Participation

Baseline and Performance Periods

CMS evaluates each hospital's performance in the Hospital VBP program by comparing performance from two distinct timeframes: the baseline period and the performance period. These comparisons are used to calculate both Achievement and Improvement scores for each applicable Hospital VBP measure.

Baseline period

The baseline period is the designated timeframe used to collect data for establishing improvement thresholds for each measure. It serves as the reference point against which current performance is assessed.

Performance period

The performance period is the timeframe during which data are collected to evaluate hospital performance for the applicable fiscal year.

Fiscal Year (FY) 2031 Baseline and Performance Periods

FY 2030 Baseline and Performance Periods

FY 2029 Baseline and Performance Periods

*As outlined in the interim rule (CMS-3401-IFC) published on September 2, 2020, CMS will exclude claims for services provided between January 1, 2020, and June 30, 2020 (Q1 and Q2 of 2020), from its calculations for Medicare quality reporting and value-based purchasing programs.

FY 2028 Baseline and Performance Periods

*As outlined in the interim rule (CMS-3401-IFC) published on September 2, 2020, CMS will exclude claims for services provided between January 1, 2020, and June 30, 2020 (Q1 and Q2 of 2020), from its calculations for Medicare quality reporting and value-based purchasing programs.

FY 2027 Baseline and Performance Periods

*As outlined in the interim rule (CMS-3401-IFC) published on September 2, 2020, CMS will exclude claims for services provided between January 1, 2020, and June 30, 2020 (Q1 and Q2 of 2020), from its calculations for Medicare quality reporting and value-based purchasing programs.

FY 2026 Baseline and Performance Periods

FY 2025 Baseline and Performance Periods

*As outlined in the interim rule (CMS-3401-IFC) published on September 2, 2020, CMS will exclude claims for services provided between January 1, 2020, and June 30, 2020 (Q1 and Q2 of 2020), from its calculations for Medicare quality reporting and value-based purchasing programs.

**In addition, CMS also finalized these baseline periods due to the COVID-19 public health emergency.

FY 2024 Baseline and Performance Periods

*As outlined in the interim rule (CMS-3401-IFC) published on September 2, 2020, CMS will exclude claims for services provided between January 1, 2020, and June 30, 2020 (Q1 and Q2 of 2020), from its calculations for Medicare quality reporting and value-based purchasing programs.

**In addition, CMS also finalized these baseline periods due to the COVID-19 public health emergency. 

FY 2023 Baseline and Performance Periods

*As outlined in the interim rule (CMS-3401-IFC) published on September 2, 2020, CMS will exclude claims for services provided between January 1, 2020, and June 30, 2020 (Q1 and Q2 of 2020), from its calculations for Medicare quality reporting and value-based purchasing programs.

 ** CMS paused MORT-30-PN measure for the FY 2023 Program Year.

FY 2022 Baseline and Performance Periods

*As outlined in the interim rule (CMS-3401-IFC) published on September 2, 2020, CMS will exclude claims for services provided between January 1, 2020, and June 30, 2020 (Q1 and Q2 of 2020), from its calculations for Medicare quality reporting and value-based purchasing programs.

FY 2021 Baseline and Performance Periods

Minimum Cases and Measures

CMS established the following minimum reporting requirements for number of cases, measures, and surveys:

Clinical Outcomes: 

• A minimum of 25 cases in at least 2 of the 6 measures for each fiscal year.

Person and Community Engagement:

• A minimum of 100 completed surveys for each fiscal year.

Safety:

• Hospitals must report the applicable case minimum for at least 2 of the 5 measures in FY 2024 and FY 2025, and at least 2 of the 6 measures in FY 2026 and FY 2027.
  • CAUTI: 1 predicted infection
  • CLABSI: 1 predicted infection
  • CDI: 1 predicted infection
  • MRSA: 1 predicted infection
  • SSI: Minimum of 1 predicted infection must be calculated in at least 1 of the 2 SSI strata to receive a score
    • SSI - Colon: 1 predicted infection
    • SSI - Abdominal Hysterectomy: 1 predicted infection
  • Sep-1 (FY 2026 and FY 2027): Minimum of 25 cases accepted and used in the denominator

Efficiency and Cost Reduction:

• 25 episodes of care for the Medicare Spending per Beneficiary (MSPB) measure for each fiscal year

Total Performance Score (TPS):

• Hospitals with sufficient data in at least 3 of the 4 domains will receive a TPS for each respective fiscal year. For more information, refer to scoring guidelines.

