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July 25, 2023
Quarterly Opinion
Morgan C. Shields
Heidi L. Allen
May 1, 2024
Apr 29, 2024
Apr 24, 2024
Back to The Milbank Quarterly Opinion
Patients of inpatient psychiatry are among the most vulnerable hospital patients and have often described care experiences that were dehumanizing and counter therapeutic. Yet, oversight of psychiatric units has been constrained by limited information on quality and a lack of rudimentary standards for clinical treatment.1,2 As one example, psychiatric patients are the only patient group to be excluded from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measure of patient experience.3 This systematic exclusion of psychiatric patients from patient experience measurement reduces opportunities to understand and improve patient-centeredness in a setting that sorely needs more scrutiny and aligned incentives.1,4,5
Progress, however, appears imminent. At the end of 2022, Congress mandated the Centers for Medicare & Medicaid Services (CMS) to start systematically collecting patient experience information from inpatient psychiatric facilities by 2031 as part of their Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program. This information will be publicly available on the Hospital Compare website along with the other IPFQR quality measures. The current IPFQR program includes measures that are self-reported by facilities and calculated among all patients (e.g., restraint, seclusion, screening for substance use, and care coordination) and claims-based measures calculated among Medicare beneficiaries by CMS (e.g., 7- and 30-day follow-up visits, 30-day all-cause readmission, and medication continuation). In response to this new mandate, CMS published its proposed regulatory rules for fiscal year 2024, which includes the adoption of a newly created measure of patient experience, the Psychiatric Inpatient Experience (PIX) measure. CMS will launch voluntary reporting in 2025 and 2026, followed by mandatory reporting in 2027 for 2029 payment determination.
The proposed regulatory rules indicate that Medicare-participating psychiatric facilities (around 1,600, or nearly all inpatient psychiatric facilities in the country) will be required to administer the PIX to all patients over the age of 12 within 24 hours of discharge, unless there are “cognitive or intellectual limitations,” as well as submit annual average scores on this patient experience instrument to CMS for public reporting on the Hospital Compare website. These data will include five distinct scores calculated from the PIX measure – one overall score and a score for each of the four domains in the PIX measure (Relationship with Treatment Team; Nursing Presence; Treatment Effectiveness; and Healing Environment).6 Failure to comply with the requirements will result in a 2% reduction in providers’ annual payment update. Similar to prior years, in 2023, a negligible number of participating facilities failed to meet the IPFQR reporting requirements and received a payment penalty (n = 15, <1%), and only 29 eligible facilities chose not to participate in the program at all. It is unknown to what extent the new reporting requirement on patient experience will affect participation rates.
We believe the proposed rule on implementing PIX is a step in the right direction. First, this policy will provide high-level systematic data about the patient experience in inpatient psychiatry that can be linked to other datasets that describe facility-level characteristics (e.g., facility type, ownership, region). Researchers can employ these data to better understand variation in care experiences across types of organizations. Second, these publicly reported data can be used by consumers to choose facilities, and by insurers to reward performance. For example, local Medicaid managed care plans can use the information to understand how facilities in their network are performing and incorporate these measures into innovative incentive designs. Third, these data can be used by hospital organizations to compare performance to peers, identify opportunities for improvement, and motivate quality improvement. Fourth, the very act of measuring and publicly reporting such information communicates that we as a society expect dignified and respectful treatment of this historically marginalized patient population.
Still, collecting patient experience data on inpatient psychiatric admissions is a necessary but not sufficient effort to drive quality improvements. While CMS is offering technical guidance to organizations to ensure compliance with reporting, there currently are no incentives to support implementation of evidence-based interventions to improve patient-centered care. For example, the Six Core Strategies is a patient-centered, trauma-informed, evidence-based model endorsed by the Substance Abuse and Mental Health Services Administration to prevent and reduce violence, trauma, and use of restraint and seclusion.7 CMS could consider additional methods to motivate and support organizations in implementing the Six Core Strategies or similar models.
In addition, the current regulations do not describe CMS’ approach to risk-adjustment for this measure, and it is unclear whether patient case-mix information will be publicly reported and available for analysis. The proposed regulations imply that only average hospital-level scores will be reported. Lack of patient-level information prevents our ability to understand within-hospital variation in care experiences across different patient groups receiving inpatient psychiatric care. Lack of even hospital-level case-mix information (e.g., annual percent of patients across racial and ethnic groups, diagnoses, age, gender, sexuality, and payer type) will constrain the ability to interpret the data, to learn about potential inequities in where patients are receiving their care, and to anticipate how using these patient experience data in incentive designs might differentially affect organizations serving a disproportionate share of minoritized patients.6 While the gap in facility-level case-mix information can be filled by other entities outside of CMS, such as through the linkage of all-payer hospital case-mix and claims data that exist in certain states and are continuing to evolve in the breadth of facilities included (e.g., freestanding inpatient psychiatric facilities), it will come at considerable effort and cost.
