CMS proposes FY 2014 Medicare IPPS update: An analysis and commentary on federal health care issues Prepared by: Tony Cawiezell, Principal, McGladrey LLP 563.888.4027, [email protected] Larry Goldberg, National Health Care Policy Advisor, McGladrey LLP May 2013 The Centers for Medicare and Medicaid Services (CMS) have released a proposed rule to update both the Hospital Inpatient Prospective Payment System (IPPS) and the Long Term Care Hospital (LTCH) Prospective Payment System for fiscal year (FY) 2014. The document is currently on public display at the Federal Register office and was published on May 10. A copy is available at: http://www.gpo.gov/fdsys/pkg/FR-2013-05-10/pdf/2013-10234.pdf. A 60-day comment period ending June 25 is provided. The IPPS tables are available only through the Internet at: http://www.cms.hhs.gov/Medicare/medicare-Feefor-Service-Payment/AcuteInpatientPPS/index.html. Click on the link on the left side of the screen titled, “FY 2014 IPPS Proposed Rule Home Page” or “Acute Inpatient—Files for Download.” The LTCH PPS tables are available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ LongTermCareHospitalPPS/LTCHPPS-Regulations-and-Notices-Items/LTCH-PPS-CMS-1599-P.html?DLPage=1&D LSort=3&DLSortDir=descending. Comment The rule is long and appears to become longer every year. The number of issues continues to grow, too, with many having significant financial consequences, such as readmissions and the hospital value-based purchasing program. CMS has tried to explain its rationale for the changes it is proposing. The rationale is sometimes exceedingly deep before the proposed change is specified. In the future, it could prove more helpful if CMS indicated the changes it is proposing upfront, followed by its rationale. While this analysis is lengthy, there are many facets that have not been covered. All involved with financial, quality and related matters need to carefully review the rule itself to ensure compliance and understanding of the issues at hand. As noted further below, CMS indicates a projected increase of only $27 million in overall IPPS payments in FY2014. There are many proposed reductions, in addition to the multiyear productivity and Affordable Care Act (ACA) requirements. Reductions to readmissions, the hospital-based value purchasing system, one-day stays and the MS-DRG weights all need careful attention. Then there are the documentation and coding reductions that will recoup $11 billion over four years. If sequestration is in effect next year, many hospitals could incur significant Medicare payment losses. Summary of the major provisions Changes to payment rates under IPPS According to CMS, the proposed rule would increase IPPS operating payment rates by 0.8 percent. This reflects a hospital market basket of 2.5 percent, adjusted by -0.4 percentage points for the multifactor productivity, and an additional adjustment of -0.3 percentage points, in accordance with the ACA; the rate is further decreased by 0.8 percent for a proposed documentation and coding recoupment adjustment required by the American Tax Relief Act of 2012 (ATRA), and by a 0.2 percent proposed adjustment to offset the cost of the proposal on inpatient admission and medical review criteria for hospital inpatient services. However, there are more adjustments that would lower the update factor further (see specifics under rate update details). Market basket CMS proposes to revise and rebase the hospital market basket for FY 2014. The proposed FY 2014 market basket will use FY 2010 data for the base year cost weights, in place of FY 2006 data. Wage index Medicare law requires CMS to adjust the labor-related share of the standardized amount to account for differences in area wage levels. CMS currently uses Office of Management and Budget (OMB) delineations of statistical areas to define the areas used in determining area wage levels. On February 28, 2013, OMB announced revisions to these statistical areas based on the 2010 Census. CMS explains that because there was not sufficient time to assess the geographic changes and their ramifications to the wage index adjustment and related policies prior to issuing this proposed rule, CMS will not be using these revised statistical area definitions for FY 2014, but expects to use these definitions for FY 2015. Capital CMS would establish a national capital federal rate of $432.03, up from $425.49. Outliers The outlier fixed-loss cost threshold for FY 2014 would be $24,140. The current amount is $21,821. Documentation and Coding Adjustment ATRA Section 631 requires CMS to recover $11 billion over the next four years to recoup documentation and coding overpayments for prior years. For FY 2014, CMS is proposing a negative 0.8 percent recoupment adjustment as the first step in this recovery process. CMS expects to make similar adjustments in FYs 2015, 2016 and 2017, in order to recover the full $11 billion. MS-DRG relative weight refinement In the FY 2009 and the FY 2011 IPPS final rules, CMS created new cost centers for Implantable Devices Charged to Patients, MRIs, CT scans and cardiac catheterization. In those rules, CMS stated that it would consider creating separate cost-to-charge ratios (CCRs) for the new cost centers to calculate the relative weights. CMS proposes to implement these new cost centers for FY 2014, which would increase the total number of CCRs used to calculate the FY 2014 proposed relative weights from 15 to 19. 2 Critical access hospitals (CAHs) conditions of participation To ensure continued access to inpatient services, the FY 2014 proposed IPPS rule would clarify critical access hospital Conditions of Participation (CoPs) to require that CAHs have the capacity to provide inpatient care on-site. Medicare-dependent hospital (MDH) program The ATRA extended the MDH program for one additional year, through FY 2013. The proposed rule includes the expiration of the MDH payment designation for discharges occurring on or after October 1, 2013. Low-volume hospitals The temporary changes to low-volume hospital definition and payment adjustment methodology provided for by the ACA and the ATRA for FY 2011 through FY 2013 are expiring. Consistent with the statute, CMS is proposing in FY 2014 to return to the low-volume hospital definition and payment adjustment methodology that was in place prior to FY 2011, before the temporary provisions took effect. Admission and medical review criteria for inpatient services CMS says it is clarifying its long-standing policy on how Medicare contractors review inpatient admissions for payment purposes. CMS is proposing that hospital inpatient admissions spanning at least two midnights (that is, at least more than one Medicare utilization day) will presumptively qualify as appropriate for payment under Medicare Part A. Conversely, hospital inpatient admissions spanning less than two midnights (that is, less than one Medicare utilization day) will presumptively be inappropriate for payment under Medicare Part A. This presumption may be overcome by documentation in the medical record supporting the admitting physician’s expectation that the beneficiary would need care spanning at least two midnights, and an unforeseen circumstance results in a shorter beneficiary stay than the physician’s expectation. Physicians must support their expectation, and accordingly their order for admission, through clear and complete medical documentation. Direct graduate medical education (GME) CMS proposes to revise the GME policy addressing inpatient labor and delivery days in the inpatient Medicare utilization calculation. CMS also proposes, for portions of cost reporting periods beginning on or after October 1, 2013, that a hospital may not claim full-time equivalent residents training at a critical access hospital (CAH) for indirect medical education (IME) or direct GME purposes. However, if a CAH itself incurs the costs of training the full-time equivalent residents when these residents rotate to the CAH, the CAH may receive payment based on 101 percent of those Medicare reasonable costs under the regulations. Finally, in accordance with ACA Section 5506, which redistributes residency slots from closed hospitals, CMS is notifying the public of the closure of a hospital and initiating another application and selection process to redistribute the closed hospital’s GME full-time equivalent caps. Medicare disproportionate share hospitals (DSH) ACA Section 3133 requires that instead of the amount that would otherwise be paid, hospitals will receive 25 percent of their current Medicare DSH payments beginning in FY 2014. The remaining 75 percent will be adjusted for decreases in the rate of uninsured individuals nationally, and distributed as additional payments to hospitals that receive DSH payments based on each hospital’s share of uncompensated care relative to all 3 hospitals that are estimated to receive DSH payments. CMS includes three factors required to determine the amount of these proposed new uncompensated care payments. Quality-related provisions CMS is proposing to make several changes to: (1) the quality measure set, including the removal of some measures, the refinement of some measures and the adoption of several new measures; (2) the administrative processes; and (3) the validation methodologies. Further, CMS is proposing to allow hospitals the option of reporting the measures in four measure sets electronically for the FY 2016 payment determination. New hospital-acquired condition reduction program ACA Section 3008 required CMS to establish a financial incentive for IPPS hospitals to improve patient safety, by imposing financial penalties on hospitals that perform poorly with regard to hospital-acquired conditions (HACs). HACs are conditions that patients did not have when they were admitted to the hospital, but that developed during the hospital stay. The proposed rule outlines a general framework for the HAC reduction program for the FY 2015 implementation. Hospital readmissions reduction program The hospital readmissions reduction program began on October 1, 2012. The maximum reduction under this program, which was one percent of payment amounts in FY 2013, will increase to two percent of payment amounts in FY 2014, as specified under the ACA. Counting of inpatient days for Medicare payment or eligibility purposes CMS is proposing that patient days associated with maternity patients who were admitted as inpatients and were receiving ancillary labor and delivery services at the time the inpatient routine census is taken, regardless of whether the patient actually occupied a routine bed prior to occupying an ancillary labor and delivery bed, and regardless of whether the patient occupies a “maternity suite” in which labor, delivery recovery and postpartum care all take place in the same room, would be included in the Medicare utilization calculation. Changes to the hospital Inpatient Quality Reporting (IQR) program and the Electronic Health Record (EHR) incentive program The hospital IQR program grew out of the hospital quality initiative developed by CMS, in consultation with hospital groups. By statute, hospitals that do not participate successfully in the hospital IQR program have their annual payment updates reduced by 2.0 percentage points. Since the implementation of this financial penalty, hospital participation has increased to well over 99 percent of Medicare-participating hospitals that are reimbursed