The main 2012 changes to the hospital inpatient measures (Table 4) that affect emergency medicine include:

• Retirement of AMI-1: Aspirin at Arrival. It was felt that the vast majority of hospitals now perform well on this measure, and the measure has outlived its purpose. ED providers should keep in mind that although the hospital reporting on this measure to CMS will cease, the hospital may continue to report performance to The Joint Commission (TJC) for reaccreditation.
• Retirement of PN-5c: Initial Antibiotic Received within 6 Hours of Arrival. ED providers should keep in mind that although the hospital reporting on this measure to CMS will cease, the hospital may continue to report performance to TJC for reaccreditation.

Value-Based Purchasing

The CMS Hospital Inpatient Value-Based Purchasing (VBP) Program became law on July 1, 2011, and applies to payments for discharges occurring on or after Oct. 1, 2012. CMS believes VBP will reduce costs by encouraging value-added health care. The VBP is an evolution of the Hospital Inpatient Quality Reporting (IQR) Program; where IQR was “pay for reporting,” VBP is “pay for performance.” Given that the funding is derived from a reduction in payment, it is more accurately described as “nonpay for nonperformance.” CMS believes that VBP will be a vehicle to incentivize value and outcome (vs. volume). This is a significant change as CMS becomes a purchaser of services instead of payer of claims.

All short-stay acute care hospitals that see a minimum of 10 cases for at least four applicable measures are required to participate in VBP. Hospitals are currently measured on 17 clinical process measures and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. To determine the hospital’s overall VBP score, clinical process measures will receive a 70% weight and HCAHPS will receive a 30% weight. The actual calculation of VBP dollars is complex and will vary depending on the hospital. The larger the specific hospital’s percentage of revenues derived from Medicare payments, the larger the financial implications to that hospital. All eligible hospitals will be splitting shares of the VBP fund, which is funded by a 1% reduction in base diagnosis-related group (DRG) reimbursement. CMS estimates that the size of the fund for FY2013 will be $850 million. On an annual basis, the reduction in base DRG reimbursement will increase by 0.25% until it totals 2% for FY2017.

Though many of the processes of care measures could feasibly touch on emergency care, four inpatient quality measures are specifically relevant to emergency care:

• AMI-7a: Thrombolytics within 30 Minutes of Hospital Arrival for STEMI.
• AMI-8a: Primary PCI within 90 Minutes of Hospital Arrival for STEMI.
• PN-3b: Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital.
• PN-6: Pneumonia Patients Given the Most Appropriate Initial Antibiotic.

In brief, for each of the above performance measures, hospitals receive an achievement score between 1 and 10 based on how much their current performance score exceeds the median for all hospitals. If the score is below the median, the hospital receives an achievement score of zero. Additionally, hospitals also receive an improvement score between 1 and 10 based on how much the score on the performance measure improved from the previous (i.e., baseline) year. If performance did not improve, the hospital receives an improvement score of zero. The final performance measure score is the higher of the achievement or improvement score.