NQF

Version Number: 13.1
Meeting Date: December 24, 2015

Measure Applications Partnership
Example Discussion Guide
DEMO--NOT ACTUAL MAP MEETING MATERIALS

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This is an example discussion guide to demonstrate how the tool works. The measures are drawn from last year's MUC list to provide a sense of what information will be available. These are not actual meeting materials for measure review.

Agenda

Agenda Synopsis

9:00 am   Welcome, Introductions, and Review of Meeting Objectives
9:15 am   Approach to Preliminary Analysis
9:30 am   Consent Calendar: Clinician
10:30 am   Consent Calendar: Hospital
11:30 am   Lunch
12:00 pm   Consent Calendar: PAC/LTC
1:00 pm   Next Steps
1:15 pm   Adjourn


Full Agenda

9:00 am   Welcome, Introductions, and Review of Meeting Objectives


9:15 am   Approach to Preliminary Analysis

Reva Winkler, NQF

9:30 am   Consent Calendar: Clinician

Reva Winkler, NQF

  1. In-hospital mortality following elective open repair of AAAs (MUC ID: E1523)
    • Description: Percentage of asymptomatic patients undergoing open repair of abdominal aortic aneurysms (AAA) who die while in hospital. This measure is proposed for both hospitals and individual providers. (Measure Specifications; Summary of Endorsement Review)
    • Programs under consideration: Physician Quality Reporting System (PQRS)
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:High-level outcome measure that is fully developed and NQF-endorsed. The measure complements existing measure PQRS#258 "Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)"
      • Impact on quality of care for patients:Measurement and quality improvement activities to reduce mortality will save lives.
    • Preliminary analysis result: Support


  2. In-hospital mortality following elective open repair of AAAs (MUC ID: E1523)
    • Description: Percentage of asymptomatic patients undergoing open repair of abdominal aortic aneurysms (AAA) who die while in hospital. This measure is proposed for both hospitals and individual providers. (Measure Specifications; Summary of Endorsement Review)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Outcome measure that consumers and patients can use to compare providers.
      • Impact on quality of care for patients:Patient selection may foster quality improvement.
    • Preliminary analysis result: Public-facing clinician web page


  3. Evaluation or Interview for Risk of Opioid Misuse (MUC ID: X3774)
    • Description: All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during COT in the medical record. (Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Patient safety measure screening for opioid misuse in all patients regardless of diagnosis. The measure can be used by a wide range of clinicians. Priority for dual eligibles. CONDITION: submit to NQF for endorsement.
      • Impact on quality of care for patients:If interventions to avoid opioid misuse are implemented as a result of the screening evaluation, patients would not suffer from this growing problem.
    • Preliminary analysis result: Conditional support


  4. Evaluation or Interview for Risk of Opioid Misuse (MUC ID: X3774)
    • Description: All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during COT in the medical record. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Narrow-focused process measure. A composite of several measures addressing opioid misuse would be more meaningful for the public-facing clinician web page.
    • Preliminary analysis result: Spreadsheet


  5. Adult Kidney Disease: Referral to Hospice (MUC ID: X3732)
    • Description: Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care (Measure Specifications)
    • Programs under consideration: Physician Quality Reporting System (PQRS)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Process measure addresses patient-centered care, end of life care and is a priority for dual eligibles.
      • Impact on quality of care for patients:Hospice care has been shown to improve quality of life at the end of life, offers personalized care with dignity, respects patient's wishes and avoids costs of futile and unnecessary care.
    • Preliminary analysis result: Encourage continued development


  6. Adult Kidney Disease: Referral to Hospice (MUC ID: X3732)
    • Description: Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Patients and consumers are interested in the quality of patient-centered care.
      • Impact on quality of care for patients:Patient selection may foster quality improvement.
    • Preliminary analysis result: Public-facing clinician web page


10:30 am   Consent Calendar: Hospital

Erin O'Rourke, NQF

  1. External Beam Radiotherapy for Bone Metastases (MUC ID: E1822)
    • Description: This measure reports the percentage of patients, regardless of age, with a diagnosis of painful bone metastases and no history of previous radiation who receive external beam radiation therapy (EBRT) with an acceptable fractionation scheme as defined by the guideline. (Measure Specifications; Summary of Endorsement Review)
    • Programs under consideration: Hospital Outpatient Quality Reporting Program
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure would address a gap in cancer care in the OQR measure set.
      • Impact on quality of care for patients:External beam radiation can help provide patients with pain relief.  This measure has a demonstrated performance gap and would would begin to expand cancer care measurement to settings beyond the PPS-exempt cancer hospitals.
    • Preliminary analysis result: Support


  2. Hospital 30-day, all-cause, unplanned risk-standardized days in acute care following pneumonia hospitalization (MUC ID: X3727)
    • Description: This measure assesses days spent in acute care after discharge from an acute care setting for a pneumonia hospitalization to provide a patient-centered assessment of the post-discharge period. Acute care utilization after discharge (return to the emergency department, observation stay and readmission), for any reason, is disruptive to patients and caregivers, costly to the healthcare system, and puts patients at additional risk of hospital-acquired infections and complications. Although some hospital returns are unavoidable, they may also result from poor quality of care or inadequate transitional care. When appropriate care transition processes are in place (for example, patient is discharged to a suitable location, communication occurs between clinicians, medications are correctly reconciled, timely follow-up is arranged), fewer patients return to an acute care setting, either for an emergency department (ED) visit, observation stay, or hospital readmission during the 30 days post-discharge. Therefore, this measure is intended to capture the quality of care transitions provided to patients hospitalized with pneumonia by collectively measuring a set of adverse outcomes that can occur post-discharge: ED visits, unplanned observation stays, and unplanned readmissions at any time during the 30 days post-discharge. In order to aggregate all three events, we measure each in terms of days of outcomes. Use of a day-count outcome generates a clinically reasonable and natural weighting scheme such that events that take more days (i.e. days rehospitalized) naturally carry more weight than events taking fewer days (i.e. ED visits). That is, the weight of each component of the composite is determined by its actual impact and burden on patients, not by an arbitrary weighting scheme. We then risk adjust the day count to account for age, gender and comorbidity. The final reported outcome is risk-standardized by subtracting the expected number of acute care days from the predicted number. The risk-standardized days of acute care are multiplied by 100 to represent risk-standardized days of events per 100 admissions. (Measure Specifications)
    • Programs under consideration: Hospital Inpatient Quality Reporting
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure would provide a more complete picture of acute care usage after discharge. Rising use of observation stays and ED visits has been noted as a growing quality problem.
      • Impact on quality of care for patients:This measure would address any return by a patient to an acute care setting including observation stays and emergency department visits. ED visits are a substantial portion of post-discharge acute care use. Studies have shown that 9.5% of patients return to the ED within 30 days of discharge and around 12% are discharged from the ED without being readmitted and would therefore not be included in the current readmission measure in IQR. Additionally, the use of observation stays has risen dramatically-from 2001-2008 there was a three-fold increase in the observation status. The Office of the Inspector General found that Medicare beneficiaries have 1.5 million observation stays annually.
    • Preliminary analysis result: Conditional support