under the IPPS. Measures reported under the IQR program are published on the “hospital compare” website (http://www. hospitalcompare.hhs.gov/), and may later be adopted for use in the hospital value-based program (VBP) mandated by the ACA, which affects payment rates to hospitals beginning in FY 2013. Proposals for LTCH, PPS-exempt cancer and inpatient psychiatric quality reporting programs The rule also proposes new quality reporting measures for LTCHs, PPS-exempt cancer hospitals and inpatient psychiatric facilities in 2015 and beyond. LTCH quality reporting CMS is continuing to expand the LTCH quality reporting program, and is proposing five new LTCH quality measures that would affect the FY 2017 and FY 2018 payment updates. For the FY 2017 payment determination, the proposal includes: an all-cause unplanned readmission measure for 30 days post- discharge 4 from long-term care hospitals, the CDC’s National Healthcare Safety Network (NHSN) facility-wide inpatient hospital-onset MRSA bacteremia outcome measure and the NHSN facility-wide inpatient hospital-onset Clostridium difficile infection (C-diff ) outcome measure. CMS is also proposing to apply the National Quality Forum (NQF) measure of the percent of residents experiencing one or more falls with major injury (long stay) for the FY 2018 payment determination. PPS-exempt cancer hospital quality reporting program The NPRM proposes new quality measures for the PPS-exempt cancer hospital quality-reporting program. A total of 11 PPS-exempt cancer hospitals would be covered in this program. In this rule, CMS proposes to add one new measure of surgical site infection for the FY 2015 program, and 13 new measures covering surgical processes of care, patient experience of care and oncology for the FY 2016 program. Inpatient psychiatric facility quality reporting program The ACA establishes an inpatient psychiatric facility quality reporting (IPFQR) Program. Under the IPFQR program, inpatient psychiatric facilities (IPFs) are required to submit quality data to CMS on selected quality measures. For the FY 2016 payment determination and subsequent years, CMS is proposing three new measures: alcohol use screening; alcohol and drug use status after discharge; and follow-up after hospitalization for mental illness. These measures would be added to the six measures adopted in FY 2013. CMS also proposes to request voluntary information on IPFs’ efforts to assess the patient experience of care for the FY 2016 payment determination. Submission of this information would be completely voluntary and would not in any way affect a facility’s FY 2016 payment determination. Hospital value-based purchasing (VBP) program CMS is outlining payment details for the FY 2014 hospital VBP program. In addition, CMS is proposing numerous policies for the FY 2016 hospital VBP program, including measures, performance standards and performance and baseline periods. CMS also is proposing a disaster and extraordinary circumstances waiver process, domain reclassification and weighting based on CMS’ national quality strategy for the FY 2017 hospital VBP program, and certain measures, performance and baseline periods and performance standards for the FY 2017 through FY 2019 programs. Policies affecting long-term care hospitals Changes to payment rates under the LTCH PPS CMS projects that LTCH PPS payments would increase by 1.1 percent, or approximately $62 million, in FY 2014. This estimated increase is attributable to several factors, including the proposed update of 1.8 percent for LTCHs that submitted quality data (based on a market basket update of 2.5 percent reduced by a multifactor productivity adjustment of 0.4 percentage points and an additional 0.3 percentage points reduction in accordance with the ACA); a “one-time” budget neutrality adjustment to standard federal rate of approximately -1.3 percent under the second year of a three-year phase-in; and projected increases in estimated high-cost outlier payments, as compared to FY 2013. Twenty-five percent patient threshold rule Under the 25 percent patient threshold policy, if an LTCH admits more than 25 percent of its patients from a single acute care hospital, Medicare will pay it at a rate comparable to IPPS hospitals for those patients above the 25 percent threshold. A statutory moratorium on application of the 25 percent rule was in place from December 2007 through December 2012. CMS extended the moratorium for FY 2013, but would allow the policy to go into effect in FY 2014. 5 Chronically ill/medically complex criteria In the FY 2014 proposed rule, CMS includes a discussion of recent research on the development of empirically derived criteria for the identification of the chronically critically ill/medically complex (CCI/MC) population, presently treated in general acute care hospitals and in LTCHs. The CCI/MC population identified by the project has been shown to have intensive service needs, high costs and negative margins in IPPS hospitals. Additionally, they typically have a predictable and consistent need for extended hospital-level care that can be met either from continued stays in the initial IPPS hospital in a step-down unit or from transfer to an LTCH. At this time, CMS is soliciting feedback on this research study and its findings, with the expectation of formulating policy proposals for FY 2015. Section-by-section analysis of major items Standardized payment rates According to CMS, the proposed rule would increase IPPS operating payment rates by 0.8 percent. This reflects a hospital market basket of 2.5 percent adjusted by -0.4 percentage points for the multifactor productivity; an additional adjustment of -0.3 percentage points, in accordance with the ACA; further decreased by 0.8 percent for a proposed documentation and coding recoupment adjustment required by the ATRA and by a 0.2 percent proposed adjustment to offset the cost of a proposed inpatient admission and medical review criteria for hospital inpatient services [2.5 -0.4 -0.3 -0.8 -0.2 = 0.8] for hospitals submitting quality data requirements. For hospitals not reporting such data, the update is reduced further by 2.0 percent, for a net update of minus 1.2 percent. Based on a rebasing of market basket rates from FY 2006 data to FY 2010 data, the labor-related percentage portions of the rates would change. The labor-related portion for areas with wage indexes greater than 1.0000 would increase from 68.8 percent to 69.6 percent. Areas with wage index values equal to or less than 1.000 would remain at 62.0 percent by law. Caution—The rules tables 1A and 1B (presented below) say the proposed FY 2014 rates would have an update factor of 1.8 percent, and not the 0.8 percent noted above. The 1.8 percent amount is the market basket update of 2.5 percent, less the 0.4 percent multifactor productivity, and the additional adjustment of -0.3 percentage points, in accordance with the ACA. See the comparison table below that reflects additional adjustments being made by CMS and arrives at the amounts in the tables below. National adjusted operating standardized amounts (69.6 percent labor share/30.4 percent non-labor, if wage index is greater than 1.0000) Full Update (1.8 percent) Reduced Update (minus 0.2 percent) Labor-related Non-labor-related Labor-related Non-labor-related $3,741.72 $1,634.32 $3,668.21 $1,602.21 Rates Currently in Effect Full Update Reduced Update Labor-related Non-labor-related Labor-related Non-labor-related $3,679.95 $1,668.81 $3,607.65 $1,636.02 6 National adjusted operating standardized amounts (62 percent labor share; 38 percent non-labor share, if wage index is less than or equal to 1.0000) Full Update (1.8 percent) Reduced Update (-0.2 percent) Labor-related Non-labor-related Labor-related Non-labor-related $3,333.14 $2,042.90 $3,267.66 $2,002.76 Rates Currently in Effect Full Update Reduced Update Labor-related Non-labor-related Labor-related Non-labor-related $3,316.23 $2,032.53 $3,251.08 $1,992.59 Additional adjustments CMS is also making the following adjustments to standardized payment amounts: yy An adjustment to the standardized amount to ensure budget neutrality for DRG recalibration and reclassification, as provided for under section 1886(d)(4)(C)(iii) of the Act. yy An adjustment to ensure the wage index changes are budget neutral, as provided for under section 1886(d)(3)(E)(i) of the Act. yy An adjustment to ensure the effects of geographic reclassification are budget neutral, as provided for under section 1886(d)(8)(D) of the Act, by removing the FY 2013 budget neutrality factor and applying a revised factor. yy An adjustment to ensure the effects of the rural community hospital demonstration program are budget neutral, as required under section 410A(c)(2) of Pub. L. 108-173. yy An adjustment to remove the FY 2013 outlier offset and apply an offset for FY 2014, as provided for under section 1886(d)(3)(B) of the Act. yy A proposed recoupment to meet the requirements of section 631 of ATRA to adjust the standardized amount to offset the estimated amount of the increase in aggregate payments as a result of not completing the prospective adjustment authorized under section 7(b)(1)(A) of Pub. L. 110-90 until FY 2013. yy A proposed adjustment to offset the cost of the policy proposal on admission and medical review criteria for hospital inpatient services under Medicare Part A. Documentation and coding ATRA Section 631 amended section 7(b)(1)(B) of Pub. L. 110-90 to require the secretary to make a recoupment adjustment totaling $11 billion by FY 2017. CMS actuaries estimate that if CMS were to fully account for the $11 billion recoupment in FY 2014, a one-time -9.3 percent adjustment to the standardized amount would be necessary. CMS is proposing a -0.8 percent recoupment adjustment to the standardized amount in FY 2014. CMS estimates that “this level of adjustment will recover up to $0.96 billion in FY 2014, with at least $10.04 billion remaining to be recovered by FY 2017. If adjustments of approximately -0.8 percent are implemented in FYs 2014, 2015, 2016, and 2017, using standard inflation factors, the agency estimates that the entire $11 billion will be accounted for by the end of the statutory 4-year timeline.” 7 Comment If removing 0.8 percent in FY 2014 amounts to approximately $1 billion, it would appear that the 0.8 reduction would have to be cumulative over the 4 years. In other words, it would have to remove at least $2 billion in FY 2015, $3 billion in FY 2016 and $4 billion in FY 2017. Even at that rate, the amount of recoupment would still be $1 billion short. How CMS has reduced the standardized payment amounts for documentation and coding over the years has never been explained in a concise way, but the 0.8 percent adjustment amount will most likely be a cumulative factor over the next years; i.e., 2014 =0.992 (1.0 - 0.008); 2015= 0.992 X 0.992=0.9846; 2016 = 0.984 X 0.992 = 0.976, etc. Medicare-dependent hospitals CMS notes that ATRA Section 606 extended the MDH program from the end of FY 2012 (that is, for discharges occurring before October 1, 2012) to the end of FY 2013 (that is, for discharges occurring before October 1, 2013). Under prior law, the MDH program was to be in effect through the end of FY 2012 only. Absent additional legislation further extending the MDH program, the MDH program will expire for discharges beginning in FY 2014. Therefore, due to the expiration of the MDH program beginning with FY 2014, CMS is not including hospitals that are currently MDHs (until October 1, 2013) in the update of the hospital-specificrates for FY 2014. Outlier payments CMS is proposing an outlier fixed-loss cost threshold for FY 2014 equal to the prospective payment rate for the DRG, plus any IME and DSH payments, and any add-on payments for new technology, plus $24,140. The current amount is $21,821. CMS currently estimates that actual outlier payments for FY 2013 will be approximately 5.17 percent of actual total MS-DRG payments, approximately 0.1 percentage points higher than the 5.1 percent projected when setting the outlier policies for FY 2013. Comparison table CMS provides the following table to show how it has arrived at its proposed FY 2014 standardized amounts. The table contains the budget neutrality adjustment factors. 