Link to original article at advisory.com

Our Take: The clock is ticking to the beginning of the penalties for 30 day readmissions. The Advisory Board has developed a great tool for assessing your hospital’s risk. It is definitely worth reviewing. ReInforced Care can reduce your risk through our Patient Experience Management System. Contact us today to learn more.

– Pat Vida, RN, MBA, VP of Innovation, ReInforced Care

Now is the time to find ways to interact with your patients after discharge to better understand the issues they face when trying to manage their care post discharge.   In order to better manage the patient experience and to reduce readmissions this is a critical “core competency.”  ReInforced Care offers a cost-effective solution to do just that.  We would be a great addition to a grant application for this new program from the Department of Health and Human Services.

–Pat Vida, RN, MBA, VP of Innovation, ReInforced Care

News Release

Up to $500 million in Affordable Care Act funding will help health providers improve care

Partnership for Patients announces Federal contracting opportunities

The U.S. Department of Health and Human Services (HHS) announced that up to $500 million in Partnership for Patients funding will be available to help hospitals, health care provider organizations and others improve care and stop millions of preventable injuries and complications related to health care acquired conditions and unnecessary readmissions. This funding, made available by the Affordable Care Act, will be awarded by the Centers for Medicare & Medicaid Services (CMS) Innovation Center through a solicitation and other procurements for federal contracts announced today.

“Since the Partnership for Patients was announced, we have had an overwhelming response from hospitals, doctors, employers, and other partners who want to be a part of this historic effort to improve patient safety,” said CMS Administrator Donald M. Berwick, M.D. “We are now looking to contract with local and statewide entities that can foster and support hospitals’ efforts to improve health care and reduce harm to patients.”

The Partnership for Patients is a new public-private partnership that will help improve the quality, safety, and affordability of health care for all Americans. The Partnership’s two goals arereducing harm in hospital settings by 40-percent and reducing hospital readmissions by 20- percent over a 3-year period. To achieve these goals, the Partnership is seeking to contract with large health care systems, associations, state organizations, or other interested parties to support hospitals in the hard work of redesigning care processes to reduce harm. “Hospital Engagement Contractors” will be asked to conduct the following:

• Design intensive programs to teach and support hospitals in making care safer;
• Conduct trainings for hospitals and care providers;
• Provide technical assistance for hospitals and care providers; and
• Establish and implement a system to track and monitor hospital progress in meeting quality
  improvement goals.

In addition to the Hospital Engagement Contractors, CMS will also be working with other contractors to develop and share ideas and practices that improve patient safety. These efforts include work with patients and families to understand their thoughts on how to best improve patient safety and transitions between different health care settings – such as when a patient is discharged from a hospital to a nursing home.

These contracts make available the first round of funding – which will ultimately total up to $500 million – that the Innovation Center has committed to this effort. Solicitations for proposals are available on the Federal Business Opportunities website at: www.fbo.gov.

When the Partnership for Patients was announced, the Obama administration committed up to $1 billion in Affordable Care Act funding to help achieve the two goals. At the time of the announcement, up to $500 million was made available through the Community-based Care Transitions Program to ensure patients safely transition between settings of care (access the Transitions Program solicitation here).Today’s announcement makes available the start of $500 million additional Innovation Center funds to help reduce health care acquired conditions and reduce unnecessary readmissions.
###

Note: All HHS press releases, fact sheets and other press materials are available at http://www.hhs.gov/news.

Last revised: June 22, 2011

ReInforced Care was discussed in Paul Levy’s Blog, “Not Running a Hospital“.

Here’s the relevant excerpt, but we urge you to read the blog directly on an ongoing basis.

THURSDAY, JUNE 09, 2011

We recently wrote about the decisions hospitals face if and when they decide to reach out to discharged patients to reduce readmissions.

http://www.reinforcedcare.com/blog/reducing-readmissions/some-thoughts-on-post-discharge-outreach-choices/

While we’re obviously biased on the subject, here are some reasons why you might want to consider outsourcing your post-discharge outreach to ReInforced Care, rather than attempting such a program in-house:

• Reduced burden on your hospital staff.
• Costs are minimal compared with using your own hospital staff.
• Our business model incorporates proven best practices, core competencies and dedicated supporting technologies.
• Outreach can be run day or night to ensure maximum successful patient contact.
• Opportunity to identify or prevent adverse events before they escalate.
• May increase patient satisfaction scores and likelihood of referrals.
• Results are immediately compiled in a central location in an electronic format.
• Insightful, actionable reporting derived from data analysis drives continuous improvement.

