Transcript Slide 1

The Hospital’s Bottom Line
in an Era of Value-Based Purchasing
A webinar for Philips customers that
tells you what Medicare is planning
and what it means for you…
June 23, 2008
The Hospital’s Bottom Line
in an Era of Value-Based Purchasing
Presenters:
Thomas Valuck, MD, JD, Medical Officer & Senior Adviser,
Center for Medicare Management, Centers for Medicare and Medicaid
Services, Washington, DC
Ann Edwards, Director, Health Industries Advisory Practice,
PricewaterhouseCoopers, Hartford, CT
Moderator:
Laurel Sweeney, Senior Director, Reimbursement and Legislative Affairs,
Philips Healthcare, Andover, MA
CONFIDENTIAL
June 23, 2008
2
Centers for Medicare & Medicaid Services
CMS’ Progress Toward
Implementing
Value-Based Purchasing
Thomas B. Valuck, MD, JD
Medical Officer & Senior Adviser
Center for Medicare Management
Procurement Sensitive
Presentation Overview
 CMS’ Value-Based Purchasing (VBP)
Principles
 CMS’ VBP Demonstrations and Pilots
 CMS’ VBP Programs
 Value-Driven Health Care
 Horizon Scanning and Opportunities for
Participation
Procurement Sensitive
CMS’ Quality Improvement
Roadmap
 Vision: The right care for every person
every time
 Make care:
 Safe
 Effective
 Efficient
 Patient-centered
 Timely
 Equitable
Procurement Sensitive
CMS’ Quality Improvement
Roadmap
 Strategies
 Work through partnerships
 Measure quality and report comparative results
 Value-Based Purchasing: improve quality and
avoid unnecessary costs
 Encourage adoption of effective health
information technology
 Promote innovation and the evidence base for
effective use of technology
Procurement Sensitive
What Does VBP Mean to CMS?
 Transforming Medicare from a passive payer to an
active purchaser of higher quality, more efficient
health care
 Tools and initiatives for promoting better quality, while
avoiding unnecessary costs
 Tools: measurement, payment incentives, public
reporting, conditions of participation, coverage
policy, QIO program
 Initiatives: pay for reporting, pay for performance,
gainsharing, competitive bidding, coverage
decisions, direct
provider support
Procurement Sensitive
Why VBP?
 Improve Quality
 Quality improvement opportunity
 Wennberg’s Dartmouth Atlas on variation in care
 McGlynn’s NEJM findings on lack of evidence-based
care
 IOM’s Crossing the Quality Chasm findings
 Avoid Unnecessary Costs
 Medicare’s various fee-for-service fee schedules
and prospective payment systems are based on
resource consumption and quantity of care, NOT
quality or unnecessary costs avoided
 Payment systems’ incentives are not aligned
Procurement Sensitive
Practice Variation
Practice Variation
Why VBP?
 Medicare Solvency and Beneficiary Impact
 Expenditures up from $219 billion in 2000 to a
projected $486 billion in 2009
 Part A Trust Fund
 Excess of expenditures over tax income in 2007
 Projected to be depleted by 2019
 Part B Trust Fund
 Expenditures increasing 11% per year over the last 6
years
 Medicare premiums, deductibles, and cost-sharing
are projected to consume 28% of the average
beneficiaries’ Social Security check in 2010
