2024 IPPS Final Rule: What Your Hospital Needs to Know

They say everything happens in threes—and that is certainly true for the 2024 IPPS Final Rule that CMS has just released. Across the board, this year’s noteworthy changes are happening in clusters of threes, which might (for once!) make them a bit easier to track as you go about updating your hospital’s quality improvement program.Here’s our recap of the most important takeaways, but, as always, we recommend reviewing the official 2024 IPPS final rule  (or, if you’re super crunched for time, the final rule fact sheet) as you prepare for what’s ahead.

Inpatient Quality Reporting: 3 New eCQMS

CMS is adding 3 new electronic clinical quality measures (eCQMs) to its Inpatient Quality Reporting (IQR) Program inventory, all of which will be available in 2025. The first two measures are noteworthy in that CMS provides very distinct health equity rationales for creating them. Stay tuned for more guidance from us on each of these measures in the coming months.

NEW: Hospital Harm—Pressure Injury (PI)

Hospital Harm – PI will assess the number of patients who suffer a new stage 2, stage 3, stage 4, deep tissue, or unstageable pressure injury. In the final rule, CMS points to research that shows people with “darker skin tones” experience a higher prevalence of and higher risk for pressure injuries, and thus it’s time to evaluate the effectiveness of “current skin assessment protocols.”

NEW: Hospital Harm—Acute Kidney Injury (AKI)

This eCQM will evaluate the number of patients who experience an acute kidney injury (stage 2 or greater) during their hospital encounter. Again, CMS notes that “AKI is more common in Black hospitalized patients than non-Black patients,” and that this measure will support its ongoing efforts to advance health equity.

NEW: Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults

The Excessive Radiation measure will calculate the percentage of CT scans that either used an excessive radiation dose or have an inadequate image quality relative to the threshold. Thresholds will be based on what the patient was scanned for. Please note! This measure seems high on CMS’s list of importance. They are also proposing to adopt a version of this measures in the Quality Payment Program (QPP) and the Outpatient Quality Reporting (OQR) program. Furthermore, they are proposing to mandate submission of this eCQM under the OQR program. We highly suggest you take a look at this measure and the requirement to implement a calculation vendor that translates the scan results into a field calculatable by an eCQM.

Inpatient Quality Reporting: 3 Modified Measures (+ 1 Modified Requirement!)

CMS has approved modifications to 2 existing hybrid measures plus the COVID-19 vax measure for your hospital staff. It also announced changes to HCAHPS that apply to both the IQR and HVBP Programs.

MODIFIED: Hybrid Hospital-Wide Readmission +

MODIFIED: Hybrid Hospital-Wide Mortality

Starting July 1, 2024, both measures will include Medicare Advantage (MA) beneficiaries in addition to the current Fee For Service (FFS) Medicare beneficiaries.

MODIFIED: COVID-19 Vaccination Coverage Among Healthcare Personnel (HCP)

Starting October 1, 2023, the COVID-19 vaccination HCP measure will be modified to replace the term “complete vaccination course” with the term “up to date” in the HCP vaccination definition and update the numerator to specify the time frames within which an HCP is considered up to date.

Also Coming: HCAHPS Modifications

CMS is also modifying your data submission and reporting requirements for the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, not only for the IQR Program but also for the Hospital Value Based Purchasing (HVBP) Program. We’ll dive into those changes in the HVBP section of this blog, but for now, let’s wrap up the IQR updates.

Inpatient Quality Reporting: 3 Eliminated Measures

CMS is officially planning to move or entirely eliminate 3 specific measures from the IQR Program.

RETIRED: Elective Delivery Prior to 39 Completed Weeks Gestation (PC-01)

This abstracted measure will be retired by CMS starting in CY 2024. Why? Because “measure performance is so high and unvarying that meaningful distinctions and improvements in performance can no longer be made.” Essentially for the last six years the measure has been top performing across most hospitals. CMS wants to make room new, more urgently needed maternal health measures moving forward. They point to the Maternal Morbidity structural measure, the birthing friendly designation, and the electronic Perinatal Care (PC) measures as more meaningful to their maternal health goals.

REMOVE & MOVE: Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)

Beginning with the April 1, 2025, through March 31, 2028, reporting period (FY 2030), the THA/TKA complication measure will move out of the Hospital IQR Program and into the Hospital Value-Based Purchasing Program. This measure has substantial adjustments adding additional mechanical complication ICD-10 codes to the measure.

