September 6, 2018
Seema Verma, Administrator
Centers for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244-8016
Dear Administrator Verma,
Thank you for the opportunity to comment on proposed Medicare Quality Payment Program (QPP) revisions and related issues for 2019. The National Committee for Quality Assurance (NCQA) strongly supports the move to reward value, which this proposed rule advances, and we thank you for the thoughtful effort you put into it. We particularly appreciate that you propose Merit-Based Incentive Payment System (MIPS) Improvement Activities credit for clinicians in NCQA Heart-Stroke Recognition and Diabetes Recognition programs. We also fully support and share your goal of reducing measurement reporting burden.
We strongly urge you to take an additional powerful step to reduce burden by providing “Promoting Interoperability” credit to Patient-Centered Medical Home (PCMH) and Patient-Centered Specialty Practice (PCSP) clinicians. PCMH and PCSP clinicians document that they meet extensive standards for using health IT to exchange data. Automatic credit would meet your twin goals of enhancing interoperability and reducing reporting burden. We also can give CMS data feeds showing which PCMH and PCSPs meet which criteria, providing more accurate MIPS payment adjustments than attestation.
We support revising the “Advancing Care Information” MIPS category to “Promoting Interoperability” and focusing it on data exchange. However, you should continue to provide some credit to clinicians for use of patient-generated data. Patient-generated data is essential for good care planning and treatment evaluation and patient-reported outcome measures that are critical for CMS’ Meaningful Measure Initiative.
We support the Medicare Advantage Qualifying Payment Arrangement Incentive Demonstration for clinicians in Medicare Advantage alternative payment models and the proposals to cover virtual visits and interprofessional consultations.
We support the proposals to include more types of clinicians in MIPS and to allow certain low-volume providers to opt in. This will help address concerns that MIPS excludes too many clinicians to appropriately advance value-based payment goals. We urge you to go farther and let all low-volume clinicians who join virtual groups opt into MIPS.
We support raising the data completeness threshold to reporting on 60% of all patients eligible for a given measure, and we urge you to continue raising this bar going forward until clinicians must report on all eligible patients. We further support adding opioid measures to the list of high-priority quality measures given the urgent need to address our nation’s addiction crisis.
Detailed comments on these and other issues are below.
Reducing Reporting Burden: We share your goal of reducing reporting burden, which the proposed rule references more than 50 times. We urge you to take an additional step to reduce burden in MIPS by giving clinicians in PCMHs/PCSPs credit for using health IT to exchange data. NCQA-Recognized PCMHs/PCSPs have documented compliance with rigorous standards for health IT interoperability that align with measures for the proposed renamed “Promoting Interoperability” category in MIPS. These include:
- Using an ONC certified EHR system, conducting a security risk analysis and implementing updates to correct identified deficiencies.
- Demonstrating electronic exchange of information with external entities, agencies and registries:
- Regional health information organization or other source that enhances the ability to manage complex patients, immunization registries or external PCMH-oriented collaborative activities, including health information exchanges.
- Immunization information systems.
- Sharing a summary-of-care record with other providers or facilities for care transitions.
- Sharing clinical information with admitting hospitals and ED and implementing a process to consistently obtain patient discharge summaries from hospitals and other facilities.
- Having a secure electronic system for patients to request appointments, prescription refills, referrals and test results and for two-way communication to provide timely clinical advice.
- Reviewing controlled substance databases when prescribing relevant medications.
- Systematically managing referrals by sharing clinical questions and the required timing and type of referral; sharing pertinent demographic and clinical data, including test results and current care plans; tracking referrals and flagging and following up on overdue reports.
- Exchanging patient information with the hospital during a patient’s hospitalization.
- A new elective component we are adding to align with the Verify Opioid Treatment Agreement
There is currently a wide range of clinician performance and capability on interoperability. NCQA can help to address this by providing data feeds to CMS on which PCMHs meet each of these criteria, which would provide more accurate MIPS payments than relying on attestation.
NCQA is also actively working to reduce reporting burden by:
- Promoting measures alignment across programs.
- Converting measures to digital formats for more efficient and accurate implementation.
- Moving to an all-electronic clinical reporting system that derives measurement data from what clinicians document in routine delivery of care, without additional input.
Data intermediaries such as registries, health information exchanges, data analytics companies and cloud-based EHRs should be able to consume EHR and other data and calculate and report measurement data on behalf of contributors. This will reduce burden and provide much-needed access to data on outcomes that claims-based measurement cannot provide.
- Building trust among clinicians and payors in results of this electronic performance reporting system via NCQA’s nationally recognized digital measures validation and testing lab.
Improvement Activities: We thank you and support your proposal for “Chronic Care and Preventative Care Management for Empaneled Patients” Improvement Activity credit to clinicians in NCQA’s Heart-Stroke Recognition and Diabetes Recognition Programs. These programs recognize and provide tools to support clinicians who provide excellent care, which perfectly aligns with Congressional and QPP Improvement Activity intent.
