TEP Current Panels

TEP Current Panels

This page serves as the designated site for information related to an established (current and past) technical expert panel (TEP). After the TEP has been established, TEPs will post membership lists, meeting agendas, and summary reports here. 

Content List:  

 

Project Title: CMS Quality Measure Development Plan and Quality Measure Index

Dates:

The initial Call for Technical Expert Panel (TEP) nomination period for the 2018–2019 TEP closed on January 8, 2018.  Supplemental nominations were
solicited in October 2019 to fill six vacancies for a term of service extending through June 2021.

Documents: 

The TEP Membership List is posted below in the download section. 

Project Overview: 

The Centers for Medicare & Medicaid Services (CMS) has contracted with Health Services Advisory Group, Inc. (HSAG) to develop and update the CMS Quality
Measure Development Plan
under the Impact Assessment of CMS Quality and Efficiency Measures Task Order (Measure & Instrument Development and Support
IDIQ contract #75FCMC18D0026; Task Order #75FCMC19F0001).  The CMS Quality Measure Development Plan (MDP) is mandated by the Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA)  and serves as a strategic framework for clinician quality measure development to support the Merit-based Incentive
Payment System (MIPS) and Advanced Alternative Payment Models (APMs), known collectively as the Quality Payment Program. The MDP was posted on the
CMS.gov website in May 2016; annual reports chronicling progress made in advancing quality measures for the Quality Payment Program have been posted on
the CMS website since 2017.

As a separate component of the Impact Assessment Task Order, HSAG is developing and refining the Quality Measure Index (QMI) as a decision support tool
for measure selection, implementation, and continued use in CMS quality reporting programs. 

As required by its contract with CMS, HSAG is convening a group of stakeholders and experts to provide input on the annual progress reports and update
of the MDP required under MACRA, as well as the QMI project.  

Project Objectives: 

  • Assess the landscape of current measures, measurement gaps, and measure development priorities for the CMS Quality Payment Program. 
  • Develop the mandated MDP Annual Report on progress in developing quality measures for the Quality Payment Program.  
  • Support the evolution of the MDP, including updates as appropriate,  to guide clinical quality measure development that is meaningful to patients and clinicians, promotes measurable improvement in health outcomes, and relieves clinicians’ reporting burden. 
  • Confirm the feasibility analysis of the newly specified and previously specified variables in the QMI for measures in various phases of the measure development lifecycle.  
  • Refine the weighting and scoring algorithm to apply the QMI to fully developed measures.  
  • Investigate additional variables to apply to measures under development or under consideration for use in a CMS quality reporting program.

TEP Requirements: 

HSAG sought a TEP of approximately 15 to 20 individuals with differing perspectives and areas of expertise. A 2018 Call for TEP recruited 23 individuals
whose term of service was limited to the remainder of the previous contract term, ending June 30, 2019.  Upon award of a new contract and by agreement
of the COR, HSAG invited those members to return to continue their essential work.  For the new contract base year beginning July 1, 2019, HSAG sought
five to seven individuals to fill vacancies and supplement the expertise of 16 returning members through targeted recruitment for the following:

Subject matter expertise: 

  • Patient or caregiver perspective 
  • Quality measure methodology 
  • Health information technology/electronic health record vendors/qualified clinical data registries (QCDRs) 

Expectations of TEP Members: 

TEP members are expected to commit to the anticipated time frame needed to perform the functions of the TEP through June 2021. In addition in quarterly
webinar meetings of approximately two hours each, members are encouraged to participate in one or more workgroups.  Each workgroup will meet via webinar
and teleconference on a schedule based on need and member availability.

Core duties of TEP members include the following:  

  • Provide input on the MDP and propose criteria for future updates. 
  • Provide input on gap analyses of clinician quality measures and other information gathered by the project team. 
  • Review and provide feedback on the outline and content of the annual MDP progress report. 
  • Inform the development of the QMI by advising how to operationalize variables and identify potential new ones. 
  • Provide expert input on the weighting of QMI scoring variables.

Section 1848(s)(1), (5) of the Social Security Act (the Act), as amended by section 102 of MACRA.
2 Section 1848(s)(1)(F), (3)(A) of the Act.

