- What is an ACO?
- Assessment of ACO Healthcare Quality Performance for 2016 to 2017
- Medicare ACO Quality Performance for 2016 and 2017
- 34 Quality Measures to Assess Healthcare ACO 2016 and 2017
- ACO 34 Measures to Assess Quality Performance for 2016 and 2017
- ACO Quality Measure Benchmarks for Reporting for 2016 and 2017
- Medicare Shared Savings Program
- ACO Healthcare
- Accountable Care
- Medicare ACO
- Healthcare ACO
- Shared Savings Program
- ACO 34 Measures
- Medicare PQRS
- PQRS Medicare
ACO Quality Measure Benchmark for Reporting Year 2016 and 2017
This dataset describes methods for calculating the quality performance benchmarks for Accountable Care Organizations (ACOs) that are participating in the Medicare Shared Savings Program (Shared Savings Program) and presents the benchmarks for the 34 quality measures for the 2016 and 2017 quality reporting years.
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ACOs are required to completely and accurately report quality data that are used to calculate and assess their quality performance. In addition, in order to be eligible to share in any savings generated, an ACO must meet the established quality performance standard that corresponds to its performance year. This document also reviews the quality performance benchmarks and scoring methodology, as described in the Shared Savings Program regulations. Enrichments have also been made to include appropriate ICD10 and HCPCS codes for each ACO measure.
In the first performance year of their first agreement period, ACOs satisfy the quality performance standard when they completely and accurately report on all quality measures (pay-for-reporting). Complete and accurate reporting in the ACO’s first performance year qualifies the ACO for the maximum sharing rate. In subsequent performance years, quality performance benchmarks are phased-in for performance measures and the quality performance standard requires ACOs to continue to completely and accurately report quality data on all measures but the ACOs final sharing rate is determined based on its performance compared to national benchmarks.
In addition, ACOs must meet minimum attainment (30th percentile benchmark) on at least 1 pay-for-performance measure in each domain in order to be eligible to share in savings. Both attainment and improvement in performance are taken into account when calculating the final sharing rate for ACOs in their second and subsequent performance years. ACOs are rewarded up to four additional points in each domain, if they demonstrate quality improvement. In this way, the ACO becomes increasingly responsible for quality performance and improvement during the first agreement period. When an ACO renews its participation in the program for a second or subsequent agreement period, the quality performance of ACOs is assessed in the same manner as ACOs in the third performance year of their first agreement period.
Quality performance benchmarks are established by the Centers for Medicare and Medicaid Services (CMS) prior to the reporting period for which they apply and are set for 2 years. This document defines and sets the quality performance benchmarks that will be used for the 2016 and 2017 reporting periods. These benchmarks will apply to all Shared Savings Program ACOs reporting quality data in 2016 and 2017.
For the 2016 reporting year, CMS will measure quality of care using 34 quality measures (32 individual measures and 1 composite measure that include 2 individual component measures). The quality measures span four quality domains: Patient/Caregiver Experience, Care Coordination/Patient Safety, Preventive Health, and At-Risk Population. Because new quality measures introduced to the Shared Savings Program are set at the level of complete and accurate reporting for the first 2 years before phasing into performance, this document will be updated prior to the 2017 reporting year to include benchmarks for 7 measures (including the Diabetes Composite) that phase into performance for the 2017 reporting year. The benchmarks for each measure along with the phase-in schedule for pay-for-performance are displayed in the Table.
It is also important to note that CMS maintains the authority to revert measures from pay-for-performance to pay-for-reporting when the measure owner determines the measure causes patient harm or no longer aligns with clinical practice. Should CMS need to make such a modification, CMS will alert the ACOs through the Spotlight newsletter.
