§ 412.164 Measure selection under the Hospital Value-Based Purchasing (VBP) Program. ( a ) CMS will select measures, other than measures of readmissions, for purposes of the Hospital VBP Program. The measures will be selected from the measures specified under section 1886(b)(3)(B)(viii) of the Act (the Hospital Inpatient Quality Reporting Program).
( b ) CMS will post data on each measure on the *Hospital Compare* website, which can be accessed via the Care Compare website at *https://www.medicare.gov/care-compare/*, for at least 1 year prior to the beginning of a performance period for the measure under the Hospital VBP Program.
( c ) ( 1 ) *Updating of measure specifications.* CMS uses rulemaking to make substantive updates to the specifications of measures used in the Hospital VBP Program. CMS announces technical measure specification updates through the QualityNet website (*https://qualitynet.cms.gov*) and listserv announcements.
( 2 ) *Measure retention.* All measures selected under paragraph (a) of this section remain in the measure set unless CMS, through rulemaking, removes or replaces them.
( 3 ) *Measure removal factors* — ( i ) *General rule.* CMS may remove or replace a measure based on one of the following factors: ( A ) *Factor 1.* Measure performance among hospitals is so high and unvarying that meaningful distinctions and improvements in performance can no longer be made (“topped out” measures), defined as: statistically indistinguishable performance at the 75th and 90th percentiles; and truncated coefficient of variation ≤0.10.
( B ) *Factor 2.* A measure does not align with current clinical guidelines or practice.
( C ) *Factor 3.* The availability of a more broadly applicable measure (across settings or populations) or the availability of a measure that is more proximal in time to desired patient outcomes for the particular topic.
( D ) *Factor 4.* Performance or improvement on a measure does not result in better patient outcomes.
( E ) *Factor 5.* The availability of a measure that is more strongly associated with desired patient outcomes for the particular topic.
( F ) *Factor 6.* Collection or public reporting of a measure leads to negative unintended consequences other than patient harm.
( G ) *Factor 7.* It is not feasible to implement the measure specifications.
( H ) *Factor 8.* The costs associated with a measure outweigh the benefit of its continued use in the program.
( ii ) *Application of measure removal factors.* CMS assesses the benefits of removing a measure from the Hospital VBP Program on a case-by-case basis.
( iii ) *Patient safety exception.* Upon a determination by CMS that the continued requirement for hospitals to submit data on a measure raises specific patient safety concerns, CMS may elect to immediately remove the measure from the Hospital VBP measure set. CMS will, upon removal of the measure— ( A ) Provide notice to hospitals and the public at the time CMS removes the measure, along with a statement of the specific patient safety concerns that would be raised if hospitals continued to submit data on the measure; and
( B ) Provide notice of the removal in the Federal Register.
[77 FR 53674, Aug. 31, 2012, as amended at 83 FR 41704, Aug. 17, 2018; 86 FR 45520, Aug. 13, 2021; 88 FR 59333, Aug. 28, 2023]