2013 Inpatient Prospective Payment System Medicare Proposed Rule Released

On April 24, 2012, the Centers for Medicare and Medicaid Services (CMS) released its proposed rule for the 2013 Inpatient Prospective Payment System (IPPS) rule, which covers payment and quality issues for services performed in an inpatient hospital between Oct. 1, 2012 and Sept. 30, 2013. The ACC will submit comments on the proposed rule by June 25 and CMS will issue a final rule covering these policies towards the end of the summer. The following are areas of interest for cardiovascular medicine.

Surgical site infection for cardiac devices

The Medicare payment system for hospitals pays more for a discharge if certain complicating conditions are present in addition to the primary diagnosis for which the patient is discharged, in order to account for the additional costs of treating these patients. Starting in 2008, CMS determined that certain complications would not allow for that increased payment unless they were present and documented on admission.  These conditions are intended to be those that could reasonably be prevented through the application of evidence-based guidelines. In this rule, CMS proposes to add a new hospital-acquired condition in this category:  surgical site infection following cardiac implantable electronic device procedures.  This means that the coding of certain ICD9 diagnostic codes will not allow for a higher payment because this could have been reasonably prevented. 

Diagnosis-related group (DRG) for ventricular assist device

CMS reviews a request made by the manufacturer of a ventricular assist device (VAD) to establish a unique DRG for VAD implantation. Currently, VADs are paid under the same DRG as heart transplant cases.  After reviewing data from the submitted claims, CMS proposes to maintain the DRG placement for these procedures. 

DRG for percutaneous mitral valve repair

CMS reviews a request to reassign the procedure code for percutaneous mitral valve repair (mitral valve clip) from the DRGs that would be used for percutaneous coronary interventions (PCIs) to the DRGs used for reporting other valve procedures.  After reviewing claims data that indicates that the costs associated with the service are significantly lower than those reported for the other valve procedures, CMS proposes to retain the mitral valve repair in the same DRG family as PCI services.

Heart failure, cardiomyopathy, and chronic total occlusion of arteries of the extremities as complicating conditions

CMS reviews the request to reclassify heart failure as a complicating condition for DRGs which would lead to a higher payment.  In addition, the request would remove cardiomyopathy as a complicating condition.  After reviewing data which suggests that heart failure does not cause a significant change in costs, CMS proposes no change – keeping cardiomyopathy as a complicating condition and congestive heart failure as non-complicating condition.  However, CMS has proposed to add chronic total occlusion of the arteries of the extremities as a complicating condition after reviewing data which shows the presence of this diagnosis greatly increases costs. 

Add-on payment for drug-eluting stent for peripheral arterial disease (PAD)

CMS considers a request to add a drug-eluting stent for PAD as a new technology add-on payment.  New technology payments are made for services that increase the costs of providing a service but also demonstrate additional value for patients.  CMS requests comments on the utility of these stents as well as when they would be typically used, which will determine if they qualify for a new technology add-on payment. 

Hospital Readmission Reduction Program

The Affordable Care Act requires CMS to reduce the payments to hospitals with high readmission levels.  CMS proposes to measure readmission levels for the conditions of heart failure, acute myocardial infarction, and pneumonia that occur within 30 days of discharge between July 1, 2008 and June 30, 2011 for the 2013 hospital fiscal year that begins Oct. 1, 2012. The measures are based on all-cause readmissions with exceptions for transfers and planned readmissions. Payments to hospitals can be reduced by as much as one percent.  The majority of hospitals will have reductions of modest amounts of less than one percent, but CMS indicates that 481 hospitals would receive one percent payment adjustments under this proposal. 

Hospital Inpatient Quality Reporting Program (IQR)

Removed measures
CMS proposes to remove 17 measures from the IQR program. Sixteen of these measures are claims-based.  None of these 17 measures specifically focus on cardiovascular care.  Most measures were removed due to redundancy with other measurement efforts or the creation of NQF-endorsed composite measures. 

In 2012, CMS suspended the collection of data for three AMI measures (aspirin at arrival, ACE/ARB for LVSD, beta blocker at discharge) that had topped out due to universal high performance. CMS proposes no change with these measures– they will continue to exist but hospitals will not report data.  By not removing the measures, CMS may restart collection of data at any time without further rulemaking. 

Proposed new measures

NQF 0228 – Care Transition (based on additional HCAHPS survey questions)

NQF 1789 (tentative) – Hospital-wide readmission – This measure is 30 day all cause readmission.  There are some exclusions for planned readmissions and cancer patients. The measure is risk-adjusted using standard CMS methods.  While this measure will be included in the IQR, it is unlikely to be allowed as part of the hospital value-based purchasing program due to the separate readmission reduction program.

Future Proposed Measures

Smoking cessation set of measures developed by The Joint Commission 

Hospital Value-Based Purchasing Program

Additional measures

CMS proposes to add AMI-10: Statin prescribed at discharge as a process measure used in the value-based purchasing calculation for the 2015 payment determination that starts Oct. 1, 2014.  This measure has been reported by hospitals since 2011 and has been reported on Hospital Compare since 2012.  CMS proposes to retain 12 of the 13 other process measures finalized for 2014. 

CMS proposes to add a Medicare spending per beneficiary measure for 2015.  This would measure costs associated with patients three days before and 30 days post discharge for all hospitalized patients.  It is risk adjusted for age and illness. This is not National Quality Forum (NQF) endorsed, but CMS plans to submit the measure to NQF in the future. 

Measure domain reclassification

CMS had placed all measures into domains last year.  For the 2016 program, they propose reclassification into six domains based on the elements of the National Quality Strategy (clinical care; person- and caregiver-centered experience and outcomes; safety; efficiency and cost reduction; care coordination; and community/population health.) The performance score is aggregated across all measures in a domain so domain placement can be relevant.  CMS requests input on how to weight each of the domains to determine the quality score. 

Measurement period for 2015 program

A number of the measures for the 2015 program will be calculated based on a nine month reporting time period because CMS is required to post them on the Hospital Compare site for one year.  CMS requests comments on whether performance can be adequately captured over that period. 

Rulemaking changes
Policies that are part of hospital value-based purchasing have been released as part of the inpatient and outpatient hospital payment rules. CMS expresses concern about this scheduling in the rule and proposes to change performance standards and performance periods for performance measures using a sub-regulatory process.  It is unclear if this process allows for public comment and response before implementation. 

Measure domain weighting

As discussed above, measures are placed in a domain.  CMS has proposed a reweighting of the domains since efficiency measures have been added.  Proposed weighting is below:

  • Clinical Process of Care – 20 percent

  • Patient Experience of Care – 30 percent

  • Outcome – 30 percent

  • Efficiency – 20 percent

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