September 6, 2022
Centers for Medicare and Medicaid Services
Department of Health & Human Services
Hubert H. Humphrey Building
200 Independence Ave., S.W.
Washington, DC 20201
Dear Administrator Brooks-LaSure:
The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to provide feedback on the Physician Fee Schedule proposed rule.
NCQA is a private, 501(c)(3) not-for-profit, independent organization dedicated to improving health care quality through our Accreditation and measurement programs. We are a national leader in quality oversight and a pioneer in digital quality measurement. Leveraging our strengths as a trusted third party, we are committed to helping organizations navigate the challenges associated with moving towards an equitable health care system. Our mission to improve the quality of health for all Americans, with an intentional focus on health equity and support for meaningful value-based payment models, propels our daily work.
NCQA is pleased to provide comments on the sections outlined in the Physician Fee Schedule proposed rule.
Measures of Social Drivers of Health
NCQA agrees with the CMS National Quality Strategy’s aim to create a more equitable, safe, outcomes-based and person-centric health care system. We are encouraged by the CMS proposals to measure and promote health equity in 2023 quality programs. We agree that patient-level, health-related social needs data are essential to encourage meaningful collaboration between health care payers, providers, and community-based organizations.
NCQA supports performance measures that evaluate assessment of health-related social needs at the patient level and in a clinical setting, and we agree with CMS’s position to not require use of a specific assessment tool—a position consistent with the work of the Gravity Project. NCQA supports aligning measures with the Gravity Project’s work to standardize interoperable social needs data, and we encourage CMS to do the same.
NCQA released the Social Need Screening and Intervention measure (for MY 2023) that assesses screening for unmet food, housing and transportation needs, and referral to intervention after a positive screen. Measure domains are based on maturity of electronic data standards and can be expanded as data standards advance. Because social needs data can be captured in a variety of electronic data sources (e.g., EMRs, resource referral platforms, case management systems), NCQA’s measure is specified for Electronic Clinical Data System (ECDS) reporting. The measure also aligns with the Gravity Project’s standards and will be subject to the traditional HEDIS audit to ensure validity of results.
We encourage CMS to align Screening for Social Drivers of Health and Screen Positive Rate for Social Drivers of Health with the Gravity Project’s efforts before making them mandatory in CMS programs. Currently there is a lack of alignment with the Gravity Project’s timeline for harmonizing social risk factor data for interoperable electronic exchange and accounting for screening outcomes. We welcome the opportunity to work with CMS to ensure that measures of social needs are reliable and valid, and that they ease the burden of collection and strive for alignment across programs.
Inclusion of CAHPS for MIPS survey questions specific to discrimination
We support the inclusion of a question focusing on the patient’s experience with discrimination on the CAHPs for MIPS survey. We also encourage CMS to explore other ways to modernize the inclusion of the patient voice in the MIPS program and across all CAHPS surveys. In addition to the addition of disparity related questions, we applaud CMS’s efforts to test a web-based mode for fielding the CAHPS survey and its plan to collect sexual orientation and gender identity data and to test new survey topics that address language and experience with remote care.
We also believe that a digital approach to patient experience can improve response rates by providing convenience and accessibility and more targeted and actionable results,and can improve identification of populations from whom feedback is most needed (such as high utilizers, people with multiple chronic conditions and those negatively impacted by social risks). We encourage CMS to explore the measurement of experience across care settings, such as in the home or for specialty groups, because where and how care is delivered is changing rapidly.
As CMS considers its approach to CAHPS in traditional Medicare, we would like to reiterate our opposition to the recent change to Medicare Advantage Star Ratings methodology that doubled the weight of patient experience, complaints and access measures We do not believe these measures should be weighted more than clinical measures (especially at a ratio of 2:1). The methodology should instead balance all important aspects of health care quality. The move to increase weight for patient experience, complaints and access measures decreases the relative weight of clinical measures in the overall ratings, and while actions such as stratifying data will shine a light on inequities, the reduced relative weighting of clinical measures may mean plans have less incentive to close those gaps.
Use of a Single Quality Measure for Advanced APM Payments
We strongly disagree with the idea that payment based on a single quality measure is sufficient to qualify as an Advanced Alternative Payment Model (APM). NCQA supports value-based purchasing programs that drive patient-centered coordination, alignment and accountability across levels of care. The ability to identify, reward and fund equitable, high-quality care is central to the success of these programs. To do so, the programs must use a sufficient, but still parsimonious, set of measures that reflect different facets of care received. This includes well-crafted process measures closely tied to outcomes for which it is fair to hold clinicians and other providers accountable. Rewarding quality and defining value based on a single measure is inappropriate, particularly when many specialties have few meaningful or relevant measures. In some instances, the availability of clinical evidence for appropriate or best treatment—a prerequisite for strong evidence-based quality metrics— is limited, posing further challenges to assessing overall quality based on a single measure.
