score (TPS)
- 20 performance measures for FY 2013
- 24 performance measures for FY 2014
– Reimbursement based on Quality Outcomes
– Funded by withholding 1% of the CMS reimbursement
– Reimbursement is based on performance scores
Pay for Performance vs. Pay for Reporting
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VBP AND ITS IMPACT
FY 2013 MEASURES
12 Clinical Process of Care Measures
1. AMI-7a Fibrinolytic Therapy received within 30 minutes of
hospital arrival.
2. AMI-8 primary PCI recevied with 90 minutes of hospital arrival.
3. HF-1 discharge instructions.
4. PN-3b blood cultures performed in the ED prior to initial
antibiotic received in hospital.
5. PN-6 initial antibiotic selection for CAP in immunocompetent
patient.
6. SCIP-Inf-1 prophylactic antibiotic received within one hour prior
to surgical incision.
7. SCIP-Inf-2 prophylactic antibiotic selection for surgical patients.
8. SCIP-Inf-3 prophylactic antibiotics discontinued within 24 hours
after surgery.
9. SCIP-Inf-4 cardiac surgery patients with controlled 6AM
postoperative serum glucose.
10. SCIP-Card-2 surgery patients on a beta blocker prior to arrival
that received a beta blocker during the perioperative period.
11. SCIP-VTE-1 surgery patients with recommended venous
thromboembolism prophylaxis ordered.
12. SCIP-VTE-2 surgery patients who received appropriate venous
thromboembolism prophylaxis within 24 hours.
70%
8 Patient Experience of
Care Dimensions
1.
2.
3.
4.
5.
6.
7.
8.
Nurse communication.
Doctor communication.
Hospital staff responsiveness.
Pain management.
Medicine communication.
Hospital cleanliness and quietness.
Discharge information.
Overall hospital rating.
30%
Source: CMS official VBP web site.
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VBP AND ITS IMPACT
VBP 2013
1% Base Operating DRG payments
12 Process of
Care Measures
70%
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HCAHPS
30%
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VBP AND ITS IMPACT
HOW ARE HOSPITALS EVALUATED?
• Hospitals are awarded points for Achievement and Improvement for each
measure or dimension, with the greater set of points used.
• Points are added across all measures to reach the Clinical Process of
Care and Outcome domain scores.
• Points are added across all dimensions and are added to the Consistency
Points to reach the Patient Experience of Care domain score.
Source: CMS official VBP web site.
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VBP AND ITS IMPACT
HOW ARE HOSPITALS EVALUATED?
• Achievement points: awarded by comparing an individual 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.
All Hospitals
Me!
Time
Achievement
Threshold
Benchmark
All Hospitals’ Baseline
SCORE
0.70
One Hospital’s Performance
1
Source: CMS official VBP web site.
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3 4 5 6 7 8 9
Achievement Range
10
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VBP AND ITS IMPACT
HOW ARE HOSPITALS EVALUATED?
• Improvement points: awarded by comparing a hospital's rates during the
performance period to that same hospital's 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
Me!
Me!
Time
Achievement
Threshold
SCORE
0.21
Benchmark
One Hospital’s Baseline
SCORE
0.70
One Hospital’s Performance
1
Source: CMS official VBP web site.
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0
1
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2
2
3 4 5 6 7 8 9
Achievement Range
3
4
5
6
Improvement Range
7
8
10
9
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VBP AND ITS IMPACT
AVERAGE VBP SCORES – OWNERSHIP
Source: CMS official VBP web site.
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VBP AND ITS IMPACT
QUALITY MEASURES HEALTHCHECK
Source: iVantage
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VBP AND ITS IMPACT
HCAHPS HEALTHCHECK
Source: iVantage
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VBP AND ITS IMPACT
WHAT IS THE FINANCIAL IMPACT OF VBP?
Withholding CMS reimbursement
• The VBP initiative is funded by withholding reimbursement from
participating hospitals’ Diagnosis Related Group (DRG) payments
– FY 2013 - 1.0%
– FY 2014 - 1.25%
– FY 2015 - 1.5%
– FY 2016 - 1.75%
– FY 2017 – 2.0%
• CMS estimates that in FY 2013, 50% of participating hospitals will receive a
net increase in payments and 50% will receive a net decrease in payments
• 1% of DRG payments withheld from eligible hospitals is estimated at
$850 million.
