§ 512.315 - Composite quality scores for determining reconciliation payment eligibility and effective and applicable discount factors.

§ 512.315 Composite quality scores for determining reconciliation payment eligibility and effective and applicable discount factors.

(a) General. An EPM participant's eligibility for a reconciliation payment under § 512.305, and the determination of effective discount factors and applicable discount factors for reconciliation and repayment, respectively, under paragraphs (b)(5), (c)(5), and (d)(5) of this section, for a performance year depend on the EPM participant's EPM composite quality score (including any quality performance points and quality improvement points earned) for that performance year.

(b) AMI model -

(1) AMI model composite quality score. CMS calculates an AMI model composite quality score for each AMI model participant for each performance year, which equals the sum of the following:

(i) The AMI model participant's quality performance points for the Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Acute Myocardial Infarction (NQF #0230) measure described in § 512.411(a)(1). This measure is weighted at 50 percent of the AMI model composite quality score.

(ii) The AMI model participant's quality performance points for the Excess Days in Acute Care after Hospitalization for AMI measure described in § 512.411(a)(2). This measure is weighted at 20 percent of the AMI model composite quality score.

(iii) The AMI model participant's quality performance points for the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (NQF #0166) measure described in § 512.411(a)(3). This measure is weighted at 20 percent of the AMI model composite quality score.

(iv) Any additional quality improvement points the AMI model participant may earn as a result of demonstrating improvement on the quality measures in § 512.411(a), as described in paragraph (b)(3) of this section.

(v) If applicable, 2 additional points for successful Hybrid Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Acute Myocardial Infarction (AMI) Hospitalization (NQF #2473) measure voluntary data submission as described in § 512.411(b)(2). Successful submission is weighted at 10 percent of the AMI model composite quality score.

(2) AMI model quality performance points. CMS computes quality performance points for each quality measure based on the AMI model participant's performance percentile relative to the national distribution of all subsection (d) hospitals that are eligible for payment under the IPPS and meet the minimum measure patient case or survey count.

(i) For the Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Acute Myocardial Infarction (NQF #0230) measure described in § 512.411(a)(1), CMS assigns the AMI model participant measure value to a performance percentile and then quality performance points are assigned based on the following performance percentile scale:

(A) 10.00 points for ≥ 90th.

(B) 9.25 points for ≥ 80th and < 90th.

(C) 8.50 points for ≥ 70th and < 80th.

(D) 7.75 points for ≥ 60th and < 70th.

(E) 7.00 points for ≥ 50th and < 60th.

(F) 6.25 points for ≥ 40th and < 50th.

(G) 5.50 points for ≥ 30th and < 40th.

(H) 0.00 points for < 30th.

(ii) For the Excess Days in Acute Care after Hospitalization for AMI measure described in § 512.411(a)(2), CMS assigns the AMI model participant measure value to a performance percentile and then quality performance points are assigned based on the following performance percentile scale:

(A) 4.00 points for ≥ 90th.

(B) 3.70 points for ≥ 80th and < 90th.

(C) 3.40 points for ≥ 70th and < 80th.

(D) 3.10 points for ≥ 60th and < 70th.

(E) 2.80 points for ≥ 50th and < 60th.

(F) 2.50 points for ≥ 40th and < 50th.

(G) 2.20 points for ≥ 30th and < 40th.

(H) 0.00 points for < 30th.

(iii) For the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (NQF #0166) measure described in § 512.411(a)(3), CMS assigns the AMI model participant measure value to a performance percentile and then quality performance points are assigned based on the following performance percentile scale:

(A) 4.00 points for ≥ 90th.

(B) 3.70 points for ≥ 80th and < 90th.

(C) 3.40 points for ≥ 70th and < 80th.

(D) 3.10 points for ≥ 60th and < 70th.

(E) 2.80 points for ≥ 50th and < 60th.

(F) 2.50 points for ≥ 40th and < 50th.

(G) 2.20 points for ≥ 30th and < 40th.

(H) 0.00 points for < 30th.

