Oct 21, 2015 | Mitul Kanzaria, MD
Advocacy

As health care costs rise, multiple strategies have been employed to try to reduce health care costs. The Patient Protection and Affordable Care Act (PPACA) includes many provisions to reduce the per capita cost of health care while improving the quality of care. These programs or provisions target five different areas generally, including process, outcome, patient experience, structure and cost. Many of these pay for performance programs are using financial incentives as a mechanism to improve outcomes and reduce costs. The pay for performance measures have shifted the financial burden from payers (Medicare, Medicaid, private insurers) to the hospitals, practices and providers. As trainees in cardiology, it is important to have an understanding of these programs since they impact care delivery both in inpatient and ambulatory care. The inpatient pay for performance programs include the Hospital Readmissions Reduction Program (HRRP), Value Based Purchasing (VBP) and Hospital Acquired Conditions (HAC) Penalties.

The HRRP began in 2013 (data was collected as part of FY 2012) as part of the PPACA as an attempt to reduce readmissions, defined as readmission to any hospital within 30 days of discharge for any cause. HRRP focuses on readmissions of Medicare patients after an index hospitalization for certain conditions, including acute myocardial infarction (AMI), congestive heart failure (CHF), pneumonia, chronic obstructive pulmonary disease (COPD) and elective hip or knee replacement. In FY 2012, the maximum penalty was 1 percent of all Medicare base payments for three diagnoses, AMI, CHF and pneumonia. The penalties have increased to a maximum of 3 percent for FY 2015, now with all five diagnoses. The data for each fiscal year includes the preceding three year period, so FY 2015 includes readmission rates from June 2010 to July 2013. The readmission rates have fallen over the time period that the HRRP has been implemented. The percent of hospitals penalized has increased each year, going from 64 percent to 66 percent to 78 percent in FY 2015. The average hospital penalty actually decreased from FY 2013 to FY 2014 but increased in FY 2015.

The Value Based Purchasing (VBP) program is a composite of 24 measures across four different areas. The goal of VBP for payers, mainly the Centers for Medicare and Medicaid Services (CMS), is to shift from being a passive payer for services in a fee for service model, to an active purchaser of high quality healthcare. Hospital payments from CMS are withheld, in FY 2016 it is 1.75 percent of CMS payments, and the portion paid by CMS is determined by performance on these 24 measures.

The four major areas are the patient experience of care, outcomes, process of care and efficiency. Each institution is compared to a baseline, and the penalty can be avoided by either significant improvement compared to the hospital's baseline or being within a certain attainment range based on the nation's averages. The clinical processes of care has three cardiology specific measures, including percutaneous coronary intervention within 90 minutes of hospital arrival for a ST-elevated myocardial infarction (STEMI), fibrinolytics given within 30 minutes of hospital arrival for STEMI and discharge instructions given to patients with CHF. The outcomes category is comprised of 30 day mortality for AMI, CHF and pneumonia. Efficiency is determined by the cost per beneficiary for Medicare patients. Lastly, the patient experience is based upon the HCAHPS survey results regarding their experience during the hospitalization. Most importantly, the care delivered by cardiologists encompasses all four of those areas.

The Hospital Acquired Condition (HAC) program is a 1 percent penalty program that is determined by two different domain scores. The first domain score is a composite score developed by the Agency for Healthcare Research and Quality (AHRQ) called the PSI 90. This includes pressure ulcers, post op DVT or sepsis, and more. This accounts for 35 percent of the HAC score. The second domain consists of central line associated blood stream infections, catheter associated urinary tract infection and surgical site infections for hysterectomy and colon procedures, which accounts for 65 percent of the HAC score. MRSA and c. difficile are to be added by FY 2017.The lowest 25 percent of hospitals are penalized up to 1 percent of all Medicare payments.

The inpatient pay for performance measures impact the way cardiology care is delivered. The potential penalties are steep, with significant money left on the table by hospitals that do not perform well. Hospitals will be implementing policies, procedures, and changes to attempt avoiding penalties.

As a cardiologist, it is important to understand these penalties, especially since these changes could impact the care of cardiology patients significantly. Lastly, cardiologists and cardiology fellows need to be part of the solution. These penalties are here to stay, and we need to be involved in the changes. The discussion also must continue to the outpatient setting, as many outpatient pay for performance measures are being implemented as well.

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By Mitul Kanzaria, MD, a fellow in training at Thomas Jefferson University Hospital.