2024 Measure Set Review Measures for Public Comment

I feel like a lot of medical staff have had mediocre training and education over the past few years. We need to be ensuring staff are adequately trained to take care of patients. It seems like many are just pretending or trying to make it by, out of fear of losing their jobs or being embarrassed. We need to promote an environment where learning is encouraged, asking questions is supported, and admitting to having a lack of knowledge is accepted and attempted to be resolved by leadership. 

The measures related to overuse are excellent. We must streamline and avoid overusing any system to the point where it becomes too costly. I believe all measures related to cancer are necessary. I would consider all other measures as secondary and not absolutely necessary.

Hello - I reviewed the list of measures proposed for review for 2024 in the pdf document on this site.  From being involved in similar processes in the past and having a good knowledge of health care I find it quite amazing that there is not one measure in the list for 2024 that is focused on mental health, substance use or IDD populations.  Given our knowledge of the importance of integrating behavioral health and medical services it would seem that at least one measure would have been identified for these populations.  Thank You

I would like this QM to remain in place.  The patients are underserved in palliative care.  Patients who undergo chemo without an opportunity for symptom management of their disease process is a disservice to patients.  All patients no matter what their treatment plan is should be offered palliative services to evaluate their status and make medication, treatment, end of life decisions.  Currently cancer centers are not utilizing palliative services to determine end of life care.  Physicians are not always symptom management experts and are very under-educated on this topic.  

Pneumonia, 'friend of the aged', can be prevented in the inpatient hospital setting by encouragement to get out of bed sooner, ambulation, head of bed elevation, assessing for aspiration risk, assessing for vaccination against respiratory pathogens such as the pneumococcus, pneumonia prevention education, family engagement, encouraging deep breathing, frequent lung auscultation, preventing dehydration, hand hygiene, etc. This metric provides valuable information with basic, essential nursing and medical care practices to promote health and prevent mortality.

I appreciate the feedback focus on actionability offering a path to improvement and alignment with respected clinical guidelines in Measure Group 1 - I believe these measures should either be removed or edited to better measure -Antiobitic stewardship, safety regarding age appropriate colonoscopy (86? or perhaps 75) unintentional overuse and inappropriate screenings where harms potentially outweigh any benefits.

I am  wondering though why MPF price accuracy is up for removal- is it because of fluctuating drug prices that impact part D plan posted prices? Patients really would appreciate knowing how accurate their drug costs  are before purchasing them- More explanation as to why this measure is up for removal here is important to some of us members of the public. 

Regarding Measure Group 2 and the possible measure removal and questions surrounding measure actionability and or impact  and or potentially duplicative measure focus (ED or Readmission may be candidates for alignment, harmonization, consolidation, or reduction as some are similar across same or different quality reporting programs) I believe it would be helpful to us Patients/ Caregivers/ Community to have more information to better understand which measures currently are similar across programs with a chart  with measures on  lines for instance where one might list: "Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy" where the measure and the program would be listed in either the X or Y axis. It also seems to me that one measure such as the 7 day outpatient colonoscopy mentioned above appears to be the same, though I do understand depending on the facility setting the denminator and numerator would be different and this is why they are listed the way we are. Having any rationale for removal with any data would help us all. (CMS page does not offer measure maintainer information and or much data on measures = seems mialigned at times (*see example below)  With missing data it can be challenging to decide what exactly to provide insights on) 

*For instance I might be interested as a Patient to search data and information as I am nervous or anxious to have a colonoscopy so I search AI = '7 day risk of being hospitalized after outpatient colonosocopy'  up pops Centers for Medicare and Medicaid Services Measures Inventory Tool (cms.gov) (00253-01-C-ASCQR).  I find that this measure includes Fee for Service > 65 Medicare though does not share what is the upper recomended age limit nor anything about Medicaid or MA?  Alas there are no exceptions listed. Looking deeper into the Cascade of Meaningful Measures data I read this:

1.  Primary Priority is 'Affordability and Efficiency' 
2.   Primary Goal is listed as 'Reduced Readmissions Including Observation' 
3.  The Secondary Priority is Safety 
4.  Scondary Goal is 'Reduced Preventable Harm'

In my Patient Cetered focused mindset it seems to me that Patient Safety should be the Primary Priority and Primary Goal should be Reduced Preventable Harm- I recognize PQMs Cycle C is looking at cost and efficiency and I am hoping the Patients and Caregivers and Clinicians as well as Hospitals might rethink this "Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy" priority hierarchy. It appears to really have these be meaningful measures that 3 and 4 listed above should really be 1 and 2. We are all Patients and we like to save money as well as stay out of the hospital so safety should be the priority I believe. I am hoping CMS sees this :)

It could also be of help to us Patients/ Caregivers/ Community if we had the CMIT coded PQMs initial findings according to actionable path to improvement, impact factors, alignment opportunities as well as duplicative measure  focus. Perhaps this will come at the MSR meeting

Thank you for your work. 

Janice Tufte

www.janicetufte.com

Patient/ Public Involved

See attached.

