PRMR MUC List Commenting

Premier supports the need to consider the aging population and improve geriatric care. However, Premier does not support adoption of this attestation-based measure which neither measures patient outcomes nor evaluates patient care. It is unclear what additional value this measure would bring to patients, caregivers, hospitals or other stakeholders. Premier strongly urges CMS to assess what (if any) gaps in quality measurement exist around geriatric care in the current quality reporting programs and to work with the stakeholder community to develop meaningful outcome measures around geriatric care if it is determined that gaps do exist. 

Dear Pre-Rulemaking Measure Review (PRMR) Clinician Committee,

The American Urological Association (AUA) appreciates the opportunity to provide comments regarding the potential addition of the Prostate Cancer episode-based cost measure (MUC2023-207) to the MIPS measure set.  With a membership of more than 23,000 physician, physician assistant, and advanced practice nursing members—15,000 of whom are U.S. based—the AUA is the premier urologic association whose members represent the world’s largest collection of expertise and insight into the treatment of urologic disease. 

The AUA supports the development and use of urology-relevant cost measures because they can help facilitate clinical quality improvement and appropriate utilization of resources.  We are pleased that CMS chose to develop a cost measure specific to prostate cancer.  We are also gratified that CMS invited several of our members to participate in its Clinician Expert Workgroup to help develop the measure.  

However, we have two key concerns about the use of MUC2023-207, as currently specified, in the MIPS program.  First, because information about clinical stage and risk of higher-acuity disease is not available in claims data, the risk-adjustment model cannot adequately control for those differences between patients, making it unfair to compare the costs of their care across providers.  Specifically, despite separating out metastatic and non-metastatic disease, there will still be differences between high-risk localized or locally advanced and low/intermediate risk localized patients that the risk model does not account for.  These differences in patient mix will impact costs because those with higher-risk localized disease likely will require more costly, yet appropriate, treatment, such as multi-modality therapy, genomic testing, and more imaging.  Thus, we believe it is possible that providers may have poor performance on this measure, even though they are providing high-quality care.  Second, the attribution methodology attributes costs to the individual or group that triggers the episode (usually a urologist).  However, that provider will be attributed all the costs associated with the episode, even if care is provided by others and is outside the control of the triggering provider (e.g., care provided by medical or radiation oncologists).  Although our representatives who were engaged in the development process expressed these concerns, it does not appear that they have been addressed in the current version of the measure, thus limiting its effectiveness in improving care and correctly identifying outliers who are spending more yet having same or worse outcomes.

Respectfully,

Karen Johnson, PhD

Director, Quality & Measurement

American Urological Association

The Alliance for Quality Improvement and Patient Safety (AQIPS) appreciates the opportunity to submit comments on a specific requirement under consideration under the proposed pre-rulemaking Patient Safety Structural Measure (Number MUC 2023-188).  AQIPS is the professional association for Federally Listed Patient Safety Organizations (PSOs) and their healthcare provider members to foster healthcare providers ability to improve patient safety and the quality of patient care delivery using the processes and protections of the Patient Safety and Quality Improvement Act of 2005 (42 U.S.C. 299b-21 et seq.; “The Patient Safety Act”).  The Patient Safety Act made possible privileged and confidential collaborative efforts to improve patient safety and the quality of the delivery of patient care across the continuum of healthcare for the benefit of patients.  The Patient Safety Act is a disclosure statute allowing healthcare providers to develop and share innovative safety strategies to improve the quality of patient care delivery. The Patient Safety Act incentivizes safety, quality and performance improvement as a shared responsibility among all healthcare providers throughout the healthcare continuum.  As organizations that are committed to fostering safety culture, systems improvement, and high reliability in healthcare, AQIPS member PSOs and our hospital members have a significant interest in this proposed MUC. 

AQIPS urges CMS to withdraw the Accountability and Transparency Domain subparagraph 2 that requires for a hospital to gain a point for this domain a hospital  must attest, among other things, that:

Our hospital reports serious safety events, near misses and precursor events to a Patient Safety Organization (PSO) listed by the Agency for Healthcare Research and Quality (AHRQ) that participates in voluntary reporting to AHRQ’s Network of Patient Safety Databases.

This provision is inconsistent with the Patient Safety Act and CMS lacks legal authority to regulate PSOs.  A plain reading of this proposed provision requires PSOs to report to the AHRQ Network of Patient Safety Databases (hereinafter “The National Patient Safety Database.) for hospitals to meet this measure.  This proposed provision also requires hospitals to report to the NPSD, although indirectly. Such reporting under this measure is not “voluntary” by hospitals or PSOs and, therefore, is inconsistent with the Patient Safety Act.  Recognizing that PSOs would be collecting a large amount of rich quality data that CMS, AHRQ, plaintiff lawyers and other entities would want to commandeer, Congress provided that PSOs cannot be compelled to disclose PSWP. 42 USC 299b-22(d)(4).  This prohibition includes being indirectly compelled through a measure in a rulemaking. 

As you know, PSOs are private, market-based programs accelerating patient safety to ensure the welfare of patients.  The PSO program is a self-regulatory program to allow quality improvement beyond regulatory requirements.  PSOs are not federally funded, are not subject to CMS jurisdiction and, as provided by the Patient Safety Act, cannot be directed by government agencies.  Hospitals choose a PSO to work with based on the PSOs programs and performance in providing value to the hospital. (See Patient Safety and Quality Improvement, 73 Fed. Reg. 70732, 70747 (Nov. 21, 2008).  Therefore, CMS cannot indirectly compel PSOs to “voluntarily” report to the NPSD.

The Patient Safety Structural Measure is an attestation-based measure that assesses whether hospitals demonstrate having a structure and culture that prioritizes patient safety.  However, this proposal goes well beyond hospitals structure and culture and extends to compelling valuable data from private sector entities.  AQIPS member PSOs gain rights to use of deidentified PSWP from their providers for patient safety activities, in the same manner as ‘23 and Me” gains rights to share genetic data with healthcare researchers, AI companies healthcare data and other private sector data collection companies.  Like claims data and genetic data, PSOs can monetize patient safety and quality event data (that does not contain PHI) which is used for research through the research disclosure permission or for patient safety activities. 

According to Agency for Healthcare Research and Quality, the work of federally listed PSOs and healthcare providers to reduce medical errors and increase patient safety in various clinical settings and specialties is highly valued, successful, and thriving. “Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety Act of 2005,” AHRQ, December 2021.  The healthcare and PSO community have developed programs, including National Safe-Tables, to revolutionize patient safety practice and to connect the healthcare system. 

The Patient Safety Structural Measure is an attestation-based measure that assesses whether hospitals demonstrate having a structure and culture that prioritizes patient safety.  The pre-regulation proposed measure goes well beyond hospitals to improperly mandate requirements that impact private sector entities and should be withdrawn.  Should you have any questions or require additional information, please contact me at [email protected].

Premier strongly supports the adoption of this measure to help hold health plans accountable for executing their contractual commitments to benefits coverage and network adequacy. Premier’s members have experienced escalating levels of inappropriate denials by Medicare Advantage plans over the past year, consistent with the findings in the most recent OIG report (https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp). Further, Premier members have reported high overturn rates of initial denials and are frequently required to engage in multiple rounds of review to collect claims payments. Inclusion of this measure incentivizes health plans to conduct administrative processes around claims payment more efficiently, expediting patient access to care.

Premier encourages CMS to continue to develop its portfolio of measures related to Medicare Advantage plans’ execution of their network adequacy and medical loss ratio program requirements. Premier specifically requests that CMS consider additional Medicare Advantage program measures of payment denials and delays, which impede Medicare beneficiaries’ access to their entitled healthcare items and services.

Please accept the attached comments from the ASC Quality Collaboration regarding MUC 2023-156.

The Defeat Malnutrition Today coalition appreciates the opportunity to submit comments in response to the release of the FY 2023 MUC List and specifically in support of the proposal to adopt the Global Malnutrition Composite Score for all adults ages 18 or older (MUC2023-114).

Defeat Malnutrition Today is a coalition of over 120 members committed to defeating older adult malnutrition across the continuum of care. We are a diverse alliance of stakeholders and organizations working to achieve a greater focus on malnutrition screening, diagnosis, and intervention through regulatory and/or legislative change across the nation’s health care system.

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. This is a great opportunity to be more inclusive and identify malnutrition and food insecurity earlier. It also serves as a reminder of the crucial role that nutrition plays in improving patient outcomes.  As few CMS measures address health equity and food insecurity, expanding GMCS is an opportunity to do both.

Malnutrition Remains a Measurement Gap in Hospital Programs

Malnutrition is often underdiagnosed and untreated in healthcare settings, and disparities exist across different racial/ethnic groups and geographic locations. It has been shown to be an independent predictor of negative patient outcomes, including mortality, lengths of hospital stay, readmissions, and hospitalization costs. An estimated 20-50% of hospital inpatients are malnourished or at risk of malnutrition, yet 2018 data from the Healthcare Cost and Utilization Project (HCUP) report that only 8.9% of discharges had a malnutrition diagnosis. The importance of malnutrition prevention, identification and intervention for at-risk and malnourished individuals is only magnified by malnutrition’s impact on independence, well-being, and the severity of medical conditions and disabilities.

Identifying and addressing malnutrition in the hospital setting using evidence-based strategies gives patients the opportunity to receive care and support that may not otherwise be available to them in ambulatory or community settings. The existing Global Malnutrition Composite Score eCQM for 65+ was one of the first quality reporting programs to include performance measures focused on nutrition care or malnutrition. It has been extensively tested and shown that adopting evidence-based malnutrition care best practices is associated with reduced costs and improved patient outcomes. 

Health Equity Implications of GCMS 

An analysis of 2019 Malnutrition Quality Improvement Initiative (MQii) Learning Collaborative data of more than 1.5 million patients found 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. Additionally, food insecurity caused by economic and social burdens can increase the risk of malnutrition. Therefore, addressing malnutrition and its root causes, as done through assessment and care planning in the health care setting, can support the reduction of health disparities. By addressing these health and social factors earlier in life, we can improve access to healthy aging.

Reporting on the GMCS is a specific and meaningful action that hospitals can take to align with three of the priorities outlined in CMS’s Framework for Health Equity: expansion of collecting, using, and analyzing standardized data, assessing causes of disparities, and building capacity of healthcare organizations to reduce disparities.

Age Friendly Hospital Measure (MUC2023-196)

We also write in support of the Age Friendly Hospital Measure, as it highlights the importance of screening for social determinants of health (SDOH), including malnutrition. Patients who screen positive can easily be referred to the appropriate professionals and community services, improving older adults’ access to needed care and follow-up services in a timely and efficient manner, ultimately improving health outcomes. 

Research showing the importance of identifying, diagnosing, and treating malnutrition at all ages continues to grow and early identification of malnutrition can allow for healthy aging. Further, the relationship between malnutrition and food insecurity and its effects on health equity has been proven to be of importance and continues to be studied. 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. 

