VBP Domains: What Drives CMS Sepsis Scores, Eliminating VBP Penalties & Why It Matters Financially

Key takeaways:  

• Total Performance Score (TPS) determines how much of the 2% VBP withheld you earn back, so small score changes can have a real financial impact. 

• Clinical Outcomes, Safety, Patient Experience, and Efficiency all matter, but measures like efficiency and safety can swing domain scores fast when performance is inconsistent. 

• Poor sepsis bundle performance lowers your domain score, which lowers TPS and reduces your share of the VBP pool. 

• Ambient Clinical Analytics helps teams target the workflows that move scores most, improving sepsis detection and bundle reliability while reducing LOS and lost reimbursement. 

Introduction  

Most hospitals do not lose Medicare dollars because one person missed one step. They lose dollars when performance is inconsistent across the system and that inconsistency shows up in the Hospital Value Based Purchasing math. 

Under CMS Hospital VBP, CMS withholds 2% of base operating payments and redistributes that money based on performance. Your performance is summarized in one number, the Total Performance Score, also called TPS. 

In the sections below, we’ll break down how TPS is calculated measure-by-measure, how the four VBP domains are weighted, and how scoring methods like achievement vs. improvement translate into incentive payments, especially when high-impact measures like the SEP-1 sepsis bundle pull domain scores up or down. 

What the Total Performance Score is and Why It Matters 

TPS is a composite score from 0 to 100. It is built measure by measure, then rolled up into four domains. It is then converted into a payment adjustment that determines how much of the Value-Based Purchasing (VBP) program pool your hospital earns back. 

Hospitals are scored on both achievement and improvement. You get credit for how you compare to national performance, but you can also earn points for making meaningful progress compared to your own baseline. CMS uses the higher of the two scores for each measure. 

The TPS is crucial for determining the financial incentives hospitals receive under the VBP program.  

The Four VBP Domains and What Drives Them 

VBP is organized into four domains that are typically weighted at 25% each. The exact weighting and the exact measures can change by year, and if a hospital does not have data in one domain, CMS redistributes that domain’s weight across the remaining domains. 

Below is the practical view of each domain, what tends to move it, and why it matters financially. 

1. Clinical Outcomes 

This domain is driven by outcome measures like mortality and complications. These are some of the hardest to improve quickly, because they depend on reliable care across many touchpoints, including the ED, inpatient units, and ICU. 

What tends to move the score: 

• Strong clinical pathways that are followed in real time 

• Fast escalation when a patient starts to deteriorate 

• Better reliability in handoffs and transitions of care 

Why it matters financially: 

If outcomes measures slip, it is difficult to recover points late in the performance period. Improving outcomes is possible, but it usually requires system level consistency, not a one time push. 

2. Safety 

Safety is where many hospitals feel the most pressure because the measures are often very specific and very visible. In recent Hospital VBP measure sets, safety includes healthcare-associated infections and also includes the Severe Sepsis and Septic Shock Management Bundle, SEP-1. 

SEP-1 is not a standalone fine. It affects your Safety domain score, which affects TPS, which affects your share of the VBP pool. A poor SEP-1 score can lower TPS and reduce payments. 

The FY 2026 Hospital VBP quick reference guide lists SEP-1 scoring inputs including an achievement threshold of 0.597482 and a benchmark of 0.843620. If your publicly reported compliance is below the threshold, you are leaving points on the table. 

What tends to move the score: 

• Earlier recognition and faster time to treatment 

• Reducing missed bundle elements by building reminders into the workflow 

• Reducing variation across units and shifts so performance is not dependent on who is on 

3. Patient Experience 

The Patient Experience domain is built from HCAHPS measures. Many hospitals treat this as a customer service project. The hospitals that score well treat it as an operational reliability project. 

What tends to move the score: 

• Nurse and physician communication consistency 

• Responsiveness, especially during peak capacity 

• Strong discharge communication and care transitions 

Why it matters financially: 

Patient experience is often one of the most recoverable areas, because small operational fixes can improve the patient experience quickly when they are focused on the right pain points. 

4. Efficiency and Cost Reduction 

The Efficiency domain is driven by Medicare Spending per Beneficiary, MSPB. When a domain is driven by one main measure, improvement can move the domain score meaningfully. 

What tends to move the score: 

• Reducing avoidable utilization and delays 

• Shortening length of stay without increasing readmissions or complications 

• Improving throughput from ED to inpatient and from inpatient to discharge 

Why it matters financially: 

Efficiency is not just about cost control. It is a major driver of VBP performance, which ties directly to reimbursement. 

How TPS translates into dollars 

CMS converts TPS into a payment adjustment using a linear exchange function. CMS publishes the adjustment factors and methodology each year. The outcome is that TPS movement can translate into real dollar changes when applied across total Medicare payments. 

For a hospital with 100 million in base operating payments, a TPS around 70 can still result in a meaningful net reduction, depending on the year’s exchange function and where the hospital lands relative to peers. That is why small improvements in a high-impact measure can pay back quickly. 

Where hospitals should focus first 

If your goal is to improve both performance and financial results, focus on areas where reliability changes points. 

High-impact targets often include: 

• Efficiency because MSPB can heavily influence the domain score 

• Safety measures where performance is all or nothing in practice, including sepsis bundle compliance 

• Patient experience drivers tied to responsiveness and care transitions 

How Ambient Clinical Analytics helps teams focus effort where it matters most 

Most hospitals do not need more dashboards. They need clearer priorities and better execution in the moments that drive performance. 

Ambient Clinical Analytics helps hospital teams see where breakdowns happen and focus on the few workflows that move the score and improve care. 

For sepsis, AWARE Sepsis DART™ automates early detection of potential sepsis, supports smart notifications and monitoring, and provides treatment bundle reminders to reduce missed steps. That helps teams improve SEP-1 reliability, reduce errors, and drive better patient outcomes. 

Key benefits of leveraging AWARE Sepsis DART™: 

Clinical benefits: 

• Automate & improve clinical communications between nurses and physicians  

• Reduce alert fatigue around sepsis detection and treatment requirements  

• Increase your publicly reported CMS Sep-1 score to 80% or greater (well above the national average)  

• Lower mortality, commonly cited at around 20% reduction, depending on baseline and execution 

Financial benefits: 

• Cost savings from reduced length of stay (LOS) 

• Recapture lost Medicare income from avoiding CMS Value Based Purchasing Penalties  

• Expand reimbursement rates from CMS Value Based Purchasing Incentives  

Conclusion  

VBP performance is about understanding what drives TPS, then building reliable systems that help clinicians deliver timely, consistent care. 

When hospitals improve reliability in high impact areas like sepsis, they protect patients and protect revenue at the same time.