1. S p e c ia l Op e n Do o r Fo ru m :
Ho s p ita l Va lu e -Ba s e d P u rc h a s in g
P ro p o s e d Ru le Ove rvie w fo r
Fa c ilitie s , P ro vid e rs , a n d S u p p lie rs
Th u rs d a y, Fe b ru a ry 10, 2011
1: 30 – 3:30 p .m . ES T

2. Ag e n d a
 In tro d u c tio n – Wh a t is th e Ho s p ita l VBP P ro g ra m ?
 Wh a t h o s p ita ls a re in c lu d e d in th is p ro g ra m ?
 Ho w will h o s p ita ls b e e va lu a te d u n d e r th is p ro g ra m ?
 Ho w will p a ym e n ts b e c a lc u la te d ?
 Wh a t a re th e lo g is tic s o f th e p ro g ra m ?
 Wh a t if I h a ve a p ro b le m with m y e va lu a tio n ?
 Ad d itio n a l In fo rm a tio n
 Ho w c a n I re a d a n d c o m m e n t o n th e ru le ?
 Qu e s tio n s & An s we rs
2

3. In tro d u c tio n : P ro p o s e d Ho s p ita l
Va lu e -Ba s e d P u rc h a s in g (VBP ) P ro g ra m
 Re q u ire d b y Co n g re s s u n d e r S e c tio n 1886(o ) o f th e S o c ia l
S e c u rity Ac t
 Ne xt s te p in p ro m o tin g h ig h e r q u a lity c a re fo r Me d ic a re
b e n e fic ia rie s
 CMS vie ws va lu e -b a s e d p u rc h a s in g a s a n im p o rta n t d rive r in
re va m p in g h o w c a re a n d s e rvic e s a re p a id fo r, m o vin g
in c re a s in g ly to wa rd re wa rd in g b e tte r va lu e , o u tc o m e s , a n d
in n o va tio n s in s te a d o f vo lu m e
 Note: Details presented here are proposals and are subject to
change in the Final Rule. CMS welcomes public comments.
3

4. Le g is la tive Re q u ire m e n ts
 Multiple requirements
 Legislation requires that the FY 2013 Hospital VBP program apply to
payments for discharges occurring on or after October 1, 2012
 Hospital VBP measures must be included on Hospital Compare website for
at least one year and specified under the Hospital IQR program
 Secretary must establish and announce the performance standards not later
than 60 days prior to the beginning of the performance period for FY involved
 Performance Period reliability (9 months beginning 7/1/11 proposed)
 Regulatory development
 CMS anticipates issuing a final rule as soon as possible after close of
comment period so it has enough time to calculate performance scores,
value-based incentive payments, etc.
4

5. Wh o is Elig ib le fo r th e
Ho s p ita l VBP P ro g ra m ? (1 o f 3)
 Ho w is “h o s p ita l” d e fin e d fo r th is p ro g ra m ?
– Hospital VBP Program applies to subsection (d)
hospitals
 Statutory definition of subsection (d) hospital
found in Section 1886(d)(1)(B)
 Applies to acute care hospitals in Maryland
5

6. Wh o is Elig ib le fo r th e
Ho s p ita l VBP P ro g ra m ? (2 o f 3)
 Exc lu s io n s u n d e r S e c tio n 1886(o )(1)(C)(ii)
– Hospitals subject to payment reductions under Hospital IQR
– Hospitals cited for deficiencies during the performance period
that pose immediate jeopardy to the health or safety of
patients
– Hospitals without the minimum number of cases or measures
6

7. Wh o is Elig ib le fo r th e
Ho s p ita l VBP P ro g ra m ? (3 o f 3)
 
Clinical Process Clinical Process Clinical Process Clinical Process Clinical Process

M easure 1 M easure 2 M easure 3 M easure 4 M easure 17
…
– Hospitals with at least 10 cases for at least 4 applicable measures
during the performance period receive a Clinical Process of Care
score
– Hospitals with at least 100 Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS) surveys during the
performance period receive a Patient Experience of Care score
7

