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HCAHPS and Value-Based Purchasing

Methods and Measurement

Deb Stargardt, Improvement Services

Darrel Shanbour, Consulting Services

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Acquire new knowledge pertaining to:

A. Hospital CAHPS Survey and Scoring Methodology

(Top Box)

B. The Impact of Social Media and Transparency on

Consumer Assessment

C. Value-Based Purchasing Evolution and Impact on

Reimbursement

Today’s Learning Objectives

© 2012 Press Ganey Associates, Inc.

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Organizational Values

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Consider the key words – “Consumer Assessment”

How do consumers assess their

patient experience?

Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS)


5 © 2012 Press Ganey Associates, Inc.

Linking Values to Behaviors

Compassion

“What does it look like?”

Being Responsive

Respect


Providing Explanations

Teamwork


Coordinating Care


Standards of Behavior

Courteous

Authentic

Competent

Cooperative

Solutions-Oriented

High Achiever

Top Performer

Team Player

Time Manager

Financial Steward

Goal-oriented

Professional

Friendly


Leadership Challenge - Connecting the Dots

Standards of Behavior

HCAHPS

Organizational Values


CAHPS Mandates a Balanced Equation

Compliance Commitment

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Consumer Assessment of Healthcare Providers and Systems

• Produce comparable data for public reporting

• Create incentives to improve

• Enhance public accountability and transparency

Hospital CAHPS

Home Health Care CAHPS

In-Center Hemodialysis CAHPS

Clinician and Group CAHPS

Family Evaluation of Hospice Care

Health Plan CAHPS

Ambulatory Surgery CAHPS (under CMS consideration)

Outpatient Diagnostic CAHPS (under CMS consideration)

The CAHPS Family of Surveys



Linking Mission to Margin with HCAHPS

Mission Margin

Mission Measures Points Scores Payments Margin

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Think about it…

We usually give

our patients the

correct

medication. We usually pull

the right patient

chart.

We probably get the correct

label on the tube.

Your doctor will usually come by

to talk to you.

We usually

respect your

privacy.


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Top Box is…

Top box is the percent of highest ranked answers on the survey:

Percent of “Always” Responses

Percent of “Yes” Responses

Percent of “9” and “10” Responses

Percent of “Strongly Agree”

Percent of “Definitely”

All other responses are irrelevant.


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Only the Highest Rank Counts

Evaluative Questions

Screening Questions

Global Rating Questions

Top Box

Top Box


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Calculating question scores

Each response scored “top box” (1) or zero (0)

Question top-box score is calculated as the total number of

“top box responses divided by the total number of questions

answered.

Calculating HCAHPS Scores Sample

Nurses treat with courtesy/respect

Patient 1 Always (top box)

Patient 2 Usually

Patient 3 Usually

Patient 4 Never

Patient 5 Sometimes


Patient 7 Usually

Patient 8 Sometimes


Patient 10 Sometimes

3 top box responses

10 total responses

For “Nurses treat with

courtesy/respect” the

Top box score is 30%


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Calculating Domain scores

Each question has a top box percentage.

The top box percentages are added and divided by the number

of questions (not the number of responses) in each domain.

Calculating HCAHPS scores

Question

Nursing

Domain

Nurses treated you with

courtesy/respect 30%

Nurses listen carefully to you 70%

Nurses explained in way you

understand 80%

(30+70+80) = 180 = 60

3 3

The Nursing Domain

score is 60% *note: Domain scores are not

weighted


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• Five new questions

– Three care transitions questions

– Two demographic questions

– Voluntary use beginning with July 1 discharges

– Likely required in 2013

– Unlikely to affect VBP for several years

Proposed New HCAHPS Dimensions



Why More Questions?

The new questions CMS must find ways to save money associated with readmissions and has funded initiatives that are taking a community level approach to improving the transition of adult care through various interventional models – notably Dr. Eric Coleman’s work.

