PRMR MUC List Commenting

The Renal Physicians Association (RPA) is the professional organization of nephrologists whose goals are to ensure optimal care under the highest standards of medical practice for patients with kidney disease and related disorders. RPA acts as the national representative for physicians engaged in the study and management of patients with kidney disease. RPA appreciates the opportunity to provide comments on the Measures under Consideration (MUC) for 2024.

MIPS Cost Measures

• Chronic Kidney Disease (MUC2023-203)
• End-Stage Renal Disease (MUC2023-204)
• Kidney Transplant Management (MUC2023-206)

RPA is concerned that critical details are missing from these measures as to the methodology that will be used to determine the numerator and denominator, clinician attribution, as well as how co-morbidities will be determined. Specifically, RPA notes that patients with kidney disease seen in an outpatient setting may have numerous co-morbidities included on the problem list, but these are not necessarily indicated as billing codes. As such, RPA is particularly concerned that all three of the measures seem to have low reliability scores.  Furthermore, all three measures also include this disclaimer: “No evidence submitted directly showing mechanisms by which clinician groups will improve … outcomes through implementation of cost containment measures.” In light of this, it is unclear what the value is of such measures. 

Additionally, RPA is concerned about two potential unintended consequences of these measures: 1) That patients will not receive medically appropriate care due to cost concerns; and 2) Entities pre-screening and refusing to accept patients with more co-morbidities who are more likely to have a higher cost of care. This is particularly a concern for transplant programs and dialysis centers.

Finally, it is unclear why there is a denominator exclusion of “Patients with extremely low treatment costs” is included in the measures. Patients with low treatment costs would seem to lower the average costs of care.

As always, RPA welcomes the opportunity to work collaboratively to improve the quality of care provided to the nation’s kidney patients. Any questions or comments regarding this correspondence should be directed to Amy Beckrich, RPA’s Director of Projects and Operations, at 301-468-3515 or [email protected].

The Renal Physicians Association (RPA) is the professional organization of nephrologists whose goals are to ensure optimal care under the highest standards of medical practice for patients with kidney disease and related disorders. RPA acts as the national representative for physicians engaged in the study and management of patients with kidney disease. RPA appreciates the opportunity to provide comments on the Measures under Consideration (MUC) for 2024.

MIPS Cost Measures

• Chronic Kidney Disease (MUC2023-203)
• End-Stage Renal Disease (MUC2023-204)
• Kidney Transplant Management (MUC2023-206)

RPA is concerned that critical details are missing from these measures as to the methodology that will be used to determine the numerator and denominator, clinician attribution, as well as how co-morbidities will be determined. Specifically, RPA notes that patients with kidney disease seen in an outpatient setting may have numerous co-morbidities included on the problem list, but these are not necessarily indicated as billing codes. As such, RPA is particularly concerned that all three of the measures seem to have low reliability scores.  Furthermore, all three measures also include this disclaimer: “No evidence submitted directly showing mechanisms by which clinician groups will improve … outcomes through implementation of cost containment measures.” In light of this, it is unclear what the value is of such measures. 

Additionally, RPA is concerned about two potential unintended consequences of these measures: 1) That patients will not receive medically appropriate care due to cost concerns; and 2) Entities pre-screening and refusing to accept patients with more co-morbidities who are more likely to have a higher cost of care. This is particularly a concern for transplant programs and dialysis centers.

Finally, it is unclear why there is a denominator exclusion of “Patients with extremely low treatment costs” is included in the measures. Patients with low treatment costs would seem to lower the average costs of care.

As always, RPA welcomes the opportunity to work collaboratively to improve the quality of care provided to the nation’s kidney patients. Any questions or comments regarding this correspondence should be directed to Amy Beckrich, RPA’s Director of Projects and Operations, at 301-468-3515 or [email protected].

The Renal Physicians Association (RPA) is the professional organization of nephrologists whose goals are to ensure optimal care under the highest standards of medical practice for patients with kidney disease and related disorders. RPA acts as the national representative for physicians engaged in the study and management of patients with kidney disease. RPA appreciates the opportunity to provide comments on the Measures under Consideration (MUC) for 2024.

