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Updates On Current Panels


Technical Expert Panels: Established TEPs

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.

 

List of Established TEPs:

Project Title: Quality Payment Program (QPP) Merit-based Incentive Payment System (MIPS) Quality Measure #335 Elective Delivery or Early Induction without Medical Indication at ≥ 37 and < 39 Weeks (Overuse). QPP MIPS Quality Measure #336 Maternity Care: Post-Partum Follow-Up and Care Coordination. QPP MIPS Quality Measure #448 Appropriate Workup Prior to Endometrial Ablation.

Dates:

The Call for TEP nomination period closed on November 28, 2017. The TEP met on March 8, 2018.

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 Signature Consulting Group (SCG) to maintain QPP MIPS Quality Measure #335 -Elective Delivery or Early Induction without Medical Indication at ≥ 37 and < 39 Weeks (Overuse), QPP MIPS Quality Measure #336 Maternity Care: Post-Partum Follow-Up and Care Coordination, and QPP MIPS Quality Measure #448 - Appropriate Workup Prior to Endometrial Ablation.

The contract name is Physician Quality Measures Management (PQMM). The contract number is HHSM-500-2013-00177C.

As part of its measure development process, CMS asks measure developers to convene groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during measure development and maintenance. 

Project Objectives:

  • The TEP objective was to perform a comprehensive review of the above stated measures to ensure the measures are based on current clinical practice. Additionally, the comprehensive review will ensure the measure is analytically valid and is represented clinically accurate.
  • The review process, led by the TEP, includes an Environmental Scan which consists of a literature review. The literature review is comprised of identifying relevant updated or new clinical practice guidelines, articles, and studies. It also includes a review of similar measures representing potential opportunities for harmonization, and identification of potential gaps in care and/or any technological or clinically based changes that affect data collection, measure implementation, or interpretation.
  • The TEP conducts a complete review of the measure specification. This process includes reviewing and potentially updating the Clinical Recommendations and Rationale for the measure and evaluating the applicable measure code set.

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Project Title: MACRA Episode-Based Cost Measures

Dates:

The Call for TEP nomination periods closed on July 5, 2016 and November 16, 2016.

The TEP met on May 11, 2018.

Acumen convened a standing TEP which was recruited for in-person meetings in August and December 2016, a webinar in March 2017, and a third in-person meeting in August 2017. The Call for Nominations periods for the first two in-person meetings closed on July 5, 2016 and November 16, 2016, respectively. Subsequent TEP meetings have consisted of members recruited in the 2016 Call for Nominations period.

Documents:

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

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Acumen, LLC to develop care episode and patient condition groups for use in cost measures to meet the requirements of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The contract name is “MACRA Episode Groups and Cost Measures.” The contract number is HHSM-500-2013-13002I, Task Order HHSM-500-T0002.

As part of its measure development process, CMS asks contractors to convene groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during measure development and maintenance.

Project Objectives:

The project’s overall objective is to develop episode-based cost measures for potential future use in the Quality Payment Program. Specific to this TEP, the objectives were to gather input on:

  • Refinement of the Medicare Spending Per Beneficiary (MSPB) and Total Per Capita Cost (TPCC) measures in the Merit-based Incentive Payment System (MIPS)  
  • Improving the report template of the Field Testing Report for episode-based cost measures currently being developed to meet the requirements of MACRA
  • Identifying approaches for incorporating patient and family perspectives in episode-based cost measures currently being developed to meet the requirements of MACRA

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Project Title: End-Stage Renal Disease Physician Level Measure Development

Dates:

  • The Call for TEP nomination period closed on January 5, 2018.
  • The Pre-TEP conference call was held on February 15, 2018.
  • The TEP in-person meeting was held on February 28, 2018.
  • The Post-TEP conference call was held on July 11, 2018.

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 the University of Michigan Kidney Epidemiology and Cost Center (UM-KECC) to develop one or more quality measures related to care provided to ESRD dialysis patients by physicians and mid-level providers. The contract name is End Stage Renal Disease (ESRD) Quality Measure Development, Maintenance, and Support. (CMS Contract number HHSM-500-2013-13017I). As part of its measure development process, CMS asks measure developers to convene groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during measure development and maintenance.

