Wednesday, 28 September 2016 05:00

Hospital Quality Reporting Programs Slow Down with Electronic Reporting and Speed Up with Cost Efficiency

Written by

v mahn dinicolaEDITOR’S NOTE: All individual years listed in this article are fiscal years, unless otherwise noted.

The Centers for Medicare & Medicaid Services (CMS) finalized multiple changes to quality reporting programs for hospitals in the Inpatient Prospective Payment System (IPPS) final rule for 2017, CMS-1655-F, which was posted to the Federal Register on Aug. 22, 2016. This article summarizes the most substantive changes for five hospital quality reporting programs.

Hospital Readmissions Reduction Program
Starting on page 56,973

In 2016 there were 3,464 hospitals in the Hospital Readmissions Reduction Program (HRRP). Of those, 2,665 received penalties for excess readmissions, totaling approximately $420 million across all U.S. hospitals. Twenty-three percent of hospitals had no penalty. The maximum allowable penalty of 3 percent was assigned to only 38 hospitals.

In the previous IPPS rule, the HRRP was expanded to include the isolated coronary artery bypass graft (CABG) population beginning in 2017. The 2016 rule specified the expansion of the pneumonia measure cohort in 2017 to include principal diagnosis codes for aspiration pneumonia, patients with a principal diagnosis of non-severe sepsis with a secondary diagnosis of pneumonia, and patients with only a principal diagnosis of viral or bacterial pneumonia. The expanded pneumonia cohort is expected to increase qualifying cases by as much as 50 percent in many hospitals. 

There were no new clinical cohorts required for future years in the new IPPS final rule, leaving the following six measures in the HRRP for 2017 and beyond:

  • Acute MI 30-Day, All-Cause, Risk-Standardized Readmission Rate
  • Heart Failure 30-Day, All-Cause, Risk-Standardized Readmission Rate
  • Pneumonia (expanded) 30-Day, All-Cause, Risk-Standardized Readmission Rate
  • COPD 30-Day, All-Cause, Risk-Standardized Readmission Rate
  • Total Hip or Knee Arthroplasty 30-Day, All-Cause, Risk-Standardized Readmission Rate
  • CABG 30-Day, All-Cause, Risk-Standardized Readmission Rate   

The applicable discharges for 2018 payment determination will be those occurring from July 1, 2013 to June 30, 2016, so there is nothing you can do to impact penalties for 2018. There are only nine months left to influence penalties for 2019, which are based on discharges occurring from July 1, 2014 through June 30, 2017. The maximum allowable penalty remains capped at 3 percent of a hospital’s Medicare payment.   

Hospital-Acquired Conditions Reduction Program
Starting on page 57,011

The most significant change in the new IPPS final rule for the Hospital Acquired Conditions (HAC) Reduction Program is the adoption of the modified AHRQ PSI-90 composite measure, beginning with payment determination for 2018. Previously, this measure, called “Patient Safety for Selected Indictors,” contained eight individual measures, which will now be expanded to 10. Three measures have been added while PSI 7 Central-line Associated Blood Stream Infections (CLABSI) has been removed due to redundancy with the HAC Reduction Program as well as other programs that include this measure. The final rule also renames the measure as the “Patient Safety and Adverse Events Composite.” 

The modified AHRQ PSI-90 Composite Measure contains the following measures:

  • PSI 3 Pressure Ulcer Rate
  • PSI 6 Latrogenic Pneumothorax
  • PSI 8 Post-op Hip Fracture Rate
  • PSI 9 Post-op Hemorrhage or Hematoma (new)
  • PSI 10 Physiologic/Metabolic Derangement (new)
  • PSI 11 Post-op Respiratory Failure (new)
  • PSI 12 Post-op PE or DVT
  • PSI 13 Post-op Sepsis Rate
  • PSI 14 Wound Dehiscence Rate
  • PSI 15 Accidental Puncture/Laceration

Note: There are substantial revisions to the risk-adjustment methodology for the modified AHRQ PSI-90 Composite, which adds assigned weights for degree of harm to the current volume measure.

Finally, CMS revised applicable periods from previous rules for 2018 and 2019, calling for a 15-month applicable period for 2018 (July 1, 2014 to Sept. 30, 2015), and a 21-month applicable period for 2019 (Oct. 1, 2015 to Sept. 30, 2017). This change was made in order to avoid mixing ICD-9 diagnosis codes with ICD-10 diagnosis codes, the latter of which went into use for all U.S. hospitals on Oct. 1, 2015. Note that the revised risk-adjusted AHRQ software for ICD-10 codes is not expected to be published until late in the 2017 calendar year. 