Continuing to Advance to Digital Quality Measurement and the Use of Fast Healthcare Interoperability Resources (FHIR) in Physician Quality Programs – Request for Information
Refined Definition of Digital Quality Measures (dQM)
NCQA supports CMS’s proposed update to the definition of dQMs as “quality measures organized as self-contained measure specifications and code packages, that use one or more sources of health information that is captured and can be transmitted electronically via interoperable systems.” As stated in our response to the FY 2023 Hospital IPPS proposed rule, dQMs should be developed in a way that allows their components to support a variety of use cases, such as decision support and quality improvement.
We also concur with CMS that eCQMs meet the definition of “dQM,” but, as CMS notes, “limitations in data standards, requirements, and technology have limited their interoperability.” We believe these limitations, and challenges aggregating QRDA files, have constrained their adoption in value-based contracts—one reason why we are working to deliver the next generation of dQMs as configurable, modular software applications that can integrate relevant data via FHIR and other standard-based APIs.
Toward that end, on June 1, NCQA launched our inaugural Digital Quality Solutions Pilot, a software development project in coordination with six trailblazing health plans, delivery systems and health IT firms. These organizations will provide vital feedback on the usefulness, feasibility and value of NCQA software and next-generation measure prototypes intended to align quality measurement across health care and prove the value of an end-to-end measure calculation solution (or measure calculation tool [MCT]) by distributing digital measures from an MCT to end users. This pioneering work can move the industry forward to realizing the full potential of dQMs and can be a prototype for CMS’s considerations for MCTs, as outlined in its recently published Digital Quality Measurement Strategic Roadmap.
Data Standardization Activities to Leverage and Advance Standards for Digital Data
Enabling a Learning Health System (LHS) through data standardization: dQMs are a critical component of a fully interoperable LHS that generates reliable knowledge when it is needed most. In our opinion, this is not accurately depicted in CMS’s latest LHS model. We request that CMS consider how dQMs fit into an LHS.
dQMs should not be a standalone “use case” for digital data in the LHS but should serve a critical role in the aggregation and processing that organizes information into knowledge. The current model CMS put forward describes dQMs as they would occur in the traditional retrospective reporting cycle and fails to unlock their full potential to support use cases beyond reporting. We welcome the opportunity to share our vision for including dQMs in the knowledge domain, as they are not only calculation tools, but a key industry standard for translating evidence-based practice guidelines into actionable clinical utility.
While we support, and are encouraged by, the promise of FHIR, CMS’s digital strategy should focus beyond moving all stakeholders to FHIR standards—an essential step—and enable migration to a set of standards and support mapping among standards. FHIR standards do not yet support all data models used by the measurement and research communities, so it may be premature to force conformance to a single model. Mapping among a variety of data models can accelerate progress, providing the most value and easing the burden of transitioning to digital measurement. We believe CMS should put resources toward efforts to advance data interoperability, and focus on making tooling and guidance freely available, to enable uptake. Collaborations like OMOP on FHIR, where the community developed tools to convert from one data model to another, is an example of advancing data standards without requiring a “one-size fits all” approach at this stage of the digital journey.
Implementation Guides (IG): We believe the IGs referenced are valuable to operationalize the current state of quality measurement (e.g., eCQMs), but are not yet adequate to operationalize future dQMs. NCQA is prepared to expend considerable resources to lead IG development and to ensure that the quality measurement use case is considered. We commend HL7 and the DaVinci Project for their enormous contributions to date.
We appreciate CMS’s consideration of additional IGs needed to support the future state of all dQMs, such as “guidance on aggregation mechanisms for reporting.” We encourage CMS to consider IGs in two categories, each with unique contributions to an all-dQM future: content/context IGs (e.g., measures expressed in FHIR-CQL) and operational IGs (e.g., for data aggregation or CMS reporting). It is essential that throughout this transition we describe digital specifications (content/context) and digital reporting (operational) as two distinct concepts supporting a single goal.