Thank you for considering our comments. Please let us know if we can provide you with any further information. 

The Fordham University Ravazzin Center on Aging and Intergenerational Studies appreciate the opportunity to submit comments in response to the release of the FY 2023 MUC List. The Ravazzin Center collaborates with students, professionals, and communities to address the needs of older adults and their families through practice, policy, and research. The Center focuses on practices and policies across the lifespan with an emphasis towards promoting social justice.

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. It is significantly important to address malnutrition and health equity.

Reporting on the GMCS is a specific and meaningful action that hospitals can take to align with three of the priorities outlined in CMS’s Framework for Health Equity: expansion of collecting, using, and analyzing standardized data, assessing causes of disparities, and building capacity of healthcare organizations to reduce disparities

The importance of identifying, diagnosing, and treating malnutrition continues to grow. Further, the relationship between malnutrition and food insecurity and its effects on health equity has been proven to be of importance and continues to be studied. It is important to ensure CMS’s inclusion of this measure in the 2024 Hospital Inpatient Quality Reporting Program which can help address the overarching burden that malnutrition has on patients and the healthcare system as a whole. If you have any questions, please do not hesitate to contact me.

Fishburne May, LLC, makers of the FishburneTabs™ for oral hydration, would like to comment on “Timely Reassessment of Non-Pain Symptom Impact” MUC2023-166.

As reimbursement for essential treatments of dental conditions coexisting with serious systemic disease becomes embedded into the CMS system, the dental and medical professions

must be equipped with saliva assessment tools utilizing indicators that provide real time information for clinical decision making.  We propose that screening in this previously endorsed MUC be refined and separated.  First, screening of hard and soft tissue disease, and second a separate assessment of saliva capacity and volume utilizing quantitative measures (dry mouth assessment).  The state of hydration becomes quantifiable and monitorable by medical and dental professionals via the use of FishburneTabs for oral hydration. FishburneTabs are easily digitized and used for teledentistry applications.   

Dry mouth is recognized by the Food and Drug Agency (FDA) as an adverse event in clinical investigations.  Recognition by CMS of the desiccation process and dry mouth would contribute to cross agency consistency.  

I am writing in support of:

Patient Safety Structural Measure Number: MUC2023-188

Current research indicates  patient safety, health care professionals' well being and hospital all  improve when there is more transparence when patients suffer a bad outcome.

Please accept the attached comments from the ASC Quality Collaboration regarding MUC 2023-171.

The AAFP supports this measure as a new health-plan level measure in the Medicare Advantage (MA) Star Rating program. It appears that this measure would not add administrative burden for primary care physicians and in fact, will likely reduce burden. Nor does it appear that this measure will introduce additional burdens for health plans being measured. Additionally, it should improve transparency with patients/beneficiaries by providing them with claim denial rate information, which could help them as they select their health plan each year.

This new measure has impressively high reliability. It does not duplicate but strongly complements the Leve 2 measure that is currently in the Star Rating program. It has the potential to reduce the frustrations experienced by beneficiaries and their physicians when dealing with the current coverage approval process in Medicare Advantage if it leads to the elimination of unnecessary prior authorizations. 

The Defeat Malnutrition Today coalition appreciates the opportunity to submit comments in response to the release of the FY 2023 MUC List and supports the proposal to adopt the Age Friendly Hospital Measure (MUC2023-196). Defeat Malnutrition Today is a coalition of over 120 members committed to defeating older adult malnutrition across the continuum of care. We are a diverse alliance of stakeholders and organizations working to achieve a greater focus on malnutrition screening, diagnosis, and intervention through regulatory and/or legislative change across the nation’s health care system.

We write in support of the Age Friendly Hospital Measure, as it highlights the importance of screening for social determinants of health (SDOH), including malnutrition. Patients who screen positive can easily be referred to the appropriate professionals and community services, improving older adults’ access to needed care and follow-up services in a timely and efficient manner, ultimately improving health outcomes. This is a great opportunity to identify nutrition needs earlier and serves as a reminder of the crucial role that nutrition plays in improving patient outcomes.  Thank you for considering our comments. Please let us know if we can provide you with any further information.

Developing preventive measures that support current evidence-based vaccinations is critically important, particularly for primary care physicians. A strong recommendation from a trusted clinician is one of the most effective strategies to increase vaccine uptake. It is important for everyone who is eligible, especially those at higher risk, to receive their updated COVID-19 vaccination (or COVID-19 primary series if not yet vaccinated). 

While the AAFP strongly supports the administration of all recommended vaccines, we do not support this measure for use as an accountability measure at the individual clinician and/or practice level. It is important to note that this measure has not been through a rigorous endorsement process. 

The economics of vaccine delivery prevent some primary care clinics from being able to administer the vaccine in their practices. Furthermore, growing misinformation and vaccine hesitancy among the American population make it unfair to hold clinicians accountable. To add to the challenges, the lack of data sharing and interoperability make this measure difficult to operationalize. For example, PCPs do not receive notification in a timely manner when their patients receive the vaccine outside of their clinic (such as at a retail pharmacy or other location). 

Vaccine distribution and storage requirements also present challenges. COVID-19 vaccines are more expensive and have additional storage and handling requirements which make them financially risky for many physicians to offer. 

Furthermore, recent surveys indicate adult COVID-19 related behaviors are highly variable depending on demographic traits, which could unfairly penalize physicians who care for certain populations. (https://www.kff.org/coronavirus-covid-19/poll-finding/vaccine-monitor-november-2023-with-covid-concerns-lagging-most-people-have-not-gotten-latest-vaccine/)

To add to the challenge, not all vaccinations are reliably reported to local or state immunization systems. An OIG report found that many immunizations cited challenges receiving complete data from pharmacy settings. Without vaccination history, physicians are unable to record a patient's vaccination status in their records. This measure would unfairly penalize physicians in states with incomplete immunization data sharing. (https://oig.hhs.gov/oei/reports/OEI-05-22-00010.pdf)

As an alternative, CMS could include this measure ONLY in programs where performance is not tied to payment and where they can collect data to help inform future policy. By allowing providers to report the data without financial implication, it would allow for comparison of provider electronic health record data, state immunization registry data, payer and claims data and highlight areas of opportunity for targeted infrastructure improvements in interoperability.

Please accept the attached comments from the ASC Quality Collaboration regarding MUC 2023-175.

We recommend the CMS recognize the need for the “Timely Reassessment of Non-Pain Symptom Impact” MUC2023-166 as related to the probable side effect of a drying oral cavity and reduced saliva production (dry mouth/xerostomia) for at-risk patients in clinical or hospital settings.  

As reimbursement for essential treatments of dental conditions coexisting with serious systemic disease becomes embedded into the CMS system, the dental and medical professions must be equipped with saliva assessment tools utilizing indicators that provide real time information for clinical decision making.  We propose that when screening for disease in the oral cavity be refined and separated into separate clinical tasks.  First, examination of hard and soft tissue disease, and second an assessment of saliva capacity and volume utilizing quantitative measures (dry mouth assessment).  The state and change of hydration can be quantified and monitored consistently by medical and dental professionals via the use of FishburneTabs for oral hydration. FishburneTabs are easily digitized and used for teledentistry applications.   

Dry mouth is recognized by the Food and Drug Agency (FDA) as an adverse event in clinical investigations.  Recognition by CMS of the desiccation process and dry mouth would contribute to cross agency consistency.  

Developing preventive measures that support current evidence-based vaccinations is critically important, particularly for primary care physicians.  A strong recommendation from a trusted clinician is one of the most effective strategies to increase vaccine uptake.  It is important for everyone who is eligible, especially those at higher risk, to receive their updated COVID-19 vaccination (or COVID-19 primary series if not yet vaccinated). 

However, it is premature to develop and subsequently implement a performance measure addressing COVID vaccination rates. Holding a clinician accountable for COVID vaccination rates is troubling given the well-documented vaccine hesitancy throughout the United States, particularly among minority populations and in rural areas. Some patients already have a lack of trust in the healthcare system, and forcing physicians to press for vaccine acceptance puts undue pressure on the patient-physician relationship. There are also patient concerns that are valid, e.g., the long-term impact of an mRNA vaccine on children. Additionally, the battle against misinformation is arduous given the widespread popularity of social media. Patients receive their information from these sites, which can be more convincing than the science-based advice from their primary care physician. While it is the primary care physician’s responsibility to combat misinformation, a physician cannot force a patient to get the vaccine. 

Measurement programs, particularly the MIPs program, include measures that are static, making it impossible to modify a measure as soon as new evidence becomes available. Although the numerator defines “up to date” as determined by the Centers for Disease Control and Prevention (CDC) guidelines, this definition does not permit for historical documentation to satisfy the numerator (e.g., 1 current vaccination formulation of Moderna or Pfizer vaccine = up to date on COVID vaccination). This adds to documentation burden and feasibility concerns.

A vaccine measure with such variability across patient populations needs to be risk adjusted to account for the geographic and racial/ethnic disparities or it will lead to misclassifications of a clinician’s performance. 2022 CDC COVID-19 vaccination statistics shows only 8 states with 25 percent or higher of residents with proper vaccination. If a state with very low COVID-19 vaccination rates improves by 100%, their score would still reflect poorly as compared to the national mean score.

ACP does not support this measure and we urge you to reconsider including this performance measure in a federal program.

ACP appreciates that episode-based cost measures represent an important opportunity to move towards more accurate, targeted cost assessment in value-based programs and models. However, the rheumatoid arthritis cost measure appears to be measuring costs without the cost effectiveness component. The cost measure rationale indicates that this gap area represents an opportunity for improving cost performance, but the evidence supporting the measure reflects better clinical outcomes.  It is challenging to measure and attribute costs to a physician while also improving patient outcomes. In most situations, you can do one or the other, but not both. The downstream savings of using cost-effective medications may be large, but how are the patient side-effects captured? 

ACP supports the level of attribution for this cost measure at the group practice level, however, not at the level of the individual clinician.  Additionally, ACP does not support attributing the same costs to multiple clinicians. This deviates from the team-based care model and improperly double counts the same costs, which skews cost calculation.

Regarding the denominator exclusions, ACP recommends defining what constitutes “extremely low” treatment costs.

It is critical to get risk adjustment right, particularly when it comes to measuring cost. Failing to properly risk adjust for socioeconomic, biological, or other factors that put patients at increased risk could jeopardize funding for hospitals and practices serving vulnerable populations and potentially threaten access to medical services for those patients as a result. While the measure numerator includes winsorized scaled costs to limit the effects of extreme values on expected costs, it is unclear whether these values will shift year by year or remain static. Additionally, many patients suffer from co-morbidities, which is a major cost factor. It is unclear how the risk-adjustment model takes this into account.  
 

This comment is for Screening for Social Drivers of Health (SDOH) and Screen Positive Rate for SDOH.

