PRMR Final MUC Recommendation Spreadsheet

Please accept the attached comments from the ASC Quality Collaboration regarding the Hospital Committee PRMR Final MUC Recommendation. 

Please accept the attached comments from the ASC Quality Collaboration regarding the Hospital Committee PRMR Final MUC Recommendation.

I am submitting this Public Comment in support of the Patient Safety Structural Measure (PSSM, MUC2023-188) in my role as a practicing physician for over 16 years who has dedicated my non-clinical work to improving the quality and safety of care and educating the next generation of leaders in the field.  I thank CMS for developing a Measure Under Consideration list that prioritizes patient safety and promotes quality improvement, including equity.  Despite the earnest efforts of many over the last few decades, preventable harm remains a major problem in health care, and much more needs to be done to achieve high reliability.  In my professional roles I regularly work with patients and families who have experienced serious harm as a result of the care they received.  The PSSM represents an important step forward.  While ultimately I believe that much more than a structural measure will be required to get patient safety where it needs to be, the structural measure is an important and good beginning.  Each component of the PSSM has been carefully crafted and represents reasonable expectations of health care organizations.  Informed by my regular interactions with leaders from other health care organizations, I believe that the PSSM will have a powerful effect on the way organizations prioritize, support, and resource the people, processes, and systems that drive patient safety.  I am particularly pleased to see the inclusion of communication and resolution programs (CRPs) in domain 4 of the PSSM.  Even in situations where harm was not preventable, the way that health care organizations respond has important implications for all stakeholders.  Emerging evidence suggests CRPs can prevent secondary harm, and as a result, even though CRPs are activated after harm has occurred, CRPs themselves should be considered patient safety interventions, further supporting their inclusion in the PSSM.  I strongly encourage CMS to approve and enact this measure as soon as possible.  I also strongly encourage CMS to ensure health care organizations' attestations to the individual components of the PSSM are publicly reported in as detailed a fashion is is feasible, so as to facilitate research, drive learning, and promote accountability.  Americans deserve to know where their health care organizations stand with regards to their primary obligation to "do no harm."

UnitedHealthcare (UHC) agrees with many of the concerns shared by the committee, echoing some of our concerns about unintended consequences of the measure to patients and providers. We continue to recommend this measure not enter the Star Ratings.

For your convenience, here are the comments we submitted in December:

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.

UnitedHealthcare (UHC) agrees with many of the concerns shared by the committee, echoing some of our legal and technological concerns about data sharing and with patients choosing to refuse treatment. We continue to recommend this measure not enter the Star Ratings.

For your convenience, here are the comments we submitted in December:

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.

UnitedHealthcare (UHC) opposes implementation of the MUC2023-212 “Level I Denials Upheld Rate Measure” proposed in 2023 because oversight processes already exist for Level 1 denials and appeals, and the measure does not accurately represent plan performance. 

Overturned Level 1 denials do not necessarily indicate that the initial denial was inappropriate. Level 1 denials are most often overturned for reasons unrelated to plan performance, like the receipt of new information, e.g. evidence of conservative care or step therapy. Level 1 denial scenarios also exist when plans do not receive records during the initial review and are often overturned on appeal when the plan receives the appropriate documentation. UHC is continuously working to drive efficiencies within the initial review process to reduce the administrative burden for providers/facilities and to ensure information is available at the time of the initial decision. However, Level 1 reviews sometimes include short turnaround times, and even after diligent and multiple outreach attempts to providers to obtain records, plans do not always receive records in a timely manner. Given overturns of Level 1 denials based on new information are top drivers of overturns on appeal, this measure does not accurately reflect plan performance.

For these reasons, UHC advises against implementation of the MUC2023-212 “Level I Denials Upheld Rate Measure.” CMS already oversees denials and appeals through MA and Part D reporting requirements and program audits. There are also existing Star Ratings measures in place to track the appropriateness of denials and the appeal processes (e.g., star measure C29 - Reviewing Appeals Decisions). 

15 February 2024

The PACT Convening Team strongly supports the Patient Safety Structural Measure (PSSM) (#MUC2023-188) on the PRMR Final MUC Recommendation Spreadsheet.

The Pathway to Accountability, Compassion, and Transparency (PACT) (is convened through a partnership 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. These three organizations 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 highly reliable response to harm events in health care settings in which patient and family needs and expectations are meaningfully addressed, event learning is comprehensive and rapid, patients and healthcare providers receive compassionate support, and trust is restored 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 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.

We were pleased to see that 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.

MUC2023-188: Patient Safety Structural Measure: The PACT convening Team strongly supports the implementation of the Patient Safety Structural Measure (PSSM) without delay, 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. 

Please see attached letter of support for the Age Friendly Hospital Measure MUC2023-196 from the Mass General Brigham Geriatrics Clinical Quality Collaborative.

We continue to reiterate our concern for this measure, and urge CMS not to adopt this measure within the Part C/D Star Ratings. CMS already uses an appeals measure (Reviewing Appeals Decisions) that looks at all Level 2 appeals decisions, not just denials. While this measure focuses on Level 1 appeals, this measure is so similar that it is duplicative and unnecessary, given the existing measure.  Second, there is insufficient evidence to demonstrate that this measure would be materially different or bring any additional value to the Star Ratings. Much of the information used by the measure steward to justify their expressed need for this measure came from the Public Use File (PUF).  Thus, the measure will not produce new information that cannot already be found in the public domain. In addition, MA plans will be reporting the more detailed metrics finalized in the new CMS Interoperability rule. Third, we note that some proper initial denials may be overturned later if an MA Organization receives more information from the provider or beneficiary between the initial decision and the appeal. However, this appeals measure fails to account for that and other situations that may result in an initial denial being overturned in the member's favor and, instead, only tracks whether the initial denial was upheld. Lastly, adding this measure to the MA / Part D Star Ratings would run counter to current CMS efforts to reduce the number of measures used in CMS programs and align those measures across CMS programs through the Universal Foundation.  

Agree with the 13 PRMR Recommendation Group members who do not recommend implementation of this measure.  The concerns presented about misplaced accountability on hospitals, concerns about availability and capability of community resources and negative publicly reported data are all scenarios which hospitals will face if this measure moves forward.  

West Health is a family of nonprofit, nonpartisan organizations that combines applied medical research, policy analysis and grantmaking to improve care, lower costs and enhance the aging experience for all Americans. In our daily work, we collaborate with researchers, patients, healthcare providers and health insurers to study, develop and advance scalable, sustainable and more affordable healthcare delivery models that enable individuals to successfully age in place with optimal well-being.

We are grateful for the opportunity to support MUC2023-196 Age Friendly Hospital Measure incorporation into the 2025 Hospital Inpatient Prospective Payment Systems (IPPS) proposed rule within the Hospital Inpatient Quality Reporting (IQR) Program. West Health commends the Centers for Medicare & Medicaid Services (CMS) for this important initial step to encourage hospitals to provide high-value care for older patients. 

Inclusion of MUC2023-196 Age Friendly Hospital Measure into the Hospital IQR Program aligns with West Health’s mission to enable access to value-based health services that preserve and protect dignity, quality of life, and independence for older adults. MUC2023-196 Age Friendly Hospital Measure will require acute care hospitals to attest whether they meet specifications outlined within five mission-aligned domains: 

Domain 1- Eliciting Patient Healthcare Goals

Domain 2- Responsible Medication Management

Domain 3- Frailty Screening and Intervention

Domain 4- Social Vulnerability

Domain 5- Age Friendly Care Leadership

The components within each domain are clinical best practice with real-world evidence demonstrating improved care for older adults and reduced healthcare spending.

Our medical research organization, the West Health Institute (WHI), conducts collaborative projects with healthcare organizations across the country. Our work with these partners exclusively focuses on the older adult population, providing us with firsthand knowledge about the care of Medicare beneficiaries nationwide. We have seen programs with the types of interventions advocated for in MUC2023-196 Age Friendly Hospital Measure positively impact patients and have witnessed that many of the structural elements and processes outlined within the components of this measure are already in place in hospitals across the country. In particular, our collaborations exploring implementation of the Geriatric Emergency Department model demonstrate that formalizing a best practice, such as screening for delirium, into hospital protocol ensures clinicians are allocated sufficient time and resources to assess patients’ needs and provide the appropriate level of care in response.

The expectations outlined within MUC2023-196 Age Friendly Hospital Measure will improve quality and should be in place to ensure value-based care for older adults. Medicare beneficiaries have a right to know which hospitals are practicing according to the highest standards of care. The protocols outlined within the five domains are evidence-based best practice, yet implementation is currently hospital dependent. Adoption of MUC2023-196 Age Friendly Hospital Measure as part of the Hospital IQR Program will encourage hospitals to implement the programmatic structure and processes required to meet these domains through policies and protocols, thereby incentivizing the domain components to become common practice. Public reporting of this measure on CMS’ Care Compare website will ensure consumers have access to information to select high-quality care.

Evidence shows that in the field of healthcare, “what gets measured, gets done.” MUC2023-196 Age Friendly Hospital Measure attestation should result in investments to improve quality across the five domains. The national heterogeneity of practice regarding domain components is precisely why an attestation-based structural measure is an appropriate design. Many of the best-in-class health systems we partner with are already successfully doing much of this work across a variety of settings, from rural and safety-net facilities to large academic medical centers. Incorporation of MUC2023-196 Age Friendly Hospital Measure into the Hospital IQR Program will encourage these practices to be adopted across all health systems, not just those performing at the highest level, while simultaneously allowing sufficient flexibility for hospitals to meet the measure requirements. 

See attached letter for references.

SHEA recommends including MUC2023-219 in a future IQR program. The society 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 MUC2023-220 in a future IQR program. The society 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 MUC2023-188 in a future IQR program.  We support 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 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.

Thank you. AFHM is pathmark.

SIDM commends CMS for its dedication to advancing patient safety and health equity through the development of the Measures Under Consideration list. Addressing preventable harm, bias, discrimination, and challenges in timely diagnoses is paramount in improving our healthcare system's effectiveness and fairness for all patients.

Recent data highlights the urgency of these issues, with alarming statistics revealing that a quarter of patients experience harm in hospitals, much of which could be prevented. Moreover, the consequences of missed or delayed diagnoses, and the failure to communicate accurate diagnoses, result in significant harm to nearly 795,000 individuals annually. Diagnostic errors not only lead to substantial malpractice claims but also contribute to unwarranted variations in diagnostic processes among disadvantaged population groups.

As we approach the 25th Anniversary of To Err is Human, it is evident that we have yet to achieve the patient safety objectives outlined in that seminal report. CMS's leadership in addressing these challenges is crucial in ensuring that our healthcare systems prioritize safety and equity for every patient, irrespective of demographic factors such as race, ethnicity, age, disability, or LGBTQ+ status.

We appreciate that patient experiences and expectations were considered in the Pre-Rulemaking Measure Review Process. This inclusion demonstrates a commitment to listening to the voices of those directly impacted by healthcare policies, and we are encouraged by the acknowledgment that our input matters.

Thank you for your ongoing efforts to improve patient safety and promote health equity within our healthcare system.

I suffered harm due to medical decisions made during my care as someone who underwent skull fracture repair as an outpatient surgery.  Three years later after recovering significantly, I reported my case with the hospital's Office of Advocacy and joined my hospital's Patient Advisory Council -all with the hope that I could help affect change so that no one else would experience the harm that I did.  As a volunteer Patient Advisor I served on hospital committees for Quality and Patient Safety, during this time, I gained an insider's view of how my hospital approaches patient safety.  For years I saw my hospital put a lot of effort and fanfare into their annual Patient Safety Week, including a dedicated nursing grand rounds, but I saw no real substance in making progress towards guaranteeing safer care for patients. 

I am clear about who I am: I was a victim of this system and of those who make health policy decisions and of those who follow them without questioning.  I clearly understand that the very same people who made these decisions are designing and implementing their own self-monitoring, self-regulating, self-disciplining and self-policing policies, practices and measures; it's a clear case of the fox guarding the henhouse.

I am attaching a file:  the printed image I was given of my CT scan before surgery and my art therapy depicting how it felt to wake up and spend the next days without postoperative pain management after reconstruction of my eye socket: a metal plate implant which was anchored by 2 screws drilled into my skull, the incredible hyper-sensory from my brain injury and full blown trigeminal neuralgia then being sent home.  Despite your instructions I believe the reviewers of this Safety Measure need to fully understand what happens to patients in our unsafe system.  Somehow I was not surprised to find that CMS now approves outpatient surgeries like mine that have now become standard operating policy.¹   

I see the Palestinian children in news reports and find I have more in common with these children than I do with folks in my own country.  When we hear the silence of our health professionals and hospitals on the safety of patients in an area experiencing genocide and criminal warfare, conditions that leave children undergoing major surgery- including amputation of body parts without anesthesia- we begin to understand just how heartless and cruel our own health system can be to patients like you and me.