MIPS Cost Measures

• Chronic Kidney Disease (MUC2023-203)
• End-Stage Renal Disease (MUC2023-204)
• Kidney Transplant Management (MUC2023-206)

RPA is concerned that critical details are missing from these measures as to the methodology that will be used to determine the numerator and denominator, clinician attribution, as well as how co-morbidities will be determined. Specifically, RPA notes that patients with kidney disease seen in an outpatient setting may have numerous co-morbidities included on the problem list, but these are not necessarily indicated as billing codes. As such, RPA is particularly concerned that all three of the measures seem to have low reliability scores.  Furthermore, all three measures also include this disclaimer: “No evidence submitted directly showing mechanisms by which clinician groups will improve … outcomes through implementation of cost containment measures.” In light of this, it is unclear what the value is of such measures. 

Therefore, RPA is concerned about two potential unintended consequences of these measures: 1) That patients will not receive medically appropriate care due to cost concerns; and 2) Entities pre-screening and refusing to accept patients with more co-morbidities who are more likely to have a higher cost of care. This is particularly a concern for transplant programs and dialysis centers.

Finally, it is unclear why there is a denominator exclusion of “Patients with extremely low treatment costs” is included in the measures. Patients with low treatment costs would seem to lower the average costs of care.

As always, RPA welcomes the opportunity to work collaboratively to improve the quality of care provided to the nation’s kidney patients. Any questions or comments regarding this correspondence should be directed to Amy Beckrich, RPA’s Director of Projects and Operations, at 301-468-3515 or [email protected].

To ensure that older adults receive the care that they need, especially follow-on and continued care, hospitals need to do more than simply screen their patients and refer them to non-emergency medical transportation services which may not operate in their home community or travel to the hospital at the needed days and times. Hospitals should be participating in local and regional transportation coordination efforts and fully engaged with CCAM’s work to develop a coordinated transportation network. When needed and allowed, hospitals should be financially supporting local transportation services or operating their own services. Without greater hospital participation, local transportation networks will become overwhelmed as the population ages, especially in rural and low-density areas.

My name is Kevin Gimeno, BSN, RN. Patient safety is important to me because I lost an aunt because of a medical mistake made by an anesthesiologist in an OR and because as a nurse I believe we need to do a lot more to keep patients safe. I write in support of the Patient Safety Structural Measure (#MUC2023-188) on the CMS list of Measures Under Consideration. The reasons I support this measure are because it states the kinds of patient safety best practices I expect as a patient in the United States. It is important to me that: 

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

2. Hospitals adopt “zero preventable harm” as their patient safety strategic goal, as recommended in the CMS National Quality Strategy. Even if that goal is aspirational, it should be what every hospital aims to achieve. 

3. Hospitals establish a culture of safety that engages all its staff and puts in place systems for preventing and learning from medical errors or other challenges that put patients at risk for harm or discrimination. All hospitals should adopt HRO principles in order to achieve this goal.

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

5. Hospitals should engage the patients and families they serve in patient safety work, as recommended by the President’s Council of Advisors on Science and Technology. Listen to our experiences and factor it in to your work to decrease preventable harm, bias and discrimination. They should also be focused on helping patients access our medical records and correct errors there when we find them. Not all hospitals are engaging with families/patients/caregivers in interdisciplinary rounding and this is something that is fundamental in safe patient care.

6. These are very similar to the requirement for skilled nursing facilities to achieve five-star ratings. These goals are very achievable in a hospital setting.

For all these reasons I strongly support the Patient Safety Structural Measure. Thank you for this opportunity to make this public comment.

Please find attached a submission which sets out Patient Safety Learning’s support for the Patient Safety Structural Measure (#MUC2023-188).

My name is Nicole Cable.  Patient safety is important to me because I acquired an infection in the hospital that has changed my life forever. I will always deal with the aftermath because the individuals I trusted to care for me did not practice patient safety.   I support the Patient Safety Structural Measure (#MUC2023-188) on the Measures Under Consideration CMS list.

