Incentives and Penalties CAUTI & Value Based Purchasing and Hospital Associated Conditions Penalties: How Your Hospital s CAUTI Rate Affects Payment Linda R. Greene, RN, MPS,CIC UR Highland Hospital Rochester, NY Linda_greene@urmc.rochester.edu 1 Objectives: Describe Federal Reporting Requirements for CAUTIs Distinguish between Hospital-Acquired Conditions and Value Based Purchasing Identify strategies to identify vulnerabilities in the ICU enviornment 2 Florida Hospital Association 1
Federal Reporting Requirements Payment Removal for Complications Hospital-Acquired Conditions Initiative from the Deficit Reduction Act of 2005: section 5001(c) No Pay Policy, October 2008 CMS was directed to choose three hospital-acquired complications for which hospitals no longer receive additional payment, guided by three criteria: 1 1. high volume and/or cost, 2. results in higher payment when listed as secondary diagnosis, 3. reasonably preventable through evidence-based guidelines. Note: This Medicare policy was rapidly adopted by most payers, including state Medicaid, BCBS, *No and riskadjustment others. 1 Federal Register. August 22 2007;72(162):47129-48175. Florida Hospital Association 2
CAUTI; double trouble Measure Score Each Hospital receives 1-10 points based upon their percentile ranking. Highest points are assigned to the lowest performing hospitals. Florida Hospital Association 3
Value Based Purchasing ( VBP) 7 HAC Weighting/Scoring Weight Measure Performance Period Domain 1 PSI 90 7/1/11 6/30/13 Domain 2 CDC HAI 1/1/12 12/31/13 Domain 2 65% Domain 1 35% If rate falls into this percentile.. 1 st 10 th 11 th 20 th 21 st 30 th 31 st 40th 41 st 50 th 51 st - 60 th 61 st 70 th 71 st 80 th 81 st 90 th 91 st 100th Then assign this number of points (lower is better) 1 2 3 4 5 6 7 8 9 10 Florida Hospital Association 4
The Cost 9 Academic Medical Centers hit hard 10 Florida Hospital Association 5
Value Based Purchasing 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 on quality of care not the volume of services they provide 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 11 Points Points Each hospital may earn two scores on each measure one for achievement and one for improvement. The final score awarded to a hospital for each measure or dimension is the higher of these two scores. 12 Florida Hospital Association 6
Achievement Points Achievement Points: During the performance period, these are awarded by comparing an individual hospital s rates with the threshold, which is the median, or 50th percentile of all hospitals performance during the baseline period, and the benchmark, which is the mean of the top decile, or approximately the 95th percentile during the baseline period.* Hospital rate at or above benchmark: 10 achievement points Hospital rate below achievement threshold: 0 achievement points Hospital rate equal to or greater than the achievement threshold and less than the benchmark: 1-9 achievement points 13 Improvement Points Improvement Points: Awarded by comparing a hospital s rates during the performance period to that same hospital s rates from the baseline period. Hospital rate at or above benchmark: 9 improvement points Hospital rate at or below baseline period rate: 0 improvement points Hospital rate between the baseline period rate and the benchmark: 0-9 improvement points 14 Florida Hospital Association 7
Value Based Purchasing ( VBP) 15 HAC and VBP HAC can only lose money scores bad VBP can recover money scores good 16 Florida Hospital Association 8
The Scenario You just received a call from administration regarding the HACs It seems that administration has just become aware that they are slated to lose over $500,000 as a result of the HAC Medicare reimbursement penalty. The major contributor CAUTIs The Question Why weren t we aware of this? 17 Understanding and Tracking the SIR The standardized infection ratio (SIR) is a summary measure used to track health careassociated infections (HAIs) at a national, state, or local level over time. The SIR adjusts for patients of varying risk within each facility. 18 Florida Hospital Association 9
Simply Put SIR less than 1 means hospital had fewer HAIs than hospitals of similar type and size SIR of 1 means hospital's HAI score no different than hospitals of similar type and size SIR more than 1 means hospital had more CLABSIs than hospitals of similar type and size Lower numbers are better A score of zero (0) meaning no CAUTIs is best 19 Standardized Infection Ratio Observed # of HAIs the number of events that are entered into NHSN Expected or predicted # of HAIs comes from national baseline data When the SIR = 1, then the number of observed = the number expected Example 0/E 5 Observed / 4 Expected = SIR 1.25 20 Florida Hospital Association 10
A Closer Look Unit Expected CAUTI Observed SIR Med Surg ICU 7.2 14 14/7.2= 1.9 Cardiothoracic ICU 4 3 3/4 = 0.75 Surgical ICU 6 7 7/6= 1.2 Total 17.2 24 24/17.2= 1.4 21 Why Use the SIR? It is a summary statistic widely used in public health (i.e. mortality data). In HAI data analysis, the SIR compares the actual number of HAIs reported with the baseline U.S. experience (referred to as the referent period). 22 Florida Hospital Association 11
What does the SIR number mean? An SIR greater than 1.0 indicates that more HAIs were observed than predicted. An SIR of 1.0 indicates that the number of HAIs observed was equal to the number predicted. An SIR less than 1.0 indicates that fewer HAIs were observed than predicted. However, the SIR alone does not imply statistical significance. The SIR is only a point estimate and needs additional information to indicate if the finding is significant and not likely due to chance (that is, statistically significantly different from 1). 23 Statistical significance A p-value and 95% confidence interval (CI) are calculated by NHSN for each SIR. The p-value identifies if the information is statistically significant. If the p-value is < 0.05, the SIR is statistically significant". The 95% CI can sometimes be used to approximate statistical significance. A 95% CI assesses the SIR s magnitude and stability. If the SIR 95% CI does not contain the value 1, the SIR is considered "statistically significant." 24 Florida Hospital Association 12
What does a significant SIR mean? While in many cases, significantly high SIRs may reflect a need for stronger CAUTI prevention efforts and significantly low SIRs may support already existing strong CAUTI prevention efforts, several other factors such as validation of reported data may play a role. The real measure of success is following the SIRs over time to indicate if positive progress occurs and is sustained. Because the ultimate goal is zero HAIs, prevention efforts are never complete. 25 Data CAUTIs ICU Quarter # CAUTIs # expected # UC Days SIR P-value 95% CI 2014 YH 1 11 3.894 1693 2.825 0.0031 1.485,4.91 0 Florida Hospital Association 13
What Else? # CAUTI # Cath DAYS CAUTI Rate CAUTI Mean Pval Pctl Pt. Days DUR DUR Mean Pval pctl 11 1785 6.1 2.4.0072 92 1993 0.896 0.68 000 92 27 Back to the Scenario Important to understand and communicate Helps prioritize opportunities What needs to be done? The DUR is High Consider nurse driven protocols, automatic stop orders, meaningful rounding etc. What about appropriate culturing? 28 Florida Hospital Association 14
Communication Strategies Connect the dots to patient safety. Clearly articulate current status and concerns. Demonstrate knowledge of the data. Know where the vulnerabilities are. Always identify actions and recommendations. 29 Helpful Hints Measurement period is different based upon what it is used for Program HAC Hospital Compare VBP Most State Reporting Measurement time frame for HAIs Currently 2 years worth of data 4 Quarters updated. Displayed Quarterly (April, July, October, December) 1 year Calendar year ( may be different by state) 30 Florida Hospital Association 15