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Submitted electronically at www.regulations.gov
June 25, 2013
Ms. Marilyn Tavenner
Administrator
Center for Medicare and Medicaid Services
Department of Health and Human Services
Attention: CMS-1599-P, Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850
Ref: CMS-1599-P
RE: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term
Care Hospital Prospective Payment System and Proposed 2014 Rates
Dear Ms. Tavenner:
Catholic Health Initiatives (CHI) appreciates the opportunity to provide comments to the Centers for
Medicare and Medicaid Services (CMS) on the Fiscal Year (FY) 2014 Inpatient Prospective Payment
System (IPPS) proposed rule. CHI is a national nonprofit health organization with headquarters in
Englewood, Colo. As one of the nation’s largest Catholic health care system, CHI operates in 18
states and includes 86 hospitals; 40 long-term care, assisted- and residential-living facilities; two
community health-services organizations; two accredited nursing colleges; and numerous home
health agencies.
The Catholic Health Association and the American Hospital Association have provided detailed
comment letters on issues of mutual concern. We specifically highlight the following:
MS-DRG Documentation and Coding Adjustment
In last year’s FY 2013 IPPS rulemaking cycle, CMS proposed a prospective reimbursement cut of 0.8
percent related to hospitals’ documentation and coding in FY 2010. CMS did not finalize this cut,
indicating that it would further analyze hospitals’ assertion that the 0.8 percent figure was
overstated – an assertion that the Medicare Payment Advisory Commission (MedPAC) agreed had
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merit. In this FY 2014 proposed rule, CMS agrees with previous comments from CHI and other
hospital associations that the 0.8 percent figure is overstated, and instead recommends a reduction
of 0.55 percent. The proposed rule solicits comments concerning whether any portion of the 0.8
percent proposed recoupment should be applied on a prospective basis to satisfy the prospective
adjustment of 0.55 percent. CMS notes that doing so would require relatively larger recoupment
adjustments for FYs 2015, 2016 and 2017, but would eliminate the need for a future prospective
adjustment.
While CHI appreciates the agency’s acknowledgement that its proposal to make a documentation
and coding cut of 0.8 percent in FY 2013 was overstated, we are troubled that CMS continues to
compare hospitals’ documentation and coding practices in FY 2010 to their documentation and
coding practices under an entirely different system in FY 2007. We also are concerned that
necessitating larger adjustments in the future would be contrary to the agency’s stated goal of
mitigating extreme annual fluctuations in payment rates. For these reasons, we urge CMS not to
apply any portion of the 0.8 percent proposed recoupment on a prospective basis.
Recommendation: CMS should not apply any portion of the proposed 0.8 percent documentation
and coding recoupment on a prospective basis.
Criteria for Medical Review of Inpatient Admissions
Increasingly, Medicare Administrative Contractors (MACs) and Recovery Audit Contractors (RACs) are
questioning and auditing clinical decisions made by physicians and other practitioners about the
need for inpatient admission versus outpatient observation. CMS recognizes this problem and, in the
FY 2013 Outpatient Prospective Payment System (OPPS) proposed rule, invited public input on the
difficult issues arising under current policies regarding Medicare coverage and inpatient versus
observation status. We appreciate CMS’s effort to clarify what is required for payment of inpatient
hospital services under Medicare Part A, particularly in light of the focus by Medicare RACs on the
medical necessity of short inpatient stays. However, the effort falls short.
Consistently, CMS recognizes that Medicare beneficiaries are receiving appropriate care and that the
admitting clinician has the broadest view of the patient, including past history, co-morbidities,
discharge support system, etc. In the 2013 OPPS, CMS even posited an option to change payment
policies to reflect the care actually provided to a patient, regardless of whether it is considered
inpatient or outpatient, as an option that might help reduce the number of rejected claims.
