CMS’ New Hybrid Readmission Measure: A ScreenPlay in One Act

There’s no doubt about it: The new CMS hybrid readmission measure is going to have lots of people buzzing. If you haven’t heard your teams discussing it yet, check out our one-act play about a conversation between a director of quality management and a quality analyst. Let’s be honest: They’d probably be rushing between two meetings and trying to put out 10 fires. But please humor us. Now, if you need us, we’ll be awaiting our Oscar for Best Fake Screenplay.

(SCENE: Interior of a breakroom. Two people are getting coffee.)

Quality Analyst: Happy Monday! How was your weekend?

Director: Happy Monday to you, too. It was good. We bought a new car on Saturday. It’s a Toyota Prius. One of those hybrid models.

Quality Analyst: Hybrids, hybrids, hybrids. That’s all I’m hearing about.

Director: Well, you’re going to hear a lot more about hybrids from CMS.

Quality Analyst: Medicare is going to start selling cars? I’m not sure that’s a good idea.

Director: Ha! No, I’m talking about the new hybrid hospital-wide 30-day readmission measure from CMS. It’s the new way Medicare is going to risk-adjust our readmission rates. It goes into effect July 1, 2023.

Quality Analyst: That’s… not very soon. Why are we talking about it now?

Director: Because we need to start planning for it.

(Quality Analyst looks confused)

Director: I’ll back up a little. So right now, CMS takes our claims data and tweaks it using different claims-based variables to come up with our hospital-wide, 30-day readmission rate. It’s a pretty passive process. We really don’t do anything other than submit the claim, and CMS takes it from there. But that’s all going to change with the hybrid measure.

Quality Analyst: Refresh my memory: Is it the same as the claims measure that CMS uses in its Hospital Readmission Reduction Program to penalize hospitals that have too many readmissions?

Director: Nope. The new hybrid measure isn’t part of the HRRP; it’s part of the Hospital Inpatient Quality Reporting program. Starting in 2023, the hybrid measure will replace the claims readmission measures in the IQR program.

Quality Analyst: OK. So… what is a hybrid measure?

Director: It works like this. CMS will pair our claims data with clinical data pulled from our EHR system to come up with our hybrid readmission rate. We’ll be responsible for submitting that clinical data to CMS.

Quality Analyst: What clinical data, exactly?

Director: We’re on the hook for 13 core clinical data elements, or CCDEs. Seven of the 13 CCDEs are lab values, like a patient’s potassium levels and white blood cell counts. The other six are vital signs, like heart rates, blood pressure readings and temperatures.

Quality Analyst: How will we submit it?

Director: Our vendor will submit a QRDA file just like they do for our eCQMs.

Quality Analyst: And how will CMS know which CCDEs go with which claims?

Director: They’ll use five different “linking variables,” including the Medicare beneficiary’s ID number, date of birth and admission date.

Quality Analyst: Sounds easy enough. I’m pretty sure we have all that stuff in the patient’s electronic medical record.

Director: True. But it’s a little more complicated than that. We’re going to have to map value set codes to each of the 13 CCDEs in our EHR, similar to what we do for eCQMs.

(IT Director enters breakroom)

IT Director: Morning! What’s the news?

Quality Analyst: We’re talking about what you’re going to be doing next.

IT Director: Uh oh. What should I be adding to the list?

Director: CMS’ new hybrid readmission measure. We have to map 13 core clinical data elements to our system and have our vendor submit the QRDA file to CMS for every Medicare claim that we submit. We’ll need your team to map those data elements, so that when we submit the QRDA to CMS, they can match the CCDEs to the claims data.

IT Director: Let me guess, this starts tomorrow.

Director: Wouldn’t that be fun? No, luckily it’s not mandatory until July 1, 2023.

IT Director: So, why are we talking about it now?

Director: Because some hospitals and health systems pilot tested the hybrid measure last year, and they ran into all kinds of problems. It’s going to take everyone a lot longer than they think to get it running efficiently. We heard from those pilot hospitals and health systems that there were more logic and submission issues than they expected. They said even if we’re already working with an experienced eCQM vendor, we need to start now. The voluntary submission period begins on July 1, 2021. That gives you a little more than 18 months to work out the bugs.

IT Director: Thanks for the heads up.

Quality Analyst: If this new hybrid measure isn’t part of the HRRP, what’s the big deal? It’s not like we’re going to get dinged for having too many readmissions, right?

Director: Right. But also: wrong. You’re right that it’s not part of the HRRP. But it will be part of the Hospital IQR program. That means if we don’t do it right—if we don’t submit all the 13 CCDEs correctly and on time—CMS could cut our Medicare payment rate by two percent in one year.

Quality Analyst: OK. I get it. But who would know, other than our revenue cycle department?

Director: Everyone! CMS is going to post every hospital’s hybrid readmission measure on the Hospital Compare website for all to see—patients, commercial insurers, employers, competitors, the media—everyone. So we want to be as accurate as possible. We don’t want missing or inaccurate clinical data to skew our results the wrong way. Plus, this is CMS’ attempt to make hospital readmission rates more precise by risk adjusting them for our particular patient population. We will be publicly and fairly compared against other hospitals with similar patient populations. No more excuses.

IT Director: What’s the bigger picture here for us and for our patients?

Director: This is CMS’ first try at using clinical data from EHR systems to risk adjust a quality measure. It won’t be the last. It’s likely they’ll want even more hybrid measures in the future to risk adjust other quality measures, like mortality rates or infection rates. And as more measures get more precise, they’ll be more valuable to us and other hospitals and health systems to use in their quality improvement programs.

Quality Analyst: And it all starts with solid clinical documentation and accurate mapping.

IT Director: Yep. So let’s get hybrid-ing!

(Scene ends)