About Pay For Peformance Programs
UTMB Health is committed to helping our patients, their families and providers make informed care decisions by publishing results in key dimensions of care – the “triple aim” that health care leaders have come to agree on:
- Better Health (outcomes): Improve the health of the population by supporting proven interventions to address behavioral, social and environmental determinants of health in addition to delivering high-quality care.
- Better Care (processes): Improve the overall quality of care by making health care more patient-centered, reliable, accessible and safe.
- Affordable Care: In the future, reduce the cost of quality health care for individuals, families, employers and government.
Measurements for these three dimensions of care must provide actionable information on cost, quality and appropriateness of care. To encourage providers to continually improve their performance under these quality measures, Pay-for-Performance payment programs were established by the federal government to reimburse hospitals and other providers based on how well they perform.
There are three Pay-for-Performance programs. Each of the three sections of the program consists of different quality and safety measures (although some measures overlap). Simply stated, all of these measures are within the control of the health care provider and/or are preventable.
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Value-Based Purchasing
Hospital Value-Based Purchasing rewards acute-care hospitals with incentive payments for the quality of care they provide to people with Medicare. Reimbursement to hospitals by CMS is withheld, and the helathcare provider must "earn back" those funds by performing well in the outcomes outlined below.
The concept of Value-Based Purchasing is that health care consumers should hold providers of health care accountable for both cost and quality of care. In calculating a VBP score for each hospital, CMS places a high premium on high and consistent performance.
The Value-Based Purchasing payments for the 2015 federal calendar year are determined by how hospitals scored the following sets of measures:
- Measures of Timely and Effective Care
- Surveys of Patients' Experiences
- 30-day Outcome Mortality measures:
- Acute Myocardial Infarction (Heart Attack)
- Pneumonia
- Flu Immunization
- Core Measures: Clinical Process of Care criteria (Agency for Healthcare Research and Quality Composite measures)
- Patient Safety Indicator (PSI-90) (e.g., bedsores, post-operative hip fractures, accidental puncture, etc.)
- 1 Healthcare Associated Infection:
- Central Line-Associated Blood Stream Infection (CLABSI)
- 1 Efficiency measure:
- Medicare Spending Per Beneficiary (MSPB)
Readmissions Program
Readmissions Program is designed to penalize hospitals by withholding reimbursement funds it they readmit too many patients within 30 days of their release. It's part of a broader federal push to improve health care quality.
For the readmissions program, CMS calculates an excess readmission rate for patients who are:
- Readmitted to the hospital within 30 days of a discharge from the same hospital, or
- Who first admitted into the hospital for three conditions: heart failure, heart attack and pneumonia.
The agency bases the rate on discharges occurring during the course of a year. CMS takes into account the severity of illness of each hospital’s patients in estimating what the hospital’s readmission rate should have been given the national averages.
Hospital-acquired Condition (HAC) Reduction Program
Hospital-acquired Condition (HAC) Reduction Program reduces hospital payments by 1 percent for hospitals that rank among the lowest-performing 25 percent with regard to HACs. Hospital-acquired conditions are undesirable, preventable conditions that affect a patient, that arose during a stay in a hospital or medical facility.
These measures include the frequency of bloodstream infections in patients with catheters inserted into a major vein to deliver antibiotics, nutrients, chemotherapy or other treatments, the rates of infections from catheters inserted into the bladder to drain urine, and a variety of avoidable safety problems in patients that occur including bedsores, hip fractures, blood clots and accidental lung punctures.
Over the next few years, Medicare will also factor in surgical site infections and infection rates from two germs that are resistant to antibiotic treatments: Clostridium difficile, known as C. diff, and Methicillin-resistant Staphylococcus aureus, known as MRSA.
Nationally, rates of some infections are decreasing. Catheter-related infections, for instance, dropped 44 percent between 2008 and 2012. Still, the CDC estimates that in 2011, about 648,000 patients—1 in 25—picked up an infection while in the hospital.
Rates of urinary tract infections have not dropped despite efforts. These infections are more likely the longer a line is left in, but sometimes they are not removed promptly out of convenience for the nurse or patient or simply institutional lethargy.
Academic medical centers are disproportionately affected by the HAC Reduction Program for several reasons. Due to infrastructure in place to monitor HACs/HAIs, they more accurately identify adverse events. In addition, some of the reported outcomes are due to severity of patient illness, for which there is currently no payment adjustment factor. In addition, another concern is that there may be little difference in the performance between hospitals that narrowly draw penalties and those that barely escape them. That is because the health law requires Medicare to penalize the worst-performing quarter of the nation’s hospitals each year, even if they have been improving. A quarter of the nation’s hospitals – those with the worst rates – will lose 1 percent of every Medicare payment for a year starting in October.