To get a good idea of what diagnoses CMS will add to the readmission reduction program or other value-based purchasing programs, look no further than the Hospital Inpatient Quality Reporting Program components.
Keep in mind that CMS won’t put anything in value-based purchasing that isn’t already a part of the inpatient quality measures, says Susan Wallace, MEd, RHIA, CCS, CDIP, CCDS, FAHIMA, vice president of inpatient services for Administrative Consultant Services, a Shawnee, OK, healthcare consulting firm.
On the other hand, anything that is part of the hospital quality reporting program and posted on Hospital Compare is fair game for inclusion in any of the CMS quality-based programs, Wallace says.
Case managers should be informed about how their hospitals perform on the current measures — all of which in the future may be included in value-based purchasing, the readmission reduction program, and the hospital-acquired conditions reduction program, Wallace says. She recommends that case managers review their hospital’s performance on the measures and identify opportunities for improvement.
Wallace points out that the hospital quality department has more specific and detailed information than what is published on Hospital Compare. “Case managers and the quality department should work closely to see where the hospital is vulnerable and where the opportunities are,” she says.
In the future, CMS is likely to continue focusing on areas that have received attention in the past, says Kurt Hopfensperger, MD, JD, vice president of compliance and education at Optum Executive Health Resources in Philadelphia.
For instance, even though CMS has canceled the cardiac bundled payment initiative, scrutiny is likely to continue because it’s a high-cost, high-volume diagnosis group, he says.
“Hospitals’ cardiac procedures are under scrutiny from CMS and its auditors, and even the Department of Justice. It’s only going to continue,” he adds.
In the Inpatient Prospective Payment System final rule for fiscal 2018, CMS announced its intention to add a 30-day episode of care for pneumonia indicator to the efficiency and cost-reduction domain in value-based purchasing, beginning in fiscal 2022.
Even though CMS has not created a bundled payments arrangement for pneumonia, it is treating the 30-day episode as a bundle in value-based purchasing, Hopfensperger says.
The Two-Midnight Rule is here to stay — at least for a while, Hopfensperger says. “CMS has had multiple opportunities to modify the rule and they didn’t change anything, including the exceptions for one-midnight inpatient stays,” he adds.
CMS has remained silent on the Two-Midnight Rule for almost two years, says Edward Hu, MD, CHCQM-PHYADV, president of the American College of Physician Advisors.
The last change was in January 2016 to allow exceptions to the rule on a case-by-case basis, Hu adds. “CMS has stopped issuing new guidance and making changes in the rule. All the Open Door forums on the Two-Midnight Rule were within the first few months after the rule was announced. CMS is sticking with the guidance that’s already been issued and so far, has not made changes,” Hu says.
However, Hu predicts that the rule will fall by the wayside as initiatives such as bundled payments and Medicare spending-per-beneficiarygrow.
“The Two-Midnight Rule and its focus on patient status is not where CMS is going. As CMS moves toward a risk-sharing environment, patient status will become irrelevant,” Hu points out. “What is becoming important is the total cost of an episode of care."