The goal of this article is to provide background on national quality measure reporting and reimbursement programs as well as updates regarding current, future, and retired quality measures relevant to the practice of emergency medicine.

The Centers for Medicare and Medicaid Services (CMS) remains the dominant player in the determination of how hospitals and providers are reimbursed for quality. Currently, CMS is transitioning from a pay-for-reporting to a pay-for-performance system. The first step in this transition is value-based purchasing. CMS directs its influence through three main programs:

• Physician Quality Reporting System (PQRS). Providers are responsible for reporting PQRS measures via claims through their billing companies. These measures include Medicare Part B patients only, but do include both admitted and discharged patients.
• Outpatient Prospective Payment System (OPPS). Hospitals are responsible for reporting these measures, which include all patients, regardless of payer, with a broad range of dispositions including admissions, transfers, and discharges.
• Inpatient Prospective Payment System (IPPS). Hospitals are responsible for reporting these measures, which include all admitted patients, regardless of payer.

Physician Quality Reporting System

The 2006 Tax Relief and Health Care Act (TRHCA) required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals who satisfactorily submitted data on quality measures for covered professional services furnished to Medicare beneficiaries beginning in the 2007 reporting period. This CMS program was formerly known as the Physician Quality Reporting Initiative (PQRI). In 2011, a name change occurred, and the program is now known as the Physician Quality Reporting System to denote that it is no longer a pilot but rather an established program. The title of the program, however, is a misnomer as the program applies not only to physicians but also to physician assistants and nurse practitioners.

Provider-based measures largely originate from the AMA-PCPI (Physician Consortium on Performance Improvement, convened by the American Medical Association). The current PQRS measures are listed in Table 1. For 2012, there were a large number of new measures, with seven that are relevant to emergency medicine. Pending National Quality Forum (NQF) measure review and the endorsement process, it is possible that some of the current PQRS measures will be retired. A number of proposed additional measures are being considered for future PQRS implementation such as confirmation of ETT, pediatric weight in kilograms, and ultrasound guidance of IJ CVC placement.

The schedule for additional financial incentives and penalties for reporting PQRS measures is outlined in Table 2.

Outpatient Prospective Payment System

Hospital measures can originate from individuals, professional societies, academic institutions, and more recently, consulting agencies such as Optimal Solutions Group and Ingenix. The bulk of hospital measures that affect emergency medicine (Table 3) come from the OPPS and its associated data reporting program, the Hospital Outpatient Quality Reporting (OQR) Program. The Hospital OQR Program was mandated by the 2006 TRHCA, which requires in Subsection (d) for hospitals to submit data on measures on the quality of care furnished by hospitals in outpatient settings. To receive the full annual payment update (APU) under the OPPS, hospitals must meet administrative, data collection and submission, and data validation requirements of the Hospital OQR Program. Hospitals that fail to successfully participate in the OQR receive reduced payments through a reduction of 2.0 percentage points to the hospital market basket update.

The OPPS rule for 2012 included eight new measures. Though the reporting requirement begins in 2012, the hospital payment update does not occur until 2013.

For each of these measures, the patient population may vary significantly, ranging from any ED visit to only transfers. It is recommended that ED providers collaborate with their hospital’s quality departments to understand the outpatient measure populations. [continued online]

One particularly contentious measure worth noting is OP-15 – Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache. OP-15 will be the first measure that has been fast-tracked for inclusion into the OPPS program despite NQF rejection. ACEP through its Quality and Performance Committee has sent comments challenging this unprecedented path as well as the validity of this measure. A recent article has challenged the appropriateness of this outpatient imaging efficiency measure, which is based on Medicare administrative claims data. The study found that CMS data was only 17% accurate in assessing which patients should have received a CT scan in the ED setting; 83% should not have been labeled as inappropriate based on either ACEP clinical policy guidelines or expert consensus standards. Because CMS utilizes administrative claims data rather than a more thorough abstracting process as was performed in the study, hospitals’ performance on the new measure as reported by CMS did not match the true proportion of CTs with a documented clinical indication. The measure uses Medicare billing records to determine whether a CT scan was clinically appropriate. When the patients’ medical records were actually reviewed, they showed that 65% of the CT scans actually complied with Medicare’s measure and another 18% of patients had valid reasons for the CT scans documented in their charts. Medicare runs the risk of publicizing inaccurate information about clinical performance and rewarding/penalizing hospitals based on unreliable data.