Why would we expect these same medical and political leaders to show any more sensitivity, more empathy, a different set of medical ethics, from what they've shown to these children, to be applied to us? 

1) 2023 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. (2023, Introduction, p.4)  https://www.cms.gov/oact/tr/2023

Domain 1: Leadership Commitment

I cannot think of a better way to demonstrate leadership commitment to patient safety than to take a look at their hospital budget and see how and where their revenue is spent.  Will this safety measure consider the following safety issues:

• Are offices/departments that are involved in patient safety sufficiently staffed so that they can handle the overwhelming amount of work that comes through their offices?  
• Do these offices all have dedicated IT personnel to work with them on analyzing the magnitude of the data they handle? 
• enforcement of each department have nurse staffing numbers with safe nurse-to-patient ratios?
• that our patient populations with communication needs will receive the translators, communication assistance, mobility assistance, and other accommodations they require to visit the hospital in a safe way? 
• the needs of patient populations, who because of physical and mobility challenges had been facing barriers to care and left behind in the past, are provided accommodations?
• will there be stockpiles, enough PPE for hospital staff, stored away in preparation for the next pandemic to occur?
• is the hospital putting as much if not more effort and money towards the safe release/ discharge of patients as the hospital is towards security checks of patients entering the hospital? 
• will the public have access to information on the hospital's collected patient safety data (details, not summary)?
• will the public be able to contribute their input and insights about the hospital leadership's performance on patient safety issues?
• will our hospital leaders take up our biggest patient safety issue with Congress, deficiencies and shortages due to insufficient funds, and demand more federal funding? 
• will our hospital leadership continue to be given salaries that, at present, require a disproportionate amount of the hospital budget?  will this measure address these costly expenses?  

Will this measure take these patient safety issues into consideration and how will it hold leadership accountable for addressing them? 

Domain 2: Strategic Planning & Organizational Policy

Our professional engineers have a fantastic ethos towards continuous quality and safety improvement; I believe there are many lessons our health leaders could learn from them and apply to our health system.  Will this measure consider the following safety issues:

• bolster initiatives to identify and address current hospital policy that create barriers to providing care and otherwise harm patients?
• ensure more effort and investment is placed into providing patients easily accessible avenues for submitting their complaints and feedback about their care (eg. mechanisms to provide real time feedback)?
• the lengths of time patients must wait for their physician/ specialist visit, scheduled procedures and bed availability?  (If you do not see this as a Patient Safety issue: scars formed after my orbital floor repair surgery before I could see a specialist and get therapy, so I now have permanent vision impairments.  Conditions worsen and become more complex and harder to treat when patients must wait to see a care professional.)
• ensure that never events never occur such as bedsores, falls, wrong limb surgeries, etc.?
• involvement of patients and families in strategic planning and organizational policy design? 

If our health institutions and professionals would be honest in their use the phrases "Patient-and Family-Centered Care" and "Patient-Driven Care", then patients and families must be involved in these decisions, program design and implementation -"nothing is done to us without us." 

Dominion 3: Culture of Safety & Learning System

As a patient who observed numerous safety events during routine visits and multiple procedures, I can honestly say I reported the events I witnessed.  But after hearing patient experience stories, nurse experience stories and even witnessed myself a health professional asking the patient in the waiting room to cover up for their error, I cannot say the same for my health system. We do not have a culture of reporting safety events;  we have a culture that is more afraid of being punished or losing their job/ professional status, etc. than they are afraid that some patient will be harmed, whether immediately or somewhere down the line, from their inaction in reporting the safety event. 

Will this safety measure help to: 

• encourage our health professionals to report events that their qualifications -or their gut- tells them is wrong/ harmful/ unethical or place the patient at risk despite the fact that a (harmful) hospital policy was followed (eg. patient is released too early)?
• include patient and family voices in safety-affirming actions such as telling their patient safety experiences to those who most need to hear?    
• include patient voices in the redesign of hospital policy and practices to better align with the promise to "do no harm"?
• ensure that the safety of patients, family and coworkers within their hospital walls is their top priority?
• ensure the protection of all whistleblowers?  

Domain 4:  Accountability and Transparency

We must recognize what our health system really is and does, in order for us to design real effective solutions.  Patients end up victims of a system that destroys our self-autonomy, making us dependent on the physicians and staff to who demonstrate more loyalty to their health institution than on our behalf,   by taking away opportunities for patients to advocate for ourselves during our appointments and for our ability to advocate for others.  Will this safety measure take into consideration:

• hospital security that is erected so that family members cannot accompany the patient to ensure they are treated with the respect and dignity they deserve as a vulnerable population,
• hospital barriers erected so that physicians who failed at providing care and caused harm are not provided the patient feedback they most need to hear,
• lack of transparency of the patient's care plan and other medical decisions made on their behalf,
• not ensuring the patient is aware of critical safety information such as: the hospital Patient's Bill of Rights, existence of the hospital's Office of Advocacy, the option of having a Patient Advocate accompany the patient and the filing process for patient complaints.
• integration of mental health in our medical health care,
• high cost of for patient advocates to attend conferences in order to add patient perspective and bear witness to the lack of patient safety within the system,
• requiring payment to view clinical and bioscience research information that should be considered public property - research that was paid for by public funding.

Domain 5: Patient and Family Engagement 

I wonder if "a diverse group of patients as partners in safety" means it recommends a Patient Advisory Council be formed*?  I hope this measure pushes hospitals to provide, more easily accessible and more numerous routes for reporting patient concerns, role of care staff to inform patients and families of their rights, encourage patients and family to contribute to the patient safety culture, offer each patient the option of being accompanied by a patient advocate who is independent of their health institution (without conflict of interest) and empowers patients by providing complete transparency of their care plan. 

Will this measure help encourage information sharing and transparency 

If the hospital forms a Patient Advisory Council, will this measure help ensure that:

• the Patient Advisories are not provided busywork, instead of meaningful work that improves patient care and patient safety?

• the council leadership is not overly-selective with its choice and number of advisor voices participating in the institution's projects?  When too few advisors (1-3) are selected to participate, it means health institutions are not hearing enough voices with insight and lived experience, perhaps so the institution can control the narrative and direction of "change."  
• The institution does not use the Advisory merely as a rubber stamp to satisfy the regulator's requirements claim that patient voices were included in the project or action.  

I have concern that factors such as:  internal oversight, a culture of nonreporting, indoctrination to following orders without question, institution loyalty, professional egos, conflict of interest, etc. will dilute the power of this safety measure. 

"When measure results are made public, patients and families will be able to make informed decisions on what facilities are best for them."  I wonder how much information will be released; three out of five stars does not tell a prospective patient much. 

Many patients who have experienced harm and/or are feeling exploited by the system, lack the trust in the system's ability to fix itself without external oversight, without an ethics board comprised of stakeholders, without patient voices sitting at every decision making table.  Why should the public trust these same medical leaders who are making decisions to dump patients on the cold street corners, to discharge patients who then die as the police escort them out.^1,2,3 

1) "It's like I'm worthless": Troubleshooters investigate patient dumping allegations. (2023, 7 min video) https://youtu.be/rFJsFdgMkYE?si=AIIFdFtjsB6AItDk

2) Investigations continue after patient discharged from Providence Milwaukie dies in police custody. (2024, 3 minute video) https://youtu.be/L0pnWL-biXw?si=8WOXCzrNuzyeVUrn

3) KPD releases body camera video of Lisa Edwards' death.  (2023, 1 min video) https://youtu.be/iIYLcZAHVkI?si=50oXn3wkHu1lgGyA

Dear Centers for Medicare & Medicaid Services,

We recognize and appreciate CMS for developing a Measures Under Consideration list prioritizing patient safety and health equity. Harm, bias and discrimination are problems affecting everyone—patients, families, clinicians—anyone who needs or provides care. It seems that there are constant studies bringing the consequence of these problems into harsh light. Thank you for offering the structural measures as a method to solve these problems.

2024 is the 25^th Anniversary of To Err is Human, the National Academy of Sciences call to improve patient safety. As the signers of this letter know, we are far from reaching the patient safety goals defined in the report. The slow progress toward greater safety and equity make CMS leadership extremely important and powerful. As Americans, we expect our health systems to be safe for everyone, regardless of patient demographics that too often lead to disparate patient outcomes.

We appreciate the opportunity to share our own experiences and those of our loved ones, as we are often driven to advocacy because the health care system has harmed us. We are pleased to know our experiences and input are valued.

We strongly support MUC2023-188: Patient Safety Structural Measure without delay as it asks hospital leaders to publicly attest to their organization’s establishment of best practices in following domains: 

1) Leadership Commitment

2) Strategy & Policy

3) Culture of Safety & Learning

4) Accountability & Transparency

5) Patient & Family Engagement. 

These measure have the potential to improve patient safety and reduce health inequities. Public reporting by hospital leaders will help Americans identify hospitals that have implemented patient safety and health equity best practices and those that have not. Implementing these measures without delay will allow data to be analyzed and used for broad improvements. 

There are several best practice guides readily available to hospitals to aid in complying with the proposed structural measures. New tools will always be welcomed, but there is no reason to wait for their development. The need for improvement is immediate.

Sincerely,

Patient & Family Advisory Committee, Collaborative for Accountability and Improvement 

Leilani Schweitzer

Jeff Goldberg

Naomi Kirtner

Carole Hemmelgarn

Teresa Gentry

John Adams

Sally Kerr

Gail Handley

Marcia Scheppler 

Daniel Kim

I support the immediate implementation of the proposed Patient Safety Structural Measures. Eighteen years ago, my son Gabriel, died after a series of mistakes made at two hospitals. Unfortunately, there is little evidence indicating the same problems that killed my son could not happen today. I have spent the last twelve years working to create a responsible, deliberate response to medical errors. I have seen first hand the indifference many health care systems use to approach safety problems. While I do not believe anyone is acting intentionally to cause harm, the current methods used to monitor and improve patient safety are ineffective at best. In other words, nothing is forcing systems to improve. The public becoming aware of patient safety issues at hospitals that will treat their loved ones, or themselves, is a step toward greater transparency and will eventually make all of us safer. 

Health care systems have many tools and methods readily available to them to make patients safer. A component that has been missing is in patient safety efforts is leadership commitment and accountability. CMS is in a position to significantly improve the lives of all people living in the US. I encourage you to approve and act on all of the proposed measures.

Thank you, Leilani Schweitzer

As a patient who was medically harmed as a result of my physicians not providing me the care that I needed, I am wondering how a MIPS Measure could be conceived to be in the patient's best interest.  From my understanding of the physician's payment program, the physician's performance scoring is tied to their patients' cost and healthcare utilization.  It seems to me that this program creates a dangerous conflict of interest:  I am concerned it would incentivize the physician to "contain the costs" of their patients' care by providing less care than the patient actually needs and discourages the physician from providing the patient care that may be expensive, but critical to the safety of patient. 

Patients who require long term supports and services, like myself, are often called "high-cost patients" by administrators, health and political leaders.¹   It makes me wonder whether it is by coincidence that my peers and I are not receiving adequate, effective and individualized care we need to help us recover from brain injury (BI).  BI care should include in the minimum: therapy for comorbid mental health issues, speech language issues, sensory issues in addition to the supports and services to meet our long term needs- but we experience that it often does not.  We know from studies that incredibly low percentages of Medicare beneficiaries are receiving the TCM and CCM services for which they are actually eligible.²  We are observing this very same trend in other patient populations across our nation.  

When we consider the cost of (system-rationed) healthcare utilization, we are NOT taking into account the REAL costs to both patients and the health system of NOT treating our patient issues- what we are seeing as the long term costs -due to worsening of our conditions which become more complex to treat because we are kicking the can down the road rather than dealing with it.  No, we cannot "manage" our way by "cutting costs" and "improving efficiency of care processes" into a balanced ledger without participating in patient harm or social murder.  Health care is our basic human right and we must set our minds towards funding it in that manner. 

Our US government serves as our sovereign currency issuer, so from the perspective of our federal government, the word "cost" does not mean the same as it does to our 50 states and our very own households.³ Our federal government contributes to the Medicare Trust Funds through creation of new US Dollars by simply clicking on a keyboard; the process of fiscal spending requires zero "cost" to any US state or citizen.⁴  What we are observing from the top of our government on downward is an arbitrarily enforced "limited budget" mentality; we are told "the government is broke".  Here in Vermont, we observe acute psych patients waiting weeks for facility beds to become available while F-35s fighter jets roar overhead on a daily basis.  One would think our leaders lack this basic understanding of fundamental US economic principals to be following along without questioning this policy of federal depravation and its disastrous effect on our health system.  For anyone who was not paying attention, the COVID pandemic exposed what has become of our health system after decades of defunding:  it's dysfunctional, deficient and lacking capacity to meet the needs of our patients. 

