ffy 2014 medicare inpatient prospective payment system ......revises the conditions of participation...

FFY 2014 Medicare Inpatient Prospective Payment System

Summary of the Final Rule

August 2013

The Centers for Medicare & Medicaid Services (CMS) has published its final rule for rate updates and

policy changes to the Medicare inpatient prospective payment system (IPPS) and long-term care hospital

prospective payment system (LTCH PPS) for federal fiscal year (FFY) 2014. The final rule was released

on August 2 and published in the August 19 Federal Register and is available at

http://www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf. Unless otherwise noted, all policy

and payment changes are effective for discharges occurring on or after October 1, 2013.

Provisions related to the LTCH PPS, including the LTCH quality reporting program, will be summarized

under separate cover and available soon on the CHA Regulatory Tracker at

http://www.calhospital.org/publication/cha-regulatory-tracker under the Final Rules tab.

The final rule:

Implements a revised Medicare DSH methodology in accordance with the ACA provisions;

Updates policies relating to the Hospital Value-Based Purchasing (VBP) program and the Hospi-

tal Readmissions Reduction program;

Establishes several aspects of the Hospital Acquired Conditions Payment Reduction program for

FFY 2015;

Updates and establishes requirements for the inpatient quality reporting program, as well as the

quality programs for PPS-exempt cancer hospitals and inpatient psychiatric facilities (IPFs) that

are participating in Medicare (LTCH quality program provisions are included in the LTCH sum-

mary);

Establishes guidelines for admission and medical review criteria for payment of hospital inpatient

services; and

Revises the conditions of participation (CoPs) for hospitals relating to the administration of vac-

cines by nursing staff, as well as the CoPs for critical access hospitals relating to the provision of

acute care inpatient services.

This rule also finalizes policy issued in separate rulemaking that included payment policies related to

Medicare Part B inpatient billing in hospitals. A summary of these provisions will be available under sep-

arate cover and posted to the CHA Regulatory Tracker soon.

FFY 2014 Final Payment and Policy Changes

CMS estimates that total Medicare operating payments to all acute care hospitals for discharges occurring

after October 1, 2013, would increase by 0.7 percent for a total of $1.2 billion compared to FFY 2013. A

summary is provided in Table 1 below. CHA estimates California hospitals will see a decrease in

overall payments of 1.2 percent, or $125.6 million, from FFY 2013. This is largely due to the signifi-

cant decrease in Medicare DSH payments discussed below.

http://www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf

http://www.calhospital.org/publication/cha-regulatory-tracker

CHA Summary: FFY 2014 Medicare Inpatient Prospective Payment System Final Rule

August 2013

Table 1: Summary of the FFY 2014 CMS Final Rule Policies

Federal Oper-

ating Rate

Hospital-

Specific Rates Federal Capital Rate

Market Basket (MB) Update/Capital Input Price Index +2.5%

(unchanged) +2.5%

(unchanged) +0.9%

(unchanged)

ACA-Mandated Productivity MB Reduction -0.5%

(proposed at -

0.4%)

-0.5%

(proposed at -

0.4%) —

ACA-Mandated Pre-Determined MB Reduction -0.3%

(unchanged) -0.3%

(unchanged) —

Subtotal –payment rate inflation update +1.7% +1.7%

American Taxpayer Relief Act (ATRA)-Mandated Ret-

rospective Coding Adjustment Reduction -0.8%

(unchanged) — —

Inpatient Admission Guidance Offset -0.2%

(unchanged) -0.2%

(unchanged) -0.2%

(unchanged)

Net Rate Change

(EXCLUDING BUDGET NEUTRALITY)

+0.7%

(proposed at

+0.8%)

+1.5%

(proposed at

+1.6%)

+0.7%

(unchanged)

Market Basket Update and Productivity Adjustments

CMS estimates the FFY 2014 IPPS market basket to be 2.5 percent. However, the Affordable Care Act

(ACA) requires an adjustment in FFY 2014 for multifactor productivity (now finalized at - 0.5 percentage

points), as well as a 0.3 percent decrease in the market basket. This results in a 1.7 percent increase in the

market basket for hospitals. Hospitals that do not report data to the hospital inpatient quality reporting

(IQR) program remain subject to the 2 percent reduction in their market basket.

Documentation and Coding Adjustments

CMS will reduce operating payments by 0.8 percent to account for the documentation and coding adjust-

ment for FFYs 2010, 2011 and 2012 that would, in part, fulfill the requirement of the American Tax Re-

lief Act of 2013 (ATRA), which requires CMS to recoup $11 billion over the next four years (FFY 2014-

2017). Because retrospective adjustments are one-time reductions, the reduction taken in FFY 2014 re-

turns to the baseline. If CMS were to proceed in reducing payments each year by 0.8 percent, in FFY 2018

payments would increase by 3.2 percent.

Federal Operating and Capital Rates

Incorporating the final rule updates with the effect of budget neutrality adjustments, the table below lists

the federal operating and capital rates for FFY 2014 compared to the rates currently in effect:

Table 2: Federal Operating and Capital Rates for FFY 2014

Final

FFY 2013

Final

FFY 2014 Percent Change

Federal Operating Rate $5,348.76 $5,370.28 +0.4%

(proposed at +0.5%)

Federal Capital Rate $425.49 $429.31 +0.9%

(proposed at +1.5%)

Effect of Sequestration for FFY 2014

While the final rule does not specifically address the 2 percent sequester reductions to all Medicare pay-

ments authorized by the Budget Control Act (BCA) of 2011 and currently in effect, sequester will contin-

ue unless Congress intervenes. Sequester is not applied to the payment rate; instead, it is applied to Medi-

care claims after determining co-insurance, any applicable deductibles, and any applicable Medicare sec-


August 2013

ondary payment adjustments. Other Medicare payment lines — such as graduate medical education

(GME), bad debt, and electronic health record (EHR) incentives — are also affected by the sequester re-

ductions.

Additional Factors Affecting Payment Impacts

Table 3 below summarizes the CMS estimates of the impact of all policy and payment changes by provid-

er type for FFY 2014.

Table 3: Summary of FFY 2014 IPPS Impact

Hospital Category CMS Total

Impact Estimate*

All Hospitals 0.5%

All Urban Hospitals 0.7%

Urban: Pacific Census Division -0.5%

Rural Hospitals -1.6%

Rural: Pacific Census Division 0%

Source: Table I on page 2,109 of the display copy of the final rule

Although the FY 2014 standardized amounts increase 0.7 percent compared to FFY 2013, the payment

impact analysis shows aggregate payments increasing 0.5 percent. Other significant factors affecting the

payment impact of the final rule include but are not limited to changes in the Medicare DSH methodolo-

gy, readmissions reduction program and the wage index. A complete summary of the national impact of

all the related provisions is available in the regulatory impact analysis section of the final rule.

Outlier Methodology and Fixed-Loss Threshold

In prior rulemaking, CMS received numerous suggestions to improve the accuracy of its methodology for

setting the outlier threshold. CMS made no changes for FFY 2013 but agreed to consider them for FFY

2014. In the final rule CMS adopts its proposed changes in the methodology to calculate a fixed-loss cost

threshold consistent with the 5.1 percent target.

1) For FFY 2014 and subsequent years, CMS will determine the charge inflation factor using a one-year period

of the most recent charge data instead of comparing periods using only the most recent six months of charge

data. To compute the one-year average annualized rate-of-change in charges per case for FFY 2014, CMS

compared the third quarter of FFY 2011 through the second quarter of FFY 2012 (April 1, 2011, through

March 31, 2012) to the third quarter of FFY 2012 through the second quarter of FFY 2013 (April 1, 2012,

through March 31, 2013). This rate of change was 4.7 percent (1.047329) or 9.7 percent (1.096898) over two

years.

2) For FFY 2014, CMS adjusts the CCRs from the March 2013 update of the Provider-Specific File

(PSF) – the most recent data available for the final rule. To make the adjustment, CMS compares the

percentage change in the national average case-weighted operating CCR and capital CCR from the

March 2013 update of the PSF to the national average case-weighted operating CCR and capital CCR

from the March 2012 update of the PSF. CMS used total transfer-adjusted cases from FFY 2012 to de-

termine the national average case-weighted CCRs for both sides of the comparison.

Adhering to its policy since the FFY 2009 IPPS final rule, CMS applies only a one-year adjustment

factor to the CCRs.

CMS finalized its proposal to not make any adjustments for the possibility that hospitals’ CCRs and outli-

er payments may be reconciled when cost reports are settled.


August 2013

CMS had proposed to exclude the new uncompensated care DSH payments from the outlier fixed-loss

threshold. CMS argued that the uncompensated care DSH payments were not factored into the methodol-

ogy for the fixed-loss threshold because it had proposed to make those payments on a periodic interim

basis rather than a per-claim basis. CHA opposed this proposal as it caused a higher outlier threshold and

was inconsistent with the statutory provisions that require all amounts attributable to Medicare DSH to be

part of the outlier determinations. CMS agreed with CHA and other commenters and has agreed to make

the uncompensated care DSH payments on a per-claim basis (see Medicare DSH section) and to account

for them in setting the threshold.

To maintain total outlier payments at 5.1 percent of total IPPS payments, CMS is adopting an outlier

threshold of $21,748 for FFY 2014 (proposed at $24,140). The new threshold amount represents a 0.3

percent decrease compared to the current threshold of $21,821.

Market Basket Rebasing

Every four years, CMS rebases and revises the inpatient PPS market basket. CMS rebases the market bas-

ket periodically so that the cost weights in the market basket will reflect recent changes between base pe-

riods in the mix of goods and services that hospitals purchase and best available data. CMS last rebased

the hospital market basket for FFY 2010, with FFY 2006 cost report data used as the base period for con-

structing the market basket cost weights. CMS finalized its proposal to establish FFY 2010 as the base

period for determining expenditures by spending category, primarily using Medicare cost report data and

supplemented by other sources. The final market basket produces an increase of 2.5 percent for FFY

2014, which is the same increase determined using the current market basket.

Hospital Area Wage Index and Labor Share

CMS is not proposing any major changes to the calculation of Medicare hospital wage indexes, the rural

floor budget neutrality policy, the imputed rural floor methodology or the current administrative reclassi-

fication rules. With that said, CMS finalized its proposal to extend the imputed rural floor through FFY

2014. Last year CMS temporarily revised the methodology, and both New Jersey and Rhode Island hospi-

tals benefit from the imputed rural floor.

CMS estimates that 424 hospitals will benefit from the rural floor and imputed rural floor, while the re-

maining 2,983 IPPS hospitals will have their wage index reduced by the rural floor budget neutrality ad-

justment of 0.990150 (or 0.99 percent). In aggregate, rural hospitals will experience a 0.3 percent de-

crease in payments as a result of the application of the rural floor budget neutrality. CMS estimates that

Massachusetts hospitals will receive approximately a 5.5 percent increase in IPPS payments due to the

application of the rural floor in FFY 2014. Other states benefitting significantly from the rural and imput-

ed rural floors are: California ($94 million, 182 of 309 hospitals), Connecticut (imputed floor, $65 mil-

lion, 19 of 32 hospitals), New Jersey (imputed floor, $14 million, 25 of 64 hospitals), Nevada ($11 mil-

lion, 19 of 24 hospitals), and New Hampshire ($9 million, nine of 13 hospitals).

In February, the Office of Management and Budget released new information regarding metropolitan sta-

tistical areas, micropolitan statistical areas and combined-based statistical areas that reflect the 2010 cen-

sus. While not as sweeping as the 2003 changes, CMS states there are enough changes regarding the ef-

fects of the new designations that would need to be considered prior to proposing and establishing revised

policies. Therefore, CMS expects to make changes in FFY 2015 to allow for sufficient time to consider

next steps. CHA is currently reviewing the changes in anticipation of rulemaking. We do know, howev-

er, that one additional hospital will be rural in the state of Massachusetts, thereby augmenting the rural

floor significantly. This will have significant implications for the area wage index next year.

CMS finalized its proposal to update the labor-related share value for hospitals with a wage index of

greater than 1 to 69.6 percent for FFY 2014, a slight increase when compared to the current labor share of


August 2013

68 percent. By law, the labor-related share for hospitals with a wage index of less than one will remain at

62 percent. This policy results in a positive impact for California’s hospitals.

Finally, applications for FFY 2015 hospital wage index reclassifications are due to the Medicare Ge-

ographic Classification Review Board (MGCRB) by September 3, 2013. Applications not received

by the MGCRB by this deadline will not be considered.

Applications/instructions for hospital wage index reclassifications are available on the CMS Web site at:

http://www.cms.gov/MGCRB/.

Updates to the MS-DRGs and Relative Weights for FFY 2014

CMS is did not propose any major changes to the Medicare-Severity Diagnosis Related Group (MS-DRG)

classifications. For FFY 2014, CMS would maintain a total of 751 MS-DRG groupings. Overall, com-

pared to the current weights, 85 percent of the MS-DRG weights would change by less than +/- 6 percent

for FFY 2014. The FFY 2014 MS-DRGs and weights are available in Table 5 on the CMS website at

www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2014-IPPS-Final-

Rule-Home-Page.html.

