Improving the submission of quality data to CMS quality reporting programs

By: Kate Goodrich, M.D., M.H.S., Director, Center for Clinical Standards & Quality, CMS

At the Centers for Medicare & Medicaid Services (CMS), we are working to build a health care delivery system that is better, smarter and healthier – a system that delivers improved care, spends health care dollars more wisely, and supports healthier communities. The use of health information technology (IT), such as electronic health records (EHR), and data are critical pieces in building this health care delivery system. Importantly, health IT can also support electronic clinical quality measurement, which allows for more timely access to richer clinical data sources, more rapid feedback for quality improvement, and reduced reporting burden for providers.

CMS and the Office of the National Coordinator for Health Information Technology (ONC) are committed to ensuring health IT systems can support accurate, reliable, and robust reporting of quality measures. To help achieve that goal, CMS, in partnership with ONC, issued a Request for Information (RFI) today entitled Certification Frequency and Requirements for the Reporting of Quality Measures under CMS Programs, available here: https://www.federalregister.gov/articles/2015/12/31/2015-32931/agency-information-collection-activities-proposals-submissions-and-approvals-certification-frequency. The RFI provides CMS and ONC with an opportunity to assess policy options that could improve the effectiveness of the certification of health IT and specifically the certification and testing of EHR products used for the reporting of quality measures. We aim to streamline/reduce provider, hospital, and health IT developer burden.

CMS and ONC request feedback on how often to require recertification, the number of clinical quality measures to which a certified Health IT Module should be certified, and ways to improve testing of certified Health IT Module(s). The feedback received will inform CMS and ONC of elements that may need to be considered for certification and testing policies and other policies relating to the use of health IT to report quality measures that may be included in the upcoming rulemaking process for CMS quality programs.

We are working diligently to improve the means for information exchange and electronic data sharing across and among providers and health systems, increase opportunities for stakeholders to provide feedback, and enhance mechanisms for the capturing of clinical information in EHRs, registries, and other systems to assist with quality reporting and care coordination.

The RFI now has a 45-day comment period with comments due February 16, 2016 https://www.federalregister.gov/articles/2016/02/02/2016-01937/requests-for-information-certification-frequency-and-requirements-for-the-reporting-of-quality. Please review the RFI for instructions on how to submit comments. We want to hear from you and value all input received from our stakeholders.

 

CMS Quality Measure Development Plan Supporting the Transition to the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs)

By: Kate Goodrich, M.D., M.H.S., Director, Center for Clinical Standards & Quality, CMS

Today we’re continuing to shift Medicare payments from volume to value by posting our draft Quality Measure Development Plan [https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html]. The Measure Development Plan is a strategic framework for future clinician quality measurement development.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) further supports the path to value in health care with the new Merit-based Incentive Payment System (MIPS) and incentives for providers to participate in alternative payment models (APMs).

To accelerate the alignment of quality measurement and program policies, MACRA sunsets payment adjustments for three existing clinician reporting and incentive programs:

• Physician Quality Reporting System (PQRS).
• Value-based Payment Modifier (VM).
• Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals (EPs), commonly known as Meaningful Use.

The Measure Development Plan outlines how we’ll draw from our quality measure development experience to build a measure portfolio for MIPS and APMs. Existing measurement strategies, policies, and principles will guide our efforts.

The Measure Development Plan focuses on gaps we identified in the quality measure sets currently in use in PQRS, VM, and the EHR Incentive Program and offers recommendations for filling these gaps. Future measure development will prioritize person- and caregiver-centered experience of care, patient-reported outcomes and patient health outcomes, communication and care coordination, and appropriate use of resources across six quality domains:

1. Clinical Care.
2. Safety.
3. Care Coordination.
4. Patient and Caregiver Experience.
5. Population Health and Prevention.
6. Efficiency and Cost Reduction.

In addition, these measures will promote efficient data collection, better ensure provider accountability—individual and shared, and yield publicly reported quality results that consumers can use to make informed health care decisions.

