1. 1 The third-party trademarks used herein are trademarks of their respective owners. Navigating The Patient Protection & Affordable Care Act and Empowerment of Vascular Access Professionals Stacey Nieporte March 19, 2014

2. 2 Stacey Nieporte is a representative of a leading provider of Infection Prevention Solutions: Ethicon Biopatch Products

3. 3 OBJECTIVES Define The Affordable Care Act _Readmission Reduction Program, HAC Program, VBP – Purpose – How it works – How does VBP impact YOU? VBP Scoring – Improvement and Achievement – What Dollars are at stake for your hospital The Eight Ways CLABSI Impacts VBP Empowerment through VBP – CLABSI Reduction, HCAHPS – Implementing Evidence Based Practice – The Efficiency Piece

4. 4 Top Concerns of Hospital CEOs Issue201320122011 Financial challenges2.42.5 Healthcare reform implementation4.34.74.5 Governmental mandates4.95.04.6 Patient safety and quality4.94.44.6 Care for the uninsured5.6 5.2 Patient satisfaction5.95.6 Physician-hospital relations6.05.85.3 Population health management7.67.9— Technology7.97.67.2 Personnel shortages8.0 7.4 Creating an accountable care organization8.6 8.4

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7. 7 CMS readmission penalties 3 Non payment of Healthcare Acquired Conditions (HACs) 1 Value-based purchasing 2 Reportable quality metrics 2,3,4 Measured patient outcomes 2,4 Patient satisfaction reporting 2,4 Evidence-based medicine practices/protocols Affordable Care Act Regulatory Requirements Provider Opportunities in Changing Landscape Lower/eliminate readmissions Eliminate healthcare acquired infections Increase patient satisfaction Improve patient outcomes 1 – Medicare Program: Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Payments for Graduate Medical Education in Certain Emergency Situations; Changes to Disclosure of Physician Ownership in Hospitals and Physician Self-Referral Rules; Updates to the Long-Term Care Prospective Payment System; Updates to Prospective Payment System; Updates to Certain IPPS-Excluded Hospitals; and Collection of Information Regarding Financial Relationship Between Hospitals; Final Rule, Federal Register, Volume 73, Volume 161, Tuesday, August, 19, 2008. 2 – Medicare Program: Hospital Inpatient Value-Based Purchasing Program, Federal Register, Volume 76, Number 88, Friday, May 6, 2011. 3 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and FY2012 Rates; Hospitals’ FTE Resident Caps for Graduate Medical Education Payment, Federal Register, Volume 76, Number 160, Thursday, August 18, 2011. 4 – Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations, Federal Register, Volume 76, Number 212, Wednesday, November, 2, 2011. Changing Healthcare Landscape

8. 8 The Affordable Care Act Readmission Reduction Program The Advisory Board Company, Healthcare Industry Committee. Hospital Readmissions Reduction Program. C-Suite Cheat Sheet Series. August 2013.

9. 9 The Affordable Care Act (HAC) Hospital Acquired Condition Program Set to start in FY 2015, the (HAC) Reduction Program is another pay for performance initiative under the Affordable Care Act The HAC Reduction Program will work in tandem with the Value Based Purchasing Program (VBP) and Readmissions Reduction Program to incentivize higher quality hospital care at a lower cost CMS has created a list of reasonably preventable HACs including: – Foreign objects retained after surgery – Air embolisms – Blood incompatibility – Pressure ulcers, falls/trauma – Manifestations of poor glycemic control – Infections – Thrombosis The Advisory Board Company, Healthcare Industry Committee. Hospital-Acquired Condition Reduction Program. C-Suite Cheat Sheet Series. August 2013.

10. 10 The Affordable Care Act Hospital Acquired Condition (HAC) Program The HAC penalty will be enforced after a hospital’s Value Based Purchasing and Readmissions Reduction adjustments are made and could decrease all inpatient payments by 1% for an institution In FY 2015, the HAC Reduction Program will rank hospitals based on their HAC rates, and those in the top 25% for HAC rates will receive a 1% reduction in their overall Medicare reimbursement rate Hospitals will be judged on their performance in two domains MetricFY2015FY 2016FY 2017 CLABSI ✓✓✓ CAUTI ✓✓✓ SSI – Colon ✓✓ SSI – Abdominal Hysterectomy ✓✓ MRSA ✓ C. Difficle ✓ Upcoming Changes to HAC Program The Advisory Board Company, Healthcare Industry Committee. Hospital-Acquired Condition Reduction Program. C-Suite Cheat Sheet Series. August 2013.

