PRMR MUC List Commenting

Johnson & Johnson does not support this measure as specified, as it may inappropriately penalize providers for costs that are out of their control, and evaluates absolute aggregate costs without context of quality of care or patient outcome, or patient severity and related course of treatment. We recommend the measure be updated to stratify costs based on patient acuity level and be linked to patient outcomes. 
 

Johnson & Johnson recognizes that the development and implementation of cost measures is required by federal statute. We are concerned that many such measures are not adequately designed to prevent care stinting as the standard of care evolves. Any cost offsets from a treatment approach that involves a higher upfront cost that are not captured within the timeframe of the measure may result in clinicians avoiding those treatments. Moreover, there are instances in care innovation where there simply are not cost savings associated with a given treatment, even though outcomes are substantively higher. This is why the concept of capturing value is so critical when designing cost metrics. Value is often expressed as cost per unit of quality. To ensure value in the care provided for Medicare beneficiaries, CMS should consider how to ensure that every cost measure is specified over an appropriate timeframe to capture instances where downstream value is derived from upstream cost. We highly encourage CMS to also ensure that every cost measure is paired with accountability to outcomes measures (including PRO-PMs) to avoid potential incentive misalignment and care stinting. We are concerned that implementation of this measure could incentivize care stinting because there is no outcome measure evaluating prostate cancer in MIPS, and providers must also be accountable for care outcomes measures when cost containment measures are implemented.  

Johnson & Johnson does not support this measure for two key reasons. First, it may inappropriately penalize providers for costs that are out of their control and may vary widely, introducing potential for outlier effects on performance. Second, it evaluates absolute aggregate costs without context of quality of care or patient outcome. While we recognize that the development and implementation of cost measures is required by federal statute, we are concerned that many such measures are not adequately designed to prevent care stinting as the standard of care evolves. Any cost offsets from a treatment approach that involves a higher upfront cost that are not captured within the timeframe of the measure may result in clinicians avoiding those treatments. Moreover, there are instances in care innovation where there simply are not cost savings associated with a given treatment, even though outcomes are substantively higher. This is why the concept of capturing value is so critical when designing cost metrics. Value is often expressed as cost per unit of quality. To ensure value in the care provided for Medicare beneficiaries, CMS should consider how to ensure that every cost measure is specified over an appropriate timeframe to capture instances where downstream value is derived from upstream cost. We highly encourage CMS to also ensure that every cost measure is paired with accountability to outcomes measures (including PRO-PMs) to avoid potential incentive misalignment and care stinting. 

Johnson & Johnson is supportive of this measure aimed at resolving health related social needs for beneficiaries. Efforts to improve food access through healthy food environments, public benefit programs, health care systems, health insurers, and evidence-based nutrition standards can lower health care costs and improve health outcomes. (https://aspe.hhs.gov/topics/health-health-care/addressing-social-determinants-health-federal-programs). Resolving at least one health-related social need (HRSN) can assist patients in achieving positive health outcomes, and we support this measure.

Johnson & Johnson supports this measure to provide accountability to the system and ensure patients are receiving evidenced-based care supported by informed clinical decision-making. Utilization management, including prior authorization (PA), concurrent and retrospective review, step edits and other techniques, are designed to manage healthcare resources efficiently and ensure medical treatment plans are appropriate (1). However, these same programs can create significant barriers for patients by delaying the start or continuation of necessary treatment, negatively affecting patient health outcomes and burdening providers by diverting time and resources from direct patient care (2). For many diseases, delays in diagnosis and treatment initiation may result in disease progression, increased morbidity and hospitalization, and decreased survival (3).  

A 2023 study showed that prior authorizations were associated with greater number of days to treatment for infusible medications for rheumatoid arthritis and irritable bowel disease (4). A report by the Office of Inspector General highlighted that current PA policies in Medicare Advantage unnecessarily create barriers and delays for patients to receive care (5). A 2023 Kaiser Family Foundation report identified that, in 2021, while only 11% of the more than two million PA denials were appealed, more than 80% of appeals fully or partially overturned the initial PA denial, and that the PAs were inconsistently applied across the Medicare plans (6).   

References 

1. ADEC Healthcare. The Value of Utilization Management Services in Healthcare. May 22, 2023. https://www.healthcare.adec-innovations.com/news-and-updates/news-updates/the-value-of-utilization-management-services-in-healthcare/#:~:text=Utilization%20management%20manages%20healthcare%20resources,to%20support%20clinical%20decision%2Dmaking. Accessed December 14, 2023. 
2. American Medical Association, Prior Authorization and Utilization Management Reform Principles. https://www.ama-assn.org/system/files/principles-with-signatory-page-for-slsc.pdf. Accessed December 14, 2023.  
3. Highland KB et al. Am J Manag Care. 2019;25(7 suppl):S119-S127. 
4. Ismail WW, Witry MJ, Urmie, JM. The association between cost sharing, prior authorization, and specialty drug utilization: A systematic review. J Manag Care Spec. Pharm. 2023 May;29(5):449-463. Doi:10.18553/jmcp.2023.29.5.449. PMID: 37121255; PMCID: PMC10388011. 
5. Some Medicare Advantage Organization Denials of Prior Authoriztion Requests Raise Concerns About Beneficiarly Access to Medically Necessary Care. OEI-09-18-00260.  
6. Kaiser Family Foundation 2023. https://www.kff.org.medicare/issue-brief/over-35-million-prior-authorization-requests-were-submitted--to-medicare-advantage-plans-in-2021/. Accessed December 14, 2023. 

Please see the attached chart for CTAC's comments on several of the MUCs. Thank you

We support CMS's aim to measure how often we are screening SDOH among our patients. However, we don't think it is fair or realistic to hold hospitals accountable for resolving a health-related social need on our own. To start, the documentation burden on this measure would be immense and would distract from critical patient care functions. This measure assumes that patients will return to the same hospitals and care setting to even track whether a particular need has improved over the course a set timeframe. This information would then need to be reassessed and documented on each visit. 

Second, while hospitals can and should screen for health-related social needs and make appropriate patient referrals, we should not be held responsible for the safety net of an entire region. Our health system plays an active role in community health improvement, but we cannot do it on our own. A measure like this sets the expectation that a hospital should not only be a provider of medical care, but also provide for every conceivable social need from utilities, transportation, food, social isolation, etc. We believe that hospitals should be accountable for collecting SDOH information and partnering with our community to deliver equitable care. However, we do not think we should assume responsibility for delivering social services across our entire region. 

Vizient, Inc. appreciates the opportunity to comment on the Partnership for Quality Measurement (P4QM) measure development process, particularly the Pre-Rulemaking Measure Review (PRMR) process. As noted by P4QM, the PRMR process makes consensus recommendations regarding the inclusion of measures being considered for CMS quality reporting and value-based programs. Vizient applauds P4QM for working with stakeholders and the public on developing these important measures, as these measures significantly impact our providers and the patients they serve. 

Vizient, Inc. provides solutions and services that improve the delivery of high-value care by aligning cost, quality and market performance for more than 60% of the nation’s acute care providers, which includes 97% of the nation’s academic medical centers, and more than 20% of ambulatory providers. Vizient provides expertise, analytics, and advisory services, as well as a contract portfolio that represents more than $130 billion in annual purchasing volume, to improve patient outcomes and lower costs. Headquartered in Irving, Texas, Vizient has offices throughout the United States. 

We commend P4QM on its efforts to prioritize health equity but have ongoing concerns regarding the Screening for Social Drivers of Health measure. Vizient and our provider members recognize the critical need to address social drivers of health for each patient to ensure equitable health outcomes and we support efforts to increase the screening of all patients for social drivers of health. However, consistent with prior comments (https://vizientinc-delivery.sitecorecontenthub.cloud/api/public/content/e46e2e8e9d704f2bbbe4250c4dd92ed9) to the Centers for Medicare and Medicaid Services (CMS), Vizient remains concerned that there is no standard definition for “screening” or “social drivers of health” as related to this measure. Whether P4QM adopts an existing standard or creates a new one, clear and consistent definitions are critical to collecting data that can be meaningfully used by the healthcare system to improve patient outcomes. Additionally, defining these terms supports identification and proper use of validated screening tools. Without consistency, it is difficult for health systems and other stakeholders to address patient needs and risks identified during screening. 

Vizient is concerned that within the measure as written, the domains of Health-Related Social Needs (HRSNs) are not clearly defined. Since CMS proposed this measure, Vizient has heard from hospitals that there is confusion around how the specific domains are defined. For example, there is no standard for what constitutes “food insecurity”, so there is a range of interpretations (e.g., lack of access to any food; lack of access to healthy food; lack of access to food over a certain period of time). As a result of varying potential interpretations of the domains, hospitals are spending excessive time trying to understand and define measures, which ultimately takes time away from initiatives that would improve health equity. Vizient is concerned that failure to provide greater clarity will have the unintended consequence of negatively impacting patient and provider interactions, particularly with historically underserved populations. 

We recommend that P4QM work with stakeholders to more clearly define terms and domains related to this measure. Vizient is concerned that this, as written, will limit the utility and comparability of collected data. As P4QM is aware, standardization is critical for ensuring that patient data collected by health systems and other providers can be effectively utilized to address patient needs and identify broader, community-wide needs to improve social drivers of health. Although this measure has already been approved for use in multiple CMS programs, these concerns have not been addressed. Expanding the use of this measure in other quality reporting programs without refining the measure, adapting it based on more recent learnings, or considering data from its use in the IQR program will significantly limit the utility of such data sets, as they may not be consistent across data collectors, leading to challenges in developing more refined or targeted measures in the future. 

