Medicare Program; Hospital Inpatient Value-Based Purchasing Program

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 422 and 480

[CMS-3239-F]

RIN 0938-AQ55

Medicare Program; Hospital Inpatient Value-Based Purchasing Program

AGENCY:

Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION:

Final rule.

SUMMARY:

This final rule implements a Hospital Inpatient Value-Based Purchasing program (Hospital VBP program or the program) under section 1886(o) of the Social Security Act (the Act), under which value-based incentive payments will be made in a fiscal year to hospitals that meet performance standards with respect to a performance period for the fiscal year involved. The program will apply to payments for discharges occurring on or after October 1, 2012, in accordance with section 1886(o) (as added by section 3001(a) of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act)). Scoring in the Hospital VBP program will be based on whether a hospital meets or exceeds the performance standards established with respect to the measures. By adopting this program, we will reward hospitals based on actual quality performance on measures, rather than simply reporting data for those measures.

DATES:

Effective Date:

These regulations are effective on July 1, 2011.

FOR FURTHER INFORMATION CONTACT:

Allison Lee, (410) 786-8691.

Table of Contents

I. Background

A. Overview

B. Hospital Inpatient Quality Data Reporting Under Section 501(b) of Public Law 108-173

C. Hospital Inpatient Quality Reporting Under Section 5001(a) of Public Law 109-171

D. 2007 Report to Congress: Plan To Implement a Medicare Hospital Value-Based Purchasing Program

E. Provisions of the Affordable Care Act

II. Provisions of the Final Rule and Response to Comments

A. Overview of the Proposed Rule

B. Overview of the Hospital Value-Based Purchasing Program

C. Performance Period

D. Measures

E. Performance Standards

F. Methodology for Calculating the Total Performance Score

G. Applicability of the Value-Based Purchasing Program to Hospitals

H. The Exchange Function

I. Hospital Notification and Review Procedures

J. Reconsideration and Appeal Procedures

K. FY 2013 Validation Requirements for Hospital Value-Based Purchasing

L. Additional Information

M. QIO Quality Data Access

III. Collection of Information Requirements

IV. Economic Analyses

A. Regulatory Impact Analysis

B. Regulatory Flexibility Act Analysis

C. Unfunded Mandates Reform Act Analysis

V. Federalism Analysis

Acronyms

Because of the many terms to which we refer by acronym in this final rule, we are listing the acronyms used and their corresponding meanings in alphabetical order below:

ACM Appropriate Care Model

AHRQ Agency for Healthcare Research and Quality

AMI Acute Myocardial Infarction

CCN CMS Certification number

CLABSI Central line-associated bloodstream infections

CMMI Center for Medicare and Medicaid Innovation

CMS Centers for Medicare & Medicaid Services

CV Coefficient of variation

DRA Deficit Reduction Act of 2005

DRG Diagnosis-Related Group

EHR Electronic Health Record

EKG Electrocardiogram

FISMA Federal Information Security and Management Act

HAC Hospital acquired conditions

HAI Healthcare-associated infections

HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems

HF Heart Failure

HIPAA Health Insurance Portability and Accountability Act

HOP QDRP Hospital Outpatient Quality Data Reporting Program

IPPS Inpatient prospective payment systems

IQI Inpatient Quality Indicator

IQR Inpatient Quality Reporting

MMA Medicare Prescription Drug, Improvement and Modernization Act of 2003

NQF National Quality Forum

PMA Patient-mix adjustment

PN Pneumonia

POA Present on Admission

PQRI Physician Quality Reporting Initiative

PRRB Provider Reimbursement Review Board

PSI Patient Safety Indicator

QIO Quality Improvement Organization

QRS Quality Review Study

RFA Regulatory Flexibility Act

RHQDAPU Reporting Hospital Quality Data for the Annual Payment Update Program

RIA Regulatory Impact Analysis

SCIP Surgical Care Improvement

SDPS Standard Data Processing System

SES Socioeconomic status

SSI Surgical site infections

VBP Value-Based Purchasing

I. Background

A. Overview

The Centers for Medicare & Medicaid Services (CMS) promotes higher quality and more efficient health care for Medicare beneficiaries. In recent years, we have undertaken a number of initiatives to lay the foundation for rewarding health care providers and suppliers for the quality of care they provide by tying a portion of their Medicare payments to their performance on quality measures. These initiatives, which include demonstration projects and quality reporting programs, have been applied to various health care settings, including physicians' offices, ambulatory care facilities, hospitals, nursing homes, home health agencies, and dialysis facilities. The overarching goal of these initiatives is to transform Medicare from a passive payer of claims to an active purchaser of quality health care for its beneficiaries.

This effort is supported by our adoption of an increasing number of widely-agreed upon quality measures for purposes of our existing quality reporting programs. We have worked with stakeholders to define measures of quality in almost every setting. These measures assess structural aspects of care, clinical processes, patient experiences with care, and, increasingly, outcomes.

We have implemented quality measure reporting programs that apply to various settings of care. With regard to hospital inpatient services, we implemented the Hospital IQR program. In addition, we have implemented quality reporting programs for hospital outpatient services through the Hospital Outpatient Quality Reporting program (HOQR), formerly known as the Hospital Outpatient Quality Data Reporting Program (HOP QDRP), and for physicians and other eligible professionals through the Physician Quality Reporting System (formerly referred to as the Physician Quality Reporting Initiative or PQRI). We have also implemented quality reporting programs for home health agencies and skilled nursing facilities based on conditions of participation, and an end-stage renal disease quality incentive program that links payment to performance.

This new program will necessarily be a fluid model, subject to change as knowledge, measures and tools evolve. We view the Hospital VBP program under section 1886(o) as the next step

in promoting higher quality care for Medicare beneficiaries and transforming Medicare into an active purchaser of quality health care for its beneficiaries.

In developing this rule as well as other value-based quality initiatives, CMS applied the following principles for the development and use of measures and scoring methodologies.

Purpose

CMS views value-based purchasing as an important step toward revamping how care and services are paid for, moving increasingly toward rewarding better value, outcomes, and innovations instead of merely volume.

Use of Measures

• Public reporting and value-based payment systems should rely on a mix of standards, process, outcomes, and patient experience measures, including measures of care transitions and changes in patient functional status. Across all programs, CMS seeks to move as quickly as possible to using primarily outcome and patient experience measures.

• To the extent possible and recognizing differences in payment system maturity and statutory authorities, measures should be aligned across Medicare's and Medicaid's public reporting and payment systems. CMS also seeks to develop a focused core-set of measures appropriate to each specific provider category that reflects the level of care and the most important areas of service furnished by that provider.

• The collection of information should minimize the burden on providers to the extent possible. As part of that effort, CMS will continuously seek to align its measures with the adoption of meaningful use standards for health information technology (HIT).

• To the extent practicable, measures used by CMS should be nationally endorsed by a multi-stakeholder organization. Measures should also be aligned with best practices among other payers and the needs of the end users of the measures.

Scoring Methodology

• Providers should be scored on their overall achievement relative to national or other appropriate benchmarks. In addition, scoring methodologies should consider improvement as an independent goal.

• Measures or measurement domains need not be given equal weight, but over time, scoring methodologies should be weighted more heavily towards outcome, patient experience, and functional status measures.

• Scoring methodologies should be reliable, as straightforward as possible, and stable over time and enable consumers, providers, and payers to make meaningful distinctions among providers' performance.

Comment:

A number of commenters expressed their general support for these principles. One commenter provided additional remarks on the principles and made a number of comments on the interactions between the principles, including risk adjustment, measure reliability, patient experience of care measures, and measure endorsement. For example, this commenter expressed agreement with our stated principle that public reporting and value-based payment systems should rely on a mix of standards, processes, outcome and payment experience measures. In supporting this principle, the commenter related that health and health care are complex, which requires a multifaceted accountability framework. This commenter also supported our statement that scoring methodologies should be reliable, as straightforward as possible, and stable over time. The commenter further remarked that VBP relies on the support of consumers in the marketplace to drive improvement, and that consumers must understand the measures and how they are used in order to make informed decisions.

Response:

We appreciate the comments and input on these principles, and will keep them in mind as we continue to enhance, develop and implement the Hospital VBP program, other quality reporting programs, and other value-based incentive programs.

Comment:

A number of commenters stated that CMS must ensure that value-based purchasing programs foster the development of innovative, quality care and provide an adequate level of reimbursement for innovative medical technologies. One commenter reiterated that value-based purchasing programs should not place the provision of lower cost services and products in conflict with what is best for the patient.

Response:

We agree that value-based purchasing programs should not hinder innovation and should result in improved patient care. We believe that the Hospital VBP program will drive improvements in the quality of care for Medicare beneficiaries, including the provision of innovative technologies, because of its financial incentives for providers to provide high-quality, patient-centered care coupled with high levels of patient satisfaction. We note that our measure development and selection activities take into account national priorities, including those established by the National Priorities Partnership and the Department of Health and Human Services, as well as other widely accepted criteria established in the medical literature. We will continue to seek to align all of our quality initiatives to promote high-quality care and continued innovation. We intend to monitor this program over time for unintended consequences.

Comment:

One commenter requested that CMS extend the 60-day comment period.

Response:

We decline to extend the comment period. Based on the volume and depth of comments we received in response to the Hospital Inpatient VBP proposed rule, we believe that commenters had ample opportunity to submit meaningful comments on our proposals and did so. Specifically, we received comments discussing a wide range of issues on nearly every aspect of that proposed rule, including its potential impact on the health care system, the provision of high-quality medical care and effects on patient satisfaction. We received comments from a wide range of stakeholders, including hospitals, health care providers, professional associations, trade groups, advocacy organizations, Medicare beneficiaries, private citizens, and others. We have had a sufficient opportunity to consider the issues raised by the commenters and have taken their comments into account in developing this final rule.

Comment:

One commenter stated that “the specific process for how the agency proposes to achieve `transparency' is not described or attained,” and that the proposed rule did not offer sufficient information and disclosure of the “methods and data the agency proposes to use” in developing the Hospital VBP program.

Response:

We disagree. We believe that we have been transparent in making public our goals for the Hospital VBP program and numerous documents that informed our rulemaking on this program, including the 2007 Report to Congress, Congressional testimony and public listening session transcripts. We also believe that the proposed rule contains detailed information regarding the data and analyses we considered in developing our proposals.

However, because we seek to ensure that the continued development of the Hospital VBP program take place in as transparent a manner as possible, we will make available additional information regarding our analyses, study results, and methods and will inform the public accordingly.

We have addressed specific issues relating to the use of measures, scoring

methodology, and other aspects of the Hospital VBP program below.

B. Hospital Inpatient Quality Data Reporting Under Section 501(b) of Public Law 108-173

Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Public Law 108-173, added section 1886(b)(3)(B)(vii) to the Act. This section established the original authority for the Hospital IQR program and revised the mechanism used to update the standardized amount for inpatient hospital operating costs. Specifically, section 1886(b)(3)(B)(vii)(I) of the Act provided for a reduction of 0.4 percentage points to the applicable percentage increase (sometimes referred to at that time as the market basket update) for FY 2005 through FY 2007 for a subsection (d) hospital if the hospital did not submit data on a set of 10 quality indicators established by the Secretary as of November 1, 2003. It also provided that any reduction applied only to the fiscal year involved, and would not be taken into account in computing the applicable percentage increase for a subsequent fiscal year. The statute thereby established an incentive for many subsection (d) hospitals to submit data on the quality measures established by the Secretary.

We implemented section 1886(b)(3)(B)(vii) of the Act in the FY 2005 IPPS final rule (69 FR 49078) and codified the applicable percentage increase change in § 412.64(d) of our regulations. We adopted additional requirements for the Hospital IQR program in the FY 2006 IPPS final rule (70 FR 47420).

C. Hospital Inpatient Quality Reporting Under Section 5001(a) of Public Law 109-171

1. Change in the Reduction to the Applicable Percentage Increase

Section 5001(a) of the Deficit Reduction Act of 2005 (DRA), Public Law 109-171, further amended section 1886(b)(3)(B) of the Act to, among other things, revise the mechanism used to update the standardized amount for hospital inpatient operating costs by adding a new section 1886(b)(3)(B)(viii) to the Act. Specifically, sections 1886(b)(3)(B)(viii)(I) and (II) of the Act, as added by the DRA, provided in part that the applicable percentage increase for FY 2007 and each subsequent fiscal year shall be reduced by 2.0 percentage points for a subsection (d) hospital that does not submit quality data in a form and manner and at a time specified by the Secretary. Section 1886(b)(3)(B)(viii)(I) of the Act also provided that any reduction in a hospital's applicable percentage increase will apply only with respect to the fiscal year involved, and will not be taken into account for computing the applicable percentage increase for a subsequent fiscal year.

In the FY 2007 IPPS final rule (71 FR 48045), we amended our regulations at § 412.64(d)(2) to reflect the 2.0 percentage point reduction required under the DRA.

2. Selection of Quality Measures

Section 1886(b)(3)(B)(viii)(V) of the Act, before it was amended by section 3001(a)(2)(B) of the Affordable Care Act, required that, effective for payments beginning FY 2008, the Secretary add other measures that reflect consensus among affected parties, and to the extent feasible and practicable, have been set forth by one or more national consensus building entities. The National Quality Forum (NQF) is a voluntary consensus standard-setting organization with a diverse representation of consumer, purchaser, provider, academic, clinical, and other health care stakeholder organizations. The NQF was established to standardize health care quality measurement and reporting through its consensus development process. We have generally adopted NQF-endorsed measures for purposes of the Hospital IQR program. However, we believe that consensus among affected parties also can be reflected by other means, including consensus achieved during the measure development process, consensus shown through broad acceptance and use of measures, and consensus achieved through public comment.

Section 1886(b)(3)(B)(viii)(VI) of the Act authorizes the Secretary to replace any quality measures or indicators in appropriate cases, such as when all hospitals are effectively in compliance with a measure, or the measures or indicators have been subsequently shown to not represent the best clinical practice. We interpreted this provision to give us broad discretion to replace measures that are no longer appropriate for the Hospital IQR program.

We adopted 45 measures under the Hospital IQR program for the FY 2011 payment determination. Of these measures, 27 are chart-abstracted process of care measures, which assess the quality of care furnished by hospitals in connection with four topics: Acute Myocardial Infarction (AMI); Heart Failure (HF); Pneumonia (PN); and Surgical Care Improvement (SCIP) (75 FR 50182). Fifteen of the measures are claims-based measures, which assess the quality of care furnished by hospitals on the following topics: 30-day mortality and 30-day readmission rates for Medicare patients diagnosed with AMI, HF, or PN; Patient Safety Indicators/Inpatient Quality Indicators/Composite Measures; and Patient Safety Indicators/Nursing Sensitive Care. Three of the measures are structural measures that assess hospital participation in cardiac surgery, stroke care, and nursing sensitive care systemic databases. Finally, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience of care survey is included as a measure for the FY 2011 payment determination.

