January 7, 2011: CMS Releases New Value-Based Purchasing Proposed Rule

on Tuesday, 15 February 2011. All News Items

The new Value-Based Purchasing (VBP) proposed rule is a step towards CMS no longer paying hospitals for simply reporting quality measures. Hospitals will be paid based upon their performance or improvement of specified quality measures. In a related CMS VBP Fact Sheet, CMS indicates that VBP “is intended to transform Medicare from a passive payer of claims based on volume of care to an active purchaser of care based on the quality of services its beneficiaries receive.” Further, VBP is just one of several reforms changing the way Medicare pays Hospitals. Other reforms tying payment to quality patient care are “incentives for implementing electronic health records, and payment adjustments based on hospitals' rates of hospital-acquired conditions and rates of readmissions.”

Key Points from the Proposed Rule:

Who will be affected? Acute Inpatient Hospitals that are paid under the Medicare Inpatient Prospective Payment System for inpatient services provided to Medicare beneficiaries.

How would incentives be determined? During a base period hospital’s performance or improvement would be evaluated.

When would the Value Based Incentives Begin? Fiscal Year 2013 on October 1, 2012.  

How would Incentives be funded? By law, payments must be funded by a reduction in base operating DRG payments for each discharge by 1% in FY 2013 and increasing to 2% by FY 2017.

Proposed Quality Measures for Hospital Value-Based Purchasing Program

Fiscal Year 2013

Clinical Process of Care Measures

Acute Myocardial Infarction

AMI-2 Aspirin Prescribed at Discharge
AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
AMI-8a Primary PCI Received Within 90 Minutes of Hospital Arrival
Heart Failure
HF-1 Discharge Instructions
HF-2 Evaluation of LVS Function
HF-3 ACEI or ARB for LVSD
Pneumonia
PN-2 Pneumococcal Vaccination
PN-3b Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital
PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient
PN-7 Influenza Vaccination
Healthcare-associated Infections
SCIP-Inf-1 Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients
SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose
Surgical Care Improvement
SCIP-Card-2 Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period
SCIP-VTE-1 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery
Patient Experience of Care Measures
Hospital Consumer Assessment of Healthcare Providers & System Survey (HCAHPS) ·       Communication with Nurses
·       Communication with Doctors
·       Responsiveness of Hospital Staff
·       Pain Management
·       Communication About Medicines
·       Cleanliness and Quietness of Hospital Environment
·       Discharge Information
·       Overall Rating of Hospital


Note: The initial proposed measures are a subset of measures already being reported to CMS as part of the Hospital Inpatient Quality Reporting Program (Hospital IQR). Data on these measures can be found on the Hospital Compare website at http://www.hospitalcompare.hhs.gov/.

Additional Proposed Quality Measures for Fiscal Year 2014
Mortality Measures
Mortality-30-AMI Acute Myocardial Infarction (AMI) 30-day Mortality Rate
Mortality-30-HF Heart Failure (HF) 30-day Mortality Rate
Mortality-30-PN Pneumonia (PN) 30-Day Mortality Rate
Hospital Acquired Condition Measures
Foreign Object Retained After Surgery
Air Embolism
Blood Incompatibility
Pressure Ulcer Stages III & IV
Falls and Trauma:  (Includes:  Fracture, Dislocation, Intracranial Injury, Crushing Injury, Burn, Electric Shock)
Vascular Catheter-Associated Infections
Catheter-Associated Urinary Tract Infection (UTI)
Manifestations of Poor Glycemic Control
Agency for Healthcare Research and Quality (AHQR) Measures
Patient Safety Indicators (PSIs)
PSI 06 Iatrogenic pneumothorax, adult
PSI 11 Post Operative Respiratory Failure
PSI 12 Post Operative PE or DVT
PSI 14 Post Operative wound dehiscence
PSI 15 Accidental puncture or laceration
Inpatient Quality Indicators (IQIs)
IQI 11 Abdominal aortic aneurysm (AAA) repair mortality rate (with or without volume)
IQI 19 Hip fracture mortality rate
Composite Measures
Complication/patient safety for selected indicators
Mortality for selected medical conditions


Proposed Baseline Performance Period for VBP Incentives Determination:

  • FY 2013 Incentives: An 8 Months Performance Period from July 1, 2011 through March 31, 2012.
  • Future FY Incentives: A full year Performance Period

Proposed Performance Scoring:

  • CMS will Score a hospital based on Achievement and Improvement ranges for each measure.
    • Each measure’s score would be based on the higher of the Achievement Score or Improvement Score for that Measure for the Performance Period.
    • Determination of which is higher would be made by comparing a hospital’s score in the Performance Period to scores during a Baseline Performance Period.
  • FY 2013: CMS is proposing that each Clinical Process Measure and Patient Experience of Care Measure would be scored.
    • Measures that fall in the Achievement Range would earn 0-10 points based on the Achievement Threshold and a Benchmark.
    • Measures that fall into an Improvement Score would earn 0-9 points based on how much the performance improved from the Baseline Period.
  • Total Performance Score (TPS) for each hospital would be determined by combining its scores on all of the measures within each domain, multiplying its performance score on each domain by the proposed weight for the domain, and adding the weighted scores for the domains.
    • Proposed weighting of measures
      • 70% Clinical Process of Care Measures
      • 30% Patient Experience of Care Measures (HCAHPS)

 Proposed Incentive Payments:

  • CMS proposed to use a linear exchange function to translate a hospital’s TPS into a VBP Incentive Payment.
    • A hospital would be notified of the estimated amount of incentive payment for FY 2013 through its QualityNet account at a minimum 60 days before October 1, 2012.
    • An exact amount will be provided to hospitals on or about November 1, 2012.

CMS is accepting public comments on this Proposed Rule through March 8, 2011. Comments will be reviewed and responded to in the final Hospital VBP rule to be released later this year.

The Medicare Fact Sheet can be accessed here.
The entire Proposed Rule can be accessed here.

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