CMS focuses on value over volume in IPPS rule

CMS continued its focus on improving the quality of patient care in the fiscal year (FY) 2016 IPPS final rule, released July 31.

 

"The final rule includes policies that advance the vision and commitment to increasingly shift Medicare payments from volume to value," says Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM trainer, director of CDI Quality Initiative for Huff DRG Review in Eads, Tennessee.

 

Most of the changes included in the final rule fall under CMS' various quality improvement measures. The agency did finalize some coding and MS-DRG changes for 2016. However, the changes are minor because of the ongoing code freeze prior to ICD-10 implementation.

 

CMS finalized the addition of seven new measures to the Hospital Inpatient Quality Reporting (IQR) Program. In addition, the agency finalized changes to the pneumonia readmission measure as part of the Hospital Value-Based Purchasing (HVBP) Program and the Hospital Readmissions Reduction Program (HRRP).

 

CMS is not adding or removing any Hospital-Acquired Condition (HAC) categories for FY 2016. It estimates that 19.4% of all hospitals will be penalized with a 1% reduction in MS-DRG payments for all traditional Medicare discharges in FY 2016 due to HAC Reduction Program (HACRP) performance.

 

CMS also addressed provider comments on its plan to expand the Bundled Payments for Care Improvement (BPCI) Initiative.

 

The BPCI Initiative is composed of four related payment models that link payments for multiple services received by Medicare beneficiaries during an episode of care into a bundled payment.

 

More than 75 stakeholders responded to CMS' request for comments on the BPCI Initiative. While CMS stated it would consider these comments if it does expand the initiative, it provided only general topics addressed by the commenters.

 

CMS included a small discussion on short stays and the 2-midnight rule. CMS did not propose any changes to the 2-midnight rule in the 2016 IPPS proposed rule, but reminded stakeholders that it did address short stays in the 2016 OPPS proposed rule. Stakeholders have until August 31 to submit comments on the short-stay proposals.

 

In the CY 2016 OPPS proposed rule, CMS states that it will look at short inpatient stays that do not cross two midnights. CMS will approve these short admissions on a case-by-case basis, based on the physician's judgment and the documentation justifying the stay.

 

CMS expects short stays for minor surgical procedures or hospital care to be rare and will monitor these types of admissions to prioritize them for medical review.

 

Beginning October 1, Quality Improvement Organizations (QIO) will conduct initial patient status reviews to determine the appropriateness of Part A payment for short-stay inpatient hospital claims. Recovery Auditors had been scheduled to conduct these reviews.

 

QIOs will base their reviews from October 1 through December 31, 2015, on Medicare's current 2-midnight policy. Beginning January 1, 2016, QIOs will incorporate any changes to the 2-midnight rule finalized in the OPPS rule to conduct the patient status reviews.

 

The IPPS final rule did not include an extension of the partial enforcement delay of the 2-midnight policy. However, CMS did extend the delay until December 31 after the rule was released.

 

CMS finalized refinements to the pneumonia readmission measure to expand the measure cohort as part of the HRRP.

 

Many hospitals are familiar with the Yale University mortality and readmission methodologies and cohorts that CMS uses in its HVBP Program.

 

In the past, CMS defined the pneumonia cohort for mortality and readmission measurement to include various pneumonia codes as a principal diagnosis, excluding cases where sepsis, aspiration pneumonia, or respiratory failure served as the principal diagnosis.

 

CMS amended the cohorts to include patients with a principal discharge diagnosis of:

 

"CMS listened to provider comments referable to their proposal to change the pneumonia readmissions measure and scaled it back significantly to a more reasonable cohort," says James S. Kennedy, MD, CCS, CDIP, president of CDIMD - Physician Champions in Smyrna, Tennessee.

 

CMS proposed to add patients with a principal diagnosis of sepsis, severe sepsis, or acute respiratory failure with pneumonia as a secondary diagnosis and to add all cases with aspiration pneumonia as a principal diagnosis to the cohort, Kennedy says. CMS opted not to add cases with acute respiratory failure as the principal diagnosis and excluded sepsis cases if there is a secondary diagnosis of severe sepsis.

 

"As such, hospitals must be diligent to identify pneumonia patients who had sepsis on admission to determine if they meet ICD-10-CM's administrative definition of severe sepsis (acute organ dysfunction, not failure, due to sepsis) which may differ from those of the Surviving Sepsis campaign," Kennedy says.

 

However, CMS chose not to include patients with a principal discharge diagnosis of respiratory failure or sepsis if they are coded as having severe sepsis.

 

"It is interesting to note that the reason CMS did not include these other populations is because, on further analysis, they found that the populations coded with respiratory failure and sepsis actually had lower risk-adjusted mortality, which was an unexpected finding attributed to 'coding patterns,' " Newell says.

 

The resulting change in the pneumonia cohort also impacts seven of the risk-adjustment variables used in the risk-adjustment algorithm. "These are important to capture to accurately reflect risk-adjusted mortality performance," Newell says.

 

The revised pneumonia cohort is expected to increase the number of discharges included in the measure by 50%, and to increase the number of hospitals (which will now meet the minimum case threshold of 25 eligible discharges). CMS expects the revised definition to impact the excess readmission rates for some hospitals.

 

Analyze and address performance improvement opportunities for all populations included in the HRRP, Newell says.