8. P ro p o s e d FY 2013 Do m a in s a n d
Me a s u re s /Dim e n s io n s
8

9. Me a s u re s P ro p o s e d fo r FY 2014 Ho s p ita l VBP P ro g ra m
(1 o f 3)
P ro p o s e d Ho s p ita l -Ac q u ire d Co n d itio n Me a s u re s :
1. Fo re ig n Ob je c t Re ta in e d Afte r S u rg e ry
2. Air Em b o lis m
3. Blo o d In c o m p a tib ility
4. P re s s u re Ulc e r S ta g e s III & IV
5. Fa lls a n d Tra u m a : in c lu d e s Fra c tu re , Dis lo c a tio n ,
In tra c ra n ia l In ju ry, Cru s h in g In ju ry, Bu rn , Ele c tric S h o c k
6. Va s c u la r Ca th e te r-As s o c ia te d In fe c tio n s
7. Ca th e te r-As s o c ia te d Urin a ry Tra c t In fe c tio n (UTI)
8. Ma n ife s ta tio n s o f P o o r Glyc e m ic Co n tro l
9

10. P ro p o s e d Ho s p ita l VBP Me a s u re s fo r FY 2014
(2 o f 3)
Ag e n c y fo r He a lth c a re Re s e a rc h a n d Qu a lity (AHRQ) P a tie n t S a fe ty
In d ic a to rs (P S I), In p a tie n t Qu a lity In d ic a to rs (IQI), a n d Co m p o s ite Me a s u re s :
1. P S I 06 – Ia tro g e n ic P n e u m o th o ra x, a d u lt
2. P S I 11 – P o s t-Op e ra tive Re s p ira to ry Fa ilu re
3. P S I 12 – P o s t-Op e ra tive P u lm o n a ry Em b o li (P E) o r De e p Ve in
Th ro m b o s is (DVT)
4. P S I 14 – P o s to p e ra tive Wo u n d De h is c e n c e
5. P S I 15 – Ac c id e n ta l P u n c tu re o r La c e ra tio n
6. IQI 11 – Ab d o m in a l Ao rtic An e u rys m (AAA) Re p a ir Mo rta lity Ra te
(with o r with o u t vo lu m e )
7. IQI 19 – Hip Fra c tu re Mo rta lity Ra te
8. Co m p lic a tio n /P a tie n t S a fe ty fo r S e le c te d In d ic a to rs (c o m p o s ite )
9. Mo rta lity fo r S e le c te d Me d ic a l Co n d itio n s (c o m p o s ite )
10

11. Me a s u re s P ro p o s e d fo r FY 2014 Ho s p ita l VBP P ro g ra m
(3 o f 3)
P ro p o s e d Mo rta lity Me a s u re s :
MORT-30-AMI: Ac u te Myo c a rd ia l In fa rc tio n (AMI) 30-Da y Mo rta lity Ra te
MORT-30-HF: He a rt Fa ilu re (HF) 30-Da y Mo rta lity Ra te
MORT-30-P N: P n e u m o n ia (P N) 30-Da y Mo rta lity Ra te
11

12. Ho s p ita l VBP Me a s u re P ro p o s a l P ro c e s s
 P ro p o s e d S u b re g u la to ry P ro c e s s fo r Ad d in g /
Re tirin g Me a s u re s
– Beginning with the FY 2013 Hospital VBP program, proposed
to expedite adding measures beginning FY 2013
– Under proposal, measures could be added to Hospital VBP if
measures have been displayed on Hospital Compare for one
year and included in Hospital IQR program
– Performance periods would begin 1 year after the measure
was posted on Hospital Compare
– Performance period end dates would be proposed through
rulemaking
– CMS will confirm the retirement of measures in rulemaking
12

13. P e rfo rm a n c e P e rio d s
 Ho s p ita ls will b e s c o re d o n th e ir p e rfo rm a n c e o n
q u a lity m e a s u re s d u rin g th e fo llo win g p e rfo rm a n c e
p e rio d s :
– FY 2013:
 Uses a 9-month Performance Period from
July 1, 2011 to March 31, 2012
– FY 2014:
 Three proposed mortality measures use 18-month
Performance Period from July 1, 2011 to December 31,
2012
13

14. Ho w Will Ho s p ita ls Be Eva lu a te d u n d e r
th e Ho s p ita l VBP P ro g ra m ?
 S u m m a ry fo r Fis c a l Ye a r (FY) 2013 P ro g ra m :
– Two domains: Clinical Process of Care (17 measures) and
Patient Experience of Care (8 HCAHPS dimensions)
– Most hospitals given two scores (Achievement and Improvement)
for each measure or dimension, with higher score used
– Measure scores summed into Clinical Process of Care domain
score
– Dimension scores summed with consistency points into Patient
Experience of Care domain score
– 70% of Total Performance Score based on Clinical Process
of Care measures
– 30% of Total Performance Score based on Patient Experience
of Care measures
14