(3) AMI model quality improvement points. If an AMI model participant's own improvement in the participant's measure point estimate from the previous year on an individual measure described in § 512.411(a), regardless of the participant's measure point estimate starting and ending values, falls into the top 10 percent of all subsection (d) hospitals that are eligible for payment under the IPPS based on the national distribution of measure improvement over the most recent 2 years, then the AMI model participant is eligible to receive quality improvement points up to 10 percent of the total available points for that measure. The AMI model composite quality score is capped at 20 points.

(4) Exception for AMI model participants without a measure value. In the case of an AMI model participant without a measure value that would allow CMS to assign quality performance points for that quality measure, CMS assigns the 50th percentile quality performance points to the AMI model participant for the individual measure.

(i) An AMI model participant does not have a measure value for the -

(A) Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Acute Myocardial Infarction (NQF #0230) measure described in § 512.411(a)(1) if the participant does not meet the minimum 25 case count.

(B) Excess Days in Acute Care after Hospitalization for AMI measure described in § 512.411(a)(2) if the participant does not meet the minimum 25 case count.

(C) Hospital Consumer Assessment of Healthcare Providers and Systems Survey (NQF #0166) measure described in § 512.411(a)(3) if the participant does not meet the minimum of 100 completed surveys and does not have 4 consecutive quarters of HCAHPS data.

(D) Measures described in paragraphs (4)(i)(A) through (C) of this section, if CMS identifies an error in the data used to calculate the measure and suppresses the measure value.

(5) Establishing AMI model reconciliation payment eligibility and effective and applicable discount factors. CMS determines reconciliation payment eligibility and the effective discount factor for reconciliation payments in all performance years and repayment amounts in performance year 5, as well as the applicable discount factor for repayment amounts in performance year 2 for AMI model participants who elect early downside risk, and performance years 3 and 4 for all AMI model participants based on the AMI model composite quality score described in paragraph (b)(1) of this section.

(i) Reconciliation payment eligibility requires an acceptable or better quality category, defined as an AMI model composite quality score of greater than or equal to 3.8.

(ii) Effective discount factor for reconciliation payments.

(A) A 3.0 percentage point effective discount factor for AMI model participants in the unacceptable or acceptable category, defined as an AMI model composite quality score that is less than 6.3.

(B) A 2.0 percentage point effective discount factor for AMI model participants in the good quality category, defined as an AMI model composite quality score that is greater than or equal to 6.3 and less than or equal to 15.0.

(C) A 1.5 percentage point effective discount factor for AMI model participants in the excellent quality category, defined as an AMI model composite quality score that is greater than 15.0.

(iii) Applicable discount factor for repayment amount in performance year 2 for AMI model participants who elect early downside risk, and years 3 and 4 for all AMI model participants.

(A) A 2.0 percentage point applicable discount factor for AMI model participants in the unacceptable or acceptable quality category, defined as an AMI model composite quality score of less than 6.3.

(B) A 1.0 percentage point applicable discount factor for AMI model participants in the good quality category, defined as an AMI model composite quality score that is greater than or equal to 6.3 and less than or equal to 15.0.

(C) A 0.5 percentage point applicable discount factor for AMI model participants in the excellent quality category, defined as an AMI model composite quality scores that is greater than 15.0.

(iv) Effective discount factor for repayment amount in performance year 5 for all AMI model participants.

(A) A 3.0 percentage point applicable discount factor for AMI model participants in the unacceptable or acceptable quality category, defined as an AMI model composite quality score of less than 6.3.

(B) A 2.0 percentage point applicable discount factor for AMI model participants in the good quality category, defined as an AMI model composite quality score that is greater than or equal to 6.3 and less than or equal to 15.0.

(C) A 1.5 percentage point applicable discount factor for AMI model participants in the excellent quality category, defined as an AMI model composite quality scores that is greater than 15.0.

(c) CABG model -

(1) CABG model composite quality score. CMS calculates a CABG model composite quality score for each CABG model participant for each performance year, which equals the sum of the following:

(i) The CABG model participant's quality performance points for the Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery (NQF #2558) measure described in § 512.412(a)(1). This measure is weighted at 70 percent of the CABG model composite quality score.

(ii) The CABG model participant's quality performance points for the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (NQF #0166) measure described in § 512.412(a)(2). This measure is weighted at 20 percent of the CABG model composite quality score.

