CMS PROPOSALS TO IMPROVE QUALITY OF CARE DURING HOSPITAL INPATIENT STAYS

OVERVIEW:  On Apr. 24, 2012, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update Medicare payment policies and rates for inpatient stays in acute care hospitals under the Inpatient Prospective Payment System (IPPS) and hospitals paid under the Long-Term Care Hospitals (LTCH) Prospective Payment System (PPS) in Fiscal Year (FY) 2013.  The proposed rule also proposes the payment update that would be used to calculate FY 2013 target amounts for certain hospitals excluded from the IPPS, such as cancer and children’s hospitals, and religious nonmedical health care institutions.  The proposed rule, which would apply to approximately 3,400 acute care hospitals and approximately 430 LTCHs, would generally be effective for discharges occurring on or after October 1, 2012. 

In addition to promoting accurate payment for inpatient services to Medicare beneficiaries, the proposed rule would strengthen the Hospital Inpatient Quality Reporting (IQR) Program, propose new policies and measures for the Hospital Value-Based Purchasing (VBP) Program, and establish the framework for two new quality reporting programs that will apply to hospitals paid under the Inpatient Psychiatric Facility (IPF) PPS and PPS-Exempt Cancer Hospitals.  It also proposes requirements for the Ambulatory Surgical Center (ASC) quality data reporting program effective for the Calendar Year (CY) 2014 payment determination.

This fact sheet discusses major quality-related provisions of the proposed rule.  A separate fact sheet on proposed payment changes is available on the CMS Web page at:

           www.cms.gov/apps/media/fact_sheets.asp.

BACKGROUND: The Hospital IQR Program and the Hospital-Acquired Conditions (HACs) payment policy represent significant steps toward implementing value-based purchasing (VBP) in Medicare.  VBP is intended to transform Medicare from a passive payer for services to a prudent purchaser of services, paying not just for quantity of services but for quality as well.

The Hospital IQR Program grew out of the Hospital Quality Initiative developed by CMS in consultation with hospital groups.  Participation in the program is voluntary, but the Medicare law now requires CMS to adjust payments to hospitals that do not participate successfully by reducing their annual payment updates by 2.0 percentage points.  Since the implementation of the financial penalty, hospital participation has increased to well over 99 percent of Medicare-participating hospitals that are reimbursed under the IPPS.

Measures reported under the IQR Program are published on the Hospital Compare Web site (http://www.hospitalcompare.hhs.gov/), and may later be adopted for use in the Hospital VBP Program that was mandated by the Affordable Care Act and that will affect payment rates to hospitals beginning in FY 2013. 

PROPOSED CHANGES TO THE HOSPITAL IQR PROGRAM:

The Hospital IQR Program measure set has grown from a starter set of 10 quality measures in 2004 to the current set of 72 quality measures.  These measures include chart-abstracted measures (e.g., heart attack, heart failure, pneumonia, surgical care improvement), claims-based measures (e.g., mortality and readmissions measures for heart attack, heart failure, pneumonia); AHRQ Patient Safety Indicators and Inpatient Quality Indicators; HACs; one survey-based measure (e.g., patient experience of care), immunization measures, and structural measures.

Proposed changes to the measures to be reported:  The proposals for the Hospital IQR Program in the FY 2013 IPPS/LTCH proposed rule are intended to reduce burden on hospitals, create a more streamlined measure set, and improve care through increased focus on perinatal care, surgical complications for hip and knee replacement procedures, readmissions, and care transitions.  The proposed rule includes proposals that would reduce the number of measures in the IQR program from 72 to 59 for the FY 2015 payment determination, and 60 for the FY 2016 payment determination.  Specifically, CMS is proposing to remove one chart-abstracted measure and 16 claims-based measures.  CMS is proposing to adopt three claims-based measures, one chart-abstracted measure on perinatal care, one structural measure, and to add care transition measure items to the existing “patient experience of care” survey.  See Appendix A for a complete list of the proposed Hospital IQR measures,

Proposed Program Requirements for the FY 2014 Update:  The CMS is proposing to reduce burden and simplify the validation requirements for the IQR program measures.  Because more than 99% of sampled hospitals were validated as reporting accurate data in the most recent year, CMS is proposing to reduce the annual random sample from 800 hospitals to 400 hospitals.  CMS is also proposing to increase the targeted sample to up to 200 hospitals to review potential reporting anomalies.  The targeted sample would include, for example, hospitals meeting CMS reporting requirements near the minimum accuracy threshold, and hospitals with large increases in their scores on quality measures.

