CMS ties outcomes, reimbursement
Role of quality manager to grow
The advent of true value-based purchasing focused not just on reporting data but on actual outcomes took a major step closer to reality with the issuance of a proposed rule by the Centers for Medicare & Medicaid Services (CMS), the final version of which would take effect starting in fiscal year 2013.
"CMS proposes to score each hospital on relative achievement and improvement ranges for each applicable measure," according to a statement posted on the CMS website. "A hospital's performance on each quality measure would be evaluated based on the higher of an achievement score in the performance period or an improvement score, which is determined by comparing the hospital's score in the performance period with its score during a baseline period of performance."
For example, CMS said, "For each of the proposed clinical process and patient experience of care measures that apply to a hospital for FY 2013 [also outlined in the statement], CMS proposes that a hospital would earn 0-10 points for achievement based on where its performance for the measure fell within an achievement range, which is a scale between an achievement threshold and a benchmark. With regard to the improvement score, CMS proposes that a hospital would earn 0-9 points based on how much its performance on the measure during the performance period improved from its performance on the measure during the baseline period. Finally, CMS would calculate a Total Performance Score (TPS) for each hospital 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." The final rule is expected to be published later this year.
"Overall, I think the concept behind this is good," says Paula Levesque, RN, MSA, corporate director, external quality measures, Beaumont Hospitals in Royal Oak, MI. "In the past, hospitals had been required to collect data and submit it to CMS, but there was never any requirement of hit thresholds or hit compliance."
The implications for Medicare reimbursement are "huge," she continues. "This is a carve-out of what Medicare dollars we get today," she explains. "They will hold back up to 2% in 2017, and we have to earn it back through our performance in measures. You could potentially lose 1% in 2013, and then it works its way up."
"It should come as no surprise that CMS will be linking quality data results to reimbursements," adds Patrice L. Spath, of Brown-Spath & Associates in Forest Grove, OR. "This was the intended result of their value-based purchasing program. First, hospitals were financially rewarded for reporting data, and now there will be financial rewards or penalties for what the data reveal.
"What caught my eye in the proposed rule was the statement, 'We estimate that no participating hospital will receive more than a net 1% increase or decrease in payments,'" Spath says. "After reviewing the intricacies of the regulation governing how CMS will calculate quality scores and reimbursement levels, it seems like a lot of work for something that results in a very small bottom-line impact for hospitals. One wonders if the costs associated with running this program at CMS and whatever costs hospitals may incur are worth the effort."
Spath says another issue embedded in these proposed rules could have even more impact than the payment reform proposal itself. "That is the requirement that quality improvement organizations [QIOs] must disclose quality review study information to CMS with identifiers of patients, practitioners, or institutions," she says. "Over the past few years, the QIOs have developed a collegial relationship with health care facilities often serving as quality advisors and partners, not regulators. If information maintained by the QIOs is now to be reported to CMS, the relationship between health care facilities and the QIOs could become more adversarial."
Bigger role for quality managers
Levesque says there's no doubt in her mind that these new realities will heighten the importance of the quality manager in the hospital. "It will bring increased pressure, and make us much more important," she asserts. "I have been in quality management for years, and it has gotten more sophisticated, but there were not actual dollars attached to make our role tangible to staff. In the past, clinicians have dismissed us as just being involved with process measures, which did not affect outcomes. This really gets people's attention."
Levesque adds that Beaumont and other systems in Michigan have a leg up because Michigan Blue Cross/Blue Shield has already been incentivizing hospitals for actual outcomes. "It's easier for us to translate what CMS is doing, but we are for the first time trying to highlight measures included in it and help understand the financial impact," she says. "We put up a dashboard, so if metric 'A' is at a certain level, we now know that could mean this many dollars. This makes things really tangible for leaders in terms of what the potential impacts could be financially."
How does she recommend that other quality managers make sure they are prepared for this new reality? "Communicate broadly, widely, and concisely," she advises. "As quality leaders, we have to help the hospital leaders understand what this means, and also be the consultant to help them figure out how they want to meet the guidelines and what we want to do through data, dashboards, scorecards, and so on and then using the PI skills we have to help resolve some of the outlying measures and correct processes when they're not where they need to be."
The advent of true value-based purchasing focused not just on reporting data but on actual outcomes took a major step closer to reality with the issuance of a proposed rule by the Centers for Medicare & Medicaid Services (CMS), the final version of which would take effect starting in fiscal year 2013.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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