CMS proposes FY 2014 Medicare IPPS update: Prepared by:

CMS proposes FY 2014 Medicare IPPS update:
An analysis and commentary on federal health care issues
Prepared by:
Tony Cawiezell, Principal, McGladrey LLP
563.888.4027, [email protected]
Larry Goldberg, National Health Care Policy Advisor, McGladrey LLP
May 2013
The Centers for Medicare and Medicaid Services (CMS) have released a proposed rule to update both the
Hospital Inpatient Prospective Payment System (IPPS) and the Long Term Care Hospital (LTCH) Prospective
Payment System for fiscal year (FY) 2014.
The document is currently on public display at the Federal Register office and was published on May 10. A copy
is available at: http://www.gpo.gov/fdsys/pkg/FR-2013-05-10/pdf/2013-10234.pdf. A 60-day comment period
ending June 25 is provided.
The IPPS tables are available only through the Internet at: http://www.cms.hhs.gov/Medicare/medicare-Feefor-Service-Payment/AcuteInpatientPPS/index.html. Click on the link on the left side of the screen titled, “FY
2014 IPPS Proposed Rule Home Page” or “Acute Inpatient—Files for Download.”
The LTCH PPS tables are available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
LongTermCareHospitalPPS/LTCHPPS-Regulations-and-Notices-Items/LTCH-PPS-CMS-1599-P.html?DLPage=1&D
LSort=3&DLSortDir=descending.
Comment
The rule is long and appears to become longer every year. The number of issues continues to grow, too,
with many having significant financial consequences, such as readmissions and the hospital value-based
purchasing program.
CMS has tried to explain its rationale for the changes it is proposing. The rationale is sometimes exceedingly
deep before the proposed change is specified. In the future, it could prove more helpful if CMS indicated the
changes it is proposing upfront, followed by its rationale.
While this analysis is lengthy, there are many facets that have not been covered. All involved with financial,
quality and related matters need to carefully review the rule itself to ensure compliance and understanding of
the issues at hand.
As noted further below, CMS indicates a projected increase of only $27 million in overall IPPS payments in
FY2014. There are many proposed reductions, in addition to the multiyear productivity and Affordable Care Act
(ACA) requirements. Reductions to readmissions, the hospital-based value purchasing system, one-day stays
and the MS-DRG weights all need careful attention. Then there are the documentation and coding reductions
that will recoup $11 billion over four years. If sequestration is in effect next year, many hospitals could incur
significant Medicare payment losses.
Summary of the major provisions
Changes to payment rates under IPPS
According to CMS, the proposed rule would increase IPPS operating payment rates by 0.8 percent. This reflects
a hospital market basket of 2.5 percent, adjusted by -0.4 percentage points for the multifactor productivity,
and an additional adjustment of -0.3 percentage points, in accordance with the ACA; the rate is further
decreased by 0.8 percent for a proposed documentation and coding recoupment adjustment required by the
American Tax Relief Act of 2012 (ATRA), and by a 0.2 percent proposed adjustment to offset the cost of the
proposal on inpatient admission and medical review criteria for hospital inpatient services.
However, there are more adjustments that would lower the update factor further (see specifics under rate
update details).
Market basket
CMS proposes to revise and rebase the hospital market basket for FY 2014. The proposed FY 2014 market
basket will use FY 2010 data for the base year cost weights, in place of FY 2006 data.
Wage index
Medicare law requires CMS to adjust the labor-related share of the standardized amount to account for
differences in area wage levels. CMS currently uses Office of Management and Budget (OMB) delineations
of statistical areas to define the areas used in determining area wage levels. On February 28, 2013, OMB
announced revisions to these statistical areas based on the 2010 Census. CMS explains that because there was
not sufficient time to assess the geographic changes and their ramifications to the wage index adjustment
and related policies prior to issuing this proposed rule, CMS will not be using these revised statistical area
definitions for FY 2014, but expects to use these definitions for FY 2015.
Capital
CMS would establish a national capital federal rate of $432.03, up from $425.49.
Outliers
The outlier fixed-loss cost threshold for FY 2014 would be $24,140. The current amount is $21,821.
Documentation and Coding Adjustment
ATRA Section 631 requires CMS to recover $11 billion over the next four years to recoup documentation
and coding overpayments for prior years. For FY 2014, CMS is proposing a negative 0.8 percent recoupment
adjustment as the first step in this recovery process. CMS expects to make similar adjustments in FYs 2015,
2016 and 2017, in order to recover the full $11 billion.
MS-DRG relative weight refinement
In the FY 2009 and the FY 2011 IPPS final rules, CMS created new cost centers for Implantable Devices Charged
to Patients, MRIs, CT scans and cardiac catheterization. In those rules, CMS stated that it would consider
creating separate cost-to-charge ratios (CCRs) for the new cost centers to calculate the relative weights. CMS
proposes to implement these new cost centers for FY 2014, which would increase the total number of CCRs
used to calculate the FY 2014 proposed relative weights from 15 to 19.
2
Critical access hospitals (CAHs) conditions of participation
To ensure continued access to inpatient services, the FY 2014 proposed IPPS rule would clarify critical access
hospital Conditions of Participation (CoPs) to require that CAHs have the capacity to provide inpatient care
on-site.
Medicare-dependent hospital (MDH) program
The ATRA extended the MDH program for one additional year, through FY 2013. The proposed rule includes
the expiration of the MDH payment designation for discharges occurring on or after October 1, 2013.
Low-volume hospitals
The temporary changes to low-volume hospital definition and payment adjustment methodology provided
for by the ACA and the ATRA for FY 2011 through FY 2013 are expiring. Consistent with the statute, CMS is
proposing in FY 2014 to return to the low-volume hospital definition and payment adjustment methodology
that was in place prior to FY 2011, before the temporary provisions took effect.
Admission and medical review criteria for inpatient services
CMS says it is clarifying its long-standing policy on how Medicare contractors review inpatient admissions for
payment purposes. CMS is proposing that hospital inpatient admissions spanning at least two midnights (that
is, at least more than one Medicare utilization day) will presumptively qualify as appropriate for payment under
Medicare Part A. Conversely, hospital inpatient admissions spanning less than two midnights (that is, less than
one Medicare utilization day) will presumptively be inappropriate for payment under Medicare Part A.
This presumption may be overcome by documentation in the medical record supporting the admitting
physician’s expectation that the beneficiary would need care spanning at least two midnights, and an
unforeseen circumstance results in a shorter beneficiary stay than the physician’s expectation.
Physicians must support their expectation, and accordingly their order for admission, through clear and
complete medical documentation.
Direct graduate medical education (GME)
CMS proposes to revise the GME policy addressing inpatient labor and delivery days in the inpatient Medicare
utilization calculation. CMS also proposes, for portions of cost reporting periods beginning on or after October
1, 2013, that a hospital may not claim full-time equivalent residents training at a critical access hospital (CAH)
for indirect medical education (IME) or direct GME purposes.
However, if a CAH itself incurs the costs of training the full-time equivalent residents when these residents
rotate to the CAH, the CAH may receive payment based on 101 percent of those Medicare reasonable costs
under the regulations.
Finally, in accordance with ACA Section 5506, which redistributes residency slots from closed hospitals, CMS
is notifying the public of the closure of a hospital and initiating another application and selection process to
redistribute the closed hospital’s GME full-time equivalent caps.
Medicare disproportionate share hospitals (DSH)
ACA Section 3133 requires that instead of the amount that would otherwise be paid, hospitals will receive
25 percent of their current Medicare DSH payments beginning in FY 2014. The remaining 75 percent will be
adjusted for decreases in the rate of uninsured individuals nationally, and distributed as additional payments
to hospitals that receive DSH payments based on each hospital’s share of uncompensated care relative to all
3
hospitals that are estimated to receive DSH payments. CMS includes three factors required to determine the
amount of these proposed new uncompensated care payments.
Quality-related provisions
CMS is proposing to make several changes to: (1) the quality measure set, including the removal of some
measures, the refinement of some measures and the adoption of several new measures; (2) the administrative
processes; and (3) the validation methodologies. Further, CMS is proposing to allow hospitals the option of
reporting the measures in four measure sets electronically for the FY 2016 payment determination.
New hospital-acquired condition reduction program
ACA Section 3008 required CMS to establish a financial incentive for IPPS hospitals to improve patient safety,
by imposing financial penalties on hospitals that perform poorly with regard to hospital-acquired conditions
(HACs). HACs are conditions that patients did not have when they were admitted to the hospital, but that
developed during the hospital stay. The proposed rule outlines a general framework for the HAC reduction
program for the FY 2015 implementation.
Hospital readmissions reduction program
The hospital readmissions reduction program began on October 1, 2012. The maximum reduction under this
program, which was one percent of payment amounts in FY 2013, will increase to two percent of payment
amounts in FY 2014, as specified under the ACA.
Counting of inpatient days for Medicare payment or eligibility purposes
CMS is proposing that patient days associated with maternity patients who were admitted as inpatients and
were receiving ancillary labor and delivery services at the time the inpatient routine census is taken, regardless
of whether the patient actually occupied a routine bed prior to occupying an ancillary labor and delivery
bed, and regardless of whether the patient occupies a “maternity suite” in which labor, delivery recovery and
postpartum care all take place in the same room, would be included in the Medicare utilization calculation.
Changes to the hospital Inpatient Quality Reporting (IQR) program and the Electronic Health Record (EHR)
incentive program
The hospital IQR program grew out of the hospital quality initiative developed by CMS, in consultation with
hospital groups. By statute, hospitals that do not participate successfully in the hospital IQR program have
their annual payment updates reduced by 2.0 percentage points. Since the implementation of this financial
penalty, hospital participation has increased to well over 99 percent of Medicare-participating hospitals that
are reimbursed under the IPPS.
Measures reported under the IQR program are published on the “hospital compare” website (http://www.
hospitalcompare.hhs.gov/), and may later be adopted for use in the hospital value-based program (VBP)
mandated by the ACA, which affects payment rates to hospitals beginning in FY 2013.
Proposals for LTCH, PPS-exempt cancer and inpatient psychiatric quality reporting programs
The rule also proposes new quality reporting measures for LTCHs, PPS-exempt cancer hospitals and inpatient
psychiatric facilities in 2015 and beyond.
LTCH quality reporting
CMS is continuing to expand the LTCH quality reporting program, and is proposing five new LTCH
quality measures that would affect the FY 2017 and FY 2018 payment updates. For the FY 2017 payment
determination, the proposal includes: an all-cause unplanned readmission measure for 30 days post- discharge
4
from long-term care hospitals, the CDC’s National Healthcare Safety Network (NHSN) facility-wide inpatient
hospital-onset MRSA bacteremia outcome measure and the NHSN facility-wide inpatient hospital-onset
Clostridium difficile infection (C-diff ) outcome measure. CMS is also proposing to apply the National Quality
Forum (NQF) measure of the percent of residents experiencing one or more falls with major injury (long stay)
for the FY 2018 payment determination.
PPS-exempt cancer hospital quality reporting program
The NPRM proposes new quality measures for the PPS-exempt cancer hospital quality-reporting program. A
total of 11 PPS-exempt cancer hospitals would be covered in this program. In this rule, CMS proposes to add
one new measure of surgical site infection for the FY 2015 program, and 13 new measures covering surgical
processes of care, patient experience of care and oncology for the FY 2016 program.
Inpatient psychiatric facility quality reporting program
The ACA establishes an inpatient psychiatric facility quality reporting (IPFQR) Program. Under the IPFQR
program, inpatient psychiatric facilities (IPFs) are required to submit quality data to CMS on selected
quality measures. For the FY 2016 payment determination and subsequent years, CMS is proposing three
new measures: alcohol use screening; alcohol and drug use status after discharge; and follow-up after
hospitalization for mental illness. These measures would be added to the six measures adopted in FY 2013.
CMS also proposes to request voluntary information on IPFs’ efforts to assess the patient experience of care
for the FY 2016 payment determination. Submission of this information would be completely voluntary and
would not in any way affect a facility’s FY 2016 payment determination.
Hospital value-based purchasing (VBP) program
CMS is outlining payment details for the FY 2014 hospital VBP program. In addition, CMS is proposing
numerous policies for the FY 2016 hospital VBP program, including measures, performance standards and
performance and baseline periods. CMS also is proposing a disaster and extraordinary circumstances waiver
process, domain reclassification and weighting based on CMS’ national quality strategy for the FY 2017
hospital VBP program, and certain measures, performance and baseline periods and performance standards
for the FY 2017 through FY 2019 programs.
Policies affecting long-term care hospitals
Changes to payment rates under the LTCH PPS
CMS projects that LTCH PPS payments would increase by 1.1 percent, or approximately $62 million, in FY 2014.
This estimated increase is attributable to several factors, including the proposed update of 1.8 percent for
LTCHs that submitted quality data (based on a market basket update of 2.5 percent reduced by a multifactor
productivity adjustment of 0.4 percentage points and an additional 0.3 percentage points reduction in
accordance with the ACA); a “one-time” budget neutrality adjustment to standard federal rate of approximately
-1.3 percent under the second year of a three-year phase-in; and projected increases in estimated high-cost
outlier payments, as compared to FY 2013.
Twenty-five percent patient threshold rule
Under the 25 percent patient threshold policy, if an LTCH admits more than 25 percent of its patients from a
single acute care hospital, Medicare will pay it at a rate comparable to IPPS hospitals for those patients above
the 25 percent threshold. A statutory moratorium on application of the 25 percent rule was in place from
December 2007 through December 2012. CMS extended the moratorium for FY 2013, but would allow the
policy to go into effect in FY 2014.
5
Chronically ill/medically complex criteria
In the FY 2014 proposed rule, CMS includes a discussion of recent research on the development of empirically
derived criteria for the identification of the chronically critically ill/medically complex (CCI/MC) population,
presently treated in general acute care hospitals and in LTCHs. The CCI/MC population identified by the
project has been shown to have intensive service needs, high costs and negative margins in IPPS hospitals.
Additionally, they typically have a predictable and consistent need for extended hospital-level care that can be
met either from continued stays in the initial IPPS hospital in a step-down unit or from transfer to an LTCH. At
this time, CMS is soliciting feedback on this research study and its findings, with the expectation of formulating
policy proposals for FY 2015.
Section-by-section analysis of major items
Standardized payment rates
According to CMS, the proposed rule would increase IPPS operating payment rates by 0.8 percent. This reflects
a hospital market basket of 2.5 percent adjusted by -0.4 percentage points for the multifactor productivity; an
additional adjustment of -0.3 percentage points, in accordance with the ACA; further decreased by 0.8 percent
for a proposed documentation and coding recoupment adjustment required by the ATRA and by a 0.2 percent
proposed adjustment to offset the cost of a proposed inpatient admission and medical review criteria for
hospital inpatient services [2.5 -0.4 -0.3 -0.8 -0.2 = 0.8] for hospitals submitting quality data requirements.
For hospitals not reporting such data, the update is reduced further by 2.0 percent, for a net update of minus
1.2 percent.
Based on a rebasing of market basket rates from FY 2006 data to FY 2010 data, the labor-related percentage
portions of the rates would change. The labor-related portion for areas with wage indexes greater than 1.0000
would increase from 68.8 percent to 69.6 percent. Areas with wage index values equal to or less than 1.000
would remain at 62.0 percent by law.
Caution—The rules tables 1A and 1B (presented below) say the proposed FY 2014 rates would have an
update factor of 1.8 percent, and not the 0.8 percent noted above. The 1.8 percent amount is the market
basket update of 2.5 percent, less the 0.4 percent multifactor productivity, and the additional adjustment of
-0.3 percentage points, in accordance with the ACA. See the comparison table below that reflects additional
adjustments being made by CMS and arrives at the amounts in the tables below.
National adjusted operating standardized amounts
(69.6 percent labor share/30.4 percent non-labor, if wage index is greater than 1.0000)
Full Update (1.8 percent)
Reduced Update (minus 0.2 percent)
Labor-related
Non-labor-related
Labor-related
Non-labor-related
$3,741.72
$1,634.32
$3,668.21
$1,602.21
Rates Currently in Effect
Full Update
Reduced Update
Labor-related
Non-labor-related
Labor-related
Non-labor-related
$3,679.95
$1,668.81
$3,607.65
$1,636.02
6
National adjusted operating standardized amounts
(62 percent labor share; 38 percent non-labor share, if wage index is less than or equal to 1.0000)
Full Update (1.8 percent)
Reduced Update (-0.2 percent)
Labor-related
Non-labor-related
Labor-related
Non-labor-related
$3,333.14
$2,042.90
$3,267.66
$2,002.76
Rates Currently in Effect
Full Update
Reduced Update
Labor-related
Non-labor-related
Labor-related
Non-labor-related
$3,316.23
$2,032.53
$3,251.08
$1,992.59
Additional adjustments
CMS is also making the following adjustments to standardized payment amounts:
yy An adjustment to the standardized amount to ensure budget neutrality for DRG recalibration and
reclassification, as provided for under section 1886(d)(4)(C)(iii) of the Act.
yy An adjustment to ensure the wage index changes are budget neutral, as provided for under section
1886(d)(3)(E)(i) of the Act.
yy An adjustment to ensure the effects of geographic reclassification are budget neutral, as provided for
under section 1886(d)(8)(D) of the Act, by removing the FY 2013 budget neutrality factor and applying a
revised factor.
yy An adjustment to ensure the effects of the rural community hospital demonstration program are budget
neutral, as required under section 410A(c)(2) of Pub. L. 108-173.
yy An adjustment to remove the FY 2013 outlier offset and apply an offset for FY 2014, as provided for under
section 1886(d)(3)(B) of the Act.
yy A proposed recoupment to meet the requirements of section 631 of ATRA to adjust the standardized
amount to offset the estimated amount of the increase in aggregate payments as a result of not
completing the prospective adjustment authorized under section 7(b)(1)(A) of Pub. L. 110-90 until FY 2013.
yy A proposed adjustment to offset the cost of the policy proposal on admission and medical review criteria
for hospital inpatient services under Medicare Part A.
Documentation and coding
ATRA Section 631 amended section 7(b)(1)(B) of Pub. L. 110-90 to require the secretary to make a recoupment
adjustment totaling $11 billion by FY 2017. CMS actuaries estimate that if CMS were to fully account for the
$11 billion recoupment in FY 2014, a one-time -9.3 percent adjustment to the standardized amount would
be necessary.
CMS is proposing a -0.8 percent recoupment adjustment to the standardized amount in FY 2014. CMS
estimates that “this level of adjustment will recover up to $0.96 billion in FY 2014, with at least $10.04 billion
remaining to be recovered by FY 2017. If adjustments of approximately -0.8 percent are implemented in FYs
2014, 2015, 2016, and 2017, using standard inflation factors, the agency estimates that the entire $11 billion
will be accounted for by the end of the statutory 4-year timeline.”
7
Comment
If removing 0.8 percent in FY 2014 amounts to approximately $1 billion, it would appear that the 0.8 reduction
would have to be cumulative over the 4 years. In other words, it would have to remove at least $2 billion in FY
2015, $3 billion in FY 2016 and $4 billion in FY 2017. Even at that rate, the amount of recoupment would still
be $1 billion short. How CMS has reduced the standardized payment amounts for documentation and coding
over the years has never been explained in a concise way, but the 0.8 percent adjustment amount will most
likely be a cumulative factor over the next years; i.e., 2014 =0.992 (1.0 - 0.008); 2015= 0.992 X 0.992=0.9846;
2016 = 0.984 X 0.992 = 0.976, etc.
Medicare-dependent hospitals
CMS notes that ATRA Section 606 extended the MDH program from the end of FY 2012 (that is, for discharges
occurring before October 1, 2012) to the end of FY 2013 (that is, for discharges occurring before October
1, 2013). Under prior law, the MDH program was to be in effect through the end of FY 2012 only. Absent
additional legislation further extending the MDH program, the MDH program will expire for discharges
beginning in FY 2014. Therefore, due to the expiration of the MDH program beginning with FY 2014, CMS is
not including hospitals that are currently MDHs (until October 1, 2013) in the update of the hospital-specificrates for FY 2014.
Outlier payments
CMS is proposing an outlier fixed-loss cost threshold for FY 2014 equal to the prospective payment rate for
the DRG, plus any IME and DSH payments, and any add-on payments for new technology, plus $24,140. The
current amount is $21,821.
CMS currently estimates that actual outlier payments for FY 2013 will be approximately 5.17 percent of actual
total MS-DRG payments, approximately 0.1 percentage points higher than the 5.1 percent projected when
setting the outlier policies for FY 2013.
Comparison table
CMS provides the following table to show how it has arrived at its proposed FY 2014 standardized amounts.
The table contains the budget neutrality adjustment factors.
8
Comparison of FY 2013 standardized amounts to the proposed FY 2014
standardized amount with full and reduced update
Full Update
(1.8 percent)
Full Update
(1.8 Percent)
Wage Index
is greater
than 1.0000;
Labor/NonLabor Share
Percentage
(69.6/30.4)
Wage index
is less than
or equal to
1.0000;
Labor/NonLabor Share
Percentage
(62/38)
FY 2013 base rate after removing:
1. FY 2013 geographic reclassification budget
neutrality (0.991276)
2. FY 2013 rural community hospital demonstration
program budget neutrality (0.999677)
3. Cumulative FY 2008, FY 2009, FY 2012, FY 2013
documentation and coding adjustment as required
under Sections 7(b)(1)(A) and 7(b)(1)(B) of Pub. L.
110-90 (0.9478)
4. FY 2013 operating outlier offset (0.948999)
Labor:
$4,176.63
Non-labor:
$1,824.27
Proposed FY 2014 update factor
Reduced
Update
(-02 percent)
Wage index
is greater
than 1.0000;
Labor/NonLabor Share
Percentage
(69.6/30.4)
Reduced
Update
(-02 percent)
Wage index
is less than
or equal to
1.0000;
Labor/NonLabor Share
Percentage
(62/38)
Labor:
$3,720.56
Non-labor:
$2,280.34
Labor:
$4,176.63
Non-labor:
$1,824.27
Labor:
$3,720.56
Non-labor:
$2,280.34
1.018
1.018
0.998
0.998
Proposed FY 2014 MS-DRG recalibration and wage index
budget neutrality factor
0.99735
0.99735
0.99735
0.99735
Proposed FY 2014 reclassification budget neutrality
factor
0.990971
0.990971
0.990971
0.990971
Proposed FY 2014 rural community demonstration
program budget neutrality factor
0.999834
0.999834
0.999834
0.999834
Proposed FY 2014 operating outlier factor
0.948997
0.948997
0.948997
0.948997
Proposed adjustment to offset the cost of the policy
proposal on admission and medical review criteria for
hospital inpatient services under Medicare Part A
0.998
0.998
0.998
0.998
Cumulative factor: FY 2008, FY 2009, FY 2012 and
FY 2013 documentation and coding adjustment, as
required under Sections 7(b)(1)(A) and 7(b)(1)(B) of Pub.
L. 110-90, and proposed documentation and coding
recoupment adjustment, as required under Section 631
of the American Taxpayer Relief Act of 2012
0.9403
0.9403
0.9403
0.9403
Proposed national standardized amount for FY 2014
Labor:
$3,741.72
Labor:
$3,333.14
Labor:
$3,668.21
Labor:
$3,267.66
Non-labor:
$1,634.32
Non-labor:
$2,042.90
Non-labor:
$1,602.21
Non-labor:
$2,002.76
9
Changes for inpatient capital-related costs for FY 2014
CMS would establish a national capital federal rate of $425.49 for FY 2014. The capital federal rate is calculated
as follows:
Comparison of factors and adjustments: FY 2013 capital federal rate and
proposed FY 2014 capital federal rate
Final FY 2013
Update factor1
GAF/DRG
adjustment factor
Change
Percent change
1.009
1.009
0.9
0.9998
0.9988
0.9988
-0.12
0.9362
0.9451
1.0095
0.95
N/A
0.998
0.998
-0.2
$425.49
$432.03
1.0154
1.54
1
Outlier adjustment
factor
Proposed FY 2013
1.012
2
Adjustment for
admission and
medical review
criteria3
Capital federal rate
The update factor and the GAF/DRG budget neutrality adjustment factors are built permanently into the capital federal rates. Thus,
for example, the incremental change from FY 2013 to FY 2014 resulting from the application of the proposed 0.9988 GAF/DRG
budget neutrality adjustment factor for FY 2014 is a net change of 0.9988 (or -0.12 percent).
1
2
The outlier reduction factor is not built permanently into the capital federal rate; that is, the factor is not applied cumulatively in
determining the capital federal rate. Thus, for example, the net change resulting from the application of the proposed FY 2014 outlier
adjustment factor is 0.9451/0.9362, or 1.0095 (or 0.95 percent).
3
The proposed adjustment to account for the estimated additional IPPS expenditures that are projected to result from CMS’ policy
proposal on admission and medical review criteria for hospital inpatient services under Medicare Part A.
Changes to payment rates for excluded hospitals: Rate-of-increase percentages
For cancer and children’s hospitals and RNHCIs, the proposed FY 2014 rate-of-increase percentage that would
be applied to the FY 2013 target amounts, in order to determine the FY 2014 target amount, is 2.5 percent.
Changes to the hospital area wage index
The wage index will continue, for FY 2014, to be calculated and assigned to hospitals on the basis of the labor
market area in which the hospital is located. CMS defines hospital labor market areas based on the core-based
statistical areas (CBSAs).
The FY 2014 wage index values are based on the data collected from the Medicare cost reports submitted by
hospitals for cost reporting periods beginning in FY 2010 (the FY 2013 wage indices were based on data from
cost reporting periods beginning during FY 2009).
CMS notes that on February 28, 2013, OMB issued OMB Bulletin No. 13-01, which established revised
delineations for metropolitan statistical areas, micropolitan statistical areas and combined statistical areas,
and provides guidance on the use of the delineations of these statistical areas. A copy of this bulletin may be
obtained at: http://www.whitehouse.gov/sites/default/files/omb/bulletins/2013/b-13-01.pdf.
CMS says it was unable to undertake a lengthy process to adopt OMB’s revised delineations before publication
of this FY 2014 proposed rule. CMS says it intends to propose changes to the wage index based on the newest
CBSA changes in the FY 2015 proposed rule.
10
The proposed FY 2014 national average hourly wage (unadjusted for occupational mix) is $38.2384.
Occupational mix adjustment
The FY 2014 wage index is based on data collected on the new 2010 Medicare wage index occupational mix
survey (Form CMS-10079 (2010)).
The proposed FY 2014 occupational mix adjusted national average hourly wage is $38.2094.
The proposed FY 2014 national average hourly wages for each occupational mix nursing subcategory of the
occupational mix calculation are as follows:
Proposed average
Occupational mix nursing subcategory
hourly wage
National RN
37.432120148
National LPN and surgical technician
21.773706724
National nurse aide, orderly and attendant
15.327583858
National medical assistant
17.213605923
31.811167234
National nurse category
Hospitals with a nurse category average hourly wage greater than the national nurse category average
hourly wage receive an occupational mix adjustment factor of less than 1.0. Hospitals with a nurse category
average hourly wage less than the national nurse category average hourly wage receive an occupational mix
adjustment factor of greater than 1.0.
Application of the rural, imputed and frontier floors
Rural floor
ACA Section 3141 requires that a national, rather than a statewide, budget neutrality adjustment be applied
in implementing the rural floor. CMS says 434 hospitals would receive an increase in their FY 2014 wage index
due to the application of the rural floor.
The table below shows the impact of the rural floor and imputed floor by state:
State
Alabama
Number of
hospitals
Number of hospitals
receiving proposed rural
floor or imputed floor
Percent change in payments due to
application of proposed rural floor and
imputed floor with budget neutrality
Difference
in millions
93
3
-0.5
($7.70)
Alaska
6
4
3.3
$4.70
Arizona
57
7
-0.4
($6.70)
Arkansas
45
0
-0.5
($5.00)
California
308
178
0.9
$86.40
Colorado
46
7
0.1
$1.50
Connecticut
32
27
4.9
$75.00
Delaware
6
0
-0.6
($2.30)
Washington, D.C.
7
0
-0.5
($2.50)
Florida
168
5
-0.4
($29.60)
Georgia
107
0
-0.5
($12.30)
11
State
Number of
hospitals
Number of hospitals
Percent change in payments due to
receiving proposed rural
application of proposed rural floor and
floor or imputed floor
imputed floor with budget neutrality
Difference
in millions
Hawaii
14
0
-0.4
($1.20)
Idaho
14
0
-0.3
($1.00)
Illinois
127
5
-0.6
($26.80)
Indiana
89
4
-0.5
($12.90)
Iowa
34
0
-0.5
($4.20)
Kansas
55
0
-0.4
($3.70)
Kentucky
65
1
-0.4
($7.60)
Louisiana
99
4
-0.5
($6.50)
Maine
20
0
-0.5
($2.40)
Massachusetts
61
60
5.6
$169.10
Michigan
95
0
-0.5
($22.10)
Minnesota
51
0
-0.5
($9.00)
Mississippi
65
1
-0.5
($5.10)
Missouri
77
0
-0.4
($10.70)
Montana
12
4
-0.1
($0.40)
Nebraska
23
0
-0.4
($2.50)
Nevada
24
19
1.6
$10.90
New Hampshire
13
9
0.8
$3.60
New Jersey
64
35
0.4
$14.80
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
25
0
-0.3
($1.50)
166
2
-0.6
($46.50)
87
0
-0.4
($15.20)
6
1
-0.3
($0.90)
137
3
-0.4
($17.70)
86
2
-0.4
($5.40)
33
0
-0.5
($4.50)
157
6
-0.5
($21.80)
Puerto Rico
52
13
0
$0.00
Rhode Island
11
4
0.5
$1.70
South Carolina
57
5
-0.3
($5.00)
South Dakota
19
0
-0.3
($1.00)
Tennessee
97
11
-0.3
($7.60)
Pennsylvania
Texas
322
3
-0.5
($31.90)
Utah
32
0
-0.4
($2.00)
6
0
-0.4
($0.80)
Vermont
Virginia
78
1
-0.4
($10.50)
Washington
49
5
-0.2
($3.60)
West Virginia
30
3
-0.3
($2.30)
Wisconsin
66
2
-0.4
($7.30)
Wyoming
11
0
-0.1
($0.20)
12
Imputed floor
The current method for computing the imputed floor benefits only New Jersey. There are 35 providers in New
Jersey that will receive an increase in their FY 2013 wage index due to the imputed floor policy.
For FY 2014, CMS is proposing to once again extend the imputed floor policy (both the original methodology
and the alternative methodology) for one additional year, through September 30, 2014, while it continues to
explore potential wage index reforms.
Frontier floor
Montana, North Dakota, South Dakota and Wyoming, covering 46 providers, would receive a frontier floor
value of 1.0000.
FY 2014 Medicare geographic classification review board (MGCRB) reclassifications
There are 332 hospitals approved for wage index reclassifications by the MGCRB for FY 2014. Because MGCRB
wage index reclassifications are effective for 3 years, hospitals reclassified during FY 2012 or FY 2013 are
eligible to continue to be reclassified to a particular labor market area based on such prior reclassifications.
There were 249 hospitals approved for wage index reclassifications in FY 2012, and 192 hospitals approved for
wage index reclassifications in FY 2013. CMS says there are 773 hospitals reclassified for FY 2014.
Applications for FY 2015 reclassifications are due to the MGCRB by September 3, 2013 (the first working day of
September 2013). Applications and other information about MGCRB reclassifications may be obtained via the
CMS Internet website at: http://cms.hhs.gov/MGCRB/02_instructions_and_applications.asp, or by calling the
MGCRB at 410.786.1174. The mailing address of the MGCRB is: 2520 Lord Baltimore Drive, Suite L, Baltimore,
MD 21244-2670.
Hospitals may withdraw from a MGCRB decision within 45 days of the publication of the FY 2014
proposed rule.
Redesignations of hospitals under Section 1886(d)(8)(B) of the Social Security Act
Section 1886(d)(8)(B) of the Social Security Act requires CMS to treat a hospital located in a rural county
adjacent to one or more urban areas as being located in the MSA (urban area) if certain criteria are met.
Hospitals located in these counties have been known as “Lugar” hospitals, and the counties themselves are
often referred to as “Lugar” counties.
The FY 2014 chart with the proposed listing of the rural counties containing the hospitals designated as urban
under section 1886(d)(8)(B) of the Act is available via the Internet on the CMS website.
Waiving Lugar redesignation for the out-migration adjustment
An eligible hospital that waives its Lugar status in order to receive the out-migration adjustment has effectively
waived its deemed urban status, and thus, is rural for all purposes under the IPPS, including being considered
rural for the DSH payment adjustment, effective for the fiscal year in which the hospital receives the outmigration adjustment.
FY 2014 wage index adjustment based on commuting patterns of hospital employees
The proposed FY 2013 out-migration adjustment is based on the same policies, procedures and computation
that were used for the FY 2013 out-migration adjustment. Table 4J lists the out-migration adjustments for the
proposed FY 2014 wage index.
13
Changes to Medicare severity DRG (MS-DRG) classifications and
relative weights
Proposed refinement of the MS-DRG relative weight calculation
CMS has previously created new cost centers on the Medicare cost report for implantable devices, MRIs, CT
scans and cardiac catheterization. CMS says “we see no reason to further delay proposing to implement the
CCRs of each of these cost centers. Therefore, beginning in FY 2014, we are proposing to calculate the MS-DRG
relative weights using 19 CCRs, creating distinct CCRs from cost report data for implantable devices, MRIs, CT
scans, and cardiac catheterization.”
As part of this proposed rule, in addition to providing Table 5, which lists the proposed MS-DRGs and
their relative weights using 19 CCRs (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
AcuteInpatientPPS/FY-2014-IPPS-Proposed-Rule-Home-Page-Items/FY-2014-Proposed-Rule-Tables-CMS1599-P.html?DLPage=1&DLSort=0&DLSortDir=ascending), CMS is providing a separate table (supplement
to Table 5) that lists all MS-DRGs and their relative weights if computed using 15 CCRs. These two formats
will allow readers to compare the proposal to calculate the MS-DRG relative weights using 19 CCRs, with the
relative weights of MS-DRGs if computed using 15 CCRs.
CMS is including in the table below the top 10 (non-labor and delivery) MS-DRGs that it predicts would
experience the largest increases and decreases in relative weights if 19 CCRs would be used, as compared to
15 CCRs.
MS-DRG
Type
Title
Relative weight
with 15 CCRs
Relative weights
with 19 CCRs
Percentage
change
MS-DRGS that would experience the largest decrease in relative weight
90
MED Concussion without CC/MCC
0.7614
0.7013
-7.90%
84
MED Traumatic stupor and coma,
0.9137
0.8516
-6.80%
0.7899
0.7369
-6.70%
1.0450
0.9800
-6.10%
0.7281
0.6845
-6.00%
MED Concussion with CC
0.9959
0.9366
-6.00%
MED Neurological eye disorder
0.7355
0.6920
-5.90%
0.9880
0.9517
-5.70%
0.9355
0.8825
-5.70%
0.8034
0.7579
-5.70%
coma >1 Hour without CC/MCC
87
MED Traumatic stupor and coma,
coma <1 Hour without
965
MED Other multiple significant
traumas without CC/MCC
185
MED Major chest trauma without CC/
MCC
89
123
343
SURG Appendectomy without
complicated principal diagnosis
without CC/MCC
53
MED Spinal disorders and injuries
66
MED Intracranial hemorrhage or
without CC/MCC
cerebral infarction without CC/
MCC
14
MS-DRG
Type
Title
Relative weight
with 15 CCRs
Relative weights
with 19 CCRs
Percentage
change
MS-DRGS that would experience the largest increase in relative weight
454
SURG Combined anterior/posterior
455
SURG Combined anterior/posterior
7.6399
8.0563
5.50%
5.9862
6.3133
5.50%
2.1211
2.238
5.50%
5.6298
5.953
5.70%
6.0956
6.4482
5.80%
4.8794
5.163
5.80%
spinal fusion with CC
spinal fusion without CC/MCC
484
SURG Major joint and limb
reattachment procedure of
upper extremity without CC/
MCC
225
SURG Cardiac defibrillator implant
with cardiac catheterization
without AMI/HF/shock without
MCC
223
SURG Cardiac defibrillator implant
with cardiac catheterization
with AMI/HF/shock without
MCC
458
SURG Spinal fusion except cervical
with spinal curve/malignant/
infection OR 9+ fusion without
CC/MCC
SURG AICD generator procedures
4.4627
4.732
6.00%
849
MED Radiotherapy
1.3423
1.4258
6.20%
946
MED Rehabilitation without CC/MCC
1.1295
1.2024
6.50%
5.2193
5.5714
6.70%
245
227
SURG Cardiac defibrillator implant
without cardiac catheterization
without MCC
Proposed changes to specific MS-DRG classifications
MDC 1 (diseases and disorders of the nervous system)
Tissue plasminogen activator (tPA) (rtPA) administration within 24 hours prior to admission – For FY 2014,
CMS is proposing to move cases with diagnosis code V45.88 from MS-DRG 066 to MS-DRG 065, and to revise
the title of MS-DRG 065 to reflect the patients status post-tPA administration within 24 hours. The proposed
revised MS-DRG title would be: MSDRG 065 (intracranial hemorrhage or cerebral infarction with CC or tPA in 24
hours).
MDC 5 (diseases and disorders of the circulatory system)
Discharge/transfer to designated disaster alternative care site - CMS is proposing to add new patient discharge
status code 69 (Discharged/transferred to a designated disaster alternative care site) to the MS-DRG GROUPER
logic for MS-DRGs 280 (acute myocardial infarction discharged alive with MCC), 281 (acute myocardial
infarction discharged alive with CC) and 282 (acute myocardial infarction discharged alive without CC/MCC)
to identify patients who are discharged or transferred to an alternative site that will provide basic patient care
during a disaster response.
15
Discharges/transfers with a planned acute care hospital inpatient readmission - CMS also is proposing to add
15 new discharge status codes to the MS-DRG GROUPER logic for MS-DRGs 280, 281 and 282 that will identify
patients who are discharged with a planned acute care hospital inpatient readmission.
Shown in the table below are the current discharge status codes that are assigned to the GROUPER logic for
MS-DRGs 280, 281 and 282, along with the proposed new discharge status codes and their titles.
Current
Code
New
Code
Title
1
81 Discharged to home or self-care with a planned acute care hospital inpatient
readmission
2
82 Discharged/transferred to a short-term general hospital for inpatient care with a
planned acute care hospital inpatient readmission
3
83 Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification with
a planned acute care hospital inpatient readmission
4
84 Discharged/transferred to a facility that provides custodial or supportive care with a
planned acute care hospital inpatient readmission
5
85 Discharged/transferred to a designated cancer center or children’s hospital with a
planned acute care hospital inpatient readmission
6
86 Discharged/transferred to home under care of organized home health service
organization with a planned acute care hospital inpatient readmission
21
87 Discharged/transferred to court/law enforcement with a planned acute care hospital
inpatient readmission
43
88 Discharged/transferred to a federal health care facility with a planned acute care
hospital inpatient readmission
61
89 Discharged/transferred to a hospital-based Medicare-approved swing bed with a
planned acute care hospital inpatient readmission
62
90 Discharged/transferred to an inpatient rehabilitation facility (IRF) including
rehabilitation distinct part units of a hospital with a planned acute care hospital
inpatient readmission
63
91 Discharged/transferred to a Medicare-certified long-term care hospital (LTCH) with a
planned acute care hospital inpatient readmission
64
92 Discharged/transferred to a nursing facility certified under Medicaid, but not certified
under Medicare, with a planned acute care hospital inpatient readmission
65
93 Discharged/transferred to a psychiatric distinct part unit of a hospital with a planned
acute care hospital inpatient readmission
66
94 Discharged/transferred to a critical access hospital (CAH) with a planned acute care
hospital inpatient readmission
70
95 Discharged/transferred to another type of health care institution not defined elsewhere
in this code list with a planned acute care hospital inpatient
MDC 15 (newborns and neonates with conditions originating in the neonatal period)
For FY 2014, CMS would reassign diagnosis codes V64.00 through V64.04, and V64.06 through V64.3 from MSDRG 794 to MS-DRG 795. Diagnosis codes V64.00 through V64.04 and V64.06 through V64.3 would be added to
the “only secondary diagnosis” list for MS-DRG 795. Diagnosis codes V64.41, V64.42 and V64.43 would continue
to be assigned to MS-DRG 794.
16
Discharges/transfers of neonates with a planned acute care hospital inpatient readmission - CMS is proposing
to add the patient discharge status codes shown in the table below to the MS-DRG GROUPER logic for MS-DRG
789 (neonates, died or transferred to another acute care facility) to identify neonates that are transferred to a
designated facility with a planned acute care hospital inpatient readmission.
New Code
Title
82 Discharged/transferred to a short-term general hospital for inpatient care with a planned
acute care hospital inpatient readmission
85 Discharged/transferred to a designated cancer center or children’s hospital with a planned
acute care hospital inpatient readmission
94 Discharged/transferred to a critical access hospital (CAH) with a planned acute care hospital
inpatient readmission
Chronic total occlusion (CTO) of artery of the extremities diagnosis code
CMS is proposing to remove the following diagnosis codes from the CC exclusion list for diagnosis code 440.4:
atherosclerosis codes 440.20 through 440.32, 443.22 and 443.29, and aneurysm codes 441.00 through 441.03,
441.1 through 441.7, 441.9, 442.0, 442.2, 442.3 and 442.9. Diagnosis codes 443.81 through 443.9 would remain
on the CC exclusion list for diagnosis code 440.4.
Note
There are no new, revised or deleted diagnosis codes for FY 2014. Therefore, there are no Tables 6A, 6C and 6E
published for FY 2014. There are no proposed additions or deletions to the MS-DRG MCC List for FY 2014. There
also are no proposed additions or deletions to the MS-DRG CC List for FY 2014. Therefore, there are no Tables
6I.1 through 6I.2 and 6J.1 through 6J.2 published for FY 2014.
Proposed add-on payments for new services and technologies
Voraxaze® is still within the three-year newness period; CMS is proposing to continue new technology add-on
payments for this technology for FY 2014.
DIFICID™ (Fidaxomicin) tablets’ three-year anniversary date will occur in the second half of the fiscal year (after
April 1, 2014); CMS is proposing to continue new technology add-on payments for FY 2014.
Zenith® fenestrated abdominal aortic aneurysm (AAA) endovascular graft is being proposed to continue new
technology add-on payments for FY 2014.
CMS received five applications for new technology add-on payments for FY 2014: Kcentra™; Argus® II Retinal
Prosthesis System; Responsive Neurostimulator (RNS®) System; Zilver® PTX® Drug Eluting Peripheral Stent; and
MitraClip® System.
None of these five applications have been proposed as new technology, although CMS is soliciting comments.
Other decisions and changes to the IPPS for operating costs
A. Rural referral centers (RRCs)
A rural hospital with less than 275 beds may be classified as an RRC if:
yy The hospital’s case-mix index (CMI) is at least equal to the lower of the median CMI for urban hospitals in
its census region, excluding hospitals with approved teaching programs, or the median CMI for all urban
hospitals nationally; and
17
yy The hospital’s number of discharges is at least 5,000 per year, or, if fewer, the median number of discharges
for urban hospitals in the census region in which the hospital is located. (The number of discharges criteria
for an osteopathic hospital is at least 3,000 discharges.)
CMS is proposing that, in addition to meeting other criteria, if rural hospitals with fewer than 275 beds are to
qualify for initial RRC status for cost reporting periods beginning on or after October 1, 2013, they must have a
CMI value for FY 2012 that is at least:
yy 1.5526; or
yy The median CMI value (not transfer-adjusted) for urban hospitals (excluding hospitals with approved
teaching programs as identified in § 413.75) calculated by CMS for the census region in which the hospital
is located.
The proposed CMI values by region are set forth in the following table:
Region
Case mix
index value
1 New England (CT, ME, MA, NH, RI, VT)
1.3319
2 Middle Atlantic (PA, NJ, NY)
1.4025
3 South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)
1.4799
4 East North Central (IL, IN, MI, OH, WI)
1.4542
5 East South Central (AL, KY, MS, TN)
1.4266
6 West North Central (IA, KS, MN, MO, NE, ND, SD)
1.5311
7 West South Central (AR, LA, OK, TX)
1.5811
8 Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)
1.6393
9 Pacific (AK, CA, HI, OR, WA)
1.5568
A hospital, if it is to qualify for initial RRC status for cost reporting periods beginning on or after October 1,
2013, must also have as the number of discharges for its cost reporting period that began during FY 2011 a
figure that is at least:
yy 5,000 (3,000 for an osteopathic hospital); or
yy The median number of discharges for urban hospitals in the census region in which the hospital is located.
All census regional discharge numbers are greater than 5,000.
B. Proposed payment adjustment for low-volume hospitals (§ 412.101)
In accordance with Section 1886(d)(12) of the Act, as amended, beginning with FY 2014, the low-volume
hospital definition and payment adjustment methodology will revert back to the statutory requirements
that were in effect prior to the amendments made by the ACA and the ATRA. FY 2014 and subsequent years,
in order to qualify as a low-volume hospital, a subsection (d) hospital must be more than 25 road miles from
another subsection (d) hospital and have less than 200 discharges (that is, less than 200 discharges total,
including both Medicare and non-Medicare discharges) during the fiscal year. Under existing policy, effective
for FY 2014 and subsequent years, qualifying hospitals would receive the low-volume hospital payment
adjustment of an additional 25 percent for discharges occurring during the fiscal year.
C. Indirect medical education (IME) payment adjustment (§ 412.105)
For discharges occurring during FY 2014, the formula multiplier continues to be 1.35.
18
Comment
The following section is intended to implement the ACA’s payment reductions for DSH as additional and
uninsured individuals acquire health care coverage. The material that follows appears complex and should be
reviewed by all providers currently receiving DSH payments.
D. Payment adjustment for Medicare disproportionate share hospitals (DSHs) (§ 412.106)
ACA Section 3133 added a new section 1886(r) to the Act that modifies the methodology for computing the
Medicare DSH payment adjustment, beginning in FY 2014.
Beginning for discharges in FY 2014, hospitals that qualify for Medicare DSH payments under section
1886(d)(5)(F) will receive 25 percent of the amount they previously would have received under the current
statutory formula for Medicare DSH payments. This provision applies equally to hospitals that qualify for DSH
payments under section 1886(d)(5)(F)(i)(II) of the Act, the so-called Pickle hospitals. Pursuant to new section
1886(r), Pickle hospitals would receive 25 percent of the 35 percent add-on adjustment for which they would
otherwise qualify under section 1886(d)(5)(F)(i)(II). Let’s call these traditional DSH hospitals or traditional DSH
payments. CMS described these DSH payments as “empirically justified Medicare DSH payments.”
The remaining amount, equal to an estimate of 75 percent of what otherwise would have been paid as
Medicare DSH payments, reduced to reflect changes in the percentage of individuals under age 65 who are
uninsured, will become available as an additional payment to each hospital that qualifies for Medicare DSH
payments and that has uncompensated care. The payments to each hospital for a fiscal year will be based
on the hospital’s amount of uncompensated care for a given time period relative to the total amount of
uncompensated care for that same time period reported by all hospitals that receive Medicare DSH payments
for that fiscal year.
In determining which classes of DSH hospitals that would be eligible for these additional uncompensated care
payments, CMS indicated the following classes of DSH hospitals, in addition to subsection (d) DSH hospitals,
would be eligible:
yy Subsection (d) Puerto Rico hospitals
yy Sole Community Hospitals (SCH)
yy IPPS hospitals participating in the Bundled Payments for Care Improvement Initiative
CMS indicated hospitals participating under a waiver from the Medicare payment methodologies (Maryland
hospitals) and hospitals participating in the rural community hospital demonstration program would not be
eligible to receive the new uncompensated care payments.
For sole community hospitals (SCH), CMS is proposing that the new uncompensated care payments would
not be accounted for in determining whether a SCH is paid the higher of the federal rate or the hospitalspecific rate. CMS’ reasoning is that uncompensated care payments are not discharge-driven payments (like
federal rate and hospital-specific rate payments), but rather payments made on the basis of a hospital’s overall
uncompensated care during the year. CMS is inviting comments on this proposal regarding SCHs.
Section 1886(r)(2) of the Act provides that, for FY 2014 and each subsequent FY, the secretary shall pay to “such
subsection (d) hospital an additional amount equal to the product of three factors.”
19
Remember, in order to qualify to receive these additional uncompensated care payments a hospital must
qualify to receive traditional DSH payments, i.e. if your hospital does not qualify to receive 25 percent of their
traditional DSH payments, then your hospital will receive no (or zero) uncompensated care payments.
The first factor is the difference between “the aggregate amount of payments that would be made to
subsection (d) hospitals under subsection (d)(5)(F) if this subsection did not apply” and “the aggregate amount
of payments that are made to subsection (d) hospitals under paragraph (1)” for each FY.
The second factor is, for FYs 2014 through 2017, 1 minus the percent change in the percent of individuals
under the age of 65 who are uninsured, determined by comparing the percent of such individuals who are
uninsured in 2013, the last year before coverage expansion under the ACA (as calculated by the secretary,
based on the most recent estimates available from the Director of the Congressional Budget Office before
a vote in either House on the Health Care and Education Reconciliation Act of 2010 that, if determined in
the affirmative, would clear such Act for enrollment), minus 0.1 percentage point for FY 2014, and minus 0.2
percentage points for FYs 2015 through 2017.
The third factor is a percent that, for each subsection (d) hospital, “represents the quotient of… the amount
of uncompensated care for such hospital for a period selected by the secretary (as estimated by the secretary,
based on appropriate data…),” including the use of alternative data “where the secretary determines that
alternative data is available which is a better proxy for the costs of subsection (d) hospitals for… treating the
uninsured,” and “the aggregate amount of uncompensated care for all subsection (d) hospitals that receive a
payment under this subsection.”
Therefore, this third factor represents a DSH hospital’s uncompensated care amount for a given time period
relative to the uncompensated care amount for that same time period for all hospitals that receive Medicare
DSH payments in that fiscal year, expressed as a percent. For each hospital, the product of these three factors
represents its additional payment for uncompensated care for the applicable fiscal year.
Proposed methodology to calculate Factor 1
Section 1886(r)(2)(A)(i) of the Act represents an estimate of the full Medicare DSH payment amount under
section 1886(d)(5)(F) prior to the 75 percent reduction, for FY 2014 and subsequent years. This subparagraph
specifies that, for each fiscal year to which the provision applies, such amount is to be “estimated by the
secretary.”
CMS would use the agency’s office of the actuary’s February 2013 Medicare DSH estimates to calculate
Factor 1. However, CMS proposes to use the office of the actuary’s July 2013 Medicare DSH estimates to
calculate Factor 1 in the final rule.
CMS estimates empirically justified Medicare DSH payments for FY 2014, with the application of section 1886(r)
(1) of the Act, is $3.084 billion (25 percent of the total amount estimated). Factor 1 is the difference of these
two estimates of the office of the actuary. Therefore, for the purpose of modeling Factor 1, CMS calculates
Factor 1 to be $9.2535 billion. CMS has published supplemental information on how Factor 1 was computed
out on their website at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/
dsh.html.
Proposed methodology to calculate Factor 2
Section 1886(r)(2)(B) of the Act establishes, as Factor 2 in the uncompensated care payment formula, the
percent change in uninsurance, based on a comparison of the percent of individuals under 65 without
20
insurance in 2013 to the percent of such individuals without insurance in the most recent period for which
CMS has data, minus 0.1 percentage point for FY 2014 and 0.2 percentage points for each of FYs 2015, 2016
and 2017.
Using a March 20, 2010 CBO projection for 2013 and a February 5, 2013 CBO projection of uninsurance for all
residents for 2014, CMS is proposing to use the following computation for Factor 2 for FY 2014:
yy Percent of individuals without insurance for 2013: 18 percent
yy Percent of individuals without insurance for 2014: 16 percent
1.0 – |[(0.16 - 0.18)/0.18]| = 1.0 - 0.111 = 0.889 (88.9 percent) 0.889 (88.9 percent) - 0.001 (0.1 percentage point)
= 0.888 (88.8 percent) 0.888 = Factor 2
Accordingly, CMS is proposing Factor 2 to be 88.8 percent for FY 2014. In conjunction with this proposal, CMS
is proposing that the amount available for uncompensated care payments for FY 2014 will be $8.217 billion
(0.888 times the proposed Factor 1 estimate of $9.2535 billion). This results in a reduction in DSH payments via
the uncompensated care calculation of approximately $1.03B ($9.25B - $8.22B).
Proposed methodology to calculate Factor 3
For FY 2014, the denominator for Factor 3 would reflect the estimated Medicaid and Medicare SSI patient days,
based on data from the 2010/2011 Medicare cost report (including the most recently available data that may
be used to update the SSI ratios) for all hospitals that CMS estimates would receive an empirically justified DSH
payment in FY 2014. The numerator of Factor 3 would be the estimated Medicaid and Medicare SSI patient
days for the individual hospital, based on its most recent 2010/2011 Medicare cost report data (including the
most recently available data that may be used to update the SSI ratios).
CMS is posting proposed tables listing Factor 3 for the hospitals that it has estimated would receive Medicare
DSH payments for FY 2014 on the CMS website at: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/AcuteInpatientPPS/dsh.html.
CMS is requesting that hospitals review these tables. In order to ensure that CMS has sufficient time to
incorporate any updated information in the tables for the final rule, hospitals should notify CMS in writing
within 60 days from the date of display of this proposed rule of any change in a hospital’s subsection (d)
hospital status.
Comment
The statute provides the formula factors to calculate DHS payments and reductions. The reduction from
$9.2535 billion to $8.217 billion under Factor 2 implies a potential loss of $1 billion in payments. All will
depend on the uninsured becoming insured.
Congress has made judicial review of CMS’ estimates and data sources basically challenge proof. However,
CMS is requesting comments on the proposed DSH and uncompensated care estimation and payment
methodologies. The hospital community should take this opportunity to comment on these methodologies
and propose alternatives to ensure DSH and uncompensated care payments are distributed to DSH hospitals
equitably for FY 2014 and after.
Hospitals should review these proposed rules very carefully and determine the impact these changes will have
on their annual DSH payments. The calculation of a hospital’s traditional DSH payments is more critical than
21
ever, as if a hospital doesn’t qualify for traditional DSH payments, they will not qualify for the 75 percent pool
of uncompensated care payments.
Additionally, each hospital’s ability to capture all of their patients that are eligible for Medicaid whether paid
or unpaid takes on even more importance as that information is now being used in both the traditional DSH
payment calculation and the uncompensated care payment calculation. Hospital’s that can accurately capture
Medicaid eligibility data will fare better than those that cannot.
E. Hospital readmissions reduction program: Proposed changes (§§412.150 through 412.154)
The hospital readmissions reduction program began on October 1, 2012. The maximum reduction was one
percent of payment amounts in FY 2013, and will increase to two percent of payment amounts in FY 2014, as
specified under the ACA.
CMS currently assesses hospitals’ readmission penalties using three readmissions measures endorsed by
the National Qualify Forum (NQF): heart attack, heart failure and pneumonia. CMS is proposing to update
the measures to: (1) incorporate the CMS-planned readmission algorithm version 2.1 to identify planned
readmissions; and (2) not count unplanned readmissions that follow planned readmissions. CMS says this
proposed change in counting practice would affect a very small percentage of readmissions (approximately
0.3 percent of index admissions nationally for AMI, 0.2 percent for HF and less than 0.1 percent for PN).
For FY 2015, CMS is proposing to expand the applicable conditions and procedures to include: (1) patients
admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD); and (2) patients
admitted for elective total hip arthroplasty (THA) and total knee arthroplasty (TKA).
F. Hospital value-based purchasing (VBP) program
For FY 2014, CMS is increasing the applicable percent reduction, the portion of Medicare payments available
to fund the VBP program’s value-based incentive payments, to 1.25 percent, as required by the ACA. CMS
estimates that the total amount available for performance-based incentive payments for FY 2014 would be
approximately $1.1 billion, and will update this estimate for the final rule.
FY 2014 hospital VBP program measures
Set out below is a complete list of the measures CMS adopted for the FY 2014 hospital VBP program:
Finalized quality measures for the FY 2014 hospital VBP program
Clinical process of care measures
Measure ID
Measure description
Acute myocardial infarction
AMI-7a
Fibrinolytic therapy received within 30 minutes of hospital arrival
AMI-8a
Primary PCI received within 90 minutes of hospital arrival
Heart failure
HF-1
Discharge instructions
Pneumonia
PN-3b
Blood cultures performed in the emergency department prior to initial
antibiotic received in hospital
PN-6
Initial antibiotic selection for CAP in immunocompetent patient
22
Health care-associated infections
SCIP-Inf-1
Prophylactic antibiotic received within one hour prior to surgical incision
SCIP-Inf-2
Prophylactic antibiotic selection for surgical patients
SCIP-Inf-3
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
SCIP-Inf-4
Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose
SCIP-Inf-9
Postoperative urinary catheter removal on postoperative day 1 or 2
Surgeries
SCIP-Card-2
Surgery patients on beta blocker therapy prior to arrival who received a betablocker during the perioperative period
SCIP-VTE-1 **
Surgery patients with recommended venous thromboembolism prophylaxis
ordered
SCIP-VTE-2
Surgery patients who received appropriate venous thromboembolism
prophylaxis within 24 hours prior to surgery to 24 hours after surgery
Patient experience of care measures
Measure ID
Measure description
HCAHPS
Hospital consumer assessment of health care providers and systems survey*
Outcome measures
Measure ID
Measure description
MORT-30-AMI
Acute myocardial infarction (AMI) 30-day mortality rate
MORT-30-HF
Heart failure (HF) 30-day mortality rate
MORT-30 PN
Pneumonia (PN) 30-day mortality rate
*The finalized dimensions of the HCAHPS survey for use in the FY 2014 hospital VBP program are: Communication with nurses,
communication with doctors, responsiveness of hospital staff, pain management, communication about medicines, cleanliness and
quietness of hospital environment, discharge information and overall rating of hospital. These are the same dimensions that CMS
adopted for the FY 2013 hospital VBP program.
**To be deleted for FY 2015
FY 2015 hospital VBP program measures
For the FY 2015 VBP program, CMS adopted 12 clinical process of care measures, one patient experience
of care measure in the form of the HCAHPS survey, 5 outcome measures, including three 30-day mortality
measures, the AHRQ PSI composite measure and the CLABSI measure and one efficiency measure.
They are the items in the above table, less SCIP-VTE-1, which is to be deleted for FY 2015, and the following
three items below.
Added finalized quality measures for the FY 2015 hospital VBP program
Outcome measures
Measure ID
Measure description
AHRQ PSI composite
Complication/patient safety for selected indicators (composite)
CLABSI
Central line-associated blood stream infection
Efficiency measures
MSPB-1
Medicare spending per beneficiary
FY 2016 hospital VBP program measures
CMS is proposing to remove measures AMI-8a, PN-3b and HF-1 for FY 2016.
23
CMS also proposes to adopt three new measures for FY 2016, including one new clinical process measure,
influenza immunization, and two new health care-associated infection measures, catheter-associated urinary
tract infection (CAUTI) and surgical site infection (SSI), the latter of which is stratified into two separate
surgery sites.
The proposed rule outlines the proposed performance and baseline periods for the FY 2016 program, and
proposes reclassification of the hospital VBP program domains to more closely align with the national quality
strategy in FY 2017. It proposes weighting for the proposed aligned domains for 2017, as well as proposed
domain weighting under the current domain structure for FY 2016.
Performance standards for the FY 2016 hospital VBP program measures
CMS has finalized FY 2016 performance standards for the three 30-day mortality measures and the AHRQ PSI
composite measure in the FY 2013 IPPS/LTCH PPS final rule, and is displaying them in the table below.
Finalized performance standards for certain FY 2016 hospital VBP program
Outcome domain measures
Measure ID
Description
Achievement threshold
Benchmark
Outcomes measures
MORT-30-AMI
Acute myocardial infarction (AMI)
30-day mortality rate
0.847472
0.862371
MORT-30-HF
Heart failure (HF) 30-day mortality rate
0.881510
0.900315
MORT-30-PN
Pneumonia (PN) 30-day mortality rate
0.882651
0.904181
PSI-90
Complication/patient safety for
selected indicators (composite)
0.622879
0.451792
The numerical values for the proposed FY 2016 performance standards for the clinical process, outcome and
efficiency measures appear in the table below:
Proposed performance standards for the FY 2016 hospital VBP program clinical process of care,
outcomes and efficiency domain measures
Measure ID
Description
Achievement threshold
Benchmark
Clinical process of care measures
AMI-7a
Fibrinolytic therapy received within
30 minutes of hospital arrival
0.88625
1.00000
IMM-2
Influenza immunization
0.89947
0.99036
PN-6
Initial antibiotic selection for CAP in
immunocompetent patient
0.96429
1.00000
SCIP-Inf-1
Prophylactic antibiotic received
within one hour prior to surgical
incision
0.98942
1.00000
SCIP-Inf-2
Prophylactic antibiotic selection for
surgical patients
0.98951
1.00000
SCIP-Inf-3
Prophylactic antibiotics
discontinued within 24 hours after
surgery end time
0.97971
1.00000
SCIP-Inf-4
Cardiac surgery patients with
controlled 6 a.m. postoperative
serum glucose
0.96797
0.99977
24
SCIP-Inf-9
Urinary catheter removed
on postoperative day 1 or
postoperative day 2
0.96743
1.00000
SCIP-Card-2
Surgery Patients on Beta-Blocker
Therapy Prior to Arrival Who
received a beta-blocker during the
perioperative period
0.97561
1.00000
SCIP-VTE-2
Surgery patients who
received appropriate venous
thromboembolism prophylaxes
within 24 hours prior to surgery to
24 hours after surgery
0.98086
1.00000
Outcomes measures
CAUTI
Catheter-associated urinary tract
infection
0.82600
0.00000
CLABSI
Central line-associated blood
stream infection
0.47300
0.00000
SSI
Surgical site infection
0.73700
0.00000
Medicare spending per beneficiary
Median Medicare spending
per beneficiary ratio across
all hospitals during the
performance period
Mean of the lowest decile
Medicare spending per
beneficiary ratios across
all hospitals during the
performance period
Efficiency measure
MSPB-1
CMS says that for information purposes, during the period of May 1, 2011 through December 31, 2011, the
achievement threshold would have been a Medicare spending per beneficiary ratio of 0.99, which corresponds
to a standardized, risk-adjusted Medicare spending per beneficiary amount of $18,079, and the benchmark
would have been 0.82, which corresponds to a Medicare spending per beneficiary amount of $14,985.
Numerical values for the proposed FY 2016 performance standards for the patient experience of care (HCAHPS
survey) measures appear in the table below.
Proposed performance standards for the FY 2016 hospital VBP program
Patient experience of care domain
HCAHPS survey dimension
Floor
Achievement threshold
Benchmark
(percent)
(percent)
(percent)
Communication with nurses
53.33
77.59
85.98
Communication with doctors
61.22
80.33
88.59
Responsiveness of hospital staff
36.44
64.65
79.72
Pain management
47.93
70.16
78.24
Communication about medicines
42.23
62.28
72.67
Hospital cleanliness and quietness
42.16
64.93
79.12
Discharge information
62.85
84.45
90.26
Overall rating of hospital
36.45
69.05
83.89
25
Certain performance standards for the FY 2017, FY 2018 and FY 2019 hospital VBP programs
CMS is proposing to adopt performance standards for the three 30-day mortality and AHRQ PSI composite
measures for the FY 2017, FY 2018 and FY 2019 hospital VBP program years.
Hospital VBP program scoring methodology
Final domain weights for the FY 2015 hospital VBP program for hospitals
Receiving a score on all proposed domains
Domain
Weight
Clinical process of care
20 percent
Patient experience of care
30 percent
Outcome
30 percent
Efficiency
20 percent
G. Proposed implementation of hospital-acquired condition (HAC) reduction program for FY 2015
Under this program, hospitals that rank in the lowest-performing quartile of hospital-acquired conditions
would be paid 99 percent of what they would otherwise be paid under the IPPS beginning in FY 2015. To
determine this quartile, CMS is proposing quality measures and a scoring methodology, as well as a process for
hospitals to review and correct their data.
For FY 2015, the first year of the program, CMS is proposing to measure HACs using measures that are either
calculated using claims or are part of the inpatient quality reporting program, and would consist of two
domains of measure sets.
The proposed Domain 1 measures would include six patient safety indicator (PSI) measures developed by
the Agency for Health Care Research and Quality (AHRQ). These measures are: pressure ulcer rate; volume
of foreign object left in the body; iatrogenic pneumothorax rate; postoperative physiologic and metabolic
derangement rate; postoperative pulmonary embolism or deep vein thrombosis rate; and accidental puncture
and laceration rate. An alternative to Domain 1 is also being proposed, which would consist of a composite PSI
measure set.
The proposed Domain 2 measures would include two health care-associated infection measures developed by
the Centers for Disease Control and Prevention’s (CDC) National Health Safety Network: central line-associated
bloodstream infection and catheter-associated urinary tract infection.
Under the scoring methodology proposed, hospitals would be given a score for each measure within the two
domains. A domain score would be calculated and the two domains would be weighted equally to determine
a total score under the program. Risk factors such as the patient’s age, gender and comorbidities would
be considered in the calculation of the measure rates, so that hospitals serving a large proportion of sicker
patients would not be unfairly penalized. In accordance with the statute, CMS proposes a process for hospitals
to review and correct their information.
26
Proposed measures for the hospital-acquired condition reduction program
Domain 1: AHRQ patient safety indicators
Proposed approach:
6 individual measures
(FY 2015 onward)
PSI-3 (Pressure ulcer rate)
PSI-5 (Foreign object left in body)
PSI-6 (Iatrogenic pneumothorax rate)
PSI-10 (Postoperative physiologic and metabolic
derangement rate)
PSI-12 (Postoperative PE/DVT rate)
PSI-15 (Accidental puncture and laceration rate)
Alternative approach:
One composite of 8 component indicators
(FY 2015 onward)
PSI-90 = PSI3, 6, 7, 8
PSI-3 (Pressure ulcer rate)
PSI-6 (Iatrogenic pneumathorax rate)
PSI-7 (Central venous catheter-related blood
stream infections rate)
PSI-8 (Postoperative hip fracture rate)
PSI-12 (Postoperative PE/DVT rate)
PSI-13 (Postoperative sepsis rate)
PSI-14 (Wound dehiscence rate)
PSI-15 (Accidental puncture and laceration rate)
Domain 2: CDC HAI measures apply to proposed approach and alternative approach
(Multiple FYs)
Central line-associated blood stream infection (CLABSI) (FY 2015 onward)
Catheter-associated urinary tract infection (CAUTI) (FY 2015 onward)
Surgical site infection (SSI):
SSI following colon surgery (FY 2016 onward)
SSI following abdominal hysterectomy (FY 2016 onward)
Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia (FY 2017 onward)
Clostridium difficile (FY 2017 onward)
For FY 2015, CMS is proposing to use the 24-month period from July 1, 2011 through June 30, 2013 as the
applicable time period for the AHRQ measures. The claims for all Medicare FFS beneficiaries discharged during
this period would be included in the calculation of measure results for FY 2015. This includes claims data from
the 2011, 2012 and 2013 inpatient standard analytic files (SAFs).
Comment
The system for scoring is complex and detailed.
H. Policy proposal on admission and medical review criteria for hospital inpatient services under
Medicare Part A
CMS is proposing a time-based presumption of medical necessity for hospital inpatient services, based on
the beneficiary’s length of stay, as part of its medical review criteria for payment of hospital inpatient services
under Part A.
CMS is proposing a new benchmark for purposes of medical review of hospital inpatient admissions, based on
how long the beneficiary is in the hospital. Under the proposal, Medicare’s external review contractors would
presume that hospital inpatient admissions are reasonable and necessary for beneficiaries who require more
than one Medicare utilization day (defined by encounters crossing two “midnights”) in the hospital receiving
medically necessary services.
27
If a hospital is found to be abusing this two-midnight presumption for non-medically necessary inpatient
hospital admissions and payment (in other words, the hospital is systematically delaying the provision of
care to surpass the two-midnight time frame), CMS review contractors would disregard the two-midnight
presumption when conducting review of that hospital.
Similarly, CMS would presume that hospital services spanning less than two midnights should have been
provided on an outpatient basis, unless there is clear documentation in the medical record supporting the
physician’s order and expectation that the beneficiary would require care spanning more than two midnights,
or the beneficiary is receiving a service or procedure designated by CMS as inpatient-only.
CMS is proposing to add a new § 412.3, titled “Admissions,” that would define a hospital inpatient admission,
as follows: “(a) For purposes of payment under Medicare Part A, an individual is considered an inpatient of
a hospital, including a critical access hospital, if formally admitted as an inpatient pursuant to an order for
inpatient admission by a physician or other qualified practitioner.”
In other words, if it was reasonable for the physician to expect the beneficiary to require a stay lasting two
midnights, even though that did not transpire, payment would be made under Medicare Part A, if the
documentation in the medical record reflected such complex medical factors (and the physician’s order and
certification requirements also are met).
In light of the widespread impact of the proposed policy on the IPPS, CMS says it believes “it is appropriate
to…use our exceptions and adjustments authority under section 1886(d)(5)(I)(i) of the Act to offset the
estimated $220 million in additional IPPS expenditures associated with this proposed policy.” This special
exceptions and adjustment authority authorizes us to provide, “for such other exceptions and adjustments to
[IPPS] payment amounts…as the secretary deems appropriate.”
CMS is proposing to reduce the standardized amount, the hospital-specific rates and the Puerto Rico-specific
standardized amount by 0.2 percent.
Proposed quality data reporting requirements for specific providers
and suppliers
Hospital IQR
The Hospital IQR program measure set has grown from a starter set of 10 quality measures in 2004, to a
set of 59 quality measures. These measures include: chart-abstracted measures, such as heart attack, heart
failure, pneumonia and surgical care improvement measures; claims-based measures, such as mortality and
readmissions; health care-associated infections measures; a surgical complications measure; survey-based
measures, such as patient experience of care; immunization measures and structural measures that assess
features of hospitals—such as hospital volume, how the hospital deploys staff or provider qualifications—to
assess their capacity to improve quality of care.
For the FY 2016 payment determination and subsequent years, CMS is proposing to remove eight measures
from the hospital IQR program. Three measures are chart-abstracted (one pneumonia measure, one heart
failure measure and one immunization measure), and one is a structural measure (systematic clinical database
registry for stroke care). CMS is also proposing to remove 4 additional chart-abstracted measures from the
hospital IQR program, because they were either recommended for removal by the measure application
partnership (MAP) during the pre-rulemaking process or are considered “topped out.”
28
Proposed removal of hospital IQR program measures for the FY 2016
payment determination and subsequent years
Topic
Acute myocardial infarction
• AMI-2 aspirin prescribed at discharge
• AMI-10 statin prescribed at discharge
Pneumonia
• PN-3b blood culture performed in the emergency department prior to first antibiotic
received in hospital
Heart failure
• HF-1 discharge instructions
• HF-3 ACEI or ARB for LVSD
Surgical care improvement project
• SCIP-Inf-10 Surgery patients with perioperative temperature management
Immunization
• IMM-1 Immunization for pneumonia
Structural measure
• Participation in a systematic clinical database registry for stroke care
CMS is proposing to incorporate refinements for several measures that are currently adopted in the hospital
IQR program. These refinements have either arisen out of the NQF endorsement maintenance process, or
during internal efforts to harmonize measurement approaches.
The measure refinements include the following:
1.Incorporation of the planned readmission algorithm in 30-day readmission measures for AMI, HF, PN, THA/
TKA and hospital-wide readmission to match recent NQF endorsement maintenance decisions beginning
in 2013
2.Expansion of CLABSI and CAUTI measures to select non-ICU locations in IPPS hospitals, beginning with
infections occurring on or after January 1, 2014 (consistent with NQF expansion of the measures beyond
ICUs)
3.Updates to SCIP Inf 4 to match recent NQF endorsement maintenance decisions, beginning with January 1,
2014 discharges
4.An update to the MSPB measure to include railroad retirement board (RRB) beneficiaries, beginning in 2014
CMS is proposing to add five new risk-adjusted claims-based outcome measures to the hospital IQR program
for the FY 2016 payment determination and subsequent years:
1.30-day risk standardized COPD readmission
2.30-day risk standardized COPD mortality
3.30-day risk standardized stroke readmission
4.30-day risk standardized stroke mortality
5.AMI payment per episode of care
CMS provides detailed information about each of the five new measures.
29
Set out below is a table showing both the previously adopted and proposed new quality measures for the FY
2016 payment determination and subsequent years. This table does not include suspended measures and
measures proposed for removal.
Topic
Previously adopted and proposed hospital IQR program measures for FY 2016
payment determination and subsequent years
Acute myocardial infarction (AMI)
• AMI-7a fibrinolytic (thrombolytic) agent received within 30 minutes of hospital
arrival
• AMI-8a timing of receipt of primary percutaneous coronary intervention (PCI)
Heart failure (HF)
• HF-2 Evaluation of left ventricular systolic function
Stroke measure set
• STK-1 VTE prophylaxis
• STK-2 antithrombotic therapy for ischemic stroke†
• STK-3 anticoagulation therapy for afib/flutter†
• STK-4 thrombolytic therapy for acute ischemic stroke†
• STK-5 antithrombotic therapy by the end of hospital day 2†
• STK-6 discharged on statin†
• STK-8 stroke education†
• STK-10 assessed for rehab†
VTE measure set
• VTE-1 VTE prophylaxis†
• VTE-2 ICU VTE prophylaxis†
• VTE-3 VTE patients with anticoagulation overlap therapy†
• VTE-4 Patients receiving unfractionated Heparin with doses/labs monitored by
protocol†
• VTE-5 VTE discharge instructions†
• VTE-6 Incidence of potentially preventable VTE†
Pneumonia (PN)
• PN-6 Appropriate initial antibiotic selection
Surgical care improvement project (SCIP)
• SCIP INF-1: Prophylactic antibiotic received within 1 hour prior to surgical
incision
• SCIP INF-2: Prophylactic antibiotic selection for surgical
• SCIP INF-3: Prophylactic antibiotics discontinued within 24 hours after surgery
end time (48 hours for cardiac surgery)
• SCIP INF-4: Cardiac surgery patients with controlled 6 a.m. postoperative serum
glucose
• SCIP INF-9: Postoperative urinary catheter removal on postoperative day 1 or 2,
with surgery being day zero
• SCIP-Cardiovascular-2: Surgery patients on a beta blocker prior to arrival, who
received a beta blocker during the perioperative period
• SCIP INF-VTE-2: Surgery patients who received appropriate VTE prophylaxis
within 24 hours pre-/post-surgery
30
Mortality measures (Medicare patients)
• Acute myocardial infarction 30-day mortality rate
• Heart failure (HF) 30-day mortality rate
• Pneumonia (PN) 30-day mortality rate
• Stroke 30-day mortality rate***
• OPD 30-day mortality rate***
Patients' experience of care measures
• HCAHPS survey (expanded to include one 3-item care transition set* and two
new “about you” items*)
Readmission measure (Medicare patients)
• Acute myocardial infarction 30-day risk standardized readmission measure
• Heart failure 30-day risk standardized readmission measure
• Pneumonia 30-day risk standardized readmission measure
• 30-day risk standardized readmission following total hip/total knee
arthroplasty*
• Hospital-wide all-cause unplanned readmission (HWR)*
• Stroke 30-day risk standardized readmission ***
• COPD 30-day risk standardized readmission***
AHRQ patient safety indicators (PSIs) composite measures
• Complication/patient safety for selected indicators (composite)
AHRQ PSI and nursing sensitive care
• PSI-4 Death among surgical inpatients with serious, treatable complications
Structural measures
• Participation in a systematic database for cardiac surgery
• Participation in a systematic clinical database registry for nursing sensitive care
• Participation in a systematic clinical database registry for general surgery
• Safe surgery checklist use**
Health care-associated infection measures
• Central line-associated blood stream infection
• Surgical site infection
-- SSI following colon surgery
-- SSI following abdominal hysterectomy
• Catheter-associated urinary tract infection
• MRSA bacteremia
• Clostridium difficile (C-diff )
• Health care personnel influenza vaccination
Surgical complications
• Hip/knee complication: Hospital-level risk-standardized complication rate
(RSCR) following elective primary total hip arthroplasty*
Emergency department throughput measures
• ED-1 median time from emergency department arrival to time of departure
from the emergency room for patients admitted to the hospital†
31
• ED-2 median time from admit decision to time of departure from the
emergency department for emergency department patients admitted to the
inpatient status†
Prevention: Global immunization (IMM) measures
• Immunization for influenza
Cost efficiency
• Medicare spending per beneficiary
• AMI payment per episode of care**
Perinatal care
• Elective delivery prior to 39 completed weeks of gestation*/†
* New or expanded measures/items for FY 2015 payment determination and subsequent years.
** New measures for FY 2016 payment determination and subsequent years.
*** Proposed measures for FY 2016 payment determination and subsequent years.
† Proposed measure for electronic reporting via CEHRT in the hospital IQR program (voluntary participation in CY 2014).
Electronic clinical quality measures
CMS says it believes that collection and reporting of data through health information technology will greatly
simplify and streamline reporting for many CMS quality reporting programs.
CMS is proposing that hospitals would be able to, on a voluntary basis, electronically report 16 measures
across four measure sets, (stroke ( STK), venous thromboembolism (VTE), emergency department (ED) and
perinatal care (PC)) in CY 2014 for the FY 2016 hospital IQR program payment determination.
PPS-exempt cancer hospital quality reporting (PCHQR) program
For the PCHQR program beginning with FY 2015, CMS is proposing to adopt one new measure: NHSN HAI
measure of surgical site infection (SSI). For the PCHQR Program beginning with FY 2016, CMS is proposing
to adopt 13 new measures: six measures of Surgical Care Improvement Project (SCIP), six clinical process/
oncology care measures and one patient experience of care measure (the HCAHPS survey). This program
affects 11 PPS-exempt cancer facilities.
Comment
CMS spends 40 pages providing detail on the PCHQR program.
Long-term care hospital quality reporting (LTCHQR) program
CMS is proposing the following revisions to the quality measures previously adopted for the LTCHQR program:
yy That the influenza vaccination coverage among health care personnel measure (NQF #0431) have its own
reporting period to align with the influenza vaccination season, which is defined by the CDC as October 1
(or when the vaccine becomes available) through March 31.
yy That for NQF #0680, the percentage of residents or patients who were assessed and appropriately given
the seasonal influenza vaccine (short-stay), to revise the previously finalized start date of January 1, 2014,
for reporting of this measure, to April 1, 2014.
32
CMS is proposing the following three new quality measures for the LTCHQR program to affect the FY 2017
payment determination and subsequent payment determinations:
yy Proposed quality measure #1: National healthcare safety network (NHSN) facility-wide inpatient hospitalonset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia outcome measure (NQF #1716)
yy Proposed quality measure #2: National healthcare safety network (NHSN) facility-wide inpatient hospitalonset Clostridium difficile infection (C-diff ) outcome measure (NQF #1717).
yy Proposed quality measure #3: All-cause unplanned readmission measure for 30 days post- discharge from
long-term care hospitals.
For the FY 2018 payment determination and subsequent payment determinations, CMS is proposing one new
quality measure, application of the percent of residents experiencing one or more falls with major injury (long
stay) (NQF #0674).
Inpatient psychiatric facilities quality reporting (IPFQR) program
CMS is proposing three new measures for the FY 2016 payment determination and subsequent years for the
IPFQR Program. The measures are:
yy SUB-1: Alcohol use screening (submitted for NQF review)
yy SUB-4: Alcohol and drug use: Assessing status after discharge (submitted for NQF review)
yy Follow-up after hospitalization for mental illness (FUH) (NQF #0576)
Changes to the MS-LTC-DRGs for FY 2014
CMS is proposing to update the standard MS-LTC federal rate by 1.8 percent, which is based on a full estimated
increase in the LTCH PPS market basket of 2.5 percent, less the MFP adjustment of 0.4 percentage points and
less the 0.3 percentage points, as mandated by the ACA.
CMS also is proposing to establish an annual update to the LTCH PPS standard federal rate of -0.2 percent (that
is, 1.8 percent minus 2.0 percentage points =-0.2 percent, or an update factor of 0.9980) for FY 2014 for LTCHs
that fail to submit quality reporting data for FY 2014 under the LTCHQR program.
Additionally, CMS is proposing to establish that the standard federal rate for FY 2014 would be further adjusted
by a proposed adjustment factor of 0.98734 for FY 2014, under the second year of the three-year phase-in of
the one-time prospective adjustment at § 412.523(d)(3)(ii).
Also, CMS is proposing to apply an area wage level budget neutrality factor of 1.000433 to the standard federal
rate to ensure that any proposed changes to the area wage level adjustment (that is, the proposed annual
update of the wage index values and labor-related share) would not result in any change (increase or decrease)
in estimated aggregate LTCH PPS payments.
Accordingly, the proposed standard federal rate for FY 2014 would be $40,622.06 (calculated as $40,397.96 ×
1.018 × 0.98734 × 1.000433). The current rate is $40,397.96.
The labor-related share that CMS is adopting to use for LTCH PPS in FY 2014 would be 62.717, down from the
current value of 63.096 percent.
CMS is proposing a fixed-loss amount of $14,139 for FY 2014. The current amount is $15,408.
33
Final comment
Below is an analysis that compares the current MS-DRG (FY 2013) weights to those proposed for FY 2014 for all
MS-DRGs having 100,000 or more discharges.
MS-DRG
Description
65 Intracranial hemorrhage or cerebral infarction w CC
Proposed FY
2014 weight
FY 2013
Percentage
difference
1.0794
1.1345
-4.86%
189 Pulmonary edema and respiratory failure
1.2191
1.2461
-2.17%
190 Chronic obstructive pulmonary disease w MCC
1.1708
1.1860
-1.28%
191 Chronic obstructive pulmonary disease w CC
0.9330
0.9521
-2.01%
193 Simple pneumonia and pleurisy w MCC
1.4553
1.4893
-2.28%
194 Simple pneumonia and pleurisy w CC
0.9753
0.9996
-2.43%
247 Perc cardiovasc proc w drug-eluting stent w/o MCC
2.0268
1.9911
1.79%
287 Circulatory disorders, except AMI, w card cath w/o
1.0783
1.0709
0.69%
291 Heart failure and shock w MCC
1.5067
1.5174
-0.71%
292 Heart failure and shock w CC
0.9952
1.0034
-0.82%
309 Cardiac arrhythmia and conduction disorders w CC
0.7881
0.8098
-2.68%
310 Cardiac arrhythmia and conduction disorders w/o
0.5514
0.5541
-0.49%
312 Syncope and collapse
0.7184
0.7339
-2.11%
313 Chest pain
0.5942
0.5617
5.79%
378 G.I. hemorrhage w CC
1.0032
1.0168
-1.34%
392 Esophagitis, gastroent and misc digest disorders
0.7337
0.7375
-0.52%
2.1515
2.0953
2.68%
603 Cellulitis w/o MCC
0.8370
0.8392
-0.26%
641 Nutritional and misc metabolic disorders w/o MCC
0.6963
0.6920
0.62%
682 Renal failure w MCC
1.5412
1.5862
-2.84%
683 Renal failure w CC
0.9635
0.9958
-3.24%
690 Kidney and urinary tract infections w/o MCC
0.7659
0.7810
-1.93%
871 Septicemia or severe sepsis w/o MV 96+ hours w MCC
1.8560
1.8803
-1.29%
872 Septicemia or severe sepsis w/o MV 96+ hours w/o
1.0689
1.0988
-2.72%
MCC
CC/MCC
w/o MCC
470 Major joint replacement or reattachment of lower
extremity w/o MCC
MCC
These MS-DRGs account for approximately 37.4 percent of the nearly 10.2 million MS-DRG discharges. Most are
declining and will negatively impact case-mix and payment.
34
800.274.3978
www.mcgladrey.com
This document contains general information, may be based on authorities that are subject to change, and is not a substitute for
professional advice or services. This document does not constitute assurance, tax, consulting, business, financial, investment, legal or
other professional advice, and you should consult a qualified professional advisor before taking any action based on the information
herein. McGladrey LLP, its affiliates and related entities are not responsible for any loss resulting from or relating to reliance on this
document by any person.
McGladrey LLP is an Iowa limited liability partnership and the U.S. member firm of RSM International, a global network of
independent accounting, tax and consulting firms. The member firms of RSM International collaborate to provide services to global
clients, but are separate and distinct legal entities that cannot obligate each other. Each member firm is responsible only for its own
acts and omissions, and not those of any other party.
McGladrey®, the McGladrey logo, the McGladrey Classic logo, The power of being understood®, Power comes from being understood®,
and Experience the power of being understood® are registered trademarks of McGladrey LLP.
© 2013 McGladrey LLP. All Rights Reserved.
`