There are no changes to domain weights, which leaves Domain 1 (containing the modified PSI-90 Composite Measure) at 15 percent of the total score and Domain 2 (containing Hospital-Acquired Infections) at 85 percent for 2018 and beyond. The hospital-acquired infections included in the 2018 HAC Reduction Program and collected for discharges in the 2015 and 2016 calendar years are: 

  • Catheter-Associated Urinary Tract Infections (CAUTI) for ICU and Non-ICU Patients
  • Central-Line Associated Blood Stream Infections (CLABSI) for ICU and Non-ICU Patients
  • Surgical Site Infection for Abdominal Hysterectomy and Colon Surgery
  • Methicillin-Resistant Staphylococcus aureus (MRSA)
  • Clostridium Difficile Infections (CDI)

The most substantive change involved the expansion of CAUTI and CLABSI measures to include both ICU and non-ICU pediatric and adult medical and surgical patients discharged in the 2015 and 2016 calendar years.

The HAC Reduction Program was originally designed so that 25 percent of all hospitals would receive performance penalties; however, current scoring methodologies have resulted in only 21.9 percent of hospitals receiving penalties in 2015 and 23.7 percent in 2016. To correct for this, CMS is revising the scoring methodology, beginning with 2018 payment determination. The revised scoring methodology uses a Winsoried Z-score instead of the previous linear scale. This approach will evaluate performance more favorably for smaller hospitals that have few cases in either Domain 1 or 2. However, it is likely to impact disproportionate share hospitals (DSHs) with a moderately high volume of underprivileged patients. CMS estimates that using this scoring methodology, top-quartile penalties for these hospitals may increase from 28 to 35 percent (affecting about 11 more).  

Hospital Value-Based Purchasing Program
Starting on page 56,979

The Hospital Value-Based Purchasing (VBP) Program, which applies to all subsection (d) hospitals in the U.S., has a current funding pool capped at 2 percent of all hospital base operating DRG payments, leaving approximately $1.8 billion ($1.489 billion in the 2016 fiscal year) available for funding value-based payment incentives in 2017.

Similar to the changes in the HAC Reduction Program described above, in order to keep ICD-9 and ICD-10 claims separate, this year’s rule modifies the timelines for the applicable period in 2018 for the PSI-90 Composite Measure to the 15 months between July 1, 2014 and Sept. 30, 2015 (this measure is currently in the Patient Safety domain). However, due to the required timelines associated with the VBP rulemaking process, which requires that measures be displayed in Hospital Compare for a full year prior to inclusion in the VBP Program, CMS is unable to adopt the modified PSI-90 Composite measure for 2019. Future rulemaking is expected to incorporate the modified version, as well as revised timelines for 2019 to align with other programs. 

Other changes include the renaming of the “Patient/Caregiver Experience of Care/Care Coordination Domain,” which reflects results from the Hospital Consumer Assessment of Health Plans and Systems (HCAHPS) survey. Effective 2019, this will be known as the “Person and Community Engagement” domain, and will retain its weighting of 25 percent. There were no changes to the existing HCAHPS measures in this domain. Also in 2019, the CAUTI and CLABSI measures will be expanded to include both ICU and non-ICU patients.

The big surprise came with the announcement that CMS is proposing to remove the PSI-90 Composite measure from the Value-Based Purchasing program beginning with 2019 payment determination, although they are suggesting that the adoption of the modified version of the PSI-90 Composite measure may be adopted in future years. 

The 2021 program will include the expanded pneumonia measure cohort in the 30-day mortality measure, as described above in the Hospital Readmission Reduction Program. In addition, two episode-of care payment measures will be added to the Care Efficiency domain for 2021, which currently contains only a single measure: Medicare Spending per Beneficiary (MSPB). These include:

  • Hospital-level, Risk-standardized Payment Associated with 30-day Episode-of-Care for Acute MI (NQF No. 2431)
  • Hospital-level, Risk-standardized Payment Associated with 30-day Episode-of-Care for Heart Failure (NQF No. 2436)

These new measures will use a baseline period of July 1, 2012 to June 30, 2015 to compare performance for discharges occurring from July 1, 2017 to June 30, 2019, so hospitals still have some time to begin examining costs for these populations prior to the applicable period. 

It is interesting to note that the National Quality Forum (NQF) Measures Application Partnership (MAP) vote on the approval of these measures reflected concerns with both of these proposed measures, including the lack of risk adjustment using sociodemographic variables and the potential that they overlap with the existing Medicare Spending per Beneficiary measure. Fifty-eight percent of NQF MAP committee members voted not to support the Acute MI 30-day Episode-of-Care measure, and 65 percent voted not to support the Heart Failure 30-day Episode-of-Care measure. 

