(a) Establishing a quality performance standard. CMS designates the quality performance standard in each performance year.
(1) For the first performance year of an ACO's first agreement period, CMS, CMS defines the quality performance standard at the level of complete and accurate reporting for all quality measures.
(2) During subsequent performance years of the ACO's first agreement period, the quality performance standard will be phased in such that the ACO must continue to report all measures but the ACO will be assessed on performance based on the quality performance benchmark and minimum attainment level of certain measures.
(3) Under the quality performance standard for each performance year of an ACO's subsequent agreement period, the ACO must continue to report on all measures but the ACO will be assessed on performance based on the quality performance benchmark and minimum attainment level of certain measures.
(4) The quality performance standard for a newly introduced measure is set at the level of complete and accurate reporting for the first two reporting periods for which reporting of the measure is required. For subsequent reporting periods, the quality performance standard for the measure will be assessed according to the phase-in schedule for the measure.
(b) Establishing a performance benchmark and minimum attainment level for measures. (1) CMS designates a performance benchmark and minimum attainment level for each measure, and establishes a point scale for the measures.
(1) CMS designates a performance benchmark and minimum attainment level for each measure, and establishes a point scale for the measures.
(2)(i) CMS will define the quality benchmarks using fee-for-service Medicare data.
(i) CMS will define the quality benchmarks using fee-for-service Medicare data.
(ii) CMS will set benchmarks using flat percentages when the 60th percentile is equal to or greater than 80.00 percent, or when the 90th percentile is equal to or greater than 95 percent.
(iii) CMS reserves the right to use flat percentages for other measures when CMS determines that fee-for-service Medicare data are unavailable, inadequate, or unreliable to set the quality benchmarks.
(3) The minimum attainment level is set at 30 percent or the 30th percentile of the performance benchmark.
(4)(i) CMS will update the quality performance benchmarks every 2 years.
(i) CMS will update the quality performance benchmarks every 2 years.
(ii) For newly introduced measures that transition to pay for performance in the second year of the 2-year benchmarking cycle, the benchmark will be established for that year and updated along with the other measures at the start of the next 2-year benchmarking cycle.
(iii) CMS will use up to three years of data, as available, to set the benchmark for each quality measure.
(c) Methodology for calculating a performance score for each measure. (1) Performance below the minimum attainment level for a measure will receive zero points for that measure.
(1) Performance below the minimum attainment level for a measure will receive zero points for that measure.
(2) Performance equal to or greater than the minimum attainment level for a measure will receive points on a sliding scale based on the level of performance.
(3) Those measures designated as all or nothing measures will receive the maximum available points if all criteria are met and zero points if one or more of the criteria are not met.
(4) Performance at or above 90 percent or the 90th percentile of the performance benchmark earns the maximum points available for the measure.
(d) Establishing quality performance requirements for domains. (1) CMS groups individual quality performance standard measures into four domains:
(1) CMS groups individual quality performance standard measures into four domains:
(i) Patient/care giver experience.
(ii) Care coordination/Patient safety.
(iii) Preventative health.
(iv) At-risk population.
(2) To satisfy quality performance requirements for a domain:
(i) The ACO must report all measures within a domain.
(ii) ACOs must score above the minimum attainment level determined by CMS on 70 percent of the measures in each domain. If an ACO fails to achieve the minimum attainment level on at least 70 percent of the measures in a domain, CMS will take the actions describe in Sec. 425.216(c).
(iii)(A) If the ACO achieves the minimum attainment level for at least one measure in each of the four domains, and also satisfies the requirements for realizing shared savings under subpart G of this part, the ACO may receive the proportion of those shared savings for which it qualifies.
(A) If the ACO achieves the minimum attainment level for at least one measure in each of the four domains, and also satisfies the requirements for realizing shared savings under subpart G of this part, the ACO may receive the proportion of those shared savings for which it qualifies.
(B) If an ACO fails to achieve the minimum attainment level on all measures in a domain, it will not be eligible to share in any savings generated.
(e) Methodology for calculating the ACO's overall performance score. (1) CMS scores individual measures and determines the corresponding number of points that may be earned based on the ACO's performance.
(1) CMS scores individual measures and determines the corresponding number of points that may be earned based on the ACO's performance.
(2) CMS adds the points earned for the individual measures within the domain and divides by the total points available for the domain to determine the domain score.
(3) Domains are weighted equally and scores averaged to determine the ACO's overall performance score and sharing rate.
(4)(i) ACOs that demonstrate quality improvement on established quality measures from year to year will be eligible for up to 4 bonus points per domain.
(i) ACOs that demonstrate quality improvement on established quality measures from year to year will be eligible for up to 4 bonus points per domain.
(ii) Bonus points are awarded based on an ACO's net improvement in measures within a domain, which is calculated by determining the total number of significantly improved measures and subtracting the total number of significantly declined measures.
(iii) Up to four bonus points are awarded based on a comparison of the ACO's net improvement in performance on the measures for the domain to the total number of individual measures in the domain.
(iv) When bonus points are added to points earned for the quality measures in the domain, the total points received for the domain may not exceed the maximum total points for the domain in the absence of the quality improvement measure.
(v) If an ACO renews its participation agreement for a subsequent agreement period, quality improvement will be measured based on a comparison between performance in the first year of the new agreement period and performance in the third year of the previous agreement period. [76 FR 67973, Nov. 2, 2011, as amended at 78 FR 74823, Dec. 10, 2013; 79 FR 68008, Nov. 13, 2014]