Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.
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Q U A L I T Y S T A N D A R D S Making Sense of Reimbursement's New Reality ures between baseline and per- than the withheld amount. formance periods, as well as on As is often the case, third-party payors comparisons will likely follow Medicare's lead. In fact, with overall some major insurers have already CMS is dangling better pay for better care. Are you ready? quality of care they provide to Medicare Daniel Cook | Executive Editor Participating hos- culled value-based purchasing reimbursement T aking good care of patients has pitals will from model, says Mr. Shoemaker. never been so important, at least begin to hospi- according to CMS. This fiscal receive incentive pay- tals inpatients. quality scores across the year, surgery centers will avoid financial ments at the start of penalties by reporting 5 quality measures fiscal year 2013. on Medicare claims. Hospitals, meanwhile, Looked at another way, GOAL ORIENTED Medicare payments are now linked to quality reporting and meeting specified quality measures. are in line to earn incentive payments for hospitals that don't meet certain quality linking surgery-related process providing quality care under CMS's value- criteria over time will face reductions in measures and patients' opinions based purchasing program. In both set- reimbursements. tings, facility reimbursement is on the cusp "The biggest difference between value- of a major transition, one that promises to based purchasing and ASC quality reporting forever alter the payment landscape. is value-based purchasing is tied to payments," says anesthesiologist David nation. CMS is announced their intent to move toward the Can you measure quality? The overall goal of the new quality measures is to ensure better patient care. But is that possible? "CMS is trying to define quality, but no one has been able to adequately define what it means," says Dr. Shapiro. of the care they received to hos- "How do you devise accurate measure- pital quality reporting in 2013 ments reflective of quality, or degrees of (see "Key Hospital Quality quality?" He concedes performance meas- Measures"). It funds the valuebased purchasing program with 1% of ures let individual facilities make better healthcare decisions, but questions Quality vs. value Shapiro, MD, immediate past president of Surgery centers that don't include new G- the ASC Association. "ASCs are currently hospital, then pays portions of the sum codes (see "G-Codes to Know") on faced with pay-for-reporting, as opposed to back to best performers at the end of the Medicare claims will see their 2014 ASC pay-for-performance." year. (The agency will increase the amount measurements of quality performance. "But withheld incrementally over the next sev- what Medicare has done is emphasize stan- the American Hospital Directory, an inde- eral years.) Hospitals performing below dards that are believed to be best practice, CMS's hospital value-based purchasing pendent data-gathering firm in Louisville, average won't get money back, average- but are really measures where there's a lot program is designed to reward acute-care Ky., says CMS bases a hospital's incentive performing hospitals will break even and of variability," he says. "Some hospitals are facilities with incentive payments for the payment on improvements in quality meas- top-performing facilities will receive more doing very well, and some are performing conversion factor reduced by 2%, meaning all claims will be paid at a lower rate. 4 SUPPLEMENT TO Paul Shoemaker, FACHE, president of O U T PAT I E N T S U R G E R Y M A G A Z I N E | J A N U A R Y 2013 inpatient revenue collected from every whether financial penalties should be attached to clinical outcomes. Mr. Shoemaker supports quantitative J A N U A R Y 2013 | S U P P L E M E N T TO O U T PAT I E N T S U R G E R Y M A G A Z I N E 5