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Unfortunately, CMS did not pursue that option in this proposed rule. Instead, CMS proposed a timebased presumption. CHI believes this time-based approach does not solve the greater problem. We
do not believe that patient care is the issue; rather it is the unwarranted auditing of clinicallyappropriate decision-making by MACs and RACs that use hindsight to guess at what the clinician
should have been able to know at the time of care. To address this problem, CMS should focus its
efforts on providing instructions to the RACs and other contractors explaining how to review the
medical necessity of Part A inpatient hospital stays.
CHI believes that a review of and change to the RAC program will better address the problems CMS
has identified regarding inpatient admission and observation stays. The time-based recommendation
is fraught with inconsistencies and will not lead to the outcome CMS hopes for. We refer you to the
recommendations of the American Hospital Association in its comment letter on this topic, and urge
CMS to consider changes to the RAC program.
Recommendation: CMS should withdraw its time-based criteria for medical review and instead
focus on changes to the RAC program.
Budget-Neutrality Proposal
CHI has serious concerns about CMS’s proposal to exercise its general authority to provide for
exceptions and adjustments to IPPS payments to offset the additional costs of the proposed medical
review policies. We strongly disagree that CMS’s proposal will lead to increased reimbursements for
hospitals or that this policy change warrants a budget neutrality adjustment of 0.2 percent.
First, CMS’s proposal attempts to resolve a problem of the agency’s own making. Medicare
contractors, especially RACs, have inappropriately ignored the central role that the treating clinician
plays in hospital admissions by routinely second-guessing those decisions after the fact, improperly
denying millions of claims, and netting billions of dollars in contingency fees on the basis that the
care should have been provided in the outpatient setting. Yet, CMS has not adequately addressed
this rampant second-guessing, leading to widespread confusion and inconsistency among hospitals.
In turn, hospitals have responded to the huge financial risk of admitting Medicare beneficiaries for
inpatient stays that may later be denied by electing to treat beneficiaries as outpatients receiving
observation services rather than admitting them as inpatients. If CMS had been more clear and
straightforward with its contractors, these beneficiaries would have been treated in the inpatient
setting all along. Hospitals would not have been forced to move them to the outpatient setting and
they would not appear to be moving back to the inpatient side under the proposed policy.
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Second, these reductions are an inappropriate use of CMS’s special exceptions and adjustments
authority. The agency has used this authority infrequently in the past, and generally only to more
fully or appropriately implement a recent congressional requirement. The special exceptions
authority has been used rarely, and never as broadly as the application included in the proposed rule
for FY 2014.
Finally, we question CMS’s projection that changes in inpatient volume will lead to a net increase in
payments. The proposed rule merely asserts this conclusion and does not provide the assumptions
and data behind it, thus denying our ability to review this critical element of the proposed policy.
Recommendation: CMS should not institute a budget-neutrality adjustment for perceived changes
to service volume based on its proposed medical review criteria.
Changes to Provider Orders as a Condition of Payment
CMS proposes to make a clinician order to admit a beneficiary a condition for payment of a Part A
inpatient stay. CHI is concerned that creating such a requirement would have very troubling
unintentional consequences. Specifically, noncompliance with payment requirements triggers
liability under the False Claims Act.
CMS seems to give contradictory value to the clinician order to admit a patient. CMS is proposing to
require a clinician’s admission order as a condition of payment, but will afford no presumptive
weight to that order in determining the medical necessity of the admission. We believe that this
inconsistency is unfair to clinicians and hospitals and will cause significant confusion. However, if
CMS believes that a clinician order to admit a beneficiary should be a condition for Medicare
payment for an inpatient hospital stay, CMS should at least conclude that the stay is presumptively
reasonable and medically necessary by virtue of the clinician’s order.
Further, if CMS makes a clinician’s order to admit a patient one of the conditions of payment, the
agency should allow that order to come from any clinician in the hospital who is knowledgeable
about the beneficiary’s condition and has admitting privileges. In the proposed rule, CMS says that
the “order must be furnished by a qualified and licensed practitioner...who is responsible for the
inpatient care of the patient” and may not be delegated. However, many beneficiaries are admitted
as inpatients from the emergency department (ED) where an ED clinician, often in consultation with
another provider, makes the decision to admit. This means that an ED clinician or a clinician in the
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hospital who consults with the ED clinician, but who is not ultimately responsible for a beneficiary’s
inpatient care, could order a beneficiary’s admission. Therefore, CMS should modify its proposal to
reflect the way admission decisions frequently are made in hospitals today.
