Quality Based Reimbursement (QBR)

Overview and Background

Maryland’s Quality-Based Rei​mbursement (QBR) program, in place since July 2009, uses similar measures to the federal Medicare Value-Based Purchasing (VBP) program, in place since October 2012. Because of Maryland’s long-standing Medicare waiver for its all-payer hospital rate-setting system and the implementation of the QBR program, the C​enters for Medicare & Medicaid Services (CMS) has given Maryland various special considerations, including annual exemption from the Medicare VBP program. The QBR program incentivizes quality improvement across a wide variety of quality measurement domains, including:

• Person and Community Engagement
  
• Clinical Care
• Patient Safety

Current Quality-Based Reimbursement (QBR) Program

On January 1, 2014 the State of Maryland entered into a new All-Payer Model demonstration contract with the Center for Medicare and Medicaid Innovation (CMMI).  Among other provisions of the Model, the Centers for Medicare & Medicaid Services (CMS) will waive the VBP program requirements for Maryland hospitals, provided that the Maryland program "submits an annual report to the Secretary that provides satisfactory evidence that a similar program in the State for Regulated Maryland Hospitals achieves or surpasses the measured results in terms of patient health outcomes and cost savings.” The State must apply annually for this exemption from the national VBP program. The exemption from the CMS VBP program grants Maryland the continued flexibility to adapt its quality-based payment programs to focus on areas specific to Maryland hospitals. This exemption additionally enables Maryland to maintain its all-payer approach to quality-based payments to hospitals and continue to align the all-payer QBR program with the operational realities of the all-payer rate setting system. Maryland’s QBR program, like the fe​deral VBP program, holds 2% of hospital revenue at risk based on performance, and measures performance in clinical care, patient safety, and person and community engagement (previously “experience of care”) domains (see rate year (RY) policies for domain weighting).  Hospital performance is scored, as is done with VBP, by comparing performance period results for each measure to historical performance, and by using a threshold and benchmark to calculate points earned by each hospital; both improvement and points are calculated for each measure, and the better of the two scores are used to calculate each hospital’s total score for the program.

The HSCRC established the following guiding principles for the QBR through stakeholder input from the Performance Measurement Work Group:​

• The measurements used for performance linked with payment must include all patients, regardless of payer.
  
• The measurements must be fair to hospitals.
• The measurements used should be generally consistent with the CMS VBP measures to support Maryland's annual waiver from the VBP.
• The approach must include the ability to track progress.