8 Comparison of FY 2013 standardized amounts to the proposed FY 2014 standardized amount with full and reduced update Full Update (1.8 percent) Full Update (1.8 Percent) Wage Index is greater than 1.0000; Labor/NonLabor Share Percentage (69.6/30.4) Wage index is less than or equal to 1.0000; Labor/NonLabor Share Percentage (62/38) FY 2013 base rate after removing: 1. FY 2013 geographic reclassification budget neutrality (0.991276) 2. FY 2013 rural community hospital demonstration program budget neutrality (0.999677) 3. Cumulative FY 2008, FY 2009, FY 2012, FY 2013 documentation and coding adjustment as required under Sections 7(b)(1)(A) and 7(b)(1)(B) of Pub. L. 110-90 (0.9478) 4. FY 2013 operating outlier offset (0.948999) Labor: $4,176.63 Non-labor: $1,824.27 Proposed FY 2014 update factor Reduced Update (-02 percent) Wage index is greater than 1.0000; Labor/NonLabor Share Percentage (69.6/30.4) Reduced Update (-02 percent) Wage index is less than or equal to 1.0000; Labor/NonLabor Share Percentage (62/38) Labor: $3,720.56 Non-labor: $2,280.34 Labor: $4,176.63 Non-labor: $1,824.27 Labor: $3,720.56 Non-labor: $2,280.34 1.018 1.018 0.998 0.998 Proposed FY 2014 MS-DRG recalibration and wage index budget neutrality factor 0.99735 0.99735 0.99735 0.99735 Proposed FY 2014 reclassification budget neutrality factor 0.990971 0.990971 0.990971 0.990971 Proposed FY 2014 rural community demonstration program budget neutrality factor 0.999834 0.999834 0.999834 0.999834 Proposed FY 2014 operating outlier factor 0.948997 0.948997 0.948997 0.948997 Proposed adjustment to offset the cost of the policy proposal on admission and medical review criteria for hospital inpatient services under Medicare Part A 0.998 0.998 0.998 0.998 Cumulative factor: FY 2008, FY 2009, FY 2012 and FY 2013 documentation and coding adjustment, as required under Sections 7(b)(1)(A) and 7(b)(1)(B) of Pub. L. 110-90, and proposed documentation and coding recoupment adjustment, as required under Section 631 of the American Taxpayer Relief Act of 2012 0.9403 0.9403 0.9403 0.9403 Proposed national standardized amount for FY 2014 Labor: $3,741.72 Labor: $3,333.14 Labor: $3,668.21 Labor: $3,267.66 Non-labor: $1,634.32 Non-labor: $2,042.90 Non-labor: $1,602.21 Non-labor: $2,002.76 9 Changes for inpatient capital-related costs for FY 2014 CMS would establish a national capital federal rate of $425.49 for FY 2014. The capital federal rate is calculated as follows: Comparison of factors and adjustments: FY 2013 capital federal rate and proposed FY 2014 capital federal rate Final FY 2013 Update factor1 GAF/DRG adjustment factor Change Percent change 1.009 1.009 0.9 0.9998 0.9988 0.9988 -0.12 0.9362 0.9451 1.0095 0.95 N/A 0.998 0.998 -0.2 $425.49 $432.03 1.0154 1.54 1 Outlier adjustment factor Proposed FY 2013 1.012 2 Adjustment for admission and medical review criteria3 Capital federal rate The update factor and the GAF/DRG budget neutrality adjustment factors are built permanently into the capital federal rates. Thus, for example, the incremental change from FY 2013 to FY 2014 resulting from the application of the proposed 0.9988 GAF/DRG budget neutrality adjustment factor for FY 2014 is a net change of 0.9988 (or -0.12 percent). 1 2 The outlier reduction factor is not built permanently into the capital federal rate; that is, the factor is not applied cumulatively in determining the capital federal rate. Thus, for example, the net change resulting from the application of the proposed FY 2014 outlier adjustment factor is 0.9451/0.9362, or 1.0095 (or 0.95 percent). 3 The proposed adjustment to account for the estimated additional IPPS expenditures that are projected to result from CMS’ policy proposal on admission and medical review criteria for hospital inpatient services under Medicare Part A. Changes to payment rates for excluded hospitals: Rate-of-increase percentages For cancer and children’s hospitals and RNHCIs, the proposed FY 2014 rate-of-increase percentage that would be applied to the FY 2013 target amounts, in order to determine the FY 2014 target amount, is 2.5 percent. Changes to the hospital area wage index The wage index will continue, for FY 2014, to be calculated and assigned to hospitals on the basis of the labor market area in which the hospital is located. CMS defines hospital labor market areas based on the core-based statistical areas (CBSAs). The FY 2014 wage index values are based on the data collected from the Medicare cost reports submitted by hospitals for cost reporting periods beginning in FY 2010 (the FY 2013 wage indices were based on data from cost reporting periods beginning during FY 2009). CMS notes that on February 28, 2013, OMB issued OMB Bulletin No. 13-01, which established revised delineations for metropolitan statistical areas, micropolitan statistical areas and combined statistical areas, and provides guidance on the use of the delineations of these statistical areas. A copy of this bulletin may be obtained at: http://www.whitehouse.gov/sites/default/files/omb/bulletins/2013/b-13-01.pdf. CMS says it was unable to undertake a lengthy process to adopt OMB’s revised delineations before publication of this FY 2014 proposed rule. CMS says it intends to propose changes to the wage index based on the newest CBSA changes in the FY 2015 proposed rule. 10 The proposed FY 2014 national average hourly wage (unadjusted for occupational mix) is $38.2384. Occupational mix adjustment The FY 2014 wage index is based on data collected on the new 2010 Medicare wage index occupational mix survey (Form CMS-10079 (2010)). The proposed FY 2014 occupational mix adjusted national average hourly wage is $38.2094. The proposed FY 2014 national average hourly wages for each occupational mix nursing subcategory of the occupational mix calculation are as follows: Proposed average Occupational mix nursing subcategory hourly wage National RN 37.432120148 National LPN and surgical technician 21.773706724 National nurse aide, orderly and attendant 15.327583858 National medical assistant 17.213605923 31.811167234 National nurse category Hospitals with a nurse category average hourly wage greater than the national nurse category average hourly wage receive an occupational mix adjustment factor of less than 1.0. Hospitals with a nurse category average hourly wage less than the national nurse category average hourly wage receive an occupational mix adjustment factor of greater than 1.0. Application of the rural, imputed and frontier floors Rural floor ACA Section 3141 requires that a national, rather than a statewide, budget neutrality adjustment be applied in implementing the rural floor. CMS says 434 hospitals would receive an increase in their FY 2014 wage index due to the application of the rural floor. The table below shows the impact of the rural floor and imputed floor by state: State Alabama Number of hospitals Number of hospitals receiving proposed rural floor or imputed floor Percent change in payments due to application of proposed rural floor and imputed floor with budget neutrality Difference in millions 93 3 -0.5 ($7.70) Alaska 6 4 3.3 $4.70 Arizona 57 7 -0.4 ($6.70) Arkansas 45 0 -0.5 ($5.00) California 308 178 0.9 $86.40 Colorado 46 7 0.1 $1.50 Connecticut 32 27 4.9 $75.00 Delaware 6 0 -0.6 ($2.30) Washington, D.C. 7 0 -0.5 ($2.50) Florida 168 5 -0.4 ($29.60) Georgia 107 0 -0.5 ($12.30) 11 State Number of hospitals Number of hospitals Percent change in payments due to receiving proposed rural application of proposed rural floor and floor or imputed floor imputed floor with budget neutrality Difference in millions Hawaii 14 0 -0.4 ($1.20) Idaho 14 0 -0.3 ($1.00) Illinois 127 5 -0.6 ($26.80) Indiana 89 4 -0.5 ($12.90) Iowa 34 0 -0.5 ($4.20) Kansas 55 0 -0.4 ($3.70) Kentucky 65 1 -0.4 ($7.60) Louisiana 99 4 -0.5 ($6.50) Maine 20 0 -0.5 ($2.40) Massachusetts 61 60 5.6 $169.10 Michigan 95 0 -0.5 ($22.10) Minnesota 51 0 -0.5 ($9.00) Mississippi 65 1 -0.5 ($5.10) Missouri 77 0 -0.4 ($10.70) Montana 12 4 -0.1 ($0.40) Nebraska 23 0 -0.4 ($2.50) Nevada 24 19 1.6 $10.90 New Hampshire 13 9 0.8 $3.60 New Jersey 64 35 0.4 $14.80 New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon 25 0 -0.3 ($1.50) 166 2 -0.6 ($46.50) 87 0 -0.4 ($15.20) 6 1 -0.3 ($0.90) 137 3 -0.4 ($17.70) 86 2 -0.4 ($5.40) 33 0 -0.5 ($4.50) 157 6 -0.5 ($21.80) Puerto Rico 52 13 0 $0.00 Rhode Island 11 4 0.5 $1.70 South Carolina 57 5 -0.3 ($5.00) South Dakota 19 0 -0.3 ($1.00) Tennessee 97 11 -0.3 ($7.60) Pennsylvania Texas 322 3 -0.5 ($31.90) Utah 32 0 -0.4 ($2.00) 6 0 -0.4 ($0.80) Vermont Virginia 78 1 -0.4 ($10.50) Washington 49 5 -0.2 ($3.60) West Virginia 30 3 -0.3 ($2.30) Wisconsin 66 2 -0.4 ($7.30) Wyoming 11 0 -0.1 ($0.20) 12 Imputed floor The current method for computing the imputed floor benefits only New Jersey. There are 35 providers in New Jersey that will receive an increase in their FY 2013 wage index due to the imputed floor policy. For FY 2014, CMS is proposing to once again extend the imputed floor policy (both the original methodology and the alternative methodology) for one additional year, through September 30, 2014, while it continues to explore potential wage index reforms. Frontier floor Montana, North Dakota, South Dakota and Wyoming, covering 46 providers, would receive a frontier floor value of 1.0000. FY 2014 Medicare geographic classification review board (MGCRB) reclassifications There are 332 hospitals approved for wage index reclassifications by the MGCRB for FY 2014. Because MGCRB wage index reclassifications are effective for 3 years, hospitals reclassified during FY 2012 or FY 2013 are eligible to continue to be reclassified to a particular labor market area based on such prior reclassifications. There were 249 hospitals approved for wage index reclassifications in FY 2012, and 192 hospitals approved for wage index reclassifications in FY 2013. CMS says there are 773 hospitals reclassified for FY 2014. Applications for FY 2015 reclassifications are due to the MGCRB by September 3, 2013 (the first working day of September 2013). Applications and other information about MGCRB reclassifications may be obtained via the CMS Internet website at: http://cms.hhs.gov/MGCRB/02_instructions_and_applications.asp, or by calling the MGCRB at 410.786.1174. The mailing address of the MGCRB is: 2520 Lord Baltimore Drive, Suite L, Baltimore, MD 21244-2670. Hospitals may withdraw from a MGCRB decision within 45 days of the publication of the FY 2014 proposed rule. Redesignations of hospitals under Section 1886(d)(8)(B) of the Social Security Act Section 1886(d)(8)(B) of the Social Security Act requires CMS to treat a hospital located in a rural county adjacent to one or more urban areas as being located in the MSA (urban area) if certain criteria are met. Hospitals located in these counties have been known as “Lugar” hospitals, and the counties themselves are often referred to as “Lugar” counties. The FY 2014 chart with the proposed listing of the rural counties containing the hospitals designated as urban under section 1886(d)(8)(B) of the Act is available via the Internet on the CMS website. Waiving Lugar redesignation for the out-migration adjustment An eligible hospital that waives its Lugar status in order to receive the out-migration adjustment has effectively waived its deemed urban status, and thus, is rural for all purposes under the IPPS, including being considered rural for the DSH payment adjustment, effective for the fiscal year in which the hospital receives the outmigration adjustment. FY 2014 wage index adjustment based on commuting patterns of hospital employees The proposed FY 2013 out-migration adjustment is based on the same policies, procedures and computation that were used for the FY 2013 out-migration adjustment. Table 4J lists the out-migration adjustments for the proposed FY 2014 wage index. 