Outpatient payments to be linked to quality reporting

Hospitals must report on seven measures in 2008

In its final rule for the Outpatient Prospective Payment System for calendar year 2008, the Centers for Medicare & Medicaid Services (CMS) took the first steps linking payment for outpatient services to the quality of care received by expanding the Hospital Outpatient Quality Data Reporting Program and requiring hospitals to report on outpatient quality measures for the first time.

Case managers will have an opportunity to impact their hospital's performance on the outpatient quality measures by educating staff on the importance and evidence supporting the measures and by conducting retrospective reviews to identify areas where the processes can be improved, says Carolyn C. Scott, BA, BSN, MHA, director, KPMG healthcare risk advisory services.

The seven quality measures, which have been endorsed by the National Quality Forum, include five measures of standards of care in the emergency department for acute myocardial infarction (AMI) patients transferred to other facilities for care and two outpatient surgical care improvement measures.

In order to receive the full OPPS payment update in 2009, hospitals will be required to submit data on the outpatient quality measures for services furnished on or after April 1, 2008.

If hospitals do not comply with the quality reporting requirement in 2008, their OPPS update will be reduced by 2% in 2009.

Move toward value-based purchasing

The outpatient quality measures are proposed to be included in the CMS value-based purchasing initiative, which links payment to quality, rather than just the delivery of services, Scott says.

CMS is required by the Deficit Reduction Act of 2005 to have a plan for value-based purchasing in place by 2009, she adds.

Value-based purchasing ultimately will replace the current hospital quality reporting system and will include both public reporting and financial incentives to drive clinical quality, Scott says.

Case managers are in a position to help their hospitals prepare for the time when payment for outpatient services will be linked to quality, rather than just delivery of services, Scott says.

The emergency department AMI measures include aspirin at arrival; median time to fibrinolysis, fibrinolytic therapy received within 30 minutes of arrival, median time to electrocardiogram, and median time to transfer for primary percutaneous coronary intervention (PCI).

Perioperative care measures include timing of antibiotic prophylaxis and selection of prophylactic antibiotic.

CMS originally had proposed going beyond these seven measures including outpatient measures for heart failure, community-acquired pneumonia, and diabetes, Scott says.

The agency reduced the number of measures for 2008 after numerous people who commented on the proposed rule said the additional measures would be too difficult to implement at this time, she says.

However, CMS has announced its intention to develop a list of additional outpatient quality measures to be implemented in future years.

ED quality measures

The emergency department quality measures that hospitals must track in 2008 apply only to AMI patients who are being transferred to other hospitals with cardiac catheterization laboratories and won't affect hospitals that can perform the procedure in-house since patients treated with PCI and not transferred are captured in the current reporting requirements for the Inpatient Prospective Payment System, Scott points out.

"Many hospitals don't have PCI capability in-house and have to transfer the patients to another facility. CMS and the American College of Cardiology want to get a better understanding of how well the transferred patients are being treated. The outpatient data on transferred AMI patients will pick up patients that hospitals don't capture in their inpatient data collection for their inpatient AMI performance since these patients never are admitted to the inpatient setting," Scott says.

Case managers probably won't have an opportunity to affect the AMI measures because of the short time the patient will be at the hospital if the emergency department is efficient, Scott points out.

"If a hospital is doing it well, these patients won't be in a facility very long. They should be transferred to another hospital in less than an hour if the emergency department staff are good at identifying patients who are having a heart attack and arranging for the transfer. In most cases, they should be out the door before the case manager knows they're in the hospital," she says.

However, case managers can play a big role in the educational piece for the AMI measures and should be prepared to discuss with staff why the measures were selected and what they mean, she adds.

Where CMs fit in: The retrospective review

The new AMI measures represent a good opportunity for retrospective review in order to identify areas where processes and patient throughput can be improved, Scott points out.

"It's particularly valuable if someone can conduct the review as soon as possible when the patients aren't transferred as quickly as they could be. This will enable the hospital to do a mini root-cause analysis and take immediate action to correct the problem for future patients," she says.

The two outpatient surgical measures revolve around antibiotics that are given within an hour of surgery. Documentation for outpatient surgical patients should include what antibiotic was administered and what time it was given.

"Case managers cannot affect the antibiotic selection for surgery patients nor the time at which it is given but they can they can take action retrospectively by analyzing the reports to determine any patterns in failure to comply, such as the practices of specific surgeons," Scott says.

The case managers can examine the patient record to make sure that the order was written and that the antibiotic was given in a timely manner specified by the quality measures.

In addition, case managers can make sure that the patient record shows that the antibiotic selection falls within guidelines; if it does not, that the reason is documented.

Case managers could be effective in increasing compliance with the perioperative antibiotic prophylaxis measures by educating the staff about why it's important to give the antibiotics in a timely fashion, Scott suggests.

"The evidence is clear on the effectiveness of these antibiotics in preventing infections if they are administered within one hour of incision time for most antibiotic types and what it means if they are given too early or too late. Clinical people always want to do the right thing for the patient and that is more likely to happen if they understand why the measures recommend specific practices," she says.

(Editor's note: For more information, contact Carolyn Scott at e-mail: carolynscott@kpmg.com.)