Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Cataloging the Set of Performance Measures Contained in CMS Performance Measurement Systems

02/01/2009

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.

Table 2. Number of Performance Measures Reported to Medicare as of 11/2008, By Measure Type and Program

Type of Measure Hospital Inpatient (RHADAPU) Hospital Outpatient (HOP QDRP) PQRI Skilled Nursing Facilities Home Health Dialysis Facilities
Clinical Process of Care 26 10 131 5 0 1
Patient Outcome 14 0 5 10 4 1
Patient Intermediate Outcome 1 0 5 0 0 1
Patient Functioning 0 0 0 4 8 0
Patient Experience 10 0 0 0 0 0
Efficiency 0 1 4 0 0 0
Structural/Health Information Technology 0 0 2 0 0 0
Other (documentation) 0 0 6 0 0 0

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.

Table 3. Performance Measures Reported to Medicare as of 11/2008, By Setting

  Condition Measure Overlap with Other Reporting Programs Measure Type26
Hospital Inpatient Acute Myocardial Infarction (AMI) Aspirin at arrival Hospital Outpatient & PQRI P
AMI Aspirin prescribed at discharge None P
AMI ACE-I or ARB for LVSD None P
AMI Adult smoking cessation advice/counseling None P
AMI Beta blocker at arrival None P
AMI Beta blocker prescribed at discharge None P
AMI Fibrinolytic medication received within 30 minutes of hospital arrival Hospital Outpatient P
AMI PCI received within 120 minutes of hospital arrival None P
AMI 30-day AMI mortality None O
Heart Failure     (HF) Discharge instructions None P
HF Left ventricular function assessment None P
HF ACE-I or ARB for LVSD PQRI P
HF Adult smoking cessation advice/counseling None P
HF 30-day HF mortality None O
HF 30-day HF readmission* None O
Community Acquired Bacterial Pneumonia (PN) Assessed and given pneumococcal vaccination None P
PN Assessed and given influenza vaccination None P
PN Blood culture performed in the emergency department before the first antibiotic received in hospital None P
PN Appropriate initial antibiotic selection PQRI P
PN Initial antibiotic received within 6 hours None P
PN Adult smoking cessation advice/counseling None P
PN 30-day PN mortality None O
Perioperative/Surgical Care Prophylactic received within 1 hour prior to surgical incision Hospital Outpatient & PQRI P
Perioperative/Surgical Care Prophylactic antibiotic selection for surgical patients Hospital Outpatient & PQRI P
Perioperative/Surgical Care Prophylactic antibiotics discontinued within 24 hours after surgery end time PQRI P
Perioperative/Sur gical Care Surgery patients with recommended venous thromboembolism prophylaxis ordered PQRI P
Perioperative/Surgical Care Surgery patients with recommended venous thromboembolism prophylaxis received within 24 hours prior to or after surgery None P
Perioperative/Surgical Care Cardiac patients with controlled 6 am post-operative serum glucose None IO
Perioperative/Surgical Care Surgery patients with appropriate hair removal None P
Perioperative/Surgical Care Surgery patients on a beta blocker prior to arrival who received a beta blocker during the perioperative period* None P
Perioperative/Surgical Care Death among surgical patients with treatable serious complications* None O
Perioperative/ Surgical Care Postoperative wound dehiscence* None O
Perioperative/Surgical Care Mortality for selected surgical procedures (composite)* None O
Cardiac Surgery Participation in a systematic database for cardiac surgery* None P
Nursing Sensitive Failure to rescue* None O
Pneumothorax Iatrogenic pneumothorax* None O
NA Accidental puncture or laceration* None O
Abdominal Aortic Aneurysm AAA mortality rate (with or without volume)* None O
Hip Fracture Hip fracture mortality rate* None O
NA Mortality for selected medical conditions (composite)* None O
NA Complication/patient safety for selected indicators (composite)* None O
Patient Experience Communication with doctors (composite) None PE
Patient Experience Communication with nurses (composite) None PE
Patient Experience Responsiveness of hospital staff (composite) None PE
Patient Experience Cleanliness of hospital (composite) None PE
Patient Experience Quietness of hospital (composite) None PE
Patient Experience Pain control (composite) None PE
