QUALITY MEASURES FOR REPORTING IN FISCAL YEAR 2009 FOR 2010 UPDATE

OVERVIEW:

On April 14, 2008, the Centers for Medicare & Medicaid Services (CMS) proposed a regulation that would update payment policies and rates under the hospital inpatient prospective payment system (IPPS) for fiscal year (FY) 2009, beginning for discharges on or after October 1, 2008.  The proposed rule continues to build on recent efforts by CMS to use Medicare payment systems to give hospitals incentives to improve the quality of care furnished to people with Medicare coverage. 

These efforts include making hospitals bear the increased costs of treatment when a patient acquires a condition during a hospital stay that has been identified as reasonably preventable through adherence to evidence-based guidelines ‑ the Hospital-Acquired Conditions (HACs) initiative ‑ and requiring hospitals to report quality measures in order to receive the full update to payment rates in the ensuing year – the Reporting Hospital Quality Data for Annual Payment Update (hospital reporting) initiative. 

The proposed rule would expand the list of HACs for which Medicare will not pay a higher weighted MS-DRG when acquired during an inpatient stay, as well as the number of quality measures hospitals will have to report in FY 2009 in order to receive the full payment update in FY 2010.  This fact sheet discusses only the proposed additions to the list of quality measures that hospitals will have to report in order to get the full update.

Proposals for expanding the HACs provisions can be found at:

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

BACKGROUND:

The Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) initiative was mandated by Section 501(b) of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003.  This section of the MMA strengthened Medicare’s voluntary hospital quality reporting program by requiring CMS to pay hospitals that participate successfully in reporting designated quality measures a higher annual update to their payment rates..  Initially, the MMA provided for a 0.4 percentage point reduction from the annual market basket (the measure of inflation in costs of goods and services used by hospitals in treating Medicare patients) update for those hospitals that did not report.  The Deficit Reduction Act of 2005 increased that to market basket minus 2.0 percentage points. 

In addition to giving hospitals a financial incentive to improve the quality of their services, the hospital reporting initiative provides CMS with data to help consumers make more informed decisions about their health care. The hospital quality of care information gathered through the initiative is available to consumers on the Hospital Compare website at: www.hospitalcompare.hhs.gov. 

In FY 2007, nearly 95 percent of hospitals participated successfully in the reporting program and received the full market basket update for FY 2008.

PROPOSED NEW MEASURES FOR REPORTING FOR FY 2010 UPDATE

CMS is proposing to add 43 new measures for the FY 2009 reporting period, and to retire one existing measure.  However, for some of the new measures, the hospitals will not have to affirmatively report data to CMS.  Instead, CMS will calculate them from administrative data.  If the proposals are adopted, the total number of measures for reporting for FY 2010 would be 72.

Measuring and reporting on these additional measures will encourage hospitals to take steps to make care safer for patients.  The new stroke and cardiac surgery measures, in particular, should help to increase the chances that patients receive all necessary stroke and cardiac care.  In addition, the agency is seeking comment on measuring re-admissions for three conditions.  Re-admissions have a significant impact on beneficiaries and their families and according to MedPAC cost the program $15 billion annually, with $12 billion of those costs potentially preventable.  Almost 18 percent of Medicare patients are re-admitted within 30 days of discharge, leading to the potential for other adverse consequences for the patient and significant worry for their families.  CMS believes that reporting these measures will encourage better coordination both during the inpatient stay and at discharge to post acute settings.  The proposed new measures are:

  A. Surgical Care Improvement Project (SCIP) Measure (1):

• SCIP Cardiovascular 2, surgery patients on a beta blocker prior to arrival who received a beta blocker during the perioperative period

  B. Re-admission Measures (3):

• Pneumonia (PN) 30 ‑ day risk standardized re-admission measure (Medicare patients)
• Heart attack (AMI) 30 ‑ day risk standardized re-admission measure (Medicare patients)
• Heart failure (HF) 30 ‑ day risk standardized re-admission measure (Medicare patients)

  C. Nursing Sensitive Measure (4):

●  Failure to rescue

●  Pressure ulcer prevalence and incidence by severity

●  Patient falls prevalence

●  Patient falls with injury

  D. AHRQ Patient Safety and Inpatient Quality Indicator Measures (9):

• Patient Safety Indicators (PSIs)

• PSI 4-Death among surgical patients with treatable serious complications
• PSI 6-Iatrogenic pneumothorax, adult
• PSI 14-Postoperative wound dehiscence
• PSI 15-Accidental puncture or laceration

• Inpatient Quality Indicators (IQIs)

• IQI 4 - Abdominal aortic aneurysm (AAA) mortality rate (with volume)
• IQI 11- AAA mortality rate (without volume)
• IQI 19-Hip fracture morality rate
• IQI - Mortality for selected medical conditions (composite)
• IQI - Mortality for selected surgical procedures (composite)
• IQI - Complication/patient safety for selected indicators (composite)