(iii) If applicable, 2 additional points for successful submission of the STS CABG data that supports the following 7 measures:

(A) NQF #0134 - CABG: Use of Internal Mammary Artery in Patients with Isolated CABG Surgery.

(B) NQF #0236 - CABG: Preoperative Beta Blocker in Patients with Isolated CABG Surgery.

(C) NQF #0129 - CABG: Prolonged Intubation (defined as >24hrs post surgery).

(D) NQF #0130 - CABG: Deep Sternal Wound Infection Rate.

(E) NQF #0131 - CABG: Stroke.

(F) NQF #0114 - CABG: Postoperative Renal Failure.

(G) NQF #0115 - CABG: Surgical Re-Exploration. The submission of this measure data is weighted at 10 percent of the CABG model composite quality score.

(iv) Any additional quality improvement points the CABG model participant may earn as a result of demonstrating improvement on the quality measures in paragraphs (b)(1)(i) and (ii) of this section, as described in paragraph (c)(3) of this section.

(2) CABG model quality performance points. CMS computes quality performance points for each quality measure based on the CABG model participant's performance percentile relative to the national distribution of all subsection (d) hospitals that are eligible for payment under the IPPS and meet the minimum measure patient case or survey count.

(i) For the Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery (NQF #2558) measure described in § 512.412(a)(1), CMS assigns the CABG model participant measure value to a performance percentile and then quality performance points are assigned based on the following performance percentile scale:

(A) 14.00 points for ≥ 90th.

(B) 12.95 points for ≥ 80th and < 90th.

(C) 11.90 points for ≥ 70th and < 80th.

(D) 10.85 points for ≥ 60th and < 70th.

(E) 9.80 points for ≥ 50th and < 60th.

(F) 8.75 points for ≥ 40th and < 50th.

(G) 7.70 points for ≥ 30th and < 40th.

(H) 0.00 points for < 30th.

(ii) For the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (NQF #0166) measure described in § 512.412(a)(2), CMS assigns the CABG model participant measure value to a performance percentile and then quality performance points are assigned based on the following performance percentile scale:

(A) 4.00 points for ≥ 90th.

(B) 3.70 points for ≥ 80th and < 90th.

(C) 3.40 points for ≥ 70th and < 80th.

(D) 3.10 points for ≥ 60th and < 70th.

(E) 2.80 points for ≥ 50th and < 60th.

(F) 2.50 points for ≥ 40th and < 50th.

(G) 2.20 points for ≥ 30th and < 40th.

(H) 0.00 points for < 30th.

(3) CABG model quality improvement points. If a CABG model participant's own improvement in the participant's measure point estimate from the previous year on an individual measure described in § 512.412(a), regardless of the participant's measure point estimate starting and ending values, falls into the top 10 percent of all subsection (d) hospitals that are eligible for payment under the IPPS based on the national distribution of measure improvement over the most recent 2 years, then the CABG model participant is eligible to receive quality improvement points up to 10 percent of the total available points for that measure. The total CABG model composite quality score is capped at 20 points.

(4) Exception for CABG model participants without a measure value. In the case of a CABG model participant without a measure value that would allow CMS to assign quality performance points for that quality measure, CMS assigns the 50th percentile quality performance points to the hospital for the individual measure.

(i) A CABG model participant does not have a measure value for the -

(A) Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery (NQF #2558) measure described in § 512.412(a)(1) if the CABG model participant does not meet the minimum 25 case count.

(B) Hospital Consumer Assessment of Healthcare Providers and Systems Survey (NQF #0166) measure described in § 512.412(a)(2) if the CABG model participant does not meet the minimum of 100 completed surveys and does not have 4 consecutive quarters of HCAHPS data.

(C) Measures described in paragraphs (c)(4)(i)(A) and (c)(4)(i)(B) of this section, if CMS identifies an error in the data used to calculate the measure and suppresses the measure value.

(5) Establishing CABG model reconciliation payment eligibility and effective and applicable discount factors. CMS determines reconciliation payment eligibility and the effective discount factor for reconciliation payments in all performance years and repayment amounts in performance year 5, as well as applicable discount factor for repayment amounts in performance years 2 for CABG model participants who elect early downside risk, and for performance years 3 and 4 for all CABG model participants, based on the CABG model composite quality score described in paragraph (c)(1) of this section.

