Hospital Outpatient Quality Reporting Program
Outpatient Hospital & Ambulatory Surgical Center (ASC)
Quality Reporting Requirements:
CY 2012 Outpatient Prospective Payment System (OPPS)/
ASC Proposed Rule with Comment Period
Anita J. Bhatia, PhD, MPH
Government Task Leader
July 2011
Announcements
o
Clinical Data Submission Deadline August 1,
2011, for Quarter 1 Data
o
Monitor your “My QualityNet” accounts to ensure
Hospital OQR requirements are met
o
Avoid submission of duplicate records
2
Structural Measure: OP-12
o
o
o
o
Data submission deadline is August 15, 2011
See Specifications Manual for Hospital Outpatient
Department Quality Measures v.4.1 for measure
information
To answer these structural measures, “QualityNet Program
Management OPPS Structural MSR Update” on My
QualityNet is required
For Security Administrator related issues, contact
QualityNet Help Desk 1-866-288-8912
3
Objectives

Outline rule deadlines

Outline policies affecting quality reporting

Outline proposed Hospital OQR & ASC Quality
Measures

Provide overview of proposed CY 2012 requirements
that affect CYs 2013 to 2016 payment updates

Receive feedback on proposals

Address concerns and answer questions
4
CY 2012 OPPS/ASC Proposed Rule: Timeline

Proposed Rule Published July 18, 2011
http://www.access.gpo.gov/su_docs/fedreg/a110718c.html

Comments due August 31, 2011, 11:59 p.m. ET
◦ Electronic
http://www.regulations.gov/#!submitComment;D=CMS2011-0130-0002
Mail (regular, Express, Overnight)
◦ Hand or Courier

Final Rule Scheduled for Display November 1, 2011

Effective with January 1, 2012, services
5
Please comment!
Your view from the field is valuable, necessary,
and much appreciated!
Finalized Hospital OQR Policies:
Technical Specifications Maintenance & Updates

Will continue to maintain technical specifications in the
Hospital OQR Specifications Manual
◦ Posted on the http://www.QualityNet.org website
◦ Released every 6 months; addenda released as necessary
◦ At least 3 months notice for substantial changes and at least 6
months for changes requiring significant system change

Will continue process for retiring measures
◦ Immediate, based upon patient safety concerns
◦ Otherwise, use of the regular rulemaking process
7
Finalized Hospital OQR Policies:
Publication on Hospital Compare

Data published by CMS Certification Number
(CCN)

Multiple campus data combined by CCN

Data made publicly available whether or not
validated for payment purposes
8
Total of 23 Quality Measures for CY 2013
Payment Determination
15 measures required for CY 2012 payment
 7 chart-abstracted
 7 Medicare FFS claims-based
 1 structural

8 previously finalized
◦ 7 chart-abstracted
◦ 1 structural
9
For CY 2013: 7 Chart-abstracted Measures
Required for CY 2012 Payment







OP-1
OP-2
OP-3
OP-4
OP-5
OP-6
OP-7
Median Time to Fibrinolysis
Fibrinolytic Therapy Received Within 30 minutes
Median Time to Transfer to Another Facility
for Acute Coronary Intervention
Aspirin at Arrival
Median Time to ECG
Timing of Antibiotic Prophylaxis
Prophylactic Antibiotic Selection for Surgical
Patients
10
For CY 2013: 7 Claims-based Measures
Required for CY 2012 Payment

OP-8
OP-9
OP-10
OP-11
MRI Lumbar Spine for Low Back Pain
Mammography Follow-up Rates
Abdomen CT: Use of Contrast Material
Thorax CT: Use of Contrast Material

OP-13

OP-14

OP-15
Cardiac Imaging for Preoperative Risk Assessment
for Non-Cardiac Low-Risk Surgery
Simultaneous Use of Brain Computed Tomography
(CT) and Sinus Computed Tomography (CT)
Use of Brain Computed Tomography (CT) in the
Emergency Department for Atraumatic Headache



