One of the objectives of the Centers for Medicare & Medicaid Services (CMS) is to move away from fee-for-service healthcare and toward pay-for-performance. But the road to pay-for-performance has not been a smooth one.

The initial accountable care organization (ACO) program design was flawed, with ACOs held financially responsible for the yearly expenses of a “mystery cohort,” a group of beneficiaries whose identities were not revealed until after the end of the year. CMS also developed the value-based purchasing (VBP) program in order to pay for value and not volume.

One of the early measures in this program involved looking at prompt treatment of patients with pneumonia. Hospitals were evaluated via reporting on the percent of patients with pneumonia who received their first dose of antibiotics within four hours of presentation. Unfortunately, this led to many patients without pneumonia receiving a dose of antibiotics “just in case,” causing real harm. And the National Quality Forum, the organization that created the quality measures, was rocked with scandal when it was revealed that Dr. Charles Denham, the co-chair of the Forum’s Safe Practices Committee, was paid over $11 million by the manufacturer of a surgical prep product that was recommended in one of its endorsed safe practices.

Scandal and missteps aside, while the goal of improving the quality of care in a fiscally responsible way is universally supported, many object to the inclusion by CMS of patient satisfaction as a measure of quality. In the CMS VBP program, 30 percent of a hospital’s potential bonus or penalty is based on the patient’s perception of care: the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score. HCAHPS measures communication by doctors and nurses, the cleanliness of bathrooms, effectiveness of pain control, the discharge process, and several other measures, yielding an overall rating.

While the patient satisfaction survey industry is obviously supportive of pay-for-satisfaction, medical literature suggests that higher patient satisfaction may actually be harmful, with highly satisfied patients getting the care they want rather than the care they need. A 2012 study from University of California, Davis found that highly satisfied patients were hospitalized more, cost more, and actually died more. CMS, though, continues to support patient satisfaction as a measure of quality of care – and since CMS pays the bills, providers are forced to play along.

One way that CMS has worked to improve the quality of patient care is through the quality improvement organization (QIO) program. According to the CMS website, the QIOs are contracted to work with hospitals to improve the quality of care for beneficiaries, protect the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary (and that are provided in the most appropriate setting), and to protect beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints, provider-based notice appeals, violations of the Emergency Medical Treatment and Labor Act (EMTALA), and other related responsibilities as articulated in QIO-related law.

In 2014, CMS divided the QIOs into two entities, creating the Beneficiary and Family Centered Care QIO (BFCC-QIO) and the Quality Innovation Network QIOs. As they are contractors for CMS, it should be obvious that the goals of CMS and these QIOs are aligned.

So it came as a surprise when CMS posted the final notice of the evaluation criteria and standards for the BNCC-QIO contract, CMS-3296-FN, and the BFCC-QIOs themselves asked to be exempted from being evaluated based on customer satisfaction. In its comments, the American Health Quality Association (AHQA), which represents the QIOs, noted that “using information from provider/facility surveys in the evaluation of BFCC-QIO performance could create an actual or apparent conflict of interest, given that BFCC-QIOs determinations may affect provider reimbursements.” It appears that the BFCC-QIOs feel that hospitals cannot possibly be objective and will seek revenge for unfavorable determinations by rating the QIO poorly.

The association also noted “that basing measures on feedback from beneficiaries about their experience with quality-of-care complaints or appeal reviews creates an actual or potential conflict of interest for the BFCC-QIO, as this could be an inducement for the QIO to find in favor of beneficiaries.” It is astounding that the AHQA admits that the BFCC-QIOs could actually disregard CMS regulations and alter their findings in favor of the beneficiary in order to get a higher satisfaction score. And to add insult to injury, a deeper dive into the notice finds that the satisfaction criteria that the BFCC-QIOs oppose only require that 70 percent of respondents report having a “positive experience.” That hardly seems like an unobtainable goal; a score of 70 percent on any HCAHPS patient satisfaction measurement for a hospital would likely place that hospital as one of the worst-performing hospitals in the country. Fortunately, CMS was consistent in its response, rejecting the plea to eliminate satisfaction scoring, noting that “based on previous experience with these surveys, we are confident that the proficiency of the work by the BFCC-QIO with beneficiaries or their representatives will be the dominant factor that impacts the willingness by beneficiaries or their representatives to participate in the survey.”

The AHQA went a step further in trying to avoid accountability, noting that the BFCC-QIOs should not be evaluated based on timeliness, which “could be negatively affected by circumstances outside the control of the BFCC-QIO contractors, including, for example, the unavailability of government-supplied equipment or systems.” Once again CMS refuted this argument, noting that “there are certain factors, such as natural calamities, for example, hurricanes or earthquakes, in addition to transitional issues at the beginning and end of the contract cycle that may, despite the best mitigating efforts, have an impact on the BFCC-QIO’s ability to conduct work in specific regions.

We are confident that these extraordinary circumstances can be addressed using our intervention and evaluation standards and criteria.” I think we’d all cut them a little slack if there was another Superstorm Sandy, but to avoid accountability for their disastrous rollout by blaming it on “circumstances outside their control” is not acceptable to CMS.

The AHQA went on to note that they “are working expeditiously with CMS to resolve BFCC implementation challenges at the start of the 11th Statement of Work,” which the many hospitals that faced 7- to 10-day delays in getting patient discharge appeals reviewed, all the while providing uncompensated care to patients, will consider to be the understatement of the year.

As previously reported on a Monitor Monday broadcast on Aug. 25, 2014, the transition from the traditional QIOs to the new BFCC-QIO was disastrous, with one hospital reporting that it was on hold for almost 10 hours when placing a call and others reporting that the QIO was giving blatantly false information when the determinations were finally made. Making this even more frustrating to hospitals is that the original solicitation and statement of work contained a very precise volume estimate, listing 15 different appeal types and noting, for example, an estimate of 18,453 discharge appeals. The BFCC-QIOs took over a process that was previously handled in a timely and accurate manner by the prior QIOs; they knew how many cases to expect based on this CMS estimates, yet they failed miserably in their duties to hospitals, beneficiaries, and to CMS.  

The validity of satisfaction as a measure of quality is still undecided. The QIOs wanted to be held to a different satisfaction standard than hospitals. But CMS has made it clear that what is good for the goose is good for the gander. Now let’s hope that the BFCC-QIOs figure out a way to do what hospitals are currently doing and provide quality service that also satisfies the customer.  

About the Author

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the American Case Management Association and a Fellow of the American College of Physicians. 

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