(i) Reconciliation payment eligibility requires an acceptable or better quality category, defined as a CABG model composite quality score of greater than 2.2.

(ii) Effective discount factor for reconciliation payments.

(A) A 3.0 percentage point effective discount factor for CABG model participants in the unacceptable or acceptable quality category, defined as a CABG model composite quality score that is less than or equal to 3.4.

(B) A 2.0 percentage point effective discount factor for CABG model participants in the good quality category, defined as a CABG model composite quality score that is greater than 3.4 and less than or equal to 16.2.

(C) A 1.5 percentage point effective discount factor for CABG model participants in the excellent quality category, defined as a CABG model composite quality score that are greater than 16.2.

(iii) Applicable discount factor for repayment amount in performance year 2 for CABG model participants who elect early downside risk, and years 3 and 4 for all EPM participants.

(A) A 2.0 percentage point applicable discount factor for CABG model participants in the unacceptable or acceptable quality category, defined as a CABG model composite quality score of less than or equal to 3.4.

(B) A 1.0 percentage point applicable discount factor for CABG model participants in the good quality category, defined as a CABG model composite quality score that is greater than 3.4 and less than or equal to 16.2.

(C) A 0.5 percentage point applicable discount factor for CABG model participants in the excellent quality category, defined as a CABG model composite quality scores that is greater than 16.2.

(iv) Effective discount factor for repayment amount in performance year 5 for all CABG model participants.

(A) A 3.0 percentage point applicable discount factor for CABG model participants in the unacceptable or acceptable quality category, defined as a CABG model composite quality score of less than or equal to 3.4.

(B) A 2.0 percentage point applicable discount factor for CABG model participants in the good quality category, defined as a CABG model composite quality score that is greater than 3.4 and less than or or equal to 16.2.

(C) A 1.5 percentage point applicable discount factor for CABG model participants in the excellent quality category, defined as a CABG model composite quality scores that is greater than 16.2.

(d) SHFFT model -

(1) SHFFT model composite quality score. CMS calculates a SHFFT model composite quality score for each SHFFT model participant for each performance year, which equals the sum of the following:

(i) The SHFFT model participant's quality performance points for the Hospital-Level Risk-Standardized Complication Rate following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (NQF #1550) measure described in § 512.413(a)(1). This measure is weighted at 50 percent of the SHFFT model composite quality score.

(ii) The SHFFT model participant's quality performance points for the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (NQF #0166) measure described in § 512.413(a)(2). This measure is weighted at 40 percent of the SHFFT model composite quality score.

(iii) Any additional quality improvement points the SHFFT model participant may earn as a result of demonstrating improvement on either or both of the quality measures in paragraphs (d)(1)(i) and (ii) of this section, as described in paragraph (d)(3) of this section.

(iv) If applicable, 2 additional points for successful THA/TKA voluntary data submission of patient-reported outcomes and limited risk variable data, as described in § 512.413(b)(2). Successful submission is weighted at 10 percent of the SHFFT model composite quality score.

(2) SHFFT model quality performance points. CMS computes quality performance points for each quality measure based on the SHFFT model participant's performance percentile on that measure relative to the national distribution of all subsection (d) hospitals that are eligible for payment under the IPPS and meet the minimum measure patient case or survey count.

(i) For the Hospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (NQF #1550) measure described in § 512.413(a)(1), CMS assigns the SHFFT model participant measure value to a performance percentile and then quality performance points are assigned based on the following performance percentile scale:

(A) 10.00 points for ≥ 90th.

(B) 9.25 points for ≥ 80th and < 90th.

(C) 8.50 points for ≥ 70th and < 80th.

(D) 7.75 points for ≥ 60th and < 70th.

(E) 7.00 points for ≥ 50th and < 60th.

(F) 6.25 points for ≥ 40th and < 50th.

(G) 5.50 points for ≥ 30th and < 40th.

(H) 0.00 points for < 30th.

(ii) For the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (NQF #0166) measure described in § 512.413(a)(2), CMS assigns the SHFFT model participant measure value to a performance percentile and then quality performance points are assigned based on the following performance percentile scale:

(A) 8.00 points for ≥ 90th.

