Quality Based Payment Reform (QBPR) Reference Guide
Version 3, February 2016
2015
Copyrighted materials
All rights reserved.
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Quality Based Payment Reform (QBPR) Program Reference Guide
Table of Contents
Value Based Purchasing (VBP) Program:
VBP FFY 2016 Program Overview
VBP FFY 2017 Program Overview
VBP FFY 2018 Program Overview
VBP General Program Methodology Guide
Readmissions Reduction Program (RRP):
RRP FFY 2016-2018 Program Overview
RRP Applicable Condition Definitions
Hospital Acquired Condition (HAC) Reduction Program:
HAC FFY 2016-2018 Program Overview
February 2016
2 of 10
Hospital Industry Data Institute
Value Based Purchasing (VBP) Overview: FFY 2016 Program
Process of Care
Measures, Performance Standards, Evaluation Periods, and Other Program Details for the FFY 2016 VBP Program
Measure ID
Measure Description
AMI–7a
PN–6
Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
National
Threshold1
National
Benchmark2
91.15%
96.55%
99.07%
98.09%
97.06%
97.73%
98.23%
90.61%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
98.88%
Initial Antibiotic Selection for CAP in Immunocompetent Patient
Prophylactic Antibiotic Selection for Surgical Patients
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
Postoperative Urinary Catheter Removal on Post Operative Day 1 or 2
Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period
SCIP–Inf–2
SCIP–Inf–3
SCIP–Inf–9
SCIP–Card–2
SCIP–VTE–2
Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours of Surgery
Patients Assessed and Given Influenza Vaccination
IMM-2 (NEW)
Total Performance Score:
Original Domain Weighting5
Minimum
Standards4
100%
Process of
Care
10%
10 Cases
90%
Patient
Experience
of Care
25%
Patient Experience of Care
Removed Measures: AMI–8a: Primary PCI Received Within 90 Minutes of Hospital Arrival, HF-1: Discharge Insructions, PN-3b: Blood Cultures Performed in the ED Prior to Initial
Antibiotic Received in Hospital, SCIP-Inf-1: Prophylactic Antibiotic received Within One Hour Prior to Surgical Incision, SCIP-Inf-4: Cardiac Surgery Patients with Controlled 6AM
Postoperative Serum Glucose
Measure ID
Measure Description
National Floor3
National
Threshold1
National
Benchmark2
53.99%
57.01%
38.21%
48.96%
34.61%
43.08%
61.36%
34.95%
77.67%
80.40%
64.71%
70.18%
62.33%
64.95%
84.70%
69.32%
86.07%
88.56%
79.76%
78.16%
72.77%
79.10%
90.39%
83.97%
100 Surveys
National
1
Threshold
National
2
Benchmark
Minimum
4
Standards
84.75%
88.15%
88.27%
0.616248
0.4650
0.8010
86.24%
90.03%
90.42%
0.449988
0.0000
0.0000
0.6680
0.7520
0.0000
0.0000
National
Threshold1
National
Benchmark2
Minimum
Standards4
Median Ratio
Across All
Mean Ratio of
Lowest Decile
25 Cases
Communication with Nurses
Communication with Doctors
Responsiveness of Hospital Staff
Pain Management
Communication about Medicines
Hospital Cleanliness & Quietness
Discharge Information
Overall Rating of Hospital
Measure Description
Outcomes of Care
Measure ID
Acute Myocardial Infarction (AMI) 30-Day Mortality Rate (converted to survival rate for VBP)
Heart Failure (HF) 30-Day Mortality Rate (converted to survival rate for VBP)
Pneumonia (PN) 30-Day Mortality Rate (converted to survival rate for VBP)
MORT–30–AMI
MORT–30–HF
MORT–30–PN
PSI-90
HAI-1 *
HAI-2 * (NEW)
Patient Safety Indicator Composite (AHRQ software v4.4)
Central Line-Associated Blood Stream Infection (CLABSI)
Catheter-Associated Urinary Tract Infection (CAUTI)
Pooled Surgical Site Infection (SSI) Measure**:
HAI-3 * (NEW)
Surgical Site Infection - Colon
Surgical Site Infection - Abdominal Hysterectomy
HAI-4 * (NEW)
Measure Description
Efficiency
Measure ID
Spending Per Hospital Patient With Medicare
SPP-1* (MSPB-1)
Hospitals
***
80%
70%
Minimum
Standards4
60%
50%
Outcomes of
Care
40%
of Hospitals
40%
25 Cases
30%
3 Cases
1 Predicted
Infection
20%
Efficiency
of Care
25%
10%
***
0%
FFY 2016 VBP Program Timeframes
2010
J
F
M
A
M
J
J
2011
A
S
O
N
D
J
F
M
A
M
J
J
2012
A
S
O
N
D
J
F
M
A
M
J
J
2013
A
S
O
N
D
J
F
M
A
M
J
J
2014
A
S
O
N
Process of Care:
D
J
F
M
A
M
J
J
2015
A
S
O
N
J
F
M
A
M
J
J
2016
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
Process of Care:
Baseline Period6
Performance Period7
Patient Experience of Care:
Patient Experience of Care:
Baseline Period6
Performance Period7
Outcomes of Care
(HAI Measures):
Outcomes of Care
(HAI Measures):
Baseline Period
D
6
Performance Period7
Outcomes of Care
(Mortality & PSI-90):
Outcomes of Care
(Mortality & PSI-90):
Baseline Period6
Performance Period7
Efficiency of Care:
Efficiency of Care:
Baseline Period6
Performance Period7
FFY 2016
Payment Adjustment
Notes:
The Affordable Care Act (ACA) of 2010 mandated the implementation of an inpatient hospital value-based purchasing (VBP) Program. The VBP Program is a pay-for-performance program that links
Medicare payment to quality performance for acute care hospitals paid under the Inpatient Prospective Payment System (IPPS). Under the VBP Program, using a subset of the quality data reported from the
Hospital Inpatient Quality Reporting (IQR) Program grouped into quality domains, hospitals can earn points towards a Total Performance Score (TPS). The TPS will serve as the basis for determining
hospitals’ VBP payments or gain/loss under the program. In calculating the TPS, the scoring methodology provides points to hospitals that achieve high quality standards as well as points to hospitals that
improve in the quality measures evaluated. As required by the ACA, a pool of funds, to be redistributed to hospitals based on their TPS, will be funded through an across-the-board reduction to Medicare
IPPS base operating payments. The reduction for FFY 2016 is set at 1.75%. Critical Access Hospitals (CAHs), hospitals in Maryland and Puerto Rico, and small hospitals with insufficient numbers of measures
and/or cases are excluded from the program.
