THE SOCIETY OF THORACIC SURGEONS 20 F STREET NW, SUITE 310 C WASHINGTON, DC 20001-6704 Phone: 202.787.1230 Fax: 202.480.1227 E-mail: [email protected] Web: http://www.sts.org

June 20, 2011 Donald M. Berwick, MD, MPP Administrator Centers for Medicare and Medicaid Services Department of Health and Human Services Hubert H. Humphrey Building – Room 445G 200 Independence Avenue SW Washington, DC 20201 RE: CMS-1518-P: Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2012 Rates Dear Administrator Berwick: On behalf of The Society of Thoracic Surgeons (STS), the largest organization representing cardiothoracic surgeons in the United States and the world, I am writing to provide comments on the FY 2012 Hospital Inpatient Prospective Payment System (IPPS) proposed rule. STS represents surgeons who are dedicated to ensuring the best possible outcomes for surgeries of the heart, lung, and esophagus, as well as other surgical procedures within the chest. As the largest specialty society representing cardiothoracic surgeons, we know that the vast majority of these lifesaving cardiothoracic procedures take place in a hospital setting. Therefore, the proposed changes in hospital payment, quality measurement, and other areas of policy could have profound effects on the way cardiothoracic surgeons deliver care to their patients. As you know, STS has a wealth of experience in measuring and improving the quality of care, and is now looking for ways to reduce costs to the Medicare program through quality improvement. We appreciate the opportunity to share our comments. Specifically, STS would like to provide comments in the following areas: • • • • •

Proposed FY 2012 MS-DRG Documentation and Coding Adjustment Preventable Hospital-Acquired Conditions (HACs), Including Infections Proposed Changes to Specific MS-DRG Classifications Hospital Inpatient Quality Reporting Program Indirect Medical Education (IME) Adjustment

June 20, 2011 Administrator Berwick Page 2 Comments Section II. D. Proposed FY 2012 MS-DRG Documentation and Coding Adjustment CMS is required by statute to apply a documentation and coding adjustment in the calculation for the hospital case mix index (CMI). Concerns have been raised over the methodology CMS has used for determining the effect of documentation and coding change on CMI in previous years. Specifically, the CMS methodology has been criticized for failing to separate documentation and coding effects from true case mix change. The criticism is based on an expert assessment that concludes that the methodology employed by CMS using claims data alone cannot separate documentation and coding effects from true case mix change. STS agrees and urges CMS to use clinical data to distinguish documentation and coding changes from real case-mix changes. Such an analysis is the best way to distinguish documentation and coding from real case-mix change and lower the documentation and coding adjustment. STS has previously urged CMS to recognize registry based reporting and mandate participation in a systematic database for cardiac surgery utilizing risk adjusted clinical data in formulating hospital payment policy. STS believes that it can assist in helping to determine a true case mix based on clinical data that is collected by the STS National Database (Database). We envision identifying patient data in the Database that match to the DRG. We welcome the opportunity to assist CMS to develop an improved methodology in determining real case mix change to calculate hospital CMI. Section II. F. Preventable Hospital-Acquired Conditions (HACs), Including Infections Since October 1, 2008, an inpatient hospital discharge is not assigned to a higher paying Medicare Severity Diagnosis-Related Group (MS-DRG) if a selected hospital-acquired condition (HAC) were not present on admission (POA). That is, the case will be paid as though the secondary diagnosis was not present. The selected HACs are among those that CMS determines: (1) are high cost, high volume, or both; (2) would result in the assignment of a case to a DRG that was a higher payment when present as a secondary diagnosis; and (3) could reasonably have been prevented through the application of evidencebased guidelines. STS is intent on helping to reduce avoidable health care complications and conditions in cardiothoracic surgery, and has spent many years of data collection and participant feedback working toward this goal. STS has articulated in previous comments to CMS that any payment methodology aimed at addressing avoidable complications that otherwise would qualify a hospital or other health care provider for higher reimbursement should include a risk adjustment component. As such, STS is concerned with the manner in which the current HAC payment policy has been implemented and how it will be incorporated into the Hospital Value Based Purchasing Program (VBP). First, STS does not believe that punitive payment mechanisms alone are the most appropriate or effective methods to reduce complications. Rather, the best way to reduce hospital or health careacquired conditions is through measurement, feedback, and focused systems efforts at improvement. Second, STS believes that any payment methodology associated with hospital or health care-acquired conditions should include risk adjustment. The lack of risk adjustment combined with a punitivepayment approach may lead to adverse consequences, including coding changes, a dramatic increase of POA coded conditions, or worse, jeopardized access to care for patients who are most likely to have or

June 20, 2011 Administrator Berwick Page 3 acquire these complications. Toward this end, STS supports implementation of Sec. 3008 of the Affordable Care Act, which modifies the current HAC payment policy by requiring the Secretary of HHS to employ an appropriate risk adjustment methodology so that hospitals are not unfairly punished for health care-acquired conditions that are not always avoidable. Section II. G. Proposed Changes to Specific MS-DRG Classifications 4b. MDC 5 (Diseases and Disorders of the Circulatory System); Aneurysm Repair Procedure Codes STS supports the proposed reclassification of thoracic aortic repair procedures 38.45 and 39.73 to Medical Severity Diagnostic Relative System (MS-DRGs) 216-221. STS feels that this reclassification will result in accurate reimbursement to hospitals for utilization of resources related to these procedures and will positively benefit patients. 13. Changes to the ICD-9-CM Coding System, Including Discussion of the Replacement of the ICD-9CM Coding System with the ICD-10-CM and ICD-10-PCS Systems in FY 2014 The International Classification of Diseases, 10th Revision (ICD-10) coding system applicable to hospital inpatient services will be implemented on October 1, 2013. The ICD-10 coding system includes the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) for diagnosis coding and the International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) for inpatient hospital procedure coding, as well as the Official ICD-10-CM and ICD-10-PCS Guidelines for Coding and Reporting. In the January 16, 2009 ICD-10-CM and ICD-10PCS final rule, there was a discussion of the need for a partial or total freeze in the annual updates to ICD-9-CM, ICD-10-CM and ICD-10-PCS codes. After multiple meetings, CMS announced at the September 15–16, 2010 ICD-9-CM Coordination and Maintenance Committee meeting that a partial freeze of both ICD-9-CM and ICD-10 codes would be implemented as follows: Date October 1, 2011

Activity Last regular, annual update to both ICD-9-CM and ICD-10.