11
For CY 2013 Payment: 1 Structural Required for CY
2012 Plus 1 Structural and 3 Claims-based Measures

Structural Measures
◦ OP-12 The Ability for Providers with Health Information
Technology (HIT) to Receive Laboratory Data Electronically
Directly into their Qualified/Certified EHR System as Discrete
Searchable Data
◦ OP-17 Tracking Clinical Results Between Visits

Claims-based Measures
◦ OP-13 Cardiac Imaging for Preoperative Risk Assessment for
Non-Cardiac Low-Risk surgery
◦ OP-14 Simultaneous Use of Brain Computed Tomography (CT)
and Sinus Computed Tomography (CT)
◦ OP-15 Use of Brain Computed Tomography (CT) in the
Emergency Department for Atraumatic Headache
12
For CY 2013 Payment: 7 Additional ChartAbstracted Measures







OP-16 Troponin Results for Emergency Department AMI or Chest
Pain Patients (with Probable Cardiac Chest Pain) Received Within 60
Minutes of Arrival
OP -18 Median Time from ED Arrival to ED Departure for Discharged
ED Patients
OP-19 Transition Record with Specified Elements Received by
Discharged Patients
OP-20 Door to Diagnostic Evaluation by a Qualified Medical
Professional
OP-21 ED – Median Time to Pain Management for Long Bone
Fracture
OP-22 ED – Patient Left Without Being Seen
OP-23 ED – Head CT Scan Results for Acute Ischemic Stroke or
Hemorrhagic Stroke who Received Head CT Scan Interpretation
13
Proposed Revision to OP-22 Left Without
Being Seen for CY 2013 Payment

Chart-abstracted measure

Propose that aggregate numerator and denominator
counts be entered once per year; no patient-level data

Propose data submission between July 1, 2012 and
August 15, 2012

January 1, 2011 thru December 31, 2011 services
14
Proposed Additional 9 Measures for CY 2014 Payment
Determination
1 NHSN HAI, 6 Chart-Abstracted, 2 Structural Measures
 OP-24: Surgical Site Infection (NHSN)
 OP-25: Diabetes: Hemoglobin A1c Management
 OP-26: Diabetes Measure Pair: A Lipid management: low density
lipoprotein cholesterol (LDL-C) <130, B Lipid management: LDL-C
<100
 OP-27: Diabetes: Blood Pressure Management
 OP-28: Diabetes: Eye Exam
 OP-29: Diabetes: Urine Protein Screening
 OP-30: Cardiac Rehabilitation Patient Referral From an Outpatient
Setting
 OP-31: Safe Surgery Checklist Use (Structural)
 OP-32: Hospital Outpatient Volume Data on Selected Outpatient
Surgical Procedures (Structural)
15
Proposed Additional 9 Measures for CY 2014 Payment
Determination: Data Submission Requirements

OP-24: Surgical Site Infection (NHSN)
◦ Submit to CDC’s National Healthcare Safety Network (NHSN)
◦ Infection events
 Q1 2013 submitted Jan 31st to Aug 1st, 2013
 Q2 2013 submitted April 30th to Nov 1st, 2013

Chart-abstracted: OP-25, OP-26, OP-27, OP-28, OP-29,
OP-30

Structural (OP-31 & OP-32)
◦ Submit data from July 1, 2013 to August 15, 2013
◦ For time period from Jan 1, 2012 to December 31, 2012
16
Proposed Measures for CY 2015 Payment
Determination

Retain 32 measures for CY 2014

Add NHSN HAI measure: OP-33 Influenza Vaccination
Coverage among Healthcare Personnel

Submitted to the NHSN

Infection Events
◦ Q1 2013 submitted Jan 31st to Aug 1st, 2013
◦ Q2 2013 submitted April 30th to Nov 1st, 2013

Total of 33 measures
17
Measure Descriptions for Newly Proposed
Outpatient Measures

CY 2012 and beyond: Measures descriptions for newly
proposed outpatient clinical measures
◦ http://www.hopqdrponline.com/tools.aspx
◦ http://www.qualitynet.org

Proposed CY 2013 payment: Descriptions of 4 additional
claims-based imaging efficiency measures
◦ http://imagingmeasures.com/measureset2.html
18
Measures & Topics Under Consideration for Future
Payment Determinations Beginning with CY 2015

