Skip to Main Content

Public Comment

Welcome to CMS Quality Measures Public Comment Page

This page serves as the designated site for CMS to solicit public comments on proposed quality measures that are included in the individual project pages. The public comment period provides an opportunity for the widest array of interested parties to provide input on the measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).

Details of the Public Comment Period:

  • The public is encouraged to submit general comments relevant to both measures or comments specific to certain measures
  • Information about each measure is found in the Downloads section below
  • Do not include personal health information in your comments
  • At the end of the public comment period, all public comments will be posted on the website along with a public comment summary report

Instructions for Providing Comments:

  • If you are providing comments on behalf of an organization, include the organization’s name and your contact information
  • If you are commenting as an individual, submit identifying or contact information
  • Please indicate which measure(s) you are commenting on
  • You may submit general comments on the entire set of measures or you may provide comments specific to individual measures

Public Comment Postings:

  • Maintenance of Nursing Home Patient Safety Measures
  • Electronic Clinical Quality Measures for (1) Emergency Department Care Coordination,  (2)  Statin Therapy, and (3) Functional Status Assessments for Total Hip or Knee Replacement.
  • Hospital Quality Star Ratings on Hospital Compare
  • Development of Measures of Payment for Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)
  • Days in Acute Care after Hospitalization for Heart Failure, Pneumonia, or Acute Myocardial Infarction (AMI)
  • Hospital Visits after Hospital Outpatient Surgery
  • Risk-Standardized Acute Admission Rates for Patients with Diabetes
  • Risk-Standardized Acute Admission Rates for Patients with Heart Failure
  • Risk-Standardized Acute Admission Rates for Patients with Multiple Chronic Conditions
  • 2015 Draft PQRS #181 Elder Maltreatment Screening and Follow-Up Plan
  • Hybrid Hospital-Wide Readmission Measure with Claims and Electronic Health Record Data
  • All-Cause Acute Admission Rates For Patients With Heart Failure and Diabetes

 

Project Title: Maintenance of Nursing Home Patient Safety Measures

Dates:

  • The Call for Public Comment period opens on March 16, 2015 and closes on March 30, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with RTI International to develop and maintain Patient Safety Measures for nursing homes. The contract name is Development and Maintenance of Symptom Management Measures. The contract number is HHSM-500-2008-000211. As part of its measure development and maintenance process, CMS requests interested parties to submit comments on the candidate or concept measures that may be suitable for this project.

Project Objectives:

  • To maintain patient safety measures that assesses nursing home quality.
  • To evaluate quality measures currently endorsed by the National Quality Forum and due for endorsement maintenance review. Evaluation including review of measure specifications, numerator and denominator definitions, exclusion criteria, and adjustment for resident characteristics associated with outcomes. Evaluation methods include statistical testing and literature review.
  • To help achieve these objective, CMS and RTI International solicit public comments on the following nursing home patient safety quality measures:
    • NQF 0674: Percent of Residents Experiencing One or More Falls with Major Injury (Long-stay)
    • NQF 0679: Percent of High Risk Residents with Pressure Ulcers (Long-stay)
    • NQF 0687: Percent of Residents Who Were Physically Restrained (Long-stay)
    • NQF 0689: Percent of Residents Who Lose Too Much Weight (Long-stay)

Documents and Measures for Comment:

To inform your comments, you can review the measure specifications for each of the four patient safety measures in the following documents found below in the Download section.

  • NQF 0674_LS_Falls_Specifications_posting.pdf
  • NQF 0679_LS_PressureUlcers_Specifications_posting.pdf
  • NQF 0687_LS_Restraints_Specifications_posting.pdf
  • NQF 0689_LS_WeightLoss_Specifications_posting.pdf

Project Specific Instructions:

  • Do not include personal health information in your comments.
  • If you are providing comments on behalf of an organization, include the organization’s name and your contact information.
  • If you are commenting as an individual, submit identifying or contact information.
  • Please indicate which measures you are providing comments on. You may submit general comments on the entire set of measures or you may provide comments specific to individual measures.
  • Send your comments to  CMSNursingHomeQM@rti.org
  • Comments are due by March 30, 2015 at midnight [12:00PM EST].