1
The National Threshold is the minimum performance standard for each measure and reflects the median performance score (50th percentile) for all hospitals in the nation during the baseline period. The
threshold is used in combination with other factors to calculate hospital-specific achievement points.
2
The National Benchmark is the top performance standard for each measure reflects the average performance score for the top 10% of all hospitals in the nation during the baseline period. The benchmark
is used in combination with other factors to calculate hospital-specific achievement and improvement points.
3
The National Floor is for Patient Experience of Care measures only and each measure reflects the lowest measure score in the nation during the baseline period. The floor is used in combination with other
factors to calculate hospital-specific consistency points.
4
Hospitals must meet minimum case and survey counts to be included in the VBP Program. In addition to the case count criteria, hospitals must have a minimum of 4 useable measures to obtain a Process of
Care Domain score, and 2 useable measures to obtain an Outcomes Domain score.
5
The Domain Weight is a weight applied to each domain to calculate a hospital-specific TPS. A hospital's weighted TPS is compared to TPSs for all hospitals to determine the hospital-specific gain or loss
under the program. If hospitals do not meet the minimum requirements on one or more domain, the other domains are proportionately reweighted to determine a TPS. For the FFY 2016 program, hospitals
are required to be scored on 2 of the 4 domains to be eligible for the program.
6
The Baseline Period is a specified period for which quality data collected under the IQR Program will be evaluated. The baseline period data is used for determining the national floors, thresholds, and
benchmarks (excluding the efficiency measure) and is also used in combination with other factors to calculate hospital-specific improvement points.
7
The Performance Period is a specified period for which quality data collected under the IQR Program will be evaluated. The performance period data is used in combination with other factors to calculate
hospital-specific achievement and improvement points.
*For these measures, lower scores are better.
**The final SSI measure score is an aggregate of the calculated scores for HAI-3 and HAI-4, which are then weighted based on the predicted infections for each measure. For purposes of domain eligibility, CMS
considers the two SSI measures as a single measure.
***
February 2016
Performance standards for the SPP-1 measure are based on the performance period and are not released in advance of the program.
3 of 10
Hospital Industry Data Institute
Quality Based Payment Reform (QBPR) Reference Guide
Value Based Purchasing (VBP) Overview: FFY 2017 Program
Measures, Performance Standards, Evaluation Periods, and Other Program Details for the FFY 2017 VBP Program
Measure Description
Measure ID
National
Threshold1
National
Benchmark2
0.4570
0.8450
0.7990
0.7500
0.777936
0.0000
0.0000
0.0000
0.0000
0.547889
0.7510
0.6980
0.0000
0.0000
1 Predicted
Infection
National
Threshold1
National
Benchmark2
Minimum
Standards4
95.4545%
95.1607%
3.1250%
100.0000%
99.7739%
0.0000%
10 Cases
Central Line-Associated Blood Stream Infection (CLABSI)
Catheter-Associated Urinary Tract Infection (CAUTI)
HAI_2*
Methicillin-resistant Staphylococcus Aureus (MRSA) Blood Laboratory-identified Events
HAI_5* (NEW)
Clostridium difficile (C.diff.)
HAI_6* (NEW)
PSI-90*
Patient Safety Indicator Composite (AHRQ Software v4.5a)
Pooled Surgical Site Infection (SSI) Measure**:
Clinical Care:
Process
Safety of Care
HAI_1*
HAI-3 *
HAI-4 *
Surgical Site Infection - Colon
Surgical Site Infection - Abdominal Hysterectomy
Measure ID
Measure Description
AMI-7a
Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
IMM-2
Patients Assessed and Given Influenza Vaccination
PC-01* (NEW)
Elective Delivery Prior to 39 completed Weeks Gestation
Total Performance Score:
Original Domain Weighting5
Minimum
Standards4
100%
1 Predicted
Infection
Safety of
Care
20%
3 Cases
70%
Clinical Care:
Outcomes
25%
Clinical Care:
Outcomes
Patient Experience of Care
National
2
Benchmark
Minimum
4
Standards
85.1458%
88.1794%
88.2986%
87.1669%
90.3985%
90.8124%
25 Cases
National Floor3
National
Threshold1
National
Benchmark2
Minimum
Standards4
58.14%
63.58%
37.29%
49.53%
41.42%
44.32%
64.09%
35.99%
78.19%
80.51%
65.05%
70.28%
62.88%
65.30%
85.91%
70.02%
86.61%
88.80%
80.01%
78.33%
73.36%
79.39%
91.23%
84.60%
100 Surveys
National
Threshold1
National
Benchmark2
Minimum
Standards4
Median Ratio
Across All
Mean Ratio of
Lowest Decile
25 Cases
MORT–30–AMI
MORT–30–HF
MORT–30–PN
Acute Myocardial Infarction (AMI) 30-Day Mortality Rate (converted to survival rate for VBP)
Heart Failure (HF) 30-Day Mortality Rate (converted to survival rate for VBP)
Pneumonia (PN) 30-Day Mortality Rate (converted to survival rate for VBP)
Measure ID
Measure Description
Communication with Nurses
Communication with Doctors
Responsiveness of Hospital Staff
Pain Management
Communication about Medicines
Hospital Cleanliness & Quietness
Discharge Information
Efficiency and
Cost Reduction
Overall Rating of Hospital
Measure Description
Measure ID
Spending Per Hospital Patient With Medicare
SPP-1* (MSPB-1)
60%
National
1
Threshold
Measure Description
Hospitals
***
of Hospitals
80%
Clinical Care:
Process 5%
Removed Measures: SCIP-Inf-2: Prophylactic Antibiotic Selection for Surgical Patients, SCIP-Inf-3: Prophylactic Antibiotics Discontinued within 24 Hours of Surgery, SCIP-Inf-9:
Postoperative Urinary Catheter Removal on Post Operative Day 1 or 2, SCIP-CARD-2: Beta Bloacker Prior to Arrival That Received a Beta Blocker During the Perioperative Period,
SCIP-VTE-2: Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery; PN-6: Initial Antibiotic Selection for CAP in Immunocompetent Patient
Measure ID
90%
50%
Patient
Experience
of Care
25%
40%
30%
20%
Efficiency
and Cost
Reduction
25%
10%
***
0%
FFY 2017 VBP Program Timeframes
2010
J
F
M
A
