Understanding Hospital Value-Based Purchasing

Transcription

1 VBP Understanding Hospital Value-Based Purchasing Updated 12/2017 Starting in October 2012, Medicare began rewarding hospitals that provide high-quality care for their patients through the new Hospital Value-Based Purchasing (VBP) Program. Hospitals paid under the Inpatient Prospective Payment System (IPPS) are paid for inpatient acute care services based in part on quality of care rather than strictly on the volume of services provided. As part of the Centers for Medicare & Medicaid Services (CMS) Quality Innovation Network-Quality Improvement Organization (QIN-QIO) Program, Lake Superior QIN offers technical assistance and support for hospitals to be successful in a value-driven environment. Instead of payment that asks, How much did you do?, the Affordable Care Act clearly moves us toward payment that asks, How well did you do?, and more importantly, How well did the patient do? Don Berwick s Points Domain Score Domain Weighting Total Performance Score Incentive Payment s The VBP program has 21 measures for fiscal year (FY) Per legislation, measures cannot be selected for VBP until they have been adopted for the hospital Inpatient Quality Reporting (IQR) Program and posted on Hospital Compare for at least one year prior to the start of the VBP performance Points For each measure, hospitals are awarded the higher of two scores one for achievement and one for improvement. Achievement Points: Awarded by comparing a hospital s rates during the, with the threshold, which is the median (50th percentile) performance of all hospitals during the baseline period, and the benchmark, which is the mean of the top decile (approximately the 95th percentile) performance of all hospitals during the baseline Note, for the Medicare Spending per Beneficiary measure, the threshold and benchmark are based on all hospitals rates in the rather than the baseline Hospitals can earn 0-10 achievement points based on performance: Hospital rate at or above benchmark (at or below for infection measures): 10 achievement points Hospital rate below achievement threshold (above for infection measures): 0 achievement points Hospital rate at or above the achievement threshold and below the benchmark (at or below the threshold and above the benchmark for infection measures): 1-9 achievement points Improvement Points: Awarded by comparing a hospital s rate during the to that same hospital s rate from the baseline Hospitals can earn 0-9 improvement points based on improvement: Hospital rate at or above benchmark (at or below for infection and complication measures): 9 improvement points Hospital rate at or below baseline period rate (at or above for infection and complication measures): 0 improvement points Hospital rate between the baseline period rate and the benchmark: 0-9 improvement points The Lake Superior Quality Innovation Network serves Michigan, Minnesota, and Wisconsin, under the Centers for Medicare & Medicaid Services Quality Improvement Organization Program. Follow us on social

2 Consistency Points: Awarded by comparing a hospital s Patient Experience of Care domain dimension rates during the to all hospitals rates from a baseline Hospitals can earn 0-20 points for consistency in this domain: If all dimension rates are at or above achievement threshold (50 th percentile): 20 Consistency Points If any dimension rate is at or below the worst-performing hospital dimension baseline period rate: 0 consistency points If the lowest dimension rate is greater than the worst-performing hospital s rate (0 percentile) but less than the achievement threshold (50 th percentile): 0-20 consistency points This formula is to be used for each dimension to determine the lowest dimension from the : Your hospital score floor National achievement threshold floor SSI Points: There will be one surgical site infection (SSI) measure score that will be a weighted average based on predicted infections for both SSI procedures: (SSI Colon measure score predicted infections) + (SSI Hysterectomy measure score predicted infections) Predicted infections for both procedures Domain Score In FY2019, VBP has four domains: the Care domain, the Person and Community Engagement domain, the Safety domain, and the domain. scores are added and divided by the total possible points x 100 to determine the Care and Outcome domain scores. Dimension scores are added together and multiplied by 8/9 to arrive at the base points. Base points plus the consistency score are added together to determine the Person and Community Engagement domain score. For the domain, the score matches the decile of performance for the one measure and domain score. Domain Weighting The federal rule defines how much each domain will be weighted to calculate the Total Performance Score for each fiscal year. See pie charts in attached summaries for specific percentages for each domain. Total Performance Score VBP domain scores are weighted and rolled up to the Total Performance Score. For instance, in FY 2019, the Total Performance Score is computed by multiplying the Care domain score by (domain weighting), the Person and Community Engagement domain score by (domain weighting), the Safety domain score by (domain weighting), and the domain score by (domain weighting) then adding those totals. The Total Performance Score is then translated into an incentive payment that makes a portion of the base diagnosis-related group (DRG) payment contingent on performance. Incentive Payment In FY 2019, 2% of DRG payments to eligible hospitals will be withheld to provide the estimated $1.7 billion available for the program incentives. Following is the schedule for withholdings since the program s inception: FY 2013: 1.00 % FY 2016: 1.75 % FY 2014: 1.25 % FY 2017: 2.00 % FY 2015: 1.50 % Succeeding years: 2.00 % Based on performance, hospitals will earn an incentive payment. The law requires CMS to redistribute the estimated $1.7 billion across all participating hospitals, based on their performance scores. CMS will use a linear exchange function to distribute the available amount of value-based incentive payments to hospitals, based on hospitals total performance scores on the hospital VBP measures. To convert the Total Performance Score to a value-based incentive payment factor that is applied to each discharge, there are six steps for each fiscal year: The Lake Superior Quality Innovation Network serves Michigan, Minnesota, and Wisconsin, under the Centers for Medicare & Medicaid Services Quality Improvement Organization Program. Follow us on social

