January 24, 2011

Hospitals are experiencing financial pressures at least as great as those of most anesthesia groups. Inflation-beating increases in Medicare payments are a thing of the past. (MedPAC, the advisory commission charged with making annual recommendations on the Medicare program to Congress, has called for a 1% increase in inpatient, outpatient and physician payments in 2012.)

The Value-Based Purchasing Program created by Section 3001 of the Patient Protection and Affordable Care Act (PPACA) will explicitly tie Medicare payments to how effectively hospitals deliver quality care. In a proposed rule issued on January 7, 2011, CMS explained how hospitals that perform well or make performance improvements would receive higher payments. Performance would be determined through quality measures relating to patient experience as well as to clinical processes.

The more than 3,000 acute care hospitals that would participate in the program would need to perform well or to improve their scores over a baseline in order to stay even financially: pursuant to PPACA, the quality payments will be funded by a reduction in the base operating diagnosis-related groups (DRG) allowances for each discharge. The reduction will be 1% in 2013, rising to 2% by 2017.

Anesthesiologists who realize that they must continuously demonstrate their value to their hospitals – and that is the vast majority – have an important opportunity here. They can work to obtain the highest possible scores on the quality measures that depend on their clinical performance, while making sure that the hospital is aware of their quality-related activities.

The Value-Based Purchasing Program Measures

For the 2013 hospital value-based purchasing program, CMS proposes to use 17 clinical process of care measures and eight measures from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that documents patients’ experience of care. One of the 17 clinical process measures is SCIP-Inf-1, Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision. Antibiotic prophylaxis is not a new responsibility for anesthesiologists and CRNAs; it has been a Physician Quality Reporting System (PQRS, formerly PQRI) measure for the past four years as well as one of the measures in the Hospital Inpatient Quality Reporting Program (Hospital IQR). Information on individual hospital performance on each of the IQR measures is available to patients and others at www.hospitalcompare.hhs.gov.

According to the Hospital Compare website, prophylactic antibiotics are administered within the appropriate time window in 99% of cases at top-performing hospitals (top decile). Elsewhere, there is room for improvement. The graph for three randomly-chosen Chicago hospitals shows that two are at or very close to the national average success rate of 92%, and one happens to be performing at only the 72% level:

The point of the above graph is not to discredit Swedish Covenant but rather to show that compliance is not perfect across the country. Check your own institution’s percentage rate at the Hospital Compare website. Could it be higher – with help from your group? Even if the rate is not credible and the data gathering process is known to be inadequate, these are the numbers that CMS will use to determine your hospital’s Value-Based Purchasing Program incentive payments beginning in 2013. The group that partners successfully with its hospital to earn a higher payment will likely remain the hospital’s anesthesia partner for other purposes.

Another quality area in which anesthesiologists may be able to support their hospitals’ improvement efforts is pain control, one of the HCAHPS measures. Here the national average is considerably lower, as is shown in the Hospital Compare graph for the same three Chicago hospitals, and the margin for higher scores at least theoretically greater:

These results are from patients who had overnight hospital stays from April 2009 through March 2010.

If patients needed medicine for pain during their hospital stay, the survey asked how often their pain was well controlled. “Well controlled” means their pain was well controlled and that the hospital staff did everything they could to help patients with their pain.

According to the proposed rule, the first hospital Value-Based Purchasing program performance period would run from July 1, 2011 – less than six months away – through March 31, 2012. The other measures on which hospitals will be evaluated during that time frame include acute myocardial infarction and heart failure interventions, pneumonia prophylaxis and certain surgical care improvement measures (beta blockade, venous thromboembolism prophylaxis).

The complete set of HCAHPS patient experience measures is:

• Communication with Nurses
• Communication with Doctors
• Responsiveness of Hospital Staff
• Pain Management
• Communication About Medicines
• Cleanliness and Quietness of Hospital Environment
• Discharge Information
• Overall Rating of Hospital

Anesthesiologists will inevitably be a factor in the hospital’s ratings on several of these measures in addition to pain management. Their actual contribution to the rating may not be capable of credible measurement, but they may wish to help develop any hospital methodologies that will quantify their share of the scores for “communication with doctors” and “overall rating of hospital,” for example, as well as “pain management.”

The proposed rule would establish a second performance period, from July 1, 2012 through December 31, 2013, for the FY 2014 Hospital Value-Based Purchasing payment determination. CMS proposes to adopt three mortality outcome measures, eight Hospital Acquired Condition (HAC) measures, and nine measures adopted by the federal Agency for Healthcare Research and Quality (AHRQ) for the 2014 program. The HAC measures include Foreign Object Retained After Surgery, Blood Incompatibility and Vascular Catheter Associated Infection. Anesthesiologists may also contribute to the performance score for several of the AHRQ measures, e.g., Post Operative Pulmonary Embolism or Deep Vein Thrombosis.

CMS has announced its intention to continue adding measures for future performance periods. For now, CMS is receiving formal public “comments” on the proposed rule, which it will finalize later this year. Although some of the measures selected for the hospital Value-Based Purchasing program may change, as may the very complicated methodology for developing scores described in CMS’ Notice of Proposed Rule-Making, the program will go forward as required by PPACA. Anesthesiologists who wish to increase their stature and their value within their hospitals should begin planning for participation now.

As always, we hope that this information is useful to you.

With best wishes,

Tony Mira
President and CEO