By using payment plans that incentivize physicians to provide less than the care their patients actually need, and that guidelines and physician training materials recommend, we are essentially creating a race to the bottom that stands directly against the best interest of patients.  And our patients with the greatest health needs are disproportionately feeling the effects of this misinformed and misdirected approach to funding health care. ⁵ 

As someone who watched her friend die of cancer and other friends who suffered illnesses, I was disheartened to learn this nation takes an average of 17 years to incorporate research findings with strong clinical evidence into standard medical practice.  I know we can do better; our federal government could prioritize and invest more into the search for biomedical solutions to our health issues.  As a trained biomedical researcher, I wonder if we had we been investing as much federal dollars into biomedical research these past decades as we did our US Military, whether we could have effective treatments of cancers and other illnesses today.  How many more American lives must be harmed or lost before we set our priorities straight and change the way our national health care system is funded?  If our leaders were listening to us, they'd know the overwhelming majority of us want them to tell Congress that we need more funding to meet the needs of 335 million Americans.    

Will this quality measure take into consideration improving the funding situation of biomedical research into effective treatments of cancer? 

References: 

1)  H.R.1976 - Medicare for All Act of 2021. (2021, "high-cost patient" appears in legislative text) https://www.congress.gov/bill/117th-congress/house-bill/1976/text/ih?q=%7B%22search%22%3A%22high+cost+patient%22%7D&s=9&r=1&overview=closed

2)  Analysis of 2019 Medicare Fee-for-Service (FFS) Claims for Chronic Care Management (CCM) and Transitional Care Management (TCM) Services.  (2022) https://aspe.hhs.gov/sites/default/files/documents/31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf  

3) Dr. Stephanie Kelton, Stony Brook Economics professor and author of The Deficit Myth, discusses how the US government fiscally operates.  (2020, 5 min video) https://youtu.be/d_udbs-wuDA?si=PXygvxizuo686bUj

4) Dr. L. Randall Wray, Professor of Economics from Bard College and author of Making Money Work for Us, response to question on what legislated funding of US healthcare should look like. (2023, at 3:01:00 Dr. Wray answers my question)  https://youtu.be/nt_nBTRdQiQ?si=IjSR7K5xDI6NnCZh

5)  "It's like I'm worthless": Troubleshooters investigate patient dumping allegations.  (2023, 7 min video) https://youtu.be/rFJsFdgMkYE?si=VYFAZPaw8e4F-ei5

As a patient who was medically harmed as a result of my physicians not providing me the care that I needed, I am wondering how a MIPS Measure could be conceived to be in the patient's best interest.  From my understanding of the physician's payment program, the physician's performance scoring is tied to their patients' cost and healthcare utilization.  It seems to me that this program creates a dangerous conflict of interest:  I am concerned it would incentivize the physician to "contain the costs" of their patients' care by providing less care than the patient actually needs and discourages the physician from providing the patient care that may be expensive, but critical to the safety of patient. 

Patients who require long term supports and services, like myself, are often called "high-cost patients" by administrators, health and political leaders.¹   It makes me wonder whether it is by coincidence that my peers and I are not receiving adequate, effective and individualized care we need to help us recover from brain injury (BI).  BI care should include in the minimum: therapy for comorbid mental health issues, speech language issues, sensory issues in addition to the supports and services to meet our long term needs- but we experience that it often does not.  We know from studies that incredibly low percentages of Medicare beneficiaries are receiving the TCM and CCM services for which they are actually eligible.²  We are observing this very same trend in other patient populations across our nation.  

When we consider the cost of (system-rationed) healthcare utilization, we are NOT taking into account the REAL costs to both patients and the health system of NOT treating our patient issues- what we are seeing as the long term costs -due to worsening of our conditions which become more complex to treat because we are kicking the can down the road rather than dealing with it.  No, we cannot "manage" our way by "cutting costs" and "improving efficiency of care processes" into a balanced ledger without participating in patient harm or social murder.  Health care is our basic human right and we must set our minds towards funding it in that manner. 

Our US government serves as our sovereign currency issuer, so from the perspective of our federal government, the word "cost" does not mean the same as it does to our 50 states and our very own households.³ Our federal government contributes to the Medicare Trust Funds through creation of new US Dollars by simply clicking on a keyboard; the process of fiscal spending requires zero "cost" to any US state or citizen.⁴  What we are observing from the top of our government on downward is an arbitrarily enforced "limited budget" mentality; we are told "the government is broke".  Here in Vermont, we observe acute psych patients waiting weeks for facility beds to become available while F-35s fighter jets roar overhead on a daily basis.  One would think our leaders lack this basic understanding of fundamental US economic principals to be following along without questioning this policy of federal depravation and its disastrous effect on our health system.  For anyone who was not paying attention, the COVID pandemic exposed what has become of our health system after decades of defunding:  it's dysfunctional, deficient and lacking capacity to meet the needs of our patients. 

By using payment plans that incentivize physicians to provide less than the care their patients actually need, and that guidelines and physician training materials recommend, we are essentially creating a race to the bottom that stands directly against the best interest of patients.  And our patients with the greatest health needs are disproportionately feeling the effects of this misinformed and misdirected approach to funding health care. ⁵ 

As someone who watched her friend die of cancer and other friends who suffered illnesses, I was disheartened to learn this nation takes an average of 17 years to incorporate research findings with strong clinical evidence into standard medical practice.  I know we can do better; our federal government could prioritize and invest more into the search for biomedical solutions to our health issues.  As a trained biomedical researcher, I wonder if we had we been investing as much federal dollars into biomedical research these past decades as we did our US Military, whether we could have effective treatments of cancers and other illnesses today.  How many more American lives must be harmed or lost before we set our priorities straight and change the way our national health care system is funded?  If our leaders were listening to us, they'd know the overwhelming majority of us want them to tell Congress that we need more funding to meet the needs of 335 million Americans.    

Will this quality measure take into consideration improving the funding situation of biomedical research into effective treatments of cancer? 

References: 

1)  H.R.1976 - Medicare for All Act of 2021. (2021, "high-cost patient" appears in legislative text) https://www.congress.gov/bill/117th-congress/house-bill/1976/text/ih?q=%7B%22search%22%3A%22high+cost+patient%22%7D&s=9&r=1&overview=closed

2)  Analysis of 2019 Medicare Fee-for-Service (FFS) Claims for Chronic Care Management (CCM) and Transitional Care Management (TCM) Services.  (2022) https://aspe.hhs.gov/sites/default/files/documents/31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf  

3) Dr. Stephanie Kelton, Stony Brook Economics professor and author of The Deficit Myth, discusses how the US government fiscally operates.  (2020, 5 min video) https://youtu.be/d_udbs-wuDA?si=PXygvxizuo686bUj

4) Dr. L. Randall Wray, Professor of Economics from Bard College and author of Making Money Work for Us, response to question on what legislated funding of US healthcare should look like. (2023, at 3:01:00 Dr. Wray answers my question)  https://youtu.be/nt_nBTRdQiQ?si=IjSR7K5xDI6NnCZh

5)  "It's like I'm worthless": Troubleshooters investigate patient dumping allegations.  (2023, 7 min video) https://youtu.be/rFJsFdgMkYE?si=VYFAZPaw8e4F-ei5

As a patient who was medically harmed as a result of my physicians not providing me the care that I needed, I am wondering how a MIPS Measure could be conceived to be in the patient's best interest.  From my understanding of the physician's payment program, the physician's performance scoring is tied to their patients' cost and healthcare utilization.  It seems to me that this program creates a dangerous conflict of interest:  I am concerned it would incentivize the physician to "contain the costs" of their patients' care by providing less care than the patient actually needs and discourages the physician from providing the patient care that may be expensive, but critical to the safety of patient. 

Patients who require long term supports and services, like myself, are often called "high-cost patients" by administrators, health and political leaders.¹   It makes me wonder whether it is by coincidence that my peers and I are not receiving adequate, effective and individualized care we need to help us recover from brain injury (BI).  BI care should include in the minimum: therapy for comorbid mental health issues, speech language issues, sensory issues in addition to the supports and services to meet our long term needs- but we experience that it often does not.  We know from studies that incredibly low percentages of Medicare beneficiaries are receiving the TCM and CCM services for which they are actually eligible.²  We are observing this very same trend in other patient populations across our nation.  

When we consider the cost of (system-rationed) healthcare utilization, we are NOT taking into account the REAL costs to both patients and the health system of NOT treating our patient issues- what we are seeing as the long term costs -due to worsening of our conditions which become more complex to treat because we are kicking the can down the road rather than dealing with it.  No, we cannot "manage" our way by "cutting costs" and "improving efficiency of care processes" into a balanced ledger without participating in patient harm or social murder.  Health care is our basic human right and we must set our minds towards funding it in that manner. 

Our US government serves as our sovereign currency issuer, so from the perspective of our federal government, the word "cost" does not mean the same as it does to our 50 states and our very own households.³ Our federal government contributes to the Medicare Trust Funds through creation of new US Dollars by simply clicking on a keyboard; the process of fiscal spending requires zero "cost" to any US state or citizen.⁴  What we are observing from the top of our government on downward is an arbitrarily enforced "limited budget" mentality; we are told "the government is broke".  Here in Vermont, we observe acute psych patients waiting weeks for facility beds to become available while F-35s fighter jets roar overhead on a daily basis.  One would think our leaders lack this basic understanding of fundamental US economic principals to be following along without questioning this policy of federal depravation and its disastrous effect on our health system.  For anyone who was not paying attention, the COVID pandemic exposed what has become of our health system after decades of defunding:  it's dysfunctional, deficient and lacking capacity to meet the needs of our patients. 

By using payment plans that incentivize physicians to provide less than the care their patients actually need, and that guidelines and physician training materials recommend, we are essentially creating a race to the bottom that stands directly against the best interest of patients.  And our patients with the greatest health needs are disproportionately feeling the effects of this misinformed and misdirected approach to funding health care. ⁵ 

As someone who watched her friend die of cancer and other friends who suffered illnesses, I was disheartened to learn this nation takes an average of 17 years to incorporate research findings with strong clinical evidence into standard medical practice.  I know we can do better; our federal government could prioritize and invest more into the search for biomedical solutions to our health issues.  As a trained biomedical researcher, I wonder if we had we been investing as much federal dollars into biomedical research these past decades as we did our US Military, whether we could have effective treatments of cancers and other illnesses today.  How many more American lives must be harmed or lost before we set our priorities straight and change the way our national health care system is funded?  If our leaders were listening to us, they'd know the overwhelming majority of us want them to tell Congress that we need more funding to meet the needs of 335 million Americans.    

Will this quality measure take into consideration improving the funding situation of biomedical research into effective treatments of cancer? 

References: 

1)  H.R.1976 - Medicare for All Act of 2021. (2021, "high-cost patient" appears in legislative text) https://www.congress.gov/bill/117th-congress/house-bill/1976/text/ih?q=%7B%22search%22%3A%22high+cost+patient%22%7D&s=9&r=1&overview=closed

2)  Analysis of 2019 Medicare Fee-for-Service (FFS) Claims for Chronic Care Management (CCM) and Transitional Care Management (TCM) Services.  (2022) https://aspe.hhs.gov/sites/default/files/documents/31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf  

3) Dr. Stephanie Kelton, Stony Brook Economics professor and author of The Deficit Myth, discusses how the US government fiscally operates.  (2020, 5 min video) https://youtu.be/d_udbs-wuDA?si=PXygvxizuo686bUj

4) Dr. L. Randall Wray, Professor of Economics from Bard College and author of Making Money Work for Us, response to question on what legislated funding of US healthcare should look like. (2023, at 3:01:00 Dr. Wray answers my question)  https://youtu.be/nt_nBTRdQiQ?si=IjSR7K5xDI6NnCZh

5)  "It's like I'm worthless": Troubleshooters investigate patient dumping allegations.  (2023, 7 min video) https://youtu.be/rFJsFdgMkYE?si=VYFAZPaw8e4F-ei5

As a patient who was medically harmed as a result of my physicians not providing me the care that I needed, I am wondering how a MIPS Measure could be conceived to be in the patient's best interest.  From my understanding of the physician's payment program, the physician's performance scoring is tied to their patients' cost and healthcare utilization.  It seems to me that this program creates a dangerous conflict of interest:  I am concerned it would incentivize the physician to "contain the costs" of their patients' care by providing less care than the patient actually needs and discourages the physician from providing the patient care that may be expensive, but critical to the safety of patient. 

Patients who require long term supports and services, like myself, are often called "high-cost patients" by administrators, health and political leaders.¹   It makes me wonder whether it is by coincidence that my peers and I are not receiving adequate, effective and individualized care we need to help us recover from brain injury (BI).  BI care should include in the minimum: therapy for comorbid mental health issues, speech language issues, sensory issues in addition to the supports and services to meet our long term needs- but we experience that it often does not.  We know from studies that incredibly low percentages of Medicare beneficiaries are receiving the TCM and CCM services for which they are actually eligible.²  We are observing this very same trend in other patient populations across our nation.  

