WHERE $850 MIL­LION WILL COME FROM

Medi­care sys­tem will re­im­burse hos­pi­tals based on qual­ity, safety and sat­is­fac­tion mea­sures

Modern Healthcare - - Front Page - Mau­reen McKinney

The CMS stuck to its guns as it launched value-based pur­chas­ing for hos­pi­tal ser­vices.

In a fi­nal rule is­sued April 29, the agency re­fused to budge on sev­eral com­po­nents of the pro­gram—in­clud­ing the weight­ing of pa­tient ex­pe­ri­ence-of-care mea­sures and the in­clu­sion of hos­pi­tal-ac­quired con­di­tions—that had ran­kled providers and in­dus­try groups when the pro­posed rule was re­leased in Jan­uary (Jan. 17, p. 6).

“We are dis­ap­pointed that CMS es­sen­tially ig­nored com­ments from the field on the pro­posed Medi­care value-based pur­chas­ing rule and did not ad­just its poli­cies ac­cord­ingly,” said Blair Childs, se­nior vice pres­i­dent of pub­lic af­fairs for the group-pur­chas­ing and qual­ity-im­prove­ment or­ga­ni­za­tion Premier, in a writ­ten state­ment.

The pro­gram is bud­get-neu­tral and the $850 mil­lion that will be avail­able for hos­pi­tal in­cen­tive pay­ments dur­ing the pro­gram’s first year will come from an across-the-board 1% re­duc­tion in hos­pi­tals’ base op­er­at­ing DRG pay­ments. That num­ber will jump to 2% in 2017, HHS said.

Some providers and groups praised the pro­gram, which marks a dra­matic shift from the cur­rent in­pa­tient prospec­tive pay­ment sys­tem and the Hos­pi­tal In­pa­tient Qual­ity Re­port­ing Pro­gram, which re­wards hos­pi­tals for re­port­ing qual­ity data.

“To­day’s pay­ment sys­tem is rid­dled with per­verse in­cen­tives that re­ward high vol­ume and high profit-mar­gin ser­vices, re­gard­less of value, out­comes or ap­pro­pri­ate­ness,” said Christine Bech­tel, vice pres­i­dent of the Na­tional Part­ner­ship for Women & Fam­i­lies. Bech­tel spoke at an HHS news brief­ing on be­half of the Cam­paign for Bet­ter Care, an

“Our big­gest concern con­tin­ues to be the in­clu­sion of hos­pi­ta­lac­quired con­di­tions.”

—Beth Feld­push, Amer­i­can Hos­pi­tal As­so­ci­a­tion

ad­vo­cacy or­ga­ni­za­tion that em­pha­sizes health­care qual­ity and ac­ces­si­bil­ity.

“This rule is a much needed ef­fort to be­gin at­tack­ing this prob­lem at its root,” Bech­tel said.

Dr. Charles O’Brien, pres­i­dent of 478-bed San­ford Univer­sity of South Dakota Med­i­cal Cen­ter, Sioux Falls, said his hos­pi­tal is fa­mil­iar with the pro­gram’s mea­sures and he does not an­tic­i­pate a prob­lem com­ply­ing. “We don’t have many wor­ries, since we’ve been work­ing on the core el­e­ments of these for some time,” O’Brien said.

The value-based pur­chas­ing pro­gram, which is man­dated by the Pa­tient Pro­tec­tion and Affordable Care Act, sets up a frame­work to re­ward hos­pi­tals for their per­for­mance on se­lected qual­ity mea­sures. To de­ter­mine pay­ments for 2013, the CMS will mon­i­tor hos­pi­tals dur­ing a per­for­mance pe­riod that runs from July 1, 2011, through March 31, 2012.

Based on scores cal­cu­lated dur­ing the ninemonth per­for­mance pe­riod, hos­pi­tals will be­gin to re­ceive in­cen­tive pay­ments for dis­charges oc­cur­ring on or af­ter Oc­to­ber 1, 2012. The CMS said it will no­tify hos­pi­tals of their es­ti­mated in­cen­tive pay­ment for 2013 at least 60 days prior to that date.

For 2013, the CMS plans to mea­sure hos­pi­tals us­ing 12 clin­i­cal process-of-care mea­sures, in ar­eas such as sur­gi­cal care, pneu­mo­nia care and preven­tion of health­care-associated in­fec- tions. That’s five fewer mea­sures than the agency orig­i­nally in­cluded in the pro­posed rule, leav­ing out as­pirin at dis­charge for heart at­tack pa­tients, pneu­mo­coc­cal vac­ci­na­tion for pneu­mo­nia care and sev­eral oth­ers that the agency deemed “topped out,” mean­ing the ma­jor­ity of hos­pi­tals had reached a high level of per­for­mance on them.

The health­care re­form law re­quires that any mea­sure that is used for value-based pur­chas­ing must have ap­peared on Hos­pi­tal Com­pare, the CMS’ con­sumer qual­ity in­for­ma­tion web­site, for at least one year.

In ad­di­tion, the agency will mea­sure hos­pi­tals’ pa­tient ex­pe­ri­ence scores, us­ing the Hos­pi­tal Con­sumer As­sess­ment of Health­care Providers and Sys­tems sur­vey. Those HCAHPS scores, which mea­sure pa­tients’ im­pres­sions of hos­pi­tal clean­li­ness, com­mu­ni­ca­tion with clin­i­cians and other fac­tors, will be given a weight of 30% in the fi­nal scor­ing. The clin­i­cal process-of-care mea­sures will be given the re­main­ing weight of 70%.

That weight­ing ra­tio is iden­ti­cal to the one the CMS in­cluded in its pro­posed rule, and for many in­dus­try groups the agency’s re­fusal to lower the weight given to the HCAHPS mea­sures is a big prob­lem.

“We re­main con­cerned with CMS’ de­ci­sion to weight the pa­tient ex­pe­ri­ences of care sur­vey data at 30% of hos­pi­tals’ to­tal scores,” the Amer­i­can Hos­pi­tal As­so­ci­a­tion said in a state­ment. “We be­lieve the HCAHPS method­ol­ogy should be re­fined to en­sure that no hos­pi­tal is sys­tem­at­i­cally bi­ased against per­form­ing well on these mea­sures. Un­til that re­fine­ment oc­curs, the HCAHPS mea­sures should re­ceive less weight.”

Ac­cord­ing to Joanna Kim, the AHA’s se­nior as­so­ciate di­rec­tor for pol­icy, the worry is that cer­tain health­care or­ga­ni­za­tions, such as aca­demic med­i­cal cen­ters, might be at a dis­ad­van­tage when it comes to pa­tient ex­pe­ri­ence scores sim­ply be­cause of the pa­tient pop­u­la­tions they serve.

Chip Kahn, pres­i­dent and CEO of the Fed­er­a­tion of Amer­i­can Hos­pi­tals, lauded the pro­gram as some­thing “solid and needed,” but he also ex­pressed concern about the weight given to HCAHPS scores.

“Re­gional dif­fer­ences are one of the rea­sons we felt so strongly that the thrust of the pro­gram needed to be about clin­i­cal care as

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