  3. Ambulatory surgery patients with appropriate method of hair removal (MUC ID: E0515)
    • Description: Percentage of ASC admissions with appropriate surgical site hair removal. (Measure Specifications; Summary of Endorsement Review)
    • Programs under consideration: Ambulatory Surgical Center Quality Reporting Program
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is not anticipated to have an impact on the program measure set. This measure is topped out with limited performance variation among providers. The measure has been removed from IQR and is not in, nor planned to be, in another program.
      • Impact on quality of care for patients:This measure is not anticipated to have an impact on the quality of care. Performance on this measure is topped out. Rates collected for 192 ASCs across the US demonstrated a mean rate of 96% and a median rate of 100%
    • Preliminary analysis result: Do not support


  4. Timely Evaluation of High-Risk Individuals in the Emergency Department (MUC ID: X1234)
    • Description: Median time from emergency department (ED) arrival to provider evaluation for individuals triaged at the two highest levels based on a five-level triage system (e.g., triaged as “immediate” or “emergent”). (Measure Specifications)
    • Programs under consideration: Hospital Inpatient Quality Reporting
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:MAP has previously stressed the importance of ED throughput measures as important markers of efficiency and safety which can dramatically impact patient experience.  This measure in particular would address severely ill patients being admitted to the ED.
      • Impact on quality of care for patients:This is a high impact measure that reviews the time it took for a severely ill patient with the highest-level triage score to be evaluated by a provider. Implementing this measure could help improve an important aspect of patient safety and experience.
    • Preliminary analysis result: Encourage continued development


11:30 am   Lunch


12:00 pm   Consent Calendar: PAC/LTC

Kathryn Streeter, NQF

  1. Skilled Nursing Facility All-Cause 30 Day Post Discharge Readmission Measure (MUC ID: S2510)
    • Description: This measure estimates the risk-standardized rate of all-cause, unplanned, hospital readmissions for patients who have been admitted to a Skilled Nursing Facility (SNF) (Medicare fee-for-service [FFS] beneficiaries) within 30 days of discharge from their prior proximal hospitalization. The prior proximal hospitalization is defined as an admission to an IPPS, CAH, or a psychiatric hospital. The measure is based on data for 12 months of SNF admissions. A risk-adjusted readmission rate for each facility is calculated as follows: Step 1: Calculate the standardized risk ratio of the predicted number of readmissions at the facility divided by the expected number of readmissions for the same patients if treated at the average facility. The magnitude of the risk-standardized ratio is the indicator of a facility’s effects on readmission rates. Step 2: The standardized risk ratio is then multiplied by the mean rate of readmission in the population (i.e., all Medicare FFS patients included in the measure) to generate the facility-level standardized readmission rate. For this measure, readmissions that are usually for planned procedures are excluded. Please refer to the Appendix, Tables 1 - 5 for a list of planned procedures. The measure specifications are designed to harmonize with CMS’s hospital-wide readmission (HWR) measure to the greatest extent possible. The HWR (NQF #1789) estimates the hospital-level, risk-standardize rate of unplanned, all-cause readmissions within 30 days of a hospital discharge and uses the same 30-day risk window as the SNFRM. (Measure Specifications)
    • Programs under consideration: Skilled Nursing Facility Value-Based Purchasing Program
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure addresses a PAC/LTC Core Concept and is a required measure for the SNF value-based purchasing program under the Protecting Access to Medicare Act of 2014 (PAMA). MAP had reviewed and supported the direction of the measure concept in the 2013 pre-rulemaking. This measure is currently under review for endorsement and was recently finalized for use in MSSP in the 2015 PFS rule.
      • Impact on quality of care for patients:There is evidence available related to the structure-process-outcome relationship specifically for reducing hospital readmissions among SNF patients. The evidence suggests there are factors that vary at the organizational level, which impact patient care and could be altered to improve rates of hospital readmission. Once hospital readmission rates are measured, the onus will be on the providers to identify which factors are most likely to impact improvement and then design, implement and monitor processes to address these factors.
    • Preliminary analysis result: Support


  2. IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (MUC ID: S2633)
    • Description: This measure estimates the average risk-adjusted mean change in self-care function between admission and discharge for patients discharged from IRFs. (Measure Specifications)
    • Programs under consideration: Inpatient Rehabilitation Facility Quality Reporting Program
    • Public comments received: 8
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:The measure is conditionally supported pending NQF endorsement. Improvement in functional status is the primary goal of rehabilitation and also a PAC/LTC core concept not currently addressed in the program. It is also a required measurement domain under the IMPACT Act. Functional status is also a priority area for measurement for the Duals population. This measure is fully specified and tested for use in IRFs and has been submitted for NQF endorsement under the person and family centered care project phase 2.
      • Impact on quality of care for patients:The primary goal in rehabilitation is function improvement. The change in function scores represent the effectiveness of the rehabilitation care provided to patients. This measure will inform IRF providers about opportunities to improve care in the area of function and strengthen incentives for quality improvement related to patient function.
    • Preliminary analysis result: Conditional support


  3. Compliance with Ventilator Process Elements during LTCH stay (MUC ID: X3705)
    • Description: This measure "Compliance with Ventilator Process Elements during LTCH stay" is a paired quality measure (QM#1 and QM#2); it assesses facility-level compliance with Ventilator Process Elements for eligible patients in the LTCH setting. Quality Measure #1: Compliance with Tracheostomy Collar Trial (TCT) or Spontaneous Breathing Trial (SBT) by the end of the first calendar day following admission to the LTCH. Quality Measure #2: Compliance with TCT or SBT during LTCH stay - day 2 through discharge date/ date when patient is fully weaned. Definitions: i. Invasive mechanical ventilation: The use of a device to assist or control pulmonary ventilation, either intermittently or continuously through a tracheostomy or by endotracheal intubation. ii. Tracheostomy Collar Trial: Trial of unassisted breathing via a tracheostomy collar (mask) with aerosol (mist), administered to patients with tracheostomy tubes. iii. Spontaneous Breathing Trial: Trial of unassisted breathing for at least X time period and full ventilator support at night, administered to patients with endotracheal tubes. (Measure Specifications)
    • Programs under consideration: Long-Term Care Hospital Quality Reporting Program
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:The measure addresses an important patient safety priority for LTCHs. It is estimated that 25% of ventilated patients in LTCHs acquire ventilator-associated pneumonia. There is evidence for interventions developed to decrease incidence of ventilator-associated pneumonia and improve ventilator care. VAP and VAE are associated with substantial morbidity, mortality, and excess healthcare costs. Further development is encouraged.
      • Impact on quality of care for patients:It is estimated that 25% of ventilated patients in LTCHs acquire ventilator-associated pneumonia.  There is evidence for interventions developed to decrease incidence of ventilator-associated pneumonia and improve ventilator care. VAP and VAE are associated with substantial morbidity, mortality, and excess healthcare costs.
    • Preliminary analysis result: Encourage continued development


