Sepsis Now Part of CMS Value-Based Purchasing Program

SUMMARY

  • The U.S. Center for Medicare and Medicaid Services (CMS) Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) lays out the process for providers to follow in the care of the sepsis patient.
  • First published in 2015, then amended in 2018, CMS is recommending SEP-1 become added to the Hospital Value Based Purchasing Program (HVBP) starting FY2026.
  • Coupled with a multiplier for care of the underserved patient population, the SEP-1 measure can net a 2.8% increase as part of the inpatient prospective payment system.
  • However. specific conditions must be met.

BACKGROUND

  • The CMS SEP-1 sepsis measures became quality indicator metrics in 2015
  • The goal of SEP-1 was to promote quality and cost effective care on a national level.
  • 2018 unveiled the newest version of the sepsis guidelines and was very similar to the 2015 guidelines.
    • Hospital sepsis compliance data became publicly available.
  • The FY 2024 CMS Hospital Inpatient prospective payment system (PPS) made a number of rule changes.
  • The only new measure was the addition of the Severe Sepsis an d Septic Shock Management Bundle.
REVIEW
  • The global burden of sepsis is not in debate.
  • The continued variability of care of sepsis still remains
  • The value of compliance with the CMS SEP-1 sepsis bundles has yet to be resolved.
    • Rhee et al JAMA Netw Open. 2021;4(12):e2138596. doi:10.1001
    • No change in mortality after SEP-1 initiation
  • Townsend SR et al CHEST 2022; 161(2):392-406
    • Compliance with SEP-1 decreased 30 day mortality
  • Potential reasons for varying results with SEP-1 compliance
    • Changing guidelines and definitions
    • 4 Surviving Sepsis campaign guidelines
    • 3 International Consensus definitions
  • SEP-1 uses outdated definitions (Sepsis-2 definitions from 2001, published in 2003).

APRIL 2023

  • CMS issued fiscal year 2024 hospital inpatient prospective payment system (IPPS) rules
  • An overall 2.8% increase for inpatient IPPS payments will occur
    • Hospitals not submitting quality data will only get 2.05% increase
    • Hospitals not meeting EHR meaningful use will only get 0.55% increase.
    • Hospitals not meeting both will get a payment decrease of 0.2%
  • Significant changes to Hospital Value Based Purchasing Program (HVBP)
    • Beginning in FY2026 CMS will add a Health Equity Adjustment (HEA)
    • HEA will be a total performance score consisting of 2 parts:
      • High quality performance
      • Extent to which underserved patients are served = proportion of dual eligible patients for Medicare and Medicaid
  • Points will be assigned based on whether the hospital scores in the:
    • Top Third
    • Middle Third
    • Bottom Third
  • THE ONLY NEW MEASURE ADDED TO HVBP IS SEVERE SEPSIS AND SEPTIC SHOCK MANAGEMENT BUNDLES

CONCLUSIONS

  • CMS Sepsis SEP-1 management bundle elements have evolved from:
    • 2015 Quality Performance Items
    • 2018 Publicly Available Quality Data
    • FY2026 Tied to hospital reimbursement
  • Although the net 2.8% increase is felt by many to be inadequate, the amount maybe lower if inpatient prospective payment programs are sub-optimal
  • Health systems must be ready for this sepsis reimbursement change.

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Erkan Hassan is the Co-Founder & Chief Clinical Officer of Sepsis Program Optimization where he designs & oversees the implementation of solutions to optimize sepsis programs.

To discuss your organization’s Barriers of Effective Sepsis Care, contact Erkan by phone (844) 4SEPSIS (844-473-7747), email (erkan@spo.icu), or video chat.