Providers reimbursed on basis of quality – not quantity – of care
Supplier success in a post-reform healthcare market depends on a lot of factors, including a thorough understanding of the foundation of healthcare reform. This is part of an ongoing series designed to help Repertoire readers understand the implications of reform.
The overall goals of the Affordable Care Act are to improve the quality of care in our country while reducing the waste and costs associated with that care. One cost-containment incentive program to come out of the ACA is Value-Based Purchasing.
Value-Based Purchasing, or VBP, is aimed at shifting Medicare’s fee-for-service payment system toward a system based on quality of care and patient outcomes.
Starting Oct. 1, 2012, participating hospitals began to be rewarded for how well they perform based on a set of quality measures as well as how much they improve relative to their performance baseline. The better a hospital does on its quality measures, the greater the reward it receives. Providers are held accountable for the quality and overall cost of the healthcare services provided. Incentives are structured to discourage inappropriate, unnecessary, and costly care.
VBP will have a huge impact on these organizations and is expected to reduce Medicare spending by approximately $214 billion over the next 10 years. It is designed to help providers focus on specific goals for their facilities:
- Improve the clinical quality of care.
- Address problems of underuse, overuse and misuse of services.
- Encourage patient-centered care.
- Reduce hospital adverse events and work to improve patient safety.
- Avoid unnecessary costs related to care.
- Improve care processes.
- Make performance results transparent and useable by consumers.
- Avoid creating additional disparities and reduce existing disparities in care.
Value-Based Purchasing could help the U.S. healthcare system address such problems as these:
- One in seven Medicare patients are expected to experience an adverse event, preventable illness or injury while in the hospital. In 2009, Medicare spent an estimated $4.4 billion to care for patients who were harmed or injured while in the hospital.
- One in three Medicare beneficiaries discharged from the hospital are readmitted within one month. These readmissions cost Medicare another $26 billion per year, including $17 billion for return trips that would not happen if the patient had received the proper care during his or her initial visit.
- Every year, 98,000 Americans die from errors due to hospital care or hospital-acquired conditions.
How the program works
Hospitals continue to receive payments based on the current Medicare Inpatient Prospective Payment System. Starting in 2013, however, these payments were reduced by 1 percent across the board to create funding for Value-Based Purchasing. This reduction created $850 million for incentive payments to be paid out during 2013 based on quality measures linked to improved care processes and patient satisfaction.
To participate in VBP, hospitals are measured on a set of 12 quality measures that have been linked to improved clinical processes of care, and eight measures dealing with patient satisfaction and experience. Hospitals are scored on their performance relative to other hospitals and how their individual performance on each measure improves over time. The incentive payments are determined by using the higher of these scores on each measure. By rewarding the higher achievement or improvement on measures, VBP gives hospitals the financial incentive to continually improve how they deliver care.
An example of one of the 12 quality measures is the following: How often do patients with heart failure get the discharge instructions they need to care for themselves? Heart failure patients leave the hospital with many new medications and treatment regimens. Their follow-up care can be overwhelming, and these patients are more likely than many other patient types to be readmitted to the hospital within 30 days. Understanding how to care for themselves after discharge can keep heart failure patients healthy and out of the hospital. Value-Based Purchasing measures how often hospital staff provide heart failure patients with the information they need to manage their symptoms after they leave the hospital. Teaching these patients to care for themselves is expected to reduce hospital readmissions and help lower healthcare costs.
An example of one of the eight measures targeting patient satisfaction is the following: How satisfied are patients with their experience of care at the hospital? VBP measures patient satisfaction by randomly surveying patients who are discharged from hospitals across the country about their experience while in the hospital. The goal of this survey is to ensure that patients feel comfortable and safe in the hospital and have the correct information they need to continue healing once they are discharged. The hoped-for results are more educated patients and fewer hospital readmissions.
MDSI – the parent company of Repertoire – has developed the Healthcare Reform Navigation Series, an online program designed to make the task of preparing your organization for 2014 and beyond easier. This series will help you and your team with online courses that explain many of the key elements integral to understanding reform and the transformation from fee-for-service to fee-for-value. The program includes a 12-month schedule of topics and live sessions with industry experts.
Value-Based Purchasing program measures
Clinical process-of-care measures
1. Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival.
2. Primary Percutaneous Coronary Intervention (PCI) Received Within 90 Minutes of Hospital Arrival.
3. Discharge Instructions.
4. Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital.
5. Initial Antibiotic Selection for Community- Acquired Pneumonia (CAP) in Immunocompetent Patient.
6. Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision.
7. Prophylactic Antibiotic Selection for Surgical Patients.
8. Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time.
9. Cardiac Surgery Patients with Controlled 6:00 a.m. Postoperative Serum Glucose.
10. Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered.
11. Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery.
12. Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period.
Patient experience-of-care measures
1. Communication with nurses.
2. Communication with doctors.
3. Responsiveness of hospital staff.
4. Pain management.
5. Communication about medicines.
6. Cleanliness and quietness of hospital environment.
7. Discharge information.
8. Overall rating of hospital.
Source: Centers for Medicare & Medicaid Services, http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/FY-2013-Program-Frequently-Asked-Questions-about-Hospital-VBP-3-9-12.pdf
Leave a Reply