The American College of Physicians (ACP) applauds CMS for tackling the critical issue of social drivers of health (SDOH) and their impact on health outcomes.  While the performance measure is well-intentioned, ACP has a number of concerns. 

Although the impact of SDOH on health outcomes is clear, ACP is not aware of evidence supporting the screening of SDOH.  The United States Preventive Care Task Force (USPSTF) has recommendations focused on screening for some SDOH, including intimate partner violence and one in progress on food insecurity.  ACP strongly supports performance measures that are evidence-based and supported by clinical practice guidelines.  With that said, the emphasis on the routine collection of SDOH is somewhat nascent and ACP understands that guidelines addressing the screening of HRSN topics may be in development or forthcoming. ACP recommends that the performance measure be updated as guidelines addressing SDOH topics are published. 

It is not clear what the expected score would be. The scoring will differ in settings that are serving populations with different levels of need. The performance measure aims to increase hospitals’ use of screening tools to identify SDOH, but how does the performance measure account for improvement in screening tool use? While ACP appreciates that there is a separate measure for positive screens of SDOH, it is unclear what action is required if a patient indicates that they need assistance with one of the five SDOH. 

ACP does not support the use of performance measures that have not been tested at the level of accountability.  Measure testing is particularly important given the high stakes nature of performance measures’ use in accountability, pay for performance programs, and public reporting. Consistent with guidance included in CMS’s blueprint, ACP agrees performance measures must demonstrate reliability and validity for all levels of analysis.  There is no testing data available for the SDOH performance measures. ACP recommends these performance measures be tested and demonstrate reliability and validity at the hospital level before implementation.

It is important for the SDOH measures to be incorporated in the Hospital Outpatient Quality Reporting program for several years to better understand its utility at that level of measurement before considering applying it to other levels of measurement. The CMS’s data highlight report notes several barriers for data collection in ambulatory care. These include the lack of a standardized screening tool, the multiplicity of codes, and the awareness among clinicians and medical coding professionals alike. The problems need addressing before applying the ASN measure at the individual physician or group practice levels.

In 2022, ACP released a position paper that supports payment reform to achieve greater equity and value in health care. ACP acknowledged that socioeconomic factors are significant contributors to health outcomes in this country. The proposal advocates that payment models be adjusted to decrease health inequities and address social drivers of health. ACP recommends that the integration of routinely identifying social needs be supported by new payment models to support these efforts.

As the father of a daughter living with ulcerative colitis and primary sclerosing cholangitis who has frequently been hospitalized, I want to express my support for the Patient Safety Structural Measure (#MUC2023-188) on the CMS list of Measures Under Consideration. I strongly believe this measure articulates the patient safety best practices all patients deserve to expect in every hospital in the United States:  

1.     Hospital leaders and boards of directors prioritize patient safety and are actively engaged in making sure the right safety practices are in place. 

2.     Hospitals adopt as their goal “zero preventable harm” as the patient safety strategic goal. Even if that goal is aspirational, it should be what every hospital is aiming to achieve.

3.     Hospitals establish a culture of safety that engages all its staff and puts in place systems for preventing and learning from medical errors or other problems that put patients at risk for harm or discrimination.

4.     Hospitals have systems in place for reporting harm events and being open and honest with patients and the public when harm events occur. I also expect hospitals to report their events to government agencies or other bodies that focus on learning and prevention.

5.     Hospitals should engage the patients and families they serve in patient safety work.  They should also be focused on helping patients access our medical records and correct errors in them when we find them.

Thank you for allowing me to express my strong support for the Patient Safety Structural Measure. I appreciate your time and consideration of my comments. Peter Howe, Newton Centre, Massachusetts

Good morning:
My name is Deanna Tarnow. I am a registered nurse, a patient advocate, a family member and friend to many who have experienced our healthcare system.   

As a healthcare provider, patient and family member who has lost loved ones due to the failures of our healthcare system, I write on behalf of and in support of the Patient Safety Structural Measure (#MUC2023-188) on the CMS list of Measures Under Consideration.  I believe we are at a crossroads in healthcare where we have the opportunity to do what is right and in the best interest of all persons within our country that touch healthcare and make patient safety a priority or turn our backs on those who have trusted us to provide safe care.  So far, we have let our patients and members of our healthcare teams down. It is time to take action and hold leadership and our hospitals accountable for safe systems and processes that support the health of both our healthcare providers and teams as well as the patients and families they serve.

Providing safe care is a fundamental moral and ethical responsibility to those we serve. To date, our hospitals and health systems have struggled in their commitment to ensure safe care because it has not been seen as a priority. 
The Patient Safety Structural Measure provide much needed guidance to hospital leaders on each of the following: improve reporting of and learning from adverse events, deliver care that is safe and reliable,  be open and honest with patients and their families about their care, engage patients and families in meaningful patient safety work,  create a culture of psychological safety that supports members of the healthcare team, and in the end, I believe, reinstill trust  that is so desperately needed within our healthcare system. The Measures also create a way to recognize the hospitals and health systems who are exemplars for their leadership and action on patient safety. We need to acknowledge those who commit to these shared goals and achieve success! The questions the Patient Safety Structural Measure asks hospital leaders to attest to reflect what patients in the United States expect all hospitals to be doing.  In addition, the PSSM aligns with other national guidance such as the Safer Together: The National Action Plan to Advance Patient Safety, the CMS National Quality Strategy, and the September 2023 Report to the President: A Transformational Effort on Patient Safety, issued by the President’s Council of Advisors on Science and Technology.
For each and all these reasons I strongly support the Patient Safety Structural Measure.  Thank you for this opportunity to make this public comment.

The Society of Hospital Medicine (SHM), representing the nation’s hospitalists, appreciates the opportunity to comment on the Respiratory Infection Hospitalization measure. This measure is a replacement for the Simple Pneumonia with Hospitalization episode-based cost measure which was removed from the MIPS through rulemaking this year. We continue to have concerns about attribution methodologies CMS uses for the episode-based cost measures in the MIPS program. Hospitalists, who will have cases attributed to them in this measure, are limited in their ability to control costs across an episode of care. Major costs associated with a hospitalization are relatively fixed, as the DRGs are the most significant driver of Medicare spending during the hospital stay. More control can be exerted over healthcare costs in the post-acute settings and post-discharge environments. We oppose its use in the MIPS program but would be supportive of the measure concept in other programs attributable at a broader system level.

The Society of Hospital Medicine (SHM), representing the nation’s hospitalists, opposes the Hospital Harm – Falls with Injury measure for inclusion in the Hospital IQR and PI programs at this time. We agree that prevention of falls in hospitals is an important priority. However, there is very little evidence-based guidance for falls prevention. Without evidence-based tools to address it, this measure risks prioritizing scarce healthcare resources away from other safety endeavors for uncertain returns on patient care or safety.

We also have concerns that this measure may inadvertently incentivize excessive labelling of patients as fall risks, requiring significant new resources and investments in strategies for patient immobilization and fall prevention. This may create a situation where more patients are identified as potential fall risks, necessitating the diversion of resources from patients at the highest risk of major injuries from falls. This measure also risks inadvertently emphasizing immobilization of patients, despite mobility being an important aspect of patient care. 

The Society of Hospital Medicine (SHM), representing the nation’s hospitalists, continues to caution against using 30-day windows with the Excess Days in Acute Care measures. Current evidence suggests that the window of impact for preventing readmissions or returns to the ER is much shorter than 30 days, and may be as short as 7 days. Therefore, the measure as structured makes hospitals and clinicians accountable for factors well outside of their control. We urge CMS to narrow the episode window for these measures to focus on the modifiable factors within hospitals and clinician’s control to prevent or reduce excess days in acute care.

The Society of Hospital Medicine (SHM), representing the nation’s hospitalists, continues to caution against using 30-day windows with the Excess Days in Acute Care measures. Current evidence suggests that the window of impact for preventing readmissions or returns to the ER is much shorter than 30 days, and may be as short as 7 days. Therefore, the measure as structured makes hospitals and clinicians accountable for factors well outside of their control. We urge CMS to narrow the episode window for these measures to focus on the modifiable factors within hospitals and clinician’s control to prevent or reduce excess days in acute care.

The Society of Hospital Medicine (SHM), representing the nation’s hospitalists, continues to caution against using 30-day windows with the Excess Days in Acute Care measures. Current evidence suggests that the window of impact for preventing readmissions or returns to the ER is much shorter than 30 days, and may be as short as 7 days. Therefore, the measure as structured makes hospitals and clinicians accountable for factors well outside of their control. We urge CMS to narrow the episode window for these measures to focus on the modifiable factors within hospitals and clinician’s control to prevent or reduce excess days in acute care.

The Society of Hospital Medicine (SHM), representing the nation’s hospitalists, is opposed to the addition of these survey items to the HCAHPS. The patient voice is a critical component of the healthcare system and is a vital tool for accountability to improve the safety and quality of care. However, we believe some of these questions may create perverse incentives regarding use of pharmacologic sleep aids which can increase the risk of confusion and falls and create a disincentive for appropriate monitoring for patients overnight (i.e., overnight vitals checks, cardiac telemetry monitoring when appropriate). Lengthening the HCAHPS survey may also decrease completion rates, which would limit the usefulness of the survey. Furthermore, question redundancy within the survey needs to be reconciled.

The Society of Hospital Medicine (SHM), representing the nation’s hospitalists, is writing to oppose inclusion of the Resolution of At Least 1 Health-Related Social Need measure in the Hospital IQR and Shared Savings Programs. We believe hospitals and hospital-based clinicians do have a key role in identifying and providing referrals to programs and services that address social needs and that CMS should be incentivizing this process. Hospitals already function as a vital safety net in communities across the country. This measure would hold hospitals accountable for the work and services of organizations unconnected to the hospital or health system, or for social services that are scarce in their communities. We would support measures that incentivize the process of referrals to social services, but do not think it would be appropriate at this time to hold hospitals or clinicians accountable for outcomes up to twelve months beyond the hospitalization.

SHEA supports stratifying the Central Line-Associated Bloodstream Infection (CLABSI) measure for oncology locations in the Inpatient Quality Reporting (IQR) program. We believe this is an important first step in evaluating the potential for success of an existing measure that is being modified for expanded performance measurement. SHEA looks forward to the ability to report this measure using patient level risk adjusted data when FHIR based interface is more widely available. SHEA recommends CMS provide additional clarity on how SIRs will be calculated at the unit level. For example, additional clarity on how to stratify data for ICU and med surge, and cancer patients in a community hospital setting who may have a CLABSI would be helpful. SHEA recommends including MUC2023-219 in a future IQR program. 