  E. Venous Thromboembolism Measures (VTEs):

• VTE-1:  VTE prophylaxis
• VTE-2:  VTE prophylaxis in the ICU
• VTE-4:  Patients with overlap in anticoagulation therapy
• VTE-5/6:  (as combined measure) patients with UFH dosages who have platelet count monitoring and adjustment of medication per protocol or nomogram
• VTE-7:  Discharge instructions to address:  follow-up monitoring, compliance, dietary restrictions, adverse drug reactions/interactions
• VTE-8:  Incidence of preventable VTE

  F. Stroke Measures (STK)

• STK-1 DVT prophylaxis
• STK-2 Discharged on antithrombotic therapy
• STK-3 Patients with atrial fibrillation receiving anticoagulation therapy
• STK-5 Antithrombotic medication by end of hospital day two
• STK-7 Dysphasia screening

  G. Cardiac Surgery Measures

• Participation in a systematic database for cardiac surgery
• Pre-operative beta blockade
• Prolonged intubation
• Deep sternal wound infection rate
• Stroke/CVA
• Post-operative renal insufficiency
• Surgical re-exploration
• Anti-platelet medication at discharge
• Beta blockade therapy at discharge
• Anti-lipid treatment at discharge
• Risk-adjusted operative mortality for CABG
• Risk-Adjusted Operative Mortality for Aortic Valve Replacement
• Risk-adjusted operative mortality for mitral valve replacement/repair
• Risk-adjusted mortality for mitral valve replacement and CABG surgery
• Risk-adjusted mortality for aortic valve replacement and CABG surgery

MEASURES ADOPTED FOR REPORTING FOR PREVIOUS UPDATES

• Heart Attack (Acute Myocardial Infarction)

• Aspirin at arrival ^1/

• Aspirin prescribed at discharge ^1/

• ACE inhibitor (ACE-I) or Angiotensin Receptor Blocker (ARBs) for left ventricular systolic dysfunction ^1/

• Beta blocker at arrival ^1/

• Beta blocker prescribed at discharge ^1/

• Thrombolytic agent received within 30 minutes of hospital arrival ^2/

• Percutaneous Coronary Intervention (PCI) received within 120 minutes of hospital arrival ^{2/, 5/}

• Adult smoking cessation advice/counseling ^2/

• Heart Failure (HF)

• Left ventricular function assessment ^1/

• ACE inhibitor (ACE-I) or Angiotensin Receptor Blocker (ARBs) for left ventricular systolic dysfunction ^1/

• Discharge instructions ^2/

• Adult smoking cessation advice/counseling ^2/

• Pneumonia (PNE)
• Initial antibiotic received within 4 hours of hospital arrival ^{1/, 6/}
• Oxygenation assessment ^{1/, 7/}
• Pneumococcal vaccination status^1/
• Blood culture performed before first antibiotic received in hospital ^2/
• Adult smoking cessation advice/counseling ^2/
• Appropriate initial antibiotic selection ^2/
• Influenza vaccination status ^2/

• Surgical Care Improvement Project (SCIP) – (Previously SIP)

• Prophylactic antibiotic received within 1 hour prior to surgical incision ^2/

• Prophylactic antibiotics discontinued within 24 hours after surgery end time^2/

• SCIP-VTE 1: Venous thromboembolism (VTE) prophylaxis ordered for surgery patient ^3/

• SCIP-VTE 2: VTE prophylaxis within 24 hours pre/post surgery^3/

• SCIP Infection 2: Prophylactic antibiotic selection for surgical patients^3/
• SCIP Infection 4: Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose ^4/
• SCIP Infection 6: Surgery Patients with Appropriate Hair Removal ^4/

• Mortality Measures

• Acute Myocardial Infarction 30-day mortality ­(Medicare patients) ^3/

• Heart Failure 30-day mortality (­Medicare patients) ^3/
• Pneumonia 30-day mortality (Medicare patients) ^4/

• Patients’ Experience of Care

• HCAHPS Patient Survey ^3/

^1/ Measure included in 10 measure starter set

^2/ Measure included in 21 measure expanded set for FY 2007

^3/ Measure included in 27 measure expanded set for FY 2008

^4/ Measure included in 30 measure expanded set for FY 2009

^5/ Measure title proposed to be replaced for FY 2009 with Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI)

^6/ Measure title proposed to be replaced for FY 2009 with Timing of receipt of initial antibiotic following hospital arrival

^7/ Measure proposed to be deleted for FY 2009 starting with January 1, 2009 discharges

Comments on the proposed rule will be accepted through June 13.  CMS will respond to comments in a final rule to be issued on or before August 1, 2008.

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