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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:

 

Project Title: Use of Antipsychotics in Older Adults in the Inpatient Hospital Setting

Dates:

  • The call for public comment period opens on April 15, 2016 and closes on May 15, 2016.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Mathematica Policy Research to develop, electronically specify, and maintain process and structural clinical quality measures for CMS hospital quality programs. The contract name is Hospital Inpatient and Outpatient Process and Structural Measure Development and Maintenance. The contract number is HHSM-500-2013-13011I/HHSM-500-T0003. As part of its measure development process, CMS asks that interested parties to submit comments on the candidate or concept measures that may be suitable for this project.

Project Objectives:

The goal of this project is to develop electronic clinical quality measures (eCQMs) for use by providers in CMS quality reporting programs. In conjunction with developing new eCQMs, the project is also tasked to re - engineer existing chart- or claims-based measures as eCQMs.

We aim to understand the scope of antipsychotic use, the potential for quality improvement opportunities, and the possible unintended consequences of implementing an antipsychotic measure in the acute inpatient hospital setting.

Documents and Measures for Comment:

CMS is currently requesting feedback on the following antipsychotics measure:

  • Use of Antipsychotics in Older Adults in the Inpatient Hospital Setting

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

  • Use of Antipsychotics Public Comment Framing Document
  • Use of Antipsychotics MAT Output
  • Use of Antipsychotics Framing Document
  • JIRA Commenting Instructions

Project Specific Instructions:

All comments are welcome, but we are particularly interested in feedback on the measure and how it may be further refined. We specifically seek to understand if the measure is likely to:

  • Increase our understanding of the magnitude of antipsychotics prescribed and administered in the inpatient setting?
  • Promote improvement in prescribing practices and reduce variation in use of antipsychotics?
  • Collect data that is feasible to obtain from electronic data sources without undue burden?
  • Address a quality gap that is important enough to justify potential changes in workflow to enable discrete measurement of antipsychotics and non-pharmacologic interventions?
  • Provide information that is a useful indicator of appropriate, patient-centered care?

To submit comments, please visit the eCQM Tracker JIRA website hosted by the Office of the National Coordinator for Health Information Technology:  https://jira.oncprojectracking.org/browse/CQM

  • For instructions on accessing JIRA and creating an account, please see the guidance included in the Downloads section below. All comments should be submitted on JIRA.
  • Please do NOT submit anything that would constitute protected health information or personally- identifiable information (e.g., date of birth, Social Security number, health insurance claim number) in your 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, include your name and contact information.

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Project Title:  Maintenance of Health and Well-Being Measures - NQF #0680: Percent of Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) 

Dates:

  • The Call for Public Comment period opens on April 18, 2016 and closes on May 6, 2016.

Project Overview

The Centers for Medicare & Medicaid Services (CMS) has contracted with RTI International to develop and maintain Health and Well-Being Measures for nursing homes, inpatient rehabilitation facilities and long-term care hospitals. The contract name is Development and Maintenance of Symptom Management Measures. The contract number is (HHSM-500-2013-13015I; Task Order HHSM-500-T0001). As part of its measure development and maintenance process, CMS requests interested parties to submit comments on the candidate or concept measures included in this project.

Project Objectives

  • To maintain health and well-being measures that assess nursing home, inpatient rehabilitation facility, and long-term care hospital 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 objectives, CMS and RTI International solicit public comments to obtain setting-specific input on the following quality measure:  NQF #0680: Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) for nursing homes, inpatient rehabilitation facilities, and long-term care hospitals.

Documents and Measures for Comment

To inform your comments, please review the draft specifications for the influenza vaccine quality measure in the following document found in the Download section below:

  • Maintenance of Health and Well-Being Measures_ NQF 0680_CS_Flu_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 conduct your review with the following topics in mind:  impact and unintended consequences of the measure, room for improvement and variation in quality across providers.
    • Send your comments to  Cross-setting_influenza_vaccine@rti.org
    • Comments are due by May 6, 2016.

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Project Title:  Maintenance of Health and Well-Being Measures - NQF #0681: Percent of Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine (Long Stay)

Dates:

  • The Call for Public Comment period opens on April 18, 2016 and closes on May 6, 2016.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with RTI International to develop and maintain Health and Well-Being Measures for nursing homes. The contract name is Development and Maintenance of Symptom Management Measures. The contract number is (HHSM-500-2013-13015I; Task Order HHSM-500-T0001). As part of its measure development and maintenance process, CMS requests interested parties to submit comments on the candidate or concept measures included in this project.

