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

1. The Changing Landscape
Value Based P h i
V l B d Purchasing, R i b
Reimbursement and it
t d its
Impact on Nursing
Troy A Trosclair, RN, DNS, CPHRM
Vice President Clinical Services
President,
HCA MidAmerica Division

2. How Did We Get Here?
Hospital payments account for the largest share of Medicare
spending
Medicare is the largest single payer for hospital services.
In 2009
I 2009, > 7M M di
Medicare b
beneficiaries h d > 12 4M IP
fi i i had 12.4M
hospitalizations
One in seven Medicare patients will experience some “adverse”
p p
event (preventable illness or injury) while in the hospital.
One in three Medicare patients who leave the hospital will have a
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

3. Health Care Reform

4. CMS Value Based Purchasing
Affordable Care Act, Section 3001
◦ The Secretary of HHS is required to establish a hospital value-
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 measure
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 p
p g pose
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.

5. CMS Immediate Jeopardy Triggers
Failure to protect from:
◦ Ab
Abuse, neglect, psychological h
l t h l i l harm, undued
adverse medication consequences,
widespread hospital-acquired infections
Failure to provide:
◦ Adequate nutrition & hydration
◦ Safety from fire, smoke, and environment
fire smoke
hazards
◦ Initial medical screening, stabilization and
safe transfers of patients with emergenc
ith emergency
medical conditions (EMTALA)
Failure to correctly identify p
y y patients
Failure to safely administer blood
products

9. CMS Value-Based Purchasing:
Value-
Linking Federal Reimbursement to Clinical
g
Performance
Over the next five years, approximately 6% of inpatient Medicare
reimbursements to hospitals will be linked to clinical performance (exclusive
of M
f Meaningful Use i
i f l U incentives).
ti )
• 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 law
intent, 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.
2011 2012 2013 2014 2015 2016 2017 2018 2019
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%
1 00% 2.00%
2 00% 3.00%
3 00%
Hospital Acquired Conditions (1%)
1.00%

10. CMS Value Based Purchasing
Affordable 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)
2013 = 1.0% = $850M to be awarded to hospitals
2014 = 1.25%
2015 = 1.5%
2016 = 1 75%
1.75%
2017 = 2.0%
All subsequent years = 2.0%
◦ Possible impact:
p
Predict that 9% of hospital payments and 11% MD payments affected by 2016
The only way to ensure full payback is to hit the benchmark
on every measure.

11. CMS Value Based Purchasing
Proposed rule released Jan. 7, 2011; Final rule released April 29, 2011
2 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 weighted
The two domains are weighted differently
◦ Process measures (70%)
◦ HCAHPS (30%)
Points assigned for:
◦ (a) level of achievement and
◦ (b) improvement

12. Incentive 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
Those hospitals with hi h TPS will
h it l ith higher ill
receive higher payments
◦ Will use a linear exchange function to
calculate the % of payment

13. Linear Exchange Curve
VBP payments are based upon the slope of the linear exchange
line. The slope of the linear exchange is determined by the
aggregate performance of all US hospitals.

19. Core Measure Selection

20. FY 2013 Clinical Process Measures
20

21. FY 2013 HCAHPS Measures
Nurse Communication Composite
Doctor Communication Composite
Cleanliness and Quietness Composite
(New C
(N Composite)it )
Responsiveness of Hospital Staff
Composite
Pain Management Composite
Communication About Medications
Composite
Discharge Information Composite
Overall Rating

25. HCAHPS Scoring
Achievement
◦ Scoring is done at the individual measure level
Hospital performance: Equal to or greater than the Benchmark = 10 point
Hospital 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 range
Hospital 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
Benchmark = 0 – 9 points b
B h k i t based on a li
d linear scale f th i
l for the improvement t
range
Hospital performance: Equal to or lower than is baseline period on the
measure = 0 points
Hospital earns the greater of the two
NEW 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
threshold

26. HCAHPS Scoring Example

27. VBP Metrics
Heavilyy
Influenced by
Nursing Care

28. FY 2014 VBP Revised
Nov 1, 2011
◦ CMS will NOT include the following:
OUTCOME MEASURES
HACs
AHRQ composites
EFFICIENCY MEASURES
Weight percentage revisions in 2014:
◦ HCAHPS = 30%
◦ Outcomes (Mortality) = 25%
◦ Clinical Performance (core) Measures = 45%
Performance Period
◦ Clinical Performance & HCAHPS (4/1/2012 – 12/31/2012)
◦ 30 day Mortality (7/1/11 – 6/30/12)

29. AHRQ is
is…..
The health services research arm of the U.S. Department of Health
and Human Services (HHS), complementing the biomedical
research mission of it sister agency, th National Institutes of
h i i f its i t the N ti l I tit t f
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. 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 y
practice and policymaking.