**Benchmark Data Sources**
These 2016 and 2017 benchmarks used all available and applicable 2012, 2013 or 2014 Medicare fee-for-service (FFS) data. This includes:
– Quality data reported through the Physician Quality Reporting System (PQRS) by physicians and groups of physicians through the Web Interface, claims, or a registry for the 2012, 2013, and2014 performance years, as available;
– Quality data reported by Shared Savings Program and Pioneer Model ACOs through the Web Interface for 2012, 2013 or 2014 performance years;
– Quality measure data collected from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for ACOs, CAHPS for PQRS and Medicare FFS CAHPS surveys administered for the 2012, 2013 or 2014 performance years;
Attestation and meaningful use data collected through the Electronic Health Record (EHR) Incentive Program for 2013 and 2014.
All of the quality measure benchmarks were calculated using ACO, group practice and individual physician data aggregated to the TIN level and included if there were at least 20 cases in the denominator. Quality data for ACOs, providers or group practices that did not satisfy the reporting requirements of the Shared Savings Program or PQRS were not included in calculation of the benchmarks.
Benchmarks for ACO Quality Measures
Benchmarks for the 23 of the 34 quality measures that are pay-for-performance for the 2016 and 2017 reporting years for an ACO’s second or third year of the ACO’s first agreement period are specified in the Table. ACOs in a second agreement period should refer to performance year 3 in the Table. In addition, the following 7 measure benchmarks will be released prior to the 2017 reporting year, because they phase into performance in 2017:
– ACO-34 Stewardship of Patient Resources
– ACO-35 Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)
– ACO-36 All-Cause Unplanned Admissions for Patients with Diabetes
– ACO-37 All-Cause Unplanned Admissions for Patients with Heart Failure
– ACO-38 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions
– ACO-39 Documentation of Current Medications in the Medical Record
– Diabetes Composite (includes 2 component measures)
A quality performance benchmark is the performance rate an ACO must achieve to earn the corresponding quality points for each measure. The Table shows the benchmark for each percentile, starting with the 30th percentile (corresponding to the minimum attainment level) and ending with the 90th percentile (corresponding to the maximum attainment level). Under the Shared Savings Program’s regulation at 42 C.F.R. 425.502, there are circumstances when the set benchmark uses flat percentages. The use of flat percentages addresses issues with measures that have an overall high level of performance and allows ACOs with high scores to be recognized for their performance and earn maximum or near maximum quality points while also recognizing a range of performance levels allowing room for improvement and rewarding that improvement in subsequent years. For 15 measures, benchmarks using flat percentages use the 60th percentile when it is equal to or greater than 80.00 percent. For 3 measures, benchmarks using flat percentages use the 90th percentile when it is equal to or greater than 95.00 percent.
In efforts to maintain consistency across benchmarks, the ACO-10 Ambulatory Sensitive Conditions Admissions were also displayed: Heart Failure observed to expected ratio percentiles as percentages. ACOs can compare their previous annual performance scores for ACO-9 and ACO-10 by multiplying their observed/expected ratio performance rates with the following national means:
– ACO-9 national mean performance rate: 6.86%
– ACO-10 national mean performance rate: 18.19%
**Quality Scoring Points System**
The Table shows the maximum possible points that may be earned by an ACO in each domain and overall. An ACO achieves the maximum points for all measures designated as pay for reporting when the ACO completely and accurately reports. For measures that are pay for performance, quality scoring will be based on the ACO’s level of performance on each measure.
An ACO will earn quality points for each measure on a sliding scale based on level of performance. Performance below the minimum attainment level (the 30th percentile) for a measure will receive zero points for that measure; performance at or above the 90th percentile of the quality performance benchmark earns the maximum points available for the measure.
For most of the measures, the higher the level of performance, the higher the corresponding number of quality points. However, it is important to note that eight ACO quality measures have a reverse scoring structure, which means that a lower score represents better performance, and a higher score represents worse performance.
The following measures are scored such that a lower rate is indicative of better performance:
– ACO-8: Risk Standardized, all condition readmissions.
– ACO-9: Ambulatory Sensitive Conditions Admissions: for COPD or asthma in older adults.
– ACO-10: Ambulatory Sensitive Conditions Admissions: for heart failure (HF).
– ACO-27: Diabetes Mellitus: Hemoglobin A1c poor control.
