Medicare Program; Hospital Inpatient Value-Based Purchasing Program, 2454-2491 [2011-454]

Agencies

• Centers for Medicare & Medicaid Services
• DEPARTMENT OF HEALTH AND HUMAN SERVICES

[Federal Register Volume 76, Number 9 (Thursday, January 13, 2011)]
[Proposed Rules]
[Pages 2454-2491]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2011-454]



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Part II





Department of Health and Human Services





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Centers for Medicare & Medicaid Services



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42 CFR Parts 422 and 480



Medicare Program; Hospital Inpatient Value-Based Purchasing Program; 
Proposed Rule

Federal Register / Vol. 76 , No. 9 / Thursday, January 13, 2011 / 
Proposed Rules

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 422 and 480

[CMS-3239-P]
RIN 0938-AQ55


Medicare Program; Hospital Inpatient Value-Based Purchasing 
Program

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Proposed rule.

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SUMMARY: In this proposed rule, we are proposing to implement a 
Hospital Value-Based Purchasing program (``Hospital VBP program'' or 
``the program'') under section 1886(o) of the Social Security Act 
(``Act''), under which value-based incentive payments will be made in a 
fiscal year to hospitals that meet performance standards with respect 
to a performance period for the fiscal year involved. The program will 
apply to payments for discharges occurring on or after October 1, 2012, 
in accordance with section 1886(o) of the Social Security Act (as added 
by section 3001(a) of the Patient Protection and Affordable Care Act 
(Pub. L. 111-148), enacted on March 23, 2010, as amended by the Health 
Care and Education Reconciliation Act of 2010 (Pub. L. 111-152), 
enacted on March 30, 2010 (collectively known as the Affordable Care 
Act)). The measures we are proposing to initially adopt for the program 
are a subset of the measures that we have already adopted for the 
existing Medicare Hospital Inpatient Quality Reporting Program 
(Hospital IQR program), formerly known as the Reporting Hospital 
Quality Data for the Annual Payment Update Program (RHQDAPU), and we 
are proposing, based on whether a hospital meets or exceeds the 
performance standards that we are proposing to establish with respect 
to the measures, to reward the hospital based on its actual 
performance, rather than simply its reporting of data for those 
measures.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. on March 8, 2011.

ADDRESSES: In commenting, please refer to file code CMS-3239-P. Because 
of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of four ways (please choose only one 
of the ways listed):
    1. Electronically. You may submit electronic comments on this 
regulation to https://www.regulations.gov. Follow the ``Submit a 
comment'' instructions.
    2. By regular mail. You may mail written comments to the following 
address only:
    Centers for Medicare & Medicaid Services, Department of Health and 
Human Services, Attention: CMS-3239-P, P.O. Box 8010, Baltimore, MD 
21244-8010.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments to 
the following address only: Centers for Medicare & Medicaid Services, 
Department of Health and Human Services, Attention: CMS-3239-P, Mail 
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    4. By hand or courier. If you prefer, you may deliver (by hand or 
courier) your written comments before the close of the comment period 
to either of the following addresses:
    a. For delivery in Washington, DC-- Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, Room 445-G, Hubert 
H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 
20201.
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without Federal government 
identification, commenters are encouraged to leave their comments in 
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing 
by stamping in and retaining an extra copy of the comments being 
filed.)
    b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, 7500 Security 
Boulevard, Baltimore, MD 21244-1850.
    If you intend to deliver your comments to the Baltimore address, 
please call telephone number (410) 786-8691 in advance to schedule your 
arrival with one of our staff members.
    Comments mailed to the addresses indicated as appropriate for hand 
or courier delivery may be delayed and received after the comment 
period.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Allison Lee, (410) 786-8691.

SUPPLEMENTARY INFORMATION: Inspection of Public Comments: All comments 
received before the close of the comment period are available for 
viewing by the public, including any personally identifiable or 
confidential business information that is included in a comment. We 
post all comments received before the close of the comment period on 
the following Web site as soon as possible after they have been 
received: https://www.regulations.gov. Follow the search instructions on 
that Web site to view public comments.
    Comments received timely will also be available for public 
inspection as they are received, generally beginning approximately 3 
weeks after publication of a document, at the headquarters of the 
Centers for Medicare & Medicaid Services, 7500 Security Boulevard, 
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 
a.m. to 4 p.m. To schedule an appointment to view public comments, 
phone 1-800-743-3951.

Table of Contents

I. Background
    A. Overview
    B. Hospital Inpatient Quality Data Reporting Under Section 
501(b) of Public Law 108-173
    C. Hospital Inpatient Quality Reporting Under Section 5001(a) of 
Public Law 109-171
    D. 2007 Report to Congress: Plan To Implement a Medicare 
Hospital Value-Based Purchasing Program
    E. Provisions of the Affordable Care Act
II. Provisions of the Proposed Regulations
    A. Overview of the Proposed Hospital Value-Based Purchasing 
Program
    B. Proposed Performance Period
    C. Proposed Measures
    D. Proposed Performance Standards
    E. Proposed Methodology for Calculating the Total Performance 
Score
    F. Applicability of the Value-Based Purchasing Program to 
Hospitals
    G. The Exchange Function
    H. Proposed Hospital Notification and Review Procedures
    I. Proposed Reconsideration and Appeal Procedures
    J. Proposed FY 2013 Validation Requirements for Hospital Value-
Based Purchasing
    K. Additional Information
    L. QIO Quality Data Access
III. Collection of Information Requirements
IV. Response to Comments
V. Regulatory Impact Statement
    A. Overall Impact
    B. Anticipated Effects
    C. Alternatives Considered
    D. Accounting Statement

Acronyms

    Because of the many terms to which we refer by acronym in this 
proposed rule, we are listing the acronyms used and their 
corresponding meanings in alphabetical order below:
AHRQ Agency for Healthcare Research and Quality

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AMI Acute Myocardial Infarction
CCN CMS Certification number
CMS Centers for Medicare & Medicaid Services
DRG Diagnosis-Related Group
FISMA Federal Information Security and Management Act
HCAHPS Hospital Consumer Assessment of Healthcare Providers and 
Systems
HF Heart Failure
HIPAA Health Insurance Portability and Accountability Act
HOP QDRP Hospital Outpatient Quality Data Reporting Program
IPPS Inpatient prospective payment systems
IQR Inpatient Quality Reporting
NQF National Quality Forum
PN Pneumonia
PQRI Physician Quality Reporting Initiative
PRRB Provider Reimbursement Review Board
PSI Patient Safety Indicator
QIO Quality Improvement Organization
QRS Quality Review Study
RFA Regulatory Flexibility Act
RHQDAPU Reporting Hospital Quality Data for the Annual Payment 
Update Program
RIA Regulatory Impact Analysis
SCIP Surgical Care Improvement
VBP Value-Based Purchasing