For FFY 2014, CMS concludes there are sufficient data in the FFY 2011 cost reports to support a mean-

ingful analysis of using distinct CCRs for implantable devices, MRIs, CT scans and cardiac catheteriza-

tion. Based on its analyses, CMS has finalized its proposal to create new distinct CCRs for these services.

Specifically, rather than having a single CCR for “Supplies and Equipment,” which includes low-cost

supplies and high-cost implantable devices, a distinct CCR will be carved out of the “Supplies and

Equipment” CCR, leaving one CCR for “Supplies” and one for “Implantable Devices.”

For radiology, which currently is comprised of general radiology ancillary services and MRIs and CT

scans, the costs for MRIs and CT scans would be separated from general radiology, creating two distinct

CCRs, one for MRIs and one for CT scans, respectively. Finally, by separating the costs of cardiac cathe-

terization out of the CCR for general cardiology, a distinct CCR has been created for cardiac catheteriza-

tion. Breaking out these four additional CCRs would increase the number of CCRs used to calculate the

relative weights from 15 to 19.

The table below, which combines data from the proposed and final rules, shows the FFY 2013 final rule

CCRs, FFY 2014 proposed rule CCRs computed with the existing 15 cost centers, FFY 2014 proposed

rule CCRs computed with 19 cost centers and the FFY 2014 final rule CCRs with the four new CCRs for

implantable devices, MRIs, CT scans and cardiac catheterization.

Group

FY 2013

Final Rule

15 CCRs

FY 2014

Proposed Rule

15 CCRs

FY 2014

Proposed Rule

19 CCRs

FY 2014

Final Rule

19 CCRs

Routine days 0.514 0.502 0.502 0.500

Intensive days 0.442 0.423 0.423 0.414

Drugs 0.199 0.193 0.193 0.193

Supplies & Equipment 0.335 0.327 0.293 0.300

Implantable Devices n/a n/a 0.361 0.356

Therapy Services 0.37 0.355 0.355 0.356

Laboratory 0.143 0.133 0.133 0.134

Operating Room 0.238 0.225 0.225 0.221

Cardiology 0.145 0.134 0.132 0.130

http://www.cms.gov/MGCRB/


August 2013

Group

FY 2013

Final Rule

15 CCRs

FY 2014

Proposed Rule

15 CCRs

FY 2014

Proposed Rule

19 CCRs

FY 2014

Final Rule

19 CCRs

Cardiac Catheterization n/a n/a 0.135 0.136

Radiology 0.136 0.128 0.170 0.171

MRI n/a n/a 0.091 0.090

CT Scans n/a n/a 0.045 0.045

Emergency Room 0.226 0.207 0.207 0.206

Blood 0.389 0.371 0.371 0.365

Other Services 0.397 0.399 0.399 0.400

Labor & Delivery 0.450 0.445 0.445 0.424

Inhalation Therapy 0.189 0.187 0.187 0.186

Anesthesia 0.109 0.120 0.120 0.119

As noted in the table below, the largest increases in MS-DRG relative weights are for MS-DRGs associ-

ated with cardiac catheterization and implantable cardiac devices. The largest reductions are in MS-DRG

relative weights for MS-DRGs associated with traumatic head injury and concussion, which are high us-

ers of CT scanning and MRI services.


August 2013

MS-DRGS THAT WOULD EXPERIENCE THE LARGEST DECREASE

IN RELATIVE WEIGHT

MS-

DRG

Type

Title

Potential

Relative

Weights

with 15

CCRs

Potential

Relative

Weights

with 19

CCRs

Percentage

Change

090 MED Concussion without CC/MCC 0.7614 0.7013 -7.9%

084 MED Traumatic Stupor & Coma, Coma >1 Hour without CC/MCC 0.9137 0.8516 -6.8%

087 MED Traumatic Stupor & Coma, Coma <1 Hour without CC/MCC 0.7899 0.7369 -6.7%

965 MED Other Multiple Significant Trauma without CC/MCC 1.0450 0.980 -6.1%

185 MED Major Chest Trauma without CC/MCC 0.7281 0.6845 -6.0%

089 MED Concussion with CC 0.9959 0.9366 -6.0%

123 MED Neurological Eye Disorder 0.7355 0.6920 -5.9%

343 SURG Appendectomy without Complicated Principal

Diagnosis without CC/MCC

0.9880 0.9517 -5.7%

053 MED Spinal Disorders & Injuries without CC/MCC 0.9355 0.8825 -5.7%

066 MED Intracranial Hemorrhage or Cerebral Infarction

without CC/MCC

0.8034 0.7579 -5.7%

MS-DRGS THAT WOULD EXPERIENCE THE LARGEST INCREASE IN RELATIVE WEIGHT

MS-

DRG

Type

Title

Potential

Relative

Weights

with 15

CCRs

Potential

Relative

Weights

with 19

CCRs

Percentage

Change

454 SURG Combined Anterior/Posterior Spinal Fusion with CC 7.6399 8.0563 5.5%

455 SURG Combined Anterior/Posterior Spinal Fusion Without CC/MCC 5.9862 6.3133 5.5%

484 SURG Major Joint & Limb Reattachment Procedure of

Upper Extremity without CC/MCC

2.1211 2.2380 5.5%

225 SURG Cardiac Defibrillator Implant with Cardiac

Catheterization without AMI/HF/Shock without MCC

5.6298 5.9530 5.7%

223 SURG Cardiac Defibrillator Implant with Cardiac

Catheterization with AMI/HF/Shock without MCC

6.0956 6.4482 5.8%

458 SURG Spinal Fusion Except Cervical with Spinal

Curve/Malignant/Infection OR 9+ Fusion without CC/MCC

4.8794 5.1630 5.8%

245 SURG AICD Generator Procedures 4.4627 4.7320 6.0%

849 MED Radiotherapy 1.3423 1.4258 6.2%

946 MED Rehabilitation without CC/MCC 1.1295 1.2024 6.5%

227 SURG Cardiac Defibrillator Implant without Cardiac

Catheterization without MCC

5.2193 5.5714 6.7%

Commenters generally supported the proposals to implement additional CCRs for implantable devices

and cardiac catheterization, but many commenters opposed implementation of distinct CCRs for MRIs

and CT scans or requested that CMS reconsider their impact before adopting them. Commenters ex-

pressed concern that CCRs are very low for these services due to hospital cost reporting practices that


August 2013

allocate capital costs for MRIs and CT scan across the entire hospital, rather than to the appropriate indi-

vidual radiology cost centers. Specifically, some hospitals currently use an imprecise “square footage”

allocation methodology for the costs of large, moveable equipment like CT scan and MRI machines.

Commenters noted that, despite the fact that CMS recommends using two alternative allocation methods

— “direct assignment” or “dollar value” — as a more accurate methodology for directly assigning

equipment costs, industry analysis suggests that approximately only half of the reported cost centers for

CT scan and MRI rely on these preferred methodologies.

The commenters expressed concern that “square footage” allocation results in CCRs that “lack face valid-

ity,” because the proposed CCRs for CT scans and MRIs are less than the proposed CCR for general radi-

ology, inaccurately reflecting the higher resources used for MRIs and CT scans relative to the less expen-

sive plain film x-rays. Commenters said that more time is needed by hospitals to modify their cost report-

ing practices.

CMS disagreed with the comments, noting that hospitals have had sufficient time to make cost reporting

changes, and believes that these changes will foster more careful cost reporting in the future.

Graduate Medical Education Payments

For the purposes of calculating the Medicare share for direct GME payments, for FFY 2014 CMS will

include inpatient days for labor and delivery services effective for cost reporting periods beginning on or

after October 1, 2013. CMS recently adopted this policy change for the Medicare DSH purposes, a policy

CHA opposed. CMS notes that this policy will reduce direct GME payments to hospitals and may impact

the eligibility of hospitals seeking SCH status.

Notices of Closure of Teaching Hospitals; Opportunity to Apply for Available Slots

CMS announces rounds 4, 5 and 6 of ACA section 5506 redistributions of residency cap slots because of

a closure of a teaching hospital.

Round Closed Hospital Notice Date Application Due Date

Round 4 Peninsula Hospital Center (Far Rockaway, NY) April 9, 2012 July 25, 2013

Round 5 1. Infirmary West Hospital (Mobile, AL)

2. Montgomery Hospital (Norristown, PA)

May 31, 2013 August 29, 2013

Round 6 1. Cooper Green Mercy Hospital (Birmingham, AL)

2. Sacred Heart Hospital (Chicago, IL)

August 2, 2013 October 31, 2013

Hospitals that seek to apply for and receive slots from one of these closed teaching hospitals must submit

their applications to the CMS central office (not the relevant CMS regional office) by the application due

date. CMS must have actually received the applications by the due date; a postmark will not suffice.

CMS encourages applicants to notify it by email ([email protected]) indicating that a

hard copy of the application has been mailed.

For FFY 2014, the IME adjustment factor will remain at 1.35.

Medicare-Dependent Hospitals

The Medicare-dependent hospitals (MDH) program is set to expire September 30, 2013. CMS notes that

all hospitals that previously qualified for MDH status will no longer have MDH status and will be paid

based on the federal rate beginning in FFY 2014. Last year, CMS proposed and finalized revisions to sole

community hospital (SCH) policies to allow MDHs to apply for SCH status and be paid as such under

certain proposed conditions following expiration of the MDH program.

mailto:[email protected]


August 2013

Rural Low-Volume Adjustment

The temporary changes to the rural low-volume adjustment made as a result of the ACA and ATRA will

expire on September 30, 2013. Without legislative action CMS will return to the low-volume hospital

definition and payment definition used prior to FFY 2011.

Hospital Acquired Conditions for FFY 2014

CMS will not expand the list of categories or conditions subject to the 2005 Deficit Reduction Act provi-

sions that would reduce payment for hospital acquired conditions not present on admission. CMS will

continue to recognize the FFY 2013 list of 12 categories.

Hospital Services Furnished under Arrangements

CMS delays until January 1, 2015, the implementation of its revised policy under which a hospital may

furnish services under arrangements (i.e., only therapeutic and diagnostic services may be furnished under

arrangements). Routine services (bed and board, or nursing services and other related services) may not

be provided under arrangements. CMS expects all hospitals to be fully compliant with the policy by Janu-

ary 1, 2015, and believes the financial impact of the additional delay will be negligible.

Medicare Disproportionate Share (DSH) Payments

Currently, a hospital is eligible to receive DSH payments on a per-discharge basis for each Medicare inpa-

tient under a complex statutory formula, if its disproportionate patient percentage (DPP) meets or exceeds

a 15 percent threshold. The DPP is calculated as follows: (Medicare Supplemental Security Income (SSI)

days / total Medicare days) + (Medicaid, non-Medicare days / total patient days). A CMS fact sheet on

the current DSH qualifying formula and adjustment factor formula is available on the CMS website at

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/downloads/Disproportionate_Share_Hospital.pdf.

The ACA requires a reduction to and redistribution of DSH funding beginning in FFY 2014. Under the

law, 25 percent of estimated DSH funding under the traditional formula will continue to be paid to each

DSH-eligible hospital as per-discharge payments. The remaining 75 percent will be reduced to reflect the

impact of insurance expansion and then redistributed to hospitals as a new and separate uncompensated

care payment. This payment will be determined based on each hospital’s ratio of uncompensated care

relative to the total for all DSH-eligible hospitals. CMS has broad authority on how to implement these

program changes and has finalized its proposed methodology for FFY 2014 in this rule. More specifically

CMS finalizes:

The amount of funding to be dedicated to the new uncompensated care payment;

How to reduce and distribute that funding as mandated by the ACA;

DSH eligibility; and

DSH payment methods, including reconciling payment at cost report settlement

Funding Dedicated to the New Uncompensated Care Payment (Factor 1)

To implement the ACA-mandated DSH payment changes, CMS must project national DSH program ex-

penditures for FFY 2014 under the traditional per-discharge formula. This projection is critical because it

sets the basis for the amount of funding that will be distributed to hospitals as lump-sum uncompensated

care payments under the new DSH payment methodology.

Using its Office of the Actuary estimate from July 2013, CMS is projecting DSH program expenditures to

be $12.772 billion for FFY 2014 (an increase of 3.5 percent from the proposed rule’s March estimates).

Absent the ACA mandated cut, California’s DSH payments were estimated at approximately $2 billion for

FFY 2014. As adopted, this estimate is based on data from 2010 Medicare cost reports and the FFY 2014


August 2013

IPPS proposed rule impact file. The estimate includes projections for inflation, utilization and case mix

changes.

As mandated by the ACA, 25 percent of projected DSH funding will continue to be paid to eligible hospi-

tals under the per-discharge formula. CMS projects this value to be $3.139 billion, but this value can and

will fluctuate based on hospital-specific utilization changes. The remaining 75 percent, projected to be

$9.579 billion, will be reduced and then serve as the basis for funding to be distributed as lump-sum un-

compensated care payments. CMS is adopting its proposal not to revise this estimate upward or down-

ward to reflect actual expenditures in a given year.

ACA-Mandated DSH Funding Reductions (Factor 2)

The ACA requires that DSH funding dedicated to uncompensated care payments ($9.579 billion) be re-

duced by a factor that reflects the impact of insurance expansion before it is distributed to hospitals.

