The OPPS rule for 2012 included eight new measures. Though the reporting requirement begins in 2012, the hospital payment update does not occur until 2013.

For each of these measures, the patient population may vary significantly, ranging from any ED visit to only transfers. It is recommended that ED providers collaborate with their hospital’s quality departments to understand the outpatient measure populations. [continued online]

One particularly contentious measure worth noting is OP-15 – Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache. OP-15 will be the first measure that has been fast-tracked for inclusion into the OPPS program despite NQF rejection. ACEP through its Quality and Performance Committee has sent comments challenging this unprecedented path as well as the validity of this measure. A recent article has challenged the appropriateness of this outpatient imaging efficiency measure, which is based on Medicare administrative claims data. The study found that CMS data was only 17% accurate in assessing which patients should have received a CT scan in the ED setting; 83% should not have been labeled as inappropriate based on either ACEP clinical policy guidelines or expert consensus standards. Because CMS utilizes administrative claims data rather than a more thorough abstracting process as was performed in the study, hospitals’ performance on the new measure as reported by CMS did not match the true proportion of CTs with a documented clinical indication. The measure uses Medicare billing records to determine whether a CT scan was clinically appropriate. When the patients’ medical records were actually reviewed, they showed that 65% of the CT scans actually complied with Medicare’s measure and another 18% of patients had valid reasons for the CT scans documented in their charts. Medicare runs the risk of publicizing inaccurate information about clinical performance and rewarding/penalizing hospitals based on unreliable data.

Also of note, OP-19 was suspended by CMS due to concerns including, but not limited to, HIPAA. CMS is currently reworking the measure, and it is expected to return with slightly different measure specifications.

Inpatient Prospective Payment System

The IPPS describes the Hospital Inpatient Quality Reporting (IQR) Program, formerly known as the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) Program. RHQDAPU was originally mandated by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. This section authorized CMS to pay hospitals that successfully report designated quality measures a higher annual update to their payment rates. To this end, CMS initially implemented a 0.4 percentage point reduction in the annual market basket for hospitals that did not successfully report. In 2005, the Deficit Reduction Act increased that reduction to 2.0 percentage points.