Further, the Screening for Social Drivers of Health Measure does not account for geographic variations in communities and therefore may be missing an opportunity to ask or prioritize screening for certain social needs drivers that are relevant to the community. Vizient’s analyses have shown significant variation in community need across large geographic areas as well as within local markets at the zip code and census tract level. If this measure does not account for geographic variation of social drivers impacting the population, interpretation of these data points could not only be misleading but could also take away the opportunity to prioritize asking patients about social needs that are meaningful to them (https://www.vizientinc.com/what-we-do/health-equity/vizient-vulnerability-index-public-access). Further, hospitals or providers with higher levels of community need may be further challenged to support patients and maintain relationships of trust with patients if they perform redundant, generic screenings without having the resources or capacity to better address social needs. To help address these concerns, accommodations for geographic variation could be achieved through benchmarking using an index of local obstacles to care (i.e., the Vizient Vulnerability Index™, more information available at: https://www.vizientinc.com/what-we-do/health-equity/vizient-vulnerability-index-public-access; see also attachment).

Vizient, Inc. appreciates the opportunity to comment on the Partnership for Quality Measurement (P4QM) measure development process, particularly the Pre-Rulemaking Measure Review (PRMR) process. As noted by P4QM, the PRMR process makes consensus recommendations regarding the inclusion of measures being considered for CMS quality reporting and value-based programs. Vizient applauds P4QM for working with stakeholders and the public on developing these important measures, as these measures significantly impact our providers and the patients they serve. 

Vizient, Inc. provides solutions and services that improve the delivery of high-value care by aligning cost, quality and market performance for more than 60% of the nation’s acute care providers, which includes 97% of the nation’s academic medical centers, and more than 20% of ambulatory providers. Vizient provides expertise, analytics, and advisory services, as well as a contract portfolio that represents more than $130 billion in annual purchasing volume, to improve patient outcomes and lower costs. Headquartered in Irving, Texas, Vizient has offices throughout the United States. 

We commend P4QM on its efforts to prioritize health equity but have ongoing concerns regarding the Screening for Social Drivers of Health measure. Vizient and our provider members recognize the critical need to address social drivers of health for each patient to ensure equitable health outcomes and we support efforts to increase the screening of all patients for social drivers of health. However, consistent with prior comments (https://vizientinc-delivery.sitecorecontenthub.cloud/api/public/content/e46e2e8e9d704f2bbbe4250c4dd92ed9) to the Centers for Medicare and Medicaid Services (CMS), Vizient remains concerned that there is no standard definition for “screening” or “social drivers of health” as related to this measure. Whether P4QM adopts an existing standard or creates a new one, clear and consistent definitions are critical to collecting data that can be meaningfully used by the healthcare system to improve patient outcomes. Additionally, defining these terms supports identification and proper use of validated screening tools. Without consistency, it is difficult for health systems and other stakeholders to address patient needs and risks identified during screening. 

Vizient is concerned that within the measure as written, the domains of Health-Related Social Needs (HRSNs) are not clearly defined. Since CMS proposed this measure, Vizient has heard from hospitals that there is confusion around how the specific domains are defined. For example, there is no standard for what constitutes “food insecurity”, so there is a range of interpretations (e.g., lack of access to any food; lack of access to healthy food; lack of access to food over a certain period of time). As a result of varying potential interpretations of the domains, hospitals are spending excessive time trying to understand and define measures, which ultimately takes time away from initiatives that would improve health equity. Vizient is concerned that failure to provide greater clarity will have the unintended consequence of negatively impacting patient and provider interactions, particularly with historically underserved populations. 

We recommend that P4QM work with stakeholders to more clearly define terms and domains related to this measure. Vizient is concerned that this, as written, will limit the utility and comparability of collected data. As P4QM is aware, standardization is critical for ensuring that patient data collected by health systems and other providers can be effectively utilized to address patient needs and identify broader, community-wide needs to improve social drivers of health. Although this measure has already been approved for use in multiple CMS programs, these concerns have not been addressed. Expanding the use of this measure in other quality reporting programs without refining the measure, adapting it based on more recent learnings, or considering data from its use in the IQR program will significantly limit the utility of such data sets, as they may not be consistent across data collectors, leading to challenges in developing more refined or targeted measures in the future. 

Further, the Screening for Social Drivers of Health Measure does not account for geographic variations in communities and therefore may be missing an opportunity to ask or prioritize screening for certain social needs drivers that are relevant to the community. Vizient’s analyses have shown significant variation in community need across large geographic areas as well as within local markets at the zip code and census tract level. If this measure does not account for geographic variation of social drivers impacting the population, interpretation of these data points could not only be misleading but could also take away the opportunity to prioritize asking patients about social needs that are meaningful to them (https://www.vizientinc.com/what-we-do/health-equity/vizient-vulnerability-index-public-access). Further, hospitals or providers with higher levels of community need may be further challenged to support patients and maintain relationships of trust with patients if they perform redundant, generic screenings without having the resources or capacity to better address social needs. To help address these concerns, accommodations for geographic variation could be achieved through benchmarking using an index of local obstacles to care (i.e., the Vizient Vulnerability Index™, more information available at: https://www.vizientinc.com/what-we-do/health-equity/vizient-vulnerability-index-public-access; see attachment).

Vizient appreciates P4QM’s efforts to prioritize health equity but believes that there is a need to develop a measure that focuses on provider process measures that are within a provider’s locus of control, rather than readmissions measures, which are influenced by several factors beyond the provider’s control. 

Vizient, Inc. provides solutions and services that improve the delivery of high-value care by aligning cost, quality and market performance for more than 60% of the nation’s acute care providers, which includes 97% of the nation’s academic medical centers, and more than 20% of ambulatory providers. Vizient provides expertise, analytics, and advisory services, as well as a contract portfolio that represents more than $130 billion in annual purchasing volume, to improve patient outcomes and lower costs. Headquartered in Irving, Texas, Vizient has offices throughout the United States. 

Regarding the Hospital Equity Index (HEI) measure, Vizient is deeply concerned that the measure, as written, continues to present a significant challenge for hospitals and other providers for several reasons. Eleven of the thirteen included measures are related to readmission rates, which can be heavily influenced by external factors outside of the provider’s locus of control. Vizient suggests P4QM consider process measures that better evaluate differences in provider care and decision making, rather than readmissions measures. For example, timely administration of antibiotics for sepsis patients is an example of a measure that captures interventions within the provider’s locus of control. 

Also, Vizient is concerned readmissions would be double counted with this measure, as using this measure alongside condition-specific measures and the Hospital-Wide 30-Day All-Cause, Risk-Standardized Readmission Rate following Hospitalization (HWR) measure would, effectively, double-count the rates of readmissions. If readmissions rates are to be used despite our concerns, Vizient recommends, at minimum, the measure be modified to use the all-cause readmission rate to avoid compounding the rates. Alternatively, as noted above, Vizient believes differences in provider care and decision making can be better evaluated with a measure that focuses on provider processes within their control.

Vizient also cautions that combining standardized Within and Across Disparity Method results will result in patient detail being lost when the measure is reported, which makes patient-specific interventions more challenging to identify. Similarly, since the measure reports a single outcome for the combined effects of eight measures, results could be distorted by the weighting of measures and handling of measures for which volume is insufficient. The measure interpretation is then severely limited and opaque at best, but potentially misleading at worst. Additionally, since the patient perspective is an important aspect of addressing specific social drivers of heath, P4QM should not recommend this measure, as it does not give hospitals the opportunity to effectively manage a patient’s HRSNs. This measure relies only on combinations of various quality measures, which does not give hospitals actionable items to pursue to address health equity in their patient populations. Vizient urges P4QM not to finalize this measure because it does not give hospitals meaningful insights regarding how to better promote health equity for their patients. 

Vizient also remains concerned with CMS’s continued use of the Area Deprivation Index (ADI) for assessing health disparities in a population. As expressed in prior comments, and supported by recent literature, the ADI is heavily weighted toward income and home values, with very little contribution from other variables (see Vizient comments on the Physician Fee Schedule CY 2024 Proposed Rule https://vizientinc-delivery.sitecorecontenthub.cloud/api/public/content/f773b4354a62447b9e795f9affc48a8d and an analysis published in Health Affairs https://www.healthaffairs.org/content/forefront/aco-benchmarks-based-area-deprivation-index-mask-inequities). The ADI has been found to underestimate the vulnerability of neighborhoods where housing prices do not reflect broader trends and fails to account for other obstacles related to accessing health and healthcare. Vizient recommends CMS and P4QM explore other indices, such as the Vizient Vulnerability Index™ (https://www.vizientinc.com/what-we-do/health-equity/vizient-vulnerability-index-public-access; see attachment) that more effectively identify common social risk factors related to health outcomes. 

Finally, Vizient is concerned that when this measure is publicly reported, patients and caregivers may struggle to interpret the single score and may also fail to understand the detailed description of the data. In the preliminary analysis, this concern is highlighted as a potential unintended consequence of adding the measure to the IQR program where it will become publicly available, as all IQR measures are. Vizient shares the concern that the public availability of this measure may confuse patients and caregivers who do not read the detailed description of how the measure is calculated and therefore misunderstand what it represents. Vizient urges P4QM not to approve this measure, as adding it to the IQR program and making the data publicly available may have unintended consequences, especially for populations with significant community needs.

P4QM seeks comment on the use of the Facility Commitment to Health Equity Measure to the ASCQR program. While the Facility Commitment to Health Equity and Hospital Commitment to Health Equity measures have already been included in some CMS quality programs, we offer various suggestions for improvement that are relevant across care settings for both measures. 

