Fact Sheets

CMS to Improve Quality of Care during Hospital Inpatient Stays

CMS to Improve Quality of Care during Hospital Inpatient Stays

OVERVIEW:  On August 1, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospitals Prospective Payment System (LTCH PPS) in Fiscal Year (FY) 2015.  

The final rule, which applies to approximately 3,400 acute care hospitals and approximately 435 LTCHs, affects discharges occurring on or after October 1, 2014.

In addition to setting the standards for payment for Medicare-covered inpatient services, the final rule updates the measures and financial incentives in the Hospital Acquired Condition Reduction, Hospital Value-Based Purchasing, Hospital Inpatient Quality Reporting (IQR), and Hospital Readmissions Reduction programs, as well as aligning the reporting and submission timelines of the Hospital IQR Program and Medicare Electronic Health Record (EHR) Incentive Program for measures reported electronically.  It also revises measures for the Long-Term Care Hospital (LTCH) Quality Reporting Program and the PPS-Exempt Cancer Hospital Quality Reporting Program.  Finally, it clarifies the process for consideration of mitigating factors in the case of solid organ transplant programs that do not meet CMS standards for data submission, clinical experience, or outcomes.

This fact sheet discusses major quality-related provisions of the final rule.  A separate fact sheet on payment changes is available on the CMS Web page at: http://www.cms.gov/Newsroom/Search-Results/index.html?filter=Fact%20Sheets.

Hospital-Acquired Condition (HAC) Reduction Program

Section 3008 of the Affordable Care Act establishes a financial incentive program for IPPS hospitals to improve patient safety by applying a one percent payment reduction to hospitals that rank in the lowest performing quartile of all subsection (d) hospitals with respect to the occurrence of hospital-acquired conditions (HACs) that appear during an applicable hospital stay.  These HACs are a group of reasonably-preventable conditions selected by CMS that patients did not have upon admission to a hospital, but which developed during the hospital stay.  

In the FY 2014 IPPS/LTCH PPS final rule, CMS finalized a scoring methodology to calculate a Total HAC Score for each hospital.  Under the scoring methodology, hospitals are given a score for each measure within two domains.  Domain 1 comprises the Patient Safety Indicator (PSI) 90 measure, an administrative claims based measure developed by the Agency for Healthcare Research and Quality (AHRQ).  PSI-90 is a composite of 8 measures: 1) PSI-03 Pressure Ulcer; 2) PSI-06 Iatrogenic Pneumothorax; 3) PSI-07 Central Venous Catheter-related Bloodstream Infections; 4) PSI-08 Postoperative Hip Fracture; 5) PSI-12 Postoperative Pulmonary Embolism or Deep Venous Thrombosis; 6) PSI-13 Postoperative Sepsis; 7) PSI-14 Postoperative Wound Dehiscence; and 8) PSI-15 Accidental Puncture or Laceration.  

Domain 2 measures include two healthcare-associated infection measures developed by the Centers for Disease Control and Prevention’s (CDC) National Health Safety Network (CDC NHSN):  Central Line-Associated Blood Stream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI).  A score is calculated for each domain and the two domains are weighted to determine a Total HAC Score.  Hospitals with a Total HAC Score in the lowest performing quartile are subject to a one percent payment penalty.  

All measures are risk adjusted and endorsed by the National Quality Forum.  Risk factors such as the patient’s age, gender, and comorbidities are considered in the calculation of the measure rates so that hospitals serving a large proportion of sicker patients are not unfairly penalized.  In accordance with the statute, a review and correction process allows hospitals to review their measure, domain and Total HAC scores.  For FY 2016 a third CDC NHSN-developed healthcare associated infection measure, Surgical Site Infections (SSI), will be added to the program in domain 2.  

In order to better assess hospital performance on these measures, CMS made refinements to the scoring methodology finalized in the FY 2014 IPPS/LTCH PPS final rule that will be implemented in FY 2016 .