I support this measure because it states the kinds of patient safety best practices I expect as a patient in the United States.  It is important to me that:

1. Hospital leaders and board directors prioritize patient safety and are actively engaged in ensuring proper safety practices.
2. Hospitals adopt “zero preventable harm” as their patient safety strategic goal, as the CMS National Quality Strategy recommends.  Even if that goal is aspirational, it should be what every hospital aims to achieve.
3. Hospitals establish a culture of safety that engages all their staff and puts in place systems for preventing and learning from medical errors or other challenges that put patients at risk for harm or discrimination.
4. Hospitals have systems for reporting harmful events and being open and honest with patients and the public when harmful events occur. I expect hospitals to report their events to government agencies, accreditation bodies, or other organizations focusing on learning and prevention.
5. Hospitals should engage the patients and families they serve in patient safety work, as the President’s Council of Advisors on Science and Technology recommended. Listen to our experiences and factor them into your work to decrease preventable harm, bias, and discrimination.  They should also focus on helping patients access and correct errors in the medical records we find them.

For all these reasons, I strongly support the Patient Safety Structural Measure.  Thank you for this opportunity to make this public comment.

Please see attached for comments on the Part C & D measures that will be review by the Clinician.

The American Medical Association (AMA) supports inclusion of this measure in the Part C & D Star Ratings program. Ensuring that patients have timely access to care that is clinically appropriate and necessary is critical and this measure will increase transparency around the prior authorization process.

The American Medical Association (AMA) has significant concerns with this measure and believes that revisions to the specifications and additional field testing are necessary. First, any measure that is submitted for consideration in the Merit-Based Incentive Payment System (MIPS) must be tested at the individual clinician level; yet, we note that only clinician group is selected as the level of analysis. It is not clear whether this indicates that CMS only intends to report this measure at the group level and if the intent is to also attribute these costs to individual clinicians, then we request that the Clinician Committee evaluate the measure’s appropriateness for MIPS using the TIN-NPI testing data. 

When reviewing the performance gap at the TIN level, we note that there is a roughly $800 difference between the 10^th and 90^th percentiles with some clear outliers and this limited variation when distributed across the current MIPS benchmarking deciles will result in the achievement or loss of points based on small differences in costs. The AMA was also made aware of at least one instance in the 2022 performance period where operating room charges were omitted from the calculations, leading to an invalid representation of the clinician’s costs associated with cataract surgery.  As a result we do not believe that this measure will result in accurate or invalid assessments of the costs attributed to a clinician. 

In addition, the AMA believes that the validity testing with only correlations to other costs (e.g., associated with adverse events) is insufficient. Evaluating costs within the context of the quality of care provided is imperative, particularly as CMS continues to move toward additional MIPS Value Pathways (MVPs) where some association between quality and cost is at a minimum implied. 

We ask that this measure only be considered for MIPS once these additional conditions are provided; specifically, around ensuring that additional testing on how the risk model performs at the TIN-NPI level if this measure is applied to individual clinicians, an evaluation of the costs within the context of the quality of care is provided, different benchmarking approaches for cost measures (e.g., outliers) are explore, and Part D prescription drug costs are not included.

The American Medical Association (AMA) has significant concerns with this measure and believes that revisions to the specifications and additional field testing are necessary. First, any measure that is submitted for consideration in the Merit-Based Incentive Payment System (MIPS) must be tested at the individual clinician level; yet, we note that only clinician group is selected as the level of analysis. It is not clear whether this indicates that CMS only intends to report this measure at the group level and if the intent is to also attribute these costs to individual clinicians, then we request that the Clinician Committee evaluate the measure’s appropriateness for MIPS using the TIN-NPI testing data. 

