CMS Value-Based Purchasing: Methodology and Documentation Opportunities Kristen Geissler, MS, PT, CPHQ, MBA Director, Clinical Economics Berkeley Research Group, LLC Cockeysville, MD

Affordable Care Act 2010 New and enhanced quality initiatives New push toward outcome measures Long-awaited move from pay-to-report to pay- to-perform Incremental increase in financial risk over several years More important than ever to understand and leverage these quality and reimbursement policies

CMS Value Timeline FY2013 FY2014 FY2015 FY2016 FY2017 VBP 1% HRRP 1% 2% FY2014 VBP 1.25% HRRP 2% 2.25% FY2015 VBP 1.5% HRRP 3% HAC 1% 5.5% FY2016 VBP 1.75% 5.75% FY2017 VBP 2% 6% Total NOTE FROM ED SERVICES: In first column, is FFY correct? Or should be FY? All set-w2

Types of Quality Measures Process Was a specific element of patient care done? “Evaluation of left ventricular function” Outcome What happened with the patient? Mortality, readmission, complication Patient-reported HCAHPS patient perception surveys Facility-reported Central line infection Concerns with hospitals using different methodologies and intensity of review

Types of Quality Measures Active Hospital must collect data from medical record and submit data Used for core measures Complex abstraction rules; time-consuming Hospital has generous amount of time for rereviews and validation Passive Claims-based Used for mortality, readmission, AHRQ PSI, HAC Based strictly on coding/claims data Less opportunity for rereviews and validation

New or Enhanced Quality Initiatives VBP – value-based purchasing New in FY 2013 HRRP – Hospital Readmissions Reduction Program HAC – hospital-acquired conditions Enhanced in FY 2015 Medicaid – HCAC, OPPC, PPC NOTE FROM ED SERVICES: Should HRRP be “Hospital Readmissions Reduction Program”? All set-w2

VBP – Value Based Purchasing Goes into effect FY13 (October 2012) Measurement period started July 1, 2011 Current measures Clinical process measures – 70% HCAHPS patient perception – 30% Future measures Mortality (FY14) AHRQ PSI and HAC (removed for FY14 – likely FY15) Medicare spending per beneficiary (removed for FY14 – likely FY15) Financial impact 1% of Medicare base DRGs at risk Increases incrementally to 2% in FY17 NOTE FROM ED SERVICES: Under “Financial impact,” change to “1% of Medicare-based DRGs at risk”? W2-stet per Brian

VBP Key Terms Clinical process measures – based on “core measures”; made up of 4 diagnosis sets: acute MI, heart failure, pneumonia, and surgical care improvement Attainment – performance as compared to a national threshold and benchmark Improvement – performance within a measure year over year Achievement threshold – national median of a measure in the base year Benchmark – national mean of the top decile in the base year

VBP Components Process measures (70%) Attainment Improvement Performance compared against a statewide threshold and benchmark (0–10) Improvement Year-over-year hospital performance (0–9) HCAHPS (30%) Consistency Based on lowest of 8 HCAHPS scores (0–20)

VBP List of Clinical Process Measures for FY 2013 AMI-7a Fibrinolytic therapy received within 30 minutes of hospital arrival AMI-8a Primary PCI received within 90 minutes of hospital arrival HF-1 Discharge instructions PN-2 Pneumococcal vaccination PN-3b Blood culture before first antibiotic PN-6 – Antibiotic selection* SCIP-INF-1 Antibiotic given within 1 hour prior to surgical incision SCIP-INF-2 Antibiotic selection SCIP-INF-3 Antibiotic discontinuance within appropriate time period postoperatively SCIP-INF-4 Cardiac surgery patients with controlled 6 am postoperative serum glucose SCIP-INF-9 Postoperative urine catheter removal on postop day 1 or 2 SCIP-VTE-1 – Surgery patient with recommended VTE prophylaxis ordered* SCIP-VTE-2 – Surgery patient with recommended TE prophylaxis given 24 hrs prior/after surgery* SCIP-Card-2 – Surg pt on beta-blocker prior to admission who received a beta-blocker in perioperative period*

