IPF Quality Reporting: CMS Plunges Ahead Without NQF Endorsment

On August 6, 2014, CMS issued the Inpatient Psychiatric Facility (IPF) Medicare Prospective Payment System (PPS) Fiscal Year (FY) 2015 Final Rule.  In addition to adjusting rates and addressing ICD-10 implementation, the Final rule also included changes to the IPF Quality Reporting (IPFQR) Program.  The IPFQR applies to both inpatient psychiatric hospitals and psychiatric units within acute care and critical access hospitals.

The IPFQR Program

Sections 3401(f) and 10322(a) of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) amended section 1886(s)(4) of the Social Security Act (the Act) to require the HHS Secretary to implement a quality reporting program for IPFs.  According to the Act, the Secretary shall reduce the standard Federal rate for discharges occurring during the FY by 2.0 percentage points for IPFs that do not comply with quality data submission requirements.  The provision is applicable to all FYs beginning with FY 2014; reductions do not affect rates in other FYs.

Quality reporting measures must be endorsed by the entity that holds a contract under section 1890(a) of the Act; currently, that entity is the National Quality Forum (NQF).  Measures are typically submitted for feedback to the Measure Application Partnership (MAP), a multi-stakeholder group convened by the NQF.  However, pursuant to section 1886(s)(4)(D)(ii) of the Act, the Secretary may specify a measure that has not been endorsed by the NQF if she gives due consideration to measures that have been endorsed or adopted by a consensus organization.  The Secretary must report the quality measures related to services furnished by IPFs on the CMS website.

The IPFQR Program is intended to support the general objectives of the HHS National Quality Strategy (NQF) and the CMS Quality Strategy, which include promotion of better health care, lowering of costs, improved quality, promotion of transparency, and support for patient decision-making. In addition, the Program will align IPF goals and measures with those of other health care providers.  Prior rules adopted seven quality measures.  Hours of Physical Restraint Use, Hours of Seclusion Use, Patients Discharged on Multiple Antipsychotic Medications, Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification, Post-Discharge Continuing Care Plan Created, and Post-Discharge Continuing Care Plan Transmitted to Next Level of Care Provider Upon Discharge applied to FY 2014 payment determinations and determinations for subsequent years; Alcohol Use Screening and Follow-Up After Hospitalization for Mental Illness will apply to FY 2016 and payment determinations and subsequent years.  All measures were endorsed by the NQF, although Patients Discharged on Multiple Antipsychotic Medications is no longer endorsed.

New Measures for FY 2016

The FY 2015 Final rule added two new measures for FY 2016, Assessment of Patient Experience of Care and Use of an Electronic Health Record.  They are a departure from previous measures in that they are not endorsed by the NQF.  Previously, CMS “implemented a voluntary collection of information as to whether IPFs administer a detailed assessment of patient experience of care using a standardized collection protocol and a structured instrument.”  IPFs answering yes were asked to provide the name of the survey they used.  CMS has decided to make this voluntary collection mandatory, changing the name to “Assessment of Patient Experience of Care” and asking IPFs if they engaged in routine assessments (occurring as a regular, commonplace activity) of patient experience of care. The MAP indicated its support for the measure, but believed it should eventually be replaced with “a robust survey of patient experience and a measure based on consumer-reported information.”  CMS, however, believes that the measure it devised would provide information on patient and family engagement and experience of care, an area of the HHS National Quality Strategy that is not currently addressed in the Program, and allow it to develop a standardized survey of patient assessment of care that can be used in the future.  The NQF did not endorse the measure; however, because the agency was unable to find other feasible and practical measures regarding patient experience of care in the IPF setting that had been endorsed or adopted by a consensus organization, the measure was deemed to meet the selection exception requirement under the SSA.  The agency emphasized that IPFs will not be penalized for failure to collect patient experience of care data.

CMS also instituted the Use of an Electronic Health Record (EHR) measure, which requires facilities to attest to whether the facility most commonly exchanged health information using paper documents, non-certified EHR technology, or certified EHR technology.  IPFs must also indicate whether health information exchanged during care transitions included the exchange of interoperable health information with a health information service provider.  The NQF did not endorse the measure, as the MAP noted that psychiatric hospitals were excluded from the Medicaid and Medicare EHR Incentive Programs, which provide financial incentives for providers meeting certain guidelines regarding the use of EHRs.  The MAP thus determined that the measure did not address the current needs of the IPFQR Program.  CMS disagreed, noting that the use of EHRs could “effectively and efficiently help providers improve internal care delivery practices, support the exchange of important information across care partners and during transitions of care, and could enable the reporting of electronically specified clinical quality measures eCQMs).”  Although EHR technology has not been specially certified for IPFs, many of the core functions of clinical care captured by EHRs are the same across care settings.  Because it was unable to find other feasible and practical ways to measure the degree to which IPFs utilize an EHR system that were endorsed or adopted by a consensus organization, CMS finalized the rule without NQF endorsement.

FY 2017 and Beyond

CMS also finalized four measures that will be included for the FY 2017 payment determination and subsequent years:  Influenza Immunization, Influenza Vaccination Coverage Among Healthcare Personnel, Tobacco Use Screening, and Tobacco Use Treatment Provided or Offered.  While the tobacco-related measures were NQF-endorsed, the influenza-related measures were not.  The Influenza Immunization measure would assess inpatients aged 6 months and older who were discharged  at any time from October through March who are screened for influenza vaccination status and vaccinated prior to discharge, if indicated.  The MAP gave conditional support to the measure, but determined that it needed more experience or testing.  CMS believes that the measure would not only reduce the rate of infection, but would also provide consumers with valuable information when choosing among health care facilities.  Furthermore, CMS stated that specifications do not need to be adjusted for IPFs, noting that the measure has been endorsed for the Hospital/Acute care facility setting, and that the characteristics of those facilities are similar to the characteristics IPFs.    The Influenza Vaccination Coverage Among HealthCare Personnel  (HCP) measure assesses the percentage of HCP who receive the influenza vaccination from October through March.  Once again, the MAP gave conditional support, concluding that the measure required more experience or testing, and stating that CMS must collaborate with the Centers for Disease Control (CDC) to adjust specifications for IPFs. CMS conferred with the CDC and added clarifying language stating that IPFs will use the CDC National Healthcare Safety Network infrastructure and protocol to report the IPFQR measures.  Furthermore, CMS believes that adoption of the measure would reduce the number of HCP receiving or transmitting influenza and provide patients with information that could aid in their selection of IPFs.  CMS finalized both measures as meeting the exception to endorsement.

CMS also noted plans to adopt one or more of the following measures in the future:  Suicide Risk Screening completed within one day of admission, Violence Risk Screening completed within one day of admission, Drug Use Screening completed within one day of admission, Alcohol Use Screening completed within one day of admission, and Metabolic Screening.  The agency also plans to develop a 30-day psychiatric readmission measure, which would include readmissions for non-psychiatric diagnoses.