(This article has been updated as of Oct. 11, 2023.)
Recently, there have been significant changes to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), the Medicare Beneficiary Quality Improvement Project (MBQIP), and the Hospital Inpatient Quality Reporting (IQR) program that are poised to reimagine how to measure and enhance patient experience and outcomes.
Final Rulings – Changes to HCAHPS
On August 1, 2023, the Centers for Medicare and Medicaid Services (CMS) issued the fiscal year (FY) 2024 Medicare hospital inpatient prospective payment system (IPPS) and long-term care hospital prospective payment system (LTCH PPS) final rule, which includes updates to the data submission and reporting requirements for HCAHPS surveys. These changes, set to begin with the CY 2025 reporting period, have a direct impact on rural healthcare organizations and aim to address many of the specific challenges they face.
- Web-First Modes of Survey Implementation for Accessibility: Rural hospitals often serve patients in geographically remote areas. The introduction of three new web-first modes of survey implementation – Web-Mail, Web-Phone, and Web-Mail-Phone– acknowledges the need for flexibility in data collection This enables patients to provide their feedback conveniently through digital channels, increasing the likelihood of a more representative sample of responses. Web-first modes of survey implementation is a long-coming change that shows CMS is evolving with the times and bringing forms of data collection into the 21st century. While a critical innovation, web-first modes may also present challenges in rural areas due to broadband issues. Rural hospitals must understand limitations within their communities when it comes to implementing web-first modes of survey completion.
- Removal of the Prohibition on Proxy Respondents: In rural communities, where familial and community connections are strong, patients may rely on family members or caregivers to assist in providing survey responses. The removal of the prohibition on proxy respondents recognizes the close-knit nature of these communities and ensures that valuable feedback from patients who may require assistance is included in the survey results. It also emphasizes the importance of engaging patients and family or caregivers in care planning.
- Extension of Data Collection Period: Rural healthcare settings often face unique scheduling challenges due to limited resources and healthcare workforce availability. This often means individuals wear numerous hats. Extending the data collection period from 42 to 49 days aims to mitigate restraints on data collection to allow for more time to gather comprehensive data.
- Limitation of Supplemental Survey Items: Rural hospitals typically have limited resources for survey administration and data analysis – and longer surveys require more time to complete, resulting in fewer responses. By limiting the number of supplemental survey items to 12, the rule acknowledges the need for practicality in data collection and analysis, ensuring that rural hospitals can effectively utilize the data they gather for quality improvement initiatives.
- Official Spanish Translation for Spanish Language-Preferring Patients: Spanish-speaking populations are prevalent in some rural communities. Requiring hospitals to collect a patient’s preferred language and official Spanish translation for Spanish-language-preferring patients reduces language barriers, making it easier for these patients to participate in the survey and provide valuable feedback about their healthcare experiences.
Final Rulings – Changes to IQR Program Requirements
In the FY 2024 IPPS/LTCH PPS final rule, CMS is finalizing the adoption of three new measures, the removal of three existing measures, and the modification of three current measures. Additionally, CMS is finalizing two changes to current policies related to data submission, reporting, and validation.
CMS is adding three new electronic clinical quality measures (eCQMs) – pressure injury, acute kidney injury, and excessive radiation dose or inadequate quality for diagnostic computer tomography in adults – to the inventory from which hospitals can select to meet eCQM reporting requirements. Acute kidney injury is more common in Black hospitalized patients than non-Black patients, and research has shown a higher prevalence of pressure injuries in patients with darker skin tones, thus, by adopting these eCQMs, CMS believes the measures will help advance CMS’ health equity goals.
CMS is also finalizing modifications to three current measures. Both the Hybrid Hospital-Wide All-Cause Risk Standardized Mortality and Hybrid Hospital-Wide All-Cause Readmission measures are being modified to include Medicare Advantage admissions and the COVID-19 Vaccination Coverage among Healthcare Personnel is being updated to ensure reporting of the cumulative number of healthcare professionals who are up to date with recommended COVID-19 vaccinations to align with the Centers for Disease Control and Prevention’s definition of “up to date.”
Lastly, CMS is finalizing removing three measures – the Hospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty, Medicare Spending Per Beneficiary, and Elective Delivery Prior to 39 Weeks Gestation. The Elective Delivery Prior to 39 Weeks measure is being removed in part due to “topped out” data – or high and unvarying performance data, meaning that meaningful distinctions and improvements cannot be made. CMS hopes that removing this measure will provide opportunities for CMS to include additional maternal health outcome measures in the future. Additionally, CMS believes current maternal health measures, like maternal mortality structural measures, the Cesarean Birth eCQM, the Severe Obstetrics Complications eCQM, and the creation of the “Birthing-Friendly” hospital quality designation will continue to drive maternal health quality and care improvements.
MBQIP Updates
In addition to HCAHPS changes, healthcare organizations are experiencing changes to the MBQIP program. CMS announced that the two outpatient measures – OP-2 Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival and OP-3 Median Time to Transfer to Another Facility for Acute Coronary Intervention – that are currently part of MBQIP will be removed following the Q1 2023 data submission. Critical Access Hospitals (CAHs) were encouraged to continue to collect these measures through Q1 2023 encounters, however, starting with Q2 encounters, the measures no longer needed to be collected and the HQR platform no longer accepts data submission of these measures.
The removal of these measures allows CAHs to redirect their efforts towards measures that are more aligned with the types of care they deliver and enables them to better target their quality improvement initiatives and resources. Additionally, it streamlines data collection efforts, reducing administrative burden and allowing CAHs to refocus their resources on delivering high-quality care that aligns with the needs of their communities.
As healthcare continues to evolve, so must our approaches to measuring and improving quality. The changes to quality regulations reflect a commitment to patient-centered care and quality improvement. Healthcare organizations should embrace these changes as opportunities to enhance patient experiences, improve outcomes, and drive excellence in care delivery.