Value-Based Purchasing Briefly Paying for quality instead of quantity This presentation provides a bit more information about the VBP program to help you understand how it affects the work we do as nurses and how it affects quality management in HCO

VBP: A provision of the ACA Change from “fee for service” to payment based on meeting a quality standard. Reimbursement $$$ for Medicare & Medicaid patients is held back. The VBP program is a provision of the ACA and is aimed at paying for the quality of care provided, instead of just paying for care that is given regardless of quality. It actually makes sense. When you pay for something, you expect a certain level of quality. In health care, before VBP was instituted, the federal government and the health insurance industry for the most part, just paid for care that was given in a fee for service model of reimbursement. In the VBP program, each fiscal year, a portion of dollars that would be paid to HCO to reimburse for services provided to Medicare and Medicaid patients is held back.

? That percentage of the reimbursement money is held until there is an analysis of the HCO’s performance on designated quality standards. A percentage of the reimbursement money is eventually paid, up to 100%, based on the achievement of the standards.

Regulation of the ACA Writing the rules to enforce the law What percent would be held back? What standards would be used? How much would each standard be worth? How would the performance be graded to determine how much would be paid? How would this process change from year to year? This provision of the law has required regulation, or the writing of the rules that would determine how the law would be enforced. This task falls to the Dept of Health and Human services and it is a big job. Questions that have needed to be answered included, What standards would be used? How much would each standard be worth? What percent would be held back? How would the performance be graded to determine how much would be paid? How would this process change from year to year?

Other Insurance Payments On the HCO side Budgeting is more complicated Unknown how well they would perform Unknown how much reimbursement they would get Reduce spending until results are in Profit? Other Insurance Payments CMS Payment VBP $$ The first cycle of VBP was difficult for HCO. While they knew that 1% of payments would be held back that first year, knew which standards would be used, and knew what the scaling for reimbursement would be, There was never-the-less, great concern over how it would turn out at the end of the year. As a result, many HCO reduced spending proactively, in case all of that 1% was not reimbursed.

How much is 1%? Not a big deal? Acute Myocardial Infarction, discharged alive with comorbidities CA: 2011 Ave Provider billing to Medicare: $57,615 1% = $ 576 10 discharge / mo = $ 5761 X 12 mo = $ 69,138 This is just an example of how quickly that 1% can matter. Consider that multiple standards are analyzed and account for a portion of that 1%. It gets complicated and potentially costly

Where do standards come from? Required Standards of Care TJC CMS VBP Standard of Care Evidence Based Expert Opinion Accreditation Regulation Suggested Standards of Care Ought to be looking at patient satisfaction Accreditation Regulation Must use this survey HCAHPS Try this survey HCAHPS Survey The measure of the patient experience

Regulations in the Federal Register

Getting information to the government The expansion in the use and functionality of electronic health care records means that the detailed information about the standards being met is contained electronically. And that means it is relatively easy to extract and send to the government. For instance, one of the items on the standard for emergency department care of a patient presenting with symptoms of an acute myocardial infarction, is getting aspirin within 30 minutes of arrival. That can be tracked in the data contained in the electronic medication administration system. The time the nurse administered the drug can be compared to the time the patient was first encountered. While the accuracy of charting has always been an important part of our work, now it is being used to some extent as a determinant of meeting a standard of care related to reimbursement. patient satisfaction data, which is almost exclusively collected for the HCO by an outside company such as Press Ganey, is also sent electronically. EHR & Satisfaction Surveys http://www.bing.com/images/search?q=Computers+in+Nursing+Informatics&view=detailv2&id=D59874B7A92F6F78DC40B6FF02D20A427D50B9E3&selectedindex=47&ccid=oaNvRbEE&simid=608023170726168688&thid=OIP.Ma1a36f45b10475511b7266d127b94191o0&mode=overlay&first=1

Hospital Compare Look at the Standards https://www.medicare.gov/hospitalcompare/search.html Recall that the IOM, back in Crossing the Quality Chasm, said there needed to be more transparency in health care delivery and services. Thus, another provision of the ACA is that all of this information has to be publically reported. Lets take a look at the current reporting.