NQF
Version Number: 9.9
Meeting
Date: December 12, 2018
Measure Applications Partnership
Clinician Workgroup Discussion
Guide
Agenda
Agenda Synopsis
Full Agenda
December 12, 2018 |
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8:00 AM |
Breakfast |
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Please log into the Poll Everywhere platform during this time
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8:30 AM |
Welcome, Introductions, Disclosures of
Interest, and Review of Meeting Objectives |
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Bruce Bagley, MD, Workgroup Co-Chair Amy Moyer, Workgroup
Co-Chair Elisa Munthali, Senior Vice President, Quality Measurement,
NQF John Bernot, MD, Vice President, Quality Initiatives,
NQF
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8:45 AM |
CMS Opening Remarks & Meaningful Measures
Update |
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Michelle Schreiber, QMVIG Group Direct, CMS
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9:05 AM |
Overview of Pre-Rulemaking Approach
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Miranda Kuwahara, NQF
- MAP uses a three step approach
- Provide program overview
- Review current measures
- Evaluate Measures Under Consideration (MUC) for what they would
add to the program measure set
- Review decision categories
- Review voting procedures
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9:30 AM |
Opportunity for Public Comment |
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9:40 AM |
Break |
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9:55 AM |
Medicare Shared Savings Program (SSP) Program
Measures |
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- Pre-Rulemaking Input
- Public Commenting Opportunity
- Feedback on Gaps in SSP
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Programs under consideration:
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- Use of Opioids from Multiple Providers in Persons Without
Cancer (MUC ID: MUC2018-077)
- Description: The rate (XX out of 1,000) of individuals
without cancer receiving prescriptions for opioids from four (4) or
more prescribers AND four (4) or more pharmacies. (Measure
Specifications; Summary
of NQF Endorsement Review)
- Public comments received: 9
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure would
encourage the monitoring of opioid prescription patterns as studies
have shown that people who see multiple providers or use multiple
pharmacies are more likely to die of drug overdoses.
- Impact on quality of care for patients:This measure is
fully developed, tested, and NQF endorsed. This measure would
strengthen and diversify the SSP program measure set by addressing
opioid use disorder treatment.
- Preliminary analysis result: Conditional support for
rulemaking with the condition that duplication is considered between
this measure and MUC2018-079
- Adult Immunization Status (MUC ID: MUC2018-062)
- Description: Percentage of members 19 years of age and
older who are up-to-date on recommended routine vaccines for
influenza; tetanus and diphtheria (Td) or tetanus, diphtheria and
acellular pertussis (Tdap); zoster; and pneumococcal. (Measure
Specifications)
- Public comments received: 5
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure would
encourage the use of evidence based practices to improve adult
vaccination coverage. These vaccines can improve health and
decrease health care costs by preventing severe disease and
hospitalization.
- Impact on quality of care for patients:This measure is
a composite measure that evaluates receipt of all routine vaccines
for the adult population.
- Preliminary analysis result: Conditional Support with the
Condition of NQF Endorsement
- Use of Opioids at High Dosage in Persons Without Cancer
(MUC ID: MUC2018-078)
- Description: The rate (XX out of 1,000) of individuals
without cancer receiving prescriptions for opioids with a daily dosage
greater than 120 mg morphine equivalent dose (MED) for 90 consecutive
days or longer. (Measure
Specifications; Summary
of NQF Endorsement Review)
- Public comments received: 9
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure would
encourage the monitoring of opioid prescription patterns as studies
have determined that patient populations taking high opioid doses
for prolonged periods are often characterized by high rates of
psychiatric and substance abuse disorders, frequently do not receive
care consistent with clinical guidelines, and have higher death
rates.
- Impact on quality of care for patients:This measure is
fully developed, tested, and NQF endorsed. This measure would
strengthen and diversify the SSP program measure set by addressing
opioid use disorder treatment.
- Preliminary analysis result: Conditional support for
rulemaking with the condition that duplication is considered between
this measure and MUC2018-079
- Use of Opioids from Multiple Providers and at High Dosage in
Persons Without Cancer (MUC ID: MUC2018-079)
- Description: The rate (XX of 1,000) of individuals
without cancer receiving prescriptions for opioids with a daily dosage
greater than 120 mg morphine equivalent dose (MED) for 90 consecutive
days or longer, AND who received opioid prescriptions from four (4) or
more prescribers AND four (4) or more pharmacies. (Measure
Specifications; Summary
of NQF Endorsement Review)
- Public comments received: 9
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure would
encourage the monitoring of opioid prescription patterns as studies
have shown that people who see multiple providers or use multiple
pharmacies are more likely to die of drug overdoses and that patient
populations taking high opioid doses for prolonged periods are often
characterized by high rates of psychiatric and substance abuse
disorders, frequently do not receive care consistent with clinical
guidelines, and have higher death rates.
- Impact on quality of care for patients:This measure is
fully developed, tested, and NQF endorsed. This measure would
strengthen and diversify the SSP program measure set by addressing
opioid use disorder treatment.
- Preliminary analysis result: Conditional support for
rulemaking with the condition potential duplication between this
measure and MUC2018-077 & 078 is considered.
- Initial opioid prescription compliant with CDC
recommendations (MUC ID: MUC2018-106)
- Description: Composite score indicating compliance with
five measurable CDC opioid prescribing guidelines. The denominator
includes new opioid prescriptions in the measurement year. The
numerator includes new opioid prescriptions that are compliant on all
5 CDC indicators. Higher is better on this measure. (Measure
Specifications)
- Public comments received: 6
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure would
encourage the monitoring of opioid prescription patterns as studies
have shown that people who see multiple providers or use multiple
pharmacies are more likely to die of drug overdoses.
- Impact on quality of care for patients:This composite
measure would help monitor and improve guideline compliance of
opioid prescriptions.
- Preliminary analysis result: Do not support for
rulemaking with the potential for mitigation. Mitigation would
include specifying the measure at the health plan
level.
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12:00 PM |
Lunch
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1:00 PM |
MAP Clinician Feedback on NQF's Rural
Work |
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Dr. Ira Moscovice, MAP Rural Health Workgroup Co-Chair Suzanne
Theberge, Senior Project Manager, NQF
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1:15 PM |
CMS Overview of MIPS Cost and Quality
Measures |
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Reena Duseja, MD, MS, Chief Medical Officer, QMVIG, CMS
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1:30 PM |
Merit-Based Incentive Payment System (MIPS)
Program Measures |
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- Pre-Rulemaking Input
- Public Commenting Opportunity
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Programs under consideration:
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- Inpatient Chronic Obstructive Pulmonary Disease (COPD)
Exacerbation (MUC ID: MUC2018-115)
- Description: The Inpatient Chronic Obstructive Pulmonary
Disease (COPD) Exacerbation Measure is meant to apply to clinicians
who manage the inpatient care of Medicare beneficiaries hospitalized
for exacerbation of COPD. This acute episode captures patients
hospitalized for an exacerbation of COPD. The measure evaluates a
clinician’s risk-adjusted cost for the episode group by averaging it
across all episodes attributed to the clinician during the performance
period. The cost of each episode is the sum of the cost to Medicare
for assigned services performed by the attributed clinician and other
healthcare providers during the episode window. (Measure
Specifications)
- Public comments received: 4
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure
assesses the cost of services performed by providers during the
patient-focused episode of care.
- Impact on quality of care for patients:This measure is
a cost and resource use measure. This measure should be submitted
to NQF for review and endorsement .
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Femoral or Inguinal Hernia Repair (MUC ID:
MUC2018-116)
- Description: The Femoral or Inguinal Hernia Repair
Measure is meant to apply to clinicians who perform this procedure for
Medicare beneficiaries. This procedural episode captures patients who
undergo a femoral or inguinal hernia repair procedure. The measure
evaluates a clinician’s risk-adjusted cost for the episode group by
averaging it across all episodes attributed to the clinician during
the performance period. The cost of each episode is the sum of the
cost to Medicare for assigned services performed by the attributed
clinician and other healthcare providers during the episode window.
(Measure
Specifications)
- Public comments received: 3
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure
assesses the cost of services performed by providers during the
patient-focused episode of care.
- Impact on quality of care for patients:This measure is
a cost and resource use measure. This measure should be submitted
to NQF for review and endorsement .
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels
(MUC ID: MUC2018-117)
- Description: The Lumbar Spine Fusion for Degenerative
Disease, 1-3 Levels Measure is meant to apply to clinicians who
perform this procedure for Medicare beneficiaries. This procedural
episode captures patients who undergo a lumbar spinal fusion surgery.
The measure evaluates a clinician’s risk-adjusted cost for the episode
group by averaging it across all episodes attributed to the clinician
during the performance period. The cost of each episode is the sum of
the cost to Medicare for assigned services performed by the attributed
clinician and other healthcare providers during the episode window.
(Measure
Specifications)
- Public comments received: 4
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure
assesses the cost of services performed by providers during the
patient-focused episode of care.
- Impact on quality of care for patients:This measure is
a cost and resource use measure. This measure should be submitted
to NQF for review and endorsement .
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Psychoses/Related Conditions (MUC ID: MUC2018-119)
- Description: The Psychoses/Related Conditions Measure is
meant to apply to clinicians who manage the inpatient care of Medicare
beneficiaries hospitalized with these conditions. This acute episode
captures patients who are treated for psychoses and related
conditions. The measure evaluates a clinician’s risk-adjusted cost for
the episode group by averaging it across all episodes attributed to
the clinician during the performance period. The cost of each episode
is the sum of the cost to Medicare for assigned services performed by
the attributed clinician and other healthcare providers during the
episode window. (Measure
Specifications)
- Public comments received: 4
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure
assesses the cost of services performed by providers during the
patient-focused episode of care.
- Impact on quality of care for patients:This measure is
a cost and resource use measure. This measure should be submitted
to NQF for review and endorsement .
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Lumpectomy, Partial Mastectomy, Simple Mastectomy
(MUC ID: MUC2018-120)
- Description: The Lumpectomy, Partial Mastectomy, Simple
Mastectomy Measure is meant to apply to clinicians who perform these
procedures for Medicare beneficiaries. This procedural episode
captures patients who receive surgical treatment for breast cancer.
The measure evaluates a clinician’s risk-adjusted cost for the episode
group by averaging it across all episodes attributed to the clinician
during the performance period. The cost of each episode is the sum of
the cost to Medicare for assigned services performed by the attributed
clinician and other healthcare providers during the episode window.
(Measure
Specifications)
- Public comments received: 4
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure
assesses the cost of services performed by providers during the
patient-focused episode of care.
- Impact on quality of care for patients:This measure is
a cost and resource use measure. This measure should be submitted
to NQF for review and endorsement .
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Acute Kidney Injury Requiring New Inpatient Dialysis
(MUC ID: MUC2018-121)
- Description: The Acute Kidney Injury (AKI) Requiring New
Inpatient Dialysis Measure is meant to apply to clinicians who
supervise dialysis procedures for AKI Medicare beneficiaries. This
acute episode captures patients previously not dependent on dialysis
who undergo AKI dialysis. The measure evaluates a clinician’s
risk-adjusted cost for the episode group by averaging it across all
episodes attributed to the clinician during the performance period.
The cost of each episode is the sum of the cost to Medicare for
assigned services performed by the attributed clinician and other
healthcare providers during the episode window. (Measure
Specifications)
- Public comments received: 4
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure
assesses the cost of services performed by providers during the
patient-focused episode of care.
- Impact on quality of care for patients:This measure is
a cost and resource use measure. This measure should be submitted
to NQF for review and endorsement .
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Lower Gastrointestinal Hemorrhage (MUC ID:
MUC2018-122)
- Description: The Lower Gastrointestinal Hemorrhage
Measure is meant to apply to clinicians who manage the inpatient care
of Medicare beneficiaries hospitalized for acute lower
gastrointestinal hemorrhage. This acute episode captures patients
hospitalized for acute lower gastrointestinal hemorrhage. The measure
evaluates a clinician’s risk-adjusted cost for the episode group by
averaging it across all episodes attributed to the clinician during
the performance period. The cost of each episode is the sum of the
cost to Medicare for assigned services performed by the attributed
clinician and other healthcare providers during the episode window.
(Measure
Specifications)
- Public comments received: 4
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure
assesses the cost of services performed by providers during the
patient-focused episode of care.
- Impact on quality of care for patients:This measure is
a cost and resource use measure. This measure should be submitted
to NQF for review and endorsement .
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Renal or Ureteral Stone Surgical Treatment (MUC
ID: MUC2018-123)
- Description: The Renal or Ureteral Stone Surgical
Treatment Measure is meant to apply to clinicians who perform this
procedure for Medicare beneficiaries. This procedural episode captures
patients who receive surgical treatment for renal or ureteral stones.
The measure evaluates a clinician’s risk-adjusted cost for the episode
group by averaging it across all episodes attributed to the clinician
during the performance period. The cost of each episode is the sum of
the cost to Medicare for assigned services performed by the attributed
clinician and other healthcare providers during the episode window.
(Measure
Specifications)
- Public comments received: 3
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure
assesses the cost of services performed by providers during the
patient-focused episode of care.
- Impact on quality of care for patients:This measure is
a cost and resource use measure. This measure should be submitted
to NQF for review and endorsement .
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Hemodialysis Access Creation (MUC ID: MUC2018-126)
- Description: The Hemodialysis Access Creation Measure is
meant to apply to clinicians who perform this procedure for Medicare
beneficiaries. This procedural episode captures patients who undergo a
procedure for the creation of access for long-term hemodialysis. The
measure evaluates a clinician’s risk-adjusted cost for the episode
group by averaging it across all episodes attributed to the clinician
during the performance period. The cost of each episode is the sum of
the cost to Medicare for assigned services performed by the attributed
clinician and other healthcare providers during the episode window.
(Measure
Specifications)
- Public comments received: 2
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure
assesses the cost of services performed by providers during the
patient-focused episode of care.
- Impact on quality of care for patients:This measure is
a cost and resource use measure. This measure should be submitted
to NQF for review and endorsement .
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Elective Primary Hip Arthroplasty (MUC ID:
MUC2018-137)
- Description: The Elective Primary Hip Arthroplasty
Measure is meant to apply to clinicians who perform this procedure for
Medicare beneficiaries. This procedural episode captures patients who
undergo elective primary hip arthroplasty. The measure evaluates a
clinician’s risk-adjusted cost for the episode group by averaging it
across all episodes attributed to the clinician during the performance
period. The cost of each episode is the sum of the cost to Medicare
for assigned services performed by the attributed clinician and other
healthcare providers during the episode window. (Measure
Specifications)
- Public comments received: 2
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure
assesses the cost of services performed by providers during the
patient-focused episode of care.
- Impact on quality of care for patients:This measure is
a cost and resource use measure. This measure should be submitted
to NQF for review and endorsement .
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Non-Emergent Coronary Artery Bypass Graft (CABG)
(MUC ID: MUC2018-140)
- Description: The Non-Emergent Coronary Artery Bypass
Graft (CABG) Measure is meant to apply to clinicians who perform this
procedure for Medicare beneficiaries. This procedural episode captures
patients who undergo a CABG procedure. The measure evaluates a
clinician’s risk-adjusted cost for the episode group by averaging it
across all episodes attributed to the clinician during the performance
period. The cost of each episode is the sum of the cost to Medicare
for assigned services performed by the attributed clinician and other
healthcare providers during the episode window. (Measure
Specifications)
- Public comments received: 2
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure
assesses the cost of services performed by providers during the
patient-focused episode of care.
- Impact on quality of care for patients:This measure is
a cost and resource use measure. This measure should be submitted
to NQF for review and endorsement .
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Medicare Spending Per Beneficiary (MSPB) clinician measure
(MUC ID: MUC2018-148)
- Description: MSPB is a payment-standardized,
risk-adjusted cost measure focused on clinicians (TIN-NPIs) /
clinician groups (TINs) providing care at acute inpatient hospitals.
The measure is an average of risk-adjusted costs across all episodes.
Each MSPB episode has a window spanning from three days prior to the
index inpatient admission through 30 days after discharge. The measure
attributes all Medicare Part A and B costs occurring in the episode
window to the clinician(s) responsible for care, as identified for
medical MS-DRGs through the use of an E&M threshold and for
surgical MS-DRGs by identification of the physician performing the
core procedure of the stay. (Measure
Specifications)
- Public comments received: 8
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure
assesses the risk adjusted total total cost of care.
- Impact on quality of care for patients:This measure is
a cost and resource use measure. This measure should be submitted
to NQF for review and endorsement.
- Preliminary analysis result: Conditional support for
rulemaking with the condition of NQF endorsement.
- Total Per Capita Cost (MUC ID: MUC2018-149)
- Description: The Total Per Capita Cost (TPCC) measure is
a payment-standardized, risk-adjusted, and specialty-adjusted cost
measure focused on clinicians/clinician groups performing primary care
services. The measure is an average of per capita costs (with the
previously mentioned adjustments applied) across all attributed
beneficiaries. The measure includes all Medicare Part A and B costs
across all attributed beneficiaries. (Measure
Specifications)
- Public comments received: 12
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure
assesses the risk adjusted total total cost of care .
- Impact on quality of care for patients:This measure is
a cost and resource use measure. This version of the measure should
be submitted to NQF for review and endorsement.
- Preliminary analysis result: Conditional support for
rulemaking with the condition of NQF
endorsement.
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3:00 PM |
Break |
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3:15 PM |
Merit-Based Incentive Payment System (MIPS)
Program Measures |
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- Pre-Rulemaking Input
- Public Commenting Opportunity
- Feedback on Gaps in MIPS
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Programs under consideration:
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- Time to surgery for elderly hip fracture patients
(MUC ID: MUC2018-031)
- Description: Percentage of patients (65 years and older)
who present to the emergency department with a hip fracture receive
surgical intervention within 48 hours of admission to the hospital.
(Measure
Specifications)
- Public comments received: 0
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure could
incentivize clinicians to ensure that elderly patients receive
necessary intervention for hip fracture within the time frame as
defined by the evidence. This offers the opportunity to improve
patient care, facilitate cost-savings, and appropriately allocate
resources.
- Impact on quality of care for patients:This measure is
fully developed. This measure would help reducing preventable
healthcare harm.
- Preliminary analysis result: Conditional support for
rulemaking with the condition of NQF endorsement
- Discouraging the routine use of occupational and/or physical
therapy after carpal tunnel release (MUC ID: MUC2018-032)
- Description: Percentage of patients who underwent carpal
tunnel release surgery who were not prescribed postoperative hand,
occupational, or physical therapy within 6 weeks of surgery (Measure
Specifications)
- Public comments received: 1
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure
assesses the appropriate use of healthcare services.
- Impact on quality of care for patients:This measure is
an appropriate use process measure. However, the measure is not
specified or tested at the clinician level. Testing results should
demonstrate reliability and validity at the clinician level. This
measure should be submitted to NQF for review and
endorsement.
- Preliminary analysis result: Do not support for
rulemaking with the potential for mitigation. Mitigation would
include specifying the measure at the clinician
level.
- International Prostate Symptom Score (IPSS) or American
Urological Association-Symptom Index (AUA-SI) change 6-12 months after
diagnosis of Benign Prostatic Hyperplasia (MUC ID:
MUC2018-038)
- Description: Percentage of patients with an office visit
within the measurement period and with a new diagnosis of clinically
significant Benign Prostatic Hyperplasia who have International
Prostate Symptoms Score (IPSS) or American Urological Association
Symptom Index (AUA-SI) documented at time of diagnosis and again 6-12
months later with an improvement of 3 points. (Measure
Specifications)
- Public comments received: 0
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure would
encourage the utilization of the American Urological Association
Symptom Index (AUA-SI) and the International Prostate Symptom Score
(IPSS) to measure outcomes for treatments of BPH
- Impact on quality of care for patients:This measure is
a patient reported outcome performance measure (PRO-PM). It would
strengthen the program by adding a PRO-PM for benign prostatic
hyperplasia (BPH),which is one of the most common conditions
affecting older men, with a prevalence of 50% by age 60 years and
90% by the ninth decade of life (Medina,1999).
- Preliminary analysis result: Conditional support for
rulemaking with the condition of NQF endorsement
- Adult Immunization Status (MUC ID: MUC2018-062)
- Description: Percentage of members 19 years of age and
older who are up-to-date on recommended routine vaccines for
influenza; tetanus and diphtheria (Td) or tetanus, diphtheria and
acellular pertussis (Tdap); zoster; and pneumococcal. (Measure
Specifications)
- Public comments received: 8
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure would
encourage the use of evidence based practices to improve adult
vaccination coverage. These vaccines can improve health and
decrease health care costs by preventing severe disease and
hospitalization.
- Impact on quality of care for patients:This measure is
a composite measure that evaluates receipt of all routine vaccines
for the adult population.
- Preliminary analysis result: Do not support for
rulemaking with the potential for mitigation. Mitigation would include
specifying the measure at the clinician level.
- Multimodal Pain Management (MUC ID: MUC2018-047)
- Description: Percentage of patients, regardless of age,
undergoing selected elective surgical procedures that were managed
with multimodal pain medicine. (Measure
Specifications)
- Public comments received: 2
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure would
encourage the use of multimodal pain interventions, which have shown
to be more effective in pain control. This would also reduce the
reliance on opioids as the primary means of pain control for
patients.
- Impact on quality of care for patients:This measure is
fully developed and tested at the clinician level. It is available
for use within registries. This measure would strengthen the
program by giving additional measures around alternatives for
opioids for pain management.
- Preliminary analysis result: Conditional Support for
Rulemaking with the condition of NQF endorsement.
- Potential Opioid Overuse (MUC ID: MUC2018-048)
- Description: Percentage of patients aged 18 years or
older who receive opioid therapy for 90 days or longer and are
prescribed a 90 milligram or larger morphine equivalent daily dose (Measure
Specifications)
- Public comments received: 6
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This clinical
quality measure would encourage providers to wean patients on
high-dose opioids to lower doses, when medically appropriate, or to
consider alternative approaches to pain management.
- Impact on quality of care for patients:This measure is
fully developed. This measure could strengthen the program measure
set by reducing potential opioid overuse.
- Preliminary analysis result: Conditional support for
rulemaking with the condition NQF endorsement.
- Annual Wellness Assessment: Preventive Care (MUC
ID: MUC2018-057)
- Description: Percentage of patients 65 years of age and
older with an Annual Wellness Visit who received age- and
sex-appropriate preventive services. This measure is a composite of
seven component measures that are based on recommendations for
preventive care by the USPSTF, ACIP, and AGS. (Measure
Specifications)
- Public comments received: 5
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure is
would encourage the providers to identify and manage a patien’s
health risks for many preventable conditions. This measure evaluates
whether clinicians ensure that patients receive key recommended
preventive services.
- Impact on quality of care for patients:This measure is
fully developed at the clinician level. It is a composite measure
of several evidenced based, recommended screening and immunizations.
- Preliminary analysis result: Conditional support for
rulemaking with the condition for NQF endorsement and harmonization of
this measure with the existing subcomponent measures already in the
MIPS program.
- Functional Status Change for Patients with Neck Impairments
(MUC ID: MUC2018-063)
- Description: This is a patient-reported outcome
performance measure (PRO-PM) consisting of a patient-reported outcome
measure (PROM) of risk-adjusted change in functional status (FS) for
patients aged 14+ with neck impairments. The change in FS is assessed
using the Neck FS PROM.* The measure is risk-adjusted to patient
characteristics known to be associated with FS outcomes. It is used as
a performance measure at the patient, individual clinician, and clinic
levels to assess quality. *The Neck FS PROM is an item-response
theory-based computer adaptive test (CAT). In addition to the CAT
version, which provides for reduced patient response burden, it is
available as a 10-item short form (static/paper-pencil). (Measure
Specifications)
- Public comments received: 0
- Preliminary analysis summary (Full
Preliminary Analysis)
- Contribution to program measure set:This measure would
encourage providers to monitor functional status for patients with
neck pain.
- Impact on quality of care for patients:This measure is
fully developed at the clinician level. This measure would add a
PRO-PM measure, which are relatively lacking in the program.
- Preliminary analysis result: Conditional Support for
rulemaking with the condition of NQF
endorsement.
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4:35 PM |
Opportunity for Public Comment |
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4:45 PM |
Summary of Day and Next
Steps |
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Bruce Bagley, Workgroup Co-Chair Amy Moyer, Workgroup Co-Chair
Vaishnavi Kosuri, Project Analyst
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5:00 PM |
Adjourn |
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Appendix A: Measure Information
Measure Index
Merit-Based Incentive Payment System
Medicare Shared Savings Program
Full Measure Information
Measure Specifications
- NQF Number (if applicable):
- Description: Percentage of patients (65 years and older) who
present to the emergency department with a hip fracture receive surgical
intervention within 48 hours of admission to the hospital.
- Numerator: Number of patients in the denominator who are operated
on within 48 hours of admission to the hospital. Numerator Criteria (Eligible
Cases): CPT: 27235, 27236, 27244, 27245, 27248, 27254, 27269
- Denominator: Number of patients age 65 or older admitted to the
hospital with a low energy hip fracture Denominator Criteria (Eligible
Cases): ICD-10-CM: S72.00, S72.001, S72.002, S72.009, S72.01, S72.011,
S72.012, S72.019, S72.02, S72.03, S72.032, S72.033, S72.034, S72.035, S72.036,
S72.04, S72.041, S72.042, S72.043, S72.044, S72.045, S72.046, S72.05, S72.051,
S72.052, S72.059, S72.060, S72.09, S72.091, S72.092, S72.099, S72.136, S72.14,
S72.141, S72.143, S72.144, S72.145, S72.1346, S72.2, S72.21, S72.22, S72.23,
S72.24, S72.25, S72.26 OR ICD-9-CM: 820.8, 820, 820.02, 820.03, 820.09, 820.2,
820.21, 820.22
- Exclusions: Patients that can be classified as having the
following: non-operative fractures, multiple injuries, periprosthetic
fracture, high energy trauma, and or meet local criteria for multiple trauma
designation
- HHS NQS Priority: Make Care Safer by Reducing Harm Caused in the
Delivery of Care
- HHS Data Source: Administrative claims, administrative clinical
data, claims, EHR, Record
- Measure Type: Process
- Steward: American Academy of Orthopaedic Surgeons
- Endorsement Status:
- Meaningful Measure Area: Preventable Healthcare Harm
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support for rulemaking
with the condition of NQF endorsement
- Preliminary analysis summary
- Contribution to program measure set:This measure could
incentivize clinicians to ensure that elderly patients receive necessary
intervention for hip fracture within the time frame as defined by the
evidence. This offers the opportunity to improve patient care, facilitate
cost-savings, and appropriately allocate resources.
- Impact on quality of care for patients:This measure is fully
developed. This measure would help reducing preventable healthcare
harm.
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of making care safer by reducing harm caused in the
delivery of care and specifically addresses preventable healthcare
harm.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. This is a process measure. The measure is
based on the American Academy of Orthopaedic Surgeons Management of Hip
Fractures in the Elderly Clinical Practice Guideline, published in 2014. There
is moderate strength evidence to support that hip fracture surgery within 48
hours of admission is associated with better outcomes.
- Does the measure address a quality challenge? Yes. This measure
addresses a guideline with a performance gap of 89-94% that is more pronounced
(75-81%) when evaluating those practitioners who are not 100%
compliant.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of existing measures within the
program.
- Can the measure can be feasibly reported? Yes. This measure was
fully tested using Cleveland Clinic data. However, no further feasibility
analysis is available for other datasets.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? Yes. This measure is specified and tested at the clinician
level.
- Measure development status: Fully Developed
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. This measure is not currently in
use.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. This
measure is not currently in use.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Nine moderate
strength studies evaluated patient outcomes in relation to timing of hip
fracture surgery (Elliot et al 25, Fox et al 26, McGuire et al 27, Moran et al
28, Novack et al 29, Orosz et al 30, Parker et al 31, Radcliff et al 32,
Siegmeth et al 33). In many of these studies the presence of increased
comorbidities represented a confounding effect, and therefore delays for medical
reasons were often excluded. The majority of studies favored improved outcomes
in regards to mortality, pain, complications, or length of stay (Elliot et al
25, McGuire et al 27, Novack et al 29, Orosz et al 30, Parker et al 31, and
Siegmeth et al 33). Although several studies showed a benefit of surgery within
48 hours, one study showed no harm with a delay up to four days for patients fit
for surgery who were not delayed for medical reasons (Moran et al 28). Patients
delayed due to medical reasons had the highest mortality and it is this subset
of patients that could potentially benefit the most from earlier surgery. Prior
to performing the literature search for this guideline, both patients and
clinicians were surveyed for topics of interest related to the management of hip
fractures in the elderly. These responses helped inform the PICO development by
the workgroup. All PICO questions and inclusion criteria were developed a
priori. AAOS staff trained in research methodology conducted a comprehensive
systematic literature review, and final recommendations were developed by a
multidisciplinary panel of experts. The workgroup that created these final
recommendations is separate from the one that evaluated these quality measures.
All included articles underwent study design quality appraisal, which assessed
risks of bias/confounders that may skew the study’s results. Only the best
available evidence was considered for inclusion in recommendations.
Measure Specifications
- NQF Number (if applicable): 3430
- Description: Percentage of patients who underwent carpal tunnel
release surgery who were not prescribed postoperative hand, occupational, or
physical therapy within 6 weeks of surgery
- Numerator: Number of patients who underwent carpal tunnel release
and did not receive postoperative hand, physical therapy (low, moderate, or
high complexity) or occupational therapy (low, moderate, or high complexity)
within 6 weeks (42 days) of carpal tunnel release Numerator Criteria (Eligible
Cases): Patient encounter (CPT): 64721 or 29848 AND No patient encounter for
postoperative hand, physical therapy (low, moderate, or high complexity)
within 6 weeks (42 days) of carpal tunnel release (CPT): 97161, 97162, 97163
AND No patient encounter for postoperative hand occupational therapy (low,
moderate, or high complexity) within 6 weeks (42 days) of carpal tunnel
release (CPT): 97165, 97166, 97167 Note: Code change implemented 2015, for
data prior to 2015 CPT codes for 97161, 97162, 97163 is equivalent to 97001
(PT) and codes 97165, 97166, 97167 is equivalent to 97003 (OT).
- Denominator: Number of patients who underwent carpal tunnel
release Denominator Criteria (Eligible Cases): Patient encounter (CPT): 64721
or 29848
- Exclusions: None
- HHS NQS Priority: Make Care Affordable
- HHS Data Source: Administrative claims, Claims, Administrative
Clinical Data, EHR
- Measure Type: Process
- Steward: American Academy of Orthopaedic Surgeons
- Endorsement Status:
- Meaningful Measure Area: Appropriate Use of
Healthcare
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Do not support for rulemaking with
the potential for mitigation. Mitigation would include specifying the measure
at the clinician level.
- Preliminary analysis summary
- Contribution to program measure set:This measure assesses the
appropriate use of healthcare services.
- Impact on quality of care for patients:This measure is an
appropriate use process measure. However, the measure is not specified or
tested at the clinician level. Testing results should demonstrate
reliability and validity at the clinician level. This measure should be
submitted to NQF for review and endorsement.
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of making care affordable and specifically
addresses the appropriate use of healthcare
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. This measure is a process measure. This
measure was developed directly from the American Academy of Orthopaedic
Surgeons Management of Carpal Tunnel Syndrome Evidence-based Clinical Practice
Guideline. The recommendation shows moderate evidence supports no additional
benefit to routine supervised therapy over home programs in the immediate
postoperative period.
- Does the measure address a quality challenge? Yes. The developer
states that data from three years examined shows a consistent variability or
gap in care.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This is an
appropriate use, process measure. There are no competing measures in the
program.
- Can the measure can be feasibly reported? No. Current
specifications are at metropolitan statistical area and have not yet
demonstrated feasibility at the clinician level.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? No. Current specifications are at metropolitan statistical
area and has not yet completed testing at the clinician level.
- Measure development status: Fully Developed
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. This is a new measure and is not
currently in use.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. This
is a new measure and is not currently in use.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Submitted.
Rationale for measure provided by HHS
Routine
post-operative therapy after carpal tunnel release was examined in 6 high
quality studies. From these, two studies (Hochberg 2001 and Jerosch-Herold 2012)
addressed interventions not relevant to current core practices of postoperative
rehabilitation. The remaining four studies (Alves 2011, Fagan 2004, Pomerance
2007, and Provinciali 2000) addressed the need for supervised therapy in
addition to a home program in the early postoperative period, the early use of
laser, or the role of sensory reeducation in the later stages of recovery. One
high quality study (Alves 2011) evaluated the use of laser administered to the
carpal tunnel in 10 daily consecutive sessions at a 3J dosage and found no
difference in pain/symptom reoccurrence in comparison to placebo. Two moderate
quality studies (Pomerance 2007 and Provinciali 2000) compared in-clinic or
therapist supervised exercise programs in addition to a home program to a home
program alone. The studies were somewhat limited by an incomplete description of
who delivered home programs, exercise/education content and dosage, and
treatment progression. Pomerance (2007) compared a two week program directed by
a therapist combined with a home program alone and found no additional benefit
in terms of grip or pinch strength in comparison to the home program alone.
Provinciali (2000) compared one hour sessions over 10 consecutive days of
in-clinic physiotherapy comprising a multimodal program with a home program that
was progressed in terms of strength/endurance. No benefit was found in outcome
when measured by a CTS-specific patient reported instrument.
Measure Specifications
- NQF Number (if applicable):
- Description: Percentage of patients with an office visit within
the measurement period and with a new diagnosis of clinically significant
Benign Prostatic Hyperplasia who have International Prostate Symptoms Score
(IPSS) or American Urological Association Symptom Index (AUA-SI) documented at
time of diagnosis and again 6-12 months later with an improvement of 3
points.
- Numerator: Patients with a documented improvement of at least 3
points in their urinary symptom score during the measurement
period.
- Denominator: Equals Initial Population. Initial population is:
Male patients newly diagnosed with benign prostatic hyperplasia, that have a
urinary symptom score (USS) within 1 month of initial diagnosis. If more than
one USS in the initial one month, then the first USS counts. The patient must
have a USS again at 6-12 months and if more than on USS in this time frame,
then the last USS counts. The patient must have an office visit during the
measurement period.
- Exclusions: Urinary retention within 1 year of BPH diagnosis BPH
diagnosis during hospitalization or within 30 days of hospitalization Morbid
obesity (BMI>40) during measurement period
- HHS NQS Priority: Strengthen Person & Family Engagement as
Partners in their Care
- HHS Data Source: EHR
- Measure Type: Patient Reported Outcome
- Steward: Large Urology Group Practice Association and Oregon
Urology Institute
- Endorsement Status:
- Meaningful Measure Area: Patient Reported Functional
Outcomes
- Is the measure specified as an electronic clinical quality
measure? Yes
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support for rulemaking
with the condition of NQF endorsement
- Preliminary analysis summary
- Contribution to program measure set:This measure would
encourage the utilization of the American Urological Association Symptom
Index (AUA-SI) and the International Prostate Symptom Score (IPSS) to
measure outcomes for treatments of BPH
- Impact on quality of care for patients:This measure is a
patient reported outcome performance measure (PRO-PM). It would strengthen
the program by adding a PRO-PM for benign prostatic hyperplasia (BPH),which
is one of the most common conditions affecting older men, with a prevalence
of 50% by age 60 years and 90% by the ninth decade of life (Medina,1999).
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure addresses the priority of strengthening person and family engagement
as partners in their care and specifically addresses patient reported
functional outcomes
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. The developer notes the evidence based
guideline of using the American Urological Association Symptom Index (AUA-SI)
or the International Prostate Symptom Score (IPSS) to measure outcomes
associated with BPH
- Does the measure address a quality challenge? Yes. The measure
monitors patient reported outcomes using a standard questionanaire. The
developer states that many urologists who have a referral from a family
practitioner or internist do not have an accompanying urology symptom score,
even when an initial treatment was already started. The AUA Aqua Registry has
a non QPP list for specialty reporting and understanding their benchmarks.
The registry average for IPSS or AUASI is 2%.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of existing measures in the program.
- Can the measure can be feasibly reported? Yes. Alpha and beta
testing demonstrated feasibility in one EHR. However, per the NQF endorsement
submission, not all EHRs contain these questionnaires.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? Yes. The measure is specified at the clinician level.
- Measure development status: Fully Developed
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The measure is not currently in
use
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measure is not currently in use
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
The symptoms of
BPH are LUTS symptoms. There are other disorders with similar symptoms and need
to be excluded. History, physical examination, and testing are required prior to
a diagnosis of BPH. IPSS by itself is not a reliable diagnostic tool for LUTS
suggestive of BPH but serves as a quantitative measure of LUTS after the
diagnosis is established (DSilva,2014). Medical and surgical interventions for
BPH recommend a follow up IPSS evaluation to determine effectiveness of
treatment. IPSS should be evaluated at the time of diagnosis and after
definitive treatment.
Measure Specifications
- NQF Number (if applicable):
- Description: Percentage of patients, regardless of age,
undergoing selected elective surgical procedures that were managed with
multimodal pain medicine.
- Numerator: Patients for whom multimodal pain management is
administered in the perioperative period from six hours prior to anesthesia
start time until discharged from the postanesthesia care unit. Numerator
Definition: Multimodal pain management is defined as the use of two or more
drugs and/or interventions, NOT including systemic opioids, that act by
different mechanisms for providing analgesia. These drugs and/or interventions
can be administered via the same route or by different routes. Opioids may be
administered for pain relief when indicated but will not count towards this
measure. Numerator note: Documentation of qualifying medications or
interventions provided from six hours prior to anesthesia start time through
PACU discharge count toward meeting the numerator.
- Denominator: Patients, regardless of age, who undergo selected
elective surgical procedures
- Exclusions: Denominator Exception: Documented allergy to multiple
classes of analgesics
- HHS NQS Priority: Promote Effective Prevention & Treatment of
Chronic Disease
- HHS Data Source: Registry
- Measure Type: Process
- Steward: American Society of Anesthesiologists
- Endorsement Status:
- Meaningful Measure Area: Prevention and Treatment of Opioid and
Substance Use Disorders
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional Support for Rulemaking
with the condition of NQF endorsement.
- Preliminary analysis summary
- Contribution to program measure set:This measure would
encourage the use of multimodal pain interventions, which have shown to be
more effective in pain control. This would also reduce the reliance on
opioids as the primary means of pain control for patients.
- Impact on quality of care for patients:This measure is fully
developed and tested at the clinician level. It is available for use within
registries. This measure would strengthen the program by giving additional
measures around alternatives for opioids for pain
management.
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of promoting effective prevention and treatment of
chronic disease and specifically addresses the prevention and treatment of
opioid and substance use disorders.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. This is a process measure. This measure
follows evidence from the American Society of Anestehesiologists Task Force on
Acute Pain Management, which recommends that clinicians use multi-modal pain
management therapy in the perioperative period and offer multi-modal analgesia
in the postoperative period. A randomized control trial found that patient
who receive multi-modal pain interventions had lower pain scores, fewer
adverse outcomes, higher satisfaction and fewer narcotics used than the cohort
that received patient-controlled analgesia.
- Does the measure address a quality challenge? Yes. This measure
addresses a critical topic of pain control. The developer presents data that
demonstrates a 74.24% performance of using multimodal pain interventions with
a range of 0.00 to 100.00.Additionally, in a preliminary sample of 2018 QCDR
data, available as of October 31, 2018, including 1,526 clinicians there was a
mean performance rate of 86.4% with performance rates ranging from 36% to
100%.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of existing measures in the program.
- Can the measure can be feasibly reported? Yes. The developer
states that the measure has been available for reporting via approved
qualified clinical data registries since the beginning of 2018. However, the
developer does not provide data regarding feasibility.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? Yes. The measure has been specified at the clinician
level.
- Measure development status: Fully Developed
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The measure is not in use in federal
programs. The develper states that they are unaware of any unintended
consequences at this time, however registry participants are able to share
measure feedback through several avenues in the registry.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measure is not in use in federal programs. The develper states that they are
unaware of any unintended consequences at this time, however registry
participants are able to share measure feedback through several avenues in the
registry.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Lamplot, Wagner
and Manning conducted a randomized control trial (RCT) that found patients that
receive multimodal pain interventions had lower pain scores, fewer adverse
outcomes, higher satisfaction and fewer narcotics used than the cohort that
received patient-controlled analgesia. Another study from Memtsoudis et al.
found that hip/knee arthroplasty patients receiving two modes of non-opioid
analgesia experienced almost 20% fewer respiratory complications and 26% fewer
gastrointestinal complications compared to those who received opioids only.
Clinical guidelines support the use of multimodal pain management strategies to
manage postoperative pain based on strong evidence. They suggest use of
multimodal techniques whenever possible and consideration of regional anesthesia
when appropriate to the reduce need for opioids to manage postoperative pain.
Citations: Lamplot, J D et al. Multimodal pain management in total knee
arthroplasty. J Arthroplasty 2014, 29(2): 329-334. Memtsoudis, S G et al.
Association of multimodal pain management strategies with perioperative outcomes
and resource utilization: A population-based study. Anesthesiology 2018, 128(5):
891-902. American Society of Anesthesiologists Task Force on Acute Pain
Management. Practice guidelines for acute pain management in the perioperative
setting. An updated report by the American Society of Anesthesiologists Task
Force on Acute Pain Management. Anesthesiology.2012;116(2):248-273. Chou R,
Gordon DB, de Leon-Casasola O, et al. Management of postoperative pain: a
clinical practice guideline from the American Pain Society, the American Society
of Regional Anesthesia and Pain Medicine, and the American Society of
Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and
Administrative Council. J Pain.2016;17(2):131-157.
Measure Specifications
- NQF Number (if applicable):
- Description: Percentage of patients aged 18 years or older who
receive opioid therapy for 90 days or longer and are prescribed a 90 milligram
or larger morphine equivalent daily dose
- Numerator: Patients with an average daily dosage of 90 morphine
milligram equivalents (MME) or greater, prescribed during the measurement
period
- Denominator: Patients 18 years of age and older prescribed a 90
day or longer supply of opioids and who have a visit during the measurement
period
- Exclusions: Patients with an active diagnosis of cancer or sickle
cell disease, or who have an order for hospice or palliative care treatment
during the measurement period
- HHS NQS Priority: Make Care Safer by Reducing Harm Caused in the
Delivery of Care
- HHS Data Source: EHR
- Measure Type: Process
- Steward: Centers for Medicare & Medicaid
Services
- Endorsement Status:
- Meaningful Measure Area: Preventable Healthcare Harm
- Is the measure specified as an electronic clinical quality
measure? Yes
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support for rulemaking
with the condition NQF endorsement.
- Preliminary analysis summary
- Contribution to program measure set:This clinical quality
measure would encourage providers to wean patients on high-dose opioids to
lower doses, when medically appropriate, or to consider alternative
approaches to pain management.
- Impact on quality of care for patients:This measure is fully
developed. This measure could strengthen the program measure set by reducing
potential opioid overuse.
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of promoting effective prevention and treatment of
chronic disease and specifically addresses the prevention and treatment of
opioid and substance use disorders
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. This is a process measure. CDC guidelines
state that when opioids are started, clinicians should prescribe the lowest
effective dosage.
- Does the measure address a quality challenge? Yes. This measure
addresses a critical population at increased risk of morbidity and mortality.
Recent research suggests an overdose mortality rate of 24.6 patients per
10,000 person-years among patients taking 200 to 250 MME per day; this rate
declines to 8.3 deaths per 10,000 person-years for patients taking opioid
doses of 100 to 120 MME per day (Dasgupta et al. 2016). The same study also
noted that only 2.8 percent of patients were prescribed an opioid at doses
greater than 150 MME per day, suggesting that this measure will target a
small, but very high risk, patient population.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of measures in the program.
- Can the measure can be feasibly reported? Yes. The developer
states that while the measure is currently feasible to implement, CMS may need
to assess the availability of data necessary for measure calculation using
values from structured fields, as the measure team had to undertake
significant post-extraction processing and creation of decision rules to clean
the analytic files used for measure calculation.Additionally, this measure is
similar to an existing NQF endorsed measure, Use of Opioids at High Dosage in
Persons Without Cancer (NQF 2940). This NQF measure is not in MIPS. NQF 2940
currently targets individuals with greater than 120mg morphine equivalent dose
(MED) as opposed to the 90mg MED in this measure.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? Yes. The measure has been specified at the clinician
level
- Measure development status: Fully Developed
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The developer states that during the
semi-structured clinician interviews, some providers to whom we spoke were
concerned that the Potential Opioid Overuse measure could unfairly punish
those clinicians who are willing to treat patients already on a long-term,
high-dose opioid and cannot easily be weaned down to a lower dose.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measure team received feedback on potential negative unintended consequences
from our project patient and family advisory board (PFAB). The PFAB is
composed of patients, family members, and patient advocates who can speak
about their experiences on a variety of clinical topics (rather than focusing
on a single area). While PFAB members acknowledged that the issue of opioid
overuse is important, some expressed concern that, if the measure was
implemented, patients may be unable to access effective and necessary
treatment for their chronic pain.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Improvement in
provider performance on this measure will benefit patients primarily by reducing
opioid-related morbidity and mortality. Recent research suggests an overdose
mortality rate of 24.6 patients per 10,000 person-years among patients taking
200 to 250 MME per day; this rate declines to 8.3 deaths per 10,000 person-years
for patients taking opioid doses of 100 to 120 MME per day (Dasgupta et al.
2016). The same study also noted that only 2.8 percent of patients were
prescribed an opioid at doses greater than 150 MME per day, suggesting that this
measure will target a small, but very high risk, patient population. Several
peer-reviewed studies have estimated the costs associated with opioid use
disorders, abuse, and dependence. In 2001, Americans lost more than $11.8
billion in societal costs because of opioid abuse (Birnbaum et al. 2011). For
non-medical opioid use, this estimate rose to $53.4 billion in 2006, including
$42.0 billion in lost productivity, $2.2 billion in treatment for opioid misuse,
$8.2 billion in criminal justice expenses, and $944 million in medical care
(Hansen et al. 2010). Lost productivity and healthcare expenditures associated
with opioid abuse continue to rise; using 2007 data, Birnbaum et al. (2011)
estimated lost productivity (including premature death, loss of employment, and
presenteeism) cost society $25.6 billion, whereas healthcare costs rose to $25
billion (of which excess medical and drug use were the primary contributors).
Estimates using 2013 data suggest total costs to society from opioid abuse and
dependence exceeded $78 billion, including costs for health care, substance
abuse treatment, criminal justice expenses, and lost productivity (Florence et
al. 2016). Patients prescribed high-dose opioids have an approximately 10-fold
increase in risk of overdose compared with those prescribed low-doses (Edlund et
al. 2014). Patients on high-dose opioids are less likely to receive care
consistent with guidelines and appropriate monitoring (Morasco et al. 2010).
High daily dose is the most common indicator of potential opioid misuse or
inappropriate prescription practices for opioids (Liu et al. 2013). Payers,
providers, and patients will all benefit from the reduction of excess health
care utilization associated with potential opioid overuse.
Measure Specifications
- NQF Number (if applicable):
- Description: Percentage of patients 65 years of age and older
with an Annual Wellness Visit who received age- and sex-appropriate preventive
services. This measure is a composite of seven component measures that are
based on recommendations for preventive care by the USPSTF, ACIP, and
AGS.
