Knowledge Base Article

The Fiscal Year (FY) 2016 Inpatient Prospective Payment System (IPPS) Final Rule builds on the CMS’s recurring theme of moving the health care system toward paying for quality rather than quantity as CMS indicates in a related Fact Sheet “the Administration has set measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on quality, rather than the quantity of care they give patients. The final rule includes policies that advance that vision and of several final rules that reflect a broader Administration-wide strategy to create a health care system that results in better care, smarter spending, and healthier people.”

This article highlights Fiscal Year 2016 IPPS Final Rule (CMS-1632-F) Payment Rate changes and changes to the Quality Programs.

Finalized Changes to Payment Rates for IPPS Participating Acute Care Hospitals

• Hospitals that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) users will see a 0.9% increase in operating payments.
• Hospitals that do not successfully participate in the Hospital IQR Program and submit the required quality data will see a one-fourth reduction in their Market Basket update.
• Hospitals that are not meaningful EHR users will see a one-half reduction in their Market Basket update.
• Additional Potential Penalties
• Hospital Value Based Purchasing (VBP) Program: Hospitals will either receive an incentive bonus or a penalty potentially as high as 3%.
• Hospital Readmission Reduction Program (HRRP): Hospitals will be penalized up to 3% for excessive readmission rates.
• Hospital Acquired Condition (HAC) Reduction Program: 1% penalty for hospitals in the lowest performing quartile.

Hospital Inpatient Quality Reporting (IQR) Program

Pneumonia Cohort Expanded

CMS finalized proposed cohort refinements to the following two previously adopted Pneumonia measures:

• The Hospital 30-Day All-Cause, Risk-Standardized Mortality Rate (RSMR) following Pneumonia Hospitalization measure
• The Hospital 30-Day All-Cause, Risk-Standardized Readmission Rate (RSRR) following Pneumonia Hospitalization measure

CMS defines “cohort” as the hospitalization, or “index admission,” that is included in each measure to determine if a patient died within 30 days of the index admission in the case of the Mortality Measure or if the patient was readmitted within 30 days in the case of the Readmission Measure.

For the FY 2017 payment determination and subsequent years the cohort for both measures has been expanded to include:

• Patients with a principal discharge diagnosis of pneumonia (the current reported cohort),
• Patients with a principal discharge diagnosis of aspiration pneumonia (new); and
• Patients with a principal discharge diagnosis of sepsis (excluding severe sepsis) with a secondary diagnosis of pneumonia coded as present on admission (POA).

More interesting than the actual cohort changes are the reasons cited by CMS for making the change.

• “Recent evidence has shown an increase in the use of sepsis and respiratory failure as principal diagnosis codes among patients hospitalized with pneumonia. Pneumonia patients with these principal diagnosis codes are not currently included in the measure cohort, and including them would better capture the complete patient population of a hospital with patients receiving clinical management and treatment for pneumonia.
• Second, “efforts to evaluate changes over time in pneumonia outcomes could be biased as coding practices change.”

CMS Adds Seven New Measures to the Hospital IQR Program

CMS finalized seven new measures for the FY 2018 and 2019 payment determinations and subsequent years. The following table highlights the new measures and the year the measure will be included in a hospital’s payment determination.

CMS Removes Nine Measures from the Hospital IQR Program

For the FY 2018 payment determination and subsequent years, CMS finalized the removal of the following nine chart-abstracted measures:

1. STK-01 Venous Thromboembolism Prophylaxis
2. STK-06 Discharged on Statin Medication*
3. STK-08 Stroke Education*
4. VTE-1 Venous Thromboembolism Prophylaxis*
5. VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis*
6. VTE-3 Venous Thromboembolism Patients with Anticoagulation Overlap Therapy*
7. IMM-1 Pneumococcal Immunization
8. SCIP-Inf-4 Cardiac Surgery Patients with Controlled Postoperative Blood Glucose
9. AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival*

Note: Measures with an asterisk (*) were finalized to be removed from chart abstraction but are being retained as Electronic Clinical Quality Measures (eCQM) for the FY 2018 payment determination and subsequent years as proposed.

Hospital Value Based Purchasing (VBP) Program

In the Final Rule CMS estimates that the total amount available for value-based incentive payments for FY 2016 is $1,499,107,502, based on the December 2014 update of the FY 2014 MedPAR file. This estimate will be updated for the FY 2016 IPPS/LTCH PPS final rule, using the March 2015 update of the FY 2014 MedPAR file.

As required by section 1886(o)(7)(B) of the Act, incentive payments will be funded for FY 2016 through a reduction to the FY 2016 base operating DRG payment for each discharge of 1.75 percent.

CMS finalized the removal of two current measures effective with the FY 2018 program year.

• IMM-2 Influenza Immunization
  Note: CMS does believe that “this measure should continue to be part of the Hospital IQR Program measure set because it is the only measure that addresses the Best Practices to Enable Healthy Living goal in the CMS Quality Strategy and priority of the same name in the National Quality Strategy.”

• AMI-7a Fibrinolytic Therapy Received within 30 Minutes of Hospital Arrival

CMS finalized a New Care Coordination Measure for the FY 2018 Program Year.

• 3-Item Care Transition Measure (CTM-3) that will add the following three questions to the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems )Survey:

1. During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.
2. Strongly disagree
3. Disagree
4. Agree
5. Strongly Agree
   
   
6. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
7. Strongly disagree
8. Disagree
9. Agree
10. Strongly Agree
11. When I left the hospital, I clearly understood the purpose for taking each of my medications.
12. Strongly disagree
13. Disagree
14. Agree
15. Strongly Agree
16. I was not given any medication when I left the hospital

Note: The CTM-3 measure was developed by Eric Coleman, MD, MPH, Professor of Medicine & Health at the Division of Health & Policy Research at the University of Colorado Anschutz Medical Campus. Dr. Coleman is the founder and director of The Care Transitions Program (www.caretransitions.org).

