CMS 30-DAY HOSPITAL MORTALITY MEASURES
Project Overview
In response to the requirements of the Deficit Reduction Act of 2005, the Centers for Medicare & Medicaid Services (CMS), with the support of its partners in the Hospital Quality Alliance (HQA), is making available its first set of outcome measures – 30-day risk-standardized mortality measures for Medicare patients with hospital discharge diagnoses of acute myocardial infarction (AMI) or heart failure (HF) for all acute care hospitals in the nation. The measures – based on hospital claims data from July 2005 to June 2006 – are being publicly reported on the Hospital Compare Web site, located at www.medicare.gov, beginning in June 2007.
Goals of the Project
This effort to publicly report outcome measures and to provide hospitals with detailed information related to their AMI and HF patients is part of the CMS goal to improve the quality and transparency of hospital care by giving the American public and healthcare professionals better access to important hospital data. The mortality measures complement the process measures already being reported on Hospital Compare to promote increased scrutiny by hospitals of patient outcomes in the service of providing the right care for every patient, every time.
Input from Hospitals
In mid-December 2006 CMS provided hospitals with confidential AMI and HF mortality measure reports based on claims data from 2003 during a “dry run” phase to test the measures and reporting model. Hospitals were asked to review their individualized reports, giving them the opportunity to ask questions and provide comments on the structure and content of the reports through January 15, 2007. Critical access hospitals, as well as hospitals without claims data for 2003, were given access to mock reports to allow them to participate in the dry run. Hospital feedback gathered in this phase helped to ensure that the annual reports delivered to hospitals in 2007 and thereafter are as informative as possible, and that the information will help them to effectively analyze and improve their quality of care.
Measure Development and Methodology
The CMS mortality measures and associated risk adjustment methodology were developed over the past several years by a team of clinical and statistical experts from Yale and Harvard Universities under the direction of CMS. Following approval by the Hospital Quality Alliance, the National Quality Forum (NQF) endorsed the HF and AMI measures using a rigorous review process involving providers, consumers, purchasers, and researchers. The model CMS uses to assess hospital mortality rates is based on administrative claims data and has been validated by models based on clinical data. It takes into account medical care received during the year prior to each patient’s hospital admission, as well as the number of AMI and HF admissions at each hospital. The model uses this information to adjust for differences in each hospital’s patient mix, so hospitals that care for older, sicker patients are on a “level playing field” with those whose patients would be expected to be at less risk of dying within 30 days of admission.
More Information about CMS Mortality Measures
Detailed information about the measures is available at www.qualitynet.org, established by the Centers for Medicare & Medicaid Services (CMS), QualityNet provides healthcare quality improvement news, resources and data reporting tools and applications used by healthcare providers and others. To access a variety of academic articles, FAQs, mock reports, and other key information about the project, hover over the “Hospitals” tab and click on “Mortality Measures” in the drop-down menu.
Metrics Development
The mortality measures compare the hospital specific Risk Standardized Mortality Rates (RSMRs) to the US National Rate for Heart Attack and Heart Failure. CMS placed hospitals into three categories with a very high degree of confidence based on their Risk Standardized Mortality Rates (RSMRs) and 95% interval estimates - “Better than US National Rate,” “Worse than US National Rate,” or “No Different than US National Rate.” The confidence interval of 95% was chosen to secure a high assurance that the data identifies true outliers in the “Better than US National Rate” and “Worse than US National Rate” categories. As a result, the total number of hospitals in these two categories are relatively low, but CMS is highly confident that they accurately reflect results that capture “better than” or “worse than” US national rate hospitals. Some high-performing or lower-performing hospitals fall into the “No Different than US National Rate” categories under this methodology. As with all of our quality measures, CMS and the Hospital Quality Alliance will be assessing ways to increase the utility of these measures to consumers, employers, and payers, while assuring validity and accuracy of the reported results.
Earlier Mortality Reporting
The Health Care Financing Administration (HCFA), the predecessor to CMS, produced measures of hospital mortality in the late 1980s and early 1990s. They were measures of overall hospital mortality for medical and surgical conditions. The methodology did not have the benefit of widespread consensus and was changed several times. By contrast the current measures are endorsed by the National Quality Forum, a voluntary consensus standard organization, and are actively supported by the Hospital Quality Alliance. The current risk adjustment models comply with scientific statements released by the American College of Cardiology and the American Heart Association, which have stated their support for these measures and are prepared to help hospital find ways to lower mortality rates. In addition the measures are displayed differently as described above and CMS is providing hospitals with detailed reports for these measures to assist them with their quality improvement efforts
Outpatient Measures
A substantial portion of hospital services are rendered in the outpatient setting. However, currently hospital measures are only being collected for inpatient services. CMS is working to expand relevant measures of quality to hospital outpatient services. CMS expects to have between 5 – 10 measures developed for a broad range of hospital outpatient services later this year. These measures are expected to be available for data collection beginning January 2008 generally using the same data collection mechanisms as are used for the inpatient setting.
