Claims-Based Measures
Claims-based measures are quality metrics that CMS calculates from Medicare fee-for-service claims rather than from assessments or surveys, requiring no separate data submission by the agency. In home health they capture hospital and emergency department use, discharge to community, and spending efficiency, and they carry 40% of the HHVBP Total Performance Score in the CY2026 measure set.
How claims-based measures are calculated
CMS links the agency's home health claims with claims from hospitals, emergency departments, and other providers to see what happened to patients during and after their home health stays. The results are risk-adjusted using diagnoses and utilization history from the claims themselves. Because measurement rides on billing data, there is nothing extra for the agency to document or submit, and also nothing to correct after the fact: the measures reflect what actually happened wherever the patient sought care, including events the agency never knew about.
The claims measures that matter now
The current claims-based measure set centers on three concepts:
- Potentially Preventable Hospitalization (PPH), covering avoidable inpatient admissions and observation stays during the home health stay
- Discharged to Community (DTC-PAC), covering successful return to the community without unplanned readmission or death shortly after discharge
- Medicare Spending Per Beneficiary Post-Acute Care (MSPB-PAC), new to the HHVBP measure set for CY2026, which compares total Medicare spending around the home health stay to expected spending
Together these carry 40% of the CY2026 HHVBP Total Performance Score, equal to the entire OASIS-based category, and MSPB-PAC brings cost efficiency into home health value-based payment for the first time.
Why claims measures are hard to manage
Three features make claims-based measures the most difficult category to run operationally. First, the lag: claims must be filed, processed, and compiled, so official results describe care delivered many months ago. Second, invisibility: a patient's ED visit on a Saturday night may never be reported to the agency, yet it lands in the measure. Third, breadth: MSPB-PAC responds to total utilization patterns, not any single documentation behavior. Agencies that perform well build their own early-warning systems, tracking self-reported hospitalizations, hospital notification feeds, and transfer OASIS events as a real-time proxy for what the claims will eventually show.
What agencies can do
Focus on the underlying events rather than the measures. Stratify patients by hospitalization risk at admission, front-load visits for the high-risk tier, tighten medication reconciliation at start of care, and make after-hours phone support genuinely responsive so the ED is not the default. For MSPB-PAC, review utilization patterns for outliers in both directions, since unnecessary services and inadequate services both show up eventually. Then reconcile internal event tracking against Interim Performance Reports each quarter to validate that your proxy numbers are honest.
Frequently asked questions
Do Medicare Advantage patients count in claims-based measures?
No. These measures are calculated from Medicare fee-for-service claims, so MA patients are excluded. Agencies with heavy MA books are scored on their FFS population, which can be a small and less representative sample.
How current are claims-based measure results?
They lag significantly. Between claims processing time and rolling measurement windows, published results typically describe care from many months to more than a year earlier, which is why internal event tracking is essential for managing performance in real time.
Where can an agency see its claims-based measure performance?
Through CMS reports, including HHVBP Interim Performance Reports and quality program review reports available via iQIES, plus the public results on Care Compare. There is no way to preview individual claim-level attribution, so internal tracking of hospitalizations and ED visits fills the gap.