Vizient, Inc. provides solutions and services that improve the delivery of high-value care by aligning cost, quality and market performance for more than 60% of the nation’s acute care providers, which includes 97% of the nation’s academic medical centers, and more than 20% of ambulatory providers. Vizient provides expertise, analytics, and advisory services, as well as a contract portfolio that represents more than $130 billion in annual purchasing volume, to improve patient outcomes and lower costs. Headquartered in Irving, Texas, Vizient has offices throughout the United States. 

Many facilities and providers have implemented substantial changes to address the social risk factors in their patient populations, and we suggest P4QM work with stakeholders to better define each domain or provide more examples that would support more meaningful changes and progression. 

Considering these Commitment to Equity measures, hospitals and provider activities and degree of engagement within each domain could vary drastically and such variation would not be apparent. For example, in the Quality Improvement domain, participation in quality improvement activities could be minimal or challenges could exist related to such participation in local, regional, or national quality improvement activities that may not be understood when the measure is reported. As a result, the value of these measures to drive change appears limited unless more support or clarity is provided to support hospitals and other facilities’ long-term plans. Vizient encourages P4QM to further explain the procedures for collecting data for this measure (e.g., general frequency in which certain activities should be performed, how often the domains should be reviewed and potentially modified) to inform the attestation when reported. Also, Vizient suggests P4QM work with stakeholders to better understand different approaches to health equity and whether there are opportunities to better validate actions within each domain. 

Further, Vizient believes that these measures may overlook common challenges to coordinated health equity responses. For example, in working with hospitals and other providers, Vizient understands that collecting information can involve identifying various efforts and breaking down silos as an initial step to understand the range of efforts underway by a given provider. Such silos make it difficult for providers to identify the correct person within the organization to work with and may require additional effort as providers contact multiple entities to identify the correct contact. This step can take additional time and resources, but may not be easily identified as reflecting a hospital’s commitment to health equity. As a result, clarity, such as better defining what these measures aim to encourage internally, would reduce this burden and allow providers to more effectively collect and act on their patient data. 

The American Society for Clinical Oncology (ASCO) is submitting these comments for MUC2023-162 Patient-Reported Pain Interference Following Chemotherapy among Adults with Breast Cancer and MUC2023-190 Patient-Reported Fatigue Following Chemotherapy among Adults with Breast Cancer. 

ASCO is supportive of PRO-PMs as they provide a patient-centered approach to assessing healthcare quality, incorporating direct input from patients on their symptoms, well-being, and treatment outcomes. By focusing on patient-reported outcomes within performance measures, PRO-PMs promote personalized care, continuous improvement, and informed decision-making, ultimately enhancing the overall quality and effectiveness of healthcare services. 

While these PRO-PMs fill a gap in the existing measurement set for cancer care, ASCO believes it’s important to allow clinicians flexibility and these measures are currently limited to one tool (PROMIS) and will therefore not have broad applicability to oncology practices that have integrated other validated instruments into their practice. Some examples of other validated pain tools that are widely used for cancer include McGill Pain Questionnaire, MD Anderson Symptom Inventory (MDASI), Functional Assessment of Cancer Therapy - Breast (FACT-B) and some examples of other validated fatigue tools include Functional Assessment of Cancer Therapy - Fatigue (FACT-F), European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - Breast Cancer Module (EORTC QLQ-BR23), Functional Living Index - Cancer (FLIC). 

Before using any specific tool, it's essential that clinicians consider the specific objectives of their assessment, the characteristics of their patient population, the feasibility for implementing the measure into their workflow and any requirements or preferences of the clinical setting. 

ASCO also supports the CMS decision to not limit which ePRO tools may be utilized in the new Enhancing Oncology Model (EOM). ASCO similarly encourages CMS to not require the use of these PRO-PMs in their programs, but either make these measures available as optional to meet reporting requirements or else request that they be modified to allow use of other validated tools.

P4QM seeks comment on the use of  the Hospital Commitment to Health Equity Measure to the Hospital Outpatient Quality Reporting (OQR) Program and the Rural Emergency Hospital (REHQR) Quality Reporting Program. While the Facility Commitment to Health Equity and Hospital Commitment to Health Equity measures have already been included in some CMS quality programs, we offer various suggestions for improvement that are relevant across care settings for both measures. 

Vizient, Inc. provides solutions and services that improve the delivery of high-value care by aligning cost, quality and market performance for more than 60% of the nation’s acute care providers, which includes 97% of the nation’s academic medical centers, and more than 20% of ambulatory providers. Vizient provides expertise, analytics, and advisory services, as well as a contract portfolio that represents more than $130 billion in annual purchasing volume, to improve patient outcomes and lower costs. Headquartered in Irving, Texas, Vizient has offices throughout the United States. 

Many facilities and providers have implemented substantial changes to address the social risk factors in their patient populations, and we suggest P4QM work with stakeholders to better define each domain or provide more examples that would support more meaningful changes and progression. 

Considering these Commitment to Equity measures, hospitals and provider activities and degree of engagement within each domain could vary drastically and such variation would not be apparent. For example, in the Quality Improvement domain, participation in quality improvement activities could be minimal or challenges could exist related to such participation in local, regional, or national quality improvement activities that may not be understood when the measure is reported. As a result, the value of these measures to drive change appears limited unless more support or clarity is provided to support hospitals and other facilities’ long-term plans. Vizient encourages P4QM to further explain the procedures for collecting data for this measure (e.g., general frequency in which certain activities should be performed, how often the domains should be reviewed and potentially modified) to inform the attestation when reported. Also, Vizient suggests P4QM work with stakeholders to better understand different approaches to health equity and whether there are opportunities to better validate actions within each domain. 

Further, Vizient believes that these measures may overlook common challenges to coordinated health equity responses. For example, in working with hospitals and other providers, Vizient understands that collecting information can involve identifying various efforts and breaking down silos as an initial step to understand the range of efforts underway by a given provider. Such silos make it difficult for providers to identify the correct person within the organization to work with and may require additional effort as providers contact multiple entities to identify the correct contact. This step can take additional time and resources, but may not be easily identified as reflecting a hospital’s commitment to health equity. As a result, clarity, such as better defining what these measures aim to encourage internally, would reduce this burden and allow providers to more effectively collect and act on their patient data. 

Vizient appreciates the need to develop measures that encourage providers to connect with community resources to help address HRSNs, but we believe this measure will put too much burden on providers to effectively address a patient’s social needs. Hospitals, providers, and community-based services providers (CSPs) do not always have the resources to support all the HRSNs in a given area. As written, this measure puts a burden on providers to both identify a range of CSPs, establish communication channels with such CSPs, and confirm that contact between the CSP and patient occurred. Further, the measure does not address what a provider should do if a patient with an HRSN is identified and unable to be connected to a CSP because there is not one readily available, or if an existing CSP is unable to serve the patient. In many areas of the country, CSPs are not available or require significant time and reliable transportation to reach. Providers should not be penalized for being unable to provide a connection to a CSP that does not exist or that would not fully meet the patient’s needs. If P4QM is going to pursue recommending this measure, Vizient believes it is important that resources, education, and incentives be provided to both providers and CSPs to ensure communications are streamlined and aspects of data-sharing are clarified. In underserved areas, this could include help connecting providers with CSPs so that there is no delay if a provider doesn’t have the information for a CSP immediately. As suggested by the MAP Rural Health Advisory Group in 2022, stratification of the measure could help ease the burden on rural providers who are unable to access CSPs. Further, the measure should not place the burden solely on the provider to follow-up with CSPs or patients to confirm contact was made. Vizient recommends that if this measure is recommended, further methodological considerations be deployed to quantify the influence of the CSP rather than simply assigning full responsibility to the provider.

Also, Vizient believes several aspects of the measure are unclear, such as definitions for HRSNs. For example, the population included in the measure may reside outside of a CSP’s operating area, yet the measure would still encourage the hospital to make a connection even if the patient would not benefit. Vizient believes more work is needed to better establish provider and CSP relationships and communications, and as a result, this measure is premature. Once such communications are established, we would also suggest refinements to the measure.

Vizient, Inc. provides solutions and services that improve the delivery of high-value care by aligning cost, quality and market performance for more than 60% of the nation’s acute care providers, which includes 97% of the nation’s academic medical centers, and more than 20% of ambulatory providers. Vizient provides expertise, analytics, and advisory services, as well as a contract portfolio that represents more than $130 billion in annual purchasing volume, to improve patient outcomes and lower costs. Headquartered in Irving, Texas, Vizient has offices throughout the United States. 

Vizient appreciates efforts to ensure that HRSNs are addressed but is deeply concerned that this measure places too much burden on providers, as resolving HRSNs can often be beyond a provider's locus of control. 

Vizient, Inc. provides solutions and services that improve the delivery of high-value care by aligning cost, quality and market performance for more than 60% of the nation’s acute care providers, which includes 97% of the nation’s academic medical centers, and more than 20% of ambulatory providers. Vizient provides expertise, analytics, and advisory services, as well as a contract portfolio that represents more than $130 billion in annual purchasing volume, to improve patient outcomes and lower costs. Headquartered in Irving, Texas, Vizient has offices throughout the United States. 

While we appreciate the intent of this measure, Vizient is concerned that this measure puts a significant burden on providers. Providers are in a unique position to address and help individuals with HRSNs, but once a patient leaves the hospital it is not necessarily feasible for providers to “follow the patient” and ensure they are accessing all available services, particularly for the time period articulated. Following patients for months after a visit and ensuring that the services are provided by an outside community group is far outside the provider’s locus of control and would put an untenable strain on providers who are already struggling to meet community needs. Additionally, the expectation that HRSNs may be resolved within a 12-month period does not adequately consider the drivers of HRSNs, patient complexities, or community dynamics or limitations. 