13 Changes to Medicare severity DRG (MS-DRG) classifications and relative weights Proposed refinement of the MS-DRG relative weight calculation CMS has previously created new cost centers on the Medicare cost report for implantable devices, MRIs, CT scans and cardiac catheterization. CMS says “we see no reason to further delay proposing to implement the CCRs of each of these cost centers. Therefore, beginning in FY 2014, we are proposing to calculate the MS-DRG relative weights using 19 CCRs, creating distinct CCRs from cost report data for implantable devices, MRIs, CT scans, and cardiac catheterization.” As part of this proposed rule, in addition to providing Table 5, which lists the proposed MS-DRGs and their relative weights using 19 CCRs (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ AcuteInpatientPPS/FY-2014-IPPS-Proposed-Rule-Home-Page-Items/FY-2014-Proposed-Rule-Tables-CMS1599-P.html?DLPage=1&DLSort=0&DLSortDir=ascending), CMS is providing a separate table (supplement to Table 5) that lists all MS-DRGs and their relative weights if computed using 15 CCRs. These two formats will allow readers to compare the proposal to calculate the MS-DRG relative weights using 19 CCRs, with the relative weights of MS-DRGs if computed using 15 CCRs. CMS is including in the table below the top 10 (non-labor and delivery) MS-DRGs that it predicts would experience the largest increases and decreases in relative weights if 19 CCRs would be used, as compared to 15 CCRs. MS-DRG Type Title Relative weight with 15 CCRs Relative weights with 19 CCRs Percentage change MS-DRGS that would experience the largest decrease in relative weight 90 MED Concussion without CC/MCC 0.7614 0.7013 -7.90% 84 MED Traumatic stupor and coma, 0.9137 0.8516 -6.80% 0.7899 0.7369 -6.70% 1.0450 0.9800 -6.10% 0.7281 0.6845 -6.00% MED Concussion with CC 0.9959 0.9366 -6.00% MED Neurological eye disorder 0.7355 0.6920 -5.90% 0.9880 0.9517 -5.70% 0.9355 0.8825 -5.70% 0.8034 0.7579 -5.70% coma >1 Hour without CC/MCC 87 MED Traumatic stupor and coma, coma <1 Hour without 965 MED Other multiple significant traumas without CC/MCC 185 MED Major chest trauma without CC/ MCC 89 123 343 SURG Appendectomy without complicated principal diagnosis without CC/MCC 53 MED Spinal disorders and injuries 66 MED Intracranial hemorrhage or without CC/MCC cerebral infarction without CC/ MCC 14 MS-DRG Type Title Relative weight with 15 CCRs Relative weights with 19 CCRs Percentage change MS-DRGS that would experience the largest increase in relative weight 454 SURG Combined anterior/posterior 455 SURG Combined anterior/posterior 7.6399 8.0563 5.50% 5.9862 6.3133 5.50% 2.1211 2.238 5.50% 5.6298 5.953 5.70% 6.0956 6.4482 5.80% 4.8794 5.163 5.80% spinal fusion with CC spinal fusion without CC/MCC 484 SURG Major joint and limb reattachment procedure of upper extremity without CC/ MCC 225 SURG Cardiac defibrillator implant with cardiac catheterization without AMI/HF/shock without MCC 223 SURG Cardiac defibrillator implant with cardiac catheterization with AMI/HF/shock without MCC 458 SURG Spinal fusion except cervical with spinal curve/malignant/ infection OR 9+ fusion without CC/MCC SURG AICD generator procedures 4.4627 4.732 6.00% 849 MED Radiotherapy 1.3423 1.4258 6.20% 946 MED Rehabilitation without CC/MCC 1.1295 1.2024 6.50% 5.2193 5.5714 6.70% 245 227 SURG Cardiac defibrillator implant without cardiac catheterization without MCC Proposed changes to specific MS-DRG classifications MDC 1 (diseases and disorders of the nervous system) Tissue plasminogen activator (tPA) (rtPA) administration within 24 hours prior to admission – For FY 2014, CMS is proposing to move cases with diagnosis code V45.88 from MS-DRG 066 to MS-DRG 065, and to revise the title of MS-DRG 065 to reflect the patients status post-tPA administration within 24 hours. The proposed revised MS-DRG title would be: MSDRG 065 (intracranial hemorrhage or cerebral infarction with CC or tPA in 24 hours). MDC 5 (diseases and disorders of the circulatory system) Discharge/transfer to designated disaster alternative care site - CMS is proposing to add new patient discharge status code 69 (Discharged/transferred to a designated disaster alternative care site) to the MS-DRG GROUPER logic for MS-DRGs 280 (acute myocardial infarction discharged alive with MCC), 281 (acute myocardial infarction discharged alive with CC) and 282 (acute myocardial infarction discharged alive without CC/MCC) to identify patients who are discharged or transferred to an alternative site that will provide basic patient care during a disaster response. 15 Discharges/transfers with a planned acute care hospital inpatient readmission - CMS also is proposing to add 15 new discharge status codes to the MS-DRG GROUPER logic for MS-DRGs 280, 281 and 282 that will identify patients who are discharged with a planned acute care hospital inpatient readmission. Shown in the table below are the current discharge status codes that are assigned to the GROUPER logic for MS-DRGs 280, 281 and 282, along with the proposed new discharge status codes and their titles. Current Code New Code Title 1 81 Discharged to home or self-care with a planned acute care hospital inpatient readmission 2 82 Discharged/transferred to a short-term general hospital for inpatient care with a planned acute care hospital inpatient readmission 3 83 Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification with a planned acute care hospital inpatient readmission 4 84 Discharged/transferred to a facility that provides custodial or supportive care with a planned acute care hospital inpatient readmission 5 85 Discharged/transferred to a designated cancer center or children’s hospital with a planned acute care hospital inpatient readmission 6 86 Discharged/transferred to home under care of organized home health service organization with a planned acute care hospital inpatient readmission 21 87 Discharged/transferred to court/law enforcement with a planned acute care hospital inpatient readmission 43 88 Discharged/transferred to a federal health care facility with a planned acute care hospital inpatient readmission 61 89 Discharged/transferred to a hospital-based Medicare-approved swing bed with a planned acute care hospital inpatient readmission 62 90 Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital with a planned acute care hospital inpatient readmission 63 91 Discharged/transferred to a Medicare-certified long-term care hospital (LTCH) with a planned acute care hospital inpatient readmission 64 92 Discharged/transferred to a nursing facility certified under Medicaid, but not certified under Medicare, with a planned acute care hospital inpatient readmission 65 93 Discharged/transferred to a psychiatric distinct part unit of a hospital with a planned acute care hospital inpatient readmission 66 94 Discharged/transferred to a critical access hospital (CAH) with a planned acute care hospital inpatient readmission 70 95 Discharged/transferred to another type of health care institution not defined elsewhere in this code list with a planned acute care hospital inpatient MDC 15 (newborns and neonates with conditions originating in the neonatal period) For FY 2014, CMS would reassign diagnosis codes V64.00 through V64.04, and V64.06 through V64.3 from MSDRG 794 to MS-DRG 795. Diagnosis codes V64.00 through V64.04 and V64.06 through V64.3 would be added to the “only secondary diagnosis” list for MS-DRG 795. Diagnosis codes V64.41, V64.42 and V64.43 would continue to be assigned to MS-DRG 794. 16 Discharges/transfers of neonates with a planned acute care hospital inpatient readmission - CMS is proposing to add the patient discharge status codes shown in the table below to the MS-DRG GROUPER logic for MS-DRG 789 (neonates, died or transferred to another acute care facility) to identify neonates that are transferred to a designated facility with a planned acute care hospital inpatient readmission. New Code Title 82 Discharged/transferred to a short-term general hospital for inpatient care with a planned acute care hospital inpatient readmission 85 Discharged/transferred to a designated cancer center or children’s hospital with a planned acute care hospital inpatient readmission 94 Discharged/transferred to a critical access hospital (CAH) with a planned acute care hospital inpatient readmission Chronic total occlusion (CTO) of artery of the extremities diagnosis code CMS is proposing to remove the following diagnosis codes from the CC exclusion list for diagnosis code 440.4: atherosclerosis codes 440.20 through 440.32, 443.22 and 443.29, and aneurysm codes 441.00 through 441.03, 441.1 through 441.7, 441.9, 442.0, 442.2, 442.3 and 442.9. Diagnosis codes 443.81 through 443.9 would remain on the CC exclusion list for diagnosis code 440.4. Note There are no new, revised or deleted diagnosis codes for FY 2014. Therefore, there are no Tables 6A, 6C and 6E published for FY 2014. There are no proposed additions or deletions to the MS-DRG MCC List for FY 2014. There also are no proposed additions or deletions to the MS-DRG CC List for FY 2014. Therefore, there are no Tables 6I.1 through 6I.2 and 6J.1 through 6J.2 published for FY 2014. Proposed add-on payments for new services and technologies Voraxaze® is still within the three-year newness period; CMS is proposing to continue new technology add-on payments for this technology for FY 2014. DIFICID™ (Fidaxomicin) tablets’ three-year anniversary date will occur in the second half of the fiscal year (after April 1, 2014); CMS is proposing to continue new technology add-on payments for FY 2014. Zenith® fenestrated abdominal aortic aneurysm (AAA) endovascular graft is being proposed to continue new technology add-on payments for FY 2014. CMS received five applications for new technology add-on payments for FY 2014: Kcentra™; Argus® II Retinal Prosthesis System; Responsive Neurostimulator (RNS®) System; Zilver® PTX® Drug Eluting Peripheral Stent; and MitraClip® System. None of these five applications have been proposed as new technology, although CMS is soliciting comments. Other decisions and changes to the IPPS for operating costs A. Rural referral centers (RRCs) A rural hospital with less than 275 beds may be classified as an RRC if: yy The hospital’s case-mix