the seventh in a series of Alerts by Center for Medicare
Advocacy regarding the Patient Protection and Affordability Care
Act of 2010 (PPACA) and the Health Care and Education
Reconciliation Act of 2010 (HCERA). This Alert focuses
on changes in PPACA that address measuring the quality of care that
is received by Medicare beneficiaries, and linking payment to those
reviewing these materials, it is important to keep in mind that
Congress has placed emphasis on efforts to measure quality and to
provide payment for only those services and procedures that meet
certain quality of care standards.
As the provisions indicate, measuring quality and obtaining
agreement on standards and norms of treatment for quality
measurement is a complex and emerging activity.
further introduction to the language and terminology of quality,
quality measurement and systems delivery, you may want to read our
recent article on delivery systems at:
PPACA § 3001. Hospital Value-Based Purchasing Program. Pursuant
to this section of the law, the Secretary of Health and Human
Services (HHS) is to establish a value-based purchasing program,
under which incentive payments are to be made to hospitals. The
incentive is to be in the form of a percentage add-on to the base
operating Diagnostic Related Group (DRG) payment per discharge in
each fiscal year. The program begins in fiscal year 2013 and
applies to payments for hospital discharges occurring on or after
October 1, 2012.
Measures selected to qualify for incentive payments for fiscal year
2013 will cover the following five specific conditions:
measured by the Surgical Care Improvement Project); and
program excludes any hospital:
Which has not
submitted the required data to HHS;
Which has been cited
by HHS for deficiencies that pose immediate jeopardy to the
health or safety of patients;
For which there are
no minimum number of measures that apply for the performance
For which there are
not a minimum number of cases for the measures that apply for
the performance period under review.
to conduct a study on the performance of the hospital value-based
purchasing program and is to include:
Ways to improve the
Ways to address any
of the Medicare program's sharing in any savings generated
through the hospital value-based purchasing program; and
Any other area
determined appropriate by HHS.
report to Congress of the study's findings is due no later January
PPACA § 3002. Improvements to the Physician Quality Reporting
System. Pursuant to this section of the law, professionals able
to receive Medicare payment, including allied healthcare providers,
who do not comply with reporting requirements, will have their
payments reduced. For 2015, the penalty for
failure to submit data is a reduction in payment to 98.5% of
the fee scheduled amount, and for 2016 and subsequent years, the
penalty is a reduction to 88% of the fee-scheduled amount.
No later than January 1, 2011, HHS is to
establish an appeals process for eligible professionals to seek
review of a determination that the professional did not
satisfactorily submit data on quality measures as required.
Reporting can also be accomplished through a Maintenance of
Certification program operated by a specialty body of the American
Board of Medical Specialties that meets certain criteria. The
maintenance of certification provisions apply for years after 2010.
Not later than January 1, 2012, HHS must
develop a plan to integrate reporting on quality measures and
Electronic Health Record (EHR) reporting related to the meaningful
use of electronic health records.
PPACA § 3003.
Improvements to the Physician Feedback Program. Under this
provision HHS must use claims data (and other data) to provide
confidential reports to physicians (and, as determined appropriate
by HHS, to groups of physicians) that measure the resources involved
in furnishing care to individuals under the Medicare program.
Beginning in 2012, HHS must provide reports to physicians that
compare, as determined appropriate by HHS, patterns of resource use
by an individual physician to patterns of use by other physicians.
PPACA § 3004. Quality
Reporting for Long-Term Care Hospitals, Inpatient Rehabilitation
Hospitals, and Hospice Programs. Starting in 2014, this
section of the law requires that the annual update to the standard
federal rate for discharges during the rate year will be reduced by
2 percentage points for each facility that does not report quality
data. Not later than October 1, 2012, HHS must publish the measures
selected that will be applicable to rate year 2014. HHS must
establish procedures for making available to the public data
submitted under this provision.
PPACA § 3005. Quality
for PPS-Exempt Cancer Hospitals. For fiscal year 2014
and each subsequent year, a PPS-Exempt Cancer hospital must submit
quality data in accordance with the requirements of HHS. Not later
than January 1, 2012, HHS must publish the measures of quality of
care, costs to be reported and the dates of implementation of the
reduction in payment due to failure to report required data
("payment modifier"). HHS must begin initial implementation of the
payment modifier through the rule-making process during 2013. No
later than October 1, 2011, HHS must submit to Congress its plan for
developing its value-based purchasing program for PPS-Exempt Cancer
PPACA § 3006. Plans
for a Value-Based Purchasing Program for Skilled Nursing Facilities
and Home Health Agencies. The law requires HHS to develop a
plan to implement a value-based purchasing program for payments
under Medicare's skilled nursing facility and hospice programs. Not
later than October 1, 2012, HHS must publish the measures selected
with respect to fiscal year 2014, including procedures for the
public to review such data. The measures, to the extent feasible
and practicable, must extend to all dimensions of quality and
efficiency in skilled nursing facilities and hospices.
PPACA § 3007. Value-based Payment Modifier Under the physician
Fee Schedule. This provision establishes a value-based payment
modifier to provide for differential payment to a physician or a
group of physicians under the fee schedule based upon the quality of
care furnished compared to cost during a performance period. The
payment modifier is to be implemented in a budget-neutral manner.