Also, it is unclear how this measure could be easily reported by providers. For example, technology may not yet be implemented to easily identify patients who should be included in both the numerator and denominator. In addition, since the numerator would require the patient to report resolution of at least one HRSN, the provider would need to make additional communication to confirm this information, increasing provider burden. 

As this measure is described, there is no clear definition of what constitutes a “resolution”. Resolving long held social determinants of health for an individual may take years, with community development and interventions that are outside providers’ control. The measure appears to rely on a subjective measure of whether the issue was resolved by asking the patient whether they feel the issue was effectively resolved within 12 months of discharge. This subjective report will create confusion and likely result in inconsistent data across providers and health systems, yielding unusable data, among other concerns. While it is important to reflect a patient’s perspective when addressing health equity, patients still need information to help them identify whether the provider and community organizations followed a protocol and should not only rely on a patient’s subjective interpretation of whether something feels resolved. Vizient urges P4QM not to recommend this measure. 

Further, as stated in comments on other measures, Vizient remains concerned that the HRSNs are not clearly and consistently defined. If data is not clearly defined, the data collected may be unactionable, inaccurate or difficult to interpret. Vizient urges P4QM not to advance this measure, as it would be extremely challenging to implement and imposes excessive burden on providers well-beyond their locus of control.

Vizient appreciates CMS’s continued focus on patient safety, but has concerns about the proposed Patient Safety Structural Measure. The proposed measure is an attestation measure focused on patient safety activities that aims to help hospitals better understand priorities for improving safety and serve as a prompt for action to reduce preventable harm to patients. Patient safety is a top concern for CMS as well as for hospitals nationwide, as preventable harms were identified as a major priority for patient safety decades ago (see: https://psnet.ahrq.gov/primer/patient-safety-101). The Agency for Healthcare Research and Quality has outlined steps required to create a “systems approach” to patient safety, which many hospitals have adopted and use as they develop patient safety practices into regular care. 

Vizient supports the commitment to advancing patient safety in hospitals and works closely with our members to ensure that preventable harms are being reduced (https://www.vizientinc.com/what-we-do/operations-and-quality/patient-safety-organization). Vizient’s concern with this measure is that it is an attestation-based measure that will be publicly available and may provide confusing information to patients as they evaluate healthcare facilities. Attestation measures capture a yes/no answer if a hospital or facility judges that it meets the requirements as laid out in the measure, without any substantive information on what the hospital is doing that constitutes that answer. For example, under Domain 1 of the proposed measure (Leadership Commitment to Eliminating Preventable Harm), a hospital may check “yes” if its leadership signed a pledge to prevent harm, while another may check “yes” because a leader allocated funding to a particular patient safety project. Both answers may be valid, and both may represent important steps toward impacting patient safety in the facility, but without more substantive information, the measure will not give the patient actionable information about how the hospital is prioritizing patient safety at the leadership level. 

Additionally, because the systems approach to patient safety has been in existence for decades, Vizient anticipates that it is unlikely any hospitals will attest “no” under any of these domains. Patient safety activities remain a priority for hospitals, but many are at a more advanced stage of addressing patient safety that is more aligned with the current, evolved landscape of patient safety work. Vizient recommends that P4QM not adopt this measure and identify better opportunities for recognizing the advanced patient safety work hospitals are doing to create a safer care environment for patients. 

Vizient, Inc. provides solutions and services that improve the delivery of high-value care by aligning cost, quality and market performance for more than 60% of the nation’s acute care providers, which includes 97% of the nation’s academic medical centers, and more than 20% of ambulatory providers. Vizient provides expertise, analytics, and advisory services, as well as a contract portfolio that represents more than $130 billion in annual purchasing volume, to improve patient outcomes and lower costs. Headquartered in Irving, Texas, Vizient has offices throughout the United States. 

Please see the attached comment letter from KCP.

The Women’s Institute for Secure Retirement (WISER) appreciates the opportunity to submit comments in response to the release of the FY 2023 MUC List. WISER is a nonprofit organization dedicated to improving the long-term financial security of all women through education and advocacy. Nutrition and health equity are critical in helping women ultimately build financial security and helping to decrease the risk of poverty in old age. 

We commend CMS for considering for inclusion in its payment programs the Global Malnutrition Composite Score for all adults ages 18 or older (MUC2023-114), which is a publicly supported measure that benefits patients, families, and caregivers across all demographic groups—as well as the healthcare system at large. The existing Global Malnutrition Composite Score eCQM for 65+ has been extensively tested and shown that adopting evidence-based malnutrition care best practices is associated with reduced costs and improved patient outcomes. These outcomes should be available to all.

Malnutrition Remains a Measurement Gap in Hospital Programs 

Malnutrition is an ongoing health issue that remains under-addressed in healthcare settings. It is often underdiagnosed and untreated, and disparities exist across different racial/ethnic groups and geographic locations. An estimated 20-50% of hospital inpatients are malnourished or at risk of malnutrition (depending on the patient population and the criteria for assessment). Yet, 2018 data from the Healthcare Cost and Utilization Project (HCUP) reports that only 8.9% of discharges have a diagnosis of malnutrition. The importance of malnutrition prevention, identification and intervention for at-risk and malnourished individuals is magnified by malnutrition’s impact on independence, well-being, and the severity of medical conditions and disabilities. There is also evidence that healthy aging is fostered by the cumulative effects of healthy nutrition earlier in life. Malnutrition is also costly for healthcare, with the cost of disease-associated malnutrition in the United States estimated as more than $147 billion per year, with $15.5 billion attributed directly to treatment costs.

Health Equity Implications of Malnutrition 

Health inequity arises from malnutrition because varying rates of the condition and associated risk factors among racial groups, geographic locations, and income brackets lead to disparities in health outcomes. An analysis of 2019 Malnutrition Quality Improvement Initiative (MQii) Learning Collaborative data of more than 1.5 million patients from the Malnutrition Quality Improvement Initiative (MQii) Learning Collaborative (see Figures 1 and 2) found substantial disparities in malnutrition diagnoses and readmissions. For example, non-Hispanic Black individuals with malnutrition experienced a readmission rate of more than 26%, while the rate was less than 19% among non-Hispanic White individuals.

As Food insecurity caused by economic and social burdens can increase the risk of malnutrition, addressing malnutrition and its root causes can therefore support the reduction of health disparities. By addressing the early-in-life health and social factors that affect health, we can improve access to healthy aging. And what is retirement without good health?

Conclusion

The importance of identifying, diagnosing, and treating malnutrition continues to grow. We fully support CMS including this measure in the 2024 Hospital Inpatient Quality Reporting Program, given the overarching burden that malnutrition has on patients and the healthcare system as a whole. CMS’ adoption of this measure will help close the gap in identification and intervention of malnutrition and help healthcare institutions better measure up to support good nutrition. 

The AHA appreciates the efforts in which CMS has engaged to leverage their quality reporting programs to address health equity. Hospitals and health systems across the country are deeply engaged in efforts to highlight the intersection of hospital care and social drivers of health. Upon review of the preliminary assessments of the MUC by Battelle, we have several conceptual and logistical questions and concerns that we hope will be addressed by CMS during the Committee meetings on each of these measures.

Hospital Equity Index (HEI), MUC-139. It appears that the HEI MUC is similar to the Health Disparity Index (HDI) measure that was under consideration for adoption in the Inpatient Quality Reporting Program (IQR) by the Measure Applications Partnership (MAP) in the 2022-2023 review cycle. The major difference that we can discern, besides the change in name, is that the HEI does not employ an imputation method that would use information from public sources to determine data regarding race and ethnicity; instead, it would use a version of the Area Deprivation Index, a multi-variable composite drawn from multiple administrative data sources intended to reflect the social drivers of health in communities. In prior comments, we have expressed our concern about the time lag and potential inaccuracy of indirectly estimated race and ethnicity. Therefore, it is possible that switching to ADI would be an improvement over the previous version of the measure. However, we would appreciate clarification on whether CMS considers the HEI a new version of the previous measure or merely a new, separate measure that may be used concurrently with the HDI.

Further, while we applaud CMS for looking for ways to address inequities by using data already available without mandating additional collection, we continue to question whether an aggregated quality score would give consumers, hospitals, clinicians and other stakeholders meaningful and actionable information to reduce disparities in health outcomes. The HEI merges performance on readmission and mortality rates for multiple conditions hospital-wide across dual eligibility status and varying area deprivation index indicating disparity with a single score. While the term “index” suggests that this measure is a holistic accounting of disparities in health outcomes, it is only based upon limited quality indicators (i.e. readmissions and mortality) that alone do not provide actionable information on how to address disparities in outcomes.

Further, by “rolling up” performance on 18 factors (seven readmission measures and two mortality measures indicating within- and between-hospital performance) across broad social risk factor subgroups, use of the measure may in fact inadvertently conceal opportunities for improvement. Conflating performance on disparate measures for many different patients would limit the “line of sight” for consumers and clinicians to how well as hospital cared for a person with specific social risk factors. At worst, a publicly displayed summary score could mislead consumers and providers by making generalized assertions about performance on addressing disparities that belie true quality of care. 

In addition to the conceptual flaws with this measure, the preliminary analysis raised logistical issues as well. For example, measure performance would be calculated only for hospitals that have at least 25 patients with a given risk factor and 12 without that risk factor for any stratification variable. Many hospitals could have insufficient volume to calculate performance, and it raises the question of whether the index would result in an “apples to apples” comparison of performance. In addition, the preliminary analysis reports that entity-level reliability and face or empiric validity was not demonstrated for this measure, as the developers used only the reliability of the individual underlying readmissions and mortality measures informing the composite.