The Measure Development Plan describes how CMS will work collaboratively with federal and state partners and private payers to create an aligned set of measures that reduces provider burden.  The plan also describes resources and activities that can contribute to the development of measures applicable to a wide variety of stakeholders.

As our portfolio of measures evolves, we will continue to seek input on the draft plan and its stated priorities from clinicians, payers, patients, caregivers, and other stakeholders. We’ll review and consider all comments we receive as we develop the final Measure Development Plan, which we will post by May 1, 2016.

The  Measure Development Plan directly supports the implementation of MIPS and APMs and your input is important to us. These programs move the Medicare program and our overall health care system toward paying for the quality rather than the quantity of care delivered to patients.

We encourage you to read the Measure Development Plan and send us your comments, questions or thoughts by March 1, 2016, either online [https://www.surveymonkey.com/r/26NYQRB]; via the MDP dedicated email address [MACRA-MDP@hsag.com]; or by U.S. mail [Attn: Eric Gilbertson, CMS MACRA Team; Health Services Advisory Group, Inc.; 3133 East Camelback Road, Suite 240; Phoenix, AZ 85016-4545].

Thank you for your feedback on Stage 3 of the EHR Incentive Programs

By Kate Goodrich, Director Center for Clinical Standards and Quality

As we approach the end of the public comment period for certain provisions of the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs final rule, we want to provide a brief update on the comment process.

As you know, the rule established new criteria that eligible professionals, eligible hospitals, and critical access hospitals (CAHs) must meet in order to participate successfully in the EHR Incentive Programs in 2015 through 2017 and Stage 3 in 2018 and beyond.

The 60-day comment period was meant to generate feedback on Stage 3 of the EHR Incentive Programs in the future, and how the program will be affected by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which establishes the Merit-Based Incentive Payment System (MIPS).

First, we want to thank the many individuals and organizations that provided feedback. To date, we have received more than 500 comments on a rule we expect will have a significant effect not only on how U.S. health care providers do their jobs, but—more importantly—on the quality of health care across the country. It’s an important task, and we appreciate the time you have spent highlighting the areas that concern you the most.

We’ve heard you. And we will continue to consider carefully what everyone has to say until the final comment is submitted at the end of the comment period. Of the comments we have received, many physician practices and health care provider organizations have emphasized that the Meaningful Use Programs should provide more flexibility and address interoperability challenges.

Above all, we heard you when you said EHRs shouldn’t be a challenge for health care providers to overcome, but rather a helpful tool to improve care for patients.

Thank you again for helping us to achieve our shared goal of delivering better care, smarter spending, and healthier people through EHRs. We look forward to reviewing the comments and continuing to work together to improve health care through health information technology. The comments may inform the development of the proposed rule for MACRA that we expect to release in the spring and will allow for additional opportunity to provide comments that will help to continue to shape the program.

If you have any questions about the current requirements in the final rule, please visit our CMS EHR Incentive Programs website.

 

Growing the Qualified Entities Program to Support Informed Decision-making by Consumers and Providers

By Niall Brennan, CMS Chief Data Officer and the Director of the Office of Enterprise Data and Analytics (OEDA)

At CMS, we are committed to providing our stakeholders with information needed to support informed decision-making as they navigate the health care system. As such, we have been a government leader in promoting increased data transparency. For example, we have released data on geographic variation in Medicare utilization and quality, as well as data on provider level utilization, including prescribing patterns. A commitment to making such resources available puts engaged and empowered individuals at the center of their care, which is essential to transforming our system to one that delivers better care, smarter spending, and healthier people.

Today, I want to share some exciting developments related to the Qualified Entity (QE) program, which was established under the Affordable Care Act. The QE program facilitates the creation of publicly available performance reports and data that can be used to help improve provider quality, increase transparency in health care performance, and provide information for employers, consumer groups, patients, and caregivers to assist them in making more informed health care decisions.

There are currently 12 certified QEs – 11 QEs that will be reporting regionally and one QE that will be reporting nationwide. Since the launch of the program, two QEs have already released public performance reports. Today, I’m excited to announce further growth in the QE program with the approval of a second nationwide QE, Amino. With the addition of Medicare data, Amino will enhance its free service to help Americans make care decisions, including, for example, determining the providers from whom they choose to receive services.