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HEALTHCHECK-2014 AND BEYOND
HEALTHCHECK-2014 AND BEYOND
FY 2014 MEASURES AND ITS IMPACT
13 Clinical Process of Care Measures
3 Mortality Measures
1.
1. MORT-30-AMI Acute Myocardial Infarction (AMI) 30-day
mortality rate.
2. MORT-30-HF Heart Failure (HF) 30-day mortality rate.
3. MORT-30-PN Pneumonia (PN) 30-day mortality rate.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
AMI-7a Fibrinolytic Therapy received within 30 minutes of
hospital arrival.
AMI-8 primary PCI received with 90 minutes of hospital
arrival.
HF-1 discharge instructions.
PN-3b blood cultures performed in the ED prior to initial
antibiotic received in hospital.
PN-6 initial antibiotic selection for CAP in
immunocompetent patient.
SCIP-Inf-1 prophylactic antibiotic received within one hour
prior to surgical incision.
SCIP-Inf-2 prophylactic antibiotic selection for surgical
patients.
SCIP-Inf-3 prophylactic antibiotics discontinued within
24 hours after surgery.
SCIP-Inf-4 cardiac surgery patients with controlled 6AM
postoperative serum glucose.
SCIP-Inf-9 postoperative urinary catheter removal on
postoperative day 1 or 2.
SCIP-Card-2 surgery patients on a beta blocker prior to
arrival that received a beta blocker during the
perioperative period.
SCIP-VTE-1 surgery patients with recommended venous
thromboembolism prophylaxis ordered.
SCIP-VTE-2 surgery patients who received appropriate
venous thromboembolism prophylaxis within 24 hours.
45%
Source: CMS official VBP web site.
MARSH
25%
8 Patient Experience of Care Dimensions
1.
2.
3.
4.
5.
6.
7.
8.
Nurse communication.
Doctor communication.
Hospital staff responsiveness.
Pain management.
Medicine communication.
Hospital cleanliness and quietness.
Discharge information.
Overall hospital rating.
30%
Represents a new measure for the FY 2014 program not in the FY 2013 program.
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HEALTHCHECK-2014 AND BEYOND
VBP 2014
1.25% Base Operating DRG payments
12 Process of
Care Measures
45%
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HCAHPS
30%
April 7, 2015
Outcomes
(Mortality, AHRQ)
25%
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HEALTHCHECK-2014 AND BEYOND
ED QUALITY INDICATORS
• Data collection began January 2012
– ED-1: Median time from ED arrival to ED departure for admitted ED
patients
– ED-2: Admit decision time to ED departure time for admitted patients
• For more information on the ED Measures, go to:
http://medicare.gov/hospitalcompare/Data/emergency-wait-times.aspx
Reimbursement Impact!
Source: CMS Specifications Manual 4.0c
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HEALTHCHECK-2014 AND BEYOND
COMING SOON TO AN ED NEAR YOU
"A patient's experience in an emergency department is an essential
component of their overall healthcare experience in a hospital, and we
believe that a patient survey evaluating such care will further support the
HHS's goals and priorities.“ - CMS statement on patient satisfaction surveys
• December 10, 2012
– Pain control
– Wait Times
– Communication with Provider
Source: Fierce Healthcare. ED Patient Satisfaction. The Future of Reimbursement.
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RISK & FINANCE: IMPACT POINTS
RISK & FINANCE: IMPACT POINTS
WHAT IS THE VBP CONNECTION?
