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Tag: HAC

Quality Program Changes

While CMS is finalizing several of the proposed changes to the hospital quality reporting and payment programs, none of these changes represent significant structural or procedural changes to the programs.
Hospital Inpatient Quality Reporting (IQR)
CMS is making the following adjustments to the program:
  • Adopt the Hybrid Hospital-Wide All-Cause Readmission (Hybrid HWR) measure, beginning with two voluntary reporting periods running from 7/1/2021 to 6/30/2022 and from 7/1/2022 to 6/30/2023.
  • Adopt the Safe Use of Opioids – Concurrent Prescribing electronic clinical quality measure (eCQM), with a clarification and update, beginning with CY 2021 reporting period/FY 2023 payment determination.
  • Remove the Claims-based Hospital-Wide All-Cause Unplanned Readmission measure (HWR claims-only measure) beginning with the FY2026 payment determination.
  • Extend current eCQM reporting and submission requirements for both the CY2020 reporting (FY2022 payment) and the CY2021 reporting (FY2023 payment) periods.
  • Change eCQM reporting and submission requirements for the CY2022 reporting (FY2024 payment) period, such that hospitals would be required to report one self-selected calendar quarter of data for three self-selected eCQMs and the proposed Safe Use of Opioids eCQM.
  • Continue requiring that EHRs be certified to all available eCQMs used in the Hospital IQR program for the CY2020 and subsequent reporting periods.
CMS is not finalizing its proposal to adopt the Hospital Harm – Opioid-related Adverse Events eCQM.
Hospital Value Based Purchasing (HVBP)
CMS will now require that the HVBP program use the same data used by the HAC program for purposes of calculating the Centers for Disease Control and Prevention (CDC) National Health Safety Network (NHSN) Healthcare-Associated Infection (HAI) measures beginning with the CY2020 data collection, when the hospital IQR program will no longer collect data on those measures.
CMS is not adding or removing any measures for the FY2022 and FY2023 program years. However, CMS will be establishing new performance standards for FY2024 and FY2025.
Hospital Readmission Reduction (HRR)
CMS will adopt the following adjustments to the program:
  • Establish the performance period for the FY 2022 program year.
  • Adopt a measure removal policy that aligns with the policies for other quality programs.
  • Update the definition of “dual-eligible” as a beneficiary who has full benefit status in both the Medicare and Medicaid programs for the month the beneficiary was discharged, except for those beneficiaries who die in the month of discharge, who will be identified using the previous month’s data.
  • Adopt a process to make nonsubstantive changes to the payment adjustment factors, which would include updated naming or locations of data file or minor discrepancies, but which would not include different methodologies to use data or the use of a different component in the methodology.
  • Update 42 CFR 412.152 and 412.154 to reflect policies finalized in previous Rules.
Hospital Acquired Conditions (HAC)
CMS will make the following adjustments to the program:
  • Adopt a measure removal policy that aligns with the policies for other quality programs.
  • Clarify policies for validating CDC NHSN HAI measures.
  • Adopt the collection periods for the FY2022 program year.
    • CMS PSI 90 measure – 24-month period from 7/1/2018 to 6/30/2020
    • CDC NHSN HAI measures – 24-month period from 1/1/2019 to 12/31/2020.
  • Update 42 CFR 412.172(f) to reflect policies finalized in the FFY2019 IPPS Final Rule.
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Results from the CMS Hospital-Acquired-Conditions Reduction Program – FFY 2016

From: CMS Fact Sheet – 12/10/15

CMS finally released the listing of hospitals that are impacted by the Hospital Acquired Conditions program.  By law (Implemented from ACA), Hospitals that fall in the 25% lowest quartile are subject to a 1% reduction in their Inpatient Medicare PPS Acute payments.  What makes this particular reduction significant is that the reduction applies to all Inpatient Medicare PPS Acute reimbursements, whereas the Hospital Readmissions and Value Base Purchasing programs impact only the base operating DRG payments.

Based on my quick review, here is a summary of the impacted hospitals on the West Coast States:

State Impacted Hospitals Total Hospitals % of Total
California 88 299 29%
Oregon 9 34 26%
Washington 16 49 33%

Click here, to download the spreadsheet file containing the HAC scoring and the hospitals impacted by the reduction.  We have added the hospital names in this enclosed file for easier navigation and analysis.

Listed below is an excerpt of the CMS fact sheet release:

Hospital-Acquired Conditions Reduction Program Overview
Section 3008 of the Patient Protection and Affordable Care Act (ACA) established the Hospital-Acquired Condition (HAC) Reduction Program to provide an incentive for applicable hospitals to reduce HACs. Effective beginning Fiscal Year (FY) 2015 (discharges beginning on October 1, 2014), the HAC Reduction Program requires the Secretary of the Department of Health and Human Services to adjust payments to applicable hospitals that rank in the worst-performing quartile of all subsection (d) non-Maryland hospitals with respect to risk-adjusted HAC quality measures. These hospitals will have their payments reduced to 99 percent of what would otherwise have been paid for such discharges.

FY 2016 HAC Reduction Program Results
In FY 2016, 758 out of 3,308 hospitals subject to the HAC Reduction Program are in the worst performing quartile and will have a one percent payment reduction applied to all Medicare discharges occurring between October 1, 2015 and September 30, 2016. In FY 2015, 724 hospitals were subject to a payment reduction.

We estimate that the total savings in FY 2016 will be $364 million.

In FY 2016, the 75th percentile of Total HAC Score cutoff was 6.75, compared to 7.00 in FY 2015. The cutoff contributed to the slight increase in the percentage of hospitals in the worst performing quartile, from 21.9 percent of applicable hospitals in FY 2015 to 22.9 percent of applicable hospitals in the FY 2016. Out of the 758 hospitals in the worst performing quartile in FY 2016, approximately 53.7 percent were also in the worst performing quartile in FY 2015.