The technical specifications for the Hospital IQR program measures, or links to Web sites hosting technical specifications, are contained in the CMS/The Joint Commission Specifications Manual for National Hospital Inpatient Quality Measures (Specifications Manual). This Specifications Manual is posted on the CMS QualityNet Web site at

https://www.QualityNet.org/.

We maintain the technical specifications by updating this Specifications Manual semiannually, or more frequently in unusual cases, and include detailed instructions and calculation algorithms for hospitals to use when collecting and submitting data on required measures. These semiannual updates are accompanied by notifications to users, providing sufficient time before the effective date of the change in order to allow users to incorporate changes and updates to the specifications into data collection systems.

3. Public Display of Quality Measures

Section 1886(b)(3)(B)(viii)(VII) of the Act, as amended by section 3001(a)(2)(C) of the Affordable Care Act, requires that the Secretary establish procedures for making information regarding measures submitted under the Hospital IQR program available to the public after ensuring a hospital has the opportunity to review its data. To meet this requirement, we display most Hospital IQR program data on the

Hospital Compare

Web site,

http://www.hospitalcompare.hhs.gov,

after a 30-day preview period. An interactive Web tool, this Web site assists beneficiaries by providing information on hospital quality of care to those who need to select a hospital. It further serves to encourage beneficiaries to work with their doctors and hospitals to discuss the quality of care hospitals provide to patients, thereby providing an additional incentive to hospitals to improve the quality of care that they

furnish. The

Hospital Compare

Web site currently makes public information on a wide range of measures, including clinical process of care measures, risk adjusted outcome measures, the HCAHPS patient experience of care survey, and structural measures. However, data that we believe is not suitable for inclusion on

Hospital Compare

because it is not salient or will not be fully understood by beneficiaries, as well as data for which there are unresolved display or design issues, may be made available on other CMS Web sites that are not intended to be used as an interactive Web tool, such as

http://www.cms.hhs.gov/HospitalQualityInits/.

In such circumstances, affected parties are notified via CMS listservs, CMS e-mail blasts, national provider calls, and QualityNet announcements regarding the release of preview reports followed by the posting of data on a Web site other than

Hospital Compare.

D. 2007 Report to Congress: Plan To Implement a Medicare Hospital Value-Based Purchasing Program

Section 5001(b) of the DRA required the Secretary to develop a plan to implement a value-based purchasing program for subsection (d) hospitals. In developing the plan, we were required to consider the on-going development, selection, and modification process for measures of quality and efficiency in hospital inpatient settings; the reporting, collection, and validation of quality data; the structure, size, and sources of funding of value-based payment adjustments; and the disclosure of information on hospital performance.

On November 21, 2007, we submitted the Report to Congress: Plan to Implement a Medicare Hospital Value-Based Purchasing Program, which is available on the CMS Web site. The report discusses options for a plan to implement a Medicare hospital value-based purchasing program that builds on the Hospital IQR program. We recommended replacing the Hospital IQR program with a new program that would include both a public reporting requirement and financial incentives for better performance. We also recommended that a hospital value-based purchasing program be implemented in a manner that would not increase Medicare spending.

To calculate a hospital's total performance score under the plan, we analyzed a potential performance scoring model that incorporated measures from different quality “domains,” including clinical process of care and patient experience of care. We examined ways to translate that score into an incentive payment by making a portion of the base DRG payment contingent on performance. We analyzed criteria for selecting performance measures and considered a potential phased approach to transition from Hospital IQR to value-based purchasing. In addition, we examined redesigning the current data transmission process and validation infrastructure, including making enhancements to the

Hospital Compare

Web site, as well as an approach to monitor the impact of value-based purchasing.

E. Provisions of the Affordable Care Act

Section 3001(a) of the Affordable Care Act added a new section 1886(o) to the Act, which requires the Secretary to establish a hospital value-based purchasing program under which value-based incentive payments are made in a fiscal year to hospitals meeting performance standards established for a performance period for such fiscal year. Both the performance standards and the performance period for a fiscal year are to be established by the Secretary. Section 1886(o)(1)(B) of the Act directs the Secretary to begin making value-based incentive payments under the Hospital VBP program to hospitals for discharges occurring on or after October 1, 2012. These incentive payments will be funded for FY 2013 through a reduction to FY 2013 base operating DRG payments for each discharge of 1.0 percent, as required by section 1886(o)(7). Section 1886(o)(1)(C) provides that the Hospital VBP program applies to subsection (d) hospitals (as defined in section 1886(d)(1)(B)), but excludes from the definition of the term “hospital,” with respect to a fiscal year: (1) A hospital that is subject to the payment reduction under section 1886(b)(3)(B)(viii)(I) for such fiscal year; (2) a hospital for which, during the performance period for the fiscal year, the Secretary cited deficiencies that pose immediate jeopardy to the health and safety of patients; and (3) a hospital for which there is not a minimum number (as determined by the Secretary) of applicable measures for the performance period for the fiscal year involved, or for which there is not a minimum number (as determined by the Secretary) of cases for the applicable measures for the performance period for such fiscal year.

II. Provisions of the Final Rule and Response to Comments

A. Overview of the January 7, 2011 Hospital Inpatient VBP Program Proposed Rule

On January 7, 2011, we issued a proposed rule that proposes to implement a Hospital VBP program under section 1886(o) of the Act (76 FR 2454, January 13, 2011). Specifically, we proposed to initially adopt for the FY 2013 Hospital VBP program 18 measures that we have already adopted for the Hospital IQR program, categorized into two domains, as follows: 17 of the measures would be clinical process of care measures, which we would group into a clinical process of care domain, and 1 measure would be the HCAHPS survey, which would fall under a patient experience of care domain. With respect to the clinical process of care and HCAHPS measures, we proposed to use a three-quarter performance period from July 1, 2011 through March 31, 2012 for the FY 2013 Hospital VBP payment determination. We proposed to determine whether hospitals meet the performance standards for the selected measures by comparing their performance during the performance period to their performance during a three-quarter baseline period of July 1, 2009 through March 31, 2010. We also proposed to initially adopt for the FY 2014 Hospital VBP program three outcome measures. With respect to the outcome measures, we proposed to use an 18-month performance period from July 1, 2011 to December 31, 2012. Furthermore, for these outcome measures, we proposed to establish performance standards and to determine whether hospitals meet those standards by comparing their performance during the performance period to their performance during a baseline period of July 1, 2008 to December 31, 2009.

We also proposed to adopt 8 Hospital Acquired Condition measures and 9 AHRQ Patient Safety Indicator and Inpatient Quality Indicator outcome measures. We further proposed to begin the performance period for each of these proposed measures 1 year after we included the measure on the

Hospital Compare

Web site.

In general, we proposed to implement a methodology for assessing the total performance of each hospital based on performance standards, under which we would score each hospital based on achievement and improvement ranges for each applicable measure. Additionally, we proposed to calculate a total performance score for each hospital by combining the greater of the

hospital's achievement or improvement points for each measure to determine a score for each domain, multiplying each domain score by a proposed weight (clinical process of care: 70 percent, patient experience of care: 30 percent), and adding together the weighted domain scores. We proposed to convert each hospital's Total Performance Score into a value-based incentive payment utilizing a linear exchange function.

We provided a 60-day public comment period in which we received approximately 319 timely comments from hospitals, health care facilities, advocacy organizations, researchers, patients, and other individuals and organizations. Summaries of the public comments, as well as our responses to those comments, are set forth below.

Comment:

A number of commenters requested clarification on the interaction between the Hospital IQR program and the Hospital VBP program. Commenters specifically requested that we explain more fully how the penalties under the two programs will interact, as well as clarify if we intend to continue the Hospital IQR program in the future.

Response:

The Affordable Care Act did not repeal section 1886(b)(3)(B)(viii), the statutory authority for the Hospital IQR program, and that program will continue to exist side-by-side with the Hospital VBP program. However, we note that beginning in FY 2015, the reduction to the applicable percentage increase under the Hospital IQR program changes from a straight 2.0 percentage point reduction to a reduction equal to “one quarter of such applicable percentage increase” (determined without regard to several other applicable statutory reductions).

We also note that under section 1886(o)(1)(C)(I), hospitals that are subject to the Hospital IQR program payment reduction for a fiscal year are excluded from the definition of “hospital” for purposes of the Hospital VBP program for that fiscal year. We interpret this provision to mean that a hospital that does not meet the requirements of the Hospital IQR program with respect to a fiscal year and, as a result, will receive a reduction to the applicable percentage increase for that fiscal year, will not be subject to the reduction to its base operating DRG payment amount under the Hospital VBP program for that fiscal year or be eligible to receive a value-based incentive payment for that fiscal year.

Comment:

Some commenters requested that CMS delay implementation of the Hospital VBP program. A number of commenters urged CMS to adopt the implementation calendar discussed in 2007 Report to Congress, in which the first performance period would begin April 1, 2013.

Response:

We are statutorily required to begin making value-based incentive payments under the Hospital VBP program to hospitals for discharges occurring on or after October 1, 2012 under section 1886(o)(1)(B) of the Act. Thus, the first performance period must begin before April 1, 2013, which is the time suggested by the commenters. As we stated in the proposed rule, in determining what performance period to propose to adopt, we were cognizant that hospitals submit data on the chart abstracted measures adopted for the Hospital IQR Program on a quarterly basis, and for that reason, we believed that the performance period should commence at the beginning of a quarter. We also recognized that we needed to balance the length of the performance period for collecting measure data with the need to undertake the rulemaking process in order to establish the performance period and provide the public with an opportunity to meaningfully comment on that proposal. With these considerations in mind, we proposed July 1, 2011 as the start of the performance period.

Comment:

Some commenters requested additional information on how we will educate consumers about the Hospital VBP program.

Response:

We understand how crucial it is to communicate clearly and consistently with all stakeholders in order to provide accurate and timely information about the Hospital VBP program. We believe that communicating in a way that promotes transparency and understanding of the Hospital VBP program will help reduce confusion and misunderstanding while enhancing the program's success.

To this end, we will be undertaking an extensive outreach and education campaign to ensure that all stakeholders understand how the Hospital VBP program works. In addition to providing information on www.cms.gov and www.medicare.gov, as well as through other existing mechanisms that we use to communicate with the public such as newsletters, e-mail blasts, listserv communications, special forums, and webinars, an important element of this campaign will be a new Hospital VBP page on

http://www.cms.gov.

In addition, as required under sections 1886(o)(10)(A) and (B), hospital specific and aggregate information for the Hospital VBP program will be made available on the Hospital Compare Web site.

Comment:

One commenter stated that the Hospital VBP program statutory authority overlaps with other provisions of the Affordable Care Act and asked CMS to address the various incentives created by the Affordable Care Act, how it intends to differentiate among separate policies, and how it will ensure that incentives will not overlap or be duplicative. The commenter specifically cited efforts to increase productivity and efficiency through Accountable Care Organizations, market basket reductions for productivity, penalties related to hospital-acquired conditions, and payment reductions for readmissions.

Response:

While there may be specific areas of overlap addressed by the various statutory provisions and policies, the legislative requirements, programs, and policies cited by the commenter represent interrelated but distinct areas of efforts to improve quality in the Medicare program. We will continue to monitor the interactions between the policies cited by the commenter and will continue discussions with stakeholders on this topic.

Comment:

One commenter stated that all purchaser/payer value-based strategies and programs should be supported and encouraged through the Center for Medicare and Medicaid Innovation (CMMI).

Response:

Created by the Affordable Care Act and launched on November 16, 2010, the CMMI will examine new ways of delivering health care and paying health care providers that can save money for Medicare and Medicaid while improving the quality of care. CMMI will consult a diverse group of stakeholders including hospitals, doctors, consumers, payers, States, employers, advocates, relevant federal agencies and others to obtain direct input and build partnerships for its upcoming work. We agree that CMMI is an important contributor in developing innovative strategies for value-based purchasing programs, and look forward to continuing to leverage the Center's resources and expertise in future years of the Hospital VBP program.

Comment:

One commenter suggested that we establish a “Pay to Share” pool under which funding would be provided to enable higher-rated hospitals to instruct lower-rated hospitals on best practices.

Response:

While we appreciate the comment, we do not believe we have the statutory authority under the Act to implement such a program at this time.

C. Performance Period

Section 1886(o)(4) of the Act requires the Secretary to establish a performance period for a fiscal year that begins and ends prior to the beginning of such

fiscal year. In considering various performance periods that could apply for purposes of the fiscal year 2013 payment adjustments, we recognized that hospitals submit data on the chart-abstracted measures adopted for the Hospital IQR program on a quarterly basis, and for that reason, we proposed that the performance period commence at the beginning of a quarter. We also recognized that we must balance the length of the period for collecting measure data with the need to undertake the rulemaking process in order to propose a performance period and provide the public with an opportunity to meaningfully comment on that proposal. With these considerations in mind, we concluded that July 1, 2011 is the earliest date that the performance period could begin.

Therefore, we proposed to use the fourth quarter of FY 2011 (July 1, 2011 through September 30, 2011) and the first and second quarters of FY 2012 (October 1, 2011 through March 31, 2012) as the performance period for the clinical process of care and HCAHPS measures we proposed to initially adopt for the FY 2013 Hospital VBP program. Under the proposed approach, hospitals would be scored based on how well they perform on the clinical process of care and patient experience measures during this performance period. For the three mortality outcome measures currently specified for the Hospital IQR program for the FY 2011 payment determination (MORT-30-AMI, MORT-30-HF, MORT-30-PN) that we proposed to adopt for the FY 2014 Hospital VBP program payment determination, we proposed to establish a performance period of July 1, 2011 to December 31, 2012. We also proposed to begin the performance period for the 8 proposed HAC measures and 9 proposed AHRQ Patient Safety Indicator (PSI) and Inpatient Quality Indicator (IQI) outcome measures 1 year after those measures were included on the

Hospital Compare

Web site. The proposed HAC and AHRQ measures were included on

Hospital Compare

on March 3, 2011.

Comment:

A number of commenters requested that we adopt a 12-month performance period for the proposed mortality measures rather than the proposed 18-month performance period. Some were concerned that seasonal fluctuations in mortality rates would impact the measure rates if an 18-month performance period were used instead of a 12-month period.

Response:

We proposed to use an 18-month performance period (July 1, 2011 through December 31, 2012) for the three proposed mortality measures in order to be able to increase the reliability of the measure rates by including more cases. However, in response to the commenters' concern about how the use of a period that is not equal to a year (or multiple years) could introduce seasonal fluctuations into the measure rates, we conducted additional reliability analyses on the hospital-level risk standardized mortality rates for the proposed 30-day mortality measures using 12 months, 18 months, and 24 months, and have concluded that 12 months of data provides moderate to high reliability for the Heart Failure and Pneumonia 30-day mortality measures, and is sufficiently reliable for the AMI 30-day mortality measure. Therefore, we are finalizing a 12-month performance period of July 1, 2011 to June 30, 2012 for the three proposed 30-day mortality measures for the FY 2014 Hospital VBP payment determination.

Comment:

Some commenters expressed concern about the proposed baseline period for the FY 2014 mortality outcome measures. Commenters noted that the proposed 18-month baseline period would lead to data overlap during each program year.

