Can't drive 55
Some hospitals say the proposed new law measures will be tough to implement
By Maureen McKinney,Modern Healthcare, April 26, 2010
A slew of newly proposed quality measures have providers clamoring for clarification and wondering about the burdens that additional reporting requirements may place on their organizations.
The CMS included the new measures for its Reporting Hospital Quality Data for Annual Payment Update program in its proposed changes to the inpatient prospective payment system, published April 19 (See related story, p. 10). If the rule is finalized, hospitals will be required in January 2011 to begin reporting on 10 additional measures to receive the full marketbasket update for 2012.
Eight of those new measures are from the agency's list of hospital-acquired conditions and the two remaining measures are patient-safety indicators from the Agency for Healthcare Research and Quality (See chart). The CMS also proposed deleting one measure—mortality for selected surgical procedures (composite)—which would bring the total number of measures required for the full 2012 update to 55.
The proposal from the CMS attracted some criticism over the measures it selected.
“We embrace reporting and being measured for the care we provide to our patients, but a lot of these measures are weakly linked to science and are subject to a lot of variation,” said Alex Hover, senior vice president of clinical excellence at St. John's Health System, a six-hospital system in Springfield, Mo. “We're going to need a lot of clarification.”
For instance, Hover said, the CMS' proposed requirement that hospitals report all falls that result in minor injury could prove difficult without clearly outlined parameters.
Some called for elaboration from the CMS. Reporting requirements on manifestations of poor glycemic control should be made clearer because control is affected by many different factors, said Shawn Stinson, vice president of clinical quality and patient safety at Palmetto Health, a three-hospital system based in Columbia, S.C. “Glucose control depends on co-morbidities and severity of illness, and while we have specific blood sugar targets for some conditions, we don't for others,” he said. “When you start to tighten control, it can result in an increased number of hypoglycemic events, which can be even more dangerous.”
Stinson said he will also be looking carefully to see how the CMS handles reporting of deep vein thrombosis. Specifically, he said he is hoping to see a method to indicate whether all steps of care were properly followed. “Sometimes we can do everything right and a patient will still have a DVT,” he said. “We need to be able to report that.”
And the quality changes may not stop with the 10 new proposed measures. The CMS is proposing 35 more measures that providers would need to begin reporting on in 2011, but which would not be used in determining annual payment update until 2013. Most of the data on those quality measures would come from registries.
For instance, 15 measures related to cardiac surgery, including post-operative renal failure and beta blockade at discharge, would come from a cardiac surgery registry. The proposed changes also include registry-based measures for stroke care and nursing sensitive care.
Additionally, the CMS proposed four more measures—two related to emergency department throughput and two related to immunizations for reporting in 2012 that would be used for 2014's annual payment update.
Finally, the agency also included 28 other measures that would not be required for reporting, but would likely be used in future rulemaking.
The steep volume of the changes also caught the attention of quality experts. “The real concern for us is how they are going to take this onslaught of new data and use it to drive better performance,” said Nancy Foster, vice president for quality and patient safety for the American Hospital Association. “Are these really the right measures? Do they have the capacity to drive improvement? I don't think we know that, and it's also possible CMS could get better results with a leaner set of measures.”
Another worry is the proposed rule's reliance on registry-based reporting, said Blair Childs, spokesman for the group-purchasing and quality-improvement organization Premier. Many providers already submit quality data to registries such as the Society of Thoracic Surgeons' Adult Cardiac Surgery Database or the American Heart Association's National Registry of CardioPulmonary Resuscitation, and that participation is a good thing, Childs said.
The problem, he argued, is a government mandate that requires providers to participate in proprietary programs—a policy that would result in “government-created monopolies,” he said. Some hospitals have data warehouses that enable them to access quality data for these measures, he said, but under the proposed rule and without access to the right algorithms, they would still be obligated to submit to registries.
“There are terrific registries out there, and I'm glad that hospitals who want to participate have the option to do it,” Childs said. “The issue is that hospitals shouldn't be forced to do it as part of public policy.”
For most hospitals, the additional reporting burdens would not be too significant, said Ben Yandell, associate vice president of clinical information analysis for Norton Healthcare, a three-hospital system in Louisville, Ky. That's particularly true for 2012's update because most of the information would come from CMS' analysis of claims data. And because most hospitals submit data to one or more quality registry, if the CMS does finalize that requirement, most hospitals will have little problem complying.
Paying licensing fees
Hospitals that are not submitting data to a registry, however, will face the task of paying licensing fees to begin reporting, and they will also need to allot time and resources for collecting data and maintaining accuracy, St. John's Hover said. For instance, annual fees for participating in the Adult Cardiac Surgery Database are $2,750 if a majority of surgeons are members of the thoracic society, and $3,450 if the majority are not members, said Cynthia Shewan, the society's director of quality research and patient safety. “We already participate in several registries, and we have a full-time employee whose only job is to go through charts and collect these measures,” Hover said.
Stinson agreed, saying that while most hospitals are already likely contributing to one of these quality registries, for those that are not, it will prove to be quite an investment. The National Rural Health Association, is wary of new quality reporting requirements that would increase the administrative burden on rural hospitals without a clear return, a spokesman said.
There is also another proposed addition that could require additional work, said Lisa Grabert, AHA's senior associate director for policy. For 2011 reporting and the 2012 update, the CMS is also proposing to add all patient volume data for 55 selected MS-DRGs that relate to the year's set of quality measures.
“That is not put into the total count, but it would really increase the work for hospitals because they are not reporting on these now,” Grabert said. “That's like adding more than 50 new measures.”
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