AAMC Comments on the Payment and Quality Proposals in the Proposed IPPS Rule for Fiscal Year 2022
The AAMC submitted comments on June 28 on the Centers for Medicare and Medicaid Services (CMS) Prospective Inpatient Payment System (IPPS) for fiscal year 2022 proposed rule. In addition to its comments on the payment and hospital quality provisions detailed below, the AAMC letter addressed several higher medical education proposals included in the rule that implements three articles of the Consolidated Appropriations Act, 2021 (sections 126, 127 and 131, PL 116-260), including the distribution of new Medicare-funded post-graduate medical education niches [refer to related story].
Below are the highlights of AAMC’s comments on the hospital quality and payment provisions in the proposed rule:
Provisions relating to hospital payments
- Data source for IPPS pricing for fiscal year 2022: CMS is seeking comments on whether the FY2019 or FY2020 data sources are the best available data to use for FY2022 pricing. The AAMC supports the use of the data fiscal year 2019 as a better overall approximation of the inpatient experience in fiscal year 2022 compared to fiscal year 2020 data impacted by COVID-19.
- Organ acquisition: CMS is proposing to revise and codify its Medicare Usable Organs Policy to count only organs transplanted in Medicare beneficiaries in its calculation of Medicare’s share of organ acquisition costs. The AAMC urges CMS not to finalize organ procurement proposals and instead engage all stakeholders to assess the impact of these proposed changes to ensure continued availability and access to rare organs .
- Disproportionate share of hospital payments and uncompensated care (UCP): CMS proposes to distribute approximately $ 7.6 billion in PCUs to hospitals disproportionately in FY2022 – a decrease of about $ 660 million from FY2021, largely due to the lower amount of Factor 1 (proposed at $ 10.573 billion for FY2022) in the UCP methodology. The AAMC requests that CMS provide clarification on how the Office of the Actuary determined the “other” factor included in the calculation of factor 1 so that stakeholders can adequately understand and assess the relevance to both the amount of Factor 1 and the considerably lower PCU pool proposed. for fiscal year 2022.
- Medicaid fraction: CMS is proposing to revise its regulations to explicitly state that a patient would only be included in the numerator of the Medicaid fraction if they are eligible for inpatient hospital services under an approved state Medicaid plan that includes coverage for inpatient hospital care that day or directly benefits that day from hospitalization insurance coverage under waiver 1115. The AAMC urges CMS not to finalize this proposal, which would exclude certain beneficiaries Medicaid receiving coverage under waiver 1115 of the hospital’s Medicaid fraction calculation.
- Wage index: CMS proposes to continue its policy of increasing the salary indices for low-wage hospitals and is also seeking comments on whether to continue to apply a transition to the salary index for fiscal year 2022 for hospitals adversely affected by adoption by the agency of redefinitions in OMB Bulletin 18-04. The AAMC supports the continuation of the low salary index policy and also recommends that CMS extend the transitional 5% ceiling in a budget neutral manner to all salary index changes for all hospitals for the FY2022. In addition, AAMC requests CMS to consider excluding salaries. data impacted by the COVID-19 public health emergency in future calculations of the salary index.
- Collection of Medicare Advantage Negotiated Rates: CMS is proposing to repeal the requirement for hospitals to report their Medicare costs, the median payer-specific negotiated fees that they have negotiated with all of its Medicare Advantage organizations, by groups related to Medicare severity diagnosis. The AAMC supports the repeal of this policy and asks CMS to finalize this proposal.
- Medicaid Enrollment for Medicare Enrolled Providers / Providers: CMS proposes to require Medicaid agencies to enroll Medicare-registered providers and providers in the Medicaid program to determine Medicaid cost-sharing responsibility for beneficiaries eligible for both Medicare and Medicaid. The AAMC supports this proposal and urges CMS to finalize it, as it would facilitate attempts by providers to determine a state’s Medicaid responsibility for cost-sharing of dual-eligible beneficiaries.