See attached

Dear Partnership for Quality Measurement,

I am pleased to submit these comments on behalf of the American Society of Clinical Oncology (ASCO) in response to the May 16, 2024, call for public comments on the 2024 Measure Set Review (MSR) process which considers measures for removal from Centers for Medicare & Medicaid Services (CMS) quality programs.

ASCO represents almost 50,000 global physicians and other health care professionals specializing in cancer treatment, diagnosis, and prevention. ASCO members are dedicated to conducting research that leads to improved patient outcomes and are committed to ensuring that evidence-based practices for the prevention, diagnosis, and treatment of cancer are available to all patients. 

We are appealing to the Partnership for Quality Measurement (PQM) to retain the three cancer measures proposed for removal from the various CMS programs.

Measure (00543-01-C-MIPS) Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score better) is proposed for removal from the Merit-based Incentive Payment System (MIPS) for clinician level reporting.

As the steward of this measure, ASCO encourages its retention for clinician level reporting. Evidence supports that a palliative approach often offers the best opportunity to maintain the highest possible quality of life for dying patients. As there are challenges to capturing a palliative care consult from a measure perspective, aggressive treatments at the end of life serve as a proxy. Therefore, the purpose of this measure is to assess rates of undesirable use of chemotherapy at a patient’s end of life in conjunction with palliative care to prioritize symptom management, rather than low utility and aggressive treatments among dying cancer patients. These quality actions are linked with the ultimate outcome of improved quality of life, a positive death experience, and a reduction in resource utilization costs. We believe the measure is actionable and impactful and is not duplicative to any other measures in the MIPS program.

Chemotherapy utilization at the end of life is associated with a worse quality of life near death among patients with good baseline performance status,[1] ED visits, cardiopulmonary resuscitation, mechanical ventilation, dying in an ICU,[2] and higher estimated costs of care.[3] By tracking this measure, healthcare providers can evaluate whether aggressive treatment at the end of life is aligned with the goals of palliative care and whether it truly benefits the patient in terms of comfort and symptom management.

This measure can help ensure that patients and their families are making informed decisions about end-of-life care. It highlights the necessity of discussions around the goals of care, prognosis, and the likely benefits and burdens of continuing chemotherapy in the final days of life.

This measure also helps assess adherence to clinical guidelines and best practices. The National Comprehensive Cancer Network (NCCN) states the following in its Palliative Care guideline “In general, patients with weeks to days to live (e.g., dying patients) and comfort-oriented goals should discontinue all treatments not directly contributing to patient comfort. Intensive palliative care focusing on symptom management should be provided in addition to preparation for the dying process. Referral for hospice care should be placed, if not already done.”[4] By measuring the use of chemotherapy at the end of life, healthcare providers can evaluate and improve their compliance with these guidelines.

Retaining this measure at both the clinician and group levels ensures a comprehensive approach to quality improvement, accountability, and patient-centered care. It enables targeted interventions, supports transparency, facilitates research, and ultimately enhances the quality of end-of-life care provided to patients. It allows for the identification of specific clinicians who may be consistently recommending aggressive chemotherapy near the end of life, facilitating targeted interventions, education, and improvements in practice. Data at the clinician level can be used to provide personalized feedback and professional development opportunities. Clinicians can receive specific guidance on how to better manage end-of-life care and improve their communication with patients and caregivers about prognosis and treatment options. Individual clinician data contributes to a more granular understanding of where improvements are needed, and this measure helps in recognizing patterns and trends in treatment decisions that might contribute to the overuse of chemotherapy.

We have seen sufficient participation in this measure's reporting to consistently establish benchmarks over the performance years. Additionally, the measure continues to demonstrate meaningful differences in performance and is not topped out. Furthermore, at the request of CMS, this measure has recently been submitted to the 2024 Measures Under Consideration (MUC) List for proposed inclusion in the Inpatient and Outpatient Quality Reporting Programs.

Lastly, the National Comprehensive Cancer Network (NCCN) Quality and Outcomes Committee reviewed 528 existing oncological quality measures and concepts to identify important cancer quality and outcome measures. Measures and concepts were evaluated according to importance, supporting evidence, opportunity for improvement, and ease of measurement; this measure was one of seven cross-cutting measures selected for endorsement as a universally appropriate measure to evaluate quality of oncology care.[5]

Measure OP-35 (00021-02-C-HOQR and 00021-01-C-PCHQR) Admissions and Emergency Department (ED) Visits for Patients Receiving Outpatient Chemotherapy is proposed for removal from the Hospital Outpatient Quality Reporting (HOQR) Program and the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program.

ASCO encourages PQM to retain this measure in both programs. It is crucial for improving quality of care, enhancing patient safety, optimizing resource utilization, improving patient experience, monitoring clinical outcomes, and fostering continuous improvement. This measure provides valuable insights that can drive better management of chemotherapy side effects, leading to more effective and patient-centered care.

High rates of admissions and ED visits can indicate complications or adverse effects from chemotherapy that might be preventable with improved outpatient care and monitoring. Tracking this measure can prevent future complications by identifying areas where care can be improved. This measure also serves as a proxy for patient safety. Frequent hospital admissions and ED visits may suggest that patients are experiencing significant side effects or complications that could potentially be managed more effectively with timely interventions in the outpatient setting.

