Medication reconciliation has been a subject of significant importance for many years, considering its role in helping reduce patient risk, improving outcomes, and reducing costs. One such organization that pays close attention to medication reconciliation is the Centers for Medicare & Medicaid Services (CMS). CMS is the federal agency tasked with working with state governments to manage Medicare and administer Medicaid and the Children's Health Insurance program. As part of this work, CMS places a priority on quality. Enter medication reconciliation. CMS highlights medication reconciliation within measures it uses in various quality, reporting, and payment programs to promote healthcare quality and quality improvement.
Medication Reconciliation: CMS Quality Measures to Know
Here are eight of the quality measures concerning medication reconciliation that CMS has addressed directly or noted as a critical aspect of other vital medication-related processes.
1. Quality ID #46 (NQF 0097): Medication Reconciliation Post-Discharge
This measure concerns medication reconciliation post-discharge (MRP). We have previously discussed the importance of MRP, stating that while 100% of patients should receive an MRP within 72 hours of discharge, statistics indicate that only about half of all patients do.
The measure looks at the percentage of discharges from any inpatient facility for patients 18 years of age and older seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing ongoing care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record.
This National Quality Forum (NQF)-endorsed measure, which is currently used for the Medicare Part C Star Rating program and Physician Compare initiative, requires the submission of data as three rates stratified by age group:
- 18-64 years of age
- 65 years and older
- All patients 18 years of age and older
CMS summaries the rationale for the measure, stating, "Medications are often changed while a patient is hospitalized. Continuity between inpatient and ongoing care is essential."
2. Medication Reconciliation for Patients Receiving Care at Dialysis Facilities
This next measure also speaks specifically to medication reconciliation. CMS describes it as follows: "The percentage of patient-months for which medication reconciliation was performed and documented by an eligible professional."
While it's not an NQF-endorsed measure, it is based upon NQF #2988. The rationale for this measure is that while medication management is a critical safety issue for all patients, it takes on an elevated level of importance for patients with end-stage renal disease (ESRD). Why? ESRD patients often:
- require 10 or more medications (i.e., major-polypharmacy);
- take an average of 17-25 doses per day;
- have numerous comorbid conditions;
- have multiple healthcare providers and prescribers; and
- undergo frequent medication regimen changes.
CMS notes that medication-related problems greatly contribute to the ~$40 billion in public and private funds spent every year on ESRD care in the United States. With medication management practices focusing on medication documentation, medication review, and medication reconciliation, CMS believes that this could help identify and resolve medication-related problems while improving ESRD patient outcomes and reducing total costs of care.
It should be noted that ESRD is just one of many chronic conditions for which patients are susceptible to polypharmacy. While these patients often require more complex medication regimens to manage their condition, providers would do well to investigate opportunities to decrease polypharmacy when appropriate.
This measure is currently used for CMS's ESRD Quality Incentive Program.
3. Transitions of Care Between the Inpatient and Outpatient Settings, Including Notifications of Admissions and Discharges, Patient Engagement, and Medication Reconciliation Post-Discharge
This measure, which is currently used for the Medicare Part C star rating program, essentially includes the data from the first measure we listed. In this case, it looks at the average of the rates for MRP performed during transitions of care and a few other essential transition processes.
As CMS notes, the Medicare population includes those with complex health needs who often receive care from multiple providers and settings. This can contribute to highly fragmented care and adverse outcomes. The population is at particular risk during transitions of care for several reasons, including increased medication use. Transitions from the inpatient setting to home often results in intentional and unintentional medication changes and inadequate beneficiary, caregiver, and provider understanding of medication needs, among other issues. Furthermore, poor hospital transitions are associated with medication errors.
Effective care coordination efforts, CMS goes on to state, must include medication reconciliation post-discharge.
In addition to being part of the Medicare Part C star rating program, we have long advocated that medication reconciliation be an ongoing process as patients transition from one setting of care to another as half of all hospital-related medication errors are due to poor communication at care transitions.
4–6. Drug Regimen Review Conducted With Follow-Up for Identified Issues-Post Acute Care: Long-Term Care Hospital, Skilled Nursing Facility, and Inpatient Rehabilitation Facility
We're summarizing three measures in one section here because they speak to the same issue and only essentially vary by facility and associated quality measurement programs. These measures concern the reporting of the percentage of patient or resident stays in which a drug regimen review was conducted at the time of admission and timely follow-up with a physician occurred each time potential clinically significant medication issues were identified throughout that stay. The three types of facilities: long-term care hospital (LTCH), skilled nursing facility (SNF), and inpatient rehabilitation facility (IRF).