Procurement Sensitive
Workers per Medicare Beneficiary
Selected Years
200
in millions
150
Covered
Workers
100
Part A
enrollment
50
0
Worker to
Beneficiary
Ratio
1966
2008
2028
4.46
3.39
2.49
Source: OACT CMS and SSA
Under Current Law, Medicare Will Place An
Unprecedented Strain on the Federal Budget
12%
Historical
Estimated
Total expenditures
Percentage of GDP
9%
HI deficit
6%
General revenue
transfers
State transfers
3%
Premiums
0%
1966
Tax on benefits
1976
1986
1996
2006
2016
2026
Calendar year
Source: 2008 Trustees Report
Payroll taxes
2036
2046
2056
2066
2076
Support for VBP
 President’s Budget
 FYs 2006-09
 Congressional Interest in P4P and Other Value-Based
Purchasing Tools
 BIPA, MMA, DRA, TRCHA, MMSEA
 MedPAC Reports to Congress
 P4P recommendations related to quality, efficiency, health
information technology, and payment reform
 IOM Reports
 P4P recommendations in To Err Is Human and Crossing the Quality
Chasm
 Report, Rewarding Provider Performance: Aligning Incentives in
Medicare
 Private Sector
 Private health plans
 Employer coalitions
Procurement Sensitive
VBP Demonstrations and Pilots
 Premier Hospital Quality Incentive
Demonstration
 Physician Group Practice Demonstration
 Medicare Care Management Performance
Demonstration
 Nursing Home Value-Based Purchasing
Demonstration
 Home Health Pay-for-Performance
Demonstration
 ESRD Bundled Payment Demonstration
 ESRD Disease Management Demonstration
Procurement Sensitive
VBP Demonstrations and Pilots
 Medicare Health Support Pilots
 Care Management for High-Cost Beneficiaries
Demonstration
 Medicare Healthcare Quality Demonstration
 Gainsharing Demonstrations
 Accountable Care Episode (ACE) Demonstration
 Better Quality Information (BQI) Pilots
 Electronic Health Records (EHR) Demonstration
 Medical Home Demonstration
Procurement Sensitive
Premier Hospital Quality
Incentive Demonstration
CMS/Premier HQID Project Participants Composite Quality Score:
Trend of Quarterly Median (5th Decile) by Clinical Focus Area
October 1, 2003 - September 30, 2006 (Year 1 and Year 2 Final Data, and Yr 3 Preliminary)
75%
70%
65%
60%
85.13%
86.69%
88.68%
90.93%
91.63%
93.40%
95.20%
95.92%
96.05%
96.89%
97.50%
97.7264%
80%
63.96%
68.11%
73.05%
76.14%
78.22%
81.57%
82.98%
84.38%
86.73%
88.79%
90.00%
89.9371%
85%
70.00%
73.06%
78.07%
80.00%
82.49%
82.72%
84.81%
86.30%
88.54%
89.28%
90.09%
91.4013%
90%
85.14%
85.92%
89.45%
90.57%
93.70%
94.89%
96.16%
97.01%
96.77%
98.28%
98.44%
98.3777%
95%
89.62%
89.95%
91.50%
92.55%
93.50%
93.36%
95.08%
95.77%
95.98%
96.14%
96.84%
96.7644%
100%
55%
AMI
CABG
Pneumonia
Heart Failure
Hip and Knee
Clinical Focus Area
4Q03
1Q04
2Q04
3Q04
4Q04
1Q05
2Q05
3Q05
4Q05
1Q06
2Q06
3Q06
VBP Programs
 Hospital Quality Initiative: Inpatient & Outpatient
 Hospital VBP Plan & Report to Congress
 Hospital-Acquired Conditions & Present on Admission
Indicator
 Physician Voluntary Reporting Program
 Physician Quality Reporting Initiative
 Physician Resource Use
 Home Health Care Pay for Reporting
 Medicaid
Procurement Sensitive
VBP Initiatives
Hospital-Acquired Conditions