M
J
J
2011
A
S
O
N
D
J
F
M
A
M
J
J
2012
A
S
O
N
D
J
F
M
A
M
J
J
2013
A
S
O
N
D
J
F
M
A
M
J
J
2014
A
S
O
N
D
J
F
M
A
M
J
J
2015
A
S
O
N
D
Clinical Care - Process:
Baseline Period
F
M
A
M
J
J
2016
A
S
O
N
D
J
F
M
A
M
J
J
2017
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
Clinical Care - Process:
6
Performance Period
Patient Experience of Care:
7
Patient Experience of Care:
Baseline Period6
Performance Period7
Clinical Care - Outcomes:
Clinical Care - Outcomes:
Baseline Period6
Performance Period7
Safety of Care (PSI-90):
Safety of Care (PSI-90):
Baseline Period
J
6
Performance Period
Safety of Care (All other):
FFY 2017
Payment Adjustment
7
Safety of Care (All other):
Baseline Period6
Performance Period7
Efficiency and Cost Reduction:
Efficiency and Cost Reduction:
Baseline Period6
Performance Period7
Notes:
The Affordable Care Act (ACA) of 2010 mandated the implementation of an inpatient hospital value-based purchasing (VBP) Program. The VBP Program is a pay-for-performance program that links Medicare
payment to quality performance for acute care hospitals paid under the Inpatient Prospective Payment System (IPPS). Under the VBP Program, using a subset of the quality data reported from the Hospital
Inpatient Quality Reporting (IQR) Program grouped into quality domains, hospitals can earn points towards a Total Performance Score (TPS). The TPS will serve as the basis for determining hospitals’ VBP
payments or gain/loss under the program. In calculating the TPS, the scoring methodology provides points to hospitals that achieve high quality standards as well as points to hospitals that improve in the
quality measures evaluated. As required by the ACA, a pool of funds, to be redistributed to hospitals based on their TPS, will be funded through an across-the-board reduction to Medicare IPPS base operating
payments. The reduction for FFY 2017 is set at 2.0%. Critical Access Hospitals (CAHs), hospitals in Maryland and Puerto Rico, and small hospitals with insufficient numbers of measures and/or cases are
excluded from the program.
1
The National Threshold is the minimum performance standard for each measure and reflects the median performance score (50th percentile) for all hospitals in the nation during the baseline period. The
threshold is used in combination with other factors to calculate hospital-specific achievement points.
2
The National Benchmark is the top performance standard for each measure reflects the average performance score for the top 10% of all hospitals in the nation during the baseline period. The benchmark is
used in combination with other factors to calculate hospital-specific achievement and improvement points.
3
The National Floor is for Patient Experience of Care measures only and each measure reflects the lowest measure score in the nation during the baseline period. The floor is used in combination with other
factors to calculate hospital-specific consistency points.
4
Hospitals must meet minimum case and survey counts to be included in the VBP Program. In addition to the case count criteria, hospitals must have a minimum of 1 measure to obtain a Clinical Care - Process
of Care Domain score, 2 measures to obtain a Clinical Care - Outcomes Domain score, and 3 measures to obtain a Safety of Care domain score.
5
The Domain Weight is a weight applied to each domain to calculate a hospital-specific TPS. A hospital's weighted TPS is compared to TPSs for all hospitals to determine the hospital-specific gain or loss under
the program. If hospitals do not meet the minimum requirements on one or more domain, the other domains are proportionately reweighted to determine a TPS. For the FFY 2017 program, hospitals are
required to be scored on 3 of the 5 domains to be eligible for the program.
6
The Baseline Period is a specified period for which quality data collected under the IQR Program will be evaluated. The baseline period data is used for determining the national floors, thresholds, and
benchmarks (excluding the efficiency measure) and is also used in combination with other factors to calculate hospital-specific improvement points.
7
The Performance Period is a specified period for which quality data collected under the IQR Program will be evaluated. The performance period data is used in combination with other factors to calculate
hospital-specific achievement and improvement points.
*For these measures, lower scores are better.
**The final SSI measure score is an aggregate of the calculated scores for HAI-3 and HAI-4, which are then weighted based on the predicted infections for each measure. For purposes of domain eligibility, CMS considers
the two SSI measures as a single measure.
***
February 2016
Performance standards for the SPP-1 measure are based on the performance period and are not released in advance of the program.
4 of 10
Hospital Industry Data Institute
Quality Based Payment Reform (QBPR) Reference Guide
Value Based Purchasing (VBP) Overview: FFY 2018 Program
Measures, Performance Standards, Evaluation Periods, and Other Program Details for the FFY 2018 VBP Program
National
Threshold1
National
Benchmark2
0.3690
0.9060
0.7670
0.7940
0.964542
2.0408%
0.0000
0.0000
0.0000
0.0020
0.709498
0.0000%
0.8240
0.7100
0.0000
0.0000
1 Predicted
Infection
National
Threshold1
National
Benchmark2
Minimum
Standards4
85.0916%
88.3421%
88.2860%
87.3053%
90.7656%
90.7900%
25 Cases
National Floor3
National
Threshold1
National
Benchmark2
Minimum
Standards4
55.27%
57.39%
38.40%
52.19%
43.43%
40.05%
62.25%
37.67%
25.21%
78.52%
80.44%
65.08%
70.20%
63.37%
65.60%
86.60%
70.23%
51.45%
86.68%
88.51%
80.35%
78.46%
73.66%
79.00%
91.63%
84.58%
62.44%
100 Surveys
National
Threshold1
National
Benchmark2
Minimum
Standards4
Median Ratio
Across All
Mean Ratio of
Lowest Decile
25 Cases
Measure Description
Measure ID
Safety of Care
Central Line-Associated Blood Stream Infection (CLABSI)
HAI_1*
Catheter-Associated Urinary Tract Infection (CAUTI)
HAI_2*
Methicillin-resistant Staphylococcus Aureus (MRSA) Blood Laboratory-identified Events
HAI_5*
Clostridium difficile (C.diff.)