When we consider the cost of (system-rationed) healthcare utilization, we are NOT taking into account the REAL costs to both patients and the health system of NOT treating our patient issues- what we are seeing as the long term costs -due to worsening of our conditions which become more complex to treat because we are kicking the can down the road rather than dealing with it.  No, we cannot "manage" our way by "cutting costs" and "improving efficiency of care processes" into a balanced ledger without participating in patient harm or social murder.  Health care is our basic human right and we must set our minds towards funding it in that manner. 

Our US government serves as our sovereign currency issuer, so from the perspective of our federal government, the word "cost" does not mean the same as it does to our 50 states and our very own households.³ Our federal government contributes to the Medicare Trust Funds through creation of new US Dollars by simply clicking on a keyboard; the process of fiscal spending requires zero "cost" to any US state or citizen.⁴  What we are observing from the top of our government on downward is an arbitrarily enforced "limited budget" mentality; we are told "the government is broke".  Here in Vermont, we observe acute psych patients waiting weeks for facility beds to become available while F-35s fighter jets roar overhead on a daily basis.  One would think our leaders lack this basic understanding of fundamental US economic principals to be following along without questioning this policy of federal depravation and its disastrous effect on our health system.  For anyone who was not paying attention, the COVID pandemic exposed what has become of our health system after decades of defunding:  it's dysfunctional, deficient and lacking capacity to meet the needs of our patients. 

By using payment plans that incentivize physicians to provide less than the care their patients actually need, and that guidelines and physician training materials recommend, we are essentially creating a race to the bottom that stands directly against the best interest of patients.  And our patients with the greatest health needs are disproportionately feeling the effects of this misinformed and misdirected approach to funding health care. ⁵ 

As someone who watched her friend die of cancer and other friends who suffered illnesses, I was disheartened to learn this nation takes an average of 17 years to incorporate research findings with strong clinical evidence into standard medical practice.  I know we can do better; our federal government could prioritize and invest more into the search for biomedical solutions to our health issues.  As a trained biomedical researcher, I wonder if we had we been investing as much federal dollars into biomedical research these past decades as we did our US Military, whether we could have effective treatments of cancers and other illnesses today.  How many more American lives must be harmed or lost before we set our priorities straight and change the way our national health care system is funded?  If our leaders were listening to us, they'd know the overwhelming majority of us want them to tell Congress that we need more funding to meet the needs of 335 million Americans.    

Will this quality measure take into consideration improving the funding situation of biomedical research into effective treatments of cancer? 

References: 

1)  H.R.1976 - Medicare for All Act of 2021. (2021, "high-cost patient" appears in legislative text) https://www.congress.gov/bill/117th-congress/house-bill/1976/text/ih?q=%7B%22search%22%3A%22high+cost+patient%22%7D&s=9&r=1&overview=closed

2)  Analysis of 2019 Medicare Fee-for-Service (FFS) Claims for Chronic Care Management (CCM) and Transitional Care Management (TCM) Services.  (2022) https://aspe.hhs.gov/sites/default/files/documents/31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf  

3) Dr. Stephanie Kelton, Stony Brook Economics professor and author of The Deficit Myth, discusses how the US government fiscally operates.  (2020, 5 min video) https://youtu.be/d_udbs-wuDA?si=PXygvxizuo686bUj

4) Dr. L. Randall Wray, Professor of Economics from Bard College and author of Making Money Work for Us, response to question on what legislated funding of US healthcare should look like. (2023, at 3:01:00 Dr. Wray answers my question)  https://youtu.be/nt_nBTRdQiQ?si=IjSR7K5xDI6NnCZh

5)  "It's like I'm worthless": Troubleshooters investigate patient dumping allegations.  (2023, 7 min video) https://youtu.be/rFJsFdgMkYE?si=VYFAZPaw8e4F-ei5

Please see attached comment letter from the American College of Surgeons (ACS). 

Thank you! 

This measure analyzes patient "compliance" or "conformity" to a medical directive which does not take into consideration individual preference and needs;  this measure stands against the patient-centered principles of respect, dignity, autonomy and shared decision making.

As a patient who was medically harmed as a result of my physicians not providing me the care that I needed, I am wondering how a MIPS Measure could be conceived to be in the patient's best interest.  From my understanding of the physician's payment program, the physician's performance scoring is tied to their patients' cost and healthcare utilization.  It seems to me that this program creates a dangerous conflict of interest:  I am concerned it would incentivize the physician to "contain the costs" of their patients' care by providing less care than the patient actually needs and discourages the physician from providing the patient care that may be expensive, but critical for the safety of the patient.  

Patients who require long term supports and services, like myself, are often called "high-cost patients" by administrators, health and political leaders.¹   It makes me wonder whether it is by coincidence that my peers and I are not receiving adequate, effective and individualized care we need to help us recover from brain injury (BI).  BI care should include in the minimum: therapy for comorbid mental health issues, speech language issues, sensory issues in addition to the supports and services to meet our long term needs- but we experience that it often does not.  We know from studies that incredibly low percentages of Medicare beneficiaries are receiving the TCM and CCM services for which they are actually eligible.²  We are observing this very same trend in other patient populations across our nation.  

When we consider the cost of (system-rationed) healthcare utilization, we are NOT taking into account the REAL costs to both patients and the health system of NOT treating our patient issues- what we are seeing as the long term costs -due to worsening of our conditions which become more complex to treat because we are kicking the can down the road rather than dealing with it.  No, we cannot "manage" our way by "cutting costs" and "improving efficiency of care processes" into a balanced ledger without participating in patient harm or social murder.  Health care is our basic human right and we must set our minds towards funding it in that manner. 

Our US government serves as our sovereign currency issuer, so from the perspective of our federal government, the word "cost" does not mean the same as it does to our 50 states and our very own households.³ Our federal government contributes to the Medicare Trust Funds through creation of new US Dollars by simply clicking on a keyboard; the process of fiscal spending requires zero "cost" to any US state or citizen.⁴  What we are observing from the top of our government on downward is an arbitrarily enforced "limited budget" mentality; we are told "the government is broke".  Here in Vermont, we observe acute psych patients waiting weeks for facility beds to become available while F-35s fighter jets roar overhead on a daily basis.  One would think our leaders lack this basic understanding of fundamental US economic principals to be following along without questioning this policy of federal depravation and its disastrous effect on our health system.  For anyone who was not paying attention, the COVID pandemic exposed what has become of our health system after decades of defunding:  it's dysfunctional, deficient and lacking capacity to meet the needs of our patients.  

By using payment plans that incentivize physicians to provide less than the care their patients actually need, and that guidelines and physician training materials recommend, we are essentially creating a race to the bottom that stands directly against the best interest of patients.  And our patients with the greatest health needs are disproportionately feeling the effects of this misinformed and misdirected approach to funding health care. ⁵ 

I wonder if we had we been investing as many federal dollars into biomedical research these past decades as we did our US Military, whether we would have basic amenities, trained staff, functioning facilities the health system is deficient in today.  How many more American lives must be harmed or lost before we set our priorities straight and change the way our national health care system is funded?  If our leaders were listening to those they serve, they'd know the overwhelming majority of us want them to tell Congress that we need more funding to meet the needs of 335 million Americans.   

References: 

1)  H.R.1976 - Medicare for All Act of 2021. (2021, "high-cost patient" appears in legislative text) https://www.congress.gov/bill/117th-congress/house-bill/1976/text/ih?q=%7B%22search%22%3A%22high+cost+patient%22%7D&s=9&r=1&overview=closed

2)  Analysis of 2019 Medicare Fee-for-Service (FFS) Claims for Chronic Care Management (CCM) and Transitional Care Management (TCM) Services.  (2022) https://aspe.hhs.gov/sites/default/files/documents/31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf  

3) Dr. Stephanie Kelton, Stony Brook Economics professor and author of The Deficit Myth, discusses how the US government fiscally operates.  (2020, 5 min video) https://youtu.be/d_udbs-wuDA?si=PXygvxizuo686bUj

4) Dr. L. Randall Wray, Professor of Economics from Bard College and author of Making Money Work for Us, response to question on what legislated funding of US healthcare should look like. (2023, at 3:01:00 Dr. Wray answers my question)  https://youtu.be/nt_nBTRdQiQ?si=IjSR7K5xDI6NnCZh

5)  "It's like I'm worthless": Troubleshooters investigate patient dumping allegations.  (2023, 7 min video) https://youtu.be/rFJsFdgMkYE?si=VYFAZPaw8e4F-ei5

As a patient who was medically harmed as a result of my physicians not providing me the care that I needed, I am wondering how a MIPS Measure could be conceived to be in the patient's best interest.  From my understanding of the physician's payment program, the physician's performance scoring is tied to their patients' cost and healthcare utilization.  It seems to me that this program creates a dangerous conflict of interest:  I am concerned it would incentivize the physician to "contain the costs" of their patients' care by providing less care than the patient actually needs and discourages the physician from providing the patient care that may be expensive, but critical to the safety of patient. 

Patients who require long term supports and services, like myself, are often called "high-cost patients" by administrators, health and political leaders.¹   It makes me wonder whether it is by coincidence that my peers and I are not receiving adequate, effective and individualized care we need to help us recover from brain injury (BI).  BI care should include in the minimum: therapy for comorbid mental health issues, speech language issues, sensory issues in addition to the supports and services to meet our long term needs- but we experience that it often does not.  We know from studies that incredibly low percentages of Medicare beneficiaries are receiving the TCM and CCM services for which they are actually eligible.²  We are observing this very same trend in other patient populations across our nation.  

When we consider the cost of (system-rationed) healthcare utilization, we are NOT taking into account the REAL costs to both patients and the health system of NOT treating our patient issues- what we are seeing as the long term costs -due to worsening of our conditions which become more complex to treat because we are kicking the can down the road rather than dealing with it.  No, we cannot "manage" our way by "cutting costs" and "improving efficiency of care processes" into a balanced ledger without participating in patient harm or social murder.  Health care is our basic human right and we must set our minds towards funding it in that manner. 

Our US government serves as our sovereign currency issuer, so from the perspective of our federal government, the word "cost" does not mean the same as it does to our 50 states and our very own households.³ Our federal government contributes to the Medicare Trust Funds through creation of new US Dollars by simply clicking on a keyboard; the process of fiscal spending requires zero "cost" to any US state or citizen.⁴  What we are observing from the top of our government on downward is an arbitrarily enforced "limited budget" mentality; we are told "the government is broke".  Here in Vermont, we observe acute psych patients waiting weeks for facility beds to become available while F-35s fighter jets roar overhead on a daily basis.  One would think our leaders lack this basic understanding of fundamental US economic principals to be following along without questioning this policy of federal depravation and its disastrous effect on our health system.  For anyone who was not paying attention, the COVID pandemic exposed what has become of our health system after decades of defunding:  it's dysfunctional, deficient and lacking capacity to meet the needs of our patients. 

By using payment plans that incentivize physicians to provide less than the care their patients actually need, and that guidelines and physician training materials recommend, we are essentially creating a race to the bottom that stands directly against the best interest of patients.  And our patients with the greatest health needs are disproportionately feeling the effects of this misinformed and misdirected approach to funding health care. ⁵ 

As someone who watched her friend die of cancer and other friends who suffered illnesses, I was disheartened to learn this nation takes an average of 17 years to incorporate research findings with strong clinical evidence into standard medical practice.  I know we can do better; our federal government could prioritize and invest more into the search for biomedical solutions to our health issues.  As a trained biomedical researcher, I wonder if we had we been investing as much federal dollars into biomedical research these past decades as we did our US Military, whether we could have effective treatments of cancers and other illnesses today.  How many more American lives must be harmed or lost before we set our priorities straight and change the way our national health care system is funded?  If our leaders were listening to us, they'd know the overwhelming majority of us want them to tell Congress that we need more funding to meet the needs of 335 million Americans.    

Will this quality measure take into consideration improving the funding situation of biomedical research into effective treatments of cancer? 

References: 

1)  H.R.1976 - Medicare for All Act of 2021. (2021, "high-cost patient" appears in legislative text) https://www.congress.gov/bill/117th-congress/house-bill/1976/text/ih?q=%7B%22search%22%3A%22high+cost+patient%22%7D&s=9&r=1&overview=closed

2)  Analysis of 2019 Medicare Fee-for-Service (FFS) Claims for Chronic Care Management (CCM) and Transitional Care Management (TCM) Services.  (2022) https://aspe.hhs.gov/sites/default/files/documents/31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf  

3) Dr. Stephanie Kelton, Stony Brook Economics professor and author of The Deficit Myth, discusses how the US government fiscally operates.  (2020, 5 min video) https://youtu.be/d_udbs-wuDA?si=PXygvxizuo686bUj

4) Dr. L. Randall Wray, Professor of Economics from Bard College and author of Making Money Work for Us, response to question on what legislated funding of US healthcare should look like. (2023, at 3:01:00 Dr. Wray answers my question)  https://youtu.be/nt_nBTRdQiQ?si=IjSR7K5xDI6NnCZh

5)  "It's like I'm worthless": Troubleshooters investigate patient dumping allegations.  (2023, 7 min video) https://youtu.be/rFJsFdgMkYE?si=VYFAZPaw8e4F-ei5

As a patient who was medically harmed as a result of my physicians not providing me the care that I needed, I am wondering how a MIPS Measure could be conceived to be in the patient's best interest.  From my understanding of the physician's payment program, the physician's performance scoring is tied to their patients' cost and healthcare utilization.  It seems to me that this program creates a dangerous conflict of interest:  I am concerned it would incentivize the physician to "contain the costs" of their patients' care by providing less care than the patient actually needs and discourages the physician from providing the patient care that may be expensive, but critical for the safety of the patient.  

