Why OIG Did This Review. Accurate data are fundamental to the integrity of the Centers for Medicare & Medicaid Services' (CMS) quality-based payment programs, several of which rely on data from Hospital Inpatient Quality Reporting (IQR). This evaluation focuses on CMS's efforts to ensure the integrity of IQR data. These data are used to adjust payments on the basis of quality measures; thus, inaccurate data pose risks to payment accuracy. CMS and the Centers for Disease Control and Prevention (CDC) issued a Joint Reminder regarding their concerns that data was being manipulated, or gamed, by hospital staff who did not follow CDC definitions for reportable infections. This report assesses CMS's validation efforts and recommends ways to strengthen program integrity safeguards. How OIG Did This Review. We analyzed CMS validation data for payment year 2016 to determine the number of hospitals that CMS selected for validation, why CMS selected them, and the outcome of the validation. We conducted structured interviews with five stakeholder experts about any concerns they had about hospital quality data or CMS's validation. We also conducted interviews with CMS and CDC staff regarding any quality assurance activities or analyses they conduct on the quality data. Finally, we reviewed training materials that CMS and CDC offered to hospitals on how to report their quality data. What OIG Found. For payment year 2016, CMS met its regulatory requirement by validating sufficient IQR data, which are used to adjust payments on the basis of quality. Almost 99 percent of hospitals that CMS reviewed passed validation, and CMS took action against the six that failed, including reducing their Medicare payments. In addition, CMS and CDC offer training to hospitals to help improve the accuracy of the quality data that hospitals report. However, CMS's approach to selecting hospitals for validation for payment year 2016 made it less likely to identify gaming of quality reporting (i.e., hospitals' manipulating data to improve their scores). CMS did not include any hospitals in its targeted sample on the basis of their having aberrant data patterns. Targeting hospitals with aberrant patterns for further review could help identify inaccurate reporting and protect the integrity of programs that make quality-based payment adjustments. What OIG Recommends. To identify potential gaming or other inaccurate reporting of quality data, we recommend that CMS make better use of analytics to ensure the integrity of hospital-reported quality data and the resulting payment adjustments. CMS could use analytics to select an increased number of hospitals in its targeted validation sample. It could analyze the data to identify outliers (i.e., hospitals with data patterns that are substantially different from other hospitals), determine which of those outliers warrant further review, and then add them to the sample. For example, CMS could use analytics to identify hospitals with abnormal percentages of patients who had infections present on admission; this might help identify hospitals that engage in some of the data manipulation highlighted in CMS and CDC's Joint Reminder. CMS concurred with our recommendation.
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