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AAMC Teleconference on Value-Based Purchasing (VBP) Proposed Rule
Jennifer Faerberg [email protected] 202-862-6221 January 26, 2011

VBP Proposed Rule Overview
· Move from pay-for-reporting to pay-for-performance · Must meet thresholds based on achievement or improvement to receive incentive payment · Phased-in reduction to base DRG payment to fund incentive pool: 1% for FY2013 increasing by quarter increments annually up to 2% in FY2017 · Applies to base DRG payment only, does not affect IME, DSH and outlier payments · Budget neutral ­ all funds are returned to hospitals · Focus is moving quickly to outcomes rather than process measures

Proposed Rule available at: http://www.gpo.gov/fdsys/pkg/FR2011-01-13/pdf/2011-454.pdf Comments due March 8, 2011

Structure of VBP Scoring
Total Performance Score
Domains
Process
HCAHPS
Outcomes (FY2014)
Measures/Dimension
17 Process Measures
8 Dimensions
21 measures

Patient Care Domains
FY 20013 FY 20014 (%TBD)
HCAHPS 30%
Outcome Measures
Process Measures
Process Measures 70%
HCAHPS

Measures
· Legislation requires measures in VBP must be reported on Hospital Compare for at least one year · FY 2013 · 17 clinical process of care measures · AMI, HF, PN, SCIP · HCAHPS · Including 8 of the 10 HCAHPS dimensions · Eliminating overall recommend · Combining cleanliness and quiet

FY2013 Clinical Process Measures
Condition Heart Attack Measure Aspirin at Discharge Fibrinolytic therapy received w/in 30 minutes of hospital arrival Primary PCI received w/in 90 minutes of hospital arrival Heart Failure Discharge instructions received Evaluation of LVS function ACEI or ARB for LVSD Pneumonia Pneumococcal vaccination Blood culture performed prior to administration of first antibiotic Initial antibiotic selection for CAP in immunocompetent patient Influenza vaccination

FY2013 Clinical Process Measures
Condition HealthcareAssociated Infection Measure Prophylactic antibiotic(s) one hour before incision Selection of antibiotic given to surgical patients Prophylactic antibiotic stopped within 24 hours after surgery Cardiac surgery patients with controlled 6am post-op serum glucose Surgical Care Surgery patients on beta blocker prior to arrival who received Improvement a beta blocker in the peri-oerative period Surgery patients with VTE prophylaxis ordered Surgery patients who received VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery

FY2013 HCAHPS Dimensions
HCAHPS Dimensions Nurse communication Doctor communication Cleanliness and quietness* Responsiveness of hospital staff Pain management Discharge information Communication about medications Overall rating*
*HCAHPS dimensions similar to what is currently reported on Hospital Compare. Two modifications are combining "cleanliness and quietness" and removing "would you recommend" from overall rating dimension.

Measures (cont'd.)
· FY2014 · HACs/AHRQ PSIs, IQIs/Surgical outcomes · 30-day mortality (AMI, HF, PN) · Efficiency · Medicare Spending per beneficiary · Specifically seeking comments on how to measure

Additional Measures for FY2014
Type Hospital Acquired Conditions Measure Foreign object retained after surgery Air Embolism Blood incompatibility Pressure Ulcer Stages III and IV Falls and Trauma Vascular Catheter Associated Infections Catheter Associated Urinary Tract Infections Manifestations of Poor Glycemic Control Mortality Efficiency 30-day mortality (AMI, HF, PN) Spending per beneficiary

Additional Measures for FY2014
Type AHRQ PSI/IQI Measure Iatrogenic Pnemothorax Post Operative Respiratory Failure Post Operative PE or DVT Postoperative wound dehiscence Accidental puncture or laceration AAA mortality rate Hip fracture mortality rate Complication/patient safety for selected indicators Mortality for selected conditions

Performance Periods for FY2013
· Baseline period · July 1, 2009 ­ March 31, 2010 · Performance period · July 1, 2011 ­ March 31, 2012

Calculating Clinical Process Measure Score

Structure of VBP Scoring
Total Performance Score
Domains
Process
HCAHPS
Outcomes (FY2014)
Measures/Dimension
17 Process Measures
8 Dimensions
21 measures

Scoring Methodology
· Points for achievement and improvement; whichever is higher = score · Achievement points based on actual performance compared to threshold and benchmark · Improvement points based on actual performance compared to baseline · Threshold = median or 50th percentile · Benchmark = mean of top decile of performance in baseline period