Project Objectives:

The University of Michigan Kidney Epidemiology and Cost Center, through its contract with the Centers for Medicare and Medicaid Services, will convene a technical expert panel (TEP) to inform the development of a quality measure(s) related to physician performance in the clinical management of chronic dialysis care and its complications. Initially, likely topic areas for measure development include adequacy of dialysis and vascular access management. Additional topic areas for potential quality measure development in future years will be explored by the technical expert panel as time and resources allow.

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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 from 1:00-3:30 pm EST.

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 Year 4. 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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Project Title: Patient-Reported Outcomes Following Elective Total Hip and/or Total Knee Arthroplasty: Hospital-Level Performance Measure(s)

Dates:

The Call for TEP nomination period closed on April 20, 2018.

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 (YNHHSC/CORE) to develop one to two Patient-Reported Outcomes Following Elective Total Hip and/or Total Knee Arthroplasty (THA/TKA) hospital-level performance measures. The contract name is Measure Instrument Development and Support- 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, CORE convenes groups of stakeholders and experts who contribute direction and thoughtful input during measure development and maintenance.

Project Objectives:

The primary objective of this project is to develop one to two Patient-Reported Outcome Performance Measures (PRO-PMs) for Medicare beneficiaries aged 65 or older who undergo an elective THA/TKA.

TEP Requirements:

We sought a TEP of approximately 15 individuals with the following perspectives and areas of expertise:

Subject matter expertise:

Experience with Patient Reported Outcomes following THA/TKA

Consumer/patient/family (caregiver) perspective

Health care disparities

Performance measurement

Quality improvement

Purchaser perspective

TEP Expected Time Commitment:

TEP members will meet in August of 2018.

The teleconference meeting will last approximately 120 minutes.

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

Dates:

The Call for TEP nomination period closed on January 20, 2017.

The TEP Charter was revised to extend the TEP through February 15, 2019 and was ratified on May 30, 2018.

The TEP met on May 30, 2018.

Documents:

The TEP Meeting Summary for the May 30, 2018 meeting and the TEP Composition (Membership List) are 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, 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). As part of its measure development process, CMS asks measure developers to convene groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during measure development and maintenance.

Project Objectives:

This project directly supports CMS and the overall mission of the IPFQR Program by developing and maintaining measures that fill important measurement gaps and that are evidence-based, scientifically acceptable (reliable and valid), feasible, and usable by CMS, providers, and the public.

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Project Title: Quality measures to satisfy the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) domain of: Transfer of Health Information and Care Preferences When an Individual Transitions. 1) Medication Profile Transferred to Provider, 2) Medication Profile Transferred to Patient

Dates:

The Call for TEP nomination period closed on August 21, 2016.

The TEP met on April 20, 2018 (Meeting 4).

Documents:

The TEP Summary Report for Meeting 4 and the TEP Composition (Membership List) are posted below in the download section.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with RTI International and Aby Associates to develop and refine a cross-setting post-acute care transfer of health information and care preferences quality measure as required by the Improving Medicare Post-Acute Care Transformation Act of 2014 (known as the IMPACT Act). The contract names are Development and Maintenance of Symptom Management Measures (contract number HHSM-500-2013-13015I; Task Order HHSM-500-T0001) and Outcome and Assessment Information Set (OASIS) Quality Measure Development and Maintenance Project (contract number HHSM -500-2013-13001I, Task Order HHSM500T0002). As part of its measure development process, CMS asks measure developers to convene groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during measure development and maintenance

To satisfy this domain, and after additional testing and modification work from prior development efforts, CMS and their contractors developed two quality measures, 1) Medication Profile Transferred to the Provider, and 2) Medication Profile Transferred to Patient/Family/Caregiver. These cross-setting measures are developed for the Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Long-Term Care Hospital (LTCH), and Home Health Agency (HHA) settings. The measures under development focus on the transfer of medication profile information from the Post-Acute Care (PAC) provider to the subsequent provider and/or to the patient/family/caregiver at discharge or transfer.