Recommendation: CMS should not make clinician orders to admit a patient a condition for
Medicare payment. However, if CMS proceeds with this policy change, CMS must stipulate that a
properly documented order to admit creates a presumption of reasonableness and medical
necessity. Further, CMS should clarify that the order for admission may come from any clinician in
the hospital who is knowledgeable about the beneficiary’s condition and has admitting privileges.
Calculating the Medicare Fraction of the Disproportionate Share Hospital (DSH) Adjustment
CMS is proposing to count in the Medicare fraction of the DSH adjustment the days of patients
enrolled in Medicare Advantage (MA) plans. CMS states that this is a “readoption” of existing policy.
We are confused, however, how CMS can “readopt” a policy that, according to the courts in
Northeast v. Sebelius and Allina v. Sebelius, does not exist and never has existed.
For background: CMS asserted a claim to count Medicare Advantage days in the Medicare fraction of
the DSH adjustment based on policy created in the FY 2004 IPPS final rule. A number of hospitals and
hospital organizations brought suit against Department of Health and Human Services (HHS) on the
grounds that this action did not constituted proper notice and comment rulemaking under the
Administrative Procedures Act (APA). In these cases, HHS argued that the final policy regarding the
treatment of MA days in the DSH calculation was a logical outgrowth of a 2004 final rule in which
HHS created the policy. However, in the November 15, 2012, decision in Allina v. Sebelius, the court
found that CMS’ final policy was not a logical outgrowth of the 2004 final rule and was otherwise
“arbitrary and capricious” agency action. The court ordered the policy be vacated. In essence, the
policy never existed.
Further confusing the issue is the proposed budget for HHS presented by President Barack Obama on
April 10, 2013. This proposed budget plan asks Congress to “clarify that individuals … who have
elected to enroll in Part C [MA] plans should be included in the calculation of the Medicare fraction
of hospitals’ Disproportionate Share Hospital (DSH) patient percentages.” Again, we would argue
that Congress cannot “clarify” a policy that the courts have vacated. CHI believes that asking
Congress to “clarify” how these MA days should be treated in the DSH calculation is an unfair
attempt to reverse unfavorable court decisions.
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As the court affirmed in Allina v. Sebelius, when stakeholders have come to rely on a certain policy,
as is the case here, an agency must give a more detailed explanation for changing its policy than
would be necessary for a policy created on a blank slate. Although CHI strongly urges CMS not to
finalize this proposal, if it does choose to move forward, the agency must provide information for
such a discussion and allow stakeholder comment on it before deciding whether to finalize its
proposal. For the FY 2014 final rule, CMS has not met this standard. The agency cannot finalize its
new proposed policy without again acting in an arbitrary and capricious manner in violation of the
APA.
We urge CMS to maintain existing policy and exclude from the Medicare fraction days those
individuals who have elected to enroll in MA plans. If CMS pursues this policy in the future, it must
make clear that the policy is prospective only.
Recommendation: CMS should maintain existing policy to exclude Medicare Advantage days from
the Medicare fraction of the DSH adjustment. In the future if CMS pursues this policy, it must use
appropriate actions under the APA and should make clear that any change to the DSH adjustment
calculation applies prospectively only.
We also are concerned with another DSH issue regarding dual eligible/Part A exhausted days. CHI
continues to believe that dual eligible/Part A exhausted days were included in the Medicaid DSH
fraction prior to October 2004 and were inappropriately “clarified” to be part of the Medicare
fraction in 2004 without proper rulemaking. CMS should include dual eligible/Part A exhausted days
in the Medicaid fraction of the DSH calculation and await the final outcome of litigation on this
issue.
