Navigating The Patient
Protection & Affordable Care
Act and Empowerment of
Vascular Access Professionals
Stacey Nieporte
March 19, 2014
The third-party trademarks used herein are trademarks of their respective1owners.
Stacey Nieporte is a representative of a leading
provider of Infection Prevention Solutions:
Ethicon Biopatch Products
2
OBJECTIVES
• Define The Affordable Care Act
_Readmission Reduction Program, HAC Program, VBP
– Purpose
– How it works
– How does VBP impact YOU?
• VBP Scoring
– Improvement and Achievement
– What Dollars are at stake for your hospital
• The Eight Ways CLABSI Impacts VBP
• Empowerment through VBP
– CLABSI Reduction, HCAHPS
– Implementing Evidence Based Practice
– The Efficiency Piece
3
Top Concerns of Hospital CEOs
Issue
2013
2012
2011
Financial challenges
2.4
2.5
2.5
Healthcare reform implementation
4.3
4.7
4.5
Governmental mandates
4.9
5.0
4.6
Patient safety and quality
4.9
4.4
4.6
Care for the uninsured
5.6
5.6
5.2
Patient satisfaction
5.9
5.6
5.6
Physician-hospital relations
6.0
5.8
5.3
Population health management
7.6
7.9
—
Technology
7.9
7.6
7.2
Personnel shortages
8.0
8.0
7.4
Creating an accountable care organization
8.6
8.6
8.4
4
5
5
6
6
Changing Healthcare Landscape
Affordable Care
Act
• CMS readmission
penalties 3
• Non payment of
Healthcare Acquired
Conditions (HACs) 1
• Value-based
purchasing 2
Regulatory
Requirements
Provider Opportunities
in Changing Landscape
• Reportable quality
metrics 2,3,4
• Lower/eliminate
readmissions
• Measured patient
outcomes 2,4
• Eliminate healthcare
acquired infections
• Patient satisfaction
reporting 2,4
• Increase patient
satisfaction
• Evidence-based
medicine
practices/protocols
• Improve patient
outcomes
1 – Medicare Program: Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Payments for Graduate Medical Education in Certain Emergency Situations; Changes to Disclosure of
Physician Ownership in Hospitals and Physician Self-Referral Rules; Updates to the Long-Term Care Prospective Payment System; Updates to Prospective Payment System; Updates to Certain IPPS-Excluded Hospitals;
and Collection of Information Regarding Financial Relationship Between Hospitals; Final Rule, Federal Register, Volume 73, Volume 161, Tuesday, August, 19, 2008.
2 – Medicare Program: Hospital Inpatient Value-Based Purchasing Program, Federal Register, Volume 76, Number 88, Friday, May 6, 2011.
3 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and FY2012 Rates; Hospitals’ FTE Resident Caps for
Graduate Medical Education Payment, Federal Register, Volume 76, Number 160, Thursday, August 18, 2011.
4 – Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations, Federal Register, Volume 76, Number 212, Wednesday, November, 2, 2011.
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The Affordable Care Act
Readmission Reduction Program
The Advisory Board Company, Healthcare Industry Committee. Hospital Readmissions Reduction Program. C-Suite Cheat Sheet Series. August 2013.
8
The Affordable Care Act
(HAC) Hospital Acquired
Condition Program
• Set to start in FY 2015, the (HAC) Reduction Program is another
pay for performance initiative under the Affordable Care Act
• The HAC Reduction Program will work in tandem with the Value Based
Purchasing Program (VBP) and Readmissions Reduction Program to
incentivize higher quality hospital care at a lower cost
• CMS has created a list of reasonably preventable HACs including:
–
–
–
–
–
–
–
Foreign objects retained after surgery
Air embolisms
Blood incompatibility
Pressure ulcers, falls/trauma
Manifestations of poor glycemic control
Infections
Thrombosis
The Advisory Board Company, Healthcare Industry Committee. Hospital-Acquired Condition Reduction
Program. C-Suite Cheat Sheet Series. August 2013.
9
The Affordable Care Act
Hospital Acquired Condition
(HAC) Program
•
•
•
The HAC penalty will be enforced after
a hospital’s Value Based Purchasing and
Readmissions Reduction adjustments are
made and could decrease all inpatient
payments by 1% for an institution
In FY 2015, the HAC Reduction Program
will rank hospitals based on their HAC
rates, and those in the top 25% for HAC
rates will receive a 1% reduction in their
overall Medicare reimbursement rate
Hospitals will be judged on their
performance in two domains
Upcoming Changes to HAC Program
Metric
FY2015
FY 2016
FY 2017
CLABSI
✓
✓
✓
CAUTI
✓
✓
✓
✓
✓
✓
✓
SSI – Colon
SSI –
Abdominal
Hysterectomy
MRSA
✓
C. Difficle
✓
The Advisory Board Company, Healthcare Industry Committee. Hospital-Acquired Condition Reduction
Program. C-Suite Cheat Sheet Series. August 2013.
