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Rural Health Information Hub

Rural Healthcare Quality – Resources

Selected recent or important resources focusing on Rural Healthcare Quality.

Merit-Based Incentive Payment System (MIPS): 2023 Opt-in and Voluntary Reporting Election Process Guide
Discusses the eligibility of clinicians, groups, and Alternative Payment Model (APM) participants that exceed some low-volume threshold criteria to opt-in to the Merit-Based Incentive Payment System (MIPS) and the APM Performance Pathway (APP) for the 2023 performance period. Compares opting in and voluntarily reporting MIPS data and provides an overview of the election process.
Date: 09/2024
Type: Document
Sponsoring organization: Centers for Medicare and Medicaid Services
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Rurality and Patients' Hospital Experience: A Multisite Analysis from a US Healthcare System
Explores the relationship between the patient experience at a Midwestern hospital system and patients' rurality of residence using data from completed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys between 2016 and 2019. Analyzes data for global, composite, and individual HCAHPS measures by hospital and patient characteristics.
Author(s): Iman Fawad, Karen M. Fischer, Hanieh Sadat Tabatabaei Yeganeh, et al.
Citation: PLoS One, 19(8), e0308564
Date: 08/2024
Type: Document
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Small Practice After-Action Review: 2022 Performance Year Final Score
Tool for small practices interested in examining their 2022 Merit-based Incentive Payment System (MIPS) final score to identify opportunities to improve performance in 2024.
Additional links: Video: Small Practice Action Planning Tool for MIPS
Date: 08/2024
Type: Tool
Sponsoring organization: Centers for Medicare and Medicaid Services
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FY 2025 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) Final Rule – CMS-1808-F
Fact sheet providing an overview of the Centers for Medicare & Medicaid Services (CMS) fiscal year 2025 hospital inpatient prospective payment system (IPPS) and long-term care hospital prospective payment system (LTCH PPS) final rule. Includes information about the extension of the low-wage index hospital policy, a separate IPPS payment for small and independent hospitals to establish and maintain a buffer stock of essential medicines, the distribution of graduate medical education (GME) residency slots, updates to quality reporting programs, and more.
Date: 08/2024
Type: Document
Sponsoring organization: Centers for Medicare and Medicaid Services
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Merit-based Incentive Payment System (MIPS): 2024 MIPS Promoting Interoperability Performance Category Hardship Exception Application Guide
Provides guidance on how clinicians can apply for a MIPS hardship exception. Highlights guidance for having your MIPS Promoting Interoperability performance category reweighted to 0% in cases of insufficient internet connectivity, decertified electronic health record technology, or other circumstances out of the clinicians control.
Date: 08/2024
Type: Document
Sponsoring organization: Centers for Medicare and Medicaid Services
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Updated Analysis: Using Population-Based Outcome Measures to Assess the Impact of Telehealth Expansion on Medicare Beneficiaries' Access to Care and Quality of Care
Explores the association between telehealth use, quality of care, and access to care when both telehealth and in-person visits are available to fee-for-service (FFS) Medicare beneficiaries. Compares data from the second half of 2018 and 2019 to the second half of 2022 by the level of telehealth utilization in Hospital Service Areas (HSAs). Describes the effects of telehealth for urban and rural beneficiaries and differentiates between telehealth utilization for behavioral and non-behavioral health services. Updates a June 2023 report that analyzed data from 2021.
Author(s): Tanvi Rao, Angshuman Gooptu, Karin Johnson, Guido Cataife, Steven Susana-Castillo
Date: 06/2024
Type: Document
Sponsoring organizations: American Institutes for Research, Medicare Payment Advisory Commission
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Merit-Based Incentive Payment System (MIPS): Traditional MIPS Scoring Guide for the 2024 Performance Year
Provides details on how scores are calculated for the Merit-Based Incentive Payment System (MIPS), one of two tracks under the Medicare Quality Payment Program. Explains the four performance categories that affect Medicare Physician Fee Schedule payments: quality, cost, improvement activities, and promoting interoperability. Includes information for small practices.
Date: 06/2024
Type: Document
Sponsoring organization: Centers for Medicare and Medicaid Services
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2024 Uniform Data Set (UDS) Measure Crosswalk to Other Quality Reporting Programs
Chart listing National Quality Forum measures and the related 2024 measures for the Uniform Data Set (UDS), CMS eCQM (electronic clinical quality measures), CMS Measure Inventory Tool (CMIT), CMS Quality Payment Program (QPP), Medicare Shared Savings Program (MSSP), Healthcare Effectiveness Data and Information Set (HEDIS), CMS Universal Foundation, and Child and Adult Health Care Quality Measures (Medicaid Core Sets). Can be used to identify which UDS measures are being used by other programs.
Date: 05/2024
Type: Document
Sponsoring organization: Rural Health Value
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With New EMS Quality Measures, Florida Aims to Have a National Impact on Rural Care
Features the Feasible, Actionable, Impactful and Relevant (FAIR) EMS Measurement Project, an initiative by the Florida Department of Health which developed rural-relevant EMS quality measures for use in the state and nationally.
Author(s): Gretel Kauffman
Citation: Rural Monitor
Date: 05/2024
Type: Document
Sponsoring organization: Rural Health Information Hub
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Calculation of Overall Hospital Quality Star Ratings With and Without Inclusion of the Peer Grouping Step
Examines potential implications of including a peer grouping step in the calculation of Centers for Medicare & Medicaid Services (CMS) Overall Star Ratings. Uses January 2023 Medicare Care Compare data on 3,076 hospitals that received a star rating to calculate the peer groups based on the number of quality measure groups for which hospitals had 3 or more reported measures. Presents data on the characteristics of each peer group, the distribution of star ratings whether the peer grouping step was used or not used, and the number of hospitals with a higher, lower, or identical star rating when the peer grouping step was applied. Compares data by hospital characteristics, including safety-net status, Critical Access Hospital status, rural or urban location, and more.
Author(s): Cameron J. Gettel, Kyle Bagshaw, Li Qin, et al.
Citation: JAMA Network Open, 7(5), e2411933
Date: 05/2024
Type: Document
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Last Updated: 9/17/2024