1:00 pm   Next Steps


1:15 pm   Adjourn



Appendix A: Measure Information

Measure Index

Ambulatory Surgical Center Quality Reporting Program

Hospital Inpatient Quality Reporting

Inpatient Rehabilitation Facility Quality Reporting Program

Long-Term Care Hospital Quality Reporting Program

Hospital Outpatient Quality Reporting Program

Physician Compare

Physician Quality Reporting System (PQRS)

Skilled Nursing Facility Value-Based Purchasing Program


Full Measure Information

Ambulatory surgery patients with appropriate method of hair removal (Program: Ambulatory Surgical Center Quality Reporting Program; MUC ID: E0515)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The literature regarding preoperative hair removal has been systematically reviewed twice, once by Kjonniksen et al in 2002 and again by Tanner et al in 2007. Three randomized controlled trials (Alexander et al 1983, Balthazar et al 1983, Ko et al 1992) compared the rates of infection at the surgical site when hair removal at the site was performed with clippers or with razors. A statistically significant difference in infection rates in the pooled results (Tanner et al 2007) was seen, with 2.8% of the patients who were shaved developing a surgical site infection compared with 1.4% rate of surgical site infection in the patients who were clipped. Additional randomized controlled trials (Court-Brown 1981, Powis et al 1976, Seropian 1971, Thur de Koos 1983) have demonstrated that patients were more likely to develop a surgical site infection when shaved as compared to having hair removal with a depilatory. Observational studies have suggested that no hair removal is less likely to result in surgical site infection, but this has not been confirmed in randomized controlled trials. The HICPAC/CDC Guideline for Prevention of Surgical Site Infection (Mangram at al 1999), the Association of Operating Room Nurses Recommended Practices for Preoperative Patient Skin Antisepsis (AORN 2002) and the SHEA/IDSA Strategies to Prevent Surgical Site Infections in Acute Care Hospitals (Anderson et al 2008) are consistent with the intent of this measure. Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ. The influence of hair-removal methods on wound infections. Arch Surg. 1983 Mar;118(3):347-52. Anderson DJ, Kaye KS, Classen D, Arias KM, Podgorny K, Burstin H, Calfee DP, Coffin SE, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Klompas M, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008 Oct;29 Suppl 1:S51-61. Association of Operating Room Nurses. Recommended practices for skin preparation of patients. AORN J. 2002 Jan;75(1):184-7. Balthazar ER, Colt JD, Nichols RL. Preoperative hair removal: a random prospective study of shaving versus clipping. South Med J. 1982 Jul;75(7):799-801. Court-Brown CM. Preoperative skin depilation and its effect on postoperative wound infections. J R Coll Surg Edinb. 1981 Jul;26(4):238-41. Kjonniksen I, Andersen BM, Sondenaa VG, Segadal L. Preoperative hair removal--a systematic literature review. AORN J. 2002 May;75(5):928-38, 940. Ko W, Lazenby WD, Zelano JA, Isom OW, Krieger KH. Effects of shaving methods and intraoperative irrigation on suppurative mediastinitis after bypass operations. Ann Thorac Surg. 1992 Feb;53(2):301-5. Powis SJ, Waterworth TA, Arkell DG. Preoperative skin preparation: clinical evaluation of depilatory cream. Br Med J. 1976 Nov 13;2(6045):1166-8. Seropian R, Reynolds BM. Wound infections after preoperative depilatory versus razor preparation. Am J Surg. 1971 Mar;121(3):251-4. Tanner J, Moncaster K, Woodings D. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2006 Jul 19;3:CD004122. Thur de Koos P, McComas B. Shaving versus skin depilatory cream for preoperative skin preparation. A prospective study of wound infection rates. Am J Surg. 1983 Mar;145(3):377-8.

Summary of Endorsement Review




Hospital 30-day, all-cause, unplanned risk-standardized days in acute care following pneumonia hospitalization (Program: Hospital Inpatient Quality Reporting; MUC ID: X3727)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The goal of this measure is to improve patient outcomes by providing patients, physicians, and hospitals with information about hospital-level, risk-standardized outcomes following hospitalization for pneumonia. Measurement of patient outcomes allows for a broad view of quality of care that cannot be captured entirely by individual process-of-care measures. Safely transitioning patients from hospital to home requires a complex series of tasks which would be cumbersome to capture individually as process measures: timely and effective communication between providers, prevention of and response to complications, patient education about post-discharge care and self-management, and timely follow-up, and more. Inadequate transitional care contributes to a variety of adverse outcomes post-discharge, including readmission, need for observation, and emergency department evaluation. There already exist measures for readmission, but there are no current measures for ED utilization and observation stay. It is thus difficult for providers and consumers to gain a complete picture of post-discharge outcomes. Moreover, separately reporting each outcome encourages “gaming,” such as recategorizing readmission stays as observation stays to avoid a readmission outcome. By constructing a composite of outcomes that are important to patients, we can produce a more complete picture of post-discharge outcomes that better informs consumers about care quality and incentivizes global improvement in outcomes. Pneumonia results in approximately 1.2 million hospital admissions each year and accounts for more than $10 billion annually in hospital expenditures. Among patients over 65 years of age, it is the second leading cause of hospitalization, and is the leading infectious cause of death (Lindenauer et al., 2011). Approximately 20% of pneumonia patients were rehospitalized within thirty days, representing the second-highest proportion of all rehospitalizations at 6.3% (Jencks et al., 2009). Acute care utilization after discharge (return to the emergency department, observation stay and readmission), for any reason, is disruptive to patients and caregivers, costly to the healthcare system, and puts patients at additional risk of hospital-acquired infections and complications. Although some readmissions are unavoidable, they may also result from poor quality of care or inadequate transitional care. Transitional care includes effective discharge planning, transfer of information at the time of discharge, patient assessment and education, and coordination of care and monitoring in the post-discharge period. Numerous studies have found an association between quality of inpatient or transitional care and early (typically 30-day) readmission rates for a wide range of conditions including pneumonia (Frankl et al., 1991; Corrigan et al., 1992; Oddone et al., 1996; Ashton et al., 1997; Benbassat et al., 2000; Courtney et al., 2003; Halfon et al., 2006; Dean et al., 2006). Several studies also have reported on the relationship between inpatient admissions and other types of hospital care including ED visits and observation stays. ED visits represent a significant proportion of post-discharge acute care utilization. Two recent studies conducted in patients of all ages have shown that 9.5% of patients return to the ED within 30 days of hospital discharge and that about 12% of these patients are discharged from the ED and are not captured by current CMS readmissions measures (Rising et al., 2013; Vashi et al., 2013). Additionally, over the past decade, the use of observation stays has rapidly increased. Specifically, between 2001 and 2008, the use of observation services increased nearly three-fold (Venkatesh et al., 2011) and significant variation has been demonstrated in the use of observation services for conditions such as chest pain (Schuur et al., 2011). These rising rates of observation stays among Medicare beneficiaries have gained the attention of patients


