Do the CMS hospital P4P regs signal ACO measures to come?

CMS released the proposed rules for the hospital inpatient value-based purchasing program, in support of Section 3001(a) of the Patient Protection and Affordable Care Act. The program, designed to reward hospitals for quality improvement, will apply in 2013 to payments for discharges occurring on or after Oct. 1, 2012. According to a CMS press release, this is an example of value-based purchasing (VBP) or pay-for-performance (P4P) that will move our healthcare system, “toward rewarding better value, outcomes, and innovations instead of merely volume.” CMS will accept public comments on the proposed rule through March 8th.

Do these Hospital VBP program measures provide some insight as to which measures will be selected by CMS for ACOs under the Shared Savings P4P program? If so, what can we learn?

In their comments, CMS acknowledges that these P4P 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.” This is a wise approach that I advocated in my posting, “ACO Quality: Don’t Forget the Processes.”

The 2013 Hospital VBP program will include measures already adopted for the Hospital Inpatient Quality Reporting Program (IQR).  In this Hospital IQR program, hospitals that do not participate in reporting measures receive an annual 2.0 percentage point reduction in their Medicare rate inflation adjustments (market basket update).

The majority of the Hospital VBP program proposed measures will be clinical process of care measures, such as whether aspirin was prescribed at discharge to a patient recovering from an acute myocardial infarction. Other categories for the 17 different processes of care measures include heart failure, pneumonia, healthcare-associated infections, and surgeries. In addition, a patient satisfaction survey called, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), will be included.  For these measures, CMS proposes that the 2013 payment be based on a three-quarter performance period from July 1, 2011 through March 31, 2012 compared to the three-quarter baseline period from July 1, 2009 to March 31, 2010.

Finally, CMS proposed to include three outcome measures in the Hospital VBP program. Instead of the three-quarter performance period proposed for the process of care and HCAHPS measures, the risk-adjusted mortality outcome measures will be aggregated for 18 months to provide sufficiently accurate information about a hospital's outcomes on which to score hospitals on these measures and base payment. CMS will use the 18-month period from July 1, 2011 to December 31, 2012 to compare to the baseline period of July 1, 2008 to December 31, 2009. Acute Myocardial Infarction 30-Day Mortality Rate (MORT-30-AMI), Heart Failure 30-Day Mortality Rate (MORT-30-HF), Pneumonia 30-Day Mortality Rate (MORT-30-PN ).

So, what’s missing? According to ACA (sec. 3001(a)), CMS could not include any measure that wasn’t already included on the Hospital Compare website for at least one year. This means that readmission measures were excluded for 2013, but CMS hopes to include those in the future. Such restrictions do not apply to the ACO Shared Savings program.

Also, CMS removed the so-called “topped-out” measures from the list. “Topped-out” measures are those where all but a few hospitals performed well and provide no meaningful differentiation between hospital quality performances. Some of these measures include aspirin at arrival (AMI-1) and beta blocker at discharge (AMI-5).

In addition, the Hospital IQR structural measures, such as participation in Stroke Registries, were excluded due to measurement and reporting problems. 

CMS did not yet propose efficiency measures, including measures of “Medicare Spending per beneficiary” or “internal hospital efficiency,” as required by statute.  CMS wants public comment as to on potential efficiency measures.

Preliminary ACO regulations are due from CMS soon. We’ll see what impact these choices have on their proposed measures.

ACA’s Medical Loss Ratio provisions

Today’s press release by the Health and Humans Services states that the Affordable Care Act’s Medical Loss Ratio floor provisions will “increase value for consumers.” In effect, the law requires health insurers to provide rebates to their policyholders if their MLR is less than 85 percent in the large group market or less than 80 percent in the small group market and individual market. There are two points that I’d like to make on these interim final regulations. The interim final regulations can be found here.

First, the regulations recognize important Quality Improvement functions that managed care purports to offer to consumers. The interim regulations define Quality Improvement as activities “grounded in evidence-based medicine, widely accepted best clinical practice, or criteria issued by recognized medical associations, accreditation bodies, government agencies, or other nationally recognized health care quality organizations.”

In addition to the obvious case/disease management initiatives, these activities include:

• “Any HIT expenditure that is attributable to improving health care, preventing hospital readmissions, improving patient safety and reducing errors, or promoting health activities and wellness to an individual or an identified segment of the population, is classified as a quality improvement activity”
• “Fraud recovery expenses … up to the amount of fraudulent claims recovered.”

The second point I want to make is regarding the regulation comments that state, “if the activity is designed primarily to control or contain costs, then expenditures for it may not be included as a quality improvement activity.” On the face, this seems to increase the “value to the consumer.”

The assumption with this comment is that more medical care is good, and that less healthcare (especially when spent on administrative activities) is bad. This is a fallacy debunked by the work done at the Dartmouth Atlas. As summarized by Dr. Skinner, “a high-intensity practice pattern is associated with lower quality of care and worse outcomes than a more conservative practice pattern.”

So, it can be said that managed care activities that control inappropriate utilization of medical care that may decrease quality healthcare outcomes. Numerous studies over the years support this notion. Here is a table of some common inappropriate treatments.

Service	% Inappropriate	Study
Childhood tube insertions	23%	Kleinman et al., 1994
Antibiotics for the common cold	60%	Mainous et al., 1996
CABG surgeries	14%	Winslow et al., 1988
Carotid endarterectomies	32%	Chassin et al., 1987
Upper GI endoscopies	17%	Chassin et al., 1987

Let me know your thoughts on the matter.