This section provides brief descriptions of the six CMS performance measurement programs. Table 2 summarizes the number of measures included in the programs by measure type (e.g. clinical process of care, patient experience). Nearly 70 percent of the measures across the programs are clinical process of care measures (173 measures). All of the performance measurement programs, except the home health program (HHQI), include clinical process measures. Patient outcome measures are included for five settings (hospital inpatient, physicians, skilled nursing facilities, home health agencies and dialysis facilities), while intermediate patient outcomes are included for 3 settings (hospital inpatient, physicians, and dialysis facilities) and two settings have measures of patient functioning (skilled nursing facilities and home health care agencies). Measures of patient experience are captured for hospital inpatient care. The physician (PQRI) and the hospital outpatient programs include a small number of efficiency (inappropriate use of services) measures and PQRI has two structural measures. PQRI also includes several measures about proper documentation which we have termed “other.” We also list (Table 3) the full set of performance measures that are reported to or constructed by CMS for each of the six settings and whether the same measure used in one setting (e.g., the hospital) is also applied in another provider setting (e.g., PQRI, hospital outpatient). Within each provider setting or payment silo, measures are organized by condition or procedure where relevant.
Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) Program This program, mandated under the Medicare Prescription Drug Improvement and Modernization Act of 200323, collects performance data from hospitals on a set of hospital inpatient measures of clinical quality (both process of care and outcomes) and patient experience with care. This “pay-for-reporting” program provides differential payment updates to Inpatient Prospective Payment System (IPPS) hospitals based on whether they publicly report their performance on the defined set of measures. The original program, established in 2004, required hospitals to report on a set of 10 performance measures in order to receive 0.4 percentage points of their annual payment update. The 2005 Deficit Reduction Act expanded the list of measures and increased the differential payment for reporting to 2 percentage points. The performance results are publicly reported on the CMS Hospital Compare website. The initial RHQDAPU list of measures has since expanded to 41 clinical measures and 10 patient experience measures required for reporting for fiscal year 2009. Of the current list, eight clinical measures are also reported in the Hospital Outpatient Quality Data Reporting Program (HOP QDRP) and/or the PQRI.
Hospital Outpatient Quality Data Reporting Program (HOP QDRP). Under Section 109 of the Tax Relief and Health Care Act of 200624, Congress established new requirements for hospitals serving Medicare beneficiaries to report outpatient quality data to secure their full annual update to the Outpatient Prospective Payment System fee schedule. Effective April 2008, hospitals were required to submit performance data on a set of seven measures of care provided in the hospital outpatient setting in order to receive their full annual update in calendar year 2009. For 2009, four new measures have been added. Those that do not participate in the program receive a reduction of 2.0 percentage points in their annual payment update. As this program is just starting, performance data is not yet publicly reported. Five of the measures included in HOP QDRP are emergency department (ED) transfer measures, two measures address perioperative care, and the four new measures address imaging appropriateness and follow-up. The number of measures to be reported for this program is expected to grow, and CMS has sought public comment on an additional 18 measures being considered for future years.
Physician Quality Reporting Initiative (PQRI). The Tax Relief and Healthcare Reform Act of 2006 required Congress to establish a physician quality reporting program. Established in 2007, this is a voluntary reporting program for physicians, practitioners and therapists. The Medicare, Medicaid, and SCHIP Extension Act of 200725] authorized the extension of the program through 2010. It also allowed for registry-based reporting and removed the cap on bonuses paid. The initial set of 74 clinical measures was expanded to 119 measures in 2008 and 153 in 2009 and addresses an array of clinical specialty areas. Eligible professionals who successfully report at least 3 of the 153 measures for calendar year 2009 receive a bonus over allowed charges for covered Medicare physician fee schedule services. The Medicare Improvements for Patients and Providers Act of 2007 (MIPPA) increased the bonus payment from 1.5 percent to 2.0 percent for 2009 and 2010. There is currently no public reporting associated with PQRI; providers' results are confidentially reported back to the individual provider mid-year following the end of the PQRI reporting period. The performance measures address 43 conditions or procedures, preventive care, and the use of health information technology (IT). The 2008 measure set included a measure for e-prescribing which was eliminated for 2009 due to the new e-prescribing incentive program included in the MIPPA. The PQRI program has also established measure groups for diabetes, chronic kidney disease, prevention, CABG, rheumatoid arthritis, perioperative care and back pain. Physicians or practitioners that elect to report on a group of measures must report all measures in the group that are applicable to each patient. PQRI measures have some degree of alignment with the hospital inpatient and outpatient measures (i.e., management of acute myocardial infarction, heart failure, perioperative/surgical care and pneumonia). Additionally, several preventive care measures (e.g., influenza and pneumococcal vaccinations) addressed in PQRI align with measures reported by SNFs.
Nursing Home Quality Initiative (NHQI). This reporting program began in 2002 and requires SNFs to provide information about the residents' health, physical functioning, and general function. The measures are constructed with data from the Minimum Data Set (MDS) Repository and the performance results are publicly reported on the CMS Nursing Home Compare website. There is no financial incentive associated with NHQI. A total of 19 measures are to be reported in 2009, with 14 relevant to long stay patients and five relevant to short stay patients; four of the five measures for short stay patients are also used for long stay patients. Long stay patients are those in an extended or permanent nursing home stay, while the short stay patients are usually recovering from a hospital stay and are expected to return home. The measures address vaccinations, pain, pressure sores, urinary incontinence, use of restraints, depression, mobility, urinary tract infections, and weight loss. There is some alignment between the conditions addressed by NHQI and PQRI (i.e., preventive care, depression, urinary incontinence), and there is overlap in the preventive measures (immunizations) included in the programs. Some of the conditions addressed by NHQI align with the home health program, HHQI, (i.e., pain, urinary incontinence), though the measures included in the two programs do not overlap.
Home Health Quality Initiative (HHQI). Beginning in 2000, every Medicare-certified home health agency was required to complete and submit health data on their clients utilizing the Outcome and Assessment Information Set (OASIS) data collection tool. Home health agencies that do not provide their data experience a two percentage point reduction in their annual market basket payment update. CMS began publicly reporting a subset of this information in late 2003 on the CMS Home Health Compare website. In 2005, the NQF endorsed the 10 measures reported on Home Health Compare, and two measures were added to the program for calendar year 2008. The performance measures address ambulation, activities of daily living, medical emergencies and discharge from home care. With the exception of pain, dyspnea, and urinary incontinence, most measures are not specific to a particular disease or condition. None of the measures are included in the other performance measurement programs.
End Stage Renal Disease (ESRD) Quality Initiative. In 2004, CMS required kidney dialysis facilities to report performance for patients with ESRD. CMS currently collects and reports three dialysis facility-specific measures that indicate the adequacy of hemodialysis, control of anemia and survival for patients with end stage renal disease (ESRD). The performance results are reported on the CMS Dialysis Facility Compare website along with the types of services offered by ESRD facilities. There is no financial incentive for reporting currently, however the 2008 MIPPA requires the establishment of a P4P program for ESRD providers effective January 1, 2012 and the establishment of a fully bundled payment system for ESRD facilities by January 1, 2011. The measures are produced from data that comes from the Standard Information Management Systems, which receive data from the ESRD Networks on a monthly basis and from the Renal Management Information System maintained by Medicare. Measures are also under development or have been recently developed for kidney transplant referral, ESRD bone disease and metabolism, and vascular access. The three existing dialysis facility-level measures are not included in the other performance measurement programs.