and Present on Admission
Indicator Reporting
Procurement Sensitive
The HAC Problem
 The IOM estimated in 1999 that as many as
98,000 Americans die each year as a result
of medical errors
 Total national costs of these errors estimated
at $17-29 billion
IOM: To Err is Human: Building a Safer Health System, November 1999.
Available at: http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf.
Procurement Sensitive
The HAC Problem
 In 2000, CDC estimated that hospitalacquired infections add nearly $5 billion to
U.S. health care costs annually
Centers for Disease Control and Prevention: Press Release, March 2000.
Available at: http://www.cdc.gov/od/oc/media/pressrel/r2k0306b.htm.
 A 2007 study found that, in 2002, 1.7 million
hospital-acquired infections were associated
with 99,000 deaths
Klevens et al. Estimating Health Care-Associated Infections and
Deaths in U.S. Hospitals, 2002. Public Health Reports. March-April
2007. Volume 122.
Procurement Sensitive
The HAC Problem
 A 2007 Leapfrog Group survey of 1,256
hospitals found that 87% of those hospitals
do not consistently follow recommendations
to prevent many of the most common
hospital-acquired infections
2007 Leapfrog Group Hospital Survey. The Leapfrog Group 2007.
Available at:
http://www.leapfroggroup.org/media/file/Leapfrog_hospital_acquired_
infections_release.pdf
Procurement Sensitive
Statutory Authority:
DRA Section 5001(c)
 Beginning October 1, 2007, IPPS hospitals
were required to submit data on their claims
for payment indicating whether diagnoses
were present on admission (POA)
 Beginning October 1, 2008, CMS cannot
assign a case to a higher DRG based on the
occurrence of one of the selected conditions,
if that condition was acquired during the
hospitalization
Procurement Sensitive
Statutory Selection Criteria
 CMS must select conditions that are:
1. High cost, high volume, or both
2. Assigned to a higher paying DRG when
present as a secondary diagnosis
3. Reasonably preventable through the
application of evidence-based guidelines
Procurement Sensitive
MS-DRG Assignment
(Examples for a single secondary diagnosis)
Principal Diagnosis: MS-DRG 066
 Stroke without CC/MCC
Principal Diagnosis: MS-DRG 065
 Stroke with CC
Example Secondary Diagnosis:
 Injury due to a fall (code 836.4 (CC))
Principal Diagnosis: MS-DRG 065
 Stroke with CC
Example Secondary Diagnosis:
 Injury due to a fall (code 836.4 (CC))
Principal Diagnosis: MS-DRG 064
 Stroke with MCC
Example Secondary Diagnosis:
 Stage III pressure ulcer (code 707.23 (MCC))
Principal Diagnosis: MS-DRG 064
 Stroke with MCC
Example Secondary Diagnosis:
 Stage III pressure ulcer (code 707.23 (MCC))
POA Status of
Secondary
Diagnosis
Average
Payment
--
$5,347.98
Y
$6,177.43
N
$5,347.98
Y
$8,030.28
N
$5,347.98
HACs Selected During
IPPS FY 2008 Rulemaking
Foreign object retained after surgery
Air embolism
Blood incompatibility
Catheter-associated urinary tract infection
Vascular catheter-associated infection
Surgical site infection – mediastinitis after
CABG
 Pressure ulcers
 Falls – specific trauma codes