HHS is to coordinate the value-based payment modifier with the
Physician Feedback Program.
Not later than January 1, 2012, HHS must publish the measures of
quality of care, the costs and the dates for implementation of the
payment modifier and initial performance period. HHS must begin
implementing the payment modifier through the rulemaking process
during 2013. In addition, HHS must specify an initial performance
period for application of the payment modifier for 2015. Beginning
January 1, 2015, HHS must apply the payment modifier to specific
physicians and groups of physicians as determined by HHS. Beginning
not later than January 1, 2017, HHS must apply the modifier to all
physicians and groups of physicians.
PPACA § 3008. Payment Adjustment for Conditions Acquired in
Hospitals. The law requires HHS to create incentives for
applicable hospitals that receive inpatient hospital service
payments on the basis of prospective rates as set by the Medicare
Geographical Classification Review Board. The incentives are meant
to reduce hospital acquired conditions with respect to discharges
occurring during fiscal year 2015 and subsequent fiscal years. The
amount of payment for such discharges during the fiscal year must be
equal to 99 percent of the amount of payment that would otherwise
apply. An applicable hospital is one that is in the top quartile of
hospitals relative to the national average of hospital acquired
conditions during the applicable period, as determined by HHS. The
term 'hospital acquired condition' means a condition identified or
determined by HHS that an individual acquires during a stay in an
applicable hospital. The term 'applicable period' means, with
respect to a fiscal year, a period specified by HHS.
Prior to fiscal year 2015 and in each subsequent fiscal year, HHS
must provide confidential reports to applicable hospitals with
respect to their hospital acquired conditions and make information
available to the public regarding hospital acquired conditions of
each applicable hospital. Information for the public shall also be
posted on the Hospital Compare Internet website.
HHS must conduct a study on expanding the healthcare acquired
conditions policy to payments made to other facilities under the
Medicare program. The report, together with recommendations, is to
be submitted to Congress not later than January 1, 2012.
NATIONAL STRATEGY TO IMPROVE HEALTH CARE QUALITY
PPACA § 3011. National Strategy. This provision requires
HHS, through a transparent collaborative process, to establish a
national strategy to improve the delivery of health care services,
patient health outcomes, and population health. The strategy is to
be updated not less than annually. Any such update must include a
review of short- and long-term goals. HHS must submit the strategy
to relevant congressional committees by not later than January 1,
2011. Also not later than January 1, 2011, HHS must create a
website to make public information regarding the national priorities
for health care quality improvement; the agency-specific strategic
plans for health care quality; and other information, as HHS
determines appropriate. The national strategy must include a
comprehensive strategic plan to achieve the priorities described
PPACA § 3012. Interagency Working Group on Health Care Quality.
The President must convene a working group to be known as the
Interagency Working Group on Health Care Quality (referred to in
this section as the ''Working Group''). The goals of the Working
Group are to achieve collaboration, cooperation, and consultation
between Federal departments and agencies with respect to developing
and disseminating strategies, goals, models, and timetables that are
consistent with the national priorities identified above. Not later
than December 31, 2010, and annually thereafter, the Working Group
must submit to the relevant Committees of Congress, and make public
on a website, a report describing the progress and recommendations
of the Working Group.
PPACA § 3013. Quality Measure Development. At least every
three years, HHS, the Director of the Agency for Healthcare
Research and Quality (AHRQ) and the Administrator of the Centers for
Medicare & Medicaid Services (CMS) must identify gaps where no
quality measures exist as well as existing quality measures that
need improvement, updating, or expansion (consistent with the
national strategy for health care quality, to the extent available)
for use in Federal health programs. HHS must make available to the
public on an Internet website a report on any gaps identified and
the process used to make such identification.
PPACA § 3014. Quality Measurement. This provision
establishes the new duties of the consensus-based entity for quality
measurement, including obtaining multi-stakeholder group input
through the convening of multi-stakeholder groups. The process must
be open and transparent. Not later than February 1 of each year
(beginning in 2012), the entity must transmit to HHS the input of
Not later than December 1 of each year (beginning in 2011), HHS must
make available to the public a list of quality measures under
consideration. Not later than February 1 of each year (beginning in
2012), the consensus-based entity must transmit to HHS the input of
multi-stakeholder groups. Not later than March 1, 2012, and at
least once every three years thereafter, HHS must conduct an
assessment of the quality impact of the use of endorsed measures and
make such assessment available to the public.
PPACA § 3015. Data Collection, Public Reporting. The law
requires HHS to collect and aggregate consistent data on quality
and resource use measures used to support health care delivery.
These data are to be used to implement the public reporting of
performance information. HHS may award grants or contracts for this
HHS must ensure that collection, aggregation, and analysis systems
span an increasingly broad range of patient populations, providers,
and geographic areas over time. To carry out this work, such sums
as may be necessary for fiscal years 2010 through 2014 are
authorized to be appropriated. HHS must make available to the
public, through standardized Internet websites, performance
information summarizing data on quality measures.
It is important that advocates learn these new quality requirements
and use them to advocate for quality health care for their clients.
As the material from PPACA summarized above indicates, quality care
and measurement will increasingly define healthcare payments and
delivery in the years ahead.