3 Step 1: Estimate the hospital s total annual base-operating DRG amount. Step 2: Calculate the estimated reduction amount across all eligible hospitals. Step 3: Calculate the linear exchange function slope. Step 4: For each hospital, calculate the value-based incentive payment percentage. Step 5: Compute the net percentage change in the hospital s base operating DRG payment. Step 6: Calculate the value-based incentive payment adjustment factor. There is a review and correction period, as well as an appeals process. This adjustment factor is then applied to the base DRG rate and affects payment for each discharge in the relevant federal fiscal year (October 1 September 30). Eligibility Eligible hospitals are paid through the Inpatient Prospective Payment System, so critical access hospitals, children s hospitals, Veterans Affairs hospitals, long-term care facilities, psychiatric hospitals, and rehabilitation hospitals are excluded. Hospitals that are ineligible do not have the initial monies withheld, nor do they receive an incentive payment. Eligible hospitals (those paid under the prospective payment system) become ineligible if the hospital: Is subject to payment reduction for the Inpatient Quality Reporting (IQR) Program Has been cited for deficiencies that pose immediate jeopardy to the health or safety of patients Does not meet the minimum number of cases, measures, or domains (See below) In order to receive a Total Performance Score, a hospital must have scores in at least three of the four domains. For hospitals with three domain scores, the excluded domain weight will be proportionality distributed to the remaining domains. The case eligibility criteria for each domain is as follows: Care Requires a minimum of two measures; each measure requires a minimum of 25 cases Person and Community Engagement Requires a minimum of 100 surveys in the Safety Requires a minimum of three measures; PC-01 requires at least 10 cases; NHSN measures require the hospital to have at least one predicted infection during the applicable period Requires at least 25 cases Public Reporting Hospital performance information will be posted on Hospital Compare in October or December of each year. This will include: rates Condition-specific scores Domain-specific scores Total Performance Scores (TPS) Resources CMS Hospital Value-Based Purchasing Program webpage Based-Purchasing-.html CMS Hospital Value-Based Purchasing fact sheet MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN pdf Hospital Compare website QualityNet Hospital Value-Based Purchasing webpage 37 Quality Reporting Center FY 2018 Value-Based Purchasing Domain Weighting _DomainWeighting_QRG_v4_ _FINAL.508cr pdf

4 Quality Reporting Center FY 2019 Value-Based Purchasing Domain Weighting Value-Based Purchasing Worksheet available at For more information If you have questions regarding the Hospital Value-Based Purchasing Program, please visit to connect with the contact for your state.