Project Objectives:

  • To maintain health and well-being measures that assess 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 objectives, CMS and RTI International solicit public comments on the following quality measure:  NQF #0681: Percent of Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine (Long Stay) for nursing homes.

Documents and Measures for Comment:

To inform your comments, please review the draft specifications for the influenza vaccine quality measure in the following document found in the Download section below:

  • Maintenance of Health and Well-Being Measures_NQF 0681_LS_Flu_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 conduct your review with the following topics in mind:  impact and unintended consequences of the measure, room for improvement and variation in quality across providers.
    • Please indicate the measure you are providing comments on. Send your comments to CMSNursingHomeQM@rti.org
    • Comments are due by May 6, 2016.

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Project Title:  Development of Potentially Preventable Readmission Measures for Skilled Nursing Facilities (SNFs), Inpatient Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs), and Home Health Agencies (HHAs)

Dates:

  • The Call for Public Comment period closed on December 1, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with RTI International and Abt Associates to develop potentially preventable readmission measures, in alignment with the Improving Post-Acute Care Transformation Act of 2014 (known as the IMPACT Act) and the Protecting Access to Medicare Act of 2014 (known as PAMA). The contract names are Development and Maintenance of Symptom Management Measures (HHSM-500-2013-13015I; Task Order HHSM-500-T0001) and Outcome and Assessment Information Set (OASIS) Quality Measure Development and Maintenance (HHSM-500-2013-13001I; Task Order HHSM-500-T0002). As part of its measure development process, CMS requested the public to submit comments on these measures under development.

The purpose of these projects is to develop, maintain, re-evaluate, and implement outcome and process quality measures that are reflective of quality care for the PAC settings, to support CMS quality missions that include the Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP), the Inpatient Rehabilitation Facility (IRF) QRP, the Nursing Home (NH)/Skilled Nursing Facility (SNF) QRP, the Home Health (HH) QRP, and SNF Value-Based Purchasing. The cross-setting readmission measures will be applicable to all post-acute care settings.

Project Objectives:

  • To develop an approach for defining potentially preventable readmissions (PPRs) for post- acute care (SNF, IRF, LTCH, HHA).
  • To develop potentially preventable readmissions measures for multiple settings (SNF, IRF, LTCH, HHA), including standardized items and specifications such as inclusion/exclusion criteria, and patient and facility characteristics—factors associated with outcome measures (risk adjusters).
  • To obtain setting-specific input on PPR quality measures’ application and implementation.

Comment Summary:

The following document can be found below in the Download section.

  • Development of Potentially Preventable Readmission Measures Public Comment Summary Report

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Project Title:  Development of a Discharge to Community Quality Measure for Skilled Nursing Facilities (SNFs), Inpatient Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs), and Home Health Agencies (HHAs)

Dates:

  • The public comment period closed on December 8, 2015.

Project Overview:

CMS has contracted with RTI International and Abt Associates to develop measures to meet the domain of resource use and other domains for post-acute care (PAC) settings in order to meet the mandate of the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), and to support CMS quality missions.  The PAC settings include SNFs, IRFs, LTCHs, and HHAs.

The contract names are Development and Maintenance of Symptom Management Measures (HHSM-500-2013-13015I; Task Order HHSM-500-T0001) and Outcome and Assessment Information Set (OASIS) Quality Measure Development and Maintenance (HHSM-500-2013-13001I; Task Order HHSM-500-T0002).  As part of its measure development process, CMS encourages the public to submit comments on the proposed measures.

The purpose of this Call for Public Comment was to seek input on the development of discharge to community measures for PAC settings, including proposed measure specifications such as inclusion/exclusion criteria, numerator and denominator definitions, and risk adjusters—patient/resident characteristics that are associated with the outcome.

Project Objectives:

  • To develop a discharge to community measure for post-acute settings (SNFs, IRFs, LTCHs, HHAs), which includes standardized items and specifications such as the discharge to community outcome definition, inclusion and exclusion criteria, and patient characteristics for risk adjustment.
  • To obtain cross-setting and setting-specific input on application and implementation of discharge to community measures for SNFs, IRFs, LTCHs, and HHAs.