– ACO-35: Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)
– ACO-36: All-Cause Unplanned Admissions for Patients with Diabetes
– ACO-37: All-Cause Unplanned Admissions for Patients with Heart Failure
– ACO-38: All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions
A maximum of 2 points can be earned for each scored individual or composite measure, except for the Percent of Primary Care Physicians who Successfully Met Meaningful Use Requirements measure (ACO-11). The ACO-11 measure is double weighted and is worth up to 4 points to provide incentive for greater levels of EHR adoption.
The matrix below shows the points earned for each measure at the corresponding decile value. For example, if an ACO’s performance rate for the Influenza immunization measure (ACO-14) is 72 percent or percentile, it would earn 1.70 points for that measure. Because the EHR measure (ACO-11) is double weighted, an ACO’s performance rate of 78 percent or percentile on that measure would earn 3.40 points.
**ACO Performance Level Quality points**
90+ percentile benchmark or 90+ percent 2.00 points
80+ percentile benchmark or 80+ percent 1.85 points
70+ percentile benchmark or 70+ percent 1.70 points
60+ percentile benchmark or 60+ percent 1.55 points
50+ percentile benchmark or 50+ percent 1.40 points
40+ percentile benchmark or 40+ percent 1.25 points
30+ percentile benchmark or 30+ percent 1.10 point
<30 percentile benchmark or <30+ percent No points
**Quality Improvement Reward**
Additionally, CMS will reward ACOs that demonstrate significant improvement in their quality measure performance by adding up to 4.00 points to each domain score. The total points in each domain cannot exceed the maximum points that are possible in that domain. For instance, an ACO may receive 4.00 additional points in the Preventive Health domain by demonstrating quality improvement; however, the ACO’s total points for the domain cannot exceed the maximum 18 possible points that can be earned for the Preventive Health domain.
The total points earned for measures in each domain, including any quality improvement points, will be summed and divided by the total points available for that domain to produce a domain score of the percentage of points earned relative to points available. The percentage score for each domain will be averaged together to generate a final overall quality score for each ACO that will be used to determine the amount of savings it shares or, if applicable, the amount of losses it owes.
About this Dataset
John Snow Labs; Centers for Medicare and Medicaid Services (CMS);
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Medicare Shared Savings Program, ACO, ACO Healthcare, Accountable Care, Medicare ACO, Healthcare ACO, Shared Savings Program, ACO 34 Measures, Medicare PQRS, PQRS Medicare
What is an ACO?, Assessment of ACO Healthcare Quality Performance for 2016 to 2017, Medicare ACO Quality Performance for 2016 and 2017, 34 Quality Measures to Assess Healthcare ACO 2016 and 2017, ACO 34 Measures to Assess Quality Performance for 2016 and 2017, ACO Quality Measure Benchmarks for Reporting for 2016 and 2017
|Domain||The description of the domain or criteria to be assessed for quality measure.||string||-|
|ACO_Measure_Number||The description of the Accountable Care Organization (ACO) number that is used to assess quality measure.||string||unique : 1|
|Measure_Description||Detailed description of the domain for quality measurement.||string||-|
|ICD10_Code||The International Classification of Diseases ICD-10 code/codes for a specific ACO measure.||string||-|
|ICD10_Description||Description used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care.||string||-|
|HCPCS_Code||The Healthcare Common Procedure Coding System (HCPCS) code/codes for a specific ACO measure.||string||-|
|HCPCS_Description||Description of the Level II of the HCPCS standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office.||string||-|
|Pay_For_Performance_Phase_Year1||The description of the pay for performance quality for Year 1 of the program.||string||-|