We also understand through correspondence with CMS that clinicians recognized through NCQA’s Oncology Medical Home program, which is based on our PCSP program, as a PCSP, receive full Improvement Activity credit. We urge you to clarify in the final rule that clinicians in our Oncology Medical Home program get full Improvement Activity credit, so everyone understands that Oncology Medical Homes qualify.
We support maintaining the 90-day reporting requirement for Improvement Activities. Because NCQA requires that practices seeking PCMH/PCSP Recognition perform the appropriate activities for a minimum of 90 days, CMS should offer full automatic credit to practices that achieve NCQA Recognition by December 31 of a performance year.
We support requiring 50% of NPIs within a Tax Identification Number (TIN) to have PCMH/PCSP Recognition to get full Improvement Activities for the entire TIN. However, we urge CMS to accept data feeds from accrediting bodies and move to requiring 100% recognition so no one not in a recognized practice receives credit.
Promoting Interoperability: We support the proposal to rename the “Advancing Care Information” category “Promoting Interoperability” and revise measures accordingly. We also support requiring 2015 certified EHR technology to help advance interoperability.
We are concerned, however, that removing the patient-generated data measure would weaken incentives to seek, accept and benefit from the higher quality and patient engagement such data can engender. Patient-generated data is essential for good care planning and treatment evaluation. It is also essential for patient-reported outcome measures, which we consider to be among our highest priorities. Given concerns about provider reporting burden, you might want to consider providing bonus points to clinicians who report their use of patient-generated data.
For Promoting Interoperability in Medicaid, we support including all electronically specified Medicaid and CHIP core set measures.
Quality: We support and commend you for proposing to require reporting quality measures for a full year, rather than for 90 days, in order to provide a more robust and accurate assessment.
We also support the proposal to limit reporting via claims to small practices to support movement from claims-based to electronic reporting. Electronic reporting reduces burden and allows access to much richer sources of clinical data not found in claims
We support raising the data completeness threshold from 50% to 60% of all eligible patients for each measure. We encourage you to continue raising this threshold over time, as 100% is ultimately necessary to identify topped-out measures and prevent gaming. Mandatory reporting of core population-based measure sets would show where there is actual limited performance variability above 95%, which defines a genuinely topped-out measure.
We also support making opioid measures high-priority, offering bonus points for reporting them in 2019 and mandating reporting thereafter. We also consider opioid measures high priority and have a growing number in use or development, specified for health plans. Our experience with this work underscores the importance of measuring drugs actually dispensed, not just prescribed or on a medication list. We have also learned that accurate measurement requires large denominators, which may be problematic when measuring at the individual clinician level. We would be happy to discuss our experience and insights as you move forward to include and expand your focus on opioid measures.
We support maintaining the end-to-end electronic reporting bonus for 2019 but we are concerned that you might not continue this important policy. Our experience with smaller practices, in particular, shows that many clinicians are not yet capable of end-to-end electronic reporting, and we urge you to consider continuing this bonus beyond next year.
We are very interested in your suggestion to classify and award points for quality measures based on their value. There is precedent for this in the Medicare Advantage Stars system which gives outcome measures greater weight than process measures. It also aligns with the goals of CMS’ Meaningful Measures initiative, which we share. How you implement such a system is critical. For example, measure ratings need to assess value and validity, rather than perceived clinician burden or ease of reporting. Your suggestion to give the highest rating to outcome measures, the second highest to process measures directly related to outcomes and lower ratings to lesser measures, appears to be a good start.
Measurement Updates: We share these comments on adding, removing or adjusting measures:
- CMS 048: We do not support removing Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older. The measure addresses the serious problem of widely undiagnosed and untreated incontinence. It does not, as suggested, duplicate Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older. The Plan of Care measure only assesses care for women who have a diagnosis of incontinence, therefore not addressing the significant quality problem of physicians not assessing patients for possible urinary incontinence. These measures work together to show a complete picture of diagnosis and treatment, and we recommend keeping both in the QPP.
- CMS 154, 155, 156: We agree, in principle, with combining the Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls However, this will require significant revisions for them to work together. We suggest waiting until clinical experts can review these revisions following the CMS Measures Management Blueprint Re-Evaluation process before you make this change. Implementing this change without thorough reevaluation could cause confusion and increase burden on providers.
- CMS 163: We do not support removing Comprehensive Diabetes Care: Foot Exam until the National Quality Forum (NQF) completes its pending comparison with it and the Diabetes Mellitus: Diabetic Foot and Ankle Care measure (which the proposed rule suggests it duplicates). NQF found no significant difference in the measures’ ability to identify the at-risk population or in the components of clinical assessment specified in them. Given this scheduled review and final determination, we recommend maintaining CMS 163 (NQF 0056) in the 2019 QPP. More than 10,000 clinicians in NCQA’s Diabetes Recognition Program report Comprehensive Diabetes Care: Foot Exam. The measure also is in the Core Quality Measures Collaborative ACO/PCHM and Primary Care set, which CMS described as “a major step forward” for quality measure alignment” and a “framework upon which future efforts can be based.”