HAI_6*
Patient Safety Indicator Composite (Recalibrated AHRQ Software v5.0.1)
PSI-90*
PC-01* (MOVED)
Elective Delivery Prior to 39 completed Weeks Gestation
Pooled Surgical Site Infection (SSI) Measure**:
Clinical Care:
Outcomes
HAI-3 *
HAI-4 *
Measure Description
Patient Experience of Care
MORT–30–AMI
MORT–30–HF
MORT–30–PN
Acute Myocardial Infarction (AMI) 30-Day Mortality Rate (converted to survival rate for VBP)
Heart Failure (HF) 30-Day Mortality Rate (converted to survival rate for VBP)
Pneumonia (PN) 30-Day Mortality Rate (converted to survival rate for VBP)
Measure ID
Measure Description
Communication with Nurses
Communication with Doctors
Responsiveness of Hospital Staff
Pain Management
Communication about Medicines
Hospital Cleanliness & Quietness
Discharge Information
Overall Rating of Hospital
Efficiency and
Cost Reduction
CTM-3 (NEW)
3-Item Care Transitions Measure
Measure Description
Measure ID
Spending Per Hospital Patient With Medicare
SPP-1* (MSPB-1)
1 Predicted
Infection
90%
Safety of
Care
25%
3 Cases
10 Cases
80%
Surgical Site Infection - Colon
Surgical Site Infection - Abdominal Hysterectomy
Measure ID
Total Performance Score:
Original Domain Weighting5
100%
Minimum
Standards4
***
Hospitals
Clinical Care:
70%
Clinical Care:
Outcomes
25%
60%
50%
Patient
Experience
of Care
25%
40%
30%
20%
of Hospitals
Efficiency
and Cost
Reduction
25%
10%
***
0%
FFY 2018 VBP Program Timeframes
2009
J
F
M
A
M
J
J
2010
A
S
O
N
D
J
F
M
A
M
J
J
2011
A
S
O
N
D
J
F
M
A
M
J
J
2012
A
S
O
N
D
J
F
M
A
M
J
J
2013
A
S
O
N
D
J
F
M
A
M
J
J
2014
A
S
O
N
D
J
F
M
A
M
J
J
2015
A
S
O
N
D
J
F
M
A
M
J
J
2016
A
S
O
N
D
Patient Experience of
Care:
Baseline Period6
Clinical Care - Outcomes:
Baseline Period6
J
F
M
A
M
J
J
2017
A
S
O
N
D
J
F
M
A
M
J
J
2018
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
Patient Experience of
Care:
Performance Period7
Clinical Care - Outcomes:
Performance Period7
Safety of Care (PSI-90):
Baseline Period6
FFY 2018
Payment
Adjustment
Safety of Care (PSI-90):
Performance Period7
Safety of Care (All
other):
Baseline Period6
Safety of Care (All
other):
Performance Period7
Efficiency and Cost
Reduction:
Baseline Period6
Efficiency and Cost
Reduction:
Performance Period7
Notes:
The Affordable Care Act (ACA) of 2010 mandated the implementation of an inpatient hospital value-based purchasing (VBP) Program. The VBP Program is a pay-for-performance program that links Medicare
payment to quality performance for acute care hospitals paid under the Inpatient Prospective Payment System (IPPS). Under the VBP Program, using a subset of the quality data reported from the Hospital
Inpatient Quality Reporting (IQR) Program grouped into quality domains, hospitals can earn points towards a Total Performance Score (TPS). The TPS will serve as the basis for determining hospitals’ VBP
payments or gain/loss under the program. In calculating the TPS, the scoring methodology provides points to hospitals that achieve high quality standards as well as points to hospitals that improve in the
quality measures evaluated. As required by the ACA, a pool of funds, to be redistributed to hospitals based on their TPS, will be funded through an across-the-board reduction to Medicare IPPS base operating
payments. The reduction for FFY 2018 is set at 2.0%. Critical Access Hospitals (CAHs), hospitals in Maryland and Puerto Rico, and small hospitals with insufficient numbers of measures and/or cases are
excluded from the program.
1
The National Threshold is the minimum performance standard for each measure and reflects the median performance score (50th percentile) for all hospitals in the nation during the baseline period. The
threshold is used in combination with other factors to calculate hospital-specific achievement points.
2
The National Benchmark is the top performance standard for each measure reflects the average performance score for the top 10% of all hospitals in the nation during the baseline period. The benchmark is
used in combination with other factors to calculate hospital-specific achievement and improvement points.
3
The National Floor is for Patient Experience of Care measures only and each measure reflects the lowest measure score in the nation during the baseline period. The floor is used in combination with other
factors to calculate hospital-specific consistency points.
4
Hospitals must meet minimum case and survey counts to be included in the VBP Program. In addition to the case count criteria, hospitals must have a minimum of 2 measures to obtain a Clinical Care Outcomes Domain score and 3 measures to obtain a Safety of Care domain score.
5
The Domain Weight is a weight applied to each domain to calculate a hospital-specific TPS. A hospital's weighted TPS is compared to TPSs for all hospitals to determine the hospital-specific gain or loss under
the program. If hospitals do not meet the minimum requirements on one or more domain, the other domains are proportionately reweighted to determine a TPS. For the FFY 2018 program, hospitals are
required to be scored on 3 of the 4 domains to be eligible for the program.