Comment Summary:

The following document can be found below in the Download section.

  • Development of Discharge to Community Measure Public Comment Summary Report

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Project Title:  Hospital Inpatient and Outpatient Process and Structural Measure Development and Maintenance (Hospital-MDM) 

Task: Electronic specification of an existing chart-based influenza immunization measure (IMM-2) and development of a new Advance Care Planning (ACP) measure

Dates:

  • The Call for Public Comment period closed on February 24, 2016.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Mathematica Policy Research and its partners to develop, electronically specify, and maintain process and structural clinical quality measures for five CMS hospital quality programs—Hospital Inpatient Quality Reporting (IQR), Hospital Outpatient Quality Reporting (OQR), Ambulatory Surgical Center Quality Reporting (ASCQR), PPS-Exempt Cancer Hospital Quality Reporting (PCHQR), and the EHR Incentive Program for Eligible Hospitals. The contract name is Hospital Inpatient and Outpatient Process and Structural Measure Development and Maintenance (Hospital-MDM). The contract number is HHSM-500-2013-13011I Task Order HHSM-500-T0003. As part of its measure development process, CMS requested interested parties to submit comments on the candidate measures being developed under this project.

Project Objectives:

The goal of this project is to develop electronic clinical quality measures (eCQMs) for use by providers in CMS quality reporting programs. In conjunction with developing new eCQMs, the project is also tasked to re-engineer existing chart- or claims-based measures as eCQMs. Mathematica is working with the National Committee for Quality Assurance to develop the new Access to Quality Advance Care Planning measure, and working with Telligen to re-engineer the IMM-2 measure. As part of the measure development process, we solicited feedback about the feasibility, usability, and face validity of these measures during a public comment period.

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.

  • Advance Care Planning (ACP) Public Comment Summary Report
  • Influenza Immunization (IMM-2) Public Comment Summary Report

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Project Title: Revisions to the Standardized Transfusion Ratio (STrR) 

Dates:

  • The Call for Public Comment period closed on March 4, 2016. 

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with the University of Michigan Kidney Epidemiology and Cost Center (UM-KECC) to develop measures of anemia management in ESRD patients. The contract name is ESRD Quality Measure Development, Maintenance, and Support. The contract number is HHSM-500-2013-13017I..

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 specifications for the Standardized Transfusion Ratio were revised, and we sought comment on these revisions. We developed a more conservative definition of transfusion events.  The revised definition excludes inpatient transfusion events for claims that include only 038 or 039 revenue codes without an accompanying procedure or value code.  In the revised measure, all inpatient transfusion events include, at a minimum, an appropriate ICD-9 Procedure Code or Value Code.  This more conservative definition of transfusion events is used to calculate the restricted STrR.  As expected from the information provided above, this more restricted definition of transfusion events results in a reduced total number of events identified as well as the range of total events for dialysis facilities.

Comment Summary:

The following documents are found below in the Download section.

  • STrR Public Comment Summary Report

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Project Title: Medicare Spending Per Beneficiary – Post-Acute Care (MSPB-PAC) Resource Use Measures

Dates:

  • The Call for Public Comment period closed on February 5, 2016.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Acumen, LLC to develop the MSPB-PAC measures.  The contract name is Calculating Episode-Based Costs from the Medicare Episode Grouper for Physician Feedback.  The contract number is HHSM-500-2011-000121.  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 goal of this project is to develop resource use measures for PAC settings as mandated by the Improving Post-Acute Care Transformation Act of 2014 (IMPACT Act). These measures apply to skilled nursing facilities (SNFs), home health agencies (HHAs), long-term care hospitals (LTCHs), and inpatient rehabilitation facilities (IRFs) and will be reported in each respective PAC setting’s quality reporting program (QRP). The proposed MSPB-PAC episode-based measures will provide actionable and transparent information to support PAC providers’ efforts to promote care coordination and deliver high quality care at a lower cost to Medicare. A given PAC provider’s risk-adjusted Medicare spending is evaluated relative to that of the national median PAC provider in the same setting. 

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.