Patient Experience Communication about medicines (composite) None PE
Patient Experience Discharge information (composite) None PE
Patient Experience Overall rating of hospital care None PE
Patient Experience Overall recommendation None PE
Hospital Outpatient
AMI Emergency department transfer: Aspirin at arrival Hospital Inpatient & PQRI P
AMI Emergency department transfer: Median time to fibrinolysis None P
AMI Emergency department transfer: Fibrinolytic therapy received within 30 minutes of arrival Hospital Inpatient P
AMI Emergency department transfer: Median time to electrocardiogram None P
AMI Emergency department transfer: Median time to transfer for primary PCI None P
Perioperative Care Timing of antibiotic prophylaxis Hospital Inpatient & PQRI P
Perioperative Care Selection of prophylactic antibiotic Hospital Inpatient & PQRI P
Low Back Pain/Imaging MRI lumbar spine for low back pain* None E
Imaging Mammography follow-up rates* None P
Imaging Abdomen CT-use of contrast material* None P
Imaging Thorax CT-use of contrast material* None P
Physicians, Practitioners, Therapists (PQRI)
Acute Bronchitis Inappropriate antibiotic treatment for adults None P
Acute Otitis Externa Topical therapy None P
Acute Otitis Externa Pain assessment None P
Acute Otitis Externa Systemic antimicrobial therapy-avoidance of inappropriate use None E
Age-Related Macular Degeneration (AMD) Dilated macular examination None P
AMD Counseling on antioxidant supplement* None P
AMI Aspirin at arrival Hospital Inpatient & Hospital Outpatient P
Asthma Assessment of symptoms None P
Asthma Pharmacologic therapy None P
Back Pain Initial visit* None P
Back Pain Physical Exam* None P
Back Pain Advice for normal activities* None P
Back Pain Advice against bed rest* None P
Breast Cancer Hormonal therapy for stage 1C-III ER/PR positive breast cancer None P
Breast Cancer Pathology reporting: pT and pN category and histologic grade None Other
CABG Use of internal mammary artery None P
CABG Pre-operative beta blocker None P
CABG Prolonged intubation* None O
CABG Deep sternal wound infection rate* None O
CABG Stroke/CVA* None O
CABG Post operative renal insufficiency* None O
CABG Surgical re-exploration* None O
CABG Anti-platelet medication at discharge* None P
CABG Beta blocker at discharge* None P
CABG Lipid management and counseling* None P
Cancer Medical and radiation-plan of care for pain* None P
Cancer Pain intensity quantified* None P
Cancer Radiation dose limits to normal tissue* None P
Cataracts Comprehensive preoperative assessment for surgery with IOL replacement* None P
Catheter-Associated Bloodstream Infections Prevention - central venous catheter insertion protocol None P
Chronic Kidney Disease   (CKD) Laboratory Testing (calcium, phosphorus, iPTH and lipid profile) None P
CKD Blood pressure management None P
CKD Plan of care; elevated hemoglobin for patients receiving Erythropoiesis Stimulating Agents None P
CKD Influenza immunization* None P
CKD Referral for AV Fistula* None P
Chronic Lymphocytic Leukemia Baseline flow cytometry None P
Chronic Obstructive Pulmonary Disease (COPD) Spirometry evaluation None P
COPD Bronchodilator therapy None P
Colon Cancer Chemotherapy for stage III patients None P
Community Acquired Bacterial Pneumonia (PN) Vital Signs None P
PN Assessment of oxygen saturation None P
PN Assessment of mental status None P
PN Appropriate antibiotic selection Hospital Inpatient P
Colorectal Cancer Pathology reporting: pT and pN category and histologic grade None Other
Coronary Artery Disease (CAD) Oral antiplatelet therapy prescribed None P
CAD Beta blocker therapy for patients with prior MI None P
CAD ACE inhibitor or ARB therapy None P
CAD Lipid profile* None P
Depression Antidepressant medication during acute phase for patients with new episode of major depression None P
Depression Diagnostic evaluation None P
Depression Assessed for suicide risk None P
Diabetes Hemoglobin A1C poor control None IO
Diabetes LDL control None IO
Diabetes Blood pressure control None IO
Diabetes Dilated eye exam None P
Diabetes Urine screening or medical attention for nephropathy None P
Diabetes Foot exam* None P
Diabetes Foot and ankle care: neurological evaluation None P
