Against the rule
CMS’ efficiency, cost link raises objections
Hospitals and healthcare consultants have serious concerns about changes to the hospital value-based purchasing program the CMS tucked into its proposed rule for outpatient care.
The comment period closed last week on proposed regulations issued July 1 that included recommendations to bolster the value-based purchasing program required by last year’s Patient Protection and Affordable Care Act. The program will tie a portion of a hospital’s payment for inpatient stays under the inpatient prospective payment system to its performance score on a set of quality measures starting in 2013.
In April, the CMS issued a final rule on the program that established 12 clinical process-ofcare measures that would be used in determining a hospital’s performance. The regulations proposed in July added one clinical process-ofcare measure to prevent urinary catheter infections, and also addressed performance periods, standards and a weighting scheme.
The first year of the program will include a process-of-care domain and patient-satisfaction domain and then in 2014 will incorporate efficiency-of-care and outcomes domains, said Jessica Roth, director of legislation and health policy at the Washington-based law firm of McDermott, Will & Emery. Roth said her clients are most concerned about the approach to efficiency, which hospitals have historically viewed in terms of lengths of stay.
“CMS decided to take a different approach and measure efficiency through cost,” she said. The CMS will measure total Medicare spending per beneficiary and then attribute that spending to the hospital. As she explained, after a patient enters a hospital, the CMS will take into account all of the care for a 30-day period to determine spending on that beneficiary.
The American Hospital Association and the Federation of American Hospitals wrote in comment letters that they are concerned with the new measure because it has not been endorsed by the National Quality Forum or any other quality organization.
The new provisions also have drawn criticism for extending the 2013 program’s reliance on the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Hospitals fear they’ll be unfairly penalized for treating sicker patients, who tend to give lower satisfaction scores (July 11, p. 10).
In its comment letter last week, the AHA expressed concern about the way the CMS has handled the notice and comment period for the value-based purchasing program. “CMS made significant changes to this program in three separate regulations,” the letter said. “It has been very difficult to track all of the moving pieces associated with these regulations.”
The CMS is scheduled to issue the final rule on the outpatient prospective payment rule by Nov. 1.