10
The Affordable Care Act
Hospital Acquired Condition
(HAC) Program
Domain 1
Domain 2
(AHRQ Measure)
(CDCMeasure)
Weighted 35%
Weighted 65%
AHRQ PSI-90 Composite
2015 (2 measures):
This measure consists of:
CAUTI
CLABSI
PSI-3:
PSI-6:
PSI-7:
PSI-8:
PSI-12:
PSI-13:
PSI-14:
PSI-15:
pressure ulcer
latrogenic pneumothorax
central venous catheter-related blood
stream infection rate
hip fracture rate
postoperative PE/DVT rate
sepsis rate
wound dehiscence rate
accidental puncture
2016 (1 additional measure):
Surgical Site Infection (Colon Surgery and
Abdominal Hysterectomy
2017 (2 additional measures):
MRSA
C Diff
Association of American Medical Colleges presentation. https://s3.amazonaws.com/public-inspection.federalregister.gov/2013-18956. Accessed February 2014.
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Value Based Purchasing – The Purpose
By adopting evidence-based care standards and protocols,
Value Based Purchasing’s aim is to:
1
2
Improve
Patient
Outcomes
Lower/
Eliminate
Readmissions
4
3
Eliminate
HAIs
Increase
Patient
Satisfaction
1 – Medicare Program: Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Payments for Graduate Medical Education in Certain Emergency
Situations; Changes to Disclosure of Physician Ownership in Hospitals and Physician Self-Referral Rules; Updates to the Long-Term Care Prospective Payment System; Updates to
Prospective Payment System; Updates to Certain IPPS-Excluded Hospitals; and Collection of Information Regarding Financial Relationship Between Hospitals; Final Rule, Federal
Register, Volume 73, Volume 161, Tuesday, August, 19, 2008.
2 – Medicare Program: Hospital Inpatient Value-Based Purchasing Program, Federal Register, Volume 76, Number 88, Friday, May 6, 2011.
3 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and FY2012 Rates;
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Hospitals’ FTE Resident Caps for Graduate Medical Education Payment, Federal Register, Volume 76, Number 160, Thursday, August 18, 2011.
4 – Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations, Federal Register, Volume 76, Number 212, Wednesday, November, 2, 2011.
The Affordable Care Act
Value Based Purchasing
As part of the Affordable Care Act, congress has authorized the
inpatient Value Based Purchasing Program, which provides a data
reporting infrastructure for hospitals to help ensure quality patient
outcomes
•
•
•
CMS will implement Value Based Purchasing to
Inpatient Prospective Payment System which
affects 3,500 hospitals, representing largest share
of Medicare spending
Hospitals will pay a percent withholding on the
front end and will either earn money back, lose
percent paid in, or earn additional dollars
Funding of Value Based Purchasing program
will be through the reduction of hospitals DRG
payments for each discharged (Inpatient
Protective Payment System)
Fiscal Year
MS-DRG Operating
Payment Reduction
FY 2013
1%
FY 2014
1.25%
FY 2015
1.50%
FY 2016
1.75%
FY 2017
and Beyond
2%
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-basedpurchasing/index.html?redirect=/hospital-value-based-purchasing/ Accessed on April 26, 2013
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The Affordable Care Act
How Does Value Based Purchasing
Impact You?
Unlike the HAC and RR Program, VBP is budget neutral,
CMS will not keep any portion of the percent withheld nationally
CMS redistributes the percent withheld
across hospitals with highest achievement
• Redistribution is based on performance
• Best performers win others break even or lose
So what does
that mean?
Your hospital’s 1-2% could be redistributed to other
hospitals with better performance, or you could
receive other underperforming hospital’s 1-2%
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-basedpurchasing/index.html?redirect=/hospital-value-based-purchasing/ Accessed on April 26, 2013
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For Example
Hospital Revenue: $1.5 Billion
CMS Patients: 40% x $1.5 Billion Revenue= $600,000,000
2016 Withholding: 1.75%= $10.5 Million
With $10.5 Million withheld, this gives you a perspective of the millions
Of dollars at stake when maintaining/implementing new practices.
