CMS Releases Proposed Changes To The IPPS And Fiscal Year 2009 Rates

On April 14, 2008, the Centers for Medicare and Medicaid

Services (CMS) released Proposed Changes to the hospital

inpatient prospective payment systems (IPPS) and fiscal year

(FY) 2009 rates. The proposed regulation addresses a variety of

issues that impact hospitals. On April 18, 2008, Foley &

Lardner LLP

reported on a number of proposed changes to the Physician

Self-Referral (Stark) law, including the implementation of

Stark's requirement for hospitals to report physician

financial relationships.

This issue addresses a variety of other topics addressed by

the proposed regulation, including: (1) an expansion of the

list of Hospital-Acquired Conditions (HACs) for which CMS will

no longer pay at a higher rate; (2) the addition of 43 new

quality measures for 2010 and others that are proposed for 2011

and beyond; (3) a proposed expansion of a hospital's

Emergency Treatment and Active Labor Act (EMTALA) obligation

where specialty care is required; (4) a clarification of a

hospital's obligation to maintain an on call list for

Emergency Departments; and (5) new proposed incentives to

reduce hospital readmissions.

Reporting Hospital Quality Data For Annual Payment

Update

CMS established the Reporting Hospital Quality Data for

Annual Payment Update (RHQDAPU) program as part of the Medicare

Prescription Drug Improvement and Modernization Act of 2003

(MMA). The RHQDAPU program now requires IPPS hospitals to

submit data regarding 27 quality measures for the treatment of

certain health conditions related to heart attack, heart

failure, pneumonia, and surgical infections. In addition, data

on 30-day mortality rates for heart attack and heart failure

patients and on certain quality measures from the patient

experience of care survey are included in the RHQDAPU quality

measure set. Failure to submit quality data "in the form

and manner specified by CMS" now results in a two-percent

reduction in the IPPS hospital's annual payment update for

the fiscal year involved. RHQDAPU quality measures are expected

to become the basis for establishing the right to payment under

Medicare's Value-Based Purchasing Program and many of the

quality measures are reported now to the public on the Hospital

Compare Web site.

For FY 2009, CMS adopted three additional quality measures,

for a total of 30 quality measures in the RHQDAPU program.

These new quality measures include a 30-day mortality measure

for Medicare pneumonia patients and two new surgical infection

measures.

For FY 2010, CMS proposes to add 43 new quality measures, to

retire one measure, and to update two existing quality

measures. For some of these new quality measures, data

submission is not required because CMS can calculate the

quality measures from existing data. However, if the proposed

rule is finalized without change, there will be a total of 72

quality measures for FY 2010.

In addition to adding quality measures to the RHQDAPU

program for FY 2010, CMS is seeking comment on 59 measures and

four quality measures sets to be included in the RHQDAPU

program for FY 2011 and subsequent years. CMS also is seeking

input from the affected parties on the challenges for data

collection posed by these quality measures and quality measures

sets.

A summary of the proposed quality measures to be included in

the RHQDAPU program for FY 2010 and beyond can be found

below.

For discharges beginning January 1, 2009, CMS proposes that

IPPS hospitals would no longer be required to submit data on

pneumonia oxygenation assessment. This is the first time CMS

has proposed to remove a quality measure from a quality measure

set. Because almost all hospitals are performing near 100

percent on the pneumonia oxygenation measure, and because

oxygenation assessments are performed routinely for all

admitted patients regardless of the specific diagnosis, CMS

determined the burden on IPPS hospitals to report this data

greatly outweighs the benefit of public reporting. CMS also

requests guidance on future quality measure retirements.

Specifically, it is inviting comment on the following:

Should a RHQDAPU quality measure be retired when hospital

performance has reached a high threshold of compliance even

if the quality measure still reflects best practice?

Are there reasons to consider retiring a quality measure

other than high overall performance?

When a quality measure is retired on the basis of

substantially complete compliance by hospitals, should data

collection on the quality measure again be required after one

or two years to assure that a high compliance level remains,

or should some other method of monitoring continued

compliance be used?

Finally, CMS proposes to implement endorsements by the

National Quality Forum (NQF) to update two existing quality

measures. These NQF-endorsed changes revise the timing interval

for percutaneous coronary interventions from within 120 minutes

of hospital arrival to within 90 minutes of arrival, and the

timing interval for the receipt of initial antibiotics for

pneumonia from within four hours of hospital arrival to within

six hours of arrival. CMS proposes to begin calculating the

quality measures using the new timing intervals effective with

discharges on or after January 1, 2009.

Additional HACs

CMS proposes to increase the number of HACs that, if not

present on admission (POA), are deemed reasonably preventable

through proper care and, therefore, will no longer be eligible

for payment. The requirement...