| (B) the valuation for the DY10 goal achievement milestone
is equal to 75 percent of the valuation for the Measure Bundle divided
by the number of measures in the Measure Bundle for which the hospital's
or physician practice's denominator has significant volume, so that
the valuations for the DY10 goal achievement milestones for the measures
in the Measure Bundle for which the hospital's or physician practice's
denominator has significant volume are equal.
(3) Measures with multiple parts. Some P4P measures
have multiple parts, as described in the Program Funding and Mechanics
Protocol and Measure Bundle Protocol.
(A) A measure with multiple parts has one baseline
reporting milestone per DY, one PY reporting milestone per DY, and
multiple goal achievement milestones per DY.
(B) The valuation for each measure part's goal achievement
milestone is equal to the measure's total goal achievement milestone
valuation divided by the number of measure parts so that the measure
parts' goal achievement milestone valuations are equal.
(C) All measure parts' baseline reporting milestones
must be reported during the same reporting period.
(D) All measure parts' PY reporting milestones must
be reported during the same reporting period.
(E) Each measure part's goal achievement milestone
will have its own goal. Therefore, the percent of goal achieved, as
described in §354.1757 of this division (relating to Disbursement
of Funds) will be determined for a measure part's goal achievement
milestone independently of the percent of goal achieved for the other
measure parts' goal achievement milestones.
(4) For measures newly selected for DY9-10, a performer
must report a baseline for a measure, and HHSC must approve the reported
baseline for reporting purposes, before a performer can report PY3
(or PY4 if HHSC approved the use of a delayed baseline measurement
period for the measure).
(A) A performer must adhere to measure specifications
and maintain a record of any variances approved by HHSC prior to reporting
a baseline for a measure.
(B) HHSC's approval of a reported baseline for reporting
purposes does not constitute approval for a performer to report a
measure outside measure specifications. If at any point HHSC or the
independent assessor finds that a performer is reporting a measure
outside measure specifications, reporting milestone payment and goal
achievement milestone payment may be withheld or recouped while the
performer works to bring reporting into compliance with measure specifications.
(5) A performer must report a P4P measure's reporting
milestone and goal achievement milestone for a given PY during the
same reporting period, with exceptions for P4P measures with a delayed
baseline measurement period.
(f) Measure eligible denominator population.
(1) Each Measure Bundle for hospitals and physician
practices has a target population as specified in the Measure Bundle
Protocol.
(2) A measure's eligible denominator population must
include all individuals served by the performer's system during a
given measurement period that are included in the performer's DSRIP-attributed
population and the target population for a measure for hospitals and
physician practices, and that meet the measure's specifications as
specified in the Measure Bundle Protocol.
(3) A performer may not use a performer-specific facility,
co-morbid condition, age, gender, race, or ethnicity subset not otherwise
specified in the Measure Bundle Protocol.
(4) Reporting milestones.
(A) A hospital or physician practice must do the following
to be eligible for payment of a measure's reporting milestones for
each DY, with the exceptions described in subparagraphs (C) and (D)
of this paragraph:
(i) report its performance on the measure for the all-payer,
Medicaid-only, and Low-income Uninsured-only (LIU-only) payer types;
and
(ii) update reporting on related strategies associated
with each Measure Bundle.
(B) A CMHC or LHD must do the following to be eligible
for payment of a measure's reporting milestones for each DY, with
the exceptions described in subparagraphs (C) and (D) of this paragraph:
(i) report its performance on the measure for the all-payer,
Medicaid-only, and Low-income Uninsured-only (LIU-only) payer types;
and
(ii) update reporting on related strategies associated
with each measure or group of measures.
(C) A performer that demonstrates good cause may request
in the RHP plan update submission to be exempted from reporting its
performance on a measure for the Medicaid-only payer type or the LIU-only
payer type as specified in the Program Funding and Mechanics Protocol.
(D) A performer that demonstrates good cause may submit
a RHP plan update modification request to HHSC to be exempted from
reporting its performance on a measure for the Medicaid-only payer
type or the LIU-only payer type as specified in the Program Funding
and Mechanics Protocol.
(5) Goal achievement milestones. Payment for a P4P
measure's goal achievement milestone is based on the performer's performance
on the measure for the MLIU payer type.
(A) A performer that demonstrates good cause may request
in the RHP plan update submission that payment for a P4P measure's
goal achievement milestone be based on the performer's performance
on the measure for the all-payer, Medicaid-only, or LIU-only payer
type as specified in the Program Funding and Mechanics Protocol.
(B) A performer that demonstrates good cause may submit
a RHP plan update modification request to HHSC to change the payer
type on which payment for a P4P measure's goal achievement milestone
is based as specified in the Program Funding and Mechanics Protocol.
(g) Methodology for P4P measure goal setting.
(1) A P4P measure's goals are set as an improvement
over the baseline.
(2) A P4P measure is designated as either Quality Improvement
System for Managed Care (QISMC) or Improvement over Self (IOS) as
specified in the Measure Bundle Protocol. A P4P measure designated
as QISMC has a defined High Performance Level (HPL) and Minimum Performance
Level (MPL) based on national or state benchmarks.
(3) If a P4P measure is selected for DY7-10, the goals
for its goal achievement milestones for DY9-10 are set as follows:
Attached Graphic
(4) If a P4P measure is newly selected for DY9-10,
the goals for its goal achievement milestones for DY9-10 are set as
follows:
Attached Graphic
(5) If a performer received HHSC approval to use a
numerator of zero for the baseline measurement period for a DY7-8
P4P measure, and the performer decides to continue that measure in
DY9-10, the goals for the DY9 and DY10 goal achievement milestones
are determined in accordance with paragraph (3) of this subsection
using an updated baseline that is set at the PY1 rate.
(h) Carry forward policy.
(1) Carry forward of reporting. If a performer does
not report a measure's baseline reporting milestone or performance
year reporting milestone during the first reporting period after the
end of the milestone's measurement period, the performer may request
to carry forward reporting of the milestone to the next reporting
period.
(2) Carry forward of achievement.
(A) A performer may request to carry forward achievement
of a measure's DY9 goal achievement milestone so that the DY9 goal
achievement milestone may be achieved in PY3 or PY4, with the exception
described in subparagraph (B) of this paragraph.
(B) If a measure newly selected for DY9-10 has a delayed
baseline measurement period, a performer will carry forward achievement
of its goal achievement milestone so that the DY9 goal achievement
milestone may be achieved in PY4.
(C) The performer must report the carried forward achievement
of a measure's goal achievement milestone during the first reporting
period after the end of the milestone's carried forward measurement
period.
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