Procedure Specific Measures
◦ Colonoscopy & other Endoscopy measures

Cancer Care
◦ Adjuvant Chemotherapy is Considered or Administered within 4 months
of Surgery to Patients Under Age 80 with AJCC III Colon Cancer
◦ Adjuvant Hormonal Therapy for Patients with Breast Cancer
◦ Needle Biopsy to Establish Diagnosis of Cancer Precedes Surgical
Excision/Resection

Heart Failure
◦ Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor
Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
◦ Left Ventricular Ejection Fraction Assessment
◦ Combination Medical Therapy for Left Ventricular Systolic Dysfunction
19
Measures Under Consideration for Future Payment
Determinations Beginning with CY 2015

Heart Failure (cont.)
◦ Beta-blocker Therapy for Left Ventricular Systolic Dysfunction
◦ Counseling Regarding Implantable Cardioverter-Defibrillator (ICD)
Implantation for Patients with Left Ventricular Systolic Dysfunction on
Combination Medical Therapy
◦ Symptom Management
◦ Symptom and Activity Assessment
◦ Patient Education
◦ Overuse of Echocardiography
◦ Post-Discharge Appointment for Heart Failure Patients

Surgical Safety
◦ Patient Fall
◦ Patient Burn
◦ Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong
Implant
◦ Hospital Transfer/Admission
20
Measures and Topics Under Consideration for Future
Payment Determinations Beginning with CY 2015

Patient Experience-of-Care
◦ Consumer Assessment of Healthcare Providers and Systems (CAHPS)
surveys for clinicians/groups
◦ CAHPS Surgical Care Survey

Anesthesia Related Complications
◦ 24 measures

6 additional topics
21
Proposed Requirements for Hospital Outpatient Quality
Reporting: Extraordinary Circumstance Extensions or
Waivers


Retaining most procedures from previous years
Information submitted using request form on the QualityNet website
◦
◦
◦
◦
◦
Hospital CCN
Hospital name
CEO, other designated personnel contact information
Evidence of impact
Date when data submission can resume

CMS will acknowledge receipt and will provide response within 90
days of receipt

NEW – extending to medical record documentation
22
Proposed Requirements for Hospital
Outpatient Quality Reporting: Administrative

Most requirements are the same as implemented last
year

Have and Maintain a QualityNet Security Administrator
◦ Security requirement
◦ 1 required; recommend having at least 2 for back-up
purposes
23
Proposed Requirements for Hospital Outpatient Quality
Reporting: Data Collection & Submission

For the CY 2014 Payment Update: Current participants
◦ 3rd Quarter 2011 through 2nd Quarter 2012 services

Existing Hospitals with Medicare acceptance dates before January
1, 2012
◦ Begin data submission with 1st Quarter 2012 services

Hospitals with Medicare acceptance dates after December 31, 2012
◦ Begin data submission with 1st full quarter after submitting participation
form

Claims-based measures will be calculated using claims with dates
of service for CY 2010
24
Proposed Requirements for Hospital OQR: Data
Collection & Submission

Sampling & Case Thresholds
◦ 5 or fewer for any measure topic: not required to submit, but may do so
voluntarily

Sampling scheme contained in the Specifications Manual

Submission deadlines will be posted on the QualityNet website

Data are to be submitted under the CCN under which the care was
furnished
25
Proposed Requirements for Hospital OQR: Data
Collection & Submission

NEW - Propose that hospitals must submit on a quarterly
basis, aggregate population and sample sizes counts for
Medicare and non-Medicare encounters for the topic areas for
which chart-abstracted data must be submitted

Deadlines for reporting these data would be the same as for
chart-abstracted data

We plan to use the aggregate population and sample size
data to assess data submission for Medicare and nonMedicare patients
26
Proposed Requirements for Hospital OQR: Validation

Retain most procedures from previous years

NEW – Reduce number of randomly selected hospitals
to 450

NEW – Sample up to 50 hospitals on proposed targeting
criteria

Sample up to 48 cases (12 per quarter) per hospital

Match rate = # measure matches ÷ total # measures
27
Proposed Requirements for Hospital OQR:
Validation