Diabetes Foot and ankle care: evaluation of footwear None P
Diabetic Retinopathy Documentation of presence or absence of macular edema and level of severity of retinopathy None P
Diabetic Retinopathy Communication with the physician managing ongoing diabetes care None P
Endarterectomy Use of patch during conventional endarterectomy* None P
ESRD Influenza vaccination None P
ESRD Plan of care for inadequate hemodialysis None P
ESRD Plan of care for inadequate peritoneal dialysis None P
ESRD Hemodialysis vascular access-placement of autogenous arterial venous fistula* None P
ESRD (pediatric) Adequacy of hemodialysis* None IO
ESRD (pediatric) Influenza immunization* None P
Falls Plan of care* None P
Falls Risk assessment* None P
Glaucoma Optic nerve evaluation None P
Glaucoma Reduction of intraocular pressure by 15% or documentation of a plan of care* None IO
Heart Failure ACE-I or ARB for LVSD Hospital Inpatient P
Heart Failure Beta blocker therapy for LVSD None P
Hepatitis C Testing for Hepatitis C Viremia None P
Hepatitis C RNA testing prior to treatment None P
Hepatitis C HCV genotype testing prior to therapy None P
Hepatitis C Consideration of antiviral therapy None P
Hepatitis C  HCV RNA testing at week 12 of therapy None P
Hepatitis C Hepatitis A vaccination* None P
Hepatitis C Hepatitis B vaccination* None P
Hepatitis C Counseling regarding use of alcohol None P
Hepatitis C Counseling regarding use of contraception prior to starting antiviral therapy None P
HIV/AIDS CD4+ cell count or CD4+ percentage* None P
HIV/AIDS Pneumocystis Jiroveci Pneumonia prophylaxis* None P
HIV/AIDS Adolescent and adult patients with HIV/AIDS who are prescribed potent antiretroviral therapy* None P
HIV/AIDS HIV RNA control after 6 months of potent antiretroviral therapy* None P
Lung, Esophageal Cancer Recording of clinical stage* None Other
Melanoma Follow-up aspects of care* None P
Melanoma Continuity of care-recall system* None S
Melanoma Coordination   of care* None P
Multiple Myeloma Treatment with bisphosphonates None P
Myelodysplastic Syndrome (MDS) Documentation of iron stores in patients receiving erythropoietin None P
MDS and Acute Leukemia Baseline cytogenetic testing performed on bone marrow None P
Non Traumatic Chest Pain Electrocardiogram performed None P
Nuclear Medicine Correlation with existing imaging studies for patients undergoing bone scintigraphy* None P
Osteoarthritis Assessment of pain and function None P
Osteoarthritis Assessment for use of anti-inflammatory or analgesic over the counter medications* None P
Osteoporosis Communication with the physician managing ongoing care post-fracture None P
Osteoporosis Screening or therapy for women aged 65 and older None P
Osteoporosis Management following fracture None P
Osteoporosis Pharmacologic therapy None P
Otis Media with Effusion (OME) Diagnostic evaluation None P
OME Hearing testing None P
Perioperative Care Timing of antibiotic prophylaxis-ordering physician None P
Perioperative Care Timing of antibiotic prophylaxis-administering physician Hospital Inpatient & Hospital Outpatient P
Perioperative Care Selection of prophylactic antibiotic Hospital Inpatient & Hospital Outpatient P
Perioperative Care Discontinuation of prophylactic antibiotic (cardiac procedures) None P
Perioperative Care Discontinuation of prophylactic antibiotic (non-cardiac procedures) Hospital Inpatient P
Perioperative Care Venous thromboembolism (VTE) prophylaxis Hospital Inpatient P
Pharyngitis Appropriate testing for children None E
Prev/Screening Medication reconciliation after discharge from inpatient setting None P
Prev/Screening Advance care plan None P
Prev/Screening Influenza vaccination for patients > 50 SNF P
Prev/Screening Pneumonia vaccination for patients > 65 SNF P
Prev/Screening Screening mammography None P
Prev/Screening Colorectal cancer screening None P
Prev/Screening Inquiry regarding tobacco use None P
Prev/Screening Advising smokers to quit None P
Prev/Screening Universal weight screening and follow-up None P
Prev/Screening Universal documentation and verification of current medications in the medical record None P
Prev/Screening Pain assessment prior to initiation of patient treatment None P