Timely Evaluation of High-Risk Individuals in the Emergency Department (Program: Hospital Inpatient Quality Reporting; MUC ID: X1234)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
This is a new eCQM that assesses a different aspect of ED provider care, and specifically assesses provider timeliness to evaluation. The anticipated effect of implementing this measure would be to reduce the time for high risk patients to be seen by a physician in the emergency department and thereby reduce adverse events (i.e., morbidity and mortality). High-risk individuals are identified by assignment of the highest or most urgent score from a valid triage system.


IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: S2633)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Given that the primary goal of rehabilitation is improvement in functional status, IRF clinicians have traditionally assessed and documented patients’ functional status at admission and at discharge to evaluate the effectiveness of the rehabilitation care provided to individual patients, as well as the effectiveness of the rehabilitation unit or hospital overall. Studies have shown differences in IRF patients’ functional outcomes by geographic region, insurance type, and race/ethnicity after adjusting for key patient demographic characteristics and admission clinical status, which supports the need to monitor IRF patients’ functional outcomes.


Compliance with Ventilator Process Elements during LTCH stay (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: X3705)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
1. There is evidence for interventions developed to decrease incidence of ventilator-associated pneumonia and improve ventilator care 2. VAP and VAE is associated with substantial morbidity, mortality, and excess healthcare costs. 3. Patients who develop VAP incur an extra $10K (2005) in hospital costs (Sadfar 2005). 4. Based on an analysis of CY 2004 MedPAR data for Medicare beneficiaries, 25% of ventilated patients in LTCHs acquired VAP (Buczko 2009).


External Beam Radiotherapy for Bone Metastases (Program: Hospital Outpatient Quality Reporting Program; MUC ID: E1822)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The measure is developed from the recommendations by the clinical-practice guideline. This measure is intended to close the gap in the demonstrated treatment variation and ensure the use of an appropriate fractionation schedule. The measure also takes into account the effective schedule for relieving pain from bone metastases, patient preferences and the time and cost effectiveness. Population: The measure is applicable to all patients, regardless of age with a diagnosis of painful bone metastases who are prescribed EBRT unless there is a documented exclusion as specified. 1. Jeremic B, Shibamoto Y, Acimovic L, et al. A randomized trial of three single-dose radiation therapy regimens in the treatment of metastatic bone pain. Int J Radiat Oncol Biol Phys 1998;42:161–167. 2. Bone Pain Trial Working Party. 8 Gy single fraction radiotherapy for the treatment of metastatic skeletal pain: Randomized comparison with a multifraction schedule over 12 months of patient follow-up. Radiother Oncol 1999;52:111–121. 3. Roos D, Turner S, O’Brien P, et al. Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic pain due to bone metastases (Trans-Tasman Radiation Oncology Group, TROG 96.05). Radiother Oncol 2005;75: 54–63. 4. Hartsell W, Konski A, Scott C, et al. Randomized trial of short versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst 2005;97:798–804.

Summary of Endorsement Review




Adult Kidney Disease: Referral to Hospice (Program: Physician Compare; MUC ID: X3732)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Palliative care services are appropriate for people who chose to undergo or remain on dialysis and for those who choose not to start or to discontinue dialysis. With the patient’s consent, a multi‐professional team with expertise in renal palliative care, including nephrology professionals, family or community‐based professionals, and specialist hospice or palliative care providers, should be involved in managing the physical, psychological, social, and spiritual aspects of treatment for these patients, including end‐of‐life care. Physical and psychological symptoms should be routinely and regularly assessed and actively managed. The professionals providing treatment should be trained in assessing and managing symptoms and in advanced communication skills. Patients should be offered the option of dying where they prefer, including at home with hospice care, provided there is sufficient and appropriate support to enable this option.


Evaluation or Interview for Risk of Opioid Misuse (Program: Physician Compare; MUC ID: X3774)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Before initiating COT, clinicians should conduct a history, physical examination and appropriate testing, including an assessment of risk of substance abuse, misuse, or addiction (strong recommendation, low‐quality evidence). Clinicians may consider a trial of COT as an option if chronic noncancer pain (CNCP) is moderate or severe, pain is having an adverse impact on function or quality of life, and potential therapeutic benefits outweigh or are likely to outweigh potential harms (strong recommendation, low‐quality evidence). A benefit‐to‐harm evaluation including a history, physical examination, and appropriate diagnostic testing, should be performed and documented before and on an ongoing basis during COT (strong recommendation, low‐quality evidence).


In-hospital mortality following elective open repair of AAAs (Program: Physician Compare; MUC ID: E1523)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Elective repair of a small or moderate sized AAA is a prophylactic procedure and the mortality/morbidity of the procedure must be contrasted with the risk of rupture over time. Surgeons should select patients for intervention who have a reasonable life expectancy and who do not have a high surgical risk.

Summary of Endorsement Review




Adult Kidney Disease: Referral to Hospice (Program: Physician Quality Reporting System (PQRS); MUC ID: X3732)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Palliative care services are appropriate for people who chose to undergo or remain on dialysis and for those who choose not to start or to discontinue dialysis. With the patient’s consent, a multi‐professional team with expertise in renal palliative care, including nephrology professionals, family or community‐based professionals, and specialist hospice or palliative care providers, should be involved in managing the physical, psychological, social, and spiritual aspects of treatment for these patients, including end‐of‐life care. Physical and psychological symptoms should be routinely and regularly assessed and actively managed. The professionals providing treatment should be trained in assessing and managing symptoms and in advanced communication skills. Patients should be offered the option of dying where they prefer, including at home with hospice care, provided there is sufficient and appropriate support to enable this option.


