February 25, 2016

What is a Hospital Specific Report, and Why Do I Care?

Today I would like to discuss several reports that relate to the three major Pay-for-Performance programs that you may want to be aware of. The “Hospital-Specific Report” (HSR) is a specific type of report compiled by the Centers for Medicare and Medicaid Services (CMS) which provides each hospital with information regarding the Pay-for-Performance programs. CMS creates hospital-specific performance reports annually for each hospital to review. Where appropriate, the reports utilize hospital data from prior years to construct each hospital’s baseline period and performance period scores.

There are a number of different HSRs and they each provide pretty much what they sound like:

  • HAC Reduction Program Hospital-Specific Report
  • Hospital Value-Based Purchasing Report, which includes the:
    • Baseline Measures Report and
    • Percentage Payment Summary Report
  • Readmission Reduction Program Hospital Specific Report

Let me be clear: there are other “Hospital Specific Reports”, produced by CMS, as well as a variety of similarly-named reports that may be available from your state Department of Health, hospital associations and specialty organizations that report on a variety of facility types (e.g., critical access hospitals, long-term care facilities, ambulatory centers etc.). All are intended to inform organizations regarding the data used to determine payment adjustments under pay-for-performance programs.

In my experience, most hospital CEOs or Board members have never seen any of their organization’s HSRs. Many don’t know they exist. This is not because they don’t care about Quality and Safety. They do. However, because of the complex nature of the reports (particularly if you download the detailed data file), and the fact that most hospitals already have more data than they can interpret, one more report is not seen as valuable. The reports often escape the notice of senior hospital executives, and they simply don’t know that the reports are available.

The Reports are available however via CMS’s QualityNet secure portal (http://www.qualitynet.org/), which allows the user to review the discharge-level data that is used by CMS to calculate a hospital’s performance and payment adjustments for each of the pay-for-performance programs.

Whoa, you lost me– QualityNet secure portal?

Each hospital must register through this portal in order to access their information.  All users requesting access to the QualityNet Secure Portal must be individually approved and verified by CMS. Providers submitting data via the QualityNet Secure Portal, using a vendor to submit data on their behalf or who want to access their data and reports are required to designate a QualityNet Security Administrator who can facilitate the registration process for other users at the organization. Typically, an organization designates two Security Administrators.

If you don’t know who your Security Administrator is, find out. The Director of your Quality department is a good place to start. Ask to see your Hospital Specific Reports. Or, if you love details, ask for access to the site as a basic user. I think that you’ll find the information both useful and interesting. In the next issue, I’ll outline the 37 key metrics that comprise the majority of these reports and which you should also be aware of.