Updates on Closed Comment Periods

Public Comments: Closed Comments

This page serves as the designated site for CMS to provide summaries of public comments on proposed quality measures.

List of Closed Public Comments:

 

Project Title: Development and Reevaluation of Outpatient Outcome Measures for the Merit-based Incentive Payment System

Dates:

The Call for Public Comment ran from April 24, 2019 to May 24, 2019.

Project Overview

The Centers for Medicare & Medicaid Services (CMS) contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation (CORE) to develop outcome measures for ambulatory care clinicians for the Merit-based Incentive Payment System (MIPS). The measures will be used to assess the quality of care provided by clinicians or clinician groups who are eligible to participate in MIPS and report their quality under a common Taxpayer Identification Number (TIN). The contract name is Measure & Instrument Development and Support (MIDS): Development, Reevaluation, and Implementation of Outpatient Outcome/Efficiency Measures. The contract number is HHSM-75FCMC18D0042.

As part of this project, CORE developed a measure of acute hospital admissions for patients with multiple chronic conditions (MCCs). Specifically, CORE adapted for MIPS a measure of acute, unplanned admissions for MCC patients that CMS currently reports for Medicare Accountable Care Organizations. The re-specified measure for MIPS will assess each TIN’s admission rate relative to that of other TINs with similar patients. The quality measure uses patient characteristics and outcomes documented on routinely submitted Medicare claims; therefore, the MIPS eligible clinicians or clinician groups whose performance will be assessed by the quality measure will not need to submit any additional data directly to CMS.

As part of its measure development process, CMS posted the measure for public comment.

Project Objectives

The primary goal of public comment was to gather expert and stakeholder input to inform quality measure development and reevaluation for patients with acute or chronic conditions. CMS will use the measure to evaluate the quality of care provided by MIPS eligible clinicians.

Comment Summary:

These documents, including a summary of public comments and the measure methodology report posted for public comment, are found in the Download section.

  1. “Public Comment Summary Report,” which provides a summary of the comments received, presents CMS’ responses, and includes the verbatim comments.
  2. “Measure Methodology Report for Public Comment: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions,” which presents the approach to measure development, measure specifications, and results of measure testing. A supplementary Microsoft Excel file accompanies the report and lists the codes for measure specification. This was posted during the call for public comment.
  3. “Clarification of Measure Attribution,” which provides additional information on measure attribution in response to stakeholder questions. This was posted during the call for public comment.

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Project Title: Overall Hospital Quality Star Ratings on Hospital Compare

Dates:

The Call for Public Comment period closed on March 29, 2019.

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, Inc. to reevaluate the Overall Hospital Quality Star Ratings on Hospital Compare. The contract name is Development, Reevaluation, and Implementation of Outcome/Efficiency Measures for Hospital and Eligible Clinicians, Base Year. The CORE contract number is HHSM-75FCMC18D0042, Task Order Number HHSM-75FCMC19F0001. The Lantana contract name is MIDS III Hospital Compare Support Contract (HCSC). The contract number is HHSM-500-2013-13010I/HHSM-500-T0001. As part of the reevaluation process, CMS requested interested parties to submit comments on the potential methodology updates and areas of future work for the Overall Hospital Quality Star Ratings on Hospital Compare.

Project Objectives:

The primary goal of this project is to reevaluate the methodology for the Overall Hospital Quality Star Ratings to improve the usability and interpretability of Hospital Compare for patients and consumers.

The Overall Hospital Quality Star Rating provides patients and consumers with a single measure to inform them about multiple dimensions of quality, represented by the existing measures on Hospital Compare, and capable of incorporating new measures that may be added in the future.

CORE sought a wide variety of stakeholder input on several methodology reevaluation items designed to improve the Overall Hospital Quality Star Rating methodology. The public input period aimed to highlight technical as well as other considerations for the public.

Comment Summary:

These documents, including a summary of public comments and the public comment materials, can be found in the Download section.

