Comments on the 2019 Outpatient Prospective Payment System

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September 24, 2018

Centers for Medicare and Medicaid Services
Department of Health and Human Services
ATTN: CMS-1695-P
P.O. Box 8013
Baltimore, MD 21244

Dear Administrator Verma,

The Society of Hospital Medicine (SHM), on behalf of the nation’s hospitalists, appreciates the opportunity to offer the following comments on the proposed rule entitled: Medicare Program, Proposed Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Requests for Information on Promoting Interoperability and Electronic Health Care Information, Price Transparency, and Leveraging Authority for the Competitive Acquisition Program for Part B Drugs and Biologicals for a Potential CMS Innovation Center Model (CMS-1695-P).

Hospitalists are front-line healthcare providers in America’s hospitals for millions of hospitalized patients each year, many of whom are Medicare and Medicaid beneficiaries. As leaders of an interdisciplinary care team, they manage the medical needs of their patients while working to enhance the performance of their hospitals and health systems. Although many hospitalists practice exclusively in the inpatient setting, there is a growing number who also practice in skilled nursing facility (SNF) and outpatient settings to more closely follow their patients.

The position of hospitalists within the healthcare system affords them a distinctive role in facilitating both the individual physician-level and systems- or hospital-level performance agendas. This includes participation and performance assessment in programs around value-based purchasing and quality improvement.

Proposed Updates to the HCAHPS Survey Measure (NQF #0166) for the FY 2024 Payment Determination and Subsequent Years

CMS proposes to remove the revised Communication About Pain questions from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This proposed change would be effective with patients discharged starting in January 2022. SHM fully supports removal of the Communication About Pain questions.

We appreciate that CMS recognizes how many external factors can influence performance on quality measures and quality programs, including how questions on pain and communication about pain may impose pressure (real or perceived) on hospital staff to prescribe opioids for pain management. It is our experience that HCAHPS scores are frequently disaggregated by hospitals and provider groups to form individual or group performance incentives, despite this not being the intended use of the survey. While patient experience is an important metric, great care must be taken to ensure unintended downstream effects are not occurring. Fear of patient dissatisfaction around pain and its resultant poor HCAHPS performance score may directly or indirectly influence prescribing practice and contribute to the ongoing opioid crisis.

The Communication About Pain questions were part of revision to the HCAHPS survey instrument effective with discharges starting in January 2018. CMS worked with stakeholders to better understand the nuances surrounding the original pain management questions on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and their potential impacts. We supported the revisions to the pain questions to focus on communication about pain, as we believed this would de-emphasize control of pain. However, even with these changes, we remained concerned about continued pressure on providers to perform on these metrics and the resulting unintended consequences.

We appreciate that CMS is taking seriously the concerns raised by us and other stakeholders about the real-world impact of their survey questions and that they are taking additional steps to respond to the perspectives and concerns of clinicians. We also appreciate the mindfulness in which CMS is proposing these changes and agree that this will be an important improvement for the HCAHPS survey overall.

Pain management is a complex aspect of inpatient medical care, with a broad range of interventions for the appropriate management of pain. Many such interventions are used instead of, or in conjunction with, prescribing opioids. Patients may see opioids as the highest level and most effective method of pain control, when other drugs or services may also be effective and lack many of the serious side effects and potential for addiction. The expectation from patients that pain must be minimized at all costs can exert pressure on the physician-patient relationship that is often expressed in responses on the HCAHPS survey instrument. Coupled with the widespread practice of hospitals and provider groups disaggregating HCAHPS scores to the individual level, this pressure can inadvertently push for prescribing the fastest, and what is perceived as the most effective, treatment for pain - opioids. We appreciate that CMS has recognized these factors in discussing the proposal to eliminate the three Communication About Pain questions.

CMS should work with stakeholders, including inpatient providers, on how to evaluate whether pain is being appropriately addressed in the inpatient setting and how to improve that care. This effort should focus on whether it is possible to develop alternatives to subjective survey questions. At this time, we do not believe that specific measures should be developed to capture facets of inpatient pain control. While we agree that pain management is important to patient care, each patient has a unique set of needs which differentiate their pain plan. A set of measures designed to be applied universally would downplay critical factors that are necessary to create individualized pain management plans. Patients experience and respond differently to pain for numerous reasons, including not all pain being of the same type or responsive to opioids and other pain treatments. As such, any pain questions or measures that are being considered should take these factors into account. SHM stands ready to work with CMS on how to improve pain plans and pain management in the inpatient setting.

CMS asks for input on whether it would be valuable to issue guidance suggesting that hospitals do not administer any surveys with pain-related questions, including adding hospital-specific supplemental items to HCAHPS. They also ask about the potential implementation of a third-party quality assurance program to assure that hospitals are not misusing survey data by creating pressure on individual clinicians to provide inappropriate clinical care. We agree that this would be a worthwhile endeavor and support CMS developing these resources. Our experience has shown that hospitals and provider groups are actively using the HCAHPS survey and supplemental items to assess the quality of care of individual clinicians and teams of clinicians. This includes using individual HCAHPS scores as part of an individual’s pay package, such as for bonus allocations. We recommend CMS consider issuing strong guidelines against disaggregation and other misuse of HCAHPS data, as we believe this is a source of opioid prescribing pressure. Dissemination of guidelines that clarify the proper use of the HCAHPS survey to both hospitals and providers could help stem this practice.

Request for Information on Promoting Interoperability/Electronic Healthcare Information Exchange and Request for Information on Price Transparency

SHM is supportive of efforts by CMS to encourage electronic health information exchange, interoperability and price transparency. The unique position of hospitalists in the healthcare system affords a distinctive perspective and systems-based approach to confronting and solving challenges at the individual provider and overall institutional level of the hospital.  As providers who practice within hospitals, hospitalists have been at the forefront of implementing and utilizing Electronic Health Records (EHRs). They have a wealth of experience of both the advantages of well-designed health information technology (HIT) initiatives, and the limitations found within current technology. We believe goals that include enhanced interoperability and health information exchange, coupled with better price transparency, are important tools for transforming the healthcare system and improving the quality and efficiency of patient care. SHM and the hospitalists we serve stand ready to contribute our expertise in these areas and to partner with CMS to move these important initiatives forward.

We appreciate CMS’ willingness to make changes to the HCAHPS survey and are ready to provide expert perspective or other assistance in improving pain management in the inpatient setting. If you have questions, or need to contact us for more information, please email Josh Boswell, Director of Government Relations at jboswell@hospitalmedicine.org.

Sincerely,

Nasim Afsar, MD, MBA, SFHM
President, Society of Hospital Medicine