Procurement Sensitive
Candidate HACs









Surgical site infections following specific elective
procedures
Staphylococcus aureus septicemia
Clostridium difficile-associated disease (CDAD)
Ventilator-associated pneumonia (VAP)
Deep vein thrombosis (DVT) / pulmonary embolism
(PE)
Legionnaires’ Disease
Iatrogenic pneumothorax
Delirium
Extreme glycemic aberrancies
Procurement Sensitive
Methicillin-Resistant Staph. aureus
(MRSA)
 Directly addressed, as MRSA could be the
cause of any of the selected infectious
conditions
 Presence of MRSA as a colonizing bacterium
does not constitute an HAC
 Presence of MRSA is not a CC or MCC
Procurement Sensitive
POA Indicator
General Requirements

Present on admission is defined as present at
the time the order for inpatient admission
occurs


Conditions that develop during an outpatient
encounter, including emergency department,
observation, or outpatient surgery, are considered
present on admission
Phased implementation
Procurement Sensitive
POA Indicator
General Requirements
 POA indicator is assigned to
 Principal diagnosis
 Secondary diagnoses
 External cause of injury codes (Medicare
requires reporting only if E-code is
reported as an additional diagnosis)
Procurement Sensitive
POA Indicator Reporting Options
POA Indicator Options and Definitions
Code
Reason for Code
Y
Diagnosis was present at time of inpatient admission.
N
Diagnosis was not present at time of impatient admission.
U
Documentation insufficient to determine if condition was
present at the time of inpatient admission.
W
Clinically undetermined. Provider unable to clinically
determine whether the condition was present at the time
of inpatient admission.
Unreported/Not used. Exempt from POA reporting. This code
is equivalent code of a blank on the UB-04; however, it was
determined that blanks are undesirable when submitting this
data via the 4010A.
1
POA Indicator Reporting
IPPS FY 2009 Proposed Rule
 POA indicator
 CMS is proposing to pay the CC/MCC for
HACs that are coded as “Y” & “W”
 CMS is proposing to NOT pay the CC/MCC
for HACs that are coded “N” & “U”
Procurement Sensitive
POA Indicator Reporting
Requires Accurate Documentation
“ A joint effort between the healthcare provider
and the coder is essential to achieve
complete and accurate documentation, code
assignment, and reporting of diagnoses and
procedures.”
ICD-9-CM Official Guidelines for Coding and Reporting
Procurement Sensitive
HAC & POA
Enhancement & Future Issues
 CMS seeks public comment on enhancements to the
HAC payment provision in the IPPS FY 2008 proposed
rule
 Risk adjustment
 Rates of HACs for VBP
 Uses of POA information
 Adoption of ICD-10
 Expansion of the IPPS HAC payment provision to
other settings
 Relationship to NQF’s Serious Reportable Adverse
Events
Procurement Sensitive
Relationship of HACs to
NQF’s “Never Events”
 In 2002, NQF created a list of 27 Serious
Reportable Adverse Events, which was
expanded to 28 events in 2006
 Of the HACs selected during IPPS FY 2008
rulemaking, 7 are on NQF’s list
 Of the HACs candidates under consideration
during IPPS FY 2009 rulemaking, 1 overlaps
with NQF’s events
Procurement Sensitive
Relationship of HACs to
NQF’s “Never Events”
 NQF’s selection criteria for Serious Reportable
Adverse Events
 Unambiguous: clearly identifiable and measurable
 Usually preventable: recognizing that some events
are not always avoidable
 Serious: resulting in death or loss of a body part,
disability, or more transient loss of a body function
 Indicative of a problem in a health care facility’s
safety systems
 Important for public credibility or public
accountability
Procurement Sensitive
NQF’s Serious Reportable Adverse Events
HAC
Surgical Events
Surgery on wrong body part
Surgery on wrong patient
Wrong surgery on a patient
Foreign object left in patient after surgery
Selected
Post-operative death in normal health patient
Implantation of wrong egg
Product or Device Events
Death/disability associated with use of contaminated
drugs, devices, or biologics
Death/disability associated with use of device other
than as intended
Death/disability associated with intravascular air
embolism
Selected
Current NQF Serious Reportable Adverse Events
HAC
Patient Protection Events
Infant discharged to wrong person
Death/disability due to patient elopement
Patient suicide or attempted suicide resulting in
disability
Care Management Events
Death/disability associated with medication error
Death/disability associated with incompatible blood
Selected
Maternal death/disability with low risk delivery
Death/disability associated with hypoglycemia
Candidate
Death/disability associated with hyperbilirubinemia in
neonates
Stage 3 or 4 pressure ulcers after admission
Death/disability due to spinal manipulative therapy
Selected
Current NQF Serious Reportable Adverse Events
HAC
Environment Events
Death/disability associated with electric shock
Selected
Incident due to wrong oxygen or other gas
Death/disability associated with a burn incurred within
facility
Selected
Death/disability associated with a fall within facility
Selected
Death/disability associated with use of restraints within
facility
Criminal Events
Impersonating a heath care provider (i.e., physician,
nurse)
Abduction of a patient
Sexual assault of a patient within or on facility grounds
Death/disability resulting from physical assault within or
on facility grounds
Combating Never Events