• Patient throughput and flow issues
• ER Efficiencies and Turn Around Times
• Medication reconciliation
• Transition of Care Delays
• Patient complaints
• Readmissions (Preventable)
• Efficiencies of Ancillary Departments (lab,
pharmacy)
• Hospital Acquired Conditions
• Sentinel Events
• Individualization of patient care/treatment
plans, including discharge plan and
education
• Patient Complications
• Rapid Response and Emergency Care
• Mortality Review
• Claims & Liability
• Medical Record Gaps or Lack of
Documented Medical Necessity
• Medical Errors, Reporting, & Disclosure
• Regulatory Audits/Surveys/Sanctions
• Health Information Management (EMR,
HIPAA, HI-TECH)
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RISK & FINANCE: IMPACT POINTS
STAYING STRONG IN THE MIDST OF REFORM
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UNHEALTHY HOSPITALS “COLLATERAL RISKS”
UNHEALTHY HOSPITALS “COLLATERAL RISKS”
• Financial Risks (Noted Previously)
• Operational and Reputational Risks
• Medical Malpractice/Litigation
• Underwriter / Carrier Issues
• Regulatory and Accreditation Impact
• Public Consumer Opinions
• Adverse Events/Mandatory Reportable Events
• Mortality and Morbidity
• Employees, Physicians, Residents, Students Satisfaction Scores
• Impact on Managed Care Contracting, Hospital Rating &
Business Partner Relationships
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HEALTHY HOSPITAL SOLUTIONS
HEALTHY HOSPITAL SOLUTIONS
• Value Based Purchasing Solutions
• ED throughput
• Readmissions reduction and management
• Revenue cycle and clinical documentation improvement Programs
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HEALTHY HOSPITAL SOLUTIONS
CLINICAL HEALTHCARE CONSULTING SERVICES
Customer Service – Door to Departure
Arrival,
Registration
and Triage
MARSH
Waiting
Test and Treat
Observation,
Reassessment
and Admission
or Discharge
ED Intake
ED Throughput
ED Output
• Quick Registration
• Triage
– Bypass
– Protocols
– Med Reconciliation
• MSE
• D2D
• Waiting Room
– Rounding
•
•
•
•
•
•
•
•
•
•
MSE
Testing – Radiology/Laboratory
Case Management
Diversions
Direct Admits
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Barriers to A/D/T
Consultants
Orders
Boarders
Diversions
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HEALTHY HOSPITAL SOLUTIONS
CLINICAL HEALTHCARE CONSULTING PROGRAMS
Readmissions Reduction and Management
The last readmission group is considered as preventable – or avoidable – readmission. There is
a great potential to reduce the number of this type of readmission by identifying causes and
developing preventable strategies in hospitals and community settings.
DRG Penalty Calculations
HF
AMI
PNE
Number of Patients Treated with MS-DRGs
500
200
800
Number of Readmissions (Risk Adjusted)
140
44
162
Risk-Adjusted Readmit Rate
28.5%
22.5%
20.8%
US 30-Day Readmission Rate
24.5%
19.9%
18.2%
Predicted/Expected Ratio
1.1632
1.1306
1.1428
.1632
.1306
.1428
Total Medicare Payments
$1,500,000
$775,000
$2,150,000
Excess Payment Amount
$245,000
$101,000
$307,000
P/E Ratio – 1
Total Penalty Payment
653,000
Source: CMS official VBP web site.
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HEALTHY HOSPITAL SOLUTIONS
READMISSIONS REDUCTION & MANAGEMENT STRATEGIES
• Facility and provider practice risk impact analysis
• Technology
• Pre-admission
• Hospital admission
• Care transition coordination
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HEALTHY HOSPITAL SOLUTIONS
CLINICAL HEALTHCARE CONSULTING PROGRAMS
• Revenue Cycle and Clinical Documentation Improvement Programs
– Operations Review
– ED Case Management
– ED Throughput
– Denial Management
– Billing, Coding and Clinical Documentation Improvement
– RACS/MICS/ZPICS/Medical Necessity
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QUESTIONS
VBP RESOURCES
• CMS official VBP web site: http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/hospital-value-based-purchasing/index.html
• CMS VBP fact sheet: http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/hospital-value-based-purchasing/Downloads/FY-2013Program-Frequently-Asked-Questions-about-Hospital-VBP-3-9-12.pdf
• Refer to the Hospital VBP Final Rule for more information on the Hospital VBP
quality measures: http://www.gpo.gov/fdsys/pkg/FR-2011-05-06/pdf/201110568.pdf.
• For detailed information on the Hospital VBP program, refer to:
http://www.cms.gov/Hospital-Value-Based-Purchasing.
• For further details about scoring for the FY 2013 Hospital VBP program, refer to the
July 2011 Open Door Forum: http://www.cms.gov/Hospital-Value-BasedPurchasing/Downloads/HospVBP_ODF_072711.pdf.
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