11. 11 The Affordable Care Act Hospital Acquired Condition (HAC) Program Domain 1 (AHRQ Measure) Association of American Medical Colleges presentation. https://s3.amazonaws.com/public-inspection.federalregister.gov/2013-18956. Accessed February 2014.https://s3.amazonaws.com/public-inspection.federalregister.gov/2013-18956 AHRQ PSI-90 Composite This measure consists of: PSI-3: pressure ulcer PSI-6: latrogenic pneumothorax PSI-7: central venous catheter-related blood stream infection rate PSI-8: hip fracture rate PSI-12: postoperative PE/DVT rate PSI-13: sepsis rate PSI-14: wound dehiscence rate PSI-15: accidental puncture Weighted 35% Domain 2 (CDCMeasure) Weighted 65% 2015 (2 measures): CAUTI CLABSI 2016 (1 additional measure): Surgical Site Infection (Colon Surgery and Abdominal Hysterectomy 2017 (2 additional measures): MRSA C Diff

12. 12 Value Based Purchasing – The Purpose By adopting evidence-based care standards and protocols, Value Based Purchasing’s aim is to: Improve Patient Outcomes Lower/ Eliminate Readmissions Eliminate HAIs Increase Patient Satisfaction 1 1 2 2 3 3 4 4 1 – Medicare Program: Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Payments for Graduate Medical Education in Certain Emergency Situations; Changes to Disclosure of Physician Ownership in Hospitals and Physician Self-Referral Rules; Updates to the Long-Term Care Prospective Payment System; Updates to Prospective Payment System; Updates to Certain IPPS-Excluded Hospitals; and Collection of Information Regarding Financial Relationship Between Hospitals; Final Rule, Federal Register, Volume 73, Volume 161, Tuesday, August, 19, 2008. 2 – Medicare Program: Hospital Inpatient Value-Based Purchasing Program, Federal Register, Volume 76, Number 88, Friday, May 6, 2011. 3 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and FY2012 Rates; Hospitals’ FTE Resident Caps for Graduate Medical Education Payment, Federal Register, Volume 76, Number 160, Thursday, August 18, 2011. 4 – Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations, Federal Register, Volume 76, Number 212, Wednesday, November, 2, 2011.

13. 13 As part of the Affordable Care Act, congress has authorized the inpatient Value Based Purchasing Program, which provides a data reporting infrastructure for hospitals to help ensure quality patient outcomes http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based- purchasing/index.html?redirect=/hospital-value-based-purchasing/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based- purchasing/index.html?redirect=/hospital-value-based-purchasing/ Accessed on April 26, 2013 The Affordable Care Act Value Based Purchasing CMS will implement Value Based Purchasing to Inpatient Prospective Payment System which affects 3,500 hospitals, representing largest share of Medicare spending Hospitals will pay a percent withholding on the front end and will either earn money back, lose percent paid in, or earn additional dollars Funding of Value Based Purchasing program will be through the reduction of hospitals DRG payments for each discharged (Inpatient Protective Payment System) Fiscal Year MS-DRG Operating Payment Reduction FY 2013 1% FY 2014 1.25% FY 2015 1.50% FY 2016 1.75% FY 2017 and Beyond 2%

14. 14 CMS redistributes the percent withheld across hospitals with highest achievement Redistribution is based on performance Best performers win others break even or lose So what does that mean? Your hospital’s 1-2% could be redistributed to other hospitals with better performance, or you could receive other underperforming hospital’s 1-2% http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based- purchasing/index.html?redirect=/hospital-value-based-purchasing/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based- purchasing/index.html?redirect=/hospital-value-based-purchasing/ Accessed on April 26, 2013 The Affordable Care Act How Does Value Based Purchasing Impact You? Unlike the HAC and RR Program, VBP is budget neutral, CMS will not keep any portion of the percent withheld nationally

15. 15 For Example CMS Patients: 40% x $1.5 Billion Revenue= $600,000,000 2016 Withholding: 1.75%= $10.5 Million Hospital Revenue: $1.5 Billion With $10.5 Million withheld, this gives you a perspective of the millions Of dollars at stake when maintaining/implementing new practices.

