Value-Based Payment Reforms in Cardiovascular Care: Progress to Date and Next Steps.

In an effort to curb excessive health care spending and incentivize high-quality care, many payers have implemented value-based payment reforms designed to pay for the quality rather than the quantity of health care services. Medicare, the largest payer in the United States, has implemented numerous value-based payment policies over the past decade, many of which affect cardiovascular care. In this review, we discuss some of these major nationwide value-based payment reforms as they relate to cardiovascular care and what we may expect in the future from cardiovascular value-based policies.

Performance and Penalties in Year 1 of the Skilled Nursing Facility Value-Based Purchasing Program.

BACKGROUND/OBJECTIVES: Launched in October 2018, Medicare's Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program mandates financial penalties for SNFs with high 30-day readmission rates. Our objective was to identify characteristics of SNFs associated with provider performance under the program. DESIGN: Retrospective cross-sectional analysis using Nursing Home Compare data for the 2019 SNF VBP. Facility-level regressions examined the relationship between structural characteristics (nursing home size, rurality, profit status, hospital affiliation, region, and Star Ratings) and patient characteristics (neighborhood income, race/ethnicity, dual eligibility, disability, and frailty) and facility performance. SETTING: US Medicare. PARTICIPANTS: A total of 14 558 SNFs. MEASUREMENTS: The 2019 SNF VBP performance scores and penalties. RESULTS: Nationally, 72% (10 436) of SNFs were penalized; 21% (2996) received the maximum penalty of 1.98%. In multivariate analyses, rural SNFs were less likely to be penalized (odds ratio [OR] = 0.85; 95% confidence interval [CI] = 0.78-0.92; P < .001; vs urban), while small SNFs were more likely to be penalized (≤70 beds: OR = 1.28; 95% CI = 1.15-1.42; P < .001; 71-120 beds: OR = 1.15; 95% CI = 1.05-1.26; P = .003; vs >120 beds). SNFs with lower nurse staffing had higher odds of penalties (low: OR = 1.15; 95% CI = 1.03-1.27; P = .010; vs high); nonprofit and government-owned SNFs had lower odds of penalties (OR = 0.79; 95% CI = 0.72-0.87; P < .001; government: OR = 0.72; 95% CI = 0.61-0.84; P < .001; vs for profit); and SNFs with higher Star Ratings had lower odds of penalties (5 stars: OR = 0.47; 95% CI = 0.40-0.54; P < .001; vs 1 star). In terms of patient population, SNFs located in low-income ZIP codes (OR = 1.17; 95% CI = 1.03-1.34; P = .019) or serving a high proportion of frail patients (OR = 1.39; 95% CI = 1.21-1.60; P < .001) were more likely to be penalized than other SNFs. SNFs with high proportions of dual, black, Hispanic, or disabled patients did not have higher odds of penalization. CONCLUSION: Structural and patient characteristics of SNFs may significantly impact provider performance under the SNF VBP. These findings have implications for policy makers and clinical leaders seeking to improve quality and avoid unintended consequences with VBP in SNFs. J Am Geriatr Soc 68:826-834, 2020.

Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNF) Final Rule for FY 2019, SNF Value-Based Purchasing Program, and SNF Quality Reporting Program. Final rule.

This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2019. This final rule also replaces the existing case-mix classification methodology, the Resource Utilization Groups, Version IV (RUG­IV) model, with a revised case-mix methodology called the Patient- Driven Payment Model (PDPM) beginning on October 1, 2019. The rule finalizes revisions to the regulation text that describes a beneficiary's SNF "resident" status under the consolidated billing provision and the required content of the SNF level of care certification. The rule also finalizes updates to the SNF Quality Reporting Program (QRP) and the Skilled Nursing Facility Value-Based Purchasing (VBP) Program.

Association Between Medicare's Mandatory Hospital Value-Based Purchasing Program and Cost Inefficiency.

BACKGROUND: The Patient Protection and Affordable Care Act instituted pay-for-performance programs, including Hospital Value-Based Purchasing (HVBP), designed to encourage hospital quality and efficiency. OBJECTIVE AND METHOD: While these programs have been evaluated with respect to their implications for care quality and financial viability, this is the first study to assess the relationship between hospitals' cost inefficiency and their participation in the programs. We estimate a translog specification of a stochastic cost frontier with controls for participation in the HVBP program and clinical and outcome quality for California hospitals for 2012-2015. RESULTS: The program-participation indicators' parameters imply that participants were more cost inefficient than their peers. Further, the estimated coefficients for summary process of care quality indexes for three health conditions (acute myocardial infarction, pneumonia, and heart failure) suggest that higher quality scores are associated with increased operating costs. CONCLUSION: The estimated coefficients for the outcome quality variables suggest that future determination of HVBP payment adjustments, which will depend solely on mortality rates as measures of clinical care quality, may not only be aligned with increasing healthcare quality but also reducing healthcare costs.