**In the FY 2023 IPPS final rule, CMS finalized the removal of the NHSN healthcare-associated infections (HAI), HCAHPS survey, and Pneumonia 30-Day Mortality Rate measures from the FY 2022 and 2023 Hospital VBP Program due to the effects of the COVID-19 Public Health Emergency. As a result, no Total Performance Scores were calculated, and no payment adjustments were made under the Hospital VBP Program for FY 2022 and 2023.

Scoring

A hospital's performance in Hospital Value-Based Purchasing (VBP) is based on measures/dimensions for the domains per fiscal year (FY). The hospital's TPS is composed of the following:

FY 2021 - FY 2028 Scoring

Weighting

The TPS will be re-weighted proportionately to the scored domains for hospitals with only three (3) out of four (4) domain scores. The TPS will be scored out of a possible 100 points, and the relative weights for the scored domains will remain equivalent.

For example, when a hospital meets the minimum case and measure requirements for the Safety domain, Person and Community Engagement domain, and Efficiency domain, but does not meet the minimum case requirements for the Clinical Outcomes domain, the weighting will be reallocated to the remaining applicable domains.

The scoring is based on each of the four domains weighted equally at 25 percent each. Therefore, in the previous example the reallocation of weighting would be as follows:

• Safety = 33.3%
• Person and Community Engagement = 33.3%
• Efficiency and Cost Reduction = 33.3%

The formula to calculate the re-weighting of the measures is as follows:

Original weight of each remaining domain / total weight of remaining domains x 100

The reallocated weights must total 100 percent.

Achievement and Improvement

Hospitals will receive 2 scores on each measure and dimension: one for achievement and one for improvement.

• The achievement score measures how the hospital performed compared to other hospitals.
• The improvement score measures how much a hospital has improved compared to its own previous performance.

Scores are determined based on the hospital's performance compared to achievement and improvement ranges for each measure/dimension. The Centers for Medicare & Medicaid Services (CMS) will use the greater of either achievement or improvement scores on each measure and dimension to calculate the hospital's overall total performance. When calculating achievement points and improvement points, CMS rounds the resulting value to the nearest whole number.

The Person and Community Engagement domain is based on two components: a Base Score (0 to 80 points) and a Consistency Score (0 to 20 points). The Base Score is determined using the greater of a hospital’s improvement or achievement points across the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey dimensions. The Consistency Score is based on the hospital’s lowest-performing HCAHPS dimension during the performance period, compared to all hospitals’ scores from the baseline period. For more information on how Consistency Points are calculated, see https://hcahpsonline.org/globalassets/hcahps/vbp/hospital-vbp-domain-score-calculation-step-by-step-guide-february-2018.pdf.

Note: If a hospital was not open during a program year's baseline period but was open during the performance period, points will be awarded based on achievement only for that program year. Additionally, small hospitals are measured for performance and reimbursement according to the same criteria as a large hospital, if the small hospital meets the finalized minimum case and measure criteria.

Previous Scoring

A hospital’s performance in Hospital Value-Based Purchasing (VBP) was based on measures/dimensions for the domains per fiscal year (FY). The hospital’s Total Performance Score (TPS) was composed of the following:

FY 2013 Scoring

FY 2014 Scoring

FY 2015 Scoring

Weighting for FY 2015

For FY 2015, the TPS was re-weighted proportionately to the scored domains for hospitals with at least two (2) out of four (4) domain scores. The TPS was scored out of a possible 100 points, and the relative weights for the scored domains remained equivalent.

For example, if a hospital met the minimum case and measure requirements for the Clinical Process of Care and Patient Experience of Care domains but did not meet the minimum case requirements for the Outcome or Efficiency domains, the weighting would have been reallocated to the remaining applicable domains.

As noted above, the weight of the Outcome domain was 30 percent and the Efficiency domain was 20 percent; therefore, the total weight between the remaining applicable domains—Clinical Process of Care (20 percent) and Patient Experience of Care (30 percent) - would have been 50 percent.

In this example, the reallocated weighting for the remaining applicable domains would have been:

• Clinical Process of Care = 40%
• Patient Experience of Care = 60%

Note: Calculated reallocated weighting has been rounded. A greater precision of the calculated value was used on the Percentage Payment Summary Reports.