In its review of the HDI, the MAP raised several additional questions that remain relevant for the HEI. For example, providers already get confidential feedback reports on the individual measures, which are also publicly reported; how would this composite measure add value? Will the measure be field-tested? What are the future plans for such an index by CMS—does the agency plan to add factors to the composite to augment readmissions and mortality, or additional social risk factors to define subgroups? In its final recommendation, the Hospital Workgroup of the MAP declined to support the measure for rulemaking, but noted that answers to these questions may mitigate the lack of support. It is unclear from the materials provided that CMS has addressed any of these concerns, and we hope the agency can shed additional light on this measure.

Connection to Community Service Provider, MUC-199, and Resolution of At Least One HRSN, MUC-210. As we understand it, the basic concept behind these two measures is to hold hospitals accountable for “closing the loop” of identifying HRSNs as determined by the recently adopted Screening for Social Drivers of Health (SDOH) and Screen Positive Rate for SDOH measures in the IQR. This concept has potential appeal for a program like the Medicare Shared Savings Program (MSSP), for which the measures are also under consideration. In the MSSP, a clinician entity is accountable for a defined population for a defined time period, and thus tracking the care provided across the continuum for individual patients is potentially feasible. However, inpatient episodic care does not lend itself readily to the practice of long-range tracking of referrals and follow-up with community providers. 

Further, both MSSP ACOs and hospitals would face the same fundamental challenge – that is, the availability of resources to address HRSNs is not the same across communities. Addressing these challenges takes collaboration and resources from public and private sector partners. In some communities, those partners are willing, able and have the resources to bring to bear to address these challenges, but this is not the case everywhere. As a result, we are concerned that performance on this measure will be more reflective of factors that are not entirely within the control of an inpatient hospital or an ACO -- such as the economic health of the patient’s community or availability of community providers – than of provider performance. 

Lastly, we hope CMS can provide insight into how it intends to coordinate the use of these measures across various quality reporting programs. If CMS were to adopt the measure into both the IQR and the MSSP, we are concerned that it may increase patient burden as patients would be asked to answer the same HRSN-related questions multiple times during the same year, and providing results that may not be consistent over time.

Connection to Community Service Provider, MUC-199, and Resolution of At Least One HRSN, MUC-210. As we understand it, the basic concept behind these two measures is to hold hospitals accountable for “closing the loop” of identifying HRSNs as determined by the recently adopted Screening for Social Drivers of Health (SDOH) and Screen Positive Rate for SDOH measures in the IQR. This concept has potential appeal for a program like the Medicare Shared Savings Program (MSSP), for which the measures are also under consideration. In the MSSP, a clinician entity is accountable for a defined population for a defined time period, and thus tracking the care provided across the continuum for individual patients is potentially feasible. However, inpatient episodic care does not lend itself readily to the practice of long-range tracking of referrals and follow-up with community providers. 

Further, both MSSP ACOs and hospitals would face the same fundamental challenge – that is, the availability of resources to address HRSNs is not the same across communities. Addressing these challenges takes collaboration and resources from public and private sector partners. In some communities, those partners are willing, able and have the resources to bring to bear to address these challenges, but this is not the case everywhere. As a result, we are concerned that performance on this measure will be more reflective of factors that are not entirely within the control of an inpatient hospital or an ACO -- such as the economic health of the patient’s community or availability of community providers – than of provider performance. 

Lastly, we hope CMS can provide insight into how it intends to coordinate the use of these measures across various quality reporting programs. If CMS were to adopt the measure into both the IQR and the MSSP, we are concerned that it may increase patient burden as patients would be asked to answer the same HRSN-related questions multiple times during the same year, and providing results that may not be consistent over time.

Screening for SDOH, MUC-156, Screen Positive Rate for SDOH, MUC-171, and Hospital Commitment to Health Equity, MUC-176. These three measures appear to be identical to the versions of the measures adopted in the IQR. As a result, we ask CMS to provide feedback on how they would use these health equity-related measures in the Outpatient Quality Reporting Program (OQR). Would the agency utilize the measures as it has with other measures used in both program, such as the COVID-19 Vaccination Among Healthcare Personnel measure, where a single rate is reported at the facility level that includes both inpatient and outpatient services? Or would the agency calculate two separate rates for each program, even if the measure was reported by the same facility? We think the former approach would make more sense than the latter. 

Screening for SDOH, MUC-156, Screen Positive Rate for SDOH, MUC-171, and Hospital Commitment to Health Equity, MUC-176. These three measures appear to be identical to the versions of the measures adopted in the IQR. As a result, we ask CMS to provide feedback on how they would use these health equity-related measures in the Outpatient Quality Reporting Program (OQR). Would the agency utilize the measures as it has with other measures used in both program, such as the COVID-19 Vaccination Among Healthcare Personnel measure, where a single rate is reported at the facility level that includes both inpatient and outpatient services? Or would the agency calculate two separate rates for each program, even if the measure was reported by the same facility? We think the former approach would make more sense than the latter. 

Screening for SDOH, MUC-156, Screen Positive Rate for SDOH, MUC-171, and Hospital Commitment to Health Equity, MUC-176. These three measures appear to be identical to the versions of the measures adopted in the IQR. As a result, we ask CMS to provide feedback on how they would use these health equity-related measures in the Outpatient Quality Reporting Program (OQR). Would the agency utilize the measures as it has with other measures used in both program, such as the COVID-19 Vaccination Among Healthcare Personnel measure, where a single rate is reported at the facility level that includes both inpatient and outpatient services? Or would the agency calculate two separate rates for each program, even if the measure was reported by the same facility? We think the former approach would make more sense than the latter. 

HCAHPS Sub-Measures, MUC-146-149. The HCAHPS Survey has been in use for nearly two decades, and it is encouraging to the AHA to see that CMS is beginning to modernize the survey by updating how the survey may be administered (e.g., by allowing web-based survey administration) as well as considering updates to what questions are asked. However, we have questions and concerns about the sub-measures as proposed on the MUC list. First, would all four sub-measures and the multiple elements within replace existing questions/elements, or would they be wholly additive to an already lengthy survey? Next, we have concerns regarding how data gleaned from these sub-measures could be used to improve performance, as the preliminary analysis noted that the measures are not based upon clinical practice guidelines and the measure description did not include an articulation of how providers could improve. Lastly, we ask CMS to clarify whether these new items have been field tested, and would urge that such testing take place before they are proposed for a CMS program.

HCAHPS Sub-Measures, MUC-146-149. The HCAHPS Survey has been in use for nearly two decades, and it is encouraging to the AHA to see that CMS is beginning to modernize the survey by updating how the survey may be administered (e.g., by allowing web-based survey administration) as well as considering updates to what questions are asked. However, we have questions and concerns about the sub-measures as proposed on the MUC list. First, would all four sub-measures and the multiple elements within replace existing questions/elements, or would they be wholly additive to an already lengthy survey? Next, we have concerns regarding how data gleaned from these sub-measures could be used to improve performance, as the preliminary analysis noted that the measures are not based upon clinical practice guidelines and the measure description did not include an articulation of how providers could improve. Lastly, we ask CMS to clarify whether these new items have been field tested, and would urge that such testing take place before they are proposed for a CMS program.

HCAHPS Sub-Measures, MUC-146-149. The HCAHPS Survey has been in use for nearly two decades, and it is encouraging to the AHA to see that CMS is beginning to modernize the survey by updating how the survey may be administered (e.g., by allowing web-based survey administration) as well as considering updates to what questions are asked. However, we have questions and concerns about the sub-measures as proposed on the MUC list. First, would all four sub-measures and the multiple elements within replace existing questions/elements, or would they be wholly additive to an already lengthy survey? Next, we have concerns regarding how data gleaned from these sub-measures could be used to improve performance, as the preliminary analysis noted that the measures are not based upon clinical practice guidelines and the measure description did not include an articulation of how providers could improve. Lastly, we ask CMS to clarify whether these new items have been field tested, and would urge that such testing take place before they are proposed for a CMS program.

Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure (Information Transfer PRO-PM), MUC-172. In addition to the concerns raised with the additional HCAHPS measures discussed above, the AHA is concerned by the  increasing burden on patients of the ever-growing list of provider survey questions they are being asked to answer. To be sure, hospitals and health systems deeply value the patient perspective on their care, and use data from patient experience and PRO-PM measures across their efforts to make care safer, higher quality and more equitable. PRO-PMs are a newer measure type that carries important potential to capture whether patients are regaining function and activities that matter in their daily lives. 

At the same time, such measures also require patients to provide a significant amount of information—often, the same information multiple times.  With the recent adoption of the PRO-PM for THA/TKA for both the IQR and OQR, and the eventual adoption of the OAS CAHPS survey (which is voluntarily reported today-- not to mention individual CAHPS surveys from individual clinicians who were involved in an outpatient procedure, we worry that CMS’ plans to rely upon patients for an increasing amount of data production could affect survey response rates across the board. It also could lead to confusion among patients about what aspect of their care they are being asked to assess. This is especially true of MUC-172, which could potentially overlap with the PRO-PM for THA/TKA. 

ESRD Dialysis Patient Life Goals Survey (PaLS), MUC-138. We note that the PQM recently voted not to recommend this measure for endorsement. It is clear from the preliminary analysis that the measure is deficient is multiple ways that should prevent it from being considered for rulemaking. First, the level of analysis of the measure is community, county or city rather than facility level, making it inappropriate for a facility quality reporting program; indeed, entity-level reliability testing was not reported, and empirical validity testing was not performed at the hospital level. Second, the survey upon which the PALS is based is currently only available in English, which seriously limits its usability and undermines efforts to ensure equity in our work on quality. Third, there is not an explicit articulation of the resources and context that might facilitate improvement in performance. For these reasons, we question the suitability of this measure on the MUC list.

