MSPB - The New Value Proposition

by Stefani Daniels, Managing Partner, PhoenixMed
Published on Jun 26, 2015

The Medicare program's emphasis on care management took a new turn this year when it added a new measure - Medicare spending per beneficiary, or MSPB - to the formula that determines how much each hospital is paid.  The measure is noteworthy because, for the first time, not only is the hospital being held accountable for its costs, CMS is also holding hospitals accountable for the costs of some of the outpatient and post acute care.  

Baseline measures are already posted on Medicare's Hospital Compare website  .  A score of 1 indicates the hospital performs at the average efficiency of all hospitals nationally; a score higher than 1 indicates the hospital is more costly than average and a score below 1 shows greater efficiency.  So even though the hospital often has no influence over physician or patient decisions about post acute care or the provider of that care, the hospital is being evaluated on how efficiently those providers provide care. Those scores are calculated using hundreds of data points that detail spending for the three phases of care - 3 days before admission, the inpatient stay, and the 30-day period after discharge - for each major diagnostic category, such as circulatory system or digestive system.

The reports compare a hospital's spending levels in each category with state and national averages. Further, the reports reveal the spending in each phase by type of claim - outpatinety, inpatient, skilled nursing, durable medical equipment, and others. Thus the reports allow hospitals to see how their various service lines stack up to their peers in efficiency and hight areas that might be dragging down the hospital's overall performance. 

The role of the care managers in pre-admission and post-acute service service coordination are part of the industry's move toward patient-specific care management for selected patients as it moves to consolidate services across the continuum. And while there are reports that the variations in care provided in SNFs and by HHC providers are responsbile for much of the variation in Medicare spending, inpatient costs still offer the largest pool of untapped savings. Its true that hospitals have worked hard to cut direct and indirect costs by reducing programs, eliminating staff, and streamlining services.  But the problem of excessive, wasteful, duplicative, and potentially harmful medical interventions that add avoidable costs has not been aggressively addressed.  Hospital HIT systems still allow serial testing; imaging studies are still not monitored by radiologists to ensure that they are appropriate to the patient's needs; and pharmaceutical stewardship is still not the norm in many hospitals. Hospital case managers are not expected to policy physician practice behaviors but they are expected to advocate for their patient.  If they encounter a situation where their patients are being placed at either clinical or financial risk due to a physician's practice decision, I belive they should speak up.  What do you thinki?