The formula to calculate the re-weighting of the measures was as follows:

Original weight of each remaining domain ÷ total weight of remaining domains x 100

The reallocated weights must total 100 percent.

FY 2016 Scoring

Weighting for FY 2016

For FY 2016, the TPS was re-weighted proportionately to the scored domains for hospitals with at least two (2) out of four (4) domain scores. The TPS was scored out of a possible 100 points, and the relative weights for the scored domains remained equivalent.

For example, if a hospital met the minimum case and measure requirements for the Clinical Process of Care, Patient Experience of Care, and Outcome domains but did not meet the minimum case requirements for the Efficiency domain, the weighting would have been reallocated to the remaining applicable domains.

As noted above, the weight of the Efficiency domain was 25 percent; therefore, the total weight between the remaining applicable domains—Clinical Process of Care (10 percent), Patient Experience of Care (25 percent), and Outcome (40 percent)—would have been 75 percent.

In this example, the reallocated weighting for the remaining applicable domains would have been:

• Clinical Process of Care = 13.3%
• Patient Experience of Care = 33.3%
• Outcome = 53.3%

Note: Calculated reallocated weighting has been rounded. A greater precision of the calculated value was used on the Percentage Payment Summary Reports.

The formula to calculate the re-weighting of the measures was as follows:

Original weight of each remaining domain ÷ total weight of remaining domains x 100

The reallocated weights must total 100 percent.

Refer to the Hospital VBP FY 2016 Baseline Report Overview handout from the April 29, 2014, National Provider Call for details regarding measure re-weighting.

FY 2017 Scoring

Weighting for FY 2017

For FY 2017, the TPS was re-weighted proportionately to the scored domains for hospitals with at least three (3) out of four (4) domain scores. The TPS was scored out of a possible 100 points, and the relative weights for the scored domains remained equivalent.

For example, if a hospital met the minimum case and measure requirements for the Clinical Care -Process subdomain, Safety domain, and Efficiency and Cost Reduction domain but did not meet the minimum case  or survey requirements for the Clinical Care – Outcomes subdomain and the Patient- and Caregiver-Centered Experience of Care/Care Coordination domain, the weighting would have been reallocated to the remaining applicable domains.

As noted above, the weight of the Patient- and Caregiver-Centered Experience of Care/Care Coordination domain was 25 percent and the Clinical Care – Outcomes subdomain was 25%; therefore, the total weight between the remaining applicable domains—Clinical Care – Process subdomain (5 percent), Safety domain (20 percent), and Efficiency and Cost Reduction domain (25 percent)—would have been 50 percent.

In this example, the reallocated weighting for the remaining applicable domains would have been:

• Clinical Care - Process = 10%
• Safety = 40%
• Efficiency and Cost Reduction = 50%

The formula to calculate the re-weighting of the measures was as follows:

Original weight of each remaining domain ÷ total weight of remaining domains x 100

The reallocated weights must total 100 percent.

Note: A hospital meeting the minimum cases in both or either of the Clinical Care subdomains was treated as meeting the minimum measures for the count of one domain (Clinical Care).

See the Overview of the Hospital Value-Based Purchasing (VBP) Fiscal Year (FY) 2017 handout from the February 17, 2015 National Provider Call for details regarding measure re-weighting.

FY 2018 Scoring

Weighting for FY 2018

For FY 2018, the TPS will be re-weighted proportionately to the scored domains for hospitals with at least three (3) out of four (4) domain scores. The TPS will be scored out of a possible 100 points, and the relative weights for the scored domains will remain equivalent.

For example, when a hospital meets the minimum case and measure requirements for the Clinical Care domain, Safety domain and Efficiency and Cost Reduction domain but does not meet the minimum survey requirements for the Patient- and Caregiver-Centered Experience of Care/Care Coordination domain, the weighting will be reallocated to the remaining applicable domains.

As noted above, the FY 2018 scoring is based on each of the four domains weighted equally at 25 percent each. Therefore, in the previous example the reallocation of weighting would be as follows:

• Clinical Care = 33.3%
• Safety = 33.3%
• Efficiency and Cost Reduction = 33.3%

The formula to calculate the re-weighting of the measures was as follows:

Original weight of each remaining domain ÷ total weight of remaining domains x 100

The reallocated weights must total 100 percent.

See the Hospital VBP Program: Percentage Payment Summary Report Overview handouts from the July 25, 2017 National Provider Call for details regarding measure re-weighting.