  • Medicare Spending Per Beneficiary – Post-Acute Care Measures Public Comment Summary Report  (PDF)
  • Medicare Spending Per Beneficiary – Post-Acute Care Measures Public Comment Verbatim Report (PDF)

Medicare Spending Per Beneficiary – Post-Acute Care Measures Public Comment Summary Report: Supplementary Materials (PDF)

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Project Title: End-Stage Renal Disease Evaluation of Potential Prevalent Comorbidity Adjustments in the Standardized Hospitalization Ratio (SHR) and the Standardized Mortality Ratio (SMR)

Dates:

  • The Call for Public Comment period closed on February 29, 2016. 

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with The University of Michigan – Kidney Epidemiology and Cost Center (UM-KECC) to evaluate the potential of including prevalent comorbidities in the SHR and SMR risk adjustment models. The contract name is End-Stage Renal Disease Evaluation of Potential Prevalent Comorbidity Adjustments in the Standardized Hospitalization Ratio (SHR) and the Standardized Mortality Ratio (SMR). The contract number is HHSM-500-2013-13017I. 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 University of Michigan Kidney Epidemiology and Cost Center, through its contract with the Centers for Medicare and Medicaid Services, convened a technical expert panel to evaluate the potential of including prevalent comorbidities in the SMR (NQF 0369) and SHR (NQF 1463) risk adjustment models. Specific objectives included:

  • Review of the comorbidity adjustment in the current NQF endorsed SMR and SHR measures
  • Consideration of what, if any, prevalent comorbidities would be appropriate to include in each measure.

Comment Summary:

The following documents are found below in the Download section.

  • ESRD SMR SHR Public Comment Summary Report

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Project Title: End-Stage Renal Disease Vascular Access Measure Development

Dates:

  • The Call for Public Comment period closed on February 5, 2016.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with the University of Michigan Kidney Epidemiology and Cost Center (UM-KECC) to review the NQF endorsed Vascular Access measures (Minimizing Use of Catheters as Chronic Dialysis Access, and Maximizing Placement of Arterial Venous Fistula) and consider possible revisions to the existing measures, including potential risk adjustment. The contract name is ESRD Quality Measure Development, Maintenance, and Support. The contract number is HHSM-500-2013-13017I. As part of its measure development process, CMS has requested interested parties to submit comments on the candidate or concept measures that may be suitable for this project.

Project Objectives:

The University of Michigan Kidney Epidemiology and Cost Center, through its contract with the Centers for Medicare and Medicaid Services, convened a technical expert panel to evaluate the existing NQF-endorsed vascular access measures. Specific objectives included:

  • Review of the current NQF endorsed Vascular Access measures (Minimizing Use of Catheters as Chronic Dialysis Access, and Maximizing Placement of Arterial Venous Fistula)
  • Consider revisions to the vascular access measure set
  • Consider including potential risk adjustment

Comment Summary:

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

  • Vascular Access Public Comment Summary Report
  • Hemodialysis Vascular Access: Long-term Catheter Rate
    • Measure Information Form
    • Measure Justification Form
  • Hemodialysis Vascular Access: Standardized Fistula Rate
    • Measure Information Form
    • Measure Justification Form

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Project Title: End-Stage Renal Disease Access to Kidney Transplantation Measure Development

Dates:

  • The Call for Public Comment period closed on February 5, 2016.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with the University of Michigan Kidney Epidemiology and Cost Center (UM-KECC) develop Access to Kidney Transplantation measures (Standardized First Kidney Transplant Waitlist Ratio for Incident Dialysis Patients (SWR) and Percentage of Prevalent Patients Waitlisted (PPPW)). The contract name is ESRD Quality Measure Development, Maintenance, and Support. The contract number is HHSM-500-2013-13017I. As part of its measure development process, CMS has requested interested parties to submit comments on the candidate or concept measures that may be suitable for this project.

Project Objectives:

The University of Michigan Kidney Epidemiology and Cost Center, through its contract with the Centers for Medicare and Medicaid Services, convened a technical expert panel to develop quality access to kidney transplantation measures. Specific objectives included:

  • Develop quality measures that address important quality gaps across the spectrum of the kidney transplantation process, such as transplant education, referral, waitlisting, and transplant
  • Provide input on relevant measures currently used as part of the provider feedback program Dialysis Facility Reports (DFR), including facility waitlisting rate and the Standardized Transplantation Ratio (STR).
  • Consider the degree to which performance on a potential measure is under the control of the dialysis facility, as well as the strength of the link between performance on a measure and outcomes that are valued by patients
  • Consider issues of data element availability and collection
  • Discuss the potential need for exclusion criteria and/or risk adjustment