Achievement v Improvement
3 Scenarios:
Performance Exceeds Benchmark
Full Achievement Points
Threshold Benchmark
Performance Between Threshold & Benchmark
Partial Achievement Points OR Possible Improvement Points
Threshold
Benchmark
Performance Below Threshold
Possible Improvement Points ­ No Achievement Points
Threshold
Benchmark

Scoring Methodology: Process Domain Achievement
· Points awarded on a 10-point scale · If hospital score is less than threshold = no points · If hospital score is equal to or more than benchmark = 10 points · If hospital score is between threshold and benchmark = 1-9 points based on linear scale [9* ((hospital's performance period score-achievement threshold/(benchmark-achievement threshold))] + .5

Scoring Methodology: Process Domain Improvement
· Points awarded on a 9 point scale · If hospital's score was greater than its baseline but below benchmark = 0-9 points based on a linear scale · If hospital's score is lower than the baseline period = 0 points [10*((hospital performance period score-hospital baseline period score/(benchmark-hospital baseline period score))] - .5

Scoring example
Source: Federal Register January 13, 2011

Calculating Domain Score
· Total earned points for each domain = sum of points earned for applicable measures · Total possible points = total number of applicable measures *10 points · Domain score = total earned points / total possible points *100

Calculating HCAHPS Dimension Scores

Structure of VBP Scoring
Total Performance Score
Domains
Process
HCAHPS
Outcomes (FY2014)
Measures/Dimension
17 Process Measures
8 Dimensions
21 measures

FY2013 HCAHPS Dimensions
HCAHPS Dimensions Nurse communication Doctor communication Cleanliness and quietness* Responsiveness of hospital staff Pain management Discharge information Communication about medications Overall rating*
*HCAHPS dimensions similar to what is currently reported on Hospital Compare. Two modifications are combining "cleanliness and quietness" and removing one of the "overall " dimensions

HCAHPS Domain - Scoring
· Micro component (achievement/improvement points) · Evaluated by dimension · Similar to process measures · Max 80 points (10 pts for 8 dimensions) · Macro component (consistency points) · Evaluates consistency across dimensions · Max 20 points · Max HCAHPS domain score = 100 points

HCAHPS Dimensions Scoring Achievement/Improvement
· Threshold = median performance · Benchmark = 95th percentile of performance during baseline · 0-10 points for achievement · ((Hospital HCAHPS performance period dimension score -50)/5) + .5 · 0-9 points for improvement · [10*((Hospital performance period score ­ hospital baseline period score)/(benchmarkhospital baseline period score))] -.5

HCAHPS Domain Consistency Points
· To incentivize all dimensions to move towards the median and above · 0-20 points scored based on the lowest scored dimension · 20 points for hospitals where all 8 dimensions are at or above the minimum performance threshold · 0 points if lowest performance score is at or below the 0th percentile · Formula to calculate consistency score · (2*(lowest percentile/5)) - .5

HCAHPS Domain Performance Score
· For each of the 8 dimensions, determine achievement and improvement scores · Sum all scores · Calculate consistency points · Sum base score and consistency score HCAHPS total earned points = HCAHPS base score + consistency score

Calculating Total Performance Score

Structure of VBP Scoring
Total Performance Score
Domains
Process
HCAHPS
Outcomes (FY2014)
Measures/Dimension
17 Process Measures
8 Dimensions
21 measures

Weighting
· The FY2013 domains will be weighted as follows: · Process of care = 70% · HCAHPS = 30%

Calculating Total Performance Score
Source: Federal Register January 13, 2011

Minimum Samples
Clinical Process of Care Measures · Must have 10 cases per measure · Must have 4 measures in the domain HCAHPS · Must have 100 HCAHPS surveys Otherwise excluded from VBP program

Exchange Function
· CMS will translate Total Performance Score into a value-based payment utilizing a linear exchange function · All hospitals with a score above zero will receive an incentive payment

Timing of Incentive Payment
Notification of estimated value based payment 60 days prior to October 1, 2012
Notification of actual value based payment November 1, 2012
CMS processing systems updated in January 2013
Reduction/bonus (per discharge)

Validation and Public Reporting

Validation
· Utilize process in place for the inpatient reporting program for VBP · Random sample of 800 hospitals

Reporting on Hospital Compare
· CMS proposes to post on Hospital Compare each hospital's · Scores for each measure · Condition-specific scores · Domain scores · Total performance score · Performance information will be available on Quality Net November 1, 2012 · 30-day review to submit corrections

Issues
· · · · · Weighting scheme Benchmarks Efficiency measures FY2014 measures ­ HAC/AHRQ Bigger hit/bonus in January or retro back to October?

Questions?

Contact Information
Jennifer Faerberg 202-862-6221 [email protected] Karen Fisher 202-862-6140 [email protected]