Project Objectives:

  • To develop quality measures for the transfer of health information and care preferences domain for use in post-acute care settings such as Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, and Home Health Agencies
  • To obtain specific input on the draft measure specifications and data elements for the following potential measures:
    • Medication Profile Transferred to Provider
    • Medication Profile Transferred to Patient

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Project Title: Hospital Quality Star Ratings on Hospital Compare

Dates:

The TEP nomination period opened on December 28, 2016.

The TEP nomination period closed on January 30, 2017.

The TEP met in-person on June 8, 2018 and over teleconference on March 9, 2018.

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) and Lantana, Inc. for the development and maintenance of the publicly reported Star Ratings. The CORE 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 development and maintenance processes, CORE and HCSC convenes groups of stakeholders and experts who contribute direction and thoughtful input during methodology refinement and maintenance.

Project Objectives:

The primary goal of this TEP is to support the evolution of the Overall Star Ratings methodology. This approach is consistent with CMS’s approach for iterative improvement of quality measures and quality programs. The Star Rating project is designed to create a picture 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. However, 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.

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Project Title: MACRA Episode-Based Cost Measures - Call for Clinical Subcommittee

Dates:

The Call for Clinical Subcommittee nomination period closed on March 20, 2018.

Documents:

The Clinical Subcommittee Membership List is posted below in the download section.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Acumen, LLC to develop care episode and patient condition groups for use in cost measures to meet the requirements of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The contract name is “MACRA Episode Groups and Cost Measures.” The contract number is HHSM-500-2013-13002I, Task Order HHSM-500-T00002. As part of its measure development process, CMS asks contractors to convene groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during cost measure development and maintenance.

Project Objectives:

The project’s overall objective is to develop episode-based cost measures suitable for potential use in the Quality Payment Program. From August – September 2016, Acumen convened a Clinical Committee comprised of more than 70 clinical experts from over 50 professional societies. This Committee provided input on identifying a candidate list of episode groups for development and in determining the billing codes that trigger each episode group. The clinical review and recommendations obtained from the Clinical Committee were used to inform the draft list of episode groups and trigger codes posted by CMS in December 2016 for public comment.

The Clinical Subcommittees currently convened build on the work of the August – September 2016 Clinical Committee and the work of the first wave of the Clinical Subcommittees convened from May 2017 – January 2018. Each Clinical Subcommittee will focus on a set of procedural and acute inpatient medical episode groups relevant to a particular clinical area.

Specific to these Clinical Subcommittees, the objectives are to:

  • Refine episode triggers from the draft list of episode groups posted by CMS in December 2016
  • Recommend what services should be included in episode costs

Clinical Subcommittee Requirements:

The ten Clinical Subcommittees convened in this second wave are: Cardiovascular Disease Management, Gastrointestinal Disease Management - Medical and Surgical, Musculoskeletal Disease Management - Non-Spine, Musculoskeletal Disease Management - Spine, Oncologic Disease Management - Medical, Radiation, and Surgical, Neuropsychiatric Disease Management, Peripheral Vascular Disease Management, Pulmonary Disease Management, Renal Disease Management, and Urologic Disease Management.

Future Clinical Subcommittees under this project will be convened through separate nomination periods. Future Clinical Subcommittees for procedural and acute inpatient medical condition episode groups may include the following: Ophthalmologic Disease Management (convened initially in Wave 1), Endocrine Disease Management, Head and Neck Disease Management, Hematologic Disease Management, Infectious Disease Management, Pain Management, and Rheumatologic Disease Management. Future Clinical Subcommittees will also be convened to provide input on chronic condition episode groups.

Clinical Subcommittee Expected Time Commitment:

Members of each Subcommittee are expected to meet for one half-day, in-person meeting in the Washington-Baltimore metropolitan area in the second and third week of April 2018, during which they will (i) select which episode-based cost measure to develop, and (ii) discuss the desired composition of the workgroup that will build out the selected measure. After each Subcommittee selects which measure(s) to develop during Wave 2, a smaller measure-specific workgroup will be formed to complete the majority of measure development.