Also of note, OP-19 was suspended by CMS due to concerns including, but not limited to, HIPAA. CMS is currently reworking the measure, and it is expected to return with slightly different measure specifications.

Inpatient Prospective Payment System

The IPPS describes the Hospital Inpatient Quality Reporting (IQR) Program, formerly known as the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) Program. RHQDAPU was originally mandated by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. This section authorized CMS to pay hospitals that successfully report designated quality measures a higher annual update to their payment rates. To this end, CMS initially implemented a 0.4 percentage point reduction in the annual market basket for hospitals that did not successfully report. In 2005, the Deficit Reduction Act increased that reduction to 2.0 percentage points.

The main 2012 changes to the hospital inpatient measures (Table 4) that affect emergency medicine include:

• Retirement of AMI-1: Aspirin at Arrival. It was felt that the vast majority of hospitals now perform well on this measure, and the measure has outlived its purpose. ED providers should keep in mind that although the hospital reporting on this measure to CMS will cease, the hospital may continue to report performance to The Joint Commission (TJC) for reaccreditation.
• Retirement of PN-5c: Initial Antibiotic Received within 6 Hours of Arrival. ED providers should keep in mind that although the hospital reporting on this measure to CMS will cease, the hospital may continue to report performance to TJC for reaccreditation.

Value-Based Purchasing

The CMS Hospital Inpatient Value-Based Purchasing (VBP) Program became law on July 1, 2011, and applies to payments for discharges occurring on or after Oct. 1, 2012. CMS believes VBP will reduce costs by encouraging value-added health care. The VBP is an evolution of the Hospital Inpatient Quality Reporting (IQR) Program; where IQR was “pay for reporting,” VBP is “pay for performance.” Given that the funding is derived from a reduction in payment, it is more accurately described as “nonpay for nonperformance.” CMS believes that VBP will be a vehicle to incentivize value and outcome (vs. volume). This is a significant change as CMS becomes a purchaser of services instead of payer of claims.

All short-stay acute care hospitals that see a minimum of 10 cases for at least four applicable measures are required to participate in VBP. Hospitals are currently measured on 17 clinical process measures and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. To determine the hospital’s overall VBP score, clinical process measures will receive a 70% weight and HCAHPS will receive a 30% weight. The actual calculation of VBP dollars is complex and will vary depending on the hospital. The larger the specific hospital’s percentage of revenues derived from Medicare payments, the larger the financial implications to that hospital. All eligible hospitals will be splitting shares of the VBP fund, which is funded by a 1% reduction in base diagnosis-related group (DRG) reimbursement. CMS estimates that the size of the fund for FY2013 will be $850 million. On an annual basis, the reduction in base DRG reimbursement will increase by 0.25% until it totals 2% for FY2017.

Though many of the processes of care measures could feasibly touch on emergency care, four inpatient quality measures are specifically relevant to emergency care:

• AMI-7a: Thrombolytics within 30 Minutes of Hospital Arrival for STEMI.
• AMI-8a: Primary PCI within 90 Minutes of Hospital Arrival for STEMI.
• PN-3b: Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital.
• PN-6: Pneumonia Patients Given the Most Appropriate Initial Antibiotic.

In brief, for each of the above performance measures, hospitals receive an achievement score between 1 and 10 based on how much their current performance score exceeds the median for all hospitals. If the score is below the median, the hospital receives an achievement score of zero. Additionally, hospitals also receive an improvement score between 1 and 10 based on how much the score on the performance measure improved from the previous (i.e., baseline) year. If performance did not improve, the hospital receives an improvement score of zero. The final performance measure score is the higher of the achievement or improvement score.