USCDI: We are encouraged by the collaboration of federal agencies to define data classes and elements needed for digital quality measurement and public reporting through USCDI+. Although this idea is novel for circumventing the limitations of burdening USCDI, we urge CMS and ONC to release additional details for stakeholder input. Plans, vendors, systems and providers are adopting solutions to meet both federal and commercial needs and USCDI+ should not be limited only to meeting “federal agency data needs.”
Furthermore, we commend USCDI and USCDI+ for defining standardized data elements and classes, but they are insufficient for measurement purposes as the level of detail is inadequate to ensure validity or reliability. The role of aggregation will be critical to normalize, standardize and provide quality controls to ensure that digital data have been extracted, transformed and loaded from a clinical data source through appropriate and valid methods. We thank CMS for noting the importance of providing guidance and processes to ensure appropriate aggregation in the CMS Digital Quality Measurement Strategic Roadmap, and for highlighting NCQA’s Data Aggregator Validation program as an avenue to ensure that data transmitted by aggregators are complete, accurate, reliable and standardized.
We are grateful to be partnering with ONC in a series of discussions on developing a model for mapping clinical concepts to computable specifications to provide guidance to the broader community as well as data mapping for measures to USCDI+.
Approaches to Achieving FHIR eCQM Reporting
NCQA continues to strongly support the proposed transition from the Quality Data Model to the FHIR standard for all CMS quality measure reporting, including eCQM reporting. We have already created 22 FHIR-CQL digital HEDIS measures, and we intend to advance our digital measures portfolio by converting existing HEDIS measures to digital specifications and creating de novo dQMs.
We continue to evolve our HEDIS portfolio and HEDIS Audit and Certification methodology, with the goal of optimizing data flow and providing a seamless infrastructure to align measurement principles across the American health care system. Our Digital Solutions Pilot, mentioned earlier, will help us define the data model that enables connected measures across the levels of health care and provides timely information to clinicians, health systems, plans and governments to support quality improvement.
Advancing the Trusted Exchange Framework (TEFCA) and Common Agreement (CA)—Request for Information
We applaud CMS’s interest in advancing the TEFCA and CA within the Medicare Promoting Interoperability Program, and we agree that eligible clinicians should get credit for the Health Information Exchange objective by signing a “Framework Agreement” as defined in the CA. We encourage CMS to continue to incentivize standardized data exchange under TEFCA through other CMS programs and value-based payment models. This will greatly enhance our ability to automatically extract data for quality measurement from HIEs and other non-EMR clinical data sources.
Medicare Part B Payments for Services Involving Community Health Workers – Request for Information
Community health workers (CHWs) are essential to long-term health equity for the communities they serve. The unique skills and experiences of CHWs can help address structural racism and the policy systems and environments of inequality that contribute to health disparities. There is also a large body of evidence that CHWs can improve chronic disease management and mental health and can be a cost-effective addition to the care team.
In considering whether and how CHWs provide services to Medicare beneficiaries, NCQA encourages CMS to work with key stakeholders, including private and public partners and local CHW networks, to develop organization level standards to support successful CHW programs. NCQA recently released a white paper with the Penn Center for Community Health Workers, Critical Inputs for Successful Community Health Worker Programs , which highlights nine organization level concepts needed for CHWs to be well supported to do their best work. CHWs are well-positioned to bill under the general supervision of physicians based on their ability to integrate with clinical care teams, a best practice for CHW programs. Physicians do not need to replace existing CHW supervisors, who are individuals with deep knowledge of the most effective ways to supervise and support CHWs.
CMS must include the full range of CHW services, going beyond preventive services to include critical domains such as social support, advocacy and coaching. CMS should also not impose CHW certification requirements, as these have no proven relationship to patient outcomes and can weed out authentic, grassroots CHWs. NCQA encourages CMS to work with key stakeholders, including private and public partners and local CHW networks to create system level changes that allow CHWs to be better supported and secure in their roles. These changes should include a mechanism for consistent reimbursement for services beyond preventive care to include a broad range of services, including non-medical interventions.
Thank you again for the opportunity to comment. We welcome the chance to discuss our experience and findings, and we remain committed to working with CMS to build a more equitable, sustainable, and responsible American health care system. If you have any questions, please contact Eric Musser, NCQA Assistant Vice President of Federal Affairs, at (202) 955-3590 or at email@example.com, or Olivia Umoren, NCQA Federal Affairs Manager, at (202) 827-9450 or at firstname.lastname@example.org.
Margaret E. O’Kane
National Committee for Quality Assurance