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OIG to CMS: Target Reviews of Hospital Quality Data

The Office of Inspector General (OIG) has issued a review of the Centers for Medicare & Medicaid Services (CMS) oversight and efforts to ensure the quality of the Inpatient Quality Reporting (IQR) data. OIG recommends that CMS use additional tools to identify anyone gaming the system.

CMS typically uses a random sample of 400 hospitals to validate IRQ data, but can scrutinize an additional 200 hospitals that have suspicious data. OIG found that CMS did meet its regulatory burden in 2016 by validating IRQ data from 400 hospitals — 99% of which passed validation. However, the OIG was critical of CMS for not including “any hospitals in its target sample on the basis of their having aberrant data patterns.” If hospitals with aberrant data were included in the sample, it would increase CMS’s likelihood of identifying hospitals that were “gaming” the system and ultimately protect the integrity of the IRQ based programs, according to OIG.

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CMS and the CDC recently issued a Joint Reminder that manipulated IRQ data, especially with regards to reportable hospital infections, negatively affects the integrity of the programs that rely on this data. The reminder included several analytical tools that CMS could use to improve their ability to identify outliers with respect to hospital-based infection reporting. According to the OIG report, CMS has failed to use these analytics to validate targeted hospitals. “For example, CMS could use analytics to identify hospitals with abnormal percentages of patients who had infections present on admission; this might help identify hospitals that engage in some of the data manipulation highlighted in CMS and CDC’s Joint Reminder,” the report stated.

Accurate IRQ data is essential to several CMS quality based payment programs, such as the Hospital Value-Based Purchasing Program, the Hospital-Acquired Conditions Reduction Program, and the Hospital Readmissions Reduction Program.

Robert B. Vogel, MD, JD
Retinal Ophthalmologist at Piedmont Eye Center, Lynchburg VA;
Attorney, Overbey Hawkins & Wright, PLLS, Lynchburg, VA;
Adjunct Professor, Humanities and Bioethics, Liberty University School of Medicine, Lynchburg, VA.