5 FY 2018 Value-Based Purchasing Domain Weighting from October 1, 2017 to September 30, 2018) Care October 1, 2009 June 30, 2012 Experience of Care October 1, 2013 June 30, day mortality, AMI day mortality, heart failure day mortality, pneumonia Standardized infection ratio. 2 There will be one SSI measure score that will be a weighted average based on predicted infections for both procedures. Safety PATIENT AND CAREGIVER-CENTERED EXPERIENCE OF CARE/CARE COORDINATION January 1, 2014 December 31, 2014 with nurses with doctors Responsiveness of hospital staff Floor about medications Cleanliness and quietness Discharge information New! CTM-3 3-item Care Transitions Overall rating of hospital Complication/Patient Safety for Selected Indicators July 1, 2010 June 30, 2012 July 1, 2014 September 30, 2015 AHRQ PSI 90 composite January 1, 2014 December 31, 2014 (Moved from Care) Healthcare-Associated Infections* *Current standard population data January 1, 2014 December 31, CLABSI CAUTI SSI Colon 2 Abdominal Hysterectomy C. difficile (CDI) MRSA January 1, 2014 December 31, 2014 MSPB-1 Medicare ratio Mean of lowest decile of Medicare spending per ratios

6 FY 2019 Value-Based Purchasing Domain Weighting from October 1, 2018 to September 30, 2019) Care Person and Community Engagement Safety PERSON AND COMMUNITY ENGAGEMENT January 1, 2015 December 31, 2015 January 1, 2017 December 31, 2017 Floor with nurses with doctors Responsiveness of hospital staff about medications Cleanliness and quietness Discharge information Care Transition Overall rating of hospital January 1, 2015 December 31, Healthcare-Associated Infections July 1, 2009 June 30, 2012 Mortality July 1, 2014 June 30, day mortality, AMI day mortality, heart failure day mortality, pneumonia Complications July 1, 2010 June 30, 2013 New! THA/TKA Total hip/total knee arthroplasty complications January 1, 2015 June 30, January 1, 2015 December 31, CLABSI * 0.000* CAUTI * 0.000* SSI Colon 3 Abdominal Hysterectomy * 0.000* 0.762* 0.000* C. difficile 0.924* 0.113* MRSA Bacteremia 0.854* 0.000* 1 Includes selected ward (non-icu) locations. 2 Standardized infection ratio. 3 There will be one SSI measure score that will be a weighted average based on predicted infections for both procedures. *HAI thresholds and benchmarks updated utilizing new 2015 re-baselining data. January 1, 2015 December 31, 2015 MSPB-1 Medicare ratio Mean of lowest decile of Medicare spending per ratios

7 FY 2020 Value-Based Purchasing Domain Weighting from October 1, 2019 to September 30, 2020) Care Person and Community Engagement Safety PERSON AND COMMUNITY ENGAGEMENT with nurses with doctors Responsiveness of hospital staff about medications Cleanliness and quietness Floor Discharge information Care Transition Overall rating of hospital Healthcare-Associated Infections July 1, 2010 June 30, 2013 Mortality July 1, 2015 June 30, day mortality, AMI day mortality, heart failure day mortality, pneumonia Complications July 1, 2010 June 30, 2013 July 1, 2015 June 30, CLABSI CAUTI SSI Colon 3 Abdominal Hysterectomy C. difficile MRSA Bacteremia THA/TKA Total hip/total knee arthroplasty complications Includes selected ward (non-icu) locations. 2 Standardized infection ratio. 3 There will be one SSI measure score that will be a weighted average based on predicted infections for both procedures. MSPB-1 Medicare ratio Mean of lowest decile of Medicare spending per ratios

8 FY 2021 PROJECTED Value-Based Purchasing Domain Weighting from October 1, 2020 to September 30, 2021) Care Mortality July 1, 2011 June 30, 2014 July 1, 2016 June 30, day mortality, AMI day mortality, heart failure New! 30-day mortality, COPD July 1, 2012 June 30, 2015 September 1, 2017 June 30, day mortality, pneumonia * * April 1, 2011 March 31, 2014 THA/TKA Total hip/total knee arthroplasty Person and Community Engagement Complications Safety April 1, 2016 March 31, 2019 *MORT-30-PN threshold and benchmark data updated to reflect the expanded measure cohort. 1 Standardized infection ratio. 2 There will be one SSI measure score that will be a weighted average based on predicted infections for both procedures PERSON AND COMMUNITY ENGAGEMENT with nurses with doctors Responsiveness of hospital staff about medications Cleanliness and quietness Floor Discharge information Care Transition Overall rating of hospital Healthcare-Associated Infections 1 1 CLABSI CAUTI SSI Colon 2 Abdominal Hysterectomy C. difficile MRSA Bacteremia MSPB-1 Medicare ratio Mean of lowest decile of Medicare spending per ratios Payment July 1, 2012 June 30, 2015 July 1, 2017 June 30, 2019 New! 30-day episode of care AMI New! 30-day episode of care heart failure Median hospital-level with a 30-day episode-of-care during the Mean of the lowest decile hospital-level with a 30-day episodeof-care across all hospitals during the

