VALUE BASED PURCHASING Rosanne Raso RN, MS, NEA-BC Chief Integration Officer NYU Lutheran New York THE TRIPLE AIM 3 1
Gerhardt et al, Deloitte University Press, 2015. Continuum of Payment Models Episodic Cost Accountability Total Cost Accountability Traditional Fee-for-Service Pay-for- Performance Bundled Payments Shared Savings Partial Risk Full Risk Shared Savings Source: The Advisory Board Company: Accountable Care Forum-Briefing for Health Plan Executives FFS vs VBC: Night and Day 2
70% to 10% Process example www.hospitalcompare.gov SCIP DVT Prophylaxis 99% national average Performance Measures Part of IQR program HospitalCompare for one year Not topped out 3
HOSPITALCOMPARE: NURSING COMMUNICATION 4
HCAHPS STAR RATINGS WHAT S DIFFERENT? Linear mean score used Not Top box Includes full range of responses Always, Frequently, Sometimes, Never Final: 3548 hospitals @ 10-37-37-14-4 5
AHRQ PSI-90 HAI COMPONENT OF OUTCOME DOMAIN OUTCOMES: CAUTI ON HOSPITALCOMPARE 6
MSPB EXAMPLE: PNEUMONIA 7
Coming Next: FY2017 Domains Process - 5% Experience - 25% Efficiency - 25% Outcomes - 25% (mortality) NEW Safety - 20% CLABSI/CAUTI PSI-90 MRSA bacteremia CDiff Coming Next: FY2018 Domains Process IMM - Remove flu immunization AMI Remove fibrinolytic within 30 minutes Experience Add 3-item Care Transition Measure DOMAIN CHANGES FY2017-2019 Domain FY2017 FY2018 Clinical Outcomes 25% Clinical Process 5% Clinical Care 25% Safety 20% 25% Patient Experience with Care Coordination FY2018 25% 25% Efficiency 25% 25% FY2019 CAUTI/CLABSI all hospital, updated SIR; MSPB condition specific 8
Performance now determines reimbursement two years down the line A HIGH STANDARD FOR EACH MEASURE: 0-10 POINTS BETWEEN THRESHOLD AND BENCHMARK NO POINTS Ex Nurse Comm 79% 0-10 POINTS Ex Nurse Comm 86%, AMI 100% 9
ACHIEVEMENT VS IMPROVEMENT POINTS HCAHPS CONSISTENCY SCORE = 2 0 P O I N T S / 1 0 0 0-20 points each measure 0 th (floor) to 50 th (threshold) Lowest Score is your consistency score ALL HCAHPS measures are important 1-5 Star Rating. Achievement only DETERMINATION OF AMOUNT FOR REWARD OR PUNISHMENT 10
FY2014 1.25% WITHHOLD = $1.1B FY2015 1.50% WITHHELD = $1.4B Rewarded Break Even Penalized we found very little impact of the demonstration on nursing home performance 11
HOSPITAL ACQUIRED CONDITIONS PROGRAM NHSN: CLABSI/CAUTI 65% FY2017 85% FY2018 add non-icu AHRQ: PSI-90 35% FY2017 15% Lowest quartile penalized 1% The HAC program has drawn sharp criticism from hospitals and some experts, who predict that it will disproportionately affect hospitals that serve poorer and sicker patient populations. TRIPLE JEOPARDY CLABSI count twice on its own and in the PSI-90 12
ZERO HACs 750 HOSPITALS/$330M IN PENALTIES WHO S AT MOST RISK? CMS thinks hospital-acquired conditions penalties are fair. A JAMA study isn't so sure. Hospitals with more complex patient mix, more beds more likely to be penalized July 31, 2015 Admission within 30 days of discharge from same or another hospital Affects AMI FY2017 HF ALL Medicare discharges receive Adding PN if PN negative secondary dx in sepsis COPD adjustment or respiratory failure TKA/THA 13
3400 HOSPITALS - 2665 WITH READMISSION PENALTIES The CMS is continuing to monitor the impact of socio-economic status on provider results within quality reporting programs. The agency is working with the National Quality Forum on a two-year trial to test risk-adjusting the measures for socio-demographic factors. 14
1% 3% 1.75% 1.2% FY2015 - only 20% of hospitals avoided any penalty, 50% getting multiple penalties Goal Improve care coordination and decrease costs (Triple Aim) Setting target payment (risk considerations) Cost/case Post-acute care Why: LOS and cost reductions Who: >2000 voluntary participants How: Quarterly reconciliation $10K - $100K!! 15
Costs: $345 million less than expected in 2014 Baltimore, MD (July 30, 2015) In its fourth full year of operation, CareFirst BlueCross BlueShield s (CareFirst) Patient-Centered Medical Home (PCMH) program continues to show dramatic impacts on overall medical spending and key health care quality indicators. 19% fewer hospital admissions* 15% fewer days in the hospital* 20% fewer hospital readmissions for all causes* 5% fewer outpatient health facility visits* * Per 1,000 CareFirst Members 16
MODERN HEALTHCARE FFS TO VBP 78% of executives said should be the dominant form of payment. but only 20% said they were willing to completely abandon FFS FFS VS VBP IN NY COMMERCIAL AND MEDICAID F F S S T I L L K I N G S H A R E D R I S K I S R A R E 100% 80% 60% 40% 20% 0% VBP FFS 50% 40% 30% 20% 10% 0% Provider Risk Shared Risk 17
CHARTING THE VBP COURSE. ROI FROM VBP? http://www.beckershospitalreview.com/finance/survey NOW FUTURE 18
S Y LV I A B U R W E L L HHS 50% of FFS payments will be tied to value by 2018. How: quality incentives care coordination HIT I N S U R E R S Bulk of payments will be tied to value-based reimbursement IAN MORRISON IN H&HN OBSERVATIONS ON THE VALUE JOURNEY Many hospitals will be caught between two paradigms for the next five years (at-risk vs. fee-for-service) Bundled payment presents a major step toward promoting value and care coordination that does not require population health Value-based payment trends are not enthusiastically embraced by providers expect public payers to make more payment innovations mandatory t o b e a value - based p e r former 19
KNOW YOUR DATA 20
HHS announced an unprecedented decline in avoidable hospital harm from 2010 to 2013, which officials said prevented an estimated 50,000 deaths and saved nearly $12 billion much of that progress attributed the $1 billion Partnership for Patients. NYS PARTNERSHIP FOR PATIENTS 62 21
Tying Revenue to Quality Cost Accountability Risk Population Health 22