I. Background

A. Overview

    The Centers for Medicare & Medicaid Services (CMS) promotes higher 
quality and more efficient health care for Medicare beneficiaries. In 
recent years, we have undertaken a number of initiatives to lay the 
foundation for rewarding health care providers and suppliers for the 
quality of care they provide by tying a portion of their Medicare 
payments to their performance on quality measures. These initiatives, 
which include demonstration projects and quality reporting programs, 
have been applied to various health care settings, including 
physicians' offices, ambulatory care facilities, hospitals, nursing 
homes, home health agencies, and dialysis facilities. The overarching 
goal of these initiatives is to transform Medicare from a passive payer 
of claims to an active purchaser of quality health care for its 
beneficiaries.
    This effort is supported by our adoption of an increasing number of 
widely-agreed upon quality measures for purposes of our existing 
quality reporting programs. We have worked with stakeholders to define 
measures of quality in almost every setting. These measures assess 
structural aspects of care, clinical processes, patient experiences 
with care, and, increasingly, outcomes.
    We have implemented quality measure reporting programs that apply 
to various settings of care. With regard to hospital inpatient 
services, we implemented the Hospital IQR program. In addition, we have 
implemented quality reporting programs for hospital outpatient services 
through the Hospital Outpatient Quality Data Reporting Program (HOP 
QDRP), and for physicians and other eligible professionals through the 
Physician Quality Reporting Initiative (PQRI). We have also implemented 
quality reporting programs for home health agencies and skilled nursing 
facilities based on conditions of participation, and an end-stage renal 
disease quality reporting program based on conditions for coverage.
    This new program will necessarily be a fluid model, subject to 
change as knowledge, measures and tools evolve. We view the Hospital 
VBP program under section 1886(o) of the Social Security Act (the Act) 
as the next step in promoting higher quality care for Medicare 
beneficiaries and transforming Medicare into an active purchaser of 
quality health care for its beneficiaries.
    In developing this rule as well as other value-based payment 
initiatives, CMS applied the following principles for the development 
and use of measures and scoring methodologies.
    Purpose:
    CMS views value-based purchasing as an important step to revamping 
how care and services are paid for, moving increasingly toward 
rewarding better value, outcomes, and innovations instead of merely 
volume.
    Use of Measures:
     Public reporting and value-based payment systems should 
rely on a mix of standards, process, outcomes, and patient experience 
measures, including measures of care transitions and changes in patient 
functional status. Across all programs, CMS seeks to move as quickly as 
possible to the use of primarily outcome and patient experience 
measures. To the extent practicable and appropriate, outcomes and 
patient experience measures should be adjusted for risk or other 
appropriate patient population or provider characteristics.
     To the extent possible and recognizing differences in 
payment system maturity and statutory authorities, measures should be 
aligned across Medicare's and Medicaid's public reporting and payment 
systems. CMS seeks to evolve to a focused core-set of measures 
appropriate to the specific provider category that reflects the level 
of care and the most important areas of service and measures for that 
provider.
     The collection of information should minimize the burden 
on providers to the extent possible. As part of that effort, CMS will 
continuously seek to align its measures with the adoption of meaningful 
use standards for health information technology (HIT), so the 
collection of performance information is part of care delivery.
     To the extent practicable, measures used by CMS should be 
nationally endorsed by a multi-stakeholder organization. Measures 
should be aligned with best practices among other payers and the needs 
of the end users of the measures.
    Scoring Methodology:
     Providers should be scored on their overall achievement 
relative to national or other appropriate benchmarks. In addition, 
scoring methodologies should consider improvement as an independent 
goal.
     Measures or measurement domains need not be given equal 
weight, but over time, scoring methodologies should be more weighted 
towards outcome, patient experience and functional status measures.
     Scoring methodologies should be reliable, as 
straightforward as possible, and stable over time and enable consumers, 
providers, and payers to make meaningful distinctions among providers' 
performance.

CMS welcomes comments on these principles.

B. Hospital Inpatient Quality Data Reporting Under Section 501(b) of 
Public Law 108-173

    Section 501(b) of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (MMA), Public Law 108-173, added section 
1886(b)(3)(B)(vii) to the Act. This section established the original 
authority for the Hospital IQR program and revised the mechanism used 
to update the standardized payment amount for inpatient hospital 
operating costs. Specifically, section 1886(b)(3)(B)(vii)(I) of the Act 
provided for a reduction of 0.4 percentage points to the annual 
percentage increase (sometimes referred to at that time as the market 
basket update) for FY 2005 through FY 2007 for a subsection (d) 
hospital if the hospital did not submit data on a set of 10 quality 
indicators established by the Secretary as of November 1, 2003. It also 
provided that any reduction applied only to the fiscal year involved, 
and would not be taken into account in computing the applicable 
percentage increase for a subsequent fiscal year. The statute thereby 
established an incentive for many subsection (d) hospitals to submit 
data on the quality measures established by the Secretary.
    We implemented section 1886(b)(3)(B)(vii) of the Act in the FY

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2005 IPPS final rule (69 FR 49078) and codified the applicable 
percentage change in Sec.  412.64(d) of our regulations. We adopted 
additional requirements under the Hospital IQR program in the FY 2006 
IPPS final rule (70 FR 47420).

C. Hospital Inpatient Quality Reporting Under Section 5001(a) of Public 
Law 109-171

1. Change in the Reduction to the Annual Percentage Increase
    Section 5001(a) of the Deficit Reduction Act of 2005 (DRA), Public 
Law 109-171, further amended section 1886(b)(3)(B) of the Act to, among 
other things, revise the mechanism used to update the standardized 
payment amount for hospital inpatient operating costs by adding new 
section 1886(b)(3)(B)(viii) to the Act. Specifically, sections 
1886(b)(3)(B)(viii)(I) and (II) of the Act as added by the DRA 
originally provided that the annual percentage increase for FY 2007 and 
each subsequent fiscal year shall be reduced by 2.0 percentage points 
for a subsection (d) hospital that does not submit quality data in a 
form and manner, and at a time, specified by the Secretary. Section 
1886(b)(3)(B)(viii)(I) of the Act also provided that any reduction in a 
hospital's annual percentage increase will apply only with respect to 
the fiscal year involved, and will not be taken into account for 
computing the applicable percentage increase for a subsequent fiscal 
year.
    In the FY 2007 IPPS final rule (71 FR 48045), we amended our 
regulations at Sec.  412.64(d)(2) to reflect the 2.0 percentage point 
reduction required under the DRA.
2. Selection of Quality Measures
    Section 1886(b)(3)(B)(viii)(V) of the Act, before it was amended by 
section 3001(a)(2)(B) of the Affordable Care Act, required that, 
effective for payments beginning with FY 2008, the Secretary add other 
measures that reflect consensus among affected parties, and to the 
extent feasible and practicable, have been set forth by one or more 
national consensus building entities. The National Quality Forum (NQF) 
is a voluntary consensus standard-setting organization with a diverse 
representation of consumer, purchaser, provider, academic, clinical, 
and other health care stakeholder organizations. The NQF was 
established to standardize health care quality measurement and 
reporting through its consensus development process. We have generally 
adopted NQF-endorsed measures for purposes of the Hospital IQR program. 
However, we believe that consensus among affected parties also can be 
reflected by other means, including consensus achieved during the 
measure development process, consensus shown through broad acceptance 
and use of measures, and consensus achieved through public comment.
    Section 1886(b)(3)(B)(viii)(VI) of the Act authorizes the Secretary 
to replace any quality measures or indicators in appropriate cases, 
such as when all hospitals are effectively in compliance with a 
measure, or the measures or indicators have been subsequently shown to 
not represent the best clinical practice. We interpreted this provision 
to give us broad discretion to replace measures that are no longer 
appropriate for the Hospital IQR program.
    We have adopted 45 measures under the Hospital IQR program for the 
FY 2011 payment determination. Of these measures, 27 are chart-
abstracted process of care measures, which assess the quality of care 
furnished by hospitals in connection with four topics: Acute Myocardial 
Infarction (AMI); Heart Failure (HF); Pneumonia (PN); and Surgical Care 
Improvement (SCIP) (75 FR 50182). Fifteen of the measures are claims-
based measures, which assess the quality of care furnished by hospitals 
on the following topics: 30-day mortality and 30-day readmission rates 
for Medicare patients diagnosed with either AMI, HF, or PN; Patient 
Safety Indicators/Inpatient Quality Indicators/Composite Measures; and 
Patient Safety Indicators/Nursing Sensitive Care. Three of the measures 
are structural measures that assess hospital participation in cardiac 
surgery, stroke care, and nursing sensitive care systemic databases. 
Finally, the Hospital Consumer Assessment of Healthcare Providers and 
Systems (HCAHPS) patient experience of care survey is included as a 
measure for the FY 2011 payment determination.
    The technical specifications for the Hospital IQR program measures, 
or links to Web sites hosting technical specifications, are contained 
in the CMS/The Joint Commission Specifications Manual for National 
Hospital Inpatient Quality Measures (Specifications Manual). This 
Specifications Manual is posted on the CMS QualityNet Web site at 
https://www.QualityNet.org/. We maintain the technical specifications 
by updating this Specifications Manual semiannually, or more frequently 
in unusual cases, and include detailed instructions and calculation 
algorithms for hospitals to use when collecting and submitting data on 
required measures. These semiannual updates are accompanied by 
notifications to users, providing sufficient time between the change 
and the effective date in order to allow users to incorporate changes 
and updates to the specifications into data collection systems.
3. Public Display of Quality Measures
    Section 1886(b)(3)(B)(viii)(VII) of the Act, before it was amended 
by section 3001(a)(2)(C) of the Affordable Care Act, required that the 
Secretary establish procedures for making data submitted under the 
Hospital IQR program available to the public after ensuring that a 
hospital has the opportunity to review the data before it is made 
public. To meet this requirement, we have displayed most Hospital IQR 
program data on the Hospital Compare website, https://www.hospitalcompare.hhs.gov, after a 30-day preview period. An 
interactive Web tool, this Web site assists beneficiaries by providing 
information on hospital quality of care to those who need to select a 
hospital. It further serves to encourage beneficiaries to work with 
their doctors and hospitals to discuss the quality of care hospitals 
provide to patients, thereby providing an additional incentive to 
hospitals to improve the quality of care that they furnish. The 
Hospital Compare website currently makes public data on clinical 
process of care measures, risk adjusted outcome measures, the HCAHPS 
patient experience of care survey, and structural measures. However, 
data that we believe is not suitable for inclusion on Hospital Compare 
because it is not salient or will not be fully understood by 
beneficiaries, as well as data for which there are unresolved display 
or design issues may be made available on other CMS Web sites that are 
not intended to be used as an interactive Web tool, such as https://www.cms.hhs.gov/HospitalQualityInits/. In such circumstances, affected 
parties are notified via CMS listservs, CMS e-mail blasts, national 
provider calls, and QualityNet announcements regarding the release of 
preview reports followed by the posting of data on a Web site other 
than Hospital Compare.

D. 2007 Report to Congress: Plan To Implement a Medicare Hospital 
Value-Based Purchasing Program

    Section 5001(b) of the DRA required the Secretary to develop a plan 
to implement a value-based purchasing program for payments made under 
the Medicare program for subsection (d) hospitals. In developing the 
plan, we were required to consider the on-going development, selection, 
and modification process for measures of

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quality and efficiency in hospital inpatient settings; the reporting, 
collection, and validation of quality data; the structure, size, and 
sources of funding of value-based payment adjustments; and the 
disclosure of information on hospital performance.
    In 2007, we submitted to Congress a report that discusses options 
for a plan to implement a Medicare hospital VBP program that builds on 
the Hospital IQR program. We recommended replacing the Hospital IQR 
program with a new program that would include both a public reporting 
requirement and financial incentives for better performance. We also 
recommended that a hospital VBP program be implemented in a manner that 
would not increase Medicare spending.
    To calculate a hospital's total performance score under the plan, 
we analyzed a potential performance scoring model that incorporated 
measures from different quality ``domains,'' including clinical process 
of care and patient experience of care. We examined ways to translate 
that score into an incentive payment by making a portion of the base 
diagnosis-related group (DRG) payment contingent on performance. We 
analyzed criteria for selecting performance measures and considered a 
potential phased approach to transition from Hospital IQR to value-
based purchasing. In addition, we examined redesigning the current data 
transmission process and validation infrastructure, including making 
enhancements to the Hospital Compare Web site, as well as an approach 
to monitor the impact of value-based purchasing.

E. Provisions of the Affordable Care Act

    Section 3001(a) of the Patient Protection and Affordable Care Act 
(Pub. L. 111-148), enacted on March 23, 2010, as amended by the Health 
Care and Education Reconciliation Act of 2010 (Pub. L. 111-152), 
enacted on March 30, 2010 (collectively known as the Affordable Care 
Act), added a new section 1886(o) to the Social Security Act (the Act) 
which requires the Secretary to establish a hospital value-based 
purchasing program under which value-based incentive payments are made 
in a fiscal year to hospitals meeting performance standards established 
for a performance period for such fiscal year. Both the performance 
standards and the performance period for a fiscal year are to be 
established by the Secretary. Section 1886(o)(1)(B) of the Act directs 
the Secretary to begin making value-based incentive payments under the 
Hospital VBP program to hospitals for discharges occurring on or after 
October 1, 2012. These incentive payments will be funded for FY 2013 
through a reduction to FY 2013 base operating DRG payments for each 
discharge of 1%, as required by section 1886(o)(7). Section 
1886(o)(1)(C) provides that the Hospital VBP program applies to 
subsection (d) hospitals (as defined in section 1886(d)(1)(B)), but 
excludes from the definition of the term ``hospital,'' with respect to 
a fiscal year: 1) a hospital that is subject to the payment reduction 
under section 1886(b)(3)(B)(viii)(I) for such fiscal year; 2) a 
hospital for which, during the performance period for the fiscal year, 
the Secretary cited deficiencies that pose immediate jeopardy to the 
health and safety of patients; and 3) a hospital for which there is not 
a minimum number (as determined by the Secretary) of applicable 
measures for the performance period for the fiscal year involved, or 
for which there is not a minimum number (as determined by the 
Secretary) of cases for the applicable measures for the performance 
period for such fiscal year.

II. Provisions of the Proposed Regulations

A. Overview of the Proposed Hospital VBP Program

    This proposed rule proposes to implement a Hospital Value-Based 
Purchasing program (``Hospital VBP program'' or ``the program'') under 
section 1886(o) of the Social Security Act (``Act''), under which 
value-based incentive payments will be made in a fiscal year (beginning 
FY 2013) to hospitals that meet performance standards established with 
respect to a performance period ending prior to the beginning of such 
fiscal year. This proposed rule was developed based on extensive 
research we conducted on hospital value-based purchasing, including 
research that formed the basis of a 2007 report we submitted to 
Congress, entitled ``Report to Congress: Plan to Implement a Medicare 
Hospital Value-Based Purchasing Program'' (November 21, 2007), a copy 
of which is available on the CMS Web site, and takes into account input 
from both stakeholders and other interested parties. As described more 
fully below, we are proposing to initially adopt for the FY 2013 
Hospital VBP program 18 measures that we have already adopted for the 
Hospital IQR Program, categorized into two domains, as follows: 17 of 
the proposed measures will be clinical process of care measures, which 
we will group into a clinical process of care domain, and 1 measure 
will be the HCAHPS survey, which will fall under a patient experience 
of care domain. With respect to the clinical process of care and HCAHPS 
measures, we are proposing to use a three-quarter performance period 
from July 1, 2011 through March 31, 2012 for the FY 2013 payment 
determination and to determine whether hospitals meet the proposed 
performance standards for these measures by comparing their performance 
during the proposed performance period to their performance during a 
proposed three-quarter baseline period from July 1, 2009 through March 
31, 2010. We are also proposing to initially adopt for the FY 2014 
Hospital VBP program three outcome measures. With respect to the 
proposed outcome measures, we are proposing to use an 18-month 
performance period from July 1, 2011 to December 31, 2012. Furthermore, 
for the proposed outcome measures, we are proposing to establish 
performance standards and to determine whether hospitals meet those 
standards by comparing their performance during the proposed 
performance period to their performance during a proposed baseline 
period of July 1, 2008 to December 31, 2009.
    In general, we are proposing to implement a methodology for 
assessing the total performance of each hospital based on performance 
standards, under which we will score each hospital based on achievement 
and improvement ranges for each applicable measure. Additionally, we 
are proposing to calculate a total performance score for each hospital 
by combining the greater of the hospital's achievement or improvement 
points for each measure to determine a score for each domain, 
multiplying each domain score by a proposed weight (clinical process of 
care: 70 percent, patient experience of care: 30 percent), and adding 
together the weighted domain scores. We are proposing to convert each 
hospital's total performance score into a value-based incentive payment 
utilizing a linear exchange function. All of these proposals are 
addressed in greater detail below.

B. Proposed Performance Period

    Section 1886(o)(4) of the Act requires the Secretary to establish a 
performance period for a fiscal year that begins and ends prior to the 
beginning of such fiscal year. In considering various performance 
periods that could apply for purposes of the fiscal year 2013 payment 
adjustments, we recognized that hospitals submit data on the chart-
abstracted measures adopted for the Hospital IQR Program on a quarterly

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basis, and for that reason, we would propose that the performance 
period commence at the beginning of a quarter. We also recognize that 
we must balance the length of the period for collecting measure data 
with the need to undertake the rulemaking process in order to establish 
the performance period and provide the public with an opportunity to 
meaningfully comment on that proposal. With these considerations in 
mind, we concluded that July 1, 2011 is the earliest date that the 
performance period could begin.
    We then considered how long the performance period should be. Our 
preference would have been to propose to use a full year as the 
performance period for the clinical process of care and HCAHPS measures 
we are proposing to initially adopt for the FY 2013 Hospital VBP 
program, consistent with our analysis that using a full year 
performance period provides high levels of data accuracy and 
reliability for scoring hospitals on these measures. We concluded, 
however, that this would not give us sufficient time to calculate the 
total performance scores, calculate the value-based incentive payments, 
notify hospitals regarding their payment adjustments, and implement the 
payment adjustments. We subsequently analyzed how a shorter performance 
period might affect a hospital's performance score. Using the most 
recent clinical process of care and HCAHPS measure data available, we 
examined the feasibility of proposing to adopt a one quarter, two 
quarter, or three quarter performance period by comparing each of these 
periods to a four quarter baseline period. We did this to determine how 
closely a hospital's total performance score calculated using one, two, 
or three quarters of data would approximate what the hospital's total 
performance score would be if we proposed to use four quarters of data. 
Under our analysis, the total performance scores approximated using 
three quarters of data closely correlated with total performance scores 
approximated using four quarters of data. Specifically, our analysis 
showed that the three quarter performance period would have a 
correlation coefficient of 0.96815 (p-value .0001), while a two quarter 
performance period would have a correlation coefficient of 0.90358 (p-
value .0001).
    We also recognize that under the Hospital IQR program, hospitals 
have 135 days to submit chart abstracted data following the close of 
each quarter. Because we are proposing to implement a Hospital VBP 
program that builds on the Hospital IQR program, we would like, to the 
extent possible, to maintain our existing Hospital IQR program 
requirements. We believe that the 135 day time lag supports the 
adoption of a three quarter performance period based on the analysis 
discussed above, and that a one or two quarter performance period would 
provide lower data accuracy for scoring hospitals and adjusting their 
payments.
    Therefore, we propose to use the fourth quarter of FY 2011 (July 1, 
2011-September 30, 2011) and the first and second quarters of FY 2012 
(October 1, 2011-March 31, 2012) as the performance period for proposed 
clinical process of care and HCAHPS measures we are proposing to 
initially adopt for the FY 2013 Hospital VBP program. Hospitals will be 
scored based on how well they perform on the proposed clinical process 
of care and HCAHPS measures during this proposed performance period. We 
note that we anticipate proposing to use a full year as the performance 
period for the clinical process of care and HCAHPS measures in the 
future. For the three mortality outcome measures currently specified 
for the Hospital IQR program for the FY 2011 payment determination 
(MORT-30-AMI, MORT-30-HF, MORT-30-PN) that we propose below to adopt 
for the FY 2014 Hospital VBP program payment determination, we are 
proposing to establish a performance period of July 1, 2011 to December 
31, 2012. An eighteen-month performance period for mortality measures 
is intended to ensure the measures' reliability by capturing more cases 
than could be observed over one year of measurement. We plan to add 
additional measures to the Hospital VBP program, including but not 
limited to AHRQ and HAC measures that have been specified for the 
Hospital IQR program and propose that the performance period for those 
measures will begin one year after these measures have been displayed 
on the Hospital Compare Web site for the reasons discussed below.

C. Proposed Measures

    Section 1886(o)(2)(A) of the Act requires the Secretary to select 
for the Hospital VBP program measures, other than readmission measures, 
from the measures specified for the Hospital IQR program. Section 
1886(o)(2)(B)(i) requires the Secretary to ensure that the selected 
measures include measures on six specified conditions or topics: Acute 
Myocardial Infarction (AMI); Heart Failure (HF); Pneumonia (PN); 
Surgeries, as measured by the Surgical Care Improvement Project (SCIP); 
Healthcare-Associated Infections (HAI); and, the Hospital Consumer 
Assessment of Healthcare Providers and Systems survey (HCAHPS). Section 
1886(o)(2)(C)(i) provides that the Secretary may not select a measure 
with respect to a performance period for a fiscal year unless the 
measure has been specified under section 1886(b)(3)(B)(viii) of the Act 
and included on the Hospital Compare website for at least one year 
prior to the beginning of the performance period. Section 
1886(o)(2)(C)(ii) provides that a measure selected under section 
1886(o)(2)(A) shall not apply to a hospital if the hospital does not 
furnish services appropriate to the measure.
    Our measure development and selection activities for the Hospital 
IQR Program take into account national priorities, such as those 
established by the National Priorities Partnership,\1\ and the 
Department of Health and Human Services,\2\ as well as other widely 
accepted criteria established in medical literature.\3\ Because we must 
select measures for the Hospital VBP program from the pool of measures 
that have been adopted for the Hospital IQR program, the measures to be 
selected for inclusion in Hospital VBP would also reflect these 
priorities.
---------------------------------------------------------------------------

    \1\ https://www.nationalprioritiespartnership.org/.
    \2\ https://www.hhs.gov/secretary/about/priorities/priorities.html.
    \3\ Chassin, M.R.; Loeb, J.M.; Schmaltz, S.P. and Wachter, R.M. 
(2010) ``Accountability Measures--Using Measurement to Promote 
Quality Improvement.'' New England Journal of Medicine. Vol 363: 
683-688.
---------------------------------------------------------------------------

    In the FY 2011 IPPS/RY 2011 LTCH PPS final rule, we stated that in 
future expansions and updates to the Hospital IQR program measure set, 
we would be taking into consideration several important goals. These 
goals include: (a) Expanding the types of measures beyond process of 
care measures to include an increased number of outcome measures, 
efficiency measures, and patients' experience of care measures; (b) 
expanding the scope of hospital services to which the measures apply; 
(c) considering the burden on hospitals in collecting chart-abstracted 
data; (d) harmonizing the measures used in the Hospital IQR program 
with other CMS quality programs to align incentives and promote 
coordinated efforts to improve quality; (e) seeking to use measures 
based on alternative sources of data that do not require chart 
abstraction or that utilize data already being reported by many 
hospitals, such as data that hospitals report to clinical data 
registries, or all payer claims databases; and (f) weighing the 
relevance and utility of the measures compared to the burden on 
hospitals in submitting data under the Hospital IQR program. In 
addition, we believe that we

[[Page 2459]]

must act with all speed and deliberateness to expand the pool of 
measures used in the Hospital VBP program. This goal is supported by at 
least two Federal reports documenting that tens of thousands of 
patients do not receive safe care in the nation's hospitals.\4\ For 
this reason, we believe that we need to adopt measures for the Hospital 
VBP program relevant to improving care, particularly as these measures 
are directed toward improving patient safety, as quickly as possible. 
We believe that speed of implementation is a critical factor in the 
success and effectiveness of this program.
---------------------------------------------------------------------------

    \4\ See OEI-06-09-00090 ``Adverse Events in Hospitals: National 
Incidence Among Medicare Beneficiaries.'' Department of Health and 
Human Services, Office of Inspector General, November 2010. See 
also, 2009 National Healthcare Quality Report, pp. 107-122. 
``Patient Safety,'' Agency for Healthcare Research and Quality.
---------------------------------------------------------------------------

    The Hospital VBP program that we are proposing to implement has 
been developed with the focused intention to motivate all subsection 
(d) hospitals to which the program applies to take immediate action to 
improve the quality of care they furnish to their patients. Because we 
view as urgent the necessity to improve the quality of care furnished 
by these hospitals, and because we believe that hospitalized patients 
in the United States currently face patient safety risks on a daily 
basis, we are proposing in this proposed rule to adopt an initial 
measure set for the Hospital VBP program. However, we are also 
proposing to add additional measures to the Hospital VBP program in the 
future in such a way that their performance period will begin 
immediately after they are displayed on Hospital Compare for a period 
of time of at least one year, but without the necessity of notice and 
comment rulemaking. We propose this because of the urgency to improve 
the quality of hospital care, and in order to minimize any delay to 
take substantive action in favor of patient safety. The details of this 
proposal are discussed below.
    We have stated that for the Hospital IQR Program, we give priority 
to quality measures that assess performance on: (a) Conditions that 
result in the greatest mortality and morbidity in the Medicare 
population; (b) conditions that are high volume and high cost for the 
Medicare program; and (c) conditions for which wide cost and treatment 
variations have been reported, despite established clinical guidelines. 
In addition, we stated that we seek to select measures that address the 
six quality aims of effective, safe, timely, efficient, patient-
centered, and equitable healthcare. Current and long term priority 
topics include: Prevention and population health; safety; chronic 
conditions; high cost and high volume conditions; elimination of health 
disparities; healthcare-associated infections and other adverse 
healthcare outcomes; improved care coordination; improved efficiency; 
improved patient and family experience of care; effective management of 
acute and chronic episodes of care; reduced unwarranted geographic 
variation in quality and efficiency; and adoption and use of 
interoperable health information technology.
    We have also stated that these criteria, priorities, and goals are 
consistent with section 1886(b)(3)(B)(viii)(X) of the Act, as added by 
section 3001(a)(2)(D) of the Affordable Care Act, which requires the 
Secretary, to the extent practicable and with input from consensus 
organizations and other stakeholders, to take steps to ensure that the 
Hospital IQR program measures are coordinated and aligned with quality 
measures applicable to physicians and other providers of services and 
suppliers under Medicare.
    Currently, there are 45 measures specified under the Hospital IQR 
program for the FY 2011 payment determination. We view all of these 
measures (with the exception of the measures of readmission) as 
``candidate measures'' for the Hospital VBP program. We recognize that 
we cannot add any measure to the program unless it meets the 
requirements of section 1886(o). In determining what measures to 
initially propose for the FY 2013 Hospital VBP program we considered 
several factors. First, a measure must be included on the Hospital 
Compare Web site for at least one year prior to the beginning of the 
performance period and specified under the Hospital IQR program. The 
SCIP-Inf-9 and 10 measures do not meet this requirement nor do any of 
the nine (previously ten given the Nursing Sensitive Care--Failure to 
Rescue measure was harmonized with the Death Among Surgical Patients 
with Serious, treatable Complications) Agency for Healthcare Research 
and Quality (AHRQ) measures. Therefore, these measures were not 
considered candidate measures. It is our intention to add measures to 
the Hospital VBP program as soon as this requirement is met in order to 
help improve patient care as quickly as possible.
    As noted above, we recognize that we cannot include in the measure 
set any readmission measures in accordance with section 1886(o)(2)(A) 
of the Act. We also are not proposing at this time to adopt the current 
Hospital IQR structural measures because we believe that these measures 
require further development if they are to be used for the Hospital VBP 
program. We seek public comment at this time on the possible utility of 
adopting structural measures for the Hospital VBP program measure set 
and how these measures might contribute to the improvement of patient 
safety and quality of care. Table 1 contains a list of the remaining 
initial eligible measures.

 Table 1--Initial Eligible Measures for the FY 2013 Hospital VBP Program
------------------------------------------------------------------------
            Measure ID                       Measure description
------------------------------------------------------------------------
                            Process Measures
------------------------------------------------------------------------
AMI-1.............................  Aspirin at Arrival.
AMI-2.............................  Aspirin Prescribed at Discharge.
AMI-3.............................  ACE/ARB Inhibitor.
AMI-4.............................  Adult Smoking Cessation Advice/
                                     Counseling.
AMI-5.............................  Beta Blocker Prescribed at
                                     Discharge.
AMI-7a............................  Fibrinolytic Therapy Received Within
                                     30 Minutes of Hospital Arrival.
AMI-8a............................  Primary PCI Received Within 90
                                     Minutes of Hospital Arrival.
HF-1..............................  Discharge Instructions.
HF-2..............................  Evaluation of LVS Function.
HF-3..............................  ACEI or ARB for LVSD.
HF-4..............................  Adult Smoking Cessation Advice/
                                     Counseling.

[[Page 2460]]

 
PN-2..............................  Pneumococcal Vaccination.
PN-3b.............................  Blood Cultures Performed in the
                                     Emergency Department Prior to
                                     Initial Antibiotic Received in
                                     Hospital.
PN-4..............................  Adult Smoking Cessation Advice/
                                     Counseling.
PN-5c.............................  Timing of Receipt of Initial
                                     Antibiotic Following Hospital
                                     Arrival.
PN-6..............................  Initial Antibiotic Selection for CAP
                                     in Immunocompetent Patient.
PN-7..............................  Influenza Vaccination.
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 6AM Postoperative Serum
                                     Glucose.
SCIP-Inf-6........................  Surgery Patients with Appropriate
                                     Hair Removal.
SCIP-Card-2.......................  Surgery Patients on a Beta Blocker
                                     Prior to Arrival That Received a
                                     Beta Blocker 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.
------------------------------------------------------------------------
                            Outcome Measures
------------------------------------------------------------------------
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.
------------------------------------------------------------------------
                             Survey Measures
------------------------------------------------------------------------
HCAHPS............................  Hospital Consumer Assessment of
                                     Healthcare Providers and Systems
                                     Survey.
------------------------------------------------------------------------