index (CMI) is at least equal to the lower of the median CMI for urban hospitals in its census region, excluding hospitals with approved teaching programs, or the median CMI for all urban hospitals nationally; and 17 yy The hospital’s number of discharges is at least 5,000 per year, or, if fewer, the median number of discharges for urban hospitals in the census region in which the hospital is located. (The number of discharges criteria for an osteopathic hospital is at least 3,000 discharges.) CMS is proposing that, in addition to meeting other criteria, if rural hospitals with fewer than 275 beds are to qualify for initial RRC status for cost reporting periods beginning on or after October 1, 2013, they must have a CMI value for FY 2012 that is at least: yy 1.5526; or yy The median CMI value (not transfer-adjusted) for urban hospitals (excluding hospitals with approved teaching programs as identified in § 413.75) calculated by CMS for the census region in which the hospital is located. The proposed CMI values by region are set forth in the following table: Region Case mix index value 1 New England (CT, ME, MA, NH, RI, VT) 1.3319 2 Middle Atlantic (PA, NJ, NY) 1.4025 3 South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV) 1.4799 4 East North Central (IL, IN, MI, OH, WI) 1.4542 5 East South Central (AL, KY, MS, TN) 1.4266 6 West North Central (IA, KS, MN, MO, NE, ND, SD) 1.5311 7 West South Central (AR, LA, OK, TX) 1.5811 8 Mountain (AZ, CO, ID, MT, NV, NM, UT, WY) 1.6393 9 Pacific (AK, CA, HI, OR, WA) 1.5568 A hospital, if it is to qualify for initial RRC status for cost reporting periods beginning on or after October 1, 2013, must also have as the number of discharges for its cost reporting period that began during FY 2011 a figure that is at least: yy 5,000 (3,000 for an osteopathic hospital); or yy The median number of discharges for urban hospitals in the census region in which the hospital is located. All census regional discharge numbers are greater than 5,000. B. Proposed payment adjustment for low-volume hospitals (§ 412.101) In accordance with Section 1886(d)(12) of the Act, as amended, beginning with FY 2014, the low-volume hospital definition and payment adjustment methodology will revert back to the statutory requirements that were in effect prior to the amendments made by the ACA and the ATRA. FY 2014 and subsequent years, in order to qualify as a low-volume hospital, a subsection (d) hospital must be more than 25 road miles from another subsection (d) hospital and have less than 200 discharges (that is, less than 200 discharges total, including both Medicare and non-Medicare discharges) during the fiscal year. Under existing policy, effective for FY 2014 and subsequent years, qualifying hospitals would receive the low-volume hospital payment adjustment of an additional 25 percent for discharges occurring during the fiscal year. C. Indirect medical education (IME) payment adjustment (§ 412.105) For discharges occurring during FY 2014, the formula multiplier continues to be 1.35. 18 Comment The following section is intended to implement the ACA’s payment reductions for DSH as additional and uninsured individuals acquire health care coverage. The material that follows appears complex and should be reviewed by all providers currently receiving DSH payments. D. Payment adjustment for Medicare disproportionate share hospitals (DSHs) (§ 412.106) ACA Section 3133 added a new section 1886(r) to the Act that modifies the methodology for computing the Medicare DSH payment adjustment, beginning in FY 2014. Beginning for discharges in FY 2014, hospitals that qualify for Medicare DSH payments under section 1886(d)(5)(F) will receive 25 percent of the amount they previously would have received under the current statutory formula for Medicare DSH payments. This provision applies equally to hospitals that qualify for DSH payments under section 1886(d)(5)(F)(i)(II) of the Act, the so-called Pickle hospitals. Pursuant to new section 1886(r), Pickle hospitals would receive 25 percent of the 35 percent add-on adjustment for which they would otherwise qualify under section 1886(d)(5)(F)(i)(II). Let’s call these traditional DSH hospitals or traditional DSH payments. CMS described these DSH payments as “empirically justified Medicare DSH payments.” The remaining amount, equal to an estimate of 75 percent of what otherwise would have been paid as Medicare DSH payments, reduced to reflect changes in the percentage of individuals under age 65 who are uninsured, will become available as an additional payment to each hospital that qualifies for Medicare DSH payments and that has uncompensated care. The payments to each hospital for a fiscal year will be based on the hospital’s amount of uncompensated care for a given time period relative to the total amount of uncompensated care for that same time period reported by all hospitals that receive Medicare DSH payments for that fiscal year. In determining which classes of DSH hospitals that would be eligible for these additional uncompensated care payments, CMS indicated the following classes of DSH hospitals, in addition to subsection (d) DSH hospitals, would be eligible: yy Subsection (d) Puerto Rico hospitals yy Sole Community Hospitals (SCH) yy IPPS hospitals participating in the Bundled Payments for Care Improvement Initiative CMS indicated hospitals participating under a waiver from the Medicare payment methodologies (Maryland hospitals) and hospitals participating in the rural community hospital demonstration program would not be eligible to receive the new uncompensated care payments. For sole community hospitals (SCH), CMS is proposing that the new uncompensated care payments would not be accounted for in determining whether a SCH is paid the higher of the federal rate or the hospitalspecific rate. CMS’ reasoning is that uncompensated care payments are not discharge-driven payments (like federal rate and hospital-specific rate payments), but rather payments made on the basis of a hospital’s overall uncompensated care during the year. CMS is inviting comments on this proposal regarding SCHs. Section 1886(r)(2) of the Act provides that, for FY 2014 and each subsequent FY, the secretary shall pay to “such subsection (d) hospital an additional amount equal to the product of three factors.” 19 Remember, in order to qualify to receive these additional uncompensated care payments a hospital must qualify to receive traditional DSH payments, i.e. if your hospital does not qualify to receive 25 percent of their traditional DSH payments, then your hospital will receive no (or zero) uncompensated care payments. The first factor is the difference between “the aggregate amount of payments that would be made to subsection (d) hospitals under subsection (d)(5)(F) if this subsection did not apply” and “the aggregate amount of payments that are made to subsection (d) hospitals under paragraph (1)” for each FY. The second factor is, for FYs 2014 through 2017, 1 minus the percent change in the percent of individuals under the age of 65 who are uninsured, determined by comparing the percent of such individuals who are uninsured in 2013, the last year before coverage expansion under the ACA (as calculated by the secretary, based on the most recent estimates available from the Director of the Congressional Budget Office before a vote in either House on the Health Care and Education Reconciliation Act of 2010 that, if determined in the affirmative, would clear such Act for enrollment), minus 0.1 percentage point for FY 2014, and minus 0.2 percentage points for FYs 2015 through 2017. The third factor is a percent that, for each subsection (d) hospital, “represents the quotient of… the amount of uncompensated care for such hospital for a period selected by the secretary (as estimated by the secretary, based on appropriate data…),” including the use of alternative data “where the secretary determines that alternative data is available which is a better proxy for the costs of subsection (d) hospitals for… treating the uninsured,” and “the aggregate amount of uncompensated care for all subsection (d) hospitals that receive a payment under this subsection.” Therefore, this third factor represents a DSH hospital’s uncompensated care amount for a given time period relative to the uncompensated care amount for that same time period for all hospitals that receive Medicare DSH payments in that fiscal year, expressed as a percent. For each hospital, the product of these three factors represents its additional payment for uncompensated care for the applicable fiscal year. Proposed methodology to calculate Factor 1 Section 1886(r)(2)(A)(i) of the Act represents an estimate of the full Medicare DSH payment amount under section 1886(d)(5)(F) prior to the 75 percent reduction, for FY 2014 and subsequent years. This subparagraph specifies that, for each fiscal year to which the provision applies, such amount is to be “estimated by the secretary.” CMS would use the agency’s office of the actuary’s February 2013 Medicare DSH estimates to calculate Factor 1. However, CMS proposes to use the office of the actuary’s July 2013 Medicare DSH estimates to calculate Factor 1 in the final rule. CMS estimates empirically justified Medicare DSH payments for FY 2014, with the application of section 1886(r) (1) of the Act, is $3.084 billion (25 percent of the total amount estimated). Factor 1 is the difference of these two estimates of the office of the actuary. Therefore, for the purpose of modeling Factor 1, CMS calculates Factor 1 to be $9.2535 billion. CMS has published supplemental information on how Factor 1 was computed out on their website at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/ dsh.html. Proposed methodology to calculate Factor 2 Section 1886(r)(2)(B) of the Act establishes, as Factor 2 in the uncompensated care payment formula, the percent change in uninsurance, based on a comparison of the percent of individuals under 65 without 20 insurance in 2013 to the percent of such individuals without insurance in the most recent period for which CMS has data, minus 0.1 percentage point for FY 2014 and 0.2 percentage points for each of FYs 2015, 2016 and 2017. Using a March 20, 2010 CBO projection for 2013 and a February 5, 2013 CBO projection of uninsurance for all residents for 2014, CMS is proposing to use the following computation for Factor 2 for FY 2014: yy Percent of individuals without insurance for 2013: 18 percent yy Percent of individuals without insurance for 2014: 16 percent 1.0 – |[(0.16 - 0.18)/0.18]| = 1.0 - 0.111 = 0.889 (88.9 percent) 0.889 (88.9 percent) - 0.001 (0.1 percentage point) = 0.888 (88.8 percent) 0.888 = Factor 2 Accordingly, CMS is proposing Factor 2 to be 88.8 percent for FY 2014. In conjunction with this proposal, CMS is proposing that the amount available for uncompensated care payments for FY 2014 will be $8.217 billion (0.888 times the proposed Factor 1 estimate of $9.2535 billion). This results in a reduction in DSH payments via the uncompensated care calculation of approximately $1.03B ($9.25B - $8.22B). Proposed methodology to calculate Factor 3 For FY 2014, the denominator for Factor 3 would reflect the estimated Medicaid and Medicare SSI patient days, based on data from the 2010/2011 Medicare cost report (including the most recently available data that may be used to update the SSI ratios) for all hospitals that CMS estimates would receive an empirically