Hospital Inpatient Quality Reporting Program
Starting on page 57,111

Perhaps the biggest surprise in this year’s final rule was an unexpected reduction in the number of electronic clinical quality measures (eCQMs) required for submission for discharges occurring in the 2017 calendar year (for 2019 payment determination).  After a great deal of public comment about the barriers and challenges facing hospitals in achieving accurate eCQM data, CMS modified the original proposal to transition from a requirement of four to 15 eCQMs to only eight. Hospitals may select which eight measures they submit. However, in order to meet Hospital IQR program requirements, a full year of data for discharges taking place from Jan. 1, 2017 to Dec. 31, 2017 will be required for electronic submission to CMS. 

Hospitals may submit their data quarterly, biannually, or annually using a QRDA-1 format from a 2014 or 2015 version of certified healthcare reporting technology (CEHRT) software.  Submissions for discharges must be complete by Feb. 28, 2018.

Thirteen eCQM measures have been finalized for removal, leaving the following 15 for hospitals to choose from when selecting their eight eCQM measures: 

  • AMI-8a PCI Within 90 Minutes of Arrival
  • CAC-3 Home Management Plan Given to Patient or Caregiver
  • EHDI-1a Hearing Screening Prior to DC
  • ED-1 Mean Time from Arrival to ED Departure for Admitted ED Patients
  • ED-2 Admit Decision Time to ED Departure for Admitted Patients
  • PC-01 Elective Delivery
  • PC-5 Exclusive Breast Milk Feeding
  • STK-2 Discharged on Antithrombotic
  • STK-3 Anticoagulation for Atrial Fib/Flutter
  • STK-05 Antithrombotic Therapy by End of Hospital Day 2
  • STK-06 Discharged on Statin Meds
  • STK-8 Stroke Education
  • STK-10 Assessed for Rehabilitation
  • VTE-1 VTE Prophylaxis
  • VTE-2 ICU VT Prophylaxis

CMS is encouraging hospitals to submit early and to use pre-submission testing tools, such as the CMS Pre-Submission Validation Application (PSVA), which can be downloaded from Quality Net at Note that these tools check for file formatting errors, not data accuracy.  

Not surprisingly, the number of chart-abstracted measures continues to decline. In this year’s final rule, both the eCQM and chart-abstraction versions of STK-4 Thrombolytic Therapy for Acute Ischemic Stroke and VTE-5 Discharge Instructions have been removed. These measures have “topped out” statistically and are no longer useful for public reporting. In addition, the electronic version of VTE-5 has met substantial technical feasibility issues in capturing specific clinical details needed for accurate measure computation. The following six chart-abstracted measures remain for 2017 and beyond:

  • ED-1 Median Time from ED Arrival to ED Departure for Admitted Patients **
  • ED-2 Admit Decision Time to ED Departure Time for Admitted Patients **
  • PC-01 Elective Delivery Prior to 39 Completed Weeks of Gestation **
  • VTE-6 Incidence of Potentially Preventable VTE
  • IMM-2 Influenza Immunization
  • Severe Sepsis and Septic Shock: Management Bundle (Composite Measure)

** Note: ED-1, ED-2, and PC-01 are required for chart-abstracted submission even if hospitals select these as three of their eight required eCQM measures. 

This year’s final rule marks the end of the remaining Pneumonia and Surgical Care Improvement Project (SCIP) core measures for submission to CMS due to the fact that they have also statistically “topped out.” In addition, the Healthy Term Newborn Measure has been removed due to the fact that the measurement steward has changed the measure construct to focus on unexpected complications in newborns. These changes are effective with discharges taking place in the 2017 calendar year for 2019 payment determination.

No changes were made to the CMS claims-based measures evaluating mortality and 30-day unplanned readmissions or to the National Healthcare Safety Network (NHSN) Infection measures. However, the PSI-90 Composite measure in the complications domain will transition to the modified PSI-90 Patient Safety and Adverse Events Composite beginning with the 2018 program, following the same specifications and timelines as described above in the HAC Program.   

Two “structure of care” Measures were also retired for 2019 payment determination.  These include the web-based reporting measures for participation in a systematic clinical database registry for nursing sensitive care and general surgery. These changes reflect CMS’s opinion that reporting to these registries bears little correlation to favorable patient outcomes. The remaining structure of care measures for the patient surgery checklist and the patient safety culture reporting requirements remain in effect.

Additional proposed changes to the Hospital IQR Program were finalized, including minor revisions to data validation procedures, which will require 200 randomly selected hospitals that are submitting eCQMs to provide copies of their electronic health records for 32 cases. These records will be used to validate data accuracy of electronic measures, compared to the details of the patient encounter found in the clinical documentation. Requirements for full payment in 2019 will not require a given percentage of data accuracy, but instead will be based on whether the hospitals comply with submitting at least 24 of the 32 (75 percent) requested records in a timely manner (30 days from the request) to CMS.   