October 1, 2012

Limited code updates to both the ICD-9-CM and ICD-10 coding systems to capture new technologies and new diseases.

October 1, 2013

No updates to ICD-9-CM, as the system will no longer be a HIPAA standard. There will only be limited code updates to ICD-10 code sets to capture new technology and new diseases.

October 1, 2014

Regular updates to ICD-10 will begin.

STS supports the implementation of the partial code freeze. We agree with CMS that there is a need to allow providers time to prepare for the implementation of ICD-10 and the accompanying system and product updates. The transition to ICD-10 will be quite costly to providers, and it comes at a time of tight budgets for health care entities. Accordingly, we support the limited freeze described above.

June 20, 2011 Administrator Berwick Page 4 Section IV. A. Hospital Inpatient Quality Reporting Program Under the Hospital Inpatient Quality Reporting (IQR) program (formerly referred to as the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program), hospitals must meet the requirements for reporting specific quality information to receive the full market basket update for that year, and hospitals that do not meet the requirements will receive a two percentage point reduction in that year’s inpatient hospital payment update factor. 3c. Proposed Hospital IQR Program Quality Measures for the FY 2015 Payment Determination In the proposed rule, CMS asserts that hospitals will be able to switch to electronic health record (EHR)based submission of chart abstracted and other measures submitted for the IQR program by 2015. STS would caution against any policy that would deliberately or inadvertently allow data collection via EHR to preempt participation in a clinical registry. The proposed rule states that CMS intends to establish an EHR system that will be able to automatically collect and report data, streamlining reporting for various CMS quality reporting programs. Further, CMS expects that, by 2015, hospitals will be able to switch solely to EHR-based reporting of data that are currently manually chart-abstracted and submitted to CMS for the Hospital IQR program. CMS also states that future goals for the IQR program include “seeking to use measures based on alternative sources of data that do not require chart abstraction or utilize data already being reported by many hospitals, such as data that hospitals report to clinical data registries.” STS is concerned that, without complete interoperability of clinical registry reporting across all EHR systems, our health system could lose the benefit of our hard-won and potential future gains in the provision of quality health care. Collection of data according to the specifications of national clinical registries like the Database ensures comparable, valid data from all data sources. Allowing EHR to preempt clinical registries means relying on private industry to keep pace with the current clinical practice and clinical guidelines. A registry is designed to be considerably more responsive to cutting-edge medicine and changing clinical standards. Further, EHR vendors cannot provide representative regional and national benchmarking of care. Reliance on their technologies would effectively limit the scope and utility of the data collected nationwide. STS supports full interoperability of its innovative, cutting-edge clinical registries into CMS data collection models for purposes of improving the quality and efficiency of care provided to beneficiaries. However, we feel that CMS must undertake these efforts with appropriate caution and regard for the capabilities of EHR systems, and with sensitivity to the research processes of clinical registries. 4. Possible New Quality Measures and Measure Topics for Future Years CMS has proposed a list of Hospital IQR program measures and topics to be considered in future IQR reporting requirements. We appreciate that CMS has articulated its priorities for selecting quality measures for the IQR program. STS is currently collecting data on the cardiac surgery measures and supports their inclusion in the IQR. In addition to the cardiac surgery measures listed, STS supports inclusion of the following measures and topics.

June 20, 2011 Administrator Berwick Page 5 -

Surgical checklist use for surgical procedures CABG 30-day risk standardized readmission rate All-patient condition-specific readmission rates for AMI, heart failure, pneumonia, CABG, COPD, PCI, other vascular conditions Overall inpatient hospital average length of stay (ALOS) and ALOS by medical service category Short half-life prophylactic administered preoperatively redosed within 4 hours after preoperative dose Cardiac rehabilitation referral for AMI, Heart Failure, cardiac surgery Heart Failure – Symptom and activity assessment TAM-1: Tobacco use screening

STS also supports maintaining participation in a systematic database for cardiac surgery as a structural measure under the IQR program. STS believes that measures should be endorsed by a multi-stakeholder organization and should be developed through a rigorous and stringent process that is transparent, physician-led, and consensus-based. Section IV. F. Indirect Medical Education (IME) Adjustment STS supports the CMS proposal to continue the IME adjustment factor at 5.5 percent for every 10percent increase in the hospital’s resident-to-bed ratio. This adjustment factor is the result of a formula and multiplier that have remained unchanged since 2008. STS is committed to graduate medical education, the practice of academic medicine, and the successful training of cardiothoracic surgical residents. Accordingly, we support the continued IME adjustment factor as IME Medicare payments are a crucial component of ensuring a strong cardiothoracic surgery workforce, which is currently experiencing a growing shortage as cited in the report Shortage of Cardiothoracic Surgeons is Likely by 2020, published in the journal Circulation, July 27, 2009. On behalf of the Society, thank you for the opportunity to provide these comments on the FY 2012 IPPS proposed rule. If you have any questions, please contact Phil Bongiorno, STS Director of Government Relations, at (202) 787-1221 or [email protected].

Sincerely,

Michael J. Mack, MD President