We’re glad to have your thoughts and feedback on these issues – the more discussion, the better!

-sk

Value Based Purchasing is creating both opportunities and threats for health systems.  CMS is setting the bar for high quality lower cost care.  More than ever health systems need to know what their patients are thinking.  Until now the “voice of the patient” has been silent.  As we follow up with patients, we hear of many opportunities for providers to improve the quality of care they are delivering.  To date we have followed over 20,000 discharges and have provided data to our clients which can help them in both the quality of their care and the experience they are creating for their patients and their families.  The article below explains VBP from the perspective of the Hospitalist.  We find many opportunities for this provider in particular to improve their portion of the care.

–Pat Vida, RN, MBA, VP Innovation, ReInforced Care

From: The Hospitalist, May 2011

As Medicare pins big money on quality, hospitals demand more from hospitalists

by Bryn Nelson, PhD

Mock scorecards, interactive blueprints, quality dashboards: Hospitals are frantically seeking out any advantage that might help them excel in a fast-approaching, mandatory competition with millions of dollars on the line. Value-based purchasing (VBP), a program authorized by the Patient Protection and Accountable Care Act of 2010, gives the Centers for Medicare & Medicaid Services (CMS) the power to base a portion of hospital reimbursement payments on how well hospitals perform in 25 core measures.

The move is intended to help CMS flex its muscles and move from being a passive bystander to an active buyer of what its officials have deemed higher-quality healthcare. Analysts and healthcare experts warn that if hospitalists aren’t paying attention, however, they could put themselves at unnecessary risk or lose out on a major opportunity to demonstrate their value in what Patrick Torcson, MD, SFHM, is calling a “team sport.”

Dr. Torcson, chair of SHM’s Performance and Standards Committee, says every hospitalist should be aware of the core-measures concept, which has been around since 2003 in what’s now called the Hospital Inpatient Quality Reporting (IQR) Program. “We’re not reinventing the wheel; we’re just transforming the program from pay-for-reporting to actual pay-for-performance,” he says. Value-based purchasing, though, is raising the stakes considerably. “It’s really significant because it marks the beginning of an era of accountability and true pay-for-performance at the hospital level.”

A major reason for the heightened concern is the structure of the program. In other quality demonstration projects, CMS has established a score to beat: “Anyone above that threshold is in the money. If you didn’t make it, there was no harm, no foul,” says Trent Haywood, MD, JD, chief medical officer of the Irving, Tex.-based for-profit healthcare cooperative VHA Inc.

We are really honing in on that kind of a quality dashboard, and [VBP’s arrival] is definitely going to be a big boost toward doing that. We are talking about making it part of our credentialing process, part of our privileging process, and part of our physician reimbursement and pay schedule process.

What’s different this time is that value-based purchasing is not collaboration but competition in which every hospital is pitted against the entire market, says Dr. Haywood, the former deputy chief medical officer at CMS. It’s also a zero-sum game. That means there will be winners and losers, with the entire cost-neutral program funded by extracting money from the worst performers to financially reward the best. “In this competition-type model, you need to know who you can beat,” he says.

Race to the Top

That new reality has set off a mad scramble among hospitals hoping to gain any edge they can and spawned a cottage industry of consultants, lawyers, and quality specialists advising them on how to maximize their points. The drive to achieve and maintain a high level of performance is also spurring hospitals to seek more individual accountability as they look to minimize their financial risk.

Hospitals’ baseline scores already have been set, and the initial nine-month performance evaluation period begins July 1. Beginning with discharges on Oct. 1, 2012 (fiscal year 2013), the payment phase will kick in. CMS will start by withholding 1% of the base DRG reimbursement paid to hospitals. That money can be earned back based on how well each hospital scores on the performance measures during the evaluation period. The amount initially withheld will rise by 0.25 percentage points per year until it is capped at 2% in 2017 and beyond.

Think of the competition as an annual decathlon with a pool of prize money funded by the participants, except that hospitals will be evaluated on far more measures. So far, the program includes 17 core Clinical Process of Care measures and eight measures based on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Twenty other potential measures are waiting in the wings, including ones related to hospital-acquired conditions, patient safety, inpatient quality, and mortality, some of which likely will be introduced in fiscal year 2014.

CMS intends to monitor and evaluate the program’s impact on access and quality of care, especially for “vulnerable populations,” the percentage of patients who receive appropriate care, the rates of hospital-acquired conditions, and the best practices of high-performing hospitals.