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Project Title: Impact Assessment of CMS Quality and Efficiency Measures

Dates:

The initial Call for TEP nomination period closed on November 2, 2018.  Supplemental nominations were solicited by October 9, 2019, to fill select
vacancies.

Documents:     

The TEP Membership List is posted below in the download section. 

Project Overview: 

The Centers for Medicare & Medicaid Services (CMS) has contracted with Health Services Advisory Group, Inc. (HSAG) to conduct a triennial assessment of
the quality and efficiency impact of endorsed measures used in Medicare programs and report the findings to the public in the National Impact Assessment
of CMS Quality Measures Report (Impact Assessment Report). The contract name is the Measure & Instrument Development and Support (MIDS) Contract. The
contract number is HHSM-500-2013-13007I; HHSM-500-T0002. As required by its contract with CMS, HSAG is convening a group of stakeholders and experts to
contribute thoughtful input on the development of the fourth triennial report, scheduled for release in 2021.  The TEP will meet jointly with the
Federal Assessment Steering Committee appointed by CMS.

Project Objectives: 

  • Assess the quality and efficiency impacts of the use of measures in CMS reporting programs.
  • Inform CMS, patients, providers, researchers, quality improvement entities, measure developers, and federal partners on progress toward achieving goals and objectives related to the CMS healthcare quality priorities expressed in the Meaningful Measures framework.
  • Inform policy on measure development, selection, implementation, removal, alignment, and gaps.
  • Build infrastructure/methods to support CMS efforts to assess impact.

TEP Requirements: 

HSAG sought a TEP of approximately 15 to 20 individuals with differing perspectives and areas of expertise, such as: 

Subject matter expertise: 

  • Patient/family/caregiver perspectives
  • Consumer and patient advocacy
  • Social risk factors and disparities
  • Health care quality improvement and clinical expertise in various settings (e.g., long-term care, acute care, ambulatory care, hospice)
  • Quality measure development and evaluation, including statistical methods and survey design
  • Health care economics and policy

The November 2018 Call for TEP recruited 17 individuals—15 subject matter experts and two patient representatives—whose term of service was limited to
the remainder of Option Year 4.  Upon award of a new contract and by agreement of the COR, HSAG invited those members to return to support development
of the 2021 Impact Assessment Report.  For the new contract base year beginning July 1, 2019, HSAG sought to increase patient/caregiver representation
and recruit an individual to fill the vacancy of a former member with rural health care experience.  Targeted recruitment of three individuals
supplemented the 15 returning members of the TEP.

Expectations of TEP Members: 

  • Participate on one or two workgroups, each anticipated to meet up to three times via webinar:  the first meetings during the fourth quarter of 2019; others to be scheduled during the first and second quarters of 2020.
  • Participate in a TEP webinar in June 2020.
  • Review meeting materials in advance.
  • Prepare to participate in the discussion and provide recommendations during the meetings.
  • Provide periodic expert advice and feedback (via email or on a shared website), as needed.

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Project Title: Reevaluation of Inpatient Claims-Based Outcome Measures

Dates:

The Call for TEP nomination period closed on October 25, 2019.

Documents:

The TEP Membership List is posted below in the downloads section.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation – Center for Outcomes Research and Evaluation (CORE) to reevaluate CMS claims-based hospital outcome measures previously developed by CORE. This work is done under the Development, Reevaluation, and Implementation of Outcome/Efficiency Measures for Hospital and Eligible Clinicians, Base Year contract; (HHSM-75FCMC18D0042, Task Order HHSM-75FCMC19F0001). As part of its measure reevaluation process, CORE convenes groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during measure development and maintenance.

Project Objectives:

The primary goal of this project is to gather expert and stakeholder input on the reevaluation of previously developed claims-based hospital outcome measures currently in public reporting. TEP feedback will inform the refinement of claims-based hospital outcome measure risk models.