Medicare and Medicaid Programs; CY 2018 Home Health Prospective Payment System Rate Update and CY 2019 Case-Mix Adjustment Methodology Refinements; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. Final rule.

This final rule updates the home health prospective payment system (HH PPS) payment rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor, effective for home health episodes of care ending on or after January 1, 2018. This rule also: Updates the HH PPS case-mix weights using the most current, complete data available at the time of rulemaking; implements the third year of a 3-year phase-in of a reduction to the national, standardized 60-day episode payment to account for estimated case-mix growth unrelated to increases in patient acuity (that is, nominal case-mix growth) between calendar year (CY) 2012 and CY 2014; and discusses our efforts to monitor the potential impacts of the rebasing adjustments that were implemented in CY 2014 through CY 2017. In addition, this rule finalizes changes to the Home Health Value-Based Purchasing (HHVBP) Model and to the Home Health Quality Reporting Program (HH QRP). We are not finalizing the implementation of the Home Health Groupings Model (HHGM) in this final rule.

Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2018, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, Survey Team Composition, and Correction of the Performance Period for the NHSN HCP Influenza Vaccination Immunization Reporting Measure in the ESRD QIP for PY 2020. Final rule.

This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2018. It also revises and rebases the market basket index by updating the base year from 2010 to 2014, and by adding a new cost category for Installation, Maintenance, and Repair Services. The rule also finalizes revisions to the SNF Quality Reporting Program (QRP), including measure and standardized resident assessment data policies and policies related to public display. In addition, it finalizes policies for the Skilled Nursing Facility Value-Based Purchasing Program that will affect Medicare payment to SNFs beginning in FY 2019. The final rule also clarifies the regulatory requirements for team composition for surveys conducted for investigating a complaint and aligns regulatory provisions for investigation of complaints with the statutory requirements. The final rule also finalizes the performance period for the National Healthcare Safety Network (NHSN) Healthcare Personnel (HCP) Influenza Vaccination Reporting Measure included in the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) for Payment Year 2020.

Medicare and Medicaid Programs; CY 2017 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. Final rule.

This final rule updates the Home Health Prospective Payment System (HH PPS) payment rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor; effective for home health episodes of care ending on or after January 1, 2017. This rule also: Implements the last year of the 4-year phase-in of the rebasing adjustments to the HH PPS payment rates; updates the HH PPS case-mix weights using the most current, complete data available at the time of rulemaking; implements the 2nd-year of a 3-year phase-in of a reduction to the national, standardized 60-day episode payment to account for estimated case-mix growth unrelated to increases in patient acuity (that is, nominal case-mix growth) between CY 2012 and CY 2014; finalizes changes to the methodology used to calculate payments made under the HH PPS for high-cost "outlier" episodes of care; implements changes in payment for furnishing Negative Pressure Wound Therapy (NPWT) using a disposable device for patients under a home health plan of care; discusses our efforts to monitor the potential impacts of the rebasing adjustments; includes an update on subsequent research and analysis as a result of the findings from the home health study; and finalizes changes to the Home Health Value-Based Purchasing (HHVBP) Model, which was implemented on January 1, 2016; and updates to the Home Health Quality Reporting Program (HH QRP).

Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Organ Procurement Organization Reporting and Communication; Transplant Outcome Measures and Documentation Requirements; Electronic Health Record (EHR) Incentive Programs; Payment to Nonexcepted Off-Campus Provider-Based Department of a Hospital; Hospital Value-Based Purchasing (VBP) Program; Establishment of Payment Rates Under the Medicare Physician Fee Schedule for Nonexcepted Items and Services Furnished by an Off-Campus Provider-Based Department of a Hospital. Final rule with comment period and interim final rule with comment period.

This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2017 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program. Further, in this final rule with comment period, we are making changes to tolerance thresholds for clinical outcomes for solid organ transplant programs; to Organ Procurement Organizations (OPOs) definitions, outcome measures, and organ transport documentation; and to the Medicare and Medicaid Electronic Health Record Incentive Programs. We also are removing the HCAHPS Pain Management dimension from the Hospital Value-Based Purchasing (VBP) Program. In addition, we are implementing section 603 of the Bipartisan Budget Act of 2015 relating to payment for certain items and services furnished by certain off-campus provider-based departments of a provider. In this document, we also are issuing an interim final rule with comment period to establish the Medicare Physician Fee Schedule payment rates for the nonexcepted items and services billed by a nonexcepted off-campus provider-based department of a hospital in accordance with the provisions of section 603.

