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The Changing Landscape The Changing Landscape Vl B dP h i Ri b t d it V alue Based Purchasing, Reimbursement and its Impact on Nursing Troy A Trosclair, RN, DNS, CPHRM Vice President Clinical Services Vice President, Clinical Services HCA MidAmerica Division
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The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division

Oct 31, 2014

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Troy Trosclair, HCA MidAmerica Division - Speaker at the marcus evans National Healthcare CNO Summit, held in Hollywood, FL, April 26-28, 2012, delivered his presentation entitled The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing
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Page 1: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division

The Changing LandscapeThe Changing LandscapeV l B d P h i R i b t d itValue Based Purchasing, Reimbursement and its Impact on Nursing

Troy A Trosclair, RN, DNS, CPHRMVice President Clinical ServicesVice President, Clinical ServicesHCA MidAmerica Division

Page 2: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division

How Did We Get Here?How Did We Get Here?How Did We Get Here?How Did We Get Here?Hospital payments account for the largest share of Medicare spending

Medicare is the largest single payer for hospital services.

I 2009 > 7M M di b fi i i h d > 12 4M IPIn 2009, > 7M Medicare beneficiaries had > 12.4M IP hospitalizations

One in seven Medicare patients will experience some “adverse” p pevent (preventable illness or injury) while in the hospital.

One in three Medicare patients who leave the hospital will have a readmission within one month.readmission within one month.◦ In 2009, readmissions cost Medicare $26 billion

Every year, >98,000 Americans die from errors in hospital care $◦ In 2009, Medicare spent $4.4 billion for patients harmed in hospitals

Page 3: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division

Health Care ReformHealth Care ReformHealth Care ReformHealth Care Reform

Page 4: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division

CMS Value Based PurchasingCMS Value Based PurchasingCMS Value Based PurchasingCMS Value Based PurchasingAffordable Care Act, Section 3001◦ The Secretary of HHS is required to establish a hospital value-The Secretary of HHS is required to establish a hospital value

based purchasing program◦ Effective with discharges of Oct. 1, 2012◦ Applies to short term, general, acute care hospitals

Hospitals excluded from the VBP program include:◦ Psych, rehab, LTC, Children’s, Cancer ,and Critical Access hospitals.◦ Hospitals without data in at least four process measures with a minimum of 10 cases in

each measureeach measure.◦ Hospitals without at least 100 completed HCAHPS surveys during the Performance Period◦ Hospital without at least 10 cases for each of at least 4 applicable clinical measures during

the Performance Period◦ Hospitals cited for deficiencies during the Performance Period that pose p g p

IMMEDIATE JEOPARDY to the health or safety of patients (results in immediate suspension from VBP for 12 months).

The application of this exclusion is under further discussion by CMS due to several posed concerns; CMS clarification to follow in the future.

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CMSCMS Immediate JeopardyImmediate Jeopardy TriggersTriggersCMS CMS Immediate Jeopardy Immediate Jeopardy TriggersTriggersFailure to protect from:

Ab l t h l i l h d◦ Abuse, neglect, psychological harm, undue adverse medication consequences, widespread hospital-acquired infections

Failure to provide:◦ Adequate nutrition & hydration◦ Safety from fire smoke and environment◦ Safety from fire, smoke, and environment

hazards◦ Initial medical screening, stabilization and

safe transfers of patients ith emergencsafe transfers of patients with emergency medical conditions (EMTALA)

Failure to correctly identify patientsy y pFailure to safely administer blood products

Page 6: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division
Page 7: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division
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CMS ValueCMS Value--Based Purchasing:Based Purchasing:Linking Federal Reimbursement to Clinical Linking Federal Reimbursement to Clinical ggPerformancePerformance

Over the next five years, approximately 6% of inpatient Medicare reimbursements to hospitals will be linked to clinical performance (exclusive

f M i f l U i ti )of Meaningful Use incentives).• CMS has stated its intention to extend the performance-based reimbursement to

the state-run Medicaid program.

This is not only federal administrative intent it is lawThis is not only federal administrative intent, it is law.• Affordable Care Act mandates “Value-Based Purchasing” in the Medicare program

and stipulates:Payment tied to hospital performance on core measures and HCAHPS.Decreased reimbursement for high readmission rates.Decreased reimbursement for high rates of HACs.