- Numerator: Numerator 1: Patients who were screened for fall risk
at least once in the 12 months before or during a Medicare Annual Wellness
Visit (AWV) Numerator 2: Patients who were screened for depression during the
AWV or in the 12 months before (during an encounter) using an age-appropriate
standardized tool Numerator 3: Patients who received an influenza immunization
OR who reported previous receipt of an influenza immunization in the 153 days
before the start of the measurement period (August 1) to the end of the most
recent flu season (March 31) Numerator 4: Patients who have ever received a
pneumococcal vaccination before the end of the measurement period Numerator 5:
Women who had one or more mammograms during the measurement period, or in the
15 months prior to the measurement period Numerator 6: Patients with one or
more screenings for colorectal cancer. Appropriate screenings are defined by
any one of the following criteria: - Colonoscopy during the measurement
period or the nine years prior to the measurement period - Flexible
sigmoidoscopy during the measurement period or the four years prior to the
measurement period - Fecal occult blood test (FOBT) during the measurement
period - FIT-DNA during the measurement period or the two years prior to the
measurement period - CT colonography during the measurement period or the
four years prior to the measurement period Numerator 7: Female patients who
have ever received a central (that is, hip or spine) DXA scan before the end
of the measurement period
- Denominator: Denominator 1: Patients 65 years of age and older
with an AWV during the measurement period. Denominator 2: Patients 65 years of
age and older with an AWV during the measurement period. Denominator 3:
Patients 65 years of age and older with an AWV during the measurement period,
with an encounter from October 1 of the year before the measurement period to
March 31 of the measurement period. Denominator 4: Patients 65 years of age
and older with an AWV during the measurement period. Denominator 5: Female
patients 65 to 74 years of age during the measurement period, with an AWV
during the measurement period. Denominator 6: Patients age 65 to 75 years of
age, with an AWV during the measurement period. Denominator 7: Female
patients 65 to 85 years of age, with an AWV during the measurement period.
- Exclusions: Denominator Exclusion Population 1: Patients whose
hospice care overlaps the 12 months before or during the AWV. Patients who
were assessed to be non-ambulatory in the 12 months before or during the AWV.
Denominator Exclusion Population 2: Patients with an active diagnosis of
depression or bipolar disorder that starts before start of and overlaps the
AWV. Denominator Exception Population 2: Patient refusal or medical reasons
for not completing a depression screening in the 12 months before or during
the AWV. Denominator Exclusion Population 3: None Denominator Exceptions
Population 3: Documentation of medical reasons (e.g., patient allergy, other
medical reasons), patient reasons (e.g., patient declined, other patient
reasons), and system reasons (e.g., vaccine not available, other system
reasons) for not receiving influenza immunization in the 153 days before the
start of the measurement period (August 1) to the end of the most recent flu
season (March 31). Documentation of an active allergy any time before the end
of the most recent flu season. Denominator Exclusion Population 4: Patients
whose hospice care overlaps the measurement period. Denominator Exclusion
Population 5: Patients who had a bilateral mastectomy or who have a history of
a bilateral mastectomy or for whom there is evidence of a right and a left
unilateral mastectomy. Patients whose hospice care overlaps the measurement
period. Denominator Exclusion Population 6: Patients with a diagnosis or past
history of total colectomy or colorectal cancer. Patients whose hospice care
overlaps the measurement period. Denominator Exclusion Population 7: Patients
with a diagnosis of osteoporosis at the time of the AWV. Patients whose
hospice care overlaps the measurement period.
- HHS NQS Priority: Promote Effective Prevention & Treatment of
Chronic Disease
- HHS Data Source: EHR
- Measure Type: Composite
- Steward: Centers for Medicare & Medicaid
Services
- Endorsement Status:
- Meaningful Measure Area: Preventive Care
- Is the measure specified as an electronic clinical quality
measure? Yes
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support for rulemaking
with the condition for NQF endorsement and harmonization of this measure with
the existing subcomponent measures already in the MIPS program.
- Preliminary analysis summary
- Contribution to program measure set:This measure is would
encourage the providers to identify and manage a patien’s health risks for
many preventable conditions. This measure evaluates whether clinicians
ensure that patients receive key recommended preventive services.
- Impact on quality of care for patients:This measure is fully
developed at the clinician level. It is a composite measure of several
evidenced based, recommended screening and immunizations.
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of promoting effective prevention and treatment of
chronic disease and specifically addresses preventive care.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. This is a composite measure. This measure is
based upon evidence for services (screenings and immunizations) the United
States Preventive Services Task Force, the American Geriatrics Society, or the
Advisory Committee on Immunization Practices recommended for the general older
adult population.
- Does the measure address a quality challenge? Yes. This measure
addresses the important issue of preventive care. The develpoer states that
the median performance on the composite measure was 85 percent, with an
interquartile range of 78 percent to 88 percent.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of existing measures in the program. However, the
subcomponents of the measure overlap with measures currently in the program.
The following measures are represented in the composite: NQF 0101: Falls:
Screening for Future Fall RiskNQF 0418: Preventive Care and Screening:
Screening for Depression and Follow-Up PlanNQF 0041: Preventive Care and
Screening: Influenza Immunization NQF 0043: Pneumococcal Vaccination Status
for Older Adults (no longer endorsed)NQF 2372: Breast Cancer Screening NQF
0034: Colorectal Cancer ScreeningNQF 0037: Osteoporosis Testing in Older
WomenNQF 0046: Screening for Osteoporosis for Women 65-85 Years of
Age
- Can the measure can be feasibly reported? Yes. All of the
component measures are based on measures currently implemented in
MIPS.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? Yes. The measure is specified at the clinician
level.
- Measure development status: Fully Developed
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The developer notes that some
clinicians mentioned general concerns the impact on scores from patients who
refuse services, or among clinicians who serve end-of-life patients who might
not benefit from preventive services. The developer states that they do not
expect these concerns to bias results, because the patients who refuse
services are likely to be sparse and distributed evenly across clinicians.
Furthermore, this measure is in alignment with existing NQF measures that it
is based on, which have individual exclusion criteria for patients.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measures is not currently in use in a program.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Each component
measure corresponds to an NQF-endorsed measure, meaning the evidence for each
measure has been evaluated by an NQF committee and determined to have enough
evidence to support the measure intent.
Measure Specifications
- NQF Number (if applicable):
- Description: Percentage of members 19 years of age and older who
are up-to-date on recommended routine vaccines for influenza; tetanus and
diphtheria (Td) or tetanus, diphtheria and acellular pertussis (Tdap); zoster;
and pneumococcal.
- Numerator: Numerator 1 (N1): Members in Denominator 1 (D1) who
received an influenza vaccine on or between July 1 of the year prior to the
measurement period and June 30 of the measurement period. N2: Members in D2
who received at least 1 Td vaccine or 1 Tdap vaccine between 9 years prior to
the start of the measurement period and the end of the measurement period. N3:
Members in D3 who received at least 1 dose of the herpes zoster live vaccine
or 2 doses of the herpes zoster recombinant vaccine anytime on or after the
members 50th birthday. N4: Members in D4 who were administered both the
13-valent pneumococcal conjugate vaccine and the 23-valent pneumococcal
polysaccharide vaccine at least 12 months apart, with the first occurrence
after the age of 60. N5: The actual number of required immunizations
administered to members in D5.
- Denominator: Denominator 1: Members age 19 and older at the start
of the measurement period. Denominator 2: Members age 19 and older at the
start of the measurement period. Denominator 3: Members age 50 and older at
the start of the measurement period. Denominator 4: Members age 66 and older
at the start of the measurement period. Denominator 5: The total number of
possible immunizations required for members age 19 and older determined by
their age at the start of the measurement period.
- Exclusions: Members with any of the following: - Prior
anaphylactic reaction to the vaccine or its components any time during or
before the measurement period. - History of encephalopathy within seven days
after a previous dose of a Td-containing vaccine. - Active chemotherapy during
the measurement period. - Bone marrow transplant during the measurement
period. - History of immunocompromising conditions, cochlear implants,
anatomic or functional asplenia, sickle cell anemia & HB-S disease or
cerebrospinal fluid leaks any time during the member’s history prior to or
during the measurement period. - In hospice or using hospice services during
the measurement period.
- HHS NQS Priority: Promote Effective Prevention & Treatment of
Chronic Disease
- HHS Data Source: Administrative clinical data, Claims, EHR,
Facility Discharge Data, Other, Registry
- Measure Type: Composite
- Steward: National Committee for Quality Assurance
- Endorsement Status:
- Meaningful Measure Area: Preventive Care
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Do not support for rulemaking with
the potential for mitigation. Mitigation would include specifying the measure
at the clinician level.
- Preliminary analysis summary
- Contribution to program measure set:This measure would
encourage the use of evidence based practices to improve adult vaccination
coverage. These vaccines can improve health and decrease health care costs
by preventing severe disease and hospitalization.
- Impact on quality of care for patients:This measure is a
composite measure that evaluates receipt of all routine vaccines for the
adult population.
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of promoting effective prevention and treatment of
chronic disease and specifically addresses preventative care.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. This measure is a process measure. It is a
composite measure that includes NQF endorsed measures, 1653, 0043, 0682, 0683,
0039, 0041, 1659, 0680, 0681, and 0431. The Advisory Committee on Immunization
Practices (ACIP) recommends annual influenza vaccination; and tetanus,
diphtheria and acellular pertussis (Tdap) and/or tetanus and diphtheria (Td)
vaccine; herpes zoster vaccine; and the 13-valent pneumococcal conjugate
vaccine (PCV13) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23)
for adults at various ages.
- Does the measure address a quality challenge? Yes. This measure
assesses the immuzations for all routine vaccines recommended for
adults.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is the only measure that assesses receipt of all routine vaccines for
the adult population. However, sub components of this measure could be
related or competing measures.
- Can the measure can be feasibly reported? Yes. The developer
states that in field testing, three health plans each with commercial,
Medicaid and Medicare lines of business reported data for approximately 6.6
million enrolled adults ages 19 and older.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? Yes. The measure was tested at the health plan
level.
- Measure development status: Field Testing; Fully
Developed
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Vaccines are
recommended for adults to prevent serious diseases. Routine vaccination against
influenza, tetanus, diphtheria and pertussis is recommended for all adults,
while vaccines for herpes zoster and pneumococcal disease are recommended for
older adults (Kim et al. 2017). Administration of the influenza, Tdap/Td, herpes
zoster and pneumococcal vaccines can improve health and decrease health care
costs by preventing severe disease and hospitalization. Evidence supporting
administration of each individual vaccine follows. Influenza The influenza
vaccine protects against influenza, a serious disease that can lead to
hospitalization and death (Centers for Disease Control and Prevention [CDC]
2016a), particularly among older adults and vulnerable populations. It is
characterized by a variety of symptoms related to the nose, throat and lungs
that can range in severity (CDC 2015a), and it is easily spread (CDC 2016a).
Although anyone can get the flu, people 65 and older, pregnant women, young
children and those with chronic conditions are at higher risk of developing
serious complications (CDC 2016a). Influenza can have severe consequences. The
CDC estimates that since 2010, yearly influenza cases have ranged from 9.2-35.6
million; influenza-related hospitalizations, from 140,000-710,000; and
influenza-related deaths, from 12,000-56,000 (CDC 2017a). Deaths associated with
influenza are typically higher in older adults. In an analysis based on the
2010-2011 and 2012-2013 flu seasons, 71 percent-85 percent of deaths from
influenza were among adults 65 and older (Grohskopf et al. 2016). Influenza is a
leading cause of outpatient medical visits and worker absenteeism among adults.
The average annual burden of seasonal influenza among adults 18-49 includes
approximately 5 million illnesses, 2.4 million outpatient visits, 32,000
hospitalizations and 680 deaths (Grohskopf et al. 2016). A study in 2016
estimated that the cost-effectiveness ratio of the influenza vaccine was
approximately $100,000 per quality-adjusted life year (Xu et al 2016). ACIP
recommends routine annual influenza vaccination for all people 6 months of age
and older (Grohskopf et al. 2017). For people 19 and older, any age-appropriate
inactivated influenza vaccine (IIV) formulation or recombinant influenza vaccine
(RIV) formulation are acceptable options. ACIP notes that live attenuated
influenza vaccine (LAIV) should not be used during the 2017-2018 season for any
population. Vaccination should occur before the onset of influenza activity in
the community, ideally by the end of October; however, vaccination efforts
should continue throughout flu season into February and March (Grohskopf et al.
2017). People who have a history of severe allergic reaction (e.g., anaphylaxis)
to any component of the vaccine should not receive the influenza vaccine (CDC
2017b). Td/Tdap vaccine Tetanus, diphtheria and pertussis can have serious
health effects. Tetanus results in painful muscle spasms that can cause
fractures, difficulty breathing, arrhythmia and death (CDC 2015b).
Complications from diphtheria include myocarditis, which can lead to heart
failure, and neuritis, which may temporarily paralyze motor nerves. Death occurs
in 5-10 percent of cases (CDC 2015c). Pertussis, also known as whooping cough,
is a respiratory infection characterized by a prolonged cough; it is highly
communicable, and infection can lead to secondary pneumonia, the most common
cause of pertussis-related deaths (CDC 2015d). Due to vaccines, tetanus and
diphtheria are now uncommon. On average, there were 29 reported cases of tetanus
per year from 1996-2009, and nearly all were among people who had never received
a tetanus vaccine or were not up to date on their booster shots (CDC 2013). In
the past decade, fewer than 5 diphtheria cases were reported to the CDC,
although the disease is more prevalent in other countries: In 2014, 7,321 cases
of diphtheria were reported to the World Health Organization, and there are
likely many more unreported cases (CDC 2016b). Pertussis is much more prevalent
today than tetanus and diphtheria, even though vaccines offer protection against
the disease. Before the vaccine was introduced in the 1940s, there were about
200,000 cases of pertussis annually (CDC 2015d). Since widespread use of the
vaccine, pertussis cases have decreased by 80 percent (CDC 2015d). However,
pertussis cases have been increasing since the 1980s; currently, there are
10,000-40,000 pertussis cases and up to 20 deaths reported each year (CDC
2015d). Pertussis is usually milder in children, adolescents and adults than in
infants and young children who may not be fully immunized. Older adults are
often the source of infection for infants and children (CDC 2015d).
Administering the Tdap vaccine to adults helps prevent the spread of pertussis
to infants and prevents such hospitalizations; in 2010, the average cost of
hospitalizing an infant with pertussis was $16,339, an increase from $12,377 in
2000 (Davis 2014). Because there has been a rise in pertussis over the past
several decades in the U.S., studies have evaluated the cost-effectiveness of
providing Tdap immunizations to adults. One study found that providing a dose of
Tdap to people at age 11 or 12, as currently recommended, and again at age 21,
could reduce outpatient visits for pertussis by 4 percent and hospitalizations
for pertussis by 5 percent; costs per quality-adjusted life years saved would be
$204,556 (Kamiya et al. 2016). Another study found that vaccinating all adults
2-64 at least once with Tdap is cost-effective (<$50,000 per quality-adjusted
life years) if pertussis incidence in adults is greater than 120 cases per
100,000 people (Lee et al. 2007). McGarry et al. found that vaccinating all
adults ages 65 and older with Tdap is a cost-effective intervention and would
prevent 97,000 cases of pertussis annually—from the payer perspective, it would
provide a net cost savings of $44.8 million (2014). ACIP recommends that all
adults 19 and older who have not yet received a dose of Tdap receive a single
dose (ACIP 2012; ACIP 2011). Tdap should be administered regardless of the
interval since the last tetanus or diphtheria toxoid-containing vaccine.
Adults 19 and older should receive a decennial Td vaccine booster, beginning 10
years after receipt of the Tdap vaccine (Kretsinger et al. 2006). People who
have a history of severe allergic reaction (e.g., anaphylaxis) to any component
of the Tdap or Td vaccine should not receive it. Tdap is contraindicated for
adults with a history of encephalopathy (e.g., coma or prolonged seizures) not
attributable to an identifiable cause within seven days of administration of a
vaccine with pertussis components (CDC 2017b). Herpes zoster vaccine The herpes
zoster vaccine protects against herpes zoster, commonly known as shingles.
Herpes zoster is a painful skin rash caused by reactivation of the varicella
zoster virus (CDC 2016c). After a person recovers from primary infection of
varicella (chickenpox), the virus stays inactive in the body and can reactivate
years later. Most people typically only have one episode of herpes zoster, but
second or third episodes are possible. People with compromised immune systems
are at higher risk of developing herpes zoster (CDC 2016c). The most common
complication of herpes zoster is post-herpetic neuralgia (PHN) (CDC 2016c),
which is severe, debilitating pain at the site of the rash that has no treatment
or cure. Herpes zoster can also lead to serious complications of the eye,
pneumonia, hearing problems, blindness, encephalitis or death (CDC 2016d). In
the U.S., there are 1 million new cases of herpes zoster each year; 1 of every 3
people will be diagnosed with herpes zoster in their lifetime (CDC 2016c). A
person’s risk for developing herpes zoster increases sharply after age 50 (CDC
2016c). As people age, they are more likely to develop PHN; it rarely occurs in
people under 40, but can be seen in a third of untreated adults 60 and older
(CDC 2016c). Between 1 and 4 percent of adults with herpes zoster are
hospitalized for complications, and an estimated 96 deaths each year are
directly caused by the virus (CDC 2016c). The vaccine can reduce the risk of
developing herpes zoster and PHN. In 2011, total annual direct medical costs in
the U.S. from herpes zoster were estimated to be $1.9 million; costs are
expected to rise as the population ages (Friesen et al. 2017). A study of the
cost-effectiveness of the herpes zoster vaccine among people at 50, 60 and 70
years found that vaccination at age 60 would prevent the most cases (26,147
cases per 1 million people), compared with vaccination at 50 or 70 (Hales et al.
2014). It also found that vaccination at 60 costs $86,000 per quality-adjusted
life year, compared with $37,000 at 70 and $287,000 at 50 (Hales et a. 2014).
There are currently two types of zoster vaccines recommended for older adults:
the zoster vaccine live (ZVL) and a recombinant zoster vaccine (RZV). The ZVL is
a 1-dose vaccine licensed for immunocompetent adults 50 and older; ACIP
recommends ZVL for immunocompetent adults 60 and older. ZVL vaccine coverage for
adults 60 and older has increased each year since ACIP first recommended it in
2008 (Dooling et al. 2018). In October 2017, the Food and Drug Administration
approved the RZV for adults 50 and older. In January 2018, ACIP published a
guideline recommending RZV for immunocompetent adults 50 and older, irrespective
of prior receipt of varicella vaccine or ZVL (Dooling et al. 2018). RZV is a
two-dose series; the second dose should be given 2-6 months after the first
dose. If the second dose of RZV is given less than four weeks after the first,
the second dose should be repeated; if the second dose is more than six months
after the first dose, the vaccine series need not be restarted although
individuals may be at higher risk for zoster. ZVL remains a recommended vaccine
for immunocompetent adults 60 and older (Dooling et al. 2018). Patients with a
severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a
vaccine component should not receive either zoster vaccine (Dooling et al.
2018). Pneumococcal vaccine Vaccines protect against pneumococcal disease, which
is a common cause of illness and death in older adults and in persons with
certain underlying conditions. The major clinical syndromes of pneumococcal
disease include pneumonia, bacteremia and meningitis, with pneumonia being the
most common (CDC 2015e). Pneumonia symptoms generally include fever, chills,
pleuritic chest pain, cough with sputum, dyspnea, tachypnea, hypoxia
tachycardia, malaise and weakness. There are an estimated 400,000 cases of
pneumonia in the U.S. each year and a 5-7 percent mortality rate, although it
may be higher among older adults and adults in nursing homes (CDC 2015f;
Janssens and Krause 2004). Bacteremia, a blood infection, is another
complication of pneumococcal disease (CDC 2015f). Approximately 30 percent of
patients with pneumonia also have bacteremia, and 12,000 patients have
bacteremia without pneumonia each year (CDC 2015f). Bacteremia has a 20 percent
mortality rate among all adults and a 60 percent mortality rate among older
adults. Pneumococcal disease causes 3,000-6,000 cases of meningitis each year
(CDC 2015f). Meningitis symptoms may include headache, lethargy, vomiting,
irritability, fever, nuchal rigidity, cranial nerve signs, seizures and coma.
Meningitis has a 22 percent mortality rate among adults (CDC 2015f).
Pneumococcal infections result in significant health care costs each year.
Geriatric patients with pneumonia require hospitalization in nearly 90 percent
of cases, and their average length of stay is twice that of younger adults
(Janssens and Krause 2004). Pneumonia in the older adult population is
associated with high acute-care costs and an overall impact on total direct
medical costs and mortality during and after an acute episode (Thomas et al.
2012). Total medical costs for Medicare beneficiaries during and one year
following a hospitalization for pneumonia were found to be $15,682 higher than
matched beneficiaries without pneumonia (Thomas et al. 2012). It was estimated
that in 2010, the total annual excess cost of hospital-treated pneumonia in the
fee-for-service Medicare population was approximately $7 billion (Thomas et al.
2012). Pneumococcal vaccines have been shown to be highly effective in
preventing invasive pneumococcal disease. When comparing costs, outcomes and
quality adjusted life years, immunization with the two recommended pneumococcal
vaccines was found to be more economically efficient than no vaccination, with
an incremental cost-effectiveness ratio of $25,841 per quality-adjusted life
year gained (Chen et al. 2014). There currently are two licensed pneumococcal
vaccines in the U.S.: the 13-valent pneumococcal conjugate vaccine (PCV13) and
the 23-valent pneumococcal polysaccharide vaccine (PPSV23) (Kobayashi et al.
2015). For immunocompetent adults 65 and older who have not previously received
pneumococcal vaccination, ACIP recommends a dose of PCV13, followed by a dose of
PPSV23 one or more years later (Kobayashi et al. 2015). Immunocompetent adults
65 and older who received a dose of PPSV23 at younger than 65 should also
receive a dose of PCV13 at least one year after the initial dose of PPSV23, and
then another dose of PPSV23 at least 1 year after PCV13 and at least 5 years
after the most recent dose of PPSV23 (Kobayashi et al. 2015). Adults should not
receive either vaccine if they have had a severe allergic reaction (e.g.,
anaphylaxis) after a previous dose or to a vaccine component. Adults should not
receive the PCV13 vaccine if they have had severe allergic reaction after any
diphtheria-toxoid-containing vaccine (CDC 2017b).
Measure Specifications
- NQF Number (if applicable):
- Description: This is a patient-reported outcome performance
measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of
risk-adjusted change in functional status (FS) for patients aged 14+ with neck
impairments. The change in FS is assessed using the Neck FS PROM.* The measure
is risk-adjusted to patient characteristics known to be associated with FS
outcomes. It is used as a performance measure at the patient, individual
clinician, and clinic levels to assess quality. *The Neck FS PROM is an
item-response theory-based computer adaptive test (CAT). In addition to the
CAT version, which provides for reduced patient response burden, it is
available as a 10-item short form (static/paper-pencil).
- Numerator: The proportion of a provider’s (clinic’s or
clinician’s) patient care episodes that met or exceeded the risk-adjusted
predicted Residual Change Score. The Residual Change Score is defined as the
difference between the Actual and Predicted Change Scores where - The Actual
Score is the patient’s Functional Status (FS) Score, - The Actual Change
Score is the change in the patient’s FS score from Admission to Discharge, and
- The Predicted Change Score is the risk-adjusted prediction of FS change.
(Please see the Comments section of JIRA submission for details of the
Risk-adjustment component.) Calculating the Residual - Example Actual Score at
Admission 45 Actual Score at Discharge 60 Actual Change Score (Discharge minus
Admission) +15 Predicted Change Score +10 Residual (Actual Change minus
Predicted) +5 Numerator Options Performance Met The Residual Change Score is
equal to or greater than 0 Performance Not Met The Residual Change Score is
less than 0 Performance may be calculated on 3 levels: 1. Patient Level:
For the individual patient episode, the patient’s Actual FS scores relative to
the risk-adjusted predicted. This level should be used for optimizing care as
described below.* 2. Clinician Level: The average of the Residuals for
patient care episodes managed by a clinician (individual provider) over a 12
month time period. 3. Clinic Level: The average of the Residuals for patient
care episodes managed by a group of clinicians within a clinic over a 12 month
time period. * A provider’s (clinician’s or clinic’s) performance must be
assessed based on an average all of the provider’s patient episodes. On the
level of the individual patient, variation is expected. When an individual
episode does not result in meeting or exceeding the performance standard, the
functional data should be useful to the provider in optimizing the balance of
effectiveness/efficiency for that particular care episode. For example, if
patient-perceived function is not improving, or has plateaued in progress,
that data may be a component of provider-patient communication and care
decision-making such as the following examples: 1) does the provider
understand the patient’s perception of his/her current level of function? 2)
should the treatment plan be modified? 3) should the patient be discharged
sooner than later? 4) should the patient be referred to a different care
provider?
- Denominator: Patients aged 14+ who initiated rehabilitation
therapy, chiropractic, or medical episodes of care for neck impairments
including but not limited to cervical (neck) pain, radiculopathy, strain,
sprain, stenosis, myelopathy, spondylosis or disc disorders
- Exclusions: Denominator Exceptions - Patient refused to
participate at admission and/or discharge - Patient unable to complete the
Neck FS PROM at admission or discharge due to cognitive deficit, visual
deficit, motor deficit, language barrier, or low reading level, and a suitable
proxy/recorder is not available. - Patient self-discharged early (e.g.,
financial or insurance reasons, transportation problems, or reason unknown) -
Medical reasons (e.g., scheduled for surgery or hospitalized) Denominator
Exclusions - Patients with diagnosis of a degenerative neurological condition
such as ALS, MS, Parkinson’s diagnosed at any time before or during the
episode of care - Ongoing care not indicated, patient seen only 1-2 visits
(e.g., home program only, referred to another provider or facility,
consultation only)
- HHS NQS Priority: Strengthen Person & Family Engagement as
Partners in their Care
- HHS Data Source: Registry
- Measure Type: Patient Reported Outcome
- Steward: Focus on Therapeutic Outcomes
- Endorsement Status:
- Meaningful Measure Area: Patient Reported Functional
Outcomes
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional Support for rulemaking
with the condition of NQF endorsement.
- Preliminary analysis summary
- Contribution to program measure set:This measure would
encourage providers to monitor functional status for patients with neck
pain.
- Impact on quality of care for patients:This measure is fully
developed at the clinician level. This measure would add a PRO-PM measure,
which are relatively lacking in the program.
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority area of strengthening person and family engagement
as partners in their care and specifically addresses patient reported
functional outcomes.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. This is a patient reported outcome
performance measure (PRO-PM). This measure is evidence based, and notes
research to suppport the the use of neck functional status
questionnaires.
- Does the measure address a quality challenge? Yes. This measure
addresses a relative deficiency in PRO-PMs in the program. The developer
states that 24.24% of clinics were classified as Low Performers, 60.01% as
Average, and 15.75% as High performers.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of existing measures in the program. It is related
to the existing measure QPP #223 (NQF 0428): Functional Status Change for
Patients with General Orthopaedic Impairments. However, this measure uses
specific questions around neck pain and functional status.
- Can the measure can be feasibly reported? Yes. The FOTO
measurement system and database has existed since 1994 and consists of
approximately 21 million patient assessments. The FOTO Registry has functioned
in CMS payment programs (PQRS and MIPS) since 2009. The Neck FS PROM is widely
used throughout the U.S., being completed by patients in rehabilitation
settings 414,436 times during 2017 alone. The Neck FS PROM and risk adjustment
components needed to calculate all of the NQF endorsed PRO-PM measures
stewarded by FOTO are freely available for use by patient care providers at
https://www.fotoinc.com/science-of-foto/nqf-measure-specifications. However,
the in-house resources required for a provider to administer, score, report
for individual patient-provider communication, aggregate, risk adjust and
report on aggregate levels are extensive and more cost-efficiently served for
providers who opt to subscribe to the services provided by the FOTO
measurement system (www.fotoinc.com).
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? Yes. This measure is specified at the clinician
level.
- Measure development status: Fully Developed
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. This measure is not in the program.
The developer did not provide any information regarding implementation
challenges.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. This
measure is not in the program. The developer did not provide any information
regarding unintended consequences to the patient.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Wang YC, Cook KF,
Deutscher D, Werneke MW, Hayes D, Mioduski JE. The development and psychometric
properties of the patient self-report Neck Functional Status Questionnaire. J
Orthop Sports Phys Ther. 2015;45(9):683-692. The findings by Wang and colleagues
supported the uni-dimensionality and local independence of responses to the Neck
FS PROM CAT. The items were found to have negligible differential item
functioning and no ceiling or floor effects. The CAT-based measure yielded
precision equal to fixed measure that included all items. N=439, age 48.4 +/-
13.8, 59% female. Deutscher D, Werneke MW, Hayes D, Mioduski JE, Cook KF, Fritz
J, Woodhouse LJ, Stratford PW. Impact of risk-adjustment on provider ranking for
patients with low back pain receiving physical therapy. J Orthop Sports Phys
Ther. 2018 May 22:1-35 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pubmed/29787696 The primary sample in the study by
Deutscher et al. included 250,741 patients, ages 14-89, who completed the Neck
FS PROM CAT at admission (age/SD=54/16; 65% women). Of these, 169,039 patients
completed the Neck FS CAT at discharge, resulting in a completion rate of 67%.
The scale-level reliability of the Neck FS CAT was 0.91. Standard Errors of
Measurement (SEMs) were stable across the measurement continuum ranging from 3.7
to 3.9 points (range = 0 to 100), which corresponds to 6.1 to 6.4 points at the
90% confidence interval (CI). Minimal Detectable Improvement (MDI) at the 90% CI
ranged between 6.6 to 7.0 points. A half standard deviation of baseline scores
was 6.2 points. Minimal clinically important improvement (MCII) estimates ranged
from 15 to 4 points from 1st to 4th quartile of baseline Neck FS CAT scores,
respectively. Thus, greater change was needed to achieve MCII for patients with
lower baseline functional status. The majority of patients (61%) demonstrated
functional staging change during treatment.
Measure Specifications This measure's specifications have
been modified. Please consult this Document
for more information.
- NQF Number (if applicable):
- Description: The Inpatient Chronic Obstructive Pulmonary Disease
(COPD) Exacerbation Measure is meant to apply to clinicians who manage the
inpatient care of Medicare beneficiaries hospitalized for exacerbation of
COPD. This acute episode captures patients hospitalized for an exacerbation of
COPD. The measure evaluates a clinician’s risk-adjusted cost for the episode
group by averaging it across all episodes attributed to the clinician during
the performance period. The cost of each episode is the sum of the cost to
Medicare for assigned services performed by the attributed clinician and other
healthcare providers during the episode window.
- Numerator: The numerator for the Inpatient Chronic Obstructive
Pulmonary Disease (COPD) Exacerbation measure is the sum of the ratio of
observed to expected payment-standardized cost to Medicare for all episodes
attributed to a clinician. This sum is then multiplied by the national average
observed episode cost to generate a dollar figure. Mathematically, this is
represented as: sum of (observed episode cost/expected episode cost) *
national average observed cost.
- Denominator: The denominator for the Inpatient Chronic
Obstructive Pulmonary Disease (COPD) Exacerbation measure is the total number
of episodes from this episode group attributed to a clinician.
- Exclusions: The following episode-level exclusions apply: (a)
The beneficiary has a primary payer other than Medicare for any amount of time
overlapping the episode window or in the lookback period. (b) No attributed
clinician is found for the episode. (c) The beneficiary’s date of birth is
missing. (d) The beneficiary’s death date occurred before the episode ended.
(e) The beneficiary was not enrolled in Medicare Part A and B for the entirety
of the lookback period plus episode window, or is enrolled in Part C for any
part of the lookback period plus episode window. (f) The episode trigger
claim was not performed in an office, IP, OP, or ASC setting based on its
place of service. Exclusions specific to the Inpatient COPD Exacerbation
measure are developed with input from the Pulmonary Disease Management
Clinical Subcommittee.
- HHS NQS Priority: Make Care Affordable
- HHS Data Source: Claims
- Measure Type: Cost/Resource Use
- Steward: Centers for Medicare & Medicaid
Services
- Endorsement Status:
- Meaningful Measure Area: Patient-focused Episode of
Care
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Preliminary analysis summary
- Contribution to program measure set:This measure assesses the
cost of services performed by providers during the patient-focused episode
of care.
- Impact on quality of care for patients:This measure is a cost
and resource use measure. This measure should be submitted to NQF for
review and endorsement .
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of making care affordable and specifically
addresses a patient-focused episode of care.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. The measure is a newly developed cost
measure. Health expenditures continue to increase in the United States.
According to the National Health Expenditure Accounts, total health care
spending increased by 4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018).
Medicare spending, which is still predominantly paid on a fee-for-service
(FFS) basis, also grew 3.6 percent, reaching $672.1 billion (CMS,
2018)
- Does the measure address a quality challenge? Yes. Policymakers
contend that an estimated 80 percent of overall health care costs are
attributable to decisions made by clinicians (Fred, 2016). However, these same
clinicians are often unaware of how their care decisions influence the overall
costs of care. One of the goals for using cost measures is to help inform
clinicians on the costs attributable to their decision making, as well as the
total cost of their patient’s care.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of other measures in the program and the measure
captures a broad population. This measure is new and is not in use in any
program.
- Can the measure can be feasibly reported? Yes. This is a
claims-based measure.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? No. This measure is fully developed and has completed
field testing (see supplemental document with updates to the MUC list)This is
a new measure that has not been submitted for NQF endorsement.
- Measure development status: Early Development; Field
Testing
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The measure is not in current use. The
developer considered the potential adverse effects of making unfair
comparisons among certain types of clinicians in assessing cost measure
performance, and/or rewarding lower costs without appropriately balancing
performance on quality.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measure is not in use. During development, the developer considered the
potential adverse events of reducing access to care and stinting care.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Health
expenditures continue to increase in the United States. According to the
National Health Expenditure Accounts, total health care spending increased by
4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018). Medicare spending,
which is still predominantly paid on a fee-for-service (FFS) basis, also grew by
3.6 percent, reaching $672.1 billion (CMS, 2018). However, this growth is slower
than the previous two years due to a slowed growth in spending for both Medicare
FFS and Medicare Advantage. In the United States, Medicare is the largest single
purchaser of health care, and successfully establishing payment models under
MIPS can have significant impacts on reducing costs and making care more
affordable (MedPAC, 2017). COPD is a serious condition defined as the
“physiologic finding of nonreversible pulmonary function impairment,” and
includes chronic bronchitis and emphysema (NHLBI, 2012). In the United States,
COPD is the third leading cause of death, affecting approximately 24 million
Americans, accounting for more than 56 percent of deaths from lung disease, and
representing over 700,000 hospital admissions in 2010 (CDC, 2017). In addition,
evidence from the 1988 -1994 National Health and Nutrition Examination Survey
suggests that as many as 12 million people in the United States may have
undiagnosed COPD (NHLBI, 2012). Exacerbation of COPD and subsequent
complications lead to a large majority of COPD costs. Studies in 2008 found
Medicare beneficiaries with COPD incur annual health care costs $15,000 to
$20,000 greater than costs for beneficiaries without COPD, with the majority of
this cost resulting from inpatient hospitalizations for COPD (Menzin, 2008).
Approximately 56 percent of patients with COPD were hospitalized in 2004
compared to 14 percent for patients without COPD (Vogelmeier 2017).
Hospitalization for an acute exacerbation of COPD (AECOPD) is a known cause and
predictor of COPD progression (Vogelmeier, 2017). In one study, hospitalizations
due to COPD cost over $19,000 on average whereas hospitalizations unrelated to
COPD had an average cost below $4,000 (Menzin, 2008). Mitigation of COPD
readmissions and subsequent complications therefore has potential for
substantial improvement in patients’ quality of life, care quality, as well as
cost savings to Medicare. CDC. "Faststats: Chronic Obstructive Pulmonary Disease
(COPD) Includes: Chronic Bronchitis and Emphysema." Centers for Disease Control
and Prevention, 2017 https://www.cdc.gov/nchs/fastats/copd.htm. “Data Book:
Health Care Spending and the Medicare Program.” MedPAC, 2017 Menzin, J., L.
Boulanger, J. Marton, L. Guadagno, H. Dastani, R. Dirani, A. Phillips, and H.
Shah. "The Economic Burden of Chronic Obstructive Pulmonary Disease (COPD) in a
U.S. Medicare Population." [In Eng]. Respir Med 102, no. 9 (Sep 2008): 1248-56.
“National Health Expenditure Projections, 2017-2026.” US Centers for Medicare
& Medicaid Services, 2018. NHLBI. Morbidity & Mortality: 2012 Chart Book
on Cardiovascular, Lung, and Blood Diseases. Edited by National Institutes of
Health: National Heart, Lung, and Blood Institute, 2012. Vogelmeier, C. F., G.
J. Criner, F. J. Martinez, A. Anzueto, P. J. Barnes, J. Bourbeau, B. R. Celli,
et al. "Global Strategy for the Diagnosis, Management, and Prevention of Chronic
Obstructive Lung Disease 2017 Report. Gold Executive Summary." [In Eng]. Am J
Respir Crit Care Med 195, no. 5 (Mar 01 2017): 557-82.
Measure Specifications This measure's specifications have
been modified. Please consult this Document
for more information.
- NQF Number (if applicable):
- Description: The Femoral or Inguinal Hernia Repair Measure is
meant to apply to clinicians who perform this procedure for Medicare
beneficiaries. This procedural episode captures patients who undergo a femoral
or inguinal hernia repair procedure. The measure evaluates a clinician’s
risk-adjusted cost for the episode group by averaging it across all episodes
attributed to the clinician during the performance period. The cost of each
episode is the sum of the cost to Medicare for assigned services performed by
the attributed clinician and other healthcare providers during the episode
window.
- Numerator: The numerator for the Femoral or Inguinal Hernia
Repair measure is the sum of the ratio of observed to expected
payment-standardized cost to Medicare for all episodes attributed to a
clinician. This sum is then multiplied by the national average observed
episode cost to generate a dollar figure. Mathematically, this is represented
as: sum of (observed episode cost/expected episode cost) * national average
observed cost.
- Denominator: The denominator for the Femoral or Inguinal Hernia
Repair measure is the total number of episodes from this episode group
attributed to a clinician.
- Exclusions: The following episode-level exclusions apply: (a)
The beneficiary has a primary payer other than Medicare for any amount of time
overlapping the episode window or in the lookback period. (b) No attributed
clinician is found for the episode. (c) The beneficiary’s date of birth is
missing. (d) The beneficiary’s death date occurred before the episode ended.
(e) The beneficiary was not enrolled in Medicare Part A and B for the entirety
of the lookback period plus episode window, or is enrolled in Part C for any
part of the lookback period plus episode window. (f) The episode trigger
claim was not performed in an office, IP, OP, or ASC setting based on its
place of service. Exclusions specific to the Femoral or Inguinal Hernia
Repair measure are developed with input from the Gastrointestinal Disease
Management Clinical Subcommittee.
- HHS NQS Priority: Make Care Affordable
- HHS Data Source: Claims
- Measure Type: Cost/Resource Use
- Steward: Centers for Medicare & Medicaid
Services
- Endorsement Status:
- Meaningful Measure Area: Patient-focused Episode of
Care
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Preliminary analysis summary
- Contribution to program measure set:This measure assesses the
cost of services performed by providers during the patient-focused episode
of care.
- Impact on quality of care for patients:This measure is a cost
and resource use measure. This measure should be submitted to NQF for
review and endorsement .
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of making care affordable and specifically
addresses a patient-focused episode of care.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. The measure is a newly developed cost
measure. Health expenditures continue to increase in the United States.
According to the National Health Expenditure Accounts, total health care
spending increased by 4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018).
Medicare spending, which is still predominantly paid on a fee-for-service
(FFS) basis, also grew 3.6 percent, reaching $672.1 billion (CMS,
2018)
- Does the measure address a quality challenge? Yes. Policymakers
contend that an estimated 80 percent of overall health care costs are
attributable to decisions made by clinicians (Fred, 2016). However, these same
clinicians are often unaware of how their care decisions influence the overall
costs of care. One of the goals for using cost measures is to help inform
clinicians on the costs attributable to their decision making, as well as the
total cost of their patient’s care.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of other measures in the program and the measure
captures a broad population. This measure is new and is not in use in any
program.
- Can the measure can be feasibly reported? Yes. This is a
claims-based measure.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? No. This measure is fully developed and has completed
field testing (see supplemental document with updates to the MUC list)This is
a new measure that has not been submitted for NQF endorsement.
- Measure development status: Early Development; Field
Testing
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The measure is not in current use. The
developer considered the potential adverse effects of making unfair
comparisons among certain types of clinicians in assessing cost measure
performance, and/or rewarding lower costs without appropriately balancing
performance on quality.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measure is not in use. During development, the developer considered the
potential adverse events of reducing access to care and stinting care.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Health
expenditures continue to increase in the United States. According to the
National Health Expenditure Accounts, total health care spending increased by
4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018). Medicare spending,
which is still predominantly paid on a fee-for-service (FFS) basis, also grew
3.6 percent, reaching $672.1 billion (CMS, 2018). However, this growth is slower
than the previous two years due to a slow growth in spending for both Medicare
FFS and Medicare Advantage. In the United States, Medicare is the largest single
purchaser of health care, and successfully establishing payment models under
MIPS can have significant impacts on reducing costs and making care more
affordable (MedPAC, 2017). Treating abdominal wall hernias, including femoral
and inguinal hernias, is a common procedure. In the US, more than 1 million
abdominal wall hernias are treated and or repaired annually, the majority of
which are inguinal hernias (Matthews & Neumayer, 2008). On average, these
hernia repair procedures cost approximately $2000 to $2500, representing nearly
$2.5 billion in annual health care costs (Rutkow, 2003). Inguinal hernia repair
remains one of the most performed surgical operations around the world and is a
common surgical problem for older patients (Sanjay et al., 2011). Femoral or
inguinal hernia repair has been shown to be safe for elderly patients, despite
some surgeon reluctance to offer the procedure to elderly patients due to
concerns of increased risk (Kurzer et al., 2009; Sinha et al., 2017; Wu et al.,
2017). Cost calculations for hernia are confounded by the many surgical and
anesthesia treatment options available, according to the International
Guidelines for Groin Hernia Management (2018). Open procedures have been found
to be less costly than laparoscopic procedures in some instances (Smink et al.,
2009) “Data Book: Health Care Spending and the Medicare Program.” MedPAC, 2017
"International Guidelines for Groin Hernia Management." Hernia: The Journal Of
Hernias And Abdominal Wall Surgery 22, no. 1 (2018): 1-165. Kurzer, M., A. Kark,
and S. T. Hussain. "Day-Case Inguinal Hernia Repair in the Elderly: A Surgical
Priority." Hernia: The Journal Of Hernias And Abdominal Wall Surgery 13, no. 2
(2009): 131-36. Matthews, R. Douglas and Leigh Neumayer. "Inguinal Hernia in the
21st Century: An Evidence-Based Review." Current Problems In Surgery 45, no. 4
(2008): 257-59. “National Health Expenditure Projections, 2017-2026.” US Centers
for Medicare & Medicaid Services, 2018. Rutkow, Ira M. "Demographic and
Socioeconomic Aspects of Hernia Repair in the United States in 2003." The
Surgical Clinics Of North America 83, no. 5 (2003): 1045. Sanjay, Pandanaboyana,
Heather Leaver, Irshad Shaikh, and Alan Woodward. "Lichtenstein Hernia Repair
under Different Anaesthetic Techniques with Special Emphasis on Outcomes in
Older People." Australasian Journal on Ageing 30, no. 2 (2011): 93-97. Sinha,
Surajit, G. Srinivas, J. Montgomery, and D. DeFriend. "Outcome of Day-Case
Inguinal Hernia in Elderly Patients: How Safe Is It?". Hernia: The Journal Of
Hernias And Abdominal Wall Surgery 11, no. 3 (2007): 253-56. Smink, Douglas S.,
Ian M. Paquette, and Samuel R. G. Finlayson. "Utilization of Laparoscopic and
Open Inguinal Hernia Repair: A Population-Based Analysis." Journal Of
Laparoendoscopic & Advanced Surgical Techniques. Part A 19, no. 6 (2009):
745-48. Wu, J. J., B. C. Baldwin, E. Goldwater, and T. C. Counihan. "Should We
Perform Elective Inguinal Hernia Repair in the Elderly?". Hernia: The Journal Of
Hernias And Abdominal Wall Surgery 21, no. 1 (2017): 51-57.
Measure Specifications This measure's specifications have
been modified. Please consult this Document
for more information.
- NQF Number (if applicable):
- Description: The Lumbar Spine Fusion for Degenerative Disease,
1-3 Levels Measure is meant to apply to clinicians who perform this procedure
for Medicare beneficiaries. This procedural episode captures patients who
undergo a lumbar spinal fusion surgery. The measure evaluates a clinician’s
risk-adjusted cost for the episode group by averaging it across all episodes
attributed to the clinician during the performance period. The cost of each
episode is the sum of the cost to Medicare for assigned services performed by
the attributed clinician and other healthcare providers during the episode
window.
- Numerator: The numerator for the Lumbar Spine Fusion for
Degenerative Disease, 1-3 Levels measure is the sum of the ratio of observed
to expected payment-standardized cost to Medicare for all episodes attributed
to a clinician. This sum is then multiplied by the national average observed
episode cost to generate a dollar figure. Mathematically, this is represented
as: sum of (observed episode cost/expected episode cost) * national average
observed cost.
- Denominator: The denominator for the Lumbar Spine Fusion for
Degenerative Disease, 1-3 Levels measure is the total number of episodes from
this episode group attributed to a clinician.
- Exclusions: The following episode-level exclusions apply: (a)
The beneficiary has a primary payer other than Medicare for any amount of time
overlapping the episode window or in the lookback period. (b) No attributed
clinician is found for the episode. (c) The beneficiary’s date of birth is
missing. (d) The beneficiary’s death date occurred before the episode ended.
(e) The beneficiary was not enrolled in Medicare Part A and B for the entirety
of the lookback period plus episode window, or is enrolled in Part C for any
part of the lookback period plus episode window. (f) The episode trigger
claim was not performed in an office, IP, OP, or ASC setting based on its
place of service. Exclusions specific to the Lumbar Spine Fusion for
Degenerative Disease, 1-3 Levels measure are developed with input from the
Musculoskeletal Disease Management - Spine Clinical Subcommittee.
- HHS NQS Priority: Make Care Affordable
- HHS Data Source: Claims
- Measure Type: Cost/Resource Use
- Steward: Centers for Medicare & Medicaid
Services
- Endorsement Status:
- Meaningful Measure Area: Patient-focused Episode of
Care
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Preliminary analysis summary
- Contribution to program measure set:This measure assesses the
cost of services performed by providers during the patient-focused episode
of care.
- Impact on quality of care for patients:This measure is a cost
and resource use measure. This measure should be submitted to NQF for
review and endorsement .
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of making care affordable and specifically
addresses a patient-focused episode of care.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. The measure is a newly developed cost
measure. Health expenditures continue to increase in the United States.
According to the National Health Expenditure Accounts, total health care
spending increased by 4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018).