The monitoring of admissions and ED visits can highlight issues in care coordination. Effective coordination between oncologists, primary care providers, and other healthcare professionals can reduce the need for emergency care by ensuring that patient symptoms and complications are managed proactively. Ensuring appropriate follow-up and support for patients undergoing chemotherapy is critical. This measure can indicate whether patients are receiving the necessary support, such as timely follow-up appointments, access to supportive care services, and clear communication about managing side effects at home.

Frequent admissions and ED visits are costly for both healthcare systems and patients. By tracking this measure, healthcare providers can identify opportunities to reduce unnecessary hospitalizations and ED visits, thereby controlling costs and improving the efficiency of care delivery. Understanding patterns of admissions and ED visits helps in optimizing resource allocation. It can guide the development of programs aimed at managing chemotherapy side effects more effectively in the outpatient setting, such as dedicated oncology urgent care clinics, the availability of short-notice or urgent outpatient appointments, or enhanced home care services.

Hospital admissions and ED visits are stressful and disruptive for patients. Reducing the frequency of these events can significantly improve the overall patient experience by minimizing disruptions to their daily lives and reducing the physical and emotional burden associated with hospital visits. Patients receiving chemotherapy often prefer to be treated in outpatient settings where they are more comfortable and less exposed to hospital-related risks such as infections. This measure helps ensure that care is patient-centered and that efforts are made to manage side effects in a way that keeps patients out of the hospital whenever possible.

High rates of admissions and ED visits can indicate suboptimal management of chemotherapy side effects, potentially impacting the overall effectiveness of the cancer treatment. Monitoring this measure helps ensure that patients are able to continue their chemotherapy regimens as planned without unnecessary interruptions due to preventable complications. This measure can help identify trends and patterns that may be linked to specific chemotherapy protocols, patient populations, or comorbidities, allowing for targeted interventions to improve clinical outcomes.

Tracking admissions and ED visits allows for benchmarking against other practices, hospitals, and healthcare systems. This comparative analysis can identify best practices and areas for improvement, fostering a culture of continuous quality improvement. Data from this measure can inform policy decisions and guide the development of guidelines and protocols aimed at reducing admissions and ED visits. This can lead to systemic changes that enhance the overall quality of cancer care.

Measure (00004-01-C-PCHQR) 30-Day Unplanned Readmissions for Cancer Patients is proposed for removal from the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program.

ASCO encourages PQM to retain this measure. It is critical in maintaining and enhancing the quality of care, reducing costs, and ensuring better patient outcomes. It provides valuable insights into the healthcare system's performance, encourages continuous improvement, and supports the delivery of patient-centered care. Retaining this measure not only helps to identify and address systemic issues but also promotes the well-being of cancer patients during a vulnerable period of their treatment journey.

This measure helps to assess the effectiveness of the initial treatment and discharge planning. High readmission rates may indicate issues with the quality of care, such as inadequate treatment during the initial hospital stay or poor post-discharge follow-up. Tracking unplanned readmissions can identify gaps in patient safety and care coordination. Cancer patients are particularly vulnerable due to the complexity of their treatment regimens, making it crucial to monitor their transitions between different care settings to prevent adverse events.

Unplanned readmissions are often costly for healthcare systems. By identifying and addressing the causes of these readmissions, hospitals can implement strategies to reduce unnecessary readmissions, thus lowering overall healthcare costs. Keeping readmission rates low ensures that hospital resources are used more efficiently, with beds and medical staff being available for new patients rather than those who are readmitted shortly after discharge.

Reducing unplanned readmissions can directly improve patient outcomes. Cancer patients who are readmitted may experience interruptions in their treatment plans, which can negatively affect their prognosis. Frequent unplanned readmissions can be distressing for patients and their families. By minimizing these occurrences, hospitals can enhance the overall patient experience and satisfaction with care.

This measure allows the PPS Exempt Cancer Hospitals to benchmark their performance against their peers. It provides a metric for evaluating and comparing the quality of cancer care provided. Monitoring readmissions promotes accountability among healthcare providers and institutions. It encourages transparency and the continuous improvement of care practices. By focusing on readmissions, hospitals can improve coordination across various healthcare providers, including primary care, oncology specialists, non-oncology specialists, and home health services, to ensure a seamless continuum of care for cancer patients. 

ASCO thanks PQM for the opportunity to provide these comments and we encourage you to not remove these three measures from MIPS, HOQR or PCHQR programs.