 

Project Title:  Electronic Clinical Quality Measures for (1) Emergency Department Care Coordination,  (2)  Statin Therapy, and (3) Functional Status Assessments for Total Hip or Knee Replacement.

Dates: 

  • The public comment period begins at 9:00 a.m. (EST) on March 2, 2015, and ends at 11:59 p.m. (EST) on April 5, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Mathematica Policy Research to develop provider-level measures based on data from electronic health records. The contract name is Electronic Clinical Quality Measures Development and Maintenance for Eligible Professionals. The contract number is HHSM-500-2013-13011I/HHSM-500-T0001. CMS requests interested parties to submit comments on five candidate measures being developed under this project.

Project Objectives:

The goal of this project is to develop clinical quality measures that use data from electronic health records for use by providers in CMS quality reporting programs. As part of the measure development process, we are soliciting feedback about the feasibility, usability and face validity of the draft measures during a public comment period.

Documents and Measures for Comment:

CMS is requesting feedback on the following five proposed measures:

  • Coordinating Care—Emergency Department Referrals
  • Coordinating Care—Follow-Up with Eligible Provider
  • Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
  • Functional Status Assessment and Improvement for Patients who Received a Total Hip Replacement
  • Functional Status Assessment and Improvement for Patients who Received a Total Knee Replacement

All comments are welcome, but we are particularly interested in feedback in the following areas:

  • Usefulness of the measures to assess the quality of care for Medicare or Medicaid beneficiaries
  • Appropriateness of the measures to assess performance by Eligible Professionals (or, in the case of the “Coordinating Care—Emergency Department Referrals” measure, to assess performance of a hospital emergency department)
  • Feasibility of data collection for the proposed measures using EHRs for the purpose of public reporting under the EHR Incentive Program

The following information for the five measures is provided for your review. All files are found in the Downloads section at the bottom of the site page:

  • A summary narrative of measure specifications
  • A health quality measure format header
  • A additional framing document on risk adjustment for the Functional Status Assessment and Improvement measures

Project Specific Instructions:

The JIRA comment tool will be used to collect comments on the measure specifications listed above. Please use the following links to submit your comments:

If you are a current JIRA user with an active account:

http://jira.oncprojectracking.org

(Select “Log In” at the top right corner)

If you are new to JIRA and do NOT have an account:

http://jira.oncprojectracking.org/login.jsp

(Select “Sign up” to set up a new account and log into the JIRA tool)

Once logged into the JIRA tool:

  1. Select “Projects” at the top middle of the home screen.
  2. Select “View all Projects”
  3. Under Quality-Measures, select “Comments on eCQMs under development” project.
  4. To enter comments, select “Create issue” (Orange button) at the top middle of the screen.
  5. Select the type of issue from the “Issue type” drop-down menu.
  6. Please fill out the fields labeled: “Summary,” “Contact name,” “Contact email,” and “Contact phone.”
  7. In the “Summary” field, type in one of the following titles, based on the measure you are commenting on:
    • “Comment - EDCC_ED” for the “Coordinating Care—Emergency Department Referrals” measure
    • “Comment - EDCC_PC” for the “Coordinating Care—Follow-Up with Eligible Provider” measure
    • “Comment - Statin Therapy” for the “Statin Therapy for the Prevention and Treatment of Cardiovascular Disease” measure
    • “Comment - FSA Hip” for the “Functional Status Assessment and Improvement for Patients who Received a Total Hip Replacement” measure
    • “Comment - FSA Knee” for the “Functional Status Assessment and Improvement for Patients who Received a Total Knee Replacement” measure
  1. Enter your comments in the “Description” field.
  2. Select the measure name you are commenting on from the “Draft measures” drop-down box:
    • For the “Coordinating Care—Emergency Department Referrals” measure, select “EDCC_ED
    • For the “Coordinating Care—Follow-Up with Eligible Provider” measure, select “EDCC_PC
    • For the “Statin Therapy for the Prevention and Treatment of Cardiovascular Disease,” measure, select “Statin_Therapy
    • For the “Functional Status Assessment and Improvement for Patients who Received a Total Hip Replacement” measure, select “FSA_Hip
    • For the “Functional Status Assessment and Improvement for Patients who Received a Total Knee Replacement” measure, select “FSA_Knee
  1. Select “Create” at the bottom left to submit your comments. If you would like to enter more comments, select “Create another” and then “Create.”