HAC payment provision
Conditions of Participation
VBP Plan—measurement, financial incentives, and
public reporting
Coverage policy
Quality Improvement Organization (QIO) 8th and 9th
Scopes of Work
The President’s FY 2009 Budget proposal
1. Prohibit hospitals from billing Medicare for never
events
2. Require hospitals to report occurrence of these
events or receive
a reduced annual payment
Procurement Sensitive
update
Opportunities for HAC & POA
Involvement
 IPPS Rulemaking
 IPPS FY 2009 proposed rule on display April 14,
2008
 60 day comment period ended on June 13,
2008
 IPPS FY 2009 final rule released in August 2008
 Updates to the CMS HAC & POA website:
www.cms.hhs.gov/HospitalAcqCond/
 Hospital Open Door Forums
 Hospital Listserv Messages
Procurement Sensitive
VBP Programs
Hospital Value-Based
Purchasing
Procurement Sensitive
Hospital Quality Initiative
 MMA Section 501(b)
 Payment differential of 0.4% for reporting
(hospital pay for reporting)
 FYs 2005-07
 Starter set of 10 measures
 High participation rate (>98%) for small incentive
 Public reporting through CMS’ Hospital Compare
website
Procurement Sensitive
Hospital Quality Initiative
 DRA Section 5001(a)
 Payment differential of 2% for reporting
(hospital P4R)
 FYs 2007- “subsequent years”
 Expanded measure set, based on IOM’s
December 2005 Performance Measures Report
 Expanded measures publicly reported through
CMS’ Hospital Compare website
 DRA Section 5001(b)
 Report for hospital VBP beginning with FY 2009
 Report must consider: quality and cost measure
development and
refinement,
data infrastructure,
Procurement
Sensitive
Hospital VBP Workgroup
Tasks & Timeline
2006
Oct

Dec

2007
Jan 17


Apr 12

May

June

Nov 21

Environmental Scan
Issues Paper
Listening Session #1 for
Stakeholder Input on Issues Paper
Options Paper
Listening Session #2 for Input on
Hospital VBP Options Paper
Final Design
Final Report, Including Design,
Process, and Environmental Scan
Report Submitted to Congress
Performance Model Overview

Hospitals submit data for all VBP measures that apply

CMS determines each hospital’s performance score on each measure:
higher of 0 - 10 points on attainment or improvement

For each hospital, CMS aggregates scores across all measures within a
domain (e.g., clinical process-of-care measures, HCAHPS)

CMS weights and combines each hospital’s domain scores to determine
the hospital’s Total Performance Score