Prior to the Affordable Care Act, provider reporting was fragmented, making it difficult for providers and consumers to access a comprehensive picture of provider performance on quality and cost. The QE program enables qualified entities to create a more complete picture of provider quality and cost of care by combing Medicare data with data from multiple health plans.

As we continue our effort to make actionable information available to consumers and providers alike, we are looking forward to the future release of a Notice of Proposed Rulemaking (NPRM) that will implement changes to the QE program enacted by Congress under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This legislation expands permissible uses and disclosures under the QE program. We look forward to receiving comments from interested stakeholders when the NPRM is released.

 

Electronic Health Records Incentive Programs

Kate Goodrich, Director Center for Clinical Standards & Quality

We are living in a time of unprecedented change for health IT.  Initiatives like the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs are at the forefront of hospitals, physicians and nurse practitioners to adopt an electronic medium for patient information.   CMS and physicians have a shared goal in the EHR program of helping physicians, clinicians, and hospitals to deliver better care, smarter spending, and healthier people.

The requirements of ‘Meaningful use’ are defined in 42 CFR Part 495, but the general intent of meaningful use is for providers to show they’re using certified EHR technology in ways that improve care.

EHRs also have the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting.  EHRs are the next step in the continued progress of healthcare that can strengthen the relationship between patients and clinicians.  The data, and the timeliness and availability of it, will enable providers to make better decisions and provide better care.

CMS has heard from physicians and other providers about the challenges they face making EHRs work well for their individual practices and for their patients.  CMS is committed to actively engaging with stakeholders and the general public to obtain the input that is needed on how to improve the EHR Incentive Programs over time. CMS encourages all stakeholders and the general public to submit comments on the recent final rule with comment period for the Medicare and Medicaid EHR Incentive Programs final rule by December 15, 2015.

Medicare eligible professionals are encouraged to consider applying for exceptions to the Medicare payment adjustments if they need to switch technology or have other technology difficulties with their EHR vendor. Information on the exception process and the relevant dates in 2016 are available here. CMS looks forward to feedback from physicians to inform future policy developments for the EHR Incentive Programs.

 

Weekly Data Analysis

By Niall Brennan, Director & CMS Chief Data Officer

During the second Open Enrollment period (OE2), CMS began releasing weekly snapshots about states using the HealthCare.gov platform to provide additional details about enrollment progress; this has continued during the third Open Enrollment period (OE3). These weekly snapshots include point-in-time estimates of weekly and cumulative plan selections.  This document provides some guidance for interpreting the numbers in these snapshots, particularly when comparing this year’s (OE3) weekly results to last year’s.

1. Deadlines drive plan selections. Just like many Americans who file taxes on April 15, experience has shown that the majority of consumers sign up for health coverage closer to deadlines. In fact, last year, more than half of sign-ups occurred in the two weeks leading up to the December 15 deadline. If you look at the November 29 – December 5 time period, as shown in Table 1, you’ll see a similar trend this year. Both this year and last year, the only deadline in November or December is December 15, for January 1 coverage, and we expect enrollment to continue to grow in the period from December 6 – 15, as it did last year. Last year, the deadline to sign up for January 1 coverage (December 15) was one month after Open Enrollment began, compared to the 6 week lead time before the deadline this year. 

2. The third Open Enrollment period started earlier than last year. Open Enrollment for 2016 coverage started two weeks earlier (November 1) and finishes 2 weeks earlier (January 31) than 2015. Because of this two-week difference, if people want to compare snapshots they should do so for the same time periods. For example, the most appropriate comparison for the OE3 week 5 snapshot released this week is actually the OE2 week 3 snapshot from the corresponding time period last year. 

