Critical Path Network

Quality measures gain importance as CMS moves to value-based purchasing

Payments will be linked to quality, not just delivery of service

As the Centers for Medicare & Medicaid Services (CMS) moves toward its value-based purchasing initiative, case managers are in a position to help their hospitals prepare for the time when payment will be linked to quality, rather than just delivery of service.

CMS is authorized through the Deficit Reduction Act of 2005 to have a plan for value-based purchasing in place by 2009, points out Carolyn C. Scott, RN, MEd, MHA, director of KPMG's health care advisory practice.

Value-based purchasing (VBP) links payment to quality, rather than just the delivery of service, Scott points out. The initiative ultimately will replace the current hospital quality reporting system and will include both public reporting and financial incentives to drive clinical quality, Scott says.

In the interim, CMS has added six new quality metrics, for a total of 27, which hospitals must report to avoid a 2% reduction in the payment update for Medicare patients in fiscal year 2008. As part of the Deficit Reduction Act of 2005, beginning with discharges that occur on or after Oct. 1, 2008, CMS will begin to eliminate additional payments for some complications of care that occur after a patient is admitted to the hospital.

CMS is expected to start requiring hospitals to incorporate the "present on admission code" on all DRGs, starting in October 2007, but has not yet published an official deadline.

The "present on admission" reporting will include five options that must be included on all diagnoses:

  • Y for yes;
  • N for no;
  • U for "no information in the record"
  • W if it can't be determined clinically;
  • blank if the condition is exempt from "present on admission" reporting.

When the value-based purchasing initiative is implemented, a specified percentage of a hospital's payment from CMS would be based on the hospital's performance on the VBP incentive payment measures.

CMS is working with a task force to develop measures that will be included in the initial round of quality measures in the value-based purchasing initiative. The agency is considering excluding from the current quality measures those on which hospitals are already performing at high levels and those around which there is some controversy, Scott says.

For instance, CMS is considering not including for value-based purchasing incentive pay the requirement for administering beta-blockers at arrival for AMI patients because the measure is under evaluation by the American College of Cardiology and the American Heart Association and may need "stability" prior to inclusion in the program, Scott says.

It is proposing to remove oxygenation assessment for pneumonia because there is little opportunity for hospitals to improve their compliance, according to CMS in its proposed measure set for the value-based purchasing program.

In the meantime, beginning Oct. 1 2007, hospitals will be required to publicly report data on new performance measures included in the Surgical Care Improvement Project (SCIP), 30-day mortality measures for acute myocardial infarction and heart failure Medicare patients, and results of a survey that measures the patient experience.

The three new measures that are part of SCIP include venous thromboembolism (VTE) prophylaxis ordered, VTE prophylaxis given within 24 hours of surgery, and appropriate antibiotic selection for surgery patients.

"As with other process measures, case managers can take a role in ensuring their hospital's compliance with the VTE prophylaxis measures by examining the patient record to make sure that the order was written and that the prophylaxis is given in a timely manner and that the documentation reflects that it has. If this hasn't occurred, the case managers should prompt those who are responsible to ensure that the hospital complies," Scott suggests.

CMS can help ensure compliance

While case managers cannot affect the appropriate antibiotic selection for surgery patients, they can take action retrospectively by analyzing the reports to determine any patterns in failure to comply, such as the practices of specific surgeons. In addition, case managers can make sure that the documentation shows that the antibiotic selection falls within guidelines and, if it does not, that the reason why is documented. CMS has added the 30-day mortality measures for AMI and heart failure Medicare patients to encourage hospitals to evaluate what happened during the episode of care of patients who did not survive and determine if anything could have been done differently, Scott says.

Depending on their size, hospitals will be required to submit between 100 and 300 survey results from the 27-item Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).

The HCAHPS measures patient perception of care in seven categories that include nurse communication, physician communication, responsiveness of hospital staff, communication about medicine, cleanliness and quiet of hospital environment, pain management, and discharge information, along with two questions about overall quality of care and whether patients would recommend the hospital to others.

The surveys may be completed by telephone, mail, or a combination, Scott says.

Beginning in the first quarter of 2008, patients will be able to go on-line and see how other patients rated their hospital experience along with other Hospital Compare data, Scott says. CMS also has announced its intention to add at least five new metrics in FY 2009 and has solicited comments on 32 different metrics/measure sets it is considering for 2009. The comment period on the proposed measures ended June 12.

In addition to linking a portion of a hospital's payments to quality in fiscal year 2009, the Deficit Reduction Act of 2005 requires CMS to stop paying for some complications of care that developed during the hospital stay, Scott points out.

CMS considering complications

CMS has not yet selected what complications of care will be included but has announced the top six complications under consideration, Scott says, which are:

  • catheter-associated urinary tract infections;
  • pressure ulcers;
  • objects left in during surgery;
  • air embolism;
  • blood incompatibility;
  • Staphylococcus aureus bloodstream infection/septicemia.

The act requires CMS to select at least two complications of care using the following criteria: complications with a high cost, a high volume or both; a complication that results in a DRG that has a higher payment when it is present as a secondary diagnosis; and a condition that could have been prevented by use of evidence-based guidelines.

For instance, CMS reports that there are 561,667 catheter-associated urinary tract infections a year and that in fiscal year 2006, there were 11,780 reported cases of Medicare patients who had a catheter-associated urinary tract infection as a secondary diagnosis.

CAUTI considered a complication

According to CMS' figures, hospital-acquired urinary tract infections resulted in nearly 1 million extra patient days a year at a cost of $424 million to $451 million.

"We believe the condition of catheter-associated urinary tract infection meets all our requirements for selection as one of the initial hospital-acquired conditions. The condition is a complication or comorbidity under both the current and the proposed-MS-DRGs . . . The condition meets our burden criterion with its high cost and high frequency," CMS said in its proposed inpatient prospective payment system rule for 2008.

CMS also pointed out in the proposed rule that there are widely recognized guidelines for the prevention of catheter-associated urinary tract infections.

"The Deficit Reduction Act is written to make it clear that CMS is not going to pay for poor quality care. These adverse events can be tied to poor quality care," Scott says.

(For more information contact Carolyn C. Scott, RN, MEd, MHA; e-mail: