After substantial input from hospitals and health systems, Centers for Medicare and Medicaid Services (CMS) published its final rules related to Value-Based Purchasing (VBP) in November 2011. Due to take effect in 2014, the new regulations have settled on three factors that will determine the final “grade” and the financial bonus or penalty for hospitals. How will hospitals and health systems be graded? It’s all about, patient experience, clinical processes and clinical outcomes. 

The only unchanged component of the proposed regulation was the 30 percent attributed to the patient experience. While the term “patient experience” has become quite a buzzword during current reform efforts, “studying to the test” won’t achieve the best HCAHPS scores. Instead, hospitals must shift their organizational culture to refocus on experience. Hospitals will need to develop relationships with their patients – before, during and after they receive care. 

The 45 percent incentive based on clinical processes will reward hospitals that are investing time, technology and human resources in best practices, rather than operational models. In the end, clinical integration and evidenced-based care will indirectly improve Medicare efficiency. The primary beneficiary, of course, will be the patient. CMS removed the Medicare efficiency component, originally proposed to account for 20 percent of reimbursement. In the final calculation, the efficiency factor was reallocated, increasing clinical processes to nearly half of the total calculation.

As hospitals become accustomed to the changes to the final rules related to value-based purchasing, there is still anxiety about timing. VBP is not the only change in the Affordable Care Act that will impact reimbursement. In addition, even though most hospitals and health systems started making adjustments to optimize both care and revenue, they are scrambling to make the operational and cultural adjustments that will ensure success. With these growing pains comes the opportunity and impetus for innovation and collaboration. For the patient, the end result will be better coordination of care and a welcomed change from “business as usual” in the delivery of their healthcare.