Overall Hospital Quality Star Rating on Hospital Compare Public Input Executive Summary

Overall Hospital Quality Star Rating on Hospital Compare Public Input Request

Overall Hospital Quality Star Rating on Hospital Compare Public Input Summary Report

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Project Title: Development of Facility-Level Quality Measure of Unplanned Hospital Visits after General Surgery Ambulatory Surgical Center Procedures

Dates:

The Call for Public Comment period closed on August 7, 2017.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) is developing a quality measure of hospital visits following general surgery procedures performed at ambulatory surgical centers (ASCs):

  • Hospital Visits after General Surgery Ambulatory Surgical Center Procedures

Yale New Haven Health Services Corporation – Center for Outcomes Research and Evaluation (CORE) is leading the work under contract to CMS (contract name: Development, Reevaluation, and Implementation of Outpatient Outcome/Efficiency Measures; contract number: HHSM-500-2013-13018I).

The measure assesses ASC-level quality, using near-term hospital visits that patients experience following ASC procedures, to evaluate the quality of general surgery procedures performed at ASCs. CMS plans to use this measure to report on the quality of ASCs and to prompt improvements in care for Medicare beneficiaries. CMS will calculate the measure score using routinely submitted claims. Therefore, facilities will not need to submit any new data to CMS for this measure.

As part of its measure development process, CMS requested interested parties to submit comments on the measure.

Comment Summary:

The following documents including a summary of public comments and materials posted during the Call for Public Comment are found below in the Download section:

  • “Public Comment Summary Report,” which presents a summary of the public comments received and recommendations.

The following documents were posted during the Call for Public Comment:

  • “Hospital Visits after General Surgery Procedures Performed at Ambulatory Surgical Centers – Measure Technical Report: Public Comment,” which presents the approach to measure development, measure specifications, and results of measure testing.
  • “Technical Expert Panel (TEP) Summary Report,” which summarizes the feedback and recommendations provided by the TEP regarding the measures.

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Project Title: Inpatient Psychiatric Facility (IPF) Outcome and Process Measure Development and Maintenance: Follow-Up After Psychiatric Hospitalization (FAPH) Measure

Dates:

The Call for Public Comment period closed on February 13, 2019.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) 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). 1 As part of its measure development process, HSAG asked interested parties to submit comments on the candidate measures or measure concepts that could be suitable for this project. (During the public comment period, HSAG was the contractor for this work. (HSAG’s contract expired and, after the public comment period closed, Mathematica was awarded the contract for continued work (Contract #5FCMC18D0032 Task Order: #75FCMC19F0001), including writing this public comment summary report. HSAG is referred to as the prior measure developer)

Project Objectives:

CMS contracted with HSAG to develop, specify, and maintain process and structural clinical quality measures for the IPFQR. The project’s primary objectives are to develop new measures that drive quality improvement, are patient-centered, are aligned with other programs, and that fill could critical gaps in the CMS IPFQR Program in the future; maintain and reevaluate existing IPF measures; and support measure implementation in the IPFQR Program.

As part of its measure development process, HSAG asked interested parties to submit comments on the Follow-Up After Psychiatric Hospitalization (FAPH) measure. This measure is primarily an expanded and enhanced version of the Follow-Up After Hospitalization for Mental Illness (IPFQR FUH) measure currently in use in the IFPQR program, and is a replacement for that measure (the Follow-Up After Hospitalization for Mental Illness [HEDIS® FUH] and the Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence [HEDIS FUA] measures were reviewed as well).

Developing the denominator encompassed expanding the list of qualifying principal diagnoses and reevaluating the inclusion and exclusion criteria to ensure they were appropriately specified for the patient population and harmonized with other measures. Roughly 1,000 diagnosis codes were added to the denominator, representing a wide variety of conditions including dementias; psychiatric diagnoses; and poisoning, medication, and toxic effects.

Developing the numerator encompassed reevaluating the list of qualifying follow-up visit types and determining how best to operationalize the numerator calculation and follow-up period. The measure’s importance, rate reliability, and validity were evaluated by standard methods. Measure development and testing were informed by an expert workgroup and a technical expert panel (TEP) made up of patient representatives, psychiatrists, nurses, quality improvement specialists, and informaticists. The measure’s importance was evaluated by assessing the gaps and variation in performance among inpatient psychiatric facilities (IPFs) nationally.