Comment Summary:

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

  • Access to Transplantation Public Comment Summary Report

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Project Title: Inpatient Psychiatric Facility (IPF) Outcome and Process Measure Development and Maintenance

Dates:

  • The Call for Public Comment period closed on December 11, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Health Services Advisory Group, Inc. (HSAG), to develop, maintain, reevaluate, and support the implementation of quality outcome and process measures for the CMS Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program under the Measure & Instrument Development and Support (MIDS) Contract (Contract #: HHSM-500-2013-13007I), and Task Order Inpatient Psychiatric Facility Outcome and Process Measure Development and Maintenance (Task Order #: HHSM-500-T0004).

Project Objectives:

The primary project objectives are as follows:

  • Develop new measures that drive quality improvement, are patient centered, are aligned with other programs, and that fill critical gaps for future inclusion in the CMS IPFQR Program;
  • Maintain and reevaluate existing IPF measures; and
  • Support measure implementation in the IPFQR Program.

To provide an important indicator of the quality of care patients receive in the IPF setting, HSAG developed a measure that estimates an unplanned, 30-day, risk-standardized readmission rate for adult Medicare fee-for-service (FFS) patients with a principal discharge diagnosis of psychiatric disorder. To obtain input from stakeholder organizations and interested parties, public comments were solicited for this proposed quality measure, Thirty-day All-cause Unplanned Readmission Following Psychiatric Hospitalization in an Inpatient Psychiatric Facility (IPF). 

Comment Summary:

The following documents including a summary of public comments and the measure technical report are found below in the Download section.

  •  Public Comment Summary-IPF Readmission Measure
  • IPF Readmission Measure Technical Report

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Project Title:  Electronic Clinical Quality Measures (eCQM) Development and Maintenance for Eligible Professionals

Dates:

  • The Call for Public Comment period closed on November 20, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Mathematica Policy Research and its partners to develop, electronically specify, and maintain electronic clinical quality measures for use in CMS quality reporting programs for eligible professionals. The name of the contract is Electronic Clinical Quality Measures Development and Maintenance for Eligible Professionals. The contract number is HHSM-500-2013-13011I. As part of its measure development process, CMS requested interested parties to submit comments on the draft eCQM, Non-Recommended Prostate-Specific Antigen (PSA)-Based Screening.

Project Objectives:

  • Develop, electronically specify and maintain electronic clinical quality measures for use in CMS quality reporting programs for eligible professionals.

Comment Summary:

The following document includes CMS’s response along with a summary of public comments for this measure. The document is found below in the Download section.

  • eCQM Development and Maintenance for Eligible Professionals_CMS_PSA_Response_Public Comment.pdf (Updated March 24, 2016)

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Project Title:  Hospital Inpatient and Outpatient Process and Structural Measure Development and Maintenance (Hospital-MDM).  Electronic specification for one set of three re-engineered Tobacco Treatment (TOB) measures.

Dates:

  • The Call for Public Comment period closed on December 4, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Mathematica Policy Research and its partners to develop, electronically specify, and maintain process and structural clinical quality measures for five CMS hospital quality programs—Hospital Inpatient Quality Reporting (IQR), Hospital Outpatient Quality Reporting (OQR), Ambulatory Surgical Center Quality Reporting (ASCQR), PPS-Exempt Cancer Hospital Quality Reporting (PCHQR), and the EHR Incentive Program for Eligible Hospitals. The contract name is Hospital Inpatient and Outpatient Process and Structural Measure Development and Maintenance (Hospital-MDM). The contract number is HHSM-500-2013-13011I Task Order HHSM-500-T0003. As part of its measure development process, CMS requested interested parties to submit comments on the candidate measures being developed under this project.

Project Objectives:

The goal of this project is to develop electronic clinical quality measures (eCQMs) for use by hospitals in CMS quality reporting programs. Along with developing new eCQMs, the project will be re-engineering existing chart- or claims-based measures as eCQMs. Mathematica is working with the TOB measure developer and steward, The Joint Commission, to re-engineer three TOB measures. As part of the measure development process, we solicited feedback about the feasibility, usability, face validity, and related/competing measures during a public comment period.

