How the ACA’s Pay-For-Performance Programs Target Catheter-Related Bloodstream Infections
The mainstream media has primarily covered the Patient Protection and Affordable Care Act (also known as the ACA or Obamacare) for how it affects health insurance. But as healthcare insiders, readers of this blog know there’s much more to this groundbreaking piece of legislation — including its provisions aimed at upping healthcare quality and lowering healthcare costs. Many of those provisions affect the practice of vascular access because catheter-related bloodstream infections (CRBSIs) have both quality and cost implications.
Healthcare providers should be taking a close look at these sections of the law because they can affect everything from reimbursements to materials management. Vascular access specialists (VAS’s) should know the provisions, too, because the ACA targets vascular access outcomes.
To help you navigate this new territory, we’re going to break down the vascular access-related changes brought about by the ACA for you. Whether you’re an employer of VAS’s or a VAS yourself, we’ll suggest some strategies that help you maximize provider reimbursements, avoid financial penalties, and most importantly, produce improved results for patients with IV lines. We’ll do this in three parts because there’s a lot to talk about!
Here in Part One, we’ll discuss the ACA’s Pay-for-Performance initiatives, because they are intended in part to minimize healthcare-acquired conditions (HACs) including CRBSIs.
In Part Two, we’ll look at the argument for using protected catheters. These are catheters embedded with substances that can prevent CRBSIs and even thrombosis, which is a potential precursor to bloodstream infections. In the new ACA universe, fewer CRBSIs are healthier for both patients and the provider’s bottom line.
In Part Three, we’ll examine a policy and cultural change that can potentially prevent vascular access-related complications such as CRBSIs as well as the reimbursement penalties the ACA levies for high CRBSI rates. That change: Allowing non-physician VAS’s to insert central venous catheters (CVCs) and arterial lines.
How the ACA’s Pay-For-Performance Programs Affect Vascular Access Specialists and Their Employers
The public-at-large may think the ACA is all about health insurance but healthcare executives and practitioners know better. The law tackles some of the biggest issues in healthcare beyond insurance, including reducing HACs and the contribution they make to high healthcare costs. The ACA uses both carrots and sticks to accomplish this but when it comes to HACs, the sticks significantly outnumber the carrots.
This hugely ambitious piece of legislation ultimately attempts to transform the entire incentive structure of the healthcare system so that providers are rewarded for providing higher quality, not quantity, of care. Before the ACA, providers were paid for each service they delivered. This incentive sometimes led to providers’ delivering unnecessary services and being fully reimbursed for them, which raised healthcare costs for everyone. The ACA instead rewards providers that:
* Improve patient outcomes
* Improve quality of care
* Manage costs
How is this done? Primarily through what the ACA calls Pay-for-Performance (P4P) programs that withhold Medicare reimbursements – or in one case, increase them – in the name of pushing providers to improve healthcare quality and reduce (unnecessary) quantity. There are three P4P programs and for every one of them, the incentives put more dollars at stake every year.
For example, a hospital that misses the mark in all three programs could lose up to 5.5% of their Medicare reimbursements this year. In 2017, that same hospital could lose up to 6% of their reimbursements, a big difference for hospitals that receive millions from Medicare annually.
Here are the three programs and how they work:
1. The Hospital-Acquired Condition Reduction Program creates a ranking of all hospitals in the country by their HAC rates. The lowest quartile of hospitals – in other words, the most poorly performing 25% — then have their overall Medicare reimbursement rate reduced by 1%. The ranking is based on hospital performance scores in two domains: Agency for Healthcare Research and Quality (AHRQ) measures and CDC measures. Domain 1 (AHRQ) scores make up 35% of the score with Domain 2 (CDC) scores making up the remaining 65%.
Central line-associated bloodstream infection (CLABSI) rates are one of the criteria for both the AHRQ and CDC scores, with the intent of nudging hospitals to deliver vascular access as safely as possible. The program began last October and so far 721 hospitals have been dunned the 1% penalty.
2. The Value-Based Purchasing Program (VPB), true to the ACA’s goal, doles out reimbursements to hospitals based on the quality of care they deliver rather than the number of services. Hospitals are either rewarded or penalized in reimbursement dollars according to how they score on quality measures from Medicare (CMS). The program is funded by withholding a percentage of inpatient payments from CMS from all hospitals annually. If a hospital is to be penalized, it doesn’t get the money back. If its score is adequate, it does recoup withheld monies. If its score is exceptional, it gets a bonus.
VBP quality measures slightly vary every year, both in what they measure and how measurement categories are weighted. For FY 2015, Outcomes Measures include CLABSIs and make up 30% of the total score. The weighting increases to 40% of the total score for FY 2016. CLABSIs will still be one of the outcomes scored that year. The amount of Medicare payments withheld is also increasing, from approximately 1% in FY 2013 to 2% by 2017.
3. The Hospital Readmissions Reduction Program doles out penalties to hospitals for high readmission rates of designated conditions. Currently, the conditions include heart failure, heart attack, pneumonia, chronic lung problems such as emphysema and bronchitis, and elective hip and knee replacements. Vascular access performance is not affected by this program.
Some 44% of hospitals are expected to receive multiple P4P penalties for FY 2015, with the average penalty being $1 million and minus 3.42% the largest combined penalty. Only 14% of hospitals are expected to completely escape penalization.
On the CLABSI front, be aware that all CLABSIs in the facility — not just CLABSIs in the ICU — are now required to be reported to CMS. That puts them in the crosshairs for the relevant ACA programs, too. Also keep in mind that 50% of all HACs are VAD-related, so hospitals’ stake in the safest possible vascular access is substantial, to say the least.
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