Response:

For the reasons noted above, we are finalizing a 12-month performance period of July 1, 2011 to June 30, 2012 for the three proposed 30-day mortality measures for the FY 2014 Hospital VBP payment determination. In accordance with our proposal that hospital performance should be evaluated based on how well hospitals performed during the same quarters in a baseline period, we are finalizing a 12-month baseline period for the mortality outcomes measures' performance standards calculations from July 1, 2009 to June 30, 2010. We believe that this change will address commenters' concerns about seasonal fluctuations in the data or overlap between program years.

Comment:

Some comments requested that we require 2-3 years' worth of data for outcome measures to ensure that the measures do not result in any unintended consequences.

Response:

As noted above, our reliability analyses for the proposed 30-day mortality measures indicate that using 12-months of data yields sufficient reliability (moderate to high) for the HF, PN and AMI 30-day mortality measures. We believe this time frame will enable us to calculate the measures using reliable data. CMS will monitor this policy to ensure that negative consequences do not occur as a result of the shortened performance period and, if indicated, would consider proposing to lengthen the performance period for future program years.

Comment:

Many commenters generally supported our performance period proposals given the statutory deadlines.

Response:

We thank commenters for their support.

Comment:

Some commenters suggested that we use 12-month performance periods for all measures as soon as possible.

Response:

We anticipate proposing to use a full year as the performance period for all measures in the future.

After considering the public comments, we are finalizing a performance period of July 1, 2011 through March 31, 2012 that will apply to the clinical process of care and patient experience measures for the FY 2013 Hospital VBP program. With respect to the FY 2014 Hospital VBP program, we are finalizing a 12-month performance period of July 1, 2011 through June 30, 2012 that will apply to the three 30-day mortality measures (AMI, HF, PN) that we are finalizing below. We are also finalizing our proposal to adopt a performance period that begins 1 year after any HAC and/or AHRQ measures that are specified for the Hospital IQR program are included on Hospital Compare, and in accordance with that finalized policy, the performance period for the 8 finalized HAC measures and 2 finalized AHRQ measures (discussed below) will begin on March 3, 2012. We intend to propose the end performance period date for the 8 finalized HAC measures and 2 finalized AHRQ measures in the CY 2012 Outpatient Prospective Payment System proposed rule.

D. Measures

Section 1886(o)(2)(A) of the Act requires the Secretary to select for the Hospital VBP program measures, other than readmission measures, from the measures specified for the Hospital IQR program. Section 1886(o)(2)(B)(i) of the Act requires the Secretary to ensure that the selected measures for FY 2013 include measures on the following specified conditions or topics: AMI; HF; PN; surgeries, as measured by the Surgical Care Improvement Project (SCIP); HAIs; and the HCAHPS survey. Section 1886(o)(2)(C)(i) of the Act provides that the Secretary may not select a measure with respect to a performance period for a fiscal year unless the measure has been specified under section 1886(b)(3)(B)(viii) of the Act and included on the

Hospital Compare

Web site for at least 1 year prior to the beginning of the performance period. Section 1886(o)(2)(C)(ii) of the Act provides that a measure selected under section

1886(o)(2)(A) of the Act shall not apply to a hospital if the hospital does not furnish services appropriate to the measure.

In the FY 2011 IPPS/RY 2011 LTCHPPS Final Rule (75 FR 50188), we stated that in future expansions and updates to the Hospital IQR program measure set, we will be taking into consideration several important goals. These goals include: (1) Expanding the types of measures beyond process of care measures to include an increased number of outcome measures, efficiency measures, and patients' experience of care measures; (2) expanding the scope of hospital services to which the measures apply; (3) considering the burden on hospitals in collecting chart-abstracted data; (4) harmonizing the measures used in the Hospital IQR program with other CMS quality programs to align incentives and promote coordinated efforts to improve quality; (5) seeking to use measures based on alternative sources of data that do not require chart abstraction or that utilize data already being reported by many hospitals, such as data that hospitals report to clinical data registries, or all payer claims databases; and (6) weighing the relevance and utility of the measures compared to the burden on hospitals in submitting data under the Hospital IQR program.

In addition, we stated in the proposed rule our belief that we must act with all speed and deliberateness to expand the pool of measures used in the Hospital VBP program. This goal is supported by at least two Federal reports documenting that tens of thousands of patients do not receive safe care in the nation's hospitals. For this reason, we proposed to adopt measures for the Hospital VBP program relevant to improving care, particularly as these measures are directed toward improving patient safety, as quickly as possible. We believe that speed of implementation is a critical factor in the success and effectiveness of this program.

The Hospital VBP program that we proposed to implement has been developed with the focused intention to motivate all subsection (d) hospitals to which the program applies to take immediate action to improve the quality of care they furnish to their patients. Because we view as urgent the necessity to improve the quality of care furnished by these hospitals, and because we believe that hospitalized patients in the United States currently face patient safety risks on a daily basis, we proposed to adopt an initial measure set for the Hospital VBP program. However, we also proposed to add additional measures to the Hospital VBP program in the future in such a way that their performance period would begin immediately after they are displayed on Hospital Compare for a period of time of at least one year, but without the necessity of notice and comment rulemaking. We proposed this because of the urgency to improve the quality of hospital care, and in order to minimize any delay to take substantive action in favor of patient safety.

We stated that for the Hospital IQR Program, we give priority to quality measures that assess performance on: (a) Conditions that result in the greatest mortality and morbidity in the Medicare population; (b) conditions that are high volume and high cost for the Medicare program; and (c) conditions for which wide cost and treatment variations have been reported, despite established clinical guidelines. In addition, we stated that we seek to select measures that address the six quality aims of effective, safe, timely, efficient, patient centered, and equitable healthcare. Current and long term priority topics include: Prevention and population health; safety; chronic conditions; high cost and high volume conditions; elimination of health disparities; healthcare-associated infections and other adverse healthcare outcomes; improved care coordination; improved efficiency; improved patient and family experience of care; effective management of acute and chronic episodes of care; reduced unwarranted geographic variation in quality and efficiency; and adoption and use of interoperable health information technology.

We also stated that these criteria, priorities, and goals are consistent with section 1886(b)(3)(B)(viii)(X) of the Act, as added by section 3001(a)(2)(D) of the Affordable Care Act, which requires the Secretary, to the extent practicable and with input from consensus organizations and other stakeholders, to take steps to ensure that the Hospital IQR program measures are coordinated and aligned with quality measures applicable to physicians and other providers of services and suppliers under Medicare.

As discussed in the Hospital Inpatient VBP Program proposed rule (76 FR 2459), to determine which measures to propose to initially adopt for the FY 2013 Hospital VBP program, we examined whether any of the eligible Hospital IQR measures should be excluded from the Hospital VBP program measure set because hospital performance on them is “topped out,” meaning that all but a few hospitals have achieved a similarly high level of performance on them. We stated our belief that measuring hospital performance on topped-out measures would have no meaningful effect on a hospital's total performance score.

We also stated that scoring a topped-out measure for purposes of the Hospital VBP program would present a number of challenges. First, as discussed below, we proposed that the benchmark performance standard for all measures would be performance at the mean of the top decile of hospital performance during the baseline period. We noted in the Hospital Inpatient VBP Program proposed rule that, when applied to a topped-out measure, this proposed benchmark would be statistically indistinguishable from the highest attainable score for the measure and, in our view, could lead to unintended consequences as hospitals strive to meet the benchmark. Examples of unintended consequences could include, but would not be limited to, inappropriate delivery of a service to some patients (such as delivery of antibiotics to patients without a confirmed diagnosis of pneumonia), unduly conservative decisions on whether to exclude some patients from the measure denominator, and a focus on meeting the benchmark at the expense of actual improvements in quality or patient outcomes. Second, we stated that we have found that for topped-out measures, it is significantly more difficult to differentiate among hospitals performing above the median. Third, because a measure cannot be applied to a hospital unless the hospital furnishes services appropriate to the measure, we stated our belief that data reporting under the Hospital VBP program would not be the same for all hospitals. To the extent that a hospital could report a higher proportion of topped-out measures, for which its scores would likely be high, we stated that we believed such a hospital would be unfairly advantaged in the determination of its Total Performance Score.

To determine whether an eligible Hospital IQR measure is topped out, we initially focused on the top distribution of hospital performance on each measure and noted if their 75th and 90th percentiles were statistically indistinguishable. Based on our analysis, we identified 7 topped-out measures: AMI-1 Aspirin at Arrival; AMI-5 Beta Blocker at Discharge; AMI-3 ACEI or ARB at Discharge; AMI-4 Smoking Cessation; HF-4 Smoking Cessation; PN-4 Smoking Cessation; and SCIP-Inf-6 Surgery Patients with Appropriate Hair Removal. We then observed that two of these measures identified as topped out (AMI-3 ACEI or

ARB at Discharge and HF-4 Smoking Cessation) had significantly lower mean scores than the others, which led us to question whether our analysis was too focused on the top ends of distributions and whether additional criteria that could account for the entire distribution might be more appropriate. To address this, we analyzed the truncated coefficient of variation (CV) for each of the measures. The CV is a common statistic that expresses the standard deviation as a percentage of the sample mean in a way that is independent of the units of observation. Applied to this analysis, a large CV would indicate a broad distribution of individual hospital scores, with large and presumably meaningful differences between hospitals in relative performance. A small CV would indicate that the distribution of individual hospital scores is clustered tightly around the mean value, suggesting that it is not useful to draw distinctions between individual hospital performance scores. We used a modified version of the CV, namely a truncated CV, for each measure, in which the 5 percent of hospitals with the lowest scores, and the 5 percent of hospitals with highest scores were first truncated (set aside) before calculating the CV. This was done to avoid undue effects of the highest and lowest outlier hospitals, which if included, would tend to greatly widen the dispersion of the distribution and make the measure appear to be more reliable or discerning. For example, a measure for which most hospital scores are tightly clustered around the mean value (a small CV) might actually reflect a more robust dispersion if there were also a number of hospitals with extreme outlier values, which would greatly increase the perceived variance in the measure. Accordingly, the truncated CV was added as an additional criterion requiring that a topped-out measure also exhibit a truncated CV < 0.10. Using both the truncated CV and data showing whether hospital performance at the 75th and 90th percentiles was statistically indistinguishable, we reexamined the available measures and determined that the same seven measures continue to meet our proposed definition for being topped-out.

Our analysis of the impact of including the topped-out measures discussed above indicated that their use would mask true performance differences among hospitals and, as a result, would fail to advance our priorities for the Hospital VBP program. We therefore proposed to not include these 7 topped-out measures (AMI-1 Aspirin at Arrival; AMI-5 Beta Blocker at Discharge; AMI-3 ACEI or ARB at Discharge; AMI-4 Smoking Cessation; HF-4 Smoking Cessation; PN-4 Smoking Cessation; and SCIP-Inf-6 Surgery Patients with Appropriate Hair Removal) in the list of measures we proposed to initially adopt for the FY 2013 Hospital VBP program. We sought comment on that proposal.

We also examined and sought comment on whether the following outcome measures adopted for the Hospital IQR program were appropriate for inclusion in the FY 2013 Hospital VBP program. These measures are as follows: (1) AHRQ PSIs, IQIs and composite measures; (2) AHRQ PSI and nursing sensitive care measure; and (3) AMI, HF, and PN mortality measures (Medicare patients). We stated our belief that these outcome measures provide important information relating to treatment outcomes and patient safety. We also stated in the proposed rule that we believe that adding these outcome measures would significantly improve the correlation between patient outcomes and Hospital VBP performance. However, because under section 1886(o)(2)(C)(i) of the Act, we may only select measures if they have been included on Hospital Compare for a least 1 year prior to the beginning of the performance period, we stated that the AHRQ PSIs, IQIs and composite measures, and the AHRQ Nursing Sensitive Care measure were not yet eligible for inclusion in the FY 2013 Hospital VBP program. Although these measures are currently specified for the Hospital IQR program, we acknowledged that as of the time we issued the proposed rule, they did not meet the one year Hospital Compare inclusion requirement.

We also considered whether the current publicly-reported 30-day mortality claims-based measures (Mort-30-AMI, Mort-30-HF, Mort-30-PN) should be included in the FY 2013 Hospital VBP program. The mortality measures assess hospital-specific, risk-standardized, all-cause 30-day mortality rates for patients hospitalized with a principal diagnosis of heart attack, heart failure, and pneumonia. All-cause mortality is defined for purposes of these measures as death from any cause within 30 days after the index admission date, regardless of whether the patient died while still in the hospital or after discharge. The eligible clinical process of care measures we considered covered AMI, HF, PN, and surgeries as measured by the SCIP. Therefore, we believe that they meet the requirements of section 1886(o)(2)(B)(i)(I)(aa)-(dd) of the Act, which requires us to include measures covering these conditions or procedures. Section 1886(o)(2)(B)(i)(ee) of the Act also requires the Secretary to select for purposes of the FY 2013 Hospital VBP program measures that cover HAIs “as measured by the prevention metrics and targets established in the HHS Action Plan to Prevent Healthcare-Associated Infections (or any successor plan) of the Department of Health and Human Services.” The SCIP measures discussed above were developed to support practices that have demonstrated an ability to significantly reduce surgical complications such as HAIs. Compliance with the selected SCIP infection measures is also included as a targeted metric in the HHS

Action Plan to Prevent Healthcare-Associated Infections

issued in 2009, available on the HHS Web site. As a result, we believe that the SCIP-Inf-1; SCIP-Inf-2; SCIP-Inf-3; and SCIP-Inf-4 measures we have adopted for the Hospital IQR program meet the requirement in section 1886(o)(2)(B)(i)(I)(ee); we proposed to adopt them for the FY 2013 Hospital VBP program and to categorize them under the HAI condition topic instead of under the SCIP condition topic.

Under section 1886(o)(2)(B)(i)(II), the Secretary must select measures for the FY 2013 Hospital VBP program related to the HCAHPS survey. CMS partnered with AHRQ to develop HCAHPS. The HCAHPS survey is the first national, standardized, publicly reported survey of patients' experience of hospital care, and we proposed to adopt it for the FY 2013 Hospital VBP program. HCAHPS, also known as the CAHPS® Hospital Survey, is a survey instrument and data collection methodology for measuring patients' perceptions of their hospital experience.

The HCAHPS survey asks discharged patients 27 questions about their recent hospital stay that are used to measure the experience of patients across 10 dimensions in the Hospital IQR program. The survey contains 18 core questions about critical aspects of patients' hospital experiences (communication with nurses and doctors, the responsiveness of hospital staff, the cleanliness and quietness of the hospital environment, pain management, communication about medicines, discharge information, overall rating of the hospital, and whether they would recommend the hospital). The survey also includes four items to direct patients to relevant questions if a patient did not have a particular experience covered by the survey, such as taking new medications or needing medicine for pain. Three

items in the survey are used to adjust for the mix of patients across hospitals, and two items related to race and ethnicity support congressionally-mandated reports on disparities in health care.