Medicare spending, which is still predominantly paid on a fee-for-service
(FFS) basis, also grew 3.6 percent, reaching $672.1 billion (CMS,
2018)
- Does the measure address a quality challenge? Yes. Policymakers
contend that an estimated 80 percent of overall health care costs are
attributable to decisions made by clinicians (Fred, 2016). However, these same
clinicians are often unaware of how their care decisions influence the overall
costs of care. One of the goals for using cost measures is to help inform
clinicians on the costs attributable to their decision making, as well as the
total cost of their patient’s care.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of other measures in the program and the measure
captures a broad population. This measure is new and is not in use in any
program.
- Can the measure can be feasibly reported? Yes. This is a
claims-based measure.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? No. This measure is fully developed and has completed
field testing (see supplemental document with updates to the MUC list)This is
a new measure that has not been submitted for NQF endorsement.
- Measure development status: Early Development; Field
Testing
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The measure is not in current use. The
developer considered the potential adverse effects of making unfair
comparisons among certain types of clinicians in assessing cost measure
performance, and/or rewarding lower costs without appropriately balancing
performance on quality.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measure is not in use. During development, the developer considered the
potential adverse events of reducing access to care and stinting care.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Health
expenditures continue to increase in the United States. According to the
National Health Expenditure Accounts, total health care spending increased by
4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018). Medicare spending,
which is still predominantly paid on a fee-for-service (FFS) basis, also grew by
3.6 percent, reaching $672.1 billion (CMS, 2018). However, this growth is slower
than the previous two years due to a slow growth in spending for both Medicare
FFS and Medicare Advantage. In the United States, Medicare is the largest single
purchaser of health care, and successfully establishing payment models under
MIPS can have significant impacts on reducing costs and making care more
affordable (MedPAC, 2017). Lower back pain is the most common medical problem
worldwide and the top cause of years lived with disability, with over 600,000
cases in 2013, a 56.75 percent increase from 1990 (Global Burden of Disease,
2015). Common conditions responsible for lower back pain include: degenerative
disk disease, spondylolysis, spondylolisthesis, trauma and spinal stenosis.
Surgery is one of several options to consider for older patients with
symptomatic lumbar spine disease that causes lower back pain. Between 2006 and
2012, over 6 million Medicare patients were diagnosed with lumbar degenerative
conditions (Buser et al., 2017), and lumbar spine procedures are increasingly
used in elderly patients to treat these conditions. For example, lumbar fusion
rates have increased from 0.3 per 1000 Medicare beneficiaries in 1992 to 1.1 per
1000 in 2003 (Puvanesarajah, 2016). One study found that 5.9 per 100 patients
progressed to lumbar fusion within 1 year, and there was an increase of 18.5
percent in the incidence of fusion procedures within 1 year of diagnosis between
2006 and 2011, with the age group 65 to 69 having the highest incidence (Buser
et al., 2017). Furthermore, the 65 to 69 years age group also had the highest
incidence of patients that underwent fusion within 1 year of diagnosis, while
patients 80 to 84 and greater than 85 years of age had the greatest relative
increase in fusion incidence between 2008 and 2011 (Buser et al., 2017). The
cost of lumbar fusion has also increased, as noted by a 2012 study looking at
the trends in spinal fusion from 1998 to 2008, where the cost per case increased
from $24,676 to $81,960 (Rajaee et al., 2012). Based on a review of the Medicare
Provider Analysis and Review file, total spending on lumbar spinal fusion
surgery is also one of the highest admission outlays in the Medicare program,
costing over $3.6 billion dollars in 2013 (Culler et al., 2016). Buser, Z., B.
Ortega, A. D'Oro, W. Pannell, J. R. Cohen, J. Wang, R. Golish, M. Reed, and J.
C. Wang. "Spine Degenerative Conditions and Their Treatments: National Trends in
the United States of America." [In eng]. Global Spine J 8, no. 1 (Feb 2018):
57-67. Culler, S. D., D. S. Jevsevar, K. G. Shea, K. J. McGuire, M. Schlosser,
K. K. Wright, and A. W. Simon. "Incremental Hospital Cost and Length-of-Stay
Associated with Treating Adverse Events among Medicare Beneficiaries Undergoing
Lumbar Spinal Fusion During Fiscal Year 2013." [In eng]. Spine (Phila Pa 1976)
41, no. 20 (Oct 15 2016): 1613-20. “Data Book: Health Care Spending and the
Medicare Program.” MedPAC, 2017. "Global, Regional, and National Incidence,
Prevalence, and Years Lived with Disability for 301 Acute and Chronic Diseases
and Injuries in 188 Countries, 1990-2013: A Systematic Analysis for the Global
Burden of Disease Study 2013." [In eng]. Lancet 386, no. 9995 (Aug 22 2015):
743-800. “National Health Expenditure Projections, 2017-2026.” US Centers for
Medicare & Medicaid Services, 2018. Puvanesarajah, V., B. C. Werner, J. M.
Cancienne, A. Jain, H. Pehlivan, A. L. Shimer, A. Singla, F. Shen, and H.
Hassanzadeh. "Morbid Obesity and Lumbar Fusion in Patients Older Than 65 Years:
Complications, Readmissions, Costs, and Length of Stay." [In eng]. Spine (Phila
Pa 1976) 42, no. 2 (Jan 15 2017): 122-27. Rajaee, S. S., H. W. Bae, L. E. Kanim,
and R. B. Delamarter. "Spinal Fusion in the United States: Analysis of Trends
from 1998 to 2008." [In eng]. Spine (Phila Pa 1976) 37, no. 1 (Jan 1 2012):
67-76.
Measure Specifications This measure's specifications have
been modified. Please consult this Document
for more information.
- NQF Number (if applicable):
- Description: The Psychoses/Related Conditions Measure is meant to
apply to clinicians who manage the inpatient care of Medicare beneficiaries
hospitalized with these conditions. This acute episode captures patients who
are treated for psychoses and related conditions. The measure evaluates a
clinician’s risk-adjusted cost for the episode group by averaging it across
all episodes attributed to the clinician during the performance period. The
cost of each episode is the sum of the cost to Medicare for assigned services
performed by the attributed clinician and other healthcare providers during
the episode window.
- Numerator: The numerator for the Psychoses/Related Conditions
measure is the sum of the ratio of observed to expected payment-standardized
cost to Medicare for all episodes attributed to a clinician. This sum is then
multiplied by the national average observed episode cost to generate a dollar
figure. Mathematically, this is represented as: sum of (observed episode
cost/expected episode cost) * national average observed cost.
- Denominator: The denominator for the Psychoses/Related Conditions
measure is the total number of episodes from this episode group attributed to
a clinician.
- Exclusions: The following episode-level exclusions apply: (a)
The beneficiary has a primary payer other than Medicare for any amount of time
overlapping the episode window or in the lookback period. (b) No attributed
clinician is found for the episode. (c) The beneficiary’s date of birth is
missing. (d) The beneficiary’s death date occurred before the episode ended.
(e) The beneficiary was not enrolled in Medicare Part A and B for the entirety
of the lookback period plus episode window, or is enrolled in Part C for any
part of the lookback period plus episode window. (f) The episode trigger
claim was not performed in an office, IP, OP, or ASC setting based on its
place of service. Exclusions specific to the Psychoses/Related Conditions
measure are developed with input from the Neuropsychiatric Disease Management
Clinical Subcommittee.
- HHS NQS Priority: Make Care Affordable
- HHS Data Source: Claims
- Measure Type: Cost/Resource Use
- Steward: Centers for Medicare & Medicaid
Services
- Endorsement Status:
- Meaningful Measure Area: Patient-focused Episode of
Care
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Preliminary analysis summary
- Contribution to program measure set:This measure assesses the
cost of services performed by providers during the patient-focused episode
of care.
- Impact on quality of care for patients:This measure is a cost
and resource use measure. This measure should be submitted to NQF for
review and endorsement .
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of making care affordable and specifically
addresses a patient-focused episode of care.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. The measure is a newly developed cost
measure. Health expenditures continue to increase in the United States.
According to the National Health Expenditure Accounts, total health care
spending increased by 4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018).
Medicare spending, which is still predominantly paid on a fee-for-service
(FFS) basis, also grew 3.6 percent, reaching $672.1 billion (CMS,
2018)
- Does the measure address a quality challenge? Yes. Policymakers
contend that an estimated 80 percent of overall health care costs are
attributable to decisions made by clinicians (Fred, 2016). However, these same
clinicians are often unaware of how their care decisions influence the overall
costs of care. One of the goals for using cost measures is to help inform
clinicians on the costs attributable to their decision making, as well as the
total cost of their patient’s care.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of other measures in the program and the measure
captures a broad population. This measure is new and is not in use in any
program.
- Can the measure can be feasibly reported? Yes. This is a
claims-based measure.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? No. This measure is fully developed and has completed
field testing (see supplemental document with updates to the MUC list)This is
a new measure that has not been submitted for NQF endorsement.
- Measure development status: Early Development; Field
Testing
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The measure is not in current use. The
developer considered the potential adverse effects of making unfair
comparisons among certain types of clinicians in assessing cost measure
performance, and/or rewarding lower costs without appropriately balancing
performance on quality.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measure is not in use. During development, the developer considered the
potential adverse events of reducing access to care and stinting care.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Health
expenditures continue to increase in the United States. According to the
National Health Expenditure Accounts, total health care spending increased by
4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018). Medicare spending,
which is still predominantly paid on a fee-for-service (FFS) basis, also grew
3.6 percent, reaching $672.1 billion (CMS, 2018). However, this growth is slower
than the previous two years due to a slow growth in spending for both Medicare
FFS and Medicare Advantage. In the United States, Medicare is the largest single
purchaser of health care, and successfully establishing payment models under
MIPS can have significant impacts on reducing costs and making care more
affordable (MedPAC, 2017). Psychotic disorders, which are associated with
disturbances in thought processing and behaviors that result in a loss of
contact with reality, occur throughout the lifespan. Chronic psychotic
disorders, including schizophrenia spectrum disorders, cause impairment in
social, self-care and/or occupational functioning, and are among the most
disabling disorders worldwide. Data from the 2010 Global Burden of Diseases,
Injuries, and Risk Factors Study shows that mental and substance use disorders
are the leading cause of years lived with disability. Despite being less
prevalent than other disorders, schizophrenia accounted for 7.4 percent of
disability-adjusted life years worldwide (Whiteford et al., 2013). Schizophrenia
is diagnosed in between 0.3 percent and 1.6 percent of the US population and is
one of the costliest mental illnesses, with treatment costs approximately double
than that for major depression disorder and quadruple that for anxiety disorders
(Desai et al., 2013; Zhu et al., 2008). Additionally, adults with schizophrenia
represent a greater percent of Medicare beneficiaries than the general adult US
population (approximately 1.5 percent and 1 percent, respectively) (Feldman et
al., 2014). The direct costs of treating schizophrenia in the US are estimated
to be between $33 and $65 billion annually, with inpatient services and
medication representing the largest proportion of the costs (Wilson et al.,
2011). Indirect costs represent a large cost burden as well and are estimated to
cost $18.68 billion annually, which includes costs associated with lost
productivity due to missed work, reduced employment and employability, premature
death, and caregivers’ costs (Desai et al., 2013). “Data Book: Health Care
Spending and the Medicare Program.” MedPAC, 2017 Desai, Pooja R., Kenneth A.
Lawson, Jamie C. Barner, and Karen L. Rascati. "Estimating the Direct and
Indirect Costs for Community-Dwelling Patients with Schizophrenia." Journal of
Pharmaceutical Health Services Research 4, no. 4 (2013): 187-94. Feldman,
Rachel, Robert A. Bailey, James Muller, Jennifer Le, and Riad Dirani. "Cost of
Schizophrenia in the Medicare Program." Population Health Management 17, no. 3
(2014): 190-96. “National Health Expenditure Projections, 2017-2026.” US Centers
for Medicare & Medicaid Services, 2018. Whiteford, Harvey A., Louisa
Degenhardt, Jürgen Rehm, Amanda J. Baxter, Alize J. Ferrari, Holly E. Erskine,
Fiona J. Charlson, et al. "Global Burden of Disease Attributable to Mental and
Substance Use Disorders: Findings from the Global Burden of Disease Study 2010."
The Lancet 382, no. 9904 (2013): 1575-86. Wilson, Leslie S., Gitlin, Matthew,
Lightwood, Jim. "Schizophrenia Costs for Newly Diagnosed Versus Previously
Diagnosed Patients." The American Journal of Pharmacy Benefits, vol. 3, no. 2,
2011, pp. 107-115. Zhu, Baojin, Haya Ascher-Svanum, Douglas E. Faries, Xiaomei
Peng, David Salkever, and Eric P. Slade. "Costs of Treating Patients with
Schizophrenia Who Have Illness-Related Crisis Events." BMC Psychiatry 8 (2008):
72-72.
Measure Specifications This measure's specifications have
been modified. Please consult this Document
for more information.
- NQF Number (if applicable):
- Description: The Lumpectomy, Partial Mastectomy, Simple
Mastectomy Measure is meant to apply to clinicians who perform these
procedures for Medicare beneficiaries. This procedural episode captures
patients who receive surgical treatment for breast cancer. The measure
evaluates a clinician’s risk-adjusted cost for the episode group by averaging
it across all episodes attributed to the clinician during the performance
period. The cost of each episode is the sum of the cost to Medicare for
assigned services performed by the attributed clinician and other healthcare
providers during the episode window.
- Numerator: The numerator for the Lumpectomy, Partial Mastectomy,
Simple Mastectomy measure is the sum of the ratio of observed to expected
payment-standardized cost to Medicare for all episodes attributed to a
clinician. This sum is then multiplied by the national average observed
episode cost to generate a dollar figure. Mathematically, this is represented
as: sum of (observed episode cost/expected episode cost) * national average
observed cost.
- Denominator: The denominator for the Lumpectomy, Partial
Mastectomy, Simple Mastectomy measure is the total number of episodes from
this episode group attributed to a clinician.
- Exclusions: The following episode-level exclusions apply: (a)
The beneficiary has a primary payer other than Medicare for any amount of time
overlapping the episode window or in the lookback period. (b) No attributed
clinician is found for the episode. (c) The beneficiary’s date of birth is
missing. (d) The beneficiary’s death date occurred before the episode ended.
(e) The beneficiary was not enrolled in Medicare Part A and B for the entirety
of the lookback period plus episode window, or is enrolled in Part C for any
part of the lookback period plus episode window. (f) The episode trigger
claim was not performed in an office, IP, OP, or ASC setting based on its
place of service. Exclusions specific to the Lumpectomy, Partial Mastectomy,
Simple Mastectomy measure are developed with input from the Oncologic Disease
Management - Medical, Radiation, and Surgical Clinical Subcommittee.
- HHS NQS Priority: Make Care Affordable
- HHS Data Source: Claims
- Measure Type: Cost/Resource Use
- Steward: Centers for Medicare & Medicaid
Services
- Endorsement Status:
- Meaningful Measure Area: Patient-focused Episode of
Care
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Preliminary analysis summary
- Contribution to program measure set:This measure assesses the
cost of services performed by providers during the patient-focused episode
of care.
- Impact on quality of care for patients:This measure is a cost
and resource use measure. This measure should be submitted to NQF for
review and endorsement .
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of making care affordable and specifically
addresses a patient-focused episode of care.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. The measure is a newly developed cost
measure. Health expenditures continue to increase in the United States.
According to the National Health Expenditure Accounts, total health care
spending increased by 4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018).
Medicare spending, which is still predominantly paid on a fee-for-service
(FFS) basis, also grew 3.6 percent, reaching $672.1 billion (CMS,
2018)
- Does the measure address a quality challenge? Yes. Policymakers
contend that an estimated 80 percent of overall health care costs are
attributable to decisions made by clinicians (Fred, 2016). However, these same
clinicians are often unaware of how their care decisions influence the overall
costs of care. One of the goals for using cost measures is to help inform
clinicians on the costs attributable to their decision making, as well as the
total cost of their patient’s care.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of other measures in the program and the measure
captures a broad population. This measure is new and is not in use in any
program.
- Can the measure can be feasibly reported? Yes. This is a
claims-based measure.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? No. This measure is fully developed and has completed
field testing (see supplemental document with updates to the MUC list)This is
a new measure that has not been submitted for NQF endorsement.
- Measure development status: Early Development; Field
Testing
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The measure is not in current use. The
developer considered the potential adverse effects of making unfair
comparisons among certain types of clinicians in assessing cost measure
performance, and/or rewarding lower costs without appropriately balancing
performance on quality.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measure is not in use. During development, the developer considered the
potential adverse events of reducing access to care and stinting care.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Health
expenditures continue to increase in the United States. According to the
National Health Expenditure Accounts, total health care spending increased by
4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018). Medicare spending,
which is still predominantly paid on a fee-for-service (FFS) basis, also grew
3.6 percent, reaching $672.1 billion (CMS, 2018). However, this growth is slower
than the previous two years due to a slow growth in spending for both Medicare
FFS and Medicare Advantage. In the United States, Medicare is the largest single
purchaser of health care, and successfully establishing payment models under
MIPS can have significant impacts on reducing costs and making care more
affordable (MedPAC, 2017). The American Cancer Society estimates that breast
cancer accounts for 29 percent of all new cancer diagnoses in women and has the
highest treatment costs among all cancer types; estimated at $16.5 billion in
2010 (Siegel et al., 2016, Greenup et al., 2017). Breast cancer is the second
most common cause of cancer mortality for women and surgery remains the primary
treatment modality. Furthermore, the adoption and use of screening mammography
has resulted in increased rates of detection of early-stage breast cancer and
increased demand for surgical intervention (Helvie et al., 2014). As such, the
surgical treatment of breast cancer including lumpectomy, partial mastectomy,
and simple mastectomy represent a significant economic burden (Al-Hilli et al.,
2015). Al-Hilli, Zahraa, Kristine M. Thomsen, Elizabeth B. Habermann, James W.
Jakub, and Judy C. Boughey. "Reoperation for Complications after Lumpectomy and
Mastectomy for Breast Cancer from the 2012 National Surgical Quality Improvement
Program (Acs-Nsqip)." Annals Of Surgical Oncology 22 Suppl 3 (2015): S459-S69.
“Data Book: Health Care Spending and the Medicare Program.” MedPAC, 2017.
Greenup, Rachel A., Rachel C. Blitzblau, Kevin L. Houck, Julie Ann Sosa, Janet
Horton, Jeffrey M. Peppercorn, Alphonse G. Taghian, Barbara L. Smith, and E.
Shelley Hwang. "Cost Implications of an Evidence-Based Approach to Radiation
Treatment after Lumpectomy for Early-Stage Breast Cancer." Journal Of Oncology
Practice 13, no. 4 (2017): e283-e90. Helvie, Mark A., Joanne T. Chang, R. Edward
Hendrick, and Mousumi Banerjee. "Reduction in Late-Stage Breast Cancer Incidence
in the Mammography Era: Implications for Overdiagnosis of Invasive Cancer."
Cancer 120, no. 17 (2014): 2649-56. “National Health Expenditure Projections,
2017-2026.” US Centers for Medicare & Medicaid Services, 2018. Siegel,
Rebecca L., Kimberly D. Miller, and Ahmedin Jemal. "Cancer Statistics, 2016."
CA: A Cancer Journal For Clinicians 66, no. 1 (2016): 7-30.
Measure Specifications This measure's specifications have
been modified. Please consult this Document
for more information.
- NQF Number (if applicable):
- Description: The Acute Kidney Injury (AKI) Requiring New
Inpatient Dialysis Measure is meant to apply to clinicians who supervise
dialysis procedures for AKI Medicare beneficiaries. This acute episode
captures patients previously not dependent on dialysis who undergo AKI
dialysis. The measure evaluates a clinician’s risk-adjusted cost for the
episode group by averaging it across all episodes attributed to the clinician
during the performance period. The cost of each episode is the sum of the cost
to Medicare for assigned services performed by the attributed clinician and
other healthcare providers during the episode window.
- Numerator: The numerator for the Acute Kidney Injury Requiring
New Inpatient Dialysis measure is the sum of the ratio of observed to expected
payment-standardized cost to Medicare for all episodes attributed to a
clinician. This sum is then multiplied by the national average observed
episode cost to generate a dollar figure. Mathematically, this is represented
as: sum of (observed episode cost/expected episode cost) * national average
observed cost.
- Denominator: The denominator for the Acute Kidney Injury
Requiring New Inpatient Dialysis measure is the total number of episodes from
this episode group attributed to a clinician.
- Exclusions: The following episode-level exclusions apply: (a)
The beneficiary has a primary payer other than Medicare for any amount of time
overlapping the episode window or in the lookback period. (b) No attributed
clinician is found for the episode. (c) The beneficiary’s date of birth is
missing. (d) The beneficiary’s death date occurred before the episode ended.
(e) The beneficiary was not enrolled in Medicare Part A and B for the entirety
of the lookback period plus episode window, or is enrolled in Part C for any
part of the lookback period plus episode window. (f) The episode trigger
claim was not performed in an office, IP, OP, or ASC setting based on its
place of service. Exclusions specific to the AKI Requiring New Inpatient
Dialysis measure are developed with input from the Renal Disease Management
Clinical Subcommittee.
- HHS NQS Priority: Make Care Affordable
- HHS Data Source: Claims
- Measure Type: Cost/Resource Use
- Steward: Centers for Medicare & Medicaid
Services
- Endorsement Status:
- Meaningful Measure Area: Patient-focused Episode of
Care
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Preliminary analysis summary
- Contribution to program measure set:This measure assesses the
cost of services performed by providers during the patient-focused episode
of care.
- Impact on quality of care for patients:This measure is a cost
and resource use measure. This measure should be submitted to NQF for
review and endorsement .
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of making care affordable and specifically
addresses a patient-focused episode of care.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. The measure is a newly developed cost
measure. Health expenditures continue to increase in the United States.
According to the National Health Expenditure Accounts, total health care
spending increased by 4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018).
Medicare spending, which is still predominantly paid on a fee-for-service
(FFS) basis, also grew 3.6 percent, reaching $672.1 billion (CMS,
2018)
- Does the measure address a quality challenge? Yes. Policymakers
contend that an estimated 80 percent of overall health care costs are
attributable to decisions made by clinicians (Fred, 2016). However, these same
clinicians are often unaware of how their care decisions influence the overall
costs of care. One of the goals for using cost measures is to help inform
clinicians on the costs attributable to their decision making, as well as the
total cost of their patient’s care.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of other measures in the program and the measure
captures a broad population. This measure is new and is not in use in any
program.
- Can the measure can be feasibly reported? Yes. This is a
claims-based measure.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? No. This measure is fully developed and has completed
field testing (see supplemental document with updates to the MUC list)This is
a new measure that has not been submitted for NQF endorsement.
- Measure development status: Early Development; Field
Testing
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The measure is not in current use. The
developer considered the potential adverse effects of making unfair
comparisons among certain types of clinicians in assessing cost measure
performance, and/or rewarding lower costs without appropriately balancing
performance on quality.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measure is not in use. During development, the developer considered the
potential adverse events of reducing access to care and stinting care.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Health
expenditures continue to increase in the United States. According to the
National Health Expenditure Accounts, total health care spending increased by
4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018). Medicare spending,
which is still predominantly paid on a fee-for-service (FFS) basis, also grew
3.6 percent, reaching $672.1 billion (CMS, 2018). However, this growth is slower
than the previous two years due to a slow growth in spending for both Medicare
FFS and Medicare Advantage. In the United States, Medicare is the largest single
purchaser of health care, and successfully establishing payment models under
MIPS can have significant impacts on reducing costs and making care more
affordable (MedPAC, 2017). AKI is one of the most serious complications among
hospitalized patients. It is associated with a significant number of acute and
chronic conditions, worse operative outcomes, increased mortality, and high
resource utilization (Lysak et al., 2017; Hsu et al., 2016). The severity of AKI
is associated with worse outcomes, and negatively affects length of stay,
resource use, and in-hospital and post-discharge costs. The annual expenditure
of hospital-based AKI exceeds $10 billion, and each year there is approximately
600,000 cases of AKI (Lysak et al., 2017; Chawla et al., 2011). From 2000 to
2014, hospitalization rates for dialysis-requiring AKI increased by 57% among
adults with diagnosed diabetes and by 64% among adults without diagnosed
diabetes (Pavkov et al., 2018). In 2015, 4.3 percent of Medicare beneficiaries
experienced a hospitalization complicated by AKI (USRDS, 2017). Older patients
in particular have higher rates for poor outcomes, including a greater chance of
nonrecovery renal function upon discharge after treatment (Coca et al., 2011).
In 2009, the inpatient case fatality rate for a single episode of AKI-D was 23.5
percent (Hsu et al., 2012). Therefore, developing a measure that leads to
improved care for, or prevention of, AKI-D could lead to significant cost
savings. Chawla, Lakhmir S, Richard L Amdur, Susan Amodeo, Paul L Kimmel, and
Carlos E Palant. “The Severity of Acute Kidney Injury Predicts Progression to
Chronic Kidney Disease.” Kidney International, vol. 79, no. 12, 2011, pp.
1361-1369. Coca, Steven G, Kerry C Cho, and Chi-yuan Hsu. “Acute Kidney Injury
in the Elderly: Predisposition to Chronic Kidney Diseases and Vice Versa.”
Nephron Clinical Practice, vol. 119, 2011, pp. c19-c24. “Data Book: Health Care
Spending and the Medicare Program.” MedPAC, 2017 Hsu, Raymond K, Charles E
McCulloch, Michael Heung, Rajiv Saran, Vahakn B Shahinian, Meda E Pavkov, Nilka
Ríos Burrows, Neil R Powe, and Chi-yuan Hsu, for the Centers for Disease Control
and Prevention Chronic Kidney Disease Surveillance Team. “Exploring Potential
Reasons for the Temporal Trend in Dialysis-Requiring AKI in the United States.”
The Clinical Journal of the American Society of Nephrology, vol. 11, no. 1,
2016, pp. 14-20. Hsu, Raymond K, Charles E McCulloch, R Adams Dudley, Lowell J
Lo, and Chi-yuan Hsu. “Temporal Changes in incidence of Dialysis-Requiring AKI.”
Journal of the American Society of Nephrology, vol. 24, no. 1, 2012, pp. 37-42
Lysak, Nicholas, Azra Bihorac, and Charles Hobson. “Mortality and Cost of Acute
and Chronic Kidney Disease After Cardiac Surgery.” Current Opinion in
Anesthesiology, vol. 30, no. 1, 2017, pp. 113-117. “National Health Expenditure
Projections, 2017-2026.” US Centers for Medicare & Medicaid Services, 2018.
Pavkov, Meda E, Jessica L. Harding, and Nilka Ríos Burrows. “Trends in
Hospitalizations for Acute Kidney Injury — United States, 2000–2014.” MMWR Morb
Mortal Wkly Rep, vol. 67, no. 10, 2018, pp. 289–293. United States Renal Data
System. 2017 USRDS annual data report: Epidemiology of kidney disease in the
United States. National Institutes of Health, National Institute of Diabetes and
Digestive and Kidney Diseases, Bethesda, MD, 2017.
Measure Specifications This measure's specifications have
been modified. Please consult this Document
for more information.
- NQF Number (if applicable):
- Description: The Lower Gastrointestinal Hemorrhage Measure is
meant to apply to clinicians who manage the inpatient care of Medicare
beneficiaries hospitalized for acute lower gastrointestinal hemorrhage. This
acute episode captures patients hospitalized for acute lower gastrointestinal
hemorrhage. The measure evaluates a clinician’s risk-adjusted cost for the
episode group by averaging it across all episodes attributed to the clinician
during the performance period. The cost of each episode is the sum of the cost
to Medicare for assigned services performed by the attributed clinician and
other healthcare providers during the episode window.
- Numerator: The numerator for the Lower Gastrointestinal
Hemorrhage measure is the sum of the ratio of observed to expected
payment-standardized cost to Medicare for all episodes attributed to a
clinician. This sum is then multiplied by the national average observed
episode cost to generate a dollar figure. Mathematically, this is represented
as: sum of (observed episode cost/expected episode cost) * national average
observed cost.
- Denominator: The denominator for the Lower Gastrointestinal
Hemorrhage measure is the total number of episodes from this episode group
attributed to a clinician.
- Exclusions: The following episode-level exclusions apply: (a)
The beneficiary has a primary payer other than Medicare for any amount of time
overlapping the episode window or in the lookback period. (b) No attributed
clinician is found for the episode. (c) The beneficiary’s date of birth is
missing. (d) The beneficiary’s death date occurred before the episode ended.
(e) The beneficiary was not enrolled in Medicare Part A and B for the entirety
of the lookback period plus episode window, or is enrolled in Part C for any
part of the lookback period plus episode window. (f) The episode trigger
claim was not performed in an office, IP, OP, or ASC setting based on its
place of service. Exclusions specific to the Lower Gastrointestinal
Hemorrhage measure are developed with input from the Gastrointestinal Disease
Management Clinical Subcommittee.
- HHS NQS Priority: Make Care Affordable
- HHS Data Source: Claims
- Measure Type: Cost/Resource Use
- Steward: Centers for Medicare & Medicaid
Services
- Endorsement Status:
- Meaningful Measure Area: Patient-focused Episode of
Care
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Preliminary analysis summary
- Contribution to program measure set:This measure assesses the
cost of services performed by providers during the patient-focused episode
of care.
- Impact on quality of care for patients:This measure is a cost
and resource use measure. This measure should be submitted to NQF for
review and endorsement .
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of making care affordable and specifically
addresses a patient-focused episode of care.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. The measure is a newly developed cost
measure. Health expenditures continue to increase in the United States.
According to the National Health Expenditure Accounts, total health care
spending increased by 4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018).
Medicare spending, which is still predominantly paid on a fee-for-service
(FFS) basis, also grew 3.6 percent, reaching $672.1 billion (CMS,
2018)
- Does the measure address a quality challenge? Yes. Policymakers
contend that an estimated 80 percent of overall health care costs are
attributable to decisions made by clinicians (Fred, 2016). However, these same
clinicians are often unaware of how their care decisions influence the overall
costs of care. One of the goals for using cost measures is to help inform
clinicians on the costs attributable to their decision making, as well as the
total cost of their patient’s care.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of other measures in the program and the measure
captures a broad population. This measure is new and is not in use in any
program.
- Can the measure can be feasibly reported? Yes. This is a
claims-based measure.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? No. This measure is fully developed and has completed
field testing (see supplemental document with updates to the MUC list)This is
a new measure that has not been submitted for NQF endorsement.
- Measure development status: Early Development; Field
Testing
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The measure is not in current use. The
developer considered the potential adverse effects of making unfair
comparisons among certain types of clinicians in assessing cost measure
performance, and/or rewarding lower costs without appropriately balancing
performance on quality.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measure is not in use. During development, the developer considered the
potential adverse events of reducing access to care and stinting care.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Health
expenditures continue to increase in the United States. According to the
National Health Expenditure Accounts, total health care spending increased by
4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018). Medicare spending,
which is still predominantly paid on a fee-for-service (FFS) basis, also grew
3.6 percent, reaching $672.1 billion (CMS, 2018). However, this growth is slower
than the previous two years due to a slow growth in spending for both Medicare
FFS and Medicare Advantage. In the United States, Medicare is the largest single
purchaser of health care, and successfully establishing payment models under
MIPS can have significant impacts on reducing costs and making care more
affordable (MedPAC, 2017). Gastrointestinal (GI) diseases are highly prevalent,
costly, and utilize a significant amount of health care resources, especially in
the Medicare population (Peery et al., 2015). Gastrointestinal bleeding is the
most common cause of hospitalizations for gastrointestinal diseases, and over
500,000 patients are hospitalized annually for GI bleeds (Gralnek & Strate,
2017; Strate & Gralnek, 2016). Lower gastrointestinal bleeding (LGIB) is
responsible for approximately 30-40 percent of all GI bleeding cases, with an
incidence of around 36 per 100,000 persons (Gralnek & Strate, 2016; Parekh
et al., 2014). Typically, bleeding resolves spontaneously for most patients with
LGIB. However, tests and procedures to determine the bleeding source, as well as
preventative treatments, may still be initiated to mitigate the risk for future
catastrophic bleeding episodes (Gralnek & Strate, 2016). Patients who
experience LGIB without spontaneous resolution are at risk for significant
complications, including severe hemodynamic compromise, which may necessitate
urgent and aggressive resuscitation and intervention measures. Morbidity and
mortality also increase significantly for patients who are older and for those
with preexisting medical conditions, leading to higher costs and resource use,
particularly for Medicare patients (Jansen et al, 2009). The three most common
causes of LGIB are diverticulosis, vascular ectasia, and hemorrhoids (Ghassemi
& Jensen, 2013). On average, $33,630 is spent per Medicare patient for
further evaluation of obscure GI bleeding (OGIB) (Parekh et al., 2014).
Diverticular disease as a whole is responsible for around 300,000
hospitalizations annually, costing the United States approximately 2.6 billion
dollars per year (Papageorge et al., 2016). Ghassemi, Kevin A and Dennis M
Jensen. “Lower GI Bleeding: Epidemiology and Management.” Current
Gastroenterology Reports vol. 15, no. 7, 2013. Gralnek, Ian M, Ziv Neeman, and
Lisa L Strate. “Acute Lower Gastrointestinal Bleeding.” The New England Journal
of Medicine, no. 376, 2017, pp. 1054-1063. “Data Book: Health Care Spending and
the Medicare Program.” MedPAC, 2017 Jansen, Antje, Sabine Harenberg, Uwe Grenda,
and Christoph Elsing. “Risk Factors for Colonic Diverticular Bleeding: A
Westernized Community Based Hospital Study.” World Journal of Gastroenterology,
vol. 15, no. 4, 2009, pp. 457-461. Papageorge, Christina M, Gregory D Kennedy,
and Evie H Carchman. “National Trends in Short-term Outcomes Following
Non-emergent Surgery for Diverticular Disease.” Journal of Gastrointestinal
Surgery, vol. 20, 2016, pp. 1376-1387. Parekh, Parth J, Ross C Buerlein, Rouzbeh
Shams, Harlan Vingan, and David A Johnson. “Evaluation of Gastrointestinal
Bleeding: Update of Current Radiologic Strategies.” World Journal of
Gastrointestinal Pharmacology and Therapeutics, vol. 5, no. 4, 2014, pp.
200-208. Peery, Ann F, Seth D Crockett, Alfred S Barrit, Evan S Dellon, Swathi
Eluri, Lisa M Gangarosa, Elizabeth T Jensen, Jennifer L Lund, Sarina Pasricha,
Thomas Runge, Monica Schmidt, Nicholas J Shaheen, and Robert S Sandler. “Burden
of Gastrointestinal, Liver, and Pancreatic Diseases in the United States.”
Gastroenterology, vol. 149, no. 7, 2015, pp. 1731-1741. “National Health
Expenditure Projections, 2017-2026.” US Centers for Medicare & Medicaid
Services, 2018. Strate, Lisa L and Ian M Gralnek. “ACG Clinical Guideline:
Management of Patients with Acute Lower Gastrointestinal Bleeding.” The American
Journal of Gastroenterology, vol. 111, 2016, pp. 459-474.
Measure Specifications This measure's specifications have
been modified. Please consult this Document
for more information.
- NQF Number (if applicable):
- Description: The Renal or Ureteral Stone Surgical Treatment
Measure is meant to apply to clinicians who perform this procedure for
Medicare beneficiaries. This procedural episode captures patients who receive
surgical treatment for renal or ureteral stones. The measure evaluates a
clinician’s risk-adjusted cost for the episode group by averaging it across
all episodes attributed to the clinician during the performance period. The
cost of each episode is the sum of the cost to Medicare for assigned services
performed by the attributed clinician and other healthcare providers during
the episode window.
- Numerator: The numerator for the Renal or Ureteral Stone Surgical
Treatment measure is the sum of the ratio of observed to expected
payment-standardized cost to Medicare for all episodes attributed to a
clinician. This sum is then multiplied by the national average observed
episode cost to generate a dollar figure. Mathematically, this is represented
as: sum of (observed episode cost/expected episode cost) * national average
observed cost.
- Denominator: The denominator for the Renal or Ureteral Stone
Surgical Treatment measure is the total number of episodes from this episode
group attributed to a clinician.
- Exclusions: The following episode-level exclusions apply: (a)
The beneficiary has a primary payer other than Medicare for any amount of time
overlapping the episode window or in the lookback period. (b) No attributed
clinician is found for the episode. (c) The beneficiary’s date of birth is
missing. (d) The beneficiary’s death date occurred before the episode ended.
(e) The beneficiary was not enrolled in Medicare Part A and B for the entirety
of the lookback period plus episode window, or is enrolled in Part C for any
part of the lookback period plus episode window. (f) The episode trigger
claim was not performed in an office, IP, OP, or ASC setting based on its
place of service. Exclusions specific to the Renal or Ureteral Stone Surgical
Treatment measure are developed with input from the Urologic Disease
Management Clinical Subcommittee.
- HHS NQS Priority: Make Care Affordable
- HHS Data Source: Claims
- Measure Type: Cost/Resource Use
- Steward: Centers for Medicare & Medicaid
Services
- Endorsement Status:
- Meaningful Measure Area: Patient-focused Episode of
Care
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Preliminary analysis summary
- Contribution to program measure set:This measure assesses the
cost of services performed by providers during the patient-focused episode
of care.
- Impact on quality of care for patients:This measure is a cost
and resource use measure. This measure should be submitted to NQF for
review and endorsement .
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of making care affordable and specifically
addresses a patient-focused episode of care.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. The measure is a newly developed cost
measure. Health expenditures continue to increase in the United States.
According to the National Health Expenditure Accounts, total health care
spending increased by 4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018).
Medicare spending, which is still predominantly paid on a fee-for-service
(FFS) basis, also grew 3.6 percent, reaching $672.1 billion (CMS,
2018)
- Does the measure address a quality challenge? Yes. Policymakers
contend that an estimated 80 percent of overall health care costs are
attributable to decisions made by clinicians (Fred, 2016). However, these same
clinicians are often unaware of how their care decisions influence the overall
costs of care. One of the goals for using cost measures is to help inform
clinicians on the costs attributable to their decision making, as well as the
total cost of their patient’s care.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of other measures in the program and the measure
captures a broad population. This measure is new and is not in use in any
program.
- Can the measure can be feasibly reported? Yes. This is a
claims-based measure.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? No. This measure is fully developed and has completed
field testing (see supplemental document with updates to the MUC list)This is
a new measure that has not been submitted for NQF endorsement.
- Measure development status: Early Development; Field
Testing
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The measure is not in current use. The
developer considered the potential adverse effects of making unfair
comparisons among certain types of clinicians in assessing cost measure
performance, and/or rewarding lower costs without appropriately balancing
performance on quality.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measure is not in use. During development, the developer considered the
potential adverse events of reducing access to care and stinting care.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Health
expenditures continue to increase in the United States. According to the
National Health Expenditure Accounts, total health care spending increased by
4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018). Medicare spending,
which is still predominantly paid on a fee-for-service (FFS) basis, also grew
3.6 percent, reaching $672.1 billion (CMS, 2018). However, this growth is slower
than the previous two years due to a slow growth in spending for both Medicare
FFS and Medicare Advantage. In the United States, Medicare is the largest single
purchaser of health care, and successfully establishing payment models under
MIPS can have significant impacts on reducing costs and making care more
affordable (MedPAC, 2017). Urinary stone disease, or urolithiasis, is one of the
most common and expensive urologic conditions. In the United States, one in 11
people will have a history of urinary stones in their lifetime, and
approximately 50 percent of patients will experience a recurrence within 5 years
of their first urinary stone (Scales et al., 2012). Urolithiasis is the second
most expensive urologic problem, accounting for $2.1 billion of $11 billion
spent annually on urologic diseases (NIH, 2007). From 2003 to 2007, the total
expenditure among Medicare beneficiaries 65 and older for treatment of urinary
tract stones exceeded $1.04 billion each year (HHS, 2012). Urolithiasis tends to
be more severe in geriatric patients, who also have a two-fold increase risk of
being hospitalized for treatment (Arampatzis et al., 2012). The treatment of
urinary stones has a significant economic impact on health care spending, making
this an important measure to establish to reduce costs related to renal and
ureteral stone surgical treatment. Arampatzis, Spyridon, Gregor Lindner, Filiz
Irmak, Georg-Christian Funk, Heinz Zimmermann, and Aristomenis K Exadaktylos.
“Geriatric Urolithiasis in the Emergency Department: Risk Factors for
Hospitalization and Emergency Management Patterns of Acute Urolithiasis.” BMC
Nephrology, no.13, 2012, pp. 117. “Data Book: Health Care Spending and the
Medicare Program.” MedPAC, 2017 Table 14-46. Economic Impact of Urologic
Disease. In:Chapter 14. Litwin MS, Saigal CS, editors. Urologic Diseases in
America. US Department of Health and Human Services, Public Health Service,
National Institutes of Health, National Institute of Diabetes and Digestive and
Kidney Diseases. Washington, DC: US Government Printing Office, 2012; NIH
Publication No. 12-7865 pp. 486. “National Health Expenditure Projections,
2017-2026.” US Centers for Medicare & Medicaid Services, 2018. “Urologic
Diseases Cost Americans $11 Billion a Year.” National Institutes of Health,
2007. Scales, Jr. Charles D, Alexandria C Smith, Janet M Hanley, Christopher S
Saigal, and Urologic Diseases in America Project. “Prevalence of Kidney Stones
in the United States.” European Urology, vol. 62, no. 1, 2012, pp. 160-165.
Measure Specifications This measure's specifications have
been modified. Please consult this Document
for more information.
- NQF Number (if applicable):
- Description: The Hemodialysis Access Creation Measure is meant to
apply to clinicians who perform this procedure for Medicare beneficiaries.
This procedural episode captures patients who undergo a procedure for the
creation of access for long-term hemodialysis. The measure evaluates a
clinician’s risk-adjusted cost for the episode group by averaging it across
all episodes attributed to the clinician during the performance period. The
cost of each episode is the sum of the cost to Medicare for assigned services
performed by the attributed clinician and other healthcare providers during
the episode window.
- Numerator: The numerator for the Hemodialysis Access Creation
measure is the sum of the ratio of observed to expected payment-standardized
cost to Medicare for all episodes attributed to a clinician. This sum is then
multiplied by the national average observed episode cost to generate a dollar
figure. Mathematically, this is represented as: sum of (observed episode
cost/expected episode cost) * national average observed cost.
- Denominator: The denominator for the Hemodialysis Access Creation
measure is the total number of episodes from this episode group attributed to
a clinician.
- Exclusions: The following episode-level exclusions apply: (a)
The beneficiary has a primary payer other than Medicare for any amount of time
overlapping the episode window or in the lookback period. (b) No attributed
clinician is found for the episode. (c) The beneficiary’s date of birth is
missing. (d) The beneficiary’s death date occurred before the episode ended.
(e) The beneficiary was not enrolled in Medicare Part A and B for the entirety
of the lookback period plus episode window, or is enrolled in Part C for any
part of the lookback period plus episode window. (f) The episode trigger
claim was not performed in an office, IP, OP, or ASC setting based on its
place of service. Exclusions specific to the Hemodialysis Access Creation
measure are developed with input from the Peripheral Vascular Disease
Management Clinical Subcommittee.
- HHS NQS Priority: Make Care Affordable
- HHS Data Source: Claims
- Measure Type: Cost/Resource Use
- Steward: Centers for Medicare & Medicaid
Services
- Endorsement Status:
- Meaningful Measure Area: Patient-focused Episode of
Care
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Preliminary analysis summary
- Contribution to program measure set:This measure assesses the
cost of services performed by providers during the patient-focused episode
of care.
- Impact on quality of care for patients:This measure is a cost
and resource use measure. This measure should be submitted to NQF for
review and endorsement .
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of making care affordable and specifically
addresses a patient-focused episode of care.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. The measure is a newly developed cost
measure. Health expenditures continue to increase in the United States.
According to the National Health Expenditure Accounts, total health care
spending increased by 4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018).
Medicare spending, which is still predominantly paid on a fee-for-service
(FFS) basis, also grew 3.6 percent, reaching $672.1 billion (CMS,
2018)
- Does the measure address a quality challenge? Yes. Policymakers
contend that an estimated 80 percent of overall health care costs are
attributable to decisions made by clinicians (Fred, 2016). However, these same
clinicians are often unaware of how their care decisions influence the overall
costs of care. One of the goals for using cost measures is to help inform
clinicians on the costs attributable to their decision making, as well as the
total cost of their patient’s care.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of other measures in the program and the measure
captures a broad population. This measure is new and is not in use in any
program.
- Can the measure can be feasibly reported? Yes. This is a
claims-based measure.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? No. This measure is fully developed and has completed
field testing (see supplemental document with updates to the MUC list)This is
a new measure that has not been submitted for NQF endorsement.
- Measure development status: Early Development; Field
Testing
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The measure is not in current use. The
developer considered the potential adverse effects of making unfair
comparisons among certain types of clinicians in assessing cost measure
performance, and/or rewarding lower costs without appropriately balancing
performance on quality.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measure is not in use. During development, the developer considered the
potential adverse events of reducing access to care and stinting care.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Health
expenditures continue to increase in the United States. According to the
National Health Expenditure Accounts, total health care spending increased by
4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018). Medicare spending,
which is still predominantly paid on a fee-for-service (FFS) basis, also grew
3.6 percent, reaching $672.1 billion (CMS, 2018). However, this growth is slower
than the previous two years due to a slow growth in spending for both Medicare
FFS and Medicare Advantage. In the United States, Medicare is the largest single
purchaser of health care, and successfully establishing payment models under
MIPS can have significant impacts on reducing costs and making care more
affordable (MedPAC, 2017). Because of a growing and aging population, the
prevalence of beneficiaries with end-stage renal disease (ESRD) and enrollment
for dialysis is rising (Ahmed et al., 2018). In 2015, there were 124,114 newly
reported cases of ESRD, reaching a total of 703,243 people with ESRD for the
year (NIH, 2017). Over 207,000 of those individuals were aged 65 and older, and
accounted for approximately half of all individuals who received hemodialysis
access for that year, which is a 22 percent increase from 2010 (NIH, 2017). The
number ESRD cases increases by approximately 20,000 per year, with individuals
aged 65 to 75 having the highest prevalence of ESRD and individuals aged 75 and
older having the highest rate of new ESRD cases (NIH, 2017). Though the ESRD
population is less than 1 percent of the total Medicare population, they
accounted for 7.1 percent of Medicare spending in 2015. The United States Renal
Data System (USRDS) 2017 Annual Data Report found that Medicare spent $33.9
billion on beneficiaries with ESRD, and when combined with the cost of Chronic
Kidney Disease (CKD), a total of over $98 billion. For hemodialysis care,
Medicare spent a total of $88,750 per patient per year, excluding unknown
modalities, and $1,677 for vascular access procedures (procedures to place or
create vascular accesses and procedures to maintain them) (NIH, 2017). Ahmed,
Osman, Ketan Patel, Rana Rabei, Mikin V Patel, Michael Ginsburg, Bishir Clayton,
and Bulent Arslan. "Hemodialysis Access Maintenance in the Medicare Population:
An Analysis Over a Decade of Trends by Provider Specialty and Site of Service."
Journal Of Vascular And Interventional Radiology, JVIR vol. 29, no. 2, 2018, pp.