Provisions relating to hospital quality
- Request for Information – Closing the Health Equity Gap in CMS Hospital Quality Programs: CMS is asking for feedback on how to make social risk factor-based health disparity reporting more comprehensive and actionable for hospitals, clinicians and patients. The AAMC commends CMS for its efforts to inform future proposals to address inequalities in the outcomes of its hospital quality programs. CMS should take a thoughtful and thoughtful approach in working with stakeholders to improve data collection to better measure and analyze disparities in a way that builds an evidence-based, valid and reliable framework towards supplier accountability for health equity.
- Future stratification of quality measures by race and ethnicity: CMS seeks feedback on the potential future application of an algorithm to indirectly estimate race and ethnicity to support stratification of quality measures for hospital-level disparity reports, building on the reports current confidential disparities provided to hospitals for readmission measures using dual eligibility. The AAMC urges CMS not to use indirectly estimated race and ethnicity data due to concerns about the accuracy and actionability of such data. Instead, CMS should invest in data collection improvements that standardize and use data already collected by hospitals and encourage the communication and use of actionable data on social risk factors instead of using social risk factors. indirect estimates of race and ethnicity data to stratify measurement reports. Race and ethnicity in themselves are not risk factors, and reliance on unchanging characteristics on their own is not informative for the intervention.
- Improve the collection of demographic data: CMS is looking for feedback on how to improve data collection. The AAMC supports efforts to improve data collection and believes that CMS should pursue a policy supporting the collection of standardized information on multisectoral risks to support better stratification and adjustment of risks beyond data elements. demographic at the individual level. Data collection and systems for social risk factors at the individual and community level should be used together to better identify disparities in quality and equity and guide interventions for improvement.
- Potential creation of a hospital equity score: CMS is seeking feedback on the potential development of a similar hospital equity score (and built from) the recently developed Health Equity Summary Score for Medicare Advantage contracts and plans. The AAMC urges CMS to ensure that measurement of health equity includes and expands stratified clinical quality measures. CMS should assess the development of structural measures and processes that will promote improved health equity. The agency should also commit to expanding the social risk factors included in the measurement that build on advances in measurement science and expanded data collection on social risks.
- Adoption of measure suppression factors in pay-for-performance quality performance programs to address the impacts of the COVID-19 public health emergency: CMS proposes to adopt a policy of removing cross-program measures, based on four proposed removal factors, to address the impacts of the current COVID-19 public health emergency on the quality performance of hospitals. The AAMC supports this new policy and urges CMS to finalize the suppression factors as proposed in addition to committing to study the impact of their use. After further study, CMS is expected to adopt revised measures removal factors for wider applicability to a future national public health emergency.
- New metrics adopted for inpatient quality reporting (IQR) program: CMS proposes to adopt five new measures in the IQR program, including a new measure concerning COVID-19 vaccination among health workers. The AAMC urges CMS to implement a voluntary reporting period of at least one year to sufficiently address critical vaccine questions, such as timelines and supplies of potential boosters that impact the design of measures before making the declaration of hospitals compulsory.
- Potential report of a structural measure to assess the engagement of hospital leaders with health equity performance data: CMS is seeking feedback on the development of a new structural metric to assess engagement with health equity performance data. The AAMC believes that structural measures can be an appropriate first step towards a measure that promotes improvement. CMS should engage experts in the development of structural measures as a critical first step to assess current practice and encourage new evidence-based methodologies that advance collective health equity goals.
- Inquiry – Advancing Digital Quality Measurement: CMS is seeking comments on matters related to the agency’s goal of moving to digital quality measurements (dQM) by 2025, including a broad definition of dQM. AAMC requests CMS to further refine the definition of dQMs to focus first on valid and reliable digital data sources currently available and to define clear and specific parameters for what the agency hopes to achieve and what that it expects from hospitals in its objective of transitioning to dQMs in the near future.