REMOVE & MOVE: Medicare Spending Per Beneficiary (MSPB)

Just like the THA/TKA measure above, MSPB will be moving out of the IQR program and into the Hospital Value-Based Purchasing Program, starting in CY 2026/FY 2028. They also made substantial measures adjustments allowing readmissions to trigger new episodes.

Promoting Interoperability: 3 Noteworthy Changes

The Promoting Interoperability Program has (surprise!) three noteworthy changes that could impact your hospital or critical access hospital.

NEW: SAFER Attestation

Starting In CY 2024, your hospital will be required to attest “yes” to conducting an annual self-assessment of all 9 Safety Assurance Factors for EHR Resilience (SAFER) Guides during the calendar year in which the EHR reporting period occurs.

NEW: 3 eCQMs Added

The same 3 eCQMs that are being introduced to the IQR Program (see above) will be added into the 2025 PI Program as well: Hospital Harm – PI, Hospital Harm – AKI, and Excessive Radiation.

MODIFIED: Increased Reporting Period

Under the final rule, the minimum EHR reporting period in CY 2025 will be increased to any continuous 180-day period within that year.

Hospital Value Based Purchasing: 3 Additional Changes

In addition to moving the aforementioned MSPB and THA/TKA complication measures into the Hospital Value Based Purchasing (HVBP) Program, CMS has agreed to move forward with 3 additional program modifications.

NEW: Adding the Sepsis Measure (SEP-01)

Everyone’s favorite measure, Severe Sepsis and Septic Shock: Management Bundle (SEP-1), will be part of the HVBP Program’s Safety Domain beginning with the FY 2026 program year. Fiscal Year 2026 translates to Calendar Year 2024 for your performance year. So, your performance on SEP-1 starting January 1, 2024 will either cost or make your facility money. We highly recommend getting a head start by reading our tips on how to prepare for the new sepsis requirements.

NEW: Health Equity Bonus Points

FY 2026 will also be the first year CMS offers the Health Equity Adjustment Bonus. Based on your hospital’s performance and your share of dual eligible (Medicare and Medicaid) patients, you will have the opportunity to earn up to 10 bonus points towards your total HVBP score.

Check out our guide to the CMS health equity adjustment bonus to learn more.

MODIFIED: HCAHPS Requirements  

As we hinted above, CMS is moving forward with several changes to the HCAHPS survey that, when pilot tested in a 2021 mode experiment, resulted in higher response rates and better patient representation across nearly every intersection from age to race and ethnicity. These changes begin in Calendar Year 2025 and affect both the IQR and HVBP Programs, and will include:

• 3 new web-first modes of survey implementation (web-mail, web-phone, and web-mail-phone)
• Allowing proxies to respond on behalf of the patient by removing the requirement that only the patient can respond
• Limiting the number of supplemental survey items to 12 (the number of additional questions you can ask)
• Requiring hospitals to collect the patient’s preferred language while they are an inpatient and providing the official CMS Spanish translation of the survey to patients who mark Spanish as their preferred language
• Extending the data collection period from 42 to 49 days 

Additional Things to Note

• There are no changes to the Hospital Readmission Reduction Program.
• There are minor changes to the Hospital Acquired Condition Reduction Program, including the establishment of a validation reconsideration process for hospitals that fail to meet data validation requirements (FY 2025 program year), and modifying the data validation criteria for hospitals that receive an Extraordinary Circumstances Exception (FY 2027 program year). Hopefully these will not impact you, but don’t hesitate to contact us if you like more guidance on these changes.

More Tools to Prepare for What’s Coming

As you can imagine, the final rule is still very much focused on advancing CMS’s goals around health equity. So, as you’re preparing for the above changes, be on the lookout for ways to improve your health equity efforts at the same time. And if you need any assistance with navigating the final rule, health equity, or (no pressure!) the overall future of healthcare quality improvement, we’re always available to talk.

• Guide: How to Prepare for the HVBP’s New Sepsis Requirements
• Guide: How to Measure Health Equity at Your Hospital
• Article: What is the CMS Health Equity Adjustment Bonus?
• Article: An Intro to CMS’s SDOH Measures
• Article: 4 Lessons Learned from Hybrid Measure Submissions