Find­ing value in pro­posed PPS regs

An­nual Medi­care pay­ment reg fo­cuses on qual­ity

Modern Healthcare - - FRONT PAGE - Mau­reen Mckin­ney

The CMS may have taken steps ini­tially to ease providers into its val­ue­based pur­chas­ing pro­gram, but those days are over. In a 1,313-page pro­posed rule de­tail­ing pay­ment poli­cies for acute-care and longterm-care hos­pi­tals, re­leased April 24, the agency in­cluded a slew of pro­vi­sions re­lated to qual­ity im­prove­ment and pa­tient safety.

The pro­posed rule, which would in­crease op­er­at­ing pay­ments to acute-care hos­pi­tals by about 0.9% in 2013, in­cludes changes to the CMS’ In­pa­tient Qual­ity Re­port­ing Pro­gram, new qual­ity mea­sures for long-term care, up­dates to the list of hospi­tal-ac­quired condi- tions, and more de­tails about the gov­ern­ment’s Hospi­tal Read­mis­sions Re­duc­tion Pro­gram.

“It is part of a com­pre­hen­sive strat­egy to use Medi­care’s pay­ment sys­tems to foster bet­ter care and bet­ter value in all set­tings, thereby re­duc­ing over­all Medi­care spend­ing,” CMS act­ing Ad­min­is­tra­tor Marilyn Taven­ner said of the rule, in a news re­lease.

For its In­pa­tient Qual­ity Re­port­ing Pro­gram, the CMS pro­posed re­duc­ing the num­ber of mea­sures from the cur­rent set of 72 to 59 for fis­cal 2015’s pay­ment up­date. Un­der the Hospi­tal IQR pro­gram, hos­pi­tals vol­un­tar­ily sub­mit qual­ity data or re­ceive a 2% re­duc­tion in their an­nual pay­ment up­date. More than 99% of hos­pi­tals are now par­tic­i­pat­ing in the pro­gram, the CMS said.

The CMS also pro­posed low­er­ing its an­nual ran­dom sam­ple from 800 hos­pi­tals to 400 un­der the IQR, as pre­vi­ous data has shown high ac­cu­racy rates.

For its value-based pur­chas­ing pro­gram, the CMS pro­posed adding sev­eral new mea­sures for 2015, in­clud­ing one clin­i­cal process-of-care mea­sure: statin pre­scribed at dis­charge for heart at­tack pa­tients. Ad­di­tion­ally, that year’s pro­gram would in­clude two new out­come mea­sures, one of which tar­gets cen­tral line-as­so­ci­ated blood­stream in­fec­tions and an­other com­pos­ite pa­tient-safety in­di­ca­tor from the Agency for Health­care Re­search and Qual­ity.

Fi­nally, 2015’s value-based pur­chas­ing pro­gram would also mark the in­tro­duc­tion of an ef­fi­ciency mea­sure that tracks Medi­care spend­ing per ben­e­fi­ciary. The pro­posed rule should al­lay some fears about the ef­fi­ciency mea­sure, said Nancy Foster, vice pres­i­dent of qual­ity and pa­tient-safety pol­icy

for the Amer­i­can Hospi­tal As­so­ci­a­tion.

“They have taken care to craft a mea­sure that rec­og­nizes that some hos­pi­tals have higher costs for case mixes they serve but also for ac­counts for pol­icy-re­lated ad­just­ments like dis­pro­por­tion­ate share and in­di­rect med­i­cal ed­u­ca­tion,” Foster said. “They re­moved those from the com­par­isons, which is ap­pro­pri­ate.”

Still, Foster said the mea­sure won’t show why some ar­eas have lower per-ben­e­fi­ciary spend­ing than oth­ers and what providers can do to em­u­late high-per­form­ers.

“It’s hard to tell what’s go­ing on and whether there are higher costs in some regions be­cause pa­tients don’t have ready ac­cess to pri­mary care,” she added. “It is crit­i­cally im­por­tant to have this in­for­ma­tion out and avail­able, and it’s the first time we are see­ing this kind of thought­ful com­par­i­son. Now we need to un­der­stand what it means.”

The CMS also pro­posed adding care co­or­di­na­tion and pop­u­la­tion health as new mea­sure­ment do­mains for 2016’s pro­gram.

But the agency didn’t stop there. As man­dated by the health­care re­form law, the CMS also pro­posed new qual­ity re­port­ing pro­grams for can­cer hos­pi­tals and in­pa­tient psy­chi­atric hos­pi­tals, and it pro­posed new re­quire­ments for the Am­bu­la­tory Surgery Cen­ter Qual­ity Re­port­ing Pro­gram.

Cod­ing cuts also in­cluded in the pro­posed rule drew the ire of hospi­tal groups. In a state­ment re­leased April 25, Richard Umb­den­stock, AHA pres­i­dent and CEO, said the cuts were based on “out­dated data and a flawed method­ol­ogy,” and would re­sult in lower pay­ments for hos­pi­tals.

Chip Kahn, pres­i­dent and CEO of the Fed­er­a­tion of Amer­i­can Hos­pi­tals, also took is­sue with the cuts.

“They have a method­ol­ogy that shows them that part of the growth in spend­ing was due to cod­ing, rather than to real case-mix growth and—con­sis­tently—the in­dus­try has had dif­fer­ent find­ings,” Kahn said in an in­ter­view. “And also with the se­quester loom­ing, we think this was a ter­ri­ble time to ap­ply this re­duc­tion.”

In­dus­try groups also expressed con­cern about pro­vi­sions af­fect­ing long-term acute­care hos­pi­tals, in­clud­ing a pro­posed 3.75% cut in fund­ing.

“Even with a three-year phase-in, this new re­duc­tion will have a neg­a­tive ef­fect on (longterm acute-care hos­pi­tals’) abil­ity to care for pa­tients,” Umb­den­stock said in the state­ment. “Now is not the time to fur­ther re­duce fund- To im­prove the qual­ity of hospi­tal care Medi­care pays for, the CMS plans to: Mea­sure Re­ward re­duc­tions in Add Sur­vey pa­tients about Im­ple­ment

in value- based pur­chas­ing to in­pa­tient qual­ity re­port­ing

in HCAHPS ing for crit­i­cal hospi­tal ser­vices.”

The As­so­ci­a­tion of Amer­i­can Med­i­cal Col­leges, mean­while, crit­i­cized an ad­just­ment to the way teach­ing hos­pi­tals would be paid un­der the prospec­tive pay­ment sys­tem. The change would in­clude la­bor and de­liv­ery beds when cal­cu­lat­ing to­tal bed counts for the in­di­rect med­i­cal ed­u­ca­tion ad­just­ment, mean­ing hos­pi­tals would get paid less for the same num­ber of res­i­dents, Lori Mi­halich-levin, the AAMC’S di­rec­tor of hospi­tal and grad­u­ate med­i­cal ed­u­ca­tion pay­ment po­lices, said in an in­ter­view.

“We don’t be­lieve this is an ap­pro­pri­ate pol­icy decision,” Mi­halich-levin said, adding that the CMS had pre­dicted the pro­posed change would re­sult in an over­all de­crease of $170 mil­lion in pay­ments to teach­ing hos­pi­tals.

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