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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: Quality Measure Development and Maintenance for CMS Programs Serving Medicare-Medicaid Enrollees and Medicaid-Only Enrollees

Dates:

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

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Mathematica Policy Research and its partners, Brandeis University and the National Committee for Quality Assurance, to develop measures for the following populations of Medicaid beneficiaries:

  • People eligible for both Medicare and Medicaid, or “Dual-eligible beneficiaries”
  • People receiving long-term services and supports (LTSS) through managed care organizations
  • People with substance use disorders; beneficiaries with complex care needs and high costs; beneficiaries with physical and mental health needs; or beneficiaries who receive LTSS in the community

The contract name is Quality Measure Development and Maintenance for CMS Programs Serving Medicare-Medicaid Enrollees and Medicaid-Only Enrollees. The contract number is HHSM-500-2013-13011I, Task Order #HHSM-500-T0004.

As part of its measure development process, CMS requested interested parties to submit comments on the candidate measures that may be suitable for this project.

This call for public comment concerned the measure specifications, and justification, for a measure for Medicaid enrollees with opioid use disorder.

Project Objectives:

The primary objectives of this three-year project are to:

  • Identify and prioritize candidate measures and measure concepts for development
  • Develop and refine measure specifications for priority measures
  • Conduct alpha and beta testing to evaluate measure importance, feasibility, usability, and scientific validity and reliability
  • Submit validated, reliable measures to the National Quality Forum (NQF) for endorsement The following documents including a summary of public comments and the original measure specification and justification are found below in the Download section: 

Comment Summary:

  • Public Comment Summary Report_SUD-18.pdf
  • MIF_SUD-18.pdf
  • MJF_SUD-18.pdf

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Project Title: Claims-Only Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure, and Hybrid Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure with Electronic Health Record Extracted Risk Factors

Dates:

  • The Call for Public Comment period closed on February 27, 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 two hospital‑level outcome performance measures of all-cause mortality across a broad mix of medical and surgical patients admitted to the hospital. The intent is to create measures that can be used to assess hospital‑level performance for Medicare fee-for-service (FFS) patients. The overarching purpose of the project is to develop measures that can be used to enhance the quality of care provided to Medicare beneficiaries. The contract name is Development, Reevaluation, and Implementation of Outcome/Efficiency Measures for Hospital and Eligible Clinicians, Option Year 4. The contract number is HHSM-500-2013-13018I Task Order HHSM-500-T0001. As part of its measure development process, CMS requested interested parties to submit comments on the measure specifications, including measure concepts, cohorts, outcomes, and approaches to risk adjustment, of two hospital-level measures of hospital-wide mortality, one that utilizes claims data and another that utilizes both claims and electronic health record data for risk adjustment. The goal of creating two measures of hospital‑wide mortality, one that uses administrative claims-only data and one that also uses electronic health record data, is to provide CMS with two implementation options.

Project Objectives:

The primary goal is to develop measures of hospital-wide mortality that utilize claims and electronic health record data and allow CMS to assess a broad range of hospitals’ performance while ensuring hospitals and patients have access to meaningful information to enable quality improvement.

Comment Summary:

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

Hospital-Wide Mortality Public Comment Period - Overview

Claims-Only Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure

Hybrid Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure with Electronic Health Record Extracted Risk Factors

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Project Title: Development, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) - Stream 2

Dates:

  • The Call for Public Comment period closed on November 30, 2017.

 Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Econometrica, Inc., to develop, 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 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 PACE.
  • Propose quality measures to improve the performance and effectiveness surrounding specific domains of interest to PACE.
  • Conduct testing to assess the validity, reliability, and feasibility of the proposed measures.
  • Develop an implementation plan for each of the proposed measures.
  • Seek public comments throughout the measure development process. 

Comment Summary:

The summary of public comments is found below in the Download section.

  • PACE Stream 2 Public Comment Summary Report with Verbatim Comments (PACE_Stream2_Comment_Summary_Report)

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Project Title: Development, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) - Stream 3

Dates:

  • The Call for Public Comment period closed on December 15, 2017.

 Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Econometrica, Inc., to develop, 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 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 PACE.
  • Propose quality measures to improve the performance and effectiveness surrounding specific domains of interest to PACE.
  • Conduct testing to assess the validity, reliability, and feasibility of the proposed measures.
  • Develop an implementation plan for each of the proposed measures.
  • Seek public comments throughout the measure development process.