As CMS notes, potential and actual medication errors are prevalent among post-acute care settings and often occur during transitions in care. Medication regimen review is designed to improve patient and resident safety by identifying and addressing potential and actual clinically significant medication issues at the time of admission and throughout the stay.
These measures are actively used for several CMS quality programs: LTCH quality reporting, Long-Term Care Hospital Compare, SNF quality reporting, IRF quality reporting, and Inpatient Rehabilitation Facility Compare.
7. Drug Regimen Review Conducted With Follow-Up for Identified Issues Post-Acute Care: Home Health
We'd be remiss not to include this measure, which shares similarities to the three measures just discussed. The most significant difference: setting. This measure pertains to home health (HH) settings. It looks at the percentage of HH quality episodes in which a drug regimen review was conducted at the start of care or resumption of care and completion of recommended actions from timely follow-up with a physician occurred whenever potential clinically significant medication issues were identified throughout that episode. As CMS notes, "Medication reconciliation and drug regimen review have been shown to reduce medication errors and adverse drug events in multiple healthcare settings, including home health."
This CMS quality measure is currently used for HH quality reporting and Home Health Compare.
8. All-Cause Hospital Readmission
The final measure we'll highlight speaks to one of the most important reasons to perform medication reconciliation. CMS describes the measure as follows: "The 30-day all-cause hospital readmission measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge."
CMS goes on to state that the NQF-endorsed measure was developed to identify institutions whose performance is better or worse than would be expected based on their patient case mix and hospital service mix. This information could help promote quality improvement and better inform consumers about care quality. One of the strategies highlighted to improve performance in this measure: pharmacy involvement concerning medication reconciliation.
The measure is currently used for hospital inpatient quality reporting.
Medication Reconciliation: CMS and HEDIS®
When reading about CMS quality measures, a term that's regularly mentioned is HEDIS — the Healthcare Effectiveness Data and Information Set. It's important to understand how CMS and HEDIS are related to each other.
HEDIS is a widely used set of performance measures for managed care. As the Agency for Healthcare Research and Quality notes, more than 90% of health plans use HEDIS to measure performance. HEDIS is managed by the National Committee for Quality Assurance (NCQA), a private, non-profit organization that accredits and certifies healthcare organizations. NCQA states that nearly 200 million people are enrolled in plans that report HEDIS results.
Over the years, CMS and NCQA have partnered in a number of ways concerning HEDIS, including CMS using HEDIS to oversee Medicare managed care organizations, CMS displaying HEDIS data on Medicare.gov, CMS contracting with NCQA to support the implementation of the HEDIS Medicare Health Outcomes Survey and Medicare Health Outcomes Survey, and CMS contracting with NCQA to develop a strategy to evaluate special needs plans' quality of care.
Concerning the subject of this blog about medication reconciliation and CMS, we wanted to note that there are HEDIS measures that address or relate to medication reconciliation, a few of which overlap with CMS quality measures discussed above. We've already discussed medication reconciliation post-discharge (MRP). As NCQA notes about its MRP HEDIS measure, "Medication reconciliation is a critical piece of care coordination for all individuals who use prescription medications."
Included in the HEDIS "Transitions of Care" measure is the rate of medication reconciliation performed on the date of inpatient discharge through 30 days after discharge (31 total days) for Medicare beneficiaries 18 years of age and older.
While the "Annual Monitoring for Patients on Persistent Medications" concerns monitoring and assessing the usage of medications, medication reconciliation should be performed whenever these individuals experience a change to their regimen.
The "Plan All-Cause Readmissions" HEDIS measure speaks to the rate of adult acute inpatient and observation stays followed by an unplanned acute readmission for any diagnosis within 30 days following discharge. We have a blog that speaks specifically to reducing hospital readmissions by preventing medication mishaps.
The HEDIS measure "Use of Opioids from Multiple Providers" does not speak to medication reconciliation. However, we know that when patients receive prescriptions from multiple prescribers who cannot effectively review and reconcile a patient's medication regimen prior to making changes to it, this will increase the likelihood of adverse drug events.
Finally, let's look at the "Antidepressant Medication Management." As NCQA notes, "Effective medication treatment of major depression can improve a person's daily functioning and well-being and can reduce the risk of suicide. With proper management of depression, the overall economic burden on society can be alleviated, as well." For this patient population — and all populations, for that matter — effective medication treatment must involve medication reconciliation whenever a change is made to a medication regimen.