How Hospitals’ Quality Bonuses And Penalties Were Determined And How To Use The Data

The Kaiser Health News story and data on Medicare’s quality payment program are based on data from the Centers for Medicare & Medicaid Services (CMS). On Dec. 20, 2012, CMS posted a table containing the Hospital Value-Based Purchasing Adjustment Factors for individual hospitals.

The Value-Based Purchasing payments are determined by how hospitals scored on two sets of measures. The first are 12 “measures of timely and effective care” also known as “process” measures. These rate how often hospitals adhered to these clinical guidelines:

–Percent of heart attack patients given medication to avert blood clots within 30 minutes of arrival at the hospital.

–Percent of heart attack patients given percutaneous coronary interventions within 90 minutes of arrival.

–Percent of heart failure patients given instructions upon discharge about how to take care of themselves.

–Percent of pneumonia patients who had a blood culture taken before they were given antibiotics.

–Percent of pneumonia patients that received the correct kind of antibiotics.

–Percent of patients that received an antibiotic within an hour of surgery.

–Percent of surgical patients that received the correct kind of antibiotic.

–Percent of patients who had their antibiotics stopped within 24 hours of surgery.

–Percent of heart surgery patients who had their blood sugar kept under control after an operation.

–Percent of heart surgery patients already taking beta blockers who were given a beta blocker just before and after surgery.

–Percent of surgery patients who received an appropriate treatment to prevent blood clots.

–Percent of surgery patients who received anti-blood clot treatment within 24 hours before to 24 hours after the operation.

The second set of eight measures is culled from surveys of patients who had recently left the hospital. These are frequently called “patient experience” or “patient satisfaction” measures. For these measures, Medicare only looked at the percent of patients who said they “always” had a favorable experience in these areas:

–How well nurses communicated with patients.

–How well doctors communicated with patients.

–How responsive hospital staff were to patients’ needs.

–How well caregivers managed patients’ pain.

–How well caregivers explained medication to patients before giving it to them.

–How clean and quiet the hospital room and hall were.

–How often caregivers explained to patients how to take care of themselves after discharge.

–How the hospital stay rated overall.

For this year, the process measures account for 70 percent of a hospital’s score and the patient satisfaction measures account for 30 percent. Medicare looked at both how a hospital did compared to its peers and how much it improved its own performance over time, and whichever score was higher was the one used to calculate its payment factor. Hospitals stood to lose or gain up to 1 percent of their regular Medicare reimbursements in this first year of the program. The amount of money at stake increases incrementally over the next four years to reach 2 percent of payments.

Medicare’s Bonuses And Penalties for Hospitals

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Medicare lists and explains its measures, and also lists other measures it may incorporate in coming years. Medicare has said it plans to reduce the weight of the process measures as “outcomes” measures that assess how patients actually fared become more available. The first outcomes measure, death rates for heart attack, heart failure and pneumonia patients, will be incorporated into value-based purchasing in the fiscal year starting Oct. 1.

The measures used in the program are publicly available on Medicare’s Hospital Compare website, along with other measures not used presently in value-based purchasing. Hospital Compare allows you to see how hospitals rate on individual measures and see how they compare to the national and state averages.

Be aware that the time frame for the Hospital Compare data displayed on the web site covers an entire year of hospital performance, from April 2011 through March 2012, while Medicare only used data for nine months, from July 2011 through March 2012, in determining the value-based purchasing scores. To determine improvement, Medicare compared each hospital’s scores with how it performed in the same period two years before.

You can download all the Hospital Compare data in zip file form, examine older, archived hospital scores, or look at individual measures with Data.Medicare.Gov’s interactive tools. The patient satisfaction measures are all in one spreadsheet, while the process measures are distributed in various spreadsheets for heart failure, heart attacks, pneumonia and surgical care.

The value based purchasing adjustment factor is a multiplier CMS applies to Medicare payments to cover each patient’s stay during the fiscal year beginning in October 2012. The factor is not applied to payments for capital expenses, the cost of teaching residents and for treating large numbers of low-income patients.

In the interests of clarity, Kaiser Health News expressed the adjustment factor as a percentage change in payment, and included basic information about the hospitals, including their names and locations. You can view the data on KHN’s interactive chartPDF file or download it in csv format. KHN also has created a table showing how hospitals fared in each state.

KHN’s data tables also include readmissions penalties from prior reporting, and calculations of what the combined impact on hospitals will be. From these two programs together, hospitals this year were able to earn up to 1 percent extra for each Medicare patients’ stay or lose as much as 2 percent.

jrau@kff.org