159-169 “Data Book: Health Care Spending and the Medicare Program.” MedPAC, 2017
“National Health Expenditure Projections, 2017-2026.” US Centers for Medicare
& Medicaid Services, 2018. United States Renal Data System, 2017 Annual
Data Report: Epidemiology of Kidney Disease in the United States. National
Institutes of Health, National Institute of Diabetes and Digestive and Kidney
Diseases, Bethesda, MD, 2017.
Measure Specifications This measure's specifications have
been modified. Please consult this Document
for more information.
- NQF Number (if applicable):
- Description: The Elective Primary Hip Arthroplasty Measure is
meant to apply to clinicians who perform this procedure for Medicare
beneficiaries. This procedural episode captures patients who undergo elective
primary hip arthroplasty. The measure evaluates a clinician’s risk-adjusted
cost for the episode group by averaging it across all episodes attributed to
the clinician during the performance period. The cost of each episode is the
sum of the cost to Medicare for assigned services performed by the attributed
clinician and other healthcare providers during the episode
window.
- Numerator: The numerator for the Elective Primary Hip
Arthroplasty measure is the sum of the ratio of observed to expected
payment-standardized cost to Medicare for all episodes attributed to a
clinician. This sum is then multiplied by the national average observed
episode cost to generate a dollar figure. Mathematically, this is represented
as: sum of (observed episode cost/expected episode cost) * national average
observed cost.
- Denominator: The denominator for the Elective Primary Hip
Arthroplasty measure is the total number of episodes from this episode group
attributed to a clinician.
- Exclusions: The following episode-level exclusions apply: (a)
The beneficiary has a primary payer other than Medicare for any amount of time
overlapping the episode window or in the lookback period. (b) No attributed
clinician is found for the episode. (c) The beneficiary’s date of birth is
missing. (d) The beneficiary’s death date occurred before the episode ended.
(e) The beneficiary was not enrolled in Medicare Part A and B for the entirety
of the lookback period plus episode window, or is enrolled in Part C for any
part of the lookback period plus episode window. (f) The episode trigger
claim was not performed in an office, IP, OP, or ASC setting based on its
place of service. Exclusions specific to the Elective Primary Hip
Arthroplasty measure are developed with input from the Musculoskeletal Disease
Management - Non-Spine Clinical Subcommittee.
- HHS NQS Priority: Make Care Affordable
- HHS Data Source: Claims
- Measure Type: Cost/Resource Use
- Steward: Centers for Medicare & Medicaid
Services
- Endorsement Status:
- Meaningful Measure Area: Patient-focused Episode of
Care
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Preliminary analysis summary
- Contribution to program measure set:This measure assesses the
cost of services performed by providers during the patient-focused episode
of care.
- Impact on quality of care for patients:This measure is a cost
and resource use measure. This measure should be submitted to NQF for
review and endorsement .
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of making care affordable and specifically
addresses a patient-focused episode of care.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. The measure is a newly developed cost
measure. Health expenditures continue to increase in the United States.
According to the National Health Expenditure Accounts, total health care
spending increased by 4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018).
Medicare spending, which is still predominantly paid on a fee-for-service
(FFS) basis, also grew 3.6 percent, reaching $672.1 billion (CMS,
2018)
- Does the measure address a quality challenge? Yes. Policymakers
contend that an estimated 80 percent of overall health care costs are
attributable to decisions made by clinicians (Fred, 2016). However, these same
clinicians are often unaware of how their care decisions influence the overall
costs of care. One of the goals for using cost measures is to help inform
clinicians on the costs attributable to their decision making, as well as the
total cost of their patient’s care.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of other measures in the program and the measure
captures a broad population. This measure is new and is not in use in any
program.
- Can the measure can be feasibly reported? Yes. This is a
claims-based measure.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? No. This measure is fully developed and has completed
field testing (see supplemental document with updates to the MUC list)This is
a new measure that has not been submitted for NQF endorsement.
- Measure development status: Early Development; Field
Testing
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The measure is not in current use. The
developer considered the potential adverse effects of making unfair
comparisons among certain types of clinicians in assessing cost measure
performance, and/or rewarding lower costs without appropriately balancing
performance on quality.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measure is not in use. During development, the developer considered the
potential adverse events of reducing access to care and stinting care.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Health
expenditures continue to increase in the United States. According to the
National Health Expenditure Accounts, total health care spending increased by
4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018). Medicare spending,
which is still predominantly paid on a fee-for-service (FFS) basis, also grew
3.6 percent, reaching $672.1 billion (CMS, 2018). However, this growth is slower
than the previous two years due to a slow growth in spending for both Medicare
FFS and Medicare Advantage. In the United States, Medicare is the largest single
purchaser of health care, and successfully establishing payment models under
MIPS can have significant impacts on reducing costs and making care more
affordable (MedPAC, 2017). Joint replacement surgery is a common procedure in
the older population. According to a 2015 study, the 2010 prevalence of total
hip replacement in the United States population was 0.83 percent, and increased
with age, reaching 1.49 percent at sixty years, and 5.87 percent at ninety years
of age. There were an estimated 2.5 million individuals with total hip
replacement in 2010, and the demand for primary Total Hip Arthroplasties (THAs)
is estimated to grow by 174 percent between 2005 and 2030 (Kremers et al., 2015;
Kurtz et al., 2007). Studies also suggest that hip arthroplasty accounts for a
significant share of Medicare spending. A 2008 study found that the utilization
of elective joint arthroplasty increases and Medicare becomes the primary payer
after age 65 for these arthroplasties (Matlock, 2008). A 2016 study estimated
that CMS payments per episode totaled between $18,030 and $21,661, depending on
the presence of obesity (Meller et al., 2016). Hospital reimbursement for total
hip replacement and knee replacement represented the largest payment group for
CMS in 2008, combining for 4.6% of total payments (AHD, 2013). American Hospital
Directory (AHD). American Hospital Directory, 2013. Available at:
http://www.ahd.com/ip_ipps08.html. Accessed January 29, 2014. “Data Book: Health
Care Spending and the Medicare Program.” MedPAC, 2017 Kremers et al. (2015).
“Prevalence of Total Hip and Knee Replacement in the United States.” Journal of
Bone and Joint Surgery 97(17):1386-97. Kurtz et al. (2007). “Projections of
primary and revision hip and knee arthroplasty in the United States from 2005 to
2030.” Journal of Bone and Joint Surgery 89(4):780-5. Matlock, Dan. (2008).
“Utilization of Elective Hip and Knee Arthroplasty by Age and Payer.” Clinical
Orthopaedics and Related Research 466(4): 914-919. Meller, M. M., et al. (2016).
"Surgical Risks and Costs of Care are Greater in Patients Who Are Super Obese
and Undergoing THA." Clinical Orthopaedics and Related Research 474(11):
2472-2481. “National Health Expenditure Projections, 2017-2026.” US Centers for
Medicare & Medicaid Services, 2018.
Measure Specifications This measure's specifications have
been modified. Please consult this Document
for more information.
- NQF Number (if applicable):
- Description: The Non-Emergent Coronary Artery Bypass Graft (CABG)
Measure is meant to apply to clinicians who perform this procedure for
Medicare beneficiaries. This procedural episode captures patients who undergo
a CABG procedure. The measure evaluates a clinician’s risk-adjusted cost for
the episode group by averaging it across all episodes attributed to the
clinician during the performance period. The cost of each episode is the sum
of the cost to Medicare for assigned services performed by the attributed
clinician and other healthcare providers during the episode
window.
- Numerator: The numerator for the Non-Emergent Coronary Artery
Bypass Graft (CABG) measure is the sum of the ratio of observed to expected
payment-standardized cost to Medicare for all episodes attributed to a
clinician. This sum is then multiplied by the national average observed
episode cost to generate a dollar figure. Mathematically, this is represented
as: sum of (observed episode cost/expected episode cost) * national average
observed cost.
- Denominator: The denominator for the Non-Emergent Coronary Artery
Bypass Graft (CABG) measure is the total number of episodes from this episode
group attributed to a clinician.
- Exclusions: The following episode-level exclusions apply: (a)
The beneficiary has a primary payer other than Medicare for any amount of time
overlapping the episode window or in the lookback period. (b) No attributed
clinician is found for the episode. (c) The beneficiary’s date of birth is
missing. (d) The beneficiary’s death date occurred before the episode ended.
(e) The beneficiary was not enrolled in Medicare Part A and B for the entirety
of the lookback period plus episode window, or is enrolled in Part C for any
part of the lookback period plus episode window. (f) The episode trigger
claim was not performed in an office, IP, OP, or ASC setting based on its
place of service. Exclusions specific to the Non-Emergent CABG measure are
developed with input from the Cardiovascular Disease Management Clinical
Subcommittee.
- HHS NQS Priority: Make Care Affordable
- HHS Data Source: Claims
- Measure Type: Cost/Resource Use
- Steward: Centers for Medicare & Medicaid
Services
- Endorsement Status:
- Meaningful Measure Area: Patient-focused Episode of
Care
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support with the
condition of NQF endorsement.
- Preliminary analysis summary
- Contribution to program measure set:This measure assesses the
cost of services performed by providers during the patient-focused episode
of care.
- Impact on quality of care for patients:This measure is a cost
and resource use measure. This measure should be submitted to NQF for
review and endorsement .
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of making care affordable and specifically
addresses a patient-focused episode of care.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. The measure is a newly developed cost
measure. Health expenditures continue to increase in the United States.
According to the National Health Expenditure Accounts, total health care
spending increased by 4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018).
Medicare spending, which is still predominantly paid on a fee-for-service
(FFS) basis, also grew 3.6 percent, reaching $672.1 billion (CMS,
2018)
- Does the measure address a quality challenge? Yes. Policymakers
contend that an estimated 80 percent of overall health care costs are
attributable to decisions made by clinicians (Fred, 2016). However, these same
clinicians are often unaware of how their care decisions influence the overall
costs of care. One of the goals for using cost measures is to help inform
clinicians on the costs attributable to their decision making, as well as the
total cost of their patient’s care.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of other measures in the program and the measure
captures a broad population. This measure is new and is not in use in any
program.
- Can the measure can be feasibly reported? Yes. This is a
claims-based measure.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? No. This measure is fully developed and has completed
field testing (see supplemental document with updates to the MUC list)This is
a new measure that has not been submitted for NQF endorsement.
- Measure development status: Early Development; Field
Testing
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The measure is not in current use. The
developer considered the potential adverse effects of making unfair
comparisons among certain types of clinicians in assessing cost measure
performance, and/or rewarding lower costs without appropriately balancing
performance on quality.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measure is not in use. During development, the developer considered the
potential adverse events of reducing access to care and stinting care.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Health
expenditures continue to increase in the United States. According to the
National Health Expenditure Accounts, total health care spending increased by
4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018). Medicare spending,
which is still predominantly paid on a fee-for-service (FFS) basis, also grew by
3.6 percent, reaching $672.1 billion (CMS, 2018). However, this growth is slower
than the previous two years due to a slow growth in spending for both Medicare
FFS and Medicare Advantage. In the United States, Medicare is the largest single
purchaser of health care, and successfully establishing payment models under
MIPS can have significant impacts on reducing costs and making care more
affordable (MedPAC, 2017). CABG is a major component of the management of
advanced coronary artery disease (CAD), although its use has decreased since
2000. According to a 2016 study, an average of approximately 100,000 Medicare
beneficiaries underwent CABG surgery annually between 2000 and 2012 with a
steady decline in the number of procedures performed from 131,385 in 2000 to
71,086 in 2012 (McNeely et al., 2016). A 2011 study using Medicare outpatient
hospital claims and the Healthcare Cost and Utilization Project’s Nationwide
Inpatient Sample for data between 2001 and 2008 found that the annual CABG
surgery rate in the United States decreased from about 17 per 10,000 adults in
2001 to about 11 per 10,000 adults in 2008 (Epstein et al., 2011). This decline
is due in part to changes in patient populations and treatment options,
including wider use of coronary stenting. Still, CABG remains a standard therapy
and one of the most commonly used treatment options for CAD in patients with
multi-vessel disease or diabetes (ElBardissi et al., 2012). ElBardissi, Andrew
W., Sary F. Aranki, Shubin Sheng, Sean M. O'Brien, Caprice C. Greenberg, and
James S. Gammie. "Trends in Isolated Coronary Artery Bypass Grafting: An
Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database."
The Journal of Thoracic and Cardiovascular Surgery 143, no. 2 (2012): 273-81.
Epstein, Andrew J., Daniel Polsky, Feifei Yang, Lin Yang, and Peter W.
Groeneveld. "Coronary Revascularization Trends in the United States, 2001-2008."
JAMA 305, no. 17 (2011): 1769-76. “Data Book: Health Care Spending and the
Medicare Program.” MedPAC, 2017 McNeely, Christian, Stephen Markwell, and
Christina Vassileva. "Trends in Patient Characteristics and Outcomes of Coronary
Artery Bypass Grafting in the 2000 to 2012 Medicare Population." The Annals Of
Thoracic Surgery 102, no. 1 (2016): 132-38. “National Health Expenditure
Projections, 2017-2026.” US Centers for Medicare & Medicaid Services, 2018.
Measure Specifications This measure's specifications have
been modified. Please consult this Document
for more information.
- NQF Number (if applicable):
- Description: MSPB is a payment-standardized, risk-adjusted cost
measure focused on clinicians (TIN-NPIs) / clinician groups (TINs) providing
care at acute inpatient hospitals. The measure is an average of risk-adjusted
costs across all episodes. Each MSPB episode has a window spanning from three
days prior to the index inpatient admission through 30 days after discharge.
The measure attributes all Medicare Part A and B costs occurring in the
episode window to the clinician(s) responsible for care, as identified for
medical MS-DRGs through the use of an E&M threshold and for surgical
MS-DRGs by identification of the physician performing the core procedure of
the stay.
- Numerator: The numerator for the measure is the sum of the ratio
of payment-standardized observed to expected MSPB episode costs for all MSPB
episodes for the TIN-NPI or TIN. The sum of the ratios is then multiplied by
the national average payment-standardized observed episode cost, to convert
the ratio to a dollar amount.
- Denominator: The denominator for the MSPB measure is the total
number of MSPB episodes for the TIN-NPI or TIN.
- Exclusions: The MSPB measure assesses costs during episodes of
care initiated by acute inpatient hospital stays. Episodes for a beneficiary
are excluded from the MSPB measure if they meet any of the following
conditions: - the beneficiary was not continuously enrolled in both Medicare
Parts A and B from 93 days prior to the index admission through 30 days after
discharge. - the beneficiary’s death occurred during the episode - the
beneficiary is enrolled in a Medicare Advantage plan or Medicare is the
secondary payer at any time during the episode window or 90-day lookback
period. - the index admission for the episode did not occur in a subsection
(d) hospital paid under the Inpatient Prospective Payment System (IPPS) or an
acute hospital in Maryland. - the discharge of the index admission occurred in
the last 30 days of the performance period - the index admission for the
episode is involved in an acute-to-acute hospital transfer (i.e., the
admission ends in a hospital transfer or begins because of a hospital
transfer) - the index admission inpatient claim indicates a $0 actual payment
or a $0 standardized payment After applying the exclusions outlined above, all
remaining episodes are included in the calculation of the MSPB
measure.
- HHS NQS Priority: Make Care Affordable
- HHS Data Source: Claims
- Measure Type: Cost/Resource Use
- Steward: Centers for Medicare & Medicaid
Services
- Endorsement Status:
- Meaningful Measure Area: Patient-focused Episode of
Care
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support for rulemaking
with the condition of NQF endorsement.
- Preliminary analysis summary
- Contribution to program measure set:This measure assesses the
risk adjusted total total cost of care.
- Impact on quality of care for patients:This measure is a cost
and resource use measure. This measure should be submitted to NQF for
review and endorsement.
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of making care affordable and specifically
addresses a risk-adjusted total cost of care.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. The measure is a newly developed cost
measure. Health expenditures continue to increase in the United States.
According to the National Health Expenditure Accounts, total health care
spending increased by 4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018).
Medicare spending, which is still predominantly paid on a fee-for-service
(FFS) basis, also grew 3.6 percent, reaching $672.1 billion (CMS,
2018)
- Does the measure address a quality challenge? Yes. Policymakers
contend that an estimated 80 percent of overall health care costs are
attributable to decisions made by clinicians (Fred, 2016). However, these same
clinicians are often unaware of how their care decisions influence the overall
costs of care. One of the goals for using cost measures is to help inform
clinicians on the costs attributable to their decision making, as well as the
total cost of their patient’s care.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of other measures in the program and the measure
captures a broad population. This measure is new and is not in use in any
program.
- Can the measure can be feasibly reported? Yes. This is a
claims-based measure.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? No. This measure is undergoing substantial changes. The
version of this measure under consideration has not been submitted for NQF
endorsement.In addition, the developer notes attribution concerns that
all-cost measures such as MSPB and TPCC could be holding providers accountable
for costs that they may not have had the opportunity to
influence.
- Measure development status: Early Development; Field
Testing
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. This version of the measure is not in
current use. The developer considered the potential adverse effects of making
unfair comparisons among certain types of clinicians in assessing cost measure
performance, and/or rewarding lower costs without appropriately balancing
performance on quality.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measure is currently in use, but is undergoing substantial changes. During
development, the developer considered the potential adverse events of reducing
access to care and stinting care.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
CMS and Acumen,
LLC are undertaking a re-evaluation of the MSPB clinician measure. The Blueprint
for the CMS Measure Management System (V 13.0, May 2017) provides a basis for
measure re-evaluation. This document describes a “CMS ad hoc review” as a
“limited examination of the measure based on new information” (CMS 2017). This
new information can come from a variety of sources including ongoing
surveillance of the scientific literature or from stakeholders. In this case,
the motivation for CMS and Acumen to pursue re-evaluation is to address
stakeholder feedback received via public comment in 2016. As discussed further
in the Recommendation for the Measure section, stakeholders expressed a desire
for the measure to be more actionable for clinicians and more statistically
reliable. Aside from these particular stakeholder concerns, the MSPB clinician
measure continues to be important as a means of measuring Medicare spending.
Health expenditures continue to increase in the United States. According to the
National Health Expenditure Accounts, total health care spending is estimated to
have increased by 4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018).
Medicare spending grew more slowly in 2017 than in the previous two years due to
slowed growth in spending for both Medicare FFS and Medicare Advantage.
Nonetheless, spending for Medicare, which is still predominantly paid on a
fee-for-service (FFS) basis, still grew by 3.6 percent, reaching $672.1 billion
(CMS, 2018). In 2016, Medicare FFS paid $183 billion for approximately 10
million Medicare inpatient admissions and 200 million outpatient services, which
reflects a 2.3 percent increase in hospital spending per FFS beneficiary between
2015 and 2016 (MedPAC, 2018). In the United States, Medicare is the largest
single purchaser of health care, and successfully establishing payment models
under MIPS can have significant impacts on reducing costs and making care more
affordable (MedPAC, 2017). “Blueprint for the CMS Measures Management System.
Version 13.0.” US Centers for Medicare & Medicaid Services, 2017. “Data
Book: Health Care Spending and the Medicare Program.” MedPAC, 2017. “National
Health Expenditure Projections, 2017-2026.” US Centers for Medicare &
Medicaid Services, 2018. “Report to the Congress: Medicare Payment Policy.”
MedPAC, 2018.
Measure Specifications This measure's specifications have
been modified. Please consult this Document
for more information.
- NQF Number (if applicable): 2165
- Description: The Total Per Capita Cost (TPCC) measure is a
payment-standardized, risk-adjusted, and specialty-adjusted cost measure
focused on clinicians/clinician groups performing primary care services. The
measure is an average of per capita costs (with the previously mentioned
adjustments applied) across all attributed beneficiaries. The measure includes
all Medicare Part A and B costs across all attributed
beneficiaries.
- Numerator: The numerator for the measure is the sum of the
risk-adjusted, specialty-adjusted Medicare Part A and Part B costs across all
beneficiaries’ episodes of care attributed to a TIN or TIN-NPI.
- Denominator: The denominator for the measure is the number of all
Medicare beneficiaries’ episodes of care who received Medicare-covered
services and are attributed to a TIN or TIN-NPI during the performance
period.
- Exclusions: Beneficiaries are excluded from the population
measured if they meet any of the following conditions: - were not enrolled in
both Medicare Part A and Part B for every month during the performance period,
unless part year enrollment was the result of new enrollment or death - were
enrolled in a private Medicare health plan (for example, a Medicare Advantage
HMO/PPO or a Medicare private FFS plan) for any month during the performance
period - resided outside the United States, its territories, and its
possessions during any month of the performance period.
- HHS NQS Priority: Make Care Affordable
- HHS Data Source: Claims
- Measure Type: Cost/Resource Use
- Steward: Centers for Medicare & Medicaid
Services
- Endorsement Status:
- Meaningful Measure Area: Risk adjusted total cost of
care
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support for rulemaking
with the condition of NQF endorsement.
- Preliminary analysis summary
- Contribution to program measure set:This measure assesses the
risk adjusted total total cost of care .
- Impact on quality of care for patients:This measure is a cost
and resource use measure. This version of the measure should be submitted
to NQF for review and endorsement.
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of making care affordable and specifically
addresses a risk-adjusted total cost of care.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. The measure is a newly developed cost
measure. Health expenditures continue to increase in the United States.
According to the National Health Expenditure Accounts, total health care
spending increased by 4.6 percent in 2017, reaching $3.5 trillion (CMS, 2018).
Medicare spending, which is still predominantly paid on a fee-for-service
(FFS) basis, also grew 3.6 percent, reaching $672.1 billion (CMS,
2018)
- Does the measure address a quality challenge? Yes. Policymakers
contend that an estimated 80 percent of overall health care costs are
attributable to decisions made by clinicians (Fred, 2016). However, these same
clinicians are often unaware of how their care decisions influence the overall
costs of care. One of the goals for using cost measures is to help inform
clinicians on the costs attributable to their decision making, as well as the
total cost of their patient’s care.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of other measures in the program and the measure
captures a broad population. This measure is new and is not in use in any
program.
- Can the measure can be feasibly reported? Yes. This is a
claims-based measure.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? No. This measure is undergoing substantial changes. The
version of this measure under consideration has not been submitted for NQF
endorsement.In addition, the developer notes attribution concerns that
all-cost measures such as MSPB and TPCC could be holding providers accountable
for costs that they may not have had the opportunity to
influence.
- Measure development status: Early Development; Field
Testing
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. This version of the measure is not in
current use. The developer considered the potential adverse effects of making
unfair comparisons among certain types of clinicians in assessing cost measure
performance, and/or rewarding lower costs without appropriately balancing
performance on quality.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
measure is currently in use but is undergoing substantial changes. During
development, the developer considered the potential adverse events of reducing
access to care and stinting care.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Failed Endorsement.
Rationale for measure provided by HHS
CMS and Acumen,
LLC are undertaking a re-evaluation of the TPCC measure. The Blueprint for the
CMS Measure Management System (V 13.0, May 2017) provides a basis for measure
re-evaluation. This document describes a “CMS ad hoc review” as a “limited
examination of the measure based on new information” (CMS 2017). This new
information can come from a variety of sources including ongoing surveillance of
the scientific literature or from stakeholders. In this case, the motivation for
CMS and Acumen to pursue re-evaluation is to address stakeholder feedback
received via public comment in 2016. As discussed further in the Recommendation
for the Measure section, stakeholders expressed a desire for the measure to be
more actionable for clinicians. Aside from these particular stakeholder
concerns, the TPCC measure continues to be important as a means of measuring
Medicare spending. Health expenditures continue to increase in the United
States. According to the National Health Expenditure Accounts, total health care
spending is estimated to have increased by 4.6 percent in 2017, reaching $3.5
trillion (CMS, 2018). Medicare spending grew more slowly in 2017 than in the
previous two years due to slowed growth in spending for both Medicare FFS and
Medicare Advantage. Nonetheless, spending for Medicare, which is still
predominantly paid on a fee-for-service (FFS) basis, still grew by 3.6 percent,
reaching $672.1 billion (CMS, 2018). Spending on services for physicians and
other health professionals totaled $69.9 billion and accounted for 15 percent of
Medicare FFS spending in 2016 (MedPAC, 2018). In the United States, Medicare is
the largest single purchaser of health care, and successfully establishing
payment models under MIPS can have significant impacts on reducing costs and
making care more affordable (MedPAC, 2017). Given the focus of the TPCC measure,
it is also worth focusing more specifically on the importance of establishing
successful payment models for primary care management. The American Academy of
Family Physicians (AAFP) notes that numerous studies have found reductions to
the total cost of care for patients in a Patient-Centered Medical Home (PCMH),
brought about by the provision of primary care management services, and ranging
from 4.4% to 11.2% for especially high-cost, elderly patients (AAFP, 2018).
Primary care management can lead to such savings in various ways, including by
improving the treatment of chronic conditions, obviating the need for high-cost
hospital or emergency department services. Another impact that primary care
management can have is directing patients to lower cost hospitals for the
provision of necessary inpatient services. Given these potential linkages
between primary care management and cost savings, it is critical to measure the
costs of primary care management in a manner that captures broader healthcare
costs influenced by primary care. “Blueprint for the CMS Measures Management
System. Version 13.0.” US Centers for Medicare & Medicaid Services, 2017.
“Data Book: Health Care Spending and the Medicare Program.” MedPAC, 2017.
“National Health Expenditure Projections, 2017-2026.” US Centers for Medicare
& Medicaid Services, 2018. “Report to the Congress: Medicare Payment
Policy.” MedPAC, 2018. “Valuation of Care Management Performed by Primary Care
Services: An Issue Brief.” American Academy of Family Physicians, 2018.
Measure Specifications
- NQF Number (if applicable):
- Description: Percentage of members 19 years of age and older who
are up-to-date on recommended routine vaccines for influenza; tetanus and
diphtheria (Td) or tetanus, diphtheria and acellular pertussis (Tdap); zoster;
and pneumococcal.
- Numerator: Numerator 1 (N1): Members in Denominator 1 (D1) who
received an influenza vaccine on or between July 1 of the year prior to the
measurement period and June 30 of the measurement period. N2: Members in D2
who received at least 1 Td vaccine or 1 Tdap vaccine between 9 years prior to
the start of the measurement period and the end of the measurement period. N3:
Members in D3 who received at least 1 dose of the herpes zoster live vaccine
or 2 doses of the herpes zoster recombinant vaccine anytime on or after the
members 50th birthday. N4: Members in D4 who were administered both the
13-valent pneumococcal conjugate vaccine and the 23-valent pneumococcal
polysaccharide vaccine at least 12 months apart, with the first occurrence
after the age of 60. N5: The actual number of required immunizations
administered to members in D5.
- Denominator: Denominator 1: Members age 19 and older at the start
of the measurement period. Denominator 2: Members age 19 and older at the
start of the measurement period. Denominator 3: Members age 50 and older at
the start of the measurement period. Denominator 4: Members age 66 and older
at the start of the measurement period. Denominator 5: The total number of
possible immunizations required for members age 19 and older determined by
their age at the start of the measurement period.
- Exclusions: Members with any of the following: - Prior
anaphylactic reaction to the vaccine or its components any time during or
before the measurement period. - History of encephalopathy within seven days
after a previous dose of a Td-containing vaccine. - Active chemotherapy during
the measurement period. - Bone marrow transplant during the measurement
period. - History of immunocompromising conditions, cochlear implants,
anatomic or functional asplenia, sickle cell anemia & HB-S disease or
cerebrospinal fluid leaks any time during the member’s history prior to or
during the measurement period. - In hospice or using hospice services during
the measurement period.
- HHS NQS Priority: Promote Effective Prevention & Treatment of
Chronic Disease
- HHS Data Source: Administrative clinical data, Claims, EHR,
Facility Discharge Data, Other, Registry
- Measure Type: Composite
- Steward: National Committee for Quality Assurance
- Endorsement Status:
- Meaningful Measure Area: Preventive Care
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional Support with the
Condition of NQF Endorsement
- Preliminary analysis summary
- Contribution to program measure set:This measure would
encourage the use of evidence based practices to improve adult vaccination
coverage. These vaccines can improve health and decrease health care costs
by preventing severe disease and hospitalization.
- Impact on quality of care for patients:This measure is a
composite measure that evaluates receipt of all routine vaccines for the
adult population.
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of promoting effective prevention and treatment of
chronic disease and specifically addresses preventative care.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. This measure is a process measure. It is a
composite measure that includes NQF endorsed measures, 1653, 0043, 0682, 0683,
0039, 0041, 1659, 0680, 0681, and 0431. The Advisory Committee on Immunization
Practices (ACIP) recommends annual influenza vaccination; and tetanus,
diphtheria and acellular pertussis (Tdap) and/or tetanus and diphtheria (Td)
vaccine; herpes zoster vaccine; and the 13-valent pneumococcal conjugate
vaccine (PCV13) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23)
for adults at various ages.
- Does the measure address a quality challenge? Yes. This measure
assesses the immuzations for all routine vaccines recommended for
adults.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is the only measure that assesses receipt of all routine vaccines for
the adult population. However, sub components of this measure could be
related or competing measures.
- Can the measure can be feasibly reported? Yes. The developer
states that in field testing, three health plans each with commercial,
Medicaid and Medicare lines of business reported data for approximately 6.6
million enrolled adults ages 19 and older.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? No. The measure was tested at the health plan
level.
- Measure development status: Field Testing; Fully
Developed
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
Vaccines are
recommended for adults to prevent serious diseases. Routine vaccination against
influenza, tetanus, diphtheria and pertussis is recommended for all adults,
while vaccines for herpes zoster and pneumococcal disease are recommended for
older adults (Kim et al. 2017). Administration of the influenza, Tdap/Td, herpes
zoster and pneumococcal vaccines can improve health and decrease health care
costs by preventing severe disease and hospitalization. Evidence supporting
administration of each individual vaccine follows. Influenza The influenza
vaccine protects against influenza, a serious disease that can lead to
hospitalization and death (Centers for Disease Control and Prevention [CDC]
2016a), particularly among older adults and vulnerable populations. It is
characterized by a variety of symptoms related to the nose, throat and lungs
that can range in severity (CDC 2015a), and it is easily spread (CDC 2016a).
Although anyone can get the flu, people 65 and older, pregnant women, young
children and those with chronic conditions are at higher risk of developing
serious complications (CDC 2016a). Influenza can have severe consequences. The
CDC estimates that since 2010, yearly influenza cases have ranged from 9.2-35.6
million; influenza-related hospitalizations, from 140,000-710,000; and
influenza-related deaths, from 12,000-56,000 (CDC 2017a). Deaths associated with
influenza are typically higher in older adults. In an analysis based on the
2010-2011 and 2012-2013 flu seasons, 71 percent-85 percent of deaths from
influenza were among adults 65 and older (Grohskopf et al. 2016). Influenza is a
leading cause of outpatient medical visits and worker absenteeism among adults.
The average annual burden of seasonal influenza among adults 18-49 includes
approximately 5 million illnesses, 2.4 million outpatient visits, 32,000
hospitalizations and 680 deaths (Grohskopf et al. 2016). A study in 2016
estimated that the cost-effectiveness ratio of the influenza vaccine was
approximately $100,000 per quality-adjusted life year (Xu et al 2016). ACIP
recommends routine annual influenza vaccination for all people 6 months of age
and older (Grohskopf et al. 2017). For people 19 and older, any age-appropriate
inactivated influenza vaccine (IIV) formulation or recombinant influenza vaccine
(RIV) formulation are acceptable options. ACIP notes that live attenuated
influenza vaccine (LAIV) should not be used during the 2017-2018 season for any
population. Vaccination should occur before the onset of influenza activity in
the community, ideally by the end of October; however, vaccination efforts
should continue throughout flu season into February and March (Grohskopf et al.
2017). People who have a history of severe allergic reaction (e.g., anaphylaxis)
to any component of the vaccine should not receive the influenza vaccine (CDC
2017b). Td/Tdap vaccine Tetanus, diphtheria and pertussis can have serious
health effects. Tetanus results in painful muscle spasms that can cause
fractures, difficulty breathing, arrhythmia and death (CDC 2015b).
Complications from diphtheria include myocarditis, which can lead to heart
failure, and neuritis, which may temporarily paralyze motor nerves. Death occurs
in 5-10 percent of cases (CDC 2015c). Pertussis, also known as whooping cough,
is a respiratory infection characterized by a prolonged cough; it is highly
communicable, and infection can lead to secondary pneumonia, the most common
cause of pertussis-related deaths (CDC 2015d). Due to vaccines, tetanus and
diphtheria are now uncommon. On average, there were 29 reported cases of tetanus
per year from 1996-2009, and nearly all were among people who had never received
a tetanus vaccine or were not up to date on their booster shots (CDC 2013). In
the past decade, fewer than 5 diphtheria cases were reported to the CDC,
although the disease is more prevalent in other countries: In 2014, 7,321 cases
of diphtheria were reported to the World Health Organization, and there are
likely many more unreported cases (CDC 2016b). Pertussis is much more prevalent
today than tetanus and diphtheria, even though vaccines offer protection against
the disease. Before the vaccine was introduced in the 1940s, there were about
200,000 cases of pertussis annually (CDC 2015d). Since widespread use of the
vaccine, pertussis cases have decreased by 80 percent (CDC 2015d). However,
pertussis cases have been increasing since the 1980s; currently, there are
10,000-40,000 pertussis cases and up to 20 deaths reported each year (CDC
2015d). Pertussis is usually milder in children, adolescents and adults than in
infants and young children who may not be fully immunized. Older adults are
often the source of infection for infants and children (CDC 2015d).
Administering the Tdap vaccine to adults helps prevent the spread of pertussis
to infants and prevents such hospitalizations; in 2010, the average cost of
hospitalizing an infant with pertussis was $16,339, an increase from $12,377 in
2000 (Davis 2014). Because there has been a rise in pertussis over the past
several decades in the U.S., studies have evaluated the cost-effectiveness of
providing Tdap immunizations to adults. One study found that providing a dose of
Tdap to people at age 11 or 12, as currently recommended, and again at age 21,
could reduce outpatient visits for pertussis by 4 percent and hospitalizations
for pertussis by 5 percent; costs per quality-adjusted life years saved would be
$204,556 (Kamiya et al. 2016). Another study found that vaccinating all adults
2-64 at least once with Tdap is cost-effective (<$50,000 per quality-adjusted
life years) if pertussis incidence in adults is greater than 120 cases per
100,000 people (Lee et al. 2007). McGarry et al. found that vaccinating all
adults ages 65 and older with Tdap is a cost-effective intervention and would
prevent 97,000 cases of pertussis annually—from the payer perspective, it would
provide a net cost savings of $44.8 million (2014). ACIP recommends that all
adults 19 and older who have not yet received a dose of Tdap receive a single
dose (ACIP 2012; ACIP 2011). Tdap should be administered regardless of the
interval since the last tetanus or diphtheria toxoid-containing vaccine.
Adults 19 and older should receive a decennial Td vaccine booster, beginning 10
years after receipt of the Tdap vaccine (Kretsinger et al. 2006). People who
have a history of severe allergic reaction (e.g., anaphylaxis) to any component
of the Tdap or Td vaccine should not receive it. Tdap is contraindicated for
adults with a history of encephalopathy (e.g., coma or prolonged seizures) not
attributable to an identifiable cause within seven days of administration of a
vaccine with pertussis components (CDC 2017b). Herpes zoster vaccine The herpes
zoster vaccine protects against herpes zoster, commonly known as shingles.
Herpes zoster is a painful skin rash caused by reactivation of the varicella
zoster virus (CDC 2016c). After a person recovers from primary infection of
varicella (chickenpox), the virus stays inactive in the body and can reactivate
years later. Most people typically only have one episode of herpes zoster, but
second or third episodes are possible. People with compromised immune systems
are at higher risk of developing herpes zoster (CDC 2016c). The most common
complication of herpes zoster is post-herpetic neuralgia (PHN) (CDC 2016c),
which is severe, debilitating pain at the site of the rash that has no treatment
or cure. Herpes zoster can also lead to serious complications of the eye,
pneumonia, hearing problems, blindness, encephalitis or death (CDC 2016d). In
the U.S., there are 1 million new cases of herpes zoster each year; 1 of every 3
people will be diagnosed with herpes zoster in their lifetime (CDC 2016c). A
person’s risk for developing herpes zoster increases sharply after age 50 (CDC
2016c). As people age, they are more likely to develop PHN; it rarely occurs in
people under 40, but can be seen in a third of untreated adults 60 and older
(CDC 2016c). Between 1 and 4 percent of adults with herpes zoster are
hospitalized for complications, and an estimated 96 deaths each year are
directly caused by the virus (CDC 2016c). The vaccine can reduce the risk of
developing herpes zoster and PHN. In 2011, total annual direct medical costs in
the U.S. from herpes zoster were estimated to be $1.9 million; costs are
expected to rise as the population ages (Friesen et al. 2017). A study of the
cost-effectiveness of the herpes zoster vaccine among people at 50, 60 and 70
years found that vaccination at age 60 would prevent the most cases (26,147
cases per 1 million people), compared with vaccination at 50 or 70 (Hales et al.
2014). It also found that vaccination at 60 costs $86,000 per quality-adjusted
life year, compared with $37,000 at 70 and $287,000 at 50 (Hales et a. 2014).
There are currently two types of zoster vaccines recommended for older adults:
the zoster vaccine live (ZVL) and a recombinant zoster vaccine (RZV). The ZVL is
a 1-dose vaccine licensed for immunocompetent adults 50 and older; ACIP
recommends ZVL for immunocompetent adults 60 and older. ZVL vaccine coverage for
adults 60 and older has increased each year since ACIP first recommended it in
2008 (Dooling et al. 2018). In October 2017, the Food and Drug Administration
approved the RZV for adults 50 and older. In January 2018, ACIP published a
guideline recommending RZV for immunocompetent adults 50 and older, irrespective
of prior receipt of varicella vaccine or ZVL (Dooling et al. 2018). RZV is a
two-dose series; the second dose should be given 2-6 months after the first
dose. If the second dose of RZV is given less than four weeks after the first,
the second dose should be repeated; if the second dose is more than six months
after the first dose, the vaccine series need not be restarted although
individuals may be at higher risk for zoster. ZVL remains a recommended vaccine
for immunocompetent adults 60 and older (Dooling et al. 2018). Patients with a
severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a
vaccine component should not receive either zoster vaccine (Dooling et al.
2018). Pneumococcal vaccine Vaccines protect against pneumococcal disease, which
is a common cause of illness and death in older adults and in persons with
certain underlying conditions. The major clinical syndromes of pneumococcal
disease include pneumonia, bacteremia and meningitis, with pneumonia being the
most common (CDC 2015e). Pneumonia symptoms generally include fever, chills,
pleuritic chest pain, cough with sputum, dyspnea, tachypnea, hypoxia
tachycardia, malaise and weakness. There are an estimated 400,000 cases of
pneumonia in the U.S. each year and a 5-7 percent mortality rate, although it
may be higher among older adults and adults in nursing homes (CDC 2015f;
Janssens and Krause 2004). Bacteremia, a blood infection, is another
complication of pneumococcal disease (CDC 2015f). Approximately 30 percent of
patients with pneumonia also have bacteremia, and 12,000 patients have
bacteremia without pneumonia each year (CDC 2015f). Bacteremia has a 20 percent
mortality rate among all adults and a 60 percent mortality rate among older
adults. Pneumococcal disease causes 3,000-6,000 cases of meningitis each year
(CDC 2015f). Meningitis symptoms may include headache, lethargy, vomiting,
irritability, fever, nuchal rigidity, cranial nerve signs, seizures and coma.
Meningitis has a 22 percent mortality rate among adults (CDC 2015f).
Pneumococcal infections result in significant health care costs each year.
Geriatric patients with pneumonia require hospitalization in nearly 90 percent
of cases, and their average length of stay is twice that of younger adults
(Janssens and Krause 2004). Pneumonia in the older adult population is
associated with high acute-care costs and an overall impact on total direct
medical costs and mortality during and after an acute episode (Thomas et al.
2012). Total medical costs for Medicare beneficiaries during and one year
following a hospitalization for pneumonia were found to be $15,682 higher than
matched beneficiaries without pneumonia (Thomas et al. 2012). It was estimated
that in 2010, the total annual excess cost of hospital-treated pneumonia in the
fee-for-service Medicare population was approximately $7 billion (Thomas et al.
2012). Pneumococcal vaccines have been shown to be highly effective in
preventing invasive pneumococcal disease. When comparing costs, outcomes and
quality adjusted life years, immunization with the two recommended pneumococcal
vaccines was found to be more economically efficient than no vaccination, with
an incremental cost-effectiveness ratio of $25,841 per quality-adjusted life
year gained (Chen et al. 2014). There currently are two licensed pneumococcal
vaccines in the U.S.: the 13-valent pneumococcal conjugate vaccine (PCV13) and
the 23-valent pneumococcal polysaccharide vaccine (PPSV23) (Kobayashi et al.
2015). For immunocompetent adults 65 and older who have not previously received
pneumococcal vaccination, ACIP recommends a dose of PCV13, followed by a dose of
PPSV23 one or more years later (Kobayashi et al. 2015). Immunocompetent adults
65 and older who received a dose of PPSV23 at younger than 65 should also
receive a dose of PCV13 at least one year after the initial dose of PPSV23, and
then another dose of PPSV23 at least 1 year after PCV13 and at least 5 years
after the most recent dose of PPSV23 (Kobayashi et al. 2015). Adults should not
receive either vaccine if they have had a severe allergic reaction (e.g.,
anaphylaxis) after a previous dose or to a vaccine component. Adults should not
receive the PCV13 vaccine if they have had severe allergic reaction after any
diphtheria-toxoid-containing vaccine (CDC 2017b).
Measure Specifications
- NQF Number (if applicable): 2950
- Description: The rate (XX out of 1,000) of individuals without
cancer receiving prescriptions for opioids from four (4) or more prescribers
AND four (4) or more pharmacies.
- Numerator: Any member in the denominator who received opioid
prescription claims from 4 or more prescribers AND 4 or more pharmacies.
- Denominator: Any member with two or more prescription claims for
opioids filled on at least two separate days, for which the sum of the days’
supply is greater than or equal to 15.
- Exclusions: Any member with a diagnosis for Cancer or a
Prescription Drug Hierarchical Condition Category (RxHCC) 8, 9, 10, 11 for
Payment Year 2015; or RxHCC 15, 16, 17, 18, or 19 for Payment Year 2016, or a
hospice indicator from the enrollment database.
- HHS NQS Priority: Promote Effective Prevention & Treatment of
Chronic Disease
- HHS Data Source: Administrative claims
- Measure Type: Process
- Steward: Pharmacy Quality Alliance
- Endorsement Status:
- Meaningful Measure Area: Prevention and Treatment of Opioid and
Substance Use Disorders
- Changes to Endorsed Measure Specifications?: The MUC list
indicates the measure has not been modified from its endorsed
version.
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support for rulemaking
with the condition that duplication is considered between this measure and
MUC2018-079
- Preliminary analysis summary
- Contribution to program measure set:This measure would
encourage the monitoring of opioid prescription patterns as studies have
shown that people who see multiple providers or use multiple pharmacies are
more likely to die of drug overdoses.
- Impact on quality of care for patients:This measure is fully
developed, tested, and NQF endorsed. This measure would strengthen and
diversify the SSP program measure set by addressing opioid use disorder
treatment.
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of promoting effective prevention and treatment of
chronic disease and specifically addresses the prevention and treatment of
opioid and substance use disorders
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. This is an NQF endorsed process measure.
Evidence shows that abuse and overdose of prescription drugs is a major public
health issue in the United States. Studies have shown that people who see
multiple providers or use multiple pharmacies are more likely to die of drug
overdoses. Clinical guidelines from the Centers for Disease Control and
Prevention (CDC) encourage clinicians to use state prescription drug
monitoring program (PDMP) data to determine whether their patient is receiving
opioid dosages or combinations that put them at risk for overdose.
- Does the measure address a quality challenge? Yes. This measure
addresses a critical population at increased risk of morbidity and mortality.
According to the CDC, overdose involving opioid analgesics killed nearly
17,000 persons in 2010 and the number of people with opioid analgesic use
disorders increased to nearly 2 million.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of existing measures in the SSP. It should be
noted; however, that this measure is a subcomponent of MUC2018-079, which is
also under consideration by the MAP this year.
- Can the measure can be feasibly reported? Yes. Pilot test sites
indicated the measure was feasible and results were able to be reported
efficiently and accurately. CMS calculates the measure for Part D plans. The
data is readily available (prescription claims data and medical
data).
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? Yes. The measure has been endorsed at the health plan
level.
- Measure development status: Fully Developed
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The measure is not in use in a federal
program. However, it is currently being used by the CMS Medicare Part D Drug
Benefit and Medicare Part D Overutilization Monitoring System to monitor the
utilization of opioids for members with the Medicare drug benefit. No
implementation issues have been noted by the developer.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
developer considered concerns have been that prescribing changes such as dose
reduction (without offering or arranging evidence-based treatment for patients
with opioid use disorder) might be associated with unintended negative
consequences, such as patients seeking heroin or other illicitly obtained
opioids (1,2) or interference with appropriate pain treatment. These were
taken into consideration with the balance of the damages from the opioid
epidemic.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Endorsed.
Rationale for measure provided by HHS
A PubMed search
was conducted using combinations of the following search terms: opioid,
overdose, doctor shopping, pharmacy shopping, multiple prescribers, multiple
pharmacies. Articles referenced in the identified articles were scanned for
relevance. The CDC Guideline and Clinical and Contextual Evidence Reviews were
also reviewed for relevant references (CDC Guideline: Dowell D, Haegerich TM,
Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States,
2016. MMWR Recomm Rep. 2016 Mar 18;65(1):1-49. doi: 10.15585/mmwr.rr6501e1.
Available at: http://www.cdc.gov/drugoverdose/prescribing/guideline.html.; CDC
Clinical Evidence Review. Available at: http://stacks.cdc.gov/view/cdc/38026;
CDC Contextual Evidence Review. Available at:
http://stacks.cdc.gov/view/cdc/38027). Further information on evidence for the
measure can be found on the “National Quality Forum - Measure Testing” document
in Section 1a.8.2. (National Quality Forum - Measure Testing; Section 1a.8.1.)
Summary of NQF Endorsement
Review
- Year of Most Recent Endorsement Review: 2017
- Project for Most Recent Endorsement Review: Patient Safety
2016
- Review for Importance: 1. Importance to Measure and Report: The
measure meets the Importance criteria(1a. Evidence, 1b. Performance Gap)1a.
Evidence: 0-H; 20-M; 0-L; 0-I 1b. Performance Gap: 13-H; 7-M; 0-L;
0-IRationale:• The evidence suggests that prescriptions for opioids from
multiple prescribers and pharmaciescorrelate with undesired health outcomes.
The use of multiple prescribers and pharmacies are 35associated with increased
risks for opioid overdose. The Committee noted this is highlyimportant to
measure given the current national opioid overuse problem.• The measure was
tested in three different health plan data sources – the Medicare
population(mean was 23.31 per 1,000 and the median was 26.12 per 1,000), one
commercial heath plan(rate for this plan was 20.57 per 1,000), and the
Medicaid population (mean was 72.28 per 1,000and the median was 69.93 per
1,000). The Committee noted that these rates demonstrate asignificant
performance gap.
- Review for Scientific Acceptability: 2. Scientific Acceptability
of Measure Properties: The measure meets the Scientific
Acceptabilitycriteria(2a. Reliability - precise specifications, testing; 2b.