Other CMS Activities to Improve Transparency and Quality of Care in the Hospital Setting
- Current Hospital Compare: www.hospitalcompare.hhs.gov. Launched in 2005, this website was developed collaboratively between CMS and the Hospital Quality Alliance (HQA). Twenty-one measures are currently available on the site for consumers to view, including: 8 measures related to heart attack care, 4 measures related to heart failure care, 7 measures related to pneumonia care, and 2 measures related to surgical infection prevention. Ten of the measures were considered the “starter set;” as such, hospitals were required to report them in order to receive their full Annual Provider Updates (the other 11 measures were not included in the RHQDAPU program until 3rd quarter 2006.) The website provides information on how often hospitals provide recommended treatments known to get the best results for most patients, for these conditions. This includes information about some of the care that should be received when arriving at the hospital, some care that should be received while in the hospital, and instructions for care that should be received upon discharge.
- June 21 Changes to Hospital Compare: www.hospitalcompare.hhs.gov. These enhancements are in line with the U.S Government’s ongoing commitment to increased healthcare transparency, and include new process of care measures being reported in areas such as surgery and heart care, updated results for hospital performance on process measures, and CMS’ first ever reporting of hospital outcomes in the form of its newly developed 30-day mortality measures. Beginning this month, results will be available for all hospitals on 22 process-of-care measures, up from the 10 measure “starter set” that served as the foundation of Hospital Compare when it was launched in 2005. An additional 11 measures had previously not been part of the RHQDAPU program, but are now required for most hospitals to receive full payment updates for inpatient services through Medicare. One non-RHQDAPU measure is being added in June 2007. Overall hospital performance on the process measures appears to have held steady or increased slightly. This is a testament to the ongoing focus on quality by our nation’s hospitals.
- Medicare Hospital Value-Based Purchasing Plan:
On August 22, 2006, President Bush issued an Executive Order, “Promoting Quality and Efficient Health Care,” which requires the Federal Government to: (1) Ensure that Federal health care programs promote quality and efficient delivery of health care and (2) Make readily-useable information available to beneficiaries, enrollees, and providers, to the maximum extent permitted by law. These actions are designed to drive improvements in the value of services provided by Federal health care programs.
To support the President’s Order, Secretary Leavitt has embraced four cornerstones for building a value-driven health care system:
1) Connecting the health system through the use of interoperable health information technology,
2) Measuring and making transparent quality information,
3) Measuring and making transparent price information, and
4) Using incentives to promote high-quality and cost-effective care.
Building on the Secretary’s four cornerstones and pursuant to a Deficit Reduction Act of 2005 requirement, the Centers for Medicare & Medicaid Services (CMS) is proposing a plan for hospital value-based purchasing (VBP). Through the use of VBP performance-based incentives and quality information transparency for Medicare’s payment systems, CMS will be transformed from a passive payer to an active purchaser of care for millions of Medicare beneficiaries.
- Inpatient Prospective Payment System Rule Update: On April 13, 2007, CMS issued a proposed rule to update the hospital inpatient prospective payment system (IPPS) for fiscal year 2008. The Deficit Reduction Act of 2005 provides that, beginning with the payment update for 2007 and each subsequent year, the annual percentage increase amount will be reduced by 2.0 percentage points for any “subsection (d) hospital” that does not submit certain quality data. . This requirement is just one of several requirements that must be satisfied in order to receive the full payment update.
- Hospital-Acquired Conditions: The Deficit Reduction Act (DRA) requires that for discharges occurring on or after October 1, 2008, the presence of selected preventable conditions that are acquired during a hospitalization would not lead to payment for the higher paying CC DRG. That is, the case would be paid as though the preventable condition had not occurred during the hospitalization. CMS must identify by October 1, 2007 at least two preventable conditions that could cause patients to be assigned to a CC DRG. The conditions must be either high cost or high volume or both and be reasonably preventable through the application of evidence-based guidelines. The DRA also requires hospitals to identify on their claims whether secondary diagnoses are present on admission. In the FY 2008 IPPS Proposed Rule, CMS proposed six conditions for initial implementation and an additional seven for discussion. CMS sought comment in the period that is just ending on how many conditions should be selected and the justification for the selection.
- Patient Perspectives of Care Reporting: Beginning in October 2006 hospitals began voluntarily reporting HCAHPS (Consumer Assessment of Healthcare Providers and Systems) data on patient perspectives of care, and beginning in July 2007, HCAHPS reporting will be required under the RHQDAPU program. Beginning in fiscal year 2008, HCAHPS will be added to the set of clinical measures linked to the annual payment update for hospitals. HCAHPS will be first reported on Hospital Compare in March 2008.
- Medicare Hospital Gainsharing Demonstration: Beginning in 2007, this demonstration will test and evaluate collaborative efforts between hospitals and physicians to improve overall quality and efficiency. The demonstration will determine if gainsharing (i.e. the sharing of cost savings due to hospital-physician collaboration) aligns incentives in order to improve Medicare inpatient care, as well as hospital operational and financial performance.
- Physician Hospital Collaboration Demonstration: This five year program will examine health delivery factors that improve quality of care beyond a hospital episode to determine the impact of hospital-physician collaborations on preventing short and longer-term complications, duplication of services, coordination of care across settings, and other quality improvements that may eliminate preventable complications and unnecessary costs.
- Premier Hospital Quality Initiative Demonstration: CMS is pursuing a vision to improve quality by expanding information available about quality of care and through direct financial incentives to reward the delivery of superior care for five specific conditions. The demonstration involves a CMS partnership with Premier Inc., a nationwide organization of not-for-profit hospitals.