Members of the measure-specific workgroup resulting from the measure selected by the Clinical Subcommittees are expected to attend the following meetings and perform the following tasks between April and August 2018, which comprises an expected time commitment of 3 days total (does not include the expected time commitment described above):

    • Meet for one day-long in-person meeting for workgroup members only for episode group specification in downtown Washington, D.C. in June 2018 (plus travel time)
      • Exact dates for each workgroup will be determined based on workgroup member availability
    • Prepare for the Service Assignment and Risk Adjustment Webinar (2 – 4 hours)
    • Attend Service Assignment and Risk Adjustment Webinar (2 hours)
    • Prepare for the Refinement Webinar (2 – 4 hours)
    • Attend the Refinement Webinar (2 hours)

Additional input will be sought from the Clinical Subcommittees in between meetings via tasks completed by workgroup members independently through a web-based clinical input tool and via discussion boards on the project web portal. Specifically, these tasks will include: (i) refining episode triggers for episode groups from the December 2016 draft list, and (ii) recommending what services should be included in episode costs.

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Project Title: Quality Measure Development: Supporting Efficiency and Innovation in the Process of Developing CMS Quality Measures

Dates:

The final Call for TEP nomination period closed on August 14, 2017. The TEP met on October 16, 2017 and January 18, 2018. Additional meetings are planned for April 30, 2018 and July 31-August 1, 2018.

Documents:

The TEP Membership List and TEP Summary Reports for the October 16, 2017 and January 18, 2018 TEP meetings are posted below in the download section.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Battelle to manage CMS’s Measure Management System (MMS) and provide periodic updates to the CMS Blueprint. The contract name is Measures Management System. The contract number is HHSM-500-2013-13005I. As part of its measure development process, CMS asks measure developers to convene groups of stakeholders and experts who contribute direction and thoughtful input to the measure development process.

Project Objectives:

As the MMS Contractor, Battelle supports CMS in its work coordinating among multiple internal Department of Health and Human Services, CMS, and key external organizations including the National Quality Forum, quality alliances, and major measure developers. This coordination is critical in establishing consensus on measurement policies, coordinating measure inventories, and promoting alignment across programs and settings of care. In this role, Battelle also works with CMS to advance clinical quality measure development science through the engagement of stakeholders such as measure developers, clinicians, clinical specialty societies, patient advocacy groups, healthcare systems, and electronic health record (EHR) vendors. This work is reflected through updates to the MMS Blueprint. 

TEP Objectives:

In its role as the MMS Contractor, Battelle is seeking input from a broad group of 20 stakeholders to develop a set of recommendations to assist CMS with improving the measure development process. Stakeholders include CMS Measure Instrument Development & Support (MIDS) measure development contractors, non-CMS measure developers, EHR vendors, hospital/clinician system representatives, and patient advocacy group representatives. Members of the TEP have expertise in one or more of the following areas:

Measure development and consensus endorsement processes

Patient advocate perspective

Performance measurement

Quality improvement

Purchaser perspective

Health care disparities

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Project Title: CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs)

Dates:

The Call for TEP nomination period closed on January 8, 2018.

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: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). CMS initiated this project under the contract titled Impact Assessment of CMS Quality and Efficiency Measures, #HHSM-500-2013-13007I; Task Order #HHSM-500-T0002. As part of its measure development process, CMS asks measure developers to convene groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during measure development and maintenance. 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 MIPS and Advanced APMs, together known as the Quality Payment Program. To meet the requirements of the statute, CMS posted the draft MDP on December 18, 2015, and opened a public comment period through March 1, 2016. The revised MDP incorporates key themes and specific recommendations identified during review of the public comments. The plan was posted on the CMS.gov website in May 2016, to be followed by updates as appropriate. An annual report chronicling the progress made in advancing quality measures for the Quality Payment Program is required to be posted on the CMS website. The first MDP Annual Report was posted in June 2017.

