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CHA DataSuite Releases Three Quality Program Analyses

CHA DataSuite has issued three hospital-specific analyses related to quality programs. The analyses are for quality program measure trends, federal fiscal year (FFY) 2024 Value-Based Purchasing program (first quarter 2023), and the FFY 2024 Hospital Acquired Condition Reduction program (first quarter 2023).  

The measures analyzed represent those included in the Medicare quality programs: 

  • Value-Based Purchasing 
  • Readmissions Reduction  
  • Hospital Acquired Conditions (HAC) Reduction  
  • Comprehensive Care for Joint Replacement  

Measures that CMS has adopted for use in at least one of the four programs for the current program year and forward are also included, though some measures do not apply to all program years. Measures collected by CMS that have not been adopted for use in one of the programs — but are included in the Care Compare database — are not evaluated in this analysis, with the exception of star ratings. Measures that have been finalized for use in one of the four programs — but are lacking complete data in Care Compare — are not evaluated in this analysis. In order to focus on the measures relevant to the quality programs going forward, this analysis does not include measures that CMS has removed from the current program year.  

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FFY 2024 Analysis of Value-Based Purchasing Program (First Quarter 2023)  

This analysis of the Value-Based Purchasing (VBP) program, designed in the business intelligence platform, is intended to provide hospitals a preview of the program’s potential impact for FFY 2024, based on the most recent publicly available data and program rules established by CMS.  

CMS is neither penalizing nor rewarding hospitals for the FFY 2022 and FFY 2023 VBP programs due to the impact of the COVID-19 pandemic. CMS did provide a subset of data for individual measures and the clinical outcomes (FFYs 2022 and 2023) and efficiency (FFY 2023) domains, but did not provide the total performance score or adjustment factors, and therefore, no impacts were calculated.   

For FFY 2024, VBP performance periods are impacted by the extraordinary circumstances exception granted by CMS in response to the public health emergency, so no claims data or chart-abstracted data reflecting services provided from Jan. 1 to June 30, 2020, will be used in the calculations for VBP.   

The FFY 2024 figures are estimates, based on CMS’ first quarter 2023 update of Care Compare. Estimated FFY 2024 VBP scores, FFY 2024, adjustment factors, and FFY 2024 dollar impacts in this analysis may differ slightly from analyses provided by other organizations due to differences in data source and analytic methods.  

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FFY 2024 Hospital Acquired Conditions Reduction Program Analysis (First Quarter 2023)   

This analysis of the FFY 2024 Medicare inpatient HAC Reduction program is intended to provide hospitals with a preview of the potential impact of the program based on publicly available data and program rules established by CMS.   

Hospital performance is evaluated under the FFY 2024 program in this analysis. This analysis uses the first quarter 2023 update of Care Compare for healthcare associated infections (HAI) measures and the fourth quarter 2022 update of Care Compare for patient safety indicator-90. The analysis includes estimates and details on how HAC measures and domain scores are calculated as well as how payment penalties are determined and applied under the program.   

For FFY 2023 HAC, CMS is not penalizing any hospitals due to the impact of the COVID-19 pandemic. CMS did provide a subset of data for individual measures but did not provide total HAC scores and therefore no impacts are calculated. For FFY 2024 HAC, performance periods are impacted by the extraordinary circumstances exception granted by CMS in response to the public health emergency. As a result, no claims data for chart-abstracted data reflecting services provided in calendar years 2020 or 2021 for HAI measures will be used in calculations for the HAC program.   

The estimated scores and dollar impacts shown in this analysis may differ from the final CMS calculations and may vary from those provided by other organizations due to differences in source data and analytic methods.   

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