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October 22, 2010


Washington Letter
October 22, 2010

ATS Opposes NQF ICU Measures

The ATS, the American College of Chest Physicians and the American Associations of Critical-Care Nurses contacted the National Quality Forum (NQF) in a joint letter to express concerns with NQF's recently adopted quality measures for intensive care units.

NQF recently adopted the below two measures:

Intensive Care Unit Length of Stay
For all patients admitted to the ICU, total duration of time spent in the ICU until time of discharge; both observed and risk-adjusted LOS reported with the predicted LOS measured using a adjustment model based on the (Mortality Probability Model) MPM III

Intensive Care Unit: In-hospital Mortality Rate
For all adult patients admitted to the intensive care unit (ICU), the percentage of patients whose hospital outcome is death; both observed and risk-adjusted mortality rates are reported with predicted rates based on the Mortality Probability Admission (MPM III) model.

In joint comments on the two measures, the ATS and sister societies noted the measures reflect processes of care that are independent of quality and are subject to manipulation. Both measures may be altered by transferring ICU patients early in their course of treatment to post-acute care facilities such as skilled nursing facilities or long-term acute care hospitals. Adoption of these measures could have unintended negative consequences for the patients and unfairly reward hospitals that transfer a large number of patients to post-acute care facilities, encouraging overuse of post-acute care and potentially increasing healthcare costs.

The joint letter also expressed the concern about the potential of harm caused by "gaming," which could potentially apply to any measure. Paryicularly in the case of an ICU LOS measure, the ATS, ACCP and AACN felt that the risk of unintended negative patient consequences is quite high and the correlation to quality of care is particularly weak, given the lack of availability of well validated risk adjustment for this outcome.

Registering our collective comments on these ICU measures is important because the Centers for Medicare and Medicaid Services (CMS)often use quality measures that have been adopted by NQF.


CMS Proposes New Fraud Prevention Powers

Last month, the Centers for Medicare and Medicaid Services (CMS) issued new proposed rules regarding implementation of their expanded fraud and abuse prevention authority granted under the Affordable Care Act (ACA). The ACA providers CMS with three new expanded powers, including screening of new and reapplying Medicare Part B, Medicaid and CHIP providers; temporary new provider moratoriums; suspension of payments in cases of "credible allegations of fraud."

Provider Screening

Under the proposal, CMS sorts providers by type into three categories of likely fraud activity, "limited", "moderate" and "high. " Those provider types in the "limited" category would continue to meet the existing requirements of provider/suppler requirement verification, state licensure verification and database checks. There are no new requirements for provider types in the limited category. Examples of provider types in the limited category include; physicians and non-physician providers, group practices and clinics; ambulatory surgery centers, hospitals and rural health clinics.

Providers in the "moderate" category would face the existing requirements of provider/suppler requirement verification, state licensure and database checks in addition to new requirement of periodic unscheduled and unannounced sited visits. Examples of providers in the moderate category include: Comprehensive outpatient rehabilitation facilities; hospice organizations; independent diagnostic testing facilities; independent clinical laboratories; and nonpublic, nongovernment owned or affiliated ambulance services suppliers.

Providers in the "high" category would be subject to criminal background checks and finger printing in addition to previously listed screening requirements. Provider groups in the "high" category are limited to newly enrolling, privately owned/not publicly traded home health agencies and durable medical equipment suppliers. Please note DME suppliers and home health agencies that are publicly traded are considered "limited" risk.

New Supplier Moratoriums

Under the proposed rule, the Secretary of Health and Human Services can issue a temporary moratorium on new provider participants in the Medicare Medicaid or CHIP program if such a moratorium will help prevent or address know or suspected fraud. The moratorium can be by provider type (example DME suppliers) or by geographic area (example Dade County, FL). Moratoriums must be time limited (not to exceed 6 months) and the Secretary must be sure that the moratorium will not impede patient access to necessary medical services.

Payment Suspension

The ACA gives CMS expanded authority address fraud by suspending payments to providers who are under credible suspicion of fraudulent activity. The payment suspension could occur before the initiation or completion of a fraud investigation.

The American Thoracic Society is carefully reviewing the proposed rule and will submit comments outlining our concerns and recommendations. A significant part of our comments will be how CMS intends to define "credible suspicion" and how it intends to implement its payment suspension authority.

The deadline for submitting public comments is November 16, 2010.


ATS Supports NIH and CDC Funding

This week, the ATS signed letters to support increased funding in 2011 for NIH research and CDC public health programs. The NIH effort, coordinated by the Ad-Hoc Group for Medical Research, calls on congressional leaders to pass a $1 billion funding increase for the NIH as part of the Labor-Health and Human Services and Education (Labor-HHS-ED) Appropriations bill, rather than a year-long spending measure, called a continuing resolution, that would freeze funding at FY2010 levels. In the letter, the Ad-Hoc Group states, "A long-term, continuing resolution (CR) will slow research progress and squander invaluable scientific opportunities, to the detriment of our nation's health and our ability to maintain leadership in the global innovation economy." The letter lists a new initiative to identify biomarkers and drug targets for lung diseases such as chronic obstructive pulmonary disease as one of several examples of research opportunities that could be lost or delayed by a long-term continuing resolution. The proposed FY2011 House and Senate Labor-HHS-ED Appropriations bills would provide $32 billion for the NIH in FY2011, a 3.2% funding increase over the FY2010 level of $31 billion.

The ATS also joined a letter supporting increased funding for the CDC in FY2011. This letter, coordinated by the CDC Coalition, calls on the Congress to provide the highest possible funding levels for the agency's core public health programs and points to coalition's recommendation of $8.8 billion for CDC in FY2011. The House and Senate Labor-HHS-ED Appropriations bills differ slightly on CDC funding, with the House bill proposing $6.782 billion in funding and the Senate bill proposing $6.906 billion for the agency in FY2011. In the letter, the coalition states, "In addition to playing a key role in maintaining a strong public health infrastructure and protecting Americans from public health threats and emergencies, the CDC Coalition believes that CDC programs will continue to play a crucial role in reducing healthcare costs and improving the public's health as Congress and the Administration move forward with implementation of the Affordable Care Act." The ATS will continue working to support the higher Senate funding level for CDC.


The Washington Letter is written by the American Thoracic Society government relations office and emailed to all ATS members living in the United States. The letter keeps clinicians, scientists, and patients abreast of legislative, judicial, and regulatory issues in pulmonary, critical care, and sleep medicine. Each week's edition is archived on the ATS Web site, www.thoracic.org. If you have any questions or one more information about becoming involved in advocacy, please contact the ATS Washington office at 202-296-9770.