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Proposed rule leaves many questions
Concerns in field on many fronts
It's a proposed rule. So it's up for comment. And that's a good thing, because there are many in the field. Though experts agreed there were not many surprises in terms of quality measures laid out for fiscal year 2013 in the Centers for Medicare & Medicaid Services' proposed rule on value-based purchasing (VBP), they are concerned with other things.
"Most of what is included in the value-based purchasing proposal is driven off the MedPAC report from several years ago," says Kathleen Ciccone, RN, MBA, executive director of the Healthcare Association of New York State (HANYS) Quality Institute.
"The major concepts are the same, the themes are the same. I think what's new and different is the details," she says. While CMS historically talked about building a VBP program from the pay-for-reporting or Hospital Inpatient Quality Reporting programs, she says, the information still up in the air was which measures, time frames, and reimbursement formula would be used.
These details are what we're seeing now, says Stephen Harwell, vice president, economics, finance, and information for HANYS. Echoing the concerns of others in the field, he says the financial impact is still to be seen.
"What one individual hospital does depends on how its score, starting in July 2011, measures up against every other hospital. So you really can't know ahead of time. In fact, in this proposed rule, CMS lays out the whole thing conceptually; the mechanism is laid out, but they don't give you the scales and exactly how to calculate [a score] because they won't know until they actually see every hospital's performance beginning in July," he says.
What this means for hospitals, Ciccone says, is that they will, in essence, always be chasing a moving target. "For hospitals, pace matters because they can be improving, but if others are improving at a faster rate, then they're losing ground."
One of the biggest concerns is the inclusion of eight hospital-acquired conditions as quality measures for FY 2014. "We are very strongly opposed to the inclusion of those measures in two places in hospital regulations," says Beth Feldpush, DrPH, senior associate director for policy at the American Hospital Association (AHA).
First, as part of the Affordable Care Act, Feldpush says, beginning in 2015, hospitals with high rates of hospital-acquired conditions are to be penalized. With CMS' proposal to also add those conditions to the VBP program, that "really puts hospitals at risk for double jeopardy and potentially being dinged twice on exactly the same measures. And that, we are strongly opposed to."
There also is the policy already in place dictating that for patients who have no present-on-admission indicators and then get a hospital-acquired condition, hospitals don't receive a higher DRG payment as part of the inpatient prospective payment system. Reminded of this, Feldpush says, "so in a sense this shows up three times... That's really triple jeopardy, so to speak."
"That seems inherently unfair," Ciccone says.
Feldpush says the AHA will definitely be commenting to CMS "that we strongly oppose the inclusion of these HACs in two different places in regulation related to the health care reform delivery changes." Ciccone agrees.
Another contentious element of the proposed rule is the inclusion of mortality measures, also on tap for FY 2014, specifically 30-day mortality rates related to AMI, heart failure, and pneumonia.
"Measuring mortality is certainly a very important component of looking at quality metrics. I think we would like to see from CMS more information on the proposed rule about how they would exactly incorporate those measures into the scoring," Feldpush says.
With the clinical measures, such as administering aspirin, it's a simple yes or no the hospital complied or it didn't. But with the mortality measures, CMS would have to account for risk adjustment for hospitals with differing sizes and patient populations, Feldpush says, as well as accounting for patients near end of life and those who elected not to receive life-sustaining treatment.
"I think there's still some outstanding questions around these mortality measures as to whether or not we've gotten the risk-adjustment methodology down."
Risk adjustment in general is a concern many experts have. Jessica Roth, assistant director of legislation and health policy at McDermott Will & Emery, says: "One of the things that we're thinking about here is that maybe what CMS should do is utilize that reporting structure for determining points related to outcome. So, perhaps hospitals that are better than the national average would get 10 points on that measure. Hospitals that are at the national average would get five points. Hospitals that are worse would get none.
"So, rather than looking at raw mortality data because of the issues around risk adjustment [make] sure that the measure is actually reflecting care that's within the hospital's control. I think that's one of the issues with the outcomes measure is, are you measuring something that is within the hospital's control? And, if it isn't, then is it fair to be measuring them on it? And, I think most people would say no, even CMS," Roth says.
"So, if that is, in fact, a concern because of these issues around the risk-assessment methodology, then we understand that outcomes are important and that CMS wants to look at those and consider those in this program; maybe a way to do it is, again, utilizing these more general categories rather than raw mortality rates."
Another concern is the way the rule, specifically the scoring methodology, includes the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey measures. A hospital's total score in the proposed rule would be calculated with 70% going to the process measures and 30% to the HCAHPS measures. "As we talk to hospitals, it seems that the general sense in the field is that that 30% weight for HCAHPS is too high," Feldpush says.
Ciccone also questions the 70-30 weighting.
Not only are HCAHPS scores subjective, but "I think the jury is still out on our understanding of what really impacts patients' responses, and we're beginning to learn more about [the fact that] patients who have more serious medical conditions tend to be more depressed, not surprisingly," Feldpush says. "And people who are depressed tend not to view their hospital experience so positively. Again, not necessarily surprising. But that's an example of the kind of relationship that's not captured in the current measures, so we have no way of risk-adjusting for sicker or depressed patients in HCAHPS."
Ciccone says in looking at HCAHPS scores, "one of the things that's clear to us is that there is a regional distribution of HCAHPS scores that varies by hospital size, even geography. The larger urban centers tend to have lower HCAHPS scores. People in some of the Northeastern states tend to have lower HCAHPS scores, and we are uncertain if there is any inherent bias in the survey."
Elimination of topped-out measures
In the proposed rule, CMS decided to exclude what it referred to as topped-out measures, "meaning that all but a few hospitals have achieved a similarly high level of performance on them. We believe that measuring hospital performance on topped-out measures will have no meaningful effect on a hospital's total performance score," the agency wrote.
But if they are important and hospitals should be doing them, why not include them, asks Roth. "I would say, on the whole, that CMS shouldn't deny hospitals the opportunity to gain points. And if these measures are, in fact, providing hospitals that opportunity, they should not be excluded."
In a November letter from the AHA and other stakeholders, says "the selection of measures for the VBP program should be based on the measures' ability to improve patient care and patient outcomes."
Regan E. Tankersley, attorney with Hall Render, also questions the possibility for appeals. "So, I think it's really going to drive home for hospitals the importance of tracking and reporting the data, especially now that this data is going to be taken, and it's going to be put into a formula, and you're going to get a value-based purchasing based on your performance and how that's weighted.
Now, what that says to me is, it's almost similar to what hospitals go through, let's say, for a wage data correction. You give the contractor a lot of information, they have to review it, and who knows how that calculation is going to come out in the end. And, you would think that providers would have some opportunity to either appeal it, adjust it, make sure errors were not reported, because of the way these calculations are going to work," she says.
"So, I'm curious to see if that is going to be brought up in commentary, if that is going to be addressed; is there going to be a mechanism for hospitals to see how their data are being reported and calculated, is there going to be an opportunity to correct, is there an opportunity to appeal a determination of what their payment is?"