Getting their Money’s Worth…Value-Based Purchasing

August 29th, 2014 / By Cheryl Manchenton, RN

Value-based purchasing further emphasizes the ripple effect and spider web of CDI, HIM and Quality. Everyone “knows” about value-based purchasing, but what is it comprised of?

Value-based purchasing (VBP) is both a broad and narrow quality measurement tool. Broadly defined, pay for performance (P4P)/ VBP is payer-developed metrics to measure value compared to reimbursement given. Two examples are accountable care organizations (ACOs) and bundled payments. A narrow definition is a program mandated by the Affordable Care Act of 2010 and administered by CMS. VBP has been in development for almost 10 years but was formally introduced for FY 2013. Through the Medicare program, incentive payments are made to hospitals based on either how well they perform or improve against their own baseline on each domain comprising VBP. There are four domains: clinical process of care, patient experience of care, outcome (FY 2014 forward) and efficiency (FY 2015 forward). Each domain is assigned an associated weight. For example, in FY 2015 clinical process is 20 percent of the total VBP score, patient experience is 30 percent, outcome is weighted at 30 percent and efficiency rounds it out at 20 percent.

Clinical process of care includes hospital performance in meeting certain core measures requirements for heart failure, acute MI, pneumonia and SCIP. CDI and HIM staff may impact performance in one of two ways: 1) careful review of all principal diagnosis options (as discussed in my previous blog about the ripple effect) and 2) concurrent identification and referral of core measures cases to Quality or Core Measures teams.

Patient experience of care is based on scores in eight elements of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) This is obviously not amenable to CDI or HIM involvement, but how we act as employees may influence the overall reputation included in this measure.

Outcome encompasses five elements: 30 day mortality for AMI, 30 day mortality for heart failure, 30 day mortality for pneumonia, AHRQ PSI 90, and, for FY 2015 only, incidence of central line associated blood stream infections (CLABSI). Again, CDI and HIM cannot influence 30 day mortality outcomes but the other elements are more amenable to CDI/HIM involvement than any other elements in VBP. Review of possible/probable complications with attempts for confirmation/rule out, clarification of POA status and of conflicting documentation is certainly an appropriate and necessary part of CDI and HIM responsibilities.

The efficiency domain includes Medicare Spending per Beneficiary (MSPB), which measures both Medicare part A and B payments provided to a beneficiary during an episode of care from three days prior to inpatient admission through 30 days post discharge.

Value-based purchasing is funded in FY 2014 by a 1.25percent reduction from participating hospitals’ base-operating Diagnosis-Related Group (DRG) payments. The percentage available each year varies from a low of 1 percent in FY 2013, 1.5 percent for FY 2015 and 2 percent for 2017 forward. Whether or not this actually results in improved patient care is debatable, but VBP is here!

Cheryl Manchenton is a Senior Inpatient Consultant and Project Manager for 3M Health Information Systems