Claims-Based and Hybrid Measure
The Centers for Medicare & Medicaid Services (CMS) uses a variety of data sources to determine the quality of care that Medicare beneficiaries receive.
For the quality of care measure sets listed below, CMS uses Medicare enrollment data and Part A and Part B claims data submitted by hospitals for Medicare fee-for-service patients. (Hospitals are not required to submit additional data for the claims-based measures.) Each measure set is calculated using a separate, distinct methodology and, in some cases, separate discharge periods. The mortality, readmission, complication, payment, and excess days in acute care (EDAC) measures do not use administrative data from Veterans Administration (VA) medical centers for Fiscal Year (FY) 2018 reporting.
- Agency for Healthcare Research and Quality (AHRQ) Indicators – Includes the Patient Safety Indicators (PSIs) measure.
- Mortality Measures – Includes the condition-specific acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure (HF), pneumonia and stroke measures; and the procedure-specific coronary artery bypass graft (CABG) measure.
- Hospital Value-Based Purchasing (VBP) Mortality and AHRQ Measures
- Readmission Measures – Includes the condition-specific AMI, COPD, HF, pneumonia and stroke measures, the procedure-specific CABG and total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) measures; and the hospital-wide all-cause readmission (HWR) measure.
- Complication Measure – Includes the procedure-specific risk-standardized THA/TKA complication measure.
- Medicare Spending Per Beneficiary (MSPB) Measure
- Payment Measures – Includes the condition-specific AMI, HF, and pneumonia payment measures, as well as the procedure-specific THA/TKA payment measure.
- Excess Days in Acute Care (EDAC) Measures – Includes the condition-specific AMI and HF EDAC measures.
- Episode-Based Payment Measures – Includes information regarding procedural episode-based payment measures (Aortic Aneurism Procedure, Cholecystectomy and Common Duct Exploration, and Spinal Fusion) and condition episode-based payment measures (Kidney/Urinary Tract Infection, Cellulitis, and Gastrointestinal Hemorrhage).
- Hybrid Measure – Includes information regarding the Voluntary Hybrid Hospital-Wide Readmission (HWR) Measure. The Hybrid HWR Measure differs from the claims-based HWR measure as it merges electronic health record (EHR) data elements with claims data to calculate the risk-standardized readmission rate.