Validity - testing, threats to validity)2a. Reliability: 9-H; 11-M; 0-L;0-I
2b. Validity: 19-M; 0-L; 1-IRationale:• The developer tested the measure at
the score level using several data sets for reliability testing:o For Medicare
testing, the analysis included a convenience sample of over 700 MedicarePart D
prescription drug plans (comprising a total of 7,067,445 individuals aged 18
andolder)o Testing was also conducted in one Commercial health plan
(comprising a total of209,191 individuals age 18 and older)o For Medicaid
testing, the analysis included 8 state-based prescription drug planscovering 6
states (comprising a total of 1,437,410 individuals age 18 and older)• To
demonstrate reliability, the developer conducted a signal-to-noise analysis of
the computedmeasure score using a beta-binomial model.• The mean reliability
score across all plans is 0.9355.• The developer assessed the face validity
(only) of the measure using a technical expert panelfrom the Pharmacy Quality
Alliance (PQA). 67 percent strongly agreed that the measure resultsreflected
quality of care. Five PQA member organizations also tested the measure using
theirown data, and all strongly agreed that the measure reflected the quality
of care provided fortheir populations.
- Review for Feasibility: 3. Feasibility: 18-H; 2-M; 0-L; 0-I(3a.
Clinical data generated during care delivery; 3b. Electronic sources;
3c.Susceptibility to inaccuracies/unintended consequences identified 3d. Data
collection strategy can be implemented)Rationale:• All data elements are in
defined field in electronic claims.• Pilot test sites indicated the measure
was feasible and results were able to be reportedefficiently and
accurately.
- Review for Usability: 4. Usability and Use: 10-H; 9-M; 1-L;
0-I(Used and useful to the intended audiences for 4a. Accountability and
Transparency; 4b. Improvement;and 4c. Benefits outweigh evidence of unintended
consequences)Rationale:• The measure is currently being used in the Medicare
Part D Overutilization Monitoring Systemto monitor the utilization of opioids
for members with the Medicare drug benefit.36• Although no unintended negative
consequences to individuals or populations were identifiedduring testing, ,
concerns have been raised that prescribing changes such as dose
reduction(without offering or arranging evidence-based treatment for patients
with opioid use disorder)might be associated with unintended negative
consequences, such as patients seeking heroin orother illicitly obtained
opioids (1,2) or interference with appropriate pain treatment
- Review for Related and Competing Measures: 5. Related and
Competing Measures• Measure 2940: Use of Opioids at high Dosage in Persons
without Cancer- The proportion (XX outof 1,000) of individuals without cancer
receiving prescriptions for opioids with a daily dosagegreater than 120mg
morphine equivalent dose (MED) for 90 consecutive days or longer.• Measure
2951: Use of Opioids from Multiple Providers and at High Dosage in Persons
withoutCancer- The proportion (XX out of 1,000) of individuals without cancer
receiving prescriptionsfor opioids with a daily dosage greater than 120mg
morphine equivalent dose (MED) for 90consecutive days or longer, AND who
received opioid prescriptions from four (4) or moreprescribers AND four (4) or
more pharmacies.• These measures are also being considered for endorsement.
The Committee determined thatthey are related but not competing
- Endorsement Public Comments: 6. Public and Member
CommentComment:The measure received 1 comment in support of the measure with a
few recommendations for how themeasure could be improved.Developer
Response:The recommendations in the 2015 American Geriatrics Society Beers
Criteria are based on a systematicevidence review conducted by American
Geriatrics Society Beers Criteria Expert Panel. The review isfocused on the
evidence for potential harms of medications in older adults. Medications then
includedin the Beers Criteria recommendations are those that the panel found
evidence indicating that themedications should in general be avoided in all
older adults or avoided in older adults with certainconditions or diseases,
due to their associated risks for these populations. The Beers Criteria is
updatedregularly based on currently available literature. We believe it's
important for this quality measure to bebased on the systematic evidence
review that is conducted by the Beers Criteria Expert Panel. Thecomplete
evidence tables for the systematic review can be accessed on the American
Geriatrics Society'swebsite here:
http://geriatricscareonline.org/toc/american-geriatrics-society-updated-beers-criteria-forpotentially-inappropriate-medication-use-in-older-adults/CL001NCQA
recognizes that some of the medications that are most attributable to adverse
drug events inolder adults that result in ED visits and hospitalizations are
not included in the Beers Criteria asmedications to be generally avoided
(e.g., warfarin, antidiabetics and oral antiplatelets - although someoral
antiplatelets are in fact included in the Beers Criteria and this measure:
Dipyridamole, Ticlopidine).These other high-risk medications should be
addressed in separate quality measures that focus on safeprescribing and
appropriate monitoring, rather than this measure which focuses on medications
thatshould be generally avoided. We agree with the need for such quality
measures to improve safeprescribing of anticoagulants, antidiabetics, and
opioids and have current work underway at NCQA to 37explore development of
measures in these areas. Of note, the Pharmacy Quality Alliance has
severalmeasures addressing opioid prescribing that are currently being
considered for NQF endorsement aspart of this Patient Safety project. NCQA
supports the endorsement of these measures and has plans toadapt them for
health plan reporting in the near future.In terms of the way this measure is
currently specified to include a number of different medications, webelieve
that creating separate quality measures or indicators for all the specific
medications in the BeersCriteria, or for each drug-disease interaction, would
be burdensome for measurement and reporting byhealth plans. Plans can look at
medications on an individual basis to see where improvements andinterventions
are needed, however we do not think this level of detail would be desirable
for nationalreporting by health plans.As a measure of potentially
inappropriate medication use, NCQA does not expect this measure'sperformance
to ever reach 0% (i.e., no prescribing of high-risk medications). There will
always be caseswhere the benefits of prescribing a high-risk medication may
outweigh the risks for certain patients.Clinicians should take into account
various factors when considering the risk-benefit ratio of prescribinga
high-risk medication to an individual. A companion paper to the Beers Criteria
was published by theAmerican Geriatrics Society Workgroup on Improving Use of
the Beers Criteria in 2015. The paperspecifically states "the AGS 2015 Beers
Criteria are reasonable to use for performance measurementacross large groups
of patients and providers but should not be used to judge care for any
individual"(Steinman et al., 2015, JAGS). We believe measuring this concept of
potentially inappropriatemedication use among elderly at the health plan
(i.e., population) level is an important and usefulmedication safety measure
that health plans can use to identify high-risk medication
prescribing.Committee Response:The Committee agrees with the developer
response and maintains their decision to recommend thismeasure for continued
endorsement.
- Endorsement Committee Recommendation: Steering Committee
Recommendation for Endorsement: 20-Y; 0-N
Measure Specifications
- NQF Number (if applicable): 2940
- Description: The rate (XX out of 1,000) of individuals without
cancer receiving prescriptions for opioids with a daily dosage greater than
120 mg morphine equivalent dose (MED) for 90 consecutive days or
longer.
- Numerator: Any member in the denominator with opioid prescription
claims where the MED is greater than 120mg for 90 consecutive days or longer.
- Denominator: Any member with two or more prescription claims for
opioids filled on at least two separate days, for which the sum of the days’
supply is greater than or equal to 15.
- Exclusions: Any member with a diagnosis for Cancer or a
Prescription Drug Hierarchical Condition Category (RxHCC) 8, 9, 10, or 11 for
Payment Year 2015; or RxHCC 15, 16, 17, 18, 19 for Payment Year 2016; or a
hospice indicator (Medicare Part D) from the enrollment database.
- HHS NQS Priority: Promote Effective Prevention & Treatment of
Chronic Disease
- HHS Data Source: Administrative claims
- Measure Type: Process
- Steward: Pharmacy Quality Alliance
- Endorsement Status:
- Meaningful Measure Area: Prevention and Treatment of Opioid and
Substance Use Disorders
- Changes to Endorsed Measure Specifications?: The MUC list
indicates the measure has not been modified from its endorsed
version.
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support for rulemaking
with the condition that duplication is considered between this measure and
MUC2018-079
- Preliminary analysis summary
- Contribution to program measure set:This measure would
encourage the monitoring of opioid prescription patterns as studies have
determined that patient populations taking high opioid doses for prolonged
periods are often characterized by high rates of psychiatric and substance
abuse disorders, frequently do not receive care consistent with clinical
guidelines, and have higher death rates.
- Impact on quality of care for patients:This measure is fully
developed, tested, and NQF endorsed. This measure would strengthen and
diversify the SSP program measure set by addressing opioid use disorder
treatment.
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of promoting effective prevention and treatment of
chronic disease and specifically addresses the prevention and treatment of
opioid and substance use disorders
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. This is an NQF endorsed process measure.
Evidence shows that abuse and overdose of prescription drugs is a major public
health issue in the United States. Studies have determined that patient
populations taking high opioid doses for prolonged periods are often
characterized by high rates of psychiatric and substance abuse disorders,
frequently do not receive care consistent with clinical guidelines, and have
higher death rates.
- Does the measure address a quality challenge? Yes. This measure
addresses a critical population at increased risk of morbidity and mortality.
According to the CDC, overdose involving opioid analgesics killed nearly
17,000 persons in 2010 and the number of people with opioid analgesic use
disorders increased to nearly 2 million.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of existing measures in the SSP. It should be
noted; however, that this measure is a subcomponent of MUC2018-079, which is
also under consideration by the MAP this year.
- Can the measure can be feasibly reported? Yes. Pilot test sites
indicated the measure was feasible and results were able to be reported
efficiently and accurately. CMS calculates the measure for Part D plans. The
data is readily available (prescription claims data and medical
data).
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? Yes. The measure has been endorsed at the health plan
level.
- Measure development status: Fully Developed
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The measure is not in use in a federal
program. However, it is currently being used by the CMS Medicare Part D Drug
Benefit and Medicare Part D Overutilization Monitoring System to monitor the
utilization of opioids for members with the Medicare drug benefit. No
implementation issues have been noted by the developer.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
developer considered concerns have been that prescribing changes such as dose
reduction (without offering or arranging evidence-based treatment for patients
with opioid use disorder) might be associated with unintended negative
consequences, such as patients seeking heroin or other illicitly obtained
opioids (1,2) or interference with appropriate pain treatment. These were
taken into consideration with the balance of the damages from the opioid
epidemic.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Endorsed.
Rationale for measure provided by HHS
This measure
received systematic review by Clinical Practice Guideline recommendation, other
systematic review and grading of the body of evidence, and review by The Centers
for Medicare and Medicaid (CMS) Part D Overutilization Monitoring System (OMS)
and PubMed. Further information on evidence for the measure can be found on the
“National Quality Forum - Measure Testing” document in Section 1a.8.2. (National
Quality Forum - Measure Testing; Section 1a.8.1.)
Summary of NQF Endorsement
Review
- Year of Most Recent Endorsement Review: 2017
- Project for Most Recent Endorsement Review: Patient Safety
2016
- Review for Importance: 1. Importance to Measure and Report: The
measure meets the Importance criteria(1a. Evidence, 1b. Performance Gap)1a.
Evidence: 16-H; 3-M; 0-L; 0-I; 1b. Performance Gap: 13-H; 7-M; 0-L;
0-IRationale:• The developer provided a systematic review of the evidence
demonstrating the benefits of highdoseopioids for chronic pain are not
established and the risks for serious harm related to opioidtherapy increases
at higher doses.• Lower dosages of opioids reduce the risk for overdose, but a
single dosage threshold for safeopioid use has not been identified.• The
measure was tested in three different health plan data sources – the Medicare
population(mean rate=39.27 per 1,000), one commercial heath plan (mean rate=
32.003 per 1,000), andthe Medicaid population (mean rate =34.04 per 1,000).
The Committee noted that these ratesdemonstrate a significant performance
gap.• The Committee noted this is highly important to measure given the
current national opioidoveruse problem.
- Review for Scientific Acceptability: 2. Scientific Acceptability
of Measure Properties: The measure meets the Scientific
Acceptabilitycriteria(2a. Reliability - precise specifications, testing; 2b.
Validity - testing, threats to validity)2a. Reliability: 13-H; 7-M; 0-L; 0-I
2b. Validity: 14-M; 7-L; 0-IRationale:• The developer used several data sets
for reliability testing:o For Medicare testing, the analysis included a
convenience sample of over 700 MedicarePart D prescription drug plans
(comprising a total of 7,067,445 individuals aged 18 andolder)o Testing was
also conducted in one Commercial health plan (comprising a total of209,191
individuals age 18 and older)o For Medicaid testing, the analysis included 8
state-based prescription drug planscovering 6 states (comprising a total of
1,437,410 individuals age 18 and older)32• The mean reliability score across
all plans is 0.9938.• The developer assessed the face validity (only) of the
measure using a technical expert panelfrom the Pharmacy Quality Alliance
(PQA). 67 percent strongly agreed that the measure resultsreflected quality of
care. Five PQA member organizations also tested the measure using theirown
data, and all strongly agreed that the measure reflected the quality of care
provided fortheir populations.
- Review for Feasibility: 3. Feasibility: 13-H; 8-M; 0-L; 0-I(3a.
Clinical data generated during care delivery; 3b. Electronic sources;
3c.Susceptibility to inaccuracies/unintended consequences identified 3d. Data
collection strategy can be implemented)Rationale:• Pilot test sites indicated
the measure was feasible and results were able to be reportedefficiently and
accurately.• All the data elements are in defined fields in electronic
claims
- Review for Usability: 4. Usability and Use: 11-H; 9-M; 1-L;
0-I(Used and useful to the intended audiences for 4a. Accountability and
Transparency; 4b. Improvement;and 4c. Benefits outweigh evidence of unintended
consequences)Rationale:• The measure is currently being used in the Medicare
Part D Overutilization Monitoring Systemto monitor the utilization of opioids
for members with the Medicare drug benefit.• Although no unintended negative
consequences to individuals or populations were identifiedduring testing,
concerns have been raised that prescribing changes such as dose
reduction(without offering or arranging evidence-based treatment for patients
with opioid use disorder)might be associated with unintended negative
consequences, such as patients seeking heroin orother illicitly obtained
opioids (1,2) or interference with appropriate pain treatment.
- Review for Related and Competing Measures: 5. Related and
Competing MeasuresRelated measures:• Measure 2950: Use of Opioids from
Multiple Providers in Persons without Cancer- Theproportion (XX out of 1,000)
of individuals without cancer receiving prescriptions for opioidsfrom four (4)
or more prescribers AND four (4) or more pharmacies.• Measure 2951: Use of
Opioids from Multiple Providers and at High Dosage in Persons withoutCancer-
The proportion (XX out of 1,000) of individuals without cancer receiving
prescriptionsfor opioids with a daily dosage greater than 120mg morphine
equivalent dose (MED) for 90consecutive days or longer, AND who received
opioid prescriptions from four (4) or moreprescribers AND four (4) or more
pharmacies.• These measures are also being considered for endorsement. The
Committee determined thatthey are related but not competing.
- Endorsement Public Comments: 6. Public and Member
CommentComments:This measure received 3 comments. The commenters noted that
the measure may be too inclusive andthe developer should consider narrowing
the measure to specific chronic conditions or diagnoses to bemore
meaningful.Developers Response:The recommendations in the 2015 American
Geriatrics Society Beers Criteria are based on a systematicevidence review
conducted by American Geriatrics Society Beers Criteria Expert Panel. The
review isfocused on the evidence for potential harms of medications in older
adults. Medications then includedin the Beers Criteria recommendations are
those that the panel found evidence indicating that themedications should in
general be avoided in all older adults or avoided in older adults with
certainconditions or diseases, due to their associated risks for these
populations. The Beers Criteria is updatedregularly based on currently
available literature. We believe it's important for this quality measure to
bebased on the systematic evidence review that is conducted by the Beers
Criteria Expert Panel. Thecomplete evidence tables for the systematic review
can be accessed on the American Geriatrics Society'swebsite here:
http://geriatricscareonline.org/toc/american-geriatrics-society-updated-beers-criteria-forpotentially-inappropriate-medication-use-in-older-adults/CL001NCQA
recognizes that some of the medications that are most attributable to adverse
drug events inolder adults that result in ED visits and hospitalizations are
not included in the Beers Criteria asmedications to be generally avoided
(e.g., warfarin, antidiabetics and oral antiplatelets - although someoral
antiplatelets are in fact included in the Beers Criteria and this measure:
Dipyridamole, Ticlopidine).These other high-risk medications should be
addressed in separate quality measures that focus on safeprescribing and
appropriate monitoring, rather than this measure which focuses on medications
thatshould be generally avoided. We agree with the need for such quality
measures to improve safeprescribing of anticoagulants, antidiabetics, and
opioids and have current work underway at NCQA toexplore development of
measures in these areas. Of note, the Pharmacy Quality Alliance has
severalmeasures addressing opioid prescribing that are currently being
considered for NQF endorsement aspart of this Patient Safety project. NCQA
supports the endorsement of these measures and has plans toadapt them for
health plan reporting in the near future.In terms of the way this measure is
currently specified to include a number of different medications, webelieve
that creating separate quality measures or indicators for all the specific
medications in the BeersCriteria, or for each drug-disease interaction, would
be burdensome for measurement and reporting byhealth plans. Plans can look at
medications on an individual basis to see where improvements andinterventions
are needed, however we do not think this level of detail would be desirable
for nationalreporting by health plans.As a measure of potentially
inappropriate medication use, NCQA does not expect this measure'sperformance
to ever reach 0% (i.e., no prescribing of high-risk medications). There will
always be caseswhere the benefits of prescribing a high-risk medication may
outweigh the risks for certain patients.Clinicians should take into account
various factors when considering the risk-benefit ratio of prescribinga
high-risk medication to an individual. A companion paper to the Beers Criteria
was published by theAmerican Geriatrics Society Workgroup on Improving Use of
the Beers Criteria in 2015. The paperspecifically states "the AGS 2015 Beers
Criteria are reasonable to use for performance measurementacross large groups
of patients and providers but should not be used to judge care for any
individual"(Steinman et al., 2015, JAGS). We believe measuring this concept of
potentially inappropriatemedication use among elderly at the health plan
(i.e., population) level is an important and usefulmedication safety measure
that health plans can use to identify high-risk medication
prescribing.
- Endorsement Committee Recommendation: Steering Committee
Recommendation for Endorsement: 21-Y; 0-N
Measure Specifications
- NQF Number (if applicable): 2951
- Description: The rate (XX of 1,000) of individuals without cancer
receiving prescriptions for opioids with a daily dosage greater than 120 mg
morphine equivalent dose (MED) for 90 consecutive days or longer, AND who
received opioid prescriptions from four (4) or more prescribers AND four (4)
or more pharmacies.
- Numerator: Any member in the denominator with opioid prescription
claims where the MED is greater than 120 mg for 90 consecutive days or longer
AND who received opioid prescriptions from 4 or more prescribers AND 4 or more
pharmacies.
- Denominator: Any member with two or more prescription claims for
opioids filled on at least two separate days, for which the sum of the days’
supply is greater than or equal to 15.
- Exclusions: Any member with a diagnosis for Cancer or
Prescription Drug Hierarchical Condition Category (RxHCC) 8, 9, 10, or 11 for
Payment Year 2015; or RxHCC 15, 16, 17, 18, or 19 for Payment Year 2016; or a
hospice indicator (Medicare Part D) from the enrollment database.
- HHS NQS Priority: Promote Effective Prevention & Treatment of
Chronic Disease
- HHS Data Source: Administrative claims
- Measure Type: Process
- Steward: Pharmacy Quality Alliance
- Endorsement Status:
- Meaningful Measure Area: Prevention and Treatment of Opioid and
Substance Use Disorders
- Changes to Endorsed Measure Specifications?: The MUC list
indicates the measure has not been modified from its endorsed
version.
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Conditional support for rulemaking
with the condition potential duplication between this measure and MUC2018-077
& 078 is considered.
- Preliminary analysis summary
- Contribution to program measure set:This measure would
encourage the monitoring of opioid prescription patterns as studies have
shown that people who see multiple providers or use multiple pharmacies are
more likely to die of drug overdoses and that patient populations taking
high opioid doses for prolonged periods are often characterized by high
rates of psychiatric and substance abuse disorders, frequently do not
receive care consistent with clinical guidelines, and have higher death
rates.
- Impact on quality of care for patients:This measure is fully
developed, tested, and NQF endorsed. This measure would strengthen and
diversify the SSP program measure set by addressing opioid use disorder
treatment.
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of promoting effective prevention and treatment of
chronic disease and specifically addresses the prevention and treatment of
opioid and substance use disorders
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. This is an NQF endorsed process measure.
Evidence shows that abuse and overdose of prescription drugs is a major public
health issue in the United States. Studies have determined that patient
populations taking high opioid doses for prolonged periods are often
characterized by high rates of psychiatric and substance abuse disorders,
frequently do not receive care consistent with clinical guidelines, and have
higher death rates.
- Does the measure address a quality challenge? Yes. This measure
addresses a critical population at increased risk of morbidity and mortality.
According to the CDC, overdose involving opioid analgesics killed nearly
17,000 persons in 2010 and the number of people with opioid analgesic use
disorders increased to nearly 2 million.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of existing measures in the SSP. It should be
noted; however, that measures MUC2018-077 and MUC2018-078, which are also
under consideration by MAP this year, are subcomponents of
MUC2018-079.
- Can the measure can be feasibly reported? Yes. Pilot test sites
indicated the measure was feasible and results were able to be reported
efficiently and accurately. CMS calculates the measure for Part D plans. The
data is readily available (prescription claims data and medical
data).
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? Yes. The measure has been endorsed at the health plan
level.
- Measure development status: Fully Developed
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a. The measure is not in use in a federal
program. However, it is currently being used by the CMS Medicare Part D Drug
Benefit and Medicare Part D Overutilization Monitoring System to monitor the
utilization of opioids for members with the Medicare drug benefit. No
implementation issues have been noted by the developer.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a. The
developer considered concerns have been that prescribing changes such as dose
reduction (without offering or arranging evidence-based treatment for patients
with opioid use disorder) might be associated with unintended negative
consequences, such as patients seeking heroin or other illicitly obtained
opioids (1,2) or interference with appropriate pain treatment. These were
taken into consideration with the balance of the damages from the opioid
epidemic.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Endorsed.
Rationale for measure provided by HHS
This measure
received systematic review by Clinical Practice Guideline recommendation, other
systematic review and grading of the body of evidence, and review by The Centers
for Medicare and Medicaid (CMS) Part D Overutilization Monitoring System (OMS)
and PubMed. Further information on evidence for the measure can be found on the
“National Quality Forum - Measure Testing” document in Section 1a.8.2. (National
Quality Forum - Measure Testing; Section 1a.8.1.)
Summary of NQF Endorsement
Review
- Year of Most Recent Endorsement Review: 2017
- Project for Most Recent Endorsement Review: Patient Safety
2016
- Review for Importance: 1. Importance to Measure and Report: The
measure meets the Importance criteria(1a. Evidence, 1b. Performance Gap)1a.
Evidence: 0-H;17-M; 1-L; 0-I; 1b. Performance Gap: 10-H; 6-M; 0-L;
0-IRationale:• The benefits for high dose opioids for chronic pain are not
established and the risks for seriousharms related to opioid therapy increase
at higher opioid dosage. The use of multipleprescribers and pharmacies are
associated with increased risks for opioid overdose. The risk foroverdose
increases with the number of prescribers and pharmacies.• The measure’s
performance was tested in three different health plan data sources –
theMedicare population (mean was 3.03 per 1,000 and the median was 2.89 per
1,000), onecommercial heath plan (mean rate 1.45 per 1,000), and the Medicaid
population (mean was2.68 per 1,000 and the median was 2.38 per
1,000).
- Review for Scientific Acceptability: 2. Scientific Acceptability
of Measure Properties: The measure meets the Scientific
Acceptabilitycriteria(2a. Reliability - precise specifications, testing; 2b.
Validity - testing, threats to validity)2a. Reliability: 11-H; 5-M; 0-L;0-I
2b. Validity: 16-M; 2-L; 0-IRationale:• The measure was tested at the score
level. The developer used several data sets for reliabilitytesting:• For
Medicare testing, the analysis included a convenience sample of over 700
Medicare Part Dprescription drug plans (comprising a total of 7,067,445
individuals aged 18 and older)• Testing was also conducted in one Commercial
health plan (comprising a total of 209,191individuals age 18 and older)39• For
Medicaid testing, the analysis included 8 state-based prescription drug plans
covering 6states (comprising a total of 1,437,410 individuals age 18 and
older)• The mean reliability score across all plans is 0.9208.• The developer
assessed the face validity (only) of the measure using a technical expert
panelfrom the Pharmacy Quality Alliance (PQA). 83.3 percent strongly agreed
that the measureresults reflected quality of care. Five PQA member
organizations also tested the measure usingtheir own data, and all strongly
agreed that the measure reflected the quality of care providedfor their
populations.
- Review for Feasibility: 3. Feasibility: 15-H; 2-M; 0-L; 0-I(3a.
Clinical data generated during care delivery; 3b. Electronic sources;
3c.Susceptibility to inaccuracies/unintended consequences identified 3d. Data
collection strategy can be implemented)Rationale:• All data elements are
defined in field in electronic claims• Pilot test sites indicated the measure
was feasible and results were able to be reportedefficiently and
accurately.
- Review for Usability: 4. Usability and Use: 10-H; 9-M; 1-L;
0-I(Used and useful to the intended audiences for 4a. Accountability and
Transparency; 4b. Improvement;and 4c. Benefits outweigh evidence of unintended
consequences)Rationale:• The measure is currently being used in the Medicare
Part D Overutilization Monitoring Systemto monitor the utilization of opioids
for members with the Medicare drug benefit.• Although no unintended negative
consequences to individuals or populations were identifiedduring testing, ,
concerns have been raised that prescribing changes such as dose
reduction(without offering or arranging evidence-based treatment for patients
with opioid use disorder)might be associated with unintended negative
consequences, such as patients seeking heroin orother illicitly obtained
opioids (1,2) or interference with appropriate pain treatment.(3) Dataindicate
that if access to prescription opioids is limited, some users of opioid
analgesics willtransition to heroin or other illicitly obtained opioids,
leading to increased overdose deathcoincident with prescribing
restrictions.(
- Review for Related and Competing Measures: 5. Related and
Competing Measures• Measure 2950: Use of Opioids from Multiple Providers in
Persons without Cancer- Theproportion (XX out of 1,000) of individuals without
cancer receiving prescriptions for opioidsfrom four (4) or more prescribers
AND four (4) or more pharmacies.• Measure 2940: Use of Opioids at high Dosage
in Persons without Cancer- The proportion (XX outof 1,000) of individuals
without cancer receiving prescriptions for opioids with a daily dosagegreater
than 120mg morphine equivalent dose (MED) for 90 consecutive days or longer.•
These measures are also being considered for endorsement. The Committee
determined thatthey are related but not competing.
- Endorsement Public Comments: None
- Endorsement Committee Recommendation: Steering Committee
Recommendation for Endorsement: 18-Y; 0-N
Measure Specifications
- NQF Number (if applicable):
- Description: Composite score indicating compliance with five
measurable CDC opioid prescribing guidelines. The denominator includes new
opioid prescriptions in the measurement year. The numerator includes new
opioid prescriptions that are compliant on all 5 CDC indicators. Higher is
better on this measure.
- Numerator: Individuals in the denominator whose new opioid
medication meets all of the following CDC guidelines: 1. Initial opioid
prescription is prescribed while patient is not exposed to benzodiazepines 2.
Initial opioid prescription is not for methadone 3. Initial opioid
prescription is for short acting formulation 4. Initial opioid prescription is
for less than 50 MME/day 5. Initial opioid prescription is for a 7-day supply
or less
- Denominator: All new opioid prescriptions in the measurement year
(a new opioid prescription is defined as no evidence of an opioid prescription
12 months prior to the earliest detected claim in the measurement
year).
- Exclusions: Denominator exclusions include: Evidence of malignant
cancer, chemotherapy, or radiation in the measurement year. Patients in
hospice or palliative care. Patients in long term care, nursing home, or
skilled nursing facility for >=90 days at any time during the measurement
year.
- HHS NQS Priority: Promote Effective Prevention and Treatment of
Chronic Disease
- HHS Data Source:
- Measure Type: Composite
- Steward: OptumLabs
- Endorsement Status:
- Meaningful Measure Area: Prevention and Treatment of Opioid and
Substance Use Disorders
- Is the measure specified as an electronic clinical quality
measure? No
Preliminary Analysis of
Measure
- Preliminary analysis result: Do not support for rulemaking with
the potential for mitigation. Mitigation would include specifying the measure
at the health plan level.
- Preliminary analysis summary
- Contribution to program measure set:This measure would
encourage the monitoring of opioid prescription patterns as studies have
shown that people who see multiple providers or use multiple pharmacies are
more likely to die of drug overdoses.
- Impact on quality of care for patients:This composite measure
would help monitor and improve guideline compliance of opioid prescriptions.
- Does the measure address a critical quality objective not currently
adequately addressed by the measures in the program set? Yes. This
measure meets the priority of promoting effective prevention and treatment of
chronic disease and specifically addresses the prevention and treatment of
opioid and substance use disorders.
- Is the measure evidence-based and either strongly linked to outcomes
or an outcome measure? Yes. Evidence shows that abuse and overdose of
prescription drugs is a major public health issue in the United States.
Studies have determined that patient populations taking high opioid doses for
prolonged periods are often characterized by high rates of psychiatric and
substance abuse disorders, frequently do not receive care consistent with
clinical guidelines, and have higher death rates.
- Does the measure address a quality challenge? Yes. This measure
addresses a critical population at increased risk of morbidity and mortality.
According to the CDC, overdose involving opioid analgesics killed nearly
17,000 persons in 2010 and the number of people with opioid analgesic use
disorders increased to nearly 2 million.
- Does the measure contribute to efficient use of measurement resources
and/or support alignment of measurement across programs? Yes. This
measure is not duplicative of existing measures in the SSP.
- Can the measure can be feasibly reported? Yes. This measure was
developed using standard administrative claims and enrollment data for
Medicare Advantage and commercial health plan participants. Similar data are
currently available to CMS and may be feasibly shared with ACOs.
- Is the measure applicable to and appropriately specified for the
program's intended care setting(s), level(s) of analysis, and
population(s)? Yes. The measure was tested at the county
level.
- Measure development status: Field Testing
- If the measure is in current use, have negative unintended issues to
the patient been identified? n/a.
- If the measure is in current use, have implementation challenges
outweighing the benefits of the measure have been identified? n/a.
- Is the measure NQF endorsed for the program's setting and level of
analysis? Never Submitted.
Rationale for measure provided by HHS
This measure was
developed using the CDC Guideline for Prescribing Opioids for Chronic Pain –
United States, 2016 (https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm), and
the Surgeon General’s Report on Alcohol, Drugs, and Health
(https://addiction.surgeongeneral.gov/) and is therefore based on scientific
evidence consistent with establishing each of the 5 components that comprise the
composite. The CDC Guideline provides clarity on opioid prescribing
recommendations based on the most recent scientific evidence, informed by expert
opinion and stakeholder and public input. A large body of research has
identified high-risk prescribing practices that contribute to the overdose
epidemic (e.g., high-dose and duration prescribing, overlapping opioid and
benzodiazepine prescriptions, and extended-release/long-acting [ER/LA] opioids
for acute pain). This composite measure, derived from the CDC Guideline, is
aimed at addressing problematic initial prescribing. It has the potential to
optimize treatment and improve patient safety using evidence-based, best
practices, as well as mitigate opioid pain medication misuse that contributes to
the opioid overdose epidemic. CDC Guideline References 24.Bohnert AS, Valenstein
M, Bair MJ, et al. Association between opioid prescribing patterns and opioid
overdose-related deaths. JAMA 2011;305:1315–21. 26.Jamison RN, Sheehan KA,
Scanlan E, Matthews M, Ross EL. Beliefs and attitudes about opioid prescribing
and chronic pain management: survey of primary care providers. J Opioid Manag
2014;10:375–82. 27.Wilson HD, Dansie EJ, Kim MS, Moskovitz BL, Chow W, Turk DC.
Clinicians’ attitudes and beliefs about opioids survey (CAOS): instrument
development and results of a national physician survey. J Pain 2013;14:613–27.
28.Haegerich TM, Paulozzi LJ, Manns BJ, Jones CM. What we know, and don’t know,
about the impact of state policy and systems-level interventions on prescription
drug overdose. Drug Alcohol Depend 2014;145:34–47. 33.Liu Y, Logan JE, Paulozzi
LJ, Zhang K, Jones CM. Potential misuse and inappropriate prescription practices
involving opioid analgesics. Am J Manag Care 2013;19:648–65. 34.Mack KA, Zhang
K, Paulozzi L, Jones C. Prescription practices involving opioid analgesics among
Americans with Medicaid, 2010. J Health Care Poor Underserved 2015;26:182–98.
77.Miller M, Barber CW, Leatherman S, et al. Prescription opioid duration of
action and the risk of unintentional overdose among patients receiving opioid
therapy. JAMA Intern Med 2015;175:608–15 191.Chou R, Cruciani RA, Fiellin DA, et
al. ; American Pain Society; Heart Rhythm Society. Methadone safety: a clinical
practice guideline from the American Pain Society and College on Problems of
Drug Dependence, in collaboration with the Heart Rhythm Society. J Pain
2014;15:321–37 127.Bohnert ASB, Logan JE, Ganoczy D, Dowell D. A detailed
exploration into the association of prescribed opioid dosage and prescription
opioid overdose deaths among patients with chronic pain. Med Care 2016. Epub
ahead of print.
http://journals.lww.com/lww-medicalcare/Abstract/publishahead/A_Detailed_Exploration_Into_the_Association_of.98952.aspx
192.Chu J, Farmer B, Ginsburg B, Hernandez S, Kenny J, Majlesi N. New York City
emergency department discharge opioid prescribing guidelines. New York, NY: New
York City Department of Health and Mental Hygiene; 2013.
https://www1.nyc.gov/assets/doh/downloads/pdf/basas/opioid-prescribing-guidelines.pdf
193.Cheng D, Majlesi N. Clinical practice statement: emergency department opioid
prescribing guidelines for the treatment of non-cancer related pain. Milwaukee,
WI: American Academy of Emergency Medicine; 2013. 194.American College of
Emergency Physicians. Maryland emergency department and acute care facility
guidelines for prescribing opioids. Baltimore, MD: Maryland Chapter, American
College of Emergency Physicians; 2014.
http://www.mdacep.org/MD%20ACEP%20Pamphlet%20FINAL_April%202014.pdf 195.Paone D,
Dowell D, Heller D. Preventing misuse of prescription opioid drugs. City Health
Information 2011;30:23–30. 196.Thorson D, Biewen P, Bonte B, et al. Acute pain
assessment and opioid prescribing protocol. Bloomington, MN: Institute for
Clinical Systems Improvement; 2014.
https://crh.arizona.edu/sites/default/files/u35/Opioids.pdf 197.Cantrill SV,
Brown MD, Carlisle RJ, et al. ; American College of Emergency Physicians Opioid
Guideline Writing Panel. Clinical policy: critical issues in the prescribing of
opioids for adult patients in the emergency department. Ann Emerg Med
2012;60:499–525 212.Park TW, Saitz R, Ganoczy D, Ilgen MA, Bohnert AS.
Benzodiazepine prescribing patterns and deaths from drug overdose among US
veterans receiving opioid analgesics: case-cohort study. BMJ 2015;350:h2698.
213.Paquin AM, Zimmerman K, Rudolph JL. Risk versus risk: a review of
benzodiazepine reduction in older adults. Expert Opin Drug Saf 2014;13:919–34.
214.Schweizer E, Case WG, Rickels K. Benzodiazepine dependence and withdrawal in
elderly patients. Am J Psychiatry 1989;146:529–31.
Appendix B: Program Summaries
The material in this
appendix was drawn from the CMS
Program Specific Measure Priorities and Needs document, which was released
in May 2018.
Program Index
Full Program Summaries
The material in this appendix
was drawn from the CMS
Program Specific Measure Priorities and Needs document, which was released
in May 2018.
Program History and Structure: The Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate (SGR)
formula, which would have resulted in a significant cut to payment rates for
clinicians participating in Medicare. MACRA requires CMS by law to implement an
incentive program for clinicians. This program, referred to as the Quality
Payment Program, provides two participation pathways for clinicians: (1) The
Merit-based Incentive Payment System (MIPS), and (2) Advanced Alternative
Payment Models (Advanced APMs). MIPS combines three Medicare “legacy” programs –
the Physician Quality Reporting System (PQRS), Value-based Payment Modifier
(VM), and the Medicare EHR Incentive Program for Eligible Professionals – into a
single program. Under MIPS, there are four connected performance categories that
will affect a clinician’s future Medicare payments. Each performance category is
scored independently and has a specific weight, indicating its contribution
towards the MIPS Final Score. The MIPS performance categories and their 2018
weights towards the final score are: Quality (50%); Advancing Care information
(25%); Improvement Activities (15%); and Cost (10%). The final score (100%) will
be the basis for the MIPS payment adjustment assessed for MIPS eligible
clinicians.
High Priority Domains for Future Measure Consideration:
CMS identified
the following five domains as high-priority for future measure consideration:
1.Person and
Family Engagement (Care is Personalized and Aligned with Patient's Goals, End of
Life Care According to Preferences, Patient’s Experience and Functional
Outcomes): This means that the measure should address the experience of each
person and their family; and the extent to which they are engaged as partners in
their care. a. CMS wants to specifically focus on patient reported outcome
measures (PROMs). Person or family-reported experiences of being engaged as
active members of the health care team and in collaborative partnerships with
providers and provider organizations.
2. Communication
and Coordination of Care (Medication Management, Admissions and Readmissions to
Hospitals, Seamless Transfer of Health Information): This means that the measure
must address the promotion of effective communication and coordination of care;
and coordination of care and treatment with other providers.
3. Making Care
Affordable (Appropriate Use of Healthcare, Patient-focused Episode of Care, Risk
Adjusted Total Cost of Care): This means that the measure must address the
affordability of health care including unnecessary health services,
inefficiencies in health care delivery, high prices, or fraud. Measures should
cause change in efficiency and reward value over volume.
4. Making Care
Safer (Healthcare-Associated Infections, Preventable Healthcare Harm): This
means that the measure must address either an explicit structure or process
intended to make care safer, or the outcome of the presence or absence of such a
structure or process; and harm caused in the delivery of care. This means that
the structure, process or outcome described in “a” must occur as a part of or as
a result of the delivery of care.
5. Appropriate
Use: CMS wants to specifically focus on appropriate use measures. This means
that the measure must address appropriate use of services, including measures of
over use.
Measure Requirements: CMS applies criteria for measures that
may be considered for potential inclusion in the MIPS. At a minimum, the
following criteria and requirements must be met for selection in the MIPS: CMS
is statutorily required to select measures that reflect consensus among affected
parties, and to the extent feasible, include measures set forth by one or more
national consensus building entities. To the extent practicable, quality
measures selected for inclusion on the final list will address at least one of
the following quality domains: Effective Prevention and Treatment, Making Care
Safer, Communication and Coordination of Care, Best Practices of Healthy Living,
Making Care Affordable or Person and Family Engagement. In addition, before
including a new measure in MIPS, CMS is required to submit for publication in an
applicable specialty-appropriate, peer-reviewed journal the measure and the
method for developing the measure, including clinical and other data supporting
the measure. Measures implemented in MIPS may be available for public reporting
on Physician Compare. Measures must be fully developed, with completed testing
results at the clinician level and ready for implementation at the time of
submission (CMS’ internal evaluation). Preference will be given to measures
that are endorsed by the National Quality Forum (NQF). Measures should not
duplicate other measures currently in the MIPS. Duplicative measures are
assessed to see which would be the better measure for the MIPS measure set.
Measure performance and evidence should identify opportunities for improvement.
CMS does not intend to implement measures in which evidence identifies high
levels of performance with little variation or opportunity for improvement,
e.g., measures that are “topped out.” Claims measures must also be reportable
via another data submission mechanism (e.g. registry, eCQM). MIPS is not
accepting claims only measures. Section 101(c)(1) of the MACRA requires
submission of new measures for publication in applicable specialty-appropriate,
peer-reviewed journals prior to implementing in MIPS. The Peer-Review Journal
template provided by CMS, must accompany each measures submission. Please see
the template for additional information. eCQMs must meet EHR system
infrastructure requirements, as defined by MIPS regulation. Beginning with
calendar year 2019, eCQMs will use clinical quality language (CQL) as the
expression logic used in the Health Quality Measure Format (HQMF). CQL replaces
the logic expressions currently defined in the Quality Data Model (QDM). The
data collection mechanisms must be able to transmit and receive requirements as
identified in MIPS regulation. For example, eCQMs being submitted as Quality
Reporting Data Architecture (QRDA) III must meet QRDA – III standards as defined
in the CMS QRDA III Implementation Guide. eCQMs must have HQMF output from the
Measure Authoring Tool (MAT), using MAT v5.4, or more recent, with
implementation of the clinical quality language logic. Additional information on
the MAT can be found at
https://ecqi.healthit.gov/ecqm-tools/tool-library/measure-authoring-tool Bonnie
test cases must accompany each measure submission. Additional information on
eCQM Tools and resources can be found at
https://ecqi.healthit.gov/ecqm-tools-key-resources. Reliability and validity
testing must be conducted for measures. In addition to the above, feasibility
testing must be conducted for eCQMs. Testing data must accompany submission. For
example, if a measure is being reported as registry and eCQM, testing data for
both versions must be submitted.
Current Measures: NQF staff have compiled the program's
measures in a spreadsheet organized according to concepts.
The material in this appendix was drawn
from the CMS
Program Specific Measure Priorities and Needs document, which was released
in May 2018.
Program History and Structure: Section 3022 of the
Affordable Care Act (ACA) requires the Centers for Medicare & Medicaid
Services (CMS) to establish a Shared Savings Program that promotes
accountability for a patient population, coordinates items and services under
Medicare Parts A and B, and encourages investment in infrastructure and
redesigned care processes for high-quality and efficient service delivery. The
Medicare Shared Savings Program (Shared Savings Program) was designed to
facilitate coordination and cooperation among providers to improve the quality
of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce the rate of
growth in health care costs. Eligible providers, hospitals, and suppliers may
voluntarily participate in the Shared Savings Program by creating or
participating in an Accountable Care Organization (ACO). If ACOs meet program
requirements and the ACO quality performance standard, they are eligible to
share in savings, if earned. There are four shared savings options: 1) one-
sided risk model (Track 1 ACOs do not assume downside risk (shared losses) if
they do not lower growth in Medicare expenditures), Medicare ACO Track 1+ Model
(Medicare ACO Track 1+ Model (Track 1+ Model) ACOs assume limited downside risk
(less than Track 2 or Track 3); 2) two-sided risk model (Track 2 ACOs may share
in savings or repay Medicare losses depending on performance. Track 2 ACOs may
share in a greater portion of savings than Track 1 ACOs); and, 3) two-sided risk
model (Track 3 ACOs may share in savings or repay Medicare losses depending on
performance. Track 3 ACOs take on the greatest amount of risk, but may share in
the greatest portion of savings if successful)
Measure Requirements: Specific measure requirements include:
Outcome measures that address conditions that are high-cost and affect a high
volumeof Medicare patients. Measures that are targeted to the needs and gaps in
care of Medicare fee-for-service patients and their caregivers. Measures that
align with CMS quality reporting initiatives, such as the Quality Payment
Program. Measures that support improved individual and population health.
Measures addressing high-priority healthcare issues, such as opioid use.
Measures that align with recommendations from the Core Quality Measures
Collaborative.
Current Measures: NQF staff have compiled the program's
measures in a spreadsheet organized according to concepts.
Index of Measures (by Program)
All measures are included in the
index, even if there were not any public comments about that measure for that
program.
Merit-Based Incentive Payment System
Medicare Shared Savings Program
Full Comments (Listed by Measure)
(Program: Merit-Based Incentive Payment
System; MUC ID: MUC2018-032) |
- The American Occupational Therapy Association (AOTA) appreciates the
opportunity to comment on this measure. While we agree with the AAOS
recommendation that routine use of occupational therapy or physical therapy
following carpal tunnel release (CTR) surgery is not recommended, we believe
that the use of this measure as written is not ready for use in the MIPS
program, especially because these MIPS measures are benchmarked for
performance and can change eligible clinician’s reimbursement. We think that
the measure specifications have several problems: (1) the measure may have low
specificity: it could capture beneficiaries who receive therapy for unrelated
reasons; (2) the measure contains no exclusions: the literature on which the
rationale is based is primarily non-Medicare literature and does not consider
the addition of complications or comorbidities. The measure may have the
unintended consequence of limiting Medicare beneficiary access to needed
services. The measure would capture beneficiaries who receive therapy for
unrelated conditions or medical reasons. The measure includes all
beneficiaries who receive any OT or PT evaluation within 6 weeks of the CTR
date. A surgeon would be attributed an increased (worse) score on this measure
if their patient received an OT or PT evaluation for any reason during this
period of time. We would recommend considering a CPT and ICD combination in
the numerator to reduce the likelihood of incorrectly counting a beneficiary
in the numerator. The measure contains no exclusions. We believe that this may
lead to limited access. While the AAOS recommendation is that OT and PT
services should not be routine, the measure can be interpreted to mean that OT
and PT services should be never events. Based on our discussions with AOTA
subject matter experts, while OT and PT services should not be routine, there
are instances in which the services are warranted (e.g., when an UE fracture
is also present, the presence of severe arthritis, complications related to
sensation or scar management). The measure as written could penalize surgeons
for referring the beneficiary to therapy in these appropriate contexts. The
literature provided in the rationale does not address these populations. Alves
(2011), the high quality study, only addresses one specific modality (that is
not recommended by AOTA) and includes a median age of 44 years compared to a
median age of 52 years. Pomerance (2007) includes participants with a median
age of 46 years. And, Provinciali (2000) includes participants with a mean age
of 55 years. None of the studies discuss chronic or co-occurring conditions.
