August 24, 2017 

Seema Verma, Administrator
Center for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD, 21244 

 Attention: CMS-1676-P 

Dear Administrator Verma, 

Thank you for the opportunity to comment on proposed Revisions to Medicare Physician Fee Schedule Payment Policies, Shared Savings and Diabetes Prevention Programs. The National Committee for Quality Assurance (NCQA) supports proposals to expand telehealth, move toward site-neutral payments, and improve evaluation and management service documentation. We also believe increased support for reporting clinical quality performance measurement data via electronic clinical data systems is an essential component for improving flexibility and efficiency at many levels. Details comments on these and other issues in the proposed rule are below. 

Telehealth: We applaud the proposed addition of new services, including: 

  • Lung cancer screening counseling for shared decision making and eligibility determinations; 
  • Psychotherapy for crises; 
  • Interactive complexity; 
  • Patient and caregiver health risk assessments; and 
  • Comprehensive chronic care planning. 

We also support addition of other services on which you seek comment, including: 

  • Remote patient monitoring, especially for physiologic data like blood pressure and glucose; and 
  • Analysis of clinical data, such as blood pressure and hematologic data, stored in computers. 

These additions will expand access to care for those who need it, and parallel with NCQA’s own efforts to incorporate the use of telehealth into our HEDIS® clinical quality measures. 

We continue to believe that Medicare’s current telehealth criteria are too narrow and harming beneficiaries who lack needed access to services that telehealth can effectively deliver. We understand concerns about telehealth’s potential for overuse, fraud and abuse. Advanced care models like Patient-Centered Medical Homes and Alternative Payment Models, in particular, should be able to expand telehealth while minimizing such concerns because they are designed to manage costs and improve quality. 

We urge you to work with all stakeholders, including other payers who use telehealth much more extensively, to identify best practices for expanding its use in Medicare while protecting program integrity. 

Off-Campus Provider-Based Hospital Departments: We strongly support reducing nonexempted off-campus provider-based hospital department payments 50%. This is an important step toward site-neutral payment that is fiscally prudent, fair and needed to align with the move toward value-based purchasing. 

Imaging: We support lowering payments for film imaging to encourage digital imaging. This will help get more clinical data into electronic data systems that better support both care coordination and richer, more efficient clinical quality measure data collection. 

We also support the proposal to mandate consultation of specified Appropriate Use Criteria (AUC) through qualified clinical decision support mechanisms (CDSMs). This includes reporting via claims on the clinical decision support mechanism used, if a service did or did not meet the criteria, or if the criteria were not applicable. The proposed delay in implementing this policy until 2019 makes sense, given that many electronic health record systems still do not incorporate CDSMs. Also, since radiologists or other furnishing clinicians have more specialized imaging knowledge and perform, interpret and bill for imaging, you may want to focus this requirement on those clinicians rather than clinicians who order the imaging tests. 

We do not support providing high-level Clinical Practice Improvement Activity credit under the Merit-based Incentives Payment System for mandatory clinical decision support use. Such credit is intended for voluntary efforts clinicians do to improve and thus is not appropriate for mandated activities. 

E&M Documentation: We support your interest in decreasing burden and increasing meaningful documentation for evaluation and management services. A guiding principle for doing so is that documentation should support clinical care, not just billing, as suggested by the American College of Physicians. This would entail incorporating a care narrative and supporting the patient, their family and clinical team in the documentation. It also should include continued promotion of electronic clinical data systems for documentation. 

Care Coordination: We support new G-codes allowing Rural Health Clinics (RHCs) and Federally Qualified Health Clinics (FQHCs) to bill, in addition to their standard payments, for general care management and psychiatric co-care management. This would appropriately recognize the additional resources and effort such care management entails. 

Medicare Shared Savings Program: We support revising the assignment methodology, per the 21st Century Cure Act, to assign patients based on currently excluded RHC and FQHC services. We further support adding chronic care management and behavioral health integration as primary care services for attribution. These services are increasingly recognized as essential components of primary care and should be treated as such for attribution. 

However, we do not support reducing the validation match threshold from 90% to 80% and decreasing quality scores by the percentage that MSSP entities score below that 80% threshold. Doing so would reduce both the accuracy and integrity of MSSP performance measurement. 

MACRA Patient Relationship Categories: We appreciate the proposal to let clinicians use HCPCS codes voluntarily at first for determining MACRA patient relationship categories. We urge you to monitor this approach closely for the extent to which clinicians take up this approach – which may be limited – and for the accuracy of results, which may be skewed by how clinicians choose to code. We continue to encourage you to develop a less burdensome, more accurate automated system that presents categories in a decision tree that can be embedded in health IT systems. This could be based, in part, on routinely collected information such as clinician specialty, location of service, prior history of services rendered by the treating clinician, and CPT codes. 

Flexibilities & Efficiency – Reducing Reporting Burden with Electronic Clinical Data Systems: Finally, on your Request for Information on CMS Flexibilities and Efficiencies, we seek your support for our effort to significantly reduce burden with a fully automated system for quality measure reporting. 

This will: 

  • Allow physicians and other health professionals to focus on patient care; 
  • Provide ready access to much richer clinical data in electronic systems – including outcomes – than in the claims used for most quality reporting today; 
  • Support use of that richer data for broader and faster quality improvement; and 
  • Substantially improve the accuracy of data used for value-based payments under the Medicare Access & CHIP Reauthorization Act (MACRA) and other pay-for-performance programs. 

NCQA is working toward multiple solutions to achieve these important goals. The first is our eMeasure Certification program, which tests systems’ ability to produce valid performance measure results. By using industry standards to test target systems, NCQA’s certification helps ensure that when clinicians correctly document care in electronic health records (EHRs), they can be assured the certified system will be interoperable with other EHR modules and accurately report performance. The burden on the clinician is minimized because the data needed to report quality measures would be automated due to the validated interoperability and reporting tests that NCQA conducts. 

Here’s how it works. 

  1. NCQA’s eMeasure Certification evaluates a system’s ability to ingest Continuity of Care Documents (CCDs) – the equivalent of the medical record. 
  2. The program expects the system to parse through data provided by NCQA and accurately identify the records that meet a given measure specification. 
  3. The system must then be able to send NCQA the correct records in QRDA 1 and QRDA 3 formats. These are the formats used for the Healthcare Effectiveness Data & Information Set (HEDIS©), Medicare Advantage Stars, and other ambulatory quality reporting programs. 

Relying on this certification will facilitate greater automation in quality reporting. For example, once a data intermediary such as a Qualified Clinical Data Registry (QCDR) achieves certification, it can automatically pull correct data from EHRs to build reliable and valid performance measures. 

This takes the work involved in measurement reporting out of clinicians’ hands so they can spend more time with patients instead of computers. 

Eventually NCQA wants to streamline this further. At present, as measure specifications evolve with clinical guidelines, vendors must update individual iterations of their quality reporting software. Often the same software has hundreds of iterations at different practices across the country, causing significant burden for both vendors and practice managers. 

NCQA wants to change that. We intend to intervene upstream of this problem by working directly with certified data intermediaries, such as QCDRs, to update measure specifications within their software instead of the individual EHR installations. In this new world, data intermediaries would continue to pull data from EHRs as they normally would. However, because we can work directly with intermediaries to ensure their measure specifications are up-to-date, vendors and practices managers would no longer be responsible for burdensome updates to quality reporting software. 

Thank you again for considering our comments. If you have questions, please contact Paul Cotton, Director of Federal Affairs, at cotton@ncqa.org or (202) 955-5162. 

Sincerely 

Margaret O’Kane
President