For FFY 2014, CMS is adopting with modifications its proposal to utilize insurance coverage estimates

from the Congressional Budget Office (CBO) to calculate this factor. As adopted, CMS will use CBO’s

March 2010 and May/July 2013 (most recent) estimates. CMS will also utilize CBO estimates for all res-

idents, including unauthorized immigrants. CMS believes the inclusion of unauthorized immigrants more

fully reflects the levels of uninsured.

CHA supported the use of these estimates and the inclusion of the unauthorized immigrants but urged

CMS to modify its methodology to shift CBO’s insurance coverage estimates from a calendar year to the

federal fiscal year. CMS agreed, and the effect of this change is a higher rate of uninsured and, therefore,

a smaller DSH funding reduction.

Based on CBO’s projections, from FFY 2013 to FFY 2014, the rate of uninsured is estimated to drop from

18 percent to 16 percent, an 11.1 percent reduction. Factoring in an additional ACA-mandated reduction

of 0.1 percentage points, CMS had proposed to reduce the funding dedicated to uncompensated care pay-

ments by 11.2 percent, or about $1.0365 billion. As a result, for FFY 2014, the fixed amount available for

distribution as uncompensated care payments would have been $8.217 billion.

In the final rule, CMS adjusted the uninsured estimates so the weighted average of uninsured equals 17 percent

(rather than 16 percent, as noted above). This change results in a new adjustment factor of 0.943. Using this fac-

tor, the final rule amount available for uncompensated care payments for FY 2014 is approximately $9.033 bil-

lion (0.943 times the Factor 1 estimate of $9.579 billion), an increase of 9.9 percent from the proposed rule.

Distribution of Uncompensated Care Payments

The ACA-mandated DSH payment methodology requires that the funding dedicated to uncompensated

care payments (finalized at $9.033 billion) be distributed to hospitals based on each hospital’s ratio of un-

compensated care relative to the total for all DSH-eligible hospitals.

FFY 2014, CMS will use Medicaid days and Medicare SSI days as a proxy for uncompensated care in-

stead of the S-10 data reported on the Medicare Cost Report. These days currently make up the numerator

of the DPP formula used to determine DSH eligibility under the traditional per-discharge formula. CMS

believes, and CHA agrees, that the use of low-income patient days is a valid proxy for the treatment costs

associated with uninsured patients. With that said, CMS responded to several comments regarding its dis-

cussion and use of the uncompensated care data reported on Worksheet S-10 of the Medicare cost report

for use in future years. CMS notes in the final rule that it plans to work with the industry to review and

make any necessary revision and clarifications to the S-10 instructions to ensure accurate and consistent

reporting across hospitals. In addition, CMS agreed to examine for possible future rulemaking the sugges-

tion to include insured low-income days from exempt units (for example, inpatient rehabilitation units


August 2013

paid under the IRF PPS or inpatient psychiatric units paid under the IPF PPS) of the hospital in order to

better capture the treatment costs of the uninsured by the hospital.

To calculate the uncompensated care payment factor, CMS will use the cost report data in its cur-

rent form and will not provide a review and update/correction period for hospitals. CMS has made a

file available on its website that includes the patient days relevant to the adopted formula and each hospi-

tal’s uncompensated care payment factor. The file is available at www.cms.gov/Medicare/Medicare-Fee-

for-Service-Payment/AcuteInpatientPPS/FY2014-IPPS-Final-Rule-Home-Page.html. This file also in-

cludes other data critical to the new DSH payment methodology. CMS has calculated a payment factor

for every hospital in the country based on its share of days to total days for all FFY 2014 CMS-projected

DSH-eligible hospitals. If a hospital is not determined to be DSH-eligible until cost report settlement,

CMS will use this pre-determined payment factor to make the new uncompensated care payment. As pro-

posed and adopted, CMS will not revise these factors upward or downward to reflect actual patient days.

California Impact

CHA estimates that California hospitals will experience a 21 percent decrease in Medicare DSH payments

for FFY 2014 or $429 million. This is a slight decrease in the size of the cut as compared to the proposed

rule which was estimated at $466 million for FFY 2014.

Estimated DSH Payments at

100% of the Traditional Per-

Discharge Formula

Estimated DSH Payment Under Newly

Proposed Methodology — 25% Rate-

Based Payment plus New Uncompen-

sated Care Payment

Estimated Impact of

Newly Proposed

Methodology

US Estimate B

(18.74% Scaling Factor)

$12,772,390,592 $12,226,370,894 ($546,019,698)

CA Estimate B

$2,056,259,320 $1,626,982,463 ($429,276,857)

Source: CHA DataSuite Analysis. This estimate includes an 18.74 percent scaling factor that allows CMS to predict

the estimated uncompensated care payments which are fixed. The 25 percent traditional DSH payments will still

vary based on volume as it would have done absent any change in the methodology.

DSH Eligibility

CMS is projecting that 2,437 hospitals will be eligible for DSH payments in FFY 2014. Hospitals not

identified as DSH-eligible will not receive any DSH payments unless/until determined to be DSH-eligible

at cost report settlement. For example, CMS excludes over 200 sole community hospitals that it believes

will not become eligible for Medicare DSH payments from the files.

CMS’ list is based on the Medicaid fraction listed in the March 2013 update of the Provider Specific File

(based on 2010 or 2011 cost report data) and the FFY 2011 SSI ratios (based on FFY 2011 Medicare inpa-

tient claims) published June 27, 2013 on the CMS website at www.cms.gov/Medicare/Medicare-Fee-for-

Service-Payment/AcuteInpatientPPS/dsh.html. According to CMS, this is the most recently available data

on the DPP for hospitals that are qualified to receive Medicare DSH payments.

CMS has made a file available on its website that includes DSH eligibility status. The file is available at

www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2014-IPPS-Final-

Rule-Home-Page.html. This file also includes other data critical to the new DSH payment methodology.


August 2013

For Sole Community Hospitals (SCHs) that are eligible for DSH payments, CMS will consider the new

uncompensated care payments in determining whether a SCH will be paid at the federal or hospital-

specific rate. In addition, CMS noted in the final rule that the 12 percent cap for SCHs will only apply to

the empirically calculated DSH payments (25 percent pool) and not applied to the uncompensated care

DSH payments.

Hospitals participating in the Bundled Payments for Care Improvement (BPCI) initiative and hospitals in

Puerto Rico will be eligible for DSH payments. As has been the case in prior years, Maryland hospitals

and hospitals participating in the Rural Community Hospital Demonstration Program will not be eligible

for DSH payments.

DSH Payment and Cost Report Settlement

CMS is adopting its proposal to continue the practice of determining final DSH-eligibility at cost report

settlement. Eligibility will continue to be determined based on the traditional formula’s threshold (a DPP

of 15 percent or more).

In response to CHA and industry comments and concerns over potential cash flow issues and appropriate

payment levels from Medicare Advantage (MA) plans, CMS is not adopting its proposal to make the un-

compensated care payment as a lump-sum payment on a periodic basis. Instead, CMS will make these

payments on a per-discharge basis through the claims process based on a CMS-estimated claims figure

(three-year average, FFY 2010-2012). As a result, CMS will make both the traditional DSH payment at

25 percent and the uncompensated care payment on a per-discharge basis. CHA is very pleased that CMS

made this important change.

The FFY 2014 Medicare IPPS PRICER software will provide both the traditional DSH payment at 25

percent and the uncompensated care per-claim amount. This modification will assist MA plans that use

the PRICER to estimate FFS payments and will ensure full DSH payment to hospitals from non-

contracting MA plans and hospitals that have contractually linked MA payments to the fee-for-service

IPPS rate.

Following current practice, CMS will determine DSH eligibility and reconcile traditional DSH payments

(at the 25 percent level) based on actual program year cost report data.

CMS will also reconcile the new uncompensated care payments to ensure that hospitals receive the exact

payment amount adopted in this final rule. CMS will recoup any overpayments that may occur when the

actual number of hospital claims is higher than the CMS-estimated claims figure adopted in the final rule

and used for distribution of this payment.

For hospitals projected by CMS to be DSH-eligible, but ultimately determined to be ineligible at cost re-

port settlement, CMS will recoup both the traditional DSH and uncompensated care payments. Alterna-

tively, hospitals not determined to be DSH-eligible until cost report settlement will be paid both the tradi-

tional DSH payment amount and the uncompensated care amount based on the pre-determined hospital-

specific uncompensated care payment factor. CMS has calculated a payment factor for every hospital in

the country based on its share of days to total days for all FFY 2014 CMS-projected, DSH-eligible hospi-

tals. As proposed and adopted, the data and factors used to determine the distribution of the uncompen-

sated care payments are fixed and will not be re-estimated at time of settlement.


August 2013

Schematic for Newly Adopted DSH Payment Methodology

2. Continue to pay traditional DSH at 25% of current DSH adjustment val-ue. Final rule:

$3.193 billion

Will fluctuate based on hospital-specific utilization changes

Pay on per-discharge basis dur-ing FFY 2014

1. Project DSH-eligible hospitals using traditional DSH formula (15 % DPP or more) and project total DSH payments for the nation using traditional per-discharge formula. Final rule:

$12.772 billion

Includes adjustments for inflation, utilization, and case mix changes

Fixed amount as finalized – re-estimated each year

3a. Take 75% of total DSH payments to fund uncompensated care payments . Final rule:

$9.579 billion - fixed amount as finalized

3b. Adjust amount for uncompensated care payments to reflect impact of insurance expansion. Final rule:

$9.033 billion (5.7% cut) - fixed amount as finalized

5.6% decrease in the uninsured + ACA-mandated 0.1 percentage point

Based on CBO projections

3c. Distribute amount for uncompensated care payments to each DSH-eligible hospital based on hospital’s ratio of uncompensated care relative to the total for all DSH-eligible hospitals. Final rule: Uncompensated care Proxy = Medicaid days + Medicare SSI days/Total Na-tionwide

Pay on per-discharge basis during FFY 2014

4. Cost report settlement Final rule:

Determine actual DSH eligibility at cost report settlement.

Reconcile 25% traditional DSH per-discharge payment based on actual program year cost re-port data.

Reconcile uncompensated care per-discharge payment to ensure value paid out = hospital-specific value adopted in final rule.

Do not update nationwide value of uncompensated care payment amount or hospital-specific uncompensated care factors – these data are fixed as adopted by CMS.

Recoup both 25% traditional DSH payment and uncompensated care payment if projected by CMS to be DSH-eligible, but ultimately determined to be ineligible at cost report settlement.

Pay both 25% traditional DSH payment and uncompensated care payment if not determined to be DSH-eligible until cost report settlement.


August 2013

Counting of Patient Days Associated with Medicare Advantage Plans in the Medicare and Medicaid

Fractions of the Disproportionate Patient Percentage (DPP) Calculation

Making both policy and legal arguments, commenters disagreed that MA beneficiaries are entitled to Part

A and that they should be included in the DPP fraction as proposed by CMS. The final rule responds care-

fully to the comments, but finalizes its proposal to readopt its policy of counting the days patients are en-

rolled in Medicare Advantage in the Medicare fraction of the DSH calculation beginning FFY 2014.

Admission and Medical Review Criteria for Hospital Inpatient Services

CMS largely codified several of its proposals to revise the requirements for inpatient admission and medi-

cal review criteria under Part A. CMS notes that additional guidance is in development and will be made

available on or before October 1, 2013, when the policies become effective. Questions regarding the pro-

posal should be sent via email to [email protected]. CMS also notes that it will undertake

significant provider education to answer many of the questions not addressed in the final rule.

As a first step, CMS hosted a national provider call on August 15. The transcript and audio file from the

call, regarding the inpatient hospital admission and medical review criteria (two-midnight provision) and

Part B inpatient billing, are available at www.cms.gov/Outreach-and-

Education/Outreach/OpenDoorForums/ODFSpecialODF.html.

CMS finalized the following policies effective October 1, 2013. CHA has provided s separate summary

related to the Part B inpatient rebilling guidelines that are also effective October 1.

Physician Orders for Inpatient Admission

A patient must be formally admitted as an inpatient pursuant to an order for inpatient admission by a phy-

sician or other qualified practitioner who has admitting privileges at the hospital or CAH and who is re-

sponsible for the inpatient care of the patient at the hospital or CAH.

CMS does not finalize any new documentation requirements nor require any particular form or procedure

for documentation. CMS finalizes a requirement under new §412.3 that the physician order must be pre-

sent in the medical record and supported by physician admission and progress notes, and further clarifies

that the physician order is a required component of the physician certification (§412.3(c)). CMS also re-

quires the physician certification to be signed and documented in the medical record before discharge

(§424.13(b)); however, a recertification of an extended stay is required earlier (such as in the case of inpa-

tient psychiatric services where recertification is first required as of the 12th day of hospitalization and no

less frequently than every 30 days thereafter).

