This article aims to provide background on quality measure reporting and reimbursement programs, as well as to update readers on the current, future, and disabled quality measures relevant to the practice of emergency medicine.

The Centers for Medicare and Medicaid Services (CMS) remain the dominant player in the determination of how hospitals and providers are reimbursed with respect to quality.

The CMS directs its influence through three main programs: the Physician Quality Reporting System (PQRS), the Outpatient Prospective Payment System (OPPS), and the Inpatient Prospective Payment System (IPPS).

While hospitals are responsible for reporting the “core measures” (i.e., OPPS and IPPS programs), providers are responsible for reporting PQRS measures via claims through their billing companies. The OPPS and IPPS apply to all patients regardless of payer, with admitted patients reported via the IPPS and discharged/transferred patients via the OPPS. PQRS measures include admitted and discharged Medicare Part B patients only.

Physician Quality Reporting System (PQRS)

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 report 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) or the Pay for Performance (P4P) program. In 2011, the name was changed to the Physician Quality Reporting System (PQRS) to denote that it is no longer a pilot but rather an established program.

Provider-based measures largely originate from the AMA-PCPI (Physician Consortium on Performance Improvement, convened by the American Medical Association). This year, there are no additional measures that affect emergency medicine. Current PQRS measures are listed in Table 1; the new emergency department–relevant PQRS measures for 2011 are measures 91-93.

In addition, a number of proposed additional PQRS measures are now being considered for future implementation (see Table 2).

The schedule for additional financial incentives and penalties for satisfactorily reporting PQRS measures are outlined in Table 3.

Also, beginning in 2011, physicians will have the opportunity to earn an additional incentive of 0.5% by working with a Maintenance of Certification (MOC) entity and by 1) satisfactorily submitting data on quality measures under PQRS for a 12-month reporting period, either as an individual physician or as a member of a selected group practice; and by 2) participating in an MOC program and successfully completing a qualified MOC program practice assessment.

Outpatient Prospective Payment System (OPPS)

Hospital measures can originate from individuals, professional societies, academic institutions, and more recently, consulting agencies (e.g., Optimal Solutions Group and Ingenix). The bulk of hospital measures that affect emergency medicine come from the OPPS and its associated data reporting program, the Hospital Outpatient Quality Reporting Program (OQR). The Hospital OQR was mandated by the Tax Relief and Health Care Act of 2006, which requires subsection (d) 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. 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 proposed OPPS rule for 2011 does not have any changes to the current 11 outpatient quality measurements. However, CMS has added 16 additional quality reporting measures across seven different clinical areas in 2012. The four that may directly affect emergency medicine are listed in Table 4. OP-13 through OP-15 have already been subjected to CMS dry runs, resulting in reports delivered to applicable hospitals in April 2011.

Also, CMS is proposing to not implement national coding guidelines for emergency department visits. In the most recent proposed rule, CMS indicates that implementing a national system posed significant complexities, and data submitted by hospitals over the past several years appeared to be reasonable and did not warrant implementation of such a system. CMS did point out, however, that it would continue to monitor hospital emergency department OP service levels and reevaluate implementing national guidelines on a going-forward basis.

Inpatient Prospective Payment System (IPPS)

On Aug. 1, CMS released its Final Rule on the Inpatient Prospective Payment System (IPPS), which describes the current Hospital Inpatient Quality Reporting Program (IQR), 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. Alternatively stated, reporting hospitals escaped a reduction in payment rates for failure to comply. Initially, it was a 0.4 percentage point reduction in the annual market basket for hospitals that did not successfully report, but the Deficit Reduction Act of 2005 increased that reduction to 2.0 percentage points.

The main changes for 2012 that affect emergency medicine include the removal of AMI-1: Aspirin at Arrival from the list because it was felt that the vast majority of hospitals now perform well on this measure and the measure has served its purpose. Also, PN-5c: Initial Antibiotic Received within 6 Hours of Arrival will be removed. In 2014, both the median time from arrival to departure for admitted patients and the median time from admit decision to departure for admitted patients (i.e., the boarding measure) will take effect. However, if hospitals desire to receive “meaningful use” incentives starting in 2011 according to the HITECH Act, they will need to begin reporting these measures immediately.

Also included in the Final Rule was the initial framework for the Hospital Readmission Reduction Program (HRRP), which is set to begin in FY 2013. Unlike other measures in the Hospital IQR, hospitals will be penalized for high readmission rates (compared with a baseline period from July 1, 2008, to June 30, 2011) for applicable conditions, initially including heart failure, pneumonia, and acute myocardial infarction. For the first year of the program, payment reductions will be capped at a maximum of 1% of inpatient payments. The payment reduction rates will increase by 1% each year, capping at 3% for FY 2015 and beyond. In FY 2015, the list of applicable conditions will expand to include other high-volume and high-cost conditions, likely COPD, CABG, PTCA, and other vascular procedures (Table 5).

National Quality Forum (NQF)

Historically, the final common pathway for quality measure endorsement has been approval by a voluntary consensus standards-setting organization that CMS has deemed necessary for inclusion into the IPPS and OPPS programs. The National Quality Forum (NQF) has become the de facto quality measure endorsement organization. In addition, CMS contracts with NQF to identify and vet certain measure sets. Table 6 lists the NQF-endorsed measures in both Phase 1 and Phase 2 of the Voluntary Consensus Standards for Ambulatory Care that mainly affects emergency care, with the most recent phase being adopted in January 2011.

One particularly contentious measure worth noting is OP-15 or 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. Through its Quality and Performance Committee, ACEP has sent comments challenging this unprecedented path as well as the validity of this measure. A coordinated national study is nearly complete to evaluate how the OP-15 measure derived from administrative claims data compares with actual clinical data derived from chart review, as well as compliance with other established guidelines for CT utilization in atraumatic headache.

Another group of quality measures that may soon affect emergency medicine reimbursement involves the new Episode of Care (EOC) prototype. Recent 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 a “value-based purchasing” paradigm, rather than the current fee-for-service payment system, which reimburses providers and institutions based on the volume of services provided. The mandated development of global payment systems reimburses both hospitals and providers for the complete management of a patient over a defined period of time.

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. Eighteen 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 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 NCQA, still have resource use measures under consideration.

Last, 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 gathered at the end of July 2011 to discuss a set of 12 new measures that may affect emergency medicine.

Conclusion

Quality measures continue to exert considerable influence on the practice and reimbursement of emergency care. While provider-based measures mainly focus on the clinical care of specific medical conditions, the overwhelming share of upcoming hospital-based measures address emergency department throughput, timeliness of care, and imaging utilization issues. The passage of Episodes of Care measures constructed on a value-based purchasing and bundled payment paradigm may be imminent.

All of the authors are members of ACEP’s Quality and Performance Committee.