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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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)

11. 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*

12. 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

13. 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

14. 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

15. 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%

16. 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”?

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

18. 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

19. 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

20. 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

21. 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.