FY 2022 Annual Performance Plan and Report - Goal 1 Objective 2

Fiscal Year 2022
Released June, 2021

Topics on this page: Goal 1. Objective 2 | Objective 1.2 Table of Related Performance Measures

Goal 1. Objective 2: Expand safe, high-quality health care options, and encourage innovation and competition

Strengthening the nation's health care system is not achievable without improving health care quality and safety for all Americans.  The immediate consequences of poor quality and safety include health care-associated infections, adverse drug events, and antibiotic resistance.

Health care safety is a national priority.  HHS investments in prevention have yielded both human and economic benefits.  From 2010 to 2014, efforts to reduce hospital-acquired conditions and infections resulted in a decrease of 17 percent nationally, which translates to 87,000 lives saved, $19.8 billion in unnecessary health costs averted, and 2.1 million instances of harm avoided.²

In the previous administration, the Office of the Secretary led this objective.  The following divisions are responsible for implementing programs under this strategic objective: ACL, AHRQ, CDC, CMS, HRSA, OCR, ONC, and SAMHSA.  HHS has determined that performance toward this objective is progressing.  The narrative below provides a brief summary of progress made and achievements or challenges, as well as plans to improve or maintain performance.

Objective 1.2 Table of Related Performance Measures

Reduce all-cause hospital readmission rate for Medicare-Medicaid Enrollees (Lead Agency - CMS; Measure ID - MMB2)

A "hospital readmission" occurs when a patient who has recently been discharged from a hospital is once again readmitted to a hospital.  A thirty-day period for readmission data has been standard across the quality measure industry for several years.  Discharge from a hospital is a critical transition point in a patient's care; incomplete handoffs at discharge can lead to adverse events for patients and avoidable readmissions.  Hospital readmissions may indicate poor care, missed opportunities to better coordinate care, and result in unnecessary costs.

While many studies have pointed to opportunities for improving hospital readmission rates, the rate of readmissions for individuals who are dually eligible for both Medicare and Medicaid (also referred to as Medicare-Medicaid Enrollees) is often higher than for Medicare beneficiaries overall.  In 2019, an estimated 12.3 million beneficiaries were dually eligible for Medicare and Medicaid.

CMS calculates this measure using the number of readmissions per 1,000 eligible beneficiaries.  Eligible beneficiaries are dually eligible individuals of any age.  CMS found an increase in the readmissions rate from 2018 to 2019 of 1.07 percent.  CMS continues to believe the experience from 2015 to 2019 demonstrates a similar "plateauing" of readmissions around 84.0 per 1,000 rate.  Therefore, CMS is maintaining the target reduction for CY 2022 of 0.25 percent in the future based on this measure's apparent plateau and national trends (https://www.hcup-us.ahrq.gov/reports/statbriefs/sb248-Hospital-Readmissions-2010-2016.pdf) reflecting a slowing in readmissions reductions for all Medicare beneficiaries (after a number of years of larger declines).

CMS will continue to implement programs and innovations aimed at incentivizing a reduction in Medicare fee-for-service hospital readmissions:

• The Medicare-Medicaid Financial Alignment Initiative managed fee-for-service demonstration in Washington State, which focuses on improving care coordination for high-risk dually eligible beneficiaries and holds the state accountable for readmission and associated costs;
• The Medicare Hospital Readmissions Reduction Program (HRRP) assesses a hospital's performance relative to other hospitals with a similar proportion of patients who are dually eligible for Medicare and full Medicaid benefits; and
• The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program rewards incentive payments based on hospital readmissions.
• Accountable care organizations, including the Medicare Shared Savings Program (MSSP).

An array of CMS Innovation Center models with financial incentives to reduce utilization and readmissions, including Bundled Payments Care Improvement (BPCI) initiative, the Next Generation ACO model, and Primary Care First.

Improve hospital patient safety by reducing preventable patient harms (Lead Agency – CMS; Measure ID – QIO11)^3, 4

The purpose of this measure is to determine the national impact of patient safety efforts by counting the number of preventable patient harms that take place per 1,000 inpatient discharges.  Preventable harms can cause additional pain, stress, and costs to the patient and their family during intended treatment and increase spending on the part of payers.  This measure utilizes the AHRQ National Scorecard, which includes abstraction from a nationally representative sample of approximately 20,000 hospital charts per year that yields clinical relevant yet highly standardized national hospital safety metrics.  This represents an enormous contribution to the government's ability to measure, monitor, and improve patient safety at a national scale.  As a composite of many different harms, the AHRQ National Score Card also includes data from the CDC's National Healthcare Safety Network and AHRQ's Healthcare Cost and Utilization Project databases.