justified DSH payment in FY 2014. The numerator of Factor 3 would be the estimated Medicaid and Medicare SSI patient days for the individual hospital, based on its most recent 2010/2011 Medicare cost report data (including the most recently available data that may be used to update the SSI ratios). CMS is posting proposed tables listing Factor 3 for the hospitals that it has estimated would receive Medicare DSH payments for FY 2014 on the CMS website at: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/AcuteInpatientPPS/dsh.html. CMS is requesting that hospitals review these tables. In order to ensure that CMS has sufficient time to incorporate any updated information in the tables for the final rule, hospitals should notify CMS in writing within 60 days from the date of display of this proposed rule of any change in a hospital’s subsection (d) hospital status. Comment The statute provides the formula factors to calculate DHS payments and reductions. The reduction from $9.2535 billion to $8.217 billion under Factor 2 implies a potential loss of $1 billion in payments. All will depend on the uninsured becoming insured. Congress has made judicial review of CMS’ estimates and data sources basically challenge proof. However, CMS is requesting comments on the proposed DSH and uncompensated care estimation and payment methodologies. The hospital community should take this opportunity to comment on these methodologies and propose alternatives to ensure DSH and uncompensated care payments are distributed to DSH hospitals equitably for FY 2014 and after. Hospitals should review these proposed rules very carefully and determine the impact these changes will have on their annual DSH payments. The calculation of a hospital’s traditional DSH payments is more critical than 21 ever, as if a hospital doesn’t qualify for traditional DSH payments, they will not qualify for the 75 percent pool of uncompensated care payments. Additionally, each hospital’s ability to capture all of their patients that are eligible for Medicaid whether paid or unpaid takes on even more importance as that information is now being used in both the traditional DSH payment calculation and the uncompensated care payment calculation. Hospital’s that can accurately capture Medicaid eligibility data will fare better than those that cannot. E. Hospital readmissions reduction program: Proposed changes (§§412.150 through 412.154) The hospital readmissions reduction program began on October 1, 2012. The maximum reduction was one percent of payment amounts in FY 2013, and will increase to two percent of payment amounts in FY 2014, as specified under the ACA. CMS currently assesses hospitals’ readmission penalties using three readmissions measures endorsed by the National Qualify Forum (NQF): heart attack, heart failure and pneumonia. CMS is proposing to update the measures to: (1) incorporate the CMS-planned readmission algorithm version 2.1 to identify planned readmissions; and (2) not count unplanned readmissions that follow planned readmissions. CMS says this proposed change in counting practice would 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). For FY 2015, CMS is proposing to expand the applicable conditions and procedures to include: (1) patients admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD); and (2) patients admitted for elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). F. Hospital value-based purchasing (VBP) program For FY 2014, CMS is increasing the applicable percent reduction, the portion of Medicare payments available to fund the VBP program’s value-based incentive payments, to 1.25 percent, as required by the ACA. CMS estimates that the total amount available for performance-based incentive payments for FY 2014 would be approximately $1.1 billion, and will update this estimate for the final rule. FY 2014 hospital VBP program measures Set out below is a complete list of the measures CMS adopted for the FY 2014 hospital VBP program: Finalized quality measures for the FY 2014 hospital VBP program Clinical process of care measures Measure ID Measure description Acute myocardial infarction AMI-7a Fibrinolytic therapy received within 30 minutes of hospital arrival AMI-8a Primary PCI received within 90 minutes of hospital arrival Heart failure HF-1 Discharge instructions Pneumonia PN-3b Blood cultures performed in the emergency department prior to initial antibiotic received in hospital PN-6 Initial antibiotic selection for CAP in immunocompetent patient 22 Health care-associated infections SCIP-Inf-1 Prophylactic antibiotic received within one hour prior to surgical incision SCIP-Inf-2 Prophylactic antibiotic selection for surgical patients SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time SCIP-Inf-4 Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose SCIP-Inf-9 Postoperative urinary catheter removal on postoperative day 1 or 2 Surgeries SCIP-Card-2 Surgery patients on beta blocker therapy prior to arrival who received a betablocker during the perioperative period SCIP-VTE-1 ** Surgery patients with recommended venous thromboembolism prophylaxis ordered SCIP-VTE-2 Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery Patient experience of care measures Measure ID Measure description HCAHPS Hospital consumer assessment of health care providers and systems survey* Outcome measures Measure ID Measure description MORT-30-AMI Acute myocardial infarction (AMI) 30-day mortality rate MORT-30-HF Heart failure (HF) 30-day mortality rate MORT-30 PN Pneumonia (PN) 30-day mortality rate *The finalized dimensions of the HCAHPS survey for use in the FY 2014 hospital VBP program are: Communication with nurses, communication with doctors, responsiveness of hospital staff, pain management, communication about medicines, cleanliness and quietness of hospital environment, discharge information and overall rating of hospital. These are the same dimensions that CMS adopted for the FY 2013 hospital VBP program. **To be deleted for FY 2015 FY 2015 hospital VBP program measures For the FY 2015 VBP program, CMS adopted 12 clinical process of care measures, one patient experience of care measure in the form of the HCAHPS survey, 5 outcome measures, including three 30-day mortality measures, the AHRQ PSI composite measure and the CLABSI measure and one efficiency measure. They are the items in the above table, less SCIP-VTE-1, which is to be deleted for FY 2015, and the following three items below. Added finalized quality measures for the FY 2015 hospital VBP program Outcome measures Measure ID Measure description AHRQ PSI composite Complication/patient safety for selected indicators (composite) CLABSI Central line-associated blood stream infection Efficiency measures MSPB-1 Medicare spending per beneficiary FY 2016 hospital VBP program measures CMS is proposing to remove measures AMI-8a, PN-3b and HF-1 for FY 2016. 23 CMS also proposes to adopt three new measures for FY 2016, including one new clinical process measure, influenza immunization, and two new health care-associated infection measures, catheter-associated urinary tract infection (CAUTI) and surgical site infection (SSI), the latter of which is stratified into two separate surgery sites. The proposed rule outlines the proposed performance and baseline periods for the FY 2016 program, and proposes reclassification of the hospital VBP program domains to more closely align with the national quality strategy in FY 2017. It proposes weighting for the proposed aligned domains for 2017, as well as proposed domain weighting under the current domain structure for FY 2016. Performance standards for the FY 2016 hospital VBP program measures CMS has finalized FY 2016 performance standards for the three 30-day mortality measures and the AHRQ PSI composite measure in the FY 2013 IPPS/LTCH PPS final rule, and is displaying them in the table below. Finalized performance standards for certain FY 2016 hospital VBP program Outcome domain measures Measure ID Description Achievement threshold Benchmark Outcomes measures MORT-30-AMI Acute myocardial infarction (AMI) 30-day mortality rate 0.847472 0.862371 MORT-30-HF Heart failure (HF) 30-day mortality rate 0.881510 0.900315 MORT-30-PN Pneumonia (PN) 30-day mortality rate 0.882651 0.904181 PSI-90 Complication/patient safety for selected indicators (composite) 0.622879 0.451792 The numerical values for the proposed FY 2016 performance standards for the clinical process, outcome and efficiency measures appear in the table below: Proposed performance standards for the FY 2016 hospital VBP program clinical process of care, outcomes and efficiency domain measures Measure ID Description Achievement threshold Benchmark Clinical process of care measures AMI-7a Fibrinolytic therapy received within 30 minutes of hospital arrival 0.88625 1.00000 IMM-2 Influenza immunization 0.89947 0.99036 PN-6 Initial antibiotic selection for CAP in immunocompetent patient 0.96429 1.00000 SCIP-Inf-1 Prophylactic antibiotic received within one hour prior to surgical incision 0.98942 1.00000 SCIP-Inf-2 Prophylactic antibiotic selection for surgical patients 0.98951 1.00000 SCIP-Inf-3 Prophylactic antibiotics discontinued within 24 hours after surgery end time 0.97971 1.00000 SCIP-Inf-4 Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose 0.96797 0.99977 24 SCIP-Inf-9 Urinary catheter removed on postoperative day 1 or postoperative day 2 0.96743 1.00000 SCIP-Card-2 Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who received a beta-blocker during the perioperative period 0.97561 1.00000 SCIP-VTE-2 Surgery patients who received appropriate venous thromboembolism prophylaxes within 24 hours prior to surgery to 24 hours after surgery 0.98086 1.00000 Outcomes measures CAUTI Catheter-associated urinary tract infection 0.82600 0.00000 CLABSI Central line-associated blood stream infection 0.47300 0.00000 SSI Surgical site infection 0.73700 0.00000 Medicare spending per beneficiary Median Medicare spending per beneficiary ratio across all hospitals during the performance period Mean of the lowest decile Medicare spending per beneficiary ratios across all hospitals during the performance period Efficiency measure MSPB-1 CMS says that for information purposes, during the period of May 1, 2011 through December 31, 2011, the achievement threshold would have been a Medicare spending per beneficiary ratio of 0.99, which corresponds to a standardized, risk-adjusted Medicare spending per beneficiary amount of $18,079, and the benchmark would have been 0.82, which corresponds to a Medicare spending per beneficiary amount of $14,985. Numerical values for the proposed FY 2016 performance standards for the patient experience of care (HCAHPS survey) measures appear in the table below. Proposed performance standards for the FY 2016 hospital VBP program Patient experience of care domain HCAHPS survey dimension Floor Achievement threshold Benchmark (percent) (percent) (percent) Communication with nurses 53.33 77.59 85.98 Communication with doctors 61.22 80.33 88.59 Responsiveness of hospital staff 36.44 64.65 79.72 Pain management 47.93 70.16 78.24 Communication about medicines 42.23 62.28 72.67 Hospital cleanliness and quietness 42.16 64.93 79.12 Discharge information 62.85 84.45 90.26 Overall rating of hospital 36.45 69.05 83.89 25 Certain performance standards for the FY 2017, FY 2018 and FY 2019 hospital VBP programs CMS is proposing to adopt performance standards