(B) 7.40 points for ≥ 80th and < 90th.

(C) 6.80 points for ≥ 70th and < 80th.

(D) 6.20 points for ≥ 60th and < 70th.

(E) 5.60 points for ≥ 50th and < 60th.

(F) 5.00 points for ≥ 40th and < 50th.

(G) 4.40 points for ≥ 30th and < 40th.

(H) 0.00 points for < 30th.

(3) SHFFT quality improvement points. If a SHFFT model participant's quality performance percentile on an individual measure described in § 512.413(a) increases from the previous performance year by at least 2 deciles on the performance percentile scale, then the SHFFT model participant is eligible to receive quality improvement points up to 10 percent of the total available points for that individual measure. The total SHFFT model composite quality score is capped at 20 points.

(4) Exception for SHFFT model participants without a measure value. In the case of a SHFFT model participant without a measure value that would allow CMS to assign quality performance points for that quality measure, CMS assigns the 50th percentile quality performance points to the participant for the individual measure.

(i) A SHFFT model participant does not have a measure value for the -

(A) Hospital-Level Risk-Standardized Complication Fate Following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (NQF #1550) measure described in § 510.413(a)(1) if the participant does not meet the minimum 25 case count; or

(B) Hospital Consumer Assessment of Healthcare Providers and Systems Survey measure (NQF #0166) described in § 510.413(a)(2) if the participant does not meet the minimum of 100 completed surveys and does not have 4 consecutive quarters of HCAHPS data.

(C) Measures described in paragraphs (d)(4)(i)(A) and (d)(4)(i)(B) of this section, if CMS identifies an error in the data used to calculate the measure and suppresses the measure value.

(5) Establishing SHFFT model reconciliation payment eligibility and effective and applicable discount factors. CMS determines reconciliation payment eligibility and the effective discount factor for reconciliation payments in all performance years and repayment amounts in performance year 5, as well as applicable discount factor for repayment amounts in performance year 2 for SHFFT model participants who elect early downside risk and for performance years 3 and 4 for all SHFFT model participants, based on the SHFFT model composite quality score described in paragraph (d)(1) of this section.

(i) Reconciliation payment eligibility requires an acceptable or better quality category, defined as a SHFFT model composite quality score of greater than or equal to 5.0.

(ii) Effective discount factor for reconciliation payments.

(A) A 3.0 percentage point effective discount factor for SHFFT model participants in the unacceptable or acceptable quality category, defined as a SHFFT model composite quality score that is less than 6.9.

(B) A 2.0 percentage point effective discount factor for SHFFT model participants in the good quality category, defined as a SHFFT model composite quality score that is greater than or equal to 6.9 and less than or equal to 15.0.

(C) A 1.5 percentage point effective discount factor for SHFFT model participants in the excellent quality category, defined as a SHFFT model composite quality score that are greater than 15.0.

(iii) Applicable discount factor for repayment amount in performance year 2 for SHFFT model participants who elect early downside risk, and years 3 and 4 for all EPM participants.

(A) A 2.0 percentage point applicable discount factor for SHFFT model participants in the unacceptable or acceptable quality category, defined as a SHFFT model composite quality score of less than 6.9.

(B) A 1.0 percentage point applicable discount factor for SHFFT model participants in the good quality category, defined as a SHFFT model composite quality score that is greater than or equal to 6.9 and less than or equal to 15.0.

(C) A 0.5 percentage point applicable discount factor for SHFFT model participants in the excellent quality category, defined as a SHFFT model composite quality scores that is greater than 15.0.

(iv) Effective discount factor for repayment amount in performance year 5 for all SHFFT model participants.

(A) A 3.0 percentage point applicable discount factor for SHFFT model participants in the unacceptable or acceptable quality category, defined as a SHFFT model composite quality score of less than 6.9.

(B) A 2.0 percentage point applicable discount factor for SHFFT model participants in the good quality category, defined as a SHFFT model composite quality score that is greater than or equal to 6.9 and less than or equal to 15.0.

(C) A 1.5 percentage point applicable discount factor for SHFFT model participants in the excellent quality category, defined as a SHFFT model composite quality score that is greater than 15.0.