(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 its RHP.
(B) Each Measure Bundle is assigned a point value 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 DY7 and DY8. If a hospital or physician practice
does not select Measure Bundles worth enough points to meet its MPT,
its total DY7 valuation will be reduced proportionately across its
RHP Plan Update and Categories B-D funds for DY7, and its total DY8
valuation will be reduced proportionately across its Categories B-D
funds for DY8, based on the point values of the Measure Bundles it
selects.
(E) 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.
(F) A hospital or physician practice with a valuation
greater than $2,500,000 per demonstration year (DY) for DY7-8 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.
(G) A hospital or physician practice with an MPT of
75 must select at least one Measure Bundle with at least one population-based
clinical outcome measure as specified in the Measure Bundle Protocol.
(H) 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.
(I) Only a hospital with a valuation less than or equal
to $2,500,000 per DY for DY7-8 may select a Measure Bundle identified
as a rural Measure Bundle in accordance with the requirements in the
Measure Bundle Protocol.
(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 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 DY7 and DY8 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 DY7 and DY8. If the hospital or physician
practice does not select measures worth enough points to meet its
MPT, its total DY7 valuation will be reduced proportionately across
its RHP Plan Update and Categories B-D funds for DY7, and its total
DY8 valuation will be reduced proportionately across its Categories
B-D funds for DY8, 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. A hospital or physician
practice may allocate its Category C valuation among its selected
Measure Bundles in the RHP plan update for its RHP as it chooses,
provided the following requirements are met:
(A) The valuation for each selected Measure Bundle
must be greater than or equal to (the Measure Bundle point value divided
by the sum of all the selected Measure Bundles' point values) multiplied
by 0.75 multiplied by the Category C valuation.
(B) The valuation for each selected Measure Bundle
without any required or selected optional three-point measures must
be less than or equal to (the Measure Bundle point value divided by
the sum of all the selected Measure Bundles' point values) multiplied
by the Category C valuation.
(C) The valuation for each selected Measure Bundle
with a required or selected optional three-point measure must be less
than or equal to (the Measure Bundle point value divided by the sum
of all the selected Measure Bundles' point values) multiplied by 1.25
multiplied by the Category C valuation.
(D) If a hospital or physician practice allocates to
a Measure Bundle a percentage of its Category C valuation that is
one percent greater than the Measure Bundle's point value as a percentage
of all the selected Measure Bundles' point values, the hospital or
physician practice must provide sufficient justification as specified
in the Program Funding and Mechanics Protocol.
(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 an innovative measure:
(i) the valuation for each innovative measure in the
Measure Bundle is equal to the Measure Bundle valuation divided by
the number of the measures in the Measure Bundle subtracted by 0.5
for each innovative measure and divided by 2; and
(ii) the valuation for each measure in the Measure
Bundle that is not an innovative measure is equal to the Measure Bundle
valuation divided by the number of measures in the Measure Bundle
subtracted by 0.5 for each 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 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 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.
Cont'd... |