Over the last two weeks, we have brought you highlights from the 2024 Inpatient Prospective Payment System (IPPS) Proposed Rule (PR) published last month by the Centers for Medicare and Medicaid Services (CMS). Today’s article will focus on the incentive programs applicable to hospital inpatient services that are being proposed for the 2024 fiscal year (FY).

Hospital Inpatient Quality Reporting Program

The Hospital Inpatient Quality Reporting (IQR) Program involves a pay-for-reporting concept relative to Medicare cases in the inpatient setting. Hospitals that do not submit quality measure data or fail to meet all Hospital IQR Program requirements are subject to a one-fourth reduction in their Annual Payment Update (APU) under the IPPS.

In the 2024 PR, CMS is proposing to adopt three new quality measures, remove three existing quality measures, and modify three current quality measures. Two changes to current policies related to data submission, reporting, and validation are also being proposed. Here are the specifics:

New Measures

• Hospital Harm — Pressure Injury eCQM, with inclusion in the eCQM measure set beginning with the CY 2025 reporting period/FY 2027 payment determination.
• Hospital Harm — Acute Kidney Injury eCQM, with inclusion in the eCQM measure set beginning with the CY 2025 reporting period/FY 2027 payment determination.
• Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Hospital Level — Inpatient) eCQM, with inclusion in the eCQM measure set beginning with the CY 2025 reporting period/FY 2027 payment determination.

Modified Measures

• Hybrid hospital-wide all-cause risk standardized mortality measure beginning with the FY 2027 payment determination. CMS is proposing to modify this measure to include Medicare Advantage (MA) admissions.
• Hybrid hospital-wide all-cause readmission measure beginning with the FY 2027 payment determination. CMS is proposing to modify this measure to include MA admissions.
• COVID-19 Vaccination among Healthcare Personnel (HCP) measure, beginning with the Quarter 4 CY 2023 reporting period/FY 2025 payment determination. The proposed measure update would report the cumulative number of HCP who are up to date with recommended COVID-19 vaccinations.

Deleted Measures

• Hospital-level risk-standardized complication rate following elective primary total hip arthroplasty and/or total knee arthroplasty measure beginning with the FY 2030 payment determination.
• Medicare spending per beneficiary (MSPB) hospital measure beginning with the FY 2028 payment determination.
• Elective delivery prior to 39 completed weeks’ gestation: Percentage of babies electively delivered prior to 39 completed weeks’ gestation measure (also known as PC-01) beginning with the CY 2024 reporting period/FY 2026 payment determination.

Medicare Promoting Interoperability Program

The 2024 PR contains the following changes to the Medicare Promoting Interoperability Program for eligible hospitals and critical access hospitals (CAHs):

• Modify requirements for the Safety Assurance Factors for EHR Resilience (SAFER) Guides measure to require eligible hospitals and CAHs to attest “yes” to having conducted an annual self-assessment of all nine SAFER Guides at any point during the calendar year in which the EHR reporting period occurs, beginning with the EHR reporting period in CY 2024, in order to satisfy the definition of a meaningful EHR user under 42 CFR 495.4.
• Amend the definition of “EHR reporting period for a payment adjustment year” for participating eligible hospitals and CAHs to define the EHR reporting period in CY 2025 as a minimum of any continuous 180-day period within CY 2025.
• Amend the definition of “EHR reporting period for a payment adjustment year,” for eligible hospitals that have not successfully demonstrated meaningful EHR use in a prior year, to remove the requirement to attest to meaningful use by October 1st of the year prior to the payment adjustment year, beginning with the EHR reporting period in CY 2025.    
• Modify the response options related to unique patients or actions, for objectives and measures for the Medicare Promoting Interoperability Program, for which there is no numerator and denominator, and for which unique patients or actions are not counted. The response option would read “N/A (measure is Yes/No).”
• Adopt three new eCQMs for eligible hospitals and CAHs to select as one of their three self-selected eCQMs, in alignment with the Hospital IQR Program, beginning with the CY 2025 reporting period:
  • Hospital Harm — Pressure Injury eCQM;
  • Hospital Harm — Acute Kidney Injury eCQM; and
  • Excessive Radiation Dose or Inadequate Image Quality for Diagnostic CT in Adults (Hospital Level — Inpatient) eCQM.

PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program

The PCHQR Program is a quality reporting program for the eleven cancer hospitals that are statutorily exempt from the IPPS. CMS collects and publishes data from PCHs on applicable quality measures. In the FY 2024 IPPS/LTCH PPS proposed rule, CMS is proposing the following:

• Begin public display of the Surgical Treatment Complications for Localized Prostate Cancer measure beginning with data from the FY 2025 program year.
• Adopt four new measures for the PCHQR Program:
  • Facility Commitment to Health Equity beginning with the FY 2026 program year.
  • Screening for Social Drivers of Health beginning with voluntary reporting in the FY 2026 program year and mandatory reporting in the FY 2027 program year.
  • Screen Positive Rate for Social Drivers of Health beginning with voluntary reporting in the FY 2026 program year and mandatory reporting in the FY 2027 program year.
  • Documentation of Goals of Care Discussions Among Cancer Patients beginning with the FY 2026 program year.
• Modify the COVID-19 Vaccination among HCP measure, in alignment with the Hospital IQR Program and LTCH QRP.
• Modify the data submission and reporting requirements for the HCAHPS survey measure, beginning with the FY 2027 program year.

Again, if you wish to see the fact sheet published by CMS that summarizes the 2024 IPPS PR, please go to FY 2024 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) Proposed Rule – CMS-1785-P | CMS.

With best wishes,

Chris Martin
Senior Vice President—BPO