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CMS recently published the FY 2022 Inpatient Prospective Payment System (IPPS) Proposed Rule which includes several proposed changes to the Hospital Inpatient Quality Reporting (IQR) Program and Medicare Promoting Interoperability Program for eligible hospitals and critical access hospitals (CAHs). For the full text of the rule, see the Federal Register.
Hospital Inpatient Quality Reporting (IQR) Program
CMS has proposed numerous changes related to the Hospital Inpatient Quality Reporting (IQR) Program including the adoption of five new measures and the removal of five existing measures.
New Measures
First, CMS has proposed a new structural measure, Maternal Morbidity Structural Measure, beginning with a shortened reporting period from October 1, 2021 through December 31, 2021 for CY2021 reporting/FY2023 payment. Following this first year, the reporting period would be the full calendar year (January 1, 2022 through December 31, 2022) impacting FY2024 payment. Once a year, hospitals would attest to a two-part question via a CMS-approved web-based tool on the QualityNet website.
Second, CMS has proposed adopting the Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Measure (Hybrid HWM measure), which is reported as a single summary score capturing hospital-level, risk-standardized mortality within 30 days of hospital admission for most conditions or procedures. This measure uses three main sources of data: Medicare Part A claims data, a set of core clinical data elements from a hospital’s EHR, and mortality status from the Medicare Enrollment Database. Hospitals are already collecting nine of the ten core clinical data elements used in the Hybrid HWM measure for reporting on the Hybrid HWR measure (previously finalized in the FY2021 IPPS Rule), with platelets being the only additional data element used specifically for the Hybrid HWM measure. For this measure, CMS is proposing a voluntary reporting period from July 1, 2022 through June 30, 2023 (aligning with the second voluntary reporting period for the Hybrid HWR measure) and a mandatory reporting period beginning July 1, 2023 through June 30, 2024 affecting the FY 2026 payment determination and subsequent years (also aligning with the Hybrid HWR measure). Data submission of QRDA I files would be required 3 months following the end of the reporting period. While the voluntary data submission would not be publicly reported, the mandatory data submission would be publicly reported on Care Compare website or its successor website.
Next, CMS has proposed adding the COVID-19 Vaccination Coverage Among Health Care Personnel (HCP) beginning with a shortened reporting period from October 1, 2021 through December 31, 2021 for CY2021 reporting/FY2023 payment. However, beginning with the CY2022 reporting period/FY2024 payment determination, CMS proposes quarterly reporting deadlines in which hospitals would report at least one self-selected week during each month of the reporting quarter to the NHSN Healthcare Personal Safety Component. CMS would publicly report each quarterly COVID-19 HCP vaccination coverage rate as calculated by the CDC.
Finally, CMS has proposed adding two new eCQMs beginning with the CY2023 reporting period/FY2025 payment determination: Hospital Harm—Severe Hypoglycemia and Hospital Harm—Severe Hyperglycemia. These would be available, but not required eCQMs for IQR reporting.
Proposed Removals
CMS has also proposed to remove five measures. First, CMS proposed to remove PSI-04 Death Among Surgical Inpatients with Serious Treatable Complications, a claims-based measure, beginning with the CY2021 reporting period/FY2023 payment determination, should the Hybrid HWM measure be finalized as proposed. Secondly, CMS proposes to remove PC-05 Exclusive Breast Milk Feeding eCQM beginning with the CY2024 reporting period/FY2026 payment determination, should the Maternal Morbidity Structural Measure be finalized as proposed. Lastly, CMS proposed removing three more eCQMs: ED-2 Admit Decision Time to ED Departure Time for Admitted Patients, STK-03 Anticoagulation Therapy for Atrial Fibrillation/Flutter, and STK-06 Discharged on Statin Medication because the costs associated with these measures outweigh the benefits of their continued use in IQR. These measures are proposed for removal beginning with the CY2024 reporting period/FY2026 payment determination.
Other IQR Changes
In the FY2021 IPPS Final Rule, CMS finalized a progressive increase in the numbers of required reported quarters of eCQMs, from one self-selected quarter of data to four quarters of data over a three-year period. In this rule CMS proposed no changes related to this but clarified that the self-selected eCQMs must be the same eCQMs across all quarters in a given reporting year.
Beginning with the CY2023 reporting period/FY2025 payment determination, CMS proposed that hospitals would be required to use only certified technology that has been updated to the 2015 Edition Cures Update. This aligns with the requirement per ONC that health IT developers must make technology updated to the 2015 Edition Cures Update by December 31, 2022.