The Relationship Between Nurse-Reported Safety Culture and the Patient Experience.

OBJECTIVE: The purpose of this study was to better understand the relationship between nurse-reported safety culture and the patient experience in a multistate sample of nurses and patients, matched by hospital unit/service line and timeframe of care delivery. BACKGROUND: Nurses play a key role in the patient experience and patient safety. A strong safety culture may produce positive spillover effects throughout the nurse caregiving experience, resulting in patient perception of a high-quality experience. METHODS: Multivariate mixed-effects regression models were specified using data from a multistate sample of hospital units that administered both the Agency for Healthcare Research and Quality (AHRQ) staff safety culture survey and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey over a 12-month period. Survey response variables are measured at the unit (service line) and hospital level. RESULTS: Key variables in the HCAHPS and AHRQ surveys were significantly correlated. Findings highlight the relationship between 3 safety culture domains: teamwork, adequate staffing, and organizational learning on the achievement of a positive patient experience. CONCLUSION: Modifiable aspects of hospital culture can influence the likelihood of achieving high HCAHPS top box percentages in the nursing and global domains, which directly impact hospital reimbursement.

Hospice Value-Based Purchasing Program: A Model Design.

With the implementation of the Affordable Care Act, the U.S. government committed to a transition in payment policy for health care services linking reimbursement to improved health outcomes rather than the volume of services provided. To accomplish this goal, the Department of Health and Human Services is designing and implementing new payment models intended to improve the quality of health care while reducing its cost. Collectively, these novel payment models and programs have been characterized under the moniker of value-based purchasing (VBP), and although many of these models retain a fundamental fee-for-service (FFS) structure, they are seen as essential tools in the evolution away from volume-based health care financing toward a health system that provides "better care, smarter spending, and healthier people." In 2014, approximately 20% of Medicare provider FFS payments were linked to a VBP program. The Department of Health and Human Services has committed to a four-year plan to link 90% of Medicare provider FFS payments to value-based purchasing by 2018. To achieve this goal, all items and services currently reimbursed under Medicare FFS programs will need to be evaluated in the context of VBP. To this end, the Medicare Hospice benefit appears to be appropriate for inclusion in a model of VBP. This policy analysis proposes an adaptable model for a VBP program for the Medicare Hospice benefit linking payment to quality and efficiency in a manner consistent with statutory requirements established in the Affordable Care Act.

Opinions on the Hospital Readmission Reduction Program: results of a national survey of hospital leaders.

OBJECTIVES: To determine the opinions of US hospital leadership on the Hospital Readmissions Reduction Program (HRRP), a national mandatory penalty-for-performance program. STUDY DESIGN: We developed a survey about federal readmission policies. We used a stratified sampling design to oversample hospitals in the highest and lowest quintile of performance on readmissions, and hospitals serving a high proportion of minority patients. METHODS: We surveyed leadership at 1600 US acute care hospitals that were subject to the HRRP, and achieved a 62% response rate. Results were stratified by the size of the HRRP penalty that hospitals received in 2013, and adjusted for nonresponse and sampling strategy. RESULTS: Compared with 36.1% for public reporting of readmission rates and 23.7% for public reporting of discharge processes, 65.8% of respondents reported that the HRRP had a "great impact" on efforts to reduce readmissions. The most common critique of the HRRP penalty was that it did not adequately account for differences in socioeconomic status between hospitals (75.8% "agree" or "agree strongly"); other concerns included that the penalties were "much too large" (67.7%), and hospitals' inability to impact patient adherence (64.1%). These sentiments were each more common in leaders of hospitals with higher HRRP penalties. CONCLUSIONS: The HRRP has had a major impact on hospital leaders' efforts to reduce readmission rates, which has implications for the design of future quality improvement programs. However, leaders are concerned about the size of the penalties, lack of adjustment for socioeconomic and clinical factors, and hospitals' inability to impact patient adherence and postacute care. These concerns may have implications as policy makers consider changes to the HRRP, as well as to other Medicare value-based payment programs that contain similar readmission metrics.

Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2017, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and SNF Payment Models Research. Final rule.

This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2017. In addition, it specifies a potentially preventable readmission measure for the Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP), and implements requirements for that program, including performance standards, a scoring methodology, and a review and correction process for performance information to be made public, aimed at implementing value-based purchasing for SNFs. Additionally, this final rule includes additional polices and measures in the Skilled Nursing Facility Quality Reporting Program (SNF QRP). This final rule also responds to comments on the SNF Payment Models Research (PMR) project.