Hospital Readmissions Reduction Program   

The Hospital Readmissions Reduction program began on October 1, 2012. The maximum reduction under this program, which was one percent of payment amounts in FY 2013 and two percent of payment amounts in FY 2014, will increase to three percent of payment amounts in FY 2015, as specified under section 3025 of the Affordable Care Act.  
For FY 2015, CMS will assess hospitals’ readmission penalties using five readmissions measures endorsed by the National Qualify Forum (NQF):  heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease, and hip/knee arthroplasty. CMS has finalized an updated methodology to take into account planned readmissions for these five existing readmissions measures, as well as refinement in the hip/knee arthroplasty readmission measure methodology.  CMS will add a new readmission measure beginning in FY 2017: readmissions for coronary artery bypass graft (CABG) surgical procedures.

Changes to the Hospital Inpatient Quality Reporting (IQR) Program and the Medicare EHR Incentive Program

The Hospital IQR Program grew out of the Hospital Quality Initiative developed by CMS in consultation with hospital groups.  Previously, hospitals that do not participate successfully in the Hospital IQR Program have their applicable percentage increase reduced by two percentage points.  Since the implementation of this financial penalty, hospital participation has increased to well over 99 percent of Medicare-participating hospitals that are paid under the IPPS.  Starting for the FY 2015 payment determination, however, that reduction will be one quarter a hospital’s annual payment increase that would otherwise apply.

Measures reported under the Hospital IQR Program are published on the Hospital Compare Web site (http://www.medicare.gov/hospitalcompare/search.html), and may later be adopted for use in the Hospital VBP Program.

The Hospital IQR Program measure set has grown from a starter set of 10 quality measures in 2004 to the set of 57 quality measures for the FY 2016 payment determination.  These measures include chart-abstracted measures, such as heart attack and surgical care improvement measures; claims-based measures such as mortality and readmissions; healthcare-associated infections measures; survey-based measures, such as patient experience of care; and structural measures that assess features of hospitals to assess their capacity to improve quality of care.

CMS is finalizing a total of 63 measures (47 required and 16 voluntary electronic clinical quality measures) in the Hospital IQR Program measure set for the FY 2017 payment determination and subsequent years. The number of required measures, 47, is down from 57 measures in FY 2016.    We added 11 new measures (1 chart-abstracted, 4 claims-based, and 6 voluntary electronic clinical quality measures).  We proposed to remove 20 measures, but are only finalizing the removal of 19.  The SCIP-INF-4 measure was proposed for removal, but will be retained as it was recently retooled for the 2014 collection period. 10 of these 19 measures are topped-out, chart-abstracted measures that are being retained as voluntary electronic clinical quality measures.    Outcome and cost measures are among the measures being adopted for the FY 2017 payment determination.  The list of FY 2017 payment determination measures is included in Appendix 1.

Providers participating in the Hospital IQR Program have the option to voluntarily report a minimum of 16 electronically specified clinical quality measures over three domains from 28 available measures.  The finalized proposals increase the number of electronic clinical quality measures in the Hospital IQR Program.  

CMS is finalizing a modification of its proposal to align the Medicare Electronic Health Record (EHR) Incentive Program with the reporting and submission timelines of the Hospital IQR Program for measures reported electronically.  While CMS is finalizing its proposal to align the reporting and submission timelines of the Medicare EHR Incentive Program with those of the Hospital IQR Program on the calendar year for CQMs that are reported electronically for 2015, it is not finalizing the proposal to require quarterly submission of CQM data. Hospitals can voluntarily submit one calendar year (CY) quarter’s data for quarter 1, quarter 2, or quarter 3 of 2015 by November 30, 2015 in order to partially fulfill requirements for both programs.

Changes to the Hospital VBP Program:

Payment Details for FY 2015.   The proposed rule outlined the Hospital VBP Program payment details for FY 2015, including an increase in the applicable percent reduction to 1.5 percent of base operating DRG payment amounts to all participating hospitals.   The total estimated amount available for value-based incentive payments in FY 2015 is approximately 1.4 billion.  

New Program Requirements.  The final rule updates the FY 2017 measure set by adding two new Safety measures and one new Clinical Care - Process measure, re-adopting the current version of the CLABSI measure, and removing six “topped-out” clinical process measures.  Over 80 percent of the measures in the Hospital VBP Program will assess health outcomes, patient experience and cost.