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.

  • Hospital-MDM_TOB Public Comment Summary Report_FINAL

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Project Title:  Development, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE)

Dates:

  • The Call for Public Comment period closed on September 24, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Econometrica, Inc., to adapt, implement, and maintain quality measures for the PACE programs nationwide. The contract name is Development, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE). The contract number is HHSM-500-2013-13006I.  As part of its measure development process, CMS encourages interested parties to submit comments on the proposed adapted measures and the suitability of these measures to the PACE program.

Project Objectives:

The primary objectives of this project are to:

  • Analyze existing quality measure sets to determine the extent to which they can be uniquely modified, refined, or enhanced for the PACE programs.
  • Focus on four areas of measurement developed during the first year of the project: 30-Day Readmissions, Falls, Falls With Injury, and Pressure Ulcers Prevalence (with prevention).
  • Conduct field testing to assess the feasibility of data collection for the four proposed adapted measures.
  • Develop an auditing and validation plan for each of the proposed measures.
  • Seek public comments throughout each stage of the measure development process.

Comment Summary:

CMS and Econometrica produced a Preliminary Public Comment Report based on comments received through a public comment period that closed on August 17, 2015.  A revised Preliminary Public Comment Report requesting comments and feedback on additional questions was shared as part of the second round of public comment period that closed on September 24, 2015.  This Final Public Comment Report summarizes all comments and questions posted during both rounds of public comment. It provides individual responses to these comments and questions.

The following document includes a summary of public comments and the original measures; this associated document is found below in the Download section.

  • Final Public Comment Report

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Project Title: IMPACT Act of 2014 Cross-Setting Quality Measure: Drug Regimen Review

Dates:

  • The Call for Public Comment period closed on October 6, 2015  

Project Overview:

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 was signed into law on October 6, 2014.1 This Act requires Post-Acute Care (PAC) providers to report standardized patient assessment data and quality measure data to the Secretary of the Department of Health and Human Services.
 

The Centers for Medicare & Medicaid Services (CMS) is working to ensure that data elements within PAC assessment instruments are standardized and interoperable. Current federal assessment instruments are setting-specific and contain assessment items with varying concepts, definitions, and measurement scales. The move towards standardized assessment data elements facilitates cross-setting data collection, quality measurement, outcome comparison, and interoperable data exchange.
 

The Centers for Medicare & Medicaid Services (CMS) has contracted with Abt Associates and RTI International to develop a cross-setting PAC measure for the quality measure domain—medication reconciliation. The contract names are Development and Maintenance of Symptom Management Measures (contract number HHSM-500-2013-13015I) and Outcome and Assessment Information Set (OASIS) Quality Measure Development and Maintenance Project (contract number HHSM-500-2013-13001I, Task Order HHSM-500T0002). As part of its measure development process, CMS asks contractors to convene groups of stakeholders and experts who contribute direction and thoughtful input to the measure contractor during measure development and maintenance.
 

In this measure, medication reconciliation and drug regimen review are defined as:
 

Medication Reconciliation – the process of comparing the medications a patient is taking (and should be taking) with newly ordered medications in order to identify and resolve discrepancies. (Reference: The Joint Commission, National Patient Safety Goals).

Drug Regimen Review – a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. (Reference: Home Health Conditions of Participation §484.55c).

Project Objectives:

  • Introduce drug regimen data elements for capturing data for a drug regimen measure in the medication reconciliation domain for PAC settings.
  • Refine measure specifications.
  • Identify setting-specific needs/concerns/barriers for capturing drug regimen review/medication reconciliation information using the data elements.
  • Gather feedback on importance, feasibility, usability and potential impact of adding drug regimen review data elements for quality measurement as new items to existing PAC assessment instruments in Home Health (HH), Inpatient Rehabilitation Facilities (IRF), Long Term Care Hospital (LTCH) and Skilled Nursing Facilities (SNF) settings.
  • Identify additional guidance required for the implementation in each setting of care.

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.

