Outpatient Prospective Payment System (OPPS)

Hospital measures can originate from individuals, professional societies, academic institutions, and more recently, consulting agencies (e.g., Optimal Solutions Group and Ingenix). The bulk of hospital measures that affect emergency medicine come from the OPPS and its associated data reporting program, the Hospital Outpatient Quality Reporting Program (OQR). The Hospital OQR was mandated by the Tax Relief and Health Care Act of 2006, which requires subsection (d) hospitals to submit data on measures on the quality of care furnished by hospitals in outpatient settings.

To receive the full Annual Payment Update (APU) under the OPPS, hospitals must meet administrative, data collection and submission, and data validation requirements of the

Hospital OQR. Hospitals that fail to successfully participate in the OQR receive reduced payments through a reduction of 2.0 percentage points to the hospital market basket update.

The proposed OPPS rule for 2011 does not have any changes to the current 11 outpatient quality measurements. However, CMS has added 16 additional quality reporting measures across seven different clinical areas in 2012. The four that may directly affect emergency medicine are listed in Table 4. OP-13 through OP-15 have already been subjected to CMS dry runs, resulting in reports delivered to applicable hospitals in April 2011.

Also, CMS is proposing to not implement national coding guidelines for emergency department visits. In the most recent proposed rule, CMS indicates that implementing a national system posed significant complexities, and data submitted by hospitals over the past several years appeared to be reasonable and did not warrant implementation of such a system. CMS did point out, however, that it would continue to monitor hospital emergency department OP service levels and reevaluate implementing national guidelines on a going-forward basis.

Inpatient Prospective Payment System (IPPS)

On Aug. 1, CMS released its Final Rule on the Inpatient Prospective Payment System (IPPS), which describes the current Hospital Inpatient Quality Reporting Program (IQR), 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. Alternatively stated, reporting hospitals escaped a reduction in payment rates for failure to comply. Initially, it was a 0.4 percentage point reduction in the annual market basket for hospitals that did not successfully report, but the Deficit Reduction Act of 2005 increased that reduction to 2.0 percentage points.