CMS new quality measure requirements worry some health systems

Mari Devereaux\August 26, 2022

Health systems strapped for resources worry that reporting on new quality measures and transitioning to interoperability as part of the Centers for Medicare & Medicaid Services' final rule will be overly burdensome.

As a result, some hospitals want CMS to offer adequate financial and technological support. For larger systems with deeper resources, the rule doesn't seem to be a big lift.

The 2023 Medicare Hospital Inpatient Prospective Payment System rule, released Aug. 1, outlined 10 new quality reporting measures, including equity and social risk factor data, rates of cesarean sections and severe obstetrics complications, opioid-related adverse events and Medicare spending per beneficiary. 

Most updates and measures in the final rule will become mandatory in 2024 and affect health systems’ payment determinations starting in 2025 or 2026.

CMS also is placing a focus on digital quality measures and reporting based on the Fast Healthcare Interoperability Resources standard, with a goal of easier data transmission between different databases and electronic health records. 

The cost of building software and infrastructure necessary for interoperability could be around $60,000 for health systems, not including hundreds of thousands of dollars in additional annual expenses for maintenance, labor and employee training, according to Iron Bridge, a healthcare interoperability company. 

New measures in the final rule align with work already underway in some systems. 

At Hartford HealthCare, providers have begun implementing many of the electronic clinical quality measures listed by CMS, particularly those focusing on maternal health and social determinants of health, said Dr. Ajay Kumar, chief clinical officer.

“There was a lot of excitement I had when I looked into the measures. which aligned with our thinking,” Kumar said. “We consider ourselves very well-positioned.”

Leaders at Atrium Health have worked for years to train clinicians on how to code and document electronic clinical quality measures using medical records, said Dr. Andrea Fernandez, regional chief medical officer at Atrium Health Wake Forest Baptist. 

Mount Sinai Health System in New York is optimizing its electronic health records and developing dashboards in order to get a better look at care quality and patient outcomes, said Dr. LeWanza Harris, vice president of quality and regulatory affairs.

She said the system realizes it needs to have better feedback for its providers to use to improve, and is working on the right structures and processes to facilitate change. 

To smaller and/or more rural health systems, the final rule is a pile of deadlines and new responsibilities, said Christina Badaracco, research scientist at Avalere Health, a healthcare business consulting firm.

“Certain hospitals are much more ready for this transition than others,” Badaracco said “There are some who might be ready and have specific suggestions about how to facilitate the process, whereas others might just be implementing and refining their EHR, so they're making arguments for slowing the transition.” 

Following the pandemic's economic strains, hiring another full-time employee to just collect data on additional measures for an unfunded federal mandate isn't financially viable, said Christina Campos, administrator of Guadalupe County Hospital in Santa Rosa, New Mexico.

Also, some of the new measures in the final rule are more likely to penalize hospitals with less resources, she said. 

For example, hospitals that don't have obstetrics departments might see more pregnant patients in their emergency department who haven't received any prenatal care, potentially causing them to score worse on cesarean birth and severe obstetric complication measures, Campos said.

In written feedback to CMS, the University of Pittsburgh Medical Center urged the agency not to penalize health systems without giving them adequate time to embed measures into electronic health records and build trust with their communities to be able to collect data on measures like social drivers of health, said Tami Minnier, senior vice president of the health services division.

“What folks forget is 30% of our patients don't even answer the question of what race they are, because their underlying belief is that somehow they'll be targeted just by answering the question,” Minnier said.

Keeping pace with changes from CMS has required MyMichigan Health, located in Midland, Michigan, to invest additional time and resources into its data analytics and quality structures, which is not always possible for hospitals, said Kay Wagner, system vice president and chief quality officer. 

"We encourage CMS to make interfaces available that help us automate our reporting as much as possible, and to help educate our consumers on what measure definitions are and how different performance outcomes are impacted by differences in patient populations," Wagner said.

Kumar said he is concerned by how small the increase is in operating payment rates for general acute care hospitals participating in the Inpatient Quality Reporting program. 

In light of the inflationary pressures and ongoing staffing issues at hospitals, a 4.3% increase is not enough to offset costs incurred during the pandemic, he said. 

Other suggestions from providers include CMS integrating data sources outside of electronic health records, changing the way digital quality measures are defined and extending the timeline to transition to digital measures, Badaracco said.

Under the final rule, hospitals will have to submit 100% of requested medical records to successfully complete the electronic clinical quality measures validation policy, and report on a total of six electronic clinical quality measures—three mandatory and three self-selected. 

Over the next several years, CMS plans to build upon existing technological infrastructure and transition to digital quality measurement as a way to eventually streamline care and reduce healthcare costs.

The healthcare industry should continue to develop more meaningful clinical quality metrics across specialties and share the data publicly, using transparency and accountability as a way to drive improvement, said Dr. Allen Kachalia, senior vice president for patient safety and quality at Johns Hopkins Medicine.

“The direction we're moving in is the right one,” Kachalia said. “We have to figure out how quickly we can feasibly do it. That's the question.”