IMPROVING QUALITY OF CARE DURING INPATIENT HOSPITAL STAYS

OVERVIEW:   On Aug. 1, 2011, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that revises policies and payment rates for general acute care hospitals under the Inpatient Prospective Payment System (IPPS), effective for discharges in fiscal year (FY) 2012 – that is, on or after Oct. 1, 2011. The final rule also updates payment policies and rates for Long-term Care Hospitals (LTCHs) under the LTCH Prospective Payment System (LTCH PPS), and the payment update used to determine target amounts for certain hospitals that are excluded from the IPPS, such as cancer and children’s hospitals and religious nonmedical health care institutions.

The final rule, which applies to approximately 3,400 acute care hospitals and approximately 420 LTCHs, will be effective for discharges occurring on or after Oct. 1, 2011.  CMS projects that total Medicare operating payments to acute care hospitals for inpatient services occurring in FY 2012 will increase by $1.13 billion, or 1.1 percent, in FY 2012 compared with FY 2011.  Medicare payments to LTCHs in FY 2012 are projected to increase by $126 million or 2.5 percent in FY 2012 relative to FY 2011.

In addition to promoting accurate payment for inpatient services furnished to Medicare beneficiaries, the final rule strengthens the relationship between payment and quality of service in the following ways:

1. The final rule establishes the initial readmissions measures that will be part of a new Hospital Readmissions Reduction Program required by the Affordable Care Act. 
2. It expands the quality measures that hospitals must report under the Hospital Inpatient Quality Reporting (IQR) Program – formerly called the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) Program ‑ in order to receive the full update to the standardized amount in FYs 2014 and 2015. 
3. It creates a new quality reporting program, as authorized by the Affordable Care Act, which would apply to hospitals that are paid under the LTCH PPS.

After issuing the FY 2012 proposed rule for the IPPS and LTCH PPS, CMS issued a separate final rule implementing a new Hospital Value-Based Purchasing (VBP) program.  This program, which was authorized by the Affordable Care Act, will provide additional incentives to hospitals to improve the way care is delivered.  The IPPS final rule being issued today contains additional provisions relating to the Hospital VBP program.

This fact sheet discusses the provisions in the final rule that are intended to promote continued improvements in the quality and safety of care that beneficiaries receive during inpatient hospital stays.  Other policy and payment adjustments included in the final rule are addressed in a separate fact sheet dated August 1, 2011 that is available on the CMS Web page at:

           http://www.cms.gov/About-CMS/Public-Affairs/MediaReleaseDatabase/Fact-Sheets/index.html

HOSPITAL READMISSIONS REDUCTION PROGRAM REQUIRED BY THE AFFORDABLE CARE ACT:

Section 3025(a) of the Affordable Care Act established a new Hospital Readmissions Reduction Program, under which payments to certain hospitals will be reduced to account for excess readmissions.   These payment adjustments will apply to discharges on or after Oct. 1, 2012 (FY 2013).  This year, CMS is finalizing a number of policies as part of the new program, including selecting three 30-day risk-standardized all-cause readmission measures for the first year of the program.  These measures cover three conditions: acute myocardial infarction (AMI) or heart attack, heart failure, and pneumonia.  CMS plans to continue implementation of this program in future rulemaking. 

HOSPITAL VALUE-BASED PURCHASING:

CMS issued a final rule establishing the Hospital VBP program on April 29, 2011, which included the set of measures that will be used to assess hospital performance for FY 2013 and a number of measures that will be used to assess hospital performance for FY 2014.  The IPPS final rule adopts an additional measure ‑ Medicare spending per beneficiary ‑ that will be used both in the Hospital IQR and the Hospital VBP programs.  This new measure, which will affect payment determinations for FY 2014, will assess Part A and Part B beneficiary spending during a “Medicare spending per beneficiary episode,” that spans from three days prior to a Medicare beneficiary’s admission to a hospital through 30 days after the patient is discharged.

For each hospital, CMS will add up nearly all of the Medicare Part A and Part B payments made for services rendered during Medicare spending per beneficiary episodes and then divide this sum by the number of Medicare spending per beneficiary episodes for the hospital.   CMS will then calculate each hospital’s Medicare spending per beneficiary ratio by dividing this amount by the median Medicare spending per beneficiary amount across all hospitals.  The goal of this measure is to encourage hospitals to provide high quality care to Medicare beneficiaries at a lower cost and to promote greater efficiencies across care settings.  CMS originally proposed to measure spending through 90 days after discharge.  In response to comments, CMS adopted a Medicare spending per beneficiary episode that assesses spending through 30 days after discharge. 

