1. All CMS Measures at a Glance
2. CMS Star Rating Measures
3. Value-Based Purchasing (VBP)
4. Hospital-Acquired Condition Reduction Program (HACRP)
5. Hospital Readmission Reduction Program (HRRP)
6. Impact of Different Measures on CMS Programs

All CMS Measures at a Glance

CMS has come up with different programs to improve health outcomes by focusing on improving various aspects of the healthcare system. Dexur’s data provides in-depth information on the metrics of different programs such as CMS Star Ratings, VBP, HRRP, and HAC. While hospitals have to wait for more than a year to get this data from CMS, Dexur replicates CMS algorithms and updates the data at DRG levels only with a 5-6 month delay.

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CMS Star Rating

CMS has implemented a 5-star rating system to evaluate the experiences medicare beneficiaries have with their healthcare service providers. The hospitals are rated on a scale of 1 to 5, with 5 being the highest. While there are no financial incentives linked to the program, the rating determines the reputation of hospitals, and patients are motivated to go with the hospitals that have the highest rating. There is a total of 5 measure groups with each one contributing a different percentage to the overall rating.

Generally, the four outcome measure groups (Mortality, Safety of Care, Patient Experience, Timely and Effective Care) were weighted at 22% each, and the three process measure groups (Effectiveness of Care, Timeliness of care, Efficient Use of Medical Imaging) were weighted at 4% each in FY 2017, 2019, and 2020. In FY 2021, four outcome measure groups' weightage remain the same at 22% and three process measure groups (Effectiveness of Care, Timeliness of Care, and Efficient Use of Medical Imaging) are consolidated into one process measure group called Timely and Effective Care with a weightage of 12%.

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Value Based Purchasing

The hospital Value-Based Purchasing (VBP) program was implemented to improve the clinical outcomes, efficiency, safety of patients during the inpatient stays. CMS has developed different metrics to evaluate the performance of the hospitals and provide financial incentives to hospitals based on the measures. CMS has grouped these measures under four domains namely: Clinical outcomes, Efficiency and Cost reduction, Safety, and Person and Community engagement. Each domain weighs 25% of the Total Performance Score.

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Hospitals Readmissions Reduction Program

HRRP is intended to improve the communication and coordination between caregivers and patients in developing discharge plans to avoid possible readmissions. The program achieves the goal by linking payments to value outcomes. CMS considers 6 conditions as part of the program and calculates the 30-day readmission measure. The payments are determined based on the performance of the hospital during a 3-year period.

• Acute myocardial infarction (AMI)

• Chronic obstructive pulmonary disease (COPD)

• Heart failure (HF)

• Pneumonia

• Coronary artery bypass graft (CABG) surgery

• Elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA)

*Abbreviated performance periods due to the data exclusions stipulated in an Interim Final Rule (CMS-3401-IFC) which specifies that CMS will exclude claims data and HAI data that hospitals have submitted for Q1 2020 and Q2 2020 from program calculations for the HRRP.

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Hospital-Acquired Condition Reduction Program

Through this program, CMS aims to reduce hospital-acquired infections that occur as a result of negligence and improve the quality of care during inpatient stays. CMS links financial payments to the HAC measures to encourage hospitals to improve their score. CMS uses the total HAC score to determine the lowest-scoring hospitals and reduces payment while paying the medicare claims. The total HAC score is calculated using 6 measures:

• Patient Safety Indicator (PSI) 90

• Central Line-Associated Bloodstream Infection (CLABSI)

• Catheter-Associated Urinary Tract Infection (CAUTI)

• Surgical Site Infection (SSI) – colon and hysterectomy

• Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia

• Clostridium difficile Infection (CDI)

*Abbreviated performance periods due to the data exclusions stipulated in an Interim Final Rule (CMS-3401-IFC) which specifies that CMS will exclude claims data and HAI data that hospitals have submitted for Q1 2020 and Q2 2020 from program calculations for the HAC Reduction Program.

CMS finalized the adoption of the Equal Measure Weights approach in the FY 2019. The Equal Measure Weights approach applies an equal weight to each measure for which a hospital has a measure score. In the following diagram standard weight for each measure is 16.67% when hospital has all 6 measures score. In Re-proportioned Weight Scenario A, hospital has 5 measures score and weight for each measure is 20% as per Equal Measure Weights approach. In Re-proportioned Weight Scenario B, hospital has 4 measures score and weight for each measure is 25% as per Equal Measure Weights approach. In Re-proportioned Weight Scenario C, hospital has 3 measures score and weight for each measure is 33.33% as per Equal Measure Weights approach. In Re-proportioned Weight Scenario D, hospital has 2 measures score and weight for each measure is 50% as per Equal Measure Weights approach.