    To determine which measures we would propose to initially adopt for 
the FY 2013 Hospital VBP program, we then examined whether any of the 
eligible Hospital IQR measures (table above) should be excluded from 
the Hospital VBP program measure set because hospital performance on 
them is ``topped out,'' meaning that all but a few hospitals have 
achieved a similarly high level of performance on them. We believe that 
measuring hospital performance on topped-out measures will have no 
meaningful effect on a hospital's total performance score. Scoring a 
topped-out measure for purposes of the Hospital VBP program would also 
present a number of challenges. First, as we discuss below, we are 
proposing that the benchmark performance standard for all measures will 
be the performance at the mean of the top decile (defined in section 
II. E. of this proposed rule). Applied to a topped-out measure, the 
benchmark would be statistically indistinguishable from the highest 
attainable score for the measure and, in our view, could lead to 
unintended consequences as hospitals strive to meet the benchmark. 
Examples of unintended consequences could include, but are not limited 
to, inappropriate delivery of a service to some patients (such as 
delivery of antibiotics to patients without a confirmed diagnosis of 
pneumonia), unduly conservative decisions on whether to exclude some 
patients from the measure denominator, and a focus on meeting the 
benchmark at the expense of actual improvements in quality or patient 
outcomes. Second, we have found that for topped-out measures, it is 
significantly more difficult to differentiate among hospitals 
performing above the median. Third, because a measure cannot be applied 
to a hospital unless the hospital furnishes services appropriate to the 
measure, data reporting under the Hospital VBP program will not be the 
same for all hospitals. To the extent that a hospital can report a 
higher proportion of topped-out measures, for which its scores would 
likely be high, we believe that such a hospital would be unfairly 
advantaged in the determination of its total performance score.
    To determine whether an eligible Hospital IQR measure is topped 
out, we initially focused on the top distribution of hospital 
performance on each measure and noted if their 75th and 90th 
percentiles were statistically indistinguishable. Based on our 
analysis, we identified 7 topped-out measures: AMI-1 Aspirin at 
Arrival; AMI-5 Beta Blocker at Discharge; AMI-3 ACEI or ARB at 
Discharge; AMI-4 Smoking Cessation; HF-4 Smoking Cessation; PN-4 
Smoking Cessation; and SCIP-Inf-6 Surgery Patients with Appropriate 
Hair Removal. We then observed that two of these measures identified as 
topped out (AMI-3 ACEI or ARB at Discharge and HF-4 Smoking Cessation) 
had significantly lower mean scores than the others, which led us to 
question whether our analysis was too focused on the top ends of 
distributions and whether additional criteria that could account for 
the entire distribution might be more appropriate. To address this, we 
analyzed the truncated coefficient of variation for each of the 
measures. The coefficient of variation (CV) is a common statistic that 
expresses the standard deviation as a percentage of the sample mean in 
a way that is independent of the units of observation. Applied to this 
analysis, a large CV would indicate a broad distribution of individual 
hospital scores, with large and presumably meaningful differences 
between hospitals in relative performance. A small CV would indicate 
that the distribution of individual hospital scores is clustered 
tightly around the mean value, suggesting that it is not useful to draw 
distinctions between individual hospital performance scores. We used a 
modified version of the CV, namely a truncated CV, for each measure, in 
which the five percent of hospitals with the lowest scores, and the 
five percent of hospitals with highest scores were first truncated (set 
aside) before calculating the CV. This was done to avoid undue effects 
of the highest and lowest outlier hospitals, which if included, would 
tend to greatly widen the dispersion of the distribution and make the 
measure appear to be more reliable or discerning. For example, a 
measure for which most hospital scores are tightly clustered

[[Page 2461]]

around the mean value (a small CV) might actually reflect a more robust 
dispersion if there were also a number of hospitals with extreme 
outlier values, which would greatly increase the perceived variance in 
the measure. Accordingly, the truncated CV was added as an additional 
criterion requiring that a topped-out measure also exhibit a truncated 
CV < 0.10. Using both the truncated CV and data showing whether 
hospital performance at the 75th and 90th percentiles was statistically 
indistinguishable, we reexamined the available measures and determined 
that the same seven measures continue to meet our proposed definition 
for being topped-out.
    Our priorities for the Hospital VBP program are to transform how 
Medicare pays for care and to encourage hospitals to continually 
improve the quality of care they furnish. Our analysis of the impact of 
including the topped-out measures discussed above shows that their use 
would mask true performance differences among hospitals and, as a 
result, would fail to advance these priorities. Therefore, we are 
proposing to not include these 7 topped-out measures (AMI-1 Aspirin at 
Arrival; AMI-5 Beta Blocker at Discharge; AMI-3 ACEI or ARB at 
Discharge; AMI-4 Smoking Cessation; HF-4 Smoking Cessation; PN-4 
Smoking Cessation; and SCIP-Inf-6 Surgery Patients with Appropriate 
Hair Removal) in the list of measures we are proposing to initially 
adopt for the FY 2013 Hospital VBP program.
    We examined whether the following outcome measures adopted for the 
Hospital IQR program are appropriate for inclusion in the FY 2013 
Hospital VBP program. These measures are as follows: (1) AHRQ patient 
safety indicators (PSIs), inpatient quality indicators (IQIs) and 
composite measures; (2) AHRQ PSI and nursing sensitive care measure; 
and (3) AMI, HF, and PN mortality measures (Medicare patients). We 
believe that these outcome measures provide important information 
relating to treatment outcomes and patient safety. We also believe that 
adding these outcome measures would significantly improve the 
correlation between patient outcomes and Hospital VBP performance. 
However, because under section 1886(o)(2)(C)(i) of the Act, we may only 
select measures if they have been included on the Hospital Compare 
Internet website for a least one year prior to the beginning of the 
performance period, we believe that the AHRQ Patient Safety Indicators 
(PSI) and Inpatient Quality Indicators (IQI) and composite measures, 
and the AHRQ Nursing Sensitive Care measure are not yet eligible for 
inclusion in the FY 2013 Hospital VBP program. These measures are 
currently specified for the Hospital IQR program but have not yet been 
included on Hospital Compare. Because of the urgency to act quickly to 
improve patient safety, we plan to adopt them for use in the Hospital 
VBP Program as rapidly as possible and will continue working to develop 
additional robust outcome measures for the Hospital VBP program. We 
invite comments on the addition of the AHRQ PSI, IQI, and Nursing 
Sensitive Care measures for Hospital VBP program inclusion in FY 2014 
and future years.
    We considered whether the current publicly-reported 30-day 
mortality claims-based measures (Mort-30-AMI, Mort-30-HF, Mort-30-PN) 
should be included in the FY 2013 Hospital VBP program. The mortality 
measures assess hospital-specific, risk-standardized, all-cause 30-day 
mortality rates for patients hospitalized with a principal diagnosis of 
heart attack, heart failure, and pneumonia. All-cause mortality is 
defined for purposes of these measures as death from any cause within 
30 days after the index admission date, regardless of whether the 
patient died while still in the hospital or after discharge. On July 1, 
2009, the specifications for these measures were changed from a one-
year reporting period to a three-year rolling average. This was done to 
address concerns regarding the reliability of the measures, and the 
three-year rolling average allows us to include a larger number of 
cases in the measure calculations, although our analysis shows that 
eighteen months of these data is also reliable. We do not believe that 
the three-quarter performance period we are proposing to use for the 
initial clinical process of care and HCAHPS measures for the FY 2013 
Hospital VBP program would be appropriate to use for these mortality 
outcome measures because we do not believe that the data collected for 
these mortality measures during those three quarters will provide us 
with sufficiently accurate information about a hospital's outcomes on 
which to score hospitals on these measures and base payment. The 
detailed methodology for the 30-day risk standardized mortality 
measures is available on https://www.qualitynet.org.
    However, we propose to adopt these currently reported 30-day 
mortality claims-based measures (MORT-30-AMI, MORT-30-HF, and MORT-30-
PN) as measures for the FY 2014 Hospital VBP program and, as proposed 
above, to establish a performance period with respect to these measures 
of July 1, 2011 to December 31, 2012.
    The eligible clinical process of care measures that have not been 
excluded for reasons previously discussed cover acute myocardial 
infarction, heart failure, pneumonia, and surgeries (as measured by the 
Surgical Care Improvement Project (SCIP)). Therefore, we believe that 
they meet the requirements in section 1886(o)(2)(B)(i)(I)(aa)-(dd) of 
the Act. Section 1886(o)(2)(B)(i)(ee) of the Act requires the Secretary 
to also select for purposes of the FY 2013 Hospital VBP program 
measures that cover healthcare-associated infections (HAI) ``as 
measured by the prevention metrics and targets established in the HHS 
Action Plan to Prevent Healthcare-Associated Infections (or any 
successor plan) of the Department of Health and Human Services.'' The 
SCIP measures that we discuss above were developed to support practices 
that have demonstrated an ability to significantly reduce surgical 
complications such as HAIs. Compliance with these SCIP infection 
measures is also included as a targeted metric in the HHS Action Plan 
to Prevent Healthcare-Associated Infections issued in 2009, available 
on the HHS website. As a result, we believe that the SCIP-Inf-1; SCIP-
Inf-2; SCIP-Inf-3; and SCIP-Inf-4 measures we have adopted for the 
Hospital IQR program meet the requirement in section 
1886(o)(2)(B)(i)(I)(ee) and we propose to categorize them under a HAI 
condition topic instead of under the SCIP condition topic.
    Under section 1886(o)(2)(B)(i)(II), the Secretary must select 
measures for the FY 2013 Hospital VBP program related to the Hospital 
Consumer Assessment of Healthcare Providers and Systems survey 
(HCAHPS). CMS partnered with the Agency for Healthcare Research and 
Quality (AHRQ) to develop HCAHPS. The HCAHPS survey is the first 
national, standardized, publicly reported survey of patients' 
experiences of hospital care, and we propose to adopt it for the FY 
2013 Hospital VBP program. HCAHPS, also known as the CAHPS[supreg] 
Hospital Survey, is a survey instrument and data collection methodology 
for measuring patients' perceptions of their hospital experience.
    The HCAHPS survey asks discharged patients 27 questions about their 
recent hospital stay that are used to measure the experience of 
patients across 10 dimensions in the Hospital IQR program. The survey 
contains 18 core questions about critical aspects of patients' hospital 
experiences (communication with nurses and doctors, the responsiveness 
of hospital staff, the cleanliness and quietness of the hospital 
environment, pain