CMS translates each hospital’s Total Performance Score into an
incentive payment using an exchange function
Procurement Sensitive
Earning Clinical Process of Care Points:
Example
Measure: PN Pneumococcal Vaccination
.47
.87
Benchmark
Attainment Threshold
Hospital I
Attainment Range
Score
•
Score
baseline
.21
.70
performance
•
1
2
3
•
4
•
5
••
6
7
•
8
9
Attainment Range
•
1
•
2
•
3
•4
•5
•
6•
7
Improvement Range
•8
•9
Hospital I Earns: 6 points for attainment
7 points for improvement
Hospital I Score: maximum of attainment or improvement
= 7 points on this measure
Calculation of Clinical Process of Care
Performance Score
Total Earned Points =
Sum of points earned across all reported measures
Total Possible Points =
Number of measures reported by hospital x 10
Clinical Process of Care Performance Score =
Total Earned Points / Total Possible Points x 100
Procurement Sensitive
Earning HCAHPS Points: Example
Dimension: Doctor Communication
50th Baseline
95th Baseline
Percentile
Percentile
Attainment Threshold
Benchmark
Attainment Range
Score
Hospital I
baseline
Score
•nd
42
63rd
•
performance
1
2
3
4
5
6
7
8
9
Attainment Range
1
2
3
4
5
6
7
Improvement Range
Hospital I Earns:
3 points for attainment
4 points for improvement
Hospital I Score: maximum of attainment or improvement
= 4 points on this measure
8
9
10
Earning Points Based on Minimum Performance Across
All Eight HCAHPS Dimensions: Examples
50th Baseline
0th Baseline
Percentile
Percentile
Attainment Threshold
Hospital L
Score
6th
•
lowest
performance
1 2 3 4
Hospital I
Hospital B
Score
Score
18th
67th
•
•
5 6 7 8
9 10 11 12 13 14 15 16 17 18 19 20
Minimum Percentile Point Range
Hospital L’s Lowest Percentile: 6th
Hospital L Earns: 2 minimum percentile points
Hospital I’s Lowest Percentile: 18th
Hospital I Earns: 8 minimum percentile points
Hospital B’s Lowest Percentile: 67th
Hospital B Earns: 20 minimum percentile points
20 points
Calculation of HCAHPS
Performance Score
Total Earned Points =
Sum of points earned across all dimensions
Total Possible Points = 100
HCAHPS Performance Score =
Total Earned Points / 100 Total Possible Points
x 100
Procurement Sensitive
Calculation of
Total Performance Score
 Each domain of measures is initially scored separately,
weighting each measure within that domain equally
 All domain scores are then combined, with the
potential for different weighting by domain
 Possible weighting to combine clinical process
measures and HCAHPS:
 70% clinical process + 30% HCAHPS
 As new domains are added (e.g., outcomes), weights
will be adjusted
Procurement Sensitive
Translating Performance Score into
Incentive Payment: Example
100%
90%
80%
Hospital A
70%
Percent
Of VBP
Incentive
Payment
Earned
60%
50%
40%
30%
20%
10%
0%
0%
10%
20%
30%
40%
50%
60%
70%
Hospital Performance Score:
% Of Points Earned
80%
90%
Full Incentive
Earned
100%
Source of Incentive Payments
 VBP incentive proposed to be a percent of
base operating DRG payment
 Base payment would include geographic and
DRG relative weight adjustments
 Approach links incentive payment most directly
to clinical services provided
 Would apply to all DRGs, not just clinical areas
measured
Procurement Sensitive
VBP Measures Overview

Measure selection considerations

Proposed process for introducing and
managing measures in VBP

FY 2009 candidate measures for VBP
financial incentive

Additional measures for FY 2010 and
beyond

Small numbers issue
Procurement Sensitive
VBP Data Infrastructure &
Validation Overview