With respect to its proposed requirement that only the physician or other qualified practitioner "who is

responsible for the inpatient care of the patient at the hospital" could sign the inpatient admission order,

commenters noted that emergency department physicians, hospitalists, physicians in group practices and

residents working under the supervision of attending physicians all currently sign orders for admission but

are not responsible for inpatient care of the patient. CMS agrees and modifies this requirement to permit

inpatient admission orders by practitioners who may not be responsible for the inpatient care but are oth-

erwise qualified to admit patients and are knowledgeable about the patient's hospital course, medical plan

of care and current condition to order the admission (§412.3(b)).

Inpatient Admission Guidance

The final rule establishes the guidelines for when physicians should order an inpatient admission. This

guidance applies to all hospitals, CAHs and LTCHs, but does not apply to IRFs. IRFs have separate ad-

mission criteria that are applied.


http://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/ODFSpecialODF.html

http://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/ODFSpecialODF.html


August 2013

CMS finalized its proposal to generally consider a hospital inpatient admission spanning two midnights as

reasonable and necessary for payment under Part A. In response to several comments raised by CHA and

other provider groups, CMS made some improvements to the proposal that are detailed below.

CMS underscores in the final rule that a physician’s order and certification regarding medical necessity

will be given no presumptive weight; claim reviewers will look to all documentation in the medical rec-

ord, as well as the order for inpatient admission.

Under the final rule, services on the inpatient-only list that are designated as inpatient-only (even if per-

formed as inpatient, one-day procedures) are appropriate for inpatient hospital admission and payment

under Part A.

In addition, if a physician expects a patient to require an inpatient stay for a surgical procedure, diagnostic

test, and other treatment that will cross at least two midnights (one Medicare utilization day) and admits

the patient to the hospital based on that expectation (with the requisite documentation), the inpatient ad-

mission will be generally deemed appropriate for Part A payment.

Notably, if an unforeseen circumstance, such as beneficiary death or transfer, or an unexpected event such

as a discharge against medical advice or unexpected rapid improvement, results in a shorter beneficiary

stay than the physician’s expectation of at least two midnights, the patient may still be considered to be

appropriately treated on an inpatient basis, and payment may be made under Part A. In developing manu-

al guidance, CMS will identify additional unusual situations that would qualify for this exception, but

notes that treatment in an ICU would not qualify. Commenters sought guidance on how to make admis-

sion decisions for transfer patients from another hospital; CMS responds that because transfer scenarios

are complex, it will provide guidance in manual instructions, which it indicates will be one of its highest

priorities.

CMS distinguishes in the final rule between the two-midnight benchmark and the two-midnight presump-

tion. The two-midnight benchmark is guidance for admitting practitioners and reviewers to identify when

an inpatient admission is generally appropriate for coverage and payment.

In response to CHA’s and others’ comments, CMS revises the starting point for determining whether the

two-midnight benchmark will be met as: The starting point is when the beneficiary begins receiving hos-

pital care on either an inpatient basis or outpatient basis, including time spent receiving observation ser-

vices, emergency department treatment, and procedures provided in an operating room or other treatment

area. CMS notes that, where a physician cannot reliably predict whether the patient will require a stay of

longer than two midnights, he/she should continue to treat the patient as an outpatient and admit when

additional information suggests a stay that would meet the benchmark.

The two-midnight presumption is guidance for Medicare review contractors (e.g., MACs, RACs, CERT)

to select claims for review under the presumption that the occurrence of two midnights after admission

appropriately signifies an inpatient status for a medically necessary claim. Inpatient hospital claims with

lengths of stay greater than two midnights after formal admission will be presumed generally appropriate

for Part A payment; they will not be the focus of medical review efforts unless there is evidence of sys-

tematic gaming, abuse or delays in the provision of care in an attempt to qualify for the two-midnight pre-

sumption. CMS does not define systematic gaming or abuse in the final rule.

CMS notes it will monitor all hospitals for intentional or unwarranted delays, or patterns of incorrect DRG

assignments, and contractors may still review claims for medical necessity of services or stay, validation

of provider coding and documentation, or if directed by CMS or the HHS OIG.


August 2013

Impact of Admission and Medical Review Criteria

Finally, CMS notes that it will share additional guidance with its medical review contractors in the near

future. CHA will review and share that guidance with the membership when it is available. CMS does

note, however, that while time spent as an outpatient does not count toward inpatient time for a qualifying

SNF stay, Medicare review contractors (as well as the hospital) may take that time into account to deter-

mine whether the two-midnight benchmark was met and, therefore, payable under Part A.

As noted earlier in this summary, CMS is finalizing its policy to adjust the standardized amount by -0.2

percent to account for what it believes will be an increase in inpatient utilization as a result of this policy.

CHA and others strongly objected to this payment reduction and find the policy unwarranted and unjusti-

fied. We will continue to work with our national association partners to track the true impact of this poli-

cy going forward.

Change to Hospital CoPs for Administration of Pneumococcal Vaccines

42 CFR 482.23(c)(3) contains the Medicare hospital condition of participation related to preparation and

administration of influenza and pneumococcal polysaccharide vaccines. CMS had intended to establish a

policy under which hospitals had the flexibility to administer these vaccines without prior practitioner or-

der and only after assessing patients for contraindications to the vaccine administration; it had not intend-

ed to exclude other pneumococcal vaccines available currently or in the future. Commenters supported

the proposal to delete “polysaccharide” from the text of the regulation to clarify CMS policy that a hospi-

tal may include any type of pneumococcal vaccine in its physician-approved policy for administration by

nurses without prior practitioner order, if the vaccine has been FDA-approved for the patient population

involved. The effective date of the change is October 1, 2013.

CMS indicates it cannot estimate costs (or savings) for this clarification but is confident that it will not

impose any burdens on hospitals. CMS notes benefits of improved patient access to pneumococcal vac-

cines as well as the benefit of having more than one supply of vaccine, especially in the case of a shortage.

Inpatient Quality Reporting Program (IQR)

In the FFY 2013 IPPS final rule, CMS finalized its proposal to reduce the number of measures for the

FFY 2015 payment year to 59. See Appendix A for a complete listing of the IQR measures for FFY

2014-16.

Refinements to the Hospital IQR Measures for FFY 2014

CMS has finalized its proposals for the following measures with limited exception as noted below:

1. Modifies the 30-day readmission measures (for AMI, HF, PN, THA/TKA and hospital-wide re-

admission) to incorporate an algorithm identifying planned readmissions that would be excluded

from the measures, beginning in 2013. The algorithm was endorsed by the National Quality Fo-

rum (NQF) during its recent review of the measures. CHA supported this change but will contin-

ue to seek additional refinements in the readmission measures in the future.

2. Expands the CLABSI and CAUTI measures to select non-ICU locations beginning with infections

occurring on or after January 1, 2015. CMS has delayed implementation until one year from the

proposed rule due to concerns raised by CHA and others regarding the significant administrative

complexities that must be addressed prior to implementation. Beginning in 2015, CMS will ex-

pand the measure to medical wards, surgical wards and medical/surgical wards.

3. Adopts revised specifications of the measure SCIP Inf 4: Controlled 6AM Glucose for Cardiac

Surgery Patients, to incorporate recent NQF endorsement maintenance decisions, beginning with

January 1, 2014, discharges. The NQF changed the measure from controlled glucose at 6AM to a

more comprehensive measure of controlled glucose 18-24 hours post-cardiac surgery, and re-

quires that corrective action be documented if post-operative glucose is over 180mg/dl.


August 2013

4. Revises the Medicare spending per beneficiary (MSPB) measure to include Railroad Retirement

Board beneficiaries for the FFY 2016 payment determinations.

Addition/Removal of Hospital IQR Program Measures for FFY 2016

For FFY 2016, CMS finalized its proposal to remove seven of the eight measures proposed from the IQR

program. Below is a table noting each of the measures removed and the reason cited by CMS.

Measure Proposed for Removal for FFY 2016 CMS Reason for Proposed Removal

AMI-2: Aspirin prescribed at discharge Either recommended for removal by MAP or “topped out”

AMI-10: Statin prescribed at discharge Either recommended for removal by MAP or “topped out”

PN-3b: Blood culture performed in the emergency

department prior to first antibiotic received in hospital

No longer NQF endorsed, MAP recommended removal;

MAP believes it is topped out, and there is inadequate link to

patient outcomes

HF-1: Discharge instructions No longer NQF endorsed, MAP recommended removal,

challenges in validating efficacy

HF-3: ACEI or ARB for LVSD Either recommended for removal by MAP or “topped out”

SCIP-Inf-10: Surgery patients with perioperative tem-

perature management Either recommended for removal by MAP or “topped out”

Participation in a systematic clinical database registry

for stroke care Stroke measure set more meaningful

CMS chose to suspend IMM-1: Immunization for pneumonia rather than remove the measure. CMS notes

that, while it cannot feasibly implement the measure currently as newly defined, it does not meet the crite-

ria for removal from the IQR program. Therefore, CMS reserves the right to at a later date reintroduce

data collection through sub-regulatory guidance.

Despite significant concerns raised by the field and CHA, CMS has finalized five new measures for FFY

2016 and beyond. The addition of five new measures and the removal of seven measures would bring the

FFY 2016 measure set to 58 quality measures. The five new measures are:

1) 30-day Risk Standardized COPD Readmission

Similar to the AMI, HF and PH, this measure assesses 30-day readmission rates for patients hospital-

ized with acute exacerbation of COPD. This measure also incorporates the new planned readmission

algorithm that will exclude several planned readmissions.

2) 30-day Risk Standardized Stroke Readmission

The measure assesses the readmissions rate for patients hospitalized for an acute ischemic stroke.

This measure is not NQF endorsed, and CHA raised concerns that the measures as currently adopted

do not appropriately take into account stroke severity. CMS acknowledges the concerns raised by

commenters and notes that it will continue to refine the measures

3) 30-day Risk Standardized COPD Mortality

This measure assesses the 30-day mortality rates of patients hospitalized with acute exacerbation of

COPD. This is an NQF-endorsed measure.

4) 30-day Risk Standardized Stroke Mortality

This measure assesses the 30-day mortality rate for patients hospitalized with acute ischemic stroke.

Similar to the stroke readmissions measure, this measure failed to receive NQF endorsement in 2012.

5) AMI Payment Per Episode of Care

CMS notes evidence of variation in payments at hospitals for AMI patients. Mean 30-day risk-

standardized payment among Medicare FFS patients aged 65 or older hospitalized for AMI in 2008


August 2013

was $20,207, and ranged from $15,521 to $27,317 across 1,846 hospitals. The AMI payment meas-

ure assesses hospital risk-standardized payment associated with a 30-day episode-of-care for AMI for

any non-federal acute care hospital. The measure includes Medicare FFS patients aged 65 or older

admitted for an AMI and calculates payments for these patients over a 30-day episode-of-care begin-

ning with the index admission. In general, the measure uses the same approach to risk-adjustment as

the 30-day outcome measures previously adopted for the Hospital IQR program, including the AMI,

HF and PN readmission and mortality measures. This measure has not yet been submitted to NQF for

review.

Additional details regarding the measure methodologies are available at http://cms.gov/Medicare/Quality-

Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html.

CHA opposed many of the measures adopted into the FFY 2016 IQR program and will continue to work

with others in raising our concerns with CMS directly and through the Measures Application Partnership.

The MAP will reconvene this fall to review a new set of measures that CMS must submit for review by

not later than December 1, 2013. CHA is an active participant in the MAP process and will participate in

the fall meetings. Additional information regarding the MAP is available at www.qualityforum.org/map/.

Form, Manner, and Timing of Quality Data Submission for the IQR Program

CMS finalizes the following changes to the IQR Program procedural requirements:

The deadline for a hospital to withdraw from participation in the IQR program for a fiscal year is

changed from August 15 of the preceding fiscal year to May 15 of the prior year (e.g., May 15, 2014

for the FFY 2016 payment determination).

For chart-abstracted measures, current procedures will continue, but the quarterly data submission

deadline time is clarified to mean 11:59 p.m. Pacific time.

Data submission requirements for HCAHPS are retained for FFY 2017 with no changes. Certain re-

quirements are codified.

The deadline for submission of data on the previously adopted Healthcare Provider Influenza Vac-

cination measure is May 15t of the calendar year when the flu season ends. For example, the deadline

May 15, 2014, applies for the period between October 1, 2013 (or when flu vaccines they become

available) and March 31, 2014.

The Medicare Beneficiary ID number must be reported to the NHSN system for all events reported for

Medicare beneficiaries beginning with CY Q3 2014 events, the first quarter for which validation will

be required for the FFY 2017 payment determination. CMS had proposed to begin this requirement

earlier (for the FFY 2016 payment determination) but delayed the start in response to comments.

CMS does not finalize proposed changes to the submission deadlines for structural measures or for the

annual Data Accuracy and Completeness Acknowledgement (DACA). For structural measures, re-

porting with respect to a calendar year must occur from April 1 through May 15t of the subsequent

year. For the DACA, the submission deadline remains May 15t with respect to data submitted for the

previous calendar year.

Beginning with the FFY 2015 payment determination, hospitals with a quarterly overall validation

result of <75 percent may no longer appeal mismatched data elements to state quality improvement

organizations (QIOs). CMS believes this process is redundant because a hospital can request recon-

sideration of a determination that it has not met the IQR program requirements.

