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Outpatient Quality Steamroller Coming

November 25, 2008
by Mark Hagland
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Late last month, the federal Centers for Medicare and Medicaid Services (CMS) announced that it would more tightly link payment to quality of care for hospital outpatient departments. In publishing a final rule establishing Medicare payment and policy changes for services in hospital outpatient departments and ambulatory surgery centers for 2009, CMS announced that it would no longer pay hospitals for care related to illness or injuries acquired by the patient during a hospital outpatient encounter. This policy change, which could be implemented in the relatively near future, would extend the Medicare program’s recent change in policy on payments for inpatient hospital-acquired conditions.

Among other specific elements of the final rule, “CMS will reduce the calendar-year 2009 payment update factor by 2 percentage points for most services for hospitals that were required to report quality measures but failed to meet requirements of the HOP QDRP [Hospital Outpatient Quality Data Reporting Program] for CY 2009,” CMS announced on its website. And the number of quality of care measures that hospitals will be required to report in order to receive the full CY 2010 market basket update will be raised from 7 measures in CY 2008 to 11 measures in CY 2009, with the addition of four imaging efficiency measures to be calculated using Medicare claims data.

In short, the feds are wising up to outpatient department-acquired infections and illnesses as well as to inpatient-acquired ones. And they’re adding ever more quality measures that must be collected and reported.

The implication for us is clear. Developing optimal systems for tracking, collecting, and reporting all the kinds of clinical data that CMS, and increasingly private payers, will be demanding, will only become more urgent and timely. Are your organization's information systems up to current requirements? How about near-future requirements?



My question is around responsibility. Where does the patient's responsibility end and the providers begin? Is anyone familiar with the evolving medical home model, in which one primary caregiver coordinates treatment? Of course, today this is supposed to be the primary physician, but they often do not completely fill that role. It seems to me that, at least for now, the patient is ultimately responsible for their own care and coordination.

Mark: One of the challenges in getting accurate quality information in ambulatory care is that most patients have medical data gathered by providers in multiple group practices settings and it is hard for any provider to have quality measures they can rely on since they may be unaware of or not tracking care data from the patients encounters with providers outside of their system. These is particularly a problem for specialty focused groups such as academic practice plans where there may be poor data exchange with the primary care physician

This has already been a problem with chronic care management and is likely to make it difficult to track/impact post procedure infection rates as well.

It is also problematic in ambulatory care to track compliance with treatments prescribed (such as antibiotics) since the patient most frequently goes to an outside pharmacy to fill the prescription and there are not medication administration records as in the acute care environment.

Payors turn out to have the most comprehensive records of ambulatory care provided (encounter records for all providers and medications filled) except where the patient is in a closed HMO system.

Hello, Tom Anthony
Yes, your points are well-taken. I think this is an area where it will be undoubtedly crucial for all providers and all payers to find ways to collaborate for the benefit of patients/health care consumers. Will this be a challenge? Most definitely. But the alternative is continuing to accept a system that simply isn't paying properly for quality care. Thank you again for your important points, with which I agree.