HSAG is convening this group of stakeholders and experts (e.g., frontline clinicians, patients/caregivers, and professional society representatives) to contribute direction and thoughtful input on the annual progress report and updates of the MDP required under MACRA. The following individuals were selected and have agreed to serve as the Technical Expert Panel for this project. They will continue the essential work to support the MDP in guiding and prioritizing measure development for a payment program that promotes measurable improvement in patient outcomes, relieves clinicians’ reporting burden, and includes measures that are meaningful to patients and clinicians.

Project Objectives:

The primary objectives of this project include:

Assess the landscape of current measures, measurement gaps, and measure development priorities for the CMS Quality Payment Program.

Identify a comprehensive list of variables to consider for inclusion in a quantitative approach to assess quality measures.

Develop the mandated annual report on progress in developing quality measures for the Quality Payment Program.

Propose and apply criteria to evaluate CMS progress on measure development for the Quality Payment Program.

Support the continuing evolution of the MDP as a strategic framework for clinician quality measure development for the Quality Payment Program.

TEP Requirements:

We sought a TEP of approximately 20 individuals, including physicians as well as non-physician practitioners, representatives of stakeholder organizations, health care consumers, and others with the following perspectives and areas of expertise:

Consumer/patient/family (caregiver) perspective

Frontline clinicians with experience in emergency medicine, neurology, allergy/immunology, rheumatology, or physical medicine and rehabilitation

Individual clinical practices, medical groups, or accountable care organizations

Consumer or patient advocacy

Personal experience receiving care for a neurological condition, a rheumatic disease, asthma or another allergic or immunological disorder, or a musculoskeletal disorder, or emergency medical care

Experience as a family member or caregiver of a person receiving such care

Clinical quality measurement, including domains such as care coordination, patient safety, appropriate use, and population health and prevention

Qualified clinical data registries

Health information technology

TEP Expected Time Commitment:

The duration of commitment is expected to be from March 2018 through June 2019. All potential TEP members must commit to the anticipated time frame needed to perform the functions of the TEP. Members must be available to convene in person for the initial meeting in Tampa, Florida, in May 2018. The meeting will last one full day and one partial day. Subsequently, up to four virtual conferences of one to three hours may also be scheduled through webinar and teleconference capability. Dates for subsequent web conference meetings will be determined based on need and member availability. TEP members will be asked to read briefing materials in advance of meetings.

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

Dates:

The Call for TEP nomination period closed on August 8, 2017. The TEP met on September 14, 2017.

Documents:

The TEP 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 Yale New Haven Health Services Corporation Center for Outcomes Research and Evaluation (CORE) to adapt one or two claims-based hospital measures to assess the quality of care provided to Medicare beneficiaries by clinicians who are eligible to participate in the MIPS (hereinafter, MIPS eligible clinicians).

Previously, CMS/CORE developed a range of measures to assess hospital quality. CMS/CORE plans to adapt one or two of these existing measures to assess care provided by MIPS eligible clinicians. The measure(s) already specified for the hospital setting cover a range of acute and/or chronic conditions, and elective procedures. The adapted measure(s) will likely include one outcome measure assessing a range of hospitalized patients and one measure based on an elective procedure. The measure(s) will assess each clinician’s outcome rate, such as readmission rate or complications rate, relative to that of other MIPS eligible clinicians with similar patients. The quality measure scores will be calculated using patient characteristics and outcomes documented on routinely submitted Medicare claims; therefore, the clinicians whose performance will be assessed by the quality measures will not need to submit any additional data directly to CMS.

CORE is completing this work under contract to CMS. The contract name is Development, Reevaluation, and Implementation of Hospital Outcome/Efficiency Measures for Hospital and Eligible Clinicians; the contract number is Contract Number: HHSM-500-2013-13018I, Task Order HHSM-500-T0001.

As part of its measure development process, CMS asks measure developers to convene 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 to inform quality measure development for patients with a range of acute and/or chronic conditions, or patients undergoing elective procedures. CMS will use the measures to evaluate the quality of care provided by MIPS eligible clinicians.