The forms for extraordinary circumstances waivers or extensions may be signed by hospital-

designated personnel other than the CEO. In addition, the forms may be submitted online via the

QualityNet website. Further, a waiver or extension may be granted if a problem with the CMS data

collection system directly affected the ability of a hospital to submit data.


August 2013

Additional information regarding modifications to the validation process for measures in the IQR program

is detailed in the final rule and available upon request.

Voluntary Electronic Submission of IQR Program Measures in CY 2014

CMS made several modifications from the proposed rule regarding data submission requirements for hos-

pitals that elect to volunteer to submit electronically reporting measures in CY 2014.

Hospitals may voluntarily report up to four measure sets electronically for one quarter (CY Q1, CY Q2 or

CY Q3) for purposes of the FFY 2016 IQR program. (The proposed rule would have required hospitals

opting for electronic reporting to electronically report all four measure sets for one quarter.) The

measures sets are: stroke (seven of the eight measures), venous thromboembolism (six measures), perina-

tal care (one measure) and emergency department (two measures). CMS clarifies that hospitals that

choose to engage in voluntary electronic reporting must continue to report measures via chart abstraction

for all four quarters of 2014 unless the measure is in one of the measure sets it has reported electronically

for one quarter. Also, if a hospital chooses to report the stroke measure set electronically, it must still re-

port the measure STK-1 via chart-abstracted methods. In addition, the hospital must report all measures

in the measure set electronically. That is, a hospital that reports some of the measures in a measure set

electronically and others via chart abstraction will not receive credit for reporting the measures under the

IQR program. In addition, if a hospital chooses to report more than one measure set electronically, they

must all be reported in the same calendar quarter.

A hospital that would like CMS to use the electronically reported IQR program data to determine whether

the hospital has satisfied the meaningful use quality measure reporting requirement of the Medicare EHR

Incentive program must electronically report the data for CY Q1, CY Q2 or CY Q3 by November 30,

2014, or, if it is in its first year of demonstrating meaningful use, by July 1, 2014. Because the EHR Incen-

tive program is fiscal-year based, CMS will not be able to use electronic submission of IQR program data

for the fourth quarter of CY 2014 to determine whether a hospital has satisfied the Medicare EHR Incen-

tive program clinical quality reporting requirement. The hospital must satisfy all other requirements of the

Medicare EHR Incentive program.

The Medicare EHR Incentive program data submission process will be used, following submission re-

quirements finalized in the stage 2 final rule (77 FR 54088) and subsequent rulemaking. For hospitals

choosing voluntary electronic reporting, the QualityNet account will be used. Data will be extracted from

the Certified Electronic Health Record Technology (CEHRT) and submitted to CMS using the Health

Level Seven (HL7) Quality Reporting Document Architecture (QRDA) Category I Revision 2 standard.

After considering public comments, CMS finalizes its proposal to adopt the QRDA I reporting standard

for hospitals voluntarily submitting measures electronically for the IQR program.

CMS proposed that data submitted through the voluntary electronic submission in CY 2014 would not be

publicly reported, but reports that a majority of commenters opposed withholding these data from Hospital

Compare. In this section of the final rule, CMS finalizes a policy that it will make the data publicly avail-

able if it deems that the data are accurate enough to be publicly reported. Elsewhere in the final rule,

CMS contradicts this by stating that no comments were received and that the proposed policy not to report

these data is finalized. CHA will work to bring clarity to this CMS policy and notify hospitals when that

information is available.

Data submitted electronically for the FFY 2016 IQR program will not be validated. CMS notes concern

among commenters, including CHA, about the need for validation of electronically submitted measure

data, and notes that it intends to develop and propose a validation strategy for electronically reported qual-

ity measures in future rulemaking that will complement the vendor certification process for electronic

clinical quality measures.


August 2013

CMS intends to recognize on the Hospital Compare website hospitals electing to voluntarily report clini-

cal quality measures electronically in CY 2014 for the IQR program. While not required, CMS encour-

ages hospitals that elect to report quality measures electronically for one quarter to also submit the same

data via chart abstraction. CMS notes that many hospitals will be reporting chart-abstracted data on these

same measures to the Joint Commission, so no additional reporting burden would be involved.

Responding to comments, CMS states that it does not expect that implementation of ICD-10 will have

significant impacts on electronic reporting of measures because the electronic specifications include ICD-

10 codes. CHA remains concerned about the CMS approach to electronic reporting of the IQR measures

and will continue to urge CMS to make additional refinements in future rulemaking.

Hospital Value Based Purchasing Program (VBP)

As required by law, the available funding pool for the hospital value-based purchasing program (VBP)

was equal to 1 percent of the base-operating, diagnosis related group (DRG) payments to all participating

hospitals in FFY 2013. For FFY 2014, this will increase to 1.25 percent. CMS estimates the total amount

available for VBP for FFY 2014 is $1.1 billion. VBP program payments overall would be budget neutral.

As noted in Appendix A of the final rule, CMS estimates that 44 percent of hospitals would have a change

in base operating DRG payment amounts that is between -0.2 percent and +0.2 percent. The estimated

effects shown in the Appendix table by hospital type all fall within that range, with the largest effects for

high DSH hospitals (-0.23 percent) and small urban bed size (+.18 percent). These estimates are only

slightly revised from the proposed rule.

FFY 2014 and 2015 VBP

In previous rulemaking CMS adopted 17 measures for the Hospital VBP program for FFY 2014. Each

year CMS includes a table in the proposed and final rules that includes a proxy hospital-specific incentive

payment adjustment factors. Table 16A posted on the CMS website lists the factors for FFY 2014. Once

the review and correction process is complete, CMS will publish a new table (16B) that will reflect the

actual adjustment factors used in calculating the FFY 2014 value based purchasing payment. The revised

table is expected to be posted in October of this year.

In the FFY 2013 IPPS final rule, CMS adopted 19 measures for the FFY 2015 program. A complete list of

measures for FFY 2015 is noted in Appendix B.

VBP Measures Proposed for FFY 2016

In total 17 measures are finalized for the FFY 2016 program. CMS has finalized its proposal to modify the

VBP measure set for the FFY 2016 payment determination. For FFY 2016, CMS will remove the follow-

ing measures.

Measures Removed Beginning with the FFY 2016

Payment Determination

Measure Reason for Removal

AMI-8, Primary PCI received within 90 minutes

of hospital arrival

Topped out

*SCIP-Inf-1, Prophylactic antibiotic received

within one hour prior to surgical incision

Topped out (determined after publication of pro-

posed rule)

PN-3b, Blood cultures performed in the ED prior

to initial antibiotic received in hospital

No longer endorsed by the NQF

HF-1, Discharge planning No longer endorsed by the NQF

*SCIP-Inf-4 Measure specifications changed beginning Janu-

ary 1, 2014.

Notes: *Measure not identified for removal in proposed rule.


August 2013

In addition, CMS finalized the following measures for inclusion in the FFY 2016 program:

IMM-2: Influenza Immunization

This is an NQF-endorsed measure of whether patients age six months and older are screened for influenza

immunization status and vaccinated prior to discharge if indicated. Hospitals began reporting this measure

under the Hospital Inpatient Quality Reporting (IQR) program with January 1, 2012, discharges.

CAUTI: Catheter- associated Urinary Tract Infection

Data collection on this measure, which occurs through the CDC National Healthcare Safety Network

(NHSN), began for the IQR program with January 1, 2012, discharges. CMS notes that it may consider

adopting the expansion of the CAUTI measure beyond the non-ICU settings in future rulemaking, but for

now remains limited to the ICU setting for the purposes of inclusion in the VBP Program.

SSI: Surgical Site Infection (colon and abdominal hysterectomy)

Reporting on this measure is currently limited to colon and abdominal hysterectomy procedures. Data col-

lection and public reporting on this measure are currently stratified by surgery site. In response to public

comment CMS did modify its proposed scoring methodology from the proposed rule. CMS will award

points to each strata and then compute a weighted average of the points awarded based on predicted infec-

tions. CMS provides an example of a hospital that received five improvement points for the SSI-colon

stratum, with 1.0 predicted SSI-colon infections, and eight achievement points for the SSI-abdominal hys-

terectomy stratum, with 2.0 predicted SSI-abdominal hysterectomy infections, would receive a composite

SSI measure score as follows: ((5 * 1.0) + (8 * 2.0)) / (1.0 + 2.0) = 7 points.

The CLABSI measure, which is part of the FFY 2015 VBP program measure set, is now finalized for con-

tinuation in FFY 2016.

CHA had expressed significant concerns regarding the overlap of measures between the VBP program and

measures finalized in the Hospital Acquired Conditions Reduction Program for FFY 2015. CMS disa-

greed with stakeholder comment and noted that outcome measures such as CLABSI and CAUTI track

infections that could cause significant health risks to Medicare beneficiaries, and as a result it is appropri-

ate to provide hospitals with incentives to avoid these infections under more than one program. CMS indi-

cates it will consider ways to align the programs to minimize provider burden and incentivize high-quality

care.

With respect to HCAHPS, CMS indicates that it is analyzing the effects of patients’ overall mental or

emotional health on HCAHPS scores (a new item added to the survey beginning in January 2013) and,

based on that analysis, will determine whether a patient-mix adjustment for these factors is warranted.

CHA will monitor this development closely, as we had urged CMS not to adopt this item in the HCAHPS

measure.

Finally, CMS believes that the Medicare Spending Per Beneficiary (MSPB) measure, which CHA op-

posed for inclusion in the program, gives hospitals incentive to redesign systems of care and coordinate

with other providers to improve quality and efficiency. In addition, CMS believes that hospitals have a

significant influence on Medicare spending surrounding a hospitalization. The MSPB efficiency measure

is combined with quality measures to calculate a hospital’s total performance score under the VBP pro-

gram.

A complete list of the FFY 2014, 2015 and 2016 VBP measures are noted in Appendix B. A discussion of

future measures under consideration in the VBP program is noted in the final rule and will also be dis-

cussed this fall at the MAP meetings.


August 2013

Baseline and Performance Periods

CMS adopts in the final rule the CY 2014 performance period and corresponding CY 2012 baseline peri-

od for three domains: clinical process of care, patient experience of care (HCAHPS) and efficiency (Med-

icare spending per beneficiary). CMS already adopted baseline and performance periods for FFY 2016

mortality and AHRQ PSI measures in last year’s rulemaking. The following table shows the performance

periods for FFY 2016; for reference, the FFY 2015 periods are shown as well. CMS inadvertently ex-

cluded performance periods for CLABSI, CAUTI and SSI but has done so in the CY 2014 OPPS pro-

posed rule (78 FR 43659) for inclusion.

Domain/Measures Baseline Period Performance Period

FY 2015 (Final)

Clinical process of care Jan. 1, 2011 – Dec. 31, 2011 Jan.1, 2013 – Dec. 31, 2013

Patient experience of care

(HCAHPS)

Jan. 1, 2011 – Dec. 31, 2011 Jan.1, 2013 – Dec. 31, 2013

Efficiency (Medicare spending

per beneficiary)

May 1, 2011 – Dec. 31, 2011 May 1, 2013 – Dec. 31, 2013

Outcomes

Mortality Oct. 1, 2010 – June 30, 2011 Oct. 1 2012 – June 30, 2013

AHRQ PSI Oct. 15, 2010 – June 30, 2011 Oct. 15, 2012 – June 30, 2013

CLABSI Jan. 1, 2011 – Dec. 31, 2011 Feb. 1, 2013 – Dec. 31, 2013

FY 2016 (Final)

Clinical process of care Jan. 1, 2012 – Dec. 31, 2012 Jan.1, 2014 – Dec. 31, 2014

Patient experience of care

(HCAHPS)

Jan. 1, 2012 – Dec. 31, 2012 Jan.1, 2014 – Dec. 31, 2014

Efficiency (Medicare spending

per beneficiary)

Jan. 1, 2012 – Dec. 31, 2012 Jan.1, 2014 – Dec. 31, 2014

Outcomes

Mortality Oct. 1, 2010 – June 30, 2011 Oct. 1, 2012 – June 30, 2014


CLABSI (Dates proposed in CY 2014

OPPS proposed rule)

January 1, 2011 – December

31, 2011

(Dates proposed in CY 2014

OPPS proposed rule)

February 1, 2013 – December

31, 2013

For the mortality and AHRQ measures, CMS finalizes the baseline and performance periods for FFYs

2017 through 2019 shown in the next table. CMS notes that, while the performance periods for the mor-

tality measure would ultimately be 36 months, the AHRQ PSI 90-measure performance period would

have a 24-month span, which it says is consistent with the AHRQ recommendation for public reporting

on this measure.

Outcome Measure

Proposed

Baseline Period

Proposed

Performance Period

FY 2017



FY 2018


AHRQ PSI July 1, 2010 – June 30, 2012 July 1, 2014 – June 30, 2016

FY 2019

Mortality July 1, 2009 – June 30, 2012 July 1, 2014 – June 30, 2017

Performance Standards and Scoring Methodology


August 2013

The final rule includes tables presenting CMS’ achievement thresholds and benchmarks for the FFY 2016

VBP program. The updated achievement thresholds and benchmarks reflect the CMS decision to calcu-

late separate scores for the two SSI strata (discussed above).