The AHA appreciates CMS’ efforts to measure safety with more sophisticated approaches that utilize clinical and EHR-based data in addition to administrative data. However, several aspects of the proposed harm event measures raise questions about their suitability for federal programs. Patient harm event measures must be reliable and accurate in order to best inform how to prevent those harm events in the future while maintaining a healthy culture of safety that does not unfairly penalize clinicians for making medically appropriate decisions. We encourage CMS and the Hospital Committee to consider whether use of these measures would achieve those goals.

Thirty-day Risk-standardized Death Rate among Surgical Inpatients with Complications (Failure-to-Rescue), MUC-049. While it is not entirely clear from the specifications presented on the MUC list, it appears that this measure is an updated version of Patient Safety Indicator 4 (PSI 4), a longstanding IQR measure with regrettably low reliability. This measure appears to expand the denominator of patients to include those with a complication who die within 30 days from the date of the first operating room (OR) procedure regardless of the site of the qualifying OR procedure, but limits the denominator to patients in specific MS-DRGs. Ostensibly, CMS is considering this expanded population to focus on severe complications as it would include patients with a lower risk of death. Conceptually, this approach has merit. However, it is unclear whether the risk adjustment methodology for the measure would appropriately account for between-hospital differences that might escalate the severity of the complication (which would make rescue on behalf of the subsequent hospital more of a challenge). In fact, information from the preliminary analysis suggests that this measure has questionable reliability. Furthermore, assuming this measure continues to be based on only billing data, it will continue to suffer from the questionable reliability[1] and profound disconnects between performance captured in billing data and clinical reality[2] that have long limited the utility of the PSI measures used in CMS programs. That is because billing data simply cannot and do not capture all of the underlying clinical factors that may affect a patient’s likelihood for serious safety events, making it fraught to use PSIs for performance comparisons across hospitals. Furthermore, a reliance on billing data means the results of the PSI measure have a significant time lag between when they are captured and when hospitals see the results, making these measures virtually useless for quality improvement efforts. 

Over the longer term, measures calculated on only Medicare fee-for-service billing data – such as PSIs – also will struggle to meaningfully reflect the performance of hospitals and other providers as Medicare Advantage enrollment continues to grow. It will be especially challenging to compare performance across geographies given that the uptake of Medicare Advantage varies widely across the country. During the committee discussion, we encourage CMS to discuss any planned methodology updates that would capture Medicare Advantage patients.

Lastly, while the measure is under consideration for the IQR, the measure has also been considered for pay-for-performance programs including the Hospital-Acquired Conditions Payment Reduction Program and the Hospital Value-Based Purchasing Program in the past.  it is concerning that CMS may consider using a measure that may not reflect true hospital performance to assess financial penalties, so we are interested to hear from the agency whether that is the planned trajectory of this measure.

[1] See http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/HVBP_Measure_Reliability-.pdf

[2] Among other studies, see Azad TD et al. Patient Safety Indicator 04 Does Not Consistently Identify Failure to Rescue in the Neurosurgical Population. Neurosurgery. 2023 Feb 1;92(2):338-343.

Hospital Harm: Falls with Injury, MUC-048 and Postoperative Respiratory Failure, MUC-050. As noted elsewhere, we appreciate that CMS is considering ways to incorporate clinical data into patient safety measures to increase their accuracy. However, information provided by the developers raised significant concerns about the suitability of these measures in the IQR. Across both measures, issues with workflow were noted: depending on the EHR vendor used, clinicians may be using structured fields differently to input data, and documentation may not be captured in a standardized manner. We are concerned that measure performance may be more dependent on the sensitivity of the screening technologies and approaches used than on underlying performance. For example, the postoperative respiratory failure measure was only tested in teaching hospitals, meaning it is not clear how well the measure functions in other types of facilities. These operational issues could undermine the improved accuracy of measures informed by clinical data.

More concerning was that both measures carried serious potential unintended consequences. The use of the post-operative respiratory failure measure may result in inappropriate use of non-invasive PPV in lieu of mechanical respiration, excessive use of preventive tracheostomy, or avoidance of offering necessary procedures for high-risk patients. These outcomes would seriously detract from the usefulness of the measures in improving patient outcomes, and we recommend that CMS and the Committees judiciously incorporate these factors in their evaluation of the measures.

Hospital Harm: Falls with Injury, MUC-048 and Postoperative Respiratory Failure, MUC-050. As noted above, we appreciate that CMS is considering ways to incorporate clinical data into patient safety measures to increase their accuracy. However, information provided by the developers raised significant concerns about the suitability of these measures in the IQR. Across both measures, issues with workflow were noted: depending on the EHR vendor used, clinicians may be using structured fields differently to input data, and documentation may not be captured in a standardized manner. We are concerned that measure performance may be more dependent on the sensitivity of the screening technologies and approaches used than on underlying performance. For example, the postoperative respiratory failure measure was only tested in teaching hospitals, meaning it is not clear how well the measure functions in other types of facilities. These operational issues could undermine the improved accuracy of measures informed by clinical data.

More concerning was that both measures carried serious potential unintended consequences. The use of the falls measure may result in reduced patient mobilization, which can be crucial for recovery. These outcomes would seriously detract from the usefulness of the measures in improving patient outcomes, and we recommend that CMS and the Committees judiciously incorporate these factors in their evaluation of the measures.

Patient Safety Structural Measure, MUC-188. The AHA agrees that there are certainly essential structures and policies that can support the safe delivery of care, which this measure attempts to assess. Many of the practices included in the measure have merit and are already widely adopted across hospitals and health systems. However, it also appears that several of these practices are redundant with other regulatory or accreditation requirements for hospitals. For this reason, we question whether the addition of this measure to the IQR would meaningfully distinguish performance among hospitals, or meaningfully advance patient safety efforts.

For example, the practices in the Leadership (Domain 1) and Strategic Planning and Organizational Policy (Domain 2) reflect whether hospitals have patient safety included in their strategic plans, and have mechanisms for sharing both the goals and progress with senior organizational leaders and their Boards. It appears most of these practices overlap with the Quality Assessment and Performance Improvement (QAPI) requirements that hospitals must meet under CMS’s Conditions of Participation (CoPs). In addition, providing access to patient information (Domain 5, practice #3) is already a requirement of the CMS Promoting Interoperability program. 

Further, the measure appears not to have been fully developed, as entity-level reliability testing was not performed, performance scores were not reported, workflow analysis was not conducted, and empirical evidence of an association with the study population was not provided by the developer. This information would be important to understanding the suitability of the measure for rulemaking. We are especially interested in understanding whether there is a performance gap on the measure and whether the number of attestations could be streamlined for focus on those practices where hospitals do not consistently attest “yes.” 

Lastly, we encourage CMS to ensure it provides sufficient measure specification detail on the MUC list to fully evaluate a measure’s specifications. While we were ultimately able to find additional detail about the individual attestations comprising the measure, only the five measure domains were included on the MUC list’s measure specifications. Going forward, CMS and Battelle should ensure that either the MUC list itself includes sufficient detail, or that links to the relevant detailed measure specification information are included in public information with instructions on how to access them.

The Florida Alliance for Healthcare Value (the Florida Alliance) is an employer-led business coalition of nearly 90 public and private sector employers working together to improve the quality and value of the health care that they purchase for their employees and their families. Our employer members provide comprehensive healthcare benefits to their covered lives, and an array of health and wellbeing programs designed to meet the needs of their diverse populations.

Cancer care has been a major focus of our work with our members due to the high cost of oncology treatment but also due to concerns with quality, safety, and the patient experience. There is a need for more outcomes measures for cancer and in particular for measures that address quality of care during curative treatment.  

With increased numbers of cancer survivors returning to work during or after treatment, it is important that symptoms be well managed, including fatigue.  We are supportive of MUC2023-190 Patient-Reported Fatigue Following Chemotherapy among Adults with Breast Cancer which assesses fatigue among women with breast cancer entering survivorship after completion of chemotherapy administered with curative intent. It is our understanding that the measure concept is based on the premise that medical oncologists who provide the highest quality care, in particular medical and non-medical support to patients with curative-intent cytotoxic therapy, will be able to reduce symptom burden and, therefore improve patient transition into the cancer survivorship period.  

Our employer members believe that patient-reported outcomes measures are an essential element of care delivery and in particular for oncology.  Adoption of patient-reported outcomes measures should result in better-managed side effects of treatment and increase the ability for patients to return to work and family roles.   

Name: Patient Safety Structural Measure.  Number: MUC2023-188.

I lost my wife to a medical error in 2017.   She was having a tracheostomy due to breathing problems, and was asphyxiated (per her death certificate) by a blockage in the respirator.  Local police were called in by the hospital staff as they suspected tampering with the equipment.  But it turned out to be a stray part was responsible.  My family and I were kept in the dark with minimal information.  
Therefore our suffering and period of grief was extended by this lack of understanding of the details.   When I began searching for answers, I was appalled by the number of deaths from medical error and especially that the actual number is not reported and therefore not tracked.   As Peter Drucker once said “you must measure in order to manage”.  I believe this lack of transparency is responsible for the large number of repeat errors and the lack of progress in reducing the total number.  To me, it would be like an airline discovering an issue with a particular aircraft and not notifying the rest of the industry.  
Also since the risk management and legal departments view efforts to be open and sharing of information as threats to their mission, it is imperative that CMS approve this PSSM measure.  This will assure that hospital boards of directors and executives realize that action must be taking now to address the whole patient safety issue.  Only then will there be widespread acceptance with corresponding reduction in these errors. 

