There are 68 quality metrics collectively levied under Medicare’s Hospital Value-Based Purchasing program, Hospital Readmission Reduction Program, and Accountable Care Organization program. Because there are so many performance metrics affecting hospital and ACO reimbursement, co-management arrangements are emerging as a strong alternative to traditional medical directorships.
Co-management agreements are the most commonly used type of pay-for-performance arrangements between hospitals and physicians. They are contractual service arrangements whereby a hospital engages a group of physicians (independent or employed) to manage quality aspects of specific hospital service lines. Cardiology, orthopedics, and surgery are examples of service lines commonly managed by through co-management arrangements.
Co-management arrangements have two main advantages over traditional medical director arrangements.
1) First, whereas traditional medical directorships engage only one physician to provide oversight over a hospital service line, co-management arrangements engage groups of physicians. Groups of physician specialists are likely to be more effective in affecting change among medical staff peers and hospital staff than a single physician.
2) Second, whereas traditional medical directors are paid the same hourly compensation rates regardless of the performance of the service line, a substantial portion of co-management compensation is based on the achievement of pre-defined clinical quality goals.
The 68 quality metrics levied by Medicare are listed below. The underlying drivers for these quality metrics can be incorporated in service line co-management arrangements between physicians and hospitals.
Simply tying physician co-management compensation to a metric like heart failure patient readmissions by itself may not be perceived as reasonable because a significant portion of the underlying drivers of readmission rates are dependent upon the actions of hospital staff. However, the underlying readmission drivers that physicians directly control can positively affect readmission rates. This may include a “driver” metric such as physician communication to applicable patients and their family members regarding the importance of post-discharge cardiac rehabilitation adherence while they are still in the hospital.
Medicare’s 30 Quality Metrics under the Hospital Value-Based Purchasing Program1) Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
2) Primary PCI Received Within 90 Minutes of Hospital Arrival
3) Discharge Instructions
4) Influenza Immunization
5) Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital
6) Initial Antibiotic Selection for CAP in Immunocompetent Patient
7) Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period
8) Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
9) Prophylactic Antibiotic Selection for Surgical Patients
10) Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
11) Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose
12) Postoperative Urinary Catheter Removal on Post Operative Day 1 or 2
13) Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
14) Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery
15) Communication with Nurses
16) Communication with Doctors
17) Responsiveness of Hospital Staff
18) Pain Management
19) Communication about Medicines
20) Cleanliness and Quietness of Hospital Environment
21) Discharge Information
22) Overall Rating of Hospital
23) Acute Myocardial Infarction (AMI) 30-Day Mortality Rate
24) Heart Failure (HF) 30-Day Mortality Rate
25) Pneumonia (PN) 30-Day Mortality Rate
26) Complication/Patient safety for selected indicators (Composite)
27) Catheter-Associated Urinary Tract Infection
28) Central Line-Associated Blood Stream Infection
29) SSI – Colon Surgery & SSI – Abdominal Hysterectomy
30) Medicare Spending Per Beneficiary
Medicare’s 5 Quality Metrics under the Hospital Readmission Reduction Program31) Heart failure 30-day readmission rate
32) Heart attack 30-day readmission rate
33) Pneumonia 30-day readmission rate
34) Hip/knee replacement 30-day readmission rate
35) COPD 30-day readmission rate
Medicare’s 33 Quality Metrics under the Accountable Care Organization Program36) Getting Timely Care, Appointments, and Information
37) How Well Your Doctors Communicate
38) Patients’ Rating of Doctor
39) Access to Specialists
40) Health Promotion and Education
41) Shared Decision Making
42) Health Status/Functional Status
43) Risk Standardized, All Condition Readmissions
44) ASC Admissions: COPD or Asthma in Older Adults
45) ASC Admission: Heart Failure
46) Percent of PCPs who Qualified for EHR Incentive Payment
47) Medication Reconciliation
48) Falls: Screening for Fall Risk
49) Influenza Immunization
50) Pneumococcal Vaccination
51) Adult Weight Screening and Follow-up
52) Tobacco Use Assessment and Cessation Intervention
53) Depression Screening
54) Colorectal Cancer Screening
55) Mammography Screening
56) Proportion of Adults who had blood pressure screened in past 2 years
57) Hemoglobin A1c Control (HbA1c) (<8 percent)
58) Low Density Lipoprotein (LDL) (<100 mg/dL)
59) Blood Pressure (BP) < 140/90
60) Tobacco Non Use
61) Aspirin Use
62) Percent of beneficiaries with diabetes whose HbA1c in poor control (>9 percent)
63) Percent of beneficiaries with hypertension whose BP < 140/90
64) Percent of beneficiaries with IVD with complete lipid profile and LDL control < 100mg/dl
65) Percent of beneficiaries with IVD who use Aspirin or other antithrombotic
66) Beta-Blocker Therapy for LVSD
67) Drug Therapy for Lowering LDL Cholesterol
68) ACE Inhibitor or ARB Therapy for Patients with CAD and Diabetes and/or LVSD
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HCTA provides services to physicians, hospitals, health systems, ACOs, and other organizations seeking to develop pay-for-performance programs that align providers with reimbursement payment systems. Contact HCTA today to discuss feasibility and development services for new pay-for-performance programs.