Evaluation or Interview for Risk of Opioid Misuse (Program: Physician Quality Reporting System (PQRS); MUC ID: X3774)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Before initiating COT, clinicians should conduct a history, physical examination and appropriate testing, including an assessment of risk of substance abuse, misuse, or addiction (strong recommendation, low‐quality evidence). Clinicians may consider a trial of COT as an option if chronic noncancer pain (CNCP) is moderate or severe, pain is having an adverse impact on function or quality of life, and potential therapeutic benefits outweigh or are likely to outweigh potential harms (strong recommendation, low‐quality evidence). A benefit‐to‐harm evaluation including a history, physical examination, and appropriate diagnostic testing, should be performed and documented before and on an ongoing basis during COT (strong recommendation, low‐quality evidence).


In-hospital mortality following elective open repair of AAAs (Program: Physician Quality Reporting System (PQRS); MUC ID: E1523)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Elective repair of a small or moderate sized AAA is a prophylactic procedure and the mortality/morbidity of the procedure must be contrasted with the risk of rupture over time. Surgeons should select patients for intervention who have a reasonable life expectancy and who do not have a high surgical risk.

Summary of Endorsement Review




Skilled Nursing Facility All-Cause 30 Day Post Discharge Readmission Measure (Program: Skilled Nursing Facility Value-Based Purchasing Program; MUC ID: S2510)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The Skilled Nursing Facility All-Cause 30 Day Post Discharge Readmission Measure is a SNF VBP measure.



Appendix B: Program Summaries

The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which accompanied the 2015 MUC list, and the CMS Measure Inventory,which is regularly updated to include the most recent measures in different federal programs.

Program Index


Full Program Summaries

Physician Quality Reporting System (PQRS)  
The material for this program was drawn from the program summary developed for last year's MAP pre-rulemaking cycle. This program will be replaced by the Merit-Based Incentive Payment System (MIPS) per recent legislation. 

Program History and Structure: PQRS is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EPs).

Current Program Measure Information: In 2012-2014, EPs could receive an incentive payment equal to a percentage (2% in 2010, gradually decreasing to 0.5% in 2014) of the EP’s estimated total allowed charges for covered Medicare Part B services under the Medicare Physician Fee Schedule. Beginning in 2015, EPs and group practices that do not satisfactorily report data on quality measures will receive a reduction (1.5% in 2015 and 2% in subsequent years) in payment.

High Priority Domains for Future Measure Consideration: The goal of the PQRS program is to encourage widespread participation by EPs to report quality information. In 2012, only 36% of EPs satisfactorily submitted quality information to PQRS.

Measure Requirements:

Current Measures:
The proposed measures for this program include:



Physician Compare 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which accompanied the 2015 MUC list, and the CMS Measure Inventory,which is regularly updated to include the most recent measures in different federal programs.

Program History and Structure: Section 10331 of the 2010 Patient Protection & Affordable Care Act (ACA) requires CMS to establish the Physician Compare website to publicly report physician performance data. The goal of the Physician Compare website is to provide reliable information for consumers to encourage informed health care decisions; and to create explicit incentives for physicians to maximize performance. To meet the statutory mandate, CMS repurposed the Medicare.gov Healthcare Provider Directory into Physician Compare. On December 30, 2010, CMS officially launched the Physician Compare website using the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) as its underlying data source. Based on stakeholder feedback and understanding the Affordable Care Act (ACA) requirements for the site, CMS redesigned Physician Compare in June 2013. Since that time, CMS has been working continually to enhance the site and its functionality, improve the information available, and include more and increasingly useful information about the physicians and other health care professionals who are on the website.

The 2012 Physician Fee Schedule final rule indicated that the first measures available for public reporting on Physician Compare would be a sub-set of the 2012 Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO) measures collected via the Web Interface. CMS publicly reported this first set of measure data in February 2014 for the 66 group practices and 141 ACOs. In December 2014, the next phase of public reporting was accomplished with the posting of a sub-set of the 2013 PQRS GPRO Diabetes Mellitus (DM) and Coronary Artery Disease (CAD) measures collected via the Web Interface for 139 group practices and 214 Shared Savings Program and 23 Pioneer ACOS. In addition, CAHPS for ACO summary survey measures were added to Physician Compare. The following quality measures were publicly reported in December 2014:

2013 PQRS GPRO and ACO measures


2013 CAHPS for ACOs measures

For 2014 data, all PQRS GPRO measures collected via the Web Interface, as well as a sub-set of measures reported via registry and EHR are available for public reporting on Physician Compare. All measures reported by Shared Savings Program and Pioneer ACOs are also available for public reporting. CMS will continue to publicly report 2014 CAHPS for ACOs and will publish the first set of CAHPS for PQRS measures for groups of 100 or more EPs who participate in PQRS GPRO and for group practices of 25-99 EPs reporting via a certified CAHPS vendor. In addition, twenty individual measures reported by EPs under the 2014 PQRS via claims, EHR, or registry are available for public reporting. All 2014 data are targeted for publication in late 2015.

For 2015 data, at the group practice level, all 2015 PQRS GPRO measures reported via the Web Interface, registry, or EHR are available for public reporting. In addition, the 12 summary survey 2015 CAHPS for PQRS and CAHPS for ACO measures are available for public reporting for group practices of 2 or more EPs and ACOs reporting via a CMS-approved certified survey vendor. At the individual EP level, all 2015 PQRS measures reported via registry, EHR, or claims are available for public reporting. In addition, individual EP-level 2015 Qualified Clinical Data Registry (QCDR) measures, which include PQRS and non-PQRS data, will be available for public reporting on Physician Compare in late 2016.

Current Program Measure Information: Table 1 below provides the number of quality measures under each domain of measurement from the National Quality Strategy (NQS) priorities that were finalized in the 2012, 2013, 2014 and 2015 PFS final rules as available for public reporting. Only those measures that are comparable, valid, reliable, and suitable for public reporting will be publicly reported on Physician Compare (see “Measure Requirements” below).

Table 1: Quality Measures Finalized for Public Reporting by the 2012, 2013, 2014, & 2015 PFS Final Rules

NQS Priority Domains
Number of Measures Finalized for Potential Reporting on Physician Compare
2012 PFS Final Rule
2013 PFS Final Rule
2014 PFS Final Rule
2015 PFS Final Rule
Groups
ACOs
Groups
ACOs
EPs
Groups
ACOs
EPs
Groups
ACOs
Effective Clinical Care
27
20
20
20
13
14
14
110
138
8
Patient Safety
1
1
1
1
2
2
2
26
34
2
Communication/Care Coordination
1
1
1
1
0
0

29
37
0
Community/Population Health
0
0
0
0
5
5
5
14
15
5
Efficiency and Cost Reduction
0
0
0
0
0
0
0
15
16
0
Person and Caregiver Centered Experience and Outcomes
0
0
25
35
0
12
12
12
14
12

High Priority Domains for Future Measure Consideration: As we move more toward expanded public reporting, it is critical to include consumer-friendly measures. This means that measure development needs to focus on creating measures that look at the types of information consumers need to know to make informed health care decisions. PQRS was originally a pay-for-reporting program without explicit intent to publicly report quality measures. However, starting with 2015 data, all PQRS measures are available for public reporting on Physician Compare. Based on this expansion of public reporting and the changing use of PQRS measures, it is critical to consider public reporting and the consumer perspective during measure development. CMS identified the key areas to consider when developing consumer-friendly measures.