Beginning in FY 2018, CMS lists the result as "data unavailable" due to analytic issues surrounding the preliminary 2018 all cause harm metrics.  Due to the inability to collect, track, and report on data in accordance to the specified methodology as well as inconsistencies in availability of patient charts due to COVID-19, CMS will discontinue reporting on this measure.  Ensuring patient safety continues to be a CMS priority.

Reduce the standardized infection ratio (SIR) central line-associated bloodstream infection (CLABSI) in acute care hospitals (Lead Agency - CDC; Measure ID - 3.3.3)^5, 6

Reducing health care-associated Infections (HAIs) across all health care settings supports the HHS mission to prevent infections and their complications as well as reduce excess health care costs in the United States.  These efforts also align with the National Action Plan to Prevent Health Care Associated Infections: Roadmap to Elimination (National HAI Action Plan),⁷ National Action Plan for Combatting Antibiotic Resistance Bacteria (CARB), and Healthy People 2030 Goals.

CDC did not meet its FY 2019 target for reducing the CLABSI SIR, but the result of 0.69 represents a 31 percent decrease from the 2015 baseline, showing continued progress in reducing the ratio.  Similar to previous years, infection decreases were more pronounced in certain areas, like neonatal intensive care units, than in hospital wards and other ICUs.  As more infections are prevented, it becomes more difficult to prevent remaining infections using existing technologies and techniques and prevention efforts begin to plateau.  For infections that CDC has optimal prevention approaches for, CDC has prevented and continues to prevent many, though not all, of these CLABSIs.  A greater proportion of remaining CLABSIs are less likely due to issues with central line insertion as when CDC started preventing CLABSIs on a national scale two decades ago.  More CLABSIs are now likely due to catheter maintenance practices.  Interventions to prevent these types of CLABSIs are more challenging to implement and have a less definable impact on rates. Additionally, it becomes more difficult to develop and refine performance measures to provide an accurate picture of performance overtime. As previously mentioned, the current performance is based on revised baselines computed in 2015, which followed substantial decreases from 2008.

CDC is on track to meet other 2020 National HAI Action Plan targets.  Going forward, CDC will continue to monitor HAIs and to develop strategies to support continued progress on action plan goals.

Reduce standardized infection ratio for hospital-onset Clostridioides difficile infections (Lead Agency - CDC; Measure ID - 3.2.4b)⁸

Clostridioides difficile infection (CDI)⁹ is a preventable, life-threatening bacterial infection that can occur in both inpatient and outpatient health care settings.  CDC provides data-driven strategies and tools for targeted intervention to the health care community to help prevent CDI, as well as resources to help the public safeguard its own health.  CDI prevention is a national priority, with a 2020 target to reduce CDI by 50 percent in the National Action Plan for CARB and to reduce hospital-onset CDI by 30 percent in the current National HAI Action Plan.  In FY 2019, the SIR for hospital-onset CDI was 0.58 (Measure 3.2.4b), exceeding not just the 2019 target, but also surpassing the 2020 HAI Action Plan CDI goal.  CDC is also on track to meet the 2020 National Action Plan for CARB target for CDI.

² https://www.ahrq.gov/professionals/quality-patient-safety/pfp/2014-final.html

³ Data are preliminary based on partial data from this calendar year combined with data from prior years to fill gaps. The estimates are subject to change after all data from this calendar year are available and all quality control procedures have been completed.

⁴ Examples of some of the preventable patient harms included in this measure are: adverse drug events, catheter-associated urinary tract infections, central line-associated bloodstream infections, falls, pressure ulcers, surgical site infections, ventilator-associated pneumonia/events, venous thromboembolism, and hospital readmissions.

⁵ The baseline for this measure was updated in FY 2015 and will affect future targets and data reporting for FY 2016 onward.

⁶ CDC uses a standardized infection ratio (SIR), the ratio of the observed number of infections to the number of predicted infections, to measure progress in reducing HAIs compared to the baseline period (FY 2015). In 2015, CDC developed a new baseline for all HAIs including CLABSI to better assess national and local prevention progress and identify gaps for tailored prevention.

⁷ https://health.gov/hcq/prevent-hai-action-plan.asp

⁸ CDC rebaselined measure 3.2.4b in 2015, and subsequent targets were adjusted to align to changes in the current HHS HAI Action Plan.

⁹ https://www.nejm.org/doi/full/10.1056/NEJMoa1408913 

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