TEP Requirements:

We sought a TEP of approximately 10-15 individuals with differing perspectives and areas of expertise, such as:

Subject matter expertise:

  • Methodologists
  • Biostatisticians
  • Consumers/patients/family caregivers
  • Patient advocates
  • Experts in healthcare disparities
  • Experts in quality measure development and evaluation
  • Experts in measure risk adjustment
  • Experts in medical coding (ICD or Medicare claims coding)
  • Diverse clinical experts from multiple medical or surgical specialties
  • Professionals with experience working in critical access hospitals

TEP Expected Time Commitment:

TEP members will need to be available to participate in approximately one to two teleconference meetings between December 2019 and March 2020. Teleconference meetings will each last between one and two hours. CORE recognizes that TEP members may not be able to attend all meetings, but we expect members to attend the majority of meetings, as well as review and comment on materials for the meetings they cannot attend.

In addition, the TEP members will review materials provided in advance of teleconferences and complete any online surveys.

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Project Title: Measure & Instrument Development and Support (MIDS) Patient Safety Measure Development and Maintenance: Patient Safety Indicators (PSIs)

Dates:

The Call for TEP nomination period closed on September 12, 2019.

Documents:

The TEP Membership List is posted below in the download section

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with IMPAQ International to maintain the Patient Safety Indicator (PSI) 90 composite measure, its PSI components, and PSI 04, which are harmonized with the Agency for Healthcare Research and Quality (AHRQ) PSIs where feasible, but specified explicitly for implementation in CMS’ hospital programs. The contract name is Measure & Instrument Development and Support (MIDS) Patient Safety Measure Development and Maintenance. The contract number is 75FCMC18D0027. As part of its measure development process, IMPAQ convenes groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during measure development and maintenance.

Project Objectives:

To support measure maintenance for PSI 90 and PSI 04 through:

  • Updating the Business Cases, Measure Information Forms (MIFs), and Measure Justification Forms (MJFs) for the PSI 90 composite and PSI 04
  • Providing draft documentation sets of measure specifications for public comment
  • Finalizing measure specifications based on the feedback received

TEP Requirements:

We sought a TEP of approximately 8-15 individuals with differing perspectives and areas of expertise, such as:

  • One or more individuals with experience representing the consumer/patient/family (caregiver) perspective
  • One or more individuals with expertise in healthcare disparities
  • One or more currently practicing acute care inpatient clinicians specializing in various disciplines
  • One or more individuals with inpatient nursing and/or nursing management experience
  • One or more individuals with experience using AHRQ PSI measures for assessing hospital performance and/or public reporting
  • One or more individuals with expertise in developing algorithms for relevant PSIs using administrative data
  • One or more individuals with expertise in validating ICD–10–CM codes using chart abstraction (to assess criterion validity), or assessing their accuracy in identifying individuals at risk for specific adverse outcomes (predictive validity)
  • One or more individuals with experience using HCUP or similar data for the purpose of quality measurement
  • One or more statisticians specialized in the relevant statistical methods and applications
  • One or more individuals with knowledge of ICD–10–CM coding guidelines and practices
  • One or more individuals with expertise in developing algorithms using ICD–10–CM codes to construct or modify quality indicators using administrative data
  • In addition, the work group is expected to include representatives from impacted provider groups and their professional organizations, other stakeholders, consumers and other users, quality alliances, medical or specialty societies, measure developers, accrediting organizations, and public and private payers.

Subject matter expertise:

Consumer/patient/family (caregiver) perspective

Healthcare disparities

Performance measurement

Quality improvement

Purchaser perspective 

TEP Expected Time Commitment:

The TEP members will hold a minimum two-year term with an optional extension. The TEP will meet by teleconference/WebEx up to 4 times annually for approximately two hours each. There will be approximately 1 hour of pre-work and 1-hour of post-work per scheduled meeting. The total time commitment of approximately 12-16 hours per year.

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Project Title: Clinical and Anatomic Pathology Measure Development

Dates:

The Call for TEP nomination period closed on March 1, 2019.

The TEP met on September 19, 2019.

Documents:

The TEP Membership List and TEP Summary are posted below in the download section.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has provided funding to the American Society for Clinical Pathology (ASCP) to develop a set of pathology-related quality measures to be incorporated into the Quality Payment Program (QPP). The cooperative agreement name is Medicare Access and CHIP Reauthorization Act of 2015 (MACRA): Measure Development for the Quality Payment Program. The cooperative agreement number is CMS-1V1-18-002. As part of its measure development process, the American Society for Clinical Pathology convenes groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during measure development and maintenance.

