What does Medicare cover besides hospitalization

Clinical quality made in USA

Number of quality indicators increased.

The new quality-based remuneration models for US hospitals are based on quality indicators that make valid and solid quality measurement possible in the first place. Nationally standardized clinical indicators with which the process quality in hospitals can be mapped were introduced in 2002. Just two years later, as part of the Inpatient Quality Reporting (IQR) initiative, the CMS asked the clinics to publish the corresponding indicator results. Since then, the number of quality indicators has increased massively, today there are already more than 60. The indicators include, for example, the complication rate after operations, patient satisfaction, result indicators based on administrative data, process indicators that are manually abstracted from medical records and, more recently, indicators that are taken directly from the electronic medical records can be obtained. New indicators are constantly being added. One year after clinics collected a new indicator and published the results, the Center for Medicare and Medicaid Services can already include this parameter in their quality-based compensation programs.

The Medicare Center established the Center for Medicare and Medicaid Innovation (CMMI) in Barack Obama's reign. Here the CMS can test new remuneration and pension models under realistic conditions. After the test phase has been successfully completed, it can then introduce these models in a directly binding manner and no longer needs the approval of the House of Representatives and the Senate, as before. While new models often fell victim to political disputes before, the process has been significantly depoliticized and more technically oriented since the establishment of the CMMI.

Good houses get more money.

In 2012, CMS introduced the first quality-based program: With value-based purchasing (VBP; see glossary), various indicators are evaluated individually on the basis of excellence and improvement performance. If a hospital does not score with excellence in comparison to other clinics, it can still acquire improvement points even at a lower level of performance, if at least its own performance has significantly improved in historical comparison. To finance the program, CMS retains two percent of the total DRG base remuneration from all hospitals - this sum is then redistributed as part of the VBP program. Hospitals with a high number of points receive additional remuneration components, while those with a lower number of points forfeit parts of the remuneration. The program is highly flexible, new indicators are added every year, others are removed. The weighting of the individual indicators can also change. This gives the CMS the opportunity to create new incentives for hospitals to improve quality in various areas.

Bad clinics have to bleed.

Two other remuneration programs that relate to the DRG basic remuneration are based solely on financial deductions. The Hospital Readmissions Reduction Program (HRRP) introduced in 2013 to reduce readmissions provides for compensation losses of up to three percent of the DRG base salary if a clinic has more readmissions than the number of readmissions expected after the risk adjustment. Critics complain, however, that clinics are being financially prosecuted here, even though many of the causes of recovery are beyond their control. It was particularly controversial that in the case of readmissions, even those that had no connection with the first hospital stay led to devaluation. With the Hospital Acquired Conditions (HAC) program to reduce complications, clinics have been able to lose an additional one percent of their DRG base remuneration since 2015 if their complication rate is in the upper quarter of all hospitals.

In total, up to six percent of the DRG basic remuneration is at stake due to the three quality-based programs mentioned. With the usual profit margins of hospitals, this usually means the difference between profitability and red numbers.