 Comment Summary:

The summary of public comments is found below in the Download section.

  • PACE Stream 3 Public Comment Summary Report with Verbatim Comments (PACE_Stream3_Comment_Summary_Report)

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Project Title: Claims-Only Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure, and Hybrid Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure with Electronic Health Record Extracted Risk Factors

Dates:

  • The Call for Public Comment period closed on February 27, 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 two hospital-level outcome performance measures of all-cause mortality across a broad mix of medical and surgical patients admitted to the hospital. The intent is to create measures that can be used to assess hospital-level performance for Medicare fee-for-service (FFS) patients. The overarching purpose of the project is to develop measures that can be used to enhance the quality of care provided to Medicare beneficiaries. The contract name is Development, Reevaluation, and Implementation of Outcome/Efficiency Measures for Hospital and Eligible Clinicians, Option Year 4. The contract number is HHSM-500-2013-13018I Task Order HHSM-500-T0001. 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. Specifically, CMS is seeking public input on the measure specifications of two hospital-level measures of hospital-wide mortality, one that utilizes only claims data and another that utilizes both claims and electronic health record data for risk adjustment. The goal of creating two hospital-wide mortality measures, one that uses administrative claims-only data one that also uses electronic health record data, is to provide CMS with two implementation options. The public can comment on any aspect of the measures, including the measure concepts, measure cohorts, measure outcomes, and approaches to risk adjustment.

Project Objectives:

The primary goal is to develop measures of hospital-wide mortality that utilize claims and electronic health record data and allow CMS to assess a broad range of hospitals’ performance while ensuring hospitals and patients have access to meaningful information to enable quality improvement.

Documents and Measures for Comment:

The following documents are provided for your review and comment. The files are found below in the Download section. Summary documents will be posted in the coming weeks.

  • Hospital-Wide Mortality Public Comment Period - Overview
  • Claims-Only Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure
  • Hybrid Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure with Electronic Health Record Extracted Risk Factors

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Project Title:

Hospital Harm – Hypoglycemia;

Hospital Harm – Hospital-Acquired Pressure Injury;

Hospital Harm – Opioid-Related Adverse Event; and

Hospital Harm – Acute Kidney Injury.

Dates:

The Call for Public Comment period closed on March 2, 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 four hospital-level outcome electronic clinical quality measures (eCQMs) on dimensions of patient harm or adverse patient safety events that can be improved with high quality care. The contract name is Development, Reevaluation, and Implementation of Outcome/Efficiency Measures for Hospital and Eligible Clinicians, Option Year 4. The contract number is HHSM-500-2013-13018I, Task Order HHSM-500-T0001. 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:

The goal of this project is to develop Hospital Harm eCQMs for potential future use in CMS quality reporting programs. Specifically, CORE developed four new eCQMs in the areas of hypoglycemia, opioid-related adverse events, hospital-acquired pressure injury, and acute kidney injury. We consulted with clinical experts and a Technical Expert Panel comprised of multiple stakeholders to develop the four Hospital Harm eCQMs. CORE is working with Mathematica Policy Research, Inc. to develop and test the measures. CMS is currently requesting feedback on these four new Hospital Harm eCQMs under development.

Comment Summary:

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

  • Hospital Harm Public Comment Summary Report;
  • Hospital Harm Public Comment Verbatim Table;
  • Measure Authoring Tool (MAT) header documentation for each of the four measures; and
  • Framing document for each of the four measures.

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Project Title: Electronic Clinical Quality Measure (eCQM) Development and Maintenance for Eligible Professionals (EP eCQM) – Potential Opioid Overuse

Dates:

  • The Call for Public Comment ran from January 10, 2018 to February 9, 2018.
  • The public comment summary was submitted to the Centers for Medicare & Medicaid Services (CMS) on February 26, 2018.

Project Overview:

CMS has contracted with Mathematica Policy Research to develop an eCQM that assesses potential opioid overuse. 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. As part of its measure development process, CMS requests that interested parties submit comments on the candidate or concept measures that are developed under this project.