6
The Baseline Period is a specified period for which quality data collected under the IQR Program will be evaluated. The baseline period data is used for determining the national floors, thresholds, and
benchmarks (excluding the efficiency measure) and is also used in combination with other factors to calculate hospital-specific improvement points.
7
The Performance Period is a specified period for which quality data collected under the IQR Program will be evaluated. The performance period data is used in combination with other factors to calculate
hospital-specific achievement and improvement points.
*For these measures, lower scores are better.
**The final SSI measure score is an aggregate of the calculated scores for HAI-3 and HAI-4, which are then weighted based on the predicted infections for each measure. For purposes of domain eligibility, CMS considers
the two SSI measures as a single measure.
***
Performance standards for the SPP-1 measure are based on the performance period and are not released in advance of the program.
February 2016
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Hospital Industry Data Institute
Quality Based Payment Reform (QBPR) Reference Guide
Value Based Purchasing (VBP) General Program Methodology
Hospital Scoring Methods and Other Program Details for the VBP Program
As required by the ACA, VBP eligible hospitals contribute a set percentage of their Medicare IPPS base operating payments to a national VBP pool of dollars. All VBP pool dollars are then paid
out, in full, based on each hospitals performance under the program. Under the Program, hospitals are evaluated on a measure by measure basis and receive a score of 0-10 on each measure
where they meet each measure's minimum requirement. Next, similar measures are grouped into domains and overall domain scores are calculated based on the average measure score in
the domain. Domain scores are then combined to find a Total Performance Score (TPS). The TPS serves as the basis for determining hospitals’ VBP payments or gain/loss under the program.
Using all program-eligible hospitals' Total Performance Scores, CMS calculates a VBP slope that redistributes all VBP contributions and makes the program budget neutral nationally. Each
hospitals TPS multiplied by the slope determines payout percentages. The basic program methodology is shown below:
Measure Scores
Domain
Scores
Total
Performance
Score
Payout
Percentage
VBP Slope
Adjustment
Factor
Program
Impact
Measure Score Calculation
For each measure, hospitals can receive a score of 0-10 depending on where they fall in relation to national performance standards (acheivement points) and/or how much they have
improved from historical rates/ratios (improvement points). After acheivement and improvement points are calculated, the higher of the two determines final points for each measure.
Patient Experience of Care - Consistency Points Calculation
In addition to individual measure scores, the Patient Experience of Care domain scores hospitals based on how consistently they perform across all measures within the domain. Each
hospital can receive between 0-20 consistency points based on the measure with the lowest Consistency Multiplier calculated as shown below:
Domain Score and Total Performance Score (TPS) Calculation
Individual measure scores for similar measures are combined to find overall Domain scores. On each domain, a minimum number of measures must be scored in order to be eligible for the
domain. Once domain scores are calculated, a total performance score is calculated, combining domain scores based on the program year's applicable domain weights. For the FFY 2013
and 2014 programs, hospitals must be scored on all domains to be eligible for the program. For FFY 2015 and future program years, domain weights are reweighted proportionally when
hospitals are not eligible for one or more domains.
VBP Slope/Linear Function, Payout Percentage, Adjustment Factor, and Program Impact Calculation
Once TPS scores are calculated for all eligible hospitals, the VBP slope is calculated such that all program contributions are paid out, making the program budget neutral nationally. The VBP
slope/linear function is used to determine each hospitals payout percentage (the amount of their contribution to the VBP pool they receive back) as well as final adjustment factors, and
impacts under the program.
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Quality Based Payment Reform (QBPR) Reference Guide
Readmission Reduction Program (RRP) Overview
Applicable conditions, performance timeframes, and other details for the FFY 2016, 2017, and 2018 programs
The Readmission Reduction Program (RRP) adjusts Medicare Inpatient payments based on hospital readmission rates for several conditions. This program is punitive only and
does not give hospitals credit for improvement over time or lower readmission rates than the nation. First, CMS compares hospital risk-adjusted readmission rates to national
rates to calculate excess readmission ratios for each condition. Next, CMS applies the excess ratio to aggregate payments for each condition to find excess readmission dollars
by condition. The sum of all excess readmission dollars for all applicable conditions divided by all inpatient operating revenue determines program adjustment factors/impacts
under the program. The basic program methodology is shown below:
Total Excess
Readmission Revenue
(all conditions)
Excess Readmission
Revenue by Condition
Excess Readmission
Ratios by Condition
RRP Adjustment Factor
Program Impact
Applicable Conditions:
$60
The RRP program evaluates hospital readmission rates for several
conditions. In FFY 2013/2014, hospitals were evaluated on AMI, Heart
Failure, and Pneumonia. Additional conditions, COPD and THA/TKA, were
added to the program in 2015, and CABG is added in 2017, along with an
expansion to the Pneumonia measure. Readmission rates, aggregate
payments by condition, and excess readmission dollars by condition are
all defined by a predetermined list of procedure and/or diagnoses codes
specific to each condition. Each condition excludes certain planned
readmissions or regular, scheduled followup care.
PN Expansion:
$9.10 Billion
$50
CABG:
$4.39 Billion
$40
2015 & 2016 Program
Each condition increases the revenue exposed under the program and
the potential for excess readmissions that results in penalties under the
program. The total estimated revenue across all hospitals for each
condition is shown in the graph to the right to indicate the relative
magnitude of each condition under the program.
COPD:
$6.49 Billion
2013 & 2014 Program
PN:
$6.77 Billion
Importantly, the two new measures added in FFY 2015 expanded the
program substantially and increased the national revenue exposure
under the program by 81%. The expansion in FFY 2017 is slightly less
significant, but increases the revenue at risk for excess readmissions for
the nation by an additional 33%. However, the magnitude of Hospital
specific revenue/exposure in each condition may vary.
