CMS released their 2023 IPPS Final Rule and there was a lot in it. The biggest takeaway from this ruling is that CMS is moving toward all digital measurement at rapid speed. They are ramping up eCQM requirements, increasing performance visibility, adding new measure types and continuing to define dQMs (digital quality measures).
In this article we are covering only the changes to the Hospital Inpatient Quality Reporting (IQR) program.
For more information about dQMs read dQMs: Preparing for the Unknown
Let’s take a look at what CMS has in store for us in 2023 and beyond.
First, some resources:
Hospital IQR Program Changes
Measure List Changes
New Measures for This Year
There are two measure they added back into your 2022 IQR program requirements – the Medicare Spending Per Beneficiary (MSPB) measure and the Hospital-Level Risk-Standardized Complication Rate Following Elective Primary THA/TKA measure. Both have been modified and CMS said they “plan to subsequently propose this for the Hospital VPB Program measure set under the Efficiency and Cost Reduction Domain sometime in the future.”
New Measures Released in 2023
eCQMs
CMS is making two eCQMs available in 2023: PC-02 Cesarean Birth and PC-07 Severe Obstetric Complications. These two measures are currently available through The Joint Commission’s ORYX® quality initiative program and now CMS is adopting these measures into the IQR program.
The Cesarean Birth measure assesses the rate of cesarean births for first-time moms with no excluding conditions.
From CMS:
“C-sections have higher morbidity and mortality (9.2 percent) than vaginal deliveries (8.6 percent).
The total rate of … c-sections has risen in the U.S. since the 1990s. C-sections accounted for 31.8% of U.S. live births in 2020, and there is a considerable amount of variation in the rates based on U.S. region, state, and healthcare institution. There is also substantial variability across races and ethnicities.”
The second eCQM, Severe Obstetric Complications, measures how many moms had unexpected outcomes due to complications at labor and delivery that result in significant consequences to a woman’s health, and includes, but is not limited to, hemorrhage, embolism, severe hypertension, stroke, and other serious complications. Note: this is a risk-adjusted measure.
From CMS:
“Despite the highest rate of spending on maternity care, totaling $1.4 billion dollars in FY 2021, the U.S. ranks worse than most other developed nations in pregnancy related deaths and the rate of SMM (Severe Maternal Morbidity) is continuing to steadily increase.”
Structural Measure
There is one new structural measure added to the IQR program that focus on health equity.
From CMS:
“Significant and persistent disparities in healthcare outcomes exist in the U.S. For example, belonging to a racial or ethnic minority group, living with a disability, being a member of the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community, being a member of a religious minority, living in a rural area, or being near or below the poverty level, is often associated with worse health outcomes.”
The Hospital Commitment to Health Equity measure requires you to attest to whether or not your organization is reviewing and prioritizing equitable care. It’s a series of yes/no questions that are organized into 5 “domains.”
- Equity is a Strategic Priority
- Data Collection
- Data Analysis
- Quality Improvement
- Leadership Engagement
Process Measures
There are two Social Drivers of Health (SDOH) measures that work in conjunction with each other: the Screening for Social Drivers of Health measure and the Screen Positive Rate for Social Drivers of Health measure.
From CMS:
“Social risk factors disproportionately impact underserved communities, promoting screening for these factors could serve as evidence-based building blocks for supporting hospitals and health systems in actualizing commitment to address disparities, improve health equity through addressing the social needs with community partners, and implement associated equity measures to track progress.”
The first measure captures whether or not your facility is screening your patients for health-related social needs and the other is the proportion of patients who screen positive for having one or more of those needs.
The 5 “domains” of health-related social needs are:
- Food insecurity
- Housing instability
- Transportation needs
- Utility difficulty
- Interpersonal safety
These SDOH measures are the first patient-level measurement of social drivers of health in the Hospital IQR Program.
PRO-PM
For the first time ever, the IQR program is incorporating a PRO-PM measure – a Patient-Reported Outcome Performance Measure. The Hospital-Level Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) PRO-PM assesses the number of patients who experience substantial improvement after surgery.
From CMS:
The clinical practices for surgery and the patient results for improvement after surgery varies widely across the U.S. This risk-standardized measure assesses where there has been “substantial clinical improvement” for a patient following elective THA/TKA for Medicare FFS beneficiaries aged 65 years and older.
Substantial clinical improvement is measured by achieving a pre-defined improvement in scores on joint-specific PRO instruments measuring hip or knee pain and functioning, from the pre-operative assessment (data collected 90 to 0 days before surgery) to the post-operative assessment (data collected 300 to 425 days following surgery).
CMS will gather and calculate this data from four sources: PRO data, claims data, Medicare enrollment and beneficiary data, and U.S. Census Bureau survey data.
New Measures in 2024
eCQMs
CMS is introducing two new eCQMs in 2024 and unlike the eCQMs in 2023, these brand new measures are not available in other regulatory programs.
The first eCQM relates to opioid medication administration in a hospital: Hospital-Harm—Opioid-Related Adverse Events.
From CMS:
“There is significant variation in how opioids are administered in a hospital setting … [and they are] the most frequently implicated medications in adverse drug events among hospitalized patients.”
This is an outcome measure focusing specifically on opioid-related adverse events during an admission to an acute care hospital by assessing the administration of naloxone – which is used to save patients from an opioid overdose.
The other eCQM is a composite measure: the Global Malnutrition eCQM. Malnutrition is defined as undernutrition (wasting, stunting, underweight), inadequate vitamins or minerals, overweight, and obesity. Malnutrition can result in diet-related noncommunicable diseases.
From CMS:
“While it is estimated that 60% of older adults manage two or more chronic health conditions, many underuse preventive services, including those related to nutrition.
Research indicates that preventive screening and interventions may reduce risk of malnutrition in older adults and improve quality of life, particularly for individuals with chronic conditions.
While disease-related malnutrition is not limited to older adults, it is more frequent among those with higher age, and the consequences appear to be more severe in older persons due to their impaired regenerative capacity, inflammation, and other factors.”
The measure assesses admitted inpatients 65 and older who received care appropriate to their level of malnutrition risk and malnutrition diagnosis. It includes four component measures, which are first scored separately, and then given an overall composite score. The components are:
- Screening for malnutrition risk at admission
- Completing a nutrition assessment for patients who screened for risk of malnutrition
- Appropriate documentation of malnutrition diagnosis in the patient’s medical record if indicated by the assessment findings
- Development of a nutrition care plan for malnourished patients including the recommended treatment plan
IQR Requirement Changes
2023
All current 2022 reporting requirements and:
- Mandatory reporting of the Hospital Commitment to Health Equity structural measure
2024
All 2023 reporting requirements and:
- Mandatory reporting of PC-02 Cesarean Birth eCQM
- Mandatory reporting of PC-07 Severe Obstetric Complications eCQM
- Mandatory reporting of the two SDOH process measures
2025
All 2024 reporting requirements and:
- Mandatory reporting of Hospital-Level THA and/or TKA PRO-PM
Other things to note
CMS has established a new designation reported on Care Compare for those who attest "yes" to the Maternal Morbidity structural measure. These hospitals will be noted as a “Birthing-Friendly” facility on Care Compare.
This is a very high-level summary of the changes. We will be rolling out more information on each of these subjects this year. Our client education on the changes to requirements and measure specification updates begins in early fall.
If you’d like to learn more about how Medisolv can help your organization with your IQR program measurement needs, please contact us today to get started.
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On-Demand Webinar Learn more about future measures by watching our on-demand webinar, Future Measures: Why Start Now? Click here to get access to the recording. |
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