 

Project Title:  Hospital Quality Star Ratings on Hospital Compare

Dates:

  • The Call for Public Comment period opens on January 27, 2015 and closes on February 25, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale-New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (CORE) and Lantana Consulting Group to develop hospital quality star ratings for the Hospital Compare website. The purpose of the project is to improve the usability and interpretability of quality measurement for patients, caregivers, and consumers using Hospital Compare to inform their healthcare decision making. The star ratings system will provide a clear and easy to interpret summary of currently available data regarding hospital quality measurement. The contract number is HHSM-500-2013-13018I- T0001 Modification 000002.

As part of its measure development process, CMS requests that interested parties submit comments on the measures selected for the hospital summary star rating by the contractors and their technical expert panel (TEP). CMS asks that stakeholders provide comments regarding the selected measures to be included in the overall hospital summary star rating. The public may also offer suggestions regarding other current Hospital Compare measures that may be suitable for the summary star rating. The public comment period provides an opportunity for the widest range of stakeholder input during the measure development process.

Project Objectives:

  • To develop a hospital quality star ratings system for the Hospital Compare website and present its information in a useful way to patients and consumers.
  • Each hospital’s star rating will be a summary measure of hospital quality information based on currently available, publicly reported quality measures on the Hospital Compare website.

Documents and Measures for Comment:

The following documents are provided for your review and comment. The files are found below in the Download section.

  • The strategy and outline for developing the star ratings system, including the measure selection process and rationale, in the Background and Measure Selection Process Supplemental Report.
  • The TEP 1 Summary Report, which includes the comments provided by the TEP during its discussion of measure inclusion.

Project Specific Instructions:

  • Please note this public comment period is for the review of the selected measures under the overall hospital summary star rating.  The methodology of the summary star rating will be posted for review in a future public comment period.

Instructions for Providing Comments:

  • If you are providing comments on behalf of an organization, include the organization’s name and contact information.
  • If you are commenting as an individual, submit identifying or contact information.
  • Comments are due by close of business February 25, 2015.
  • Please do not include personal health information in your comments.
  • Send your comments to cmsstarratings@lantanagroup.com.

 

Project Title: Development of Measures of Payment for Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)

Dates: 

  • The Call for Public Comment period closed on November 21, 2014.

Project Overview: 

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Systems Corporation/Center for Outcomes Research and Evaluation (CORE) to develop a hospital-level measure of risk-standardized, 90-day episode-of-care payments for elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA). The contract name is Development, Reevaluation, and Implementation of Hospital Outcome/Efficiency Measures. The contract number is HHSM-500-2013-13018I. As part of its measure development process, CMS requests interested parties to submit comments on the candidate or concept measures that may be suitable for this project.

The purpose of the project is to develop an outcome measure that can be used to support quality improvement. The public comment period provides an opportunity for the widest array of interested parties to provide input on the measure under development. Comments from the public can offer critical suggestions in additions to those identified by the measure contractors and their technical expert panel (TEP).

Project Objectives: 

  • To develop a hospital-level measure of risk-standardized, 90-day episode-of-care payments for elective primary THA/TKA.

Comment Summary:

The following documents including a summary of public comments and the original measures; and documents for comment are found below in the Download section.

  • Public Comment Summary Report and Verbatim Comments

 

 

Project Title: Days in Acute Care after Hospitalization for Heart Failure, Pneumonia, or Acute Myocardial Infarction (AMI)

Dates: 

The public comment period closed on July 31, 2014.

Project Overview: 

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (CORE) to reevaluate three administrative claims-based, hospital-level, risk-adjusted measures of care transitions for patients hospitalized with AMI, heart failure, and pneumonia. The contract name is Measure & Instrument Development and Support (MIDS). The contract number is HHSM-500-2013-13018I. As part of its measure reevaluation, CMS requested interested parties to submit comments on the draft measure specifications.

Project Objectives: 

  • The primary goal of this project is to reevaluate three administrative claims-based, hospital-level, risk-adjusted measures of care transitions for patients hospitalized with AMI, HF, and pneumonia.
  • The public comment period provided an opportunity for the widest array of interested parties to provide input on measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).
  • At that stage of measure reevaluation and testing, we were seeking feedback on the preliminary measure specifications of the three revised measures of post-discharge acute care utilization, for patients hospitalized with heart failure, pneumonia, and AMI.