These proposals would help ensure that accurate quality data are used on the Hospital Compare website and in the Hospital VBP Program.

LTCH Quality Reporting Program proposals: CMS is proposing the measures that will be used in the FY 2014 quality reporting program for LTCHs for the FY 2015 payment determination year. In addition, CMS proposes five new quality measures for the FY 2016 payment determination year. These new measures are: 1) Percent of Nursing Home Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short-Stay); 2) Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine (Short-Stay); 3) Influenza Vaccination Coverage among Healthcare Personnel; 4)Ventilator Bundle; and 5) Restraint Rate per 1,000 Patient Days.

The LTCH Quality Reporting Program ties a portion of an LTCH's payment to its participation in the Program. LTCHs that do not comply with the new LTCH quality reporting program will see their yearly Federal update payments reduced by two percentage points beginning in FY 2014.

PROPOSALS FOR NEW QUALITY REPORTING PROGRAMS:

Sections 3005 and 10322 of the Affordable Care Act called for CMS to create new quality reporting programs for two types of hospitals that are exempt from payment under the IPPS.  These include 11 hospitals that have been exempted from the IPPS as cancer hospitals and as IPFs.  This proposed rule would implement both of those programs. 

Specifically, CMS is proposing an initial set of five quality measures and program requirements for reporting in FY 2013 by IPPS-Exempt Cancer Hospitals.  The proposed measures include two healthcare-associated infection (HAI) measures developed by the Centers for Disease Control and Prevention (CDC) — Central Line Associated Blood Stream Infection and Catheter Associated Urinary Tract Infection—along with three cancer “process of care” measures on chemotherapy and hormone therapy developed by the American College of Surgeons. 

CMS is also proposing a new quality data reporting program for IPFs that would reduce the IPF-PPS annual payment update by 2.0 percentage points for IPFs that do not comply with the quality data submission requirements.   For this program, CMS is proposing an initial set of six “process of care” quality measures for reporting in FY 2013 for the FY 2014 payment update.  The six proposed measures focus on administration of antipsychotic medications, use of restraints, hours of patient seclusion, creation of post-discharge continuing care plans,  and transmission of those plans to subsequent care providers after discharge.  These measures were developed by the Joint Commission. 

See Appendix B for the proposed measure for reporting by cancer hospitals and IPFs.

PROPOSALS FOR ASC QUALITY REPORTING PROGRAM

CMS is also proposing several requirements for the ASC Quality Reporting Program relating to the measures that were finalized for the CYs 2014, 2015, and 2016 payment determinations in the CY 2012 Outpatient Prospective Payment System/ASC Payment System final rule with comment period that appeared in the Nov. 30, 2011 Federal Register.  Specifically, CMS is proposing new administrative, data completeness, and extraordinary circumstance waivers or extension request requirements, as well as a reconsideration process.  ASCs that fail to report quality data or to comply with these requirements will incur a 2.0 percentage point reduction in their annual payment update for that payment determination year, beginning in CY 2014.  Data collection for the CY 2014 payment determination will begin with services furnished on Oct. 1, 2012.

PROPOSALS TO UPDATE HACS LIST:

The HACs payment policy, which was mandated by the Deficit Reduction Act of 2005, prevents hospitals from being paid at the higher MS-DRG rate for patients with complications or major complications if the sole reason for the higher payment is the occurrence, during the beneficiary’s hospital stay, of one of the conditions on the HACs list.

CMS is proposing to add Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED) and Iatrogenic Pneumothorax with Venous Catheterization as conditions subject to the HAC payment provision for FY 2013.

More than 500,000 CIEDs are implanted each year in the United States, and 70 percent of CIED recipients are age 65 or older.  CIED therapy reduces morbidity and mortality in selected patients with cardiac rhythm disturbances.  However, the benefit of CIED therapy is somewhat reduced by complications following device placement, including infections.  Patients can present with early or late infections because of CIED placement. 

Pneumothorax is defined as the presence of air or gas in the space between the tissue of the lung and parietal pleura, or surface lining of the lung (the pleural cavity).  The presence of air in this space partially or completely collapses the lung and is life threatening.  Air can enter the intrapleural space through the chest wall.  Iatrogenic pneumothorax is a type of traumatic pneumothorax that results from infiltration into the pleural space during the course of a diagnostic or therapeutic medical intervention, such as needle placement for central line catheter guidance.

