NQF

Version Number: 9.9
Meeting Date: December 12, 2018

Measure Applications Partnership
Clinician Workgroup Discussion Guide

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Agenda

Agenda Synopsis

Time Session
December 12, 2018  
8:00 AM   Breakfast
8:30 AM   Welcome, Introductions, Disclosures of Interest, and Review of Meeting Objectives
8:45 AM   CMS Opening Remarks & Meaningful Measures Update
9:05 AM   Overview of Pre-Rulemaking Approach
9:30 AM   Opportunity for Public Comment
9:40 AM   Break
9:55 AM   Medicare Shared Savings Program (SSP) Program Measures
12:00 PM   Lunch
1:00 PM   MAP Clinician Feedback on NQF's Rural Work
1:15 PM   CMS Overview of MIPS Cost and Quality Measures
1:30 PM   Merit-Based Incentive Payment System (MIPS) Program Measures
3:00 PM   Break
3:15 PM   Merit-Based Incentive Payment System (MIPS) Program Measures
4:35 PM   Opportunity for Public Comment
4:45 PM   Summary of Day and Next Steps
5:00 PM   Adjourn


Full Agenda

December 12, 2018  
8:00 AM   Breakfast
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8:30 AM   Welcome, Introductions, Disclosures of Interest, and Review of Meeting Objectives
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


8:45 AM   CMS Opening Remarks & Meaningful Measures Update
Michelle Schreiber, QMVIG Group Direct, CMS


9:05 AM   Overview of Pre-Rulemaking Approach
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


9:30 AM   Opportunity for Public Comment
9:40 AM   Break
9:55 AM   Medicare Shared Savings Program (SSP) Program Measures
  • Pre-Rulemaking Input
  • Public Commenting Opportunity
  • Feedback on Gaps in SSP
Programs under consideration:
  1. 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


  2. 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


  3. 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


  4. 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.


  5. 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.


12:00 PM   Lunch
1:00 PM   MAP Clinician Feedback on NQF's Rural Work
Dr. Ira Moscovice, MAP Rural Health Workgroup Co-Chair
Suzanne Theberge, Senior Project Manager, NQF

1:15 PM   CMS Overview of MIPS Cost and Quality Measures
Reena Duseja, MD, MS, Chief Medical Officer, QMVIG, CMS


1:30 PM   Merit-Based Incentive Payment System (MIPS) Program Measures
  • Pre-Rulemaking Input
  • Public Commenting Opportunity
Programs under consideration:
  1. 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.


  2. 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.


  3. 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.


  4. 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.


  5. 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.


  6. 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.


  7. 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.


  8. 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.


  9. 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.


  10. 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.


  11. 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.


  12. 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.


  13. 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.


3:00 PM   Break
3:15 PM   Merit-Based Incentive Payment System (MIPS) Program Measures
  • Pre-Rulemaking Input
  • Public Commenting Opportunity
  • Feedback on Gaps in MIPS
Programs under consideration:
  1. 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


  2. 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.


  3. 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


  4. 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.


  5. 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.


  6. 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.


  7. 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.


  8. 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.


4:35 PM   Opportunity for Public Comment
4:45 PM   Summary of Day and Next Steps
Bruce Bagley, Workgroup Co-Chair
Amy Moyer, Workgroup Co-Chair
Vaishnavi Kosuri, Project Analyst


5:00 PM   Adjourn

Appendix A: Measure Information

Measure Index

Merit-Based Incentive Payment System

Medicare Shared Savings Program


Full Measure Information

Time to surgery for elderly hip fracture patients (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-031)

Measure Specifications

Preliminary Analysis of Measure

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.


Discouraging the routine use of occupational and/or physical therapy after carpal tunnel release (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-032)

Measure Specifications

Preliminary Analysis of Measure

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.


International Prostate Symptom Score (IPSS) or American Urological Association-Symptom Index (AUA-SI) change 6-12 months after diagnosis of Benign Prostatic Hyperplasia (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-038)

Measure Specifications

Preliminary Analysis of Measure

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.


Multimodal Pain Management (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-047)

Measure Specifications

Preliminary Analysis of Measure

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.


Potential Opioid Overuse (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-048)

Measure Specifications

Preliminary Analysis of Measure

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.


Annual Wellness Assessment: Preventive Care (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-057)

Measure Specifications

Preliminary Analysis of Measure

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.


Adult Immunization Status (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-062)

Measure Specifications

Preliminary Analysis of Measure

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).


Functional Status Change for Patients with Neck Impairments (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-063)

Measure Specifications

Preliminary Analysis of Measure

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.


Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-115)

Measure Specifications This measure's specifications have been modified. Please consult this Document for more information.

Preliminary Analysis of Measure

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.


Femoral or Inguinal Hernia Repair (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-116)

Measure Specifications This measure's specifications have been modified. Please consult this Document for more information.

Preliminary Analysis of Measure

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.


Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-117)

Measure Specifications This measure's specifications have been modified. Please consult this Document for more information.

Preliminary Analysis of Measure

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.


Psychoses/Related Conditions (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-119)

Measure Specifications This measure's specifications have been modified. Please consult this Document for more information.

Preliminary Analysis of Measure

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.


Lumpectomy, Partial Mastectomy, Simple Mastectomy (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-120)

Measure Specifications This measure's specifications have been modified. Please consult this Document for more information.

Preliminary Analysis of Measure

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.


Acute Kidney Injury Requiring New Inpatient Dialysis (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-121)

Measure Specifications This measure's specifications have been modified. Please consult this Document for more information.

Preliminary Analysis of Measure

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.


Lower Gastrointestinal Hemorrhage (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-122)

Measure Specifications This measure's specifications have been modified. Please consult this Document for more information.

Preliminary Analysis of Measure

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.


Renal or Ureteral Stone Surgical Treatment (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-123)

Measure Specifications This measure's specifications have been modified. Please consult this Document for more information.

Preliminary Analysis of Measure

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.


Hemodialysis Access Creation (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-126)

Measure Specifications This measure's specifications have been modified. Please consult this Document for more information.

Preliminary Analysis of Measure

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.


Elective Primary Hip Arthroplasty (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-137)

Measure Specifications This measure's specifications have been modified. Please consult this Document for more information.

Preliminary Analysis of Measure

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.


Non-Emergent Coronary Artery Bypass Graft (CABG) (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-140)

Measure Specifications This measure's specifications have been modified. Please consult this Document for more information.

Preliminary Analysis of Measure

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.


Medicare Spending Per Beneficiary (MSPB) clinician measure (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-148)

Measure Specifications This measure's specifications have been modified. Please consult this Document for more information.

Preliminary Analysis of Measure

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.


Total Per Capita Cost (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-149)

Measure Specifications This measure's specifications have been modified. Please consult this Document for more information.

Preliminary Analysis of Measure

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.


Adult Immunization Status (Program: Medicare Shared Savings Program; MUC ID: MUC2018-062)

Measure Specifications

Preliminary Analysis of Measure

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).


Use of Opioids from Multiple Providers in Persons Without Cancer (Program: Medicare Shared Savings Program; MUC ID: MUC2018-077)

Measure Specifications

Preliminary Analysis of Measure

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




Use of Opioids at High Dosage in Persons Without Cancer (Program: Medicare Shared Savings Program; MUC ID: MUC2018-078)

Measure Specifications

Preliminary Analysis of Measure

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




Use of Opioids from Multiple Providers and at High Dosage in Persons Without Cancer (Program: Medicare Shared Savings Program; MUC ID: MUC2018-079)

Measure Specifications

Preliminary Analysis of Measure

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




Initial opioid prescription compliant with CDC recommendations (Program: Medicare Shared Savings Program; MUC ID: MUC2018-106)

Measure Specifications

Preliminary Analysis of Measure

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

Merit-Based Incentive Payment System 
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.

Medicare Shared Savings Program 
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.


Appendix C: Public Comments

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)

Discouraging the routine use of occupational and/or physical therapy after carpal tunnel release (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-032)
Multimodal Pain Management (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-047)
Potential Opioid Overuse (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-048)
Annual Wellness Assessment: Preventive Care (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-057)
Adult Immunization Status (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-062)
Adult Immunization Status (Program: Medicare Shared Savings Program; MUC ID: MUC2018-062)
Use of Opioids from Multiple Providers in Persons Without Cancer (Program: Medicare Shared Savings Program; MUC ID: MUC2018-077)
Use of Opioids at High Dosage in Persons Without Cancer (Program: Medicare Shared Savings Program; MUC ID: MUC2018-078)
Use of Opioids from Multiple Providers and at High Dosage in Persons Without Cancer (Program: Medicare Shared Savings Program; MUC ID: MUC2018-079)
Initial opioid prescription compliant with CDC recommendations (Program: Medicare Shared Savings Program; MUC ID: MUC2018-106)
Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-115)
Femoral or Inguinal Hernia Repair (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-116)
Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-117)
Psychoses/Related Conditions (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-119)
Lumpectomy, Partial Mastectomy, Simple Mastectomy (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-120)
Acute Kidney Injury Requiring New Inpatient Dialysis (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-121)
Lower Gastrointestinal Hemorrhage (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-122)
Renal or Ureteral Stone Surgical Treatment (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-123)
Hemodialysis Access Creation (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-126)
Elective Primary Hip Arthroplasty (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-137)
Non-Emergent Coronary Artery Bypass Graft (CABG) (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-140)
Medicare Spending Per Beneficiary (MSPB) clinician measure (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-148)
Total Per Capita Cost (Program: Merit-Based Incentive Payment System; MUC ID: MUC2018-149)

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

Content


Appendix E: Instructions for Joining the Meeting Remotely

Remote Participation Instructions:

Streaming Audio Online Teleconference