Especially in the Medicare population, a surgeon may identify additional
complications or conditions that could indicate a clinical need for OT or PT
for optimal care following a CTR. This should be addressed before the measure
is used in a pay for performance program like MIPS. Another potential solution
could be a shorter time horizon for the measure. As an example, a 2 week
horizon rather than a 6 week horizon would likely capture less beneficiaries
evaluated by OT or PT for other reasons. It would also allow a follow up visit
to the surgeon’s office to identify if there are potential complications that
would warrant a therapy referral. And, it should still measure the routine
post-operation referral. (Submitted by: American Occupational Therapy
Association)
(Program: Merit-Based Incentive Payment
System; MUC ID: MUC2018-047) |
- NHPCO Comments: Not all chronically ill/seriously ill individuals have
access to palliative care services. We recommend considering a broader group
of diagnoses for “excludes” and/or use of the standard definition of serious
illness: a health condition that carries a high risk of mortality AND either
negatively impacts a person’s daily function or quality of life, OR
excessively strains their caregivers (Kelley et al Journal of Palliative
Medicine 2018). (Submitted by: National Hospice and Palliative Care
Organization)
- We support this measure as the evidence suggests multimodal pain
management for acute pain is more effective than single agents alone and, in
surgical patients, could achieve better pain control with less risk of
potential overuse/abuse of opioids. (Submitted by: Coalition to Transform
Advanced Care)
(Program: Merit-Based Incentive Payment
System; MUC ID: MUC2018-048) |
- NHPCO Comments: Not all chronically ill/seriously ill individuals have
access to palliative care services. We recommend considering a broader group
of diagnoses for “excludes” and/or use of the standard definition of serious
illness: a health condition that carries a high risk of mortality AND either
negatively impacts a person’s daily function or quality of life, OR
excessively strains their caregivers (Kelley et al Journal of Palliative
Medicine 2018). (Submitted by: National Hospice and Palliative Care
Organization)
- The AANS and CNS disagree with the fundamental premise of this measure
that daily dose and duration of therapy involving prescription opioid
analgesics can serve on its own as a measure of quality patient care. Instead,
quality measurement needs to focus on how well patients’ pain is controlled,
whether functional improvement goals are met, and what therapies are being
used to manage pain. A reduction in opioid dose, in the absence of other
findings, is not an appropriate goal and it is not consistent with the Centers
for Disease Control & Prevention (CDC) Guideline for Prescribing Opioids
for Chronic Pain, which allows for physicians to document a clinical rationale
or justification for the clinical use of dosages exceeding a daily threshold
of 90 morphine milligram equivalents (MME). If this measure does not
adequately define the patients for whom higher doses of opioids may be
appropriate, it will provide invalid representations of physician performance.
There is also a risk that physicians may reduce opioid prescriptions to score
well on this measure and harm patients for whom the benefits of opioid therapy
exceed the risks. CMS should explore more appropriate methods to assess a
patient’s chronic pain, including the use of patient-reported data as the
basis for performance measures. CMS also should test this measure in
different patient populations to understand whether differences in performance
scores are due to the complexity of patients treated across various
specialties and whether the measure as defined is actually appropriate for
quality improvement and/or accountability purposes. In addition, understanding
the feasibility of directly calculating the measure from the EHR is critical
because it is not clear that EHRs uniformly capture MMEs, which is a necessary
calculation to populate the measure's numerator. In light of these concerns,
the AANS and CNS do NOT support MUC18-48 Potential Opioid Overuse for
implementation in MIPS at this time. (Submitted by: American Association of
Neurological Surgeons )
- The AMA disagrees with the fundamental premise of this measure that daily
dose and duration of therapy involving prescription opioid analgesics can
serve on its own as a measure of quality patient care. Instead, quality
measurement needs to focus on how well patients’ pain is controlled, whether
functional improvement goals are met, and what therapies are being used to
manage pain. A reduction in opioid dose, in the absence of other findings, is
not an appropriate goal and it is not consistent with the Centers for Disease
Control & Prevention (CDC) Guideline for Prescribing Opioids for Chronic
Pain, which allows for physicians to document a clinical rationale or
justification for the clinical use of dosages exceeding a daily threshold of
90 morphine milligram equivalents (MME). CMS should explore more appropriate
methods to assess a patient’s chronic pain such as the Pain Assessment
Screening Tool and Outcomes Registry (PASTOR) and use this patient-reported
data as the basis for performance measures. This tool utilizes the Patient
Reported Outcomes Measurement Information System (PROMIS) and through the use
of Computer Adaptive Testing, key domains such as sleep disturbance and
physical function can be assessed in a targeted and patient-directed way.
During CMS’ public comment on this draft measure, the AMA raised significant
concerns around the intent of the measure, with its broad denominator
population and limited exclusions, and questioned whether the current
specifications adequately captured the recommendations from the CDC such as
acknowledging the ability to justify prescriptions exceeding 90 MME/day. The
measure currently includes buprenorphine (for pain management) and it is not
clear how the clinical indication for prescribing can be captured in an
electronic health record (EHR). Because it is most often used for medication
assisted treatment (MAT) of opioid use disorder, and existing MME calculators
do not account for buprenorphine required for MAT, we believe that this drug
should be removed. In addition, the unintended consequences of this measure
must be clearly evaluated prior to moving forward. Specifically, if the
measure does not adequately define the patients for whom higher doses of
opioids may be appropriate, it will provide invalid representations of
physician performance. There is also a risk that physicians may reduce opioid
prescriptions to score well on this measure and harm patients for whom the
benefits of opioid therapy exceed the risks. Prior to finalization of the
measure, the AMA has already requested that it be tested in different patient
populations and medical specialties to understand whether differences in
performance scores are due to the complexity of patients treated across
various specialties and whether the measure as defined is actually appropriate
for quality improvement and/or accountability purposes. In addition,
understanding the feasibility of directly calculating the measure from the EHR
is critical because it is not clear that EHRs uniformly capture MMEs; this
calculation is necessary to populate the measure's numerator. Therefore, in
light of the multiple uncertainties and concerns with the measure, as well as
the existence of proposed measures that are similar and overlapping, the AMA
recommends that the highest level of MAP recommendation be “Do Not Support
With Potential For Mitigation”. (Submitted by: American Medical
Association)
- The Renal Physicians Association (RPA) is the professional organization of
nephrologists whose goals are to ensure optimal care under the highest
standards of medical practice for patients with kidney disease and related
disorders. RPA acts as the national representative for physicians engaged in
the study and management of patients with kidney disease. RPA supports this
measure. (Submitted by: Renal Physician Association )
- We appreciate that this measure has exclusions for cancer/sickle cell,
hospice, and palliative care. We urge CMS to closely monitor implementation
for unintended consequences for patients with serious illness who don’t fall
under these exclusions, but for whom higher doses of opioids are clinically
indicated. (Submitted by: Center to Advance Palliative Care)
- We support this but recognize other people with advanced illnesses outside
of the excluded categories, including those with chronic pain, can also
justifiably need opioids for longer and at higher doses (Submitted by:
C-TAC)
(Program: Merit-Based
Incentive Payment System; MUC ID: MUC2018-057) |
- AVAC believes the MUC18- 57 Annual Wellness Assessment: Preventive Care
satisfy many of the objectives of the Meaningful Measures Framework, including
addressing high impact measure areas that safeguard public health, patient
centered and meaningful to patients, minimize the level of burden for health
care providers, significant opportunity for improvement, fulfill each
program’s statutory requirements and align across programs and with other
payers. The two measures also strongly align with the Meaningful Measure
areas and overarching quality priorities outlined in the MUC announcement.
MUC18-57 also address the cross-cutting measure criteria: eliminating
disparities; tracking measurable outcomes and impact; safeguarding public
health; achieving cost savings; improving access for rural communities and
reducing burden. (Submitted by: Adult Vaccine Access Coalition)
- BIO supports the inclusion of influenza and pneumococcal immunization as
components of the Annual Wellness Assessment measure. Measures that monitor
immunization status as well as reporting of immunizations offered and
administered for beneficiaries represent critical preventative service
benchmarks on the value of immunizations under new payment models and such
measures help to identify where gaps in access remain. We applaud the measure
for aligning with the Standards for Adult Immunization Practice
[https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/index.html]
and urging the assessment, recommendation, administration or referral, and
documentation of immunization status of these serious diseases at each
clinical encounter. Adult immunization rates lag behind childhood rates in the
U.S. According to the 2016 National Health Interview Survey, 70.4% of adults
age 65 years and older were vaccinated against influenza and 66.9% of adults
age 65 years and older were vaccinated against pneumococcal disease.
Additionally, stark racial and ethnic disparities for adult immunizations
exist.
[https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubs-resources/NHIS-2016.html]
Adoption of MUC18-057 in the MIPS program will help to improve the consistency
and reporting for adult immunization status for all Medicare beneficiaries.
Increasing adult immunization rates will improve health outcomes and decrease
healthcare usage from vaccine-preventable diseases. Annually, the U.S. spends
nearly $26.5 billion treating influenza, pneumococcal, zoster, and pertussis
among adults age 50 years and over.
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4486398/] Not preventing these
vaccine-preventable diseases has a significant cost to the U.S. healthcare
system; the Adult Immunization Status measure will help drive increases in
adult immunization rates, leading to the dual benefits of improving patient
health and lowering federal healthcare expenditures. To maximize the impact of
the measure, MUC18-057 should include all ACIP-routinely recommended adult
vaccines, including zoster and Td/Tdap. Influenza and pneumococcal represent a
great burden among older adults, but inclusion of all recommended vaccines
will encourage providers to offer and report all vaccines consistently,
increasing the positive health impact for patients. (Submitted by:
Biotechnology Innovation Organization (BIO))
- In general the AAFP opposes the use of all-or-none composite measures in
MIPS. All-or-none composite measures do not award partial credit. Thus, a
physician/group that does well on 6/7 measures but poorly in one measure will
be scored similarly to a physician that does poorly in all measures. At
minimum the numerators of each measure could be summed, the denominators of
each measure summed, and a composite score calculated by dividing numerator by
denominator. Composite measures may be useful for internal quality improvement
but not for accountability as in QPP. --While an exclusion exists for patient
refusal for influenza and pneumococcal vaccination, there is no exclusion for
the remaining measures in the AWV composite. Yet it is known that patients
frequently refuse such procedures as mammograms and colorectal screenings, or
simply do not follow-through with orders of their primary care physician.
--The measure must represent indisputable basics of care, yet there is
widespread disagreement among medical specialties in the mammography measure.
--Errors in measurement are amplified by composite measures. Since 5/7
actions included in the AWV composite measure are frequently or exclusively
performed outside the primary care office (e.g., mammograms, influenza
vaccination, pneumococcal vaccination, colorectal cancer screenings, DXA
scans) there is a high likelihood that lack of data sharing and
interoperability, and lack of access to claims data from payers will lead to
poor data accuracy for these measures, resulting in lower scores. --The
scores from these measures are likely to reflect the extent of EHR
documentation rather than performance of the action. (Submitted by: American
Academy of Family Physicians)
- While the AMA supports the individual components included in this
composite, we are concerned that the complexity of the measure with seven
numerators, denominators and exclusions/exceptions will directly impact the
feasibility, reliability and validity of the measure. Several of the
components require longitudinal data, which are likely not to be readily
available in electronic health records (EHRs) and are often captured in
physician notes or other unstructured fields. It is critical that the measure
be tested across multiple EHR vendor systems to understand how well each
captures the required data elements and the degree to which the data produced
is valid. We also note that there are overlapping and inconsistent
immunizations included in this measure as well as MUC18-62 Adult Immunization
Status. For example, each measure examines the rate of influenza immunizations
but uses a different timeframe (MUC18-57 is August 1 to March 31 and MUC18-62
requires it be given between July 1 and June 30) and MUC18-57 only requires
only one of the two pneumococcal vaccines while MUC18-62 requires that both
have been given at least 12 months apart with the first occurrence after the
age of 60 years. Both measures as well as any current measures that capture
the same immunizations must be harmonized before they are finalized for
implementation in MIPS or MSSP. Therefore, the AMA recommends that the highest
level of MAP recommendation be “Do Not Support With Potential For Mitigation”.
(Submitted by: American Medical Association)
- December 6, 2018 National Quality Forum 1030 15th Street, NW, Suite 800
Washington, DC 20005 RE: List of Measures under Consideration Dear Members
of the Measure Applications Partnership, On behalf of the National Association
of County and City Health Officials (NACCHO), I write to provide comments on
the Centers for Medicare and Medicaid Services’ (CMS) List of Measures under
Consideration (MUC) for December 1, 2018. NACCHO commends CMS for its
consideration of adult immunization in two of the thirty-nine measures for use
in Medicare programs: • MUC18- 57 Annual Wellness Assessment: Preventive Care
--Percentage of patients 65 years of age and older with an Annual Wellness
Visit who received age and sex-appropriate preventive services. This measure
is a composite of seven component composite measures that are based on
recommendations for preventive care by the US Preventive Services Task Force,
Advisory Committee on Immunization Practices, and the American Geriatrics
Society. Specifically, the measure is under consideration for use in the
Merit-Based Incentive Payment System – Quality (MIPS-Quality). • MUC18- 62
Adult Immunization Status -- Percentage of members 19 years of age and older
who are up-to-date on recommended routine vaccines for influenza; tetanus and
diphtheria (Td) or tetanus, diphtheria and acellular pertussis (Tdap); zoster;
and pneumococcal. This measure is under consideration for use in the Medicare
Shared Savings Program and the Merit-Based Incentive Payment System – Quality
(MIPS-Quality). NACCHO is the voice for nearly 3,000 local health departments
across the country. These city, county, metropolitan, district, and tribal
departments work daily to ensure that communities have access to vital public
health programs and services such as adult immunizations. Notably, adult
immunizations are the clinical service most often provided by local health
departments (90%) , and it is estimated that 63% of the nation’s local health
departments conduct targeted immunization and outreach efforts for adults .
Given that local health departments are significant providers of adult
immunization services and counseling, NACCHO appreciates the opportunity to
provide the local health department perspective regarding measures that will
improve the access and utilization of adult immunizations. Immunization has
been one of the most successful and safest public health measures available to
populations worldwide, with an unparalleled record of disease reduction and
prevention. Despite the establishment and implementation of immunization
recommendations by the Advisory Committee on Immunization Practices, Centers
for Disease Control and Prevention, and many other professional organizations,
adult immunization coverage rates are less than optimal for routinely
recommended vaccines, and many rates remain below the Healthy People 2020
targets. Recognizing the need for improved quality measures that will
facilitate the identification, implementation, and monitoring of adult vaccine
improvement opportunities, NACCHO strongly supports CMS’ proposed measures as
a means to increase adult immunization coverage rates. The inclusion of MUC
18- 57 Annual Wellness Assessment: Preventive Care and MUC 18- 62 Adult
Immunization Status would address many of the Meaningful Measures Framework
objectives and fulfill the cross-cutting measure criteria. Though MUC 18- 62
is under consideration for use in the Medicare Shared Savings Program and the
Merit-Based Incentive Payment System – Quality (MIPS-Quality), NACCHO
encourages CMS to also evaluate including the revised measure under several
other quality and payment programs on the MUC list. The proposal would make
MUC 18- 62 applicable to home health, inpatient rehabilitation, long-term care
hospital, skilled nursing facility, ambulatory surgical center, hospital
inpatient and outpatient, inpatient psychiatric facility, and PPS-exempt
cancer hospital reporting programs. However, broader inclusion of MUC 18- 62
in other quality reporting and payment programs would further facilitate
consistent monitoring and reporting of adult immunization status for Medicare
beneficiaries. Widespread use of this new composite measure is particularly
timely and important in settings where patients are especially susceptible and
vulnerable to the negative health outcomes of a vaccine-preventable disease
such as the flu or pneumonia. Inclusion of the composite measure under these
additional programs would also update, streamline, and align the varied adult
immunization measures presently being used to monitor influenza, pneumococcal,
and zoster vaccination. Additionally, implementation of MUC 18- 62 across
quality programs would substantially contribute to increasing adult
immunization coverage rates. Local health departments across the nation play
a vital role in providing immunizations, investigating cases of
vaccine-preventable disease, and maintaining high immunization coverage rates.
Local health departments are uniquely positioned to improve the capacity of
the healthcare system for delivering immunizations and strengthening the
coordination between public, professional, and private sector stakeholders.
Given this, NACCHO champions efforts that can be instrumental in helping to
achieve optimal immunization rates, and we look forward to further action to
refine and implement the proposed measures under consideration. Should you
have any questions, please contact Michelle Cantu, NACCHO’s Director for
Infectious Disease and Immunization, at mcantu@naccho.org. Sincerely, Lori
Tremmel Freeman, MBA Chief Executive Officer (Submitted by: National
Association of County and City Health Officials)
(Program: Merit-Based Incentive Payment
System; MUC ID: MUC2018-062) |
- : In general, the AAFP opposes the use of all-or-none composite measures
in QPP. All-or-none composite measures do not award partial credit. Thus, a
physician/group that does very well in 6/7 measures but poorly in one measure
will be scored similarly to a physician/group that does poorly in all
measures. At minimum the numerators of each measure could be summed, the
denominators of each measure summed, and a composite score calculated by
dividing numerator by denominator. Composite measures may be useful for
internal quality improvement but not for accountability as in MIPS. The
numerators, denominators, and exclusions for the influenza and pneumococcal
vaccine measures within this composite are not consistent with those in the
AWV composite. NQF must make certain measures are aligned to the extent
possible prior to endorsing any measure, and CMS must also make alignment a
top priority for QPP. Errors in measurement are amplified by composite
measures. Since 5/7 actions included in the AWV composite measure are
frequently or exclusively performed outside the primary care office (e.g.,
mammograms, influenza vaccination, pneumococcal vaccination, colorectal cancer
screenings, DXA scans) there is a high likelihood that lack of data sharing
and interoperability and lack of access to claims data from payers will lead
to poor data accuracy for these measures, resulting in lower scores. The
scores from these measures are likely to reflect the extent of EHR
documentation rather than performance of the action. Insurance coverage and
expense of the vaccines may impact patient willingness to be vaccinated.
(Submitted by: American Academy of Family Physicians)
- BIO supports the development, endorsement, and CMS adoption of this
composite adult immunization measure, which includes influenza; zoster;
pneumococcal; and tetanus and diphtheria (Td) or tetanus, diphtheria, and
acellular pertussis (Tdap) vaccination in both the CMS MIPS and MSSP programs.
We applaud the measure for aligning with the Standards for Adult Immunization
Practice
[https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/index.html]
and urging the assessment, recommendation, administration or referral, and
documentation of immunization status of these serious diseases at each
clinical encounter. Adult immunization rates lag behind childhood rates in the
U.S. According to the 2016 National Health Interview Survey, 70.4% of adults
age 65 years and older were vaccinated against influenza; 66.9% of adults age
65 years and older were vaccinated against pneumococcal; 33.4% of adults age
60 years and older were vaccinated against zoster; and 26.6% of adults age 19
years and older received a Tdap vaccine. Additionally, stark racial and ethnic
disparities for adult immunizations exist.
[https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubs-resources/NHIS-2016.html]
Adoption of MUC18-062 in both the MIPS and MSSP programs will help to improve
the consistency and reporting for adult immunization status for all Medicare
beneficiaries. Increasing adult immunization rates will improve health
outcomes and decrease healthcare usage from vaccine-preventable diseases.
Annually, the U.S. spends nearly $26.5 billion treating influenza,
pneumococcal, zoster, and pertussis among adults age 50 years and over.
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4486398/] Not preventing these
vaccine-preventable diseases has a significant cost the U.S. healthcare
system; the Adult Immunization Status measure will help drive increases in
adult immunization rates, leading to the dual benefits of improving patient
health and lowering federal healthcare expenditures. Additionally, the use of
a composite measure such as MUC18-062 Adult Immunization Status can aid in the
harmonization of adult immunization measures across Medicare programs.
Currently, Medicare programs utilize a variety of disease-specific measures.
The use of this composite measure may allow for efficiencies in monitoring and
reporting, and the elimination of duplicative or outdated measures. For
consistency and to have the greatest impact on patient outcomes, CMS should
also consider including the measure in other quality and payment programs.
(Submitted by: Biotechnology Innovation Organization (BIO))
- December 6, 2018 National Quality Forum 1030 15th Street, NW, Suite 800
Washington, DC 20005 RE: List of Measures under Consideration Dear Members
of the Measure Applications Partnership, On behalf of the National Association
of County and City Health Officials (NACCHO), I write to provide comments on
the Centers for Medicare and Medicaid Services’ (CMS) List of Measures under
Consideration (MUC) for December 1, 2018. NACCHO commends CMS for its
consideration of adult immunization in two of the thirty-nine measures for use
in Medicare programs: • MUC18- 57 Annual Wellness Assessment: Preventive Care
--Percentage of patients 65 years of age and older with an Annual Wellness
Visit who received age and sex-appropriate preventive services. This measure
is a composite of seven component composite measures that are based on
recommendations for preventive care by the US Preventive Services Task Force,
Advisory Committee on Immunization Practices, and the American Geriatrics
Society. Specifically, the measure is under consideration for use in the
Merit-Based Incentive Payment System – Quality (MIPS-Quality). • MUC18- 62
Adult Immunization Status -- Percentage of members 19 years of age and older
who are up-to-date on recommended routine vaccines for influenza; tetanus and
diphtheria (Td) or tetanus, diphtheria and acellular pertussis (Tdap); zoster;
and pneumococcal. This measure is under consideration for use in the Medicare
Shared Savings Program and the Merit-Based Incentive Payment System – Quality
(MIPS-Quality). NACCHO is the voice for nearly 3,000 local health departments
across the country. These city, county, metropolitan, district, and tribal
departments work daily to ensure that communities have access to vital public
health programs and services such as adult immunizations. Notably, adult
immunizations are the clinical service most often provided by local health
departments (90%) , and it is estimated that 63% of the nation’s local health
departments conduct targeted immunization and outreach efforts for adults .
Given that local health departments are significant providers of adult
immunization services and counseling, NACCHO appreciates the opportunity to
provide the local health department perspective regarding measures that will
improve the access and utilization of adult immunizations. Immunization has
been one of the most successful and safest public health measures available to
populations worldwide, with an unparalleled record of disease reduction and
prevention. Despite the establishment and implementation of immunization
recommendations by the Advisory Committee on Immunization Practices, Centers
for Disease Control and Prevention, and many other professional organizations,
adult immunization coverage rates are less than optimal for routinely
recommended vaccines, and many rates remain below the Healthy People 2020
targets. Recognizing the need for improved quality measures that will
facilitate the identification, implementation, and monitoring of adult vaccine
improvement opportunities, NACCHO strongly supports CMS’ proposed measures as
a means to increase adult immunization coverage rates. The inclusion of MUC
18- 57 Annual Wellness Assessment: Preventive Care and MUC 18- 62 Adult
Immunization Status would address many of the Meaningful Measures Framework
objectives and fulfill the cross-cutting measure criteria. Though MUC 18- 62
is under consideration for use in the Medicare Shared Savings Program and the
Merit-Based Incentive Payment System – Quality (MIPS-Quality), NACCHO
encourages CMS to also evaluate including the revised measure under several
other quality and payment programs on the MUC list. The proposal would make
MUC 18- 62 applicable to home health, inpatient rehabilitation, long-term care
hospital, skilled nursing facility, ambulatory surgical center, hospital
inpatient and outpatient, inpatient psychiatric facility, and PPS-exempt
cancer hospital reporting programs. However, broader inclusion of MUC 18- 62
in other quality reporting and payment programs would further facilitate
consistent monitoring and reporting of adult immunization status for Medicare
beneficiaries. Widespread use of this new composite measure is particularly
timely and important in settings where patients are especially susceptible and
vulnerable to the negative health outcomes of a vaccine-preventable disease
such as the flu or pneumonia. Inclusion of the composite measure under these
additional programs would also update, streamline, and align the varied adult
immunization measures presently being used to monitor influenza, pneumococcal,
and zoster vaccination. Additionally, implementation of MUC 18- 62 across
quality programs would substantially contribute to increasing adult
immunization coverage rates. Local health departments across the nation play
a vital role in providing immunizations, investigating cases of
vaccine-preventable disease, and maintaining high immunization coverage rates.
Local health departments are uniquely positioned to improve the capacity of
the healthcare system for delivering immunizations and strengthening the
coordination between public, professional, and private sector stakeholders.
Given this, NACCHO champions efforts that can be instrumental in helping to
achieve optimal immunization rates, and we look forward to further action to
refine and implement the proposed measures under consideration. Should you
have any questions, please contact Michelle Cantu, NACCHO’s Director for
Infectious Disease and Immunization, at mcantu@naccho.org. Sincerely, Lori
Tremmel Freeman, MBA Chief Executive Officer (Submitted by: National
Association of County and City Health Officials)
- Sanofi supports the implementation of the Adult Immunization Status into
the MIPS program. Immunizations play an important part in public health and
prioritizing this measure can assist in improving the immunization rates and
make progress on immunization goals stated in Healthy People 2020. (Submitted
by: Sanofi)
- The current MUC list has MUC18- 62 Adult Immunization Status only under
consideration for use in the Medicare Shared Savings Program and the
Merit-Based Incentive Payment System – Quality (MIPS-Quality). AVAC strongly
supports its inclusion in both programs and urges CMS to consider also
including the revised measure under several other quality and payment programs
on the MUC, including: Home Health Quality Reporting Program Inpatient
Rehabilitation Facility Quality Reporting Program Long-Term Care Hospital
Quality Reporting Program Skilled Nursing Facility Quality Reporting Program
Skilled Nursing Facility Value-Based Purchasing Program Ambulatory Surgical
Center Quality Reporting Hospital Inpatient Quality Reporting Hospital
Outpatient Quality Reporting Inpatient Psychiatric Facility Quality Reporting
PPS-Exempt Cancer Hospital Quality Reporting (Submitted by: Adult Vaccine
Access Coalition )
- This measure appears to be developed and tested for use in health plans.
Its unclear if the plan level measure can be adapted for use in ACOs given the
differences in reporting mechanisms between ACOs and health plans.
Additionally, the pneumoccocal vaccination measure was recently removed from
MSSP because of measure reporting issues in the ACO program, this measure does
not resolve those issues. (Submitted by: Premier, Inc.)
- This measure proposal appears to combine three separate existing measures
related to influenza, pneumonia and herpes zoster immunization status.
Combining the separate measures into one single measure reduces the impact of
each individual measure. The performance data would not be actionable, as it
would combine immunization rates and would not provide specific data to allow
clinicians to act upon any individual immunization rate. The Academy is
concerned about the impact this would have on patients. If this is intended as
a substitute for existing individual measures, the American Academy of
Ophthalmology encourages MAP not to recommend this measure for inclusion in
QPP. (Submitted by: American Academy of Ophthalmology)
- While the AMA supports the individual components included in this
composite, we are concerned that the complexity of the measure with five
numerators, denominators and exclusions/exceptions will directly impact the
feasibility, reliability and validity of the measure for use in MIPS. It is
not clear at what data source the measure is specified but we anticipate that
implementation will be challenging given that several of the components
require longitudinal data. It is critical that the measure be tested at the
clinician level to understand how well each of the required data elements are
captured and the degree to which the data produced is valid. We also note
that there are overlapping and inconsistent immunizations included in this
measure as well as MUC18-62 Adult Immunization Status. For example, each
measure examines the rate of influenza immunizations but uses a different
timeframe (MUC18-57 is August 1 to March 31 and MUC18-62 requires it be given
between July 1 and June 30) and MUC18-57 only requires only one of the two
pneumococcal vaccines while MUC18-62 requires that both have been given at
least 12 months apart with the first occurrence after the age of 60 years.
Both measures as well as any current measures that capture the same
immunizations must be harmonized before they are finalized for implementation
in MIPS or MSSP. Therefore, the AMA recommends that the highest level of MAP
recommendation be “Do Not Support With Potential For Mitigation”. (Submitted
by: American Medical Association)
(Program: Medicare Shared Savings
Program; MUC ID: MUC2018-062) |
- BIO supports the development, endorsement, and CMS adoption of this
composite adult immunization measure, which includes influenza; zoster;
pneumococcal; and tetanus and diphtheria (Td) or tetanus, diphtheria, and
acellular pertussis (Tdap) vaccination in both the CMS MIPS and MSSP programs.
We applaud the measure for aligning with the Standards for Adult Immunization
Practice
[https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/index.html]
and urging the assessment, recommendation, administration or referral, and
documentation of immunization status of these serious diseases at each
clinical encounter. Adult immunization rates lag behind childhood rates in the
U.S. According to the 2016 National Health Interview Survey, 70.4% of adults
age 65 years and older were vaccinated against influenza; 66.9% of adults age
65 years and older were vaccinated against pneumococcal; 33.4% of adults age
60 years and older were vaccinated against zoster; and 26.6% of adults age 19
years and older received a Tdap vaccine. Additionally, stark racial and ethnic
disparities for adult immunizations exist.
[https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubs-resources/NHIS-2016.html]
Adoption of MUC18-062 in both the MIPS and MSSP programs will help to improve
the consistency and reporting for adult immunization status for all Medicare
beneficiaries. Increasing adult immunization rates will improve health
outcomes and decrease healthcare usage from vaccine-preventable diseases.
Annually, the U.S. spends nearly $26.5 billion treating influenza,
pneumococcal, zoster, and pertussis among adults age 50 years and over.
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4486398/] Not preventing these
vaccine-preventable diseases has a significant cost the U.S. healthcare
system; the Adult Immunization Status measure will help drive increases in
adult immunization rates, leading to the dual benefits of improving patient
health and lowering federal healthcare expenditures. Additionally, the use of
a composite measure such as MUC18-062 Adult Immunization Status can aid in the
harmonization of adult immunization measures across Medicare programs.
Currently, Medicare programs utilize a variety of disease-specific measures.
The use of this composite measure may allow for efficiencies in monitoring and
reporting, and the elimination of duplicative or outdated measures. For
consistency and to have the greatest impact on patient outcomes, CMS should
also consider including the measure in other quality and payment programs.
(Submitted by: Biotechnology Innovation Organization (BIO))
- Including MUC18- 62 Adult Immunization Status more broadly across quality
reporting and payment programs is critically important for several reasons.
First, it will ensure more consistent monitoring and reporting of adult
immunization status for Medicare beneficiaries. Widespread use of this new
composite measure is particularly timely and important in the hospital
inpatient and outpatient settings, as well as in long-term care and skilled
nursing facilities where patients are especially susceptible and vulnerable to
the negative health outcomes of a vaccine-preventable illness such as the flu
or pneumonia. Inclusion of the composite measure for additional consideration
under these programs would also update, streamline and align the varied adult
immunization measures presently being used to monitor influenza, pneumococcal
and zoster vaccination. Additionally, implementation of MUC18- 62 Adult
Immunization Status across quality programs would drive increases in adult
immunization rates and would ultimately yield lower federal health care
expenditures. Most importantly, beneficiaries would see improved health
outcomes over the long-term as a result of fewer hospitalizations, provider
visits and other ancillary services required in the treatment of a vaccine
preventable illness. (Submitted by: Adult Vaccine Access Coalition
)
- Sanofi supports inclusion of the adult immunization status measure into
the MSSP. Immunizations are an important part of public health and caring for
populations. (Submitted by: Sanofi)
- While the AMA supports the individual components included in this
composite, we note that there are overlapping and inconsistent immunizations
included in this measure as well as MUC18-62 Adult Immunization Status. For
example, each measure examines the rate of influenza immunizations but uses a
different timeframe (MUC18-57 is August 1 to March 31 and MUC18-62 requires it
be given between July 1 and June 30) and MUC18-57 only requires only one of
the two pneumococcal vaccines while MUC18-62 requires that both have been
given at least 12 months apart with the first occurrence after the age of 60
years. Both measures as well as any current measures that capture the same
immunizations must be harmonized before they are finalized for implementation
in MIPS or MSSP. Therefore, the AMA recommends that the highest level of MAP
recommendation be “Do Not Support With Potential For Mitigation”. (Submitted
by: American Medical Association)
- While written comments were not provided, the commenter indicated their
support for this measure in this program (Submitted by: National Association
of County and City Health Officials)
(Program:
Medicare Shared Savings Program; MUC ID: MUC2018-077) |
- NHPCO Comments: Include cancer patients receiving palliative care services
in “excludes”. (Submitted by: National Hospice and Palliative Care
Organization)
- The AAN agrees with the need to measure and monitor cases where a patient
may be receiving a prescription for an opiate from multiple providers and
pharmacies. However, we believe that four different providers and four
different pharmacies is too many. We suggest that anything above a
prescription from one physician or one pharmacy should be of concern and
therefore the numbers should in fact be reduced to one. A single physician can
then properly monitor the patient through the use of an opiate contract,
questionnaires and screening to ensure that the medications are being used
appropriately. (Submitted by: American Academy of Neurology)
- The AMA has significant concerns with the proposed inclusion of this
measure in the MSSP because it was developed with the intention of determining
the quality of care provided by prescription drug health plans, and not for
ACOs. The measure as currently specified requires access to health plan
medical and pharmacy claims and member enrollment information; such data may
not be readily available across all ACOs given their varying composition and
access to pharmacy claims data. Comprehensive assessment of the feasibility of
collecting and reporting these data at the ACO level must be determined. For
example, for those MSSP participants that provide care across state lines or
have patients that receive care outside of the ACO, it is unclear whether they
can access data to confirm that prescriptions were not received outside of the
network. Ensuring that ACOs can collect the data needed to satisfy the measure
requirements is necessary to inform and allow thorough evaluations of the
reliability and the validity of the performance scores. For example, it is not
clear what the minimum sample size is to ensure that performance scores are
reliable across ACOs. The evaluation completed by the Pharmacy Quality
Alliance included more than 700 Medicare Part D prescription drug plans, eight
state-based Medicaid prescription drug plans, and one commercial health plan.
In addition, the current measure specifications include buprenorphine, which
is primarily used to treat opioid use disorder. We believe that its inclusion
is not consistent with the intent of this measure and it should be removed.
The AMA believes that this measure must be adequately specified and tested
across ACOs prior to its implementation in MSSP and the MAP must address the
number of proposed measures on opioid use that are similar and/or overlapping.
Therefore, the AMA recommends that the highest level of MAP recommendation be
“Do Not Support With Potential For Mitigation” for this measure. (Submitted
by: American Medical Association)
- The Federation of American Hospitals questions CMS’ rationale for
submitting four similar and potentially competing measures for consideration
in MSSP. These duplicative measures seem to be contradictory to recent CMS
efforts to streamline the number of measures in response to the Patients Over
Paperwork initiative. We request that the MAP thoughtfully consider whether
all of these measures should be recommended for potential implementation. In
addition, while it is difficult to determine the underlying data source that
will be used for MUC18-106 Initial opioid prescription compliant with CDC
recommendations, we assume that all four measures will be derived from claims
data. As a result, FAH has significant concerns with recommending these
measures at this time. Specifically, it is not clear that the developers have
demonstrated how well any of these measures perform within an accountable care
organization (ACO). ACOs currently receive prescription claims data from CMS,
which is not as robust and accurate on opioid utilization as would be required
to ensure that these measures represent reliable and valid performance and
limits an ACO’s ability to impact clinical care in a timely way. Therefore,
the FAH requests that the highest level of MAP recommendation be “Do Not
Support With Potential For Mitigation” for all four opioid-related measures
proposed for MSSP. (Submitted by: Federation of American
Hospitals)
- The Pharmacy Quality Alliance (PQA), the measure steward of three of the
opioid-related quality measures (listed here) on the Measures Under
Consideration (MUC) List, supports CMS’ consideration of the measures for
adoption in the designated federal program of the Medicare Shared Savings
Program (MSSP) through rulemaking under Medicare. The three related measures,
developed by PQA, address safe and appropriate prescribing of opioids by
identifying cases with high potential of misuse/abuse of opioid analgesics:
1. Use of Opioids from Multiple Providers in Persons Without Cancer
(MUC18-77) 2. Use of Opioids at High Dosage in Persons Without Cancer
(MUC18-78) 3. Use of Opioids from Multiple Providers and at High Dosage in
Persons Without Cancer (MUC18-79) The designated Medicare program for
consideration of these three measures, the MSSP, encourages health care
provider groups to come together as an Accountable Care Organization (ACO) to
give coordinated, high quality care to their Medicare patients. With the
stated goals of MSSP to promote accountability for a patient population,
coordinate items and services for beneficiaries, incentivize investment in
high quality and cost-efficient services, in the presence of the
ever-increasing challenge of the opioid crisis, the inclusion of performance
measures in the program to support safe prescribing of opioids is an important
program update. Reinforcingly, PQA has received several unsolicited requests
from ACOs interested in using the PQA opioid measures, offering an early
positive indication of interest by these alternative payment model entities to
support achievement of quality and cost goals. Lastly, the three PQA opioid
measures developed in 2015 have been updated to align with the CDC Guideline
for Prescribing Opioids for Chronic Pain published in 2016. The revised
specifications for 2019 (measurement year 2018) were provided to CMS for the
purpose of informing pre-rule making and Measure Application Partnership
stakeholders. (Submitted by: Pharmacy Quality Alliance)
- This measure is developed and tested for assessing PBMs. It is unclear if
the measure can readily apply to ACOs. Moreover, ACOs do not administer the
Part D benefit and have less control over these measures. CMS has sought
comment on providing additional information to ACOs on Part D claims and
incorporating Part D into ACO models. In the absence of more data or managing
the benefit, ACOs should not be held accountable for these measures. However,
since these are claims-based measures CMS should calculate the measures and
provide ACO with confidential performance information. (Submitted by: Premier,
Inc.)
- Updated PQA comment from what was sent yesterday The Pharmacy Quality
Alliance (PQA), the measure steward of three of the opioid-related quality
measures (listed here) on the Measures Under Consideration (MUC) List,
supports CMS’ consideration of the measures for adoption in the designated
federal program of the Medicare Shared Savings Program (MSSP) through
rulemaking under Medicare. The three related PQA measures address safe
prescribing of opioids by identifying prescribing patterns associated with
increased risk of opioid overdose: 1. Use of Opioids from Multiple Providers
in Persons Without Cancer (MUC18-77) 2. Use of Opioids at High Dosage in
Persons Without Cancer (MUC18-78) 3. Use of Opioids from Multiple Providers
and at High Dosage in Persons Without Cancer (MUC18-79) The designated
Medicare program for consideration of these three measures, the MSSP,
encourages health care provider groups to come together as an Accountable Care
Organization (ACO) to give coordinated, high quality care to their Medicare
patients. With the stated goals of MSSP to promote accountability for a
patient population, coordinate items and services for beneficiaries,
incentivize investment in high quality and cost-efficient services, in the
presence of the ever-increasing challenge of the opioid crisis, the inclusion
of performance measures in the program to support safe prescribing of opioids
is an important program update. Reinforcingly, PQA has received several
unsolicited requests from ACOs interested in using the PQA opioid measures,
offering an early positive indication of interest by these alternative payment
model entities to support achievement of quality and cost goals. Lastly, the
three PQA opioid measures developed in 2015 have been updated to align with
the CDC Guideline for Prescribing Opioids for Chronic Pain published in 2016.
The revised specifications for 2019 (measurement year 2018) were provided to
CMS for the purpose of informing pre-rule making and Measure Application
Partnership stakeholders. (Submitted by: Pharmacy Quality
Alliance)
- We appreciate that this measure has exclusions for patients receiving
hospice services, but suggest additional exclusions for palliative care. We
note that this is consistent with the CDC Guideline that includes an exclusion
for patients receiving palliative care. (Submitted by: Center to Advance
Palliative Care)
- We support this measure but it needs to exclude those receiving palliative
care. We also have a concern that patients in hospice and palliative care
programs with multiple providers may be inappropriately flagged by this aspect
of this measure and urge that that be addressed. We do support monitoring the
number of pharmacies dispensing opioids (Submitted by: CTAC)
(Program: Medicare
Shared Savings Program; MUC ID: MUC2018-078) |
- NHPCO Comments: Include cancer patients receiving palliative care services
in “excludes”. (Submitted by: National Hospice and Palliative Care
Organization)
- The AANS and CNS disagree with the fundamental premise of a measure that
focuses only on daily dose and duration of therapy involving prescription
opioid analgesics because on its own it is not a valid indicator of quality
patient care. In fact, since the Centers for Disease Control & Prevention
(CDC) Guideline for Prescribing Opioids for Chronic Pain was issued, there
have been many reports of patients who have been successfully managed on
opioid analgesics for long periods of time, and in whom the benefits of such
therapy exceed the risks, of being forced to abruptly reduce or discontinue
their medication regimens. Such involuntary tapers are associated with
sometimes extremely adverse outcomes, including depression, anxiety and
emergence of other mental health disorder, loss of function and the ability to
perform daily activities, and even suicide. There has been considerable
discussion of these unintended consequences at meetings of the HHS Interagency
Pain Management Best Practices Task Force. Identifying those patients for
whom the daily prescribed morphine milligram equivalents (MME) are considered
high may serve as an indicator of whether a patient is at risk of overdose and
should be co-prescribed naloxone, but it alone is not an appropriate marker of
the quality of care provided. The CDC recommendations allow physicians to
document a clinical rationale or justification when suggested dose levels are
exceeded; yet, the existing measures that focus on MME do not capture if a
justification exists nor do they provide a well-defined and targeted
denominator. If CMS implements a measure that focuses on MME, it must
adequately define the patients for whom higher doses of opioids may be
appropriate. Otherwise, the measure will provide invalid representations of
performance. In addition, the current measure specifications include
buprenorphine, which is primarily used to treat opioid use disorder. CMS also
should explore more appropriate methods to assess a patient’s chronic pain,
including the use of patient-reported data as the basis for performance
measures. Given these concerns, we do NOT recommend MUC18-78 Use of Opioids at
High Dosage in Persons Without Cancer for implementation in the Medicare
Shared Savings Program (MSSP) at this time. (Submitted by: American
Association of Neurological Surgeons )
- The AMA disagrees with the fundamental premise of a measure that focuses
only on daily dose and duration of therapy involving prescription opioid
analgesics because on its own it is not a valid indicator of quality patient
care. In fact, since the Centers for Disease Control & Prevention (CDC)
Guideline for Prescribing Opioids for Chronic Pain was issued, there have been
many reports of patients who have been successfully managed on opioid
analgesics for long periods of time, and in whom the benefits of such therapy
exceed the risks, of being forced to abruptly reduce or discontinue their
medication regimens. Such involuntary tapers are associated with sometimes
extremely adverse outcomes, including depression, anxiety and emergence of
other mental health disorder, loss of function and the ability to perform
daily activities, and even suicide. There has been considerable discussion of
these unintended consequences at meetings of the HHS Interagency Pain
Management Best Practices Task Force. Identifying those patients for whom
the daily prescribed morphine milligram equivalents (MME) are considered high
may serve as an indicator of whether a patient is at risk of overdose and
should be co-prescribed naloxone, but it alone is not an appropriate marker of
the quality of care provided. The CDC recommendations allow physicians to
document a clinical rationale or justification when suggested dose levels are
exceeded; yet, the existing measures that focus on MME do not capture if a
justification exists nor do they provide a well-defined and targeted
denominator. CMS should explore more appropriate methods to assess a patient’s
chronic pain such as the Pain Assessment Screening Tool and Outcomes Registry
(PASTOR) and use this patient-reported data on areas as the basis for
performance measures. This tool utilizes the Patient Reported Outcomes
Measurement Information System (PROMIS) and through the use of Computer
Adaptive Testing, key domains such as sleep disturbance and physical function
can be assessed in a targeted and patient-directed way. If CMS implements a
measure that focuses on MME, it must adequately define the patients for whom
higher doses of opioids may be appropriate. Otherwise, the measure will
provide invalid representations of performance. In addition, the current
measure specifications include buprenorphine, which is primarily used to treat
opioid use disorder. We believe that its inclusion is not consistent with the
intent of this measure and it should be removed. CMS should consider and
explore alternative measures or ones that provide complementary information on
the quality of care in managing substance use disorders and/or pain, for
example, NQF #2597 for assessing substance use screening and intervention.
Given the ongoing concerns with this measure and the number of proposed
measures on opioid use that are similar and/or overlapping, the AMA recommends
that the highest level of MAP recommendation be “Do Not Support With Potential
For Mitigation”. (Submitted by: American Medical Association)
- The Federation of American Hospitals questions CMS’ rationale for
submitting four similar and potentially competing measures for consideration
in MSSP. These duplicative measures seem to be contradictory to recent CMS
efforts to streamline the number of measures in response to the Patients Over
Paperwork initiative. We request that the MAP thoughtfully consider whether
all of these measures should be recommended for potential implementation. In
addition, while it is difficult to determine the underlying data source that
will be used for MUC18-106 Initial opioid prescription compliant with CDC
recommendations, we assume that all four measures will be derived from claims
data. As a result, FAH has significant concerns with recommending these
measures at this time. Specifically, it is not clear that the developers have
demonstrated how well any of these measures perform within an accountable care
organization (ACO). ACOs currently receive prescription claims data from CMS,
which is not as robust and accurate on opioid utilization as would be required
to ensure that these measures represent reliable and valid performance and
limits an ACO’s ability to impact clinical care in a timely way. Therefore,
the FAH requests that the highest level of MAP recommendation be “Do Not
Support With Potential For Mitigation” for all four opioid-related measures
proposed for MSSP. (Submitted by: Federation of American
Hospitals)
- The Pharmacy Quality Alliance (PQA), the measure steward of three of the
opioid-related quality measures (listed here) on the Measures Under
Consideration (MUC) List, supports CMS’ consideration of the measures for
adoption in the designated federal program of the Medicare Shared Savings
Program (MSSP) through rulemaking under Medicare. The three related measures,
developed by PQA, address safe and appropriate prescribing of opioids by
identifying cases with high potential of misuse/abuse of opioid analgesics:
1. Use of Opioids from Multiple Providers in Persons Without Cancer
(MUC18-77) 2. Use of Opioids at High Dosage in Persons Without Cancer
(MUC18-78) 3. Use of Opioids from Multiple Providers and at High Dosage in
Persons Without Cancer (MUC18-79) The designated Medicare program for
consideration of these three measures, the MSSP, encourages health care
provider groups to come together as an Accountable Care Organization (ACO) to
give coordinated, high quality care to their Medicare patients. With the
stated goals of MSSP to promote accountability for a patient population,
coordinate items and services for beneficiaries, incentivize investment in
high quality and cost-efficient services, in the presence of the
ever-increasing challenge of the opioid crisis, the inclusion of performance
measures in the program to support safe prescribing of opioids is an important
program update. Reinforcingly, PQA has received several unsolicited requests
from ACOs interested in using the PQA opioid measures, offering an early
positive indication of interest by these alternative payment model entities to
support achievement of quality and cost goals. Lastly, the three PQA opioid
measures developed in 2015 have been updated to align with the CDC Guideline
for Prescribing Opioids for Chronic Pain published in 2016. The revised
specifications for 2019 (measurement year 2018) were provided to CMS for the
purpose of informing pre-rule making and Measure Application Partnership
stakeholders. (Submitted by: Pharmacy Quality Alliance)
- This measure is developed and tested for assessing PBMs. It is unclear if
the measure can readily apply to ACOs. Moreover, ACOs do not administer the
Part D benefit and have less control over these measures. CMS has sought
comment on providing additional information to ACOs on Part D claims and
incorporating Part D into ACO models. In the absence of more data or managing
the benefit, ACOs should not be held accountable for these measures. However,
since these are claims-based measures CMS should calculate the measures and
provide ACO with confidential performance information. (Submitted by: Premier,
Inc.)
- This needs the CDC guideline exclusion of those receiving: palliative
care. We would also note that others with serious illness or chronic pain may
justifiably need these medications at higher/longer doses (Submitted by:
CTAC)
- Updated PQA comment from what was sent yesterday The Pharmacy Quality
Alliance (PQA), the measure steward of three of the opioid-related quality
measures (listed here) on the Measures Under Consideration (MUC) List,
supports CMS’ consideration of the measures for adoption in the designated
federal program of the Medicare Shared Savings Program (MSSP) through
rulemaking under Medicare. The three related PQA measures address safe
prescribing of opioids by identifying prescribing patterns associated with
increased risk of opioid overdose: 1. Use of Opioids from Multiple Providers
in Persons Without Cancer (MUC18-77) 2. Use of Opioids at High Dosage in
Persons Without Cancer (MUC18-78) 3. Use of Opioids from Multiple Providers
and at High Dosage in Persons Without Cancer (MUC18-79) The designated
Medicare program for consideration of these three measures, the MSSP,
encourages health care provider groups to come together as an Accountable Care
Organization (ACO) to give coordinated, high quality care to their Medicare
patients. With the stated goals of MSSP to promote accountability for a
patient population, coordinate items and services for beneficiaries,
incentivize investment in high quality and cost-efficient services, in the
presence of the ever-increasing challenge of the opioid crisis, the inclusion
of performance measures in the program to support safe prescribing of opioids
is an important program update. Reinforcingly, PQA has received several
unsolicited requests from ACOs interested in using the PQA opioid measures,
offering an early positive indication of interest by these alternative payment
model entities to support achievement of quality and cost goals. Lastly, the
three PQA opioid measures developed in 2015 have been updated to align with
the CDC Guideline for Prescribing Opioids for Chronic Pain published in 2016.