15. Ho w Will Ho s p ita ls Be Eva lu a te d u n d e r
th e Ho s p ita l VBP P ro g ra m ?
15

16. Ho w Will Ho s p ita ls Be Eva lu a te d ?
Im p ro ve m e n t vs . Ac h ie ve m e n t
16

17. Ho w Will Ho s p ita ls Be Eva lu a te d ?
Im p ro ve m e n t S c o re s
 Im p ro ve m e n t p o in ts a re a wa rd e d b y c o m p a rin g a h o s p ita l’s
s c o re s d u rin g th e p e rfo rm a n c e p e rio d to th a t s a m e h o s p ita l’s
s c o re s fro m th e b a s e lin e p e rio d
 Ho w a re im p ro ve m e n t p o in ts a wa rd e d ?
– Hospital score above benchmark: 10 achievement points, so no need to
calculate improvement
– Hospital score ≤ baseline period score: 0 improvement points
– If the hospital’s score is between the baseline period score and the benchmark:
0-9 improvement points
For example:
17

18. Ho w Will Ho s p ita ls Be Eva lu a te d ?
Ac h ie ve m e n t S c o re s
 Ac h ie ve m e n t p o in ts a re a wa rd e d b y c o m p a rin g a n in d ivid u a l
h o s p ita l’s s c o re s d u rin g th e p e rfo rm a n c e p e rio d with a ll
h o s p ita ls ’ s c o re s fro m th e b a s e lin e p e rio d
 Ho w a re a c h ie ve m e n t p o in ts a wa rd e d ?
– Hospital score above benchmark: 10 achievement points
– Hospital score < achievement threshold: 0 points
– If the score is equal to or greater than the achievement threshold
and less than the benchmark: 1-9 points
For example:
18

19. Ho w Will Ho s p ita ls Be Eva lu a te d ?
Clin ic a l P ro c e s s o f Ca re Fo rm u la s
 Clin ic a l P ro c e s s o f Ca re im p ro ve m e n t s c o re s :

10 *
(Hospital performance period score − Hospital baseline score ) − 0.5
 (Benchmark − Hospital baseline score ) 
 
– Hospitals must score higher than their baseline score in order to
receive improvement points
 Clin ic a l P ro c e s s o f Ca re a c h ie ve m e n t s c o re s :
(Hospital' s performance period score − achievement threshold )
9*  + 0.5
 (Benchmark − achievement threshold ) 
19

20. Ho w Will CMS Ca lc u la te th e Clin ic a l
P ro c e s s o f Ca re Do m a in S c o re ?
 To ensure comparability between hospitals with different numbers
of applicable measures, CMS will norma lize the doma in s core s for
Clinica l P roce s s of Ca re .
– Each measure is worth up to 10 points
– Possible points = Number of applicable measures * 10
– (Scored points / Possible points) * 100 = Clinical Process of Care
domain score
Ho s p ita l 1 Ho s p ita l 2
Nu m b e r o f Ap p lic a b le
Me a s ure s 5 11
S c o re o n Ea c h Me a s u re 9 9
S c o re d P o in t /
P o s s ib le P o in ts 45 / 50 99 / 110
Clin ic a l P ro c e s s o f Ca re
Do m a in S c o re 90 90
20

21. Clin ic a l P ro c e s s S c o rin g Exa m p le #1:
Ho s p ita l B
Hospital B earns: 10 achievement points for
performance exceeding the benchmark
21

22. Clin ic a l P ro c e s s S c o rin g Exa m p le #2:
Ho s p ita l L
Hospital L earns: 0 achievement points and 0 improvement points
Hospital L scores 0 points on this measure
22

23. Clin ic a l P ro c e s s S c o rin g Exa m p le #3:
Ho s p ita l I
Hospital I earns: 6 achievement points or 7 improvement points
Hospital I scores 7 points on this measure
23