UnitedHealth Group (UHG) does not support adding Initial Opioid Prescribing for Long Duration (IOP-LD) in its current form to the Part C & D Star Ratings measure set. As UHG has previously commented, since both the PQA IOP-LD and HEDIS Risk of Continued Opioid Use (COU) measures look at initial opioid prescriptions, we believe the COU measure specifications allow for a more appropriate approach to minimize unintended consequences that adversely impact a beneficiary’s access to medically necessary prescribed opioids. For example, the COU measure:

1. Excludes beneficiaries if a diagnosis is 12 months before the initial prescription start date (IPSD) through 61 days after, compared to only 90 days prior or during the measurement year for IOP-LD;
2. Has a 180-day negative lookback period which may be more clinically appropriate than IOP-LD’s 90 days;
3. Has a continuous enrollment requirement of 180 days before the IPSD through 61 days after, to ensure that beneficiaries new to a plan have enough prescription claims history to be appropriately targeted for the measure. The IOP-LD measure is unclear on how the negative lookback of 90 days will apply to beneficiaries new to a plan. 

Additionally, UHG believes IOP-LD would benefit from the following enhancements to help eliminate biases in measurement: 

1. Exclude beneficiaries from the denominator when it is determined utilization in excess of 7 days is necessary through pharmacist point-of-sale edit overrides or a provider’s supporting statement. These allowances are currently permitted by CMS. CMS has indicated that safety edits such as the 7-day supply limit should not be implemented as prescribing limits. CMS could utilize data within Part D reporting requirements to determine members who should be excluded from the measure. 
2. Exclude beneficiaries in Institutional Special Needs Plans (I-SNP) because older adults living in a long-term setting experience higher incidences of chronic pain, anxiety, and dementia than those in community plans. 

We encourage CMS to perform additional analysis of all relevant opioid measures and continue to monitor notable utilization trends as these may drive appropriate rulemaking. UHG asks CMS to take the above considerations into account to ensure that Star Ratings measures represent an unbiased measure of true health plan quality.

SHEA supports stratifying the Catheter-Associated Urinary Tract Infection (CAUTI) measure for oncology locations in the Inpatient Quality Reporting (IQR) program. We believe this is an important first step in evaluating the potential for success of an existing measure that is being modified for expanded performance measurement. SHEA looks forward to the ability to report this measure using patient-level risk-adjusted data when FHIR based interface is more widely available. SHEA recommends CMS provide additional clarity on how SIRs will be calculated at the unit level. For example, additional clarity on how to stratify data for ICU and med surge, and cancer patients in a community hospital setting who may have a CAUTI would be helpful.  SHEA recommends including MUC2023-220 in a future IQR program. 

SHEA supports measuring hospitals’ commitment to fostering a system-level culture that prioritizes patient safety through measurable action and progress toward zero preventable harm. This a good step forward and CMS should consider additional steps to encourage hospitals to demonstrate commitment to safety culture through attestation such as addressing differences between unit-level performance. Hospitals should be encouraged to provide evidence that demonstrates these activities will lead to an improved patient safety culture. This measure sets the stage for substantive quality improvement. SHEA recommends including MUC2023-188 in a future IQR program. 

UnitedHealth Group (UHG) opposes moving the Initiation and Engagement of Substance Use Disorder Treatment (IET) measure to the Star Ratings. Currently, barriers exist that prevent primary care physicians and other providers from receiving diagnosis notification and related records for patients with alcohol and Substance Use Disorder (SUD) diagnoses. For instance, federal and numerous state privacy laws relating to alcohol and SUD information strictly limit the re-disclosure of such information without written authorization. Health plans receive claims for SUD treatment but typically do not receive the corresponding authorization allowing plans to further re-disclose the information, thereby limiting plans’ ability to effectively move this measure. UHG recommends addressing this barrier to disclosing such information before CMS considers moving this measure from the display page into Star Ratings.

Dear Members of the 2023-2024 Pre-Rulemaking Measure Review (PRMR) Committee Hospital Workgroup:

Education Development Center (EDC) writes to express support for the inclusion of the Age-Friendly Hospital measure in the CMS Hospital Inpatient Quality Reporting (IQR) Program. This is a new type of measure, a “programmatic composite” measure, which considers the full program of care needed for geriatric patients in the hospital. Developed in partnership with the American College of Surgeons (ACS), the Institute for Healthcare Improvement (IHI), and the American College of Emergency Physicians (ACEP), this measure is meant to help build a better, safer environment for older adults and will help patients and their family caregivers know where to find best care.

The US population is rapidly aging, and the US health care system struggles to care for older adults. Based on 2019 US Census data, the 65-and-older population grew by over a third since 2010, and by 2030 this population is estimated to grow to 72 million (20 percent of the total population).[1]^,[2] Over one third of all inpatient surgeries are performed on individuals over the age of 65, and frailty is associated with poor post-operative outcomes and increased surgical cost of care.[3]^,[4],[5],[6] One study showed that only 25 percent of patients undergoing high risk surgery had advance care plans documented.[7] This is even more profound for patients of low socioeconomic status.[8] Hospitals are increasingly faced with older patients who have complex medical, physiological, and psychosocial needs that are often inadequately addressed by the current health care infrastructure. In response to this gap in care, the Age-Friendly measure was created and built on evidence-based best practices to provide-centered, clinically effective care for older patients. 

The Age-Friendly Hospital measure is an updated measure that combines two measures previously reviewed by the National Quality Forum’s Measures Application Partnership (MAP) in 2022: the Geriatrics Hospital Measure (MUC-2022-112) and the Geriatrics Surgical Measure (MUC-2022-032). While the MAP Hospital Workgroups were very supportive of both measures, they conditionally supported the Geriatric Surgical Measure with mitigating factors: 1) combining the two geriatrics measures into a single measure that is less burdensome, or 2) focusing on only one measure. In the 2024 IPPS proposed rule, CMS highlights the need for a comprehensive measure that addresses the aging population during hospital stays and solicited comments on the measure concept. The measure concept has support across organizations who care for older adults and was recently highlighted in Health Affairs.[9] 

Based on this feedback, ACS submitted a new single combined measure, the Age-Friendly Hospital Measure. The new streamlined measure now includes domains which target high-yield points of intervention for older adults—Eliciting Patient Healthcare Goal, Responsible Medication Management, Frailty Screening and Intervention (i.e., Mobility, Mentation, and Malnutrition), Social Vulnerability (social isolation, economic insecurity, ageism, limited access to healthcare, caregiver stress, elder abuse), and Age-Friendly Care Leadership. The new measure encourages hospital systems to reconceptualize the way they approach care for older patients with multiple medical, psychological, and social needs who are at highest risk for adverse events. It also puts an emphasis on the importance of defining patient and family caregiver goals not only from the immediate treatment decision, but also for long-term health and aligning care with what the patient values.

The concept behind the programmatic measure is based on several decades of history implementing programs that demonstrably improve patient care provided by the clinical team along with the facility. The Age-Friendly Hospital Measure incorporates The John A. Hartford Foundation and the IHI’s Age-Friendly Health Systems’ framework known as the 4Ms (What Matters, Medication, Mentation, Mobility), standards from the Geriatric Emergency Department Accreditation (GEDA) criteria developed from guidelines endorsed by the American Geriatrics Society, the Emergency Nurses Association, the Society for Academic Emergency Medicine and the American College of Emergency Physicians (ACEP), and ACS Geriatric Surgical Verification (GSV) standards. The programmatic approach is modeled after ACS quality programs, which lead to demonstrable improvements in patient outcomes across a broad range of populations. 

We appreciate the opportunity to share our strong support for the Age-Friendly Hospital measure for inclusion in the CMS Hospital IQR program. The measure is a critical piece in the optimization of care for older patients using a holistic approach to create a quality program that better serves the needs of this unique population. We believe these measures will help build a better, safer environment for the geriatric patient, and when the information is shared publicly, it will help patients and caregivers know where to get best care that is in line with their values. 

Sincerely,

Rebecca Jackson Stoeckle

EDC Senior Vice President and Director of Strategic Partnerships

Additional Background

Developed in partnership with the ACS, IHI, and ACEP, the Age-Friendly Hospital Measure is meant to assure Medicare that the conditions surrounding frailty in the geriatric population are brought into focus and that geriatric patients and their families know where to find good care. 

The Age-Friendly Hospital Measure was developed with the Modified Delphi method, receiving input from more than fifty organizations, including the ACS. The multistakeholder group identified a clinical construct based on evidence and best practices that provides goal-centered, clinically effective care for older patients. As a result, this programmatic measure consists of structural and process measures which address all six Institute of Medicine domains (safe, effective, patient-centered, timely, efficient, equitable), and is comprehensive across the full spectrum of geriatric care. Surgery, the emergency department, and hospitalization (in general) were targeted because this is where older adults are especially vulnerable.

Evidence in the Literature
ACEP’s GEDA standards improve the care of the older adult population in the ED and allocate health care resources, optimize admission and readmission rates, decrease iatrogenic complications, and decrease extended length-of-stay due to complications. The surgical components of the Age-Friendly measure use the four-part ACS Quality Model, which includes 1) standards, 2) infrastructure, 3) data, and 4) verification. Programs with Geriatrics Surgical Pathways (GSPs) have demonstrated a reduction in the loss of independence (LOI) in patients greater than 65, decrease in major complications in patients greater than 65, and a decreased length of stay in frail patients.[10] There is also a demonstrated cost savings during hospitalization in programs with GSPs which align with ACS-GSV standards.^{10, [11]} 

Additionally, the most recognized of the ACS programs are the Trauma Center Verification Program, the Commission on Cancer (CoC), and the Metabolic and Bariatric Surgery Verification program. Evidence in peer-reviewed literature demonstrates that mortality in verified trauma centers is statistically lower than in non-verified centers; bariatric surgical care in verified bariatric centers (MBSAQIP – Metabolic and Bariatric Surgical Quality Improvement Program) has lower mortality, lower costs, lower complications, and lower failure-to-rescue (FTR); and breast cancer care is statistically superior in verified breast cancer centers.[12]^{,[13],[14],[15],[16],[17],[18]}

[1] United States Census Bureau. 65 and Older Population Grows Rapidly as Baby Boomers Age. 2020. CB20-99. Accessed December 1, 2023. https://www.census.gov/newsroom/press-releases/2020/65-older-population-grows.html. 

[2] ProximityOne. Demographic Characteristics of the Population Age 65 & Over. Accessed December 1, 2023. https://proximityone.com/demographics65up.htm. 