Proposed data submission process
Improved data infrastructure
Strengthening validation methodology
Proposed changes to sampling
Procurement Sensitive
VBP Public Reporting Overview
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Design Considerations
Content
Suppressing Measures
Data Displays
Other Transparency Issues
Procurement Sensitive
VBP Program
Monitoring & Evaluation
 CMS will foster an active learning system to
promote breakthrough improvements
 Requires real-time program monitoring and
systematic evaluation
 Ongoing CMS access to patient-level data will
be essential
 Resources must be dedicated to monitoring
and evaluation
Procurement Sensitive
VBP Plan Testing & Completion
 Objectives:
 Use most current RHQDAPU and Medicare
hospital payment data to test VBP Performance
Assessment Model
 Complete methodology development
 Small N
 Outcome scoring methodology
 Inclusion of Outcome Domain in determining Total
Performance Score
 Examine financial impacts of VBP Incentive
Procurement Sensitive
Hospital VBP Report to Congress
 The Hospital Value-Based Purchasing Report
Congress can be downloaded from the CMS
website at:
http://www.cms.hhs.gov/center/hospital.asp
Procurement Sensitive
Value-Driven Health Care
 Executive Order
 CMS’ Posting of Quality and Cost
Information
 Better Quality Information for Medicare
Beneficiaries Pilots
 Chartered Value Exchanges
Procurement Sensitive
Value-Driven Health Care
 Executive Order 13410
 Promoting Quality and Efficient Health Care in
Government Administered or Sponsored Health
Care Programs
 Directs Federal Agencies to:
 Encourage adoption of health information technology
standards for interoperability
 Increase transparency in healthcare quality measurements
 Increase transparency in healthcare pricing information
 Promote quality and efficiency of care, which may include
pay for performance
Procurement Sensitive
Horizon Scanning and
Opportunities for Participation
 IOM Payment Incentives Report
 Three-part series: Pathways to Quality Health Care
 MedPAC
 Ongoing studies and recommendations regarding
VBP
 Congress
 VBP legislation this session?
 CMS Proposed Regulations
 Seeking public comment on the VBP building blocks
 CMS Demonstrations and Pilots
 Periodic evaluations and opportunities to participate
Procurement Sensitive
Horizon Scanning and
Opportunities for Participation
 CMS Implementation of MMA, DRA, TRHCA, and
MMSEA VBP provisions
 Demonstrations, P4R programs, VBP planning
 Measure Development
 Foundation of VBP
 Value-Driven Health Care Initiative
 Expanding nationwide
 Quality Alliances and Quality Alliance Steering
Committee
 AQA Alliance and HQA adoption of measure sets
and oversight of transparency initiative
Procurement Sensitive
Thank You
Thomas B. Valuck, MD, JD
Medical Officer & Senior Adviser
Center for Medicare Management
Centers for Medicare & Medicaid Services
Procurement Sensitive
Value Based Purchasing
Implementation and Approach
Ann Edwards, Director, Health Industries Advisory Practice
June 23, 2008
Practical Approaches to address CMS requirements
Transition in format from “pay for reporting” to “pay for
performance”
•
• Introduction of drivers for evidenced based quality care and
measurement
• This will require true coordination between clinicians, coders and
billing office
•This is not ONLY a documentation issue
•Cannot be addressed solely as a coding or revenue cycle
issue
Value Based Purchasing • Implementation and Approach
3 Initiatives – Same Solutions
• Hospital Acquired Conditions
• Present on Admission
• Never Events
Value Based Purchasing • Implementation and Approach
Hospital Acquired Conditions (HACs)
Effective 10/01/08, CMS will no longer pay hospital’s for a DRG
using the higher paying CC or MCC within one or more of these
conditions unless the condition was POA (present on admission)
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Foreign Object Retained After Surgery
Air Embolism
Blood Incompatibility
Stage III and Stage IV Pressure Ulcers
Falls and Trauma
Catheter – Urinary Tract Infection
Vascular Catheter – Infection
Surgical Site Infection – Mediastinitis after Coronary Artery Bypass Graft
Value Based Purchasing • Implementation and Approach
Proposed Change
Hospital Acquired Conditions (HACs)
Under Consideration for Inclusion
Surgical Site Infections Following Elective Surgery:
Total Knee Replacement
Laparoscopic Gastric Bypass and Gastroenterostomy
Ligation and Stripping of Varicose Veins
Legionnaires Disease
Glycemic Control
Diabetic Ketoacidosis
Nonketotic Hyperosmolar Coma
Diabetic coma
Hypoglycemic Coma
Iatrogenic Pneumothorax
Delirium
Ventilator-Associated Pneumonia
Deep Vein Thrombosis/Pulmonary Embolism
Staphylococcus aureus Septicemia
Clostridium Difficile – Associated Disease
Methicillin-Resistant Staphylococcus aureus
Value Based Purchasing • Implementation and Approach
Practical Steps
• Clinical teams should review literature of evidence to establish
local evidenced based protocols and steps to avoid HACs, and
Never Events
• Not the carepaths of yesteryear
• Establish interpretation and documentation expectations for
POAs
• Templates to support documentation
• Expectation of compliance with protocols - measure and
monitor
• Carrots and sticks
• Resources requirements