CMS takes an extended amount of time in calculating the measures and releasing the scores to healthcare service providers. Hospitals can not devise any actionable plans to address the low scoring areas due to the time delay. Dexur replicates the same algorithms and provides data at DRG levels at a much faster rate to help hospitals develop specific plans to improve their score.

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Impact of different measures on CMS programs

Mortality Rates

The mortality rate is an important metric that has a significant weightage in different CMS programs. It weighs 22% in the CMS Star Rating program and 25% in the VBP program under the Clinical Outcomes domain. Dexur provides the mortality rates for different time periods at DRG levels to help hospitals understand their performance. Hospitals can give special attention to conditions that have a high mortality rate and come up with specific treatment plans to improve their score. Only certain conditions are taken into account in calculating the mortality score for VBP and Star Rating program.

• AMI 30 Day Mortality Rate

• CABG 30 Day Mortality Rate

• COPD 30 Day Mortality Rate

• Heart Failure 30 Day Mortality Rate

• Pneumonia 30 Day Mortality Rate

• Stroke 30-day Mortality Rate

• Death rate among surgical inpatients with serious treatable complications

Safety/Hospital-Acquired Conditions

Safety is another important metric that impacts multiple CMS programs. The safety measure forms an integral part of VBP program contributing 25% to it. The metric also weighs 22% in the star rating program. The metric is used to assess the safety aspect of hospitals and prevent the occurrence of infections during the inpatient stay.

MSPB

MSPB is the sole metric used to calculate the Efficiency and Cost reduction domain in the VBP program. It measures the cost to Medicare for services performed by healthcare providers. The costs incurred from 3-day prior admission period to 30-day post-discharge is used to calculate the MSPB costs. In order to calculate the MSPB for each hospital, Dexur determined the time frame of the spending per beneficiary episode during which Medicare payments would be aggregated and the type of Medicare payments to be aggregated over this time frame. See Dexur’s MSPB features here.

Readmission Rates

The readmission rate weighs 22% in the star rating program and also has a significant impact on the VBP program under the MSPB domain. The star rating program only considers the readmission rate of certain conditions, the same ones used to calculate the mortality rate. The readmission rates are calculated post 30 days from the discharge period.

HCAHPS scores

CMS uses the HCAHPS score to calculate the Personal and Community Engagement domain in the VBP program and Patient Experience in the star rating program. CMS developed a standardized survey of patient’s healthcare experience in collaboration with AHRQ (Agency for Healthcare Research and Quality). The survey is comprised of 27 questions that measure a patient’s experience with:

• Communication with healthcare service providers

• Information about medicines

• 3-item care transition

• Responsiveness

• Hospital hygiene

• Discharge information

• Overall rating of the hospital

The survey is not limited to Medicare beneficiaries and any patient who has spent at least one night in a hospital facility can participate in the survey. The patients would be requested to fill the survey from 48 hours to 6 weeks after the discharge.

Timely and Effective Care Measures

The measures of timely and effective care, also known as process of care measures, part of the CMS Star-Rating, show how often or how quickly hospitals provide care that research shows gets the best results for patients with cataract surgery, a colonoscopy, a heart attack, emergency department care, preventative care, a stroke, a blood clot, or childbirth. Hospitals voluntarily submit data from their medical records about the treatments their patients receive for these conditions, including patients with Medicare and those who do not have Medicare.

Efficient Use of Medical Imaging

The measures on the use of medical imaging show how often a hospital provides specific imaging tests for Medicare beneficiaries under circumstances where the imaging may not be medically appropriate. Lower percentages suggest more efficient use of medical imaging. The measure is only aplicaple for Medicare patients who were treated in an outpatient setting. Measures included in calculator of CMS Star Rating are as following:

• MRI lumbar spine for low back pain

• Abdomen CT - use of contrast material

• Thorax CT Use of Contrast Material

• Cardiac imaging for preoperative risk assessment for non-cardiac low-risk surgery

• Outpatients with brain CT scans who got a sinus CT scan at the same time