[3] Deiner S, Westlake B, Dutton RP. Patterns of Surgical Care and Complications in the Elderly. J Am Geriatric Soc. 2014;62(5):829-835. doi: 10.1111/jgs.12794 

[4] Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc. 2012;60(8):1487-1492. doi: 10.1111/j.1532-5415.2012.04054.x

[5] Nidadavolu LS, Ehrlich AL, Sieber FE, Oh ES. Preoperative Evaluation of the Frail Patient. Anesth Analg. 2020;130(6):1493-1503. doi: 10.1213/ANE.0000000000004735

[6] Wilkes JG, Evans JL, Prato BS, Hess SA, MacGillivray DC, Fitzgerald TL. Frailty Cost: Economic Impact of Frailty in the Elective Surgical Patient. J Am Coll Surg. 2019;288(6):861-870. doi: 10.1016/j.jamcollsurg.2019.01.015

[7] Tang VL, Dillon EC, Yang Y, et al. Advance Care Planning in Older Adults with Multiple Chronic Conditions Undergoing High-Risk Surgery. JAMA Surg. 2019;154(3):261-264. doi:10.1001/jamasurg.2018.4647

[8] Waite KR, Federman AD, McCarthy DM, et al. Literacy and Race as Risk Factors to Low Rates of Advance Directives Among Older Adults. J Am Geriatric Soc. 2013; 61(3):403-406. doi: 10.1111/jgs.12134

[9] Snyder RE, Fulmer T. The Need for Geriatrics Measures. Health Affairs. April 14, 2023. Accessed December 1, 2023. https://www.healthaffairs.org/content/forefront/need-geriatrics-measures. 

[10] Ehrlich AL, Owodunni OP, Mostales JC, et al. Early Outcomes Following Implementation of a Multispecialty Geriatric Surgery Pathway. Ann Surg. 2023;277(6):e1254-e1261. doi: 10.1097/SLA.0000000000005567

[11] Ehrlich AL, Owodunni OP, Mostales JC, et al. Implementation of a Multispecialty Geriatric Surgery Pathway Reduces Inpatient Cost for Frail Patients. Ann Surg. 2023;278(4):e726-e732. doi: 10.1097/SLA.0000000000005902

[12] MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A National Evaluation of the Effect of Trauma-Center Care on Mortality. N Engl J Med. 2006;354(4):366-378. doi: 10.1056/NEJMsa052049

[13] Nguyen NT, Nguyen B, Nguyen VQ, Ziogas A, Hohmann S, Stamos MJ. Outcomes of Bariatric Surgery Performed at Accredited vs. Nonaccredited Centers. J Am Coll Surg. 2012;215(4):467-474. doi: 10.1016/j.jamcollsurg.2012.05.032

[14] Morton JM, Garg T, Nguyen N. Does hospital accreditation impact bariatric surgery safety? Ann Surg. 2014;260(3):504-508. doi: 10.1097/SLA.0000000000000891

[15] Baidwan NK, Bachiashvili V, Mehta T. A meta-analysis of bariatric surgery-related outcomes in accredited versus unaccredited hospitals in the United States. Clin Obes. 2020;10(1):e12348. doi: 10.1111/cob.12348.

[16] Berger ER, Wang CE, Kaufman CS, et al. National Accreditation Program for Breast Centers Demonstrates Improved Compliance with Post-Mastectomy Radiation Therapy Quality Measure. J Am Coll Surg. 2017;224(3):236-244. doi: 10.1016/j.jamcollsurg.2016.11.006

[17] Miller ME, Bleicher RJ, Kaufman CS, et al. Impact on Breast Center Accreditation on Compliance with Breast Quality Performance Measures at Commission on Cancer-Accredited Centers. Ann Surg Oncol. 2019;26(5):1202-1211. doi: 10.1245/s10434-018-07108-7

[18] Winchester DP. The National Accreditation Program for Breast Centers: quality improvement through standard setting. Surg Oncol Clin N Am. 2011; 20(3):581-586. doi: 10.1016/j.soc.2011.01.011

PACT: The Pathway to Accountability, Compassion, and Transparency Convening Team endorses the Patient Safety Structural Measure (PSSM) (#MUC2023-188) on the CMS list of Measures Under Consideration.

The PACT Convening Team is comprised of The Collaborative for Accountability and Improvement (a program of the University of Washington), Ariadne Labs (a joint center for health systems innovation at  Brigham and Women’s Hospital and the Harvard TH Chan School of Public Health), and the Institute for Healthcare Improvement who have come together with a shared commitment to facilitate implementation and sustainability of Communication and Resolution Programs (CRPs) in hospitals and health systems across the U.S. Such programs create a standard framework for response to adverse events/harm events in healthcare settings in which patient and family needs and expectations are meaningfully addressed, event learning through comprehensive patient safety core methods occurs rapidly, and efforts to support reconciliation and resolution with the patient and family are responsive to identified needs and commensurate with the impact of the event.

At the core, CRPs represent the expression of fiduciary obligation to patients by caregivers and health systems. Communication and Resolution Programs address the concerns of patients/families regarding disclosure of circumstances surrounding harm events, they accelerate learning from events for rapid, system-level modifications to prevent similar occurrences in the future, and they enable health systems to restore trust with patients, families, and communities through ethical and moral accountability for events. Additionally, CRPs foster well-being in the health care workforce by enabling supported disclosure conversations with patients and incorporating “care for the caregiver” programs that assist clinicians with processing their emotions about the event. Ultimately, these well-being benefits may have desired impacts on retention of clinicians.

Barriers to adoption of CRPs by health systems come in many forms.  Courage and faith of early adopters to surmount the obstacles are steeped in alignment with medical ethics and patient/family centered care principles. The medicolegal climate in many jurisdictions, though, is an overriding concern that disincentivizes transparency with patients and families which can then be perceived as an absence of caring and result in a loss of trust. The structure and processes of CRPs support appropriate accountability of health systems, compassion of clinicians, and transparency with patients to maintain trust in the institution of American health care.

Domain 4: Accountability and Transparency clearly articulates the requirement for hospitals to implement CRPs and describes the necessary components. These components also map to leadership accountability and governing board responsibilities in Domain 1, cultivating a just culture and patient safety competencies in Domain 2, event analysis and high reliability processes in Domain 3, and patient/family access to medical records and input about safety events in Domain 5.  The distribution of CRP features outside of Domain 4 and the activating benefit of the other Domains on the CRP component of Domain 4 are synergizing when a health system implements and maintains all of them in concert.

The PACT Convening Team is fully supportive of the Patient Safety Structural Measure for its inclusion of Communication and Resolution Programs as a required component that dismantles barriers to accountability, compassion, and transparency of health systems and clinicians with patients and families following a harm event. Thank you for the opportunity to comment on this important measure.

SHEA is concerned the MUC2023-120 Excess Days in Acute Care (EDAC) after Hospitalization for Pneumonia (PN) measure may not exclude post-discharge diagnoses of pneumonia that are not preventable. Additional clarification on how pneumonia is defined as well as how discharge location is identified is needed. 

The Washington Association of Area Agencies on Aging (W4A), the collective voice of the state’s 13 Area Agencies on Aging (AAA), appreciates the opportunity to submit comments in response to the release of the FY 2023 MUC List. Our AAAs offer services to enhance the lives of older adults, unpaid caregivers, and adults with disabilities. This includes funding local senior nutrition programs to address malnutrition by providing nutritious meals through congregate and home-delivered meal programs.

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 Measure for 65+ has been extensively tested. We know 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—with demonstrated impacts on patient outcomes and healthcare costs—that remains under-addressed in healthcare settings. It has been shown to be an independent predictor of mortality, lengths of hospital stay, readmissions, and hospitalization costs. An estimated 20-50% of hospital inpatients are malnourished or at risk of malnutrition. Yet, 2018 data from the Healthcare Cost and Utilization Project (HCUP) report that the percentage of discharges with a diagnosis of malnutrition was 8.9%. Early identification of malnutrition can allow for healthy aging. The nutrition care plan for discharge in this measure is also key to ensuring continuity of care as patients transition home from acute care hospitals into community settings. Nutrition care plans typically involve connecting patients to community resources, like our meal programs for patients 60 years old or older. 

Health Equity Implications of Malnutrition 

Malnutrition impedes health equity due to the disparities in health that result from differing prevalence of the condition and related risk factors across racial groups, geographic settings, and income levels. Because food insecurity caused by economic and social burdens can increase the risk of malnutrition, addressing malnutrition and its root causes, as done through the thorough assessment and care planning in the health care setting, can therefore support the reduction of health disparities. 

Conclusion

The importance of identifying, diagnosing, and treating malnutrition continues to grow. The relationship between malnutrition and food insecurity and its effects on health equity has been proven to be of importance and continues to be studied. We fully support CMS including this measure in the 2024 Hospital Inpatient Quality Reporting Program. CMS’ adoption of this measure will help close the gap in identification and intervention of malnutrition and help our healthcare institutions better serve their communities. 

Thank you for the opportunity to comment.

While this measure is currently only proposed for the inpatient setting and MSSP, it sounds like CMS intends to implement it within ambulatory care settings in future years. The AAFP appreciates the overall intent of this measure and shares a strong desire to increase social needs screening and intervention with an aim to help patients and improve outcomes. However, it is premature to implement this measure in a payment program that holds ACOs and clinicians accountable. The health care and social care infrastructures prevent this measure from feasibility in “the real world” without an incredible amount of added administrative burden for ACOs and clinicians. 

We would like to share the following more detailed feedback:

• The measure is not endorsed, which means it has not been rigorously reviewed by a consensus-based entity. We believe measures should go through a rigorous endorsement process and be further tested and refined, as necessary, before they are considered for implementation. 
• This measure has been tested and analyzed only at the facility (hospital) level. However, this measure is being proposed for use in the MSSP program. ACOs should not be held accountable for a measure that has only been tested and validated at the facility level. 
• There is variability in the screening for health-related social needs attributable to the selection of the screening instrument. Multiple low-cost, low-literacy tools are available for social risk screening in clinical settings, but psychometric data are very limited. More research is needed on clinic-based screening tool reliability and validity, as these factors should influence both adoption and utility.
• The current health and social care systems and IT infrastructure make this measure very difficult to operationalize.
• The data sources cited for this measure include EHR data, which means that clinicians will likely have to submit data from their EHR systems, thus increasing administrative burden. 
• The measure developer did not provide any empirical evidence that the benefits of this measure exceed the burden of administration.
• Reliability was not analyzed for this measure. The single value of 0.18 (reported as the mean, minimum, and maximum) is not adequate information to simulate or assess reliability for this measure.
• Another potential unintended consequence of the measure is that hospitals and/or ACOs might not be equipped to act on patients’ health-related social needs due, in part, to the lack of community resources in their region.

Thank you for the opportunity to comment on the two PRO measures submitted by PBGH on pain and fatigue for breast cancer. CMSS is supportive of these two measures since they fill important gaps in patient experience during breast cancer treatment, as well as palliative care. We would like to support the comments of ASCO that these measures be adapted and tested over time to allow for submission of other validated PROs  beyond PROMIS.   

Thank you for the opportunity to comment on the two PRO measures submitted by PBGH on pain and fatigue for breast cancer. CMSS is supportive of these two measures since they fill important gaps in patient experience during breast cancer treatment, as well as palliative care. We would like to support the comments of ASCO that these measures be adapted and tested over time to allow for submission of other validated PROs  beyond PROMIS.   

Please see attached PDF.