Respectfully,

Stephanie Jones

Director, Performance Measurement

[1]Prigerson, H. G., Bao, Y., Shah, M. A., Paulk, M. E., Leblanc, T. W., Schneider, B. J., Garrido, M. M., Reid, M. C., Berlin, D. A., Adelson, K. B., Neugut, A. I., & Maciejewski, P. K.. (2015). Chemotherapy Use, Performance Status, and Quality of Life at the End of Life. JAMA Oncology, 1(6), 778. https://doi.org/10.1001/jamaoncol.2015.2378

[2]Crawford, G. B., Dzierżanowski, T., Hauser, K., Larkin, P., Luque-Blanco, A. I., Murphy, I., Puchalski, C. M., & Ripamonti, C. I.. (2021). Care of the adult cancer patient at the end of life: ESMO Clinical Practice Guidelines. ESMO Open, 6(4), 100225. https://doi.org/10.1016/j.esmoop.2021.100225

[3]Garrido, M. M., Prigerson, H. G., Bao, Y., & Maciejewski, P. K.. (2016). Chemotherapy Use in the Months Before Death and Estimated Costs of Care in the Last Week of Life. Journal of Pain and Symptom Management, 51(5), 875–881.e2. https://doi.org/10.1016/j.jpainsymman.2015.12.323

[4]National Comprehensive Cancer Center (NCCN) Practice Guidelines in Oncology. Palliative Care, V.1.2024. https://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf

[5]D’Amico, T. A., Bandini, L. A. M., Balch, A., Benson, A. B., Edge, S. B., Fitzgerald, C. L., Green, R. J., Koh, W.-J., Kolodziej, M., Kumar, S., Meropol, N. J., Mohler, J. L., Pfister, D., Walters, R. S., & Carlson, R. W.. (2020). Quality Measurement in Cancer Care: A Review and Endorsement of High-Impact Measures and Concepts. Journal of the National Comprehensive Cancer Network, 18(3), 250–259. https://doi.org/10.6004/jnccn.2020.7536

This is the same measure that was recently retired by both CMS (for the IQR program) and TJC due to it being topped-out.  Hence, this retirement appears to be a good rationale for NOT including this measure in the MIPS program. 

The American Medical Association (AMA) appreciates the opportunity to comment on the 2024 Measure Set Review (MSR): List of Measures. Our comments are on the overall process and selection considerations used to identify which measures will be discussed as well as the individual measures in the groups.

The measure removal process is intended to identify those measures that should be no longer included in a specific quality program, yet the report does not address that question for any of the measures included in Groups 1 or 2 and more specifically the selection considerations used to evaluate the measures make no mention that this objective will a part of the discussion. We believe that it is critical that the individuals reviewing these measures understand the overall purpose of this process and fully understand the scope and intent of the programs in which each measure is included. Without this understanding, we do not believe that they will be able to appropriately evaluate each measure. 

Furthermore, the selection considerations included in the report are extremely subjective and if the review only included the measure description, numerator, denominator, and exclusions, then it is not clear what information confirmed that a measure was not actionable, based on established clinical guidelines, and/or was duplicative to another measure. While we do not believe that this review should be a repeat of the endorsement process, it should be grounded in a set of criteria that were vetted and approved using multi-stakeholder input and clearly articulated with detailed information on how a measure was selected for discussion and ultimately recommended for removal. 

As a result, we question why a measure was proposed for Group 1 versus Group 2 nor is it clear what were the reasons for proposing the measures in Appendix B were not appropriate for review. For example, the AMA has repeatedly notified CMS of concerns with the continued use of the Total Per Capita Cost measure in the Merit-based Incentive Payment System (MIPS) but the selection considerations are not designed to identify those measures with concerns regarding attribution, reliability, validity or other unintended consequences. Other examples are the hospital-level risk-standardized  payment measures for acute myocardial infarction, heart failure, pneumonia, and elective primary total hip arthroplasty and/or total knee arthroplasty. The FY2025 Inpatient Prospective Payment System proposed rule includes potential removal of these measures from the Hospital Inpatient Quality Reporting Program – the last program in which they are implemented. If a measure is no longer in use in a program, it would seem logical to consider removing them from the portfolio of possible measures.

The AMA believes that the Partnership for Quality Measurement must clearly articulate the reason for the removal discussion, the criteria against which these measures should be evaluated, and the process by which these decisions are made. Until these actions are taken, we do not believe that this work will result in meaningful and actionable decisions that can be supported by stakeholders. 

Thank you for the opportunity to comment. 

I strongly support his measure.
There needs to be a threshold for doctors to recommend an MRI or ultrasound. To pursue diagnostics may and does lead doctors to NOT pursue treatments that are often effective and easily done. Specifically in my case, my pain in the lumbar region would have been lessened considerable with a regime of stretching. In fact after diagnostics, the treatment included drugs which in my case created more problems, prolonged my recovery by years and significantly impacted my family as well.

Immediately after my MRI and x-rays, I visited a PT who was hesitant to do much since doctors had recommended x-rays and a more comprehensive approach. Now, after recovery from Lyrica toxicity, many visits to PT, and consultations with 2 neurologists, I am left believing that strengthening my core and legs along with stretching is my best approach to life.
I have not read all the details but I understand the MSR process. The challenge is how to incentivize facilities and doctors to properly access the need for MRIs. Doctors should not fear doing less invasive approaches where there is no indication of prior injury or restrictions on mobility. 

As someone who just scheduled a colonoscopy yesterday, this measure leaves me speechless.  My first 3 colonoscopies were trouble free and I think I am actually tolerating the prep better.  I support this measure especially after reading the statistics.

I quickly reviewed the measure; especially the numerator and denominator definition. It seems to focus on cost effectiveness, one facility vs. a mean. 

