Large employer coalitions and consumer advocates are angrily pushing back against a Centers for Medicare & Medicaid Services (CMS) proposed rule to suppress public reporting of key measures of preventable hospital-caused harms, such as pressure ulcers or falls resulting in hip fractures.
If the rule is finalized, CMS would not calculate scores under the Hospital-Acquired Condition Reduction Program (HACRP). Hospitals would still report on some safety measures, but certain scores — in particular those for the 10-measure Patient Safety and Adverse Events Composite (PSI 90), a key component of the HACRP — would be hidden from public data files and would not appear on the CMS Hospital Compare website.
Furthermore, CMS would not dock hospitals in the worst-performing quartile 1% of their Medicare reimbursement, as it usually does, and would end up paying these hospitals what would normally be withheld — an estimated $350 million — an amount that would be lost to the Medicare trust fund.
The agency gave several reasons — all related to COVID-19 — why hospitals need to be let off the hook, including wide variation in performance scores; unprecedented changes in clinical guidelines, treatments, and drugs; and rapid changes in what clinicians understand about a pathogen of unknown origin. In particular, they noted huge shortages of healthcare personnel and high rates of burnout, specifically among nurses, which could affect a variety of measures, such as infection rates and avoidable falls.
CMS began suppressing some measures at the beginning of the pandemic in 2020, and many assumed that would be the end of it.
‘Outrageous’ and ‘Ludicrous’
The CMS proposal “is outrageous,” Bill Kramer, executive director for health policy at the Purchaser Business Group on Health, told MedPage Today.
“Patients will be unable to know whether the provider they want to go to has more patient safety problems, more risky providers, so clinicians as well as purchasers and policymakers will be unable to identify and help patients choose those hospitals with the best patient safety record,” he said. Without that information, patients are more likely to suffer from avoidable accidents, “and some of them will die as a result.”
James Gelfand, executive vice president of public affairs for the ERISA Industry Committee, a trade association representing about 100 of the nation’s largest self-insured employers who purchase health benefits for their employees and families, called the CMS proposed rule “ludicrous.”
“Essentially what they’re saying is that patients got treated badly, so they’re going to report badly, and so the hospitals are going to score badly. And, therefore, we have to keep the data secret,” he said.
“The federal government has data that would be really useful in making decisions about plan design and decisions about whether to steer people to a particular hospital or health system, but they’re not going to give it to you because it’s bad for the hospitals? I can’t express to you how alarming that is,” he noted.
Leah Binder, president and CEO of the Leapfrog Group, which uses the CMS data to score hospitals with safety grades from A to F, told MedPage Today that she worries that not only will this proposed rule be finalized, but that CMS will extend the suppressed public reporting indefinitely, because they don’t want “to make hospitals unhappy with them.”
“The American public trusts hospitals to deliver care, and not to cause them to suffer unnecessarily,” she said. “As a hospital or as a hospital worker, you have a job that’s difficult, that requires you to keep your patients safe.”
“It scares me,” she continued. “I know enough to be frightened … if hospitals are not able to manage their operations in order to protect their patients.”
However, a spokesman for the American Hospital Association told MedPage Today, “we agree with the agency that it would be unfair to base hospital performance on data that have been distorted by the pandemic.”
“To the best of our knowledge, the current methodologies for most quality report cards that use CMS quality measurement program data are based on individual measures, and not the overall scores from the HACRP and Hospital Value-Based Purchasing program,” the spokesman wrote in an email.
The PSI 90 score measures in-hospital serious and potentially fatal pressure ulcers, falls resulting in hip fracture, and several preventable postoperative complications, such as sepsis, respiratory failure, and hemorrhage. CMS proposed to suppress individual metrics for each, meaning that consumers would not be able to compare, for example, an individual facility’s postoperative pulmonary embolism rates or perioperative hemorrhage rates.
Binder pointed to a February 17 Perspective in the New England Journal of Medicine, authored by CMS and CDC officials, which showed that after years of quality improvement on a variety of safety measures, infections and other complications soared during the pandemic, completely reversing the progress that had been made.
For example, central line-associated bloodstream infections decreased 31% in the 5 years before the pandemic, a trend “totally reversed by a 28% increase in the second quarter of 2020,” the authors wrote. Increases were also reported in catheter-associated urinary tract infections, ventilator-associated events, and methicillin-resistant Staphylococcus aureus bacteremia.
These are some of the very measures whose scores will no longer be available to the public under the agency’s proposed rule, Binder pointed out.
Kramer said that PSI 90 scores are also used by insurers and employers to identify preferred provider networks and to monitor quality of care, so they can let employees know if there’s a problem with a particular hospital or system.
Nurse burnout and personnel shortages could negatively affect the way patients respond to CMS-required Hospital Consumer Assessment of Healthcare Providers and Systems surveys on how they perceived the quality of their care, which CMS proposed to suppress because of hardships during the pandemic.
Because patient volumes and personnel shortages affected facilities’ rates of adverse events, the agency noted that they are “concerned … that we will not be able to score hospitals fairly or reliably for national comparison and payment adjustment purposes.”
However, Binder said that she is adamant that hospitals with poor quality scores should not be given a pass on accountability.
“If hospitals had a problem — that they didn’t have enough staff or had a high rate of problems with patient safety, that they were killing some patients — that needs to be made public and people need to know and be able to choose to not go to a hospital that’s under this kind of stress and is not safe,” she noted.
Gelfand and Binder said they understand that hospitals had staffing problems during the pandemic, and that in some facilities, a shortage of staff physically capable of assisting patients may have meant a higher number of complications, such as preventable falls.
“But when I judge a hospital, one of the things I judge them for is, are they able to roll with the punches,” said Gelfand. “And when I hear things like, ‘well, we dropped people because we made decisions about staffing,’ what I’m hearing is that they’re not capable of making decisions and planning to provide a safe environment.”
The proposed rule is also worrisome because it assumes that this pandemic is unique, and that hospitals won’t ever have to face such extreme circumstances again, he noted.
“As much as we would like to think that this is the only pandemic that we’re ever going to experience, that’s just not very likely. If the facts of the matter are that certain systems aren’t up to it, not able to keep people safe during a pandemic, we need to know that and they don’t have the right to keep that secret,” he said.