Project Objectives:

The goal of this project is to develop eCQMs for use by eligible clinicians for CMS quality payment programs. We consulted with clinical experts and a multi-stakeholder technical expert panel to develop the measure of Potential Opioid Overuse. As part of the measure development process, we solicited comments from the public about the face validity, feasibility, usability, and potential use of the draft measure.

Comment Summary:

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

  • Potential Opioid Overuse Public Comment Summary Report

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Project Title: Electronic Clinical Quality Measure (eCQM) Development and Maintenance for Eligible Professionals (EP eCQM) – Changes in Patient-Reported Outcomes (PROs) Following Non-Emergent Percutaneous Coronary Intervention (PCI) Summary Report

Dates:

  • The Call for Public Comment period closed on November 29, 2017.

Project Overview:

CMS has contracted with Mathematica Policy Research and its partners, including the Lewin Group, to develop an eCQM that assesses Changes in Patient-Reported Outcomes (PROs) Following Non-Emergent Percutaneous Coronary Intervention (PCI). 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. As part of its measure development process, CMS requests that interested parties 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 eCQMs for use by eligible clinicians for CMS quality payment programs. To develop the Changes in Patient-Reported Outcomes Following Non-Emergent Percutaneous Coronary Intervention (PROs for PCI) measure, the project team has conducted a review of the relevant literature, done preliminary qualitative testing, and consulted with clinical experts and a technical expert panel made up of multiple stakeholders. To harmonize efforts across similar measures, the project team has collaborated with the Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation (Yale CORE), which is developing a similar measure for the Hospital Inpatient Quality Reporting Program under contract with CMS. Under CMS direction, the project team has worked closely with Yale CORE to align the two measures. The teams have shared research and findings as well as the narrative specifications, cohort exclusions, and measure outcome information (a minimally important difference approach); the two teams collaborated to identify the preferred PROM tools—the SAQ-7 and RDS. Finally, as part of the measure development process, the project team solicited feedback from the public about the feasibility, face validity, and usability of the draft measure.

Comment Summary:

A summary of public comments can be found below in the Download section.

  • eCQM Public Comment Summary Report PCI FSA

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Project Title: Development and Maintenance of Post-Acute Care Cross-Setting Standardized Assessment Data

Dates:

  • The Call for Public Comment period closed on June 26, 2017.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with the RAND Corporation to develop standardized assessment-based data elements to meet the requirements as set forth under the IMPACT Act of 2014, Section 2(a). The contract name is “Development and Maintenance of Post-Acute Care Cross-Setting Standardized Assessment Data”. The contract number is HHSM-500-2013-13014I. As part of its data element development process, CMS encourages interested parties to submit comments on the data elements described in this posting, which are being considered for this project.

Project Objectives:

The project objective is to develop standardized patient assessment data elements to meet the requirements of the IMPACT Act of 2014, Section 2(a). These data elements may be used to inform a number of important things, including case-mix adjustment, medical complexity, interoperable exchange, clinical decision support, and measure development.

Comment Summary:

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

  • Development and Maintenance of Post-Acute Care Cross-Setting Standardized Assessment Data

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Project Title: Hospital Quality Star Ratings on Hospital Compare 

Dates:

  • The Call for Public Comment period closed on September 27, 2017.

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, Inc. to develop the Overall Hospital Quality Star Rating. The contract name is Development, Reevaluation, and Implementation of Outcome/Efficiency Measures for Hospital and Eligible Clinicians, Option Year 4 contract number HHSM-500-2013-13018I, Task Order HHSM-500-T0001, and the Lantana contract is called Hospital Compare Support Contract (HCSC) Option Year 4; contract number HHSM-500-2013-13010I/HHSM-500-T0001. As part of the re-evaluation process, CMS requested interested parties to submit comments on the Star Ratings methodology refinement and maintenance.

Project Objectives:

The primary goal of this project is to develop 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.

CMS and the development team sought a wide variety of stakeholder input on several methodology re-evaluation items designed to possibly enhance the Overall Star Rating methodology. The public input period aimed to highlight technical and policy considerations for the public.

Comment Summary:

The following documents including a summary of public comments and the proposed enhancements for the project methodology are found below in the Download section.

  1. Hospital Quality Star Ratings Public Input Period Summary Report
  2. Hospital Quality Star Ratings Public Input Period: Enhancements of the Overall Hospital Quality Star Rating

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