Patients who require long term supports and services, like myself, are often called "high-cost patients" by administrators, health and political leaders.¹   It makes me wonder whether it is by coincidence that my peers and I are not receiving adequate, effective and individualized care we need to help us recover from brain injury (BI).  BI care should include in the minimum: therapy for comorbid mental health issues, speech language issues, sensory issues in addition to the supports and services to meet our long term needs- but we experience that it often does not.  We know from studies that incredibly low percentages of Medicare beneficiaries are receiving the TCM and CCM services for which they are actually eligible.²  We are observing this very same trend in other patient populations across our nation.  

When we consider the cost of (system-rationed) healthcare utilization, we are NOT taking into account the REAL costs to both patients and the health system of NOT treating our patient issues- what we are seeing as the long term costs -due to worsening of our conditions which become more complex to treat because we are kicking the can down the road rather than dealing with it.  No, we cannot "manage" our way by "cutting costs" and "improving efficiency of care processes" into a balanced ledger without participating in patient harm or social murder.  Health care is our basic human right and we must set our minds towards funding it in that manner. 

Our US government serves as our sovereign currency issuer, so from the perspective of our federal government, the word "cost" does not mean the same as it does to our 50 states and our very own households.³ Our federal government contributes to the Medicare Trust Funds through creation of new US Dollars by simply clicking on a keyboard; the process of fiscal spending requires zero "cost" to any US state or citizen.⁴  What we are observing from the top of our government on downward is an arbitrarily enforced "limited budget" mentality; we are told "the government is broke".  Here in Vermont, we observe acute psych patients waiting weeks for facility beds to become available while F-35s fighter jets roar overhead on a daily basis.  One would think our leaders lack this basic understanding of fundamental US economic principals to be following along without questioning this policy of federal depravation and its disastrous effect on our health system.  For anyone who was not paying attention, the COVID pandemic exposed what has become of our health system after decades of defunding:  it's dysfunctional, deficient and lacking capacity to meet the needs of our patients.  

By using payment plans that incentivize physicians to provide less than the care their patients actually need, and that guidelines and physician training materials recommend, we are essentially creating a race to the bottom that stands directly against the best interest of patients.  And our patients with the greatest health needs are disproportionately feeling the effects of this misinformed and misdirected approach to funding health care. ⁵ 

I wonder if we had we been investing as many federal dollars into biomedical research these past decades as we did our US Military, whether we would have basic amenities, trained staff, functioning facilities the health system is deficient in today.  How many more American lives must be harmed or lost before we set our priorities straight and change the way our national health care system is funded?  If our leaders were listening to those they serve, they'd know the overwhelming majority of us want them to tell Congress that we need more funding to meet the needs of 335 million Americans.    

References: 

1)  H.R.1976 - Medicare for All Act of 2021. (2021, "high-cost patient" appears in legislative text) https://www.congress.gov/bill/117th-congress/house-bill/1976/text/ih?q=%7B%22search%22%3A%22high+cost+patient%22%7D&s=9&r=1&overview=closed

2)  Analysis of 2019 Medicare Fee-for-Service (FFS) Claims for Chronic Care Management (CCM) and Transitional Care Management (TCM) Services.  (2022) https://aspe.hhs.gov/sites/default/files/documents/31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf  

3) Dr. Stephanie Kelton, Stony Brook Economics professor and author of The Deficit Myth, discusses how the US government fiscally operates.  (2020, 5 min video) https://youtu.be/d_udbs-wuDA?si=PXygvxizuo686bUj

4) Dr. L. Randall Wray, Professor of Economics from Bard College and author of Making Money Work for Us, response to question on what legislated funding of US healthcare should look like. (2023, at 3:01:00 Dr. Wray answers my question)  https://youtu.be/nt_nBTRdQiQ?si=IjSR7K5xDI6NnCZh

5)  "It's like I'm worthless": Troubleshooters investigate patient dumping allegations.  (2023, 7 min video) https://youtu.be/rFJsFdgMkYE?si=VYFAZPaw8e4F-ei5

As a patient who was medically harmed as a result of my physicians not providing me the care that I needed, I am wondering how a MIPS Measure could be conceived to be in the patient's best interest.  From my understanding of the physician's payment program, the physician's performance scoring is tied to their patients' cost and healthcare utilization.  It seems to me that this program creates a dangerous conflict of interest:  I am concerned it would incentivize the physician to "contain the costs" of their patients' care by providing less care than the patient actually needs and discourages the physician from providing the patient care that may be expensive, but critical for the safety of the patient.  

Patients who require long term supports and services, like myself, are often called "high-cost patients" by administrators, health and political leaders.¹   It makes me wonder whether it is by coincidence that my peers and I are not receiving adequate, effective and individualized care we need to help us recover from brain injury (BI).  BI care should include in the minimum: therapy for comorbid mental health issues, speech language issues, sensory issues in addition to the supports and services to meet our long term needs- but we experience that it often does not.  We know from studies that incredibly low percentages of Medicare beneficiaries are receiving the TCM and CCM services for which they are actually eligible.²  We are observing this very same trend in other patient populations across our nation.  

When we consider the cost of (system-rationed) healthcare utilization, we are NOT taking into account the REAL costs to both patients and the health system of NOT treating our patient issues- what we are seeing as the long term costs -due to worsening of our conditions which become more complex to treat because we are kicking the can down the road rather than dealing with it.  No, we cannot "manage" our way by "cutting costs" and "improving efficiency of care processes" into a balanced ledger without participating in patient harm or social murder.  Health care is our basic human right and we must set our minds towards funding it in that manner. 

Our US government serves as our sovereign currency issuer, so from the perspective of our federal government, the word "cost" does not mean the same as it does to our 50 states and our very own households.³ Our federal government contributes to the Medicare Trust Funds through creation of new US Dollars by simply clicking on a keyboard; the process of fiscal spending requires zero "cost" to any US state or citizen.⁴  What we are observing from the top of our government on downward is an arbitrarily enforced "limited budget" mentality; we are told "the government is broke".  Here in Vermont, we observe acute psych patients waiting weeks for facility beds to become available while F-35s fighter jets roar overhead on a daily basis.  One would think our leaders lack this basic understanding of fundamental US economic principals to be following along without questioning this policy of federal depravation and its disastrous effect on our health system.  For anyone who was not paying attention, the COVID pandemic exposed what has become of our health system after decades of defunding:  it's dysfunctional, deficient and lacking capacity to meet the needs of our patients.  

By using payment plans that incentivize physicians to provide less than the care their patients actually need, and that guidelines and physician training materials recommend, we are essentially creating a race to the bottom that stands directly against the best interest of patients.  And our patients with the greatest health needs are disproportionately feeling the effects of this misinformed and misdirected approach to funding health care. ⁵ 

I wonder if we had we been investing as many federal dollars into biomedical research these past decades as we did our US Military, whether we would have basic amenities, trained staff, functioning facilities the health system is deficient in today.  How many more American lives must be harmed or lost before we set our priorities straight and change the way our national health care system is funded?  If our leaders were listening to those they serve, they'd know the overwhelming majority of us want them to tell Congress that we need more funding to meet the needs of 335 million Americans.    

References: 

1)  H.R.1976 - Medicare for All Act of 2021. (2021, "high-cost patient" appears in legislative text) https://www.congress.gov/bill/117th-congress/house-bill/1976/text/ih?q=%7B%22search%22%3A%22high+cost+patient%22%7D&s=9&r=1&overview=closed

2)  Analysis of 2019 Medicare Fee-for-Service (FFS) Claims for Chronic Care Management (CCM) and Transitional Care Management (TCM) Services.  (2022) https://aspe.hhs.gov/sites/default/files/documents/31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf  

3) Dr. Stephanie Kelton, Stony Brook Economics professor and author of The Deficit Myth, discusses how the US government fiscally operates.  (2020, 5 min video) https://youtu.be/d_udbs-wuDA?si=PXygvxizuo686bUj

4) Dr. L. Randall Wray, Professor of Economics from Bard College and author of Making Money Work for Us, response to question on what legislated funding of US healthcare should look like. (2023, at 3:01:00 Dr. Wray answers my question)  https://youtu.be/nt_nBTRdQiQ?si=IjSR7K5xDI6NnCZh

5)  "It's like I'm worthless": Troubleshooters investigate patient dumping allegations.  (2023, 7 min video) https://youtu.be/rFJsFdgMkYE?si=VYFAZPaw8e4F-ei5

We disagree with the Committee’s recommendation to support the Level I Denials Upheld Rate Measure for the Part C Star Ratings program and oppose it moving forward. We all agree that measures used in Medicare programs, including MA Star Ratings, should be evidence-based, reflect the quality of care provided, and share meaningful information with beneficiaries. Yet, this measure accomplishes none of these; instead, it introduces a new, duplicative measure of administrative processes that cannot be accurately interpreted for consumer choice as written.   

The measure is inappropriately constructed to suggest that all instances of a claim or prior authorization overturned on appeal are a deficiency by the health plan. As noted by the measure developer during the Clinician Workgroup meeting, this measure is not able to differentiate when a denial is overturned because of health plan or health care provider factors. The 2018 GAO report notes that denials are not overturned only because of incorrect decisions by a health plan. The GAO found that denials are also overturned when an MA Organization makes a correct initial decision based on the information available at the time but the provider or beneficiary later add new information in an appeal that demonstrates the denial should be overturned. One recent analysis[1] found that provider staff shortages and attrition as well as inaccuracies due to changing coding practices to account for the COVID-19 public health emergency are key contributors to claims denials. A measure that conflates the rationales for denials, risks providing inaccurate information to consumers and unfairly penalizing plans. 

In addition, the measure does not provide the context that providers only appeal denials that they believe they can win. With no outside benchmark it is difficult to discern what a best practice rate should be. There is no context such as what the traditional Medicare overturn rate is or that certain plans may serve more enrollees with complex conditions for which coverage and payment determinations are more difficult to determine. Without benchmarks or balancing measures, the results will not mean much to enrollees or worse, mislead them. 

This measure would also be redundant to other administrative measures. Currently, there are 2 appeals measures in the Part C Star Ratings program. One measure focuses on how fast an MA plan sends information on a denial that has been appealed for an independent review and the other measure focuses on how often an independent reviewer found the health plan’s decision to deny coverage to be reasonable. This proposed measure duplicates this second Part C appeals measure that is already part of the MA Star Ratings program. However, the existing measure focuses on appeals that are overturned by an independent review entity (IRE).  Focusing on appeals reviewed by an IRE allows for an opportunity for plans and providers to resolve denials that may be caused by factors such as provider staff errors or coding inaccuracies without unduly penalizing plans.  Moreover, CMS recently finalized a list of metrics that plans participating in federal programs will be required to report about their prior authorization processes. These metrics will include percentages of prior authorizations that are approved, denied, and appealed.  These metrics along with the existing measures in the Star Ratings program will provide greater transparency on rates of denials and appeals. 

In addition to the two appeals measures already in the Part C Star Ratings program, CMS has authority to oversee and does address denials and appeals through MA reporting requirements and audits/enforcement. Adding additional appeals- related measures to quality programs would be inconsistent with the agency’s latest efforts to streamline measure sets and move towards a “Universal Foundation” of quality measures in CMS’ quality rating and value-based care programs, including MA Star Ratings. 

We urge CMS not to adopt this measure for the Part C Star Ratings program. 

[1] https://www.definitivehc.com/blog/rise-claims-denials

As a patient who was medically harmed as a result of my physicians not providing me the care that I needed, I am wondering how a MIPS Measure could be conceived to be in the patient's best interest.  From my understanding of the physician's payment program, the physician's performance scoring is tied to their patients' cost and healthcare utilization.  It seems to me that this program creates a dangerous conflict of interest:  I am concerned it would incentivize the physician to "contain the costs" of their patients' care by providing less care than the patient actually needs and discourages the physician from providing the patient care that may be expensive, but critical for the safety of the patient.  

Patients who require long term supports and services, like myself, are often called "high-cost patients" by administrators, health and political leaders.¹   It makes me wonder whether it is by coincidence that my peers and I are not receiving adequate, effective and individualized care we need to help us recover from brain injury (BI).  BI care should include in the minimum: therapy for comorbid mental health issues, speech language issues, sensory issues in addition to the supports and services to meet our long term needs- but we experience that it often does not.  We know from studies that incredibly low percentages of Medicare beneficiaries are receiving the TCM and CCM services for which they are actually eligible.²  We are observing this very same trend in other patient populations across our nation.  