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Project Title: Development, Reevaluation, and Implementation of Outcome and Efficiency Measures

Dates:

The Call for TEP nomination period closed on November 10, 2017.

Documents:

The TEP Membership List and Charter 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), and its partner, the Lewin Group (Lewin), to develop an electronic clinical quality measure (eCQM) that assesses the percentage of patients that received fibrinolytic therapy within 30 minutes of emergency department (ED) arrival. The contract name is Development, Reevaluation, and Implementation of Outcome and Efficiency Measures. The contract number is HHSM-500-2013-13018I. As part of its measure development process, CMS asks measure developers to convene groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during measure development and maintenance.

Per the MMS Blueprint for the CMS Measures Management System, eCQMs are based on information readily available in electronic health records (EHR) in a structured format and can be readily accessed without affecting facility workflow. The electronic specification of the measure will ensure that all data elements used to calculate the measure’s performance score can be captured in the EHR.

Project Objectives:

The project’s primary objective is to retool OP-2 (Fibrinolytic Therapy Received within 30 Minutes of ED Arrival) to an eCQM, including its electronic specification, and testing of feasibility, validity, and effectiveness, recommending improvements as needed.

TEP Requirements:

We sought a TEP of approximately 11 individuals with the following perspectives and areas of expertise:

Subject matter expertise:

Clinicians and caregivers

Cardiology

Emergency medicine

Rural and critical access communities

EHR vendors and implementers

Informaticists

Epidemiologists

Methodologists

Quality measure experts

Disparities experts

Patient and family perspective


TEP Expected Time Commitment:

The TEP’s expected time commitment include the following:

Participating in two to three TEP teleconference meetings per year, up to 120 minutes each; and,

Reviewing and providing feedback on the measure specifications and testing results, recommending improvements as needed.

TEP members will be asked to review meeting materials prior to meetings. Additionally, TEP members may be called upon periodically to review information and provide comments between meetings.

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Project Title: Hospital Harm Performance Measure

Dates:

The Call for TEP nomination period closed on January 16, 2017.

The TEP met on April 13, 2017 from 3:00-4:30 pm EST and December 7, 2017 from 4:00-5:30 pm EST.

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 hospital-level electronic health record (EHR)-based performance measures of patient harm or adverse patient safety events that can be improved with high quality of 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 asks measure developers to convene 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 is to develop a hospital-level electronic measure of multiple dimensions of patient harm that allows CMS to assess hospitals’ performance while ensuring hospitals have access to meaningful information to enable quality improvement.

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Project Title: Claims-Only and Hybrid Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measures  

Dates:

The Call for TEP nomination period closed on March 23, 2016. The TEP met on May 17, 2016 from 5:00-6:30 pm EST, on July 12, 2016 from 4:30-6:30 pm EST, on March 22, 2017 from 4:30 – 6:30 pm EST, and on July 26, 2017 from 3:00 – 5:00 pm EST.

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 CORE to develop a claims-only and hybrid hospital-wide risk-standardized mortality measure 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 measurement 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 Hospital Outcome/Efficiency Measures for Hospital and Eligible Clinicians, Option Year 3; the contract number is Contract Number: HHSM-500-2013-13018I, Task Order HHSM-500-T0001. As part of its measure development process, CMS asks contractors to convene groups of stakeholders and experts who contribute direction and thoughtful input to the measure contractor during measure development and maintenance.

Project Objectives:

The primary goal is to develop a claims-only and hybrid hospital-wide risk-standardized mortality measure that allows CMS to assess a broad range of hospitals’ performance while ensuring hospitals have access to meaningful information to enable quality improvement.

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Project Title: Development of the Hospice Quality Reporting Program HEART Comprehensive Patient Assessment Instrument

Dates:

The TEP nomination period closed on August 9, 2017.

Documents:

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

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with RTI International to develop an expanded item set called the Hospice Evaluation & Assessment Reporting Tool (HEART), covering the comprehensive patient assessment for hospice providers. The contract name is Hospice Quality Reporting Program Measure Development, Maintenance and Support. The contract number is HHSM-500-2013-13015I. As part of its item development process, CMS asks contractors to convene groups of stakeholders and experts who contribute direction and thoughtful input to the contractor during the item development process.

