On July 6, 2016, the Centers for Medicare & Medicaid Services (“CMS”) issued a proposed rule addressing potential modifications to the Hospital Value-Based Purchasing Program (“Proposed Rule”).1 The Proposed Rule, if implemented as currently drafted, would eliminate the Pain Management dimension from the Hospital Value-Based Purchasing (“VBP”) Program’s Hospital Consumer Assessment of Healthcare Providers and Systems (“HCAHPS”) Surveys.


As part of the Affordable Care Act, CMS is required to establish and maintain a program under which value-based incentive payments are made to hospitals that meet certain predetermined performance standards during the applicable fiscal year.

The VBP Program operates as part of CMS’s continued effort to transition Medicare’s fee-for-service payment system to a system that pays based on the quality of care provided to Medicare beneficiaries. Under the VBP Program, participating hospitals are paid for inpatient acute care services based on clinical processes, patient experience, outcomes, efficiencies and cost reductions, care coordination, safety and clinical care outcomes.

CMS adopted the HCAHPS Survey2 as part of the VBP Program beginning in FY 2013. The HCAHPS Survey was the first national, standardized, publicly reported survey of patients’ experience in the hospital setting. The HCAHPS Survey asks patients various questions about their recent hospital stay and factors into the reimbursement hospitals receive under the VBP Program. The HCAHPS Survey is based directly on patient responses and attempts to score nine dimensions of the patient’s experience of care for the VBP Program. One of these HCAHPS metrics measures is Pain Management.

The Proposed Rule

The Proposed Rule,3 which also proposes other significant changes to CMS reimbursement rates for hospitals’ off-campus facilities, proposes modifications to the HCAHPS Survey questions, due to confusion about the intent of some questions and the current public health concerns regarding the ongoing opioid addiction epidemic.

In particular, the Proposed Rule would eliminate the Pain Management dimension of the HCAHPS Survey beginning in FY 2018. Currently, the Pain Management dimension of the HCAHPS Survey contains three questions:

  1. During this hospital stay, did you need medicine for pain?
  2. During this hospital stay, how often was your pain well controlled?
  3. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

The Proposed Rule is in response to stakeholder concerns that the above three questions, and the Pain Management dimension as a whole, place pressure on hospital staff to prescribe more opioids in order to achieve higher scores on the HCAHPS Survey.4

Some stakeholders have also expressed a belief that incentivizing aggressive pain management contributes to the overprescribing of opioid medication in the United States and to the country’s larger struggle with opioid addiction and overdose.

Under the Proposed Rule, participating hospitals would continue to ask patients questions about their pain management; however, patients’ responses to these questions would no longer factor into the hospital’s HCAHPS Survey score. CMS believes the proposed change breaks the incentivizing tether between VBP Program payments and opioid prescribing practices while still providing participating hospitals with valuable patient input.

CMS expects the elimination of the Pain Management dimension of the HCAHPS Survey to be temporary in nature and stressed that it continues to believe robust pain control to be an important part of routine inpatient care. CMS is conducting research in order to better understand if and how the HCAHPS Survey relates to the opioid epidemic and will potentially develop new pain management questions in response to its findings. If modified, pain management questions for the HCAHPS Survey will become available for use in the Hospital VBP Program, and CMS will propose to adopt them in future rulemaking.

CMS is inviting public comments on the Proposed Rule.

Practical Takeaways

Participating hospitals and industry stakeholders are encouraged to submit comments to CMS regarding the Proposed Rule and its potential impact on the United States’ struggle with opioid addiction and overdose.

Comments on the Proposed Rule must be received by CMS no later than 5:00 PM on September 6, 2016. Comments may be submitted electronically, via mail or by hand delivery.