The Weekly Quality Brief: Hybrid Measure Reports, ISCM-R Reporting Timelines, and CJRX Model Questions (6/4/24)

The Weekly Quality Brief

• 38 min

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This episode covers questions related to newly released CMS reports, measure reporting timelines, the ISCM-R measure, and the proposed CMS Innovation Center's Comprehensive Joint Replacement (CJRX) model. CMS Reports & Public Reporting Availability of spring Hybrid Hospital-Specific Reports through the HQR portal Release of readmission, mortality, EDAC, THA/TKA complication, and THA/TKA PRO-PM reports Access to preoperative patient-reported outcome (PRO) data for THA/TKA participants Timing of Care Compare refreshes and preview periods Discussion of upcoming claims-based measure releases and reporting schedules Information Transfer PRO-PM Minimum survey completion requirements for the Information Transfer PRO-PM CMS guidance regarding administration of the survey to all eligible patients Definition of a completed survey Random sampling requirements and submission expectations when the minimum survey threshold is not met Mortality & EDAC Measure Modifications Review of CMS proposals to add Medicare Advantage patients to mortality and EDAC measures Timeline for implementation across the Hospital IQR and Hospital Value-Based Purchasing programs Expected measurement periods, preview reports, and public reporting dates Introduction of the proposed Diabetes EDAC measure Explanation of how measure modifications flow from public reporting into payment programs Hospital Value-Based Purchasing Updates Timeline for incorporating modified mortality and EDAC measures into Hospital Value-Based Purchasing Future inclusion of HCAHPS Care Transition and Responsiveness of Hospital Staff measures Updates to HAI baselines and future program scoring changes Review of preview reports, baseline reports, and payment adjustment timelines ISCM-R (Formerly Failure to Rescue) Clarification of the transition from PSI-4 to Failure to Rescue and now ISCM-R CMS documentation and specification naming inconsistencies Expected timing for Hospital-Specific Reports (HSRs) Public reporting timelines and measurement periods Programs impacted by ISCM-R, including Hospital IQR, Hospital Star Ratings, and Leapfrog Safety Grades Measure Prioritization & Program Alignment Discussion of approaches for evaluating measures across multiple quality programs Examples of measures that affect public reporting, Star Ratings, Leapfrog, HAC Reduction Program, and Hospital Value-Based Purchasing Considerations for prioritizing improvement efforts based on program overlap CJRX Proposed Model Questions regarding hospital points of contact and distribution of model files CMS listserv enrollment and future communication processes Explanation of CJRX target price methodology, including: Regional benchmark pricing Prospective trend factors Risk adjustment multipliers Normalization factors Discount factors Relationship between CJRX episodes and THA/TKA PRO-PM quality measure populations Discussion of patients receiving multiple joint replacements within a 90-day episode window Collaboration agreements with post-acute care providers and gainsharing arrangements Availability of beneficiary-level claims data, including post-acute care services Eligibility considerations for hospitals participating in the Rural Community Hospital Demonstration, Critical Access Hospital program, and Rural Emergency Hospital program Explanation of how quality scores affect CJRX reconciliation payments for both underspending and overspending scenarios Upcoming Topics Planned discussion of ECAT measures and Leapfrog’s Emergency Department measures Review of Jira tickets and submission processes during a future session