When we consider the cost of (system-rationed) healthcare utilization, we are NOT taking into account the REAL costs to both patients and the health system of NOT treating our patient issues- what we are seeing as the long term costs -due to worsening of our conditions which become more complex to treat because we are kicking the can down the road rather than dealing with it.  No, we cannot "manage" our way by "cutting costs" and "improving efficiency of care processes" into a balanced ledger without participating in patient harm or social murder.  Health care is our basic human right and we must set our minds towards funding it in that manner. 

Our US government serves as our sovereign currency issuer, so from the perspective of our federal government, the word "cost" does not mean the same as it does to our 50 states and our very own households.³ Our federal government contributes to the Medicare Trust Funds through creation of new US Dollars by simply clicking on a keyboard; the process of fiscal spending requires zero "cost" to any US state or citizen.⁴  What we are observing from the top of our government on downward is an arbitrarily enforced "limited budget" mentality; we are told "the government is broke".  Here in Vermont, we observe acute psych patients waiting weeks for facility beds to become available while F-35s fighter jets roar overhead on a daily basis.  One would think our leaders lack this basic understanding of fundamental US economic principals to be following along without questioning this policy of federal depravation and its disastrous effect on our health system.  For anyone who was not paying attention, the COVID pandemic exposed what has become of our health system after decades of defunding:  it's dysfunctional, deficient and lacking capacity to meet the needs of our patients.  

By using payment plans that incentivize physicians to provide less than the care their patients actually need, and that guidelines and physician training materials recommend, we are essentially creating a race to the bottom that stands directly against the best interest of patients.  And our patients with the greatest health needs are disproportionately feeling the effects of this misinformed and misdirected approach to funding health care. ⁵ 

I wonder if we had we been investing as many federal dollars into biomedical research these past decades as we did our US Military, whether we would have basic amenities, trained staff, functioning facilities the health system is deficient in today.  How many more American lives must be harmed or lost before we set our priorities straight and change the way our national health care system is funded?  If our leaders were listening to those they serve, they'd know the overwhelming majority of us want them to tell Congress that we need more funding to meet the needs of 335 million Americans.    

References: 

1)  H.R.1976 - Medicare for All Act of 2021. (2021, "high-cost patient" appears in legislative text) https://www.congress.gov/bill/117th-congress/house-bill/1976/text/ih?q=%7B%22search%22%3A%22high+cost+patient%22%7D&s=9&r=1&overview=closed

2)  Analysis of 2019 Medicare Fee-for-Service (FFS) Claims for Chronic Care Management (CCM) and Transitional Care Management (TCM) Services.  (2022) https://aspe.hhs.gov/sites/default/files/documents/31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf  

3) Dr. Stephanie Kelton, Stony Brook Economics professor and author of The Deficit Myth, discusses how the US government fiscally operates.  (2020, 5 min video) https://youtu.be/d_udbs-wuDA?si=PXygvxizuo686bUj

4) Dr. L. Randall Wray, Professor of Economics from Bard College and author of Making Money Work for Us, response to question on what legislated funding of US healthcare should look like. (2023, at 3:01:00 Dr. Wray answers my question)  https://youtu.be/nt_nBTRdQiQ?si=IjSR7K5xDI6NnCZh

5)  "It's like I'm worthless": Troubleshooters investigate patient dumping allegations.  (2023, 7 min video) https://youtu.be/rFJsFdgMkYE?si=VYFAZPaw8e4F-ei5

As a patient who was medically harmed as a result of my physicians not providing me the care that I needed, I am wondering how a MIPS Measure could be conceived to be in the patient's best interest.  From my understanding of the physician's payment program, the physician's performance scoring is tied to their patients' cost and healthcare utilization.  It seems to me that this program creates a dangerous conflict of interest:  I am concerned it would incentivize the physician to "contain the costs" of their patients' care by providing less care than the patient actually needs and discourages the physician from providing the patient care that may be expensive, but critical for the safety of the patient.  

Patients who require long term supports and services, like myself, are often called "high-cost patients" by administrators, health and political leaders.¹   It makes me wonder whether it is by coincidence that my peers and I are not receiving adequate, effective and individualized care we need to help us recover from brain injury (BI).  BI care should include in the minimum: therapy for comorbid mental health issues, speech language issues, sensory issues in addition to the supports and services to meet our long term needs- but we experience that it often does not.  We know from studies that incredibly low percentages of Medicare beneficiaries are receiving the TCM and CCM services for which they are actually eligible.²  We are observing this very same trend in other patient populations across our nation.  

When we consider the cost of (system-rationed) healthcare utilization, we are NOT taking into account the REAL costs to both patients and the health system of NOT treating our patient issues- what we are seeing as the long term costs -due to worsening of our conditions which become more complex to treat because we are kicking the can down the road rather than dealing with it.  No, we cannot "manage" our way by "cutting costs" and "improving efficiency of care processes" into a balanced ledger without participating in patient harm or social murder.  Health care is our basic human right and we must set our minds towards funding it in that manner. 

Our US government serves as our sovereign currency issuer, so from the perspective of our federal government, the word "cost" does not mean the same as it does to our 50 states and our very own households.³ Our federal government contributes to the Medicare Trust Funds through creation of new US Dollars by simply clicking on a keyboard; the process of fiscal spending requires zero "cost" to any US state or citizen.⁴  What we are observing from the top of our government on downward is an arbitrarily enforced "limited budget" mentality; we are told "the government is broke".  Here in Vermont, we observe acute psych patients waiting weeks for facility beds to become available while F-35s fighter jets roar overhead on a daily basis.  One would think our leaders lack this basic understanding of fundamental US economic principals to be following along without questioning this policy of federal depravation and its disastrous effect on our health system.  For anyone who was not paying attention, the COVID pandemic exposed what has become of our health system after decades of defunding:  it's dysfunctional, deficient and lacking capacity to meet the needs of our patients.  

By using payment plans that incentivize physicians to provide less than the care their patients actually need, and that guidelines and physician training materials recommend, we are essentially creating a race to the bottom that stands directly against the best interest of patients.  And our patients with the greatest health needs are disproportionately feeling the effects of this misinformed and misdirected approach to funding health care. ⁵ 

I wonder if we had we been investing as many federal dollars into biomedical research these past decades as we did our US Military, whether we would have basic amenities, trained staff, functioning facilities the health system is deficient in today.  How many more American lives must be harmed or lost before we set our priorities straight and change the way our national health care system is funded?  If our leaders were listening to those they serve, they'd know the overwhelming majority of us want them to tell Congress that we need more funding to meet the needs of 335 million Americans.    

References: 

1)  H.R.1976 - Medicare for All Act of 2021. (2021, "high-cost patient" appears in legislative text) https://www.congress.gov/bill/117th-congress/house-bill/1976/text/ih?q=%7B%22search%22%3A%22high+cost+patient%22%7D&s=9&r=1&overview=closed

2)  Analysis of 2019 Medicare Fee-for-Service (FFS) Claims for Chronic Care Management (CCM) and Transitional Care Management (TCM) Services.  (2022) https://aspe.hhs.gov/sites/default/files/documents/31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf  

3) Dr. Stephanie Kelton, Stony Brook Economics professor and author of The Deficit Myth, discusses how the US government fiscally operates.  (2020, 5 min video) https://youtu.be/d_udbs-wuDA?si=PXygvxizuo686bUj

4) Dr. L. Randall Wray, Professor of Economics from Bard College and author of Making Money Work for Us, response to question on what legislated funding of US healthcare should look like. (2023, at 3:01:00 Dr. Wray answers my question)  https://youtu.be/nt_nBTRdQiQ?si=IjSR7K5xDI6NnCZh

5)  "It's like I'm worthless": Troubleshooters investigate patient dumping allegations.  (2023, 7 min video) https://youtu.be/rFJsFdgMkYE?si=VYFAZPaw8e4F-ei5

Dear Centers for Medicare & Medicaid Services,

We commend CMS for developing a Measures Under Consideration list prioritizing patient safety and health equity. Harm, bias and discrimination are problems embedded in our healthcare system affecting everyone—patients, families, clinicians—anyone who needs or provides care. It seems that there are constant studies bringing the consequence of the embedded problems into harsh light. We believe structured measures will improve these problems.

2024 is the 25^th Anniversary of To Err is Human, the National Academy of Sciences call to improve patient safety. We remain far from reaching the patient safety goals defined in the report. These challenges and the slow progress toward greater safety and equity, make CMS leadership extremely important and powerful. As Americans, we expect our health systems to be safe for all of us, regardless of race, ethnicity, age, disability, LGBTQ+ status, or other patient demographics that now, too often, lead to disparate patient outcomes.

We appreciate the opportunity to share our own experiences and those of our loved ones, as we are often driven to advocacy because the health care system has harmed us. We are pleased to know our experiences and input are valued.

We strongly support MUC2023-188: Patient Safety Structural Measure without delay as it asks hospital leaders to publicly attest to their organization’s establishment of best practices in following domains: 

1) Leadership Commitment

2) Strategy & Policy

3) Culture of Safety & Learning

4) Accountability & Transparency

5) Patient & Family Engagement. 

These measure have the potential to improve patient safety and reduce health inequities. Public reporting by hospital leaders will help Americans identify hospitals that have implemented patient safety and health equity best practices and those that have not. Implementing these measures without delay will allow data to be analyzed and used for improvements. 

There are several best practice guides readily available to hospitals to aid in complying with the structural measures. New tools will always be welcomed, but there is no reason to wait on their development. 

Sincerely,

Transparency Committee, Patients for Patient Safety, US

Leilani Schweitzer

Carole Hemmelgarn

Jeff Brown

Sally Kerr

Donna Prosser

Ariana Longley

As a patient who was medically harmed as a result of my physicians not providing me the care that I needed, I am wondering how a MIPS Measure could be conceived to be in the patient's best interest.  From my understanding of the physician's payment program, the physician's performance scoring is tied to their patients' cost and healthcare utilization.  It seems to me that this program creates a dangerous conflict of interest:  I am concerned it would incentivize the physician to "contain the costs" of their patients' care by providing less care than the patient actually needs and discourages the physician from providing the patient care that may be expensive, but critical for the safety of the patient.  

Patients who require long term supports and services, like myself, are often called "high-cost patients" by administrators, health and political leaders.¹   It makes me wonder whether it is by coincidence that my peers and I are not receiving adequate, effective and individualized care we need to help us recover from brain injury (BI).  BI care should include in the minimum: therapy for comorbid mental health issues, speech language issues, sensory issues in addition to the supports and services to meet our long term needs- but we experience that it often does not.  We know from studies that incredibly low percentages of Medicare beneficiaries are receiving the TCM and CCM services for which they are actually eligible.²  We are observing this very same trend in other patient populations across our nation.  

When we consider the cost of (system-rationed) healthcare utilization, we are NOT taking into account the REAL costs to both patients and the health system of NOT treating our patient issues- what we are seeing as the long term costs -due to worsening of our conditions which become more complex to treat because we are kicking the can down the road rather than dealing with it.  No, we cannot "manage" our way by "cutting costs" and "improving efficiency of care processes" into a balanced ledger without participating in patient harm or social murder.  Health care is our basic human right and we must set our minds towards funding it in that manner. 

Our US government serves as our sovereign currency issuer, so from the perspective of our federal government, the word "cost" does not mean the same as it does to our 50 states and our very own households.³ Our federal government contributes to the Medicare Trust Funds through creation of new US Dollars by simply clicking on a keyboard; the process of fiscal spending requires zero "cost" to any US state or citizen.⁴  What we are observing from the top of our government on downward is an arbitrarily enforced "limited budget" mentality; we are told "the government is broke".  Here in Vermont, we observe acute psych patients waiting weeks for facility beds to become available while F-35s fighter jets roar overhead on a daily basis.  One would think our leaders lack this basic understanding of fundamental US economic principals to be following along without questioning this policy of federal depravation and its disastrous effect on our health system.  For anyone who was not paying attention, the COVID pandemic exposed what has become of our health system after decades of defunding:  it's dysfunctional, deficient and lacking capacity to meet the needs of our patients.  

By using payment plans that incentivize physicians to provide less than the care their patients actually need, and that guidelines and physician training materials recommend, we are essentially creating a race to the bottom that stands directly against the best interest of patients.  And our patients with the greatest health needs are disproportionately feeling the effects of this misinformed and misdirected approach to funding health care. ⁵ 

I wonder if we had we been investing as many federal dollars into biomedical research these past decades as we did our US Military, whether we would have basic amenities, trained staff, functioning facilities the health system is deficient in today.  How many more American lives must be harmed or lost before we set our priorities straight and change the way our national health care system is funded?  If our leaders were listening to those they serve, they'd know the overwhelming majority of us want them to tell Congress that we need more funding to meet the needs of 335 million Americans.    