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Value Based Purchasing Scoring: 2 Ways
Improvement
• Hospitals will be assessed on how much their current
performance changes from their own baseline period
performance
• YOU MUST
CONTINUALLY
IMPROVE
VS
Achievement
• Hospitals measured based on how much their
current performance differs from all other
hospitals’ baseline period performance
• YOU MUST CONTINUALLY
IMPROVE OVER YOUR
NEIGHBORS
VS
Total Performance
Score (TPS)
• TPS calculated by combining
the greater of the hospital’s
achievement or improvement
points on each measure to
determine a score for each
domain, multiplying each
domain score by the
proposed domain weight and
adding the weighted scores
together
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based16
purchasing/ Accessed on April 26, 2013
The Future of VBP Domains
Clinical process of care decreases and the focus becomes patient outcomes,
experience of care and the efficiency piece
FY 2015
FY 2014
25%
45%
30%
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based17
purchasing/ Accessed on April 26, 2013
The Affordable Care Act
Value Based Purchasing –
Efficiency Domain
Medicare Spending per Beneficiary
• An MSPB Episode includes all Part A and Part B claims
between 3 days prior to index admission to 30 days after
the hospital discharge
• Claim inclusion in episode based on from date (or
admission date
for inpatient claims)
• By 2016 this one measure will account for 25% of all Value
Based Purchasing Dollars
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/NPC-MSPB-09Feb12-Final508.pdf Accessed February 2014.
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Percent of CMS Dollars at Stake by FY
2017
Value Based
Purchasing
Readmission
Reduction
Program
Healthcare Acquired
Condition Program
2%
3%
1%
The Advisory Board Company, Healthcare Industry Committee. Hospital Value-Based Purchasing. C-Suite Cheat Sheet Series. August 2013.
The Advisory Board Company, Healthcare Industry Committee. Hospital Readmissions Reduction Program. C-Suite Cheat Sheet Series. August 2013.
The Advisory Board Company, Healthcare Industry Committee. Hospital-Acquired Condition Reduction Program. C-Suite Cheat Sheet Series. August 2013.
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Your Potential Financial Impact
American Hospital Directory
Financial Data
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Your CLABSI Data and Outcome
Measures
Hospital Compare
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8 Ways CLABSIs Can Impact Reimbursement
1.
In 2008 CMS stopped payment of 10 hospital acquired conditions including
VASCULAR CATHETER RELATED INFECTIONS
2.
2015 HAC Program: Domain 1 – PSI 90
3.
2015 HAC Program: Domain 2 – CLABSI
4.
VBP: Outcomes Domain (VBP)-CLABSI specific line item
5.
VBP: Outcomes Domain (VBP)-CLABSI is one of 8 items making up composite
score for PSI-90 which is a subset of VBP outcomes domain
6.
VBP: Efficiency Domain (VBP)-CLASBI can potentially elevate Medicare spending
per beneficiary
7.
VBP: Potential Impact to Patient Satisfaction
8.
Readmission Program
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/downloads/HACFactSheet.pdf
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Culmination of
Common Care and
Maintenance Strategies
* CDC – Center for Disease Control and Prevention
**SHEA – Society for Healthcare Epidemiology of America
***IDSA – Infectious Diseases Society of America
• CDC*
• SHEA**/IDSA***
• Joint commission NPSG
2
23 3
2011 CDC Guidelines
•
Intended to provide evidence-based
recommendations for preventing
intravascular catheter-related
infections
•
5 major areas of emphasis:
1. Education of healthcare professionals
2. Use maximal sterile precautions (MSP)
3. Use of > 0.5% CHG skin prep
4. Avoiding routine replacement of CV catheters
as a strategy to prevent infections
5. Use antiseptic/antibiotic impregnated catheters and
CHG impregnated sponge dressing
(If rate of infection not decreasing despite
adherence to above 4 strategies)
•
Targets elimination of CRBSI
from all patient-care areas
CHG impregnated sponge dressings
received a Category 1B
recommendation for reducing
the risk of CLABSIs
• “strongly recommended for
implementation and supported by
some experimental, clinical, or
epidemiologic studies and a strong
theoretical rationale”
• CHG impregnated sponge dressings
are the only form of CHG dressing
recommended in new CDC guidelines
-
“No recommendation is made for other
types of chlorhexidine dressings (Unresolved Issue)”
O’Grady NP, Alexander M, et al., Guidelines for the prevention of intravascular catheter-related
infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 2011 April 1.
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SHEA Recommended Basic and Special Approaches for
Prevention of
Central Line-associated Bloodstream Infections1
Basic Practices
Catheter Checklist
B- II
Hand Hygiene
B- II
Insertion site-Femoral
A- I
Cart Kit
B- II
Maximal Barrier Precautions A- I
Chlorhexidine (CHG) Skin Prep A- I
Catheter
Insertion
Bundle
Special Approaches
CHG Baths (ICU patients)
Impregnated Catheters
CHG-impregnated
Sponge Disk
Antimicrobial Locks
B- II
A- I
B- I
Catheter
Maintenance
Bundle
A- I
1. Marschall J, et al. Supplement Article: SHEA/IDSA Practice Recommendations Strategies to Prevent Central Line- Associated Infections in Acute Care Hospitals ICHE
2008;29:S22-30.