2018 201920162011 2012 2013 2014 2015 2017

Hospital Value‐Based Purchasing (1‐2%; Phased in over 4 Years)1.00% 1.25% 1.50% 1.75% 2.00%

Hospital Readmissions (1‐3%; Phased in over 3 Years)1 00% 2 00% 3 00%

Hospital Acquired Conditions (1%)1.00%

1.00% 2.00% 3.00%

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CMS Value Based PurchasingCMS Value Based PurchasingCMS Value Based PurchasingCMS Value Based PurchasingAffordable Care Act, Section 3001◦ CMS funds the VBP program by reducing the base operating DRG

payment amount by an amount equal to the amount the hospital can earn in a VB incentive payment (i.e. no increase in overall Medicare spending for IP stays)spending for IP stays)

2013 = 1.0% = $850M to be awarded to hospitals2014 = 1.25%2015 = 1.5%2016 1 75%2016 = 1.75%2017 = 2.0%All subsequent years = 2.0%

◦ Possible impact:pPredict that 9% of hospital payments and 11% MD payments affected by 2016The only way to ensure full payback is to hit the benchmark on every measure.

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CMS Value Based PurchasingCMS Value Based PurchasingCMS Value Based PurchasingCMS Value Based PurchasingProposed rule released Jan. 7, 2011; Final rule released April 29, 20112 Domains2 Domains◦ Process (core) measures (17 12)◦ HCAHPS (8 dimensions)

Will not use “willingness to recommend”“cleanliness” and “quietness” indicators will be combined (average of the individual domain scores)

All measures within a domain are equally weightedThe two domains are weighted differentlyThe two domains are weighted differently◦ Process measures (70%)◦ HCAHPS (30%)Points assigned for:Points assigned for: ◦ (a) level of achievement and ◦ (b) improvement

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Incentive Payment CalculationsIncentive Payment CalculationsIncentive Payment CalculationsIncentive Payment Calculations

◦ CMS will notify each hospital of their estimated amount via QualityNet account at least 60 days prior to Oct 1, 2012◦ CMS will notify each hospital of the exact

amount on Nov 1, 2012.Th h it l ith hi h TPS ill◦ Those hospitals with higher TPS will receive higher payments◦ Will use a linear exchange function to◦ Will use a linear exchange function to

calculate the % of payment

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Linear Exchange CurveLinear Exchange CurveLinear Exchange CurveLinear Exchange CurveVBP payments are based upon the slope of the linear exchange line. The slope of the linear exchange is determined by theline. The slope of the linear exchange is determined by the aggregate performance of all US hospitals.

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Core Measure SelectionCore Measure SelectionCore Measure SelectionCore Measure Selection

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FY 2013 Clinical Process MeasuresFY 2013 Clinical Process Measures

20

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FY 2013 HCAHPS MeasuresFY 2013 HCAHPS MeasuresFY 2013 HCAHPS MeasuresFY 2013 HCAHPS MeasuresNurse Communication CompositeDoctor Communication CompositeCleanliness and Quietness Composite (N C it )(New Composite)Responsiveness of Hospital Staff CompositeCompositePain Management CompositeCommunication About MedicationsCommunication About Medications CompositeDischarge Information CompositeDischarge Information CompositeOverall Rating

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Page 23: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division
Page 24: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division
Page 25: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division

HCAHPS ScoringHCAHPS ScoringHCAHPS ScoringHCAHPS ScoringAchievement◦ Scoring is done at the individual measure levelScoring is done at the individual measure level

Hospital performance: Equal to or greater than the Benchmark = 10 pointHospital performance: Less than the Benchmark but equal to or greater than the Achievement Threshold = 1 – 9 points based on a linear scale for the achievement rangeHospital performance: Less than the Achievement Threshold = 0 pointsHospital performance: Less than the Achievement Threshold = 0 points

Improvement◦ Scoring is done at the individual measure level

Hospital performance: Greater than its baseline period score but less B h k 0 9 i t b d li l f th i tBenchmark = 0 – 9 points based on a linear scale for the improvement rangeHospital performance: Equal to or lower than is baseline period on the measure = 0 points

Hospital earns the greater of the twoHospital earns the greater of the twoNEW FACTOR: Consistency◦ How well the hospital performed on all the HCAHPS dimensions (applicable to

HCAHPS measures only) (0-20 points)◦ Hospital performance: All HCAHPS dimensions exceed the achievement◦ Hospital performance: All HCAHPS dimensions exceed the achievement

threshold

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HCAHPS Scoring ExampleHCAHPS Scoring ExampleHCAHPS Scoring ExampleHCAHPS Scoring Example