The HCAHPS survey is administered to a random sample of adult patients across medical conditions between 48 hours and 6 weeks after discharge; the survey is not restricted to Medicare beneficiaries. Hospitals must survey patients throughout each month of the year. The survey is available in official English, Spanish, Chinese, Russian and Vietnamese versions. The survey and its protocols for sampling, data collection and coding, and file submission can be found in the HCAHPS

Quality Assurance Guidelines, Version 5.0,

which is available on the official HCAHPS Web site,

http://www.hcahpsonline.org.

AHRQ carried out a rigorous, scientific process to develop and test the HCAHPS instrument. This process entailed multiple steps, including: A public call for measures; literature review; cognitive interviews; consumer focus groups; stakeholder input; a three-state pilot test; small-scale field tests; and soliciting public comments via several

Federal Register

notices. In May 2005, the HCAHPS survey was endorsed by the NQF, and in December 2005, the Federal Office of Management and Budget gave its final approval for the national implementation of HCAHPS for public reporting purposes. CMS adopted the entire HCAHPS survey as a measure in the Hospital IQR program in October 2006, and the first public reporting of HCAHPS results occurred in March 2008. The survey, its methodology, and the results it produces are in the public domain.

As previously discussed, in determining what clinical process of care measures to propose, we analyzed the impact of including topped-out measures and determined that their use would mask true performance differences among hospitals, thus failing to advance our quality priorities. As a result, we proposed to exclude 7 topped-out measures (AMI-1 Aspirin at Arrival; AMI-5 Beta Blocker at Discharge; AMI-3 ACEI or ARB at Discharge; AMI-4 Smoking Cessation; HF-4 Smoking Cessation; PN-4 Smoking Cessation; and SCIP-Inf-6 Surgery Patients with Appropriate Hair Removal) from the list of measures we proposed to initially adopt for the FY 2013 Hospital VBP program.

We did not propose to adopt the current Hospital IQR structural measures because we believe that these measures require further development if they are to be used for the Hospital VBP program. Therefore, we solicited public comment on the possible utility of adopting structural measures for the Hospital VBP program measure set and how these measures might contribute to the improvement of patient safety and quality of care.

Finally, we proposed to exclude the PN-5c measure from the Hospital VBP program. We do not believe that this measure is appropriate for inclusion because it could lead to inappropriate antibiotic use. We proposed retiring this measure, as well as several other measures that we will not adopt for the Hospital VBP program, from the Hospital IQR program in the FY 2012 IPPS/LTCH PPS proposed rule scheduled for publication on May 5, 2011.

We proposed to initially select 17 clinical process of care measures and the HCAHPS measure for inclusion in the FY 2013 Hospital VBP program. The proposed list of initial measures is provided in Table 1.

Table 1—Proposed Measures for FY 2013 Hospital VBP Program

Measure ID

Measure description

Clinical Process of Care Measures

Acute myocardial infarction

AMI-2

Aspirin Prescribed at Discharge.

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.

HF-2

Evaluation of LVS Function.

HF-3

ACEI or ARB for LVSD.

Pneumonia

PN-2

Pneumococcal Vaccination.

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.

PN-7

Influenza Vaccination.

Healthcare-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 6AM Postoperative Serum Glucose.

Surgeries

SCIP-Card-2

Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker 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

HCAHPS

Hospital Consumer Assessment of Healthcare Providers and Systems Survey.

1

In the

Hospital Inpatient VBP Program proposed rule, we solicited public comments on our intention to add measures to the Hospital VBP Program as rapidly as possible for their availability in future performance periods. To that end, we proposed to implement a subregulatory process to expedite the timeline for adding measures to the Hospital VBP program beginning with the FY 2013 program. Under this proposed process, we could add any measure to the Hospital VBP program if that measure is adopted under the Hospital IQR program and has been included on Hospital Compare for at least 1 year. We proposed that the performance period for all of these measures would start exactly 1 year after the date these measures were publicly posted on Hospital Compare, consistent with section 1886(o)(2)(C)(i). Under this proposed subregulatory process for adopting new Hospital VBP program measures, we would solicit comments from the public on the appropriateness of adopting 1 or more Hospital IQR measures for the Hospital VBP program. We would also assess the reported Hospital IQR measure rates using the criteria we used to select the measures for the initial FY 2013 Hospital VBP measure set and would notify the public regarding our findings. We stated that we would propose to set performance period end dates for any measure we selected for future Hospital VBP program years in rulemaking.

1

Proposed dimensions of the HCAHPS survey for use in the FY 2013 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.

We also proposed to implement a subregulatory process to retire Hospital VBP measures. Under the proposed process, we would post our intention to retire measures on the CMS Web site at least 60 days prior to the date that we would retire the measure. Also, as we do with respect to Hospital IQR measures that we believe pose immediate patient safety concerns if reporting on them is continued, we proposed that we would notify hospitals and the public of the retirement of the measure and the reasons for its retirement through the usual hospital and QIO communication channels used for the Hospital IQR program, which include e-mail blasts to hospitals and the dissemination of Standard Data Processing System (SDPS) memoranda to QIOs, as well as post the information on the QualityNet Web site. We would then confirm the retirement of the measure from the Hospital VBP program measure set in a rulemaking vehicle. We made this proposal because it would allow us to ensure that the Hospital VBP program measure set focuses on the most current quality improvement and patient safety priorities. We solicited public comment on our proposals and other methods that allow for the addition of measures to the Hospital VBP program as rapidly as possible in order to improve quality and safety for patients.

In addition, we sought public comment on efficiency measures required for inclusion in the Hospital VBP program for value-based incentive payments made with respect to discharges occurring during FY 2014 or a subsequent fiscal year. Specifically, we requested comment on what services should be included and what should be excluded in a “Medicare spending per beneficiary” calculation, and what, if any, type(s) of hospital segmentation or adjustment should be considered in such a measure. We also solicited comment on approaches for measuring internal hospital efficiency. We took these comments into account in the development of the Medicare spending per beneficiary measure that we proposed to adopt in the FY 2012 IPPS/LTCH PPS proposed rule scheduled for publication on May 5, 2011, available at

http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1

).

The public comments we received are set forth below.

Comment:

Some commenters agreed with our proposed measure set and our proposal to exclude PN-5c and structural measures.

Response:

We thank the commenters for their support. We believe that the structural measures we have adopted for the Hospital IQR program require further development before we can consider adopting them for the Hospital VBP program, including the development of an appropriate scoring methodology. We also believe that the inclusion of PN-5c measure could lead to inappropriate antibiotic use. We also note that we have proposed to retire the PN-5c measure from the Hospital IQR program in the FY 2012 IPPS/LTCH PPS proposed rule scheduled for publication on May 5, 2011 for the same reason that we proposed to not include it in the Hospital VBP program measure set.

Comments:

Some commenters noted that CMS is retiring PN-2 (Pneumococcal Vaccination) and PN-7 (Influenza Vaccination) from the Hospital IQR Program and asked why these measures were included in the proposed rule. These commenters wanted to know how the retirement of these measures from the Hospital IQR Program would affect how these measures were collected and scored under the Hospital VBP program. Other commenters were concerned about including pneumonia vaccination measures in the Hospital VBP program measure set because they stated that there may be clinical reasons why a physician does not want a patient to receive the vaccination. The commenters suggested adding an “allowable value” or allowable code to the measure specifications to avoid penalizing the hospital for that situation.

Response:

Commenters are correct in that we finalized our retirement of PN-2 (Pneumococcal Vaccination) and PN-7 (Influenza Vaccination) beginning with the FY 2014 Hospital IQR program payment determination (75 FR 50211), and hospitals will no longer be required to submit data on these measures beginning with January 1, 2012 discharges (75 FR 50221). Because these measures will cease to continue being Hospital IQR program measures midway through the performance period we are finalizing for the FY 2013 Hospital VBP program, we do not believe that we can include them in the FY 2013 Hospital VBP measure set.

Comment:

One commenter requested clarification on whether we proposed to include SCIP-Inf-6 in the FY 2013 Hospital VBP measure set.

Response:

Table 2 of the Hospital Inpatient VBP proposed rule (76 FR 2462) listed our proposed measures for FY 2013, and Table 2 of this Final Rule lists the finalized measures. As we

explained in the Hospital Inpatient VBP proposed rule (76 FR 2461), we proposed not to adopt SCIP-Inf-6 for the Hospital VBP program because we concluded that the measure had achieved a “topped out” status.

Comment:

A commenter suggested that the proposed clinical process of care measures are flawed, suggesting that hospitals might choose not to submit records that could adversely impact their total performance score when submitting quality data.

Response:

All Hospital VBP program measures must be selected from the measures specified under the Hospital IQR program, and the data that we will use to calculate a hospital's total performance score for the clinical process of care measures will be the same data that the hospital submitted on those measures under the Hospital IQR program.

We allow hospitals to submit Hospital IQR clinical process of care measure data either by abstracting the necessary data elements from all qualifying cases or by submitting data elements taken from a sample of those cases. If the hospital chooses to submit a sample, the sample must meet the population and sample requirements outlined in the Specifications Manual. This Specifications Manual is posted on the CMS QualityNet Web site at

https://www.QualityNet.org/.

The purpose of these requirements is to ensure that the sample is statistically valid. We also note that we have adopted a process for validating clinical process of care measure data submitted under the Hospital IQR program, and we stated in the Hospital Inpatient VBP program proposed rule our belief that this process will also assure us that the same data is accurate for purposes of assessing hospital performance under the Hospital VBP program.

Comment:

Several commenters asked if CMS will monitor “topped-out” measures to ensure that they remain “topped-out”.

Response:

At this time, we do not have a mechanism in place to monitor whether measures we do not adopt for the Hospital VBP program on the basis that they are topped-out remain topped-out. We will consider such monitoring in the future.

Comment:

Some commenters suggested that CMS include in the Hospital VBP program measures that meet the definition of “topped out” because some hospitals will still be able to demonstrate improvement on them.

Response:

As detailed in the Hospital Inpatient VBP proposed rule (76 FR 2460), we proposed to define a “topped out” measure as a measure for which hospital performance at the 75th and 90th percentiles are statistically indistinguishable, and the truncated CV was set at <0.10. We believe that if a measure is “topped out,” there is no room for improvement for the vast majority of hospitals, and that measuring hospital performance on that measure will not have a meaningful effect on a hospital's Total Performance Score. For that reason, we proposed to exclude 7 topped-out measures from the FY 2013 Hospital VBP measure set.

Comment:

We received several comments asking us to re-run our analysis of “topped-out” measures using more recent data to determine if any other measures also met that status.

Response:

At the time we issued the Hospital Inpatient VBP proposed rule, the most recent data that was available to assess whether the proposed measures met our proposed definition of “topped out” was data from July 1, 2008 through March 31, 2009 which was the most recent validated data available and publicly displayed under the Hospital IQR program. However, since that time, data from the period that we proposed to set as the baseline period for the FY 2013 proposed measures has been validated (that is, data from the period July 1, 2009 to March 31, 2010). Therefore, in response to these comments, we analyzed all of the proposed FY 2013 measures to see if any of them met our proposed definition of “topped out” using this more recent data. We determined that three additional measures: AMI-2: Aspirin Prescribed at Discharge; HF-2: Evaluation of LVS Function; and HF-3: ACEI or ARB for LVSD meet our proposed definition of “topped-out” based on this more recent data. Because one of our goals for the Hospital VBP program is to ensure that hospital performance can be meaningfully measured and distinguished, we believe that it is appropriate to exclude these three additional measures from the FY 2013 Hospital VBP measure set based on this more recent analysis.

Comment:

Some commenters suggested that we consider SCIP-Inf-2 and PN-3b for “topped out” status. Other commenters stated, generally, that other measures should be considered for “topped-out” status, particularly those on which the difference between median performance and top performance is small. One commenter stated that it had calculated achievement thresholds and benchmark scores for the proposed measures using data available on

Hospital Compare

that most closely matched data from CMS' proposed baseline period. The commenter stated that its analysis showed that with respect to several measures, hospital scores were clustered at a high level of achievement, and suggested that such measures should also be considered as “topped out.”

Response:

As discussed above, we examined all of the proposed measures using data from the baseline period that we are finalizing in this final rule, and determined that three additional measures (AMI-2, HF-2, HF-3) are topped-out based on this data. As for other measures, including SCIP-Inf-2 and PN-3b, for which performance is high but which do not meet the proposed definition of “topped-out” based on the more recent data, the data show that hospital performance on these measures can still be meaningfully distinguished. For this reason, we believe that it is appropriate to include these measures in the FY 2013 Hospital VBP measure set.

Comment:

One commenter suggested that we not include the HF-1 measure (Discharge Instructions) from the Hospital VBP program because the measure does not measure clinical care provided, but instead measures administrative processes. Another commenter suggested that we exclude AMI-2, HF-1, HF-2 and SCIP-VTE-2 from the Hospital VBP program because these measures do not represent a significant improvement in the clinical practices required to deliver high value health care.

Response:

We disagree. The HF-1 measure, Discharge Instructions, assesses several critical elements important to a discharged patient: Activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen. These elements are critical to ensuring that patients continue to receive appropriate, high-quality health care services after their discharge from the hospital. We believe that SCIP-VTE-2 is important for the Hospital VBP program because the optimal start of pharmacologic prophylaxis in surgical patients can significantly decrease the mortality and morbidity associated with blood clot formation.

As described above, we are not finalizing our proposal to include AMI-2 and HF-2 in the FY 2013 Hospital VBP measure set because based on an analysis involving data from the proposed baseline period, these measures meet our proposed definition of “topped-out.”

Comment:

One commenter suggested that we review the technical specifications for AMI-7a and AMI-8a to ensure that intervention timing is based on diagnosis by EKG.

Response:

The intervention timing for both AMI-7a and AMI-8a runs from the time of arrival, not the time of diagnosis by EKG. Specifically, the specifications for the AMI-7a measure state that AMI patients with ST-segment elevation or Left bundle branch block (LBBB) on the EKG closest to arrival time receiving fibrinolytic therapy during the hospital stay have a time from hospital arrival to fibrinolysis of 30 minutes or less. Similarly, the specifications for the AMI-8a measure state that AMI patients with ST-segment elevation or LBBB on the ECG closest to arrival time receiving primary PCI during the hospital stay have a time from hospital arrival to PCI of 90 minutes or less. These specifications can be found on the QualityNet Web site (

http://www.qualitynet.org

). We note that these specifications are based on clinical guidelines adopted by the American College of Cardiology (ACC) clinical guidelines for ST elevation MI.

Comment:

Some commenters expressed support for our exclusion of structural measures. Others suggested that we consider using specific structural measures in the future such as participation in a systematic database or registry.

Response:

We believe these measures require further analysis of how they could be scored, and how they would impact a hospital's total performance score before they can be adopted for the Hospital VBP program. We intend to consider these issues as the Hospital VBP program evolves.

Comment:

One commenter suggested including the three smoking cessation measures adopted for the Hospital IQR program (AMI-4, HF-4, PN-4), despite their “topped out” status, because of the risk that hospitals will not focus on these measures and overall performance could begin to decline.