Project Objectives:

  • Re-tooling of seven measures developed for the National Pathology Quality Registry: This includes reviewing our current measures for clinical and technical content and updating them as needed due to changes in new coding, the clinical climate, and/or data sources and structure.
  • Development of electronic clinical quality measure (eCQM) specifications for seven registry-based process measures.
  • Development and preparation of measure development documentation for potential NQF endorsement consideration.

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Project Title: Measure Development: Patient-Reported Outcome-based Depression Performance Measure for Use in Primary Care Practices

Dates:

The Call for TEP nomination period closed on October 11, 2019.

Documents:

The TEP Membership List is posted below in the download section.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with the RAND Corporation (RAND) and its partners to support the development and implementation of a Patient-Reported Outcome-based Performance Measure (PRO-PM). The PRO-PM will focus on symptoms of depression among complex patients receiving care from primary care practices participating in the CMS Innovation (“Innovation Center”) Comprehensive Primary Care Plus (CPC+) model. The contract name is Patient Reported Outcome-based Performance Measure (PRO-PM) for Primary Care Practices Participating in the Comprehensive Primary Care (CPC+). The contract number is 75FCMC18D0036. As part of its measure development process, RAND and its partners plan to convene groups of stakeholders and experts to help guide the measure development and maintenance processes.

Project Objectives:

The goal of this project is to support CMS in the development, testing, electronic specification, and engagement in the NQF endorsement process of a PRO-PM for CPC+ that is focused on depression symptoms and targeted to patients who are considered complex patients in a primary care population. The key PROMs selected for this project arethePHQ-9 and the PROMIS Depression instruments.

TEP Requirements:

We sought a TEP of approximately 10-15 individuals with differing perspectives and areas of expertise, such as:

Subject matter expertise:

  • Consumer/patient/family (caregiver) perspective
  • Depression treatment and coordination with primary care and specialty clinics
  • Health Informatics
  • Clinical Quality Metrics
  • Clinician and clinical staff member perspective
  • Consumer/patient/family (caregiver) perspective
  • Performance measurement
  • Quality improvement

TEP Expected Time Commitment:

The TEP will be held on November 12, 2019, in the DC metro area. The approximate meeting time will be from 10 am to 4 pm, with in-person attendance required. An estimated 2 hours of preparation will be expected (i.e., reviewing documents) before the meeting.

We anticipate that two additional future meetings will be held via webinar, one in 2020 and one in 2021. Exact dates for these two meetings will be determined at a later date. They are estimated at 2 hours each, plus 2 hours each of preparation time.

Additional email correspondence may be solicited and/or discussions may be scheduled with specific TEP members with topical expertise. We anticipate that these additional discussions will take place via conference call and/or webinar and that they will take no more than 8 hours per TEP member, over the three year span of the project.

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Project Title: CMS Hospice Quality Reporting Program Patient Assessment Instrument and Quality Measure Development

Dates:

The Call for TEP nomination period closed on September 30th, 2019.

Documents:

The TEP Membership List is posted below in the download section.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Abt Associates to develop a hospice assessment instrument and corresponding set of Quality Measures (QM) in support of the Hospice Quality Reporting Program. The instrument and QM development work is under CMS contract number 75FCMC18D0014, and the task order number is 75FCMC19F0001. As part of its measure development process, Abt Associates will convene groups of stakeholders and experts to contribute direction and thoughtful input during measure development and maintenance.

Project Objectives:

  1. Develop an assessment instrument that supports quality measurement for hospice care.
  2. Develop quality measures based on the assessment instrument for the CMS Hospice Quality Reporting Program.
  3. Address patient, family, and caregiver needs, as well as electronic health record (EHR) and other health information technology (HIT) requirements/issues.