Consumer testing has also shown that users prefer outcome measures over process measures. In order for quality measures to be meaningful to consumers, they must resonate with consumers. We often hear that consumers do not think process measures are useful. They want to understand if patients like them better or if a procedure was successful. This is the information that will help them make informed decisions.

Composite measures can help consumers accurately interpret measures in a way that is meaningful to them while also removing the burden of interpretation from them. Composite measures help make data more digestible. It is much easier for a consumer to understand that a doctor is good at diabetes care, for instance, than it is to understand why it is important for a doctor to perform well across a series of technical measures about glucose levels and treatment best practices. Similarly, risk adjustment can ensure that consumers are more accurately comparing health care professionals and group practices.

Consumers can provide valuable feedback when engaged early in the measure development process. They can determine if measures are understandable and useful in decision making. We understand that all measures are not intended for public reporting. However, the continued growth of public reporting makes the consumer perspective increasingly important. Moving towards more consumer-friendly measures, specifically outcome measures, composite measures, and risk-adjusted measures, will be instrumental toward achieving Physician Compare’s goal, as defined by the Affordable Care Act, of providing consumers useful quality data to inform health care decisions.

Measure Requirements: Although CMS has finalized the quality measures listed in Table 1 for public reporting, not all of these quality measures may ultimately be suitable for public reporting. Only comparable, valid, reliable, and accurate data will be publicly reported. For example, the performance results for certain measures may not be statistically reliable if the total number of patients reported on is low. Hence, to select a sub-set of quality measures finalized for public reporting, CMS will need to analyze the actual measure performance results collected for each program year. At minimum, any quality measures selected for public reporting must meet the following criteria:

In addition, CMS will not publish any measures that are in their first year and only those measures that prove to resonate with consumers and are deemed to be relevant to consumers will be included on the profile pages of the website. All other comparable, valid, reliable, and accurate measures would be included in a publicly available downloadable database, similar to the databases currently available on data.medicare.gov.


Hospital Inpatient Quality Reporting 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which accompanied the 2015 MUC list, and the CMS Measure Inventory,which is regularly updated to include the most recent measures in different federal programs.

Program History and Structure: The Hospital Inpatient Quality Reporting (IQR) Program was established by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 and later amended by the Deficit Reduction Act (DRA) of 2005. The program requires hospitals paid under the Inpatient Prospective Payment System (IPPS) to report on process, structure, outcomes, patient perspectives on care, efficiency, and costs of care measures. Hospitals receive a quarter of the applicable percentage point of the annual market basket (the measure of inflation in costs of goods and services used by hospitals in treating Medicare patients) payment update. Hospitals who choose non-participation in the program receive a reduction by that same amount. Performance of quality measures are publicly reported on the CMS Hospital Compare website.

The American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5) amended Titles XVIII and XIX of the Social Security Act (the Act) to authorize incentive payments to eligible hospitals (EHs) and Critical Access Hospitals (CAHs) and other groups eligible to participate in the EHR Incentive Program, to promote the adoption and meaningful use of certified electronic health record (EHR) technology (CEHRT). EHs and CAHs are required to report on electronically specified clinical quality measures (eCQMs) using CEHRT in order to qualify for incentive payments under the Medicare and Medicaid EHR Incentive. All EHR Incentive Program requirements related to eCQM reporting will be addressed in IQR Program rulemaking including, but not limited to, new program requirements, reporting requirements, reporting and submission periods, reporting methods, and information regarding the eCQMs.

The Hospital Value-Based Purchasing (VBP) Program was established by Section 3001(a) of the Affordable Care Act, under which value-based incentive payments are made in a fiscal year to hospitals meeting performance standards established for a performance period for such fiscal year. The Secretary shall select measures, other than measures of readmissions, for purposes of the Program. However, measures of five conditions (acute myocardial infarction, pneumonia, heart failure, surgeries, and healthcare-associated infections), the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, and efficiency measures must be included. Measures are eligible for adoption in the Hospital VBP Program based on the statutory requirements, including specification under the Hospital IQR Program and posting dates on the Hospital Compare Web site.

High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

  1. Patient and Family Engagement:
    1. Measures that foster the engagement of patients and families as partners in their care.
  2. Best Practices of Healthy Living:
    1. Measures that promote best practices to enable healthy living.
  3. Making Care Affordable:
    1. Measures that effectuate changes in efficiency and reward value over volume.

CMS identified the following topics/areas as high-priority for future measure consideration:

Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the IQR program. At a minimum, the following criteria will be considered in selecting measures for IQR program implementation:

  1. Measure must adhere to CMS statutory requirements.
    1. Measures are required to reflect consensus among affected parties, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act; currently the National Quality Forum (NQF)
    2. The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration
  2. Measure must be claims-based or an electronically specified clinical quality measure (eCQM).
    1. A Measure Authoring Tool (MAT) number must be provided for all eCQMs, created in the HQMF format
    2. eCQMs must undergo reliability and validity testing including review of the logic and value sets by the CMS partners, including, but not limited to, MITRE and the National Library of Medicine
    3. eCQMs must have successfully passed feasibility testing
  3. Measure may not require reporting to a proprietary registry.
  4. Measure must address an important condition/topic for which there is analytic evidence that a performance gap exists and that measure implementation can lead to improvement in desired outcomes, costs, or resource utilization.
  5. Measure must be fully developed, tested, and validated in the acute inpatient setting.
  6. Measure must address a NQS priority/CMS strategy goal, with preference for measures addressing the high priority domains and/or measurement gaps for future measure consideration.
  7. Measure must promote alignment across HHS and CMS programs.
  8. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.


Hospital Outpatient Quality Reporting Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which accompanied the 2015 MUC list, and the CMS Measure Inventory,which is regularly updated to include the most recent measures in different federal programs.

Program History and Structure: The Hospital Outpatient Quality Reporting (OQR) Program was established by Section 109 of the Tax Relief and Health Care Act (TRHCA) of 2006. The program requires subsection (d) hospitals providing outpatient services paid under the Outpatient Prospective Payment System (OPPS) to report on process, structure, outcomes, efficiency, costs of care, and patient experience of care. Hospitals receive a 2.0 percentage point reduction of their annual payment update (APU) under the Outpatient Prospective Payment System (OPPS) for non-participation in the program. Performance on quality measures is publicly reported on the CMS Hospital Compare website.