Going public with data Today, CMS is sharing Information on 30-day readmission rates for Medicare patients experiencing heart attack, heart failure or pneumonia on Hospital Compare as above average, average or below average compared to other hospitals nationally.

Questions with a different scale Three of the new questions come directly from Dr. Coleman’s Care Transitions Measure©, a copyrighted measurement tool with considerable benchmarked data associated with the response methodology he adopted when the survey was developed. The two “about you” questions provide some demographic information about the patient that will be helpful in looking at the broader patient experience, i.e., admitted through ER and patient perception of mental health status.

Looking forward

Every day, 10,000 Baby Boomers (born between 1946 – 1964) reach the age of 65 and this will continue for the next 19 years (25% of U.S. population).

According to the Medicare Payment Advisory Commission, the government spends an estimated $12 billion a year on “potentially preventable” readmissions for Medicare patients alone.

This will be an era of accountability during which CMS will attempt to hold hospital’s to the HHS definition of health care quality – “getting the right care to the right patient at the right time – every time.”


So, how are you really doing?

Discharge Communication and Spending Ratio – is there a connection?

Consider a Patient Experience timeline that starts 3 days before hospital stay and extends until 30 days after discharge from the hospital.

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New: Care Transitions Questions


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Collaborations Across the Nation

Introduction to the Triple Aim

In October 2007 the Institute for Healthcare Improvement (IHI) launched the

Triple Aim initiative, designed to help health care organizations improve the

health of a population patients' experience of care (including quality,

access, and reliability) while lowering—or at least reducing the rate of

increase in—the per capita cost of care. Pursuing these three objectives

at once allows health care organizations to identify and fix problems such as

poor coordination of care and overuse of medical services. It also helps them

focus attention on and redirect resources to activities that have the greatest

impact on health.


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New: Demographic Questions



Rounding Enables Communication

What would you like to

understand?

Medication Communication

Rounding

What are your

concerns?

Discharge Communication

Rounding

What is your story?

Demographics

Rounding

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Linking Values through Discharge Calls

High-performing organizations

commit time and resources to post-

discharge phone calls.

Reassures patient

Identifies service concerns

Provides insights for WOW!

moments


Be Proactive

Anchor all improvement efforts to organizational mission, vision,

values and standards of behavior.

Recruit, coach, and train to behavior standards – require

compliance; inspire commitment.

The goal is to improve the perception of care through sound

business structure, efficient processes, and rigorous behavior

standards that lead to great outcomes.

Be proactive in understanding the where, why and when of CMS

to better understand how to utilize your survey results.

http://www.innovations.cms.gov/

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-

Assessment-Instruments/hospital-value-based-

purchasing/index.html?redirect=/Hospital-Value-Based-

Purchasing/



http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/Hospital-Value-Based-Purchasing/






















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Our Transparent World

More than 25 billion pieces of content (web links, news stories, blog posts, notes, photo albums, etc.) are shared on Facebook each month.

Twitter gets more than 300,000 new users every day.

80% of companies use LinkedIn as a recruitment tool.

You would need to live for around 1,000 years to watch all the videos currently on YouTube.

77% of Internet users read blogs


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Consumers Assessing Care

What do you know about you?


http://www.drscore.com/App/SearchDr/dspDetail.cfm?menuaction=view&storedSpec=Yes&ID=10615532&rightsidespec=18

http://www.vitals.com/doctors/Dr_Andres_Forero-Torres.html

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January 2011 –

CMS launches

Physician Compare

www.medicare.gov/find-a-

doctor

Provider Comparison


http://www.medicare.gov/find-a-doctor





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2011 2012 2013 2014 2015

1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q

Physician Quality

Reporting

System (PQRS)

Data Collection

for Public

Reporting

Payment

Modification for

those Impacted

by Physician

VBP

Physician

Compare

Launched

Physician Compare

Public Reporting of

PQRS

Increased Transparency and Measurement


CGCAHPS

PCMH / CA / MN

Initial launch

Value-Based Purchasing (VBP)