For years, race has been included in kidney function (estimated glomerular filtration rate or eGFR) calculations based on flawed explanations of clinical trial data suggesting that Black patients have higher levels of creatinine in their blood. Unfortunately, this has led clinicians to underestimate the severity of kidney disease in many Black patients, delaying their access to medication, specialist referrals, nutrition therapy, disease education, dialysis, and transplants. Recent changes to eGFR calculations eliminate the race adjustment allowing for potentially better health outcomes for Black patients as more laboratories become aware and adopt the new formula, but implementation is still in progress. For Black patients that have received late diagnoses or care as a result of the old eGFR formula, the cost to treat them will likely be more than non-Black patients. Measures that fail to account for this may incentivize physicians to avoid these patients to have better quality and cost scores or further skimp on or delay care for these patients in an effort to curb costs, further exacerbating existing inequities for patients. In addition, research has found that physicians who care for Black patients often have fewer resources, making the administrative burden of MIPS reporting less feasible, or have limited access to the specialists needed to complete assessments to get on the transplant list, in all of these cases putting any incentive payments out of reach. 

It is unclear how past use of a race-based formula and the still inconsistent use of successor formulas are accounted for in the cost measures transition from chronic kidney disease (CKD) to end-stage renal disease (ESRD) episode to avoid penalizing and instead incentivize physicians who are caring for patients who have previously had care delayed by use of the old formula. The Organ Procurement and Transplantation Network (OPTN) recently called for reassessing transplant waiting lists based on this issue (https://unos.org/news/waiting-time-adjustment-approved-for-kidney-transplant-candidates-affected-by-race-based-calculation/), and could serve as a model. It is unclear how the disparate resource issue is addressed in the cost measures for transition from ESRD to kidney transplant management (KTM) episode and the up-front supplement based on an administratively determined neighborhood stress score or similar alternative could serve as a model.

When reviewing the performance gap at the TIN level, we note that there is a roughly $5,000 difference between the 10^th and 90^th percentiles with some clear outliers and this limited variation when distributed across the current MIPS benchmarking deciles will result in the achievement or loss of points based on small differences in costs. 

The minimum reliability at the TIN level with at least 20 attributed episodes was 0.161, which falls well below what the AMA considers to be acceptable. Measures must achieve a minimum reliability of at least 0.7 or higher in order to be considered for inclusion in MIPS. 

In addition, the AMA believes that the validity testing with only correlations to other costs (e.g., associated with adverse events) is insufficient. Evaluating costs within the context of the quality of care provided is imperative, particularly as CMS continues to move toward additional MIPS Value Pathways (MVPs) where some association between quality and cost is at a minimum implied. 

We ask that this measure only be considered for MIPS once these additional conditions are provided; specifically, ensuring that the minimum reliability be 0.7 or higher, completing testing to address the low r-squared of the model and adjusting for social risk factors in the risk adjustment model as well as how the risk model performs at the TIN-NPI level if this measure is applied to individual clinicians, completing an evaluation of the costs within the context of the quality of care provided, exploring different benchmarking approaches for cost measures (e.g., outliers) and removing Part D prescription drug costs.

References: 

Replacing the faulty formula that led to inequity in kidney care

Widely used test kept Black people from getting kidney transplants sooner. Now that's changing.

The American Medical Association (AMA) has significant concerns with this measure and believes that revisions to the specifications and additional field testing are necessary. First, any measure that is submitted for consideration in the Merit-Based Incentive Payment System (MIPS) must be tested at the individual clinician level; yet, we note that only clinician group is selected as the level of analysis. It is not clear whether this indicates that CMS only intends to report this measure at the group level and if the intent is to also attribute these costs to individual clinicians, then we request that the Clinician Committee evaluate the measure’s appropriateness for MIPS using the TIN-NPI testing data. 

For years, race has been included in kidney function (estimated glomerular filtration rate or eGFR) calculations based on flawed explanations of clinical trial data suggesting that Black patients have higher levels of creatinine in their blood. Unfortunately, this has led clinicians to underestimate the severity of kidney disease in many Black patients, delaying their access to medication, specialist referrals, nutrition therapy, disease education, dialysis, and transplants. Recent changes to eGFR calculations eliminate the race adjustment allowing for potentially better health outcomes for Black patients as more laboratories become aware and adopt the new formula, but implementation is still in progress. For Black patients that have received late diagnoses or care as a result of the old eGFR formula, the cost to treat them will likely be more than non-Black patients. Measures that fail to account for this may incentivize physicians to avoid these patients to have better quality and cost scores or further skimp on or delay care for these patients in an effort to curb costs, further exacerbating existing inequities for patients. In addition, research has found that physicians who care for Black patients often have fewer resources, making the administrative burden of MIPS reporting less feasible, or have limited access to the specialists needed to complete assessments to get on the transplant list, in all of these cases putting any incentive payments out of reach. 