- CMS 204: We do not support removing Ischemic Vascular Disease: Use of Aspirin or Another Antiplatelet. The Million Hearts Campaign, Core Quality Measures Collaborative ACO/PCHM and Primary Care set and many other public and private programs use this measure. It promotes harmonization across programs and payers and we recommend keeping it.
- CMS 373: We do not support removing Hypertension: Improvement in Blood Pressure. It captures progress towards the goal of blood pressure control and provides an incentive to reduce hypertension risk for patients in whom reaching blood pressure targets may not be realistic. It complements, rather than duplicates, the Controlling High Blood Pressure
- CMS 447: We agree with removing Chlamydia Screening and Follow-Up. It duplicates Chlamydia Screening for Women (CMS 310), which is in the Medicaid and CHIP Child Core and Core Quality Measures Collaborative Sets.
- We support adding Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture.
- We support removing Appropriate Treatment for Children with Upper Respiratory Infection, Appropriate Testing for Children with Pharyngitis and Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis from the Infectious Disease set. That set focuses on acute care while these measures focus on primary care.
Including More Clinicians: We support your proposal to provide opportunities for more clinicians to join MIPS, including physical therapists, occupational therapists, clinical social workers and especially clinical psychologists who are particularly important to advancing needed improvements in behavioral healthcare.
We also support the proposal to let low-volume clinicians opt in to MIPS if they surpass any low-volume threshold and let these clinicians join virtual groups, which Congress specifically intended to encourage – not prevent – small practice participation in MIPS.
Each of these proposals will help address growing concerns that excluding so many clinicians from MIPS undermines Congressional intent to move to paying for value. We urge you to go farther and let any low-volume provider join a virtual group, participate in MIPS and move toward value-based pay, which will extend measurement and accountability to the large share of low-volume clinicians now exempt from MIPS.
We also urge you to provide technical support and funding to develop measures so more categories of clinicians, such as speech language pathologists, qualified audiologists, certified nurse-midwives and registered dieticians or nutritional professions, can join the program.
Alternative Payment Models (APMs): We strongly support the proposed Medicare Advantage Qualifying Payment Arrangement Incentive Demonstration, which would exempt clinicians in qualifying Medicare Advantage plan APMs from MIPS. We joined other leading stakeholder groups on letters to the Department of Health & Human Services and Center for Medicare & Medicaid Innovation urging this credit for Medicare Advantage APM clinicians and we thank you for this action. As noted in the letters, our nation’s move from volume-based compensation towards payment for value requires aligning incentives in traditional Medicare and Medicare Advantage to promote participation in risk-bearing APMs. Risk-bearing Medicare Advantage contracts deliver higher quality at lower cost than fee-for-service based Medicare Advantage contracts, but until now, these providers did not get credit under MACRA. We believe it strikes the right balance to allow such clinicians to be simply exempt from MIPS or to be Qualified Participants in Advanced Alternative Payment Models if they meet AAPM thresholds, and thus earn AAPM bonuses.
For other APMs, we support the proposal to require reporting of at least one MIPS quality measure and one MIPS outcome measure and we encourage you to increase this MIPS alignment going forward.
Other Issues: We support the proposals to pay for virtual check-ins with established patients, which is an important step to enhance both access and quality. Given the rapid advances in technology we believe it is appropriate to cover these whether through audio only or enhanced by video and/or data. We also support covering asynchronous review of images and other data from patients, which may be appropriate for both established and new patients.
We support the proposal to cover interprofessional consultations, which are a cornerstone of “medical neighborhoods” in which PCMH/PCSP clinicians collaborate to improve the quality and coordination of care for patients referred for specialty care.
We support the proposal to cut Part B drug dispensing fees from a flat 6% to 3%. This will somewhat reduce the perverse incentive to prescribe costlier drugs to obtain higher dispensing fees when there are equally effective lower cost alternatives. However, we urge you to eliminate any incentive for costlier drugs via a flat dispensing fee for all drugs, regardless of cost.
We support the proposal to reduce payment to 40% of the outpatient rate for hospital outpatient clinic visits provided at off-campus provider-based departments. This is a step toward the important goal of completely site-neutral payment, which will prevent the potential for higher reimbursement from care in costlier but not necessarily better delivery sites to outweigh value-based payment incentives.
Finally, we agree with the proposal to expand imaging appropriate use criteria to independent diagnostic facilities, to let auxiliary personnel perform required consultations and to establish G-codes for reporting via claims.
Thank you again for the opportunity to comment on these issues. If you have any questions, please contact Paul Cotton, NCQA Director of Federal Affairs, at (202) 955-5162 or firstname.lastname@example.org.
Margaret E. O’Kane