TEP Requirements:

We sought a diverse TEP of approximately 12 individuals with perspectives and areas of expertise including the following:

  • Clinical experience delivering hospice and palliative care services
  • Experience with hospice care as a patient, family member, or caregiver
  • Health care disparities
  • Culturally and linguistically appropriate services
  • Public reporting
  • Performance measurement
  • Quality improvement
  • Data collection and implementation

TEP Expected Time Commitment:

  • Up to three annual in-person meetings, to take place November 6-7, 2019 (Year 1 – subsequent years TBD), in the Baltimore, MD, area. Travel expenses will be reimbursed by Abt Associates.
  • TEP members will be expected to spend some time reviewing materials prior to the annual meetings, including attending pre-meeting webinar/s.
  • TEP members will participate in up to three post-meeting teleconferences annually.
  • The total project duration is November 2019 – November 2022.

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Project Title: Development of Outpatient Outcome Measures for the Merit-based Incentive Payment System - MIPS Heart Failure Measure Clinician Committee

Dates:

The Call for the Clinician Committee nomination period closed on October 19, 2018.

The Clinician Committee met three times during the project (October 2018 to July 2019) on January 11, 2019 (teleconference); February 27, 2019 (in person); and June 13, 2019 (teleconference).

Documents:

The Clinician Committee Membership List and Clinician Committee Summary Report are posted below in the downloads section.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) contracted with Yale New Haven Health Services Corporation - Center for Outcomes Research and Evaluation (CORE) to develop outpatient outcome measures that can be used to assess the quality of care provided by clinicians who are eligible to participate in the Merit-based Incentive Payment System (MIPS).

As part of this project, CORE developed a measure focused on care provided for patients with heart failure (hereinafter, MIPS heart failure measure). The measure assesses each clinician or group’s acute, cardiovascular-related admission rate, respectively, to that of other MIPS clinicians or groups with similar patients. and adjusts for patient complexity as well as social risk. The quality measure’s scores are calculated using patient characteristics and outcomes documented on routinely submitted Medicare claims; therefore, the clinicians 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, CORE convened groups of stakeholders and experts who contribute direction and thoughtful input during measure development and maintenance. In addition to convening a national Technical Expert Panel, CORE convened a Clinician Committee composed of relevant professional/specialty society representatives and front-line clinicians from rural and/or underserved communities who care for patients with heart failure. The Clinician Committee provided input to help shape the approach to the measure, such as which types of outcomes should be counted in the measure.

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.

Project Objectives:

The primary goal of this project was to gather expert and stakeholder input to inform quality measure development of an outpatient outcome measure for patients with heart failure. CMS will use the measure to evaluate the quality of care provided by MIPS eligible clinicians.

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Project Title: Overall Hospital Quality Star Rating on Hospital Compare

Dates:

The Call for TEP nomination period closed on August 19, 2019.

Documents:

The TEP Membership List is posted below in the download section.

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. for the maintenance and reevaluation of the publicly reported 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; contract number HHSM-75FCMC18D0042, Task Order Number HHSM-75FCMC19F0001, and the Lantana contract is called MIDS III Hospital Compare Support Contract (HCSC); contract number HHSM-500-2013-13010I/HHSM-500-T0001. As part of its maintenance and reevaluation process, CORE convenes groups of stakeholders and experts to contribute direction and thoughtful input during project maintenance.

Project Objectives:

The primary goal of this TEP is to support the evolution of the Overall Hospital Quality Star Ratings methodology. This approach is consistent with CMS’ approach for iterative improvement of quality measures and quality programs. The Star Rating project is designed to create a summary of current measures publicly reported on Hospital Compare so that these aspects of quality are presented in a meaningful and accessible way to patients and consumers. The TEP is encouraged to provide input on any or all considerations of Star Ratings as part of its deliberations. TEP recommendations and discussion will inform the refinement of the methodology.

TEP Requirements:

We sought a TEP of approximately 15-20 individuals with differing perspectives and areas of expertise, such as:

Subject matter expertise:

  • Hospital quality topic knowledge
  • Statistical modeling and expertise
  • Other topic knowledge (measure development, consumer testing, star ratings systems)
  • Patient/family (caregiver) perspective
  • Healthcare disparities
  • Performance measurement
  • Quality improvement
  • Purchaser perspective

TEP Expected Time Commitments

CORE/HCSC anticipates holding at least on meeting (in-person) between September 2019 and March 2020. In person meetings are generally a full business day and usually held in the Baltimore-Washington DC area. Teleconference meetings usually last between one and a half to two hours. As development and refinement work may occur after March 2020, TEP members may be asked to reconvene and participate in follow-up teleconference meetings after March 2020 to provide feedback for the Star Ratings methodology.