CMS is also proposing to add two codes, 999.32 (Bloodstream infection due to central catheter) and 999.33 (Local infection due to central venous catheter) to the existing Vascular Catheter-Associated Infection HAC Category.

See Appendix C for the complete list of proposed HACs.

PROPOSALS FOR HOSPITAL VBP PROGRAM:

The proposed rule includes a number of proposed policies related to the Hospital VBP Program. These proposals are intended to support the CMS three-part aim of better health care, better health in the entire population, and lower costs through improvement. 

Proposed Program Requirements for the FY 2013:  CMS is proposing important operational details for FY 2013, which is the first year in which value-based incentive payments will be made under the Hospital VBP Program.  The proposed rule makes proposals regarding when hospitals will receive:

• Total Performance Scores;
• The 1% reduction to base operating Diagnosis-Related Group (DRG) amounts; and
• Value-based incentive payments.

CMS also proposes to establish a review and corrections process that will allow hospitals to correct their performance data before that data is made public on the Hospital Compare website and an administrative appeals process that will give hospitals an opportunity to appeal the calculation of the performance assessment their total performance score.

Proposed Program Requirements for FY 2015:  CMS is proposing several policies for the FY 2015 Hospital VBP Program, including:

• Grouping and scoring measures in four domains: Clinical Process of Care, Patient Experience of Care, Outcome, and Efficiency.
• New measures, including:
  •   One new Clinical Process of Care measure - Acute Myocardial Infarction, Statin Prescribed at Discharge (AMI-10);
  • Two new Outcome measures - Central Line Associated Blood Stream Infection (CLABSI) and the Patient Safety Indicator (PSI-90) composite measure; and
  • One new Efficiency measure - Medicare Spending per Beneficiary (MSPB-1)
• Applicable minimum numbers of cases and measures for the expanded Outcome domain and the new Efficiency domain.
• Proposed performance standards, including achievement thresholds and benchmarks for all proposed measures, as well as “floors” for all eight Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) dimensions.  We provided estimates of the performance standards based on the most recently available data and will update the standards in the Final Rule.
• Proposed domain weighting for hospitals’ FY 2015 Total Performance Scores, which can be found in Appendix B of this fact sheet.

Proposed Program Requirements for FY 2016:  Additionally, CMS is proposing new domains which align with the National Quality Strategy for the Hospital VBP Program in FY 2016.  These proposals for FY 2016 would improve the links between patient outcomes, quality, safety, and lower cost with Medicare payment.  The six proposed domains, which map back to six priorities of the National Quality Strategy, are:

• Clinical Care;
• Person- and Caregiver-Centered Experience and Outcomes;
• Safety;
• Efficiency and Cost Reduction;
• Care Coordination; and
• Community/Population Health.

See Appendix D for a table of proposals for the Hospital VBP Program.

More information about the Hospital VBP Program is available online at http://www.cms.gov/hospital-value-based-purchasing.

CMS will accept comments on the proposed rule until June 25, 2012, and will respond to all comments in a final rule to be issued by August 1, 2012.  The proposed rule can be downloaded from the Federal Register at:

            http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1.

The proposed rule will appear in the May 11, 2012 Federal Register.

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APPENDIX A

MEASURES FOR REPORTING HOSPITAL INPATIENT QUALITY REPORTING PROGRAM (HIQR) FOR FY 2015 and FY 2016 PAYMENT UPDATES

*  New measures/items proposed for FY 2015 payment determination and subsequent years

**  New measures proposed for FY 2016 payment determination and subsequent years

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APPENDIX B

PROPOSED MEASURES FOR FY 2014 INPATIENT PSYCHIATRIC FACILITY QUALITY REPORTING (IPFQR) PROGRAM

PROPOSED MEASURES FOR FY 2014 PPS-EXEMPT CANCER HOSPITAL

QUALITY REPORTING (PCHQR) PROGRAM

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Appendix C

HACS ADOPTED IN PREVIOUS RULEMAKING AND PROPOSED ADDITIONS FOR FY 2013

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APPENDIX D

PROPOSED QUALITY MEASURES FOR FY 2015 AND FY 2016 HOSPITAL

VALUE-BASED PURCHASING (HVBP) PROGRAM