for the three 30-day mortality and AHRQ PSI composite measures for the FY 2017, FY 2018 and FY 2019 hospital VBP program years. Hospital VBP program scoring methodology Final domain weights for the FY 2015 hospital VBP program for hospitals Receiving a score on all proposed domains Domain Weight Clinical process of care 20 percent Patient experience of care 30 percent Outcome 30 percent Efficiency 20 percent G. Proposed implementation of hospital-acquired condition (HAC) reduction program for FY 2015 Under this program, hospitals that rank in the lowest-performing quartile of hospital-acquired conditions would be paid 99 percent of what they would otherwise be paid under the IPPS beginning in FY 2015. To determine this quartile, CMS is proposing quality measures and a scoring methodology, as well as a process for hospitals to review and correct their data. For FY 2015, the first year of the program, CMS is proposing to measure HACs using measures that are either calculated using claims or are part of the inpatient quality reporting program, and would consist of two domains of measure sets. The proposed Domain 1 measures would include six patient safety indicator (PSI) measures developed by the Agency for Health Care Research and Quality (AHRQ). These measures are: pressure ulcer rate; volume of foreign object left in the body; iatrogenic pneumothorax rate; postoperative physiologic and metabolic derangement rate; postoperative pulmonary embolism or deep vein thrombosis rate; and accidental puncture and laceration rate. An alternative to Domain 1 is also being proposed, which would consist of a composite PSI measure set. The proposed Domain 2 measures would include two health care-associated infection measures developed by the Centers for Disease Control and Prevention’s (CDC) National Health Safety Network: central line-associated bloodstream infection and catheter-associated urinary tract infection. Under the scoring methodology proposed, hospitals would be given a score for each measure within the two domains. A domain score would be calculated and the two domains would be weighted equally to determine a total score under the program. Risk factors such as the patient’s age, gender and comorbidities would be considered in the calculation of the measure rates, so that hospitals serving a large proportion of sicker patients would not be unfairly penalized. In accordance with the statute, CMS proposes a process for hospitals to review and correct their information. 26 Proposed measures for the hospital-acquired condition reduction program Domain 1: AHRQ patient safety indicators Proposed approach: 6 individual measures (FY 2015 onward) PSI-3 (Pressure ulcer rate) PSI-5 (Foreign object left in body) PSI-6 (Iatrogenic pneumothorax rate) PSI-10 (Postoperative physiologic and metabolic derangement rate) PSI-12 (Postoperative PE/DVT rate) PSI-15 (Accidental puncture and laceration rate) Alternative approach: One composite of 8 component indicators (FY 2015 onward) PSI-90 = PSI3, 6, 7, 8 PSI-3 (Pressure ulcer rate) PSI-6 (Iatrogenic pneumathorax rate) PSI-7 (Central venous catheter-related blood stream infections rate) PSI-8 (Postoperative hip fracture rate) PSI-12 (Postoperative PE/DVT rate) PSI-13 (Postoperative sepsis rate) PSI-14 (Wound dehiscence rate) PSI-15 (Accidental puncture and laceration rate) Domain 2: CDC HAI measures apply to proposed approach and alternative approach (Multiple FYs) Central line-associated blood stream infection (CLABSI) (FY 2015 onward) Catheter-associated urinary tract infection (CAUTI) (FY 2015 onward) Surgical site infection (SSI): SSI following colon surgery (FY 2016 onward) SSI following abdominal hysterectomy (FY 2016 onward) Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia (FY 2017 onward) Clostridium difficile (FY 2017 onward) For FY 2015, CMS is proposing to use the 24-month period from July 1, 2011 through June 30, 2013 as the applicable time period for the AHRQ measures. The claims for all Medicare FFS beneficiaries discharged during this period would be included in the calculation of measure results for FY 2015. This includes claims data from the 2011, 2012 and 2013 inpatient standard analytic files (SAFs). Comment The system for scoring is complex and detailed. H. Policy proposal on admission and medical review criteria for hospital inpatient services under Medicare Part A CMS is proposing a time-based presumption of medical necessity for hospital inpatient services, based on the beneficiary’s length of stay, as part of its medical review criteria for payment of hospital inpatient services under Part A. CMS is proposing a new benchmark for purposes of medical review of hospital inpatient admissions, based on how long the beneficiary is in the hospital. Under the proposal, Medicare’s external review contractors would presume that hospital inpatient admissions are reasonable and necessary for beneficiaries who require more than one Medicare utilization day (defined by encounters crossing two “midnights”) in the hospital receiving medically necessary services. 27 If a hospital is found to be abusing this two-midnight presumption for non-medically necessary inpatient hospital admissions and payment (in other words, the hospital is systematically delaying the provision of care to surpass the two-midnight time frame), CMS review contractors would disregard the two-midnight presumption when conducting review of that hospital. Similarly, CMS would presume that hospital services spanning less than two midnights should have been provided on an outpatient basis, unless there is clear documentation in the medical record supporting the physician’s order and expectation that the beneficiary would require care spanning more than two midnights, or the beneficiary is receiving a service or procedure designated by CMS as inpatient-only. CMS is proposing to add a new § 412.3, titled “Admissions,” that would define a hospital inpatient admission, as follows: “(a) For purposes of payment under Medicare Part A, an individual is considered an inpatient of a hospital, including a critical access hospital, if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner.” In other words, if it was reasonable for the physician to expect the beneficiary to require a stay lasting two midnights, even though that did not transpire, payment would be made under Medicare Part A, if the documentation in the medical record reflected such complex medical factors (and the physician’s order and certification requirements also are met). In light of the widespread impact of the proposed policy on the IPPS, CMS says it believes “it is appropriate to…use our exceptions and adjustments authority under section 1886(d)(5)(I)(i) of the Act to offset the estimated $220 million in additional IPPS expenditures associated with this proposed policy.” This special exceptions and adjustment authority authorizes us to provide, “for such other exceptions and adjustments to [IPPS] payment amounts…as the secretary deems appropriate.” CMS is proposing to reduce the standardized amount, the hospital-specific rates and the Puerto Rico-specific standardized amount by 0.2 percent. Proposed quality data reporting requirements for specific providers and suppliers Hospital IQR The Hospital IQR program measure set has grown from a starter set of 10 quality measures in 2004, to a set of 59 quality measures. These measures include: chart-abstracted measures, such as heart attack, heart failure, pneumonia and surgical care improvement measures; claims-based measures, such as mortality and readmissions; health care-associated infections measures; a surgical complications measure; survey-based measures, such as patient experience of care; immunization measures and structural measures that assess features of hospitals—such as hospital volume, how the hospital deploys staff or provider qualifications—to assess their capacity to improve quality of care. For the FY 2016 payment determination and subsequent years, CMS is proposing to remove eight measures from the hospital IQR program. Three measures are chart-abstracted (one pneumonia measure, one heart failure measure and one immunization measure), and one is a structural measure (systematic clinical database registry for stroke care). CMS is also proposing to remove 4 additional chart-abstracted measures from the hospital IQR program, because they were either recommended for removal by the measure application partnership (MAP) during the pre-rulemaking process or are considered “topped out.” 28 Proposed removal of hospital IQR program measures for the FY 2016 payment determination and subsequent years Topic Acute myocardial infarction • AMI-2 aspirin prescribed at discharge • AMI-10 statin prescribed at discharge Pneumonia • PN-3b blood culture performed in the emergency department prior to first antibiotic received in hospital Heart failure • HF-1 discharge instructions • HF-3 ACEI or ARB for LVSD Surgical care improvement project • SCIP-Inf-10 Surgery patients with perioperative temperature management Immunization • IMM-1 Immunization for pneumonia Structural measure • Participation in a systematic clinical database registry for stroke care CMS is proposing to incorporate refinements for several measures that are currently adopted in the hospital IQR program. These refinements have either arisen out of the NQF endorsement maintenance process, or during internal efforts to harmonize measurement approaches. The measure refinements include the following: 1.Incorporation of the planned readmission algorithm in 30-day readmission measures for AMI, HF, PN, THA/ TKA and hospital-wide readmission to match recent NQF endorsement maintenance decisions beginning in 2013 2.Expansion of CLABSI and CAUTI measures to select non-ICU locations in IPPS hospitals, beginning with infections occurring on or after January 1, 2014 (consistent with NQF expansion of the measures beyond ICUs) 3.Updates to SCIP Inf 4 to match recent NQF endorsement maintenance decisions, beginning with January 1, 2014 discharges 4.An update to the MSPB measure to include railroad retirement board (RRB) beneficiaries, beginning in 2014 CMS is proposing to add five new risk-adjusted claims-based outcome measures to the hospital IQR program for the FY 2016 payment determination and subsequent years: 1.30-day risk standardized COPD readmission 2.30-day risk standardized COPD mortality 3.30-day risk standardized stroke readmission 4.30-day risk standardized stroke mortality 5.AMI payment per episode of care CMS provides detailed information about each of the five new measures. 