Administrative Code

Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
9/30/2020

Chapter 216. Methodology to Measure Efficiency and Productivity of Health Care Institutions

12VAC5-216-10. Purpose; limitations; activities.

A. The methodology set forth in this chapter is market oriented. Consumers and buyers of health care will receive information from the board that will allow them to make prudent health care decisions.

B. Nothing in this chapter or the actions taken by the board pursuant to any of its provisions shall be construed as constituting approval by the Commonwealth or any of its agencies or officers of the reasonableness of any charges made or costs incurred by any health care institution.

C. The board will collect, analyze, and publish information on health care institutional provider practices relating to efficiency and productivity.

Statutory Authority

§§ 32.1-12 and 32.1-276.2 of the Code of Virginia.

Historical Notes

Former 12VAC25-30-10, 12VAC25-30-20 and 12VAC25-30-30 derived from VR 370-01-002 §§ 1.1 to 1.3, eff. June 1, 1994; amended and adopted as 12VAC5-216-10, Virginia Register Volume 13, Issue 22, eff. August 20, 1997.

12VAC5-216-20. Filing.

Each health care institution, except where otherwise indicated, will submit an annual historical performance filing. Each health care institution will submit an annual historical performance filing as prescribed in § 32.1-276.7 of the Code of Virginia. This filing will be used to collect audited financial information and other information for all of the categories listed in 12VAC5-216-40. It will provide the basis for the evaluation by the board. The annual historical performance filing shall be received by the board within 120 days after the close of the health care institution's fiscal year.

Statutory Authority

§§ 32.1-12 and 32.1-276.2 of the Code of Virginia.

Historical Notes

Former 12VAC25-30-40 derived from VR370-01-002 § 2.1, eff. June 1, 1994; amended and adopted as 12VAC5-216-20, Virginia Register Volume 13, Issue 22, eff. August 20, 1997.

12VAC5-216-30. Eliminating duplication in reporting.

In compliance with § 32.1-276.4 B of the Code of Virginia, information that is collected by other public and private entities that is used by the board in its evaluation of efficiency and productivity shall be received by the board directly from the appropriate agency or entity. Data will also be drawn from the Virginia Patient Level Data System and from other available data bases.

Statutory Authority

§§ 32.1-12 and 32.1-276.2 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 22, eff. August 20, 1997.

12VAC5-216-40. Categories of information.

Information concerning charges, costs, elements of costs, productivity, resource utilization, financial viability, and community support services will be assembled from the filings made pursuant to this chapter.

Statutory Authority

§§ 32.1-12 and 32.1-276.2 of the Code of Virginia.

Historical Notes

Former 12VAC25-30-50 derived from VR370-01-002 § 2.2, eff. June 1, 1994; amended and adopted as 12VAC5-216-40, Virginia Register Volume 13, Issue 22, eff. August 20, 1997.

12VAC5-216-50. Efficiency and productivity indicators.

Individual data elements from the general categories identified in 12VAC5-216-40 will be used to form ratio indicators. These indicators will be used to evaluate health care institutions and rank health care institutions in relation to their peers.

1. Case mix index. Each acute care hospital shall provide the board with a case mix index for all inpatients and designated categories of inpatients when it submits its annual historical performance filing. The Medicare DRG grouper process shall be utilized by the board.

2. Each nursing facility that has received a Patient Intensity Rating System (PIRS) Service Intensity Index (SII) number from the Virginia Department of Medical Assistance Services shall report the four quarterly final PIRS SII scores associated with its fiscal year. These scores are to be reported on the institution's annual historical performance filing.

Statutory Authority

§§ 32.1-12 and 32.1-276.2 of the Code of Virginia.

Historical Notes

Former 12VAC25-30-60 derived from VR370-01-002 § 2.3, eff. June 1, 1994; amended and adopted as 12VAC5-216-50, Virginia Register Volume 13, Issue 22, eff. August 20, 1997.

12VAC5-216-60. Electronic submission of data.

A. Information shall be submitted electronically.

B. Information shall be submitted using software developed by the board for the use of health institutions in submitting filings.

C. Any health care institution that does not have the computer equipment to submit electronically may apply to the board for an exemption to subsection B of this section. A fee commensurate with the cost of data entry will be assessed by the board.

Statutory Authority

§§ 32.1-12 and 32.1-276.2 of the Code of Virginia.