  • Drug Regimen Review Public Comment Summary Report

             Within this document are sections that present the following:

    • Verbatim Comments
    • Appendix
    • Drug Regimen Review Measure Information Form
    • Drug Regimen Review Measure Justification Form

1https://www.govtrack.us/congress/bills/113/hr4994

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Project Title: Hospital Inpatient and Outpatient Process and Structural Measure Development and Maintenance (Hospital-MDM)

Task: Electronic specification of an existing chart-based cesarean section measure (PC-02)

Dates:

  • The Call for Public Comment period closed on October 12, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) engaged Mathematica Policy Research and its partners to develop, electronically specify, and maintain process and structural clinical quality measures for five CMS hospital quality programs. These programs are Hospital Inpatient Quality Reporting (IQR), Hospital Outpatient Quality Reporting (OQR), Ambulatory Surgical Center Quality Reporting (ASCQR), Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR), and the Electronic Health Record (EHR) Incentive Program for Eligible Hospitals. The contract name is Hospital Inpatient and Outpatient Process and Structural Measure Development and Maintenance (Hospital-MDM). The contract number is HHSM-500-2013-13011I, task order HHSM-500-T00003. As part of its measure development process, CMS requested that interested parties submit comments on the candidate measures being developed under this project.

Project Objectives:

The goal of this project is to develop electronic clinical quality measures (eCQMs) for use by providers in CMS quality reporting programs. Along with developing new eCQMs, the project will be retooling up to 20 existing chart- or claims-based measures as eCQMs. Mathematica is working with the PC-02 measure developer and steward, The Joint Commission, to retool the PC-02 measure. As part of this process, we solicited feedback about the feasibility, usability, and face validity of this measure.

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.

  • “PC-02 Public Comment Summary Memo”
  • Public Comment Verbatim Weekly Summary Report (PDF)

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Project Title: Overall Hospital Quality Star Ratings on Hospital Compare

Dates:

  • The Call for Public Comment period closed on September 14, 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 Overall 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 interpretation and summary of currently available data regarding hospital quality measurement. CORE’s contract name is Development, Reevaluation, and Implementation of Hospital Outcome/Efficiency Measures. The contract number is HHSM-500-2013-13018I - T0001 Modification 000002. Lantana’s contract name is Hospital Quality Initiatives Option Year 1 Measure Implementation Support. The contract number is HHSM-500-2013-13010I- HHSM-500-T0001.

This second public comment period seeks input from a wide variety of stakeholders regarding several key decisions made during the development of the methodology including the analytic approach for summarizing individual measures, the use of weights to combine several aspects of quality into a single measure, and the approach to categorizing hospitals into star categories. CMS requests that interested parties submit comments on the methodology under development for the Overall Hospital Quality Star Ratings. CMS asks that stakeholders provide comments regarding the approaches to calculating hospital summary scores and translating summary scores to star ratings. The public may also offer general suggestions regarding the Overall Hospital Quality Star Ratings project.

Project Objectives:

  • To improve the usability and interpretability of Hospital Compare for patients and consumers; and
  • To develop a methodology designed to generate an overall star rating for hospitals with sufficient quality data using the existing measures on Hospital Compare.

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.

  • Hospital Quality Star Ratings on Hospital Compare Public Comment 2 Summary Report (PDF)
  • Public Comment Verbatim Weekly Summary Report (PDF)

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Project Title: Development of Claims-Based and Hybrid Measures of 30-Day Mortality Following Acute Ischemic Stroke Hospitalization that Incorporate Risk Adjustment for Stroke Severity

Dates:

  • The Call for Public Comment period closed on August 26, 2015.

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 two types of hospital-level measures of mortality following hospitalization for ischemic stroke. These measures include risk adjustment for stroke severity. The contract name is Development, Reevaluation, and Implementation of Hospital Outcome/Efficiency Measures. The contract number is HHSM-500-2013-13018I- T0001 Modification 000002. 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:

To develop two types of hospital-level measures of risk-standardized mortality for ischemic stroke patients that include an assessment of stroke severity, as measured by the first captured National Institutes of Health Stroke Scale (NIHSS) score. One type of these measures is an updated claims-only stroke mortality measure that utilizes only Medicare administrative claims data. The other type of measure is “hybrid,” which utilizes both claims data and electronic clinical data extractable from electronic health record (EHR) data. We developed two hybrid measures, with two different risk-adjustment models both of which include the NIHSS as a risk factor. One risk-adjustment model is a hybrid model and includes additional risk factors derived from claims and electronic clinical data; the other risk-adjustment model is electronic clinical data-only and includes additional risk factors only from electronic clinical data.

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

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Downloads