HF:
$9.34 Billion
AMI:
$6.83 Billion
2017 & 2018 Program
THA/TKA:
$12.02 Billion
$30
$20
$10
$0
Estimated U.S. Revenue by Condition
Program Timelines
2011
J
F M A M J
J
2012
A S O N D
J
F M A M J
J
2013
A S O N D
J
F M A M J
J
2014
A S O N D
J
F M A M J
J
2015
A S O N D
J
F M A M J
J
2016
A S O N D
FFY 2016 Program
Performance Period (All Conditions)
J
F M A M J
J
2017
A S O N D
J
F M A M J
J
2018
A S O N D
J
F M A M J
J
A S O N D
FFY 2016 Program
Payment Adjustment
FFY 2017 Program
Performance Period (All Conditions)
FFY 2017 Program
Payment Adjustment
FFY 2018 Program
Performance Period (All Conditions)
FFY 2018 Program
Payment Adjustment
Notes:
1
Predicted Readmission Rate - Reflects the hospital's risk-adjusted, observed 30-day readmission rate following inpatient discharges for each applicable condition. Rates
are risk adjusted for age, sex, comorbidities, and other patient characteristics that may contribute to higher readmission rates. These rates also include exclusions for
readmissions that are a result of planned followup care, or unrelated readmissions that are never related to the index admission. Predicted rates reflect performance
for the three year period shown above.
2
Expected Readmission Rate - Reflects the U.S. 30-day readmission rate for each condition with hospital specific risk adjustments to estimate the expected U.S.
readmission rate for each hospitals patient mix. Rates are risk adjusted for age, sex, comorbidities, and other patient characteristics that may contribute to higher
readmission rates. These rates also include exclusions for readmissions that are a result of planned followup care, or unrelated readmissions that are never related to
the index admission. Expected rates reflect adjusted national performance for the three year period shown above.
3
Excess Readmission Ratio - Calculated for each condition under the program, this ratio represents how each hospital's actual, observed readmission rate differs from
the rate for all U.S. hospitals, adjusted for case-mix. An excess ratio greater than one indicates poorer performance than the country and results in payment penalties
while an excess ratio less than one indicates better performance and has no effect on payment.
4
Excess Readmission Revenue - Reflects the portion of revenue for each condition CMS believes was paid due to excess readmissions. Excess readmission revenue for
each condition is a function of base operating revenue for the condition as well as the excess ratio on the condition. Base operating dollars reflects operating payments
without adjustments for DSH, IME, or outlier payments.
5
Readmission Reduction Program Adjustment Factor - Under the RRP program, adjustment factors are calculated by dividing total excess readmission dollars (all
conditions) by total base operating dollars for all patients for the same three year performance period as measured by the readmission rates. Adjustment factors are
used to reduce IPPS payments on a per-discharge basis for performance under the program. CMS currently sets an adjustment factor floor of 0.9700, or a 3.0% payment
penalty.
February 2016
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Quality Based Payment Reform (QBPR) Reference Guide
Readmission Reduction Program (RRP) Overview: Condition Definitions
ICD-9-CM Codes used to Identify AMI, HF, PN, THA/TKA, COPD, and CABG Patients for the RRP Program
The Readmission Reduction Program (RRP) adjusts Medicare Inpatient payments based on hospital readmission rates for several conditions. In FFY 2013 and 2014, hospitals
were evaluated based on readmission rates for AMI, Heart Failure, and Pneumonia patients. In FFY 2015, the program expanded to include COPD and THA/TKA patients. In
FFY 2017, the program expands further to evaluate readmission rates for CABG patients and additional cohorts of Pneumonia patients.
For each condition, CMS compares hospital risk-adjusted readmission rates to national rates to calculate an excess ratio. Next, CMS applies the excess ratio to aggregate
payments for each condition to find excess readmission dollars by condition. The sum of all excess readmission dollars for all applicable conditions ultimately determines
adjustment factors/impacts under the program. The ICD-9-CM codes that are used to identify patients for each condition, determine hospital readmission rates, and to
estimate total revenue by condition are shown below:
Acute Myocardial Infarction (AMI) (FFY 2013+)
ICD-9
Description
ICD-9
410.00
AMI (anterolateral wall)—episode of care unspecified.
410.50
Description
AMI (other lateral wall)—episode of care unspecified.
410.01
AMI (anterolateral wall)—initial episode of care.
410.51
AMI (other lateral wall)—initial episode of care.
410.10
AMI (other anterior wall)—episode of care unspecified.
410.60
AMI (true posterior wall)—episode of care unspecified.
410.11
AMI (other anterior wall)—initial episode of care.
410.61
AMI (true posterior wall)—initial episode of care.
410.20
AMI (inferolateral wall)—episode of care unspecified.
410.70
AMI (subendocardial)—episode of care unspecified.
410.21
AMI (inferolateral wall)—initial episode of care.
410.71
AMI (subendocardial)—initial episode of care.
410.30
AMI (inferoposterior wall)—episode of care unspecified.
410.80
AMI (other specified site)—episode of care unspecified.
410.31
AMI (inferoposterior wall)—initial episode of care.
410.81
AMI (other specified site)—initial episode of care.
410.40
AMI (other inferior wall)—episode of care unspecified.
410.90
AMI (unspecified site)—episode of care unspecified.
410.41
AMI (other inferior wall)—initial episode of care.
410.91
AMI (unspecified site)—initial episode of care.
ICD-9
Description
402.01
402.11
402.91
404.01
404.03
404.11
Hypertensive heart disease, malignant, with heart failure.
Heart Failure (HF) (FFY 2013+)
404.13
Hypertensive heart disease, benign, with heart failure.
Hypertensive heart disease, unspecified, with heart failure.
Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified.
Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage V or end stage renal disease.
Hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified.
Hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified failure and chronic kidney
disease stage V or end stage renal disease.
404.93
428.xx
Hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney disease stage V or end stage renal disease heart failure and with chronic
kidney disease stage I through stage IV, or unspecified.
Hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney disease stage V or end stage renal disease.
Heart Failure.
ICD-9
Description
ICD-9
480.0
Pneumonia due to adenovirus.
482.42
Methicillin Resistant Pneumonia due to Staphylococcus Aureus.
480.1
Pneumonia due to respiratory syncytial virus.
482.49
Other staphylococcus pneumonia.
480.2
Pneumonia due to parainfluenza virus.
482.81
Pneumonia due to anaerobes.
480.3
Pneumonia due to SARS-associated coronavirus.