The revised specifications for 2019 (measurement year 2018) were provided to
CMS for the purpose of informing pre-rule making and Measure Application
Partnership stakeholders. (Submitted by: Pharmacy Quality
Alliance)
- We appreciate that this measure has exclusions for patients receiving
hospice services, but suggest additional exclusions for palliative care. We
note that this is consistent with the CDC Guideline that includes an exclusion
for patients receiving palliative care. (Submitted by: Center to Advance
Palliative Care)
(Program: Medicare Shared Savings Program; MUC ID:
MUC2018-079) |
- NHPCO Comments: Include cancer patients receiving palliative care services
in “excludes”. (Submitted by: National Hospice and Palliative Care
Organization)
- The AMA has the significant concerns with the proposed inclusion of this
measure in MSSP, given the dearth of information on the feasibility of
collecting and reporting pharmacy claims data and the lack of specifications
and testing for the intended level of analysis (ACO). In addition, the current
measure specifications include buprenorphine, which is primarily used to treat
opioid use disorder. We believe that its inclusion is not consistent with the
intent of this measure and it should be removed. After reviewing the
performance scores provided during the NQF endorsement, we questioned whether
this measure has adequate variation in scores to enable meaningful comparisons
in performance because the testing results showed that less than a 2.5 percent
difference existed between the minimum and maximum rates for the Medicare
population and less than 5.5 percent difference existed for the Medicaid
population. If similar rates were to be found when applied to ACOs, we believe
that it will be difficult to distinguish better versus worse care;
additionally, this measure must be adequately specified and tested across ACOs
prior to its implementation in MSSP. Given the ongoing concerns with this
measure and the number of proposed measures on opioid use that are similar and
overlapping, the AMA recommends that the highest level of MAP recommendation
be “Do Not Support With Potential For Mitigation”. (Submitted by: American
Medical Association)
- The Federation of American Hospitals questions CMS’ rationale for
submitting four similar and potentially competing measures for consideration
in MSSP. These duplicative measures seem to be contradictory to recent CMS
efforts to streamline the number of measures in response to the Patients Over
Paperwork initiative. We request that the MAP thoughtfully consider whether
all of these measures should be recommended for potential implementation. In
addition, while it is difficult to determine the underlying data source that
will be used for MUC18-106 Initial opioid prescription compliant with CDC
recommendations, we assume that all four measures will be derived from claims
data. As a result, FAH has significant concerns with recommending these
measures at this time. Specifically, it is not clear that the developers have
demonstrated how well any of these measures perform within an accountable care
organization (ACO). ACOs currently receive prescription claims data from CMS,
which is not as robust and accurate on opioid utilization as would be required
to ensure that these measures represent reliable and valid performance and
limits an ACO’s ability to impact clinical care in a timely way. Therefore,
the FAH requests that the highest level of MAP recommendation be “Do Not
Support With Potential For Mitigation” for all four opioid-related measures
proposed for MSSP. (Submitted by: Federation of American
Hospitals)
- The Pharmacy Quality Alliance (PQA), the measure steward of three of the
opioid-related quality measures (listed here) on the Measures Under
Consideration (MUC) List, supports CMS’ consideration of the measures for
adoption in the designated federal program of the Medicare Shared Savings
Program (MSSP) through rulemaking under Medicare. The three related measures,
developed by PQA, address safe and appropriate prescribing of opioids by
identifying cases with high potential of misuse/abuse of opioid analgesics:
1. Use of Opioids from Multiple Providers in Persons Without Cancer
(MUC18-77) 2. Use of Opioids at High Dosage in Persons Without Cancer
(MUC18-78) 3. Use of Opioids from Multiple Providers and at High Dosage in
Persons Without Cancer (MUC18-79) The designated Medicare program for
consideration of these three measures, the MSSP, encourages health care
provider groups to come together as an Accountable Care Organization (ACO) to
give coordinated, high quality care to their Medicare patients. With the
stated goals of MSSP to promote accountability for a patient population,
coordinate items and services for beneficiaries, incentivize investment in
high quality and cost-efficient services, in the presence of the
ever-increasing challenge of the opioid crisis, the inclusion of performance
measures in the program to support safe prescribing of opioids is an important
program update. Reinforcingly, PQA has received several unsolicited requests
from ACOs interested in using the PQA opioid measures, offering an early
positive indication of interest by these alternative payment model entities to
support achievement of quality and cost goals. Lastly, the three PQA opioid
measures developed in 2015 have been updated to align with the CDC Guideline
for Prescribing Opioids for Chronic Pain published in 2016. The revised
specifications for 2019 (measurement year 2018) were provided to CMS for the
purpose of informing pre-rule making and Measure Application Partnership
stakeholders. (Submitted by: Pharmacy Quality Alliance)
- This measure is developed and tested for assessing PBMs. It is unclear if
the measure can readily apply to ACOs. Moreover, ACOs do not administer the
Part D benefit and have less control over these measures. CMS has sought
comment on providing additional information to ACOs on Part D claims and
incorporating Part D into ACO models. In the absence of more data or managing
the benefit, ACOs should not be held accountable for these measures. However,
since these are claims-based measures CMS should calculate the measures and
provide ACO with confidential performance information. (Submitted by: Premier,
Inc.)
- This needs the CDC guideline exclusion of those receiving: palliative
care. We would also note that others with serious illness or chronic pain may
justifiably need these medications at higher/longer doses (Submitted by:
CTAC)
- To reduce provider burden, we recommend that 18-79 be computed by CMS from
agency reporting on measures 18-77 and 18-78, and that 18-79 be eliminated as
a measure. (Submitted by: National Assn for Behavioral
Healthcare)
- Updated PQA comment from what was sent yesterday The Pharmacy Quality
Alliance (PQA), the measure steward of three of the opioid-related quality
measures (listed here) on the Measures Under Consideration (MUC) List,
supports CMS’ consideration of the measures for adoption in the designated
federal program of the Medicare Shared Savings Program (MSSP) through
rulemaking under Medicare. The three related PQA measures address safe
prescribing of opioids by identifying prescribing patterns associated with
increased risk of opioid overdose: 1. Use of Opioids from Multiple Providers
in Persons Without Cancer (MUC18-77) 2. Use of Opioids at High Dosage in
Persons Without Cancer (MUC18-78) 3. Use of Opioids from Multiple Providers
and at High Dosage in Persons Without Cancer (MUC18-79) The designated
Medicare program for consideration of these three measures, the MSSP,
encourages health care provider groups to come together as an Accountable Care
Organization (ACO) to give coordinated, high quality care to their Medicare
patients. With the stated goals of MSSP to promote accountability for a
patient population, coordinate items and services for beneficiaries,
incentivize investment in high quality and cost-efficient services, in the
presence of the ever-increasing challenge of the opioid crisis, the inclusion
of performance measures in the program to support safe prescribing of opioids
is an important program update. Reinforcingly, PQA has received several
unsolicited requests from ACOs interested in using the PQA opioid measures,
offering an early positive indication of interest by these alternative payment
model entities to support achievement of quality and cost goals. Lastly, the
three PQA opioid measures developed in 2015 have been updated to align with
the CDC Guideline for Prescribing Opioids for Chronic Pain published in 2016.
The revised specifications for 2019 (measurement year 2018) were provided to
CMS for the purpose of informing pre-rule making and Measure Application
Partnership stakeholders. (Submitted by: Pharmacy Quality
Alliance)
- We appreciate that this measure has exclusions for patients receiving
hospice services, but suggest additional exclusions for palliative care. We
note that this is consistent with the CDC Guideline that includes an exclusion
for patients receiving palliative care. (Submitted by: Center to Advance
Palliative Care)
(Program:
Medicare Shared Savings Program; MUC ID: MUC2018-106) |
- The AANS and CNS do not believe that the measure accurately reflects the
recommendations outlined in the Centers for Disease Control & Prevention
(CDC) Guideline for Prescribing Opioids for Chronic Pain, such as the
numerator’s requirement for a daily dose and duration of therapy without the
ability to capture instances where it may be clinically appropriate to exceed
90 morphine milligram equivalents (MME) per day. In addition, we question the
limit of 50 morphine milligram equivalents (MME) per day for an initial dose,
as it is not specifically recommended in the guideline and the numerator
requirement that the “initial opioid prescription is not for methadone”
appears intended to further refine the patient population and may be better
suited as an exclusion. Given these concerns, we do NOT recommend MUC 18–106
Initial Opioid Prescription Compliant with CDC Recommendations for
implementation in the Medicare Shared Savings Program (MSSP) at this time.
(Submitted by: American Association of Neurological Surgeons )
- The CDC recommendations, known as the CDC Guideline for Prescribing
Opioids for Chronic Pain, are meant to guide primary care physicians
prescribing opioids for chronic pain. As crafted, this measure suggests that
the CDC Guideline should be applied to all care providers, regardless of
practice setting and across the board for all patients, including those with
acute pain following a procedure or surgery and those suffering from a chronic
pain condition. ASA cautions against improperly applying the CDC Guideline; a
one-size fits all policy does not work for all patients and can have
unintended consequences. For example, mandating that a patient experiencing
acute pain following surgery be subject to the CDC Guideline could result in
that patient experiencing chronic pain down the road, as untreated acute pain
is a risk factor for developing chronic pain. Additionally, limiting
prescriptions to 7-days for acute pain is especially problematic for patients
undergoing certain invasive surgeries, such as amputation, thoracotomy, total
knee replacement or hernia. We are concerned about how pain medicine
specialists and anesthesiologists would be impacted by this measure. Pain
medicine specialists and anesthesiologists have additional training, education
and board certification that enable them to treat patients suffering from
acute pain to complex chronic pain conditions. Anesthesiologists, treating
acute pain, can best determine the appropriate pain treatment following
surgery. (Submitted by: American Society of Anesthesiologists
(ASA))
- The Federation of American Hospitals questions CMS’ rationale for
submitting four similar and potentially competing measures for consideration
in MSSP. These duplicative measures seem to be contradictory to recent CMS
efforts to streamline the number of measures in response to the Patients Over
Paperwork initiative. We request that the MAP thoughtfully consider whether
all of these measures should be recommended for potential implementation. In
addition, while it is difficult to determine the underlying data source that
will be used for MUC18-106 Initial opioid prescription compliant with CDC
recommendations, we assume that all four measures will be derived from claims
data. As a result, FAH has significant concerns with recommending these
measures at this time. Specifically, it is not clear that the developers have
demonstrated how well any of these measures perform within an accountable care
organization (ACO). ACOs currently receive prescription claims data from CMS,
which is not as robust and accurate on opioid utilization as would be required
to ensure that these measures represent reliable and valid performance and
limits an ACO’s ability to impact clinical care in a timely way. Therefore,
the FAH requests that the highest level of MAP recommendation be “Do Not
Support With Potential For Mitigation” for all four opioid-related measures
proposed for MSSP. (Submitted by: Federation of American
Hospitals)
- We do not support this measure. It is based on CDC guidelines, which are
for chronic pain only so don’t apply to initial prescription. It is good that
this includes all the populations excluded in the CDC guidelines but, again,
there are others for whom doses for acute pain may be outside of CDC
recommendations, for instance if they have a higher opioid tolerance from a
previous history of substance use but are in active treatment for it.
(Submitted by: CTAC)
- While it is difficult to adequately assess the appropriateness of this
measure for the MSSP given the limited information available for public
comment, the AMA has significant concerns with many of the components included
in this composite and the lack of precision in the measure specifications.
Specifically, we do not believe that the measure accurately reflects the
recommendations outlined in the Centers for Disease Control & Prevention
(CDC) Guideline for Prescribing Opioids for Chronic Pain, such as the
numerator’s requirement for a daily dose and duration of therapy without the
ability to capture instances where it may be clinically appropriate to exceed
90 morphine milligram equivalents (MME) per day. In addition, we question the
limit of 50 morphine milligram equivalents (MME) per day for an initial dose,
as it is not specifically recommended in the guideline and the numerator
requirement that the “initial opioid prescription is not for methadone”
appears intended to further refine the patient population and may be better
suited as an exclusion. Given the significant concerns with this measure and
the number of similar and overlapping measures on opioid use proposed, the AMA
recommends that the highest level of MAP recommendation be “Do Not Support”.
(Submitted by: American Medical Association)
- While we appreciate that this measure has exclusions for malignant cancer,
chemotherapy, or radiation in the measurement year, hospice, palliative care,
and those in LTC, nursing homes, and SNFs in the measurement year, there is
more work to be done before it is ready for use in the MSSP. The CDC Guideline
was developed for chronic pain and not for newly diagnosed pain. Furthermore,
we urge the measure steward to consider additional exclusions, since other
conditions, including non-malignant cancer, can still result in significant
pain. (Submitted by: Center to Advance Palliative Care)
(Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-115)
|
- Cost measures have been identified as a priority, and CMS addressed this
priority through the inclusion of additional episode-based cost measures on
the MUC list. The cost measures risk-adjust based on variables, such as age,
and comorbidities by using HCC data and other clinical characteristics.
However, we are concerned that the measures are not adjusted to account for
socio-demographic status. In addition to differences in patient clinical
complexity, socio-demographic status can drive differences in average episode
costs. In particular, physicians at academic medical centers (AMCs) care for
vulnerable populations of patients who are sicker, poorer, and more complex
than patients treated elsewhere. Recent reports from the National Academies of
Science, Engineering and Medicine and Assistant Secretary for Planning and
Evaluation (ASPE) have clearly acknowledged that SDS variables (such as low
income and education) may explain adverse outcomes and higher costs.
Differences in patient severity, rates of patient compliance with treatment,
sociodemographic status, patient engagement, patient preferences for treatment
approaches, and sites of care, can all drive differences in average costs.
Appropriate risk adjustment is essential so that differences in patient
characteristics that are behind a health care provider’s control do not have
an unfair impact on a provider’s resource use performance score. CMS should
look at alternative sources of data to obtain information about risk
adjustment. In regard to attribution – AAMC believes that attribution methods
used should be clear and transparent to clinicians and that it is critical
that there be an accurate determination of the relationship between a patient
and a clinician to ensure that the correct clinician is held responsible for
the patient’s outcomes and costs. This is complicated given that most patients
receive care from numerous clinicians across several facilities. In the 2019
physician fee schedule final rule CMS changed the attribution methodology for
the inpatient episode measures to measure more physicians on episode-based
cost measures. We are concerned about the impact of this change and the need
for more analysis and opportunity to provide feedback on this new attribution
approach. Attribution is complicated, given that most patients receive care
from numerous clinicians across several facilities. The AAMC believes that
better data sources and analytic techniques should be explored in the future
to support more accurate attribution. (Submitted by: Association of American
Medical Colleges)
- NHPCO Comments: NHPCO appreciates this measure and recognizes that high
quality community-based palliative care services could potentially have a
positive impact on this measure. This may be a secondary outcome of
comprehensive assessment, symptom and medication management, advance care
planning and goals of care conversations, patient and family education, and
care coordination by an interdisciplinary team. (Submitted by: National
Hospice and Palliative Care Organization)
- Overall, the AMA supports the episode-based measure development process
and movement to episode based measures over broad cost measures. However, we
cannot endorse any of the specific measures due to the paucity of analytic
information such as the measures’ mean made available prior to the deadline
for comments. We request further refinements to the process to ensure the cost
measures are accurate and fair when used in the Merit-based Incentive Payment
System and, ultimately, publicly reported. In general, we urge the MAP to make
“Conditional Support” its highest level of recommendation and to recommend “Do
Not Support with Potential for Mitigation” for any measures where relevant
specialties have raised serious concerns. Our rationale for these
recommendations is as follows: Prior to implementation of any measure, CMS
should seek and share more information on the impact the measures and the
surrounding methodological structure across different types of practices and
situations. The findings should be shared with stakeholders soon enough to be
considered in their comments on the measure. As noted above, this information
has not been made available on the new measures. We have serious concerns
with the attribution method that CMS has adopted for the acute inpatient
condition measures. This method was adopted for the three acute inpatient
condition measures that will take effect in 2019 and is proposed to be
continued in the inpatient condition measures now before the MAP. First,
the modifications were made without adequate transparency and input from the
expert panels and stakeholders. As originally designed and pilot tested, these
episodes would have only been attributed to individual physicians if they were
responsible for at least 30 percent of the inpatient evaluation and management
(E/M) services in the episode. Under the revised methodology, the 30 percent
threshold will be applied at the TIN level (i.e., if members of the TIN
participated as individuals rather than a group and the group as a whole met
the 30 percent threshold, the full Part A and Part B expenditures associated
with the episode would be attributed to any physician who provided even one
inpatient E/M service during the episode). If physicians participate as a
group, an episode could be attributed to multiple groups but no episode will
be attributed to a particular group more than once. However, if a group’s
members report as individuals, all members who bill for at least one inpatient
E/M service would be assigned the cost of the same episode and have it counted
in their cost score if they have at least 19 other episodes for the same
inpatient condition. The agency did not field test the 2019 measures based on
the revised attribution methodology, nor did CMS release information about the
anticipated impact of its revisions as compared to the initial methodology.
What we do know is that CMS has repeatedly stated its desire to increase the
number of clinicians that are counted in the cost category and the number of
attributed episodes for the three inpatient measures was 3% to 12% higher
after the revision than before. We do not know if this change increased or
decreased the reliability of the acute inpatient condition measures but we do
know that reliability was less than CMS’s modest 0.4 reliability standard for
a significant number of individually participating MIPS clinicians.
Specifically, 25% of clinicians who would have been subject to the
intracranial hemorrhage/cerebral infarction measure and 68% of those subject
to the simple pneumonia measure were below the 0.4 threshold. We are troubled
about the lack of transparency surrounding this change and its potential to
undercut the work of the clinical panels in developing these models. Second,
we are increasingly concerned that in its desire to fold more physicians into
the cost category, CMS is compromising the reliability of the measures. For
example, even though CMS considered addressing the simple pneumonia measure’s
“somewhat lower” reliability by increasing the minimum threshold for scoring a
measure from 20 episodes to 30, the agency ultimately rejected this solution
because it would have decreased the number of physicians and groups who met
the case minimum and were attributed a cost measure. The AMA believes this
choice ignores the impact of unreliable measures on real physicians and their
patients in order to increase the number of physicians who are subject to a
measure that is likely to trigger inappropriate payment adjustments for a
significant number of physicians. We urge the MAP to recommend a higher
reliability threshold for the episode measures. Alternatively, the case
minimum could be increased, the measure could be treated as optional or its
results could be provided for information only while improvements were
developed and implemented. Third, while the AMA is very appreciative of the
process that CMS and Acumen, LLP have created to obtain clinical input on the
cost episodes, we believe that the CMS timelines and certain administrative
obstacles have created several shortcomings throughout the cost measure
development and field testing process. These include: • The continued
reliance on administrative claims data, which limits risk adjustment and
exclusion criteria. CMS should allow for use of alternative sources of data,
such as clinical data registries. • The timeline for development and testing
was rushed and limited the ability of practicing physicians to engage.
• Stakeholder input was hampered by the complexity of the field testing
reports and challenges accessing the reports. Fourth, due to their
unfamiliarity with the measures and the complexity of the attribution method
for the acute inpatient condition measures, many physicians found it very
difficult to glean useful and actionable information from the reports. Even
physicians who were actively engaged in the development process had difficulty
navigating the reports, interpreting the data and determining whether the
workgroup’s decisions were accurately reflected in the draft measure.
Physicians who were not part of the development process reported challenges
understanding basic aspects of the methodology, including the time interval
for eligibility, how risk adjustment was done, and whether the cost measures
apply to Medicare or all-payers. For the acute condition measures—where there
is the potential for assignment of the same costs to up to three different
groups and more than one physician in each of those groups—tracking costs and
taking action to improve care and reduce costs will be extremely difficult.
Therefore, we are concerned about the actionability of the measures when
implemented in MIPS and physicians’ ability to make changes that could improve
their scores in the future. We would be more comfortable moving forward with
the new episode measures if CMS put in place safeguards against unintended
consequences, especially if a measure does not meet a 0.7 or higher mean
reliability for a significant percentage of groups or individuals. These
include: • Phasing in new measures over several performance periods to give
physicians an opportunity to understand how they will be evaluated on their
resource utilization during episodes; • Increasing the case minimums for new
measures while they are being introduced into the program to create better
physician buy-in, identify potential issues, and ensure that individual
physicians and small groups are not disadvantaged by a small number of
outliers; • Maintaining the current cost category weight at 15% for the next
three years while new episode measures are developed, tested, and used in
MIPS; • Releasing more detailed analyses about how the new measures will
impact physicians and groups, particularly based on group size, practice
composition and specialty. • Conducting extensive education and outreach about
the new measures. (Submitted by: American Medical Association)
- ASCO supports the episode-based measure development process, as
episode-based measures can provide a more appropriate and meaningful
assessment of care costs than extremely broad cost measures that also lack
clarity in attribution. We appreciate the opportunity to participate in the
development of those measures and look forward to working on measures related
to oncology care, in addition to oncology surgical procedures. However, as we
have stated before in numerous comment letters to CMS, the reliance on
administrative claims with the failure to consider other important sources of
data leads to a crude measure of true cost, and limits both risk adjustment
and exclusion criteria. Section 105(b) of the MACRA statute specifically
allows for the sharing of data by CMS with qualified clinical data registries;
to date, CMS has not provided a process to make this data accessible to
clinical registries, instead implementing a “quasi-qualified entity” pathway
that is onerous, time-consuming, and may provide access to the data for a
limited period. We continue to urge CMS to make this data available, as
clearly intended by the MACRA statute, and to work with stakeholders including
professional societies to assess how the potential linkage of administrative
claims data and clinical registry data could improve existing and new cost
measures. We thank NQF for this opportunity to submit comments and look
forward to engaging further in the measure development process timeline.
(Submitted by: American Society of Clinical Oncology (ASCO) )
(Program: Merit-Based Incentive
Payment System; MUC ID: MUC2018-116) |
- Cost measures have been identified as a priority, and CMS addressed this
priority through the inclusion of additional episode-based cost measures on
the MUC list. The cost measures risk-adjust based on variables, such as age,
and comorbidities by using HCC data and other clinical characteristics.
However, we are concerned that the measures are not adjusted to account for
socio-demographic status. In addition to differences in patient clinical
complexity, socio-demographic status can drive differences in average episode
costs. In particular, physicians at academic medical centers (AMCs) care for
vulnerable populations of patients who are sicker, poorer, and more complex
than patients treated elsewhere. Recent reports from the National Academies of
Science, Engineering and Medicine and Assistant Secretary for Planning and
Evaluation (ASPE) have clearly acknowledged that SDS variables (such as low
income and education) may explain adverse outcomes and higher costs.
Differences in patient severity, rates of patient compliance with treatment,
sociodemographic status, patient engagement, patient preferences for treatment
approaches, and sites of care, can all drive differences in average costs.
Appropriate risk adjustment is essential so that differences in patient
characteristics that are behind a health care provider’s control do not have
an unfair impact on a provider’s resource use performance score. CMS should
look at alternative sources of data to obtain information about risk
adjustment. In regard to attribution – AAMC believes that attribution methods
used should be clear and transparent to clinicians and that it is critical
that there be an accurate determination of the relationship between a patient
and a clinician to ensure that the correct clinician is held responsible for
the patient’s outcomes and costs. This is complicated given that most patients
receive care from numerous clinicians across several facilities. In the 2019
physician fee schedule final rule CMS changed the attribution methodology for
the inpatient episode measures to measure more physicians on episode-based
cost measures. We are concerned about the impact of this change and the need
for more analysis and opportunity to provide feedback on this new attribution
approach. Attribution is complicated, given that most patients receive care
from numerous clinicians across several facilities. The AAMC believes that
better data sources and analytic techniques should be explored in the future
to support more accurate attribution. (Submitted by: Association of American
Medical Colleges)
- Overall, the AMA supports the episode-based measure development process
and movement to episode based measures over broad cost measures. However, we
cannot endorse any of the specific measures due to the paucity of analytic
information, such as the measures’ mean, made available prior to the deadline
for comments. We request further refinements to the process to ensure the
cost measures are accurate and fair when used in the Merit-based Incentive
Payment System and, ultimately, publicly reported. In general, we urge the
MAP to make “Conditional Support” its highest level of recommendation and to
recommend “Do Not Support with Potential for Mitigation” for any measures
where relevant specialties have raised serious concerns. Please see additional
comments submitted earlier regarding the MUC18-115 Inpatient Chronic
Obstructive Pulmonary Disease (COPD) Exacerbation. (Submitted by: American
Medical Association)
- ASCO supports the episode-based measure development process, as
episode-based measures can provide a more appropriate and meaningful
assessment of care costs than extremely broad cost measures that also lack
clarity in attribution. We appreciate the opportunity to participate in the
development of those measures and look forward to working on measures related
to oncology care, in addition to oncology surgical procedures. However, as we
have stated before in numerous comment letters to CMS, the reliance on
administrative claims with the failure to consider other important sources of
data leads to a crude measure of true cost, and limits both risk adjustment
and exclusion criteria. Section 105(b) of the MACRA statute specifically
allows for the sharing of data by CMS with qualified clinical data registries;
to date, CMS has not provided a process to make this data accessible to
clinical registries, instead implementing a “quasi-qualified entity” pathway
that is onerous, time-consuming, and may provide access to the data for a
limited period. We continue to urge CMS to make this data available, as
clearly intended by the MACRA statute, and to work with stakeholders including
professional societies to assess how the potential linkage of administrative
claims data and clinical registry data could improve existing and new cost
measures. We thank NQF for this opportunity to submit comments and look
forward to engaging further in the measure development process timeline.
(Submitted by: American Society of Clinical Oncology (ASCO) )
(Program:
Merit-Based Incentive Payment System; MUC ID: MUC2018-117) |
- Cost measures have been identified as a priority, and CMS addressed this
priority through the inclusion of additional episode-based cost measures on
the MUC list. The cost measures risk-adjust based on variables, such as age,
and comorbidities by using HCC data and other clinical characteristics.
However, we are concerned that the measures are not adjusted to account for
socio-demographic status. In addition to differences in patient clinical
complexity, socio-demographic status can drive differences in average episode
costs. In particular, physicians at academic medical centers (AMCs) care for
vulnerable populations of patients who are sicker, poorer, and more complex
than patients treated elsewhere. Recent reports from the National Academies of
Science, Engineering and Medicine and Assistant Secretary for Planning and
Evaluation (ASPE) have clearly acknowledged that SDS variables (such as low
income and education) may explain adverse outcomes and higher costs.
Differences in patient severity, rates of patient compliance with treatment,
sociodemographic status, patient engagement, patient preferences for treatment
approaches, and sites of care, can all drive differences in average costs.
Appropriate risk adjustment is essential so that differences in patient
characteristics that are behind a health care provider’s control do not have
an unfair impact on a provider’s resource use performance score. CMS should
look at alternative sources of data to obtain information about risk
adjustment. In regard to attribution – AAMC believes that attribution methods
used should be clear and transparent to clinicians and that it is critical
that there be an accurate determination of the relationship between a patient
and a clinician to ensure that the correct clinician is held responsible for
the patient’s outcomes and costs. This is complicated given that most patients
receive care from numerous clinicians across several facilities. In the 2019
physician fee schedule final rule CMS changed the attribution methodology for
the inpatient episode measures to measure more physicians on episode-based
cost measures. We are concerned about the impact of this change and the need
for more analysis and opportunity to provide feedback on this new attribution
approach. Attribution is complicated, given that most patients receive care
from numerous clinicians across several facilities. The AAMC believes that
better data sources and analytic techniques should be explored in the future
to support more accurate attribution. (Submitted by: Association of American
Medical Colleges)
- Multiple neurosurgeons contributed their time and expertise to the
development of this measure. While they felt that their input was taken
seriously and appreciated the flexibility to define certain aspects of the
measure, such as trigger codes and risk adjustment factors, they continue to
believe there are multiple critical deficiencies in the underlying measure
development process that limit the measures readiness for implementation.
These include: • Adherence to a uniform measure development framework that
fails to account for uniqueness of each clinical scenario. It is not
necessarily appropriate for the Lumbar Fusion Workgroup to adhere to the same
standardized measure constructs as the Hernia Repair or the COPD Exacerbation
Workgroups. Procedures and patient populations are vastly different and
cannot be evaluated for appropriateness using a one-size-fits-all approach.
• Exclusive reliance on administrative claims data. The limitations of claims
data impact the effectiveness and accuracy of risk stratification,
subgrouping, and inclusion and exclusion criteria. In order to achieve the
most accurate assessment of cost, CMS must look beyond administrative billing
data and make use of clinical data from registries and other sources. • The
ongoing absence of a direct link to quality. By focusing simply on cost, this
process fails to account for the impact that cost reduction (or spending) may
have on patient outcomes; provides clinicians with virtually meaningless and
unactionable data in a clinical context; and belies the value-driven goals of
the Medicare Access and CHIP Reauthorization Act (MACRA). • Rushed timeline.
One of the biggest limiting factors to the utility and credibility of this
exercise has been the rushed timeline. This process was driven by a rapid and
arbitrary timeline that focused exclusively on the goal of measure
implementation, rather than actually getting the measure right. Very few
members of the Lumbar Fusion Workgroup were able to access their performance
reports during the short Field Testing period and even if they could, they
found it very difficult to decipher the reports and provide meaningful
feedback. If clinicians who were most involved in this process encountered
such problems, there is a low likelihood that Acumen collected valid and
useful feedback from the general public. In fact, Acumen informed us that the
Field Testing response rates were very low. The Lumbar Fusion measure should
not be implemented until relevant stakeholders are given a more reasonable
opportunity to review, understand, and comment on the confidential performance
reports. In light of these unresolved concerns, the AANS and CNS and the
neurosurgical representatives that served on the development Workgroup do NOT
endorse the MUC18-117: Lumbar Spine Fusion for Degenerative Disease, 1-3
Levels, Episode-Based Cost Measure and do NOT believe it is ready for
implementation in MIPS at this time or any other program with public
accountability and payment implications. For these same reasons, we recommend
that the MAP NOT support this measure for use in MIPS. (Submitted by:
American Association of Neurological Surgeons)
- Overall, the AMA supports the episode-based measure development process
and movement to episode based measures over broad cost measures. However, we
cannot endorse any of the specific measures due to the paucity of analytic
information such as the measures’ mean made available prior to the deadline
for comments. We request further refinements to the process to ensure the cost
measures are accurate and fair when used in the Merit-based Incentive Payment
System and, ultimately, publicly reported. In general, we urge the MAP to make
“Conditional Support” its highest level of recommendation and to recommend “Do
Not Support with Potential for Mitigation” for any measures where relevant
specialties have raised serious concerns. Please see additional comments
submitted earlier in response to MUC18-115 Inpatient Chronic Obstructive
Pulmonary Disease (COPD) Exacerbation. (Submitted by: American Medical
Association)
- ASCO supports the episode-based measure development process, as
episode-based measures can provide a more appropriate and meaningful
assessment of care costs than extremely broad cost measures that also lack
clarity in attribution. We appreciate the opportunity to participate in the
development of those measures and look forward to working on measures related
to oncology care, in addition to oncology surgical procedures. However, as we
have stated before in numerous comment letters to CMS, the reliance on
administrative claims with the failure to consider other important sources of
data leads to a crude measure of true cost, and limits both risk adjustment
and exclusion criteria. Section 105(b) of the MACRA statute specifically
allows for the sharing of data by CMS with qualified clinical data registries;
to date, CMS has not provided a process to make this data accessible to
clinical registries, instead implementing a “quasi-qualified entity” pathway
that is onerous, time-consuming, and may provide access to the data for a
limited period. We continue to urge CMS to make this data available, as
clearly intended by the MACRA statute, and to work with stakeholders including
professional societies to assess how the potential linkage of administrative
claims data and clinical registry data could improve existing and new cost
measures. We thank NQF for this opportunity to submit comments and look
forward to engaging further in the measure development process timeline.
(Submitted by: American Society of Clinical Oncology (ASCO) )
(Program: Merit-Based Incentive
Payment System; MUC ID: MUC2018-119) |
- Cost measures have been identified as a priority, and CMS addressed this
priority through the inclusion of additional episode-based cost measures on
the MUC list. The cost measures risk-adjust based on variables, such as age,
and comorbidities by using HCC data and other clinical characteristics.
However, we are concerned that the measures are not adjusted to account for
socio-demographic status. In addition to differences in patient clinical
complexity, socio-demographic status can drive differences in average episode
costs. In particular, physicians at academic medical centers (AMCs) care for
vulnerable populations of patients who are sicker, poorer, and more complex
than patients treated elsewhere. Recent reports from the National Academies of
Science, Engineering and Medicine and Assistant Secretary for Planning and
Evaluation (ASPE) have clearly acknowledged that SDS variables (such as low
income and education) may explain adverse outcomes and higher costs.
Differences in patient severity, rates of patient compliance with treatment,
sociodemographic status, patient engagement, patient preferences for treatment
approaches, and sites of care, can all drive differences in average costs.
Appropriate risk adjustment is essential so that differences in patient
characteristics that are behind a health care provider’s control do not have
an unfair impact on a provider’s resource use performance score. CMS should
look at alternative sources of data to obtain information about risk
adjustment. In regard to attribution – AAMC believes that attribution methods
used should be clear and transparent to clinicians and that it is critical
that there be an accurate determination of the relationship between a patient
and a clinician to ensure that the correct clinician is held responsible for
the patient’s outcomes and costs. This is complicated given that most patients
receive care from numerous clinicians across several facilities. In the 2019
physician fee schedule final rule CMS changed the attribution methodology for
the inpatient episode measures to measure more physicians on episode-based
cost measures. We are concerned about the impact of this change and the need
for more analysis and opportunity to provide feedback on this new attribution
approach. Attribution is complicated, given that most patients receive care
from numerous clinicians across several facilities. The AAMC believes that
better data sources and analytic techniques should be explored in the future
to support more accurate attribution. (Submitted by: Association of American
Medical Colleges)
- o We do not understand how this measure is intended to improve the quality
of provided healthcare, and request it be withdrawn, or better
connected/associated or proven to be indicative of some improvement in the
quality of delivered (Submitted by: National Assn for Behavioral
Healthcare)
- Overall, the AMA supports the episode-based measure development process
and movement to episode based measures over broad cost measures. However, we
cannot endorse any of the specific measures due to the paucity of analytic
information such as the measures’ mean made available prior to the deadline
for comments. We request further refinements to the process to ensure the cost
measures are accurate and fair when used in the Merit-based Incentive Payment
System and, ultimately, publicly reported. In general, we urge the MAP to make
“Conditional Support” its highest level of recommendation and to recommend “Do
Not Support with Potential for Mitigation” for any measures where relevant
specialties have raised serious concerns. Please see additional comments
submitted earlier in response to MUC18-115 Inpatient Chronic Obstructive
Pulmonary Disease (COPD) Exacerbation. (Submitted by: American Medical
Association)
- ASCO supports the episode-based measure development process, as
episode-based measures can provide a more appropriate and meaningful
assessment of care costs than extremely broad cost measures that also lack
clarity in attribution. We appreciate the opportunity to participate in the
development of those measures and look forward to working on measures related
to oncology care, in addition to oncology surgical procedures. However, as we
have stated before in numerous comment letters to CMS, the reliance on
administrative claims with the failure to consider other important sources of
data leads to a crude measure of true cost, and limits both risk adjustment
and exclusion criteria. Section 105(b) of the MACRA statute specifically
allows for the sharing of data by CMS with qualified clinical data registries;
to date, CMS has not provided a process to make this data accessible to
clinical registries, instead implementing a “quasi-qualified entity” pathway
that is onerous, time-consuming, and may provide access to the data for a
limited period. We continue to urge CMS to make this data available, as
clearly intended by the MACRA statute, and to work with stakeholders including
professional societies to assess how the potential linkage of administrative
claims data and clinical registry data could improve existing and new cost
measures. We thank NQF for this opportunity to submit comments and look
forward to engaging further in the measure development process timeline.
(Submitted by: American Society of Clinical Oncology (ASCO) )
(Program: Merit-Based
Incentive Payment System; MUC ID: MUC2018-120) |
- Cost measures have been identified as a priority, and CMS addressed this
priority through the inclusion of additional episode-based cost measures on
the MUC list. The cost measures risk-adjust based on variables, such as age,
and comorbidities by using HCC data and other clinical characteristics.
However, we are concerned that the measures are not adjusted to account for
socio-demographic status. In addition to differences in patient clinical
complexity, socio-demographic status can drive differences in average episode
costs. In particular, physicians at academic medical centers (AMCs) care for
vulnerable populations of patients who are sicker, poorer, and more complex
than patients treated elsewhere. Recent reports from the National Academies of
Science, Engineering and Medicine and Assistant Secretary for Planning and
Evaluation (ASPE) have clearly acknowledged that SDS variables (such as low
income and education) may explain adverse outcomes and higher costs.
Differences in patient severity, rates of patient compliance with treatment,
sociodemographic status, patient engagement, patient preferences for treatment
approaches, and sites of care, can all drive differences in average costs.
Appropriate risk adjustment is essential so that differences in patient
characteristics that are behind a health care provider’s control do not have
an unfair impact on a provider’s resource use performance score. CMS should
look at alternative sources of data to obtain information about risk
adjustment. In regard to attribution – AAMC believes that attribution methods
used should be clear and transparent to clinicians and that it is critical
that there be an accurate determination of the relationship between a patient
and a clinician to ensure that the correct clinician is held responsible for
the patient’s outcomes and costs. This is complicated given that most patients
receive care from numerous clinicians across several facilities. In the 2019
physician fee schedule final rule CMS changed the attribution methodology for
the inpatient episode measures to measure more physicians on episode-based
cost measures. We are concerned about the impact of this change and the need
for more analysis and opportunity to provide feedback on this new attribution
approach. Attribution is complicated, given that most patients receive care
from numerous clinicians across several facilities. The AAMC believes that
better data sources and analytic techniques should be explored in the future
to support more accurate attribution. (Submitted by: Association of American
Medical Colleges)
- Overall, the AMA supports the episode-based measure development process
and movement to episode based measures over broad cost measures. However, we
cannot endorse any of the specific measures due to the paucity of analytic
information such as the measures’ mean made available prior to the deadline
for comments. We request further refinements to the process to ensure the cost
measures are accurate and fair when used in the Merit-based Incentive Payment
System and, ultimately, publicly reported. In general, we urge the MAP to make
“Conditional Support” its highest level of recommendation and to recommend “Do
Not Support with Potential for Mitigation” for any measures where relevant
specialties have raised serious concerns. Please see additional comments
submitted earlier in response to MUC18-115 Inpatient Chronic Obstructive
Pulmonary Disease (COPD) Exacerbation. (Submitted by: American Medical
Association)
- The American Society of Breast Surgeons (ASBrS) would like to express its
ongoing concerns with the episode-based cost measure “Lumpectomy, Partial
Mastectomy, Simple Mastectomy,” which is under consideration for inclusion in
the 2020 Merit-Based Incentive Payment System (MIPS). While one of our
breast surgeon members served on the Clinical Subcommittee and several members
served on the smaller workgroup that helped to develop this measure, neither
the ASBrS nor our clinical expert volunteers endorse the measure or believe it
is ready for implementation in a program with public accountability and
payment implications. Our concerns with this measure center on the
fundamentally flawed process under which it was developed. Although workgroup
members had the flexibility to define many elements of the episode, there was
little flexibility to stray from the overall measure framework, which relied
on a one-size-fits-all-approach to measuring cost across diverse conditions,
procedures, and patient populations. This standardized process failed to
adequately account for the complexities of oncologic care and made it
challenging to measure cost variation in a meaningful and clinically relevant
manner. This project also continues to focus exclusively on cost without
evaluating what impact cost reduction (or spending) has on quality. As a
result, it fails to provide a meaningful picture of healthcare value and what
is truly best for the patient. The project also suffers from its exclusive
reliance on claims data, which impacts the accuracy of risk adjustments and
performance evaluations, overall. Finally, this project was driven by a rushed
and arbitrary timeline, which seemed to be more focused on measure
implementation than actually getting the measure right. We strongly urge the
MAP to recommend that CMS not implement this measure at this time and that it
give relevant clinical stakeholders the opportunity to more carefully craft
and test a breast surgery cost measure under a more flexible framework and
more reasonable timeline. (Submitted by: The American Society of Breast
Surgeons)
- ASCO supports the episode-based measure development process, as
episode-based measures can provide a more appropriate and meaningful
assessment of care costs than extremely broad cost measures that also lack
clarity in attribution. We appreciate the opportunity to participate in the
development of those measures and look forward to working on measures related
to oncology care, in addition to oncology surgical procedures. However, as we
have stated before in numerous comment letters to CMS, the reliance on
administrative claims with the failure to consider other important sources of
data leads to a crude measure of true cost, and limits both risk adjustment
and exclusion criteria. Section 105(b) of the MACRA statute specifically
allows for the sharing of data by CMS with qualified clinical data registries;
to date, CMS has not provided a process to make this data accessible to
clinical registries, instead implementing a “quasi-qualified entity” pathway
that is onerous, time-consuming, and may provide access to the data for a
limited period. We continue to urge CMS to make this data available, as
clearly intended by the MACRA statute, and to work with stakeholders including
professional societies to assess how the potential linkage of administrative
claims data and clinical registry data could improve existing and new cost
measures. We thank NQF for this opportunity to submit comments and look
forward to engaging further in the measure development process timeline.
(Submitted by: American Society of Clinical Oncology (ASCO) )
(Program:
Merit-Based Incentive Payment System; MUC ID: MUC2018-121) |
- Cost measures have been identified as a priority, and CMS addressed this
priority through the inclusion of additional episode-based cost measures on
the MUC list. The cost measures risk-adjust based on variables, such as age,
and comorbidities by using HCC data and other clinical characteristics.
However, we are concerned that the measures are not adjusted to account for
socio-demographic status. In addition to differences in patient clinical
complexity, socio-demographic status can drive differences in average episode
costs. In particular, physicians at academic medical centers (AMCs) care for
vulnerable populations of patients who are sicker, poorer, and more complex
than patients treated elsewhere. Recent reports from the National Academies of
Science, Engineering and Medicine and Assistant Secretary for Planning and
Evaluation (ASPE) have clearly acknowledged that SDS variables (such as low
income and education) may explain adverse outcomes and higher costs.
Differences in patient severity, rates of patient compliance with treatment,
sociodemographic status, patient engagement, patient preferences for treatment
approaches, and sites of care, can all drive differences in average costs.
Appropriate risk adjustment is essential so that differences in patient
characteristics that are behind a health care provider’s control do not have
an unfair impact on a provider’s resource use performance score. CMS should
look at alternative sources of data to obtain information about risk
adjustment. In regard to attribution – AAMC believes that attribution methods
used should be clear and transparent to clinicians and that it is critical
that there be an accurate determination of the relationship between a patient
and a clinician to ensure that the correct clinician is held responsible for
the patient’s outcomes and costs. This is complicated given that most patients
receive care from numerous clinicians across several facilities. In the 2019
physician fee schedule final rule CMS changed the attribution methodology for
the inpatient episode measures to measure more physicians on episode-based
cost measures. We are concerned about the impact of this change and the need
for more analysis and opportunity to provide feedback on this new attribution
approach. Attribution is complicated, given that most patients receive care
from numerous clinicians across several facilities. The AAMC believes that
better data sources and analytic techniques should be explored in the future
to support more accurate attribution. (Submitted by: Association of American
Medical Colleges)
- Overall, the AMA supports the episode-based measure development process
and movement to episode based measures over broad cost measures. However, we
cannot endorse any of the specific measures due to the paucity of analytic
information such as the measures’ mean made available prior to the deadline
for comments. We request further refinements to the process to ensure the cost
measures are accurate and fair when used in the Merit-based Incentive Payment
System and, ultimately, publicly reported. In general, we urge the MAP to make
“Conditional Support” its highest level of recommendation and to recommend “Do
Not Support with Potential for Mitigation” for any measures where relevant
specialties have raised serious concerns. Please see additional comments
submitted earlier in response to MUC18-115 Inpatient Chronic Obstructive
Pulmonary Disease (COPD) Exacerbation. (Submitted by: American Medical
Association)
- The Renal Physicians Association (RPA) is the professional organization of
nephrologists whose goals are to ensure optimal care under the highest
standards of medical practice for patients with kidney disease and related
disorders. RPA acts as the national representative for physicians engaged in
the study and management of patients with kidney disease. The RPA opposes the
proposed measure. First, we believe that appropriate clinician attribution is
problematic. Patients requiring dialysis for AKI usually have multiple medical
problems and complications, and multiple providers and consultants. For the
vast majority of patients, the management of AKI accounts for only a small
fraction of the inpatient cost of care. It is rare that the nephrologist has
any substantial control over the total cost. Similarly, for outpatient care,
AKI patients often require multiple non-renal services which are outside the
control of the nephrologist. Finally, RPA is concerned that holding
nephrologists responsible and accountable for these costs may have the
unintended consequence that will result in nephrologists unwilling to initiate
dialysis in AKI patients. (Submitted by: Renal Physicians Association
)
- ASCO supports the episode-based measure development process, as
episode-based measures can provide a more appropriate and meaningful
assessment of care costs than extremely broad cost measures that also lack
clarity in attribution. We appreciate the opportunity to participate in the
development of those measures and look forward to working on measures related
to oncology care, in addition to oncology surgical procedures. However, as we
have stated before in numerous comment letters to CMS, the reliance on
administrative claims with the failure to consider other important sources of
data leads to a crude measure of true cost, and limits both risk adjustment
and exclusion criteria. Section 105(b) of the MACRA statute specifically
allows for the sharing of data by CMS with qualified clinical data registries;
to date, CMS has not provided a process to make this data accessible to
clinical registries, instead implementing a “quasi-qualified entity” pathway
that is onerous, time-consuming, and may provide access to the data for a
limited period. We continue to urge CMS to make this data available, as
clearly intended by the MACRA statute, and to work with stakeholders including
professional societies to assess how the potential linkage of administrative
claims data and clinical registry data could improve existing and new cost
measures. We thank NQF for this opportunity to submit comments and look
forward to engaging further in the measure development process timeline.
(Submitted by: American Society of Clinical Oncology (ASCO) )
(Program: Merit-Based Incentive
Payment System; MUC ID: MUC2018-122) |
- Cost measures have been identified as a priority, and CMS addressed this
priority through the inclusion of additional episode-based cost measures on
the MUC list. The cost measures risk-adjust based on variables, such as age,
and comorbidities by using HCC data and other clinical characteristics.