Prev/Screening Screening for clinical depression None P
Prev/Screening Screening for alcohol abuse* None P
Prev/Screening Endoscopy and polyp surveillance-interval in patients with history of adenomatous polyps* None P
Prev/Screening Elder maltreatment screen with follow-up plan* None P
Prostate Cancer Inappropriate use of bone scan for staging low risk patients None E
Prostate Cancer Adjuvant hormonal therapy for high-risk prostate cancer patients None P
Prostate Cancer Three dimensional radiotherapy None P
Radiology Exposure time reported for procedures using fluoroscopy* None Other
Radiology Inappropriate use of "probably benign" assessment category in mammography screening* None P
Rheumatoid Arthritis (RA) Disease modifying anti-rheumatic drug therapy None P
RA Tuberculosis screening* None P
RA Periodic assessment of disease activity* None P
RA Functional limitation assessment* None P
RA Assessment and classification of disease prognosis* None P
RA Glucocorticoid management* None P
Stroke CT or MRI reports None Other
Stroke Carotid imaging reports None Other
Stroke DVT for ischemic stroke or intracranial hemorrhage None P
Stroke Discharged on antiplatelet therapy None P
Stroke Anticoagulant therapy for atrial fibrillation at discharge None P
Stroke Tissue Plasminogen Activator (t-PA) considered None P
Stroke Screening for dysphasia None P
Stroke Consideration of rehabilitation services None P
Syncope Electrocardiogram performed None P
Upper Respiratory Infection Appropriate treatment for children None E
Urinary Incontinence (UI) Assessment of presence or absence in women aged 65 years and older None P
UI Characterization of UI in women aged 65 years and older None P
UI Plan of care for women aged 65 years and older None P
Wound care Use of compression care in patients with venous ulcers* None P
NA Functional outcome assessment in chiropractic care* None P
NA Adoption/use of health information technology (electronic health records) None S
Skilled Nursing Facilities (SNFs)
Long-Stay:      
Prevention Residents given influenza vaccination during the flu season PQRI P
Prevention Residents assessed and given pneumococcal vaccination PQRI P
NA Residents whose need for help with daily living activities has increased None F
Pain Residents who have moderate to severe pain None O
Pressure Sores High risk residents who have pressure sores None O
Pressure Sores Low risk residents who have pressure sores None O
NA Residents who were physically restrained None O
Depression/Anxiety Residents who are more depressed or anxious None O
Incontinence Residents who lose control of their bowels or bladder None F
UI Residents who have had a catheter inserted and left in their bladder None P
NA Residents who spent most of their time in a bed or in a chair None F
NA Residents whose ability to move about and around their room got worse None F
Urinary Tract Infection Residents with a urinary tract infection None O
Weight Loss Residents who lost too much weight None O
Short-Stay: Prevention Residents given influenza vaccination during the flu season PQRI P
Prevention Residents assessed and given pneumococcal vaccination PQRI P
Delirium Residents with delirium None O
Pain Residents who had moderate to severe pain None O
Pressure Sores Residents with pressure sores None O
Home Health  
NA Improvement in ambulation/locomotion None F
NA Improvement in bathing None F
NA Improvement in transferring None F
NA Improvement in management of oral medication None F
Pain Improvement in pain interfering with activity None F
Dyspnea Improvement in dyspnea None F
UI Improvement in urinary incontinence None F
NA Improvement in the status of surgical wounds None F
NA Patients requiring acute care hospitalization None O
NA Patients requiring emergent care None O
NA Patients requiring emergent care for wound infections None O
NA Patients discharged to the community None O
Dialysis Facilities
ESRD Anemia control None IO
ESRD Hemodialysis adequacy None P
ESRD Patient survival None O
Note:  P=Process, O=Outcome, E=Efficiency, IO=Intermediate Outcome, F=Functioning, S=Structural, PE=Patient Experience
* Indicates measure was added for the 2009 reporting year

 

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