An additional 400 hospitals not selected for eCQM validation will be randomly selected to submit patient records for chart-abstracted measures, in addition to another 200 hospitals targeted for validation because of abnormal or conflicting data patterns or late data submissions. As required in past years, chart-abstracted validations will require a minimum agreement rate of 75 percent  in order for hospitals to receive full payment updates in 2019.

Three new clinical episode-based payment measures were finalized for the 2019 payment determination, which CMS will calculate from Medicare claims data. These include:

  • Aortic Aneurysm Procedure Clinical Episode-Based Payment
  • Cholecystectomy/Common Duct Exploration Clinical Episode-Based Payment
  • Spinal Fusion Clinical Episode-Based Payment

Finally, the expanded pneumonia cohort was designated as the third “excess days” measure for 2019 payment determination, in addition to those for acute MI and heart failure. For these measures, emergency department (ED) readmissions are counted as a half day, observation status readmissions are rounded to the nearest half-day, and inpatient readmissions are counted as full days.

CMS is inviting public comment for future measures being considered as well. These include:

  • Risk adjustment of the MORT-30-STK Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Acute Ischemic Stroke using the National Institute of Health (NIH) Stroke Scale as an Assessment of Stroke Severity
  • NHSN Antimicrobial Use Measures to evaluate antibiotic use compared to predicted antibiotic use in both adult and pediatric populations
  • Behavioral health measures for patients in acute-care hospital beds
  • Stratification of hospital IQR measures by race, ethnicity, gender, and disability

Hospital-based Inpatient Psychiatric Services Quality Reporting Program
Starting on page 57,236

There are currently 13 measures required for submission to CMS for hospital-based inpatient psychiatric facilities providing services during the 2016 calendar year that impact payment determination in 2018. These include:

  • Hours of Physical Restraint Use
  • Hours of Seclusion Use
  • Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification
  • Follow-up after Hospitalization for Mental Illness
  • Alcohol Use Screening
  • Alcohol Brief Intervention Provided or Offered (and subset measure for intervention)
  • Tobacco Use Screening
  • Tobacco Use Brief Intervention Provided or Offered (and subset measure for intervention)
  • Influenza Immunization
  • Influenza Vaccination Coverage among Healthcare Personnel
  • Assessment of Patient Experience of Care
  • Use of an Electronic Health Record

Previous rulemaking from last year’s final rule requires two new measures to begin with services delivered in the 2017 calendar year (2019 payment determination) for patients discharged from an inpatient facility to home (self-care) or any other site of care. These include:

  • Transition record with specified elements received by discharged patients
  • Timely transmission of transition record

The following new measures, one chart-abstracted and one claims-based, were finalized in this year’s rule for the Hospital-based Inpatient Psychiatric Services (HBIPS) Quality Reporting program for the 2017 calendar year (2019 payment determination):

  • SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge and SUB-3a Alcohol & Other Drug Use Disorder Treatment at Discharge (chart-abstracted)
  • 30-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an IPF (claims-based)

Finally, a modification to the Screening for Metabolic Disorder measure, originally proposed to begin with July 1, 2016 discharges, was pushed forward to begin with Jan. 1, 2017 discharges for 2019 payment determination. This measure evaluates the screening of psychiatric patients for body mass index, blood pressure, lipids, and either a glucose or HgA1c level. This modification requires the denominator cohort to exclude psychiatric patients with a length of stay greater than 365 days or less than or equal to three days. In previous measure specifications, the exclusion criteria were specified as less than three days. The data devil is in the details. 

About the Author

Vicky Mahn-DiNicola is the VP of clinical analytics and research for MidasPlus, Inc. a Xerox company for which she serves as a speaker, author, and clinical consultant in the areas of healthcare analytics, quality improvement, regulatory reporting, and healthcare transformation. A certified Lean Six Sigma Black Belt, Ms. Mahn completed her undergraduate and post-graduate studies at the University of Arizona, where she continues to serve as adjunct faculty. 

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Last modified on Thursday, 29 September 2016 23:22

Vicky Mahn-DiNicola is Vice President of Research and Market Insights at Midas+ Xerox, where she serves as a speaker, author and clinical consultant in the areas of healthcare analytics, quality improvement, regulatory reporting and healthcare transformation. A Certified Lean Six Sigma Black Belt, Ms. Mahn completed her undergraduate and post graduate studies at the University of Arizona, where she continues to serve as Adjunct Faculty.