A clear trend in the Centers for Medicare and Medicaid Services’ (CMS) 2019 Inpatient Prospective Payment System (IPPS) proposed rule update is reducing administrative burdens that the agency’s quality reporting and value-based payment programs place on physicians and hospitals.
At first glance, the update may seem counterintuitive to promoting quality in healthcare. However, new opportunities to address critical quality issues will be possible from the relief it would provide.
The Value-Based Payment Landscape
The commitment to quality improvement and the broader shift to value-based payment (VBP) models in healthcare have historically received bi-partisan support and occurred despite fluctuations in government mandates. For example, a group of democratic and republican representatives in Congress recently joined forces to announce a new healthcare innovation caucus focused on advancing legislation toward improving care quality and lowering treatment costs.
Within the industry, more than a third of healthcare professionals surveyed this past November said their organizations are moving toward value-based payments at a moderate pace, and another 27 percent said their pace is fast or very fast. Major health insurers are implementing VBP programs. And a survey of healthcare executives completed last year found two-thirds plan to increase clinical registry participation in the next five years. Registries can provide measurement infrastructure needed for VBP programs.
Proposed Rule Update Implications
CMS released its 2019 IPPS proposed rule this past April. Overall, the update would remove a total of 18 quality measures across five quality and value-based payment programs, de-duplicate another 21 measures, and adopt one measure on unplanned readmissions that will go into effect in 2021. Some proposed updates are scheduled to take effect as early as Oct. 1, 2018. Overall, they would impact more than 3,700 acute and long-term care hospitals that treat Medicare patients.
Interestingly, the update includes a new justification for measures removal based on whether the cost burden of reporting on a measure outweighs its clinical benefit. A recent Q-Centrix analysis shows that CMS's estimate for average reporting times for those measures is relatively aggressive – and overstates the cost burden by as much as $10 million. The analysis compared CMS's reporting time estimates to Q-Centrix’s, which are based on millions of reporting transactions performed over the past seven years. It also accounted for that the average hospital takes approximately five times longer to report on measures than Q-Centrix abstractors do. CMS’s aggressive estimate may signal the agency is serious about the freeing up of hospitals and physicians to focus on other quality areas.
Changes proposed to the Electronic Clinical Quality Measures (eCQMs) program as part of the proposed rule update are also consistent with the idea of reducing reporting burdens. They appear to advance the program’s evolution toward focusing on measures most suitable for electronic submission. For example, a measure evaluating time from emergency room to inpatient care admission is being proposed for electronic submission only.
Furthermore, the proposed rule update aims to overhaul CMS’s Medicare and Medicaid Electronic Health Record Incentive Programs, also known as the “Meaningful Use” program, to increase interoperability and flexibility for participants. The proposal includes updates to scoring methodology and adding new measures, including one related to the electronic prescribing of opioids and verification of doctor-patient opioid treatment agreements.
New Quality Opportunities
The measures removals and the new justification for them create a singular opportunity for hospitals to focus on other important quality areas. Resources potentially freed up by reduced reporting burdens could bring previously unattainable quality efforts within reach.
The measures the proposed rule leaves alone are likely not a coincidence. For example, healthcare-acquired conditions (HACs) measures, which include infections, would not be reduced. This is an area with broad population health implications and a considerable impact on care costs and hospital reputations. It is also one where much improvement is needed.
Last year, more than 750 hospitals saw their Medicare reimbursements lowered as part of CMS’s program to reduce healthcare-acquired infections. At current rates, one in 25 hospitalized individuals will experience at least one of these infections and 75,000 people die each year from them.
By refocusing resources potentially freed up under the proposed rule, hospitals can launch new infection prevention efforts and other safety initiatives – or strengthen existing programs. For example, putting in place the recommended number of infection preventionists per facility patient volume might be possible if fewer staff hours are needed to gather and submit quality data.
Another avenue for improvement is participation in clinical data registries. There are hundreds of registries – including many focusing on the most prevalent – yet, often preventable – conditions, such as complications associated with heart disease, cancer, and diabetes. Better outcomes in these areas could significantly reduce healthcare spending and increase quality of life among entire communities.
Registries are widely accepted across the industry as model approaches for measuring the value of specific medical interventions. They also put the discovery and implementation of evidence-based practices into the hands of the experts who understand these disciplines the best – and who serve on the front lines of care.
Often neglected when resources are tight are necessary information technology improvements. By taking advantage of an opportunity to focus resources on systems upgrades, such as Electronic Health Record implementation and automated quality data management solutions, hospitals can achieve new levels of efficiency. Streamlining these processes relieves doctors and nurses from administrative tasks that keep them from practicing to the full extent of their training.
Refocusing resources on previously unattainable quality efforts has at least one other benefit: achieving the flexibility needed to withstand fluctuations in quality reporting requirements. If the 2019 proposed rule update is any indication, we can expect an uptick in the removal and addition of measures and other program changes. And as we stare down new, previously unimagined health crises, like widespread opioid addiction and antibiotic-immune superbugs, nimbleness will be key to success.
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Brian Foy leads solutions strategy creation, product development, and healthcare quality information system engineering as Chief Product Officer for quality data solutions provider Q-Centrix.