482.82
Pneumonia due to escherichia coli [e.coli].
480.8
Viral pneumonia: pneumonia due to other virus not elsewhere classified.
482.83
Pneumonia due to other gram-negative bacteria.
480.9
Viral pneumonia unspecified.
482.84
Pneumonia due to legionnaires’ disease.
481
Pneumococcal pneumonia [streptococcus pneumoniae pneumonia].
482.89
Pneumonia due to other specified bacteria.
482.0
Pneumonia due to klebsiella pneumoniae.
482.9
Bacterial pneumonia unspecified.
482.1
Pneumonia due to pseudomonas.
483.0
Pneumonia due to mycoplasma pneumoniae.
482.2
Pneumonia due to hemophilus influenzae [h. influenzae].
483.1
Pneumonia due to chlamydia.
482.30
Pneumonia due to streptococcus unspecified.
483.8
Pneumonia due to other specified organism.
482.31
Pneumonia due to streptococcus group a.
485
Bronchopneumonia organism unspecified.
482.32
Pneumonia due to streptococcus group b.
486
Pneumonia organism unspecified
482.39
Pneumonia due to other streptococcus.
487.0
Influenza with pneumonia
482.40
Pneumonia due to staphylococcus unspecified.
488.11
Influenza due to identified 2009 H1N1 influenza virus with pneumonia
482.41
Pneumonia due to staphylococcus aureus.
ICD-9
Description
404.91
Pneumonia (PN) (FFY 2013+)
Description
PN Expansion (FFY 2017+)
ICD-9
Description
Aspiration Pneumonia
507.0
Pneumonitis due to inhalation of food or vomitus
38.0
Streptococcal septicemia
Sepsis with Secondary Diagnosis of Pneumonia (Excludes Cases of Severe Sepsis or Septic Shock)
February 2016
38.41
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Septicemia due to hemophilus influenzae (h. influenzae)
Hospital Industry Data Institute
Quality Based Payment Reform (QBPR) Reference Guide
Readmission Reduction Program (RRP) Overview: Condition Definitions
ICD-9-CM Codes used to Identify AMI, HF, PN, THA/TKA, COPD, and CABG Patients for the RRP Program
38.10
Staphylococcal septicemia unspecified
38.42
Septicemia due to escherichia coli (e. coli)
38.11
Methicillin susceptible staphylococcus aureus septicemia
38.43
Septicemia due to pseudomonas
38.12
Methicillin resistant staphylococcus aureus septicemia
38.44
Septicemia due to serratia
38.19
Other staphylococcal septicemia
38.49
Other septicemia due to gram-negative organisms
38.2
Pneumococcal septicemia
38.8
Other specified septicemias
38.3
Septicemia due to anaerobes
38.9
Unspecified septicemia
38.40
Septicemia due to gram-negative organism unspecified
995.91
Sepsis
ICD-9
Description
491.21
Obstructive chronic bronchitis; With (acute) exacerbation; acute exacerbation of COPD, decompensated COPD, decompensated COPD with exacerbation.
491.22
Obstructive chronic bronchitis; with acute bronchitis.
491.8
Other chronic bronchitis. Chronic: tracheitis, tracheobronchitis.
491.9
493.20
Unspecified chronic bronchitis.
Other emphysema; emphysema (lung or pulmonary): NOS, centriacinar, centrilobular, obstructive, panacinar, panlobular, unilateral, vesicular. MacLeod’s syndrome; SwyerJames syndrome; unilateral hyperlucent lung.
Chronic obstructive asthma; asthma with COPD, chronic asthmatic bronchitis, unspecified.
493.21
Chronic obstructive asthma; asthma with COPD, chronic asthmatic bronchitis, with status asthmaticus.
493.22
Chronic obstructive asthma; asthma with COPD, chronic asthmatic bronchitis, with (acute) exacerbation.
Chronic: nonspecific lung disease, obstructive lung disease, obstructive pulmonary disease (COPD) NOS. NOTE: This code is not to be used with any code from categories
491–493.
Chronic Obstructive Pulmonary Disease (COPD) (FFY 2015+)
492.8
496
518.81
Other diseases of lung; acute respiratory failure; respiratory failure NOS.
518.82
Other diseases of lung; acute respiratory failure; other pulmonary insufficiency, acute respiratory distress.
518.84
799.1
Other diseases of lung; acute respiratory failure; acute and chronic
respiratory failure.
Other ill-defined and unknown causes of morbidity and mortality; respiratory arrest, cardiorespiratory failure.
Total Hip Arthroplasty (THA) And/Or Total Knee Arthroplasty (TKA) (FFY 2015+)
ICD-9
Description
81.51
Total hip arthroplasty.
81.54
Total knee arthroplasty.
Coronary Artery Bypass Graft (CABG) (FFY 2017+)
ICD-9
Description
36.1x
Aortocoronary bypass for heart revascularization, not otherwise specified
36.15
36.11
(Aorto) coronary bypass of one coronary artery
36.16
Double internal mammary- coronary artery bypass
36.12
(Aorto coronary bypass of two coronary arteries
36.17
Abdominal- coronary artery bypass
36.13
(Aorto) coronary bypass of three coronary arteries
36.19
Other bypass anastomosis for heart revascularization
36.14
(Aorto) coronary bypass of four or more coronary arteries
Single internal mammary- coronary artery bypass
Notes:
Readmission rates, aggregate payments by condition, and excess readmission dollars by condition are all defined by a predetermined list of procedure/diagnoses codes specific to
each condition, listed above. Each condition also includes logic to exclude certain planned readmissions or regular, scheduled followup care.