FY 2019 Scoring

Weighting for FY 2019

For FY 2019, the TPS will be re-weighted proportionately to the scored domains for hospitals with at least three (3) out of four (4) domain scores. The TPS will be scored out of a possible 100 points, and the relative weights for the scored domains will remain equivalent..

For example, when a hospital meets the minimum case and measure requirements for the Clinical Care domain, Safety domain and Efficiency and Cost Reduction domain but does not meet the minimum survey requirements for the Person and Community Engagement domain, the weighting will be reallocated to the remaining applicable domains.

As noted above, the FY 2019 scoring is based on each of the four domains weighted equally at 25 percent each. Therefore, in the previous example the reallocation of weighting would be as follows.

• Clinical Care = 33.3%
• Safety = 33.3%
• Efficiency and Cost Reduction = 33.3%

The formula to calculate the re-weighting of the measures was as follows:

Original weight of each remaining domain ÷ total weight of remaining domains x 100

The reallocated weights must total 100 percent.

See the Hospital VBP Program: Overview of the FY 2019 Percentage Payment Summary Report handouts from the August 7, 2018 National Provider Call for details regarding measure re-weighting.

FY 2020 Scoring

Weighting for FY 2020

For FY 2020, the TPS will be re-weighted proportionately to the scored domains for hospitals with at least three (3) out of four (4) domain scores. The TPS will be scored out of a possible 100 points, and the relative weights for the scored domains will remain equivalent.

For example, when a hospital meets the minimum case and measure requirements for the Clinical Outcomes domain, Safety domain, and Efficiency and Cost Reduction domain, but does not meet the minimum survey requirements for the Person and Community Engagement domain, the weighting will be reallocated to the remaining applicable domains.

As noted above, the FY 2020 scoring is based on each of the four domains weighted equally at 25 percent each. Therefore, in the previous example the reallocation of weighting would be as follows.

• Clinical Outcomes = 33.3%
• Safety = 33.3%
• Efficiency and Cost Reduction = 33.3%

The formula to calculate the re-weighting of the measures was as follows:

Original weight of each remaining domain ÷ total weight of remaining domains x 100

The reallocated weights must total 100 percent.

See the What’s My Payment? Understanding the Hospital VBP Program Calculations Step-By-Step in the Percentage Payment Summary Report handouts from the August 8, 2019 National Provider Call for details regarding measure re-weighting.

Extraordinary Circumstances Exceptions (ECE) Policy

The Centers for Medicare & Medicaid Services (CMS) offers a process for hospitals to request and for CMS to request an exception for one or more of the measure submission requirements for the Hospital Value-Based Purchasing (VBP) Program when there are extraordinary circumstances beyond the control of the hospital that significantly affected the hospital's performance under the Hospital VBP Program. CMS will evaluate the request and grant or deny the ECE request.

Note: The same ECE Request form is used across all inpatient quality programs.

In the event of such circumstances, hospitals must submit an Extraordinary Circumstances Exceptions (ECE) Request form, with all required sections completed. The hospital may request consideration for an exception from the Hospital VBP Program for that fiscal year. The form must be signed by the hospital's chief executive officer (CEO) or designee, and submitted via one of the following methods:

• Hospital Quality Secure Portal, Managed File Transfer (MFT) to: QRFormsSubmission@hsag.com 
  • Note: When sending via MFT uncheck “Required Registered Users.”
• Secure fax to: (877) 789-4443
• Email to: QRFormsSubmission@hsag.com

For more information and access to the required forms and resources, please refer to the Inpatient Quality Reporting (IQR) Program page on QualityNet:
Inpatient Quality Reporting Program - Extraordinary Circumstances Exceptions (ECE) Policy

Here, you will find:

• Extraordinary Circumstances Exceptions (ECE) Request form
• Extraordinary Circumstance Exceptions (ECE) Information and Resources
• Extraordinary Circumstances Exceptions (ECE) Quick Reference

The Support Contractor will forward, as directed, to CMS. This form must be submitted within 60 days of the extraordinary circumstances event for the Hospital VBP Program.

Note: This process does not preclude CMS from granting exceptions to hospitals when it is determined that an extraordinary circumstance, such as an act of nature, affects an entire region or locale. If CMS makes the determination to grant an exception to hospitals in a region or locale, CMS will communicate this decision to hospitals, vendors, and QIN-QIOs through routine communication channels, including memos, emails, and notices on QualityNet.