Graduate Medical Education (GME) – Medical Resident Training at Critical Access Hospitals (CAHs)
Under existing payment policies, an IPPS teaching hospital that rotates residents to a CAH may count
the time the residents spend in the CAH for either indirect medical education (IME) or direct GME
purposes under certain circumstances. In adopting its existing policy, CMS stated that CAHs are
unique facilities that generally are not considered “hospitals” under the Social Security Act. However,
with passage of Section 5504 of the Affordable Care Act (ACA), which allows hospitals to count
resident time in “nonprovider” settings, the agency is re-evaluating the policy. CMS states that CAHs,
although not considered “hospitals,” are included in the definition of “providers” in the Social
Security Act. Therefore, the agency proposes that teaching hospitals would no longer be permitted
to count the time residents spend rotating to CAHs for either IME or direct GME purposes.
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CMS itself, however, has created the common understanding among policymakers and hospitals that
the two terms “nonhospital” and “nonprovider” are interchangeable. The agency’s sudden and
abrupt decision to now attribute distinct and different meanings to terms it previously suggested
were synonyms is inappropriate; the agency cannot presume that the difference between these two
terms and the precise consequences of using one versus the other has been clear and apparent all
along.
It seems clear that the intent of Congress when enacting Section 5504 was to remove obstacles and
to allow a flexible interpretation of GME rules that particularly advantage implementation of primary
care training programs and community-based training outside of the metropolitan teaching hospital.
CMS’s proposal is contrary to the articulated need for, and existing policies designed to, promote
more primary care physicians. The proposed rule would significantly harm the many communitybased resident training programs, almost all of which are family medicine residencies with specific
missions to train residents to serve rural and underserved populations.
CAHs are essential in meeting the health care needs of rural America. The geographic isolation and
large coverage area means that they are the medical center for, in some cases, hundreds of miles.
Yet, rural areas in general, and CAHs specifically, face ongoing difficulty recruiting and retaining
physicians, in large part because of their low volume and geographic isolation. We urge CMS to do all
it can to support CAHs and rural health care and not take away opportunities to improve access to
health care services in rural communities.
Recommendation: CHI strongly urges CMS not to finalize this policy, and to instead continue to
allow teaching hospitals to count the time residents spend rotating to CAHs for both IME and direct
GME purposes.
Affordable Care Act Adjustment Methodology for Medicare DSH Payments
Timeline
To aid passage of the ACA in 2010, hospitals agreed to significant cuts from Medicare payments in
recognition of the increased number of individuals who would have access to health insurance
through private plans on the Marketplace and through Medicaid expansion. One of these cuts is a
significant reduction in DSH payments. Since 2010, however, the Supreme Court has ruled that states
can choose to expand Medicaid or not. As a result, the Congressional Budget Office, in a March 14,
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2013, report entitled “Updated Budget Projections: Fiscal Years 2013 to 2023,” estimates that that
uninsured rate will not decrease to the level originally anticipated for 2014 until 2016.
Despite the reduced Medicaid expansion, extensive misunderstanding of the ACA and expected slow
uptake in insurance coverage that is leading to the CBO estimates, hospitals and health providers still
are expected to take significant reductions in Medicare reimbursements. The DSH payments in
particular are reliant on the number of uninsured and the amount of uncompensated care offered by
a hospital. Since insurance and Medicaid coverage is expected to be low for 2014 and 2015,
uncompensated care will not significantly decrease. We urge CMS to consider these factors and
delay implementation of the DSH payment cuts until 2016.
Recommendation: CMS should delay implementation of the DSH cuts until 2016 to account for the
anticipated slower reduction of the uninsured rate between 2014 and 2016.
Uncompensated Care Payments
The ACA requires that beginning in FY 2014 hospitals will receive only 25 percent of the DSH funds
they would have received under the current formula, with the remaining 75 percent flowing into a
separate funding pool for DSH hospitals. This pool will be reduced as the percentage of uninsured
people declines and will be distributed based on the proportion of total uncompensated care each
Medicare DSH hospital provides.
