(a) Requirements for hospitals and physician practices.
(1) Measure Bundle and measure selection.
(A) A hospital or physician practice, with the exception
of those described in subparagraph (J) of this paragraph, must select
Measure Bundles from the Hospital and Physician Practice Measure Bundle
Menu of the Measure Bundle Protocol in accordance with the requirements
in subparagraphs (B) - (I) of this paragraph in the RHP plan update
for DY9-10 for its RHP.
(B) Each Measure Bundle is assigned a point value for
DY9-10 as described in the Measure Bundle Protocol.
(C) A hospital or physician practice is assigned a
minimum point threshold (MPT) for Measure Bundle selection as described
in paragraphs (6) and (7) of this subsection.
(D) A hospital or physician practice must select Measure
Bundles worth enough points to meet its MPT in order to maintain its
total valuation for DY9 and DY10. If a hospital or physician practice
does not select Measure Bundles worth enough points to meet its MPT,
its total DY9 valuation will be reduced proportionately across its
Categories B-D funds for DY9, and its total DY10 valuation will be
reduced proportionately across its Categories B-D funds for DY10,
based on the point values of the Measure Bundles it selects.
(E) A hospital or physician practice may request to
delete a maximum of 20 points worth of its DY7-8 Measure Bundles and
measures for DY9-10 with good cause. In this context, good cause is
defined as:
(i) a significant system change, such as a hospital
merger;
(ii) updated community needs; or
(iii) a significant change in a Measure Bundle's required
system component of outpatient services or hospital services as described
in the Measure Bundle Protocol.
(F) A hospital or physician practice may only select
a Measure Bundle for which its denominators for the baseline measurement
period for at least half of the required measures in the Measure Bundle
have significant volume.
(G) A hospital or physician practice with a valuation
greater than $2,500,000 per demonstration year (DY) for DY7-8 or with
a valuation greater than $2,000,000 in DY10 must:
(i) select at least one Measure Bundle with at least
one required three-point measure for which its denominator for the
baseline measurement period has significant volume; or
(ii) select at least one Measure Bundle with at least
one optional three-point measure for which its denominator for the
baseline measurement period has significant volume and select at least
one optional three-point measure in that Measure Bundle for which
its denominator for the baseline measurement period has significant
volume.
(H) A hospital or physician practice with an MPT of
75 must report at least two population-based clinical outcome measures
as P4P as specified in the Measure Bundle Protocol.
(I) A hospital or physician practice may only select
an optional measure in a selected Measure Bundle for which its denominator
for the baseline measurement period has significant volume.
(J) If a hospital or physician practice has a limited
scope of practice, cannot reasonably report on at least half of the
required measures in the Measure Bundle(s) appropriate for it based
on its scope of practice and community partnerships, and consequently
cannot meet its MPT for Measure Bundle selection, the hospital or
physician practice may request HHSC approval to select measures, rather
than Measure Bundles, from the Measure Bundle Protocol. The hospital
or physician practice must submit a request for such approval to HHSC
prior to the RHP plan update for DY9-10 submission, by a date determined
by HHSC. Such a request may be subject to review by the Centers for
Medicare & Medicaid Services (CMS). If HHSC and CMS, as appropriate,
approve such a request, the following requirements apply:
(i) the hospital's or physician practice's total valuation
for DY9 and DY10 may be reduced;
(ii) the hospital or physician practice must select
measures from the following menus of the Measure Bundle Protocol in
accordance with the requirements in clauses (iii) - (v) of this subparagraph
in the RHP plan update for its RHP:
(I) the Measure Bundles on the Hospital and Physician
Practice Measure Bundle Menu;
(II) the Community Mental Health Center Measure Menu;
or
(III) the Local Health Department Measure Menu;
(iii) each measure in a Measure Bundle on the Hospital
and Physician Practice Measure Bundle Menu, and each measure on the
Community Mental Health Center Measure Menu and the Local Health Department
Measure Menu, is assigned a point value as described in the Measure
Bundle Protocol;
(iv) the hospital or physician practice is assigned
an MPT for measure selection as described in paragraphs (5) and (6)
of this subsection; and
(v) the hospital or physician practice must select
measures worth enough points to meet its MPT in order to maintain
its total valuation for DY9 and DY10. If the hospital or physician
practice does not select measures worth enough points to meet its
MPT, its total DY9 valuation will be reduced proportionately across
its Categories B-D funds for DY9, and its total DY10 valuation will
be reduced proportionately across its Categories B-D funds for DY10,
based on the point values of the measures it selects.
(2) DSRIP-attributed population. A hospital or physician
practice must determine its DSRIP-attributed population to be applied
to its selected Measure Bundles and measures as specified in the Measure
Bundle Protocol.
(3) Measure Bundle valuation. Each Measure Bundle selected
by a hospital or physician practice for DY9-10 is allocated a percentage
of the hospital's or physician practice's Category C valuation that
is equal to the Measure Bundle's point value as a percentage of all
of the hospital's or physician practice's selected Measure Bundles'
point values.
(4) Measure valuation. The valuation for each measure
in a selected Measure Bundle is equal to the Measure Bundle valuation
divided by the number of measures in the selected Measure Bundle,
so that the valuations of the measures in the selected Measure Bundle
are equal, with the following exceptions:
(A) If a Measure Bundle includes the innovative measure:
(i) the valuation for the innovative measure in the
Measure Bundle is equal to the Measure Bundle valuation divided by
the number of measures in the Measure Bundle subtracted by 0.5 for
the innovative measure and divided by 2; and
(ii) the valuation for each measure in the Measure
Bundle that is not the innovative measure is equal to the Measure
Bundle valuation divided by the number of measures in the Measure
Bundle subtracted by 0.5 for the innovative measure.
(B) If a hospital's or physician practice's denominator
for a required measure or numerator for a population-based clinical
outcome measure in a selected Measure Bundle for the baseline measurement
period or a performance year has no volume, the measure is removed
from the Measure Bundle, and its valuation for the applicable DY is
redistributed among the remaining measures in the Measure Bundle for
which the hospital's or physician practice's denominator for the baseline
measurement period or performance year has significant volume for
the applicable DY. The valuation for the applicable DY for each of
the remaining measures is equal to the valuation for the Measure Bundle
for the applicable DY divided by the number of measures for which
the hospital's or physician practice's denominator for the baseline
measurement period or performance year has significant volume, so
that the valuations for the applicable DY for the measures in the
Measure Bundle for which the hospital's or physician practice's denominator
for the baseline measurement period or performance year has significant
volume are equal.
(C) If a hospital's or physician practice's denominator
for a required measure or numerator for a P4R population-based clinical
outcome measure in a selected Measure Bundle for the baseline measurement
period or a performance year has insignificant volume, the measure's
milestone valuations are adjusted in accordance with subsection (e)(2)
of this section.
(5) Milestone valuation. The measure milestones and
corresponding valuations for DY9-10 are as described in subsection
(e) of this section.
(6) MPTs for hospitals.
(A) The MPT for hospitals, with the exception of those
described in subparagraphs (B) and (C) of this paragraph, is calculated
as follows:
(i) First, the hospital's statewide hospital factor
(SHF) is equal to (.64 multiplied by (the hospital's Medicaid and
uninsured inpatient days divided by the sum of all hospitals' Medicaid
and uninsured inpatient days)) plus (.36 multiplied by (the hospital's
Medicaid and uninsured outpatient costs divided by the sum of all
hospitals' Medicaid and uninsured outpatient costs)). A hospital's
Medicaid and uninsured inpatient days and uninsured outpatient costs
are those reported for federal fiscal year 2016 in Cont'd... |