Abstract
PPACA is an enormous law with far-reaching implications. PPACA was originally signed into law in 2010, but the entirety of it will not be implemented until 2016. (For more details, visit the U.S. Department of Health and Human Services sponsored website, HealthCare.gov, which provides an interactive implementation timeline. 1 ) Some of the more popular parts of PPACA have already gone into effect, including the Medicare Part D “donut hole” provision and extending coverage for dependent young adults until age 26. The more controversial parts of PPACA, such as the individual health insurance mandate and the prohibition of insurance companies to consider preexisting conditions, do not go into effect until 2014. One of the most exciting and favorable provisions for providers who care for patients with obesity is the creation of the Prevention and Public Health fund. The Prevention and Public Health fund allocates resources for programs that use proven methods to target health promotion and disease prevention, including $16 million that will be directed toward programs targeting obesity prevention and fitness. 2 Monies from this fund began being appropriated in 2010.
On October 1, 2012, Value Based Purchasing (VBP) became the most recent provision of PPACA to go into effect. While the Centers for Medicare and Medicaid Services (CMS) began developing and evaluating pay for performance reimbursement models in 2004, it was PPACA that legislated the adoption of a pay for performance program, referred to as VBP.3,4 VBP describes a program that rewards hospitals based on performance related to processes of care, outcomes of care, and the patient experience of care. Earlier this year Ms. Elizabeth Rochin described VBP for the readership of this Journal, 5 but essentially, processes of care refer to performance on core measures, including the surgical care improvement project (SCIP) core measures, while outcomes of care include 30-day mortality and hospital acquired conditions, such as healthcare acquired infections, pressure ulcers, falls with injury, and other CMS identified hospital acquired conditions. The patient experience measures include several dimensions of care measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. In 2013, 70% of a hospital's performance score will be based on the processes of care and 30% will be based on HCAHPS scores; it is anticipated that outcomes of care will be factored into the performance score in 2014. 4
While VBP is considered by CMS to be budget neutral, this program will ultimately have reimbursement implications for hospitals. This budget neutral plan involves withholding a percentage of inpatient reimbursement from the diagnostic related group (DRG) payments of Medicare beneficiary hospitals, and using those funds to provide incentive payments to hospitals that achieve the highest scores for quality performance. In short, hospitals will undergo a reduction in reimbursement rates, and the resultant money “saved” by CMS will be used to reward top performers. In the current competitive economic environment, administrators will strive to be top performers in order to collect some of the reward.
So how will VBP impact bariatric patients and the hospitals and providers that care for bariatric surgical patients? Well, it is not entirely known at this time, but it stands to reason that VBP and the bariatric surgical population will intersect. In Ms. Rochin's article earlier this year, she described different levels of patient satisfaction among bariatric surgical patients and general surgical patients on the same nursing unit. If some portion of reimbursement is based on patient satisfaction scores, it makes financial sense to understand and address this disparity. Patient related outcomes such as infection, falls, and pressure ulcer development, while not a part of VBP yet, will likely factor into VBP within 2 years. Articles previously published in this Journal and elsewhere have described the differences in these outcomes among bariatric patients and non-bariatric patients. Therefore, identification of the best practices for optimization of these outcomes in the bariatric and bariatric surgery patient population will be critical. In this issue, Dr. Melanie Mabrey et al. examine intravenous administration of insulin to postoperative diabetic bariatric surgical patients on a general surgery unit, and Ms. Suzanne Sherwood et al. describe the best practices associated with respiratory failure in patients with obesity. These two articles highlight the uniqueness of this patient population in regards to common clinical conditions while providing guidance for how best to optimize these outcomes in patients with obesity.
There is no doubt that there are forces outside of healthcare that influence how healthcare is delivered, evaluated, and reimbursed. Although there are financial implications associated with most of these influences, it is the impact of care at the individual patient level that matters most to those who choose healthcare as a profession. This dichotomy sometimes makes direct care providers feel helpless and wonder if the tail is wagging the dog. Instead of feeling helpless, become informed. The websites listed as references here are good information sources, as are journals and professional organizations. Once policies, regulations, and programs are in place, it is our responsibility not only to understand their impact on practice, but also to determine how to provide high quality care within these regulations and constraints. Ultimately, optimization of clinical outcomes and a positive patient experience is our responsibility, not the responsibility of the policy makers.