The purpose of this project is to develop an item set that would allow for a broader picture of the quality of care provided by hospice agencies, as well as a more comprehensive picture of patient need and service delivery for hospice patients. Thus, the HEART instrument includes items that are critical for high-quality patient care, including those elements that help hospice providers work with patients and families to establish goals of care consistent with the individual’s values. HEART will give CMS insights into the quality of care delivered to patients, generating the ability to calculate meaningful quality measures from the items, and help CMS identify patients who require the highest intensity of hospice services, which may allow CMS to explore future payment refinements. Finally, the HEART instrument will be useful for other CMS regulatory activities, including survey and care planning to ensure a multifunctional assessment that will meet all of CMS’s core needs.

The purpose of this standing TEP is to explore implementation and content related topics prior to and concurrent with the pilot testing of this instrument, mindful of the necessary items for potential future quality measures and payment refinements after additional reliability, validity, and national testing has been completed. This TEP will focus on the feasibility and usability of the HEART instrument as well as identifying potential barriers to implementation. Additionally, this TEP will discuss the refinement of specific patient assessment domains and items based on pilot testing findings. After pilot testing, this TEP will explore the potential for future quality measures based on HEART patient assessment items. We aim to involve participants with diverse backgrounds and experiences. This includes, but is not limited to, hospice clinicians, those with experience in hospice quality reporting and from different types of hospice organizations with distinct organizational structures, and settings, and researchers/measure developers.

Project Objectives:

Gather feedback on the feasibility and usability of the draft HEART instrument

Determine potential barriers to implementing the HEART instrument in varying hospice settings and discuss remediation strategies

Refine draft HEART patient assessment items

Determine the direction of future quality measures based on HEART patient assessment items

TEP Requirements:

We sought a TEP of approximately 14-20 individuals from a broad, diverse background with the following perspectives and areas of expertise:

Subject matter expertise: Hospice Quality related to:

Diagnosis, Prognosis, and Treatments

Symptom Management

Communication, Hearing, and Vision

Cognitive and Functional Status

Safety and Environment

Psychosocial

Patient & Family Preferences

Access, Communication, and Care Coordination

Clinician perspective

Electronic health records (EHR) (e.g., EHR vendors, those with experience working with EHR vendors)

Perspective from hospices of varying:

Average daily census

Geographic locations

Settings (i.e., urban, rural, frontier)

Profit status

Patient populations (e.g., underserved populations)

Quality reporting

Performance measurement

Quality improvement

Note: Preference was given to candidates who have not served on a previous TEP.

TEP Expected Time Commitment:

TEP members will provide input throughout the development, implementation, and refinement process. This time commitment will span from September 2017 through December 2018.

A two-day webinar TEP meeting will take place on November 2, 2017 and November 3, 2017.

And/Or, an additional in-person meeting approximately 10-12 months following the first webinar meeting.

Follow-up meetings via webinar or telephone as necessary.

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Project Title: Development of Outpatient Outcome Measures for the Merit-based Incentive Payment System (MIPS)

Dates:

The Call for Technical Expert Panel (TEP) nomination period closed on June 16, 2017.

The TEP met on July 20, 2017 and September 18, 2017. 

Documents:

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

Project Overview:

CMS is developing quality measures to assess the quality of care provided by clinicians who are eligible to participate in the MIPS (hereinafter, MIPS eligible clinicians). The measures will assess each eligible clinician’s hospital admission rate relative to that of other MIPS eligible clinicians with similar patients. The measures will be risk adjusted for patient complexity, unlike other measures currently applied at the eligible clinician or group level. The quality measure scores will be calculated using patient characteristics and outcomes documented on routinely submitted Medicare claims; therefore, the clinicians whose performance will be assessed by the quality measures will not need to submit any additional data directly to CMS. The TEP is providing input to help shape the approach to the measures, such as which types of admissions should be counted in the measures. CORE is completing this work under contract to CMS. The contract name is Measure & Instrument Development and Support (MIDS): Development, Reevaluation, and Implementation of Outpatient Outcome/Efficiency Measures. The contract number is HHSM-500-2013-13018I. As part of its measure development process, CMS asks measure developers to convene 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 to inform quality measure development and reevaluation for patients with acute or chronic conditions. CMS will use the measures to evaluate the quality of care provided by MIPS eligible clinicians.