Historical Notes

Former 12VAC25-30-80 derived from VR370-01-002 § 2.5, eff. June 1, 1994; amended and adopted as 12VAC5-216-60, Virginia Register Volume 13, Issue 22, eff. August 20, 1997.

12VAC5-216-70. Public access to data.

The board will publish an annual report which will incorporate the data collected and analysis of the data including, but not limited to, an evaluation of the relative efficiency and productivity of health care institutions. An electronic data base is open to the public.

Statutory Authority

§§ 32.1-12 and 32.1-276.2 of the Code of Virginia.

Historical Notes

Former 12VAC25-30-90 derived from VR370-01-002 § 2.6, eff. June 1, 1994; amended and adopted as 12VAC5-216-70, Virginia Register Volume 13, Issue 22, eff. August 20, 1997.

12VAC5-216-80. Initial measurement.

The performance of each health care institution will be measured using the indicators referenced in 12VAC5-216-50.

Statutory Authority

§§ 32.1-12 and 32.1-276.2 of the Code of Virginia.

Historical Notes

Former 12VAC25-30-100 derived from VR370-01-002 § 3.1, eff. June 1, 1994; amended and adopted as 12VAC5-216-80, Virginia Register Volume 13, Issue 22, eff. August 20, 1997.

12VAC5-216-90. Ranking; other peer groupings.

A. Unless exempted as provided for in 12VAC5-216-100, each health care institution will be subject to a ranking procedure.

1. Geographical peer grouping. Similar types of health care institutions (e.g., all hospitals or all nursing homes) will be grouped into geographical peer groups and ranked in relation to other institutions within their peer group.

2. Ranking procedure. Each health care institution will be ranked on each indicator and given a quartile score on each indicator. Each quartile represents 25% of institutions within the peer group. Each institution will be given a score of 1, 2, 3, or 4 on each indicator depending upon the quartile in which it falls. A quartile score of 1 on an indicator means that an institution ranked in the top quartile (top 25%) on that indicator. Quartile scores are summed over all indicators. The total is divided by the number of indicators to get an average quartile score. The top performers will be selected by using the average quartile score and identifying, to the extent possible, the top 25% of the institutions within each peer group.

B. Health care institutions may be sorted into other peer groupings (e.g., bed size, urban/rural, system/nonsystem) for purposes of analysis.

Statutory Authority

§§ 32.1-12 and 32.1-276.2 of the Code of Virginia.

Historical Notes

Former 12VAC25-30-110 and 12VAC25-30-120 derived from VR370-01-002 §§ 3.2 and 3.3, eff. June 1, 1994; amended and adopted as 12VAC5-216-90, Virginia Register Volume 13, Issue 22, eff. August 20, 1997.

12VAC5-216-100. Exemptions from the ranking procedure.

Until such time as a resource utilization adjustor, similar to the case mix index for acute care hospitals referenced in subdivision 1 of 12VAC5-216-50 is developed and adopted by the board, some institutions will be exempt from the ranking procedure as described below:

1. Psychiatric hospitals.

2. Rehabilitation hospitals.

3. Ambulatory surgery hospitals.

4. Continuing care retirement communities.

5. Children's specialty hospitals.

6. Subacute care hospitals.

Statutory Authority

§§ 32.1-12 and 32.1-276.2 of the Code of Virginia.

Historical Notes

Former 12VAC25-30-130 derived from VR370-01-002 § 3.4, eff. June 1, 1994; amended and adopted as 12VAC5-216-100, Virginia Register Volume 13, Issue 22, eff. August 20, 1997.

Forms (12VAC5-216)

Hospital Historical Filing, 03-01 (rev. 4/30/96).

Indicator Definitions – Acute Care Hospitals (rev. 10/15/96).

Special Services Utilization Calculations

Ambulatory Surgical Hospital Historical Filing, 03-02 (rev. 4/30/96).

Indicator Definitions – Ambulatory Surgery Hospitals (rev. 10/15/96).

Nursing Home Historical Filing, 03-03 (rev. 4/30/96).

Indicator Definitions – Nursing Homes (rev. 10/15/96).

Psychiatric Hospital Historical Filing, 03-05 (rev. 4/30/96).

Indicator Definitions – Psychiatric Hospitals (rev. 10/15/96).

Rehabilitation Hospital Historical Filing, 03-06 (rev. 4/30/96).

Indicator Definitions – Rehabilitation Hospitals (rev. 10/15/96).

Income Statement Reconciliation Worksheet, 04-04 (rev. 4/30/96).



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