Comment Summary: 

The following document is found below in the Download section:

1.  Public Comment Summary Report and Verbatim Comments

 

Project Title: Hospital Visits after Hospital Outpatient Surgery

Dates:

The call for public comment period closed on August 3, 2014.

Project Overview:
The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation – Center for Outcomes Research and Evaluation (CORE) to develop quality measures that use patient outcomes to assess the quality of outpatient care. The contract name is Development of Ambulatory Care Outcomes Measures and the contract number is HHSM-500-2012-00025I. As part of this project, CORE is developing a quality measure for outpatient surgeries. Specifically, CORE is developing a measure of hospital visits after outpatient surgery conducted in hospital outpatient departments (HOPDs). As part of its measure development process, CMS invited interested parties to submit comments on the draft measure specifications.

Project Objectives:

  • The primary goal of this project is to develop an administrative claims-based, risk-standardized measure of hospital visits after hospital outpatient surgery.
  • The public comment period provides an opportunity for the widest array of interested parties to provide input on the measure under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).

Comment Summary:

The following documents are found below in the Download section:

1. Measure technical report for public comment
2. Technical expert panel (TEP) summary report
3. Public comment summary report, including verbatim comments

 

Project Title: Risk-Standardized Acute Admission Rates for Patients with Diabetes. Risk-Standardized Acute Admission Rates for Patients with Heart Failure

Dates: 

The call for public comment period closed on May 19, 2014.

Project Overview: 

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (CORE) to develop quality measures for patients with diabetes and heart failure. The contract name is Development of Ambulatory Care Outcomes Measures. The contract number is HHSM-500-2012-00025I. As part of its measure development process, CMS requested interested parties to submit comments on the draft measure specifications.

Project Objectives: 

  • The primary goal of this project is to develop administrative claims-based, risk-standardized measures of acute admission rates for patients with chronic disease (diabetes and heart failure).
  • The public comment period provides an opportunity for the widest array of interested parties to provide input on measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).

Comment Summary: 

The following documents, including the draft measure specifications, TEP summary report, public comment summary report, and verbatim comments, are found below in the Download section.

  1. Public Comment Summary Report and Verbatim Comments for Diabetes and Heart Failure Admission Measures
  2. Diabetes and Heart Failure Draft Measures Technical Report
  3. Diabetes and Heart Failure Measures TEP Summary Report

 

Project Title: Risk-Standardized Acute Admission Rates for Patients with Multiple Chronic Conditions

Dates: 

The call for public comment period closed on June 19, 2014.

Project Overview: 

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (CORE) to develop quality measures for patients with multiple chronic conditions. The contract name is Development of Ambulatory Care Outcomes Measures. The contract number is HHSM-500-2012-00025I. As part of its measure development process, CMS requested interested parties to submit comments on the draft measure specifications.

Project Objectives: 

  • The primary goal of this project is to develop administrative claims-based, risk-standardized measures of acute admission rates for patients with chronic disease (multiple chronic conditions).
  • The public comment period provides an opportunity for the widest array of interested parties to provide input on measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).

Comment Summary: 

The following documents, including the draft measure specifications, TEP summary report, public comment summary report, and verbatim comments, are found below in the Download section.

  1. Public Comment Summary Report and Verbatim Comments for Multiple Chronic Conditions Admission Measure
  2. Multiple Chronic Conditions Draft Measure Technical Report
  3. Multiple Chronic Conditions Measure TEP Summary Report

 

Project Title:  2015 PQRS #181 Elder Maltreatment Screening and Follow-Up Plan

Dates:

The Call for Public Comment closed at 5:00 P.M EDT on October 22, 2014.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Signature Consulting Group to maintain Measure 181 - Elder Maltreatment Screening and Follow-Up Plan. The contract name is Physician Quality Measures Maintenance. The contract number is HHSM-500-2013-00177C. As part of its measure maintenance process, CMS requested interested parties to submit comments on this measure.

