1. 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

2. 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 Announcements 2

3. o Data submission deadline is August 15, 2011 o See Specifications Manual for Hospital Outpatient Department Quality Measures v.4.1 for measure informationSpecifications Manual for Hospital Outpatient Department Quality Measures v.4.1 o To answer these structural measures, “QualityNet Program Management OPPS Structural MSR Update” on My QualityNet is required o For Security Administrator related issues, contact QualityNet Help Desk 1-866-288-8912 Structural Measure: OP-12 3

4.  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 Objectives 4

5.  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=CMS- 2011-0130-0002 Mail (regular, Express, Overnight) ◦ Hand or Courier  Final Rule Scheduled for Display November 1, 2011  Effective with January 1, 2012, services CY 2012 OPPS/ASC Proposed Rule: Timeline 5

6. Please comment! Your view from the field is valuable, necessary, and much appreciated!

7.  Will continue to maintain technical specifications in the Hospital OQR Specifications Manual ◦ Posted on the http://www.QualityNet.org websitehttp://www.QualityNet.org ◦ 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 Finalized Hospital OQR Policies: Technical Specifications Maintenance & Updates 7

8.  Data published by CMS Certification Number (CCN)  Multiple campus data combined by CCN  Data made publicly available whether or not validated for payment purposes Finalized Hospital OQR Policies: Publication on Hospital Compare 8

9. 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 Total of 23 Quality Measures for CY 2013 Payment Determination 9

10.  OP-1Median Time to Fibrinolysis  OP-2Fibrinolytic Therapy Received Within 30 minutes  OP-3Median Time to Transfer to Another Facility for Acute Coronary Intervention  OP-4Aspirin at Arrival  OP-5Median Time to ECG  OP-6Timing of Antibiotic Prophylaxis  OP-7Prophylactic Antibiotic Selection for Surgical Patients For CY 2013: 7 Chart-abstracted Measures Required for CY 2012 Payment 10

11.  OP-8MRI Lumbar Spine for Low Back Pain  OP-9 Mammography Follow-up Rates  OP-10 Abdomen CT: Use of Contrast Material  OP-11 Thorax CT: Use of Contrast Material  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 For CY 2013: 7 Claims-based Measures Required for CY 2012 Payment 11

12.  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 For CY 2013 Payment: 1 Structural Required for CY 2012 Plus 1 Structural and 3 Claims-based Measures 12

13.  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 For CY 2013 Payment: 7 Additional Chart- Abstracted Measures 13

14.  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 Proposed Revision to OP-22 Left Without Being Seen for CY 2013 Payment 14

15. 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) Proposed Additional 9 Measures for CY 2014 Payment Determination 15

16.  OP-24: Surgical Site Infection (NHSN) ◦ Submit to CDC’s National Healthcare Safety Network (NHSN) ◦ Infection events  Q1 2013 submitted Jan 31 st to Aug 1 st, 2013  Q2 2013 submitted April 30 th to Nov 1 st, 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 Proposed Additional 9 Measures for CY 2014 Payment Determination: Data Submission Requirements 16

17.  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 31 st to Aug 1 st, 2013 ◦ Q2 2013 submitted April 30 th to Nov 1 st, 2013  Total of 33 measures Proposed Measures for CY 2015 Payment Determination 17

18.  CY 2012 and beyond: Measures descriptions for newly proposed outpatient clinical measures ◦ http://www.hopqdrponline.com/tools.aspx http://www.hopqdrponline.com/tools.aspx ◦ http://www.qualitynet.org http://www.qualitynet.org  Proposed CY 2013 payment: Descriptions of 4 additional claims-based imaging efficiency measures ◦ http://imagingmeasures.com/measureset2.html http://imagingmeasures.com/measureset2.html Measure Descriptions for Newly Proposed Outpatient Measures 18

19.  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 Measures & Topics Under Consideration for Future Payment Determinations Beginning with CY 2015 19

20.  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 Measures Under Consideration for Future Payment Determinations Beginning with CY 2015 20

21.  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 Measures and Topics Under Consideration for Future Payment Determinations Beginning with CY 2015 21

22.  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 Proposed Requirements for Hospital Outpatient Quality Reporting: Extraordinary Circumstance Extensions or Waivers 22

23.  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 Proposed Requirements for Hospital Outpatient Quality Reporting: Administrative 23

24.  For the CY 2014 Payment Update: Current participants ◦ 3 rd Quarter 2011 through 2 nd Quarter 2012 services  Existing Hospitals with Medicare acceptance dates before January 1, 2012 ◦ Begin data submission with 1 st Quarter 2012 services  Hospitals with Medicare acceptance dates after December 31, 2012 ◦ Begin data submission with 1 st full quarter after submitting participation form  Claims-based measures will be calculated using claims with dates of service for CY 2010 Proposed Requirements for Hospital Outpatient Quality Reporting: Data Collection & Submission 24

25.  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 Proposed Requirements for Hospital OQR: Data Collection & Submission 25

26.  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 non- Medicare patients Proposed Requirements for Hospital OQR: Data Collection & Submission 26

27.  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 Proposed Requirements for Hospital OQR: Validation 27

28.  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 Proposed Requirements for Hospital OQR: Validation 28

29.  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 Proposed Requirements for Hospital OQR: Validation 29

30.  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 Proposed Validation Conditions for Hospital OQR: CY 2013 and Possible Considerations 30

31.  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 Payment Reduction for Hospitals That Fail to Meet Hospital OQR Requirements 31

32.  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 Proposed Reconsideration & Appeals Procedures 32

33.  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 NEW - ASC Quality Reporting Program 33

34.  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 Proposed ASC Quality Reporting Program: 7 Claims-Based Measures 34

35.  ASC-8 Surgical Site Infection  Submitted to the NHSN  CY 2013 Infection Events ◦ Q1 2013 submitted Jan 31 st to Aug 1 st, 2013 ◦ Q2 2013 submitted April 30 th to Nov 1 st, 2013 Proposed New National Healthcare Safety Network (NHSN) Healthcare-Associated Infection (HAI) Measure for the CY 2014 Payment Determination 35

36.  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 Proposed ASC Quality Reporting Program: CY 2015 Payment Determination 36

37.  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 Proposed ASC Quality Reporting Program: CY 2016 Payment Determination 37

38. 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, toll- free, (866) 800-8756 weekdays from 7 a.m. to 6 p.m. Eastern Time. Hospital Outpatient-Outpatient Questions/Answers 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