The complicated nature of the rules and scoring, and significant money attached to the competition, have generated deep concern. In October and again in February, healthcare providers bombarded CMS representatives with questions and suggestions during open phone forums, when the regulations were still in flux. Would the rules be fair? Would CMS provide an early warning of impending losses? Was the agency giving too much weight to patient satisfaction scores?

SHM supports the program, stating, “We believe that the Medicare reimbursement system must be changed to promote value, and we strongly support policies that link quality measurement to performance-based payment.”

Other observers, though, have warned of the potential for unintended consequences. If doctors avoid complicated medical cases in order to increase a hospital’s score, for example, are they really improving care? Will poorly performing hospitals get caught in a vicious circle due to declining financial resources?

Some critics have complained that by scoring on a curve rather than on an absolute point system, the value-based purchasing program might not be a quality initiative so much as an opportunity for CMS to reduce hospital payments. “I believe that this is largely a shell game played by the Centers for Medicare & Medicaid Services to give hospitals the idea that they can win at this game, when all but a few will lose,” wrote Richard Rohr, MD, FHM, in his Feb. 1 entry at the Medical Staff Leader blog (http://blogs.hcpro.com/medicalstaff/). Hospitalist subsidies could be a prime target as the cost-reduction pressures rise, wrote Dr. Rohr, who directs HM programs for Guthrie Healthcare System in Sayre, Pa. Enhancing productivity, he stressed, could be the best defense against a rollback in salaries.

Most experts agree that investing in a quality infrastructure will be essential for success, though other hospitalists differ on the potential effects that VBP might have on their profession. “I think a big part of a quality infrastructure is a hospital medicine program,” Dr. Torcson says. In fact, he recommends that hospitalists approach a hospital CFO or CEO and offer their assistance with the program. “I really think that’s the right direction and the right attitude, kind of the way the Samurai used to serve the Japanese emperor,” he explains.

A major reason for taking the initiative, he says, is that value-based purchasing could become the new business case for HM. In the 1990s, hospitalists could put a real number on how much they saved hospitals by reducing length of stay, sparking an investment in HM programs. “I think value-based purchasing is now in the same position,” Dr. Torcson says, “and the savings is actually going to be even more quantifiable for the hospital in terms of their success or failure.”

—Laura Dietzel, PeaceHealth’s program director for High-Tech Meaningful Use

There are many alternatives available to hospitals as they consider including post-discharge outreach to reduce preventable readmissions.

As we speak to more and more hospital administrators, heads of case management, nursing, finance and the like, we learn more and more about the various approaches they plan to take.

Most often, the choice begins with assigning nurses to do follow-up calls.

It intuitively seems like a good idea: nurses are trained to provide a high level of care should a discharged patient need it. The more one looks at it, however, the less savvy a choice it seems to be. Here are some reasons why:

• Most hospital-based call programs only reach a fraction of the total discharge population because other work gets in the way.
• Often, staffing limitations mean that calls cannot be made during ‘off hours’, when patients are most reachable.
• Adding non-core calling duties taxes an already difficult staff workload and decreases availability to inpatient care, which may negatively affect satisfaction scores.
• Cost – whether adding FTEs or just more hours, you are paying full costs for work that largely can be done at a lower cost, with more flexibility.
• Learning/continuous improvement – generally, there isn’t any.

Coming next: some very tangible benefits to outsourcing/partnering on post-discharge outreach with ReInforced Care.

–sk

The Administration Implements Affordable Care Act Provision to Improve Care, Lower Costs

Value-Based Purchasing Will Reward Hospitals Based on Quality of Care for Patients

The Department of Health and Human Services launches Value Based Purchasing today.  This creates opportunities for providers to benefit from high quality, cost effective care and creating great patient experiences.  ReInforced Care can assist providers with this.    Our proactive outreach to patients post discharge allows providers to “hear the voice of the patient” during their transition home and to assist them if they are struggling with the discharge plan.  This makes the patient and their caregivers feel supported and improves their potential  manage their recovery.

“Changing the way we pay hospitals will improve the quality of care for seniors and save money for all of us,” HHS Secretary Kathleen Sebelius said in a news release. “Under this initiative, Medicare will reward hospitals that provide high-quality care and keep their patients healthy.”

–Pat Vida, RN, MBA, VP of Innovation, ReInforced Care

http://www.hhs.gov/news/press/2011pres/04/20110429a.html.