References: 

1)  H.R.1976 - Medicare for All Act of 2021. (2021, "high-cost patient" appears in legislative text) https://www.congress.gov/bill/117th-congress/house-bill/1976/text/ih?q=%7B%22search%22%3A%22high+cost+patient%22%7D&s=9&r=1&overview=closed

2)  Analysis of 2019 Medicare Fee-for-Service (FFS) Claims for Chronic Care Management (CCM) and Transitional Care Management (TCM) Services.  (2022) https://aspe.hhs.gov/sites/default/files/documents/31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf  

3) Dr. Stephanie Kelton, Stony Brook Economics professor and author of The Deficit Myth, discusses how the US government fiscally operates.  (2020, 5 min video) https://youtu.be/d_udbs-wuDA?si=PXygvxizuo686bUj

4) Dr. L. Randall Wray, Professor of Economics from Bard College and author of Making Money Work for Us, response to question on what legislated funding of US healthcare should look like. (2023, at 3:01:00 Dr. Wray answers my question)  https://youtu.be/nt_nBTRdQiQ?si=IjSR7K5xDI6NnCZh

5)  "It's like I'm worthless": Troubleshooters investigate patient dumping allegations.  (2023, 7 min video) https://youtu.be/rFJsFdgMkYE?si=VYFAZPaw8e4F-ei5

As a patient who was medically harmed as a result of my physicians not providing me the care that I needed, I am wondering how a MIPS Measure could be conceived to be in the patient's best interest.  From my understanding of the physician's payment program, the physician's performance scoring is tied to their patients' cost and healthcare utilization.  It seems to me that this program creates a dangerous conflict of interest:  I am concerned it would incentivize the physician to "contain the costs" of their patients' care by providing less care than the patient actually needs and discourages the physician from providing the patient care that may be expensive, but critical for the safety of the patient.  

Patients who require long term supports and services, like myself, are often called "high-cost patients" by administrators, health and political leaders.¹   It makes me wonder whether it is by coincidence that my peers and I are not receiving adequate, effective and individualized care we need to help us recover from brain injury (BI).  BI care should include in the minimum: therapy for comorbid mental health issues, speech language issues, sensory issues in addition to the supports and services to meet our long term needs- but we experience that it often does not.  We know from studies that incredibly low percentages of Medicare beneficiaries are receiving the TCM and CCM services for which they are actually eligible.²  We are observing this very same trend in other patient populations across our nation.  

When we consider the cost of (system-rationed) healthcare utilization, we are NOT taking into account the REAL costs to both patients and the health system of NOT treating our patient issues- what we are seeing as the long term costs -due to worsening of our conditions which become more complex to treat because we are kicking the can down the road rather than dealing with it.  No, we cannot "manage" our way by "cutting costs" and "improving efficiency of care processes" into a balanced ledger without participating in patient harm or social murder.  Health care is our basic human right and we must set our minds towards funding it in that manner. 

Our US government serves as our sovereign currency issuer, so from the perspective of our federal government, the word "cost" does not mean the same as it does to our 50 states and our very own households.³ Our federal government contributes to the Medicare Trust Funds through creation of new US Dollars by simply clicking on a keyboard; the process of fiscal spending requires zero "cost" to any US state or citizen.⁴  What we are observing from the top of our government on downward is an arbitrarily enforced "limited budget" mentality; we are told "the government is broke".  Here in Vermont, we observe acute psych patients waiting weeks for facility beds to become available while F-35s fighter jets roar overhead on a daily basis.  One would think our leaders lack this basic understanding of fundamental US economic principals to be following along without questioning this policy of federal depravation and its disastrous effect on our health system.  For anyone who was not paying attention, the COVID pandemic exposed what has become of our health system after decades of defunding:  it's dysfunctional, deficient and lacking capacity to meet the needs of our patients.  

By using payment plans that incentivize physicians to provide less than the care their patients actually need, and that guidelines and physician training materials recommend, we are essentially creating a race to the bottom that stands directly against the best interest of patients.  And our patients with the greatest health needs are disproportionately feeling the effects of this misinformed and misdirected approach to funding health care. ⁵ 

I wonder if we had we been investing as many federal dollars into biomedical research these past decades as we did our US Military, whether we would have basic amenities, trained staff, functioning facilities the health system is deficient in today.  How many more American lives must be harmed or lost before we set our priorities straight and change the way our national health care system is funded?  If our leaders were listening to those they serve, they'd know the overwhelming majority of us want them to tell Congress that we need more funding to meet the needs of 335 million Americans.    

References: 

1)  H.R.1976 - Medicare for All Act of 2021. (2021, "high-cost patient" appears in legislative text) https://www.congress.gov/bill/117th-congress/house-bill/1976/text/ih?q=%7B%22search%22%3A%22high+cost+patient%22%7D&s=9&r=1&overview=closed

2)  Analysis of 2019 Medicare Fee-for-Service (FFS) Claims for Chronic Care Management (CCM) and Transitional Care Management (TCM) Services.  (2022) https://aspe.hhs.gov/sites/default/files/documents/31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf  

3) Dr. Stephanie Kelton, Stony Brook Economics professor and author of The Deficit Myth, discusses how the US government fiscally operates.  (2020, 5 min video) https://youtu.be/d_udbs-wuDA?si=PXygvxizuo686bUj

4) Dr. L. Randall Wray, Professor of Economics from Bard College and author of Making Money Work for Us, response to question on what legislated funding of US healthcare should look like. (2023, at 3:01:00 Dr. Wray answers my question)  https://youtu.be/nt_nBTRdQiQ?si=IjSR7K5xDI6NnCZh

5)  "It's like I'm worthless": Troubleshooters investigate patient dumping allegations.  (2023, 7 min video) https://youtu.be/rFJsFdgMkYE?si=VYFAZPaw8e4F-ei5

As a patient who was medically harmed as a result of my physicians not providing me the care that I needed, I am wondering how a MIPS Measure could be conceived to be in the patient's best interest.  From my understanding of the physician's payment program, the physician's performance scoring is tied to their patients' cost and healthcare utilization.  It seems to me that this program creates a dangerous conflict of interest:  I am concerned it would incentivize the physician to "contain the costs" of their patients' care by providing less care than the patient actually needs and discourages the physician from providing the patient care that may be expensive, but critical to the safety of patient. 

Patients who require long term supports and services, like myself, are often called "high-cost patients" by administrators, health and political leaders.¹   It makes me wonder whether it is by coincidence that my peers and I are not receiving adequate, effective and individualized care we need to help us recover from brain injury (BI).  BI care should include in the minimum: therapy for comorbid mental health issues, speech language issues, sensory issues in addition to the supports and services to meet our long term needs- but we experience that it often does not.  We know from studies that incredibly low percentages of Medicare beneficiaries are receiving the TCM and CCM services for which they are actually eligible.²  We are observing this very same trend in other patient populations across our nation.  

When we consider the cost of (system-rationed) healthcare utilization, we are NOT taking into account the REAL costs to both patients and the health system of NOT treating our patient issues- what we are seeing as the long term costs -due to worsening of our conditions which become more complex to treat because we are kicking the can down the road rather than dealing with it.  No, we cannot "manage" our way by "cutting costs" and "improving efficiency of care processes" into a balanced ledger without participating in patient harm or social murder.  Health care is our basic human right and we must set our minds towards funding it in that manner. 

Our US government serves as our sovereign currency issuer, so from the perspective of our federal government, the word "cost" does not mean the same as it does to our 50 states and our very own households.³ Our federal government contributes to the Medicare Trust Funds through creation of new US Dollars by simply clicking on a keyboard; the process of fiscal spending requires zero "cost" to any US state or citizen.⁴  What we are observing from the top of our government on downward is an arbitrarily enforced "limited budget" mentality; we are told "the government is broke".  Here in Vermont, we observe acute psych patients waiting weeks for facility beds to become available while F-35s fighter jets roar overhead on a daily basis.  One would think our leaders lack this basic understanding of fundamental US economic principals to be following along without questioning this policy of federal depravation and its disastrous effect on our health system.  For anyone who was not paying attention, the COVID pandemic exposed what has become of our health system after decades of defunding:  it's dysfunctional, deficient and lacking capacity to meet the needs of our patients. 

By using payment plans that incentivize physicians to provide less than the care their patients actually need, and that guidelines and physician training materials recommend, we are essentially creating a race to the bottom that stands directly against the best interest of patients.  And our patients with the greatest health needs are disproportionately feeling the effects of this misinformed and misdirected approach to funding health care. ⁵ 

As someone who watched her friend die of cancer and other friends who suffered illnesses, I was disheartened to learn this nation takes an average of 17 years to incorporate research findings with strong clinical evidence into standard medical practice.  I know we can do better; our federal government could prioritize and invest more into the search for biomedical solutions to our health issues.  As a trained biomedical researcher, I wonder if we had we been investing as much federal dollars into biomedical research these past decades as we did our US Military, whether we could have effective treatments of cancers and other illnesses today.  How many more American lives must be harmed or lost before we set our priorities straight and change the way our national health care system is funded?  If our leaders were listening to us, they'd know the overwhelming majority of us want them to tell Congress that we need more funding to meet the needs of 335 million Americans.    

Will this quality measure take into consideration improving the funding situation of biomedical research into effective treatments of cancer? 

References: 

1)  H.R.1976 - Medicare for All Act of 2021. (2021, "high-cost patient" appears in legislative text) https://www.congress.gov/bill/117th-congress/house-bill/1976/text/ih?q=%7B%22search%22%3A%22high+cost+patient%22%7D&s=9&r=1&overview=closed

2)  Analysis of 2019 Medicare Fee-for-Service (FFS) Claims for Chronic Care Management (CCM) and Transitional Care Management (TCM) Services.  (2022) https://aspe.hhs.gov/sites/default/files/documents/31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf  

3) Dr. Stephanie Kelton, Stony Brook Economics professor and author of The Deficit Myth, discusses how the US government fiscally operates.  (2020, 5 min video) https://youtu.be/d_udbs-wuDA?si=PXygvxizuo686bUj

4) Dr. L. Randall Wray, Professor of Economics from Bard College and author of Making Money Work for Us, response to question on what legislated funding of US healthcare should look like. (2023, at 3:01:00 Dr. Wray answers my question)  https://youtu.be/nt_nBTRdQiQ?si=IjSR7K5xDI6NnCZh

5)  "It's like I'm worthless": Troubleshooters investigate patient dumping allegations.  (2023, 7 min video) https://youtu.be/rFJsFdgMkYE?si=VYFAZPaw8e4F-ei5

The American Geriatrics Society (AGS) appreciates the committee’s recognition that patients’ perspectives and goals deserve more attention. We continue to support the End-Stage Renal Disease (ESRD) Dialysis Patient Life Goals Survey measure and believe that this is a critically important area. There are many patients who do not appreciate that dialysis is life support and that being on dialysis, particularly if they have multiple chronic conditions, means greater risk for serious complications, including death. 

Unlike younger patients with ESRD, many older adults living with kidney disease are also living with other comorbidities. This can mean that older patients may have dramatically different goals than younger people living with kidney disease. AGS recommends that the data for this measure be stratified by comorbidity and, if that is not practical, to stratify by age. 

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

The American Geriatrics Society (AGS) continues to support the Screen Positive Rate for Social Drivers of Health measure. In order to ameliorate disparities and inequities, we believe it will be important to address the full spectrum of social drivers of health, including housing, food security, transportation, and social isolation (DOI:10.1377/hlthaff.2020.01470). 

The American Geriatrics Society (AGS) continues to support the CAHPS® Hospice Survey measure and believes it captures important aspects of care quality, including the care experiences and preferences of older adults and their primary care partner(s). 

The American Geriatrics Society (AGS) supports the Age-Friendly Hospital measure and appreciates the committee’s recognition of the value of advancing age-friendly care. We believe that high-quality, person-centered, affordable, and age-friendly care as we grow older is critically important.

AGS remains concerned that attestation without quantitative metrics will not lead to quantifiable improvements in quality of care and patient outcomes. However, we believe that requiring clinicians to self-report is an important step forward in terms of raising awareness on important issues and is, therefore, a helpful starting point. The measure would provide hospitals the opportunity to plan and address the various domains included in the measure as well as submit that data for review as a part of efforts to improve quality of care for older adults undergoing surgery. AGS recommends continued work with stakeholders on developing quantifiable metrics to inform quality measures that are data driven. 

I am glad to see this programmatic measure being considered and the strong support that it received from the committee.  Within the Duke University Health System we have started developing Age Friendly practices at one of our three hospitals.  We are developing plans to disseminate these practices to our other two hospitals.  Because of the complexity of medical, physical and psychosocial needs health system leadership understand the need to develop systematic care practices that address this complexity for all older adults.  

This measure will help to ensure that programs are reaching older adults in the emergency department, before surgery and at admission and discharge when they are most vulnerable.  This measure is pro-active and show cases the opportunity to provide care from a patient-centered perspective.  This measure will provide an opportunity for hospitals to be recognized for launching and maintaining this programming.