To make these calculations, CMS must first determine what the DSH payments to hospitals would
have been without this ACA requirement and use three Factors to determine payments.
•
•
•
Factor 1 equals 75 percent of the aggregate DSH payments that would otherwise be made
without application of the DSH changes made by the ACA.
Factor 2 is a ratio of the percent of the population who are insured now versus a base year
prior to ACA implementation.
Factor 3 is a single hospital’s uncompensated care (UC) represented as a percent of all
hospitals’ uncompensated care in a year.
Proposed Methodology to Calculate Factor 1:
CMS asserts that the statute gives it the authority to estimate Factor 1. CMS believes that by using
an estimate, the agency would be creating “some level of predictability and finality for hospitals
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eligible for these payments, in addition to being administratively efficient.” Therefore, CMS has
proposed to use actuarial estimates, which are based on cost report information and the FY 2013
IPPS final rule impact file, adjusted for inflation and assumptions for future changes in utilization and
case mix. CMS estimates total FY 2014 DSH payments to be $12.338 billion.
While CMS describes the methodology used to derive the $12.338 billion estimate, and CMS posted
a summary analysis supporting the estimate, CMS does not provide detailed data supporting all the
factors used in the calculation. Based on the information available, CHI offers the following
comments on the proposed update factors and methodology:
1)
Discharges – The summary analysis of the DSH estimate includes an adjustment factor for
discharges; however, CMS has not provided the detail supporting the discharge factor it
used. In addition, the footnote to the discharge column states that all inpatient hospitals
were included, not just IPPS hospitals. Since the purpose of the projection is to estimate
the amount of DSH that will go to a subset of all inpatient hospitals, CMS should use only
the hospitals projected to share in the payments when determining the factors that
drive the estimate.
2)
Case Mix - The summary analysis of the DSH estimate includes an adjustment factor for
case mix; however, CMS has not provided the detail supporting the case mix factor used.
CMS should provide the details behind this factor to allow for comprehensive comments.
Additionally, we request that CMS clarify how the case mix change from year-to-year was
derived as it relates to the documentation and coding adjustment. The trend in the
change in case mix from year-to-year does not seem to support the need for a coding
adjustment, in fact the year-to-year change in two cases is a decrease. We urge CMS to
ensure that the case mix being used does not already reflect the documentation and
coding adjustment so providers can be certain the adjustment is not being made twice.
3)
Other - The summary analysis of the DSH estimate includes an adjustment factor for
“Other;” however, CMS has not provided the detail supporting this factor. The footnote
to the “Other” column states: “Other column includes impact of only IPPS discharges and
impact of DSH payments increasing or decreasing at a different rate than other IPPS
payments.” CMS should provide the details behind this factor.
4)
Medicaid Expansion – Based on projections made by CBO, the number of uninsured
people is projected to drop 11.2 percent in 2014 compared to 2013. The projected
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decline in the uninsured rate is due in part to the potential addition of 9 million new
Medicaid recipients, according to the May 2013 CBO projections to be used by CMS.
However, it does not appear that the projected 2014 DSH amount includes expected
additional DSH payments due to Medicaid expansion. CMS must provide additional
information.
5)
2009 Medicare DSH Payments – The summary analysis of the DSH estimate indicates that
the 2009 Medicare DSH payments were used as the starting point to project expected
DSH payments for 2014. In the provider setting, 2009 is a significantly different
environment than 2014. The current 2009 DSH payments do not include several key
issues that have yet to be settled, such as Dual Eligible days and Medicare Advantage
days, or issues that have already been settled such as Labor & Delivery Room days.
Additionally, the majority of the 2009 cost reports remain unaudited. Therefore, CMS
should not use 2009 as a base year for DSH without finalizing all 2009 cost reports and
appeals. Using 2009 Medicare DSH payments as a starting points creates significant
problems:
a) The summary analysis for the adjustment factor indicates that Medicare DSH
payments for Maryland and Sole Community Hospitals as well as Rural Community
Demonstration Hospitals are included in the 2009 estimate of $10.119 billion. In this
proposed rule, these hospitals are said to be excluded from the Uncompensated Care
payments. CMS must provide clarification.
b) It appears that the starting point for estimating 2014 DSH is different than the cost
report year ends being used as the basis to distribute 2014 DSH, or the Factor 3.