Response:

These measures meet our proposed definition of topped-out status. As we have stated, we do not believe that measuring performance on a topped-out measure produces a meaningful differentiation of hospital performance. We also note that we have proposed to retire these measures from the Hospital IQR measure set in the FY 2012 IPPS/LTCH PPS proposed rule scheduled for publication on May 5, 2011. Therefore, we are excluding these measures from the Hospital VBP measure set. We will consider the feasibility of proposing to adopt a global smoking cessation measure for the Hospital VBP program.

Comment:

A number of commenters supported our proposal to include PN-6 and PN-3b in the Hospital VBP measure set, stating that these measures encourage use of new technologies after patient diagnosis.

Response:

We appreciate the support, and we believe that the inclusion of these measures will help promote the provision of quality care by promoting appropriate laboratory testing (taking of blood cultures to facilitate selection of the most effective antibiotic for the patient) and actual selection of appropriate antibiotics based on patient data.

Comment:

Some commenters supported our proposal to use SCIP measures to capture HAIs.

Response:

We thank commenters for their support. As discussed in the Hospital Inpatient VBP Program proposed rule (76 FR 2461), the SCIP measures were developed to support practices that have demonstrated an ability to significantly reduce surgical complications such as HAIs. Compliance with the proposed SCIP infection measures is also included as a targeted metric in the HHS

Action Plan to Prevent Healthcare-Associated Infections

issued in 2009, a copy of which is available on the HHS Web site.

Comment:

One commenter suggested that measures should assess services regularly provided by rural hospitals and hospitals that do not perform surgeries.

Response:

The measures selected for the Hospital VBP program address services provided by subsection (d) hospitals, including rural hospitals and hospitals that do not perform surgeries. For example, the HCAHPS dimensions measure patients' experiences of care at hospitals; none of the dimensions are surgery-specific. Additionally, pneumonia and other conditions such as heart failure and acute myocardial infarction are treated by rural hospitals.

Comment:

A number of commenters called on CMS to use the Joint Commission's accountability criteria for measure selection, which include strong scientific evidence of improved outcomes, proximity to impacted outcomes, accurate assessment of evidence-based processes and minimal adverse effects.

Response:

In August 2010, The Joint Commission published an article in the New England Journal of Medicine discussing the criteria that should be used to define a measure that is used for accountability and public reporting purposes versus criteria that is used to define measures used strictly for performance improvement. The Joint Commission identified four criteria a measure must have in order to have the greatest positive impact on patient outcomes. These criteria include: Research, Proximity, Accuracy, and Adverse Effects. Further information on the Joint Commission's accountability criteria may be found at

http://www.jointcommission.org/about/JointCommissionFaqs.aspx?CategoryId=31.

We generally agree with the Joint Commission's list of criteria that would apply to measures used for accountability purposes and considered this criteria in determining whether certain measures may warrant retirement from the Hospital IQR program. However, we do not agree with their exclusion of HF-1 from the list of accountability measures as we believe HF-1 assesses a hospital's compliance with providing critical information to patients at the time of their discharge, including instructions regarding activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen. As stated above, we believe that this information is critical for hospitals to provide in order to facilitate appropriate self-care and provider follow up care after a patient is discharged from the hospital.

Comment:

A number of commenters recommended that we analyze measures against pre-established, agreed-upon criteria to ensure that they are relevant to value-based purchasing and will improve health outcomes for patients. Some commenters suggested that our goal should be to find the most appropriate ways to tie measures to patient benefits. Some commenters argued that current measures which we have proposed to adopt for the Hospital VBP program do not sufficiently impact health outcomes. Other commenters wondered if any measures are “paper-only” and do not reflect the actual provision of quality medical care.

Response:

To ensure that measures assess the quality of care provided to Medicare beneficiaries, we agree that measures should be scrutinized by experts and evaluated against objective criteria. We believe that these elements have been incorporated into our measure selection process in a variety of ways, including through endorsement by consensus-developing entities and through notice and public comment rulemaking. For example, most of the measures that we have selected for the Hospital IQR program, (which make them candidates for the Hospital VBP program) are endorsed by the NQF, the entity with a contract with the Secretary under Section 1890(a) of the Act. To the extent that we have determined that measurement is needed in a specified area for which there are no NQF endorsed measures, we give due consideration to measures endorsed or adopted by different consensus

organizations before specifying the measure. We also consider whether the measures meet the goals of the National Priorities Partnership, enable the Department to further its strategic goals and initiatives, and whether they are adopted by the HQA. This has resulted in our adoption of meaningful measures that assess the quality of care furnished by hospitals.

Comment:

A few commenters were concerned that the HCAHPS scores publicly reported on Hospital Compare differ by bed size, type of hospital and geography and thought the HCAHPS scores should be adjusted for these factors. These commenters thought HCAHPS needs to be vetted more to understand these differences to ensure that HCAHPS is a reliable measure.

Response:

Although we recognize that HCAHPS results differ by bed size and other hospital characteristics, we do not interpret these differing results to mean that the survey should be risk adjusted. HCAHPS results also differ among hospitals with the same characteristics, which we view as evidence that the results account for differences in the quality of care received by patients. In general, risk adjustment models control for exogenous factors that are beyond the control of a hospital, not for hospital characteristics that are endogenous, or within their control.

We also believe that the HCAHPS survey has been thoroughly vetted, including through reviews in peer-reviewed journals and through notice and comment rulemaking when we adopted it for the Hospital IQR program, and it is endorsed by the NQF.

Comment:

One commenter questioned whether top-box responses in the HCAHPS survey are appropriate for urban, safety net hospitals that serve culturally diverse patients and may not be able to “always” communicate well with their patients.

Response:

The “top-box” response to HCAHPS survey items is the most positive response that a patient can provide (often presented in the survey as “Always”). Medicare does not have an indicator for a “safety net hospital.” However, we have examined the HCAHPS results submitted by urban hospitals, which we believe can serve as a rough proxy for a “safety net hospital.” Urban hospitals, particularly large ones, have historically not performed as well on HCAHPS as rural hospitals. However, our internal studies of HCAHPS results show that hospitals in the following urban areas scored in the top 25 percent of hospitals overall: New York City, Boston, Baltimore, Atlanta, Chicago, Los Angeles, San Francisco, San Diego, Phoenix, Dallas, Houston, and San Antonio. We believe that these results suggest that urban hospitals are not being disadvantaged by the HCAHPS measurement.

Comment:

Several commenters questioned the reliability of HCAHPS data. Some suggested that we consider possible negative consequences associated with its use.

Response:

Since its national implementation in October 2006, when hospitals began to administer the HCAHPS survey, our analyses of HCAHPS results has shown that this standardized, publicly reported survey of patients' experience of hospital care is satisfactorily reliable at 100 completed surveys using statistical measures of reliability that calculate the proportion of the variance in reported hospital scores that is due to true variation between hospitals, rather than within hospital variation that reflects limited sample size.

We also note that since public reporting of HCAHPS scores began under the Hospital IQR program[?] in March 2008 there have been small but statistically significant improvements in 9 of 10 HCAHPS dimensions.

2

In addition, we are aware of abundant anecdotal evidence that hospitals are engaging in quality improvement efforts aimed at improving the quality of the inpatient experience. We believe that HCAHPS, in part, motivates these efforts and expect that hospitals will continue to improve their patients' experience of care as the incentives for doing so become more salient.

2

See “Hospital Survey Shows Improvements in Patient Experience.” M.N. Elliott, W.G. Lehrman, E.H. Goldstein, L.A. Giordano, M.K. Beckett, C.W. Cohea and P.D. Cleary.

Health Affairs,

29 (11): 2061-2067. 2010.

We believe that setting the minimum number of measures and cases as low as is reasonable is an essential component of implementing the Hospital VBP program and will help to minimize the number of hospitals unable to participate due to not having the minimum number of cases for a measure or the minimum number of measures. Therefore, we also proposed that, for inclusion in the Hospital VBP program for FY 2013, hospitals must report a minimum of 100 HCAHPS surveys during the performance period. Our statistical analyses show that HCAHPS is a reliable measure of patient experience and, therefore, we see no negative consequences with its use.

Comment:

One commenter provided suggestions for additional items regarding palliative care that could be added to the HCAHPS instrument; another commenter suggested that CMS add questions about patient activation (patients' knowledge, skills, and confidence for self-management), care coordination, shared decision-making and support for patient self-management.

Response:

As part of our ongoing maintenance activities for the HCAHPS survey, which include assessing whether it needs to be updated, we will consider the feasibility of adding the suggested survey items.

Comment:

One commenter wanted to exclude the doctor communication dimension from the HCAHPS measure, reasoning that hospital payment under the IPPS should not be based in part upon physician behavior that it cannot control.

Response:

We are including the doctor communication dimension as an HCAHPS dimension because it is a key aspect of care from the perspective of consumers. In addition, many hospitals employ their own doctors (hospitalists) who are directly under the hospitals' control.

Comment:

Some commenters opposed combining the cleanliness and quiet items because they are conceptually different and the cleanliness item is important for patient safety.

Response:

We thank commenters for their input. Although these two items were originally proposed to be one composite in the survey, we separated them into two individual measures for public reporting prior to the 2006 national implementation because it made more sense for consumers to see ``clean'' and ``quiet'' as distinct environmental aspects of hospitals. The ``clean'' and ``quiet'' HCAHPS measures will continue to be publicly reported separately on Hospital Compare for the Hospital Inpatient Quality Reporting program.

For purposes of the Hospital VBP program, these two items were combined so as not to put more weight on the environmental items compared to the rest of the HCAHPS items, which are composite measures (with the exception of Overall Rating). If the environmental items were separated, quietness of the hospital environment, for example, would receive as much weight as nurse communication, which includes 3 items from the HCAHPS survey. The combined ``cleanliness and quietness'' HCAHPS dimension will be publicly reported on Hospital Compare as part of the Hospital VBP program.

Comment:

Some commenters were concerned that the risk adjustment models for the HCAHPS survey are not adequate and do not control for the severity of a patient's condition, socio-economic status, and geographic differences

Response:

HCAHPS dimensions are currently patient-mix adjusted. We adjust HCAHPS data for patient characteristics that are not under the control of the hospital that may affect patient reports of hospital experiences. The goal of adjusting for patient-mix is to estimate how different hospitals would be rated if they all provided care to comparable groups of patients. As part of the endorsement process for HCAHPS, the NQF endorsed the HCAHPS patient-mix adjustment currently in use.

The HCAHPS patient-mix adjustment (PMA) model incorporates important and statistically significant predictors of patients' HCAHPS ratings that also vary meaningfully across hospitals (O'Malley et al., 2005). The PMA model includes seven variables, as follows: Self-reported health status, education, service line (medical, surgical, or maternity care), age, response percentile order (also known as “relative lag time,” which is based on the time between discharge and survey completion), service line by linear age interactions, and primary language other than English. Initially the model also included admission through an emergency room, but because admission through an emergency room is no longer available on the UB-92 Form, this adjuster is no longer available for the patient-mix model. We are exploring other options to obtain that information in the future. We have found that evaluations of care increase with self-rated health and age (at least through age 74), and decrease with educational attainment. Maternity service has generally more positive evaluations than medical and surgical services. Percentile response order (relative lag time) findings show that late responders tend to provide less positive evaluations than earlier responders. From research conducted during the development of HCAHPS, we found little evidence that DRG matters beyond the service line, which is included in the patient mix model.

To further address specific concerns about the adjustment model, it is important to note that self-reported health status is a widely accepted measure of a person's overall health status. In general, ``how would you rate your health'' is the most widely used single self-reported health item and is used in a plethora of national health surveys. Education also captures important aspects of socio-economic status. Income is generally not available to adjust survey data.

Patient-mix adjustment is based on variation by patient-level factors within hospitals so that true differences between hospitals are not included in the adjustment.

3

Controlling for geographic region (a hospital-level factor) as part of a patient-mix adjustment model could mask important differences in quality across the country.

3

See

“Adjusting Performance Measures To Ensure Equitable Plan Comparisons.” Zaslavsky, A.M., L.B. Zaborski, D.J.A. Shaul, M.J. Cioffi, and P.D. Cleary. Health Care Financing Review'' 22(3): 109-26. 2001.

Comment:

Several commenters suggested changing the HCAHPS requirements to reduce the number of required mailings and telephone attempts, allow survey administration while patients are still in the hospital, and allow electronic administration of the survey to reduce the cost of survey administration.

Response:

We know from our HCAHPS research that, on average, late responders report less positive experiences. For this reason, we believe that allowing hospitals to reduce their effort to obtain completed surveys by reducing the required number of mailings and telephone attempts would bias the HCAHPS results. Under the current HCAHPS requirements, which can be found in the HCAHPS Quality Assurance Guidelines available at

www.hcahpsonline.org,

the administration of the HCAHPS survey begins 48 hours following discharge to ensure that the patient has had an opportunity to return home or go to an alternative location. We also believe that allowing a hospital to administer the survey while the patient is still in the hospital has the potential to create biased results because the patient might not feel that he or she can freely answer the questions with hospital staff nearby.

We note that we have tested an Internet version of HCAHPS. However, at this point, we do not believe that hospitals routinely collect e-mail addresses or that the Medicare population has enough experience with the Internet to support allowing hospitals to administer the survey via the Internet. This is a technology that we will continue to explore because we agree with the commenters that electronic administration of the survey would be less expensive for hospitals.

Comment:

One commenter was concerned that patients would be more likely to recommend larger hospitals due to the spectrum of services offered by them and, thus, smaller and rural hospitals would be disadvantaged by HCAHPS.

Response:

Because HCAHPS focuses on the actual experiences of care by asking patients about what happened during the hospital stay, the HCAHPS data are not biased by the perceptions of patients in terms of the range of services offered by different hospitals. In fact, smaller hospitals generally tend to do better on HCAHPS relative to larger ones.

While most HCAHPS survey items assess the patient's actual experience in the hospital, two survey items ask for the patient's overall impressions of the hospital stay. Because these items are highly correlated and potentially draw on wider influences, we have proposed to include only one global dimension, Overall Rating, in the Hospital VBP program scoring for the HCAHPS measure.

Comment:

Some commenters called on us to make HCAHPS patient mix adjustment formulas public.

Response:

The HCAHPS patient-mix adjustment formulas are publicly available on

http://www.hcahpsonline.org.

The data on

http://www.hcahpsonline.org

regarding the adjustments are updated quarterly.

Comment:

Some commenters opposed the use of 30-day mortality rates in the Hospital VBP program because they are “all-cause” measures and do not exclude deaths that are not attributable to a hospital's quality of care. One commenter questioned the use of the mortality measures, citing the possibility of unintended consequences and remarking that, “unless hospitals are provided with specific interventions which have been demonstrated to reduce morality, penalizing a hospital for an increase in mortality (or rewarding one for a decrease in mortality) is not rationally related to the operations of the hospital.” Other commenters argued that the Hospital VBP program should focus on outcome measures that are risk adjusted to account for extremely ill patients.