The Era of Pay-for-Performance

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Hospital Acquired Conditions (Nonpayment)

2010 2011 2012 2013 2014 2015 2016 2017

Readmission Reduction Program

HAC Reduction Program

Meaningful Use of EHR

Value-based Purchasing (VBP)

Inpatient Quality Reporting Requirement (IQR, formerly RHQDAPU) 2% of APU

1-3%

1%

1-2%

CMS-sponsored Quality Performance Programs

Outpatient Quality Reporting Requirement (OQR, formerly HOPQDRP) 2% of APU

Medicare Shared Savings: ACO (MSSP)

PQRS Phys. Quality Reporting System

Meaningful Use 1%

PQRS 1.5-2%

2-3+%

Voluntary Incentive Penalty

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Example of Potential Hospital Impact

Dollars subject to Medicare P4P programs

at a 146-bed hospital in Florida

Using MedPar 2010 data


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Example of Potential Hospital Impact

Dollars subject to Medicare Pay-for-Performance programs at a 541-bed hospital in New Jersey

Using MedPar 2010 data



Incentive/Penalty 1% of Base DRG operating payment in FY13, rising to 2% in FY17

Measurement Areas of Interest

FFY 2013 Core Measures

Patient Experience

AMI, HF, PN, SCIP

HCAHPS

FFY 2014 Core Measures

HCAHPS

Outcomes

(Largely unchanged)

(Unchanged)

30d risk- adjusted mortality AMI, HF, PN

FFY 2015 (proposed)

Core Measures

Patient Experience

Outcomes

Efficiency of Care

(Largely unchanged)

(Unchanged)

Adding AHRQ PSI composite and CLABSI

Average spending per M/care Beneficiary

FFY 2016 (proposed)

Clinical Care Person & Caregiver Experience & Outcomes Safety Efficiency & Cost Reduction Care Coordination Community/Population Health

Considerations Domain weighting for score calculation changes as new domains added

Measures within domains subject to change (additions, deletions)

Proposal for FY16 is a realignment of all measures

Value-based Purchasing (VBP): The Race to Top Box

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Threshold and Benchmark

Established with data from the baseline period

Benchmark (Mean of Top Decile) Achievement

threshold (Median)

Lower scores Higher scores


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FY 2013 Value Based Purchasing

(Discharges from October 1, 2012, to September 30, 2013)

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A New Domain Added in FY 2014

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2014 Baseline & Performance Periods

Each domain has its own baseline and performance period

and the periods are not aligned across domains

2009 2010 2011 2012 2013

1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q

Clinical

Baseline

Clinical

Performance

HCAHPS

Baseline

HCAHPS

Performance

Mortality

Baseline

Mortality

Performance

Payments affected

Oct. 1, 2013 – Sept. 30, 2014

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FFY15 (Possible): Four domains Addition of Efficiency Domain (Spending per Medicare

Beneficiary)

New measures added to Outcomes Domain: AHRQ and HAC composite measures added to Outcomes Domain


On the Horizon…

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Clinical Performance

Misses on 7 patients,

Loss $102,493

Misses on 4 patients,

Loss $102,493 Misses on 11 patients,

Loss $102,493 Misses on 4 patients,

Loss $71,745


Satisfaction Performance

What you don’t see: 19% responded Usually

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Dr. Donald Berwick’s Words…

“The problems do not lie in any failure of good will, benign

intentions or skills of our doctors, nurses, health care

managers or staffs. With rare exceptions, they are doing their

best. The problems lie in the design of the care systems in

which they work, systems never built for the levels of reliability,

safety, patient centeredness, efficiency or equity that we owe to

ourselves and our neighbors.”

How Will It Help the Patient?


(A sign that sat on the desk of Dr. Berwick

during his tenure as CMS Administrator.)