Comment Summary:

These documents, including a summary of public comments and the original measures, are found in the Download section.

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Project Title: Hospital Outcome Measurement for Patients with Social Risk Factors

Dates:

The Call for Public Comment period closed on December 14, 2018.

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 methodologies for presenting disparities in hospital outcome measures. One methodology will illuminate differences in outcomes for patient groups based on social risk factors within a hospital. The other methodology will allow for comparison of performance in care for patients with social risk factors across hospitals. The contract name is Development, Reevaluation, and Implementation of Outcome/Efficiency Measures for Hospital and Eligible Clinicians, Option Period 5. The contract number is HHSM-500-2013-13018I, Task Order # HHSM-500-T0001. As part of the development of these methodologies, CORE requests interested parties to submit comments on the concept or specifications of the methods that may be suitable for this project.

Project Objectives:

The primary goal of this project is to develop and evaluate two methodologies to report readmission rates by patient social risk factors (such as dual eligibility status or race). These methodologies serve complementary goals: to highlight disparities in healthcare quality between dual and non-dual eligible (or Black and non-Black) patients within hospitals and to illuminate variation in healthcare quality for dual eligible (or Black) patients across hospitals. The methods presented could be used to examine disparities for additional outcomes, such as mortality and complications, and other social risk factors, such as race.

Comment Summary:

These documents, including a summary of public comments and the original measures, are found in the Download section:

  • Hospital Outcome Measurement for Patients with Social Risk Factors Public Comment Summary Report
  • Hospital Outcome Measurement for Patients with Social Risk Factors Public Comment Verbatim Table
  • Assessing Hospital Disparities for Dual Eligible Patients: Thirty-Day All-Cause Unplanned Readmission Measure
  • Measuring Disparities in Hospital Outcomes - Public Comment Background

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Project Title: Development of Inpatient Outcome Measures for the Merit-based Incentive Payment System

Dates:

The Call for Public Comment period closed on January 4, 2019.

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 adapt claims-based hospital measures to assess the quality of care provided to Medicare beneficiaries by clinicians or clinician groups who are eligible to participate under the Merit-based Incentive Payment System (MIPS). The contract name is Development, Reevaluation, and Implementation of Hospital Outcome/Efficiency Measures for Hospitals and Eligible Clinicians. The contract number is HHSM-500-2013-13018I, Task Order HHSM-500-T0001.

The primary goal of this project is to re-specify (or adapt) two hospital quality measures for the measurement of clinicians or clinician groups. The two measures CORE is re-specifying are the:

  1. Hospital-Wide All-Cause Unplanned Readmission Measure (hereafter “HWR measure”).
  2. Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (hereafter “THA/TKA complication measure”).

The re-specified measures will assess each clinician or group’s readmission or complication rate, respectively, relative to that of other MIPS participating clinicians or groups with similar patients. One measure, HWR Measure #1789, is already in use in the MIPS; this is an updated re-specification. The quality measure scores will be calculated using patient characteristics and outcomes documented on routinely submitted Medicare claims; therefore, the MIPS clinicians or groups whose performance will be assessed by the quality measures will not need to submit any additional data. As part of its measure development process, CORE invites interested parties to comment on the two measures being re-specified.

Project Objectives:

The primary goal of this project is to gather expert and stakeholder input to inform quality measure development for patients with a range of acute and/or chronic conditions, or patients undergoing elective procedures. CMS plans to use the measures to evaluate the quality of care provided by MIPS clinicians or groups.

Comment Summary:

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

  1. For the HWR measure: “Measure Methodology Report for Public Comment: Clinician and Clinician Group Hospital-wide All-cause Unplanned Readmission Measure,” which presents the approach to measure development, measure specifications, and results of measure testing.
  2. For the THA/TKA complication measure: “Measure Methodology Report for Public Comment: Clinician and Clinician Group Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty,” which presents the approach to measure development, measure specifications, and results of measure testing.

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Page Last Modified:
12/09/2019 06:51 PM