CMS will adopt two new outcome measures for the new Safety domain: hospital-onset methicillin-resistant Staphylococcus aureas (MRSA) bacteremia and Clostridium difficile infection; and a Clinical Care - Process measure: early elective deliveries.  

FY 2017 Domain Weighting.  CMS adopted new quality domains based on the National Quality Strategy in the FY 2014 IPPS/LTCH final rule, and also adopted domain weighting for FY 2017.  Due to the large number of “topped out” measures that CMS will remove from the FY 2017 measure set, CMS is revising the finalized FY 2017 domain weighting by reducing the weight of the Clinical Care – Process subdomain to 5 percent and increasing the weight of the Safety domain to 20 percent.

FY 2019/2020 Measure.  CMS will adopt one new hospital-level risk-standardized complication rate following elective hip and knee arthroplasty measure with a 30-month performance period for FY 2019 and a 36-month performance period for FY 2020.  

Finalized Changes to the Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP):

Section 3004(a) of the Affordable Care Act established the LTCHQR Program. Beginning in FY 2014, the applicable annual increase factor for any LTCH that did not submit the required quality data to CMS was reduced by two percentage points.  To date, CMS has finalized 9 measures for inclusion in the LTCH QRP.  

Finalized Quality Measures:  For the FY 2018 payment determination and subsequent years, we will add three additional quality measures:  National Healthcare Safety Network (NHSN) Ventilator-Associated Event (VAE) Outcome Measure; Functional Outcome Measure: Change in Mobility among LTCH Patients Requiring Ventilator Support; and Percent of LTCH Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function.  

Finalized Policies:  We have finalized a mandatory Reconsideration procedure for the LTCH QRP, which requires that LTCH providers follow specific procedures when submitting a request for CMS’ reconsideration of an initial LTCH QRP provider compliance determination.  We will expand the exception and extension process to allow LTCH providers to request exceptions or extensions for circumstances beyond their control, including those that are not classified as natural disasters.

PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program

We are adopting a new measure beginning with the FY 2017 PCHQR Program.  The addition of this measure, external beam radiotherapy for bone metastases, will increase the number of measures beginning with the FY 2017 program to a total of 19.  Additionally, CMS is adopting a number of other reporting updates.

Mitigating Factors Process for Solid Organ Transplant Programs

We proposed to clarify and provide additional transparency for the survey, certification, and enforcement procedures under § 488.61 for transplant centers that have not met all Conditions of Participation but seek approval to continue to participate on the basis of mitigating factors.

Finalized Rule: We are finalizing the rule with some adjustments in response to comments. Apart from technical corrections, the principal adjustments are to make it clear that information not pertinent to the particular mitigating factors request is not needed, that mitigating factors applies only to deficiencies of data submission, clinical experience, or outcomes, that a transplant program is not required to disclose the results of a review by the Organ Procurement and Transplantation Network (OPTN), and that CMS may waive certain identified elements of a Systems Improvement Agreement if the agency determines that the action has already been adequately accomplished.

The final rule, which includes tables for the final and previously adopted measures referenced in this fact sheet, can be downloaded from the Federal Register at: http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1.