(Currently, 2009 is being used as the base year for Factor 1, while 2010-2012 is being
used for Factor 3 calculations.) We wonder why the baseline information cannot be
derived from the same source and urge CMS to reconcile this discrepancy.
c) CMS has underestimated the 2009 DSH amount by not including adjustments
required by the recent decision in Allina v. Sebelius. CHI estimates that the projected
2014 DSH payments, which are based off of 2009 DSH payments, are understated by
$1.1 billion as a result of the incorrect treatment of Medicare Advantage days. CMS
must use proper 2009 DSH data, including corrections required as a result of court
cases, before it can extrapolate the data for current year calculations.
CHI submits that while administrative efficiency, finality and predictability are worthwhile goals,
CMS’ primary objective should be accurate and adequate payments to hospitals. By attempting to
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estimate the amount of future payments based on numerous assumptions intended to predict the
unknown for a program that has not yet started, CMS is failing at this objective. While estimates are
listed as a viable option in the statute, Congress must have assumed that such estimates would be
based on complete and accurate data.
Recommendation: CMS should use retroactive, accurate data to calculate DSH payments rather
than a complicated set of assumptions and methodologies.
Periodic Uncompensated Care Payment
The proposed rule states that CMS will use periodic payments on an interim basis for any
uncompensated care payments. By making the payments as periodic interim payments rather than
on a per-discharge basis through the Medicare PRICER, CMS is not considering the many ways
hospitals use the PRICER to negotiate rates with Medicare Advantage plans. We are concerned that
this will dramatically reduce payments to hospitals, including many safety net hospitals.
This is another reason CMS should delay implementation of the DSH payment reduction for two
years. If CMS finalizes its policy with two years for hospitals to prepare, they will have sufficient time
to consider this change and renegotiate MA contracts accordingly. If CMS moves forward with this
proposal, hospitals will see an unanticipated decline in revenue, which will reduce the resources
available for high-quality patient care. We urge CMS to delay for two years the DSH payment
calculations, or rescind this proposal and make uncompensated care payments on a per-discharge
basis.
Recommendation: CMS should delay for two years the DSH payment calculations, or, if the DSH
payment changes move forward, rescind the proposal to pay uncompensated care payments on a
periodic basis and instead make payments on a per-discharge basis through the PRICER.
Hospital Readmissions Reduction Program
CMS is proposing a number of changes to the hospital readmissions reduction program. CHI
applauds CMS for addressing the issue of planned readmissions, and we support this change.
However, we are disappointed that CMS has not yet excluded readmissions unrelated to the initial
reason for admission, as required by the ACA. Additionally, CMS is proposing to expand the
readmissions reduction program to three new conditions: chronic obstructive pulmonary disease
(COPD), total knee arthroplasty, and total hip arthroplasty. CHI has no objection to the hip and knee
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procedures, but has some concern with including COPD. We are concerned that COPD is very much
intertwined with heart failure, a condition already covered under this program. But most concerning
is that the Measures Application Partnership (MAP) has not endorsed the criteria used to measure
COPD readmissions. For these reasons, we urge CMS not to include COPD in the readmissions
reduction program.
Recommendation: CMS should rescind its proposal to add chronic obstructive pulmonary disorder
to the hospital readmission reduction program.
Value-Based Purchasing (VBP) Program
CHI is pleased that CMS has decided to remove three measures from the VBP program beginning
with FY 2016. We have long advocated that these measures are unnecessary and do not provide
value.