 

"The actual number of observed readmissions does not impact payment under the HRRP; it is the predicted and expected performance which determines if the hospital has excess readmissions," she adds.

 

The quality of documentation and coded data has a direct impact on measure performance and associated financial penalties.

 

Given modifications to the pneumonia cohort, revisit the definitions used to capture "severe sepsis," which disqualifies discharges from inclusion in the measure, Newell advises.

 

Proactive hospitals are encouraged to study and address data quality opportunities for the coronary artery bypass graft measure. Performance for today's discharges will determine the financial impact for this measure beginning in FY 2017.

 

CMS added three new claims-based measures and one structural measure for the FY 2018 payment determination and subsequent years; it also added three new claims-based measures for the FY 2019 payment determination.

 

The seven new measures are:

 

All of the new measures are claims based except for Hospital Survey on Patient Safety Culture.

Three of the new clinical episode-based measures—kidney/UTI, cellulitis, and GI hemorrhage—will impact payment in FY 2019, Newell says.

 

CMS finalized removal of six topped-out measures:

 

CMS will retain measures STK-06, STK-08, VTE-1, VTE-2, and VTE-3 as electronic clinical quality measures for the FY 2018 payment determination and subsequent years.

 

The agency did acknowledge that "the intent of a measure is the same whether it is reported via chart-abstraction or electronically, the submission modes are not the same and measure rates may be different."

 

It also removed measures:

 

The HVBP Program adjusts payments to hospitals for inpatient services based on their performance on an announced set of measures.

 

CMS finalized removal of IMM-2 (Influenza Immunization) because it determined the measure was topped out.

 

CMS is also removing AMI-7a (Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival) because few hospitals have the minimum number of cases necessary to report the measure.

 

Because CMS finalized the removal of these two measures from the Clinical Care-Process subdomain, the agency finalized its proposal to move PC-01 (Elective Delivery) from Clinical Care-Process to the Safety domain. CMS will eliminate the Critical Care-Process subdomain and rename the Clinical Care-Outcomes subdomain as simply the Clinical Care domain.

 

The agency also adopted a new measure for FY 2018 reporting: 3-Item Care Transition Measure (CTM-3).

 

The Hospital-Associated Infection measures will expand the population in FY 2019. The Central Line-Associated Bloodstream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI) measures will include selected ward (non-ICU) locations.

 

CMS defines selected ward (non-ICU) locations as adult or pediatric medical, surgical, and medical/surgical wards.

 

CMS also finalized the addition of Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Chronic Obstructive Pulmonary Disease Hospitalization beginning in FY 2021.

 

Analyze and address performance improvement opportunities for associated new and/or modified measures, Newell says.

 

"For claims-based measures, it is important to address documentation and coding vulnerabilities that impact the population included in the measure, referred to as the 'cohort,' as well as the risk-adjustment variables which impact the mortality, complication, and efficiency measures," she adds.

 

Revisit the definitions used to capture "severe sepsis," which disqualifies discharges from inclusion in the pneumonia measure, Newell says.

 

Hospitals and CDI departments should also analyze and address data quality opportunities to improve Patient Safety Indicator (PSI) 90 measure performance under Agency for Healthcare Research and Quality (AHRQ) QI version 4.5a, which will be used in FY 2017.

 

AHRQ has rolled out more updated PSI versions that have not been adopted by CMS. "These updated version measure specifications significantly impact which discharges are included in each PSI, as well as how discharges are risk adjusted," Newell says. "Hospitals interested in integrating clinical and financial performance pertinent to CMS quality programs need to make sure they are using the correct version of the measure specifications."

 

CMS finalized the 24-month period from July 1, 2013, through June 30, 2015, as the time frame for Domain 1 measure (AHRQ PSI-90 Composite measure).

 

CMS decreased the Domain 1 weight from 25% to 15% and increased the Domain 2 weight from 75% to 85% for FY 2017.

 

CMS also finalized an expansion of data for CLABSI and CAUTI measures. The agency will include data from pediatric and adult medical ward, surgical ward, and medical/surgical ward locations, in addition to data from adult and pediatric ICU locations for the CLABSI and CAUTI measures, beginning in FY 2018.

 

As part of the discussion of the HACRP, CMS acknowledged comments about quality measures included in both the HVBP Program and the HACRP.

 

CMS noted that the overlapping measures "cover topics of critical importance to quality improvement in the inpatient hospital setting and to patient safety."

 

The agency also stated that the two programs have different purposes and policy goals.

 

CMS noted that the National Quality Forum (NQF) has not yet completed maintenance review of the PSI 90 measure.

 

"CMS clarified in the final rule that PSI 90 has not lost NQF endorsement, which is in fact not required for measure adoption into the HVBP [Program]," Newell says.

 

The NQF is considering expanding this measure from eight PSIs to 11 PSIs. The prior version of PSI 90 remains adopted. CMS will provide notification of any future refinements to this measure upon completion of NQF maintenance review.

 

"CDI departments should analyze and address data quality opportunities to improve PSI 90 measure performance under AHRQ QI version 4.5a," Newell says.

 

Newell also encourages CDI programs to assess performance for the three PSIs targeted for potential inclusion in the CMS PSI 90 measure.

 

The final rule was published in the Federal Register August 17.