CMS is considering adding three EDAC measures to the Hospital Readmissions Reduction Program (HRRP). These measures are currently used in the IQR program, and differ from the existing condition-specific inpatient readmission measures by capturing both emergency department (ED) visits and observations stays within 30 days following an inpatient discharge.

The AHA seriously questions whether the statute authorizing the HRRP permits CMS to use the EDAC measures in the program. This concern stems from the statutory definition of readmissions at 42 USC 1395ww (q)(5)(E):

“The term "readmission" means, in the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same or another applicable hospital within a time period specified by the Secretary from the date of such discharge.” (emphasis ours)

We believe this definition is precisely why CMS has used readmission measures reflecting whether patients are readmitted as inpatients within 30 days of an inpatient discharge since the program’s inception on Oct. 1, 2012. It is also why CMS does not use measures that treat either an ED visit or observation stay as index “discharges” from which it could measure inpatient admissions, ED visits or observation stays within a 30-day time period. The HRRP statute simply does not contain the terms “emergency department” or “observation stay”.

Furthermore, the definitions of “admissions” to inpatient beds,  emergency department visits and observation stays are not used interchangeably in other CMS regulations. In fact, there are multiple examples showing how CMS has separated these definitions for providers and patients alike. For example, CMS’ establishment of the “Two Midnight Rule” was specifically designed to distinguish between observation stays (which are considered outpatient visits) and inpatient admissions to the hospital. This distinction is critical because it differentiates how Medicare Part A or B benefits may apply, patient cost sharing amounts, and CMS billing system hospitals may use. Similarly, emergency department visits in which a patient returns home to the community are not “admissions,” and in fact, are not payable under Medicare Part A Hospital Insurance. CMS makes these distinctions clear to patients and families in its own fact sheet titled “Are You a Hospital Inpatient or Outpatient”, which includes the following language:

• “You’re an inpatient starting when you’re formally admitted to a hospital with a doctor’s order. The day before you’re discharged is your last inpatient day.
• “You’re an outpatient if you’re getting emergency department services, observation services, outpatient surgery, lab tests, X-rays, or any other hospital services, and the doctor hasn’t written an order to admit you to a hospital as an inpatient. In these cases, you’re an outpatient even if you spend the night at the hospital.”

For these reasons, the AHA urges CMS not to adopt the EDAC measures for the HRRP. 

The AHA supports MUC-212, Level 1 Denials Upheld Rate. The AHA has long urged CMS to provide greater transparency about the extent to which Medicare Advantage Organizations (MAOs) engage in inappropriate coverage denials along with accountability for those MAOs with high rates of such denials. MUC-212 provides insight into whether MAOs are making appropriate initial coverage denial decisions by measuring the extent to which health plans themselves uphold their own Level 1 coverage denials. Lower performance on the measure would indicate that an MAO is being too aggressive in its initial coverage denial decisions and possibly applying more restrictive criteria than Traditional Medicare, thereby contributing to delays in beneficiaries receiving necessary care that should be covered. This is especially important in the context of recent findings from the U.S. Department of Health and Human Services Office of Inspector General, which found that MAOs overturned 75 percent of their own initial denials upon appeal during a 2 year period, raising concerns that MA enrollees and their providers are routinely being denied services and payments that should have been provided. Inappropriate coverage denial decisions also contribute significant administrative and cost burden to patients and health care providers alike. The inclusion of MUC-212 in the MA Star Ratings system would provide public visibility and financial consequences for denial rates, thereby discouraging MAOs from denying care inappropriately. 

The American Society for Clinical Oncology (ASCO) is submitting these comments for MUC2023-162 Patient-Reported Pain Interference Following Chemotherapy among Adults with Breast Cancer and MUC2023-190 Patient-Reported Fatigue Following Chemotherapy among Adults with Breast Cancer. 

ASCO is supportive of PRO-PMs as they provide a patient-centered approach to assessing healthcare quality, incorporating direct input from patients on their symptoms, well-being, and treatment outcomes. By focusing on patient-reported outcomes within performance measures, PRO-PMs promote personalized care, continuous improvement, and informed decision-making, ultimately enhancing the overall quality and effectiveness of healthcare services. 

While these PRO-PMs fill a gap in the existing measurement set for cancer care, ASCO believes it’s important to allow clinicians flexibility and these measures are currently limited to one tool (PROMIS) and will therefore not have broad applicability to oncology practices that have integrated other validated instruments into their practice. Some examples of other validated pain tools that are widely used for cancer include McGill Pain Questionnaire, MD Anderson Symptom Inventory (MDASI), Functional Assessment of Cancer Therapy - Breast (FACT-B) and some examples of other validated fatigue tools include Functional Assessment of Cancer Therapy - Fatigue (FACT-F), European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - Breast Cancer Module (EORTC QLQ-BR23), Functional Living Index - Cancer (FLIC). 

Before using any specific tool, it's essential that clinicians consider the specific objectives of their assessment, the characteristics of their patient population, the feasibility for implementing the measure into their workflow and any requirements or preferences of the clinical setting. 

ASCO also supports the CMS decision to not limit which ePRO tools may be utilized in the new Enhancing Oncology Model (EOM). ASCO similarly encourages CMS to not require the use of these PRO-PMs in their programs, but either make these measures available as optional to meet reporting requirements or else request that they be modified to allow use of other validated tools.

The Florida Alliance for Healthcare Value (the Florida Alliance) is an employer-led business coalition of nearly 90 public and private sector employers working together to improve the quality and value of the health care that they purchase for their employees and their families. Our employer members provide comprehensive healthcare benefits to their covered lives and an array of health and well-being programs designed to meet the needs of their diverse populations.

Cancer care has been a major focus of our work with our members due to the high cost of oncology treatment but also due to concerns with quality, safety, and the patient experience. There is a need for more outcomes measures for cancer and in particular for measures that address quality of care during curative treatment.  

With increased numbers of cancer survivors returning to work during or after treatment, it is important that symptoms be well managed, including pain.  We are supportive of MUC2023-162 Patient-Reported Pain Interference Following Chemotherapy among Adults with Breast Cancer which assesses pain interference among adult women with breast cancer entering survivorship after completion of chemotherapy administered with curative intent.  It is our understanding that the measure concept is based on the premise that medical oncologists who provide the highest quality care, in particular, medical and non-medical support to patients with curative-intent cytotoxic therapy will be able to reduce symptom burden and, therefore improve patient transition into the cancer survivorship period. 

Our employer members believe that patient-reported outcomes measures are an essential element of care delivery and in particular for oncology.  Adoption of patient-reported outcomes measures should result in better-managed side effects of treatment and increase the ability for patients to return to work and family roles.   

These comments support the proposed PROMOnc measures for Pain (MUC2023-162) and Fatigue (MUC2023-190) Management for Breast Cancer Treatment developed by the Purchaser Business Group on Health (PBGH).

As a Healthcare Purchasers coalition, the MidAtlantic Business Group supports the PBGH developed measures because:

• Purchasers recognize the need for patient-centered oncology quality measures that go beyond survivorship and end of life care. A focus on patient experience during curative treatment or other patient-centered elements such as effective symptom management related to treatment side effects and overall function is important for addressing patients’ overall well-being.
• Capturing patient experience and tolerance for the toxicity of various treatment regimens also has important implications for patients’ engagement in self-care.
• Eliciting and quantifying patient ratings of symptom management can also contribute to health equity by helping patients articulate their priority symptoms and reducing unconscious bias.
• The new CMS Enhancing Oncology Model will also serve to accelerate adoption of patient-reported outcome measures. 

MABGH believes that the PBGH measures address these points, and there we support their adoption.

The Kansas Hospital Association is concerned that the Thirty-day Risk-Standardized Death Rate among Surgical Inpatients with Complications (Failure to Rescue) disregards site of death. KHA believes that disregard for site of death in this measure introduces many scenarios outside of a hospital's control that could result in death. E.g., transfer to a rehab facility or transfer to a long term care facility is not excluded. 

The Kansas Hospital Association questions the validity of the excess days in acute care (EDAC) measures - 117 - After Hospitalization for Acute MI (AMI); 119 - After Hospitalization for Heart Failure (HF); and 120 - After Hospitalization for Pneumonia (PN) with the readmissions being for all causes. If the measure is specific to a diagnosis, we believe that the readmission measure should be specific to the diagnosis as well.

The Kansas Hospital Association questions the validity and reliability of all of the newly proposed hospital patient experience of care questions. Specifically with regard to 146, Restfulness of Hospital Environment, patients who require care in an inpatient setting will be monitored, which by necessity will likely cause disruption in a patient's rest based on the patient's acuity and the frequency of required monitoring, medication, therapies and other services. Additionally, patients being in a different environment typically do not rest well and patient sound sensitivity is individualized. Our organization requests that this measure be abandoned.

The Kansas Hospital Association questions the validity and reliability of all of the newly proposed hospital patient experience of care questions. Specifically with regard to 147, Restfulness of Hospital Environment, patients who require care in an inpatient setting will be treated and monitored, which by necessity will likely cause disruption in a patient's rest based on the patient's acuity, frequency of required monitoring, medication, therapies and other services. Additionally, patients being in a different environment typically do not rest well and patient sound sensitivity is individualized. Our organization requests that this measure be abandoned, and that all of the newly proposed hospital patient experience of care measures undergo further validity and reliability testing.