Please attached PDF.

December 21, 2023

Partnership for Quality Measurement 

505 King Avenue

Columbus, OH 43201 

Re:        Support for Age Friendly Hospital Measure (MUC 2023-196) in the CMS Hospital Inpatient Quality Reporting (IQR) Program 

Dear Members of the 2023-2024 Pre-Rulemaking Measure Review (PRMR) Committee Hospital Workgroup:

The undersigned organizations write to express our support for the inclusion of the Age Friendly Hospital Measure (MUC 2023-196) in the CMS Hospital Inpatient Quality Reporting (IQR) Program. This is a new type of measure, a “programmatic composite” measure, which considers the full program of care needed for geriatric patients in the hospital. Developed in partnership with the American College of Surgeons (ACS), the Institute for Healthcare Improvement (IHI), and the American College of Emergency Physicians (ACEP), this measure is meant to help build a better, safer environment for older adults and will help patients and caregivers know where to find good care.

The US population is rapidly aging, and the US healthcare system struggles to care for older adults. Based on 2019 US Census data, the 65-and-older population grew by over a third since 2010, and by 2030 this population is estimated to grow to 72 million (20 percent of the total population).[1]^,[2] Over one third of all inpatient surgeries are performed on individuals over the age of 65, and frailty is associated with poor post-operative outcomes and increased surgical cost of care.[3]^,[4],[5],[6] One study showed that only 25 percent of patients undergoing high risk surgery had advance care plans documented.[7] This is even more profound for patients of low socioeconomic status.[8] Hospitals are increasingly faced with older patients who have complex medical, physiological, and psychosocial needs that are often inadequately addressed by the current healthcare infrastructure. In response to this gap in care, the Age Friendly Hospital Measure was created and built on evidence-based best practices to provide patient-centered, clinically effective care for older patients. 

The Age Friendly Hospital Measure is an updated measure that combines two measures previously reviewed by the National Quality Forum’s Measures Application Partnership (MAP) in 2022: the Geriatrics Hospital Measure (MUC 2022-112) and the Geriatrics Surgical Measure (MUC 2022-032). While the MAP Hospital Workgroups were very supportive of both measures, they conditionally supported the Geriatric Surgical Measure with mitigating factors: 1) combining the two geriatric measures into a single measure that is less burdensome, or 2) focusing on only one measure. In the 2024 Inpatient Prospective Payment System (IPPS) proposed rule, CMS highlights the need for a comprehensive measure that addresses the aging population during hospital stays and solicited comments on the measure concept. The measure concept has support across organizations who care for older adults and was recently highlighted in Health Affairs.[9] 

Based on this feedback, ACS submitted a new single combined measure, the Age Friendly Hospital Measure. The new streamlined measure now includes domains which target high-yield points of intervention for older adults—Eliciting Patient Healthcare Goals, Responsible Medication Management, Frailty Screening and Intervention (i.e., Mobility, Mentation, and Malnutrition), Social Vulnerability (social isolation, economic insecurity, ageism, limited access to healthcare, caregiver stress, elder abuse), and Age-Friendly Care Leadership. The new measure encourages hospital systems to reconceptualize the way they approach care for older patients with multiple medical, psychological, and social needs at highest risk for adverse events. It also puts an emphasis on the importance of defining patient (and caregiver) goals not only from the immediate treatment decision, but also for long-term health and aligning care with what the patient values.

The concept behind the programmatic measure is based on several decades of history implementing programs that demonstrably improve patient care provided by the clinical team along with the facility. The Age Friendly Hospital Measure incorporates elements of IHI’s Age-Friendly Health Systems program known as the 4Ms (What Matters, Medications, Mentation, Mobility), standards from the Geriatric Emergency Department Accreditation (GEDA) framework developed by ACEP, and ACS Geriatric Surgical Verification (GSV) standards. The programmatic approach is modeled after ACS quality programs, which lead to demonstrable improvements in patient outcomes across a broad range of populations. 

The undersigned organizations appreciate the opportunity to share our support for the Age Friendly Hospital Measure for inclusion in the CMS Hospital IQR program. The measure is a critical piece in the optimization of care for older patients by using a holistic approach to create a quality program that better serves the needs of this unique population. We believe this measure will help build a better, safer environment for the geriatric patient and when the information is shared publicly will help patients and caregivers know where to get good care that is in line with their values. A hospital designation that displays that the hospital has taken steps to prioritize care for older adults will help geriatric patients and their families confidently search for care that meets their needs. 

Sincerely,

American Association for the Surgery of Trauma’s (AAST)

American College of Emergency Physicians (ACEP)

American College of Surgeons (ACS) 

American Geriatrics Society (AGS)

Association of periOperative Registered Nurses (AORN)

The Brigham and Women’s Hospital Center for Geriatric Surgery

Center to Advance Palliative Care (CAPC)

Council of Medical Specialty Societies (CMSS)

Emergency Nurses Association (ENA)

Hartford Institute of Geriatric Nursing (HIGN) 

The John A. Hartford Foundation 

LifeBridge Health

Mass General Brigham Geriatrics Clinical Quality Collaborative

National Association of Social Workers (NASW)

National Transitions of Care Coalition (NTOCC) 

Nurses Improving Care for Healthsystem Elders (NICHE) 

Rochester Regional Health

Additional Background

Developed in partnership with the ACS, the Institute for Healthcare Improvement (IHI), and the American College of Emergency Physicians (ACEP), the Age Friendly Hospital Measure is meant to assure Medicare that the conditions surrounding frailty in the geriatric population are brought into focus and that geriatric patients and their families know where to find good care. 

The Age Friendly Hospital Measure is based on a framework developed by a modified Delphi method, receiving input from over 50 national organizations representing a wide variety of healthcare providers and administrators, healthcare insurers and regulators, and most importantly, patients and caregivers. The multistakeholder group identified a clinical construct based on evidence and best practices that provides goal-centered, clinically effective care for older adult patients. As a result, this programmatic measure consists of structural and process measures which address all six Institute of Medicine domains (safe, effective, patient-centered, timely, efficient, equitable), and is comprehensive across the full spectrum of geriatric care. Surgery, the emergency department (ED), and hospitalization (in general) were targeted because this is where older adults are especially vulnerable.

Evidence in the Literature
ACEP’s GEDA standards improve the care of the geriatric population in the ED and allocate healthcare resources, optimize admission and readmission rates, decrease iatrogenic complications, and decrease extended length-of-stay due to complications. The surgical components of the Age Friendly Hospital Measure use the four-part ACS Quality Model, which includes 1) standards, 2) infrastructure, 3) data, and 4) verification. Programs with Geriatric Surgical Pathways (GSPs) have demonstrated a reduction in the loss of independence (LOI) in patients greater than 65, decrease in major complications in patients greater than 65, and a decreased length of stay in frail patients.[10] There is also a demonstrated cost savings during hospitalization in programs with GSPs which align with ACS-GSV standards.[11] 

Additionally, the most recognized of the ACS programs are the Trauma Center Verification Program, the Commission on Cancer (CoC), and the Metabolic and Bariatric Surgery Verification program. Evidence in peer-reviewed literature demonstrates that mortality in verified trauma centers is statistically lower than in non-verified centers; bariatric surgical care in verified bariatric centers (MBSAQIP – Metabolic and Bariatric Surgical Quality Improvement Program) has lower mortality, lower costs, lower complications, and lower failure-to-rescue (FTR); and breast cancer care is statistically superior in verified breast cancer centers.[12]^{,[13],[14],[15],[16],[17],[18]}

Feasibility
Components of the Age-Friendly Hospital Measure have been implemented nationally, demonstrating feasibility and usability of the measure(s). As of February 2023, there are over 3400 sites of care that participate in IHI’s Age-Friendly Health Systems and GEDA verified programs across 470 sites. ACS currently has thousands of delivery systems participating in programs with measures that follow the same framework as the Geriatrics Surgery Measure—over sixty hospitals participate in the ACS-GSV program, and components of the GSV programs are in more than 500 ACS verified Trauma centers, and 1,500 CoC sites, to name a few. The GSV pilot program completed in eight hospitals demonstrated that all GSV standards could be feasibly implemented across differing environments with varying resources.[19] 

[1] United States Census Bureau. 65 and Older Population Grows Rapidly as Baby Boomers Age. 2020. CB20-99. Accessed December 1, 2023. https://www.census.gov/newsroom/press-releases/2020/65-older-population-grows.html. 

[2] ProximityOne. Demographic Characteristics of the Population Age 65 & Over. Accessed December 1, 2023. https://proximityone.com/demographics65up.htm. 

[3] Deiner S, Westlake B, Dutton RP. Patterns of Surgical Care and Complications in the Elderly. J Am Geriatric Soc. 2014;62(5):829-835. doi: 10.1111/jgs.12794 

[4] Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc. 2012;60(8):1487-1492. doi: 10.1111/j.1532-5415.2012.04054.x

[5] Nidadavolu LS, Ehrlich AL, Sieber FE, Oh ES. Preoperative Evaluation of the Frail Patient. Anesth Analg. 2020;130(6):1493-1503. doi: 10.1213/ANE.0000000000004735

[6] Wilkes JG, Evans JL, Prato BS, Hess SA, MacGillivray DC, Fitzgerald TL. Frailty Cost: Economic Impact of Frailty in the Elective Surgical Patient. J Am Coll Surg. 2019;288(6):861-870. doi: 10.1016/j.jamcollsurg.2019.01.015

[7] Tang VL, Dillon EC, Yang Y, et al. Advance Care Planning in Older Adults with Multiple Chronic Conditions Undergoing High-Risk Surgery. JAMA Surg. 2019;154(3):261-264. doi:10.1001/jamasurg.2018.4647

[8] Waite KR, Federman AD, McCarthy DM, et al. Literacy and Race as Risk Factors to Low Rates of Advance Directives Among Older Adults. J Am Geriatric Soc. 2013; 61(3):403-406. doi: 10.1111/jgs.12134

[9] Snyder RE, Fulmer T. The Need for Geriatrics Measures. Health Affairs. April 14, 2023. Accessed December 1, 2023. https://www.healthaffairs.org/content/forefront/need-geriatrics-measures. 