There needs to be more in play even for a measure that is about cost effectiveness. Whether the access is a fistula, port or other access, it is the long term viability of the access that will determine how cost effective it is.  To that point:
1. Emergency access needs to be evaluated separately.
2. I have had two fistulas and one port access while on dialysis. My first fistula did not work effectively after 3 years, which is not unusual. However I used another vascular surgeon who was able to temporarily repair that access. She also created a fistula on my other arm.  I received a transplant eventually. Three years later without being used, I could still feel the thrill. So my point is that there is a substantive difference in the skill of vascular surgeons.  Their skills determine not only dialysis adequacy but whether care is needed because of that diminished adequacy AND whether additional surgery is needed.
While I have not looked extensively, there does not seem to be a closely related measure. So if not, this factor needs to be considered in future measures.
 

I have mixed opinions on this but overall, there is more harm to continuing this measure.

Pro: I had a kidney transplant at one hospital and then a second transplant 8 years later. I saved copies of the hospital billing from both operations and it was startling. The second hospital's billing was 8% lower than the first hospital's billing. I cannot imagine that costs would be lower 8 years later for many reasons. So there needs to be a system to monitor costs.

Con: There may reasons why larger hospitals have better efficiencies than smaller facilities. In an age where there are concerns about rural and underserved communities need to continue to have healthcare, I am concerned that such measures make this measure harardous to this goal.

I am in favor of the choice to focus on the Cycle measures. From  the patient and health equity perspective, I think it holds the potential to reform how we access and experience healthcare, setting a precedent for improved health outcomes and financial security for all. It directly resolves the issues of actionability and impact.

Please see the attached letter regarding the inclusion of (00039-01-C-MIPS) Age Appropriate Screening Colonoscopy in the 2024 MSR Cycle submitted on behalf of the American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), American Society for Gastrointestinal Endoscopy (ASGE), and GI Quality Improvement Consortium (GIQuIC).

Thank you. Best, Eden

Eden Essex, Assistant Director, Quality, Practice, and Health Policy, American Society for Gastrointestinal Endoscopy

Attached are comments relative to inclusion in the 2024 MSR Cycle of (00039-01-C-MIPS) Age Appropriate Screening Colonoscopy submitted on behalf of American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and GI Quality Improvement Consortium.

The Academy of Otolaryngology – Head and Neck Surgery opposes the proposal to eliminate high-priority quality measure 331, Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse), from the Quality Payment Program. This measure is fully endorsed and in alignment with the Clinical Practice Guidelines (Update) for Adult Sinusitis, which emphasizes symptom relief as the primary goal of managing viral rhinosinusitis (VRS). Antibiotics are not recommended for VRS treatment due to their inefficacy against viral illnesses and lack of direct symptom relief. Additionally, antibiotic use may cause patient harm and foster antibiotic resistance. The measure aims to facilitate sound clinical judgment in distinguishing between viral and bacterial sinusitis and evaluating symptom timelines.¹ It encourages adherence to published clinical practice guidelines to mitigate antibiotic overuse.

In the latest Historical MIPS Quality Benchmark file for 2024, this measure neither reaches the topped-out threshold nor meets the criteria for being classified as a 7-point cap. Analysis of historical benchmarks spanning from 2019 to 2024 indicates an improvement in performance rates (inverse), declining from 61.5 percent to 23.32 percent over the past five years. However, a significant portion of patients still receive unnecessary antibiotic prescriptions, highlighting the ongoing need for quality improvement efforts. The decrease in average performance rate found within the 2024 Historical Benchmark file may be artificially low due to the leniency of reporting due to the Public Health Emergency for the 2022 performance year. 

Based on CDC data, the treatment of bacterial infections in the US may incur an additional cost of approximately $1,400 per patient due to antibiotic resistance. Global projections suggest that by 2050, the annual economic burden of antimicrobial resistance (AMR) could range from $300 billion to over $1 trillion.²

1. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok Kumar K, Kramper M, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015; 152: S1–S39.
2. Dadgostar P. Antimicrobial Resistance: Implications and Costs. Infect Drug Resist. 2019 Dec 20;12:3903-3910. doi: 10.2147/IDR.S234610. PMID: 31908502; PMCID: PMC6929930.

The American Medical Rehabilitation Providers Association (AMRPA) appreciates the opportunity to submit comments on the PQM MSR list of measures under consideration for removal from CMS quality programs. AMRPA is the national trade association representing more than 700 freestanding inpatient rehabilitation facilities and rehabilitation units of acute-care general hospitals (IRFs).^[1]  The vast majority of our members are Medicare participating providers with quality measure information publicly reported on the CMS Care Compare website. AMRPA has always looked to be a partner to regulating agencies and other key quality stakeholders in promoting meaningful and effective quality reporting in the IRF program, and we look forward to continuing this type of partnership with Battelle and the PQM moving forward.

AMRPA recognizes the importance of a consensus-based entity (CBE) and the processes “to inform the selection and removal of health care quality and efficiency measures, respectively, for use in the Department of Health and Human Services (HHS) Centers for Medicare & Medicaid Services (CMS) Medicare quality programs”. AMRPA believes that the PQM MSR process is essential and must facilitate an effective identification and removal of quality measures that are administratively burdensome, do not distinguish high-quality care in and among IRFs, or do not result in better patient outcomes.  AMRPA stands ready to work with the PQM in the next PQM MSR cycle and ensure that the PQM has sufficient information to remove existing IRF QRP measures that create unnecessary administrative burden for IRFs and their patients without delivering meaningful information to patients or policymakers.

