"The hospital inpatient measures [for SCIP], for example, are very procedure-specific and relate to post-op care administered in inpatient units. We're trying to stay away from that," says David Shapiro, MD, co-chair of the ASC Quality Collaboration. "The ASC Quality Collaboration has tried to select things we can use for all admitted patients, and the measures we put up through the National Quality Forum reflect that. They are relatively straightforward, covering a small set of data that will help ASCs drive patient care."
The ASC Quality Collaboration, a group of ASC leaders, organizations and associations dedicated to advancing high-quality, physician-led and patient-centered care in ASCs, sent 10 measures up to the National Quality Forum, a not-for-profit membership organization created to develop and implement a national strategy for healthcare quality measurement and reporting. With an end goal of enhancing the ability of ASCs to report healthcare outcomes and processes in a standardized manner, the NQF has endorsed five of the measures:
1. patient burn;
2. prophylactic intravenous antibiotic timing;
3. patient fall within the ASC;
4. wrong-site, wrong-side, wrong-patient, wrong-procedure, wrong-implant surgery; and
5. hospital transfer/admission.
A sixth measure, appropriate hair removal at the operative site, is in the NQF approval process, says Dr. Shapiro. CMS generally takes the NQF's endorsements seriously. Dr. Shapiro and others from the ASC Quality Collaboration, as well as from the NQF, recently met with CMS to discuss the proposed quality reporting measures and the practical issues raised by reporting.
"It was a great conversation and it's always great to have a face-to-face meeting, but very much one-way in terms of their receiving information and asking questions of us," he says. "We presented the case to them in terms of the capabilities of ASCs and the amount of work that will be required by us to fulfill this mandate. We wanted CMS to understand that while some ASCs are several thousand square feet, multi-specialty, performing invasive and intensive procedures, and outfitted with the latest software and IT technology, many ASCs are small, one-OR facilities. In terms of structure and administrative support, they're much more like a physician office ? quality is something a nurse is doing in her spare time, not a department with its own e-mail and phone extension, ready to do sophisticated data extraction."
The hope is that, while the data collection and reporting will inherently involve some work on the part of ASCs, CMS will develop a reporting mechanism that will not impose an undue burden, says Dr. Shapiro.
In addition to requiring a quality measure reporting system for ASCs in 2009, the Tax Relief and Health Care Act of 2006 also imposes a penalty for any ASC that fails to submit the required data. The penalty is a 2 percent reduction of future annual Medicare ASC payment updates.
"This is a bit unfortunate because, rather than reward for reporting, it punishes for not reporting," says Dr. Shapiro. "In terms of pay for performance, private payors are probably watching what happens in this regard as it relates to their own reporting requirements."
How the penalty would be applied in light of the current federal budget-balancing efforts remains to be outlined.
"Since we're in a freeze through the end of 2009 and the president's budget has proposed to extend that freeze, which would mean ASCs won't get a payment update," he says. "But 2 percent of a 0 percent update is still zero, so it seems to me that this would not be factored into reimbursement until we come out of the freeze. I would hope that this would be addressed at least in the proposed rule this summer, so that people can submit public comment."
CMS is expected to issue its proposals for the quality measure reporting system sometime this summer, and to finalize those proposals in November. Beyond that, however, CMS has given no indication of what it will decide.
"I was hoping to get some kind of tilt of the head or wink of the eye, but CMS keeps everything very close to the vest," says Dr. Shapiro. "If you use the hospital measures as an indicator, I would guess CMS will use the measures the NQF has provided through its endorsement process ? though CMS can use all or none or some combination of those measures and others ? and will add measures as the years go along. [Hospital reporting] has evolved over time to drive and improve patient care."
And that's the upshot: Overall, reporting will be good for the ASC industry because it will help prove that ASCs are providing quality care, and it's certain to improve some aspects of patient care. The fact is, there has long been a paucity of literature on ASC performance and outcomes, and implementing whatever measures come out of CMS will will provide a better understanding of these performance and outcomes. Further, the use of common definitions will allow for standardized reporting of this information on a nationwide basis ? this kind of cohesion is important and has been lacking.
"We have got to be proactive," says Dr. Shapiro. "Implementation won't necessarily go smoothly, but in the end it's a good thing. It will give us even more legitimacy when we talk to legislators, regulators or the press about what we're doing; it will prove and demonstrate our commitment. It's easy to get caught up worrying about all the details of what to report, how to track, how to report, and lose sight of the purpose. And that's improving patient care, which is what we all want."
The ASC Quality Collaboration has developed a guide that details the impending economic importance of beginning to collect, standardize and report on quality information. It is available at www.ASCQuality.org.