30. AHRQ Indicators
The Patient Safety Indicators are part of
a set of software modules of the Agency
for Healthcare Research and Quality
(
(AHRQ) Quality Indicators (
) y (QIs)
)
developed by the University of
California, San Francisco–Stanford
University Evidence-based Practice
Evidence based
Center and the University of California,
Davis under a contract with AHRQ.
The Patient Safety Indicators were
originally released in 2003
2003.

31. AHRQ Inpatient Quality Indicators
Inpatient Quality Indicators
Can be used to help hospitals identify potential problem areas that might need further
study,
study as well as for quality improvement, comparative public reporting trending and pay
improvement reporting, trending, 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 areas.
areas
Include volume indicators for procedures for which outcomes may be related to the volume
of those procedures performed.
Are free and publicly available.
A f d bli l il bl
Include risk adjustment where appropriate.

32. AHRQ Inpatient Quality Indicators
Hospital-level procedure utilization rates
• Cesarean section delivery
• Primary cesarean delivery
Mortality rates for conditions
y
• Acute myocardial infarction (AMI)
• Vaginal birth after cesarean, uncomplicated transfer
• AMI without
• Vaginal birth after cesarean, all • Congestive heart failure
• Incidental appendectomy in the • Gastrointestinal hemorrhage
elderly
• Bilateral cardiac catheterization • Hip fracture
•PPneumonia i
• Laparoscopic cholecystecomy
• Acute stroke
Area-level utilization rates (county, State) rates for
Mortality
• Coronary artery bypass graft procedures
•H t
Hysterectomy
t • Abdominal aortic aneurysm repair
• Laminectomy or spinal fusion • Coronary artery bypass graft
• Craniotomy
• Percutaneous transluminal coronary
angioplasty • Esophageal resection
• Hip replacement
• Pancreatic resection
Volume of procedures
• Percutaneous transluminal coronary
• Abdominal aortic aneurysm repair
angioplasty
• Carotid endarterectomy • Carotid endarterectomy
• Coronary artery bypass graft
• Esophageal resection
• Pancreatic resection
• Percutaneous transluminal coronary
angioplasty

33. AHRQ Patient Safety
Indicators
Patient Safety Indicators
Can be used to help hospitals and health care organizations assess, monitor,
p p g
track, 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
during
d i a patient’s h
ti t’ hospital stay.
it l t
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.

34. AHRQ Patient Safety
Indicatorsindicators
Hospital-level
Death in low-mortality diagnosis-related groups
Pressure ulcer
Death among surgical inpatients with treatable serious complications
Foreign body left in during procedure
Iatrogenic pneumothorax
Central venous catheter-related bloodstream infections
Postoperative hip fracture
Postoperative hemorrhage or hematoma
Postoperative physiologic and metabolic derangements
Postoperative respiratory failure
Postoperative pulmonary embolism or deep vein thrombosis
Postoperative sepsis
Postoperative wound dehiscence
Accidental puncture or laceration
Transfusion reaction
Birth trauma—injury to neonate
Obstetric trauma—vaginal delivery with instrument
Obstetric trauma—vaginal delivery without instrument

35. AHRQ Patient Safety and Inpatient Quality Indicators Hospital
Compare – 4Q2008 thru 2Q2010
5) No data are available for publication from the
hospital for this measure
Data Source: Hospital Compare
October 2011
.
(

36. AHRQ Strategies
AHRQ Strategies
Individual case review
Professional peer review
Validate use of evidenced based
practices
Quality of documentation & accuracy
of coding

37. Potential Future Measures and
Changes
Ch
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 Technology
Over time, scoring methodologies will be weighted more
heavily towards outcome, patient experience, and functional
status measures.
In 2015, hospitals with certain Hospital Acquired Conditions
(HAC’s) ill
(HAC’ ) will receive additional payment reductions f
i dditi l t d ti from
Medicare
With more to come………….
come

39. CMS Physician Quality Reporting System
(PQRS)
Formerly known as PQRI (initiative)
Established by 2006 Tax Relief & Health Care Act
◦ Required establishment of a PQRS
◦ Including an incentive payment for eligible professionals
who report data on q
p quality measures for covered
y
professional services furnished to Medicare beneficiaries
Annual CMS rulemaking process for each program year
◦ Program requirements and measure specifications may be
different year to year
diff t t
Eligible professionals may choose to report quality
measures or measure groups:
◦ To CMS on Medicare Part B claims
◦ To a qualified PQRS registry
◦ To CMS via a qualified EHR product

40. PQRI
Financial Incentives/Penalties for
participation
◦ Incentives: 1.0% in 2011, 0.5% in 2012-
,
2014
◦ Penalties: -1.5% in 2015, -2.0% in 2016
and beyond
2009 Experience Report Highlights
◦ $234 million total payout
◦ Average $1,956 p eligible p
g per g professional/
$18,525 per practice