Response:

We appreciate commenters' input on measures for use in the Hospital VBP program. The proposed all-cause risk adjusted 30-day mortality measures are endorsed by the National Quality Forum (NQF). There are several reasons why we believe it is appropriate for us to adopt the NQF-endorsed all-cause mortality measures for the Hospital VBP program.

First, from the patient perspective, death is the key outcome regardless of its cause. Second, cause of death may be unreliably recorded. Third, the cause of death may represent a complication related to the underlying condition. For example, a patient with HF who develops a hospital-acquired infection may ultimately die of sepsis and multi-organ failure. It would be inappropriate to consider the death as unrelated to the care the patient received for HF.

Another patient might have a complication leading to renal failure, resulting in death, and yet quality of care could have reduced the risk of the complication. A patient with PN who did not receive deep vein thrombosis prophylaxis may ultimately die of a pulmonary embolism. It would be inappropriate to consider the death as unrelated to the care the patient received for PN. Although this approach will include some patients whose death may be unrelated to their care (for example, a casualty in a motor vehicle accident), events completely unrelated to the admission are expected to be uncommon and should not be clustered unevenly among hospitals.

Furthermore the NQF-endorsed measure methodology for all three of these all-cause mortality measures includes a risk adjustment for protein-calorie malnutrition, dementia, and metastatic cancer that are common among extremely ill patients.

Comment:

Some commenters suggested that we should ensure that measures, particularly those added in FY 2014, appropriately capture services provided by hospitals, as not all hospitals treat all conditions.

Response:

We agree and note that we proposed that hospitals must have at least 10 cases per measure in order to be scored on that measure and report on at least 4 measures to be included in the Hospital VBP program. We also believe that the finalized Hospital VBP measures capture a broad range of hospital services, which will enable a large number of hospitals to participate in the program.

Comment:

One commenter suggested that we proceed cautiously in seeking to adopt outcome measures for the Hospital VBP program, and that we first demonstrate their statistical reliability for low-volume hospitals.

Response:

We agree that acceptable statistical reliability is important to our analysis in determining what measures to adopt for the Hospital VBP program. As stated above, we conducted analyses on the 30-day outcome measures we are adopting for this program and have found them to be reliable for all hospitals for purposes of Hospital VBP scoring.

Comment:

One commenter suggested that CMS use an error bar or other visual display of the confidence intervals surrounding mortality rate performance similar to the displays currently used on

Hospital Compare

for mortality measures.

Response:

The confidence intervals currently shown on

Hospital Compare

are used to classify hospitals into broad categories for purposes of that display. For the Hospital VBP program, we will score all of the Hospital VBP measures using the scoring methodology that we finalize for the program. The use of this scoring methodology will result in each hospital being assigned a point estimate that reflects its score on each of the mortality measures, and it is those scores, rather than broad confidence intervals, that will be used for purposes of the public reporting.

Comment:

Some commenters expressed general support for the 3 proposed 30-day mortality measures.

Response:

We thank commenters for their support.

Comment:

Some commenters suggested that we exclude some types of cases, including hospice or palliative care, from the mortality measure calculations. They also suggested that this “new” mortality rate measurement without hospice and palliative care patients should be displayed on

Hospital Compare

for one year prior to implementation.

Response:

The risk-adjusted mortality measure methodology excludes admissions for Medicare fee-for-service patients who elect hospice care any time in the 12 months prior to the index hospitalization, including the first day of the index admission. Information on the methodology used to calculate the measures can be found at

http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1163010398556.

Comment:

Many commenters opposed our proposal to adopt HAC measures for the FY 2014 Hospital VBP program, arguing that we will be penalizing hospitals on those measures both under the Hospital VBP program, the HAC policy required by Section 3008 of the Affordable Care Act and the Medicaid penalties required by Section 2702 of the Affordable Care Act.

Response:

We view the program authorized by section 3008 of the Affordable Care Act and the Hospital VBP Program as being related but separate efforts to reduce HACs. Although the Hospital VBP program is an incentive program that provides incentive-based payments to hospitals based on quality performance, the program established by section 3008 of ACA creates a payment adjustment resulting in payment reductions for the lowest performing hospitals. We also view programs that could potentially affect a hospital's Medicaid payment as separate from programs that could potentially affect a hospital's Medicare payment, although we intend to monitor the various interactions of programs authorized by the Affordable Care Act and their overall impact on providers and suppliers.

Comment:

Several commenters requested that we ensure the harmonization of new programs and any overlay or duplication in the Affordable Care Act, generally.

Response:

We are coordinating the development and implementation of all of these programs and will continue to monitor their impacts on providers and suppliers.

Comment:

Some commenters argued that CMS should analyze HAC measures more closely to test the validity of “present on admission” (POA) diagnosis coding. The commenters suggested that CMS compare POA coding to chart-review to test the appropriateness of using claims-based measures for payment purposes. Commenters more generally argued that the current measure format does not allow for valid comparisons due to coding issues and physician behavior.

Response:

The purpose of POA coding is to allow better discernment of whether a diagnosis is a complication of care received in the hospital or an adverse event occurring in the hospital. Beginning in FY 2007, we have proposed, solicited, and responded to public comments and have implemented the Hospital Acquired Condition Program under section 1886(d)(4)(D) of the Act and its accompanying POA coding requirement through the IPPS annual rulemaking process. For specific policies addressed in each rulemaking cycle, we direct readers to the following publications: the FY 2007 IPPS proposed rule (71 FR 24100) and final rule (71 FR 48051 through 48053); the FY 2008 IPPS proposed rule (72 FR 24716 through 24726) and final rule with comment period (72 FR 47200 through 47218); the FY 2009 IPPS proposed rule (73 FR 23547), and final rule (73 FR 48471); and the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule (74 FR 24106) and final rule (74 FR 43782). A complete list of the 10 current categories of HACs is included in section II.F.2.of FY 2011 IPPS/RY 2011 LTCH PPS (75 FR 50080 through 50101).

POA coding is also used in the specifications for the component indicators for the AHRQ Patient Safety composite measure we proposed to adopt for the Hospital VBP program for FY 2014. This composite measure consists of 8 component indicators, including PSI-3 (Pressure ulcer), PSI-6 (Iatrogenic Pneumothorax), PSI-7 (Central venous catheter-related bloodstream infections), PSI-8 (Postoperative hip fracture), PSI-12 (Postoperative pulmonary embolism or

deep vein thrombosis), PSI-13 (Postoperative sepsis), PSI-14 (Postoperative wound dehiscence), and PSI-15 (Accidental Puncture or Laceration). For each of these component indicators, present-on-admission coding is one of the exclusion criteria used to indicate whether a condition or an injury occurred before or after the patient was admitted to the hospital. Please refer to

www.qualityindicators.ahrq.gov

for further details about the technical specifications for these measures. We are using the POA information on the final adjudicated claim submitted by the hospital. These data are subject to the same scrutiny as other information on Medicare claims.

We also note that we are currently evaluating the Hospital Acquired Condition-Present on Admission (HAC-POA) Program. We appreciate the commenters' interest and will take it into consideration as we proceed with this evaluation.

Comment:

Some commenters noted that the proposed HAC measures are limited to the Medicare fee-for-service population and suggested that these measures should not be used in Hospital VBP.

Response:

The proposed HAC measures are calculated using only Medicare fee-for-service data because we do not currently have access to claims data that is submitted by hospitals to other payers. We also note that POA codes, which are required to calculate all of the proposed HAC measures and which must be included on Medicare Part A claims submitted to CMS by hospitals, may not be required to be included on inpatient claims submitted by hospitals to other payers. Despite this data limitation, we believe that the proposed HAC measures provide important information regarding patient safety events occurring during hospitalization, which reflect the quality of patient care provided, and we believe these measures should be included in the Hospital VBP program.

Comment:

Some commenters questioned whether value-based incentive payments will be available only to Medicare FFS and Medicare cost payers and not Medicare Advantage Organization (MAO) payers.

Response:

Value-based incentive payments made under the Hospital VBP program can be made only in the form of an adjustment to a subsection (d) hospital's base operating DRG payment amount under the IPPS.

Comment:

Some commenters noted that the proposed HAC measures do not capture more than 9 diagnoses.

Response:

CMS' current system limitations allow for the processing of only the first 9 diagnoses and 6 procedures. While CMS accepts all 25 diagnoses and 25 procedures submitted on the claims, we do not process all of the codes because of these system limitations.

In the FY 2011 IPPS/LTCH-PPS final rule, we discussed our plans to accept and process up to 25 diagnoses and procedures on the hospital inpatient claims submitted on the 5010 format beginning January 1, 2011 (75 FR 50127 through 50128). In the FY 2010 IPPS/RY 2010 LTCH PPS final rule, we responded to hospitals' requests that we process up to 25 diagnosis codes and 25 procedure codes (74 FR 43798). In that FY 2010 IPPS/RY 2010 LTCH PPS final rule, we referred readers to the ICD-10 final rule (74 FR 3328 through 3362) where we discuss the updating of Medicare systems prior to the implementation of ICD-10 on October 1, 2013. We mentioned that part of the system updates in preparation for ICD-10 is the “expansion of our ability to process more diagnosis and procedure codes.” In the FY 2009 IPPS final rule (73 FR 48433 through 48444), we also responded to multiple requests to increase the number of codes processed from 9 diagnosis and 6 procedure codes to 25 diagnosis and 25 procedure codes.

We are currently making extensive system updates as part of the move to 5010, which includes the ability to accept ICD-10 codes. This complicated transition involves converting many internal systems prior to October 1, 2013, when ICD-10 will be implemented. One important step in this planned conversion process is the expansion of our ability to process additional diagnosis and procedure codes. We are currently planning to complete the expansion of this internal system capability so that we are able to process up to 25 diagnoses and 25 procedures on hospital inpatient claims as part of the HIPAA ASC X12 Technical Reports Type 3, Version 005010 (Version 5010) standards system update.

Comment:

Many commenters recommended that CMS develop risk adjustment methods, measure exclusion criteria, or stratified scoring methods to account for variations in measure rates related to patient factors or hospital function. Commenters argued that many of the proposed outcome, patient experience, and other measures including HCAHPS, HACs, and mortality measures are not valid because they lack appropriate risk adjustment and exclusion criteria and called for their exclusion from the Hospital VBP program. One commenter suggested risk adjustments should specifically be employed for trauma patients. A number of commenters suggested that CMS consider other risk adjustment models used by the industry, such as those promulgated by the Society of Thoracic Surgeons. One commenter suggested that we include “median income of ZIP code of residence” in a risk adjustment methodology for mortality measures in order to account for socioeconomic variables that may lead to a greater rate of mortality. Additionally, some commenters suggested that CMS convene experts to develop a “population adjustment” and adopt only HACs that do not rely on claims data for the Hospital VBP program.

Response:

For the measures that currently employ risk adjustment, we are using the risk adjustment models that are part of the NQF-endorsed measure specifications. In developing its risk adjustment model for the 30-day measures, the NQF performed an extensive literature review of risk factors employed by other models to inform the development of its model. We note that the current risk adjustment methodology for the three proposed mortality measures for FY 2014 was recently reevaluated and approved by an NQF steering committee. There is no risk adjustment for race and socioeconomic status, which we believe is appropriate because we do not want to hold hospitals with different racial or SES mixes to different performance standards. Adjusting for race or SES would also obscure differences that are important to identify if we want to reduce disparities where they do exist. We note that the NQF has issued guidance recommending against adjusting for patient characteristics such as socioeconomic status in outcomes measures, located at:

http://www.qualityforum.org/docs/measure_evaluation_criteria.aspx.

We welcome collaboration on this issue with providers that serve unique patient populations and functions.

Furthermore, while we understand that claims-based measures such as HAC measures have certain limitations, as discussed below, HAC measures were defined in prior rulemaking, during which we conducted several listening sessions and had the benefit of receiving public comment. We note that some of the HACs are “never” events and therefore should not be risk adjusted. We will consider refinements to the HAC measures in future years. We will monitor the impact of the Hospital VBP program on the care provided to

vulnerable subpopulations of patients, including trauma patients.

Comment:

Some commenters argued that the proposed HAC measures should be risk-adjusted before they are used in Hospital VBP.

Response:

Six of the 8 HACs adopted for the Hospital VBP program are considered “never events,” for which risk adjustment would not be appropriate because, in our view, such events should never happen under any circumstances. In the event that we do decide that some type of risk adjustment would be appropriate, we will seek input from the NQF as to whether or not this constitutes a substantive change to the measures, in which a formal consensus development process will be initiated. We will consider further refinements to the HAC measures in future years. We note that when we adopted the HAC vascular catheter-associated infection measure and the catheter-associated urinary tract infection measure in the FY 2008 IPPS final rule with comment period (72 FR 47202 through 47218), there were no related risk-adjustments under the DRG payment policy reforms (72 FR 47141).

Comment:

Some commenters suggested that measures should be approved by the Hospital Quality Alliance (HQA) before use in the Hospital VBP program.

Response:

In developing the Hospital VBP program, we took into account the input of a multitude of stakeholders, including the HQA. The HQA is a national, public-private collaboration committed to making meaningful, relevant, and easily understood information about hospital performance accessible to the public and to informing and encouraging efforts to improve quality. We will also continue to consider HQA input as part of our ongoing measure selection process for the Hospital VBP program.

Comment:

Some commenters argued that the low incidence rates of HACs, particularly in academic medical centers, would lead to unstable statistics on which to base comparisons between hospitals.

Response:

Low incidence of events does not equate to unstable rates for those events. We acknowledge that the rates of some of the HACs, particularly the ones measuring `never events', may be rare. However, because these are considered events that should never happen, reporting their prevalence, though rare, is still meaningful. We have not found that HAC incidence is particularly low in academic medical centers. We believe that all of the proposed HAC measures are important to measure and report, despite their low incidence rates, and that the public reporting of the HACs on the

Hospital Compare

Web site will encourage improvement. We believe that the Hospital VBP program must emphasize patient safety and improved quality of health care, and we believe that holding hospitals accountable for HACs will further those goals.

Comment:

Some commenters asked us to discuss the inclusion of HAIs in HACs. Specifically, the commenters asked us to include additional detail on how CMS plans to implement HHS's HAI Action Plan.

Response:

Two of the eight proposed HAC measures (Vascular Catheter-Associated Infection and Catheter-Associated Urinary Tract Infection) capture HAIs. We are considering the feasibility of proposing to adopt all of the metrics listed in the HAI Action Plan for the Hospital IQR program in future years. In the FY 2011 IPPS/LTCH PPS final rule, we adopted two of the HAI measures from the HHS HAI Action Plan: the central line-associated bloodstream infection measure, for which reporting began with respect to January 2011 events; and the surgical site infection measure, which hospitals will begin reporting with respect to January 2012 events. In addition, we have proposed in the FY 2012 IPPS/LTCH PPS proposed rule scheduled for publication on May 5, 2011, to adopt additional HAI measures: Catheter-associated urinary tract infection measure, central line insertion practices adherence percentage; Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C-Diff), and Health Care Personnel Influenza Vaccination measures. All of these measures, if finalized for the Hospital IQR program, will be eligible for inclusion in the Hospital VBP program, and would allow CMS to better address the important topic area of Healthcare Associated Infections.