Domain Weighting for FFY 2016 and Reclassification for FFY 2017

As shown in the following table, for FFY 2016 CMS finalizes its proposal to modify the domain weights

used to calculate a hospital’s total performance score (TPS). CHA continues to remain concerned with the

shift in domain weights to the measures that have less reliability and validity and in some instances lack

appropriate risk adjustment.

VBP Program Weighting (Fiscal Year)

Domain 2013 2014 2015 2016 (final)

Clinical process of care 70% 45% 20% 10%

Patient experience of care 30% 30% 30% 25%

Outcomes 25% 30% 40%

Efficiency 20% 25%

CMS will continue the current policy for calculating a hospital’s performance score when it has scores for

fewer than four domains. Beginning in FFY 2015, a hospital must have scores for at least two domains in

order to have a TPS under the VBP program. (For FFYs 2013 and 2014, a hospital must have scores for

all domains in order to receive a TPS.) Under the final rule, a hospital with fewer than four domain scores

would continue to have its scores reweighted proportionately to assure that the TPS for each hospital is

based on 100 points.

Despite CHA objections to collapsing of the clinical care and process measure domain as well as the con-

tinued adoption of domains with only one measure, CMS adopts proposed changes to the program do-

mains weights for FFY 2017 and finalizes new domains that it believes align with the National Quality

Strategy.

FFY 2017 Domains for VBP FFY 2017 Weight

Patient and caregiver-centered experience of care/care coordination 25%

Clinical care

Clinical care – outcomes

Clinical care – process

35%

25%

10%

Efficiency and cost reduction 25%

Safety 15%

The proposed mapping of FFY 2016 VBP program measures into the reclassified domains is shown in the

table in Appendix B.

Hospital Readmission Reduction Program

Section 3025 of the ACA directs the Secretary to account for “excess readmissions” that began last Octo-

ber. Operating DRG payment rates are reduced based on a hospital’s ratio of actual to expected readmis-

sions. In FFY 2013, the maximum payment reduction was 1 percent; for FFY 2014 it is 2 percent, and it

will be capped at 3 percent for FFY 2015 and beyond.

Previously, CMS finalized and used the 30-day, all-cause readmission measures for acute myocardial in-

farction (AMI), heart failure (HF) and pneumonia (PN) for use in the first year of the program (FFY

2013).

Planned Readmissions Algorithm


August 2013

In response to numerous comments from CHA, AHA and other stakeholders calling for CMS to exclude

planned readmissions from the measures as required by the ACA, CMS developed an algorithm that is

applied to the Medicare FFS claims data and that identifies planned readmissions across the readmission

measures. The CMS Planned Readmission Algorithm Version 2.1 Report is available on the CMS web-

site.

For FFY 2014, CMS finalizes its proposal to apply the algorithm to the AMI, HF and PN measures. CMS

sought NQF endorsement of the revised algorithm, and each of the three measures was endorsed in Janu-

ary and March 2013, respectively. CHA supported this change but continues to seek additional refine-

ments for these measures.

In addition to the expanded list of planned readmissions through use of the algorithm, CMS finalizes its

proposal that if the first readmission is planned, it will not count as a readmission, nor will any subsequent

unplanned readmission within 30 days of the index readmission count as a readmission. In other words,

unplanned readmissions that occur after a planned readmission and fall within the 30-day post discharge

timeframe will no longer be counted as outcomes for the index admission. This change will affect a very

small percentage of readmissions (approximately 0.3 percent of index admissions nationally for AMI, 0.2

percent for HF and less than 0.1 percent for PN).

Proposed Floor Adjustment Factor and Applicable Periods for FFY 2014

A hospital’s readmissions “adjustment factor” for a fiscal year is equal to the greater of the adjustment

factor determined based on the hospital’s excess readmissions or the floor adjustment factor specified in

subparagraph (C). The final rule announces that the floor adjustment factor for FFY 2014 will be 0.98

(previously 0.99 for FFY 2013). As finalized in the FFY 2013 IPPS final rule, CMS rounds the ratio to the

fourth decimal place. Thus, for FFY 2014, a hospital subject to the Hospital Readmissions Reduction pro-

gram would have an adjustment factor that is between 1.0 and 0.9800. CMS notes that 18 hospitals are

subject to the maximum reduction of 2 percent in FFY 2014, and all but one of the hospitals also received

the 1.0 reduction in FFY 2013.

CMS finalizes that the applicable period for FFY 2014 under the Hospital Readmissions Reduction program

would be the three-year period from July 1, 2009, to June 30, 2012.

Additional Measures for FFY 2015

Despite significant comment regarding the lack of appropriate risk adjustment in the measures, CMS fi-

nalized its proposal to continue the measures from FFY 2013 and add two additional measures for FFY

2015. CMS will add the following measures for the FFY 2014 program:

30-Day, All-Cause, Risk-Standardized Readmission Rate Following Chronic Obstructive Pulmo-

nary Disease Hospitalization (NQF #1891)

30-Day, All-Cause, Risk-Standardized Readmission Rate Following Elective Total Hip Arthro-

plasty and Total Knee Arthroplasty (NQF #1551) (finalized in the IQR program in the FFY 2013

final rule.)

Hospital-Acquired Condition Payment Reduction Program for FFY 2015

Section 3008 of the ACA directs the HHS Secretary to make an adjustment to payments beginning on Oc-

tober 1, 2014 (FFY 2015), to implement the HAC payment reduction program. Payments are to be ad-

justed to account for hospital acquired conditions (HACs) with respect to discharges during FFY 2015 or

later. The amount of payment shall be equal to 99 percent of the amount of payment that would otherwise

apply. The ACA requires the Secretary to apply a risk adjustment methodology and to make available

confidential data for review and correction by hospitals prior to public reporting. Finally, the statute pro-

vides that there may be no administrative or judicial review with respect to what qualifies as an applicable


August 2013

hospital, the specifications of a HAC, the determination of an applicable period and what information is

reported to hospitals and the public.

The following provisions were finalized in the FFY 2014 IPPS final rule. Additional rulemaking in FFY

2015 is expected to fully implement this program. This program is expected to reduce IPPS payments by

about $300 million per year.

Eligibility

Under the statute all subsection d hospitals (including SCHs), including Maryland hospitals, are subject to

the HAC Reduction Program. However, Maryland hospitals may obtain a waiver.

Payment Adjustment

The payment adjustment is specified in section 3008, under which applicable hospitals would receive

payment equal to 99 percent of the amount that would otherwise apply under the IPPS. The HAC Reduc-

tion program adjustment must be applied after the adjustments made under the Hospital VBP program and

the Readmissions Reduction program. Neither the proposed or final rule provided a numerical example of

this calculation. CHA anticipates additional information will be provided in the FFY 2015 IPPS rule.

Finalized Measures and Measurement Time Periods

CMS adopts three measures for the FFY 2015 HAC program, using two domains. Additional CDC HAI

measures are also finalized for inclusion in the measure sets for FFY 2016 and FFY 2017, as noted in the

table below.

Final HAC Reduction Program Measures

FY 2015 FY 2016 FY 2017

Domain 1: AHRQ Patient Safety Indicators

PSI-90 (PSI-90 is a composite of eight PSI measures):

PSI-3 (Pressure ulcer rate)

PSI-6 (Iatrogenic pneumothorax)

PSI-7 (Central venous catheter related blood stream infections rate)

PSI-8 (Postoperative hip fracture rate)

PSI-12 (Postoperative VE or DVT rate)

PSI-13 (Postoperative sepsis rate

PSI-14 (Wound dehiscence rate)

PSI-15 (Accidental puncture or laceration)

X X X

Domain 2: CDC HAI Measures

Central Line-associated Blood Stream Infection (CLABSI) X X X

Catheter-associated Urinary Tract Infection (CAUTI) X X X

Surgical Site Infection (SSI):

◦ SSI Following Colon Surgery

◦ SSI Following Abdominal Hysterectomy

X X

Methicillin-resistant Staphylococcus aureus (MRSA) X

Clostridium difficile X

Domain 1 would include the AHRQ PSI 90 composite measure derived from Medicare FFS administra-

tive claims. This domain will be weighted at 35 percent (down from 50 percent in the proposed rule).

Domain 2 would include CDC HAI measures, which use chart-abstracted data and are reported through

the CDC National Healthcare Safety Network. This domain will be weighted 65 percent (an increase

from 50 percent in the proposed rule.) Both domains would be used to calculate a total HAC score.

CMS finalizes two years of data to calculate measure scores in both domains. The time periods for FFY

2015 are noted below.


August 2013

FFY 2015 Measurement Period

Domain 1 (PSI Composite) July 1, 2011- June 30, 2013

Domain 2 (HAI Measures) January 1, 2012 - December 31, 2013

Minimum Case Counts for Measures

In determining whether a hospital receives a score for the Domain1 PSI-90 measure, CMS will use the

same method that is used for the VBP program to determine whether a hospital has a complete score on

PSI-90. That is, a hospital must have three or more discharges for at least one indicator within the compo-

site. If a hospital has fewer than three eligible discharges for all eight of the PSI-90 components, no score

will be calculated for the composite measure. In calculating the composite score, the national rate is sub-

stituted for any PSI-90 component measure for which the hospital has fewer than three eligible discharges.

A hospital’s score, or rate, for the PSI-90 composite is a weighted average of rates of the component indi-

cators.

Similarly, for the Domain 2 CDC HAI measures, CMS will use the same inclusion criteria that apply for

these measures under the hospital IQR program. For these measures, CDC calculates a standard infection

rate (SIR) which compares the number of HAIs at a facility to a national baseline. The number of ob-

served infections is divided by the number of expected infections, which is calculated using event rates

from a standard population during a baseline period. Calculation of an SIR for a measure requires that the

facility have one or more predicted HAI events. Additional information on the SIR calculation is available

at the CDC website at www.cdc.gov/HAI/surveillance/QA_stateSummary.html#a6.

Risk Adjustment

Section 3008 requires the Secretary to establish and apply appropriate risk adjustment methodology when

determining the hospitals subject to the 1 percent payment reduction. CMS will use the existing measure-

level risk adjustments for this purpose. In responding to comments, CMS indicates that the risk adjustment

methodology for the measures meets NQF criteria. CMS does not believe the risk adjustment factors used

for the measures unfairly penalize large and teaching hospitals, but it will monitor this.

Performance Scoring Methodology

CMS finalizes a scoring methodology that differs from the proposed rule and makes modest improve-

ments. CHA believes this is a step in the right direction but remains concerned and will continue to seek

further refinements for this program.

Under the final methodology, any hospital with a score on a measure will be assigned points for that

measure, which will be counted toward the total HAC score. CMS believes that making the change to as-

sign points to the entire distribution of scores will reduce any potential artificial cut-off points, and that

taken together, the scoring changes will better reflect the variation in performance on measures and will

reduce the impact on large and teaching hospitals. CMS intends to continue examining this impact and

consider “releasing additional analysis in future rulemaking.”

The points assigned to a measure are summarized in the following table. For each measure, hospitals with

a score will be assigned to deciles – increments of 10 – with points assigned to each decile. As shown in

the table, a hospital in the eighth percentile for a measure (between the 70th and 80

th percentile) would re-

ceive eight points on the measure. For Domain 1, points will be based on the PSI-90 composite score val-

ue (rather than the independent measures within the composite).

For Domain 2, the score will consist of the average points assigned to the SIR for each NHSN measure

(CLABSI and CAUTI for FFY 2015). While the use of points is similar to the VBP program, CMS points


August 2013

out that in the case of the HAC score, having more points indicates a poorer performance, which is the

opposite of VBP program scoring.

Scoring of Measures for HAC Reduction Program

Percentile Points

1st – 10th 1

11th – 20th 2

21st - 30th 3

31st - 40th 4

41st - 50th 5

51st - 60th 6

61st - 70th 7

71st - 80th 8

81st - 90th 9

91st - 100th 10

Domain 2 scores will be based on measure results that hospitals submit to the CDC NHSN for the IQR

program. Because the two measures for FFY 2015 currently capture HAIs in the ICU only, a hospital that

participates in the IQR program but has no ICU beds can apply for an ICU waiver so that they are not pe-

nalized for not reporting on these measures. CMS reports that 377 hospitals have an ICU waiver, or 10

percent of the 3,321 hospitals participating in the IQR program.

For those hospitals with an ICU waiver from reporting on the CDC HAI measures for the IQR program,

the total HAC score will be calculated based entirely on the Domain 1 measures. However, a hospital that

is eligible to report HAIs, does not have a zero ICU beds waiver and fails to report to NHSN, will receive

the maximum score of 10 points for Domain 2.

If data are sufficient to calculate an SIR for at least one of the CDC HAI measures, a Domain 2 score will

be calculated, and the total HAC score will be a weighted average of the Domain 1 (35 percent weight)

and Domain 2 (65 percent weight) scores. If data are not sufficient to calculate an SIR, the total HAC

score will be the Domain 1 score alone. If there are data sufficient to calculate a Domain 2 score but not

sufficient data to calculate a PSI 90 (Domain 1) score, the total HAC score will equal the Domain 2

score. No total HAC score will be calculated if a hospital has insufficient data for either a Do-

main 1 or Domain 2 score.

