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CMS Validated Hospital Inpatient Quality Reporting Program Data, But Should Use Additional Tools to Identify Gaming


Accurate data are fundamental to CMS's quality-based payment programs, including Hospital Inpatient Quality Reporting (IQR). This evaluation focuses on CMS's efforts to ensure the integrity of IQR data. IQR data are used to adjust payments on the basis of quality measures, so inaccurate data poses risks to payment accuracy. CMS and CDC issued a Joint Reminder regarding their concerns about data being manipulated, or gamed, by hospital staff's not following CDC definitions for reportable infections.


We analyzed CMS validation data for payment year 2016 to determine the number of hospitals CMS selected for validation, why CMS selected them, and the outcome of the validation. We conducted structured interviews with five stakeholder experts about hospital quality data and any concerns they had about the data or CMS's validation. We also conducted interviews with CMS and CDC staff regarding quality assurance activities, as well as any 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.


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. CMS and CDC offer training to hospitals to help improve the accuracy of the quality data 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). Furthermore, CMS did not include any hospitals in its targeted sample on the basis of their having aberrant data patterns.


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 increase the number of hospitals in its targeted validation sample. It could analyze the data to identify outliers, determine which of those outliers warrant further review, and then add them to the sample. CMS could use analytics to identify hospitals with abnormal percentages of patients having infections present on admission; this might help identify hospitals engaging in overculturing patients, one of the concerns highlighted in CMS and CDC's Joint Reminder. CMS concurred with our recommendation.