CMS proposes additional quality measures
Rule to increase data collection burden on hospitals
The Centers for Medicare & Medicaid Services (CMS) has proposed significant expansion in hospital quality reporting requirements, including adding 46 new quality measures for which hospitals must submit data over the next two years, and increasing the number of hospital-acquired conditions for which Medicare won't reimburse.
In its inpatient prospective payment system (IPPS) proposed rule for FY 2009, issued April 14, CMS proposes that hospitals publicly report data on three additional quality measures in FY 2009 in order to receive the full payment update and proposes adding an additional 43 measures in FY 2010, bringing to 72 the total of quality measures on which hospitals must report data.
CMS reiterated its intention to stop providing higher payment for eight hospital-acquired conditions beginning in October of this year and proposes adding nine additional categories of hospital-acquired conditions for which it won't pay in FY 2009.
"The effect that the measures in the proposed rule will have on hospitals is huge. If implemented, the proposed new measures would almost double the amount of data that hospitals have to collect," says Carolyn C. Scott, RN, MEd, MHA, director, KPMG LLP's Healthcare Advisory Services practice.
CMS is soliciting comments on the proposed rule through June 13. The IPPS final rule will be issued on or before Aug. 1 and will go into effect Oct. 1.
It is critical for hospitals to issue a response to the proposals because once they get in the final rule, it is a long and arduous task to change them, Scott advises.
Case managers should be a part of their hospital's team that drafts a response to the proposals, she adds.
"Case managers can provide great insight into the processes because they are familiar with what it takes to manage patients. They can provide information on the effectiveness of the new measures, the data collection burden, and what it will take to implement quality improvement activities around the new measures," she adds.
CMS has gone beyond asking hospitals to report data on process measures and now includes measures on outcomes, efficiency, and patient perception of care.
The proposed changes are part of CMS' move toward value-based purchasing, Scott points out.
"The overall goal of CMS is to get away from being a passive purchaser of health care services to being an active purchaser and putting more dollars with entities that provide a higher level of care," she says.
The old health care system rewarded providers for negative outcomes. If a patient got an infection, the hospital could charge more, adds Nancy Skinner, RN, CCM, a case manager for more than 20 years and past president of the Case Management Society of America.
"With its value-based purchasing initiative, CMS is saying it's not going to reward negative outcomes any more. The ultimate goal is delivery of quality of care, not only while the patient is in the acute care hospital but as they transition to another environment, and it is the responsibility of the providers to give them the tools they need to be successful," Skinner adds.
The proposed changes and the direction in which CMS is moving make it more important than ever for hospitals to make sure that documentation is correct and complete, Scott says.
"More and more attention is being placed on the accuracy of data submitted. It's very important that everything be documented and coded correctly, especially when the Recovery Audit Contractors [RACs] come in," Scott says.
For instance, in the proposed rule, CMS announced its intention to analyze the appropriate use of codes to report conditions that are present on admission, particularly the use of "Y" to indicate that the condition is present on admission and "W" to indicate that it is not possible to determine if the condition was present on admission. The agency plans to compare the present on admission coding with the medical record to determine if there are inconsistencies.
CMS is moving with surprising speed to expand the list of hospital-acquired conditions for which it will not reimburse and the number of quality measures on which hospitals must report data.
The Deficit Reduction Act of 2005 instructed CMS to pick at least two hospital-acquired conditions for which hospitals would not be reimbursed. The conditions were to be high cost, high volume, or both; identifiable through ICD-9-CM coding as a complication/comorbidity (CC) or major complication/comorbidity (MCC) when present as a secondary diagnosis, resulting in paying at a higher MS-DRG; and reasonably preventable through use of evidence-based guidelines.
Initially, CMS pushed for six measures, ultimately identified eight, and left the door open for a few more, Scott points out.
However, this year's proposed rule adds nine additional conditions and the potential for adding more in the future, she adds.
The CMS announcement cited an estimate from the Centers for Disease Control and Prevention that hospital-acquired conditions add nearly $5 billion to hospital costs and a 2007 survey of more than 1,200 hospitals by the Leapfrog Group, which found that 87% did not follow recommendations to prevent many of the most common hospital-acquired conditions.
Beginning Oct. 1, CMS will no longer pay for the eight original hospital-acquired conditions as well as any conditions CMS is proposing to add to this year's rule.
Proposed hospital-acquired infections
Among the proposed conditions are surgical site infections following certain elective procedures including total knee replacement and laparoscopic gastric bypass, glycemic control, delirium, collapsed lung due to medical care, deep-vein thrombosis/pulmonary embolism, Staphylococcus aureus septicemia, Legionnaires' disease, Clostridium difficile-associated disease, and ventilator-associated pneumonia.
The inclusion of many of the conditions on the hospital-acquired conditions list should come as no surprise because they are conditions hospitals already are including in their quality improvement projects, Scott points out.
