On August 2, 2018, the Centers for Medicare & Medicaid Services (CMS) issued the final rule for the Inpatient Prospective Payment System (IPPS). In this rule, CMS finalizes its review of quality measures across all of the IPPS value-based programs, with a focus on minimizing duplication of measures across programs and reducing clinician burden by focusing on a smaller number of high-priority measures. CMS also recently proposed a similar narrowing of measure sets for most of its other quality reporting and pay-for-performance programs in proposed rules released this summer.
The changes are framed in the context of the Meaningful Measures initiative (an offshoot of Patients Over Paperwork), a CMS initiative aimed at reducing the administrative burden on clinicians that takes time away from patient care, consistent with the administration’s directive to “eliminate red tape.” CMS Administrator Seema Verma announced the Meaningful Measures initiative at the Healthcare Payment Learning and Action Network Fall Summit last October, citing a then-recently published American Hospital Association report on the regulatory burden faced by providers, including the burden associated with quality measure reporting. In that announcement, Verma was explicit that the first order of business would be to scale back the amount of reporting required by providers:
“Typically, repainting needs to occur every few years and before you repaint, you need to strip out the layers of paint from underneath. Otherwise it looks messy! Unfortunately, CMS has been applying new layers of paint without taking this essential step. But this Administration is beginning to peel back the layers.”
The Meaningful Measures framework defines the kinds of measures CMS considers “high priority,” with an emphasis on measures of patient outcomes rather than clinical process—measures considered more “meaningful” to patients and providers alike. However, while CMS has requested comment on a few high-priority areas in which it feels there are gaps in current measure sets, most of the focus of the past year has been on stripping away measures CMS considers to be old paint. The IPPS final rule will eliminate 18 measures from the Hospital Inpatient Quality Reporting program—a significant reduction in the size of the overall measure set—and will de-duplicate another 25 measures currently adopted in other CMS value-based purchasing programs.
Prior to this rulemaking season, provider reporting burden was not formally one of the criteria considered for retiring an implemented measure from a CMS quality reporting program. Now, most of the programs have adopted a new measure “removal factor”: The costs associated with a measure outweigh the benefit of its continued use in the program. In the past, measure removal has centered on whether a measure is still clinically appropriate—measures are typically removed when they no longer align with clinical best practice or when performance between providers can no longer be meaningfully distinguished (referred to as “topped out”). The IPPS final rule now codifies that provider burden can be taken into consideration, outlining five types of costs that can be considered:
- Provider and clinician information collection burden and related cost;
- Provider and clinician cost associated with complying with other quality programmatic requirements;
- Provider and clinician cost associated with participating in multiple quality programs, and tracking multiple similar or duplicative measures within or across those programs;
- CMS cost associated with program oversight of a measure, including measure maintenance and public display; and
- Provider and clinician cost associated with compliance with other federal and/or state regulations (if applicable).
The same removal factor was proposed for other CMS quality reporting programs this summer, and has been used to justify the proposed removal of dozens of measures across programs. CMS has been careful to note that provider burden alone is not sufficient justification to remove a measure, but that it can be considered in light of other factors—for example, when a measure does not technically meet the definition of being topped out but is coming close to doing so. When viewing the provider burden of, for example, reporting chart-abstracted data to CMS in light of the limited benefit conferred by a nearly topped-out measure, CMS may judge that the benefit of the measure no longer outweighs the cost. While this adds a fairly subjective aspect to measure removal, it may be welcome to some providers who have been struggling to keep up with the reporting requirements across CMS quality programs.
As part of its discussion on measures, CMS notes that it is considering options to reduce health disparities among patient groups within and across hospitals by increasing the transparency of disparities in quality performance across different beneficiary populations. However, CMS does not propose to make any changes with regard to accounting for social risk factors in quality measurement, despite requesting comment on the topic in both the FY 2018 rules for quality reporting and value-based purchasing programs, and receiving generally favorable feedback. In this rule, CMS seems to indicate it has not yet found a path forward that it feels appropriately balances the need to account for social risk factors when measuring provider performance against the risk of masking health disparities by using statistical adjustment. CMS notes that risk stratification may be an approach to increase transparency around health equity, but does not propose to implement any risk stratification in this rule, instead indicating it will continue to work with the assistant secretary for planning and evaluation to identify potential policy solutions.