Project Historical Review:

CMS convened a national Elder Maltreatment & Care Symposium for all relevant stakeholders on March 8, 2013. The aim of this symposium was to assess the value of continuing the implementation and development of PQRS #181 Elder Maltreatment Screening and Follow-Up Plan.

Feedback from the Elder Maltreatment & Care Symposium was incorporated into the comprehensive review of the 2014 Elder Maltreatment Screening and Follow-Up Plan measure for use in PQRS. This comprehensive review also included a literature review, measure specifications review and an evaluation of the measure code sets.

Project Objectives:

  • Assess relevance and value of elder maltreatment assessment within the clinical setting and patient behavioral response to support the continuation of development and implementation of PQRS #181: Elder Maltreatment Screening and Follow-Up Plan
  • Review public comment for consideration of potential revisions for implementation of the measure. This may include a comprehensive literature review, measure specifications review, and an evaluation of the measure code sets.

Comment Summary:

The following documents, a summary of the public comments and the 2015 PQRS #181 Elder Maltreatment Screen and Follow-Up Plan specification document are found below in the Download section.

  • Final Public Comment Summary Report 
  • 2015 PQRS 181 Elder Maltreatment Screening and Follow-up

 

Project Title: Hybrid Hospital-Wide Readmission Measure with Claims and Electronic Health Record Data

Dates:

The Public Comment period ran from July 14, 2014 to August 8, 2014

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation Center for Outcomes Research & Evaluation (CORE) to develop a hospital-wide all-cause unplanned readmission hybrid electronic clinical quality measure (HWR eMeasure). This is a hybrid measure in that it includes a combination of claims data describing patient’s conditions and clinical data from electronic health records. The contract name is Measure & Instrument Development and Support (MIDS). The contract number is HHSM-500-2013-13018I. As part of its measure development process, CMS requested interested parties to submit comments on the candidate or concept measures that may be suitable for this project.

Project Objectives:

The purpose of the HWR eMeasure was to enhance the original hospital-wide readmission measure by including clinical data elements captured at the start of an episode of care in electronic health records (EHR). This enhancement was in response to stakeholder feedback expressing a need for clinical information in risk adjustment models.

The measure uses the methodology from the original HWR measure but adds clinical data to the risk adjustment strategy. We only included clinical data elements that were found to be consistently captured under current clinical practice and feasibly retrieved from EHRs by a 2013 TEP. This measure has been tested in a dataset from an integrated hospital system consisting of 21 hospitals. At that stage of measure development and testing, we were seeking feedback on the measure concept and clinical data elements used in the risk adjustment models for each specialty cohort.

Further measure testing in a larger, more diverse data set will occur once such data is available. Similarly, the value sets and logic surrounding those value sets will be available for public comment in 2015.

Comment Summary:

The following documents, including a summary of public comments and the original measures; and documents for comment are found below in the Download section.

  • Public Comment Summary Report.

 

Project  Title: All-Cause Acute Admission Rates For Patients With Heart Failure and Diabetes

Dates:

The public comment period ended on May 19, 2014.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (CORE) to develop quality measures for patients with heart failure, diabetes, and multiple chronic conditions. We are developing claims-based risk-adjusted admission measures for patients in Accountable Care Organizations (ACOs). The purpose of this project is to assess the quality of care to Medicare beneficiaries and promote improvement.

This public comment period is for the heart failure and diabetes admission measures. We will hold a separate public comment period for the multiple chronic conditions measure later this spring.

Project Objectives:

• Identifying important quality goals related to these chronic conditions

• Conducting literature reviews and exploratory analyses

• Defining and developing specifications for each quality measure

• Convening a technical expert panel to provide input during development and evaluate the proposed measures

• Posting measures for public comment to solicit the widest possible array of input on the measures

• Testing measures for reliability, validity, and feasibility

• Refining measures as needed

Documents and Measures for Comment:

The following documents are provided for your review and comment and are found in the Downloads section of this site:

  • Heart Failure and Diabetes Draft Measures Technical Report
  •  Technical Expert Panel Summary Report

 

For more information on using JIRA, please visit click here for instructions.

Thank you for your support and participation.

Instructions/Information:

To be notified of when the next Public Comment Period is scheduled, please see the "CMS Related Links" (below) to sign up on the Mailing List.