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Joint Commission
National Patient Safety Goal #7
Hospitals implement policies and
practices aimed at reducing the risk
of central line-associated bloodstream
infections that meet regulatory
requirements and are aligned with
evidence-based standards
The Joint Commission: Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oak Brook, IL: Joint Commission Resources, 2011
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Evidence You Should Ask For…
It’s up to you
to decide what
fits best in your
hospital’s
protocol
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What if you have already implemented the
guidelines and evidence-based practice but
want to seek ongoing improvement?
NPSG 07.04.01
EP 4 – Conduct periodic assessments for central lineassociated bloodstream infections, monitor compliance
with evidence-based practices, and evaluate the
effectiveness of prevention efforts. The risk assessments
are conducted in time frames defined by the organization
, and this infection surveillance activity is organization
wide, not targeted.
http://www.jointcommission.org/assets/1/18/NPSG_Chapter_Jan2013_HAP.pdf Accessed on April 26, 2013
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Even if results are good right now, just
sustaining them isn't enough. As the quality
targets related to reimbursement get
progressively tougher, staying the same is like
standing still on a downward-moving
escalator”. Studergroup
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Why Bridge The Gap From Hospital
To Home Infusion and Outpatient Dialysis- The Efficiency Piece
• Increase patient outcomes
• Lower/eliminate re-admissions
• Patient satisfaction
• Diminished risk of Central Line-associated
Bloodstream Infection (CLA-BSI)
• Avoidance of regulatory implications
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The Ochsner Model of Success
Method:
• Standardized care and maintenance of the line;
• Develop an order set for PICC care and dressing changes;
• Checklist was developed for nurse and patient to complete together during
dressing changes; and
• Checklist and order set was linked to the hospital’s discharge home health orders
so they would print automatically when the provider discharged the patient with
home health care.
Results/Conclusions:
By bridging the gap between the inpatient and outpatient care, Ochsner Health
System was able to effectively reduce PICC infections by 46% in home infusion
patients. This was accomplished through a collaborative partnership with hospital
staff, infusion companies, and home health agencies and instituted a standardized
process for line care and maintenance with use of a home PICC care order set and
patient nursing PICC care checklist.
1. Baumgarten K , et al. Bridging the Gap: A Collaborative to Reduce PICC Infections in the Home Care Environment. Presented at AVA conference in 2012
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Next Steps – “Goal Zero”
CDC – Target elimination of CLABSIs from all patient-care areas
Dialysis
Patients
Peripheral IV
Lines
Surgical Drains
Staff Compliance
= Kits
CVC Lines &
PICC Lines
Home
Infusion
Arterial Lines
LVADs
Readmission
Rates
1 – Medicare Program: Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Payments for Graduate Medical Education in Certain Emergency Situations; Changes to Disclosure of
Physician Ownership in Hospitals and Physician Self-Referral Rules; Updates to the Long-Term Care Prospective Payment System; Updates to Prospective Payment System; Updates to Certain IPPS-Excluded Hospitals; and
Collection of Information Regarding Financial Relationship Between Hospitals; Final Rule, Federal Register, Volume 73, Volume 161, Tuesday, August, 19, 2008.
2 – Medicare Program: Hospital Inpatient Value-Based Purchasing Program, Federal Register, Volume 76, Number 88, Friday, May 6, 2011.
3 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and FY2012 Rates; Hospitals’ FTE Resident Caps for Graduate
Medical Education Payment, Federal Register, Volume 76, Number 160, Thursday, August 18, 2011.
4 – Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations, Federal Register, Volume 76, Number 212, Wednesday, November, 2, 2011.
32
In Summary
•
•
•
•
•
•
Under rules of Value Based Purchasing, hospitals will earn back dollars, receive
additional incentives or potentially lose money unless quality of care for patients
improve against baseline and measurement domains
When evaluating products, choose products that are solution-oriented and evidence-based to
help support the needs of the changing healthcare landscape
By 2017, 2% of all hospital’s Medicare Inpatient payments will be withheld to create VBP’s
bonus incentives due to budget neutrality
Continue to evaluate all hospital processes that fall within 2015 and 2016 domains today
Continue to improve on HCAHPS, Clinical processes, however realize two more
domains will be introduced in 2014 and 2015; performance period for these domains
is NOW! You have to pay attention to the future today
Focus on the efficiency piece of the Affordable Care Act as it pertains to the continuum of care
for Home Infusion and Outpatient Dialysis
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based-33
©Ethicon, Inc. 2013 BP-107-13
purchasing/ Accessed on April 26, 2013
Conclusion
The Patient Protection & Affordable Care Act
is predicated on IMPROVING, more specifically
continually IMPROVING PATIENT
SATISFACTION and continually IMPROVING
OUTCOMES over time. The hospitals that can
achieve that going forward will be the most
successful.
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Questions?
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010613-140221
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