[10] Ehrlich AL, Owodunni OP, Mostales JC, et al. Early Outcomes Following Implementation of a Multispecialty Geriatric Surgery Pathway. Ann Surg. 2023;277(6):e1254-e1261. doi: 10.1097/SLA.0000000000005567

[11] Ehrlich AL, Owodunni OP, Mostales JC, et al. Implementation of a Multispecialty Geriatric Surgery Pathway Reduces Inpatient Cost for Frail Patients. Ann Surg. 2023;278(4):e726-e732. doi: 10.1097/SLA.0000000000005902

[12] MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A National Evaluation of the Effect of Trauma-Center Care on Mortality. N Engl J Med. 2006;354(4):366-378. doi: 10.1056/NEJMsa052049

[13] Nguyen NT, Nguyen B, Nguyen VQ, Ziogas A, Hohmann S, Stamos MJ. Outcomes of Bariatric Surgery Performed at Accredited vs. Nonaccredited Centers. J Am Coll Surg. 2012;215(4):467-474. doi: 10.1016/j.jamcollsurg.2012.05.032

[14] Morton JM, Garg T, Nguyen N. Does hospital accreditation impact bariatric surgery safety? Ann Surg. 2014;260(3):504-508. doi: 10.1097/SLA.0000000000000891

[15] Baidwan NK, Bachiashvili V, Mehta T. A meta-analysis of bariatric surgery-related outcomes in accredited versus unaccredited hospitals in the United States. Clin Obes. 2020;10(1):e12348. doi: 10.1111/cob.12348.

[16] Berger ER, Wang CE, Kaufman CS, et al. National Accreditation Program for Breast Centers Demonstrates Improved Compliance with Post-Mastectomy Radiation Therapy Quality Measure. J Am Coll Surg. 2017;224(3):236-244. doi: 10.1016/j.jamcollsurg.2016.11.006

[17] Miller ME, Bleicher RJ, Kaufman CS, et al. Impact on Breast Center Accreditation on Compliance with Breast Quality Performance Measures at Commission on Cancer-Accredited Centers. Ann Surg Oncol. 2019;26(5):1202-1211. doi: 10.1245/s10434-018-07108-7

[18] Winchester DP. The National Accreditation Program for Breast Centers: quality improvement through standard setting. Surg Oncol Clin N Am. 2011; 20(3):581-586. doi: 10.1016/j.soc.2011.01.011

[19] Ma M, Peters XD, Zhang LM, et al. Multisite Implementation of an American College of Surgeons Geriatric Surgery Quality Improvement Initiative. J Am Coll Surg. 2023;237(2):171-181. doi: 10.1097/XCS.0000000000000723

MUC2023-048 Hospital Harm - Falls with Injury

AHRQ estimates that there are 230,000 – 330,000 inpatient falls with injury and an additional 11,000 die annually. The seriousness of this preventable harm warrants the need to measure and hold hospitals accountable for fall prevention. The Leapfrog Group supports the inclusion of this measure on the MUC list.

MUC2023-050 Hospital Harm – Postoperative Respiratory Failure

Post-op respiratory failure is the most prevalent serious post-op pulmonary complication. The importance of assessing patients for risk and putting them under the correct protocols early allows for proper intervention and decreased risk for respiratory failure. The Leapfrog Group supports the inclusion of this measure on the MUC list.

MUC2023-139 Hospital Equity Index (HEI)

Health Equity is one of the most difficult measures to get established and we support the adoption of this measure to ensure that it remains a focus of the health care environment. Studies have repeatedly shown that patient equity disparities result in mixed outcomes. For example, we know that black mothers face a much higher risk for maternal mortality. The Leapfrog Group supports the inclusion of this measure on the MUC list.

December 22, 2023

Partnership for Quality Measurement 

505 King Avenue

Columbus, OH 43201 

Re:        Support for Age Friendly Hospital Measure (MUC 2023-196) in the CMS Hospital Inpatient Quality Reporting (IQR) Program 

Dear Members of the 2023-2024 Pre-Rulemaking Measure Review (PRMR) Committee Hospital Workgroup:

The undersigned organizations write to express our support for the inclusion of the Age Friendly Hospital Measure (MUC 2023-196) in the CMS Hospital Inpatient Quality Reporting (IQR) Program. This is a new type of measure, a “programmatic composite” measure, which considers the full program of care needed for geriatric patients in the hospital. Developed in partnership with the American College of Surgeons (ACS), the Institute for Healthcare Improvement (IHI), and the American College of Emergency Physicians (ACEP), this measure is meant to help build a better, safer environment for older adults and will help patients and caregivers know where to find good care.

The US population is rapidly aging, and the US healthcare system struggles to care for older adults. Based on 2019 US Census data, the 65-and-older population grew by over a third since 2010, and by 2030 this population is estimated to grow to 72 million (20 percent of the total population).[1]^,[2] Over one third of all inpatient surgeries are performed on individuals over the age of 65, and frailty is associated with poor post-operative outcomes and increased surgical cost of care.[3]^,[4],[5],[6] One study showed that only 25 percent of patients undergoing high risk surgery had advance care plans documented.[7] This is even more profound for patients of low socioeconomic status.[8] Hospitals are increasingly faced with older patients who have complex medical, physiological, and psychosocial needs that are often inadequately addressed by the current healthcare infrastructure. In response to this gap in care, the Age Friendly Hospital Measure was created and built on evidence-based best practices to provide patient-centered, clinically effective care for older patients. 

The Age Friendly Hospital Measure is an updated measure that combines two measures previously reviewed by the National Quality Forum’s Measures Application Partnership (MAP) in 2022: the Geriatrics Hospital Measure (MUC 2022-112) and the Geriatrics Surgical Measure (MUC 2022-032). While the MAP Hospital Workgroups were very supportive of both measures, they conditionally supported the Geriatric Surgical Measure with mitigating factors: 1) combining the two geriatric measures into a single measure that is less burdensome, or 2) focusing on only one measure. In the 2024 Inpatient Prospective Payment System (IPPS) proposed rule, CMS highlights the need for a comprehensive measure that addresses the aging population during hospital stays and solicited comments on the measure concept. The measure concept has support across organizations who care for older adults and was recently highlighted in Health Affairs.[9] 

Based on this feedback, ACS submitted a new single combined measure, the Age Friendly Hospital Measure. The new streamlined measure now includes domains which target high-yield points of intervention for older adults—Eliciting Patient Healthcare Goals, Responsible Medication Management, Frailty Screening and Intervention (i.e., Mobility, Mentation, and Malnutrition), Social Vulnerability (social isolation, economic insecurity, ageism, limited access to healthcare, caregiver stress, elder abuse), and Age-Friendly Care Leadership. The new measure encourages hospital systems to reconceptualize the way they approach care for older patients with multiple medical, psychological, and social needs at highest risk for adverse events. It also puts an emphasis on the importance of defining patient (and caregiver) goals not only from the immediate treatment decision, but also for long-term health and aligning care with what the patient values.

The concept behind the programmatic measure is based on several decades of history implementing programs that demonstrably improve patient care provided by the clinical team along with the facility. The Age Friendly Hospital Measure incorporates elements of IHI’s Age-Friendly Health Systems program known as the 4Ms (What Matters, Medications, Mentation, Mobility), standards from the Geriatric Emergency Department Accreditation (GEDA) framework developed by ACEP, and ACS Geriatric Surgical Verification (GSV) standards. The programmatic approach is modeled after ACS quality programs, which lead to demonstrable improvements in patient outcomes across a broad range of populations. 

The undersigned organizations appreciate the opportunity to share our support for the Age Friendly Hospital Measure for inclusion in the CMS Hospital IQR program. The measure is a critical piece in the optimization of care for older patients by using a holistic approach to create a quality program that better serves the needs of this unique population. We believe this measure will help build a better, safer environment for the geriatric patient and when the information is shared publicly will help patients and caregivers know where to get good care that is in line with their values. A hospital designation that displays that the hospital has taken steps to prioritize care for older adults will help geriatric patients and their families confidently search for care that meets their needs. 

Sincerely,

American Association for the Surgery of Trauma’s (AAST)

American College of Emergency Physicians (ACEP)

American College of Surgeons (ACS) 

American Geriatrics Society (AGS)

Association of periOperative Registered Nurses (AORN)

The Brigham and Women’s Hospital Center for Geriatric Surgery

Center to Advance Palliative Care (CAPC)

Council of Medical Specialty Societies (CMSS)

Emergency Nurses Association (ENA)

Hartford Institute of Geriatric Nursing (HIGN) 

The John A. Hartford Foundation 

LifeBridge Health

Mass General Brigham Geriatrics Clinical Quality Collaborative

National Association of Social Workers (NASW)

National Transitions of Care Coalition (NTOCC) 

Nurses Improving Care for Healthsystem Elders (NICHE) 

Rochester Regional Health

Additional Background

Developed in partnership with the ACS, the Institute for Healthcare Improvement (IHI), and the American College of Emergency Physicians (ACEP), the Age Friendly Hospital Measure is meant to assure Medicare that the conditions surrounding frailty in the geriatric population are brought into focus and that geriatric patients and their families know where to find good care. 

The Age Friendly Hospital Measure is based on a framework developed by a modified Delphi method, receiving input from over 50 national organizations representing a wide variety of healthcare providers and administrators, healthcare insurers and regulators, and most importantly, patients and caregivers. The multistakeholder group identified a clinical construct based on evidence and best practices that provides goal-centered, clinically effective care for older adult patients. As a result, this programmatic measure consists of structural and process measures which address all six Institute of Medicine domains (safe, effective, patient-centered, timely, efficient, equitable), and is comprehensive across the full spectrum of geriatric care. Surgery, the emergency department (ED), and hospitalization (in general) were targeted because this is where older adults are especially vulnerable.

Evidence in the Literature
ACEP’s GEDA standards improve the care of the geriatric population in the ED and allocate healthcare resources, optimize admission and readmission rates, decrease iatrogenic complications, and decrease extended length-of-stay due to complications. The surgical components of the Age Friendly Hospital Measure use the four-part ACS Quality Model, which includes 1) standards, 2) infrastructure, 3) data, and 4) verification. Programs with Geriatric Surgical Pathways (GSPs) have demonstrated a reduction in the loss of independence (LOI) in patients greater than 65, decrease in major complications in patients greater than 65, and a decreased length of stay in frail patients.[10] There is also a demonstrated cost savings during hospitalization in programs with GSPs which align with ACS-GSV standards.[11] 

Additionally, the most recognized of the ACS programs are the Trauma Center Verification Program, the Commission on Cancer (CoC), and the Metabolic and Bariatric Surgery Verification program. Evidence in peer-reviewed literature demonstrates that mortality in verified trauma centers is statistically lower than in non-verified centers; bariatric surgical care in verified bariatric centers (MBSAQIP – Metabolic and Bariatric Surgical Quality Improvement Program) has lower mortality, lower costs, lower complications, and lower failure-to-rescue (FTR); and breast cancer care is statistically superior in verified breast cancer centers.[12]^{,[13],[14],[15],[16],[17],[18]}

Feasibility
Components of the Age-Friendly Hospital Measure have been implemented nationally, demonstrating feasibility and usability of the measure(s). As of February 2023, there are over 3400 sites of care that participate in IHI’s Age-Friendly Health Systems and GEDA verified programs across 470 sites. ACS currently has thousands of delivery systems participating in programs with measures that follow the same framework as the Geriatrics Surgery Measure—over sixty hospitals participate in the ACS-GSV program, and components of the GSV programs are in more than 500 ACS verified Trauma centers, and 1,500 CoC sites, to name a few. The GSV pilot program completed in eight hospitals demonstrated that all GSV standards could be feasibly implemented across differing environments with varying resources.[19] 

[1] United States Census Bureau. 65 and Older Population Grows Rapidly as Baby Boomers Age. 2020. CB20-99. Accessed December 1, 2023. https://www.census.gov/newsroom/press-releases/2020/65-older-population-grows.html. 