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VBP Metrics Heavily yInfluenced by Nursing Care

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FY 2014 VBP RevisedFY 2014 VBP RevisedFY 2014 VBP RevisedFY 2014 VBP RevisedNov 1, 2011◦ CMS will NOT include the following:

OUTCOME MEASURESHACs AHRQ composites

EFFICIENCY MEASURES

Weight percentage revisions in 2014:◦ HCAHPS = 30%◦ Outcomes (Mortality) = 25%◦ Outcomes (Mortality) = 25%◦ Clinical Performance (core) Measures = 45%

Performance PeriodPerformance Period ◦ Clinical Performance & HCAHPS (4/1/2012 – 12/31/2012)◦ 30 day Mortality (7/1/11 – 6/30/12)

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AHRQ isAHRQ isAHRQ is…..AHRQ is…..The health services research arm of the U.S. Department of Health and Human Services (HHS), complementing the biomedical

h i i f it i t th N ti l I tit t fresearch mission of its sister agency, the National Institutes of Health. Home to research centers that specialize in major areas of health care research: ◦ Quality improvement and patient safety. ◦ Outcomes and effectiveness of care. ◦ Clinical practice and technology assessment. ◦ Health care organization and delivery systems. g y y◦ Primary care (including preventive services). ◦ Health care costs and sources of payment.A major source of funding and technical assistance for health services research and research training at leading U.S. universitiesservices research and research training at leading U.S. universities and other institutions. A science partner, working with the public and private sectors to build the knowledge base for what works—and does not work—in health and health care and to translate this knowledge into everyday g y ypractice and policymaking.

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AHRQ IndicatorsAHRQ IndicatorsAHRQ IndicatorsAHRQ IndicatorsThe Patient Safety Indicators are part of a set of software modules of the Agencya set of software modules of the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QIs) ( ) y ( )developed by the University of California, San Francisco–Stanford University Evidence-based PracticeUniversity Evidence based Practice Center and the University of California, Davis under a contract with AHRQ.

The Patient Safety Indicators were originally released in 2003originally released in 2003.

Page 31: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division

AHRQ Inpatient Quality IndicatorsAHRQ Inpatient Quality IndicatorsAHRQ Inpatient Quality IndicatorsAHRQ Inpatient Quality IndicatorsInpatient Quality Indicators

Can be used to help hospitals identify potential problem areas that might need further study as well as for quality improvement comparative public reporting trending and paystudy, as well as for quality improvement, comparative public reporting, trending, and pay-for performance initiatives.

Can provide an indirect measure of in hospital quality of care by using administrative data found in a typical discharge record.

Include mortality indicators for conditions or procedures for which mortality can vary from hospital to hospital.

Include utilization indicators for procedures for which utilization varies across hospitals or geographic areasgeographic areas.

Include volume indicators for procedures for which outcomes may be related to the volume of those procedures performed.

A f d bli l il blAre free and publicly available.

Include risk adjustment where appropriate.

Page 32: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division

AHRQ Inpatient Quality IndicatorsAHRQ Inpatient Quality IndicatorsAHRQ Inpatient Quality IndicatorsAHRQ Inpatient Quality IndicatorsHospital-level procedure utilization rates

• Cesarean section delivery• Primary cesarean delivery Mortality rates for conditions• Primary cesarean delivery• Vaginal birth after cesarean, uncomplicated• Vaginal birth after cesarean, all• Incidental appendectomy in the elderly• Bilateral cardiac catheterization

y• Acute myocardial infarction (AMI)• AMI without transfer• Congestive heart failure• Gastrointestinal hemorrhage• Hip fracture

P i• Laparoscopic cholecystecomy

Area-level utilization rates (county, State)• Coronary artery bypass graft

H t t

• Pneumonia• Acute stroke

Mortality rates for procedures

• Hysterectomy• Laminectomy or spinal fusion• Percutaneous transluminal coronary angioplasty

• Abdominal aortic aneurysm repair• Coronary artery bypass graft• Craniotomy• Esophageal resection• Hip replacement• Pancreatic resectionVolume of procedures

• Abdominal aortic aneurysm repair• Carotid endarterectomy• Coronary artery bypass graft• Esophageal resection

• Pancreatic resection• Percutaneous transluminal coronary angioplasty• Carotid endarterectomy

• Esophageal resection• Pancreatic resection• Percutaneous transluminal coronary angioplasty

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AHRQ Patient Safety AHRQ Patient Safety IndicatorsIndicatorsPatient Safety Indicators

Can be used to help hospitals and health care organizations assess, monitor, p p gtrack, and improve the safety of inpatient care.