This article speaks to the future payment methods for Medicare.  The goals are to improve quality and the patient experience.  Our program can assist organizations in both. Our proactive outreach assists patients with their discharge plan to reduce their risk of readmission while creating an extended experience with the hospital.  The patients we call feel the continued support of the hospital as they transition home.  Given how difficult this time can be, the patients welcome the knowledge that the hospital is continuing to monitor their recovery and offering assistance when needed.  The end result of our program is a decrease in readmissions and an improvement in HCAHPS and other satisfaction surveys.

–Pat Vida, RN, MBA, VP of Innovation, ReInforcedCare

http://www.healthleadersmedia.com/print/HEP-261211/CMS-Releases-ValueBased-Purchasing-Incentive-Plan

CMS Releases Value-Based Purchasing Incentive Plan

Cheryl Clark, for HealthLeaders Media , January 11, 2011

Federal officials have issued a long-awaited proposal on how they will make value-based purchasing incentives. The document sets forth which metrics will generate payment after Oct. 1, 2012.

The Centers for Medicare & Medicaid Services proposal, issued late Friday, incorporates 17 clinical process-of-care measures used in five health categories, acute myocardial infarction, heart failure, pneumonia, healthcare associated infections and surgical care improvement. It also will use eight measures from the hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that reflects how patients view their care experiences.

Those measures include patients’ views of their communication with nurses and doctors, the responsiveness of hospital staff, their pain management and the cleanliness and quietness of the hospital environment.

These 25 measures will be used to generate FY 2013 DRG payments.

By 2014, it will add mortality outcome measures for the three health conditions, eight hospital-acquired condition measures and nine Agency for Healthcare Research and Quality measures. The hospital-acquired condition measures include surgical foreign object retention, air embolism, blood incompatibility, pressure ulcer stages III and IV, falls and trauma such as burns or electrical shocks, catheter-associated urinary tract infections and manifestations of poor glycemic control.

The regulations will apply to discharges at 3,000 acute care hospitals. All these hospitals will have their funding reduced starting with 1% in fiscal year 2013, rising to 2% by FY 2017, but will have a chance to earn that money back, and perhaps more, under the incentives algorithm.

Algorithms will be calculated to derive a Total Performance Score or TPS for each hospital.

CMS director Don Berwick, in a statement, called the proposed regulations “a huge leap forward in improving the quality and safety of America’s hospitals for both Medicare beneficiaries and all Americans.

The hospital value-based purchasing program will reward hospitals for improving patients’ experiences of care, while making care safer by reducing medical mistakes.”

Senior Associate Directors for Policy for the American Hospital Association, Beth Feldpush and Joanna Kim, say that while their organization supports the guidelines, one element sticks out they believe unfairly penalizes hospitals.

Under the proposal, hospital-acquired conditions are included in the algorithm that would result in financial penalties to a hospital that had higher percentages. That’s a problem because another section of the Patient Protection and Affordable Care Act also includes specific financial penalties for hospitals with higher rates of hospital-acquired infections.

“We were surprised to see HAI in the value based purchasing rules, and this is something the AHA will be strongly opposing,” Feldpush says. If this is allowed to stand, “hospitals will be at risk for double jeopardy, with financial penalties imposed twice on the same set of measures.”

Kim and Feldpush say the AHA is studying other parts of the proposal in order to give a more detailed response. So far, they say, “There’s a lot in here that we really do like,” and that these financial incentives, “will lift all boats.”

Hospitals will learn what their value-based incentive payment will be for FY 2013 “at least 60 days prior to Oct. 1, 2012,” CMS said. The period of evaluation begins this July 1 and lasts until March 31, 2012.

Several other parts of proposed regulations clarify how the algorithm will work. For example, hospitals will benefit not only if they have high scores, but also if they show improvement.

CMS proposes to use a linear improvement equation, so that each percentage of improvement will count the same. It had been suggested that some hospitals might get greater rewards if they improved from very low scores, or if they achieved improvement from almost perfect to perfect.

Blair Childs, senior vice president of public affairs for Premier healthcare alliance, said the rules “will evolve the Medicare payment system to reward improvements in quality and health outcomes.”

Through its five-year Hospital Quality Incentive Demonstration pilot project with CMS, Premier says, incentives like these “can achieve better outcomes for patients. In five years, participants in the HQID raised their overall quality by an average of 18.3%.”

The Centers for Medicare & Medicaid Services proposal may be viewed here.

http://runningahospital.blogspot.com/2011/04/aco-rules-wheres-beef.html

From Paul Levy’s blog.