Appendix 1
FY 2017 Payment Determination Hospital IQR Program Finalized Measures

Topic	Measure
Acute Myocardial Infarction (AMI) Measures
	●  AMI-7a Fibrinolytic therapy received within 30 minutes of hospital arrival ☠ (NQF #0164)
Surgical Care Improvement Project (SCIP) Measures
	●  SCIP-INF-4 Cardiac Surgery Patients With Controlled Postoperative Blood Glucose (NQF #0300)
Stroke Measure (STK) Set
	●  STK-4 Thrombolytic therapy ☠ (NQF #0437)
	●  STK-6 Discharged on statin medication ☠ (NQF #0439)
	●  STK-8 Stroke education â˜
Venous Thromboembolism (VTE) Measure Set
	●  VTE-1 Venous thromboembolism prophylaxis ☠ (NQF #0371)
	●  VTE-2 Intensive care unit venous thromboembolism prophylaxis ☠ (NQF #0372)
	●  VTE-3 Venous thromboembolism patients with anticoagulation overlap therapy ☠ (NQF #0373)
	●  VTE-5 VTE discharge instructions â˜
	●  VTE-6 Incidence of potentially preventable VTE ☠ (NQF #0376)
Sepsis Measure
	●  Severe sepsis and septic shock: management bundle*† (NQF #0500)
Mortality Measures
	●  Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following acute myocardial infarction (AMI) hospitalization for patients 18 and older (NQF #0230)
	●  Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following heart failure (HF) hospitalization for patients 18 and older (NQF #0229)
	●  Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following pneumonia hospitalization (NQF #0468)
	●  Stroke 30-day mortality rate
	●  Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization (NQF #1893)
	●  Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following coronary artery bypass graft (CABG) surgery* (NQF #1893)
Patient Experience of Care Measure
	●  HCAHPS survey (NQF #0166) (expanded to include two new “About You” items and the 3-item Care Transition Measure) (NQF #0228)
Readmission Measures
	●  Hospital 30-day all-cause risk-standardized readmission rate (RSRR) following acute myocardial infarction (AMI) hospitalization (NQF #0505)
	●  Hospital 30-day, all-cause, risk-standardized readmission rate (RSRR) following heart failure hospitalization (NQF #0330)
	●  Hospital 30-day, all-cause, risk-standardized readmission rate (RSRR) following pneumonia hospitalization (NQF #0506)
	●  Hospital-level 30-day, all-cause risk-standardized readmission rate (RSRR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) (NQF #1551)
	●  Hospital-Wide All-Cause Unplanned Readmission (HWR) (NQF #1789)
	●  Stroke 30-day Risk Standardized Readmission
	●  (NQF #1891)
	●  Hospital 30-day, all-cause, unplanned, risk-standardized readmission rate (RSRR) following coronary artery bypass graft (CABG) surgery*
AHRQ Patient Safety Indicators (PSIs) Composite Measure
	● PSI-90 Patient safety for selected indicators (composite) (NQF #0531)
AHRQ PSI and Nursing Sensitive Care
	●  PSI-4 Death among surgical inpatients with serious treatable complications (NQF #0351)
Structural Measures
	●  Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care (NQF #0113)
	●  Participation in a Systematic Clinical Database Registry for General Surgery (NQF #0493)
	●  Safe Surgery Checklist Use
Healthcare-Associated Infections (HAI) Measures
	●  National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome Measure (NQF #0139)
	●  American College of Surgeons – Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (NQF #0753)     - SSI following Colon Surgery     - SSI following Abdominal Hysterectomy
	●  National Healthcare Safety Network (NHSN) Catheter-associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138)
	●  National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716)
	●  National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717)
	●  Influenza vaccination coverage among healthcare personnel (HCP) (NQF #0431)
Surgical Complications
	●  Hospital-level risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) (NQF #1550)
Emergency Department (ED) Throughput Measures
	●  ED-1 Median time from ED arrival to ED departure for admitted ED patients ☠(NQF #0495)
	●  ED-2 Admit Decision Time to ED Departure Time for Admitted Patients ☠(NQF #0497)
Prevention: Global Immunization (IMM) Measure
	●  Influenza Immunization † (NQF #1659)
Cost Efficiency
	●  Payment-Standardized Medicare Spending Per Beneficiary (MSPB) (NQF #2158)
	●  AMI Payment per Episode of Care
	●  Hospital-level, risk-standardized 30-day episode-of-care payment measure for heart failure*
	●  Hospital-level, risk-standardized 30-day episode-of-care payment measure for pneumonia*
Perinatal Care (PC)
	●  PC-01 Elective delivery ☠ (NQF #0469)

KEY:

* New or expanded measures for FY 2017 payment determination and subsequent years.

† Chart Abstracted Only

★ Electronic clinical quality measure (ECQM) or Chart Abstracted

*footnote: SCIP-INF 4 will be retained in 2017

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