As CMS looks to the future of IQR, they are considering inclusion of a new hospital-level measure of all-cause mortality for Medicare beneficiaries admitted with COVID-19 infection, as well as a hospital-level, risk standardized patient reported outcomes measure following elective primary total hip and/or total knee arthroplasty. CMS invites public comment on the potential future inclusion of these two measures. Further, CMS is seeking comment on stratifying the performance results of the Hospital-Wide All-Cause Unplanned Readmission measure by dual eligibility, race, ethnicity, and disability status. Lastly, CMS invites comment on potential future reporting of a structural measure that assesses the degree of hospital leadership engagement in health equity performance data.
Medicare Promoting Interoperability (PI) Program
CMS has proposed several changes to the Medicare Promoting Interoperability (PI) Program related to measures and scoring. First, for CY 2023 reporting in the Medicare PI Program, CMS proposed to continue the EHR reporting period of a minimum of any continuous 90-day period for new and returning participants. However, for CY2024 reporting, CMS proposed an EHR reporting period of a minimum of any continuous 180-day period for new and returning participants. Additionally, for CY2022 and subsequent years, CMS proposed to increase the minimum scoring threshold for PI from 50 to 60 points. In other words, a hospital would need to score at least 60 points to avoid the negative payment adjustment.
Next, CMS has proposed numerous changes related to the PI objective measures beginning with CY2022 reporting. To begin, CMS proposed to keep the Query of the PDMP measure under the Electronic Prescribing Objective as an optional measure, but worth 10 bonus points, instead of 5. Secondly, CMS proposed to modify the Provide Patients Electronic Access to Their Health Information measure. CMS proposes requiring that patient health information remains available to the patient to access indefinitely and using any application of their choice that is configured to meet the technical specifications of the API in the eligible hospital or CAH’s CEHRT. All patient health information from encounters on or after January 1, 2016 would need to be included.
Likewise, CMS proposed to modify the reporting requirements for the Public Health and Clinical Data Exchange Objective by requiring four of the measures: Syndromic Surveillance Reporting, Immunization Registry Reporting, Electronic Case Reporting, and Electronic Reportable Laboratory Result Reporting. In addition to making Syndromic Surveillance Reporting required, CMS proposed to also change the setting from urgent care to the emergency department for which data is required to be submitted beginning with CY2022 reporting. Thus, the first exclusion for this measure would also be modified to remove the reference to urgent care. No changes are proposed to the other required measures. Given these proposed changes, CMS proposed to make the Public Health Registry Reporting and Clinical Data Registry Reporting measures optional, and a hospital can earn 5 bonus points if they report a “yes” response for either measure beginning with CY2022 reporting. Since these two measures would be optional, CMS has proposed the removal of the associated exclusions.
Further, CMS proposed adding the Health Information Exchange (HIE) Bi-Directional Exchange measure to the HIE Objective. This new measure would be an optional alternative to the two existing HIE measures: Support Electronic Referral Loops by Sending Health Information and Support Electronic Referral Loops by Receiving and Reconciling Health Information. Thus, hospitals would be able to report either the two existing measures or the new HIE Bi-directional Exchange measure. This new measure would be reported by attestation where a “yes” response would be worth 40 points. Hospitals would be required to engage in bi-directional exchange of information via an HIE for all unique patients admitted to or discharged from the hospital inpatient or emergency department and all unique patient records stored or maintained in the EHR for these departments during the EHR reporting period.
Finally, for CY2022 reporting, CMS proposed adding a new SAFER Guides measure to the Protect Patient Health Information objective. To meet this measure, a hospital must attest to one “yes/no” attestation statement to having conducted an annual self-assessment of all nine SAFER Guides at any point during the calendar year in which the EHR reporting period occurs. While this measure would be required in CY2022, it would not be scored.
As CMS continues to align the IQR and PI programs, CMS proposed the same eCQM additions and removals for Medicare PI as previously described for IQR. CMS is interested in public comments related to how the Health Information Exchange Objectives could further incorporate the use of FHIR-based API solutions.
Digital Quality Measurement
CMS’ goal is to move fully to digital quality measurement in CMS quality reporting and value-based purchasing programs by 2025. Digital quality measures (dQMs) use sources of health information that are captured and can be transmitted electronically via interoperable systems. These data sources may include administrative systems, electronically submitted clinical assessment data, case management systems, EHRs, medical/wearable devices, patient portals, HIEs and registries. Currently eCQMs are fully digital measures and CMS is currently re-specifying and testing these measures to use FHIR rather than the current Quality Data Model (QDM). CMS seeks feedback on several areas related to this aim.
If you have questions about your hospital reporting of eCQMs, Promoting Interoperability measures, or chart-abstracted measures, please contact us.