However, we are concerned that the measures are not adjusted to account for
socio-demographic status. In addition to differences in patient clinical
complexity, socio-demographic status can drive differences in average episode
costs. In particular, physicians at academic medical centers (AMCs) care for
vulnerable populations of patients who are sicker, poorer, and more complex
than patients treated elsewhere. Recent reports from the National Academies of
Science, Engineering and Medicine and Assistant Secretary for Planning and
Evaluation (ASPE) have clearly acknowledged that SDS variables (such as low
income and education) may explain adverse outcomes and higher costs.
Differences in patient severity, rates of patient compliance with treatment,
sociodemographic status, patient engagement, patient preferences for treatment
approaches, and sites of care, can all drive differences in average costs.
Appropriate risk adjustment is essential so that differences in patient
characteristics that are behind a health care provider’s control do not have
an unfair impact on a provider’s resource use performance score. CMS should
look at alternative sources of data to obtain information about risk
adjustment. In regard to attribution – AAMC believes that attribution methods
used should be clear and transparent to clinicians and that it is critical
that there be an accurate determination of the relationship between a patient
and a clinician to ensure that the correct clinician is held responsible for
the patient’s outcomes and costs. This is complicated given that most patients
receive care from numerous clinicians across several facilities. In the 2019
physician fee schedule final rule CMS changed the attribution methodology for
the inpatient episode measures to measure more physicians on episode-based
cost measures. We are concerned about the impact of this change and the need
for more analysis and opportunity to provide feedback on this new attribution
approach. Attribution is complicated, given that most patients receive care
from numerous clinicians across several facilities. The AAMC believes that
better data sources and analytic techniques should be explored in the future
to support more accurate attribution. (Submitted by: Association of American
Medical Colleges)
- Overall, the AMA supports the episode-based measure development process
and movement to episode based measures over broad cost measures. However, we
cannot endorse any of the specific measures due to the paucity of analytic
information such as the measures’ mean made available prior to the deadline
for comments. We request further refinements to the process to ensure the cost
measures are accurate and fair when used in the Merit-based Incentive Payment
System and, ultimately, publicly reported. In general, we urge the MAP to make
“Conditional Support” its highest level of recommendation and to recommend “Do
Not Support with Potential for Mitigation” for any measures where relevant
specialties have raised serious concerns. Please see additional comments
submitted earlier in response to MUC18-115 Inpatient Chronic Obstructive
Pulmonary Disease (COPD) Exacerbation. (Submitted by: American Medical
Association)
- The American College of Gastroenterology (ACG) supports the collaborative
process used by the Centers for Medicare and Medicaid Services (CMS) to
develop the episode-based cost measures but found that the recent
field-testing process was rife with challenges. We question whether physicians
had adequate time and information to complete comprehensive reviews of the
test reports and are concerned that many physicians may not understand the
basic aspects of the methodology of these complex measures, particularly if
they were not actively engaged in the development process. ACG provided
detailed comments on measure attribution methodology, construction including
triggers and assigned services, and specifications during the recent comment
period. We ask that the MAP specifically recommend that CMS incorporate the
specialty societies and technical experts’ feedback provided prior to
implementation to ensure that the measures are reliable and valid
representations of the costs attributed to physicians. (Submitted by:
American College of Gastroenterology)
- ASCO supports the episode-based measure development process, as
episode-based measures can provide a more appropriate and meaningful
assessment of care costs than extremely broad cost measures that also lack
clarity in attribution. We appreciate the opportunity to participate in the
development of those measures and look forward to working on measures related
to oncology care, in addition to oncology surgical procedures. However, as we
have stated before in numerous comment letters to CMS, the reliance on
administrative claims with the failure to consider other important sources of
data leads to a crude measure of true cost, and limits both risk adjustment
and exclusion criteria. Section 105(b) of the MACRA statute specifically
allows for the sharing of data by CMS with qualified clinical data registries;
to date, CMS has not provided a process to make this data accessible to
clinical registries, instead implementing a “quasi-qualified entity” pathway
that is onerous, time-consuming, and may provide access to the data for a
limited period. We continue to urge CMS to make this data available, as
clearly intended by the MACRA statute, and to work with stakeholders including
professional societies to assess how the potential linkage of administrative
claims data and clinical registry data could improve existing and new cost
measures. We thank NQF for this opportunity to submit comments and look
forward to engaging further in the measure development process timeline.
(Submitted by: American Society of Clinical Oncology (ASCO) )
(Program: Merit-Based
Incentive Payment System; MUC ID: MUC2018-123) |
- Cost measures have been identified as a priority, and CMS addressed this
priority through the inclusion of additional episode-based cost measures on
the MUC list. The cost measures risk-adjust based on variables, such as age,
and comorbidities by using HCC data and other clinical characteristics.
However, we are concerned that the measures are not adjusted to account for
socio-demographic status. In addition to differences in patient clinical
complexity, socio-demographic status can drive differences in average episode
costs. In particular, physicians at academic medical centers (AMCs) care for
vulnerable populations of patients who are sicker, poorer, and more complex
than patients treated elsewhere. Recent reports from the National Academies of
Science, Engineering and Medicine and Assistant Secretary for Planning and
Evaluation (ASPE) have clearly acknowledged that SDS variables (such as low
income and education) may explain adverse outcomes and higher costs.
Differences in patient severity, rates of patient compliance with treatment,
sociodemographic status, patient engagement, patient preferences for treatment
approaches, and sites of care, can all drive differences in average costs.
Appropriate risk adjustment is essential so that differences in patient
characteristics that are behind a health care provider’s control do not have
an unfair impact on a provider’s resource use performance score. CMS should
look at alternative sources of data to obtain information about risk
adjustment. In regard to attribution – AAMC believes that attribution methods
used should be clear and transparent to clinicians and that it is critical
that there be an accurate determination of the relationship between a patient
and a clinician to ensure that the correct clinician is held responsible for
the patient’s outcomes and costs. This is complicated given that most patients
receive care from numerous clinicians across several facilities. In the 2019
physician fee schedule final rule CMS changed the attribution methodology for
the inpatient episode measures to measure more physicians on episode-based
cost measures. We are concerned about the impact of this change and the need
for more analysis and opportunity to provide feedback on this new attribution
approach. Attribution is complicated, given that most patients receive care
from numerous clinicians across several facilities. The AAMC believes that
better data sources and analytic techniques should be explored in the future
to support more accurate attribution. (Submitted by: Association of American
Medical Colleges)
- Overall, the AMA supports the episode-based measure development process
and movement to episode based measures over broad cost measures. However, we
cannot endorse any of the specific measures due to the paucity of analytic
information such as the measures’ mean made available prior to the deadline
for comments. We request further refinements to the process to ensure the cost
measures are accurate and fair when used in the Merit-based Incentive Payment
System and, ultimately, publicly reported. In general, we urge the MAP to make
“Conditional Support” its highest level of recommendation and to recommend “Do
Not Support with Potential for Mitigation” for any measures where relevant
specialties have raised serious concerns. Please see additional comments
submitted earlier in response to MUC18-115 Inpatient Chronic Obstructive
Pulmonary Disease (COPD) Exacerbation. (Submitted by: American Medical
Association)
- ASCO supports the episode-based measure development process, as
episode-based measures can provide a more appropriate and meaningful
assessment of care costs than extremely broad cost measures that also lack
clarity in attribution. We appreciate the opportunity to participate in the
development of those measures and look forward to working on measures related
to oncology care, in addition to oncology surgical procedures. However, as we
have stated before in numerous comment letters to CMS, the reliance on
administrative claims with the failure to consider other important sources of
data leads to a crude measure of true cost, and limits both risk adjustment
and exclusion criteria. Section 105(b) of the MACRA statute specifically
allows for the sharing of data by CMS with qualified clinical data registries;
to date, CMS has not provided a process to make this data accessible to
clinical registries, instead implementing a “quasi-qualified entity” pathway
that is onerous, time-consuming, and may provide access to the data for a
limited period. We continue to urge CMS to make this data available, as
clearly intended by the MACRA statute, and to work with stakeholders including
professional societies to assess how the potential linkage of administrative
claims data and clinical registry data could improve existing and new cost
measures. We thank NQF for this opportunity to submit comments and look
forward to engaging further in the measure development process timeline.
(Submitted by: American Society of Clinical Oncology (ASCO) )
(Program: Merit-Based Incentive Payment
System; MUC ID: MUC2018-126) |
- Cost measures have been identified as a priority, and CMS addressed this
priority through the inclusion of additional episode-based cost measures on
the MUC list. The cost measures risk-adjust based on variables, such as age,
and comorbidities by using HCC data and other clinical characteristics.
However, we are concerned that the measures are not adjusted to account for
socio-demographic status. In addition to differences in patient clinical
complexity, socio-demographic status can drive differences in average episode
costs. In particular, physicians at academic medical centers (AMCs) care for
vulnerable populations of patients who are sicker, poorer, and more complex
than patients treated elsewhere. Recent reports from the National Academies of
Science, Engineering and Medicine and Assistant Secretary for Planning and
Evaluation (ASPE) have clearly acknowledged that SDS variables (such as low
income and education) may explain adverse outcomes and higher costs.
Differences in patient severity, rates of patient compliance with treatment,
sociodemographic status, patient engagement, patient preferences for treatment
approaches, and sites of care, can all drive differences in average costs.
Appropriate risk adjustment is essential so that differences in patient
characteristics that are behind a health care provider’s control do not have
an unfair impact on a provider’s resource use performance score. CMS should
look at alternative sources of data to obtain information about risk
adjustment. In regard to attribution – AAMC believes that attribution methods
used should be clear and transparent to clinicians and that it is critical
that there be an accurate determination of the relationship between a patient
and a clinician to ensure that the correct clinician is held responsible for
the patient’s outcomes and costs. This is complicated given that most patients
receive care from numerous clinicians across several facilities. In the 2019
physician fee schedule final rule CMS changed the attribution methodology for
the inpatient episode measures to measure more physicians on episode-based
cost measures. We are concerned about the impact of this change and the need
for more analysis and opportunity to provide feedback on this new attribution
approach. Attribution is complicated, given that most patients receive care
from numerous clinicians across several facilities. The AAMC believes that
better data sources and analytic techniques should be explored in the future
to support more accurate attribution. (Submitted by: Association of American
Medical Colleges)
- Overall, the AMA supports the episode-based measure development process
and movement to episode based measures over broad cost measures. However, we
cannot endorse any of the specific measures due to the paucity of analytic
information such as the measures’ mean made available prior to the deadline
for comments. We request further refinements to the process to ensure the cost
measures are accurate and fair when used in the Merit-based Incentive Payment
System and, ultimately, publicly reported. In general, we urge the MAP to make
“Conditional Support” its highest level of recommendation and to recommend “Do
Not Support with Potential for Mitigation” for any measures where relevant
specialties have raised serious concerns. Please see additional comments
submitted earlier in response to MUC18-115 Inpatient Chronic Obstructive
Pulmonary Disease (COPD) Exacerbation. (Submitted by: American Medical
Association)
- The Renal Physicians Association (RPA) is the professional organization of
nephrologists whose goals are to ensure optimal care under the highest
standards of medical practice for patients with kidney disease and related
disorders. RPA acts as the national representative for physicians engaged in
the study and management of patients with kidney disease. RPA believes more
information is needed regarding attribution model for this measure. (Submitted
by: Renal Physicians Association )
- ASCO supports the episode-based measure development process, as
episode-based measures can provide a more appropriate and meaningful
assessment of care costs than extremely broad cost measures that also lack
clarity in attribution. We appreciate the opportunity to participate in the
development of those measures and look forward to working on measures related
to oncology care, in addition to oncology surgical procedures. However, as we
have stated before in numerous comment letters to CMS, the reliance on
administrative claims with the failure to consider other important sources of
data leads to a crude measure of true cost, and limits both risk adjustment
and exclusion criteria. Section 105(b) of the MACRA statute specifically
allows for the sharing of data by CMS with qualified clinical data registries;
to date, CMS has not provided a process to make this data accessible to
clinical registries, instead implementing a “quasi-qualified entity” pathway
that is onerous, time-consuming, and may provide access to the data for a
limited period. We continue to urge CMS to make this data available, as
clearly intended by the MACRA statute, and to work with stakeholders including
professional societies to assess how the potential linkage of administrative
claims data and clinical registry data could improve existing and new cost
measures. We thank NQF for this opportunity to submit comments and look
forward to engaging further in the measure development process timeline.
(Submitted by: American Society of Clinical Oncology (ASCO) )
(Program: Merit-Based Incentive
Payment System; MUC ID: MUC2018-137) |
- Overall, the AMA supports the episode-based measure development process
and movement to episode based measures over broad cost measures. However, we
cannot endorse any of the specific measures due to the paucity of analytic
information such as the measures’ mean made available prior to the deadline
for comments. We request further refinements to the process to ensure the cost
measures are accurate and fair when used in the Merit-based Incentive Payment
System and, ultimately, publicly reported. In general, we urge the MAP to make
“Conditional Support” its highest level of recommendation and to recommend “Do
Not Support with Potential for Mitigation” for any measures where relevant
specialties have raised serious concerns. Please see additional comments
submitted earlier in response to MUC18-115 Inpatient Chronic Obstructive
Pulmonary Disease (COPD) Exacerbation. (Submitted by: American Medical
Association)
- ASCO supports the episode-based measure development process, as
episode-based measures can provide a more appropriate and meaningful
assessment of care costs than extremely broad cost measures that also lack
clarity in attribution. We appreciate the opportunity to participate in the
development of those measures and look forward to working on measures related
to oncology care, in addition to oncology surgical procedures. However, as we
have stated before in numerous comment letters to CMS, the reliance on
administrative claims with the failure to consider other important sources of
data leads to a crude measure of true cost, and limits both risk adjustment
and exclusion criteria. Section 105(b) of the MACRA statute specifically
allows for the sharing of data by CMS with qualified clinical data registries;
to date, CMS has not provided a process to make this data accessible to
clinical registries, instead implementing a “quasi-qualified entity” pathway
that is onerous, time-consuming, and may provide access to the data for a
limited period. We continue to urge CMS to make this data available, as
clearly intended by the MACRA statute, and to work with stakeholders including
professional societies to assess how the potential linkage of administrative
claims data and clinical registry data could improve existing and new cost
measures. We thank NQF for this opportunity to submit comments and look
forward to engaging further in the measure development process timeline.
(Submitted by: American Society of Clinical Oncology (ASCO) )
(Program: Merit-Based
Incentive Payment System; MUC ID: MUC2018-140) |
- Overall, the AMA supports the episode-based measure development process
and movement to episode based measures over broad cost measures. However, we
cannot endorse any of the specific measures due to the paucity of analytic
information such as the measures’ mean made available prior to the deadline
for comments. We request further refinements to the process to ensure the cost
measures are accurate and fair when used in the Merit-based Incentive Payment
System and, ultimately, publicly reported. In general, we urge the MAP to make
“Conditional Support” its highest level of recommendation and to recommend “Do
Not Support with Potential for Mitigation” for any measures where relevant
specialties have raised serious concerns. Please see additional comments
submitted earlier in response to MUC18-115 Inpatient Chronic Obstructive
Pulmonary Disease (COPD) Exacerbation. (Submitted by: American Medical
Association)
- ASCO supports the episode-based measure development process, as
episode-based measures can provide a more appropriate and meaningful
assessment of care costs than extremely broad cost measures that also lack
clarity in attribution. We appreciate the opportunity to participate in the
development of those measures and look forward to working on measures related
to oncology care, in addition to oncology surgical procedures. However, as we
have stated before in numerous comment letters to CMS, the reliance on
administrative claims with the failure to consider other important sources of
data leads to a crude measure of true cost, and limits both risk adjustment
and exclusion criteria. Section 105(b) of the MACRA statute specifically
allows for the sharing of data by CMS with qualified clinical data registries;
to date, CMS has not provided a process to make this data accessible to
clinical registries, instead implementing a “quasi-qualified entity” pathway
that is onerous, time-consuming, and may provide access to the data for a
limited period. We continue to urge CMS to make this data available, as
clearly intended by the MACRA statute, and to work with stakeholders including
professional societies to assess how the potential linkage of administrative
claims data and clinical registry data could improve existing and new cost
measures. We thank NQF for this opportunity to submit comments and look
forward to engaging further in the measure development process timeline.
(Submitted by: American Society of Clinical Oncology (ASCO) )
(Program:
Merit-Based Incentive Payment System; MUC ID: MUC2018-148) |
- CMS is proposing a revised MSPB measure developed and field tested by
Acumen, LLP. The AMA greatly appreciates the efforts of CMS and Acumen, LLP
to improve on this measure carried over from the Value-Based Payment Modifier.
Conceptually, we believe that the exclusion of unrelated services from costs
counted in the measure and the use of MS-DRGs to define severity are promising
changes. On the other hand, we have concerns about the medical DRG attribution
method which is essentially the same as the method employed for acute
inpatient condition episodes and could hold individual physicians accountable
for costs of a patient that they saw only once. At this time, however, we are
unable to make a definitive recommendation on this measure because information
on the validity and impact of the attribution methodology is not publicly
available nor has data on the reliability and validity of the measure itself
been released. As a result, the AMA recommends that the highest level of MAP
recommendation be “Conditional Support” for this measure. The AMA also
encourages the Measures Application Partnership (MAP) to carefully consider
whether inclusion of the MSPB and Total Per Capita Cost (TPCC) in MIPS should
be continued as the number of episode-based cost measures increases. Many of
the same beneficiaries captured in the episode-based cost measures will also
be included in one or both of the broader population measures and this “double
counting” could have negative unintended consequences because costs attributed
to a clinician for a particular beneficiary will likely differ between
measures. These differences could occur simply because of the construction of
the measures because the episode-based measures are more precise--and likely
more reflective of care that is actually within the physician’s sphere of
influence—than the broader MSPB and TPC measures even where there is no true
difference in performance. The impact that the attribution of one beneficiary
for the same episode to multiple measures will have on the overall cost
category in MIPS is not known. Generally, we can assume that the results will
be inconsistent across clinicians. CMS has removed measures from other federal
programs due to the issue of “double counting”, and we believe this principle
should also apply to the cost category of MIPS. For instance, physicians in
MIPS APMs, such as those in the Medicare Shared Savings Program (MSSP), are
not measured on cost in MIPS to avoid conflicts between the shared
savings/losses calculations in MSSP and the MIPS cost measures. Physicians may
face similar conflicts when measured on episode-based cost measures, as well
as TPCC and MSPB. (Submitted by: American Medical Association)
- General Cost Measure Comments • The AANS and CNS oppose the continued
inclusion of the Total Per Capita Cost (TPCC) and Medicare Spending Per
Beneficiary (MSPB) in MIPS given the substantial issues with these measures,
their inappropriateness for physician-level measurements, and in light of the
growing number of episode-based cost measures. In general, the TPCC and MSPB
lack the precision in representing costs that are truly within the control of
the physician related to a condition or procedure that is most likely better
represented in those that are episode-based. • Many of the same beneficiaries
captured in the episode-based cost measures will also be included in one or
both of the broader population measures, resulting in “double counting” for
purposes of MIPS scoring and payment adjustments. CMS has removed measures
from other federal programs, such as the Medicare Shared Savings Program
(MSSP) and the Impatient Quality Reporting Program (IQR), due to the issue of
“double counting”, which we believe also applies to the cost category of MIPS.
• For all cost measures currently under consideration, information on the
validity and impact of the attribution methodology is not publicly available
nor has data on the reliability and validity of the measure itself been
released. (Submitted by: American Association of Neurological
Surgeons)
- NHPCO Comments: NHPCO appreciates this measure and recognizes that high
quality inpatient palliative care services could potentially have a positive
impact on this measure, as a secondary outcome of comprehensive assessment,
symptom and medication management, advance care planning and goals of care
conversations, patient and family education, and care coordination by an
interdisciplinary team. (Submitted by: National Hospice and Palliative Care
Organization)
- The AAFP does not support inclusion of the MSPB and TPCC measures in MIPS
for the following reasons: • These measures were developed for use at the TIN
level, and their validity at the solo/small practice level is questionable. We
reiterate that a measure may be considered reliable, but can still lack
validity. The National Quality Forum (NQF) did not endorse CMS’ total per
capita cost measure (CMS Measure #2165). NQF questioned the utility of the
measure to improve cost performance due to concerns with its attribution
method. NQF noted that primary care providers may have limited ability to
meaningfully influence the cost of specialists, inpatient care, and post-acute
care, but would ultimately be held responsible for these costs. The AAFP
encourages CMS to explore alternatives to these measures and offers the two
utilization measures of the Comprehensive Primary Care Plus (CPC+) program
(inpatient hospital utilization and emergency department utilization) as such
alternatives. • Many of the same beneficiaries captured in the episode-based
cost measures will also be included in one or both of the broader population
measures, resulting in double counting and potential negative unintended
consequences. • First, the costs attributed to a clinician for one
beneficiary will likely differ between an episode-based measure versus TPCC or
MSPB for the same episode. These differences are due to how each measure is
constructed and less likely to represent true differences in performance.
Also, the TPCC and MSPB lack the precision in representing costs that are
truly within the control of the physician related to a condition or procedure
that is most likely better represented in those that are episode-based.
• Second, the impact that the attribution of one beneficiary for the same
episode to multiple measures will have on the overall cost category in MIPS is
not known. Generally, we can assume that the results will be inconsistent
across clinicians. • CMS has removed measures from other federal programs due
to the issue of “double counting”, which we believe also applies to the cost
category of MIPS. For instance, physicians in MIPS APMs, such as those in the
Medicare Shared Savings Program (MSSP), are not measured on cost in MIPS to
avoid conflicts between the shared savings/losses calculations in MSSP and the
MIPS cost measures. Physicians may face similar conflicts when measured on
episode-based cost measures, as well as TPCC and MSPB. The AAFP requests that
the MAP recommend discontinuing use of the TPCC and MSPB measures in light of
the increasing number of episode-based cost measures being proposed and
finalized. (Submitted by: American Academy of Family Physicians)
- The AAMC has concerns with the use of the total per capita cost measure in
the MIPS program. Specifically, we are concerned that the risk adjustment
model for the MSPB measure does not adequately address patient complexity and
the impact of socio-demographic factors. Vulnerable populations generally
require higher resource utilization. Appropriate risk adjustment is essential
so that differences in patient characteristics that are beyond a health care
provider’s control do not have an unfair impact on a provider’s cost
performance score. CMS should look at alternative sources of data to obtain
information about risk adjustment. In addition, many of the same beneficiaries
captured in the episode-based cost measures will also be included in the MSPB
measure and therefore it is duplicative to assess performance on both these
measures. CMS recently changed the attribution methodology and conducted
field testing on the revised MSPB measure. At this time, information on the
validity of the revised attribution methodology is not available. Given these
concerns, this measure should receive no more than “conditional support.”
(Submitted by: The Association of American Medical Colleges)
- The American College of Gastroenterology (ACG) encourages the MAP to
carefully consider the continued inclusion of the Medicare Spending Per
Beneficiary (MSPB) in MIPS considering the growing number of episode-based
cost measures. With the introduction of the Screening/Surveillance Colonoscopy
cost measure and the development of the Lower GI hemorrhage cost measure,
there are now two specialty-specific cost measures for gastroenterology.
Specialty-specific measures are better suited to evaluate how
gastroenterologists perform on costs. However, their introduction creates the
potential for the same cost episodes to be captured by multiple cost measures.
For example, episodes captured by the Lower GI Hemorrhage cost measure are
also likely to be captured by the MSPB measure. ACG is concerned about this
overlap and the potential for lower GI bleeding episodes to be “double
counted.” The Lower GI Hemorrhage measure better captures the costs specific
to these episodes and those costs should count towards that measure alone. It
is also unclear at this time what the impact of one beneficiary may have on
multiple cost measures and the overall cost category in MIPS. Generally, we
can assume that the results will be inconsistent across physicians. Thus, ACG
requests that MAP recommend that CMS develop a methodology that allows
episodes or beneficiaries captured in an episode-based cost measure to be
excluded from the MSPB measure for the same attributed physician or remove the
MSPB from future MIPS program years. (Submitted by: American College of
Gastroneterology)
- The workgroup must confirm that risk adjustment methodologies are
sufficient to capture the true costs of patients with serious illness (i.e.,
explore ways to incorporate function); otherwise the measure could unfairly
penalize clinicians caring for this population. (Submitted by: Center to
Advance Palliative Care)
- Given the growing number of episode-based cost measures, and continued
work on their development, ASCO would encourage the MAP to consider whether
the TPCC and MSPB measures still serve a purpose, as many of the beneficiaries
captured in the episode-based measures will also be included in either or both
the MSPB and TPCC measures. With the measures as proposed, a beneficiary could
potentially be attributed to multiple providers within and across multiple
measures. First, this could magnify the impact on cost measures of any
individual beneficiary and second, could complicate any true differences in
cost and value. CMS has proposed a revised attribution methodology and
conducted field testing for both of these measures. While a version of the
proposed revised measure specifications for both measures is available on the
CMS public website (for example see
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-Feedback.html),
currently we are not aware of publicly available information on the validity
and reliability of the measure. It is also currently unknown what the impact
of these measures would be compared to earlier versions. Specifically, for the
TPCC measure, ASCO is supportive of attempts to remove certain specialty
physicians such as oncologists from the measure, as its intent is to capture
overall costs of care and encourage coordination of care by primary care
providers. While the methodology does exclude chemotherapy and radiation
therapy, there is the potential for providers such as physician assistants,
nurse practitioners, and other advanced practice professionals who work with
oncologists or radiation oncologists to have beneficiaries attributed to them,
which would seem to defeat the purpose of the revised measure. In addition, if
the exclusion relies on the provider billing for chemotherapy administration
or radiation therapy under the Medicare Physician Fee Schedule, it would fail
to consider clinicians who order therapy to be delivered in the hospital
outpatient department under the Hospital Outpatient Prospective Payment
System. ASCO would therefore recommend that the MAP also consider the
following exclusion criteria: oncologists delivering primary care services to
a patient with a principle diagnosis of cancer. More generally, the proposed
attribution method for the TPCC measure will likely cause confusion, as it
relies on a complex combination of “events” and services linked to the care of
all individual physicians in a TIN, rather than just one. Further confusion
will be caused by the timing of episodes: the episode itself consists of a
month, yet the attribution period continues for a full year; it is therefore
possible for a clinician to have more than one “episode” existing concurrently
for the same beneficiary. CMS has also proposed removal of the specialty
adjustment without explicitly stating that the new attribution methodology
compensates for that removal. The specialty adjustment was used as an attempt
to overcome an inherent flaw in the TPCC, i.e. the combination of prospective
risk adjustment with retrospective attribution. That methodology can lead to
scenarios where a patient in good health in the prior year (e.g. 10% risk
quartile for Hierarchical Condition Categories) presents with acute leukemia
in the current year, leading to huge differences in observed versus expected
costs. In contrast, the MSPB measure considers diagnoses up to and during the
trigger event. In sum, the existing specialty adjustment worked to mitigate
this inherent flaw in the TPCC by adjusting those specialties most likely to
suffer adverse selection under the measure, but ultimately failed to address
the root of the problem. (Submitted by: American Society of Clinical Oncology
(ASCO) )
(Program: Merit-Based Incentive Payment System;
MUC ID: MUC2018-149) |
- AOTA appreciates the effort of Acumen and CMS to make this measure more
meaningful. We believe the reports provide more actionable feedback than they
have in the past. We encourage Acumen to continue exploring ways to make this
information available to ECs who are involved in the downstream costs.
(Submitted by: American Occupational Therapy Association)
- ASGE encourages the Measures Application Partnership to carefully consider
the continued inclusion of the Total Per Capita Cost and Medicare Spending Per
Beneficiary in MIPS in light of the growing number of episode-based cost
measures as many of the same beneficiaries captured in the episode-based cost
measures will also be included in one or both of the broader population
measures. “Double counting” could lead to several potentially negative
unintended consequences. The attribution methodology for the Total Per Capita
Cost was recently revised and there remains unanswered questions and
significant concerns relative to these revisions. Notably, the specialty
adjustment was removed, which will present problems since it is not clear that
the revised attribution methodology addresses all the reasons why it was
needed previously. Information on the validity and impact of the attribution
methodology has not been made publicly available nor has data from the field
testing of the measure on the reliability and validity of the measure itself
been released. As such, ASGE suggests this measure meets the rationale of the
new category of “Do Not Support With Potential For Mitigation”. Specifically,
we do not believe that the measure is ready for use at this time as it likely
requires substantive changes. (Submitted by: American Society for
Gastrointestinal Endoscopy)
- CMS is proposing to replace the TPCC measure carried over from the VBM
with a revised measure developed and field tested by Acumen, LLP. The AMA
greatly appreciates the efforts of CMS and Acumen, LLP to improve this
measure. However, we are concerned that due to time constraints and a less
open development process, the revised TPCC measure needs more work and
testing. Additionally, we are troubled that comments on the proposed revisions
are due prior to any public release of information on the reliability,
validity and impact of the revised attribution methodology or the measure
itself. The proposed revision is extremely complex. We do not believe that it
is reasonable or realistic to expect physicians to pore through and understand
how the new measure would work. Tracking a patient and determining how care
might be improved will be nearly impossible because: • Attribution relies on a
combination of events and services/costs. The list of services that can
contribute to attribution is long and not easily described. • The same
month-long episode of care can be attributed to multiple groups or individual
physicians; • Attribution of the month-long episode will make all these
groups/physicians responsible for total Part A and B costs for an entire year;
• A new service in a following month could trigger a new episode making the
same or additional physicians responsible for a year of costs that overlaps
with the annual costs reflected in an earlier episode. • While certain
specialties would be exempt from this measure, the services they provide would
not be exempt. Therefore, a practice comprised of exempted specialists might
still be subject to the measure if it also uses a physician assistant or nurse
practitioner who provides an E/M visit. A goal of the revised TPCC was to
eliminate the possibility that physicians could be held responsible for care
that occurred even before they saw the patient. The AMA supports this goal but
notes that physicians could still be held responsible for costs that occurred
long after they saw the patient and potentially even after the patient had
moved to another city or state. We also have concerns about the equity of
the revised measure. Elimination of the specialty adjustment is premature. We
also question the decision to make exemptions at the specialty level rather
than the service level. As noted, this will make it hard to determine which
practices are likely to be subject to the TPCC measure. It also creates a
fairness issue by exempting certain specialties regarded as not providing
primary care but it then holds primary care physicians responsible for the
costs of these non-primary-care services that they do not provide and cannot
control. If this measure is adopted, we urge the MAP and CMS to develop an
exclusion based on service, rather than specialty. Finally, we wish to
reiterate our position that measures should only cover costs that physicians
can reasonably be considered to control. Measures that hold individual
physicians or practices responsible for the entire year of all Part A and B
costs will never meet that criteria. Given these significant concerns, we do
not believe that the measure is ready for use at this time and requires
substantive changes. As a result, the AMA recommends that the highest level of
MAP recommendation be “Do Not Support With Potential For Mitigation” for this
measure. Also, as noted in our earlier comments on the MSPB measure the AMA
encourages the Measures Application Partnership (MAP) to consider eliminating
the Total Per Capita Cost (TPCC) and Medicare Spending Per Beneficiary (MSPB)
in MIPS in light of the growing number of episode-based cost measures. As also
noted earlier, we believe the MSPB and TPCC measure lead to double-counting of
many beneficiaries and will produce inconsistent results that will lead to
confusion in their use and inequities in the payment adjustments that result.
(Submitted by: American Medical Association)
- NHPCO Comments: NHPCO appreciates this measure and recognizes that high
quality community-based palliative care services could potentially have a
positive impact on this measure, as a secondary outcome of comprehensive
assessment, symptom and medication management, advance care planning and goals
of care conversations, patient and family education, and care coordination by
an interdisciplinary team. (Submitted by: National Hospice and Palliative Care
Organization)
- The AAFP does not support inclusion of the MSPB and TPCC measures in MIPS
for the following reasons: • These measures were developed for use at the TIN
level, and their validity at the solo/small practice level is questionable. We
reiterate that a measure may be considered reliable, but can still lack
validity. The National Quality Forum (NQF) did not endorse CMS’ total per
capita cost measure (CMS Measure #2165). NQF questioned the utility of the
measure to improve cost performance due to concerns with its attribution
method. NQF noted that primary care providers may have limited ability to
meaningfully influence the cost of specialists, inpatient care, and post-acute
care, but would ultimately be held responsible for these costs. The AAFP
encourages CMS to explore alternatives to these measures and offers the two
utilization measures of the Comprehensive Primary Care Plus (CPC+) program
(inpatient hospital utilization and emergency department utilization) as such
alternatives. • Many of the same beneficiaries captured in the episode-based
cost measures will also be included in one or both of the broader population
measures, resulting in double counting and potential negative unintended
consequences. • First, the costs attributed to a clinician for one
beneficiary will likely differ between an episode-based measure versus TPCC or
MSPB for the same episode. These differences are due to how each measure is
constructed and less likely to represent true differences in performance.
Also, the TPCC and MSPB lack the precision in representing costs that are
truly within the control of the physician related to a condition or procedure
that is most likely better represented in those that are episode-based.
• Second, the impact that the attribution of one beneficiary for the same
episode to multiple measures will have on the overall cost category in MIPS is
not known. Generally, we can assume that the results will be inconsistent
across clinicians. • CMS has removed measures from other federal programs due
to the issue of “double counting”, which we believe also applies to the cost
category of MIPS. For instance, physicians in MIPS APMs, such as those in the
Medicare Shared Savings Program (MSSP), are not measured on cost in MIPS to
avoid conflicts between the shared savings/losses calculations in MSSP and the
MIPS cost measures. Physicians may face similar conflicts when measured on
episode-based cost measures, as well as TPCC and MSPB. The AAFP requests that
the MAP recommend discontinuing use of the TPCC and MSPB measures in light of
the increasing number of episode-based cost measures being proposed and
finalized. (Submitted by: American Academy of Family Physicians)
- The AAMC has concerns with the use of the total per capita cost measure in
the MIPS program. The total per capita cost measure is a global measure of all
Part A and Part B resources used during the performance period. The measure
itself would be inclusive of a number of the episode condition measures that
are also included in the MIPS program. It is duplicative to assess performance
in the cost performance category on both the per capita cost measures and
episode condition measures. The AAMC is concerned that the risk adjustment
model for the total per capita cost measure does not adequately address
patient complexity and the impact of socio-demographic factors. Vulnerable
populations generally require higher resource utilization. Appropriate risk
adjustment is essential so that differences in patient characteristics that
are beyond a health care provider’s control do not have an unfair impact on a
provider’s cost performance score. CMS should look at alternative sources of
data to obtain information about risk adjustment. CMS recently changed the
attribution methodology and conducted field testing on the revised total per
capita cost measure. At this time, information on the validity of the revised
attribution methodology is not available. Without this information, it is
challenging to assess the validity of this measure. Given these concerns, the
MAP should evaluate and question whether it is appropriate to include this
measure in the MIPS program in the future (Submitted by: Association of
American Medical Colleges)
- The AAN is concerned about how the patient attribution is done as some
patients use their specialist as a PCP and the impact this could have on
specialists. (Submitted by: American Academy of Neurology)
- The American Academy of Ophthalmology has reviewed the most recent
iteration of the re-evaluated Total Per Capita Cost measure (TPCC) and is
writing to share our ongoing concerns. In our evaluation of the TPCC field
test, we find no improvement and in fact see an exacerbation of the same
attribution problems that we saw and previously commented on with the
Value-based Modifier (VBM). Accountability for costs and quality that are
within the physician’s control is an important and achievable goal, but it
cannot come at the expense of providing medically necessary services, emergent
care or alternative treatment when initial options are failing. Measuring
clinicians on costs that are entirely out of their control has not and will
not create change or accountability. For example, ophthalmologists do not and
never will have control over the costs incurred by a skilled nursing facility
or a nephrologist. Despite this, we continue to see these costs attributed to
ophthalmologists under this latest version of TPCC. Worse, this re-evaluated
TPCC measure attributes all costs to nearly all treating clinicians. These
continued and exacerbated attribution issues, particularly in the absence of
more reliable risk adjustment than the current HCC, not only create an
arbitrary and capricious basis for the MIPS Cost score, but also may create an
incentive for physicians to refer more complex/sicker patients out of their
practice. In the current MIPS TPCC measure, an ophthalmologist is attributed
a patient if the patient does not receive services from a primary care
provider and bills the plurality of a patient’s evaluation and management
codes during the performance year. In this new, re-evaluated, TPCC field test
measure, patients are attributed to all clinicians that provide an E&M
service to that patient within three days before or after any non-E&M
service provided by any TIN to the same patient or if the patient sees another
clinician from that TIN within 90 days afterward. This means that, if a
patient is seen for one follow up exam or comes in for a blood test, a
clinician that saw the patient one or two times will be attributed that
patient’s cost for 12 months. This also means that a patient who clusters
their doctor visits into the span of a few days will cause every doctor they
see to be attributed that patient, even if they only see the patient one time.
The re-evaluated measure does have an exclusion for surgeons that meet
certain criteria, but this does not capture many subspecialists. For instance,
a glaucoma physician does provide management of a chronic condition, glaucoma,
but has no control over how other, entirely unrelated, chronic conditions,
such as systemic hypertension or diabetes mellitus, are managed for that
patient. The 12-month “risk window,” or attribution period, is also confusing
as it does not align with the performance period and can make it even more
difficult for clinicians to anticipate which patients will be attributed to
them. Attribution methods such as who submits claims at what time are
arbitrary and have no relevance to actual patient care. Finally, the
re-evaluated TPCC measure does not take into account clinician specialty or
subspecialty. We strongly urge CMS to compare clinicians to their peers using
taxonomy codes rather than the two-digit specialty codes that are currently
being used. In light of the substantial attribution changes that Acumen has
indicated that they made after the field test, we strongly believe that this
measure needs to be field tested again, with these changes, before it can be
supported. (Submitted by: American Academy of Ophthalmology)
- The American College of Gastroenterology (ACG) and its members found it
very difficult to understand this measure during the recent comment period in
light of the numerous questions on attribution, and how costs are assigned to
physicians or groups with the revised methodology. On review of the feedback
reports, our members were often unable to identify which event led to a
beneficiary attribution. In addition, there are many unanswered questions and
concerns related to these revisions including the complexity of the new
attribution method, which is not easily described in a simple sentence.
Given these significant concerns, we believe that this measure meets the
rationale provided for the new category of “Do Not Support With Potential For
Mitigation.” Specifically, we do not believe that the measure is ready for use
at this time and requires substantive changes. As a result, the ACG asks that
the highest level of MAP recommendation be “Do Not Support With Potential For
Mitigation” for this measure. ACG also encourages the MAP to carefully
consider the continued inclusion of the Total Per Capita Cost (TPCC) in MIPS
considering the growing number of episode-based cost measures. Many of the
same beneficiaries captured in the episode-based cost measures will also be
included in one or both of the broader population measures (TPCC or MSPB).
This “double counting” could lead to several potentially negative and
unintended consequences such as attributing costs to a physician for one
beneficiary that will likely differ between an episode-based measure versus
TPCC for the same episode. The results will likely reflect differences in how
each measure is constructed, versus actual performance. In addition, the
impact that the attribution of one beneficiary for the same episode to
multiple measures will have on the overall cost category in MIPS is unknown.
Generally, we can assume that the results will be inconsistent across
physicians. We ask that the MAP recommend that CMS evaluate whether all the
measures, and specifically the TPCC, should be included in future MIPS program
years, particularly as an increasing number of episode-based measures are
proposed and finalized. (Submitted by: American College of
Gastroenterology)
- The American Society of Cataract and Refractive Surgery (ASCRS) is a
member of the cost measure technical expert panel (TEP) convened by Acumen
that has been tasked with refining the TPCC measure. ASCRS appreciates the
efforts Acumen and CMS have made to ensure that this measure, which we do not
support, is not attributed to specialists, such as ophthalmologists. Following
our recommendation, the measure will now exclude ophthalmologists,
optometrists, and other specialties from attribution because they cannot
control the total patient health care costs. Previously, Acumen had developed
a proposed attribution methodology that would have excluded surgeons who bill
10- or 90-day global codes, which would have excluded most ophthalmologists,
but would have included most optometrists because it attributed the measure if
a physician billed two E/M services to the same patient within 90 days.
Following our feedback that this new attribution methodology would attribute
total costs to optometrists, Acumen and CMS modified their proposed
methodology. Instead, the measure will only be attributed to a group of HCFA
primary care and internal medicine sub-specialties that frequently manage
chronic patients with significant conditions in their areas of specialty along
with other medical comorbidities. We thank CMS and Acumen for this change
which ensures that eye care providers, who do not treat the whole patient, are
not held responsible for the total cost of care for a patient. Despite this
change, ASCRS still objects to the fundamental premise of the TPCC measure
that attempts to hold a single physician responsible for all a particular
patient’s healthcare costs and does not recommend the MAP approve the measure
for inclusion in MIPS. While we understand that CMS is attempting to encourage
efficient resource use and care coordination in the Medicare program, the TPCC
measure is not an effective tool to meet those goals. Because no physician,
regardless of specialty, can reasonably be expected to control all the costs
for a single patient, we continue to support development of episode-based cost
measures that seek to measure the costs of care within an individual
physician’s control. We do not support population measures, such as TPCC, that
hold physicians responsible for the cost of care they did not provide, and
recommend they be removed from the MIPS program. (Submitted by: American
Society of Cataract and Refractive Surgery)
- workgroup must confirm that risk adjustment methodologies are sufficient
to capture the true costs of patients with serious illness (i.e., explore ways
to incorporate function); otherwise the measure could unfairly penalize
clinicians caring for this population. (Submitted by: Center to Advance
Palliative Care)
- Given the growing number of episode-based cost measures, and continued
work on their development, ASCO would encourage the MAP to consider whether
the TPCC and MSPB measures still serve a purpose, as many of the beneficiaries
captured in the episode-based measures will also be included in either or both
the MSPB and TPCC measures. With the measures as proposed, a beneficiary could
potentially be attributed to multiple providers within and across multiple
measures. First, this could magnify the impact on cost measures of any
individual beneficiary and second, could complicate any true differences in
cost and value. CMS has proposed a revised attribution methodology and
conducted field testing for both of these measures. While a version of the
proposed revised measure specifications for both measures is available on the
CMS public website (for example see
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-Feedback.html),
currently we are not aware of publicly available information on the validity
and reliability of the measure. It is also currently unknown what the impact
of these measures would be compared to earlier versions. Specifically, for the
TPCC measure, ASCO is supportive of attempts to remove certain specialty
physicians such as oncologists from the measure, as its intent is to capture
overall costs of care and encourage coordination of care by primary care
providers. While the methodology does exclude chemotherapy and radiation
therapy, there is the potential for providers such as physician assistants,
nurse practitioners, and other advanced practice professionals who work with
oncologists or radiation oncologists to have beneficiaries attributed to them,
which would seem to defeat the purpose of the revised measure. In addition, if
the exclusion relies on the provider billing for chemotherapy administration
or radiation therapy under the Medicare Physician Fee Schedule, it would fail
to consider clinicians who order therapy to be delivered in the hospital
outpatient department under the Hospital Outpatient Prospective Payment
System. ASCO would therefore recommend that the MAP also consider the
following exclusion criteria: oncologists delivering primary care services to
a patient with a principle diagnosis of cancer. More generally, the proposed
attribution method for the TPCC measure will likely cause confusion, as it
relies on a complex combination of “events” and services linked to the care of
all individual physicians in a TIN, rather than just one. Further confusion
will be caused by the timing of episodes: the episode itself consists of a
month, yet the attribution period continues for a full year; it is therefore
possible for a clinician to have more than one “episode” existing concurrently
for the same beneficiary. CMS has also proposed removal of the specialty
adjustment without explicitly stating that the new attribution methodology
compensates for that removal. The specialty adjustment was used as an attempt
to overcome an inherent flaw in the TPCC, i.e. the combination of prospective
risk adjustment with retrospective attribution. That methodology can lead to
scenarios where a patient in good health in the prior year (e.g. 10% risk
quartile for Hierarchical Condition Categories) presents with acute leukemia
in the current year, leading to huge differences in observed versus expected
costs. In contrast, the MSPB measure considers diagnoses up to and during the
trigger event. In sum, the existing specialty adjustment worked to mitigate
this inherent flaw in the TPCC by adjusting those specialties most likely to
suffer adverse selection under the measure, but ultimately failed to address
the root of the problem. (Submitted by: American Society of Clinical Oncology
(ASCO) )
Appendix D: Instructions and Help
If you have any
problems navigating the discussion guide, please contact us at: mapclinician@qualityforum.org
Navigating the Discussion Guide
- How do I get back to the section I was just looking at?
The
easiest way is to use the back button on your browser. Other options are using
your backspace button (which works for many browsers on laptops), or using the
permanent links at the upper right hand corner of the discussion guide. But
the back button is the best choice in most situations.
- Can I print the discussion guide out?
You can, but we don't
recommend it. Besides using a lot of paper (probably a couple hundred pages at
least), you'll lose all the links that allow you to move around the document.
For instance, if you're scrolling through the agenda and want to see more
information about a particular measure, the electronic format will allow you
to click a link, read more, and then bo back. If you're on paper, there will
be a lot of flipping through paper.
- If I can't print this out, how can I read it on the plane?
Although the Discussion Guide opens in a web browser, it does not require an
internet connection if you have downloaded and saved the HTML file to your
hard drive.
- How do I know that I'm looking at the most recent version?
At
the top left corner of the discussion guide is a version number. At the
beginning of the in person meetings, the NQF staff will ask everyone to load
the most recent discussion guide version and will check that everyone has the
same version loaded.
- What electronic devices can I use to view the discussion
guide?
We tried to make this as universal as possible, so it should
work on your laptop (PC, Mac, Linux), your tablet (iPad, Android), or your
phone (iPhone, Android). It should also work on many types of browsers (IE,
Firefox, Chrome, Safari, Opera, Dolphin,....). Please let us know if you have
any problems, and we'll troubleshoot with you (and improve the discussion
guide for the next go around).
- Why do I see weird characters in some places?
Because we're
joining data from many different sources, we do find some technical
challenges. This generally shows up as strange characters--extra question
marks, accented characters, or otherwise unusual items. We've been able to fix
many of these problems, but not all. We ask that you bear with us as we
improve this over time!
Content
- What is included in the discussion guide?
There are four
sections within this document:
- Agenda, with summaries of each measure under consideration
- Full information about each measure, including its specifications,
preliminary analysis of how this measure can advance the program's goals,
and the rationale by HHS for being included in the list
- Summaries for each federal health program being considered
- Public comments that have been received to date (Note that the
discussion guide may be released before the public comment period is
finished, in which case there will just be a placeholder for where comments
will go)
- How are the meeting discussions organized?
The meeting
sessions are organized around consent calendars, which are groups of measures
being considered for a particular program or groups of measures for a
particular condition or topic area. For each measure being discussed, this
document will show you the description, the public comments (if any), the
summary of the preliminary analysis, and the result of the preliminary
analysis algorithm.
Appendix E: Instructions for Joining the Meeting
Remotely
Remote Participation Instructions:
Streaming Audio Online
- Direct your web browser to: http://nqf.commpartners.com/.
- Under “Enter a Meeting” type in the meeting number for Day 1: 512118
- In the “Display Name” field, type in your first and last names and click
“Enter Meeting.”
Teleconference
- Dial (877) 303-9138 for public participants to access the audio platform.