29 Set out below is a table showing both the previously adopted and proposed new quality measures for the FY 2016 payment determination and subsequent years. This table does not include suspended measures and measures proposed for removal. Topic Previously adopted and proposed hospital IQR program measures for FY 2016 payment determination and subsequent years Acute myocardial infarction (AMI) • AMI-7a fibrinolytic (thrombolytic) agent received within 30 minutes of hospital arrival • AMI-8a timing of receipt of primary percutaneous coronary intervention (PCI) Heart failure (HF) • HF-2 Evaluation of left ventricular systolic function Stroke measure set • STK-1 VTE prophylaxis • STK-2 antithrombotic therapy for ischemic stroke† • STK-3 anticoagulation therapy for afib/flutter† • STK-4 thrombolytic therapy for acute ischemic stroke† • STK-5 antithrombotic therapy by the end of hospital day 2† • STK-6 discharged on statin† • STK-8 stroke education† • STK-10 assessed for rehab† VTE measure set • VTE-1 VTE prophylaxis† • VTE-2 ICU VTE prophylaxis† • VTE-3 VTE patients with anticoagulation overlap therapy† • VTE-4 Patients receiving unfractionated Heparin with doses/labs monitored by protocol† • VTE-5 VTE discharge instructions† • VTE-6 Incidence of potentially preventable VTE† Pneumonia (PN) • PN-6 Appropriate initial antibiotic selection Surgical care improvement project (SCIP) • SCIP INF-1: Prophylactic antibiotic received within 1 hour prior to surgical incision • SCIP INF-2: Prophylactic antibiotic selection for surgical • SCIP INF-3: Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac surgery) • SCIP INF-4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose • SCIP INF-9: Postoperative urinary catheter removal on postoperative day 1 or 2, with surgery being day zero • SCIP-Cardiovascular-2: Surgery patients on a beta blocker prior to arrival, who received a beta blocker during the perioperative period • SCIP INF-VTE-2: Surgery patients who received appropriate VTE prophylaxis within 24 hours pre-/post-surgery 30 Mortality measures (Medicare patients) • Acute myocardial infarction 30-day mortality rate • Heart failure (HF) 30-day mortality rate • Pneumonia (PN) 30-day mortality rate • Stroke 30-day mortality rate*** • OPD 30-day mortality rate*** Patients' experience of care measures • HCAHPS survey (expanded to include one 3-item care transition set* and two new “about you” items*) Readmission measure (Medicare patients) • Acute myocardial infarction 30-day risk standardized readmission measure • Heart failure 30-day risk standardized readmission measure • Pneumonia 30-day risk standardized readmission measure • 30-day risk standardized readmission following total hip/total knee arthroplasty* • Hospital-wide all-cause unplanned readmission (HWR)* • Stroke 30-day risk standardized readmission *** • COPD 30-day risk standardized readmission*** AHRQ patient safety indicators (PSIs) composite measures • Complication/patient safety for selected indicators (composite) AHRQ PSI and nursing sensitive care • PSI-4 Death among surgical inpatients with serious, treatable complications Structural measures • Participation in a systematic database for cardiac surgery • Participation in a systematic clinical database registry for nursing sensitive care • Participation in a systematic clinical database registry for general surgery • Safe surgery checklist use** Health care-associated infection measures • Central line-associated blood stream infection • Surgical site infection -- SSI following colon surgery -- SSI following abdominal hysterectomy • Catheter-associated urinary tract infection • MRSA bacteremia • Clostridium difficile (C-diff ) • Health care personnel influenza vaccination Surgical complications • Hip/knee complication: Hospital-level risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty* Emergency department throughput measures • ED-1 median time from emergency department arrival to time of departure from the emergency room for patients admitted to the hospital† 31 • ED-2 median time from admit decision to time of departure from the emergency department for emergency department patients admitted to the inpatient status† Prevention: Global immunization (IMM) measures • Immunization for influenza Cost efficiency • Medicare spending per beneficiary • AMI payment per episode of care** Perinatal care • Elective delivery prior to 39 completed weeks of gestation*/† * New or expanded measures/items for FY 2015 payment determination and subsequent years. ** New measures for FY 2016 payment determination and subsequent years. *** Proposed measures for FY 2016 payment determination and subsequent years. † Proposed measure for electronic reporting via CEHRT in the hospital IQR program (voluntary participation in CY 2014). Electronic clinical quality measures CMS says it believes that collection and reporting of data through health information technology will greatly simplify and streamline reporting for many CMS quality reporting programs. CMS is proposing that hospitals would be able to, on a voluntary basis, electronically report 16 measures across four measure sets, (stroke ( STK), venous thromboembolism (VTE), emergency department (ED) and perinatal care (PC)) in CY 2014 for the FY 2016 hospital IQR program payment determination. PPS-exempt cancer hospital quality reporting (PCHQR) program For the PCHQR program beginning with FY 2015, CMS is proposing to adopt one new measure: NHSN HAI measure of surgical site infection (SSI). For the PCHQR Program beginning with FY 2016, CMS is proposing to adopt 13 new measures: six measures of Surgical Care Improvement Project (SCIP), six clinical process/ oncology care measures and one patient experience of care measure (the HCAHPS survey). This program affects 11 PPS-exempt cancer facilities. Comment CMS spends 40 pages providing detail on the PCHQR program. Long-term care hospital quality reporting (LTCHQR) program CMS is proposing the following revisions to the quality measures previously adopted for the LTCHQR program: yy That the influenza vaccination coverage among health care personnel measure (NQF #0431) have its own reporting period to align with the influenza vaccination season, which is defined by the CDC as October 1 (or when the vaccine becomes available) through March 31. yy That for NQF #0680, the percentage of residents or patients who were assessed and appropriately given the seasonal influenza vaccine (short-stay), to revise the previously finalized start date of January 1, 2014, for reporting of this measure, to April 1, 2014. 32 CMS is proposing the following three new quality measures for the LTCHQR program to affect the FY 2017 payment determination and subsequent payment determinations: yy Proposed quality measure #1: National healthcare safety network (NHSN) facility-wide inpatient hospitalonset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia outcome measure (NQF #1716) yy Proposed quality measure #2: National healthcare safety network (NHSN) facility-wide inpatient hospitalonset Clostridium difficile infection (C-diff ) outcome measure (NQF #1717). yy Proposed quality measure #3: All-cause unplanned readmission measure for 30 days post- discharge from long-term care hospitals. For the FY 2018 payment determination and subsequent payment determinations, CMS is proposing one new quality measure, application of the percent of residents experiencing one or more falls with major injury (long stay) (NQF #0674). Inpatient psychiatric facilities quality reporting (IPFQR) program CMS is proposing three new measures for the FY 2016 payment determination and subsequent years for the IPFQR Program. The measures are: yy SUB-1: Alcohol use screening (submitted for NQF review) yy SUB-4: Alcohol and drug use: Assessing status after discharge (submitted for NQF review) yy Follow-up after hospitalization for mental illness (FUH) (NQF #0576) Changes to the MS-LTC-DRGs for FY 2014 CMS is proposing to update the standard MS-LTC federal rate by 1.8 percent, which is based on a full estimated increase in the LTCH PPS market basket of 2.5 percent, less the MFP adjustment of 0.4 percentage points and less the 0.3 percentage points, as mandated by the ACA. CMS also is proposing to establish an annual update to the LTCH PPS standard federal rate of -0.2 percent (that is, 1.8 percent minus 2.0 percentage points =-0.2 percent, or an update factor of 0.9980) for FY 2014 for LTCHs that fail to submit quality reporting data for FY 2014 under the LTCHQR program. Additionally, CMS is proposing to establish that the standard federal rate for FY 2014 would be further adjusted by a proposed adjustment factor of 0.98734 for FY 2014, under the second year of the three-year phase-in of the one-time prospective adjustment at § 412.523(d)(3)(ii). Also, CMS is proposing to apply an area wage level budget neutrality factor of 1.000433 to the standard federal rate to ensure that any proposed changes to the area wage level adjustment (that is, the proposed annual update of the wage index values and labor-related share) would not result in any change (increase or decrease) in estimated aggregate LTCH PPS payments. Accordingly, the proposed standard federal rate for FY 2014 would be $40,622.06 (calculated as $40,397.96 × 1.018 × 0.98734 × 1.000433). The current rate is $40,397.96. The labor-related share that CMS is adopting to use for LTCH PPS in FY 2014 would be 62.717, down from the current value of 63.096 percent. CMS is proposing a fixed-loss amount of $14,139 for FY 2014. The current amount is $15,408. 33 Final comment Below is an analysis that compares the current MS-DRG (FY 2013) weights to those proposed for FY 2014 for all MS-DRGs having 100,000 or more discharges. MS-DRG Description 65 Intracranial hemorrhage or cerebral infarction w CC Proposed FY 2014 weight FY 2013 Percentage difference 1.0794 1.1345 -4.86% 189 Pulmonary edema and respiratory failure 1.2191 1.2461 -2.17% 190 Chronic obstructive pulmonary disease w MCC 1.1708 1.1860 -1.28% 191 Chronic obstructive pulmonary disease w CC 0.9330 0.9521 -2.01% 193 Simple pneumonia and pleurisy w MCC 1.4553 1.4893 -2.28% 194 Simple pneumonia and pleurisy w CC 0.9753 0.9996 -2.43% 247 Perc cardiovasc proc w drug-eluting stent w/o MCC 2.0268 1.9911 1.79% 287 Circulatory disorders, except AMI, w card cath w/o 1.0783 1.0709 0.69% 291 Heart failure and shock w MCC 1.5067 1.5174 -0.71% 292 Heart failure and shock w CC 0.9952 1.0034 -0.82% 309 Cardiac arrhythmia and conduction disorders w CC 0.7881 0.8098 -2.68% 310 Cardiac arrhythmia and conduction disorders w/o 0.5514 0.5541 -0.49% 312 Syncope and collapse 0.7184 0.7339 -2.11% 313 Chest pain 0.5942 0.5617 5.79% 378 G.I. hemorrhage w CC 1.0032 1.0168 -1.34% 392 Esophagitis, gastroent and misc digest disorders 0.7337 0.7375 -0.52% 2.1515 2.0953 2.68% 603 Cellulitis w/o MCC 0.8370 0.8392 -0.26% 641 Nutritional and misc metabolic disorders w/o MCC 0.6963 0.6920 0.62% 682 Renal failure w MCC 1.5412 1.5862 -2.84% 683 Renal failure w CC 0.9635 0.9958 -3.24% 690 Kidney and urinary tract infections w/o MCC 0.7659 0.7810 -1.93% 871 Septicemia or severe sepsis w/o MV 96+ hours w MCC 1.8560 1.8803 -1.29% 872 Septicemia or severe sepsis w/o MV 96+ hours w/o 1.0689 1.0988 -2.72% MCC CC/MCC w/o MCC 470 Major joint replacement or reattachment of lower extremity w/o MCC MCC These MS-DRGs account for approximately 37.4 percent of the nearly 10.2 million MS-DRG discharges. Most are declining and will negatively impact case-mix and payment. 34 800.274.3978 www.mcgladrey.com This document contains general information, may be based on authorities that are subject to change, and is not a substitute for professional advice or services. This document does not constitute assurance, tax, consulting, business, financial, investment, legal or other professional advice, and you should consult a qualified professional advisor before taking any action based on the information herein. McGladrey LLP, its affiliates and related entities are not responsible for any loss resulting from or relating to reliance on this document by any person. McGladrey LLP is an Iowa limited liability partnership and the U.S. member firm of RSM International, a global network of independent accounting, tax and consulting firms. 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