INPATIENT QUALITY REPORTING PROGRAM FOR ACUTE CARE HOSPITALS:

BACKGROUND:   The Hospital IQR and Hospital VBP programs are closely linked because the measures selected for the VBP program must be those that have been specified for the IQR program.  VBP is intended to promote high quality, safe, patient-centered care, while reducing costs through the efficient provision of care and avoidance of preventable adverse events that not only increases the burden of illness on the patient and his or her caregivers, but also greatly increases health care spending.

The IQR Program grew out of the Hospital Quality Initiative developed by CMS in consultation with stakeholders including hospital groups.   Participation in the Hospital Quality Initiative was voluntary, but after initial levels of participation proved disappointing, Congress added a financial incentive to the program in the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003.  Under the MMA, hospitals that chose not to participate or failed to meet the criteria for successful reporting received a 0.4 percentage point reduction to the applicable percentage increase.  The Deficit Reduction Act of 2005 increased this reduction to 2.0 percentage points.  Since the implementation of the financial incentive, hospital participation has increased to 99 percent and, of participating hospitals, 97 percent are receiving the full update to the standardized amount in FY 2011. 

In the meantime, the IQR measure set has grown from a starter set of 10 quality measures in 2004 to the current set of 76 measures for the FY 2015 payment determination.  The 76 measures include:

• Chart-abstracted measures for heart attack, heart failure, stroke, venous thromboembolism, pneumonia, surgical care improvement,  emergency department throughput, and global immunization;
• Healthcare-associated infection measures collected through the Center for Disease Control and Prevention’s National Healthcare Safety Network for central line-associated bloodstream infection (CLABSI), surgical site infection (SSI), catheter-associated urinary tract infection (CAUTI), MRSA bacteremia, C. Difficile, and influenza vaccination coverage among healthcare personnel;
• Claims-based measures for mortality and readmissions for heart attack, heart failure, and pneumonia;
• Claims-based measures of Hospital Acquired Conditions (HACs)
• AHRQ Patient Safety Indicators and Inpatient Quality Indicators;
• Nursing sensitive care measure;
• An efficiency measure for Medicare spending per beneficiary;
• A survey-based measure of patient satisfaction; and 
• Structural measures for participation in a cardiac surgery, stroke care, nursing sensitive care, and general surgery database registries.

QUALITY AND MEASUREMENT STRATEGY:   The policies adopted in the final rule for the IQR Program focus on several fundamental CMS and Department of Health and Human Services priorities.  These include:

• Reducing the incidence of certain preventable healthcare associated infections (HAIs)  that are highlighted in the Department of Health and Human Services’ Action Plan to Prevent HAIs;
• Reducing hospital-acquired conditions and unnecessary readmissions in support of the goals of the Partnership for Patients;
• Reducing hospital burden by retiring four measures that are collected through chart abstraction, suspending data collection on an additional four measures, and adopting measures that can be collected by the Centers for Disease Control and Prevention’s National Healthcare Safety Network; and
• Aligning the IQR Program with the Department’s National Quality Strategy.

The IPPS final rule improves the alignment of the validation process with Administration priorities by adding to the validation sample the Central Line Associated Blood Stream Infection (CLABSI) measure that it adopted for the FY 2013 Hospital IQR measure set last year. 

SUMMARY OF CHANGES TO HOSPITAL IQR:

Improvements to Program Administration- In the FY 2012 IPPS/LTCH final rule, CMS is finalizing a number of changes to improve how the Hospital IQR Program operates and to reduce the burden on participating hospitals.

Changes to IQR Measure Set - The final rule would also make changes to the measures to be reported for the FY 2014 and FY 2015 payment updates.  Specifically, the final rule will:

• Retire four measures beginning with Jan. 1, 2012 discharges;
• Suspend data collection for four measures, noted in the chart below, starting with Jan. 1, 2012 discharges;
• Add four HAI measures over a two-year period (one for FY 2014, three for FY 2015);
• Add one claims-based Medicare spending per beneficiary measure;
• Add one structural measure of participation in a registry for general surgery for FY 2014; and
• Add Stroke and Venous Thromboembolism (VTE) chart-abstracted measures for FY 2015.

These changes will increase the IQR measure set to 76 measures, streamline IQR processes and make the IQR process less burdensome and more transparent to hospitals.   A list of all of the measures to be reported is attached as Appendix A. 