Value Based Purchasing • Implementation and Approach
7
Practical Steps (cont’d)
• Establish strong and reliable data collection systems that are
real time
• Electronic solutions
• Consistent and reliable feedback loop from coding, patient
financial services back to clinical services to drive refinement
of process
• All for one, one for all
Value Based Purchasing • Implementation and Approach
Questions?
Please type your questions into the video player window.
The moderator will read the questions to the panelists.
For more information, please visit the Philips
Healthcare Reimbursement Website at
http://www.medical.philips.com/main/reimbursement/
We would appreciate your feedback on this webinar:
http://www.surveymonkey.com/s.aspx?sm=4vzMh_2fdYhiH3Q_2bEy4D_2fpug_3d_3d
CONFIDENTIAL
June 23, 2008
74
Ann Edwards, Director, Health Industries Advisory Practice,
PricewaterhouseCoopers, Hartford, CT
Ann Edwards is a Director in the Health Industries Advisory Practice. She has over 25
years of health care administrative leadership, operational and consulting experience.
Her experience includes the areas of operations improvement in a variety of health care
provider settings, including academic medical centers, community hospitals, physician
practices and ambulatory care services. In addition, she has led business development
projects and advised on strategic planning efforts for a variety of healthcare settings.
PRIOR WORK EXPERIENCE
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CONFIDENTIAL
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Engagement leader for financial turn around endeavor for 450 bed community based
hospital in the northeast. Addressed operational inefficiencies, restructured internal
departments, issues of inappropriate utilization, staffing and supply chain review to
reduce unnecessary expenses, improve productivity and maximize capacity.
Facilitates boards of directors, medical staff members, administrative executive
teams, middle management as well as front line staff to design and implement
comprehensive change processes. Monitor process redesign and implementation to
ensure that performance targets are met and maintained.
Lead patient throughput engagements at hospitals across the country focusing on
emergency department operations, capacity management, surgical services, patient
transportation and supporting IT software implementations.
Directs emergency department redesign engagements in collaboration with
architectural firms to optimize work and patient throughput to maximum efficiency.
Conducts operational reviews of care coordination departments; restructuring for
maximum organizational effectiveness.
Performs quality metric review and implementation of plan to ensure and maintain
consistent performance at benchmark including pay for performance incentive plans.
Hospital Senior Management Team Member during merger and consolidation efforts
creating fully integrated health system
Coordinates medical staff development planning and physician enfranchisement
strategies for muti-site healthcare system.
Founding partner of 4-hospital joint venture to establish free standing radiation
therapy centers in the community setting
June 23, 2008
Thomas B. Valuck, MD, MHSA, JD, Medical Officer & Senior Advisor,
Center for Medicare Management, Centers for Medicare and
Medicaid Services, Washington, DC
Dr. Thomas Valuck is Medical Officer and Senior Advisor in the Center for Medicare
Management (CMM) at the Centers for Medicare & Medicaid Services (CMS). He
advises CMS leadership on policy issues related to Medicare’s payment systems and
quality initiatives, particularly pay for performance. Recently, Dr. Valuck served as
Director of CMS’ Special Program Office of Value-Based purchasing, which was
temporarily created to launch physician and hospital pay for performance. He earned
the 2007 Administrator’s Achievement Award for leadership in implementing Medicare
pay-for-performance initiatives.
Dr. Valuck, a native of Kirksville, Missouri, has degrees in biological science and
medicine from the University of Missouri-Kansas City. He took clinical training in
pediatrics at the Children’s Mercy Hospital in Kansas City, Missouri, before obtaining a
Master’s degree in health services administration from the University of Kansas.
Dr. Valuck was employed for over nine years in various executive roles, including Vice
President of Medical Affairs, at the University of Kansas Medical Center (KUMed) in
Kansas City, Kansas. While at KUMed, Dr. Valuck was awarded the Robert Wood
Johnson Health Policy Fellowship, a one year sabbatical during which he served on the
staff of the Senate Health, Education, Labor, and Pensions Committee
Dr. Valuck relocated to Washington, DC to attend the Georgetown University Law
Center where he worked on the Georgetown Journal of Law and Public Policy and
earned the BNA Health Law Award and the Federal Legislation Clinic Advocacy Award.
As a law student, he worked for the White House Council of Economic Advisers as a
health policy assistant to Dr. Mark McClellan, who was the President’s Chief Health
Policy Adviser at that time. Before joining CMS, Dr. Valuck was an associate at the law
firm of Latham & Watkins, where he practiced regulatory health law.
CONFIDENTIAL
June 23, 2008