NEW - Submit documentation to the CDAC within 30
days from the date of request

Letter to be addressed to the hospital’s medical record
staff identified by the hospital for submitting inpatient
records
28
Proposed Requirements for Hospital OQR:
Validation

Previously finalized procedures

Would use the upper bound of a one-tailed 95%
confidence interval to calculate the validation score

Validation score to be at or above 75%

Would use a binomial approach due to the possibility of
small sample sizes
29
Proposed Validation Conditions for Hospital OQR: CY
2013 and Possible Considerations

NEW - Targeting criteria indicating data concerns
◦ Previous validation failure
◦ Extreme outlier values for submitted data elements

NEW - For consideration
◦ Not selected for validation in 3 years
◦ Low submission numbers relative to population sizes
◦ Significant numbers of Unable to Determine values
30
Payment Reduction for Hospitals That Fail to
Meet Hospital OQR Requirements

2% reduction to the annual payment update factor

Any reduction applies only to the payment year involved

As outlined; the application of the reduction results in
reduced national unadjusted payment rates that apply to
certain items and services provided by hospitals
required to report outpatient quality data
31
Proposed Reconsideration & Appeals Procedures






Retaining all procedures from previous year; procedures for
validation results and proposing for 2013 and subsequent years
Information submitted using Reconsideration Request form on the
QualityNet website
Submit paper copies of any and all medical record documentation
that was submitted for the initial validation
Provide a written justification for each appealed data element
CMS will acknowledge receipt and will provide response to request
within 90 days of receipt
To be able to appeal validation results, must have submitted all
requested documentation in a timely manner
32
NEW - ASC Quality Reporting Program

Propose to begin data collection with CY 2012 services

Will affect CY 2014 payment

Seven claims-based measures

Codes (Quality Data Codes) placed on claims

1 HAI measure: Surgical Site Infection

Total of 8 measures
33
Proposed ASC Quality Reporting Program: 7
Claims-Based Measures






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ASC-1 Patient Burn
ASC-2 Patient Fall
ASC-3 Wrong Site, Wrong Side, Wrong Patient, Wrong
Procedure, Wrong Implant
ASC-4 Hospital Transfer/Admission
ASC-5 Prophylactic Intravenous (IV) Antibiotic Timing
ASC-6 Ambulatory Surgery Patients with Appropriate
Method of Hair Removal
ASC-7 Selection of Prophylactic Antibiotic First or
Second Generation Cephalosporin
34
Proposed New National Healthcare Safety Network
(NHSN) Healthcare-Associated
Infection (HAI) Measure for the CY 2014 Payment
Determination

ASC-8 Surgical Site Infection

Submitted to the NHSN

CY 2013 Infection Events
◦ Q1 2013 submitted Jan 31st to Aug 1st, 2013
◦ Q2 2013 submitted April 30th to Nov 1st, 2013
35
Proposed ASC Quality Reporting Program: CY
2015 Payment Determination

Propose for CY 2015 payment determination to retain 8
CY 2014 measures

Adopt 2 Structural Measures
◦ ASC-9 Safe Surgery Checklist
◦ ASC-10 ASC Volume Data on Selected ASC Surgical
Procedures
◦ Data collection July 1, 2013 to August 15, 2013, for CY
2012 services

Total of 10 measures
36
Proposed ASC Quality Reporting Program: CY
2016 Payment Determination

Propose to retain measures adopted for CY 2015
payment determination

Add a NHSN HAI measure: ASC-11 Influenza Coverage
Among Healthcare Personnel

Total of 11 measures
37
Thank you!
Anita J. Bhatia, PhD, MPH
anita.bhatia@cms.hhs.gov
Please submit all questions about the Hospital OQR to FMQAI at
Hospital Outpatient-Outpatient Questions/Answers or by calling, tollfree, (866) 800-8756 weekdays from 7 a.m. to 6 p.m. Eastern Time.
This material was prepared by FMQAI, the Support Center for the Hospital Outpatient Quality Data Reporting Program (HOP QDRP), under
contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).
FL-9SOW-2011SS1T11-7-12324