24. Ho w Will CMS Ca lc u la te th e P a tie n t
Exp e rie n c e o f Ca re (HCAHP S ) S c o re ?
 P a tie n t Exp e rie n c e o f Ca re S c o re =
(Gre a te r o f im p ro ve m e n t o r a c h ie ve m e n t s c o re s fo r e a c h
HCAHP S d im e n s io n ) + Co n s is te n c y s c o re
 Up to 20 c o n s is te n c y p o in ts p o s s ib le b a s e d o n th e s in g le
lo we s t o f a h o s p ita l's 8 HCAHP S d im e n s io n s c o re s d u rin g th e
p e rfo rm a n c e p e rio d c o m p a re d to th e m e d ia n b a s e lin e
p e rfo rm a n c e fo r th a t m e a s u re .
– Consistency points encourage hospitals to meet or exceed the
achievement threshold in all HCAHPS dimensions
– 20 points are awarded if all dimension scores ≥ achievement threshold
– If any dimension score < achievement threshold, consistency points
are awarded in proportion to percentile of the
lowest-scoring dimension
24

25. Ho w Will Ho s p ita ls Be Eva lu a te d ?
P a tie n t Exp e rie n c e o f Ca re Fo rm u la s
 P a tie n t Exp e rie n c e o f Ca re im p ro ve m e n t s c o re s :
 (Hospital perf. period score − Hospital baseline period score) − 0.5
10 * (Benchmark − Hospital baseline period score) 
 
– Hospitals must score higher than their baseline score in order to
receive improvement points
 P a tie n t Exp e rie n c e o f Ca re a c h ie ve m e n t s c o re s :
 (Hospital performance period dimension score − 50 ) 
  + 0.5
 5 
25

26. Ho w will h o s p ita ls b e e va lu a te d ?
HCAHP S Co n s is te n c y S c o re s
 Ho w a re HCAHP S c o n s is te n c y p o in ts c a lc u la te d ?
– If any dimension score ≤ worst-performing hospital dimension
score:
 0 consistency points
– If scores ≥ achievement threshold on all 8 dimensions:
 20 consistency points
– If dimensions < achievement threshold but > worst-performing
hospital’s score:
 Consistency points are awarded based on percentile of the
lowest dimension score:
(2 * (lo we s t p e rc e n tile / 5)) – 0.5
 Rounded to nearest whole number between 0-20
26

27. P a tie n t Exp e rie n c e S c o rin g Exa m p le #1:
Ho s p ita l B
Hospital B earns: 10 achievement points for
performance exceeding the benchmark
27

28. P a tie n t Exp e rie n c e S c o rin g Exa m p le #2:
Ho s p ita l L
Hospital L earns: 0 achievement points and 0 improvement points
Hospital L scores 0 points on this measure
28

29. P a tie n t Exp e rie n c e S c o rin g Exa m p le #3:
Ho s p ita l I
Hospital I earns: 3 achievement points or 4 improvement points
Hospital I scores 4 points on this measure
29

30. Ho w Will Ho s p ita ls Be Eva lu a te d ?
To ta l P e rfo rm a n c e S c o re s
 Do m a in p o in ts e a rn e d a re we ig h te d to d e te rm in e
To ta l P e rfo rm a n c e S c o re
– CMS considered many factors to develop proposed
weighting
– FY 2013 domain weighting: (Clinical process of care x 70%)
+ (Patient experience of care x 30%)
– FY 2014 and beyond:
 New domains could be added
 Domain weighting based on changes in measures will be established in
future rulemaking
– CMS welcomes public comments on the scoring
methodology, weighting, and future proposals
30

31. Th e Exc h a n g e Fu n c tio n
 2007 Re p o rt to Co n g re s s in tro d u c e d th e Exc h a n g e Fu n c tio n
to tra n s la te th e To ta l P e rfo rm a n c e S c o re s in to va lu e -b a s e d
in c e n tive p a ym e n ts
 Th e la w re q u ire s th a t th e to ta l a m o u n t o f va lu e -b a s e d in c e n tive
p a ym e n ts in a g g re g a te b e e q u a l to th e a m o u n t a va ila b le fo r va lu e -
b a s e d in c e n tive p a ym e n ts , a s e s tim a te d b y th e S e c re ta ry
 We p ro p o s e d a lin e a r e xc h a n g e fu n c tio n to tra n s la te To ta l
P e rfo rm a n c e S c o re s in to va lu e -b a s e d in c e n tive p a ym e n ts
31

32. FY 2013 Ho s p ita l VBP
Va lid a tio n Re q u ire m e n ts
 CMS will u s e th e Ho s p ita l IQR va lid a tio n p ro c e s s a s
o u tlin e d in th e FY 2011 In p a tie n t P ro s p e c tive P a ym e n t
S ys te m (IP P S ) Fin a l Ru le fo r FY 2013 Ho s p ita l VBP
– Hospitals submit the same data for Hospital IQR and Hospital VBP
– No separate medical records requests
 En s u re s a c c u ra c y o f Ho s p ita l VBP m e a s u re d a ta
32

