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November 8, 2007

Medicare Performance Measurement Updates: Outpatient, Inpatient, and Physician

Last Friday, the Centers for Medicare and Medicaid Services (CMS) released their final rules on the Medicare Hospital Outpatient, Inpatient, and Physician Quality Reporting on provider performance measurements. 

The rules identified specific measurements, time frames, and overall administration of the program. While the physician reporting is still voluntary; reporting of hospital inpatient and outpatient data is linked to percent payment increases for non-critical access hospitals. While physician reporting does not directly effect hospitals, it is important for hospitals to understand that some measurements for a patient are the same for physician reporting and hospital reporting which in the future could be used to identify discrepancies in patient care documentation.

Inpatient Reporting
As noted in the final rules covering Medicare inpatient payments that were released mid-summer, Medicare indicated that they were considering adding additional inpatient measurements for hospitals if they were approved by the National Quality Forum (NQF) by the time the outpatient rules were released in November. As a result of NQF recent approval of additional measurements as noted below, IPPS hospitals will be required to report the measurements starting with January 1, 2008 inpatient discharges in order to receive their full market basket increase in federal fiscal year 2009. The additional inpatient measurements are:

This brings the total number of measurements to 30 along with HCAHPS (Patient Experience – Satisfaction Survey) required for hospitals to receive full market basket increases.

Hospital Concerns on Continuous Inpatient Reporting Issues
IHA has continuously voiced concerns raised by hospitals on the Medicare problems with validation errors and appeal processes; multiple and continuous errors in HQA warehouse edits and processing; errors in instructions and specifications; inconsistencies among UB and clinical reporting for the same elements; and overall lack of communication about issues and problems.

While IHA has continuously voiced these concerns in written comments; it is now evident that Medicare has heard the issues and is developing responses and remedies to respond to these issues. Medicare has contracted with Mitre Corporation, a federally funded research and management corporation, to suggest operational and oversight changes. IHA was extensively interviewed by Mitre Corporation on these issues. Additionally, on Monday, October 29, IHA participated in a conference call with Herb Kuhn, CMS Director, and a few other state hospital associations and AHA to voice our concerns about the inpatient reporting problems. CMS promised to establish routine meetings with state associations and AHA to address these issues and to quickly identify future issues and develop quicker responses.

Hospital Outpatient Reporting
As we all hoped and advocated for, Medicare has delayed implementation and will begin collection of Hospital Outpatient Performance Measurements starting with 2nd Quarter 2008 Patient Cases for OPPS Hospitals.  This first quarter of reported data will not be made public as it will be an opportunity for providers to submit their data and prepare for the public release.

Third quarter 2008 hospital outpatient measurements will be the first quarter with results to be made available to the public. Third quarter 2008 outpatient performance measurements will be the first quarter of outpatient measurement data validated (2nd quarter 2008 will not be validated).

Also, as expected, the time frame for submitting data will be narrowed.  All hospital outpatient performance measurements must be submitted in final format within 4 months of the close of a quarter.  For example, 2nd quarter 2008 (April 1 2008 to June 30 2008 cases) must be submitted by November 1, 2008.

The following measurements will be required to be reported starting with April 1, 2008 cases:

Planning Ahead
I know this is welcome news for all of you --- consider using this time to better understand the volume of cases you will be reporting on; how best to ensure your hospital is capturing all the cases; and if your vendor is prepared to report on this information starting with 2nd quarter 2008 patient cases.  It will also be helpful to get a jump start on educating the staff of the process improvement measurements and standards of care identified through these measurements.

Hospital Participation Form. You will be receiving within the next few weeks a form for your hospital to complete by January 31, 2008, indicating your intention to participate.  As you may recall, reporting participation will be linked to outpatient payments for calendar year 2009.

Medicare Administrative Changes. Unlike in the past, education and training for the outpatient measurements will be from a national resource rather than individual QIOs. This change is reflective of other changes Medicare is taking with some of their administration of programs. Some of the financial administration of Medicare has moved and more areas are moving to regional or consortium administration and Medicare has announced that many of the QIO activities will also move to regional and national administrators.

Medicare has announced that they will definitely have a ‘CART’ Tool for the Hospital Outpatient reporting and the QNet will remain the same. However, CMS has not indicated how they will administer the data measurement warehouse, but will have announcements available soon.

Critical Access Hospitals. While these measurements are linked directly to hospital payment for OPPS providers, CAH providers will note that many of these are more closely tied to their outpatient services and stabilize and transfer services. While CMS has not indicated that CAH will be required to report in the future, CMS did note several times these measurements are applicable to hospitals with low volumes that often times stabilize and transfer patients. IHA will keep CAH providers updated on these measurement developments. IHA Comparative Performance Initiative and IHA’s COMPdata already receive performance measurement data from the majority of CAH providers as they voluntarily participate in public reporting for the Hospital Quality Alliance.

Physician Quality Reporting Initiative (PQRI)
While physicians will be able to report their measurements voluntarily on their billing and claim forms, it is important for hospitals to understand some of the characteristics of PQRI and some of its overlap with hospital reporting. For example, there are several measurements that are the same for both physician and hospital reporting covering the same patient population. As the Medicare Audit Contractor program evolves, it will be important for hospitals to make sure documentation is accurate and complete so there are no inconsistencies between what a hospital reports and what a physician reports for the same patient for the same measurement.

The PQRI program is rapidly expanding during calendar year 2008 to include the following measurements and initiatives: 

IHA will continue to keep you updated and to voice your concerns on performance measurements and processes to ensure accurate reporting and proper payment for hospitals. As additional details on these reporting initiatives become available over the next few weeks, IHA will keep members informed so that all hospitals will be compliant and eligible to receive their full market basket increases.

Staff Contact: Pat Merryweather