VBP HCAHPS Domains and Corresponding Survey Questions for FY 2013 1. Communication With Nurses How often did nurses treat you with courtesy and respect? (Q1) How often did nurses listen carefully to you? (Q2) How often did nurses explain things in a way you could understand? (Q3) 2. Communication With Doctors How often did doctors treat you with courtesy and respect? (Q5) How often did doctors listen carefully to you? (Q6) How often did doctors explain things in a way you could understand? (Q7) 3. Responsiveness of Hospital Staff After you pressed the call button, how often did you get help as soon as you wanted it? (Q4) How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? (Q11) 4. Pain Management How often was your pain well controlled? (Q13) How often did the hospital staff do everything they could to help you with your pain? (Q14) 5. Communication About Medicines Before giving you any new medicine… How often did hospital staff tell you what the medicine was for? (Q16) How often did hospital staff describe possible medicine side effects in a way you could understand? (Q17) 6. Cleanliness and Quietness of Hospital Environment How often were your room and bathroom kept clean? (Q8) How often was the area around your room quiet at night? (Q9) 7. Discharge Information Did hospital staff talk with you about whether you would have the help you needed when you left the hospital? (Q19) Did you get information in writing about what symptoms or health problems to look out for after you left the hospital? (Q20) 8. Overall Rating of Hospital Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay? (Q21) Domains 1–7 answered with Always, Usually, Sometimes, or Never. NOTE FROM ED SERVICES: Does the content in the box at the bottom make sense? W2-stet per Brian Each domain is weighted equally. Scored for “top box” only – Patients who answered “Always” in Domains 1–7 and “9 or 10” for Domain 8

FY 2013 & FY 2014 Thresholds and Benchmarks Threshold FY 2013 Threshold FY 2014 Benchmark FY 2013 Benchmark FY 2014 AMI-7a 65.5% 80.7% 91.9% 96.3% AMI-8a 93.4% 100% HF-1 90.8% 92.7% PN-3b 96.4% 97.3% PN-6 92.8% 94.5% 99.6% SCIP-Inf-1 97.4% 98.1% 99.9% SCIP-Inf-2 97.7% SCIP-Inf-3 95.1% 96.6% 99.7% SCIP-Inf-4 94.3% SCIP-Inf-9 na 92.9% SCIP-VTE-1 95.0% 95.7% SCIP-VTE-2 93.1% 94.6% SCIP-Card-2 94.0% 94.9% 99.8% NOTE FROM ED SERVICES: Add the percent symbol after all numbers? Remove empty column? All set-w2

FY 2013 & FY 2014 Thresholds and Benchmarks Benchmark FY 2013 Benchmark FY 2014 Communication w/ Nurses 75.2% 75.9% 84.7% 85.0% Communication w/ Doctors 79.4% 79.6% 88.9% 88.4% Responsiveness of Hosp Staff 61.8% 62.2% 77.7% 78.1% Pain Management 68.8% 69.0% 77.9% Communication About Medicines 59.3% 59.9% 70.4% 71.5% Hosp Cleanliness & Quietness 62.8% 63.5% 77.6% Discharge Information 81.9% 82.7% 89.1% 89.2% Overall Rating of Hospital 66.0% 67.3% 82.5% 82.6% NOTE FROM ED SERVICES: Add the percent symbol after all numbers? Remove empty column? All set-w2

VBP Scoring Methodology Threshold (national median) Benchmark (mean of the top decile) 2 4 6 8 10 points 0 points For example: Threshold = 90% (national median) Benchmark = 100% (mean of the top decile) 2 4 6 8 Hospital score = 94%

New Updates The following measures will NOT be used in FY 2014 VBP AHRQ Patient Safety Indicators (PSI) Hospital-acquired conditions (HAC) Medicare spending per beneficiary NOTE FROM ED SERVICES: Necessary to cap “Patient Safety Indicators”?

What’s to Come in VBP AHRQ PSI HAC Medicare spending per beneficiary New stroke process measures New VTE process measures

How Can CDI Impact VBP? Data quality before clinical quality Clinical process measures Assignment of principal diagnosis – AMI, PNA, HF Outcome measures Complete coding of secondary conditions for risk adjustment Accurate coding of complications Accurate assignment of present-on-admission (POA) indicator

How Can CDI Impact VBP? Documentation Standardization of clinical definitions Hemorrhage Sepsis Respiratory failure Renal failure Leverage of EMR opportunities Problem lists Computer-assisted coding Medication reconciliation Documenting present on admission

Physician Education Process measure requirements Clinical diagnosis coding definitions “What do you consider a complication?” Present on admission POA definitions and key points Conditions occurring before order for inpt admission are POA (ED, OBS, amb surg) Timing of documentation does NOT matter Option for “cannot clinically determine” Templates for documentation

Questions? In order to receive your continuing education certificate for this program, you must complete the online evaluation which can be found in the continuing education section at the front of the workbook.