The move of joint replacement surgery from the inpatient hospital environment to the outpatient setting is becoming more of a certainty. Experts like the consultants at Sg2 have been predicting the rise of outpatient joint replacements for many years, and their recent data shows an acceleration of the trend, with 2012 to 2015 showing a 47% increase in procedures nationally. In July CMS proposed moving joint replacement off the “inpatient only” list so it can be performed on Medicare patients in ambulatory surgery centers (ASCs). Hospitals that do not have an outpatient surgical setup have been seeking to acquire surgery centers or form joint ventures with them to capitalize on the movement. CMS is expected to publish the final outpatient payment rule in November that will determine the fate of outpatient joint replacement for 2018. In September, the agency received comments from both sides of the industry. In the following article, we will review the impact of the changes above on the orthopedic OP practices. If you want to hear more about this topic, come to our Newport Beach Interdisciplinary Conference. We will start this article with an overview of the current changes our healthcare system is undergoing.

 

Background

The American medical environment is currently experiencing a dramatic transformation and much of that relies on the Patient Protection and Affordable Care Act (ACA) and Triple Aim initiative. The Triple Aim was developed by Don Berwick of the Institute for Healthcare Improvement (IHI) in 2008 and focuses on revolutionizing US healthcare through three main tenets: (1) improving individuals’ experience of healthcare, (2) improving the health of an aging US population and (3) reducing the ever-rising per capita costs of healthcare. The ACA of 2010 has significantly altered the American healthcare system, shifting priorities to emphasize the greater importance of patient-centered outcomes. In that context, the ACA mandated public reporting programs that incorporate information collected using the Consumer Assessments of Healthcare Providers and Systems (CAHPS®) surveys. Recently the CMS has introduced the OAS CAHPS (Outpatient and Ambulatory Surgery Survey), which aims to improve quality of healthcare in the perioperative space and to measure patient experiences with surgeries performed at hospital outpatient surgery departments or ambulatory surgery centers. The purpose of this article is to briefly review the history of the development of the various CAHPS surveys and to describe the OAS CAHPS.

 

History of the CAHPS

The history of the CAHPS dates back to 1995 when the first survey that was created by the Agency for Healthcare Research and Quality (AHRQ) in conjunction with the Center for Medicare and Medicaid Services (CMS). According to the CMS and AHRQ, the CAHPS survey goals are: (1) “To develop standardized surveys that organizations can use to collect comparable information on patients’ experience of care” and (2) “To generate tools and resources to support the dissemination and use of comparative survey results to inform the public and improve health care quality”[i]. While numerous studies have reported the high reliability and validity of the CAHPS surveys, many clinicians criticize these surveys and indicate that the questions presented in the surveys are not clear and that attribution to individual specialty or physician is very difficult.

 

The OAS CAHPS Survey

The OAS CAHPS survey is aimed to measure the experiences of patients who received care in Medicare-certified hospital outpatient departments or ambulatory surgery centers. Specifically, the aim of the survey is to measure patients’ perspectives on constructs that are important (for patients) when choosing a facility for their care. The development of the OAS CAHPS has been underway since 2012 and an initial test was conducted in 2014 (24 facilities) to assess validity, reliability and implementation procedures. Following the initial testing, OAS CAHPS was revised and, in 2015, a second round of testing was conducted. The survey received accreditation as a CAHPS® survey in February 2015. The second round of testing was particularly important as its aims were to assess data collection and develop models to adjust for patient characteristics prior to public reporting. This later aim is highly important since it is well known that certain social characteristics bias the responses to CAHPS surveys and, therefore, a process of “statistical adjustment” has to be done prior to comparing an individual center to national benchmarks. Many more details regarding the development and implementation can be found at the www.OASCAHPS.org site. It is important to note that currently there is not a specific timeline for linking OAS CAHPS performance to reimbursement.

The OAS-CAHPS survey will be given to adult patients who had specific procedures or surgeries (based on a list of CMS-approved CPT codes and G codes). These procedures have to be performed in a Medicare-certified Hospital Outpatient Department or a Medicare-certified freestanding ASC; overnight-stay patients are included. Patients are only eligible to receive the OASCAHPS survey once every six months. HOPDs or ASCs can apply for exemption from mandatory OAS-CAHPS if they have 59 or fewer OAS CAHPS eligible patients annually. The OAS-CAHPS survey must be administered by an independent. CMS-approved vendor and can be administered by mail, telephone or a combination of mail with a telephone follow-up.

 

Timeline

In January 2016, CMS began voluntary, monthly data collection using the OAS CAHPS survey tool. The initial plan was for CMS to begin public reporting in January 2018, based on the OAS CAHPS data collected between July 2016 and June 2017 of the voluntary participation period. CMS did indicate that facilities will be able to request that their voluntarily collected OAS CAHPS data be suppressed from public reporting during the preview report period.

On July 20, 2017, however, the Federal Register published a new proposed rule for the OAS CAHPS. In this latest Proposed Rule, CMS proposes to delay the implementation of OAS CAHPS to 2020 payment determination (2018 data voluntary data collection). If approved, this means that OAS CAHPS would continue with the voluntary reporting throughout 2018. The rationale provided for the delay is to enable CMS “to analyze the national implementation data and consider any necessary modifications to the survey tool and/or CMS systems and review the regulatory burden for providers and investigate strategies to reduce the burden before making a determination of timing for future implementation.” “The delay will allow additional time for participating facilities to identify a survey vendor and work through. For those of us that hope that this CAHPS measure will simply go away, the CMS indicates that “CMS continues to believe that the OAS CAHPS Survey addresses an area of care that is not adequately addressed in the current measure set and will be useful to assess aspects of care where the patient is the best or only source of information. These measures will enable objective and meaningful comparisons between hospital outpatient departments and ambulatory surgery centers.”

 

References: 

[1] https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf [Accessed 02-13-2017.]

Hargraves, J. L., Hays, R. D., & Cleary, P. D. (2003). Psychometric properties of the Consumer Assessment of Health Plans (CAHPS®) 2.0 Adult Core Survey. Health Services Research, 38(6 Pt 1), 1509-1527.

Darby C, Hays R, Kletke P. Development and evaluation of the CAHPS Hospital Survey. Health Serv Res 2005;40;1973-1976.

http://www.hcahpsonline.org/home.aspx [Accessed 2-13-2017.]

Hargraves JL, Wilson IB, Zaslavsky A, et al. Adjusting for patient characteristics when analyzing reports from patients about hospital care. Med Care. 2001; 39:635–641

Thi PLN, Briancon S, Empereur F, Guillemin F. Factors determining inpatient satisfaction with care. Soc Sci Med. 2002; 54:493–504.

Agency for Healthcare Research and Quality, “CAHPS Glossary,” https://cahps.ahrq.gov/about-cahps/glossary/index.html)