Reporting of Hospital-Specific Information, Including Review and Correction of Information

As required by law, CMS finalized its proposal to make information available to the public regarding the

total HAC score for eligible hospitals (including hospitals in Maryland). Before the information is made

public, CMS will provide each hospital with a confidential hospital-specific report that contains certain

information related to claims-based measure data for the PSI measure, the domain scores for each domain

and the total HAC score.

Hospitals would be given 30 days to review and correct both the claims-based AHRQ PSI measure in do-

main 1 as well as the point allocations for the measures in each domain, the domain scores and the total

HAC score.

For the Domain 2 CDC HAI chart-abstracted measures proposed for inclusion in the FFY 2015 HAC Re-

duction program, the hospital IQR program data review and correction process will be used. Under the

hospital IQR program, chart-abstracted data are submitted for a calendar quarter, and hospitals have an


August 2013

opportunity to submit, review and correct any chart-abstracted measure during the calendar quarter and for

four-and-a-half months following the end of the calendar quarter.

The 30-day review and corrections period will begin when the hospitals’ confidential reports and accom-

panying discharge-level information are posted to their QualityNet accounts. During the review and cor-

rection period, hospitals will notify CMS of any errors in their total HAC score using the technical assis-

tance contact information provided in their confidential reports. In addition, a hospital could notify CMS

if it suspects that discrepancies exist in the application of the HAC scoring methodology (assignment of

points to measures, domain scoring, domain weighting). If CMS confirms that it made an error in creating

the data extract or in calculating the total HAC score, the calculations will be corrected and new confiden-

tial reports provided to affected subsection hospitals.

In the case of errors that take more time than anticipated to correct, CMS will notify hospitals that correct-

ed HAC scores will be made available through delivery of confidential reports followed by a second 30-

day review and correction period, subsequent publication and posting on Hospital Compare website. Any

corrections to a hospital’s total HAC score will then be used to recalculate a hospital’s quartile in order to

determine the correct HAC Reduction program adjustment factor.

Impact Analysis

The regulatory impact analysis presented in Appendix A of the final rule includes a discussion of the es-

timated effects of the proposed HAC Reduction program for FFY 2015. CMS used Medicare fee-for-

service discharges for the period July 1, 2009, through June 30, 2011, to calculate the AHRQ PSI score,

and Hospital Compare data on the CDC measures from December 2012, to estimate a total HAC score for

hospitals under the final rule methodology. CMS calculated results for 3,468 hospitals.

The table shown below summarizes the results of CMS’ analysis, which are shown more fully in a table

in the final rule’s Appendix A. CMS does not offer an explanation for the low number of teaching hospi-

tals in the HAC Reduction program analysis.

CMS Analysis of Total HAC Scores Under Final Rule

by Type of Hospital

Hospital Characteristics

Worst

Performing Quartile

Characteristic

Number of

Hospitals

Percent

Number of

Hospitals

Percent

< 50 beds 656 19.6% 119 18.1%

50 - 99 680 20.4% 181 26.6%

100 - 199 893 26.7% 204 22.8%

200 - 299 512 15.3% 133 26.0%

300 - 399 268 8.0% 71 26.5%

400 - 499 125 3.7% 37 29.6%

500+ 205 6.1% 75 36.6%

Teaching 276 8.3% 134 48.6%

Non-Teaching 3,063 91.7% 686 22.4%

Non-Profit 2,026 60.7% 511 25.2%

Government 558 16.7% 148 26.5%

For-Profit 755 22.6% 161 21.3%


August 2013

CMS Analysis of Total HAC Scores Under Final Rule

by Type of Hospital

Hospital Characteristics

Worst

Performing Quartile

Characteristic

Number of

Hospitals

Percent

Number of

Hospitals

Percent

Urban 2,493 72.1% 639 25.6%

Rural 965 27.9% 201 20.8%

Non-DSH 749 21.9% 145 19.4%

DSH Quartile 1 658 19.3% 149 22.6%

DSH Quartile 2 665 19.5% 150 22.6%

DSH Quartile 3 669 19.6% 186 27.8%

DSH Quartile 4 673 19.7% 200 29.7%

Inpatient Psychiatric Quality Reporting Program (IPFQR)

In the FFY 2013 IPPS/LTCH final rule, CMS established a quality reporting program beginning in FFY

2014 for inpatient psychiatric facilities (IPFs) as required by the ACA. An IPF that does not meet the re-

quirements of participation in the IPFQR for a fiscal year is subject to a two percentage point reduction in

the update factor for that year, and may result in a negative annual update for that year. CHA has released

its FFY 2014 payment update notice for the IPF PPS, available online at

http://www.calhospital.org/fy2014-ipf-payment-update

IPFQR Measures

Six measures were previously adopted for the FFY 2014 payment determination and subsequent years. In

this rule, CMS finalized two additional measures beginning with the FFY 2016 payment determination. A

table showing current and newly adopted FFY 2016 measures follows:

Final IPFQR Program Measures

Measure ID Description FFYs 2014

and 2015 FFY 2016

NQF #0640/HBIPS-2 Hours of Physical Restraint Use X X

NQF #0641/HBIPS-3 Hours of Seclusion Use X X

NQF #0552/HBIPS-4

Patients Discharged on Multiple Antipsychotic

Medications (HBIPS-4) X X

NQF #0560/HBIPS-5

Patients Discharged on Multiple Antipsychotic

Medications with Appropriate Justification X X

NQF #0557/HBIPS-6 Post-Discharge Continuing Care Plan X X

NQF #0558/HBIPS-7

Post-Discharge Continuing Care Plan

Transmitted to Next Level of Care Provider Upon

Discharge

X X

SUB-1: Alcohol Use Screening X

NQF# 0576 Follow-Up After Hospitalization for Mental Illness X

Despite CHA and field objections to the proposed measures, CMS has finalized two of the three measures.

CMS did not finalize SUB-4—Alcohol and Drug Use Assessing Status After Discharge, acknowledging

provider burden and noted that a claims-based version of the measure was not viable.

http://www.calhospital.org/fy2014-ipf-payment-update


August 2013

New Measures for FFY 2016

SUB-1 – Alcohol Use Screening

This measure assesses the percentage of patients 18 and older who are screened during an IPF stay for

unhealthy alcohol use. This measure was recently submitted for NQF review. The MAP supported the

direction of this measure, noting that it must receive NQF endorsement before being finalized for the pro-

gram.

This measure assesses whether discharged patients are contacted between seven and 30 days after hospital

discharge to collect information about their alcohol or drug use. Similar to SUB-1, this measure’s NQF

review is pending, and the MAP voted to support direction.

NQF#0567 – Follow-up After Hospitalization for Mental Illness (FUH)

This measure assesses the percentage of discharges for patients six and older who are admitted to IPFs for

treatment of selected mental health disorders and who subsequently receive outpatient treatment from a

provider or who received partial hospitalization services. This measure is currently specified for the

health plan setting. This measure is NQF endorsed and supported by the MAP.

This measure was proposed as a chart-abstracted measure, but is finalized instead as a claims-based

measure to address burden and privacy concerns raised by commenters. CMS will calculate this measure

using Medicare Part A and Part B claims data; no data collection or reporting by IPFs will be required.

The calculation of this measure will occur using data for the 12-month period beginning July 1 of the year

immediately preceding the reporting year for chart abstracted measures. For example, for the FY 2016

payment determination, CMS will calculate this measure for July 1, 2013 through June 30, 2014. CMS

will consider transitioning this measure to chart-abstracted data collection, taking into account comments

received in response to the proposed rule. Because this is now a claims-based measure, it will only be

reported on the over 65 Medicare FFS population, rather than for all patients over the age of six as noted

above.

CMS finalizes its proposal for voluntary submission of information regarding patient experience of care.

CMS intends to pursue adoption of a standardized measure of patient experience of care in the IPFQR in

the near future, and would like to know whether the IPFs participating in the IPFQR assess patient experi-

ence of inpatient behavioral health services using a standardized instrument. If yes, CMS would also like

to know the name of the survey they administer. Voluntary submission of this information will occur

through a web-based tool and will not affect the FFY 2016 payment determination. Additional infor-

mation will be forthcoming via the QualityNet website.

Data Collection and Reporting

CMS finalizes its data submission and public reporting periods to conform with the IQR program. Below

is a table that summarizes the payment determination year, reporting period, submission deadlines and

proposed public display timelines.

Public Display

CMS finalizes its proposal to change the timing of public display of IPFQR data in order to better align

with the IQR program. For the FFY 2014 payment determination and subsequent years, submitted data

will be displayed publicly on the CMS website in April of each calendar year following the start of the

respective payment determination year (e.g., public display for the FFY 2014 payment determination will

begin April 2014.) Hospitals may preview the data for a 30-day period approximately 12 weeks prior to

public display; this aligns with the preview and display periods for the IQR program.


August 2013

IPFQR Program Time Frames

Payment De-

termination

Year

Reporting Period for

Services Provided*

Data Submission

Time Frame

DACA

Deadline

Public

Display

Begins

FFY 2014 Q4 2012 – Q1 2013

(October 1, 2012 –

March 31, 2013)

July 1, 2013-

August 15, 2013

August 15,

2013

April 2014

FFY 2015 Q2 2013- Q4 2013

(April 1, 2013 –

December 31, 2013)

July 1, 2014 - August

15, 2014

August 15,

2014

April 2015

FFY 2016 Q1-Q4 2014 (January 1, 2013 –

December 31, 2013)

July 1, 2015- August

15, 2015

August 15,

2015

April 2016

*The claims-based measure, “Follow-up After Hospitalization for Mental Illness,” will be calculated for the 12-month

period beginning July 1 of the year immediately preceding the reporting year for chart-abstracted measures. For example,

for the FY 2016 payment determination, CMS will calculate this measure for July 1, 2013, through June 30, 2014.

PPS-Exempt Cancer Hospital Quality Reporting Program (PCHQR)

In the FFY 2013 IPPS/LTCH final rule, CMS established a quality reporting program beginning in FFY

2014 for PPS-exempt cancer hospitals (PCHs), as required under section 1866(k) of the Act, as added by

section 3005 of the ACA. The PPS-exempt Cancer Hospital Quality Reporting (PCHQR) program fol-

lows many of the policies established for the Hospital IQR program, including the principles for selecting

measures and the procedures for hospital participation in the program. No policy was adopted on the con-

sequences if a PCH fails to meet the quality reporting requirements; CMS indicated its intention to ad-

dress the issue in future rulemaking. Five measures were adopted for the new cancer hospital quality re-

porting program for FFY 2014. Existing and newly finalized measures are shown in the table below.

New PCHQR Program Measures

In this rule, CMS adopts one new measure for the PCHQR program in FFY 2015 and 12 new measures

beginning in FFY 2016. The new measures, listed below, include the NHSN measure of surgical site in-

fections following colon surgeries and abdominal hysterectomies, six surgical care improvement project

(SCIP) measures, five clinical process/oncology measures and the HCAHPS. One additional oncology

measure, Multiple Myeloma-Treatment with Bisphosphonates (NQF #0380), was proposed but not final-

ized. CMS was persuaded by comments regarding the clinical basis of the measure and concerns about

data collection burden. With the exception of the oncology measures, all the new measures adopted for

the PCHQR program are included in the Hospital IQR program. Measure specifications are available on

the QualityNet.org website.

Finalized PCHQR Program Measures

Measures Beginning with the FFY 2014 Program Year

NHSN CLABSI outcome measure (NQF #0139)

NHSN CAUTI outcome measure (NQF #0138)

Adjuvant chemotherapy is considered or administered with four months (120 days) of surgery to

patients < 80 with AJCC T1c (lymph node positive) colon cancer (NQF #0223)

Combination chemotherapy is considered or administered within four months (120 days) of

diagnosis to women < 70 with AJCC T1c or Stage II or III hormone receptor negative breast

cancer. (NQF #0559)

Adjuvant hormonal therapy (Tamoxifen or third generation aromatase inhibitor is considered or

administered within one year of diagnosis to women > 18 with AJCC T1cN0M0, or Stage II or

III hormone receptor positive breast cancer.) (NQF #0220)



August 2013

Finalized PCHQR Program Measures

Surgical Site Infection (SSI) (NQF #0753)


Surgical Care Improvement Project (SCIP)

SCIP-Inf-1: Prophylactic Antibiotic Received Within one Hour Prior to Surgical Incision

(NQF#0527)

SCIP-Inf-2: Prophylactic Antibiotic Selection for Surgical Patients (NQF #0528)

SCIP-Inf-3: Prophylactic Antibiotic Discontinued Within 24 Hrs After Surgery End Time (NQF

#0529)

SCIP-Inf-9: Urinary Catheter Removed on Post-Operative Day 1 or Post-Operative Day 2 with

Day of Surgery Being Day Zero (NQF #0453)

SCIP-Card 2: Surgery Patients on Beta Blocker Therapy Prior to Admission who Received a

Beta Blocker During the Perioperative Period (NQF #0284)

SCIP- VTE 2: Surgery Patients who Received Appropriate VTE Prophylaxis within 24 Hrs Prior

to Surgery to 24 Hrs After Surgery End Time (NQF #0218)

Clinical Process/Oncology Care Measures

Oncology-Radiation Dose Limits to Normal Tissues (NQF #0382)

Oncology: Plan of Care for Pain (NQF #0383)

Oncology: Pain Intensity Quantified (NQF #0384)

Prostate Cancer-Avoidance of Overuse Measure-Bone Scan for Staging Low-Risk Patients

(NQF #0389)

Prostate Cancer-Adjuvant Hormonal Therapy for High-Risk Patients (NQF #0390)

Patient Experience of Care

HCAHPS

Public Display

As proposed, CMS will publicly display in 2014 data for two of the five previously adopted measures.