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Project Title: Quality Measure Development (QMD): Dual Enrollees, Managed Long-Term Services and Supports (MLTSS), and Medicaid Innovation Accelerator Program (IAP). Technical Expert Panel: Medicaid Innovation Accelerator Program (IAP)-Substance Use Disorder, Beneficiaries with Complex Needs, and Physical-Mental Health Integration

Dates:

The Call for TEP nomination period closed on March 8, 2016.

The TEP met on April 18 and April 20, 2016.

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 Mathematica Policy Research to develop and implement standardized quality measures that can support health care delivery reform efforts across CMS’ programs that serve Medicare-Medicaid enrollees (also known as dual eligible beneficiaries) and Medicaid-only enrollees. Such measures are intended to be meaningful, outcomes-based and not burdensome or duplicative of measures currently available. The contract name is Quality Measure Development and Maintenance for CMS Programs Serving Medicare-Medicaid Enrollees and Medicaid-Only Enrollees (QMD). The contract number is HHSM-500-2013-13011I/HHSM-500-T0004.

As part of its measure development process, CMS asks measure developers to convene groups of stakeholders and experts to contribute direction and thoughtful input during measure development and maintenance. For this project, we will be convening two Technical Expert Panels (TEPs) for this purpose.

This panel, the Medicaid IAP – Measures for Beneficiaries with Substance Use Disorders (SUD), Beneficiaries with Complex Care Needs (BCN), and Physical and Mental Health Integration (PMH) TEP, will fill gaps in quality measures for Medicaid beneficiaries with substance use disorders, physical-mental health integration needs, behavioral health conditions, including mental illness, or other complex conditions that lead to high use of emergency room visits, and hospital admissions, or readmissions.

Project Objectives:

The primary objectives of this project, which includes a base year and 2 option years, 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 acceptability

Submit measures to the National Quality Forum for endorsement

Assist CMS with an implementation strategy

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Quick Links

Technical Expert Panels

Currently Accepting Nominations

Downloads:

QPP_MIPS_335_226_448 [ZIP]

MACRA Episode-Based Cost Measures [ZIP]

End-Stage Renal Disease Physician Level Measure Development [ZIP]

Hospital Outcome Measurement for Patients with Social Risk Factors [ZIP]

Patient-Reported Outcomes Following Elective Total Hip and/or Total Knee Arthroplasty: Hospital-Level Performance Measure(s)_Membership List [PDF]

Inpatient Psychiatric Facility (IPF) Outcome and Process Measure Development Maintenance [ZIP]

IMPACT_Transfer of Health Information and Care Preferences When an Individual Transitions_Meeting 4 [ZIP]

Hospital Quality Star Ratings on Hospital Compare [ZIP]

MACRA Episode-Based Cost Measures – Call for Clinical Subcommittee Membership List [PDF]

QMD: Supporting Efficiency and Innovation in the Process of Developing CMS Quality Measures [ZIP]

CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) Membership List [PDF]

Development of Inpatient Outcome Measures for MIPS [ZIP]

Development, Reevaluation, and Implementation of Outcome and Efficiency Measures [ZIP]

Hospital Harm Performance Measure [ZIP]

Claims-Only and Hybrid Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measures [ZIP]

Development of the Hospice Quality Reporting Program HEART Comprehensive Patient Assessment Instrument TEP Membership List [PDF]

Development of Outpatient Outcome Measures for the Merit-based Incentive Payment System (MIPS) [ZIP]

Quality Measure Development (QMD) - Medicaid Innovation Accelerator Program (IAP)-Substance Use Disorder, Beneficiaries with Complex Needs, and Physical-Mental Health Integration [ZIP, 361KB]

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