16. 16 Value Based Purchasing Scoring: 2 Ways Hospitals will be assessed on how much their current performance changes from their own baseline period performance YOU MUST CONTINUALLY IMPROVE VS Improvement Achievement Hospitals measured based on how much their current performance differs from all other hospitals’ baseline period performance YOU MUST CONTINUALLY IMPROVE OVER YOUR NEIGHBORS Total Performance Score (TPS) TPS calculated by combining the greater of the hospital’s achievement or improvement points on each measure to determine a score for each domain, multiplying each domain score by the proposed domain weight and adding the weighted scores together http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based- purchasing/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based- purchasing/ Accessed on April 26, 2013

17. 17 The Future of VBP Domains Clinical process of care decreases and the focus becomes patient outcomes, experience of care and the efficiency piece FY 2014 FY 2015 http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based- purchasing/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based- purchasing/ Accessed on April 26, 2013

18. 18 Medicare Spending per Beneficiary The Affordable Care Act Value Based Purchasing – Efficiency Domain An MSPB Episode includes all Part A and Part B claims between 3 days prior to index admission to 30 days after the hospital discharge Claim inclusion in episode based on from date (or admission date for inpatient claims) By 2016 this one measure will account for 25% of all Value Based Purchasing Dollars http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/NPC-MSPB-09Feb12-Final508.pdfhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/NPC-MSPB-09Feb12-Final508.pdf Accessed February 2014.

19. 19 Percent of CMS Dollars at Stake by FY 2017 Value Based Purchasing 2 % Readmission Reduction Program 3 % Healthcare Acquired Condition Program 1 % The Advisory Board Company, Healthcare Industry Committee. Hospital Value-Based Purchasing. C-Suite Cheat Sheet Series. August 2013. The Advisory Board Company, Healthcare Industry Committee. Hospital-Acquired Condition Reduction Program. C-Suite Cheat Sheet Series. August 2013. The Advisory Board Company, Healthcare Industry Committee. Hospital Readmissions Reduction Program. C-Suite Cheat Sheet Series. August 2013.

20. 20 Your Potential Financial Impact American Hospital Directory Financial Data

21. 21 Your CLABSI Data and Outcome Measures Hospital Compare

22. 22 8 Ways CLABSIs Can Impact Reimbursement 1.In 2008 CMS stopped payment of 10 hospital acquired conditions including VASCULAR CATHETER RELATED INFECTIONS 2.2015 HAC Program: Domain 1 – PSI 90 3.2015 HAC Program: Domain 2 – CLABSI 4.VBP: Outcomes Domain (VBP)-CLABSI specific line item 5.VBP: Outcomes Domain (VBP)-CLABSI is one of 8 items making up composite score for PSI-90 which is a subset of VBP outcomes domain 6.VBP: Efficiency Domain (VBP)-CLASBI can potentially elevate Medicare spending per beneficiary 7.VBP: Potential Impact to Patient Satisfaction 8.Readmission Program http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/downloads/HACFactSheet.pdf

23. 23 23 Culmination of Common Care and Maintenance Strategies CDC* SHEA**/IDSA*** Joint commission NPSG * CDC – Center for Disease Control and Prevention **SHEA – Society for Healthcare Epidemiology of America ***IDSA – Infectious Diseases Society of America

24. 24 2011 CDC Guidelines Intended to provide evidence-based recommendations for preventing intravascular catheter-related infections 5 major areas of emphasis: 1.Education of healthcare professionals 2.Use maximal sterile precautions (MSP) 3.Use of > 0.5% CHG skin prep 4.Avoiding routine replacement of CV catheters as a strategy to prevent infections 5.Use antiseptic/antibiotic impregnated catheters and CHG impregnated sponge dressing (If rate of infection not decreasing despite adherence to above 4 strategies) Targets elimination of CRBSI from all patient-care areas O’Grady NP, Alexander M, et al., Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 2011 April 1. “strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale” CHG impregnated sponge dressings are the only form of CHG dressing recommended in new CDC guidelines -“No recommendation is made for other types of chlorhexidine dressings (Unresolved Issue)” CHG impregnated sponge dressings received a Category 1B recommendation for reducing the risk of CLABSIs

25. 25 SHEA Recommended Basic and Special Approaches for Prevention of Central Line-associated Bloodstream Infections 1 Catheter Checklist B- II Hand Hygiene B- II Insertion site-Femoral A- I Cart Kit B- II Maximal Barrier PrecautionsA- I Chlorhexidine (CHG) Skin PrepA- I CHG Baths (ICU patients)B- II Impregnated Catheters A- I CHG-impregnated Sponge Disk B- I Antimicrobial Locks A- I Catheter Insertion Bundle Catheter Maintenance Bundle Basic Practices Special Approaches 1. Marschall J, et al. Supplement Article: SHEA/IDSA Practice Recommendations Strategies to Prevent Central Line- Associated Infections in Acute Care Hospitals ICHE 2008;29:S22-30.