They are the measures involving adjuvant chemotherapy for colon cancer (NQF #0223) and combination

chemotherapy for breast cancer (NQF #0559). CMS defers public reporting of the other measures while it

engages in testing and assessing data quality, including reliability and validity of the measure rates.

Data Submission and Other Procedures

CMS finalizes modified procedures for data submission under the PCHQR program beginning with the

FFY 2015 program year. These involve: 1) a process for granting waivers from program requirements

under extraordinary circumstances similar to other quality reporting programs, and 2) specified reporting

periods and data submission timelines for the new measures. PCHs will report on the SSI measure begin-

ning with January 1, 2014, events. HCAHPS reporting will begin with discharges occurring on April 1,

2014. The SCIP and oncology process measures will be reported beginning with January 1, 2015, dis-

charges. Certain exceptions are provided with respect to required reporting of the HAI measures to ac-

count for hospitals with few procedures and those that do not have locations that meet NHSN criteria for

CLABSI and CAUTI reporting.

Additional Information

In August, CHA issued facility-specific CHA DataSuite reports detailing the final FFY 2014 Medicare

DSH reductions. An additional set of facility-specific reports detailing the final FFY 2014 IPPS policy

and payment proposals was also distributed. Questions or comments regarding the FFY 2014 IPPS final

rule should be directed to Alyssa Keefe, vice president federal regulatory affairs at (202) 488-4688, or

[email protected]. Questions related to the FFY 2014 CHA DataSuite reports should be directed to

Amber Ott, vice president finance, at (916) 552-7669, or [email protected].




August 2013

APPENDIX A

Summary Hospital IQR Program Measures for Payment Determinations for FFYs 2014, 2015 and

2016 Measure 2014 2015 2016

Acute Myocardial Infarction (AMI) Measures

AMI-2 Aspirin prescribed at discharge X X Removed

AMI-7a Fibrinolytic (thrombolytic) agent received within

30 minutes of hospital arrival

X X X

AMI-8a Timing of receipt of primary Percutaneous

Coronary Intervention (PCI)

X X X

AMI-10 Statin prescribed at discharge X X Removed

Heart Failure (HF) Measures

HF-1 Discharge instructions X X Removed

HF-2 Evaluation of left ventricular systolic function X X X

HF-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or Angio-

tensin II Receptor Blocker (ARB) for left ventricular

systolic dysfunction

X X Removed

Stroke (STK) Measure Set

STK-1 VTE prophylaxis X X

STK-2 Antithrombotic therapy for ischemic stroke* X X

STK-3 Anticoagulation therapy for Afib/flutter* X X

STK-4 Thrombolytic therapy for acute ischemic stroke* X X

STK-5 Antithrombotic therapy by the end of hospital day 2* X X

STK-6 Discharged on statin* X X

STK-8 Stroke education* X X

STK-10 Assessed for rehabilitation services* X X

Venous Thromboembolism (VTE) Measure Set

VTE-1 VTE prophylaxis* X X

VTE-2 ICU VTE prophylaxis* X X

VTE-3 VTE patients with anticoagulation overlap therapy* X X

VTE-4 VTE patients receiving un-fractionated Heparin with dos-

es/labs monitored by protocol*

X X

VTE-5 VTE discharge instructions* X X

VTE-6 Incidence of potentially preventable VTE* X X

Pneumonia (PN) Measures

PN-3b Blood culture performed before first antibiotic

received in hospital

X X Removed

PN-6 Appropriate initial antibiotic selection X X X

Surgical Care Improvement Project (SCIP) Measures

SCIP INF-1 Prophylactic antibiotic received within 1 hour

prior to surgical incision

X X X

SCIP-INF-2 Prophylactic antibiotic selection for surgical

patients

X X X

SCIP-INF 3 Prophylactic antibiotics discontinued within

24 hours after surgery end time (48 hours for cardiac surgery)

X X X

SCIP-INF-4 Cardiac surgery patients with controlled 6 AM postop-

erative serum glucose

X X X

SCIP–INF-9 Postoperative urinary catheter removal on postopera-

tive day 1 or 2 with day of surgery being day zero

X X X

SCIP-INF-10 Surgery patients with perioperative

temperature management

X X Removed


August 2013

Measure 2014 2015 2016

SCIP-Cardiovascular-2: Surgery patients on a Beta Blocker

prior to arrival who received a Beta Blocker during the

perioperative period

X X X

SCIP-VTE-1: Surgery patients with venous

thromboembolism (VTE) prophylaxis ordered

X Previously Removed

SCIP-VTE-2: Surgery patients who received appropriate

VTE prophylaxis within 24 hours pre/post surgery

X X X

Mortality Measures (Medicare Patients)

AMI 30-day mortality rate X X X

Heart failure 30-day mortality rate X X X

Pneumonia 30-day mortality rate X X X

Stroke 30-day mortality rate X

COPD 30-day mortality rate X

Patients’ Experience of Care Measures

HCAHPS survey X X X

Readmission Measures (Medicare Patients)

AMI 30-Day Risk Standardized Readmission X X X

Heart Failure 30-Day Risk Standardized Readmission X X X

Pneumonia 30-Day Risk Standardized Readmission X X X

30-Day Risk Standardized Readmission following Total

Hip/Total Knee Arthroplasty

X X

Hospital-Wide All Cause Unplanned Readmission X X

Stroke 30-day Risk Standardized Readmission X

COPD 30-day Risk Standardized Readmission X

AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs). Composite Measures and Nurs-

ing Sensitive Care

PSI 06: Iatrogenic pneumothorax, adult X Previously Removed

PSI 11: Postoperative respiratory failure X Previously Removed

PSI 12: Postoperative PE or DVT X Previously Removed

PSI 14: Postoperative wound dehiscence X Previously Removed

PSI 15: Accidental puncture or laceration X Previously Removed

IQI 11: Abdominal aortic aneurysm (AAA) mortality rate X Previously Removed

IQI 19: Hip fracture mortality rate X Previously Removed

Complication/patient safety for selected indicators

(composite)

X X X

Mortality for selected medical conditions (composite) X Previously Removed

PSI 04: Death among surgical inpatients with serious,

treatable complications

X X X

Structural Measures

Participation in a Systematic Database for Cardiac Surgery X X X

Participation in a Systematic Clinical Database Registry for

Stroke Care

X X Removed


Nursing Sensitive Care

X X X


General Surgery

X X X

Safe Surgery Checklist Use X

Healthcare-Associated Infections Measures

Central Line Associated Bloodstream Infection (CLABSI) X X X

Surgical Site Infection X X X

Catheter-Associated Urinary Tract Infection (CAUTI) X X X

MRSA Bacteremia X X

Clostridium Difficile (C.Diff) X X


August 2013

Measure 2014 2015 2016

Healthcare Personnel Influenza Vaccination X X

Surgical Complications

Hip/Knee Complication: Hospital-Level Risk Standardized Com-

plication Rate (RSCR) following Elective Primary

Total Hip Arthroplasty

X X

Hospital Acquired Condition (HAC) Measures

Foreign Object Retained After Surgery X Previously Removed

Air Embolism X Previously Removed

Blood Incompatibility X Previously Removed

Pressure Ulcer Stages III & IV X Previously Removed

Falls and Trauma (includes Fracture, Dislocation,

Intracranial Injury, Crushing Injury, Burn, Electric Shock)

X Previously Removed

Vascular Catheter-Associated Infection X Previously Removed

Catheter-Associated Urinary Tract Infection (UTI) X Previously Removed

Manifestations of Poor Glycemic Control X Previously Removed

Emergency Department (ED) Throughput Measures

ED-1 – Median time from ED arrival to departure from the

emergency room for patients admitted to the hospital*

X X X

ED-2 – Median time from admit decision to time of departure

from the ED for ED patients admitted to the inpatient status*

X X X

Prevention

Immunization for Influenza X X X

Immunization for Pneumonia X X Suspended

Cost Efficiency

Medicare Spending per Beneficiary X X X

AMI Payment per Episode of Care X

Perinatal Care

Elective delivery < 39 completed weeks gestation* X X

* Measure adopted for voluntary electronic reporting in CY 2014


August 2013

APPENDIX B

Hospital Value Based Purchasing Program Quality Measures for

FFYs 2014 (Final), 2015 (Final), and 2016 (Final)

Measure ID Measure Description 2014 2015

Final

2016

Process of Care Measures

AMI-7a Fibrinolytic Therapy Received Within 30 Minutes

of Hospital Arrival X X X

AMI-8a Primary PCI Received Within 90 Minutes of

Hospital Arrival X X Removed

IMM-2 Influenza Immunization X

HF-1 Discharge Instructions X X Removed

PN-3b Blood Cultures Performed in the Emergency

Department Prior to Initial Antibiotic Received in Hospital X X Removed

PN-6 Initial Antibiotic Selection for CAP in

Immunocompetent Patient X X X

SCIP-Inf-1 Prophylactic Antibiotic Received Within One

Hour Prior to Surgical Incision X X Removed

SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical

Patients X X X

SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within

24 Hours After Surgery End Time X X X

SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6 AM Postoperative

Serum Glucose X X Removed

SCIP-Inf-9 Urinary Catheter Removal on Post-Operative Day

1 or 2 X X X

SCIP-Card-2 Surgery Patients on a Beta Blocker Prior to

Arrival That Received a Beta Blocker During the Periopera-

tive Period

X X X

SCIP-VTE-1 Surgery Patients with Recommended Venous Thromboembo-

lism Prophylaxis Ordered X Removed N/A

SCIP-VTE-2 Surgery Patients Who Received Appropriate

Venous Thromboembolism Prophylaxis Within

24 Hours Prior to Surgery to 24 Hours After

Surgery

X X X

Patient Experience of Care Measures

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Communication with Nurses X X X

Communication with Doctors X X X

Responsiveness of Hospital Staff X X X

Pain Management X X X

Communication About Medicines X X X

Cleanliness and Quietness of Hospital Environment X X X

Discharge Information X X X

Overall Rating of Hospital X X X

Outcome Measures

MORT-30-AMI

Acute Myocardial Infarction (AMI) 30-Day

Mortality Rate X X X

MORT-30-HF Heart Failure (HF) 30-Day Mortality Rate X X X

MORT-30-PN Pneumonia (PN) 30-Day Mortality Rate X X X

AHRQ PSI 90

Complication/patient safety for selected indicators (compo-

site) X X

CLABSI Central Line-Associated Blood Stream Infection X X

CAUTI Catheter-Associated Urinary Tract Infection X


August 2013

Measure ID Measure Description 2014 2015

Final

2016

SSI Surgical Site Infection

Colon

Abdominal Hysterectomy

X

Efficiency Measures

MSPB-1 Medicare Spending per Beneficiary X X

Final VBP Measure Domains for FFY 2017 Measure ID Name (Abbreviated) Current Domain Final FFY 2017

NQS-Based Domain

AMI-7a Fibrinolytic Therapy W/in 30 Min. Clin. Process of Care Clinical Care – Process

IMM-2 Influenza Immunization Clin. Process of Care Clinical Care – Process

PN-6 Initial Antibiotic Selection Clin. Process of Care Clinical Care – Process

SCIP-Inf-2 Prophylactic Antibiotic Selection Clin. Process of Care Clinical Care – Process

SCIP-Inf-3 Prophyl. Antibiotics Discontinued Clin. Process of Care Clinical Care – Process

SCIP-Inf-9 Urinary Catheter Removal Clin. Process of Care Clinical Care – Process

SCIP–Card-2 Surgery Patients -- Beta Blocker Clin. Process of Care Clinical Care – Process

SCIP-VTE-2 Surgery Appropriate VTE Proph. Clin. Process of Care Clinical Care – Process

HCAHPS HCAHPS Patient Experience of

Care

Patient and Caregiver

Centered Experience of

Care/Care Coordination

MORT-30-AMI AMI 30-Day Mortality Rate Outcome Clin. Care – Outcomes

MORT-30-HF Heart Failure 30-Day Mortality Outcome Clin. Care – Outcomes

MORT-30-PN Pneumonia 30-Day Mortality Rate Outcome Clin. Care – Outcomes

AHRQ PSI 90 Patient Safety Composite Outcome Safety

CLABSI

Central Line-Associated Blood

Stream Infection

Outcome Safety

CAUTI Catheter-Associated Urinary Tract Infection Outcome Safety

SSI Surgical Site Infection Outcome Safety

MSPB-1 Medicare Spending per Beneficiary Efficiency Efficiency and Cost

Reduction

ffy 2014 medicare inpatient prospective payment system ......revises the conditions of participation...

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