[2] ProximityOne. Demographic Characteristics of the Population Age 65 & Over. Accessed December 1, 2023. https://proximityone.com/demographics65up.htm. 

[3] Deiner S, Westlake B, Dutton RP. Patterns of Surgical Care and Complications in the Elderly. J Am Geriatric Soc. 2014;62(5):829-835. doi: 10.1111/jgs.12794 

[4] Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc. 2012;60(8):1487-1492. doi: 10.1111/j.1532-5415.2012.04054.x

[5] Nidadavolu LS, Ehrlich AL, Sieber FE, Oh ES. Preoperative Evaluation of the Frail Patient. Anesth Analg. 2020;130(6):1493-1503. doi: 10.1213/ANE.0000000000004735

[6] Wilkes JG, Evans JL, Prato BS, Hess SA, MacGillivray DC, Fitzgerald TL. Frailty Cost: Economic Impact of Frailty in the Elective Surgical Patient. J Am Coll Surg. 2019;288(6):861-870. doi: 10.1016/j.jamcollsurg.2019.01.015

[7] Tang VL, Dillon EC, Yang Y, et al. Advance Care Planning in Older Adults with Multiple Chronic Conditions Undergoing High-Risk Surgery. JAMA Surg. 2019;154(3):261-264. doi:10.1001/jamasurg.2018.4647

[8] Waite KR, Federman AD, McCarthy DM, et al. Literacy and Race as Risk Factors to Low Rates of Advance Directives Among Older Adults. J Am Geriatric Soc. 2013; 61(3):403-406. doi: 10.1111/jgs.12134

[9] Snyder RE, Fulmer T. The Need for Geriatrics Measures. Health Affairs. April 14, 2023. Accessed December 1, 2023. https://www.healthaffairs.org/content/forefront/need-geriatrics-measures. 

[10] Ehrlich AL, Owodunni OP, Mostales JC, et al. Early Outcomes Following Implementation of a Multispecialty Geriatric Surgery Pathway. Ann Surg. 2023;277(6):e1254-e1261. doi: 10.1097/SLA.0000000000005567

[11] Ehrlich AL, Owodunni OP, Mostales JC, et al. Implementation of a Multispecialty Geriatric Surgery Pathway Reduces Inpatient Cost for Frail Patients. Ann Surg. 2023;278(4):e726-e732. doi: 10.1097/SLA.0000000000005902

[12] MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A National Evaluation of the Effect of Trauma-Center Care on Mortality. N Engl J Med. 2006;354(4):366-378. doi: 10.1056/NEJMsa052049

[13] Nguyen NT, Nguyen B, Nguyen VQ, Ziogas A, Hohmann S, Stamos MJ. Outcomes of Bariatric Surgery Performed at Accredited vs. Nonaccredited Centers. J Am Coll Surg. 2012;215(4):467-474. doi: 10.1016/j.jamcollsurg.2012.05.032

[14] Morton JM, Garg T, Nguyen N. Does hospital accreditation impact bariatric surgery safety? Ann Surg. 2014;260(3):504-508. doi: 10.1097/SLA.0000000000000891

[15] Baidwan NK, Bachiashvili V, Mehta T. A meta-analysis of bariatric surgery-related outcomes in accredited versus unaccredited hospitals in the United States. Clin Obes. 2020;10(1):e12348. doi: 10.1111/cob.12348.

[16] Berger ER, Wang CE, Kaufman CS, et al. National Accreditation Program for Breast Centers Demonstrates Improved Compliance with Post-Mastectomy Radiation Therapy Quality Measure. J Am Coll Surg. 2017;224(3):236-244. doi: 10.1016/j.jamcollsurg.2016.11.006

[17] Miller ME, Bleicher RJ, Kaufman CS, et al. Impact on Breast Center Accreditation on Compliance with Breast Quality Performance Measures at Commission on Cancer-Accredited Centers. Ann Surg Oncol. 2019;26(5):1202-1211. doi: 10.1245/s10434-018-07108-7

[18] Winchester DP. The National Accreditation Program for Breast Centers: quality improvement through standard setting. Surg Oncol Clin N Am. 2011; 20(3):581-586. doi: 10.1016/j.soc.2011.01.011

[19] Ma M, Peters XD, Zhang LM, et al. Multisite Implementation of an American College of Surgeons Geriatric Surgery Quality Improvement Initiative. J Am Coll Surg. 2023;237(2):171-181. doi: 10.1097/XCS.0000000000000723

MUC2023-146 Care Coordination - Hospital Patient Experience of Care

The Leapfrog Group strongly supports this measure. Employers and purchasers in industries outside of health care have long recognized the pivotal importance of customer experience in guiding excellence, but for health care patient experience has too often taken a back seat. Patient experience measures are a critical consideration for purchasers and consumers in decision making, and important to hospital staff and leadership in driving toward comprehensive, culturally sensitive, and quality care. .  This measure addresses a component of care evidence suggests is essential for a patient to experience high quality care and avoid patient safety issues. Given the variation in hospital performance, hospitals need this measure to focus their attention on consulting their patients while driving toward improving outcomes. The Leapfrog Group supports the inclusion of this measure on the MUC list.

On behalf of the Greater New York Hospital Association (GNYHA) membership, we appreciate the opportunity to comment on the 2023 Measures Under Consideration List. The GNYHA membership is comprised of more than 220 acute care hospitals, which include academic medical centers, safety net facilities, and the nation’s largest public hospital system, all of which serve underserved communities and high percentages of patients with identified social needs. GNYHA member hospitals are deeply committed to health equity and addressing health-related social needs (HRSN), and have demonstrated that commitment through HRSN screening, community partnerships, and various programs to address identified needs. However, GNYHA believes that the “Connection to Community Service Provider” measure is not an appropriate addition to the Inpatient Quality Reporting (IQR) program. 

This measure would require hospital inpatient settings to refer all patients screening positive for at least one social need to a community-based organization (CBO) and would require those inpatient settings to track whether that patient had contact with the organization. This process is inappropriate for an inpatient setting and would increase costs and burden on hospitals and CBOs without commensurate funding. If included in IQR, the measure definition needs significant revisions, as the current language is unclear and it may be confusing for hospitals to capture information in certain situations.  

Appropriateness of Measure in Inpatient Setting 

This measure would require staff working in the inpatient setting to track the status of patients with at least one identified social need for up to 60 days post-discharge to ascertain whether they connected with a CBO. However, the inpatient setting is intended to treat complex, acute health issues and is not designed for longitudinal care post-discharge. Hospitals undertake several activities to ensure that patients can be safely discharged, including discharge planning with dedicated staff, and post-discharge follow-up to identify potential issues or concerns that might require clinical follow-up, such as post-operative concerns and medication questions. Increasingly, social needs screening is conducted as part of discharge planning to identify unmet needs that could contribute to a readmission, as well as to comply with the newly implemented social needs screening measures in IQR. Hospitals also schedule post-discharge visits with the patient’s primary care provider or with the appropriate specialist who would follow the patient on an outpatient basis. These are short-term activities, lasting a few days past patient discharge. 

The inpatient setting is not designed for longitudinal patient follow-up. In some cases, high risk patients may be assigned case managers or social workers to assist with immediate issues and keep in contact with them until they are resolved. But hospitals do not have staff or funding to support a high volume of CBO referral tracking activity.  

This type of activity is more appropriate for the outpatient setting, which is more likely to have resources in place to track patient activity in the community. Primary care settings, in particular those in value-based payment models, often have access to care management and patient navigation services. With the addition of Community Health Integration and Principal Illness Navigation to the calendar year 2024 Physician Fee Schedule, primary care and certain ambulatory care specialty departments may have dedicated community health workers or other auxiliary staff to connect patients to community service providers. Community connections and related tracking can be done most successfully in outpatient practices.  

Costs and Burden without Commensurate Funding 

To meet the requirements of this proposed measure, hospitals would need experts in the local social service system on staff. These individuals would have to make accurate referrals for complex social issues and complete timely follow-up. Hospitals currently do not have staff who can do this work at scale for all patients presenting with social care needs, and would therefore have to hire team members. Hospitals would also likely have to identify or develop an accurate CBO directory or create a network of CBOs that would “close the loop,” enabling the hospital to meet the measure requirement. Similarly, the hospital would have to purchase or develop technology to assist with that tracking. Most hospitals run on slim or negative margins, and the human and technological capital required to do this work would be burdensome. As there is no funding or reimbursement associated with the referral tracking activities, it would be extremely difficult for hospitals to implement these workflows at scale for all discharges. 

This measure would burden CBOs, many of which do not have the staff or the technological capabilities to manage “closed loop referrals.” In addition to putting a strain on understaffed and under-resourced CBOs, an influx of referrals resulting from hospital activities could overburden an already strained social service system. If CMS aims to improve integration between the health and social service system, it should partner with other Federal agencies to engage both sectors to design workable programs that include financial support for their efforts.  

Measure Definition Considerations 

As written, this measure is problematic, and hospitals will have challenges collecting and reporting the appropriate information in certain instances. First, it may not be possible to make CBO referrals for certain populations. For example, it may not be appropriate to make referrals to CBOs for individuals being discharged to a skilled nursing or long-term care facility. However, those individuals are not excluded from the measure. Second, some hospitals have internal programs, such as prescription pantries or benefits enrollment, that are intended to address social care needs. If the hospital addresses the need internally, a CBO referral may not be necessary, and it is unclear in the measure specification how hospitals should document that information. 

GNYHA would welcome the opportunity to further discuss hospital experiences with social needs screening, reporting, and referral tracking. GNYHA would also be open to participating in discussions to develop alternative CMS programs and guidance that would encourage continued hospital efforts to address social care needs and provide equitable care to the communities they serve.   

MUC2023-148 Responsiveness of Hospital Staff - Hospital Patient Experience of Care

We know from many studies that hospitals that provide better patient experience of care have higher adherence to clinical guidelines, lower risk adjusted mortality rates and lower readmission rates. Hospitals with better staff responsiveness ratings have been shown to also have lower rates of respiratory failure, surgical complications, and pulmonary embolism or deep venous thrombosis. The Leapfrog Group supports the inclusion of this measure on the MUC list.

MUC2023-149 Information About Symptoms - Hospital Patient Experience of Care Standalone Item

When patients have a positive experience of care they are more likely to follow clinical guidelines and will have better outcomes as a result. It is important that hospitals be held accountable for the patient experience and for these reasons The Leapfrog Group supports the inclusion of this measure on the MUC list.