HOSPITAL-ACQUIRED CONDITIONS:

CMS had proposed to add one new category ‑ Acute Renal Failure after Contrast Administration (also known as contrast-induced acute kidney injury, or CI-AKI) ‑ to the list of hospital-acquired conditions (HACs) in FY 2012 for purposes of the HACs payment policy.   This policy prevents hospitals from being paid at a higher rate for the sole reason of treating a beneficiary who acquires one of the conditions on the HAC list during a hospital stay.  Based on comments, CMS is deferring adoption of this condition as a HAC until coding revisions can be made that better distinguish CI-AKI from other conditions that are captured using the same code.

CMS is also finalizing the addition of two new codes for the Falls and Trauma HAC category, two new codes for the Surgical Site Infection (SSI) Following Certain Bariatric Procedures HAC category, and one new code for the Deep Vein Thrombosis and Pulmonary Embolism (DVT/PE) Following Certain Orthopedic Procedures HAC category.

Additionally, CMS is finalizing its proposal to change the title of the subcategory “Electric Shock” within the Falls and Trauma HAC category from ‘Electric Shock’ to ‘Other Injuries’ since it includes a variety of injury codes.   The category will continue to include the conditions within the 991-994 code ranges on the CC/MCC List.  CMS is not making any changes to the list of codes in this subcategory; we are simply renaming the subcategory title. 

The final rule includes a summary of an evaluation of FY 2010 data on HACs, including information such as frequency of occurrence and savings to Medicare.  CMS will also post the HACs data on its website.  A complete list of the current categories of conditions that are subject to the HAC payment policy is attached as Appendix B.

THE LTCH QUALITY REPORTING PROGRAM:

The Affordable Care Act requires CMS to establish a new quality reporting program that will apply to hospitals paid under the LTCH PPS.  The law requires that CMS apply a 2 percent reduction, beginning in FY 2014, to the annual payment update for LTCHs that fail to successfully report quality data to the Secretary.  The law also requires CMS to publish, by no later than Oct. 1, 2012, the quality measures selected for submission by LTCHs for FY 2014.

CMS is now finalizing quality measures for the LTCH quality reporting program that:

• Align with CMS’ aims for better care for the individual, better population health, and lower cost through better quality.
• Promote improved quality for priorities most relevant to LTCHs, including patient safety, avoidance of HAIs, and well-coordinated person-and-family-centered care.
• Cover important domains of care that are considered important by patients, national experts, and stakeholder input made via a number of existing outreach methods, including one or more Special Open Door Forums and Listening Sessions.

The final rule adopts a multi-year approach to expanding the LTCH quality reporting program.  Specifically, CMS would collect data from Oct. 1 through Dec. 31, 2012 for the LTCH’s FY 2014 payment determination on the following quality measures that focus on patient safety:

• Catheter Associated Urinary Tract Infection (CAUTI).
• Central Line Associated Blood Stream Infection (CLABSI).
• Pressure Ulcers that are New or Have Worsened. This is the percentage of patients who have one or more stage 2-4 pressure ulcers that are new or worsened from a previous assessment.

For future years, CMS plans to consider implementing additional quality measurements using the standardized assessment instrument CARE (Continuity Assessment Record & Evaluation), as a primary data source, that could be used across all post-acute care sites to support the calculation and comparison of key quality measures related to priorities such as patient safety, patient care goals, functional outcomes, HACs, acute care hospitalization, care coordination and bundled care processes.  It is also planning to consider additional measures aligning with National Quality Strategy for safer, better coordinated, affordable, person-centered care, healthy people and healthy communities, such as avoidable adverse events, prevention, patient preferences, patient/family experience of care, symptom management, coordination of care and care transitions.  The specific measures identified in the final rule for possible future inclusion in the LTCH quality reporting program are listed in Appendix C.

The final rule can be downloaded from the Federal Register at:

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

PPENDIX A

MEASURES FOR REPORTING IN 2013 FOR

FY 2014 AND 2015 PAYMENT UPDATES

† Measures for Which Data Collection Has Been Suspended with January 1, 2012 Discharges

* Measures Adopted for FY 2014 Payment Determination in FY 2011 IPPS Final Rule

** Measures Adopted for FY 2014 Payment Determination in FY 2012 IPPS Proposed Rule

*** Measures Adopted for FY 2015 Payment Determination in FY 2012 IPPS Proposed Rule

APPENDIX B

LIST OF HOSPITAL ACQUIRED CONDITIONS FOR FY 2012

(Items listed in italics represent changes from FY 2011)

APPENDIX C

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