In general, the Readmission Reduction Program (RRP) excludes certain patients from estimates of aggregate revenue by condition as well as the rates used to evaluate hospitals
on each condition. For all measures, the following patients are excluded from the rates/revenue estimates used to calculate program adjustments:
- Patients who are not enrolled in Medicare fee-for-service (FFS)
- Patients under the age of 65
- Patients without substantial post-discharge enrollment in a Medicare FFS plan
- Patients who were discharged against medical advice (AMA)
- Certain patients who were transferred to/from another inpatient hospital
For each condition, other condition-specific exclusions and adjustments may apply. Full detail on measure methodology is provided here:
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1219069855841
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Quality Based Payment Reform (QBPR) Reference Guide
Hospital Acquired Condition (HAC) Reduction Program Overview
Applicable conditions, performance timeframes, and other details for the FFY 2016, 2017, and 2018 programs
The Hospital Acquired Condition (HAC) Reduction Program sets payment penalties each year for hospitals in the top quartile (worst performance) of HAC rates for the country. The HAC reduction program is
punitive only and does not give hospitals credit for improvement over time. Under the program, hospitals are scored measure by measure based on their decile ranking nationwide. Scores for similar measures
are combined into domain scores. Domain scores are then weighted together into a Total HAC score. The Total HAC score is used to determine the top quartile (worst performance) for payment penalty in
each year. The HAC payment penalty is 1.0% of total Medicare Fee-For-Service (FFS) revenue and does not change year to year. The basic program methodology is shown below:
Domain Scores
Measure Scores
Top Quartile/1.0% Penalty
Determination
Total HAC Score
Domain 2: CDC Chart Abstracted Measures2
Domain 1: AHRQ Claims Based Measures
PSI-90: Patient Safety Indicator Composite Ratio 1
PSI 15: Accidental Puncture or Laceration
PSI 12: Postop PE Or DVT
Weight
49.2%
25.8%
PSI 13: Postop Sepsis
7.4%
PSI 6: Iatrogenic Pneumothorax
7.1%
PSI 7: Central Venous Catheter-Related Blood
6.5%
PSI 3: Decubitus Ulcer
2.3%
PSI 14: Postop Wound Dehiscence
1.7%
PSI 8: Postop Hip Fracture
0.1%
Annual Program Impact
Domain Weight4
Domain Weight4
Central Line Associated Blood Stream Infection (CLABSI)
Catheter Associated Urinary Tract Infection (CAUTI)
Surgical Site Infection (SSI) Pooled SIR3
SSI from Colon Surgery
SSI from Abdominal Hysterectomy
25% (FFY 2016)
15% (FFY 2017+)
75% (FFY 2016)
85% (FFY 2017+)
Clostridium difficile (C.diff.) SIR (FFY 2017+)
Methicillin-resistant Staphylococcus Aureus (MRSA) (FFY 2017+)
Measure Scoring
National HAC Ratio
Percentile Range
1st-10th
11th-20th
21st-20th
31st-40th
41st-50th
51st-60th
61st-70th
71st-80th
81st-90th
91st-100th
Measure Points
(Lower is Better)
1 pt.
2 pts.
3 pts.
4 pts.
5 pts.
6 pts.
7 pts.
8 pts.
9 pts.
10 pts.
For each program measure, HAC ratios for all program-eligible hospitals nationwide are separated into deciles for scoring (lowest decile = best performers).
Hospitals are awarded points based on their national decile. When multiple hospitals have the same ratio and the ratio crosses more than one decile, the lowest
decile determines the measure score.
In order to receive a score on a measure, hospitals must meet minimum requirements. For Domain 1, a hospital must have 3 or more cases in at least one of the
eight component PSI measures that make up the PSI-90 composite measure. For Domain 2, a hospital must have 1 or more predicted infections.
*Measures not meeting the minimum scoring requirements are dropped from the domain score calculation. If a domain does not contain at least one eligible
measure, then the Total HAC score is determined based solely on the other domain. Beginning 2017, hospitals will receive a score of 10 for any Domain 2
measure that is not submitted, unless provided with a waiver.
Other Program Calculations
Pooled Standardized Infection Ratio (SIR) (SSI measures only) =
(Observed Infections for Abdominal Hysterectomy + Observed Infections for Colon)
(Predicted Infections for Abdominal Hysterectomy + Predicted Infections for Colon)
Overall Domain Score = Average measure score for all scored measures
Total HAC Score = Domain1 Score x Domain1 Weight + Domain2 Score x Domain2 Weight
Annual Program Impact5 = Medicare FFS Inpatient Dollars x 1.0% - Medicare FFS Inpatient Dollars 1
Program Timelines
2012
2013
2014
2015
2016
2017
2018
J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D
FFY 2016: Domain 1
Performance Period
FFY 2016 Program
Payment Adjustment
FFY 2016: Domain 2
Performance Period
FFY 2017: Domain 1
Performance Period
FFY 2017 Program
Payment Adjustment
FFY 2017: Domain 2
Performance Period
FFY 2018: Domain 1
Performance Period
FFY 2018: Domain 2
Performance Period
FFY 2018 Program
Payment Adjustment
Notes:
1
The Domain 1 PSI-90 composite measure is calculated by combining performance on 8 individual Patient Safety Indicator (PSI) measures. While hospitals are scored on the overall PSI-90 composite measure, each
component PSI and their weight towards the overall composite are shown above. Weights shown are based on version 4.5a of the AHRQ Quality Indicators software.
2
CDC Measure Updates: Beginning in FFY 2018, CMS will rebase the CDC measure reference population data to calendar year 2015, resulting in changes to the denominators used to calculate the HAI SIRs. In addition,
the CAUTI and CLABSI measures will be expanded to include non-ICU medical, surgical, and medical/surgical wards for the FFY 2018 program year.
3
The pooled Surgical Site Infection (SSI) measure is made up of two individual SSI measures: SSI - Abdominal Hysterectomy and SSI - Colon. For the pooled SIR measure, observed infections for both SSI measures are
divided by predicted infections to calculate a pooled SIR. Hospitals are then evaluated and assigned measure points based on their pooled SIR.
4
Individual measure scores are combined into domain scores, and domain scores are combined into a Total HAC score. The number of measures included and the weight associated with Domain 2 have increased over
time.
5
Unlike the Value Based Purchasing and Readmission Reduction Program, penalties under this program are applied to total Medicare payments, inclusive of Operating, Capital, Uncompensated Care payments, and
outlier payments, inclusive of payment adjustments such as DSH, IME, and Value based purchasing (VBP)/Readmission Reduction Program (RRP) program adjustments.
February 2016
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