AMRPA comments on the list of measures up for removal and suggestions for alternative/replacement measures listed in the 2024 Measure Set Review List are detailed in the attached document.

AMRPA thanks Battelle and the PQM for allowing us the opportunity to provide feedback on the Partnership for Quality Measurement (PQM) Measure Set Review (MSR) list of measures under consideration for removal from the CMS QRPs‎. In sum, AMRPA supports the PQM MSR process and urges PQM to include the IRF QRP measures currently identified in the MSR list as well as the additional ones we have included in our comments.  AMRPA stands ready to work with Battelle and the PQM to help ensure meaningful quality measures continue to be considered for use in CMS quality programs. 

Should you wish to discuss the AMRPA comments further, please contact Troy Hillman, AMRPA Director of Quality and Health Policy ([email protected] / (202) 207-1129) or Kate Beller, JD, AMRPA President ([email protected] / 202-207-1132). 

On behalf of the Emergency Department Practice Management Association (EDPMA), we are writing to provide feedback on the Partnership for Quality Measurement’s (PQM) 2024 Measure Set Review (MSR) list of measures under consideration for removal from Centers for Medicare & Medicaid Services (CMS) quality programs. EDPMA is the only professional physician trade association focused on the delivery of high-quality, cost-effective care in the emergency department. EDPMA’s membership includes emergency medicine physician groups of all ownership models and sizes, many of whom serve rural communities, as well as billing, coding, and other professional support organizations that assist healthcare providers in our nation’s emergency departments. Together, EDPMA’s members deliver (or directly support) health care for about half of the 146 million patients that visit U.S. emergency departments each year.

EDPMA appreciates that the annual MSR process aims to optimize the CMS measure portfolio by allowing interested stakeholders to consider the purpose of each program’s measures and to weigh the impact of these measures against the burden of implementation. At the same time, we are concerned about three measures currently under consideration for removal from the Merit-Based Incentive Payment System (MIPS), which are important to and commonly used by emergency department practices.   These measures are discussed below. 

#331: Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)

This measure is under consideration for removal by the PQM due to questions surrounding actionability (i.e., do measured entities have a well-articulated path to improvement?) and/or questions about whether there is still an opportunity for impact.

We remind the PQM that this measure currently has a benchmark, which demonstrates that it is commonly reported by MIPS participants.  Unlike many other measures in the MIPS inventory, #331 also does not have topped out performance according to the 2024 MIPS historic benchmarks, which suggests that gaps in performance still exist in terms of antibiotic prescribing for acute viral sinusitis.  Additionally, CMS recently included this measure in the Adopting Best Practices and Promoting Patient Safety within Emergency Medicine MIPS Value Pathways (MVP).  CMS has clearly stated its intent to eventually move all MIPS participants into MVPs and to retire traditional MIPS.  With MVPs being CMS’ preferred future participation pathway, it is important that CMS preserve this measure as an option for MVP reporting.  Overall, this measure targets the important goal of ensuring appropriate use of antibiotics and based on existing benchmarks, it is clear there is still room for performance improvement.   

#415: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older

#416: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years 

These two measures are under consideration for removal by the PQM due to questions surrounding actionability and impact and/or because they are potentially duplicative and candidates for harmonization.  

Similar to #331, measures #415 and #416 have historic performance benchmarks in 2024, indicating wide use among MIPS participants.  While #415 is topped out, #416 is not topped out and continues to target an important and ongoing gap in performance.   Both #415 and #416 are also included in the Emergency Medicine MVP, demonstrating that CMS continues to find value in these measures and envisions them playing an important role in the future of the program.   

Emergency medicine practices face unique challenges when it comes to MIPS compliance. They manage a wide range of often unpredictable clinical scenarios and disparate patient populations. They also struggle with data capture due to a lack of control over the facility’s EHR system, which limits their reporting options and poses challenges in regard to QCDR participation.  Overall, if CMS wants to incentivize movement towards MVPs, then it must ensure that a diverse set of quality measures are available so that practices of all sizes and levels of resource can take advantage of this new, more streamlined reporting pathway. 

EDPMA appreciates the opportunity to provide feedback on these important measures.  We recognize that measure performance data were not reviewed as part of this initial selection process, but that they will be reviewed as part of the MSR process. We look forward to reviewing and providing additional feedback on these assessments when available for public comment.  In the meantime, should you have any questions, please do not hesitate to contact EDPMA Executive Director Cathey Wise at [email protected]. 

The Academy of Otolaryngology – Head and Neck Surgery opposes the proposal to eliminate high-priority quality measure 331, Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse), from the Quality Payment Program. This measure is fully endorsed and in alignment with the Clinical Practice Guidelines (Update) for Adult Sinusitis, which emphasizes symptom relief as the primary goal of managing viral rhinosinusitis (VRS). Antibiotics are not recommended for VRS treatment due to their inefficacy against viral illnesses and lack of direct symptom relief. Additionally, antibiotic use may cause patient harm and foster antibiotic resistance. The measure aims to facilitate sound clinical judgment in distinguishing between viral and bacterial sinusitis and evaluating symptom timelines.¹ It encourages adherence to published clinical practice guidelines to mitigate antibiotic overuse.