[[Page 2462]]

management, communication about medicines, discharge information, 
overall rating of the hospital, and whether they would recommend the 
hospital). The survey also includes four items to direct patients to 
relevant questions if a patient did not have a particular experience 
covered by the survey, such as taking new medications or needing 
medicine for pain. Three items in the survey are used to adjust for the 
mix of patients across hospitals, and two items related to race and 
ethnicity support congressionally-mandated reports on disparities in 
health care.
    The HCAHPS survey is administered to a random sample of adult 
patients across medical conditions between 48 hours and six weeks after 
discharge; the survey is not restricted to Medicare beneficiaries. 
Hospitals must survey patients throughout each month of the year. The 
survey is available in official English, Spanish, Chinese, Russian and 
Vietnamese versions. The survey and its protocols for sampling, data 
collection and coding, and file submission can be found in the HCAHPS 
Quality Assurance Guidelines, Version 5.0, which is available on the 
official HCAHPS website, https://www.hcahpsonline.org.
    AHRQ carried out a rigorous, scientific process to develop and test 
the HCAHPS instrument. This process entailed multiple steps, including: 
A public call for measures; literature review; cognitive interviews; 
consumer focus groups; stakeholder input; a three-state pilot test; 
small-scale field tests; and soliciting public comments via several 
Federal Register notices. In May 2005, the HCAHPS survey was endorsed 
by the National Quality Forum (NQF). CMS adopted the entire HCAHPS 
survey as a measure in the Hospital IQR program in October 2006, and 
the first public reporting of HCAHPS results occurred in March 2008. 
The survey, its methodology and the results it produces are available 
on the HCAPHS website at https://www.hcahpsonline.org/home.aspx. With 
respect to our display of the HCAHPS measure on Hospital Compare for 
purposes of the Hospital IQR program, we publicly report the measure as 
10 separate items. The ``cleanliness of hospital environment,'' 
``quietness of hospital environment,'' ``overall rating of the 
hospital,'' and ``recommend the hospital'' survey items are displayed 
as stand-alone items. The remaining 6 items (communication with nurses, 
communication with doctors, responsiveness of hospital staff, pain 
management, communication about medicines, discharge information) are 
composites of the remaining survey items.
    Finally, we propose to not include the PN-5c measure in the 
Hospital VBP program. We do not believe that this measure is 
appropriate for inclusion because it could lead to inappropriate 
antibiotic use. We intend to propose to retire this measure, as well as 
several other measures that we are not proposing to adopt for the 
Hospital VBP program, from the Hospital IQR program in the near future.
    Accordingly, we propose to initially select the following 17 
clinical process of care measures, and the HCAHPS measure, for 
inclusion in the FY 2013 Hospital VBP program. The proposed list of 
initial measures is provided in Table 2.

   Table 2--Proposed Initial Measures for FY 2013 Hospital VBP Program
------------------------------------------------------------------------
            Measure ID                       Measure description
------------------------------------------------------------------------
                    Clinical Process of Care Measures
------------------------------------------------------------------------
Acute myocardial infarction:
AMI-2.............................  Aspirin Prescribed at Discharge.
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.
HF-2..............................  Evaluation of LVS Function.
HF-3..............................  ACEI or ARB for LVSD.
Pneumonia:
PN-2..............................  Pneumococcal Vaccination.
PN-3b.............................  Blood Cultures Performed in the
                                     Emergency Department Prior to
                                     Initial Antibiotic Received in
                                     Hospital.
PN-6.........................