|Pay_For_Performance_Phase_Year2||The description of the pay for performance quality for Year 2 of the program.||string||-|
|Pay_For_Performance_Phase_Year3||The description of the pay for performance quality for Year 3 of the program.||string||-|
|Sliding_Scale_Measure_Score_30_Percent||Description of the fee percentage for a 30 percent sliding scale performance quality measure.||number||level : Ratio|
|Sliding_Scale_Measure_Score_40_Percent||Description of the fee percentage for a 40 percent sliding scale performance quality measure.||number||level : Ratio|
|Sliding_Scale_Measure_Score_50_Percent||Description of the fee percentage for a 50 percent sliding scale performance quality measure.||number||level : Ratio|
|Sliding_Scale_Measure_Score_60_Percent||Description of the fee percentage for a 60 percent sliding scale performance quality measure.||number||level : Ratio|
|Sliding_Scale_Measure_Score_70_Percent||Description of the fee percentage for a 70 percent sliding scale performance quality measure.||number||level : Ratio|
|Sliding_Scale_Measure_Score_80_Percent||Description of the fee percentage for a 80 percent sliding scale performance quality measure.||number||level : Ratio|
|Sliding_Scale_Measure_Score_90_Percent||Description of the fee percentage for a 90 percent sliding scale performance quality measure.||number||level : Ratio|
|Better_Performance_Measure||Description for a better performance measure whether a higher or lower rate is required.||string||-|
|Domain||ACO Measure Number||Measure Description||ICD10 Code||ICD10 Description||HCPCS Code||HCPCS Description||Pay For Performance Phase Year1||Pay For Performance Phase Year2||Pay For Performance Phase Year3||Sliding Scale Measure Score 30 Percent||Sliding Scale Measure Score 40 Percent||Sliding Scale Measure Score 50 Percent||Sliding Scale Measure Score 60 Percent||Sliding Scale Measure Score 70 Percent||Sliding Scale Measure Score 80 Percent||Sliding Scale Measure Score 90 Percent||Better Performance Measure|
|Patient/Caregiver Experience||ACO - 1||CAHPS: Getting Timely Care, Appointments, and Information||Z71.2||Person consulting for explanation of examination or test findings||G0495||Skilled services of a registered nurse (rn), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes||Reporting||Performance||Performance||30.0||40.0||50.0||60.0||70.0||80.0||90.0||Higher Rate|
|Patient/Caregiver Experience||ACO - 2||CAHPS: How Well Your Doctors Communicate||Z00.0||Encounter for general adult medical examination||G9483||Remote in-home visit for the evaluation and management of a new patient for use only in the Medicare-approved Comprehensive Care for Joint Replacement model, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity, furnished in real time using interactive audio and video technology. Counseling and coordination of care with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the needs of the patient or the family or both. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient or family or both via real time, audio and video intercommunications technology.||Reporting||Performance||Performance||30.0||40.0||50.0||60.0||70.0||80.0||90.0||Higher Rate|
|Patient/Caregiver Experience||ACO - 3||CAHPS: Patients' Rating of Doctor||Z51||Encounter for other aftercare and medical care||S0281||Medical home program, comprehensive care coordination and planning, maintenance of plan||Reporting||Performance||Performance||30.0||40.0||50.0||60.0||70.0||80.0||90.0||Higher Rate|
