Tuesday, 10 November 2015 08:10

2016 OIG Work Plan Targeting Quality Measures and Reporting

Written by Stanley Nachimson and Kim Charland, BA, RHIT, CCS

  The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan for the 2016 fiscal year was released last week, and it summarizes new and ongoing OIG reviews pertinent to HHS programs and operations. The OIG was created to protect the integrity of HHS programs and operations and the well-being of beneficiaries by detecting and preventing fraud, waste, and abuse; identifying opportunities to improve program economy, efficiency, and effectiveness; and holding accountable those who do not meet program requirements or who violate federal healthcare laws.  

OIG provides independent and objective oversight that promotes economy, efficiency, and effectiveness in the programs and operations of HHS. OIG’s program integrity and oversight activities are shaped by legislative and budgetary requirements.  So, the work plan reflects those areas that are of high interest to Congress and HHS. 

As we looked through the work plan to see what was new or revised, we saw two new initiatives related to quality measures and reporting. With the increased emphasis on using quality measures for payment and the HHS Secretary’s initiative to increase the Medicare payment flow to alternative payment methods, it came as no surprise to see the scrutiny of these initiatives as an OIG priority target.

The first new initiative is in the “Hospitals – Quality of Care and Safety” section:

  • CMS Validation of Hospital-submitted Quality Reporting Data:We (OIG) will determine the extent to which CMS (the Centers for Medicare & Medicaid Services) validated hospital inpatient quality reporting data. Section 1886(b)(3)(B)(viii)(XI) of the Social Security Act gives CMS the authority to conduct validation of its quality reporting program. CMS uses these quality data for the hospital value-based purchasing program and the hospital acquired condition reduction program. Therefore their accuracy and completeness are important. This study will also describe the actions that CMS has taken as a result of its validation. (OEI-01-15-00320; expected issue date: FY 2016, ACA).

The second new initiative is in the “Delivery System Reform” section:

  • Accountable Care Organizations: Strategies and Promising Practices: We will review ACOs (accountable care organizations) that participate in the Medicare Shared Savings Program (established by section 3022 of the Affordable Care Act). We will describe their performance on the quality measures and cost savings over the first three years of the program and describe the characteristics of those ACOs that performed well on measures and achieved savings. In addition, we will identify ACOs’ strategies for and challenges to achieving quality and cost savings. The Medicare Shared Savings Program is a key component of the Medicare delivery system reform initiatives and is a vehicle through which providers who work in ACOs can share in Medicare cost savings while providing high-quality care to patients. (OEI; 02-15-00450; expected issue date: FY 2017; ACA).

What this means is that there will be a review of these programs conducted by the OIG using their auditing and oversight methods. We can expect to see a report addressing how well CMS is meeting its requirements for validating the hospital-submitted quality data, some measures as to the accuracy of that data, and whether CMS is taking appropriate actions as a result of the data validation. We also may see suggestions for what additional steps CMS should take to improve data validation. Hospitals may be contacted to determine how they produced the data submitted to CMS.

For the ACO review, OIG will be reviewing the performance of ACOs during the first three years of the MSSP program and looking for the best practices of high-performing ACOs, as well as any issues that arose. This will enable the production of a report on how successful ACOs achieved high quality and cost savings. There have already been a number of articles regarding these factors. However, this OIG report also may provide a number of suggestions for CMS to remove barriers to success and improve ACO performance. 

About the Authors

Stanley Nachimson is the principle of Nachimson Advisors, a health IT consulting firm dedicated to finding innovative uses for health information technology and encouraging its adoption. The firm serves a number of clients, including, the Cooperative Exchange, EHNAC, No World Borders, and the American Osteopathic Association. Stanley advises health care providers, vendors, and plans with their ICD-10 and other regulatory implementations. He is the director of the NCHICA-WEDI Timeline Initiative and serves on the Board of Advisors for the Lott QA Group, an innovative health care IT testing company. Stanley is the author of the authoritative paper on the cost of ICD-10 for physician practices, and also co-chairs the HIMSS ICD-10 Task Force and the WEDI ICD-10 Testing Workgroup.

Stanley served for over 30 years in the US Department of Health and Human Services in a variety of statistical, management, and health technology positions. His last ten years prior to his 2007 retirement were spent developing HIPAA policy, regulations, and implementation planning and monitoring, beginning CMS’s work on Personal Health Records, and serving as the CMS liaison with several industry organizations, including WEDI and HITSP. He brings a wealth of experience and information regarding the use of standards and technology to the health care industry. 

Kim Charland is the editor of VBPmonitor.com and the senior vice president of clinical innovation with Panacea Healthcare Solutions. Kim has 30 years of experience in health information and reimbursement management for hospitals and physician offices. Kim’s primary role with Panacea is publisher of VBPmonitor.com, which is the company’s newest online monitoring website focused on value-based purchasing and quality. She is also co-host of ICD10monitor.com’s Internet news broadcast “Talk-Ten-Tuesday.” In addition, she assists with product development for Panacea’s consulting and software divisions as well as the MedLearn Publishing division. Kim is also recognized as a national speaker and has spoken for numerous organizations.

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