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Project Title: Palliative Care Measures Project

Dates:

The Call for TEP nomination period closed on January 11, 2019.

The TEP met on April 10-11, 2019.

Documents:

The TEP Membership List and TEP Summary are posted below in the download section.

Project Overview:

The Centers for Medicare and Medicaid Services (CMS) provided funding to the American Academy of Hospice and Palliative Medicine (AAHPM) as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to develop patient reported outcome performance measures, in the areas of pain and symptom management and communication, for palliative care patients with serious illness. The cooperative agreement name is the Palliative Care Measures Project. The cooperative agreement number is 1V1CMS331639-01-00. As part of its measure development process, AAHPM, along with partners the National Coalition for Hospice and Palliative Care and RAND, convenes groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during measure development and maintenance.

Project Objectives:

Under this cooperative agreement, AAHPM is working to advance clinical quality measure development for palliative care patients with serious illness through the engagement of stakeholders such as measure development technical experts, clinicians, clinical specialty societies, patient advocacy groups, patients, family members, caregivers, healthcare systems, diversity experts, and other stakeholder groups. The objectives for this project are:

  • Develop, test and implement two (2) patient reported outcome performance measures for patients with serious illness while incorporating the patient voice and patient preferences.
  • Develop cross-cutting measures broadly applicable to patients with serious illness and their families receiving care in palliative, primary or specialty care settings.
  • Convene an innovative technical expert panel that incorporates patient, caregiver, and family input directly into the measure development, specification, testing and implementation processes. This panel is called the Technical Expert Clinical User Patient Panel (TECUPP).
  • In addition, AAHPM has assembled individuals with expertise in measure development and testing methodologies to also serve on a measure specification panel (MSP), a subset of the TECUPP, to aid with the technical aspects of measure development and testing.
  • Submit palliative care measures for endorsement by the National Quality Forum (NQF) and inclusion into CMS’s Quality Payment Program (QPP) including MIPS and APMs so that clinicians can measure and improve the quality of care that patients with serious illness receive.

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Project Title: End Stage Renal Disease (ESRD) Dialysis Facility Compare (DFC) Star Ratings Technical Expert Panel (TEP)

Dates:

  • The call for nominations period closed on April 5, 2019.
  • The first pre-TEP teleconference call was held on May 6, 2019.
  • The second pre-TEP teleconference call was held on May 24, 2019.
  • The in-person TEP meeting was held on June 6, 2019.
  • The post-TEP teleconference call was held on August 21, 2019.

Documents:

TEP Membership List and TEP Summary are posted below in the download section.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with The University of Michigan Kidney Epidemiology and Cost Center (UM-KECC) to act as quality measure developer and DFC technical content support contractor, under the Kidney Disease Quality Measure Development, Maintenance, and Support contract. The contract number is 75FCMC18D0041, task order number 75FCMC18F0001. As part of this contract, UM-KECC convenes technical expert panels (TEPs) to provide valued consumer and provider input for both quality measure development and the Dialysis Facility Compare (DFC) Quality of Patient Care Star Rating (DFC Star Rating). This TEP Charter has been developed in response to CMS’ request for TEP recommendations related to options for resetting the DFC Star Rating baseline distribution. We are seeking interest from individuals with relevant experience, expertise, and a variety of perspectives to serve on this TEP, including patients.

A DFC Star Rating TEP was first convened in 2015 to review the original star rating methodology and presentation of the DFC Star Ratings on the DFC website. The 2015 TEP provided several recommendations that were implemented in the updated DFC Star Rating methodology released in October 2016. A second TEP was convened in 2017.  TEP members provided recommendations on candidate measures proposed for inclusion in the DFC Star Ratings. See the respective 2015 and 2017 DFC Star Rating TEP reports for a summary of the deliberations and TEP recommendations. These are available at https://dialysisdata.org/content/esrd-measures.