|Patient/Caregiver Experience||ACO - 4||CAHPS: Access to Specialists||Z71.2||Person consulting for explanation of examination or test findings||G0008, G0027, G0101, G0108, G0117, G0118, G0123, G0124, G0128, G0129, G0130, G0141, G0151, G0166, G0168, G0175, G0176, G0177, G0179, G0180, G0186, G0202, G0204, G0206, G0219, G0235, G0237, G0238, G0239, G0248, G0249, G0250, G0252, G0255, G0259, G0260, G0268, G0269, G0270, G0271, G0276, G0277, G0278, G0279, G0281, G0282, G0283, G0288, G0289, G0293, G0294, G0295, G0296, G0297, G0298, G0302, G0303, G0304, G0305, G0306, G0307, G0328, G0329, G0333, G0339, G0340, G0341, G0342, G0343, G0364, G0365, G0372, G0378, G0379, G0380, G0381, G0382, G0383, G0384, G0390, G0398, G0399, G0400, G0402, G0403, G0404, G0405, G0409, G0412, G0416, G0420, G0421, G0422, G0423, G0424, G0428, G0429, G0432, G0433, G0435, G0438, G0439, G0442, G0448, G0451, G0452, G0453, G0454, G0455, G0458, G0460, G0461, G0463, G0466, G0471, G0475, G0476, G0477, G0491, G0498, G0500, G0501, G0502, G0659, G0908, G0913, G0914, G0915, G0916, G0917, G0918, G6001, G6016, G6017, G6030, G9157, G9481, G9490, G9678||Procedures/Professional Services||Reporting||Performance||Performance||30.0||40.0||50.0||60.0||70.0||80.0||90.0||Higher Rate|
|Patient/Caregiver Experience||ACO - 5||CAHPS: Health Promotion and Education||Z76.1||Encounter for health supervision and care of foundling||G0495, G0496||Skilled services of a registered nurse (rn), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes, Skilled services of a licensed practical nurse (lpn), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes||Reporting||Performance||Performance||56.27||57.44||58.27||59.23||60.17||61.37||63.41||Higher Rate|
|Patient/Caregiver Experience||ACO - 6||CAHPS: Shared Decision Making||Z71.9||Counseling, unspecified||G9296||Patients with documented shared decision-making including discussion of conservative (non-surgical) therapy (e.g., nsaids, analgesics, weight loss, exercise, injections) prior to the procedure||Reporting||Performance||Performance||73.45||74.06||74.57||75.16||75.84||76.6||77.66||Higher Rate|
|Patient/Caregiver Experience||ACO - 7||CAHPS: Health Status/Functional Status||Z00, Z01, Z02, Z03, Z04, Z05, Z06, Z07, Z08, Z09, Z10, Z11, Z12, Z13, Z14, Z15, Z16, Z17, Z18, Z19, Z20, Z21, Z22, Z23, Z24, Z25, Z26, Z27, Z28, Z29, Z30, Z31, Z32, Z33, Z34, Z35, Z36, Z37, Z38, Z39, Z40, Z41, Z42, Z43, Z44, Z45, Z46, Z47, Z48, Z49, Z50, Z51, Z52, Z53, Z55, Z65, Z66, Z67, Z68, Z69, Z70, Z71, Z72, Z73, Z74, Z75, Z76, Z77, Z78, Z79, Z80, Z81, Z82, Z83, Z84, Z85, Z86, Z87, Z88, Z89, Z90, Z91, Z92, Z93, Z94, Z95, Z96, Z97, Z98, Z99||Factors influencing health status and contact with health services||G0507||Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements: initial assessment or follow-up monitoring, including the use of applicable validated rating scales; behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation; and continuity of care with a designated member of the care team||Reporting||Reporting||Reporting||Higher Rate|
|Care Coordination/Patient Safety||ACO - 8||Risk-Standardized, All Condition Readmission||T80, T81, T82, T83, T84, T85, T86, T87, T88||Complications of surgical and medical care, not elsewhere classified (T80-T88)||G9309, G9310||No unplanned hospital readmission within 30 days of principal procedure, Unplanned hospital readmission within 30 days of principal procedure||Reporting||Reporting||Performance||15.32||15.19||15.07||14.97||14.87||14.74||14.54||Lower Rate|
|Care Coordination/Patient Safety||ACO - 9||Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5)||J44, J44.0, J44.1, J44.9||Other chronic obstructive pulmonary disease, Chronic obstructive pulmon disease w acute lower resp infct, Chronic obstructive pulmonary disease w (acute) exacerbation, Chronic obstructive pulmonary disease, unspecified||G9681||This code is for onsite acute care treatment of a resident with copd or asthma; may only be billed once per day per beneficiary||Reporting||Performance||Performance||70.0||60.0||50.0||40.0||30.0||20.0||10.0||Lower Rate|
|Care Coordination/Patient Safety||ACO - 10||Ambulatory Sensitive Conditions Admissions: Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8)||150, I50.9||Heart failure, Heart failure, unspecified||G9680||This code is for onsite acute care treatment of a nursing facility resident with chf; may only be billed once per day per beneficiary||Reporting||Performance||Performance||25.04||22.16||19.67||17.28||14.95||12.01||8.31||Lower Rate|