Takeaway Quote:

Real cost savings will not result from ill-conceived government laws and regulations: They will occur when physicians and other health professionals redesign the work that takes place in their offices and hospitals. Attempts to generate that redesign by government regulations, especially self-contradictory ones like this, will fail.

As we look at the potential penalties coming soon, it becomes clear that it is time to start implementing strategies to reduce readmissions.  Although there is a potential loss of revenue for the readmissions that are still being reimbursed, the impact of programs to reduce readmissions does not happen immediately.  Given the wide variation in readmission rates over the course of a year, it can take a year to see the impact.  Clearly it is time to start now. “You can’t turn the Queen Mary on a dime!”

–Pat Vida, RN, MBA, VP of Innovation, ReInforced Care, Inc.

3 Readmissions to Reduce Now

Neal Gold, MD, Director, Sg2, for HealthLeaders Media, March 15, 2011

As the rising tide of health care reform rolls in, the time is now for health care organizations to zero in on reducing readmissions. Hospitals with risk-adjusted 30-day readmission performance in the lowest quartile will incur penalties against their total Medicare payments beginning in fiscal year 2013 (ie, starting October 1, 2012). The Centers for Medicare & Medicaid Services (CMS) will evaluate the prior year’s readmissions data, effectively starting the clock ticking on October 1, 2011. The imperative is clear and the timeline is brief—hospitals must start preparing for these penalties at once.

1. Understand the Penalty Conditions
CMS is authorized by the Hospital Readmission Reduction Program to start penalizing for excess readmissions for congestive heart failure (CHF), pneumonia, and acute myocardial infarction (AMI) in 2013. These conditions were chosen in part due to their high volumes and readmission rates, as well as their significant cost to Medicare. In 2015, the number of conditions will expand and will likely include chronic obstructive pulmonary disease, coronary artery bypass graft, percutaneous coronary interventions and vascular procedures. Again, penalties will not be limited to payment for the noted diagnoses, but will be levied against a hospital’s entire Medicare payment for the year. CMS defines readmissions as “all cause” with a few exceptions, such as hospital transfers and readmissions for hospice and radiation.

2. Calculate Your Revenue at Risk
There are 2 different methods for penalty calculation provided in the Patient Protection and Affordable Care Act (PPACA). The worse-case scenario is a 1% Medicare payment reduction across all DRGs in fiscal year 2013, increasing to 2% in 2014 and 3% in 2015. For example, if a hospital’s total inpatient payments from Medicare totaled $50 million in FY 2012, the hospital would lose $500,000 (1% of $50 million) of its inpatient operating payments in FY 2013. On the other hand, if the alternative calculation (described below) results in total excessive payments of less than the cap, Medicare payments will be reduced by that percentage.

To determine the potential penalty, the amount of excessive payments made for each of the 3 conditions must be calculated. The PPACA defines excessive payments as the product of the number of patients with the applicable condition, the base DRG payment made for those patients and the percentage of readmissions above the expected rate for that specific hospital.

Sample Hospital: (Number of patients with condition) x (Average reimbursement for condition) x (% Higher than expected) = Excessive payment for condition

Click to view full table.

Continuing with the example from the worst-case scenario, if the above sample hospital’s total inpatient operating payments from Medicare were $50 million in FY 2012, then their excessive payments were 1.4% of total operating payments ($705,000 divided by $50 million). However, the maximum penalty in FY 2013 is 1% of the total operating payments, which is less than this hospital’s total excessive payments. Based on this example, this hospital would lose $500,000 (1% of $50 million) of its inpatient operating payments in FY 2013. On the other hand, if excessive payments were determined to be 0.8% (instead of 1.4%), then the hospital would be penalized $400,000 (0.8% of $50 million).

3. Prepare for Penalties Now
Although many questions remain about how Medicare’s readmission penalties will play out, including expected readmission rates per hospital and how penalties will be levied in a bundled payment program, there are still clear actions all health care organizations can and should take immediately, including the following:

• Know your readmission metrics including original discharge disposition and origin of readmission
• Calculate readmission rates by condition, physician performance and post acute care facility
• Regularly share readmission data with key stakeholders, including physicians, senior executives and case management
• Identify opportunities based on patient demographics and common readmissions
• Screen and target patients based on risk assessments
• Compare disease-specific outcome measures to national and local competitor rates.

Neal Gold, MD, is Director of Sg2.