CMS developed the DFC Star Rating to help health care consumers (including patients and caregivers) understand CMS quality measures and more easily identify differences in overall quality when selecting dialysis facilities, as part of CMS’ broader initiative for all of the Medicare Compare sites to make quality information more accessible to patients, caregivers,  providers and policymakers.

The Medicare DFC website displays two star ratings: (1) the Quality of Patient Care Star Rating (DFC Star Rating) and (2) the Survey of Patients’ Experiences Star Ratings. Eleven of the DFC Quality Measures currently reported on the Medicare DFC website are used to calculate the Quality of Patient Care Star Rating (DFC Star Rating). Six In-center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Survey Measures are used to calculate the separate Survey of Patients’ Experiences Star Ratings. The Survey of Patients’ Experiences Star Ratings will not be covered as a discussion topic during this TEP.

This TEP will be expected to review and provide input on options for resetting the DFC Star Ratings. This is in anticipation of the need to recalibrate the DFC Star Ratings distribution in the near future to optimize the utility of the DFC Star Ratings for patients and other consumers. Recent observed trends in national performance demonstrate progressive shifts in the DFC Star Rating results over the last three years. This may obscure underlying performance differences if many facilities become concentrated at one end of the distribution. As background, prior DFC Star Rating TEPs (referenced above) identified a strong consumer interest in the ability to follow trends in dialysis facility performance over time. In addition, TEP discussions have considered how a reporting approach, that reported longitudinal facility performance trends, could be reset from time to time if the star rating system lost the ability to show meaningful differences over the range of facility performance.

The TEP will be expected to represent a diversity of perspectives and backgrounds. Members will be selected based on their personal experience as patients, caregivers and providers, or based on methodological expertise. Given that the audience for the DFC Star Ratings is primarily patients, the TEP will have ample representation from patients and patient advocates.

We anticipate that the in-person meeting will take place over one day. There will also be additional pre- and follow-up teleconference calls. TEP members are expected to attend all meetings.

Project Objectives:

The University of Michigan Kidney Epidemiology and Cost Center (UM-KECC), through its contract with the Centers for Medicare and Medicaid Services (CMS), will convene a technical expert panel to obtain recommendations on options for resetting DFC Star Ratings distribution.  Input from the TEP will inform the development of a methodology for resetting the DFC Star Ratings distribution. The final methodology developed is intended to ensure that the DFC Star Ratings to continue to be informative by reflecting meaningful performance differences among facilities.

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Project Title: Development of Meaningful Clinical Quality Measures for Mental Health and Substance Use Disorders

Dates:

The Call for TEP nomination period closed on January 16, 2019.

The TEP met on June 3, 2019.

Documents:

The TEP Membership List and TEP Summary are posted below in the download section.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has provided funding to The American Psychiatric Association (APA) to develop meaningful quality measures that fill CMS-designated high priority areas, including mental health and substance use disorders. The cooperative agreement name is MACRA Measure Development for the Quality Payment Program Mental Health/Substance Use Care. The cooperative agreement number is 1V1CMS331640-01-01. As part of its measure development process, APA convenes groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during measure development and maintenance.

Project Objectives:

The APA Initiative to Develop Meaningful Behavioral Health Quality Measures will aim to form scientifically sound quality measures that will improve processes and outcomes for those treated for mental and substance use disorders. This includes three measure domains:

1. Measurement-based care (MBC), or the systematic use of standardized tools (i.e., tools consumers use to report symptoms, functioning, and recovery; and clinician-rated outcome measurement tools for symptoms, where indicated) to support initial assessment, continuous monitoring, shared care planning, and patient engagement.

2. Evidence-based treatment for patients with suicide risk, psychosis, and opioid use; and

3. Care experience, patients’ report on the degree to which certain predefined processes (e.g., clear communication with a clinician) occurred during an episode of care.

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Project Title: Measuring Outcomes in Orthopedics Routinely (MOOR)

Dates:

The Call for TEP nomination period closed on February 17, 2019.

The TEP met on April 25, 2019 in Boston, Massachusetts. The meeting lasted one full day.