33. P ro p o s e d Ho s p ita l No tific a tio n
a n d Re vie w P ro c e d u re s
 No tic e o f a 1% re d u c tio n to FY 2013 b a s e o p e ra tin g
d ia g n o s is -re la te d g ro u p (DRG) p a ym e n ts p ro vid e d in th e
FY 2013 IP P S ru le
 No tific a tio n to h o s p ita ls o f e s tim a te d FY 2013 in c e n tive
p a ym e n ts will b e m a d e b y m e a n s o f th e ir Qu a lityNe t
a c c o u n ts
 Ac tu a l in c e n tive p a ym e n t n o tific a tio n s c h e d u le d to o c c u r
b y No ve m b e r 1, 2012
– Claims processing adjustments will be completed by January
2013
33

34. P ro p o s e d Ho s p ita l No tific a tio n
a n d Re vie w P ro c e d u re s
 Ho s p ita l s c o re s will b e p u b lis h e d o n Ho s p ita l Co m p a re :
– Measure scores
– Condition-specific scores
– Domain-specific scores
– Total performance scores
 Ho s p ita ls will h a ve 30 c a le n d a r d a ys to re vie w a n d
s u b m it c o rre c tio n s
34

35. Ho w Will Ap p e a ls o f Ho s p ita l S c o re s b e
Ha n d le d ?
 CMS will p ro p o s e a p p e a ls p ro c e s s in fu tu re ru le m a kin g
 Th e fo llo win g to p ic s a re n o t s u b je c t to a d m in is tra tive
o r ju d ic ia l re vie w:
– Value-based incentive payment determination
– Determination of the amount of funding available for incentive payments
and payment reduction
– Establishment of the performance standards and performance period
– Measures specified in the Hospital IQR program or included in Hospital VBP
– Methods and calculations for total performance scores
– Validation methodology used in the Hospital IQR program
 CMS we lc o m e s c o m m e n ts o n m a n a g in g a p p e a ls a n d a
re a s o n a b le tim e lin e fo r re s o lu tio n
35

36. Ad d itio n a l In fo rm a tio n
 We will m o n ito r a n d e va lu a te th e im p a c t o f th e
Ho s p ita l VBP p ro g ra m o n :
– Access and quality of care, especially for vulnerable
populations
– Patterns of care suggesting particular effects on:
 Percentage of patients receiving appropriate care for
measured conditions
 Rates of hospital-acquired conditions
– Best practices of high-performing hospitals
– Trends in care delivery, access, and quality
36

37. Ho w to Re a d th e Ru le
Re a d a n d c o m m e n t o n th e ru le o n lin e
a t h ttp ://www.re g u la tio n s .g o v. S e a rc h fo r “CMS -3239-P .”
37

38. Ho w to Co m m e n t o n th e Ru le (1 o f 2)
 CMS we lc o m e s p u b lic c o m m e n ts o n a ll a s p e c ts o f th e p ro p o s e d
ru le , in c lu d in g :
– Principles for value-based – Baseline and performance period
purchasing selection
– Proposed measures – Appropriate domain weighting
– Use of structural measures in – Participation in Hospital IQR/
Hospital VBP Hospital VBP
– Use of AHRQ PSI, IQI, and Nursing – Scoring hospitals without baseline
Sensitive Care measures for FY period data
2014 and beyond – Minimum numbers of cases and
– Subregulatory process for adding or measures
retiring measures – Exchange function choice
– Appropriate measures of efficiency – Appeals process structure and
– Achievement and improvement timeline
performance standards – Approaches to monitoring and
– Performance score methodology evaluation
and alternatives – Changes to QIO regulations
38

39. Ho w to Co m m e n t o n th e Ru le (2 o f 2)
 De ta ils a b o u t s u b m ittin g
c o m m e n ts a re in th e ru le
 Th e re a re two wa ys to
s u b m it c o m m e n ts :
– Via mail:
See the Rule for mailing
addresses
– Online:
Click “Submit a Comment”
next to the regulation link
 P le a s e in c lu d e file c o d e
“CMS -3239-P ” in yo u r
c o m m e n ts
Co m m e n ts a re d u e o n Tu e s d a y, Ma rc h 8, 2011
(b y 5:00 p .m . ES T via m a il a n d 11:59 p .m . ES T o n lin e )
39

40. Qu e s tio n s ?