Can be used for comparative public reporting and pay-for-performance initiatives.

Can identify potentially avoidable complications that result from a patient’s exposure to the health care system.

Include hospital-level indicators to detect potential safety problems that occur d i ti t’ h it l tduring a patient’s hospital stay.

Include area-level indicators for potentially preventable adverse events that occur during a hospital stay to help assess total incidence within a region.

Are publicly available at no charge to the user.

Include risk adjustment where appropriate.

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AHRQ Patient Safety AHRQ Patient Safety IndicatorsIndicatorsHospital-level indicators

Death in low-mortality diagnosis-related groupsPressure ulcerPressure ulcerDeath among surgical inpatients with treatable serious complicationsForeign body left in during procedureIatrogenic pneumothoraxCentral venous catheter-related bloodstream infectionsCentral venous catheter-related bloodstream infections Postoperative hip fracturePostoperative hemorrhage or hematomaPostoperative physiologic and metabolic derangementsPostoperative respiratory failurePostoperative respiratory failurePostoperative pulmonary embolism or deep vein thrombosisPostoperative sepsisPostoperative wound dehiscenceAccidental puncture or lacerationTransfusion reactionBirth trauma—injury to neonateObstetric trauma—vaginal delivery with instrumentObstetric trauma—vaginal delivery without instrument

Page 35: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division

AHRQ Patient Safety and Inpatient Quality Indicators Hospital Compare – 4Q2008 thru 2Q2010

Data Source: Hospital Compare October 2011.(

5) No data are available for publication from the hospital for this measure

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AHRQ StrategiesAHRQ StrategiesAHRQ StrategiesAHRQ Strategies

Individual case reviewProfessional peer reviewValidate use of evidenced basedValidate use of evidenced based practicesQuality of documentation & accuracyQuality of documentation & accuracy of coding

Page 37: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division

Potential Future Measures and Potential Future Measures and ChChChangesChanges

In 2013, hospitals will receive a payment reduction if they have excess 30-day readmissions for patients with AMI, HF, y p , ,and PN.

By 2015, a portion of Medicare payments will be linked to Meaningful Use Hi TechnologyMeaningful Use Hi Technology

Over time, scoring methodologies will be weighted more heavily towards outcome, patient experience, and functionalheavily towards outcome, patient experience, and functional status measures.

In 2015, hospitals with certain Hospital Acquired Conditions (HAC’ ) ill i dditi l t d ti f(HAC’s) will receive additional payment reductions from Medicare

With more to comeWith more to come………….

Page 38: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division
Page 39: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division

CMS Physician Quality Reporting System CMS Physician Quality Reporting System (PQRS)(PQRS)(PQRS)(PQRS)

Formerly known as PQRI (initiative)Established by 2006 Tax Relief & Health Care ActEstablished by 2006 Tax Relief & Health Care Act◦ Required establishment of a PQRS◦ Including an incentive payment for eligible professionals

who report data on quality measures for covered p q yprofessional services furnished to Medicare beneficiaries

Annual CMS rulemaking process for each program year◦ Program requirements and measure specifications may be

diff t tdifferent year to yearEligible professionals may choose to report quality measures or measure groups:

To CMS on Medicare Part B claims◦ To CMS on Medicare Part B claims◦ To a qualified PQRS registry◦ To CMS via a qualified EHR product

Page 40: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division

PQRIPQRIPQRIPQRIFinancial Incentives/Penalties for participation◦ Incentives: 1.0% in 2011, 0.5% in 2012-,

2014◦ Penalties: -1.5% in 2015, -2.0% in 2016

and beyond2009 Experience Report Highlights◦ $234 million total payout◦ Average $1,956 per eligible professional/ g p g p

$18,525 per practice

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PQR Eligible ProfessionalsPQR Eligible ProfessionalsPQR Eligible ProfessionalsPQR Eligible Professionals1. Medicare physicians

◦ Doctor of Medicine◦ Doctor of Medicine ◦ Doctor of Osteopathy ◦ Doctor of Podiatric Medicine ◦ Doctor of Optometry ◦ Doctor of Oral Surgery ◦ Doctor of Dental Medicine ◦ Doctor of Chiropractic