In the latest Historical MIPS Quality Benchmark file for 2024, this measure neither reaches the topped-out threshold nor meets the criteria for being classified as a 7-point cap. Analysis of historical benchmarks spanning from 2019 to 2024 indicates an improvement in performance rates (inverse), declining from 61.5 percent to 23.32 percent over the past five years. However, a significant portion of patients still receive unnecessary antibiotic prescriptions, highlighting the ongoing need for quality improvement efforts. The decrease in average performance rate found within the 2024 Historical Benchmark file may be artificially low due to the leniency of reporting due to the Public Health Emergency for the 2022 performance year. 

Based on CDC data, the treatment of bacterial infections in the US may incur an additional cost of approximately $1,400 per patient due to antibiotic resistance. Global projections suggest that by 2050, the annual economic burden of antimicrobial resistance (AMR) could range from $300 billion to over $1 trillion.²

1. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok Kumar K, Kramper M, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015; 152: S1–S39.
2. Dadgostar P. Antimicrobial Resistance: Implications and Costs. Infect Drug Resist. 2019 Dec 20;12:3903-3910. doi: 10.2147/IDR.S234610. PMID: 31908502; PMCID: PMC6929930.

Dear Partnership for Quality Measurement,

We appreciate the opportunity to submit comments regarding the Partnership for Quality Measurement (PQM) Measure Set Review (MSR) measures considered for removal from Centers for Medicare and Medicaid Services’ (“CMS”) quality program. 

Encompass Health is the nation’s leading provider of inpatient rehabilitation hospital care and services. We operate 162 freestanding rehabilitation hospitals in 37 states and Puerto Rico. In 2023, our hospitals had over 220,000 inpatient discharges, more than 80% of whom were Medicare beneficiaries.

MSR Procedural Comments

From a procedural perspective, it is unclear how measures were selected from workbook presented at the PQM Measure Strategy Summit in Baltimore on April 11^th to be reviewed as part of the 2024 MSR cycle. The workbook, titled “MSR-Breakout-Cycle-C-Measures” divided the 114 measures across Group 3 “measures to review,” Group 2 “measures to potentially review’ and Group 1 “measures not to review.” The final posted list of measures to review does not include all measures from the initial “measures to review” listing, and it is unclear how measures were selected to review from the Group 2 “measures to potentially review” listing. To further the confusion, the final list of measures to review is also divided into Measures Group 1 and 2 based on different selection considerations; however, there is not information related to why each measure was selected for review. 

Measure Group 2 Measure Comments

27. (00210-05-C-HHQR) Discharge to Community - Post Acute Care (PAC) Home Health (HH) Quality Reporting Program (QRP) 

28. (00575-04-C-HHQR) Potentially Preventable 30-Day Post-Discharge Readmission Measure for HH Quality Reporting Program

29. (00575-01-C-IRFQR) Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation Facility Quality Reporting Program 

30. (00576-01-C-IRFQR) Potentially Preventable Within Stay Readmission Measure for Inpatient Rehabilitation Facility Quality Reporting Program

31. (00210-03-C-LTCHQR) Discharge to Community-Post Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) 

32. (00575-02-C-LTCHQR) Potentially Preventable 30-Day Post-Discharge Readmission Measure for Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)

33. (00210-02-C-SNFQRP) Discharge to Community (DTC) - Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) 

34. (00575-03-C-SNFQRP) Potentially Preventable 30-Day Post-Discharge Readmission Measure for Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)

We do not recommend removing Discharge to Community or Potentially Preventable 30-Day Post-Discharge Readmissions or Potentially Preventable Within Stay Readmission Measure from the Home Health, LTCH, SNF, or IRF Quality Reporting Programs. While not specified by the Measure Set Review listing, the measures appear to be on the list regarding “questions surrounding actionability” because the measures have strong impact in the public reporting program and are not duplicative with existing measures. Discharge to Community, Potentially Preventable Within Stay Readmissions, and Potentially Preventable 30-Day Post-Discharge Readmissions are important outcomes and relevant measures in the post-acute care continuum. These measures are not only beneficial to consumers when making decisions regarding their healthcare (rates of Discharge to Community and Potentially Preventable Readmissions vary widely not only between PAC settings but amongst individual providers) but also important quality indicators on which providers work to improve. The primary opportunity to improve these measures “actionability” is providing PAC settings, like they do with acute care hospitals. Patient-level data would allow providers to understand the results of the measure, which is critical to driving improvement. PAC settings should receive the same level of detail in their quality measures as is provided to acute care hospitals.

The ACP supports the removal of this measure from the MIPS program.  

The proportion of patients above 85 years old who get a colonoscopy is very small. Moreover, there is no performance gap data to demonstrate that the measure addresses an opportunity for improvement. The specifications for the measures are confusing and the age range where overuse is more likely is 76 to 85 years of age.

ACP supports the removal of this measure from the MIPS program.

