Value Based Purchasing

[TX RN]

Seems like CMS is moving from fee for service to something called "value based purchasing" for inpatient encounters.

Anyone doing inpatient rounds have info on this?

[Corey Narry, MSN, RN, NP]

Value-Based Purchasing has been much talked about among hospital executives who are concerned about reimbursement. The concept is actually part of the provisions of the Patient Protection and Affordable Care Act of 2010. The year 2013 is the start of VBP implementation.

Simply put, this is a concept that makes hospitals accountable for the quality of clinical services offered rather than rewarding hospitals for raking in the quantity of patients served. Gone are the days when hospitals reap the benfits of beefing up caseloads and procedures to generate large revenue. Be aware that this only applies to CMS patients (Medicare and Medicaid patients). Based on how VBP works, hospitals are assessed for clinical quality based on outcome measures and are ranked into a continuum from worst to best with the best receiving the highest possible reimbursement and the worst left to suffer with the lowest possible reimbursement. Pretty scary isn't it?

What outcome measures are used you may ask? One part of it actually makes sense. Hospitals are supposed to make patients safe by following national standards of care. You don't go in to a hospital with a treatable condition and leave in a condition worse than the one you came in with. That's the reason why national standards are developed. As of the present, these outcome measures are:

1. Heart Attack and Heart Failure Quality Measures

- Percent of Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes Of Arrival

- Percent of Heart Attack Patients Given PCI Within 90 Minutes Of Arrival

- Percent of Heart Failure Patients Given Discharge Instructions

2. Pneumonia Quality Measures

- Percent of Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior To The Administration Of The First Hospital Dose Of Antibiotics

- Initial Antibiotic Selection for CAP in Immunocompetent Patient

3. Surgical Quality Measures

- Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision

- Prophylactic Antibiotic Selection for Surgical Patients

- Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time

- Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose

- Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period

- Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered

- Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery

The second part measures the patient's "hospital experience" if you will. This is where it can get a bit dicey. Patients are sent a survey when they leave the hospital which includes a set of questions. They are very similar to the Press-Ganey Patient Satisfaction Surveys we nurses are all too familiar with. Typical questions asked are:

- How well nurses communicated with patients

- How well doctors communicated with patients

- How responsive hospital staff were to patients’ needs (i.e., answering call light)

- How well caregivers managed patients’ pain

- How well caregivers explained patients’ medications to them

- How clean and quiet the hospital was

- How well caregivers explained the steps patients and families need to take to care for themselves outside of the hospital (i.e., discharge instructions)

Definitely a very subjective set of questions that can yield varying results. If you're a nurse working for a hospital right now, I'm sure you've been subjected to AIDET training in one form or another. Nurses are now being asked to follow scripts when communicating with patients in an attempt to improve the "hospital experience" by almost following a Ritz-Carlton type of service impractical for an institution for people who are sick. I have mixed feelings about it, in one end it respects nurses as valuable members of the hsopital team in teaching patients about their healthcare but on the other end, places unrealistic expectations in a setting that gets easily chaotic due to fluctuations in patient acuity and staffing levels.

This is a good starting point for discussion and I'm glad you brought it up.

[Corey Narry, MSN, RN, NP]

...and just to clarify, my understanding is that this is part of the hospital's Prospective Payment System and does not affect provider reimbursement based on E&M. NP's (and physicians) still get the same amount of dollars per patient encounter based on the level of E&M services.

[TX RN]

JDLC, as always very knowledgeable. Thanks for sharing.

I've been a NP for several years now, and with the Affordable Care Act implementation I have had heard rumblings of this occuring. Now, my understanding was that this VBP would also influence provider reimbursement. I didn't get specifics on how, but from what you're describing it seems more of the VBP incentivizing what is otherwise known as the HEDIS measures.

Some commercial payers incentivize groups/facilities with higher HEDIS measure scores.

Any link you can provide for more info on VBP?

Essentially, I'm trying to better gauge my position of where I currently stand. A group with substantial local political influence in the majority of the hospitals is offering me a position. It's volume driven and I'm a bit skeptical of how easily they will be able to adapt to change. I need to know without doubt how, if at all, VBP will affect an aggresive volume driven practice.

[Corey Narry, MSN, RN, NP]

The CMS site for VBP is:

Hospital Value-Based Purchasing | Centers for Medicare & Medicaid Services

The "patient experience" survey sent to discharged patients is called HCAHPS. The CMS website that contains information on this is:

HCAHPS - Hospital Survey

You can actually check how hospitals stack up on these outcome measures. Hospital information on this is available to the public. One site that has a searchable database is:

Medicare Hospital Compare Quality of Care

I work for a university medical center where we already adhere to standard practice but have a higher patient acuity where some standard practice do not apply. I have colleagues who work in community hospitals whose managers are worried about this change.

[Sailnskinurse]

Can anyone clarify the difference between FY 2014 payment determination and FY 2014 IPPS?

[Caribbean_cruzin]

Acute Inpatient PPS - Centers for Medicare & Medicaid Services

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/Downloads/Reconsideration-Manual-v0-2-for-downloads.pdf

Check these sites and I think this will help you. The basic difference in the 2 is the IPPS is related to the patient population your facility serves and other elements related to the hospital. The payment determination is based on core measure and the reducing of hospital acquired conditions.

[Sailnskinurse]

Thank you! This is very helpful.