structural and does not provide information on patient
outcomes, given that hospitals only state whether they
participate in registries. Additionally, CMS has added
two surgery-related measures to the IQR program for
FY 2019 and subsequent years. The first is a clinical
episode-based payment measure, Cholecystectomy
and Common Duct Exploration Clinical Episode-Based
Payment, which was added because of the high costs
and substantial variation associated with these services,
according to the final rule. The second is an outcome
measure Excess Days in Acute Care after Hospitalization for Pneumonia that was added because of concerns
that readmissions are costly, expose patients to additional risks, interfere with work and family care, and
impose significant burden on caregivers. CMS also
supports limiting the measure to inpatient utilization
because a lack of restrictions may make the measure
susceptible to gaming, or manipulating reporting, that
could distort a provider’s performance.
Changes to the VBP
The hospital VBP program is a pay-for-performance
program and part of CMS’ effort to link payment and
value to improve the quality of care provided in an
inpatient hospital setting. Under the hospital VBP
program, CMS calculates a hospital’s incentive payment based on performance on specified measures
that were reported on for the IQR.
In the IPPS final rule, CMS made changes to the
measures included in this program for FY 2018, one
of which is relevant to surgical care. CMS finalized
a reporting change for the patient safety indicator- 90
(PSI- 90): Patient Safety for Selected Indicators com-
posite measure to accommodate the 10th revision of
the International Classification of Diseases (ICD- 10)
transition. The PSI- 90 measure steward, the Agency
for Healthcare Research and Quality, is reviewing
any potential issues related to ICD- 10 conversion of
coded operating room procedures; while that effort is
being completed, CMS will only use ICD- 9 codes. The
new performance period for PSI- 90 will measure 15
months instead of the previously adopted 24 months.
The shortened performance period will apply only
in the FY 2018 program year.
In addition, CMS has adopted new measures for
FY 2021 that include risk-standardized payment
associated with a 30-day episode of care for acute
myocardial infarction (AMI) and risk-standardized
payment associated with a 30-day episode of care for
heart failure (HF). Both AMI and HF are high-volume conditions, and evidence of variation in hospital
payments shows variation in payment for patients
with these conditions among hospitals. CMS supports the position that these measures cover topics
of critical importance to quality improvement in the
inpatient hospital setting and that it is appropriate to
offer strong incentives for hospitals to provide high-value and efficient care.
Changes to the HAC Reduction Program
Since October 1, 2014, the Affordable Care Act has
required that CMS establish an incentive for hospitals
to reduce the incidence of hospital-acquired conditions (HACs) and improve patient safety by imposing
financial penalties on hospitals with high instances of
the HACs specified under this program. A 1 percent
payment reduction applies to a hospital with poor performance whose ranking is in the top 25 percent of all
applicable hospitals relative to the national average.
The HAC Reduction Program adjustment is applied
after adjustments are made under the hospital VBP
program and the Readmissions Reduction Program.
Because the IPPS rule outlines coverage criteria for Medicare
Part A inpatient hospital claims, and a large proportion
of surgical care is provided in the inpatient setting, this
rule is likely to affect many surgical practices.