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Quality Measures Linked to Payment

Medicare now adjusts its payment for hospital care according to prescribed quality measurements. Such measures drive incentive payments/penalties and are publicly reported through the Hospital Compare website.

This report summarizes a hospital's performance in programs that adjust payment according to quality measures. All data are based on Hospital Compare, CMS' official source of information about the program and supplemental data files provided by CMS.

Hospital Value-Based Purchasing Program

Beginning in FY13, the HVBP Program began rewarding hospitals for improving and maintaining high levels of measurable quality and penalizing hospitals with sub standard performance. Over subsequent years, hospitals can expect quality measurements to change as Medicare seeks to improve readmission rates, mortality measures, the incidence of hospital-acquired complications, and other patient safety indicators.

Fiscal Year
Beginning in FY 2013, the measures, comparative periods, and other components are expected to change. This report will report domain scores and TPS scores for each year as actual data are available.
Clinical Process of Care Domain
The unweighted normalized score for a set of clinical process of care measures (0-100). Each measure is scored individually according to comparison with peers during a performance period and/or improvement in performance in comparison versus a base year. Individual scores are then aggregated into a single domain score.
Patient Experience of Care Domain
The unweighted score for a set of questions from the HCAHPS survey (0-100). The Hospital Consumer Assessment of Healthcare Providers and Systems survey is a national instrument that asks patients about their experiences during a recent hospital stay.
Outcome Domain
The unweighted normalized score for a set of outcome measures (0-100). Each measure is scored individually according to comparison with peers during a performance period and/or improvement in performance in comparison versus a base year. Individual scores are then aggregated into a single domain score.
Efficiency Domain
The unweighted normalized score for a set of efficiency measures (0-100). Each measure is scored individually according to comparison with peers during a performance period and/or improvement in performance in comparison versus a base year. Individual scores are then aggregated into a single domain score.
Safety Domain
The unweighted normalized score for a set of safety measures (0-100). Each measure is scored individually according to comparison with peers during a performance period and/or improvement in performance in comparison versus a base year. Individual scores are then aggregated into a single domain score.
Total Performance Score
The TPS is an aggregated score (0-100) based on individual domain scores, with each domain weighted separately. It is used to determine the adjustment to DRG payments for an entire fiscal year.
National Percentile
In order to characterize a particular hospital's TPS, the report calculates a percentile ranking with scores for all hospitals.
Payment Adjustment
The percentage a hospital's DRG payment amount is adjusted as the result of the Value Based Purchasing program. This adjustment may be positive for better performance or negative for lower performance.

Readmission Reduction Program

Beginning in FY13, CMS reduces Medicare payments for Inpatient Prospective Payment System hospitals with excess readmissions. Excess readmissions are measured by a ratio, by dividing a hospital's number of "predicted" 30-day readmissions for heart attack, heart failure, and pneumonia by the number that would be "expected," based on an average hospital with similar patients. A ratio greater than 1 indicates excess readmissions.

Measure Name
The diagnoses for which readmissions are measured. These currently include Heart Attack, Heart Failure, Pneumonia, COPD, CABG, and Hip/Knee procedures.
Excess Readmission Ratio
The ratio of the observed readmission rate to a predicted readmission rate is computed for each measure.
Cases
The number of cases that meet inclusion criteria during the collection period are reported for each measure.
Readmissions Adjustment Factor
CMS calculates an adjustment factor based on excess readmissions for all measures. This factor is a multiplier applied to Medicare payments for each patient during the fiscal year. For example, a factor of 0.9974 indicates that that a hospital would receive only 99.74% of usual reimbursement due to an adjustment for excess readmissions.
Payment Adjustment
For additional clarity the Readmissions Adjustment Factor is also expressed as a Payment Adjustment percentage indicating the percentage change in payment attributed to excess readmissions.

Hospital-Acquired Conditions (HAC) Reduction Program

Beginning in FY15, CMS reduces Medicare payments for Inpatient Prospective Payment System hospitals with a high rate of complications occurring after admission. HACs are a group of reasonably preventable conditions that patients did not have upon admission to a hospital, but which developed during the hospital stay.

Hospital performance under the HAC Reduction Program was initially determined based on a hospital's Total HAC Score, which could range from 1 to 10. The higher a hospital's Total HAC Score, the worse the hospital performed under the HAC Reduction Program.

Beginning in FY18, CMS changed the scoring methodology for the HAC Reduction Program. Under this revised methodology, scores tend to range between -3 and 3.

Serious Complications Score
The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI) 90 composite measure is calculated using hospitals' Medicare fee-for-service claims during the collection period. It includes the following eight PSIs:
  • PSI 03 - Pressure Ulcer
  • PSI 06 - Iatrogenic Pneumothorax
  • PSI 07 - Central Venous Catheter-Related Bloodstream Infections
  • PSI 08 - Postoperative Hip Fracture
  • PSI 12 - Perioperative Pulmonary Embolism or Deep Vein Thrombosis
  • PSI 13 - Postoperative Sepsis
  • PSI 14 - Postoperative Wound Dehiscence
  • PSI 15 - Accidental Puncture or Laceration
CLABSI Score
Central line-Associated Blood Stream Infections (CLABSI) are calculated using chart-abstracted surveillance data for infections reported by hospitals.
CAUTI Score
Catheter-Assoricated Urinary Tract Infections (CAUTI) are calculated using chart abstracted surveillance data for infections reported by hospitals.
SSI Score
Surgical Site Infections (SSI) are calculated using chart abstracted surveillance data for infections reported by hospitals.
MRSA Score
Methicillin-Resistant Staphylococcus Aureus (MRSA) are calculated using chart abstracted surveillance data for infections reported by hospitals.
CDI Score
Clostridium difficile (C.diff.) Infection (CDI) are calculated using chart abstracted surveillance data for infections reported by hospitals.
Total HAC Score

A Hospital's Total HAC Score is defined by CMS as the sum of weighted Domain 1 and Domain 2 scores. For FY15 - FY 17, the Total HAC Score ranges from 1-10.

Beginning in FY18, CMS changed the scoring methodology for the HAC Reduction Program. Under this revised methodology, scores tend to range between -3 and 3.

Payment Adjustment
Hospitals that rank in the quartile of hospitals with the highest Total HAC Scores receive a 1% payment reduction in payment in FY2015.
YearHighest Quartile
FY20190.3429
FY20180.3687
FY20176.5700
FY20166.7500
FY20157.0000