Documents:

The TEP Membership List and TEP Summary are posted below in the download section.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has  provided funding to  Brigham and Women’s Hospital (BWH) to develop and refine electronic clinical quality measures (eCQMs) in the areas of orthopedic surgery outcomes and medication safety, and to develop and refine a Patient Reported Outcome Performance Measure (PRO-PM) related to orthopedic surgery clinical care. The cooperative agreement name is Measuring Outcomes in Orthopedics Routinely (MOOR). The cooperative agreement  number is 1V1CMS331637-01-00. As part of its measure development process, Brigham and Women’s Hospital convenes groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during measure development and maintenance.

Project Objectives:

To ensure alignment with CMS’s Quality Payment Program (QPP), specifically the Merit-based Incentive Payment System (MIPS), the objectives of the MOOR project are as follows:

1) Convert two existing National Quality Foundation (NQF) approved measures for complication following Total Hip Arthroplasty and Total Knee Arthroplasty (THA/TKA) to electronic clinical quality measures (eCQMs):

  • Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA)
  • Opioids in high dosage in persons without cancer following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA)

2) Develop three new eCQMs to address THA/TKA orthopedic surgery patient safety practice and measurement gaps:

  • Opioid extended use rate following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA)
  • Risk-standardized opioid-related respiratory depression rate following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA)
  • Risk-standardized bleeding-related adverse drug event rate for patients taking anticoagulant medications following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA)

3) Develop a new PRO-PM:

  • Care goal achievement following total hip arthroplasty (THA) and/or total knee arthroplasty (TKA).

4) Explore the anticipated efficacy, costs, and benefits of our proposed eCQMs and PRO-PMs to our study population (i.e., Medicare fee for service beneficiaries undergoing elective procedures). In the process of developing and refining eCQMs and PRO-PMs, use existing electronic data to automate workflow and to minimize burden of the measures we develop. 

5) Brigham and Women’s Hospital is collaborating with Massachusetts Health Quality Partners (MHQP), a stakeholder engagement organization, and with Brigham and Women’s Hospital Department of Orthopedic Surgery specialty physicians and the Partners Healthcare Patient Reported Outcomes Measurement System (PROMS) team to develop eCQMs in the areas of orthopedic surgery outcomes, medication safety, and PRO-PMs related to orthopedic surgery clinical care. The collaboration is enhanced by the mutual interests, shared by the participating organizations, that include focusing on patient engagement to improve safety and outcomes using innovative patient-centered technologies.

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Project Title: Maintenance of Nursing Home Quality Measures

Dates:

The Call for TEP nomination period closed on March 28, 2019. The TEP met for a web-based meeting on May 23, 2019.

Documents:

The TEP Composition (Membership) List and TEP Summary report are posted below in the download section.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with RTI International to develop and maintain quality measures for nursing homes based on the Minimum Data Set 3.0. The contract name is Development and Maintenance of Symptom Management Measures. The contract number is HHSM-500-2013-13015I. As part of its measure development process, RTI International convenes groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during measure development and maintenance.

Project Objectives:

Review the following nursing home quality measures.

  • Percent of Residents with a Urinary Tract Infection (Long Stay) (NQF #0685)
  • Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder (Long Stay) (NQF #0686)

Inform the direction and development of the above-referenced measures.

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

Dates:

The Call for TEP nomination period closed on February 25, 2018.

The TEP met on May 22, 2018 and January 17, 2019.

Documents:

The TEP Membership List and TEP Summary are posted below in the download section.

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, Re-evaluation, 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 developing these methodologies, CORE convenes groups of stakeholders and experts who contribute direction and thoughtful input during method development and maintenance.

Project Objectives:

The primary goal of this project is to develop and evaluate two methodologies to report readmission rates by patient dual eligibility status. These methodologies will serve two complementary goals: to highlight disparities in health care quality between dual and non-dual eligible patients within hospitals and to illuminate variation in health care quality for dual eligible patients across hospitals. It is anticipated that the methods presented could be used in examining disparities for additional outcome measures and other social risk factors. The aim of the TEP is to receive feedback on the proposed methodologies.

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01/16/2020 09:19 PM