Across the FY 2015 and FY 2016 programs, the average performance across eligible hospitals improved on two of the three measures included in both program years. In particular, the mean Patient Safety Indicator (PSI) 90 Composite Index Value decreased from 0.89 to 0.86 in FY 2016, and the mean Central Line-Associated Blood Stream Infection (CLABSI) Standardized Infection Ratio (SIR) decreased from 0.53 in FY 2015 to 0.48 in FY 2016. The mean Catheter-Associated Urinary Tract Infection (CAUTI) SIR increased slightly from 1.13 in FY 2015 to 1.17 in FY 2016. The mean Surgical Site Infection (SSI) SIR in FY 2016, which was the first year that this measure was used in the program, was 0.95.

Public Reporting
On December 10, 2015, CMS made the following HAC Reduction Program information publicly available for each eligible hospital:

  • PSI 90 Composite measure score
  • CLABSI, CAUTI, and SSI measure scores
  • Domain 1 and Domain 2 scores
  • Total HAC Score

The FY2016 HAC Reduction Program scores for hospitals can be found on the Hospital Compare Website by following this link:

Results from the CMS Hospital-Acquired-Conditions Reduction Program – FFY 2016

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Improvements in Hospital-Acquired Conditions Stall

From: HFMA News – 12/1/15

Following several years of improvements, the rate of hospital-acquired conditions (HACs) did not improve in 2014, according to new federal data.

The rate of HACs, which had fallen 17 percent from 2010 through 2013, was unchanged in 2014, according to preliminary results of a report released Dec. 1 by the U.S. Department of Health and Human Services.

Federal officials underscored the progress to date, which included an estimated 87,000 fewer patient deaths and nearly $20 billion in savings going back to 2010, but acknowledged they do not know why the decline stopped at 121 HACs per 100,000 discharges.

“We don’t have a full answer to that question,” Richard Kronick, PhD, director of the Agency for Healthcare Research and Quality, said in a call with reporters. “Part of the answer is likely that the dramatic improvements that we saw in earlier years were likely the relatively lower-hanging fruit. Hospitals are now working on the more difficult problems.”

Kronick said he expects further reductions from the widespread adoption of the National Action Plan for Adverse Drug Events, which was launched in 2014 and would not have had a measurable impact in the latest available data.

Patrick Conway, MD, principal deputy administrator and chief medical officer at the Centers for Medicare & Medicaid Services (CMS), said the agency is focused on identifying ways to reduce patient harms in “more complex areas,” such as patient falls and adverse drug events.

Industry experts had mixed views on whether the HAC rates would resume improving without additional policy or research developments.

Katharine Luther, vice president at the Institute for Healthcare Improvement (IHI), said that as hospital engagement networks—part of a federal initiative to identify and share best practices—“ramp up over the next few months, they’ll build on the good work they’ve already done and we’ll see the numbers drop even further.”

Effect of Penalties

Medicare cut payments by 1 percent for hospitals with the highest frequency of HACs as part of the latest in a series of CMS programs aimed at reducing the frequency of HACs. The Hospital-Acquired Condition Reduction Program, which took effect Oct. 1, 2014, penalized 721 hospitals in FY15 for excess rates of certain patient injuries, such as central line-associated bloodstream infections, catheter-associated urinary tract infections, and pressure ulcers, according to published reports.

Researchers have questioned the effectiveness of the penalties at driving improvements.

For instance, a July study published in JAMA found that the hospitals penalized most frequently “had more quality accreditations, offered advanced services, were major teaching institutions, and had better performance on other process and outcome measures.” The findings suggested to the researchers that the HAC penalties may not reflect poor quality of care but rather problems around measurement and the validity of the component measures.

Additionally, some have questioned whether the penalty is sufficient to change hospital policies. Specifically, some organizations have concluded that the penalties are less than the cost of the additional supports necessary to avoid the penalty, according to quality care experts.

“It’s clear that financial incentives have an impact, but the financial incentives are definitely mixed,” Michael Millenson, president of Health Quality Advisors, who has written extensively on HACs, said in an interview.  “There’s a psychological impact of having some financial incentives, which helps, but I’m not sure how much they can turn up those financial incentives in the current political environment.”

Other Steps

Some disputed the need for further study of ways to reduce patient harms from falls and adverse drug events.

“It’s difficult, but it’s not as if there’s no one who has been successful and published in the literature,” Millenson said about fall-reduction programs.

He expects additional benefit will come from the Partnership for Patients initiative, which can help hospitals identify the more difficult steps needed to further reduce HACs.

“We have also seen a change in culture over the past few years, where hospitals—because of the Partnership for Patients—see that this is possible; they are getting peer support,” Millenson said about the program, which he describes as Weight Watchers for patient safety. “Some people have lost the easy pounds, but it doesn’t mean that everyone has lost the easy pounds and more can’t be done.”

Martin Adel Makary, MD, associate professor of surgery and health policy at Johns Hopkins University, said further improvements in HAC rates may require widespread adoption of systems that allow measurement of data that are clinically valid and specific to the clinician, patient, and incidence—instead of the hospital-wide measures used in the HAC program. For instance, IHI’s Global Trigger Tool measures patient safety automatically using electronic health records.

“We can claim successes with small slivers of care,” Makary said in an interview, “but the truth is the vast majority of care in the United States still has endemic variations in quality, it’s costly, and it results in a lot of harm that is off the grid when it comes to how we measure our performance in health care.”

Improvements in Hospital-Acquired Conditions Stall

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