Medicare Hospital Value-Based Purchasing Program Includes Checks For Appropriate Drug Use

Appropriate antibiotic regimens for pneumonia and surgical patients and proper venous thromboembolism prophylaxis in surgical care are among the clinical process care measures that can help hospitals receive incentive payments from Medicare.

Several measures assessing hospitals' proper use of pharmaceutical products are included in Medicare's Hospital Inpatient Value-Based Purchasing program, which will pay hospitals for meeting performance standards.

Under a final rule released by CMS April 29, beginning in 2012, hospitals will be assessed and paid based on performance points scored in two broad areas: clinical process of care and patient experience of care. The program was established by the Affordable Care Act and builds on Medicare's efforts to refocus reimbursement on the quality of care delivered.

Scoring will be based on whether a hospital meets or exceeds performance standards established with respect to the measures during a performance period each year. The score in each measure will be the higher of an achievement score, where the hospital's achievement is compared to all other hospitals' baseline performance, or an improvement score, which will be based on how much a hospital's current performance changes from its own previous baseline performance.

The program draws many measures from the Hospital Inpatient Quality Reporting program, under which hospitals have been reporting their performance to CMS for publication on the Hospital Compare website.

Of the 12 clinical measures, many address use of drugs. For example, hospitals will be measured on the percentage of patients with pneumonia who are given blood cultures to determine the best antibiotic therapy and then on the initial antibiotic selection for pneumonia patients.

Hospitals will also be measured on their use of prophylactic antibiotics to prevent infections in surgical patients, including dosing patients one hour before surgery, choosing the right antibiotic for patients and then discontinuing therapy within 24 hours after surgery.

Also for surgical patients, hospitals will be checked on whether patients who were taking beta blockers before coming to the hospital were given beta blockers during the period just before surgery.

Prophylaxis of venous thromboembolism is also measured by looking at how often treatment to prevent blood clots was ordered for certain types of surgery and how often that was continued from 24 hours before surgery until 24 hours after. While mechanical prophylaxis can be used to prevent clots, depending on patient characteristics and the type of surgery, the standard in many cases involves use of anti-clotting drugs.

For heart failure patients, hospitals will be measured on how often they provide patients with information on how to manage heart failure symptoms - which typically includes drug therapy - when they are discharged.

Medication also comes into play in the patient experience measures. That score will be based on the Hospital Consumer Assessment of Healthcare Providers & Systems Survey, which includes ratings on staff communication about medicines used and how well they managed pain. Examples of other patient ratings include responsiveness of hospital staff, discharge information and the cleanliness and quietness of the hospital environment.

CMS noted that the initiative will support the goals of the recently announced Partnership for Patients, a public-private partnership intended to improve the quality, safety and affordability of hospital care, including reducing drug adverse events (Also see "HHS "Partnership For Patients" Plan Includes Goal Of Halving Preventable Drug Adverse Events In Hospitals" - Pink Sheet, 12 Apr, 2011.).

- Scott Steinke ([email protected])