2. Practitioners ◦ Physician Assistant◦ Physician Assistant ◦ Nurse Practitioner ◦ Clinical Nurse Specialist ◦ Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant) ◦ Certified Nurse Midwife ◦ Clinical Social Worker ◦ Clinical Psychologist ◦ Registered Dietician ◦ Nutrition Professional

A di l i t◦ Audiologists

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PQR Eligible ProfessionalsPQR Eligible ProfessionalsPQR Eligible ProfessionalsPQR Eligible Professionals3. Therapists p◦ Physical Therapist ◦ Occupational Therapist p p◦ Qualified Speech-Language Therapist

Eligible But Not Able to Participate ◦ Eligible to participate but are not able to◦ Eligible to participate but are not able to

participate for one or more reasons (specifics listed in www.cms.gov/PQRS)(specifics listed in www.cms.gov/PQRS)

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2011 PQR Measures List2011 PQR Measures List2011 PQR Measures List2011 PQR Measures List

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2012 PQR Group Measures2012 PQR Group Measures2012 PQR Group Measures2012 PQR Group Measures

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CMS Public Reporting MetricsCMS Public Reporting MetricsCMS Public Reporting MetricsCMS Public Reporting Metrics

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Future Public Measure ChangesFuture Public Measure ChangesFuture Public Measure ChangesFuture Public Measure Changes

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2012 and beyond….looking ahead….2012 and beyond….looking ahead….2012 and beyond….looking ahead….2012 and beyond….looking ahead….

Four primary buckets of quality metrics:◦ CMS VBP measures

◦ CMS HQA IPPS measures

CMS HQA OPPS measures◦ CMS HQA OPPS measures

◦ TJC Core Measures TJC Accountability ofTJC Core Measures TJC Accountability of Care Measures or TJC Non-Accountability of Care Measures

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CMS HQA Measures: Current/Future Public Reporting per OPPS 2011 Final Rule

1Measures collected in one year are used to determine Annual Payment Update status for the subsequent year.2Medicare patients only, administrative claims based data

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Joint Commission Joint Commission C M R i tC M R i tCore Measure RequirementsCore Measure Requirements

Hospitals are only required to submit data on four measure sets:measure sets:◦ AMI◦ HF◦ PN◦ Surgical Care Improvement Project (SCIP)◦ Perinatal◦ VTE◦ Stroke◦ Behavioral Health (HBIPS)◦ Children’s Asthma Care (CAC)

O t ti t◦ Outpatient◦ ED Chart Abstracted Measures◦ IMM

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TJC Accountability MeasuresTJC Accountability MeasuresTJC Accountability MeasuresTJC Accountability MeasuresAccountability measures are now used by TJC to identify their Top Performers on JC Key Quality MeasuresPerformers on JC Key Quality Measures

Top Performer – 95% on each and all measuresBased on 2010 dataAMI, HF, PN, SCIP and CAC

f◦ In January, 2012 the following measure sets were added:HBIPS (6 indicators)Stroke (5 indicators) VTE (8 indicators)Changes to current measure set (1 new indicator for AMI, PN, & SCIP)Composite Score – 85% target rate for accountability measures.Facilities not meeting 85% target will receive a Direct Impact RFI (ESC submission within 45 days)y )

Re-evaluate your measure selection decisionThe last time hospitals could make a measure selection change: December, 2011

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Managed Care VBPManaged Care VBPManaged Care VBPManaged Care VBPEngaging in P4P initiatives◦ Appropriate use of Surgical Safety

ChecklistsM it i h it l bli t dMonitoring hospital public reported metrics

H it l C◦ Hospital Compare◦ Leapfrog◦ Others◦ OthersUsing quality data to manage contract (re)negotiations(re)negotiationsUsing quality data for steerage

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First Do No Harm……..

“It may seem a strange y gprinciple to enunciate as

the very first yrequirement in a

Hospital that it should pdo the sick no harm.”

- Florence Nightingale, Notes g gon Hospitals, 1859

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CMS HospitalCMS Hospital--Acquired Conditions Acquired Conditions (HAC)(HAC)(HAC)(HAC)

Proposed rule released Feb 17, 2011Final rule released June 1 2011Final rule released June 1, 2011Requirements effective July 1, 2011◦ States have option to delay implementation through July 1,

20122012

Prohibits federal payments (Medicare & Medicaid) for 27 HAC’s◦ Excludes DVT/PE for total hip & knee replacement for pediatric and obstetric populations◦ Includes state managed care contracts

N TNew Terms◦ Provider Preventable Conditions (PPC) – two categories:

Healthcare Acquired Conditions (HCAC) – current Medicare HAC’sOther Provider Preventable Conditions (OPPC) – state specificOther Provider Preventable Conditions (OPPC) state specific

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CMS HospitalCMS Hospital--Acquired Conditions Acquired Conditions (HAC)(HAC)(HAC)(HAC)

OPPC gives states leeway to add additional preventable conditions to the list (with CMS approval) for Medicaid ( pp )nonpayment.◦ Also allows nonpayment provisions beyond IP hospital setting

(i.e. OP)◦ Minimally must include:Minimally must include:

Wrong surgical or other invasive procedure patient, site, or procedureProjected impact:◦ 1:15,000 surgery procedures results in RFB◦ Average cost of RFB is $63K per hospital stay (CMS)◦ After legal defense & indemnity payments = $166K ◦ Medicare = withhold of approximately 20M per year

Medicaid cost savings of 2M for FY 2011◦ Medicaid = cost savings of 2M for FY 2011◦ Aggregate cost savings of 35M for FY 2011 through 2015

20M for Federal share15M for State share

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Public PerceptionPublic PerceptionPublic PerceptionPublic Perception

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HAC Top Performer 5 HAC Top Performer 5 ThemesThemesThemesThemesFacilities with zero (or the fewest) HACs based on 10 quarters of coding data1 Engaged leadership1. Engaged leadership

1. Support and enforce for accountability at the unit level2. Evaluate daily process measures

1. MEDITECH NPR reports to evaluate length of time with a p gfoley and/or central line/PICC

3. Rounding daily by clinical experts (Infection Preventionist, Clinical Nurse Specialist, etc.) 1. Educating nurses and physicians based on facility needs1. Educating nurses and physicians based on facility needs2. Questioning on clinical justification for urinary catheters

and/or central line/PICC4. Supportive physician champion

1 Engaged physician champion and medical staff1. Engaged physician champion and medical staff5. Review process

1. Charts coded POA=N for HACs reviewed before bill is dropped

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ChallengesChallenges

Rapid expansion of measures

Growth in hospital and physician P4P programsmeasures

Combination of clinical, experience, and outcome

physician P4P programs◦ Physician Quality Reporting

System (PQRS)pmeasuresFocus on episode of illness

Types of performance targetsTypes of financialillness

Patients crossing measure sets (IP & OP)

Types of financial incentivesCare management ( )redesignStaffing costs

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Building a CultureBuilding a CultureBuilding a CultureBuilding a Culture“We must stop putting silos around the various facets of healthcare.”

“Th ti t i i t i l t d t R th it i th f ll i t ti“The patient experience is not an isolated event. Rather, it is the sum of all interactions, shaped by an organization's culture, that influence patient perceptions across the continuum of care.”

“ the patient experience is comprised of every impression and encounter a patient (or…the patient experience is comprised of every impression and encounter a patient (or family member) has with your health system.”

“Like it or not, the patient experience is the holy grail for healthcare providers. That said, hospitals need to focus on their culture, not on their grade…..We need to keep the focus

th ti t ”on the patient.”

“Building relationships with patients is the single most important thing hospitals can do to make a lasting change in the delivery of care. When the focus is on building a relationship with every patient, every time, there is better communication, better compliance, betterwith every patient, every time, there is better communication, better compliance, better coordination of care, and better outcomes. And yes, an enhanced bottom line as well.”

Whitehurst, S. (September 30, 2011). Patient Experience: Hospitals' Holy Grail? HealthLeaders Media

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Page 60: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division

Interdisciplinary OwnershipInterdisciplinary OwnershipInterdisciplinary OwnershipInterdisciplinary OwnershipEveryone at every level needs to “own” the quality agenda:

Senior LeadersDirectorsQualityPharmacyNursing:

LeadersCharge NursesgUnit StaffUnit Clerks

Emergency DepartmentSurgery DepartmentSurgery DepartmentNursing SupervisorsCase ManagementMedical Staff

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Page 61: The Changing Landscape: Value-Based Purchasing, Reimbursement and its Impact on Nursing - Troy Trosclair, HCA MidAmerica Division

As a resultAs a resultAs a result……………As a result……………Priorities/Initiatives…………must be di l li k ddirectly linked to: ◦ building a culture of patient centered

excellenceexcellence◦ pay for performance activities ◦ current and future public reporting metrics p p g◦ evidence-based practice guidelines

Investment in the infrastructure of your facility Quality Program is critical to your f ilit ’ f t !facility’s future success!

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