Comment:

Some commenters noted that HACs are not entirely preventable and argued that they should not be a component of quality measurement.

Response:

We believe that all 8 proposed HAC measures assess the presence of hospital acquired conditions that are reasonably preventable if high quality care is furnished to the patient. We also believe that the incidence of HACs in general raise major patient safety issues for Medicare beneficiaries. According to the 2010 Department of Health and Human Services Office of the Inspector General Report, entitled “Adverse Events in Hospitals: National Incidence among Medicare Beneficiaries,” an estimated 13.5 percent of hospitalized Medicare beneficiaries experienced adverse events during their hospital stays (OIG, November 2010, OEI-06-09-00090). We proposed to adopt 8 HAC measures for the Hospital VBP program because they are outcome measures (which are widely regarded by the provider community as strongly indicative of quality of medical care) that assess whether certain adverse events occurred during hospitalization. We believe that the adoption of these measures will facilitate our on-going efforts to hold hospitals accountable for these events, as well as reduce the incidence of these adverse events that result in harm to Medicare beneficiaries and higher costs of care.

Comment:

Some commenters asked us to explain why HACs are appropriate for quality measurement and scoring given that they are derived from billing and payment methods.

Response:

We believe that public reporting of the HACs on the

Hospital Compare

Web site will encourage improvement. We acknowledge that the incidence of HACs may be rare. However, many of the HACs are considered events that should never happen; reporting their prevalence, though rare, is still meaningful.

Medicare fee for service claims data is the source for many measures that are NQF endorsed. This data source was reviewed as part of the NQF endorsement process for such measures, and has been found to be an appropriate data source. We also refer readers to the FY 2008 IPPS final rule with comment period (72 FR 47202 through 47218); section II.F. of the FY 2009 IPPS final rule with comment period (73 FR 48474 through 48486); and section II.F. of the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43782 through 43785) for detailed discussions regarding the selection of the current 10 HAC categories.

Comment:

Some commenters suggested that CMS consider integrating HACs, complications and other causes of waste into an efficiency domain rather than in clinical process or outcomes.

Response:

We believe that the proposed HAC measures best capture health care quality outcomes rather than efficiency and are therefore best included in the outcome domain.

Comment:

One commenter suggested that we revise the definition of Falls and[?] Trauma. Specifically, the commenter suggested that the definition should be revised to require not only these injury codes, but also an e-code related to falls that are not POA.

Response:

We appreciate the suggestion to refine the definition of this

HAC, and will consider refinements for future implementation.

Comment:

Some commenters requested that we provide detailed measure specifications for the proposed HAC measures immediately if we intend to use them in the Hospital VBP program.

Response:

The specifications for these proposed measures were made available on

QualityNet

at

http://www.qualitynet.org

earlier in the year.

Comment:

Some commenters were opposed to the use of Nursing Sensitive measures in the Hospital VBP measure set while others, noting that nurses provide numerous services to patients, argued that nursing sensitive measures are essential quality indicators.

Response:

We agree that nurses provide numerous services to their patients, and we are interested in nursing sensitive measures because those measures capture many processes and outcomes that are influenced by nursing practice. Currently, we only have one nursing sensitive measure in the Hospital IQR Program: Death among surgical inpatients with serious treatable complications (AHRQ PSI-04). We are also collecting the structural measure “Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care”. We will consider adopting one or more measures in the nursing sensitive category for the Hospital IQR and Hospital VBP programs in the future.

Comment:

Some commenters opposed the use of any AHRQ PSI and IQI measures or their composites in Hospital VBP. Others suggested that those measures should be evaluated for validity and reliability as they were not developed to be performance measures and are based on claims data. Others noted that hospitals have encountered technical and programming issues with respect to the proposed AHRQ measures.

Response:

We thank commenters for their input. The AHRQ PSI and IQI measures that we proposed to adopt for the Hospital VBP measure set are NQF endorsed. In order to achieve NQF endorsement, measures must meet all of the criteria of the NQF consensus development process. Information on this process can be found at:

http://www.qualityforum.org/Measuring_Performance/Consensus_Development_Process.aspx.

We believe this consensus development process includes the necessary steps to assure that measures that are NQF endorsed have been tested for validity and reliability of the data. This endorsement includes the data source needed to calculate the measures (Medicare fee for service claims). We believe these measures are appropriate for use in the Hospital VBP program as they meet the statutory requirements for inclusion and address the topic of patient safety, which is a high priority that we believe should be addressed in the Hospital VBP program. We also note that because these measures are claims-based, no separate data reporting is needed.

Comment:

One commenter objected to the use of PSI 4, arguing that about 25 percent of surgical patients are admitted with sepsis or acute illness and multiple organ failure for surgical exploration, then coded as surgical patients even if the surgery doesn't find anything and doesn't contribute to death.

Response:

We have not proposed to adopt PSI 4, Death among surgical inpatients with serious, treatable complications, for inclusion in the Hospital VBP program. However, we note that the specifications for that measure specifically exclude patients with a diagnosis of sepsis or infection in the primary diagnosis field and patients who are immunosuppressed.

Comment:

Some commenters argued that the proposed AHRQ measures amount to double-counting for purposes of scoring, as two of the proposed AHRQ measures are composites of the other AHRQ measures.

Response:

We appreciate commenters' concerns. We agree that the use of all of the proposed AHRQ measures, including the two composite measures, would result in “double-counting” each of the individual measures. While each of the individual AHRQ measures capture important components of quality care, we believe that scoring hospital performance on the two composite measures simply and clearly captures the provision of high quality care that we wish to incentivize in the Hospital VBP program. Therefore, we are only finalizing the 2 proposed AHRQ composite measures, which will avoid any double-counting.

Comment:

Some commenters argued that all outcome, process, and patient experience measures should be posted on

Hospital Compare

for one year prior to use in the Hospital VBP program, and that, during this year, CMS should provide quarterly hospital preview reports on

qualitynet.org

with a percentile ranking for each measure in order to prepare for public reporting.

Response:

In accordance with statutory requirements, all measures will be included on

Hospital Compare

for at least one year prior to the beginning of the performance period for which we propose to adopt them under the Hospital VBP program. The process of care measures and HCAHPS are updated quarterly, and facilities that submit data are provided a 30-day preview of their data before public reporting occurs. The outcomes of care measures are updated annually, usually in July. The new outcomes data is included in the preview reports for this display period. As stated below, we will provide details on the information to be reported on

Hospital Compare

in future rulemaking. We will consider commenters' suggestion for quarterly preview reports on

qualitynet.org

before public reporting. However, we believe that providing robust quality information to the public as soon as possible is a desired outcome of quality reporting and performance scoring.

Comment:

One commenter noted that the requirement that measures be included on

Hospital Compare

appears to be a significant barrier to timely adoption of the HAI Action Plan metrics in the Hospital VBP program. Other commenters encouraged us to accelerate the adoption of those metrics for the Hospital IQR program,

Hospital Compare,

and NQF endorsement.

Response:

We agree that the requirement that measures be included on the Hospital Compare Web site for at least one year before the performance period for them can begin under the Hospital VBP program has the potential to limit the speed at which we can adopt measures for the program, however we intend to propose to adopt measures that drive quality improvements and improve patient safety, such as the prevention metrics included in the HHS Action Plan to Prevent HAIs, as quickly as possible within that constraint.

Comment:

Some commenters argued that CMS's data collection system does not adequately differentiate among conditions acquired in the hospital and those that are “present on admission” (POA) for purposes of scoring outcome measures. Commenters recommended that CMS allow hospitals to use POA claims indicators or consider other methods for outcome measure scoring, particularly since certain types of hospitals such as trauma centers or tertiary referral centers could be penalized on those measures because they receive a disproportionate share of transfers from other hospitals. Some commenters suggested that transferee and transferor hospitals should share in mortality rates for transferred patients.

Response:

We are currently using the POA indicator to calculate the proposed HAC and AHRQ patient safety composite measures, and we believe that the use of this indicator will better enable us to identify patient safety events, conditions and complications arising during hospital stays. We also

note that, under the specifications for the 30-day mortality measures, if the primary discharge diagnosis at the receiving hospital matches the primary discharge diagnosis at the transferring hospital, the patients are included in the transferring hospital's mortality measure calculations. We believe this approach encourages coordination between hospitals and their referral networks. Further, we believe that this approach promotes the best interests of the patient because it does not create an incentive for hospitals to transfer patients who are critically ill or at high risk of dying.

Comment:

Some commenters were concerned about the accuracy of claims-based quality measures. In particular, they questioned how claims-based quality measurements will be accurate given hospitals' technical and programming issues with the AHRQ measures, which are claims based rather than chart abstracted.

Response:

Both the AHRQ measures and their data source have been endorsed by NQF. We note that other quality initiatives, such as the Medicare End-Stage Renal Disease Quality Incentive Program, require reporting on claims-based measures. While they have certain limitations, claims-based measures provide important information on hospital quality of care. We also note that hospitals are not required to submit data for the AHRQ measures; rather, the calculations are derived from Medicare fee-for-service claims data. Thus, neither technical nor programming issues should arise. For the reasons discussed above, we are only finalizing the two composite AHRQ measures.

Comment:

Some commenters opposed our proposal to implement a subregulatory process for adding or retiring measures, calling on CMS to use full notice and comment rulemaking instead. A few commenters supported the proposed subregulatory process.

Response:

We appreciate the comments, and understand that stakeholder input is critical to ensuring that the Hospital VBP program and measure set improves the quality of care and patient safety. As stated in the Hospital Inpatient VBP proposed rule (76 FR 2458 through 2459), we believe that we must act with all speed and deliberateness to expand the pool of measures used in the Hospital VBP program. This goal is supported by at least two Federal reports documenting that tens of thousands of patients do not receive safe care in the nation's hospitals.

4

4

See OEI-06-09-00090 “Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.” Department of Health and Human Services, Office of Inspector General, November 2010. See also, 2009 National Healthcare Quality Report, pp. 107-122. “Patient Safety,” Agency for Healthcare Research and Quality.

For this reason, we believe that we should adopt measures for the Hospital VBP program relevant to improving care, particularly as these measures are directed toward improving patient safety, as quickly as possible. Additionally, we believe that we should retire measures from the Hospital VBP program as quickly as possible to ensure that they do not detract from other measures that we believe will be more impactful in improving patient health. We believe that speed of implementation is a critical factor in the success and effectiveness of this program.

However, we are aware of stakeholders' concerns about the proposed subregulatory process. We understand commenters' point that notice-and-comment rulemaking is important to ensure that hospitals are aware of the applicable measures. In response to those comments, we will not finalize the proposed subregulatory process for adding or retiring measures. Instead, we have proposed in the FY 2012 IPPS/LTCH PPS proposed rule scheduled for publication on May 5, 2011 that we might choose to propose to simultaneously adopt one or more measures for both the Hospital IQR Program and the Hospital VBP program. We refer readers to that proposal for further information.

Comment:

Some commenters suggested that we consider adopting quality measures covering more conditions to ensure that hospitals improve the quality of care that they furnish to all patients, not just those diagnosed with conditions covered by current quality measures.

Response:

We thank commenters for the suggestion. The Affordable Care Act specifically names AMI, HF, PN, SCIP, HAIs and HCAHPS as initial topics to be included in the Hospital VBP program in FY 2013. We will consider other measures and conditions for inclusion in the Hospital VBP program for future years.

Comment:

Some commenters strongly opposed use of the IQI stroke mortality measure, arguing that it is not adjusted for stroke severity.

Response:

We thank commenters for their suggestion. The current methodology for this measure, including the risk adjustment methodology is NQF endorsed.

Comment:

A number of commenters asked how hospitals will be scored and payments will be adjusted when measure specifications change.

Response:

We understand that from time to time measure specifications require updating. We maintain the technical specifications by updating the Specifications Manual semiannually, or more frequently in unusual cases, and include detailed instructions and calculation algorithms for hospitals to use when collecting and submitting data on required measures. While many of these updates or changes do not impact the calculation of the measures, we are aware that substantive changes to the specifications for a measure may impact the score a hospital receives.

Comment:

Some commenters asked if measure adoption will expand at a rate that keeps pace with hospital resources. Other commenters expressed concern that measure reporting might burden hospitals, while others suggested that we consider how difficult measures are for hospitals to improve upon.

Response:

We are cognizant of the reporting burden on hospitals associated with the adoption of new measures under both the Hospital IQR program and the Hospital VBP program. In proposing to adopt new measures for the Hospital IQR program, which make them candidates for the Hospital VBP program, we have emphasized on many occasions that we take into consideration the burden that additional reporting will have on hospitals, and we seek, for that reason, to limit our proposals to adopt chart-abstracted measures. We also carefully consider whether the benefit that we believe will be realized from adopting additional measures (such as encouraging hospitals to improve their performance on those measures) will outweigh the burden associated with their collection.

Comment:

Some commenters asked if 30-day readmission rates will be included in the Hospital VBP program.

Response:

Measures of readmissions are statutorily excluded under section 1886(o)(2)(A) of the Act and therefore cannot be included in the Hospital VBP program.

Comment:

A commenter asked if measure scores will be based on all-payer data or Medicare data only. Some commenters argued that the Hospital VBP program's measures should capture data for all patients, not Medicare patients only so that hospitals are ranked and incentivized according to their care for all patients, rather than for Medicare patients only.

Response:

Measures in the clinical process and patient experience domains are scored using all-patient data while measures in the outcome domain will be scored using Medicare claims data only. Although we generally agree that all-patient data would be a preferable

source of data for purposes of calculating all Hospital VBP measures, we currently do not have access to claims data submitted by hospitals to other payers.

Comment:

Some commenters suggested that we more forcefully endorse the NQF process, expressing concern that marginalizing the NQF endorsement process might discourage hundreds of hard working volunteers.

Response:

We work closely with the NQF on issues related to measure endorsement because that entity holds the contract under section 1890(a) of the Act. However, we note that in the case of a specified area or medical topic determined appropriate by the Secretary for which there is no NQF-endorsed measure, section 1886(b)(3)(B)(viii)(IX)(bb) of the Act allows us to specify a measure that is not NQF-endorsed so long as due consideration has been given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary.

Comment:

Several commenters suggested that we consider adopting a central line-associated blood stream infections measure, a surgical site infections measure, and/or the National Database of Nursing Quality Indicators for the Hospital VBP program.

Response:

We thank commenters for their input. We note that we have adopted a central line-associated blood stream infection measure (CLABSI) and surgical site infection measure (SSI) for the Hospital IQR program, and we anticipate proposing to adopt these measures for the Hospital VBP program in the future. The National Database of Nursing Quality Indicators (NDNQI) were previously considered for Hospital IQR program adoption (See 72 FR 47351), and we remain interested in these measures.

Comment:

Some commenters asked us to explain why the current requirement by CMS for NHSN reporting begins with January 2011 events for CLABSI and with January 2012 events for SSI.