There also is a lack of justification for the proposed methodological approach to report average scores rather than top-box scores (i.e., proportion of respondents indicating excellence in a given domain). HCAHPS currently reports its patient experience measure as top-box scores, helping to account for ceiling effects that are typical of patient experience measures and orienting stakeholders toward excellence.8
While there are advantages to having these data collected at discharge from all patients, this approach could introduce biases. Patients might experience coercion or feel pressured to produce positive evaluations of care for fear of retaliation or a desire to be discharged as soon as possible. Patients might also evaluate their care differently post-discharge when they have had time to process their experience outside the hospital’s walls. Facilities will also vary in the ways in which they administer the survey (the setting, assurances of confidentiality, information verbalized to patients, time provided) that might affect responses. The current PIX measure was tested in the Yale New Haven Health system, which is likely different in significant ways from other types of facilities and systems, and the very act of reporting for purposes of accountability as opposed to research might also affect these dynamics.
This policy change also could create a burden on providers, though CMS has projected that there would be no additional burden to facilities in the near future, and over two-thirds of facilities have reported already administering some kind of measure of patient experience. Furthermore, there is a lack of justification for the use of the PIX measure (only recently developed in 2022) as opposed to other patient experience measures, such as the recently validated Consumer Assessment for Psychiatric Environments measure.9 It is unclear whether the PIX would demonstrate the same predictive qualities.
Because the PIX is a specialized measure for inpatient psychiatry, with psychiatric patients still excluded from the HCAHPS measure, it will still be impossible to compare the quality of care experiences between psychiatric settings and other hospital settings. Given how marginalized this patient population has been from national efforts to measure and improve quality of care, there is value in being able to compare baseline standards of care across psychiatric and non-psychiatric hospital settings. Further, the proposed regulations lack a clear definition for “cognitive or intellectual limitations,” do not explain the methods that would be used to identify such limitations, and lack justification for this type of discriminatory exclusion. Indeed, a broad interpretation of this exclusion could be applied to mental health conditions where the primary symptoms are difficult to disentangle from “cognition”. Even if narrowly applied to patients with “intellectual disabilities,” concerns regarding discrimination remain, especially considering that there are methods that could be used to enable participation by patients with such disabilities.14,15 Indeed, there is evidence of discrimination and inequities in care quality for patients with developmental and intellectual disabilities in both general and mental health care settings, underscoring the need for collecting patient experience data to better understand how interpersonal and structural discrimination might exist within the context of inpatient psychiatry.10
The systematic measurement and public reporting of patient experience information from inpatient psychiatric facilities is a welcome development. However, it should be viewed as just the beginning of a long road toward assuring that patients in these settings receive patient-centered, evidence-based, and appropriate care. CMS should consider the details of its regulations closely and aim to support patient-centered care in all decisions. It is in the details where well-intentioned policies can either promote or undermine progress on equity and justice.
Dr. Morgan Shields is an Assistant Professor of Social Work at Washington University in St. Louis’ Brown School, where she directs the Inclusive, Dignified, Equitable, Accountable, and Loving (IDEAL) lab. Dr. Shields researches the quality and accountability of healthcare, with a focus on behavioral health services. Most of her work has focused on institutional settings (e.g., inpatient psychiatric care) given the extreme power imbalances and vulnerabilities that patients face in such settings. Her work has been published in leading journals and has had impact at both the federal and state levels.
Heidi Allen, PhD, MSW, is an associate professor at Columbia University School of Social Work. She studies the impact of social policies, like Medicaid–America’s health insurance for the poor–on health and financial well-being. She is a former emergency department social worker and spent several years in state health policy, where she focused on health system redesign and public health insurance expansions. In 2014-2015, she was an American Political Science Association Congressional Fellow in Health & Aging Policy. She was a speaker at TEDMED on the cost of being uninsured in America. Allen was recently honored by the Society for Social Work and Research with a 2019 Social Policy Researcher Award. She is currently involved in a number of research projects focused on social policy at the intersection of health and poverty.
