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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:

  • Development of Method for Measuring Accountable Care Organization Improvement on Risk-Adjusted Admission Rates
  • Development of Claims-Based and Hybrid Measures of 30-Day Mortality Following Acute Ischemic Stroke Hospitalization that Incorporate Risk Adjustment for Stroke Severity
  • Overall Hospital Quality Star Ratings on Hospital Compare
  • Development, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE)
  • Electronic Specifications for the Core Clinical Data Elements for Risk Adjustment of Hospital-Level Outcome Measures

 

Project Title:  Development of Method for Measuring Accountable Care Organization Improvement on Risk-Adjusted Admission Rates

Dates:

The Call for Public Comment period opens on August 27, 2015 and closes on September 17, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) is developing a novel methodology to assess Accountable Care Organization (ACO) year-to-year improvement on three risk-adjusted outcome measures. Yale New Haven Health Services Corporation – Center for Outcomes Research and Evaluation (CORE) is leading the work under contract to CMS. The contract name is the Measure & Instrument Development and Support (MIDS): Development, Reevaluation, and Implementation of Outpatient Outcome/Efficiency Measures. The contract number is HHSM-500-2013-13018I, Task Order HHSM-500-T0002. As part of the development process, CMS requests interested parties to submit comments on the methodology under development.

CMS/CORE previously developed three ACO risk-adjusted acute admission measures that CMS has added to the Medicare Shared Savings Program (Shared Savings Program) quality measure set. The three ACO admission measures assess each ACO’s performance relative to that of other providers with a similar mix of patients in a given year. Hence, if all providers lower their rates substantially from one year to the next but one ACO lowers its rate less than average, this ACO’s performance on these measures of relative performance will look relatively worse compared to its peers in the second year, even though it is improving.

To complement these three measures, CMS has contracted with CORE to develop a method of measuring year-to-year improvement for individual ACOs. The methodology under development, in contrast to the relative measures, will assess whether each individual ACO improved its acute admission rate, independent of other providers’ progress.

Project Objective:

The primary goal of this project is to develop an administrative claims-based, risk-adjusted method for measuring ACO-level year-to-year improvement in the rate of acute, unplanned admissions.

Documents and Measures for Comment:

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

  • Method for Measuring Accountable Care Organization Improvement on Risk-Adjusted Admission Rates Technical Report, which presents the approach to methodology development.
  • Technical Expert Panel (TEP) Summary Report, which summarizes the feedback and recommendations provided by the TEP regarding the methodology.

Project Specific Instructions:

  • CMS encourages you to submit comments on the methodology.
  • At the end of the public comment period, all public comments will be posted on this website.
  • If you are providing comments on behalf of an organization, please include the organization’s name and your contact information.
  • If you are commenting as an individual, please submit identifying or contact information.
  • Send your comments to primarycaremeasures@yale.edu by close of business on September 17, 2015.

 

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 opens on July 27, 2015 and closes 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 requests 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-based stroke mortality measure that utilizes only Medicare administrative claims data. The other type is a “hybrid” measure that utilizes both claims data and clinical data extractable from electronic health record (EHR) data. We developed two risk-adjustment models for the hybrid measure, both of which include the NIHSS as a risk factor. One risk-adjustment model includes additional risk factors derived from claims and EHR data; and the other includes additional risk factors only from clinical EHR data.

Documents and Measures for Comment:

The following document, found below in the Download section, is provided for your review and comment:

  • Claims-Based and Hybrid Measures of 30-Day Mortality Following Acute Ischemic Stroke Hospitalization Incorporating Risk Adjustment for Stroke Severity: Technical Report

Project Specific Instructions:

  • CMS encourages you to submit comments on the measure methodology.
  • At the end of the public comment period, all public comments will be posted on this Web site.
  • 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, please include the organization’s name and your contact information.
  • If you are commenting as an individual, please submit identifying or contact information.
  • Please indicate which measure you are providing comments on.
  • Send your comments to StrokeMeasures@yale.edu.
  • Comments are due by close of business on August 26, 2015.

 

Project Title:  Overall Hospital Quality Star Ratings on Hospital Compare

Dates:

  • The second Call for Public Comment period opens on July 17, 2015 and closes 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. The contract number is HHSM-500-2013-13018I - T0001 Modification 000002.

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:

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

Documents and Measures for Comment:

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

  • Methodology of Overall Hospital Quality Star Ratings, which presents the methodology that will be used during the July 2015 Hospital Dry Run.
  • The TEP Summary Report, which summarizes the feedback and recommendations provided by the TEP regarding the Overall Hospital Quality Star Ratings.

Project Specific Instructions:

  1. Please note this public comment period is for the review of the methodology under development for the Overall Hospital Quality Star Ratings.
  2. If you are providing comments on behalf of an organization, include the organization’s name and contact information.
  3. If you are commenting as an individual, submit identifying or contact information.
  4. nbsp;      Comments are due by close of business August 17, 2015.
  5. 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.

Send your comments to cmsstarratings@yale.edu.

 

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 opens on July 17, 2015 and closes on August 17, 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 during the first year of the project: 30-Day Readmissions, Falls, Falls With Injury, and Pressure Ulcers (with prevention).
  • Conduct field testing to assess the feasibility of data collection for these four proposed adapted measures.
  • Develop an auditing and validation plan for each of the proposed measures.

Documents and Measures for Comment:

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

  • Public Description of Measures
  • Measure Information Forms for all Measures
  • Measure Justification Forms for all Measures
  • Measure Evaluation Report
  • Environmental Scan

Project Specific Instructions:

  • Do not include personal health information in your comments.
  • If you are providing comments on behalf of an organization, please 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:   PACEQMcomments@econometricainc.com
  • Comments are due by August 17, 2015 at midnight [12:00AM EST].

 

Project Title: Electronic Specifications for the Core Clinical Data Elements for Risk Adjustment of Hospital-Level Outcome Measures

Dates: 

  • The Call for Public Comment period closed on June 16, 2015.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has a contract with Yale New Haven Health Services Corporation Center for Outcomes Research & Evaluation (CORE) to develop the core clinical data elements, a set of 21 clinical variables from electronic health records (EHR) that are routinely collected and can be feasibly extracted for use in risk-adjusted hospital-level outcome measures. The contract name is: Development, Reevaluation, and Implementation of Hospital Outcome/Efficiency Measures; Contract Number: HHSM-500-2013-13018I- T0001 Modification 000002. CMS envisions using core clinical data elements in conjunction with other sources of data, such as administrative claims-based data, to calculate “hybrid” outcome measures, which are hospital quality measures that utilize more than one source of data.

CORE worked with Mathematica Policy Research to electronically specify the core clinical data elements. As part of its measure development process, CMS requests interested parties to submit comments on the electronic specifications and value sets for the core clinical data elements. We also ask that comments focus on technical aspects of the electronic specifications as opposed to comments focusing on policy related issues or concerns associated with the implementation of core clinical data elements.  Specifically, we are looking for comments on the:

  • Ease of electronically extracting these data from an electronic health record (EHR) without the need for manual abstraction;
  • Measure logic (i.e., the clarity and specificity of the instructions for obtaining data to be reported); and
  • Appropriateness of codes contained in value sets for identifying relevant encounters and first captured clinical data during a clinical encounter.

Project Objectives:

  • To create valid and easily interpreted electronic specifications with Quality Data Model (QDM) elements that will facilitate accurate extraction of the core clinical data elements from the most currently operating EHRs.

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