Others, such as Legionnaires' disease and iatrogenic pneumothorax (collapsed lung), may have come as a surprise, she adds.
CMS is seeking comments on how to improve the hospital-acquired conditions program including how to risk-adjust certain patients, how to use present-on-admission data to calculate hospital-specific rates, and how to tie the data to value-based purchasing.
In addition, CMS is exploring ways to apply nonpayment of hospital-acquired infections to other settings. The rationale behind this is to align incentives across settings of care and to help ensure that Medicare would not inappropriately pay for the downstream effects of a preventable condition acquired in the first setting but treated in the second setting.
Case managers are in a position to be invaluable to their hospitals as CMS increases the quality data that hospitals must report, Scott says.
"In a lot of progressive organizations, case managers are actively involved in part of the quality team. As we move forward, that link becomes very important. This is where case managers can be incredibly valuable. They should sit with the team and evaluate the new measures that CMS proposes," she says.
CMS' expansion of the list of quality measures and hospital-acquired conditions could have a big impact on case managers who are often called on to handle quality measures and risk management issues, and who typically have primary responsibility for patient education, Skinner says.
For instance, CMS has proposed adding six quality measures dealing with venous thromboembolism and includes deep-vein thrombosis (DVT)/pulmonary embolism as one of the hospital-acquired conditions for which it will not pay, she points out.
The Agency for Healthcare Quality and Research (AHRQ) has cited DVT and embolism as the No. 1 cause of hospital death, she adds.
"Just that one measure could have a huge impact on case management. According to an analysis of patient safety standards, the No. 1 safety practice for prevention of complications for DVT and pulmonary embolism is appropriate prophylaxis," Skinner says.
Since DVT is a complication that often occurs when the patient goes home, injectable low-molecular-weight heparin is often prescribed post-discharge for patients at risk for DVT, Skinner says.
Before they are discharged, patients have to understand how to take their prescribed medicine, where and how to inject it, and the importance of doing it, she adds.
"Case managers can give patients the information they need to take their medication correctly and to empower them to take care of their health successfully after discharge," Skinner says.
CMS proposes that in FY 2009, hospitals continue to report data on 27 measures for heart attack, heart failure, surgical care, and the 27-item Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) that measures patient perception of care. The proposed rule adds two additional measures for surgical site prevention and the 30-day mortality rate for pneumonia.
CMS proposes to add 43 new measures for FY 2010 and retire one measure (pneumonia oxygenation assessment), bringing the total to 72 measures. CMS has announced its intention to remove oxygen saturation data from the list of quality measures by FY 2010 because hospitals are doing well on the measure, Scott says.
"The proposal to increase the number of measures from 30 to 72 is surprising, but CMS is considering reducing the data collection burden by staggering the start date for the measures," Scott says.
The proposed new measures include one measure from the Surgical Care Improvement Project (SCIP): three hospital readmission measures; four nursing care measures; five patient safety indicators developed by the AHRQ; four inpatient quality indicators developed by the AHRQ; six venous thromboembolism measures; five stroke measures; and 15 cardiac surgery measures.
Some of the measures, such as hospital readmission rates, will be available from claims data and the hospital won't have to submit data.
CMs seeks comments
In the proposed rule, CMS asked for comments about ways in which patient readmissions can be tied to value-based purchasing. The agency is looking at financial incentives as well as non-financial incentives, such as public reporting of hospital admission rates.
CMS noted that almost 17% of Medicare patients are readmitted to the hospital within 30 days of discharge and cited data from the Medicare Payment Advisory Commission (MedPAC) that readmissions cost $15 billion annually, with $12 billion of the costs potentially preventable.
CMS is proposing to expand the post-acute transfer policy for discharge to home with home health services to include patients who are discharged to home under a written plan for home health services that begin within seven days after discharge instead of the current time frame of three days post-discharge. The proposal applies only to discharge to home with home health services and not discharges to skilled nursing facilities.
Under the IPPS, if patients in the 273 covered MS-DRGs are transferred to other providers of post-acute services before completing the geometric mean length of stay for that MS-DRG, the hospital receives only a portion of the full reimbursement for that MS-DRG.
CMS began a three-year transition to relative weights based on costs rather than relative weights based on charges in FY 2007. Beginning Oct. 1, the start of FY 2009, the transition will be complete and relative weights will be based strictly on costs.
(For more information, contact Carolyn C. Scott, director, KPMG Healthcare Advisory Services, e-mail: [email protected]; or Nancy Skinner, e-mail: [email protected].)
The Centers for Medicare & Medicaid Services (CMS) has proposed significant expansion in hospital quality reporting requirements, including adding 46 new quality measures for which hospitals must submit data over the next two years, and increasing the number of hospital-acquired conditions for which Medicare won't reimburse.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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