It is unclear how past use of a race-based formula and the still inconsistent use of successor formulas are accounted for in the cost measures transition from chronic kidney disease (CKD) to end-stage renal disease (ESRD) episode to avoid penalizing and instead incentivize physicians who are caring for patients who have previously had care delayed by use of the old formula. The Organ Procurement and Transplantation Network (OPTN) recently called for reassessing transplant waiting lists based on this issue (https://unos.org/news/waiting-time-adjustment-approved-for-kidney-transplant-candidates-affected-by-race-based-calculation/), and could serve as a model. It is unclear how the disparate resource issue is addressed in the cost measures for transition from ESRD to kidney transplant management (KTM) episode and the up-front supplement based on an administratively determined neighborhood stress score or similar alternative could serve as a model.

When reviewing the performance gap at the TIN level, we note that there is a roughly $11,000 difference between the 10^th and 90^th percentiles with some clear outliers and this limited variation when distributed across the current MIPS benchmarking deciles will result in the achievement or loss of points based on small differences in costs. 

In addition, the minimum reliability at the TIN level with at least 20 attributed episodes was 0.274, which falls well below what the AMA considers to be acceptable. Measures must achieve a minimum reliability of at least 0.7 or higher in order to be considered for inclusion in MIPS. 

In addition, the AMA believes that the validity testing with only correlations to other costs (e.g., associated with adverse events) is insufficient. Evaluating costs within the context of the quality of care provided is imperative, particularly as CMS continues to move toward additional MIPS Value Pathways (MVPs) where some association between quality and cost is at a minimum implied. 

We ask that this measure only be considered for MIPS once these additional conditions are provided; specifically, ensuring that the minimum reliability be 0.7 or higher, completing testing to address the low r-squared of the model and adjusting for social risk factors in the risk adjustment model as well as how the risk model performs at the TIN-NPI level if this measure is applied to individual clinicians, completing an evaluation of the costs within the context of the quality of care provided, exploring different benchmarking approaches for cost measures (e.g., outliers) and removing Part D prescription drug costs.

References: 

Replacing the faulty formula that led to inequity in kidney care

Widely used test kept Black people from getting kidney transplants sooner. Now that's changing.

The American Medical Association (AMA) has significant concerns with this measure and believes that revisions to the specifications and additional field testing are necessary. First, any measure that is submitted for consideration in the Merit-Based Incentive Payment System (MIPS) must be tested at the individual clinician level; yet, we note that only clinician group is selected as the level of analysis. It is not clear whether this indicates that CMS only intends to report this measure at the group level and if the intent is to also attribute these costs to individual clinicians, then we request that the Clinician Committee evaluate the measure’s appropriateness for MIPS using the TIN-NPI testing data. 

When reviewing the performance gap at the TIN level, we note that there is a roughly $4,000 difference between the 10^th and 90^th percentiles with some clear outliers and this limited variation when distributed across the current MIPS benchmarking deciles will result in the achievement or loss of points based on small differences in costs. 

In addition, the minimum reliability at the TIN level with at least 20 attributed episodes was 0.315, which falls well below what the AMA considers to be acceptable. Measures must achieve a minimum reliability of at least 0.7 or higher in order to be considered for inclusion in MIPS. 

In addition, the AMA believes that the validity testing with only correlations to other costs (e.g., associated with adverse events) is insufficient. Evaluating costs within the context of the quality of care provided is imperative, particularly as CMS continues to move toward additional MIPS Value Pathways (MVPs) where some association between quality and cost is at a minimum implied. 

