With two federal initiatives to measure ambulatory surgery center quality expected in the next few years, the outlines of those programs may come into focus this year as rulemaking gets under way, according to David Shapiro, MD, chairman of the Ambulatory Surgery Center Association.
CMS is expected to issue proposed rules for an ASC quality reporting initiative this summer. The agency has long had authority to review ASC quality but has been holding off, Dr. Shapiro says. But in its rule-making process for ASCs issued last year, "CMS telegraphed its intentions to consider quality data reporting in the proposed final rule this year," he says.
The CMS initiative, expected to start in 2012, would most likely involve a pay-for-reporting system in which ASCs would keep their full reimbursement if they met reporting requirements, he says.
The other ASC quality initiative would be part of HHS' planned value-based purchasing system for hospitals, ASCs and other healthcare facilities. The program, mandated by the healthcare reform law, would pay providers for performance on quality measures.
A proposed rule for the program was expected in January but still hasn't been issued and is now expected in May, Dr. Shapiro says. Actual federal reporting by ASCs could still be years away, he says. Without any proposed rules out yet, "we're in a holding pattern," he says. The programs still lack specifics on how they would function.
The government has given no indication on how measures would be reported. Dr. Shapiro says there are many ways to do it, such as through chart abstraction or an electronic registry, but he thinks claims submission is the most likely. This would probably involve expanding the amount of information required in each claims submission, he says.
Initiatives may eventually merge
The prospect of two separate federal quality-reporting programs for surgery centers perplexes many ASC operators. "When I go out in the field, people are often confused about two programs," Dr. Shapiro reports. Since the two initiatives are so similar, he expects they may eventually merge into one program. But for several years, at least, ASCs will probably have to deal with two separate initiatives, he says.
One or both of the federal quality initiatives may include patient satisfaction data, which is already collected from hospitals through the Hospital Consumer Assessment of Healthcare Providers and Systems.
So far, HCAHPS reporting has not been required from ASCs, but Dr. Shapiro is looking forward to federal patient satisfaction data for ASCs. "We think quality and patient satisfaction are very important," Dr. Shapiro says.
Concerns about the rule-making process
Despite a few concerns about the rule-making process, the ASC industry is eager to be measured for quality. "We have a great story to tell on infection rates," Dr. Shapiro says. "ASCs on the whole have had a very, very low incidence of healthcare-acquired infections and surgical site infections."
ASC leaders have been advising CMS and HHS officials on how to undertake quality reporting for some time now. "We have submitted letters and comments on this and provided input to assist both agencies," Dr. Shapiro says.
For example, the ASC industry has asked CMS to make sure reporting requirements do not significantly increase administrative and management burdens for ASCs, particularly smaller facilities. "I reminded CMS that most ASCs are small," he says. In many of these facilities, for example, the administrator does double-duty in the OR and doesn't have a great deal of time to collect statistics.
Dr. Shapiro says ASCs need their own set of federal quality standards. Centers are eager to compare their data to the very same metrics at hospitals, but they do not want to report standards that are only applicable to hospitals, such as monitoring catheter-associated urinary tract and central line infections, he says.
In patient satisfaction metrics, as well, "we want ASC-appropriate HCAHPS," he says. "We want a customized instrument." For example, asking patients to comment on the quality of meal services or interactions with patients in prolonged stays is applicable to hospitals but would not be applicable to ASCs, he says. On the other hand, "we do want to be involved in measures like communication," he says. "The point is that the ASC process needs to be tailored to ASCs."
Voluntary reporting is a good way to get ready
The ASC industry has set up its own voluntary quality reporting system that, in addition to helping centers improve operations, is good practice for the upcoming federal programs.
The ASC Association's Outcomes Monitoring Project is a voluntary program that involves more than 700 participating ASCs. In addition to quality metrics, the project's database includes demographic and financial statistics.
The quality portion includes metrics from the ASC Quality Collaboration, which was formed by ASC organizations in 2006. The collaboration uses measures endorsed by the National Quality Foundation. The metrics are rates of patient falls, burns, hospital transfer or admission, surgical site hair removal, appropriate antibiotic timing and situations involving wrong site, side, patient, procedure or implant.
The collaboration has a bigger budget this year and is expanding the scope of its activities, Dr. Shapiro says. Since the current measures carry a time-limited endorsement from NQF, the foundation is planning to reexamine the measures probably some time this year.
The collaboration has engaged a statistician to help with the NQF review process, Dr. Shapiro says. "We're in the midst of getting ready to re-submit two of our measures," he says. "We are also piloting and developing other measures."
Other quality benchmarking sources
In addition to participating in the Outcomes Monitoring Project, ASCs can prepare for the federal quality measures by comparing their own performance against outside benchmarks.
Dr. Shapiro lists the following sources for monitoring and benchmarking:
1. Data complied by ASC associations in California, Ohio, Texas and other states. Each association has different reporting requirements.
2. States that track quality data. For example, Florida offers benchmarking data for the whole state, which an individual ASCs can compare to its own outcomes.
3. Outcomes monitoring through private companies.
4. Proprietary benchmarking from each ASC management company for its own affiliated ASCs.
Quality reporting is an "evolving issue," Dr. Shapiro says. ASCs will have more information once the proposed rules come out for the federal programs. "Right now," he says, "we're waiting for the other shoe to drop."
Learn more about the Ambulatory Surgery Center Association.
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