41. PQR Eligible Professionals
1. Medicare physicians
◦ 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
◦ Nurse Practitioner
◦ Clinical Nurse Specialist
◦ Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant)
◦ Certified Nurse Midwife
◦ Clinical Social Worker
◦ Clinical Psychologist
◦ Registered Dietician
◦ Nutrition Professional
◦ Audiologists
A di l i t

42. PQR Eligible Professionals
3. 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
participate for one or more reasons
(specifics listed in www.cms.gov/PQRS)

43. 2011 PQR Measures List

44. 2012 PQR Group Measures

45. CMS Public Reporting Metrics

46. Future Public Measure Changes

47. 2012 and beyond….looking ahead….
Four primary buckets of quality metrics:
◦ CMS VBP measures
◦ CMS HQA IPPS measures
◦ CMS HQA OPPS measures
◦ TJC Core Measures TJC Accountability of
Care Measures or TJC Non-Accountability of
Care Measures

49. 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

50. Joint Commission
Core M
C Measure R
Requirements
i t
Hospitals are only required to submit data on four
measure sets:
◦ AMI
◦ HF
◦ PN
◦ Surgical Care Improvement Project (SCIP)
◦ Perinatal
◦ VTE
◦ Stroke
◦ Behavioral Health (HBIPS)
◦ Children’s Asthma Care (CAC)
◦ Outpatient
O t ti t
◦ ED Chart Abstracted Measures
◦ IMM

51. TJC Accountability Measures
Accountability measures are now used by TJC to identify their Top
Performers on JC Key Quality Measures
Top Performer – 95% on each and all measures
Based on 2010 data
AMI, HF, PN, SCIP and CAC
◦ In January, 2012 the f
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 decision
The last time hospitals could make a measure selection change:
December, 2011

52. Managed Care VBP
Engaging in P4P initiatives
◦ Appropriate use of Surgical Safety
Checklists
Monitoring hospital public reported
M it i h it l bli t d
metrics
◦HHospital C
it l Compare
◦ Leapfrog
◦ Others
Using quality data to manage contract
(re)negotiations
Using quality data for steerage

53. First Do No Harm……..
“It may seem a strange
y g
principle to enunciate as
the very first
y
requirement in a
Hospital that it should
p
do the sick no harm.”
- Florence Nightingale, Notes
g g
on Hospitals, 1859

54. CMS Hospital-Acquired Conditions
Hospital-
(HAC)
Proposed rule released Feb 17, 2011
Final rule released June 1 2011
1,
Requirements effective July 1, 2011
◦ States have option to delay implementation through July 1,
2012
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
New T
N Terms
◦ Provider Preventable Conditions (PPC) – two categories:
Healthcare Acquired Conditions (HCAC) – current Medicare HAC’s
Other Provider Preventable Conditions (OPPC) – state specific

55. CMS Hospital-Acquired Conditions
Hospital-
(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:
Wrong surgical or other invasive procedure patient, site, or procedure
Projected 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
◦ Aggregate cost savings of 35M for FY 2011 through 2015
20M for Federal share
15M for State share

56. Public Perception

57. HAC Top Performer 5
Themes
Facilities with zero (or the fewest) HACs based on
10 quarters of coding data
1.
1 Engaged leadership
1. Support and enforce for accountability at the unit level
2. Evaluate daily process measures
1. MEDITECH NPR reports to evaluate length of time with a
p g
foley 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 needs
2. Questioning on clinical justification for urinary catheters
and/or central line/PICC
4. Supportive physician champion
1.
1 Engaged physician champion and medical staff
5. Review process
1. Charts coded POA=N for HACs reviewed before bill is
dropped

58. Challenges
Rapid expansion of Growth in hospital and
measures physician P4P programs
Combination of clinical, ◦ Physician Quality Reporting
experience, and outcome
p System (PQRS)
measures Types of performance
Focus on episode of targets
illness Types of financial
Patients crossing incentives
measure sets (IP & OP)
( ) Care management
redesign
Staffing costs

59. Building a Culture
“We must stop putting silos around the various facets of healthcare.”
“The ti t
“Th patient experience i not an i l t d event. Rather, it is the sum of all interactions,
i is t isolated t R th i th f ll i t ti
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
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
on th patient.”
the ti t ”
“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, 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
59

60. Interdisciplinary Ownership
Everyone at every level needs to
“own” the quality agenda:
Senior Leaders
Directors
Quality
Pharmacy
Nursing:
Leaders
Charge Nurses
g
Unit Staff
Unit Clerks
Emergency Department
Surgery Department
Nursing Supervisors
Case Management
Medical Staff
60

61. As a result……………
result
Priorities/Initiatives…………must be
directly li k d to:
di l linked
◦ building a culture of patient centered
excellence
◦ 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
facility’s future success!
f ilit ’ f t !

62. Questions/Comments