26. 26 Joint Commission National Patient Safety Goal #7 Hospitals implement policies and practices aimed at reducing the risk of central line-associated bloodstream infections that meet regulatory requirements and are aligned with evidence-based standards The Joint Commission: Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oak Brook, IL: Joint Commission Resources, 2011

27. 27 Evidence You Should Ask For… FDA Cleared Indication for Reduction of CRBSI Highest Level of Evidence/ Studies National Guideline Recommendations It’s up to you to decide what fits best in your hospital’s protocol

28. 28 What if you have already implemented the guidelines and evidence-based practice but want to seek ongoing improvement? NPSG 07.04.01 EP 4 – Conduct periodic assessments for central line- associated bloodstream infections, monitor compliance with evidence-based practices, and evaluate the effectiveness of prevention efforts. The risk assessments are conducted in time frames defined by the organization, and this infection surveillance activity is organization wide, not targeted. http://www.jointcommission.org/assets/1/18/NPSG_Chapter_Jan2013_HAP.pdfhttp://www.jointcommission.org/assets/1/18/NPSG_Chapter_Jan2013_HAP.pdf Accessed on April 26, 2013

29. 29 Even if results are good right now, just sustaining them isn't enough. As the quality targets related to reimbursement get progressively tougher, staying the same is like standing still on a downward-moving escalator”. Studergroup

30. 30 Why Bridge The Gap From Hospital To Home Infusion and Outpatient Dialysis- The Efficiency Piece Increase patient outcomes Lower/eliminate re-admissions Patient satisfaction Diminished risk of Central Line-associated Bloodstream Infection (CLA-BSI) Avoidance of regulatory implications

31. 31 The Ochsner Model of Success Method: Standardized care and maintenance of the line; Develop an order set for PICC care and dressing changes; Checklist was developed for nurse and patient to complete together during dressing changes; and Checklist and order set was linked to the hospital’s discharge home health orders so they would print automatically when the provider discharged the patient with home health care. Results/Conclusions: By bridging the gap between the inpatient and outpatient care, Ochsner Health System was able to effectively reduce PICC infections by 46% in home infusion patients. This was accomplished through a collaborative partnership with hospital staff, infusion companies, and home health agencies and instituted a standardized process for line care and maintenance with use of a home PICC care order set and patient nursing PICC care checklist. 1. Baumgarten K, et al. Bridging the Gap: A Collaborative to Reduce PICC Infections in the Home Care Environment. Presented at AVA conference in 2012

32. 32 Next Steps – “Goal Zero” CDC – Target elimination of CLABSIs from all patient-care areas 1 – Medicare Program: Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Payments for Graduate Medical Education in Certain Emergency Situations; Changes to Disclosure of Physician Ownership in Hospitals and Physician Self-Referral Rules; Updates to the Long-Term Care Prospective Payment System; Updates to Prospective Payment System; Updates to Certain IPPS-Excluded Hospitals; and Collection of Information Regarding Financial Relationship Between Hospitals; Final Rule, Federal Register, Volume 73, Volume 161, Tuesday, August, 19, 2008. 2 – Medicare Program: Hospital Inpatient Value-Based Purchasing Program, Federal Register, Volume 76, Number 88, Friday, May 6, 2011. 3 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and FY2012 Rates; Hospitals’ FTE Resident Caps for Graduate Medical Education Payment, Federal Register, Volume 76, Number 160, Thursday, August 18, 2011. 4 – Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations, Federal Register, Volume 76, Number 212, Wednesday, November, 2, 2011. Readmission Rates Peripheral IV Lines Peripheral IV Lines Surgical Drains Home Infusion Arterial Lines Staff Compliance = Kits Staff Compliance = Kits CVC Lines & PICC Lines CVC Lines & PICC Lines Dialysis Patients LVADs

33. 33 In Summary Under rules of Value Based Purchasing, hospitals will earn back dollars, receive additional incentives or potentially lose money unless quality of care for patients improve against baseline and measurement domains When evaluating products, choose products that are solution-oriented and evidence-based to help support the needs of the changing healthcare landscape By 2017, 2% of all hospital’s Medicare Inpatient payments will be withheld to create VBP’s bonus incentives due to budget neutrality Continue to evaluate all hospital processes that fall within 2015 and 2016 domains today Continue to improve on HCAHPS, Clinical processes, however realize two more domains will be introduced in 2014 and 2015; performance period for these domains is NOW! You have to pay attention to the future today Focus on the efficiency piece of the Affordable Care Act as it pertains to the continuum of care for Home Infusion and Outpatient Dialysis http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based- purchasing/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based- purchasing/ Accessed on April 26, 2013 ©Ethicon, Inc. 2013 BP-107-13

34. 34 Conclusion The Patient Protection & Affordable Care Act is predicated on IMPROVING, more specifically continually IMPROVING PATIENT SATISFACTION and continually IMPROVING OUTCOMES over time. The hospitals that can achieve that going forward will be the most successful.

35. 35 Questions? © 2014 Ethicon US, LLC. 010613-140221