Overview: Direct Contracting Quality Measurement Methodology
(Updated January 2022)
Under the Direct Contracting Quality Measurement Methodology, which was updated on December 1, 2021, Direct Contracting Entities (DCEs) will not need to report on any measures. All measures are either claims-based or based on a patient survey. This is also the first time the Center for Medicare and Medicaid Innovation (Innovation Center) is giving additional weight to patient-reported measures. The full quality measurement methodology paper is posted on the Innovation Center’s website. This document has been updated to reflect that updated paper.
NAACOS is actively engaged in shaping the Direct Contracting Model, providing advocacy to improve the model and education to prepare providers for participation. Please visit our Direct Contracting Model website to learn more, and submit questions or feedback to us at [email protected].
Quality Measures
The Innovation Center will assess quality using four quality measures, none of which are reported by DCEs. Standard and New Entrant DCEs will be report: Risk-Standardized All-Condition Readmission, All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions, Timely Follow-Up After Acute Exacerbations of Chronic Conditions, and Consumer Assessment of Healthcare Providers & Systems (CAHPS®) Survey. For High Needs DCEs, the Timely Follow-Up measure is replaced with Days at Home for Patients with Complex, Chronic Conditions, a measure that is still under development.
Measure Descriptions:
Risk-Standardized All-Condition Readmission: Measures how many hospital stays result in a readmission within 30 days after patient discharge. This is a claims measure.
All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions: Measures unplanned hospital admissions among Medicare fee-for-service beneficiaries 65 years of age and older with multiple chronic conditions. This is a claims measure.
CAHPS is based on the Clinician and Group CAHPS Survey and includes additional content relevant to patient/caregiver experience with care delivered by a DCE. The survey asks patients about their experiences with care at their most recent visit with an ambulatory care provider. It is applicable to any type of synchronous visit, regardless of whether the interaction occurred in person, by phone, or by video. DCEs must contract with a CMS-approved CAHPS Survey vendor for each reporting year to administer the CAHPS Survey.
Timely Follow-Up is defined as the percentage of acute events related to one of six chronic conditions where follow-up was received within the timeframe recommended by clinical practice guidelines in a non-emergency outpatient setting. Acute events are those that required either an emergency department visit or hospitalization. The six chronic conditions include hypertension, asthma, heart failure, coronary artery disease, chronic obstructive pulmonary disease, and Type I/II diabetes mellitus. This is a claims measure.
Days at Home for Patients with Complex, Chronic Conditions: Measures the number of days that adults with complex, chronic disease spend at home and out of acute and post-acute care settings. This is a claims measure.
Quality Withhold
As described in previous model documents, 5 percent of a DCE’s financial benchmark is at risk based on quality performance. For the first two performance years of the model (2021 and 2022), only 1 percent is tied to quality performance, with the other 4 percent tied only to quality reporting. Pay-for-reporting measures do not impact a DCE’s quality score. Beginning in 2023, the full 5 percent will be tied to quality performance. DCEs that begin participation in Performance Year 2 (PY2) (2022) will only have one year under the 4 percent pay-for-reporting/1 percent pay-for-performance scheme. If CMMI adds any new measures during the model, any such measures will be pay-for-reporting only for its first year of use. For 2021, CMS will set the benchmark using two 12-month periods (2019 and 2021). Beginning in 2022, CMS will use concurrent benchmarking.
Quality Score
For each performance year, the Innovation Center will calculate a quality score for each DCE (the DCE’s Total Quality Score) on a scale of 1–100 percent, which is then applied to the 5 percent quality withhold. The Total Quality Score is the combination of a DCE’s score on pay-for-reporting measures and its score on pay-for-performance measures.
For pay-for-reporting measures, a DCE gets a 100 percent score if it successfully reports the measure and a 0 percent score if it fails to completely report the measure. Because all but the CAHPS measure are claims measures, reporting is automatic. For the CAHPS measure, reporting requires the DCE’s survey vendor to successfully report the survey results to the Innovation Center.
For each pay-for-performance measure, the Innovation Center will set a Quality Benchmark using TIN-level claims data from large physician practices and other non-DCE organizations. CMS will set a separate benchmark for each of the High Needs DCE measures. Each DCE will receive a quality score by comparing is score on a quality measure to the Quality Benchmark for that measure.
Standard and New Entrant DCEs
PY1 (2021): A DCE must report on All-Condition Readmissions and Unplanned Admissions for Patients with Multiple Chronic Conditions only. A DCE can meet the pay-for-performance requirement with either the All-Condition Readmissions or Unplanned Admissions for Patients with Multiple Chronic Conditions.
PY2 (2022): A DCE must report on all four applicable measures, which are the All-Condition Readmissions, Unplanned Admissions for Patients with Multiple Chronic Conditions, CAHPS, and Timely Follow-Up. The pay-for-reporting requirement is attributed 2 percent to CAHPS and 2 percent for the other three measures, collectively. For the pay-for-performance requirement, All-Condition Readmissions and Unplanned Admissions for Patients with Multiple Chronic Conditions are evaluated together as a combined component. A DCE can meet the pay-for-performance requirement (30th percentile) with either the All-Condition Readmission or Unplanned Admissions for Patients with Multiple Chronic Conditions.
PY3 (2023): Beginning in PY3, the quality score will be based solely on pay-for-performance for the four applicable measures. Each of these four measures will be tied to 1.25 percent of the 5 percent quality withhold.
High Needs DCEs
PY1 (2021): A DCE must report only on All-Condition Readmissions, Unplanned Admissions for Patients with Multiple Chronic Conditions, and Days at Home. A DCE can meet the pay-for-performance requirement with either the All-Condition Readmission or Unplanned Admissions for Patients with Multiple Chronic Conditions.
PY2/3 (2022/2023): A DCE must report on all 4 applicable measures, which are which are the All-Condition Readmissions, Unplanned Admissions for Patients with Multiple Chronic Conditions, CAHPS, and Days at Home. The pay-for-reporting requirement is attributed 2 percent to CAHPS and 2 percent for the other three measures, collectively. A DCE can meet the pay-for-performance requirement with either the All-Condition Readmission or Unplanned Admissions for Patients with Multiple Chronic Conditions.
Future Quality Methodology Policies
Continuous Improvement/Sustained Exceptional Improvement (CI/SEP)
Beginning in PY3, the Innovation Center will implement the CI/SEP threshold, which determines whether a DCE can earn back 2.5 percent or the full 5 percent of the quality withhold. The Innovation Center has not released details on the criteria for this threshold. More information will be provided prior to PY3.
High Performers Pool (HPP)
Beginning in PY3, the Innovation Center will create an HPP, funded by the portion of DCEs’ quality withholds that are not earned back from DCEs that meet the CI/SEP threshold but do receive a 100 percent Total Quality Score. The Innovation Center will distribute these HPP funds to the highest performing DCEs, meaning those DCEs may earn back more than the 5 percent withhold. More details on the criteria for the HPP will be released prior to PY3.