As someone who had suffered a moderate traumatic brain injury and who had actually fallen in an outpatient hospital setting (suffered double vision, lack of spacial orientation, was taking pain medications after 2 back-to-back skull fracture repair surgeries), neither my fall risk nor that actual occurrence of a fall were ever noted.  In fact I "passed" a balance test conducted by my physiatrist so I never received Physical Therapy or therapy to address this issue.  So I understand firsthand 1) how the assessment for a patient's fall risk is not sensitive enough, 2) these data on patient falls most likely under-represent the actual frequency of occurrence of inpatient hospital falls  3) given we have a patient safety culture of non-reporting (also witnessed and generally accepted).  I would ask that this measure include recommendation that patients themselves and their families are provided the opportunity, verbally and in written form, during and after their hospitalization, to report whether they feared or actually did suffer a fall; hospitals need to make accessible more ways to collect patient self-reports to contribute to and strengthen these data to more accurately reflect actual rate of patient falls to make the data more reflective of our patient experiences.   

            I also understand that falls themselves can cause traumatic brain injury- an injury for which patients are rarely evaluated and consequentially, for which patients often go undiagnosed and untreated.  Several of my brain injured peers have been hospitalized after taking a fall in their home or during recreational activities and required inpatient rehabilitation.  Numerous of the members of my brain injury peer support groups had fallen as the cause of their "mild" brain injuries and are currently not receiving the diagnosis and treatments that they need.  They are examples of patients suffering long lasting symptoms from their falls, their conditions although called "mild" should be considered "moderate injury" because the functioning of their lives is dramatically affected as a result of this kind of injury.  

            Additionally, I understand it is standard medical practice for patients who come into the emergency facilities after physical trauma, such as a car accident, to be released once they are stabilized, yet these patients are never assessed and evaluated for a potential traumatic brain injury.  There is no mention of the prevalence of brain injury suffered by those who sustain "moderate" or "severe injury" falls in this measurement to help make health professionals more aware of its possible occurrence.   As a result of ignoring the possibilities of brain injury, and not realizing its impact on our lives, none of our 50 states have a good grasp of how many persons who suffered brain injury are undiagnosed, untreated in our communities and among the populations who are incarcerated, in shelters, homeless, or had committed suicide.           

In summary, our health system demonstrates time and time again that does not provide patient care in a truly brain injury-informed manner.  Proper action would be to refer the patients who suffer "moderate or severe injury falls" to a qualified physician to evaluate them for a potential brain injury, as should be done for anyone after suffering such a physical fall or blow to the body.   If we are claiming to provide quality patient care, are we taking this step?

Reference:  https://www.cdc.gov/mmwr/volumes/69/wr/mm6909a2.htm

 The Kansas Hospital Association is concerned that 199 - Connection to Community Service Provider - does not take into account many critical issues associated with connecting patients to services in rural and frontier communities. Many rural, especially frontier communities, do not have community service providers that can address or have the resources available to address health related social needs. We ask that there be an exclusion for patients residing in communities where there are no community service providers to address the patients' health related social needs, such as transportation, housing, food instability. Further, a significant safety concern is for patients who identify interpersonal safety as an issue. Documentation of any health related social need for patients who are victims of domestic violence could put those patients at increased risk. We believe that thoughtful consideration must be given to protecting patients who are victims of domestic violence and consider the unintended consequences of required reporting on this measure, and who would have access to the information provided to connect these patients to services.

As a Patient Advisor at my hospital or as a volunteer patient advocate anywhere around town, I talk openly about my patient experience; perhaps this tends to make people feel safe enough to open up and disclose to me when they too have suffered a negative patient experience themselves.  Along with other patients' storytelling, I hear stories from nurses, retired nurses and other health professionals.  When "cost" of our health care is a consideration in care provision, health leadership tends to cut corners, cut back where they perceive that care is unnecessary but to us the patients the same care may be adequate, proper, effective and fulfilling of our needs, which IS the mission of our health care system.  I have heard of patients moved from their intensive care ward to another of less intense care because of shortage of staff -against the warnings of other nurses- and as an outcome, the patient died and nurses were silenced.  I have heard nurses tell me of patients who appeared not ready for discharge being released despite stated concerns.  In my Patient Advisory Council we were told of one case an elderly gentleman was released to his home, where he lives by himself, after his leg surgery.  To add to these stories are the visuals from the investigated cases of Louisville, KY patients being released -dumped- still in their patient gowns onto Louisville's cold streets.  This exemplifies what poor quality- how bad- our health system has become. 

            Patients do not heal on a predetermined, scheduled basis. What may be considered "Excess Days" to our health leaders and administrators (perhaps because the average, healthy, well-to-do, well-supported and networked patient required fewer days to recoup) is considered "the number of days we needed to heal" for us outlier patients.  What works for the herd does not necessarily work for each individual person.  So I would like this phrase "Excess Days" to be stripped from this measure. 

            I am stating this as someone who took it upon herself to better understand why I was sent home by hospital staff immediately after skull fracture repair surgery- instead of addressing the inhumane level of pain from a damaged cranial nerve- and provided adequate pain alleviation through an opioid drip - just as I had been provided post-op after right ankle repair surgery nearly a decade ago.  I know because I experienced what quality care looks like after receiving it from another health institution at an earlier time.  The more I dig into the medical literature on patient safety, the more I am seeing this trend: our health institutions' profits/ ledger balance are being given more priority in the making of health care decisions than their patients' safety. 

            The more I dug into the economic reasons why our system doesn't provide service at the level of our patient need, the more I learned about how deficient, lacking in capacity and dysfunctional the system is statewide -and nationally.  A physician speaker at our hospital's 2018 Integration Summit Conference stated its lack of capacity is "unsustainable". 

            We must ask the questions why don't our ICUs have adequate staffing, our hospitals enough beds for patients, we have enough health professionals, enough personal protective equipment for pandemic outbreaks...?  Why aren't our medical and mental health leaders banging on the doors of their Congresspeople asking for more federal spending on our healthcare?  Why are they medically harming us instead?  Why do our US Health System's quality measures allow these harmful things happen to patients? 

References for Patient Safety:

https://youtu.be/rFJsFdgMkYE?si=OX3InqId6xbZrO1G  (News Report Investigation of Dumping of Patients in Louisville, KY) 

https://youtu.be/2xh45ml9NgQ?si=prBppK69FvxE74pL  (Video of my patient experience story, analysis of quality care and solutions given at a Medicare for All rally in 2021)

https://www.cnbc.com/2018/02/22/medical-errors-third-leading-cause-of-death-in-america.html (CNBC article based on the Johns Hopkins study of estimated 250,000 deaths annually due to poor patient care in the USA.)

References for Fiscal Spending Process:

https://youtu.be/d_udbs-wuDA?si=-NQGpry7lo3TkZxr   (5 min video of  Dr. Stephanie Kelton, former Economics Advisor of US Senator Bernard Sanders and author of NYT Bestselling book The Deficit Myth speaks on the process of federal spending which she had studied and written peer-reviewed articles on since the 1990s. ) 

References for a Universal National Healthcare Program or Medicare for All: 

https://realprogressives.org/podcast_episode/episode-192-mmt-for-m4a-with-fadhel-kaboub/

https://realprogressives.org/podcast_episode/episode-234-rp-book-club-presents-randy-wrays-making-money-work-for-us/

(Scroll to 3:01:09 where I ask the Economics Professor, Dr. Randal Wray how our health care system could be funded followed by his response. ) 

The Kansas Hospital Association is concerned that 210 - Resolution of at Least 1 Health-Related Social Need - will penalize hospitals in communities that do not have community service providers (CSPs) to address one or more health-related social needs. Rural and frontier communities lack CSPs with resources to address health-related social needs. Very few CSPs exist in rural Kansas communities that are able to address transportation or housing needs or food instability. Further, our organization has the same concern as expressed regarding measure 199 - Connection to a Community Service Provider - and protecting the identity of patients who are victims of domestic violence. A major concern is that the resolution of health-related social needs is not reimbursed. Hospitals are already reimbursed below cost by Medicare and Medicaid; and by many commercial plans. Our organization requests that this measure be tabled until a reimbursement structure is developed to reimburse hospitals for connecting patients to CSPs who are able to resolve their health-related social needs. Further, we ask that patients who reside in communities that do not have a CSP to address their health-related social need be excluded.

The American Geriatrics Society (AGS) appreciates the opportunity to review and comment on the 2023 Measures Under Consideration list. 

AGS supports the End-Stage Renal Disease (ESRD) Dialysis Patient Life Goals Survey measure and believes that this is a critically important area. There are many patients who do not appreciate that dialysis is life support and that requiring dialysis means greater risk for serious complications, including death. 

Given that discussions of goals would be dramatically different between younger patients (who are most likely to have a single, severe kidney disease) relative to older patients (who are most likely to have multiple intersection conditions with their kidney disease), AGS recommends that the data for this measure be stratified by comorbidity and if that is not practical, to stratify by age. 

While AGS is concerned that a Likert scale may not capture the quality of care in goal discussions, we support the PaLS measure as a starting point. We encourage continued work to develop more nuanced and robust measures of the quality of these discussions, beyond the mere occurrence of such discussions.   

AGS appreciates the ongoing attention to social drivers of health (SDOH) and continues to support the Screening for SDOH measure. This measure will be particularly important for the frail and palliative populations. In order to ameliorate disparities and inequities, it will be important to address the full spectrum of social drivers of health, including housing, food security, transportation, and social isolation (DOI:10.1377/hlthaff.2020.01470). 

AGS appreciates the ongoing attention to social drivers of health (SDOH) and continues to support the Screen Positive Rate for SDOH measure. This measure will be particularly important for the frail and palliative populations. In order to ameliorate disparities and inequities, it will be important to address the full spectrum of social drivers of health, including housing, food security, transportation, and social isolation (DOI:10.1377/hlthaff.2020.01470).