High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

  1. Making Care Safer:
    1. Measures that address processes and outcomes designed to reduce risk in the delivery of health care, e.g., emergency department overcrowding and wait times.
  2. Best Practices of Healthy Living:
    1. Measures that focus on primary prevention of disease or general screening for early detection of disease unrelated to a current or prior condition.
  3. Patient and Family Engagement:
    1. Measures that address engaging both the person and their family in their care.
    2. Measures that address cultural sensitivity, patient decision-making support or care that reflects patient preferences.
  4. Communication/Care Coordination:
    1. Measures to embed best practices to manage transitions across practice settings.
    2. Measures to enable effective health care system navigation.
    3. Measures to reduce unexpected hospital/emergency visits and admissions.

Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the HOQR program. At a minimum, the following criteria will be considered in selecting measures for HOQR program implementation:

  1. Measure must adhere to CMS statutory requirements.
    1. Measures are required to reflect consensus among affected parties, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act
    2. The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration
  2. Measure must address a NQS priority/CMS strategy goal, with preference for measures addressing the high priority domains for future measure consideration.
  3. Measure must address an important condition/topic for which there is analytic evidence that a performance gap exists and that measure implementation can lead to improvement in desired outcomes, costs, or resource utilization.
  4. Measure must be fully developed, tested, and validated in the hospital outpatient setting.
  5. Measure must promote alignment across HHS and CMS programs.
  6. Feasibility of Implementation: An evaluation of feasibility is based on factors including, but not limited to
    1. The level of burden associated with validating measure data, both for CMS and for the end user.
    2. Whether the identified CMS system for data collection is prepared to accommodate the proposed measure(s) and timeline for collection.
    3. The availability and practicability of measure specifications, e.g., measure specifications in the public domain.
    4. The level of burden the data collection system or methodology poses for an end user.
  7. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.


Ambulatory Surgical Center Quality Reporting Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which accompanied the 2015 MUC list, and the CMS Measure Inventory,which is regularly updated to include the most recent measures in different federal programs.

Program History and Structure: The Ambulatory Surgical Center (ASC) Quality Reporting Program was established under the authority provided by Section 109(b) of the Medicare Improvements and Extension Act of 2006, Division B, Title I of the Tax Relief and Health Care Act (TRHCA) of 2006. The statute provides the authority for requiring ASCs paid under the ASC fee schedule (ASCFS) to report on process, structure, outcomes, patient experience of care, efficiency, and costs of care measures. ASCs receive a 2.0 percentage point payment penalty to their ASCFS annual payment update for not meeting program requirements. CMS implemented this program so that payment determinations were effective beginning with the Calendar Year (CY) 2014 payment update.

High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

  1. Making Care Safer
    1. Measures of infection rates
  2. Person and Family Engagement
    1. Measures that improve experience of care for patients, caregivers, and families.
    2. Measures to promote patient self-management.
  3. Best Practice of Healthy Living
    1. Measures to increase appropriate use of screening and prevention services.
    2. Measures which will improve the quality of care for patients with multiple chronic conditions.
    3. Measures to improve behavioral health access and quality of care.
  4. Effective Prevention and Treatment
    1. Surgical outcome measures
  5. Communication/Care Coordination
    1. Measures to embed best practice to manage transitions across practice settings.
    2. Measures to enable effective health care system navigation.
    3. To reduce unexpected hospital/emergency visits and admissions.

Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the ASCQR program.
At a minimum, the following requirements will be considered in selecting measures for ASCQR Program implementation:

  1. Measure must adhere to CMS statutory requirements.
    1. Measures are required to reflect consensus among affected parties, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act
    2. The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration
  2. Measure must address a NQS priority/CMS strategy goal, with preference for measures addressing the high priority domains for future measure consideration.
  3. Measure must address an important condition/topic for which there is analytic evidence that a performance gap exists and that measure implementation can lead to improvement in desired outcomes, costs, or resource utilization.
  4. Measure must be field tested for the ASC clinical setting.
  5. Measure that is clinically useful.
  6. Reporting of measure limits data collection and submission burden since many ASCs are small facilities with limited staffing.
  7. Measure must supply sufficient case numbers for differentiation of ASC performance.
  8. Measure must promote alignment across HHS and CMS programs.
  9. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.


Skilled Nursing Facility Value-Based Purchasing Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which accompanied the 2015 MUC list, and the CMS Measure Inventory,which is regularly updated to include the most recent measures in different federal programs.

Program History and Structure: The Skilled Nursing Facility Value-Based Purchasing (SNF-VBP) Program was established by Section 215 (b)of the Protecting Access to Medicare Act of 2014. The facility adjusted Federal per diem rate will be reduced by 2% and an incentive payment will then be applied to facilities based upon readmission measure performance.

The legislation mandates that CMS will specify a SNF all-cause all-condition hospital readmission measure by no later than October 1, 2015. It further requires that a resource use measure that reflects resource use by measuring all-condition risk-adjusted potentially preventable hospital readmission rates for SNFs will be specified no later than October 1, 2016 and replace the all-cause all-condition measure as soon as is practicable.

High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

  1. The sole measure requirement at this time is the specification of a potentially preventable readmission measure. CMS lacks the authority to implement additional measures beyond the two described in the statute.

Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the SNF-VBP program. At a minimum, the following requirements must be met for selection in the SNF-VBP program:



Inpatient Rehabilitation Facility Quality Reporting Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which accompanied the 2015 MUC list, and the CMS Measure Inventory,which is regularly updated to include the most recent measures in different federal programs.

Program History and Structure: The Quality Reporting Program (QRP) for Inpatient Rehabilitation Facilities (IRFs) was established in accordance with section 1886(j) of the Social Security Act as amended by section 3004(b) of the Affordable Care Act. The IRF QRP applies to all IRF facilities that receive the IRF PPS (e.g., IRF hospitals, IRF units that are co-located with affiliated acute care facilities, and IRF units affiliated with critical access hospitals [CAHs]). Data sources for IRF QRP measures include Medicare FFS claims, the Center for Disease Control’s National Health Safety Network (CDC NHSN) data submissions, and Inpatient Rehabilitation Facility - Patient Assessment instrument (IRF-PAI) records. The IRF QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2014, IRFs that fail to submit data will be subject to a 2.0 percentage point reduction of the applicable IRF Prospective Payment System (PPS) payment update. Plans for future public reporting of IRF QRP measures are under development.