I strongly support the implementation of a patient safety structural measure. The only way to reduce preventable harm in healthcare is to create more highly reliable systems, and far too few hospitals have begun this work. This measure would allow for greater visibility  into which organizations have already begun to implement these best practices, and would also provide the impetus for others to follow. 

As someone who has been involved in public policy for years, I believe the CMS vendor, Battelle, has produced a comment template that is not public-friendly. Under "Hospital Commitee Measures," there is no "All" section, only "none" and individual measures, suggesting that the public has to file a comment separately for each measure. Certainly, that makes it easy for whatever database Battelle is putting together for CMS, but it is clunky for members of the public.  As someone active as a Champion in Patients for Patient Safety, and as someone who has been an activist in this space for 27 years, I support the inclusion of patient safety and health equity measures in the FY2025 Medicare Propose Rule and certainly encourage CMS to implement them without delay starting in FY2025. I support the specific comments submitted by Patients for Patient Safety and would note that the first article in the medical literature about the pervasiveness of medical error that had actual patient death estimates attached came out in the 1970s. The 25th anniversary of "To Err is Human" is actually about articles in the medical literature from the 1980s. Voluntarism has not worked. CMS has a duty to use its unrivaled influence in American medicine to actively promote patient safety.

My friend suffers from Rheumatoid Arthritis.  She discusses suffering from issues such as: mental health, debilitating pain, mental stresses from a caregiver role -and from not being able to perform daily activities when her pain is at its worst (eg. essential farm chores).  She also experiences other issues stemming from the health system like the lack of transparency of her care plan, slow or no responsiveness to her needs and the fact that she belongs to a minority population means that she experiences provider bias that affects the quality of the care she receives.  As someone who suffers from a different chronic condition (brain injury), I hear these common complaints among my peers, too. How can we address these issues so that folks with complex and chronic conditions are provided the quality patient care they deserve and need- and that our private insurance, government programs SHOULD be covering?   

I am concerned I do not see in this quality measure recognition that Peer Support -either as a one-on-one mentorship or as group therapy- which can be incredibly effective, socially and emotionally/ psychologically beneficial, inspiring, helpful to the patient who is struggling to find their healing path.  Without peer support, we are isolated and "inventing our own wheel" instead of benefitting from a treasure trove of knowledge from others' lived experiences. 

Patients who suffer complex chronic conditions should be considered vulnerable and at risk of being exploited by our health system.  Peer support empowers the patient and counters those forces by  information- and experience-sharing about provider performance, alternative forms and availability of treatments: we become empowered with the knowledge of what quality patient care SHOULD look like- information that our providers fail to share with us. 

Will this quality measure ensure physician referrals are made to Case Managers, Community Health Workers and Social Workers, other health professionals who are critical for connecting the patient to the supports and services they need?    

As a patient who was medically harmed as a result of my physicians not providing me the care that I needed, I am wondering how a MIPS Measure could be conceived to be in the patient's best interest.  From my understanding of the physician's payment program, the physician's performance scoring is tied to their patients' cost and healthcare utilization.  It seems to me that this program creates a dangerous conflict of interest:  I am concerned it would incentivize the physician to "contain the costs" of their patients' care by providing less care than the patient actually needs and discourages the physician from providing the patient care that may be expensive, but critical for the safety of the patient.  

Patients who require long term supports and services, like myself, are often called "high-cost patients" by administrators, health and political leaders.¹   It makes me wonder whether it is by coincidence that my peers and I are not receiving adequate, effective and individualized care we need to help us recover from brain injury (BI).  BI care should include in the minimum: therapy for comorbid mental health issues, speech language issues, sensory issues in addition to the supports and services to meet our long term needs- but we experience that it often does not.  We know from studies that incredibly low percentages of Medicare beneficiaries are receiving the TCM and CCM services for which they are actually eligible.²  We are observing this very same trend in other patient populations across our nation.  

When we consider the cost of (system-rationed) healthcare utilization, we are NOT taking into account the REAL costs to both patients and the health system of NOT treating our patient issues- what we are seeing as the long term costs -due to worsening of our conditions which become more complex to treat because we are kicking the can down the road rather than dealing with it.  No, we cannot "manage" our way by "cutting costs" and "improving efficiency of care processes" into a balanced ledger without participating in patient harm or social murder.  Health care is our basic human right and we must set our minds towards funding it in that manner. 

Our US government serves as our sovereign currency issuer, so from the perspective of our federal government, the word "cost" does not mean the same as it does to our 50 states and our very own households.³ Our federal government contributes to the Medicare Trust Funds through creation of new US Dollars by simply clicking on a keyboard; the process of fiscal spending requires zero "cost" to any US state or citizen.⁴  What we are observing from the top of our government on downward is an arbitrarily enforced "limited budget" mentality; we are told "the government is broke".  Here in Vermont, we observe acute psych patients waiting weeks for facility beds to become available while F-35s fighter jets roar overhead on a daily basis.  One would think our leaders lack this basic understanding of fundamental US economic principals to be following along without questioning this policy of federal depravation and its disastrous effect on our health system.  For anyone who was not paying attention, the COVID pandemic exposed what has become of our health system after decades of defunding:  it's dysfunctional, deficient and lacking capacity to meet the needs of our patients.  

By using payment plans that incentivize physicians to provide less than the care their patients actually need, and that guidelines and physician training materials recommend, we are essentially creating a race to the bottom that stands directly against the best interest of patients.  And our patients with the greatest health needs are disproportionately feeling the effects of this misinformed and misdirected approach to funding health care. ⁵ 

I wonder if we had we been investing as many federal dollars into biomedical research these past decades as we did our US Military, whether we would have basic amenities, trained staff, functioning facilities the health system is deficient in today.  How many more American lives must be harmed or lost before we set our priorities straight and change the way our national health care system is funded?  If our leaders were listening to those they serve, they'd know the overwhelming majority of us want them to tell Congress that we need more funding to meet the needs of 335 million Americans.    

References: 

1)  H.R.1976 - Medicare for All Act of 2021. (2021, "high-cost patient" appears in legislative text) https://www.congress.gov/bill/117th-congress/house-bill/1976/text/ih?q=%7B%22search%22%3A%22high+cost+patient%22%7D&s=9&r=1&overview=closed

2)  Analysis of 2019 Medicare Fee-for-Service (FFS) Claims for Chronic Care Management (CCM) and Transitional Care Management (TCM) Services.  (2022) https://aspe.hhs.gov/sites/default/files/documents/31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf  

3) Dr. Stephanie Kelton, Stony Brook Economics professor and author of The Deficit Myth, discusses how the US government fiscally operates.  (2020, 5 min video) https://youtu.be/d_udbs-wuDA?si=PXygvxizuo686bUj

4) Dr. L. Randall Wray, Professor of Economics from Bard College and author of Making Money Work for Us, response to question on what legislated funding of US healthcare should look like. (2023, at 3:01:00 Dr. Wray answers my question)  https://youtu.be/nt_nBTRdQiQ?si=IjSR7K5xDI6NnCZh

5)  "It's like I'm worthless": Troubleshooters investigate patient dumping allegations.  (2023, 7 min video) https://youtu.be/rFJsFdgMkYE?si=VYFAZPaw8e4F-ei5

Will this measure help ensure that breast cancer patients will be screened and treated to effectively meet their needs for pain relief?   Will this measure help to ensure that breast cancer patients are provided information on alternative forms of pain relief so they can be properly informed to make their own decisions on what treatment suits them best?  Will this measure help to ensure the breast cancer patient is referred to pain management clinic, that their pain management clinics are adequately staffed, have enough beds to meet the level of patient needs?  

I have a family member who was employed when they were diagnosed with a lymphoma.  Thankfully, they are finishing off their chemotherapy and looking good with their prognosis.  Their employer gave them medical leave, but my fear was for their stress level to detrimentally affect their body's fight with cancer.   I feared for them as a cancer patient worrying whether or not they would be employed after their return to work and whether they would be able to keep up with the work schedule the employer push onto them.   I believe our physicians could and should stand up for their patients in their medical authorization letters saying the patient needs sufficient time to battle their cancer and to recover at home- without undue stress.  

My own moderate traumatic brain injury required longer than my surgeon and primary care physician  believed it would take for me to regain the ability to go back to work and school.  I suffered a mental breakdown as a result.  Please do not allow this to happen to other patients.   Will this quality measure support breast cancer patients' need to adequate rest, time and space to recover from their illness? 

As someone who's been involved in patient safety for 27 years, I strongly support the recommendations of Patients for Patient Safety and urge CMS to implement patient safety and equity measures as of FY 2025.

As someone who's been active in this area for 27 years, I strongly agree with the Patients for Patient Safety comments and urge implementation by 2025.

The National Hospice and Palliative Care Organization (NHPCO) is the nation’s largest membership organization for hospice providers and professionals who care for people and loved ones experiencing serious and life-limiting illness. NHPCO members provide care in more than 4,000 hospice and palliative care locations and care for over two-thirds of the Medicare beneficiaries served by hospice nationwide. In addition, hospice and palliative care members employ thousands of professionals and volunteers. On behalf of our members, NHPCO appreciates the opportunity to comment on the 2023-2024 Pre-Rulemaking Measure Review (PRMR) results.

The measure, while capturing the intent of timely reassessment of pain symptoms, is unclear as to the process, tools and implementation.

Timely assessment of pain symptoms is best done in a measurable or comparative manner, in the context of a standardized (and/or) consistent pain assessment tool. It would provide claorty and directional guidance to providers to incldue mention of a standardized and / or consistemt pain assessment tool.

It bears clarification whether telephonic pain reassessment will be included in measure compliance. If so, does the telephonic reassessment focus on beneficiary interaction, or also include family/ caregiver interaction. Would also clarification of measure compliance actions when beneficiary is semi-conscious or not in conscious state (active dying process, pain management outcomes, etc).

Reassessment of pain and other symptoms is often a process that is undertaken and included in the assessment and interactions of all interdisciplinary group (IDG) team members. Does this measure identify specifically which IDG members are expected to engage in timely reassessment (may also depend on instrument used) and whether the care plan update would need to follow usual course or requires additional or different elements?

The measure as described in committee comments “derives information from the clinicians providing care, which means they make determinations based on their perceived impact of the pain the patient is experiencing.” While this may be a useful measure, it is difficult to support its inclusion without more information regarding the  outcome measures that HOPE will include for patient pain assessment.  Members report that pain assessments are routinely completed on admission and within one to two calendar days of reported pain as a standard of care, but we don’t have enough information regarding what this clinician-centric assessment of pain impact would entail and to what extent the patient and family would be included in providing their own input as to the impact of the patient’s pain.  Would there be a corresponding measure that would also include timely reassessment of pain itself, or only of clinician-reported pain impact?

NHPCO appreciates the opportunity to provide comment and brings forward challenges and ideas that include hospice provider feedback.

The National Hospice and Palliative Care Organization (NHPCO) is the nation’s largest membership organization for hospice providers and professionals who care for people affected by serious and life-limiting illness. NHPCO members provide care in more than 4,000 hospice and palliative care locations and care for over two-thirds of the Medicare beneficiaries served by hospice nationwide. In addition, hospice and palliative care members employ thousands of professionals and volunteers. On behalf of our members, NHPCO appreciates the opportunity to comment on the 2023-2024 Pre-Rulemaking Measure Review (PRMR) results.  

The measure, while capturing the intent of timely reassessment of non-pain symptoms, is unclear as to the process, tools and implementation.

Timely assessment of non-pain symptoms is best done in a measurable or comparative manner, in the presence of standardized (and/or) consistent assessment tool. It bears notice that there are multiple domains of non-pain symptoms. Would need further clarification as to which non-pain symptoms (dyspnea, constipation, nausea, etc) fall within the scope of this measure and clarify which kinds of symptoms (if any) do not fall within measure scope.

It bears clarification whether telephonic symptom reassessment will be included in measure compliance. If so, does the telephonic reassessment focus on beneficiary interaction, or also include family/ caregiver interaction. Would also clarification of measure compliance actions when beneficiary is semi-conscious or not in conscious state (active dying process, pain management outcomes, etc).

Reassessment of overt symptoms such as dyspnea and nausea is often a process that is undertaken and included in the assessment and interactions of all interdisciplinary group (IDG) team members. Does this measure identify specifically which IDG members are expected to engage in timely reassessment (may also depend on instrument used) and whether the care plan update would need to follow usual course or requires additional or different elements?

Presumably, this measure would be paired with a corresponding timely reassessment of non-pain symptoms outcome measure, but without more information on the proposed contents of the HOPE tool, it is difficult to recommend inclusion of this measure, especially as it is unclear how much the patient and family would be able to contribute perspectives to the non-pain symptom impact clinician determination.

NHPCO appreciates the opportunity to provide comments and brings forward challenges and ideas that include hospice provider feedback.