Response:

In response to public comments on the FY 2011 IPPS/LTCH PPS proposed rule, we adopted one NHSN collected measure (the CLABSI measure) for the FY 2013 Hospital IQR payment determination (with reporting beginning with respect to January 2011 events) to allow hospitals to gain experience with the NHSN collection mechanism for one year before requiring hospitals to begin reporting a second measure (SSI) using that mechanism (75 FR 50202).

Comment:

Some commenters argued that the FY 2013 measures do not reflect nurses' contributions to patient care.

Response:

We disagree. Many of the process of care measures reflect the contributions of a broad range of healthcare professionals, including nurses. Furthermore, a number of measures rely heavily on nursing input and documentation. Additionally, one of the eight HCAHPS dimensions focuses exclusively on nurses' role in communicating with patients regarding their care.

Comment:

One commenter suggested that we post measure information on

Hospital Compare

for 2 years prior to adopting them in the Hospital VBP program.

Response:

We thank the commenter for the input. Although we acknowledge that section 1886(o)(2)(C)(i) provides, in part, that measures must be included on the Hospital Compare Web site for at least one year prior to the performance period, we believe that a one year period is sufficient to ensure that hospitals, Medicare beneficiaries and other stakeholders are fully aware of and familiar with the measures before they are added to the Hospital VBP program. We also believe that any further delay would unnecessarily postpone the adoption of important measures for the Hospital VBP program.

Comment:

One commenter noted that care coordination measures are not included in the Hospital VBP measure set.

Response:

We will consider this comment as we seek to expand the Hospital VBP measure set in the future.

Comment:

One commenter called on us not to use the Krumholtz methodology for mortality measures. The commenter noted that this methodology has only been applied in very narrow ranges of diagnoses; may not be useful for comparing mortality rates; has weak explanatory power; omits variables that should be considered; and would be difficult if not impossible to generalize.

Response:

We disagree. The risk-standardized mortality rates for the three proposed mortality measures are derived from administrative data for Medicare patients with a principal discharge diagnosis of AMI, HF, and PN from all acute care and critical access hospitals in the nation. The model used for calculation includes several variables and has a relatively high discrimination rate. As a result we believe this methodology is appropriate to use. Additionally, this methodology falls within the scope of the NQF-endorsement for the three proposed mortality measures.

Comment:

One commenter asked us to clarify whether hospital data reported on

Hospital Compare

that are also collected by the Joint Commission will continue to be included on

Hospital Compare.

Response:

Yes. Many of the AMI, Heart Failure, Pneumonia and SCIP measures reported to CMS for Hospital IQR and publicly reported on

Hospital Compare

are also collected and utilized by the Joint Commission. In addition, hospitals can voluntarily choose to allow CMS to publicly report the Joint Commission's children's asthma care measures, which are not part of Hospital IQR, on

Hospital Compare.

We will continue to publicly report all Hospital IQR measures and other quality information on

Hospital Compare.

Comment:

One commenter questioned whether the proposed clinical process of care measures have been tested in older patients and women to assure applicability to Medicare's patient subpopulations.

Response:

The clinical process of care measures proposed for the Hospital VBP program have been tested and used in all patients 18 years and older which includes older patients and women if they meet criteria for inclusion in the measure.

Comment:

Some commenters recommended that CMS and outside experts study the measures' actual impact on patients and caregivers. Commenters also expressed concern about possible unintended consequences for patient care due to measure design, such as some hospitals refusing to admit high-risk patients in an effort to improve their Total Performance Score.

Response:

We thank commenters for their input. We intend to monitor the initial impacts of the Hospital VBP program, including its impacts on costs, quality, outcomes, and patient experiences with care. We believe the Hospital VBP program represents a significant next step in aligning payment with the quality of care delivered to beneficiaries. We firmly believe that these efforts will increase the quality of care provided, resulting in improved health outcomes. However, we will monitor and evaluate the impact of the Hospital VBP program on access to and quality of care, including monitoring any unintended consequences.

Comment:

One commenter stated that the proposal to use electronic submission for measures in future years was misaligned with one of the potential future measures. The measure, “median time from admit decision time to time of departure from the emergency department (ED) for ED patients admitted to inpatient status” differs from the specifications put forth by

HITSP (Health Information Technology Standards) which specifies the measure as, Admit Decision Time to ED Departure Time. The difference is that the former does not allow for the use of Admit Orders Date (or Admit Orders Time) in the measures specification while the HITSP specifications do allow the use of this data.

Response:

We agree that the measure specifications for “median time from admit decision time to time of departure from the emergency department (ED) for ED patients admitted to inpatient status” require manual chart abstraction, and is specified slightly different than electronic health record version of the measure. This is because of the availability of the data. When abstracting data manually, a human abstractor uses specific guidelines for abstraction. Admit order date/time are not included in the chart abstracted version as the intent of the measure is to calculate throughput time (that is, how long the patient is in the ED) which is calculated from admit decision to departure from the Emergency Department. The admit decision time is generally found in a note written in the chart, and therefore, a human abstractor can interpret that data element per the guidelines for abstractions. In contrast, admit date/time are used in the electronic specifications as the two fields are readily available in the electronic health record (EHR), and there is no human interpretation. At this time, data from a progress note is not considered a discreet data element and therefore cannot be used for EHR abstraction.

After consideration of public comments, we are finalizing our proposed definition of “topped out” for purposes of measure selection under the Hospital VBP program. We will use this definition to inform our measure proposals for future Hospital VBP program years and will use the most recently available data at the time to conduct our analysis. Additionally, we are finalizing our proposal to adopt 12 of the 17 proposed clinical process of care measures for the FY 2013 Hospital VBP program, but for the reasons discussed above, are not finalizing our proposal to adopt the following measures: PN-2, PN-7, AMI-2, HF-2 and HF-3.

Table 2 lists the 13 measures we are finalizing for the FY 2013 Hospital VBP measure set.

Table 2—Final Measures for FY 2013 Hospital VBP Program

Measure ID

Measure description

Clinical Process of Care Measures

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.

Healthcare-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 6AM Postoperative Serum Glucose.

Surgeries

SCIP-Card-2

Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker 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

HCAHPS

Hospital Consumer Assessment of Healthcare Providers and Systems Survey.

5

With respect

to the FY 2014 Hospital VBP measure set, we are finalizing our proposal to adopt the three 30-day mortality claims-based measures, MORT-30-AMI, MORT-30-HF, and MORT-30-PN, as well as the 8 proposed HAC measures. In light of the public comments we received regarding the proposed AHRQ measures and as discussed above, we are only finalizing the 2 composite measures: Complication/patient safety for selected indicators (composite) and Mortality for selected medical conditions (composite). The measures that we are finalizing in this final rule for the FY 2014 Hospital VBP Program are listed in Table 3 below.

5

Proposed dimensions of the HCAHPS survey for use in the FY 2013 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.

Table 3—Finalized Outcome Measures for the FY 2014 Hospital VBP Program

Mortality Measures (Medicare Patients):

• Acute Myocardial Infarction (AMI) 30-day mortality rate

• Heart Failure (HF) 30-day mortality rate

• Pneumonia (PN) 30-day mortality rate

AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs) Composite Measures:

• Complication/patient safety for selected indicators (composite)

• Mortality for selected medical conditions (composite)

Hospital Acquired Condition Measures:

• Foreign Object Retained After Surgery

• Air Embolism

• Blood Incompatibility

• Pressure Ulcer Stages III & IV

• Falls and Trauma: (Includes: Fracture Dislocation Intracranial Injury Crushing Injury Burn Electric Shock)

• Vascular Catheter-Associated Infection

• Catheter-Associated Urinary Tract Infection (UTI)

• Manifestations of Poor Glycemic Control

As noted above, we have proposed in the FY 2012 IPPS/LTCH PPS proposed rule scheduled for publication on May 5, 2011 to adopt an additional measure, Medicare spending per beneficiary, for the FY 2014 Hospital VBP program. We also intend to propose to adopt additional measures for the FY 2014 Hospital VBP program in the CY 2012 OPPS proposed rule.

E. Performance Standards

To determine what the performance standard for each proposed clinical process of care measure and the proposed HCAHPS measure should be for purposes of the FY 2013 Hospital VBP program, we analyzed the most reliable and current hospital data that we had on each of these measures by virtue of the Hospital IQR program. Because we proposed to adopt a performance period that was less than a full year for FY 2013, we were sensitive to the fact that hospital performance on the proposed measures could be affected by seasonal variations in patient mix, case severity, and other factors. To address this potential variation and ensure that the hospital scores reflect their actual performance on the measures, we believe that the performance standard for each clinical process of care measure and HCAHPS should be based on how well hospitals performed on the measure during the same time period in the applicable baseline period. In determining what three-quarter baseline period would be the most appropriate to propose to use for the FY 2013 Hospital VBP program, we wanted to ensure that the baseline would be as close in time to the proposed performance period as possible. We stated our belief that selecting a three-quarter baseline period from July 1, 2009 to March 31, 2010 will enable us to achieve this goal. We also believe that an essential goal of the Hospital VBP program is to provide incentives to all hospitals to improve the quality of care that they furnish to their patients. In determining what level of hospital performance would be appropriate to select as the performance standards for each measure, we focused on selecting levels that would challenge hospitals to continuously improve or maintain high levels of performance.

As required by Section 1886(o)(3)(D), we specifically considered hospitals' practical experience with the measures, particularly through the Hospital IQR program, examining how different achievement and improvement thresholds would have historically impacted hospitals, how hospital performance may have changed over time, and how hospitals could continue to improve.

We proposed to set the achievement performance standard (achievement threshold) for each proposed FY 2013 Hospital VBP measure at the median of hospital performance (50th percentile) during the baseline period of July 1, 2009 through March 31, 2010. As proposed in the Hospital Inpatient VBP proposed rule (76 FR 2463 through 2464), hospitals would receive achievement points only if they exceed the achievement performance standard and could increase their achievement score based on higher levels of performance. We believe these achievement performance standards represent achievable standards of excellence and will reward hospitals for meritorious performance on quality measures. We also proposed to set the improvement performance standard (improvement threshold) for each measure at each specific hospital's performance on the measure during the baseline period of July 1, 2009 through March 31, 2010. We believe that these proposed improvement performance standards ensure that hospitals will be adequately incentivized to improve.

We proposed to set the achievement performance standard (achievement threshold) for each of the proposed FY 2014 Hospital VBP mortality measures at the median of hospital performance (50th percentile) during the baseline period. We proposed to set the improvement performance standard (improvement threshold) for each mortality measure at each specific hospital's performance on each measure during the baseline period of July 1, 2008 to December 31, 2009. The comments we received on these proposals and our responses are set forth below.

Comment:

A number of commenters suggested that we publish baseline achievement thresholds and benchmarks for clinical process measures and HCAHPS dimensions on

Hospital Compare.

Response:

The finalized achievement thresholds and benchmarks that apply to the FY 2013 Hospital VBP program are provided in Table 4 of this final rule. We will consider the commenters suggestion to publish baseline achievement thresholds and benchmarks on Hospital Compare in the future.

Comment:

One commenter requested that CMS clarify whether hospitals lacking the minimum number of patients or measures would be included in baseline period calculations of thresholds and benchmarks.

Response:

The achievement thresholds and benchmarks will be calculated using data from a baseline period comparable in length to the performance period. For this reason, we believe that we should also use the same minimums for purposes of those calculations.

Comment:

One commenter suggested that we compare performance among similar hospitals rather than against

national data. Other commenters asked if CMS was going to adjust the baseline period data based on any factors such as geographic region.

Response:

We believe that achievement thresholds and benchmarks based on national data provide balanced, appropriate standards of high quality care for hospitals to work towards under the Hospital VBP program. Some groups of hospitals may perform better or worse than other hospitals on certain measures, but we do not believe it would appropriate to raise or lower the performance standards based on such observations. For example, we do not wish to lower the performance standards for a hospital simply because average performance in its local region is subpar compared to national performance. Similarly, we do not wish to raise or lower the performance standards for large hospitals, teaching hospitals, or others based on any observations that classes of hospitals differed in their average performance on individual measures. We note that consumers will be able to compare geographically and demographically similar hospitals' performance on measures as they currently do on the

Hospital Compare

Web site.

Comment:

One commenter asked us to clarify the baseline periods for Hospital VBP program years after FY 2013.

Response:

We intend to propose all future baseline periods in future rulemaking and specifically, intend to propose the FY 2014 Hospital VBP payment determination baseline period in the CY 2012 OPPS rule.

Comment:

One commenter asked how CMS will address hospital mergers that occur during the performance period.

Response:

The issue of how to address the calculation of the total performance score in the context of hospital mergers will be the subject of future rulemaking.

After considering the public comments, we are finalizing the proposed definitions of the achievement performance standard (achievement threshold) and the improvement performance standard (improvement threshold) for the FY 2013 Hospital VBP program as displayed below in Table 4. Because our process for validating the proposed baseline period of data was not yet complete at the time we issued the proposed rule, we were unable to provide the precise achievement threshold values; instead we provided example achievement performance standards. We also stated that these values would be specified in the final rule (76 FR 2464), and they are shown below.

Table 4—Achievement Thresholds That Apply to the FY 2013 Hospital VBP Program Measures

Measure ID

Measure description

Performance standard (achievement threshold)

Clinical Process of Care Measures

AMI-7a

Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival

0.6548

AMI-8a

Primary PCI Received Within 90 Minutes of Hospital Arrival

0.9186

HF-1

Discharge Instructions

0.9077

PN-3b

Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital

0.9643

PN-6

Initial Antibiotic Selection for CAP in Immunocompetent Patient

0.9277

SCIP-Inf-1

Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision

0.9735

SCIP-Inf-2

Prophylactic Antibiotic Selection for Surgical Patients

0.9766

SCIP-Inf-3

Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time

0.9507

SCIP-Inf-4

Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose

0.9428

SCIP-VTE-1

Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered

0.9500

SCIP-VTE-2

Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery

0.9307

SCIP-Card-2

Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period

0.9399

Patient Experience of Care Measures

HCAHPS

Communication with Nurses

75.18%

Communication with Doctors

79.42%

Responsiveness of Hospital Staff

61.82%

Pain Management

68.75%

Communication About Medicines

59.28%

Cleanliness and Quietness of Hospital Environment

62.80%

Discharge Information

81.93%

Overall Rating of Hospital

66.02%

We are also finalizing the achievement thresholds for the three mortality measures, (displayed as survival rates) in Table 5 below based on a 12-month baseline period from July 1, 2009 to June 30, 2010:

Table 5—Achievement Thresholds for the FY 2014 Hospital VBP program Mortality Outcome Measures (Displayed as Survival Rates)

Measure ID

Measure description

Performance standard (achievement threshold)

Mortality Outcome Measures

MORT-30-AMI

Acute Myocardial Infarction (AMI) 30-Day Mortality Rate

84.8082%

MORT-30-HF

Heart Failure (HF) 30-Day Mortality Rate

88.6109%

MORT-30 PN

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