The payment measures calculate hospital-level, risk-standardized payments (RSPs). Hospital Compare reports the following payment measures:
- Payment for heart attack patients
- Payment for heart failure patients
- Payment for pneumonia patients
- Payment for hip/knee replacement
Each of these measures summarizes payments made by Medicare patients or on behalf of Medicare patients for healthcare services starting on the first day of a hospitalization through the next (a) 30 days for heart attack, heart failure and pneumonia (b) 90 days for hip/knee replacement. This includes payments from Medicare, secondary insurance providers, and patients for services and supplies in multiple settings, including:
- Skilled nursing facility
- Home health
- Physician, clinical laboratory, ambulance services
- Durable medical equipment
Medicare aligned each of the payment measures with their respective death (mortality) or complication measure, making it possible to use the pair of measures for a particular condition together to assess the value of care provided to patients with that condition. Medicare is using the four payment measures for heart attack patients, heart failure patients, pneumonia patients, and hip/knee replacement patients in the Hospital Inpatient Quality Reporting (IQR) program.
Patients included in the payment measures
The measures include Medicare beneficiaries 65 years or older who were enrolled in Original Medicare for the entire 12 months before their hospitalization, as well as the 30 days (or 90 days for hip/knee replacement) after admission.
Where the information comes from
The payment measures calculate payments from claims that hospitals and other providers submit to Medicare as well as from other CMS administrative data sources and enrollment information. Using administrative data makes it possible to calculate the measures without requiring hospitals and other providers to report additional information to CMS.
Risk and payment adjustments
The goal of risk adjustment for the payment measures is to account for patient characteristics that are clinically relevant and strongly related to the outcome. These characteristics include the patient’s age, past medical history, and other diseases or conditions (comorbidities) the patient had during the hospital admission that are known to increase payments in the 30 days (or 90 days for hip/knee replacement) following admission. The measures also remove payment differences unrelated to care, including geographic factors and policy adjustments. Together these adjustments ensure that the measure results reported on Hospital Compare reflect variation in payments unrelated to how sick a hospital’s patients were or where the hospital is located.
The statistical model used to calculate the risk-standardized payments (RSPs) for the payment measures also determines the precision of the results, and provides the upper and lower bounds of the 95% interval estimates for each hospital’s RSP amount. Interval estimates, which are like confidence intervals, describe the level of uncertainty around the RSPs.
Comparing hospital payments to the national average payment
To categorize hospital payments, the hospital’s interval estimate is compared to the national average payment. The table below describes the performance categories and classification criteria in detail:
|Payment Measure Performance Categories|
|Category||Less than the national average payment||No different than the national average payment||Greater than the national average payment||The number of cases is too small|
|Criterion||The entire 95% interval estimate surrounding the hospital’s RSP is below the national average payment.||The 95% interval estimate surrounding the hospital’s RSP includes the national average payment.||The entire 95% interval estimate surrounding the hospital’s RSP is above the national average payment.||Fewer than 25 cases|
For more detail on how the payment measures are calculated, please refer to QualityNet-Claims-Based Measures.Exit Disclaimer - Opens in a new windowExit Disclaimer - Opens in a new window For questions regarding the payment measures, please email firstname.lastname@example.org.