Further, the Improving Medicare Post-Acute Care Transformation (IMPACT Act of 2014, amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCH), Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF) and Home Health Agencies (HHA) to report data on resource use and other measures and standardized patient assessment data on quality measures and specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers; amending the Social Security Act for each of the provider types to add such requirements under the IMPACT Act. The IMPACT Act delineates the reporting of standardized assessment data on quality measures in at least the following domains: Functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. It also delineates the implementation of resource use and other measures in at least these following domains: Total estimated Medicare spending per beneficiary Discharge to the community, all condition risk adjusted potentially presentable hospital readmission rates. Further, the IMPACT Act requires the modification of such assessment instruments to achieve the standardization of such data.

High Priority Domains for Future Measure Consideration: CMS identified the following four domains as high-priority for future measure consideration:

  1. Making Care Safer (subdomains: hospital-acquired infections and hospital-acquired conditions): Patient safety is an important priority domain for the IRF QRP as IRF patients are at risk for injury due to falls, new or worsened pressure ulcers and infections such as CAUTI, C. Diff. and MRSA.
  2. Patient and Family Engagement: A primary focus of IRF care is restoring functional status. Metrics showing change in self-care and mobility function and discharge self-care and mobility are under development. Metric for achievement of functional status goals such as discharge to community. In addition, the experiences of patients and caregivers are important to measure and are important priority for the IRF QRP.
  3. Making Care Affordable: An important consideration for the IRF QRP is to better assess medical costs based on PAC episodes of care. Therefore, CMS is considering developing efficiency-based measures such as a Medicare Spending per Beneficiary measure concept.
  4. Communication/Care Coordination: Assessing patient care transitions and rehospitalizations are important. Therefore, CMS is considering developing measures that assesses discharge to the community and potentially preventable readmissions.
  5. Communication/Care Coordination: Infrastructure and processes for care coordination are important for the IRF QRP. Therefore, a medication reconciliation quality measure for IRF patients is being considered for future quality measure development. Medication reconciliation conceptually highlights care transitions and resident follow-up.


Long-Term Care Hospital Quality Reporting Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which accompanied the 2015 MUC list, and the CMS Measure Inventory,which is regularly updated to include the most recent measures in different federal programs.

Program History and Structure: The Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) was established in accordance with section 1886(m) of the Social Security Act, as amended by Section 3004(a) of the Affordable Care Act. The LTCH QRP applies to all LTCHs facilities designated as an LTCH under the Medicare program. Data sources for LTCH QRP measures include Medicare FFS claims, the Center for Disease Control and Prevention’s National Health Safety Network (CDC’s NHSN) data submissions, and the LTCH Continuity Assessment Record and Evaluation Data Sets (LCDS). The LTCH QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2014, LTCHs that fail to submit data will be subject to a 2.0 percentage point reduction of the applicable Prospective Payment System (PPS) increase factor.

Further, the Improving Medicare Post-Acute Care Transformation (IMPACT Act of 2014, amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCH), Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF) and Home Health Agencies (HHA) to report data on resource use and other measures and standardized patient assessment data on quality measures and specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers; amending the Social Security Act for each of the provider types to add such requirements under the IMPACT Act. The IMPACT Act delineates the reporting of standardized assessment data on quality measures in at least the following domains: Functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. It also delineates the implementation of resource use and other measures in at least these following domains: Total estimated Medicare spending per beneficiary Discharge to the community, all condition risk adjusted potentially presentable hospital readmission rates. Further, the IMPACT Act requires the modification of such assessment instruments to achieve the standardization of such data.

High Priority Domains for Future Measure Consideration: CMS identified the following domains as high-priority for LTCH QRP future measure consideration:

  1. Effective Prevention and Treatment: Having measures related to ventilator use, ventilator-associated event and ventilator weaning rate are a high priority for CMS as prolonged mechanical ventilator use is quite common in LTCHs and respiratory diagnosis with ventilator support for 96 or more hours is the most frequently occurring diagnosis.
  2. Effective Prevention and Treatment (Aim: Healthy People/Healthy Communities): In discussions with LTCH providers, it was noted that mental health status is an important measure of care for LTCH patients. CMS is considering a Depression Assessment & Management quality measure.
  3. Patient and Family Engagement: While rehabilitation and restoring functional status are not the primary goals of patient care in the LTCH setting, functional outcomes remain an important indicator of LTCH quality as well as key to LTCH care trajectories. Providers must be able to provide functional support to patients with impairments. Thus, metrics showing change in self-care and mobility function are under development.
  4. Patient and Family Engagement: CMS would like to explore measures that will evaluate the patient’s experiences of care as this is a high priority of providers. Therefore, the HCAHPS and Care Transition quality measure (CTM)-3 is being considered.
  5. Making Care Affordable: An important consideration for the LTCH QRP is to better assess medical costs based on PAC episodes of care. Therefore, CMS is considering developing efficiency-based measures such as a Medicare Spending per Beneficiary measure concept.
  6. Communication/Care Coordination: Assessing patient care transitions and rehospitalizations are important. Therefore, CMS is considering developing measures that assesses discharge to the community and potentially preventable readmissions.
  7. Communication/Care Coordination: Infrastructure and processes for care coordination are important for the LTCH QRP. Therefore, a medication reconciliation quality measure for LTCH patients is being considered for future quality measure development. Medication reconciliation conceptually highlights care transitions and resident follow-up.



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.

Ambulatory Surgical Center Quality Reporting Program

Hospital Inpatient Quality Reporting

Inpatient Rehabilitation Facility Quality Reporting Program

Long-Term Care Hospital Quality Reporting Program

Hospital Outpatient Quality Reporting Program

Physician Compare

Physician Quality Reporting System (PQRS)

Skilled Nursing Facility Value-Based Purchasing Program


Full Comments (Listed by Measure)

Ambulatory surgery patients with appropriate method of hair removal (Program: Ambulatory Surgical Center Quality Reporting Program; MUC ID: E0515)
Skilled Nursing Facility All-Cause 30 Day Post Discharge Readmission Measure (Program: Skilled Nursing Facility Value-Based Purchasing Program; MUC ID: S2510)
IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (Program: Inpatient Rehabilitation Facility Quality Reporting Program; MUC ID: S2633)
Compliance with Ventilator Process Elements during LTCH stay (Program: Long-Term Care Hospital Quality Reporting Program; MUC ID: X3705)
Hospital 30-day, all-cause, unplanned risk-standardized days in acute care following pneumonia hospitalization (Program: Hospital Inpatient Quality Reporting; MUC ID: X3727)
Adult Kidney Disease: Referral to Hospice (Program: Physician Quality Reporting System (PQRS) ; MUC ID: X3732)
Evaluation or Interview for Risk of Opioid Misuse (Program: Physician Quality Reporting System (PQRS) ; MUC ID: X3774)

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