CMS is proposing new weighting for the four domains measured by the VBP program. CHI opposes
these changes. First, we continue to believe that the Medicare spending per beneficiary measure is
not an appropriate efficiency measures for the VBP program. Hospitals have very little control over
differences in the value of this measure over the time period it covers (three days prior to admission
and 30 days post-discharge), with the possible exception of preventable readmissions, which are
measured separately in the Readmission Reduction Program. Factors that are outside the control of
the hospital, such as the availability of post-acute care services in the community and physician
practice patterns, contribute to differences in this measure.
In addition, the proposed 40 percent weight for the outcome domain is too high given the limitations
of the current outcome measures. We believe that the risk adjustment for the mortality measures is
insufficient, and the claims-based Agency for Healthcare Research and Quality (AHRQ) patient safety
indicator measures are not reliable for payment purposes. While we support the addition of
infection measures to the VBP program outcomes domain, use of the measures is still in its early
stages. Finally, we believe that the proposed weight of 10 percent for the clinical process of care
measures understates their importance in light of the limitations of the outcomes measures.
Given the many moving parts in these domains, we recommend CMS maintain the weighting from FY
2015 when finalizing this rule.
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Recommendation: CMS should maintain the FY 2015 domain weighting for the VBP program in FY
2016.
Hospital Acquired Conditions (HACs)
Beginning in FY 2015, the ACA requires CMS to impose a 1 percent reduction to Medicare payments
for all MS-DRGs for hospitals in the top quartile of risk-adjusted national HAC rates. In this rule, CMS
proposes eligibility requirements and the basic payment adjustment methodology. CMS generally is
using measures in three domains (individual patient safety indicators, composite patient safety
indicators and hospital-acquired infection measures) to measure a hospital’s HAC rate.
CHI is concerned that many of the patient safety indicators in CMS’s proposed Domain 1 measures
are not endorsed by the National Quality Forum (NQF). In addition, several of the proposed
measures have not yet been reviewed by MAP. The ACA requires that all measures be reviewed by
MAP prior to inclusion in federal quality payment and reporting programs.
Recommendation: We urge CMS to follow the requirements set forth by the ACA and use only
measures that have been reviewed by MAP.
Inpatient Quality Reporting (IQR) Program
CHI supports the proposed removal of eight measures from the IQR program beginning in FY 2016.
We also agree that participation in the stroke registry is not necessary, and suggest that CMS
reconsider the usefulness of continuing to include all the other registry participation measures.
CHI does not support the proposed addition of mortality and readmission measures for acute
ischemic stroke because these measures have not been endorsed by NQF. It is important that all
measures proposed for addition to the IQR program have subjected to the rigors of the NQF
evaluation process and found to be qualified for endorsement before they are used in public
reporting. Similarly, the proposed measure of Medicare payment associated with a 30-day episodeof-care for acute myocardial infarction (AMI) patients is not NQF-endorsed and should not be added
to the IQR program measure set. CHI has further concerns about this proposed measure because,
like the overall Medicare spending per beneficiary measure, it assumes that hospitals have more
control over Medicare spending for services outside the inpatient stay than is realistic. It does not
make sense to add a measure of Medicare spending that essentially duplicates the AMI readmission
measure and additionally reflects cost variation that the hospital cannot control.
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Recommendation: CMS should not add new mortality and readmission measures for acute
ischemic stroke to the IQF program because the measures are not NQF-endorsed.
Inpatient Psychiatric Facility (IPF) Quality Reporting Program
The ACA mandates a quality reporting program for inpatient psychiatric facilities (IPFs) reimbursed
under the IPF PPS. Failure to meet the data submission requirements of the program subjects IPFs to
a two-percentage point reduction to their annual market basket update, beginning in FY 2014.
Similar to arguments stated above, CHI does not support inclusion of the SUB-1, alcohol use
screening, and SUB-4, alcohol and drug use: assessing status after discharge, because neither
measure is endorsed by NQF.
Recommendation: CMS should not use measures in the Inpatient Psychiatric Facility Quality
Reporting Program that are not NQF-endorsed.
Thank you for the opportunity to provide these comments. If you would like additional information,
please contact me at 303-383-2693.
Sincerely,
Colleen Scanlon, RN, JD
Senior Vice President, Advocacy