The HCAHPS surveys ask discharged inpatients about their hospital experience, including items relating to communication with nurses and doctors, responsiveness of hospital staff, cleanliness and quietness of hospital environment, pain management, communication about medicines and discharge information, and overall rating of hospital and recommendation of hospital. The HCAHPS survey touches on every aspect of the patient’s care including emergency care. For example, one of the HCAHPS questions is: “During this hospital stay, how often did doctors explain things in a way you could understand?” The options for the patient to select are never, sometimes, usually, or always. The survey only reports the percentage of patient responses that report always, and therefore each and every member of the health care team is integral to HCAHPS performance.

While the emergency medicine community has focused efforts on other payment reform initiatives, the Hospital Inpatient VBP Program may have received less attention. Yet ED leaders may soon experience heightened pressure from hospital administrators to achieve high performance and/or improve scores on these measures.

National Quality Forum

Historically, the final common pathway for quality measure endorsement has been approval by a voluntary consensus standards-setting organization, which CMS has deemed necessary for inclusion into the IPPS and OPPS programs. The NQF has become the de facto quality measure endorsement organization. In addition, CMS contracts with the NQF to identify and vet certain measure sets. Table 5 lists the NQF-endorsed ED-relevant measures (that are not current CMS quality measures) in both Phase 1 and Phase 2 of the Voluntary Consensus Standards for Ambulatory Care. In the future, CMS may choose to incorporate some of these NQF-endorsed measures into their IPPS, OPPS, or PQRS programs.

The NQF issued a call for candidate measures in July 2011 under the Endorsing Resource Use Standards project. The research and education foundation of the American Board of Medical Specialties (ABMS-REF) and the Brookings Institution, working under a grant from the Robert Wood Johnson Foundation, recently developed 22 separate measure specifications spanning 12 high-impact conditions; 18 of the 22 measures were submitted. ACEP members contributed to this project known as the High Value Health Care Project: Characterizing Episodes and Costs of Care (C3). A controversial aspect of this project included attribution of the cost of the care at the individual physician level. As of September 2011, these measures were withdrawn from NQF review until further field testing could be performed. Two other organizations, Ingenix and the National Committee for Quality Assurance (NCQA), still have resource use measures under consideration.

Last, the NQF is in the early stages of developing palliative care and regionalized emergency care measures. A group spearheaded by the University of North Carolina developed a white paper on regionalized emergency care for the NQF. Comments from ACEP were submitted in August 2011 during the solicitation period. A steering committee for palliative and end-of-life care was gathered at the end of July 2011 to discuss a set of 12 new measures that may affect emergency medicine.

Another group of quality measures that may soon affect emergency medicine reimbursement involves the new episode of care (EOC) prototype. Passage of the Patient Protection and Affordable Care Act (ACA) legislation in 2010 includes methods to develop and test novel models of health care delivery and payment reform. The goals are to reduce costs by eliminating waste and to improve patient health outcomes by aligning provider and hospital incentives. The proposed reforms are based on the VBP paradigm, rather than the current fee-for-service payment system, which reimburses providers and institutions based on the volume of services provided. The ACA-mandated development of global payment systems reimburses both hospitals and providers for the complete management of a patient over a defined period of time. Only time will tell how the ACA will affect ED practice.

On the Horizon

Hospitals are beginning to focus on the Hospital Readmission Reduction Program (HRRP). This starts in 2013 and focuses on pneumonia, heart failure, and MI readmissions within 30 days of discharge. It is reported that in 2015, the HRRP will expand to include COPD, CABG, PTCA, and potentially other high-cost and high-volume conditions.

In addition, for FY2015, CMS has adopted a proposed efficiency outcome measure titled Medicare Spending Per Beneficiary. It was originally adopted for FY2014, but because of the requirement that hospital performance on measures be posted on the Hospital Compare website for at least 1 year prior, it has been delayed 1 year.

Conclusion

Quality measures continue to exert considerable influence on the practice and reimbursement of emergency care. While provider-based measures focus mainly on the clinical care of specific medical conditions, an overwhelming number of hospital-based measures address ED throughput, timeliness of care, imaging utilization, and system issues. There is uncertainty surrounding the ACA and its affect on emergency medicine; however, it is clear that there will be further transition to pay-for-quality systems.