More from the IPPS Proposed Rule: Quality Measures

Medicare Severity DRGs (MS-DRGs) are getting a lot of attention right now, on this weblog and in the media (see here and here). But MS-DRGs are not the only important aspect of the 1200-page proposed rule. My colleague Cheryl D’Amato has already discussed proposed “present on admission” requirements on this blog (see here and here). I’ll discuss another important point from the proposed rule: new quality measures.

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) required that base reimbursement under the inpatient prospective payment program (IPPS) be reduced by 0.4% for hospitals not submitting data on a set of ten CMS-established quality indicators.

These initial quality indicators involved treatment and assessment procedures for patients with heart attack, heart failure and pneumonia.

The 0.4% reduction was initially applicable to fiscal years 2005 through 2007. However, the Deficit Reduction Act (DRA) of 2005 made this reduction permanent and, beginning with FY 2007, increased the reduction to 2.0% for any hospital not submitting appropriate quality data. DRA 2005 also required CMS to expand the “starter set” of ten quality indicators. In the FY2007 IPPS final rule, CMS implemented the two percent reduction and added eleven other quality measures.

For FY2008, CMS is required to add other measures that reflect consensus among affected parties. Because CMS is required to notify hospitals well in advance of any updates to the required quality measures, the FY2008 additions were published in November 2006, in the CY2007 OPPS final rule. For FY2008, CMS is adding six additional quality measures, including three SCIP quality measures, two mortality measures, and the HCAHPS patient satisfaction survey. In total, for FY 2008, hospitals are required to report on the following 27 measures to avoid a two percentage point reduction in base IPPS reimbursement:

Heart Attack (Acute Myocardial Infarction)

• Aspirin at arrival*
• Aspirin prescribed at discharge*
• ACE inhibitor (ACE-I) or Angiotensin Receptor Blocker (ARBs) for left ventricular systolic dysfunction*
• Beta blocker at arrival*
• Beta blocker prescribed at discharge*
• Thrombolytic agent received within 30 minutes of hospital arrival**
• Percutaneous Coronary Intervention (PCI) received within 120 minutes of hospital arrival**
• Adult smoking cessation advice/counseling**

Heart Failure (HF)

• Left ventricular function assessment*
• ACE inhibitor (ACE-I) or Angiotensin Receptor Blocker (ARBs) for left ventricular systolic dysfunction*
• Discharge instructions**
• Adult smoking cessation advice/counseling**

Pneumonia (PNE)

• Initial antibiotic received within 4 hours of hospital arrival*
• Oxygenation assessment*
• Pneumococcal vaccination status*
• Blood culture performed before first antibiotic received in hospital**
• Adult smoking cessation advice/counseling**
• Appropriate initial antibiotic selection**
• Influenza vaccination status**

Surgical Care Improvement Project (SCIP)

• Prophylactic antibiotic received within 1 hour prior to surgical incision**
• Prophylactic antibiotics discontinued within 24 hours after surgery end time**
• SCIP-VTE 1: Venous thromboembolism (VTE) prophylaxis ordered for surgery patients***
• SCIP-VTE 2: VTE prophylaxis within 24 hours pre/post surgery***
• SCIP Infection 2: Prophylactic antibiotic selection for surgical patients***

Mortality Measures (Medicare patients)

• Acute Myocardial Infarction 30-day mortality Medicare patients***
• Heart Failure 30-day mortality Medicare patients***

Patients’ Experience of Care

• HCAHPS patient survey***

* Measure included in 10 measure starter set.
** Measure included in 21 measure expanded set.
*** Measure added in CY 2007 OPPS final rule.

CMS has revised filing and reporting procedures for the quality indicators and has posted the revised procedures on the QualityNet Exchange Web site. A full listing of those hospitals meeting quality reporting requirements is maintained on www.qualitynet.org. Instructions for filing of the FY 2008 quality measures will continue to be available on the quality net exchange website. Also, CMS will continue to require that hospitals meet chart validation requirements as implemented in the FY 2006 IPPS final rule. These requirements include a minimum of 80 percent reliability based on chart review.

In the FY 2008 proposed rule, CMS has identified one new outcome measure and four process measures to this 27 measure set, to establish a proposed set of 32 quality measures to be used for payment determination in FY 2009. The new proposed measures, already put forth by the Hospital Quality Alliance (HQA) for inclusion in its public reporting set, are:

• Pneumonia 30-day mortality for Medicare patients
• SCIP Infection 4: Cardiac surgery patients with controlled 6AM postoperative serum glucose
• SCIP Infection 6: Surgery patients with appropriate hair removal
• SCIP Infection 7: Colorectal patients with immediate postoperative normothermia
• SCIP Cardiovascular 2: Surgery patients won a beta-blocker prior to arrival who received a beta-blocker during the perioperative period

CMS also includes a list of 18 measures and 8 measure sets from which additional quality measures could be selected for FY 2009 reporting. These new measures were selected with a particular focus on the quality of surgical care and patient outcomes. CMS is requesting feedback on these proposed measures.