In its Aug. 29 letter, the AHA also expressed concern with the way in which the CMS added the new measures for efficiency, hospital-acquired conditions and the composites of safety and mortality. The AHA asserted that the CMS failed to meet requirements spelled out in the health reform law because the CMS did not post the measures on the federal Hospital Compare website before adding them to the value-based purchasing program.
The CMS has also said it plans to drop measures in subsequent years once they “top out,” meaning that the average score for all hospitals is near the top, making comparisons among hospitals' scores useless.
The process through which total performance scores will be calculated is complex. In the first year of the program, each of the 12 clinical process-of-care measures will be scored on a 10-point scale. Hospitals will earn points for achievement and improvement. The achievement score is based on a comparison of a hospital's score to a threshold—the minimum level of performance required to earn points—and a benchmark—representing high scores achieved nationally during a baseline period. The improvement score compares a hospital's performance during an achievement period to its score during a baseline period. The CMS will use the higher of the achievement and improvement scores in the tally for each process measure.
Scoring for HCAHPS is similar but hospitals also can earn up to 20 additional points for consistency. In calculating the total performance score, the CMS will exclude any process-of-care measure for which the hospital has fewer than 10 cases. Hospitals that do not qualify for at least four of the process-of-care measures will be excluded from the value-based purchasing program. Hospitals with fewer than 100 HCAHPS surveys during the performance period also will be excluded from the program.
The HFMA's Mulvany worries that the 10-case minimum to be scored on a process-of-care measure is too few, putting small hospitals at a disadvantage. “If you have a random anomaly, it could end up being a significant strike against you. For a larger hospital, the random anomaly washes out.” For 2013, the performance period began July 1 and will end March 31, 2012. The baseline period ran from July 1, 2009, to Dec. 31, 2009.
The performance period also began July 1 for the three outcome measures to be added in 2014—30-day mortality rates for heart attack, heart failure and pneumonia. The performance period for these measures will end on June 30, 2012; the baseline period ran from July 1, 2009, to June 30, 2010.
Other baseline and performance periods for 2014 have been proposed but not finalized. The CMS has proposed a baseline period of April 1, 2010, through Dec. 31, 2010, and a performance period of April 1, 2012, through Dec. 31, 2012, for both the process-of-care and HCAHPS measures. For the hospital-acquired conditions and composite measures of complications/patient safety and mortality, the proposed baseline period would run from March 3, 2010, through Sept. 30, 2010, and the performance period would run from March 3, 2012, through Sept. 30, 2012.
Given the complexity of the value-based purchasing program and the number of details in proposed form, Daily says she believes hospital executives should first focus their efforts on the process-of-care measures. “I am inclined, because this is already upon us, to dedicating some resources to dealing with the known quantity and making strides if there are strides to be made.”
At least some hospital executives agree with her and are driving their organizations to achieve scores of 100% on all 12 process measures included in 2013. Moving toward perfection on the process measures is important because the average scores nationally on each of these measures are already quite high. Of the 12 measures, the CMS set benchmark scores for six of them at 1.0.
“If you are already at a high level of excellence, the challenge is to maintain it. You know that all hospitals are going to get up to the top of the mountain eventually—that is kind of the way these process measures are,” Mort says.