On August 2, 2021, the Centers for Medicare and Medicaid Services (CMS) filed its annual Inpatient Prospective Payment System (IPPS) final rule. As continued effects of the COVID-19 public health emergency (PHE) spill over into the quality reporting programs, CMS is focused on closing gaps in public health services, emphasizing interoperability and intentions to incorporate more health equity and social determinants of health (SDOH) factors into their programs.

The Biggest Implication

In our review of the Promoting Interoperability (PI) Program updates, the most striking implication to prepare for in the calendar year (CY) 2022 is that eligible hospitals (EHs) and critical access hospitals (CAHs) will be required to report four Public Health measures.

  • This is a new change in direction as CMS was going to remove the Public Health and Clinical Data Exchange objective by CY 2022. Now CMS is requiring that four specific measures of the six public health measures be reported.
  • CMS very strongly indicates that public health measures are a high priority; so much so, that if an EH or CAH fails to report on any one of the four required measures or reports a “no” response for one or more of these measures, they would receive a score of zero for the Public Health and Clinical Data Exchange objective, and a total score of zero for the Medicare Promoting Interoperability (PI) Program. Applicable exclusions are available for the four measures, but not for the two optional measures.
  • Receiving a total score of zero for the PI program means that EHs and CAHs are subject to a payment reduction for failure to be a Meaningful Electronic Health Record (EHR) User.
  • Health IT developers have until December 31, 2022 to make the new criterion for electronic case reporting (eCR) available to customers. The timing of the 90-day EHR reporting period in CY 2022 is dependent on the EHR vendor’s certification timeline of the eCR capabilities.
  • So, while many had done away with reporting three measures since only two were required, now one has to ask, do you still have the infrastructure to support bi-directional exchanges with your state public health agencies?

Highlights

Our focus is on the finalized updates to the Promoting Interoperability Program, the electronic Clinical Quality Measures (eCQMs) for the Inpatient Quality Reporting (IQR) and PI Programs; and briefings on CMS’ requests for information to advance digital quality measures (dQMs) and close the health equity gap in CMS hospital quality programs.

Promoting Interoperability Program Updates

  • Scoring: CMS increased the minimum threshold from 50 to 60 points out of 100 to be considered a Meaningful EHR User.
  • Information blocking: CMS removed information blocking attestation Statements 2 and 3 and is only requiring attestation to Statement 1.
  • EHR Reporting Period: CMS is maintaining a minimum of any continuous 90-day reporting period for CY 2023; and for CY 2024, CMS is increasing the EHR reporting period to a minimum of any continuous 180-day period for new and returning EHs and CAHs.
  • e-Prescribing Objective: CMS increased the bonus points from five to ten for the Query of Prescription Drug Monitoring Program (PDMP) measure.
  • Health Information Exchange (HIE) Objective: CMS added a new optional bi-directional exchange measure. EHs and CAHs can report the original two measures or attest to the new measure for a total of 40 points.
  • Provider to Patient Exchange Objective: CMS did not finalize a new data requirement for the Provide Patients Electronic Access to Their Health Information measure that would have required patient health information to be available to patients from encounters beginning January 1, 2016.
  • Public Health and Clinical Data Exchange Objective: CMS finalized a Yes attestation requirement for four specific Public Health measures: Syndromic Surveillance Reporting, Immunization Registry Reporting, Electronic Case Reporting and Electronic Reportable Laboratory Result Reporting. Five bonus points are also made available for attesting to one of the other two measures, Public Health Registry Reporting or Clinical Data Registry Reporting.
  • Protect Patient Health Information Objective: CMS finalized a new attestation requirement for completing an annual assessment of all nine Safety Assurance Factors for EHR Resilience Guides (SAFER Guides) during the EHR reporting period. A Yes or No attestation to this measure is required for CY 2022 reporting, but will not be scored.

CMS Requests for Information (RFIs) on Digital Quality Measures (dQMs) and Health Equity

Digital Quality Measures (dQMs): CMS intends to fully transition to dQMs by 2025 and is considering defining and developing dQM software as end-to-end measure calculation solutions. These solutions will retrieve data from primarily Fast Healthcare Interoperability Resources (FHIR)-based resources maintained by providers, payers, CMS and others, calculate measure score(s) and produce reports.

  • Our take: The healthcare industry has made some progress in transitioning to dQMs for process measures, but the outcome measures will be more complex. Clinical data has a lot more nuanced context for computing quality measures and currently, FHIR resources do not adequately describe all the data elements that are available or required for these measures.

Health Equity: CMS intends to close the health equity gap in CMS programs and policies by making the reporting of health disparities based on social risk factors, race and ethnicity more comprehensive and actionable for hospitals, providers and patients.

  • Our take: CMS will continue soliciting comments from hospitals, the public and other key stakeholders to identify policy solutions. It will take some work and a focus on data standardization to achieve this goal.

eCQM Updates

  • eCQMs: CMS is removing three eCQMs beginning in CY 2024 and adding two new eCQMs in CY 2023 reporting year. They will require EHs and CAHs to use only certified technology consistent with the 2015 Edition Cures Update to submit eCQM data beginning in CY 2023.
  • Hybrid measures: CMS is adopting a second Hybrid Measure, the Hybrid Hospital-Wide Mortality (Hybrid HWM) measure. It will have one volunteer reporting period, with timing for mandatory reporting aligned with the Hybrid Hospital-Wide Readmission (Hybrid HWR) measure. Payment determination will be affected beginning in FY 2026.

To explore more, download our latest white paper for further details on the changes, including clarifications and considerations of the requirements.

Sources

  1. IPPS Final Rule Full Title: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2022 Rates; Quality Programs and Medicare Promoting Interoperability Program Requirements for Eligible Hospitals and Critical Access Hospitals; Changes to Medicaid Provider Enrollment; and Changes to the Medicare Shared Savings ProgramUnpublished version filed on 8/2/2021; Published in Federal Register on 8/13/2021.
  2. CMS Fact Sheet, 8/2/2021: Fiscal Year (FY) 2022 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) Rates Final Rule (CMS-1752-F)
  3. QualityNet Webinar: Reporting the Hybrid Hospital-Wide Readmission Measure to the Hospital IQR Program; Tuesday, May 18, 2021.

Acronyms

Calendar Year (CY); Centers for Medicare and Medicaid Services (CMS); Certified EHR Technology (CEHRT); Critical Access Hospital (CAH); Digital Quality Measures (dQMs); Electronic Case Reporting (eCR); Electronic Clinical Quality Measures (eCQMs); Electronic Health Record (EHR); Electronic Laboratory Reporting (ELR); Eligible Hospital (EH); Fast Healthcare Interoperability Resources (FHIR); Fiscal Year (FY); Health Information Exchange (HIE); Hospital Harm (HH); Hybrid Hospital-Wide Mortality (Hybrid HWM measure); Hybrid Hospital-Wide Readmission (Hybrid HWR measure); Inpatient Quality Reporting (IQR); Inpatient Prospective Payment System (IPPS); Office of the National Coordinator for Health Information Technology (ONC); Promoting Interoperability (PI); Public Health Emergency (PHE); Query of Prescription Drug Monitoring Program (PDMP); Request for Information (RFI); Safety Assurance Factors for EHR Resilience Guides (SAFER Guides); Social Determinants of Health (SDOH).

About emids Regulatory Review Board (eMRB)

Collaboration of content for this blog was provided by eMRB subject matter experts, covering important quality reporting topics for our customers and partners. Points of view and interpretation were relevant at time of authorship; however, they are subject to change over time. For more information about these changes, contact us at engage@emids.com.