9 FY 2022 PROJECTED Value-Based Purchasing Domain Weighting from October 1, 2021 to September 30, 2022) Care Person and Community Engagement Safety Mortality July 1, 2012 June 30, 2015 July 1, 2017 June 30, day mortality, AMI day mortality, heart failure day mortality, COPD New! 30-day mortality, CABG July 1, 2012 June 30, 2015 September 1, 2017 June 30, day mortality, pneumonia Complications April 1, 2012 March 31, 2015 April 1, 2017 March 31, 2020 THA/TKA Total hip/total knee arthroplasty Updated cohort. 2 Potential removal in future rulesmaking. 3 Includes selected ward (non-icu) locations. 4 Standardized infection ratio. 5 There will be one SSI measure score that will be a weighted average based on predicted infections for both procedures. PERSON AND COMMUNITY ENGAGEMENT with nurses with doctors Responsiveness of hospital staff about medications Cleanliness and quietness January 1, 2020 December 31, 2020 Floor Discharge information Care Transition Overall rating of hospital January 1, 2020 December January 1, 2018 December 2018 Healthcare-Associated Infections January 1, 2020 December CLABSI CAUTI SSI Colon 5 Abdominal Hysterectomy C. difficile MRSA Bacteremia MSPB-1 Medicare January 1, 2020 December 31, 2020 July 1, 2012 June 30, 2015 Payment ratio Mean of lowest decile of Medicare spending per ratios July 1, 2017 June 30, day episode of care AMI Median hospital-level Mean of the lowest decile hospital-level 30-day episode of care heart failure with a 30-day episode-of-care with a 30-day episodeof-care during the across all hospitals during the July 1, 2013 June 30, 2016 August 1, 2018 June 30, 2020 New! 30-day episode of care pneumonia Median hospital-level with a 30-day episode-of-care during the Mean of the lowest decile hospital-level with a 30-day episodeof-care across all hospitals during the

10 FY 2023 PROJECTED Value-Based Purchasing Domain Weighting from October 1, 2022 to September 30, 2023) Care Person and Community Engagement Safety Mortality July 1, 2013 June 30, 2016 July 1, 2018 June 30, day mortality, AMI day mortality, heart failure day mortality, COPD day mortality, CABG day mortality, pneumonia Complications April 1, 2013 March 31, 2016 April 1, 2018 March 31, 2021 THA/TKA Total hip/total knee arthroplasty Updated cohort. 2 Potential removal in future rulesmaking. 3 Includes selected ward (non-icu) locations. 4 Standardized infection ratio. 5 There will be one SSI measure score that will be a weighted average based on predicted infections for both procedures. The Lake Superior Quality Innovation Network serves Michigan, Minnesota, and Wisconsin, under the Centers for Medicare & Medicaid Services Quality Improvement Organization Program. This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-D PERSON AND COMMUNITY ENGAGEMENT January 1, 2021 December 31, 2021 Floor with nurses with doctors Responsiveness of hospital staff about medications Cleanliness and quietness Discharge information Care Transition Overall rating of hospital Complication/Patient Safety for Selected Indicators October 1, 2015 June 30, 2017 July 1, 2019 June 30, 2021 New! Patient Safety and Adverse Events Composite January 1, 2021 December Healthcare-Associated Infections January 1, 2021 December CLABSI CAUTI SSI Colon 5 Abdominal Hysterectomy C. difficile MRSA Bacteremia MSPB-1 Medicare January 1, 2021 December 31, 2021 July 1, 2013 June 30, 2016 Payment ratio across all hospitals during performance Mean of lowest decile of Medicare ratios across all hospitals during performance July 1, 2018 June 30, day episode of care AMI Median hospital-level Mean of the lowest decile hospital-level 30-day episode of care heart failure with a 30-day episodeof-care across all with a 30-day hospitals during the episode-of-care during the July 1, 2013 June 30, 2016 August 1, 2018 June 30, day episode of care pneumonia Median hospital-level with a 30-day episodeof-care across all hospitals during the Mean of the lowest decile hospital-level with a 30-day episode-of-care during the