The harms of overuse from dual-energy x-ray absorptiometry (DXA) scans are relatively low and this performance measure does not fill a performance gap. The denominator exclusion criterion do not follow current guidelines and the exclusion criterion combinations are too stringent for physicians, adding unnecessary burden. If this measure were to remain in the program, ACP recommends clarifying the risk factor language and defining “osteoporotic fracture” more specifically.

May 31, 2024

PQM Public Comment 

RE: Comments on the 2024 Measure Set Review (MSR) for Cycle C Measures

To Whom It May Concern,

Covered California and CalPERS appreciate the opportunity provided by the Pre-Rulemaking Measure Review (PRMR) process to comment on the proposed measures for the 2024 Measure Set Review (MSR). We recognize the importance of this annual review in enhancing the quality and efficiency of healthcare delivery across the United States. After careful consideration of the measures outlined for Cycle C, focusing on cost-effectiveness and efficiency in healthcare utilization, we wish to express our perspectives and recommendations.

Themes for Consideration:

1. Significant Measurement Burden:  The healthcare landscape faces a significant challenge with the inclusion of 34 measures, potentially expanding with public input, creating a substantial measurement burden on providers. This extensive list of measures risks diluting the focus on areas crucial for enhancing patient care and reducing costs. These additional measures are not clearly aligned with the CMS Universal Measure Set and may introduce added complexity and hinder alignment efforts across healthcare settings. Furthermore, measure misalignment between PQM and Medicaid Core Set interfere with the ability to successfully align across payers.
2. Total Cost of Care and Quality Reporting: As highlighted in a recent JAMA article (Saraswathula, et al., JAMA Vol. 329, No. 21, pp 1840-47) on the impact of hospital quality reporting on the total cost of care, it is imperative that quality measures are evaluated not only on their immediate clinical impact but also on their broader financial implications. Measures should be assessed for the potential cost of data collection with a preference for electronic metrics, their ability to contribute to cost efficiency while maintaining or enhancing the quality of care.
3. Gaps in Measure Development: If new measures are to be created, we recommend a focus on domains with gaps such as utilization-based measures, coordination across care settings (e.g., emergency room/urgent care to primary care transitions), and specialty care quality.      Development of measures should ensure comprehensive coverage of quality and efficiency in healthcare delivery rather than duplicate or create redundant metrics. 
4. Focus on performance improvement: With the current set of measures, there has not been meaningful or sustained improvement across all-populations. In fact, several areas have witnessed a decline during the pandemic. A number of measures such as CIS-10 and Well Child Visit rates have yet to recover to pre-pandemic performance levels, underscoring the need not for more measures, but rather attention to improvement and implementation of an equity lens.

In conclusion, Covered California and CalPERS are committed to collaborating with PQM, CMS, and other stakeholders to approach the development of new measures with caution and care. Our collective goal is to enhance healthcare quality and efficiency, ultimately benefiting patients and the healthcare system at large. We look forward to engaging in further discussions and contributing to the development of a focused, impactful measure set. Thank you for considering our comments.

Sincerely,

S. Monica Soni, MD                                                                           Marcie Frost

Chief Deputy Executive Director                                                  Chief Executive Officer

Chief Medical Officer                                                                         CalPERS

Covered California                                                                                   

The American Geriatrics Society (AGS) greatly appreciates the opportunity to review and comment on the measures up for removal for the 2024 Measure Set Review (MSR) process. 

Potentially Preventable 30-Day Post-Discharge Readmission Measure for Skilled Nursing Facility (SNF) Quality Reporting Program (QRP). 

We agree with the removal of this measure. According to the measure specifications, there is no evidence available for this measure. While the rationale states that there is no significant peer-reviewed literature specific to potentially preventable readmissions post SNF discharge, most readmissions are due to five potentially preventable conditions: heart failure, electrolyte imbalance, respiratory infection, sepsis, and urinary tract infection (MedPAC, 2007). We believe it may be beneficial to create measures around care processes for these common preventable conditions that could ultimately lead to reduction in readmissions. 

Discharge to Community - Post Acute Care (PAC) Home Health (HH) Quality Reporting Program (QRP)

AGS recommends clarifying the rationale for proposing to remove this measure. While there may be some concerns, it seems there is evidence for specific interventions that could have an impact on this measure. Further, care coordination between settings is critically important and can be conducted with care processes via telehealth particularly for specific diseases such as diabetes mellitus, chronic obstructive pulmonary disease, and congestive heart failure. 

Hospital Visits After Orthopedic and Urology Ambulatory Surgical Center Procedures and Hospital Visits After Urology Ambulatory Surgical Center Procedures 

We recommend keeping these measures as they provide actionable data that is meaningful to the patient experience after specific outpatient surgical procedures and do not appear to be duplicative. It would be important to provide a balance to the incentive for providers to refer to emergency rooms as many of the Current Procedural Terminology (CPT) codes employed at ambulatory surgical centers would be 10- or 90-day globals. While some of the emergency room visits assigned to the numerator of the measure specification will be unrelated to the procedure, the performance benchmark will naturally include unrelated visits for all providers. 

Thank you for taking the time to review our feedback and recommendations.