Claims-Based Measures
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.)
- Agency for Healthcare Research and Quality (AHRQ) Indicators – including Patient Safety Indicators (PSIs) and Inpatient Quality Indicators (IQIs)
- Hospital-Acquired Conditions (HAC) Measures
- Mortality Measures – including acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN)
- Hospital Value-Based Purchasing (HVBP) Mortality Measures
- Readmission Measures – including AMI, HF, PN, Hospital-Wide All-Cause Unplanned Readmission Measure (HWR), Hospital-Level 30-Day All-Cause Risk-Standardized Readmission Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)
- Complication Measure – including Hospital-level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)
- Medicare Spending Per Beneficiary (MSPB) Measure
Each measure set is calculated using a separate, distinct methodology and, in some cases, separate discharge periods. (For the AMI, HF, PN Mortality and Readmission measures, administrative data from Veterans Administration (VA) medical centers are also used.)