3. There were far more returning consumers heading into Open Enrollment this year. Because of the success of OE2, we are starting this Open Enrollment with more Marketplace consumers than there were in 2014 and, correspondingly fewer currently uninsured Americans to sign up. Therefore, one should expect returning consumers will make up a larger fraction of total enrollment as compared to new enrollees this year – a trend that will become even more pronounced in future years as the Marketplace continues to grow and stabilize.                                                                                                                                                                                           Table 1: Week-by-Week Total Plan Selections 2014 and 2015 
   

   YEAR	Nov 1 – 7	Nov 8 – 14	Nov 15 – 21	Nov 22 – 28	Nov 29 – Dec 5	Dec 6 – 12	Dec 13 – 19
   OE3 Total Plan Selections	543,098	534,778	567,822	394,732	804,338	**	**
   OE2 Total Plan Selections	*	*	462,125	303,010	618,548	1,082,879	3,927,484

   *Open Enrollment for 2015 coverage did not start until November 15, 2014.

   **Data from December 6 – December 19 is not yet available.                                                                                                                                                                                                                                                                                                   

   Chart 1: Plan Selections by Enrollment Week

   

CMS awards five year $110 million in ESRD Network funding to continue improvements in quality and access to care for people living with end stage renal disease

By: Patrick Conway, M.D., MSc, Acting Deputy Administrator and Chief Medical Officer, CMS

The Centers for Medicare & Medicaid Services (CMS) awarded $110 million in end stage renal disease (ESRD) Network funding for the 18 ESRD Networks to seven entities. These seven entities will work over a five year contract period, 2016 – 2020, to continue efforts in improving quality of care and access to care for individuals with irreversible kidney disease who require dialysis or transplantation to sustain life.

ESRD beneficiaries make up less than one percent of the Medicare population, but account for 7.1 percent of the Medicare spending. The ESRD Networks, created by statutory mandate in 1978, were developed to improve cost-effectiveness, ensure quality of care, encourage kidney transplantation and home dialysis, provide assistance to ESRD beneficiaries and providers, and increase ESRD Network Program accountability.

The following entities have been awarded ESRD Network Contracts:

AWARDED ENTITY	ESRD NETWORKS
IPRO	1,2,6,9
Quality Insights	·        3,4,5
Health Services Advisory Group (HSAG)	·        7,13,15,17
Alliant Health Solutions	·        8,14
Qsource/Network Strategies and Innovation (NSI)	·        10,12
Renal Network of the Upper Midwest	·        11
Health Insights	16,18

The 2016 – 2020 ESRD Network Contract requires the 18 ESRD Networks to deploy interventions that target patients, dialysis/transplant providers, other providers, and/or stakeholders to substantively impact specific areas of focus. ESRD Networks’ quality improvement activities will incorporate the attributes of innovation; rapid cycle improvement; teamwork; customer-focus; and sustainability. Specific quality improvement activities will include efforts to impact the ESRD population by increasing Pneumococcal and Hepatitis B vaccination rates in dialysis patients; reducing the use of long term catheters for vascular access and reducing hospital acquired infections. Additionally, ESRD Networks will work on Pilot Projects to increase transplant referrals, increase home dialysis rates, improve quality of life and reduce hospitalizations for persons with ESRD.

During the 2013 – 2016 ESRD Network Contract Cycle, ESRD Networks saw great successes. These successes included leadership in Patient and Family Engagement through learning and action network activities. Additionally, ESRD Networks have moved arteriovenous fistula (AVF) vascular access use to above 60 percent nationally. Also, in collaboration with the Centers for Disease Control, and in support of the ESRD Quality Incentive Program, ESRD Networks assisted over 99 percent of the nation’s dialysis facilities in enrollment in the National Healthcare Safety Network. This 2016 – 2020 Contract represents the first time that CMS has awarded the ESRD Networks a five year contract. This will allow ESRD Networks to implement quality improvement activities over a more continuous timeframe with the goal of reaching and engaging more patients and providers as partners in this life-sustaining work.

This announcement is part of a broader effort to transform our health care system into one that works better for the American people. After completing a large, national, full and open competition for our ESRD Network Program, we are excited to work with these seven entities over the next five years to improve the quality of care for people living with end stage renal disease. More information on the activities of the ESRD Networks can be found at http://www.esrdncc.org.