CMS focuses on quality, not quantity in IPPS
Hospitals stand to lose more reimbursement
In the Inpatient Prospective Payment System (IPPS) final rule for 2014, the Centers for Medicare & Medicaid Services (CMS) continues its emphasis on quality and pay for performance.
"CMS is focusing more and more on quality versus quantity. Not only do hospitals need to focus on providing high-quality care, case managers need to work with physicians to make sure that documentation reflects severity of illness and the services the patients received," says Linda Sallee, MS, RN, CMAC, ACM, IQCI, director for Huron Healthcare with headquarters in Chicago.
In the final rule, issued Aug. 2, 2013, CMS announced new diagnoses being targeted in its readmissions reduction program and Value-based Purchasing Program and announced a new program to impose financial penalties on hospitals that perform poorly on the new Hospital Acquired Conditions Reduction Program.
And the penalties are rising. Penalties in the value-based purchasing program rise to 1.25% in October and go up by 0.25% each year until they top out at 2%. Penalties in the hospital readmission program are rising from 1% to 2% beginning with discharges on Oct. 1, 2013.
In the Hospital Acquired Conditions Reduction Program, which will begin in fiscal 2015, hospitals that rank in the lowest 25th percentile will receive a 1% reduction in the base operating MS-DRG payment. CMS already is not paying for treatment of certain hospital-acquired conditions.
The program gives hospitals scores in two domains of measure sets, taking risk factors such as patient age, gender and comorbidities into account. Measures in Domain 1 are weighted at 35% and include pressure ulcer rate, volume of foreign objects left in body, iatrogenic pneumothorax rate, central venous catheter-related blood stream infection, postoperative hip fracture rate, perioperative hemorrhage or hematoma rate, postoperative physiologic and metabolic derangement rate, postoperative respiratory failure rate, postoperative pulmonary embolism or deep vein thrombosis rate, postoperative sepsis rate, postoperative wound dehiscence rate, and accidental puncture or laceration rate.
Domain 2, which is weighted at 65%, includes central line-associated blood stream infection and catheter-associated urinary tract infections.
In addition, CMS is adding three new diagnoses—chronic obstructive pulmonary disease, elective total knee replacement, and elective total hip replacement—to the readmission reduction program with penalties beginning in fiscal 2015.
CMS is likely to continue to expand the number of diagnoses in the readmission reduction program the future, Sallee says. "This means that hospitals need to look globally at readmissions and not just concentrate on the ones in the program in order to prevent losses in the future," she says.
CMS announced 15 new discharge status codes that indicate a planned acute care hospital readmission. For example, one code specifies discharged to home and self care with a planned acute care inpatient readmission. The codes apply to all planned readmissions, not just those that occur within 30 days. "Case managers will need to pay more attention to discharge plans and to make sure the documentation indicates it if there is a planned readmission. It’s really important that the discharge documentation is clear when there is a plan for the patient to come back as an inpatient," Sallee says.