In its March 8 comment letter to the CMS, the Association of American Medical Colleges called the proposed HCAHPS weighting “inappropriately high,” particularly because recent research has shown that a sicker patient population may translate into lower satisfaction scores.
Jennifer Faerberg, the AAMC's director of healthcare affairs, said the organization strongly supports the inclusion of HCAHPS measures in the government's value-based purchasing program. But she cautioned that 30% was too high until the measures could be studied further.
“Until some of those biases can be looked at and addressed, weighting for HCAHPS should be a much smaller percentage of overall score,” Faerberg said.
Another worry cited by many groups is the proposed addition of eight hospital-acquired conditions to the program in fiscal 2014. They include air embolisms, late-stage pressure ulcers and blood incompatibility.
Adding hospital-acquired conditions opens the door for multiple penalties incurred for the same incident, groups say. That's because there is already a nonpayment policy for the hospital-acquired conditions in place, and the Patient Protection and Affordable Care Act mandates a penalty of 1% of Medicare payments, beginning in 2015, for hospitals with the highest rates of these conditions.
“Of course we never want anything like this to happen to patients,” Chip Kahn, president of the Federation of American Hospitals, said of the hospital-acquired conditions. “But we have a policy overlap,” Kahn said, because the reform law “has a very punitive policy for this coming down the line already.”
In its letter to the CMS, the FAH pushed for complete transparency in terms of dollar flow, Kahn said. The program is set up to be budget-neutral, meaning all of the money collected will be rewarded back to the highest performers, he said.
Also, Kahn expressed concern about the proposed rule's benchmarks and thresholds, which he said are set too high for the first year. The CMS proposed setting the achievement threshold at the national median for each measure and the benchmark at the average hospital performance within the top decile.
“We think it's important for everyone to feel confident going in to the first year,” Kahn said. “You can always raise benchmarks and thresholds, but once you start the process, it's very hard to reel them back.”
Premier, a Charlotte, N.C.-based quality-improvement and group purchasing organization, echoed the FAH's and AAMC's concerns in its March 2 comment letter. Premier also urged the CMS to convene an expert panel to address the need to more effectively risk-adjust measures.
“We believe that an adjustment methodology should consider demographic factors such as age, sex, race and severity of illness, as well as the type of services being provided,” Premier said in the letter.
Despite their reservations, most groups said their suggestions were only tweaks to what is generally a very good start.
“CMS has been a very good collaborative partner throughout this whole process,” the AAMC's Faerberg said. “They have really reached out to us and to the hospital community. We're optimistic that they will recognize that we are supportive of the program, but that we want it to be the best it can be.”
The final rule is expected this year.