The Center for Medicare and Medicaid Services (CMS) continues to increase the proportion of Medicare payments linked to value-based purchasing measures, affecting payment for inpatient stays in more than 3,500 U.S. hospitals.In 2016, 1.75% of hospital’s base diagnosis-related groups’ base operating payments will be tied to four value-based domains. Patient experience of care will account for 25% of the weighting, down from 30% in 2015 and outcomes will be 40% (up from 30% from 2015). Process of care measures will drop to 10% of the calculation and efficiency measures will rise to 25%.
The metrics within two of the domains have also changed; influenza immunization has been added to the process of care measures for FY 2016 and five previous metrics have been removed:1
- Primary PCI received within 90 minutes of hospital arrival
- Discharge instructions
- Blood cultures performed in the emergency department prior to initial antibiotic received in the hospital
- Prophylactic antibiotic received within one hour prior to surgical incision
- Cardiac surgery patients with controlled 6 AM postoperative serum glucose
Seven measures continue to factor into process of care. They include:
- Fibrinolytic therapy received within 30 minutes of hospital arrival
- Initial antibiotic selection for community-acquired pneumonia in immunocompetent patient
- Prophylactic antibiotic selection for surgical patients
- Prophylactic antibiotics discontinued within 24 hours after surgery end time
- Postoperative urinary catheter removal on postoperative day 1 or 2
- Surgery patients on a beta blocker prior to arrival that received a beta blocker during the perioperative period
- Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours following surgery
The benchmarks for these seven measures are set at 100% and the influenza immunization benchmark is 98.88%. To maximize reimbursement, hospitals need to ensure they perform these processes of care every time for every affected patient. 2
For Fiscal Year 2016, CMS added two new measures to the outcome domain: catheter-associated urinary tract infection (CAUTI) and surgical site infection (SSI) following colon surgery and abdominal hysterectomy. Benchmarks for both are set at zero. The new SSI score will be a weighted average based on both procedures.
Benchmarks for the five outcome measures that carry over from 2015 have mostly stayed the same or incrementally increased. They are:
- Acute myocardial infarction (AMI) 30-day mortality rate (86.24 survival rate)
- Heart failure 30-day mortality rate (90.03 survival rate),
- Pneumonia 30-day mortality rate (90.42 survival rate)
- Patient safety indicator composite (.452)
- Central line-associated bloodstream infections (0.00)
The patient safety indicators in the composite remain the same: pressure ulcer rate, iatrogenic pneumothorax rate, central venous catheter-related bloodstream infection rate, postoperative hip fracture rate, postoperative pulmonary embolism or deep vein thrombosis rate, postoperative sepsis rate, postoperative wound dehiscence rate, and accidental puncture or laceration rate.
The efficiency measure remains the same with a threshold of median Medicare spending per beneficiary ratio across all hospitals and a benchmark of the lowest decile of Medicare spending per beneficiary ratios across all hospitals.
The patient experience of care measures also remains unchanged, though all but two of the measures saw increases in their benchmarks. Half of the measures focus on communication with patients which should be a high priority for hospitals. The measures and their 2016 benchmarks are: communication with nurses (86.07), communication with doctors (88.56), communication about medicines (72.77), discharge information (90.36), responsiveness of hospital staff (79.76), pain management (78.16), hospital cleanliness and quietness (79.10), and overall rating of hospital (83.97).
CMS has also announced proposed changes to future year metrics, which hospitals should plan to address as soon as possible. In Fiscal Year 2018, CMS will add a three-item care transition measure. In 2019, CMS plans to expand the non-intensive care unit measures for CLABSI and CAUTI, and in 2021, CMS has proposed including the 30-day, all cause, risk-standardized mortality rate following hospitalization for chronic obstructive pulmonary disease.3
Hospital value-based purchasing. CMS.org. Updated October 30, 2015. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based-purchasing/
Value-based Purchasing at a Glance: Fiscal Year 2016 and Your Organization. Studer Group.
CMS releases final FY 2016 payment rules for inpatient, long-term and post-acute care. Premier. Updated September 10, 2015.