Performance Measurement in the Hospital Outpatient Setting. Federal Actions to Reform the System


On August 22, 2006, President Bush issued an Executive Order, “Promoting Quality and Efficient Health Care,” that requires the federal government to: (1) ensure that federal health care programs promote quality and efficient delivery of health care and (2) make readily useable information available to beneficiaries, enrollees, and providers (Bush, 2006). To support this mandate, DHHS Secretary Michael Leavitt embraced “four cornerstones” for building a value-driven health care system:

  • Connecting the health system through the use of health information technology (HIT)
  • Measuring and making transparent quality information
  • Measuring and making transparent price information
  • Using incentives to promote high-quality and cost-effective care (Leavitt, 2006).

Building on these four cornerstones, CMS has taken steps toward measuring and making quality information transparent to become a value-based purchaser of care. A key example is the CMS Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) Program, initially enacted under the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA)5, and expanded through the Deficit Reduction Act (DRA) of 20056. The RHQDAPU Program provides differential payment updates in the Inpatient Prospective Payment System (IPPS) to hospitals based on whether they publicly report their performance on a defined set of inpatient care performance measures. As part of Section 109 of the Tax Relief and Health Care Act of 2006 (TRHCA)7, Congress established new requirements such that hospitals are required to report hospital outpatient quality data in order to secure the full annual payment update under the OPPS. The new program is referred to as the Hospital Outpatient Quality Data Reporting Program (HOP QDRP).

According to the Proposed OPPS Rule, effective January 2008, hospitals will be required to submit performance data on a set of 10 measures of care provided in the hospital outpatient setting (Table 1.2) to secure their full payment update in Calendar Year (CY) 2009 and each subsequent year;8 the Medicare annual OPPS fee schedule increase amount will be reduced by 2.0 percentage points for any "subsection (d) hospital" that does not submit required outpatient department quality data (CMS, 2007).9

Measure Source
Table 1.2. Proposed Hospital Outpatient Measures for the Hospital Outpatient Quality Data Reporting Program (HOP QDRP)Anchor
Emergency Department Transfer: Aspirin at Arrival for AMI (acute myocardial infarction) Oklahoma Foundation for Medical Quality (OFMQ)
Emergency Department Transfer: Median Time to Fibrinolysis for AMI OFMQ
Emergency Department Transfer: Fibrinolytic Therapy Received Within 30 Minutes of Arrival OFMQ
Emergency Department Transfer: Median Time to Electrocardiogram OFMQ
Emergency Department Transfer: Median Time to Transfer for Primary PCI OFMQ
Heart Failure: ACE or ARB Therapy for LVSD American Medical Association Physician Consortium for Performance Improvement (AMA/PCPI)
Perioperative Care: Timing of Antibiotic Prophylaxis AMA/PCPI
Perioperative Care: Selection of Prophylactic Antibiotic AMA/PCPI
Empiric Antibiotic for Community Acquired Pneumonia AMA/PCPI
Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus National Committee for Quality Assurance (NCQA)

Of the 10 measures, the five emergency department transfer measures were developed by the Oklahoma Foundation for Medical Quality (OFMQ), while the five other measures are physician-level measures for which existing measurement specifications have been revised by the OFMQ to address care provided in hospital outpatient settings. Anticipating the need for a broader range of measures to support this legislative mandate, CMS is seeking public comment on 30 additional measures of care provided in the hospital outpatient setting that are under consideration for reporting in future years (CMS, 2007) (see Appendix A).

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