CMS indicated that they intend to propose in future rulemaking the inclusion of non-ICU locations in the Catheter Association Urinary Tract Infection (CAUTI) and Central Line-Associated Blood Stream Infection (CLABSI) measures beginning with the FY 2019 program year. “Selected ward (non-ICU) locations are defined as adult or pediatric medical, surgical, and medical/surgical wards [79 FY 50061; 78 FR 50787].”

CMS finalized a Hospital 30-day All-Cause, Risk-Standardized Mortality rate Following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization Measure for the FY 2021 Program Year.

CMS indicates that this measure “is appropriate for the Hospital VBP Program because it addresses a high volume, high cost condition, and chronic lower respiratory disease (including COPD) is the third leading cause of mortality in the United States. The measure aligns with the CMS Quality Strategy Goal of Effective Prevention and Treatment.”

Hospital Acquired Conditions (HAC) Reduction Program

Even though there were no proposals to add or remove measures for FY 2016, the CMS reminds readers that in the FY 2015 IPPS Final Rule they finalized the following measures for the FY 2016 Program:

• AHRQ PSI – 90 Composite

This measure currently consists of the following eight component indicators:             

• PSI-3 Pressure ulcer rate,
• PSI-6 Iatrogenic pneumothorax rate,
• PSI-7 Central venous catheter-related blood stream infections rate,
• PSI-8 Postoperative hip fracture rate,
• PSI-12 Perioperative pulmonary embolism or Deep vein thrombosis rate,
• PSI-13 Postoperative sepsis rate,
• PSI-14 Postoperative Wound dehiscence rate; and
• PSI-15 Accidental puncture and laceration rate.
• CDC Central Line-Associated Bloodstream infection (CLABSI),
• Catheter-Associated Urinary Tract Infection (CAUTI); and
• Colon and Abdominal Hysterectomy Surgical Site Infection (SSI).

As part of the National Quality Foundation maintenance review process, the Agency for Healthcare Research and Quality (AHRQ) is considering adding the following to the PSI Composite measure:

• PSI-9 Perioperative hemorrhage rate,
• PSI-10 Perioperative physiologic metabolic derangement rate; and
• PSI-11 Post-operative respiratory failure rate.

CMS indicates that the potential inclusion of these measures would be a significant change and that they would engage in notice-and-comment rulemaking prior to requiring the reporting of a revised composite for the HAC Reduction Program.

Hospital Readmissions Reduction Program (HRRP)

CMS Expands the Pneumonia Readmission Measure Cohort

CMS finalized a refinement to the pneumonia readmissions measure which would expand the cohort for the FY 2017 payment determination and subsequent years. As discussed earlier in this article, CMS defines “cohort” as the hospitalizations or “index admissions,” that are included in the measure.

Currently, this measure includes hospitalizations for patients with a principal discharge diagnosis of pneumonia indicating viral or bacterial pneumonia. CMS finalized a modified version of their proposal to include patients with a principal discharge diagnosis of pneumonia or aspiration pneumonia, and patients with a principal discharge diagnosis of sepsis (excluding severe sepsis) with a secondary diagnosis of pneumonia coded as POA.

CMS indicates that “the purpose of expanding the cohort of the current pneumonia readmission measure is to include a broader spectrum of pneumonia patients and respond to changes in coding practices that were potentially biasing estimates of the performance of hospitals.”

A related Fact Sheet indicates that the “CMS is also continuing to monitor the impact of socioeconmomic status on provider results in our quality programs, and is working with the National Quality Forum as they undertake a two-year trial to test sociodemographic factor risk adjustment. The Office of the Assistant Secretary for Planning and Evaluation is currently researching the impact of sociodemographic status as directed by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), and CMS will closely examine the findings presented in their reports to Congress and related Secretarial recommendations at such time as they are available.”

Do You Know Your Hospital’s Readmission Penalty?

With hospitals facing financial challenges, do you know your Hospital’s Readmission Penalty for the coming Fiscal Year? Kaiser Health News (KHN) is a nonprofit national health policy news service and on August 3rd, Jordan Rau of KHN released the article Half of Nation’s Hospitals Fail Again To Escape Medicare’s Readmission Penalties. This article provides the reader a link to a PDF file of Medicare Readmission Penalties by Hospital for all four years of the program (FY 2013 through FY 2016).

The entire article can be accessed at: http://khn.org/news/half-of-nations-hospitals-fail-again-to-escape-medicares-readmission-penalties/?utm_campaign=KHN%3A+Afternoon+Edition&utm_source=hs_email&utm_medium=email&utm_content=21032373&_hsenc=p2ANqtz--tfj9Nw4n9neCfizWv04BocrIp3tC95xA5l23W02GylGLyB4LwwY-TqyPtYDzFc3SMx6mV8RP_X1MzflMnd3EhbTYe4g&_hsmi=21032373

The entire Final Rule can be accessed at http://www.gpo.gov/fdsys/pkg/FR-2015-08-17/pdf/2015-19049.pdf.

For those closely involved with Quality Initiatives in your facility here is list of where you can find the specific Quality Program Updates in the Final Rule pdf.

• Hospital Readmission Reduction Program is on pages 206-219,
• Hospital Value-Based Purchasing (VBP) Program is on pages 220-246,
• Hospital-Acquired Condition (HAC) Reduction Program is on pages 246 – 257; and
• Hospital Inpatient Quality Reporting (IQR) Program is on pages 316-380.