We ask that this measure only be considered for MIPS once these additional conditions are provided; specifically, ensuring that the minimum reliability be 0.7 or higher, completing testing to address the low r-squared of the model and adjusting for social risk factors in the risk adjustment model as well as how the risk model performs at the TIN-NPI level if this measure is applied to individual clinicians, completing an evaluation of the costs within the context of the quality of care provided, exploring different benchmarking approaches for cost measures (e.g., outliers) and removing Part D prescription drug costs.

The American Medical Association (AMA) has significant concerns with this measure and believes that revisions to the specifications and additional field testing are necessary. First, any measure that is submitted for consideration in the Merit-Based Incentive Payment System (MIPS) must be tested at the individual clinician level; yet, we note that only clinician group is selected as the level of analysis. It is not clear whether this indicates that CMS only intends to report this measure at the group level and if the intent is to also attribute these costs to individual clinicians, then we request that the Clinician Committee evaluate the measure’s appropriateness for MIPS using the TIN-NPI testing data. 

For years, race has been included in kidney function (estimated glomerular filtration rate or eGFR) calculations based on flawed explanations of clinical trial data suggesting that Black patients have higher levels of creatinine in their blood. Unfortunately, this has led clinicians to underestimate the severity of kidney disease in many Black patients, delaying their access to medication, specialist referrals, nutrition therapy, disease education, dialysis, and transplants. Recent changes to eGFR calculations eliminate the race adjustment allowing for potentially better health outcomes for Black patients as more laboratories become aware and adopt the new formula, but implementation is still in progress. For Black patients that have received late diagnoses or care as a result of the old eGFR formula, the cost to treat them will likely be more than non-Black patients. Measures that fail to account for this may incentivize physicians to avoid these patients to have better quality and cost scores or further skimp on or delay care for these patients in an effort to curb costs, further exacerbating existing inequities for patients. In addition, research has found that physicians who care for Black patients often have fewer resources, making the administrative burden of MIPS reporting less feasible, or have limited access to the specialists needed to complete assessments to get on the transplant list, in all of these cases putting any incentive payments out of reach. 

It is unclear how past use of a race-based formula and the still inconsistent use of successor formulas are accounted for in the cost measures transition from chronic kidney disease (CKD) to end-stage renal disease (ESRD) episode to avoid penalizing and instead incentivize physicians who are caring for patients who have previously had care delayed by use of the old formula. The Organ Procurement and Transplantation Network (OPTN) recently called for reassessing transplant waiting lists based on this issue (https://unos.org/news/waiting-time-adjustment-approved-for-kidney-transplant-candidates-affected-by-race-based-calculation/), and could serve as a model. It is unclear how the disparate resource issue is addressed in the cost measures for transition from ESRD to kidney transplant management (KTM) episode and the up-front supplement based on an administratively determined neighborhood stress score or similar alternative could serve as a model.

When reviewing the performance gap at the TIN level, we note that there is a roughly $10,000 difference between the 10^th and 90^th percentiles with some clear outliers and this limited variation when distributed across the current MIPS benchmarking deciles will result in the achievement or loss of points based on small differences in costs. 

In addition, the minimum reliability at the TIN level with at least 20 attributed episodes was 0.177, which falls well below what the AMA considers to be acceptable. Measures must achieve a minimum reliability of at least 0.7 or higher in order to be considered for inclusion in MIPS. 

In addition, the AMA believes that the validity testing with only correlations to other costs (e.g., associated with adverse events) is insufficient. Evaluating costs within the context of the quality of care provided is imperative, particularly as CMS continues to move toward additional MIPS Value Pathways (MVPs) where some association between quality and cost is at a minimum implied. 

We ask that this measure only be considered for MIPS once these additional conditions are provided; specifically, ensuring that the minimum reliability be 0.7 or higher, completing testing to address the low r-squared of the model and adjusting for social risk factors in the risk adjustment model as well as how the risk model performs at the TIN-NPI level if this measure is applied to individual clinicians, completing an evaluation of the costs within the context of the quality of care provided, exploring different benchmarking approaches for cost measures (e.g., outliers) and removing Part D prescription drug costs.

References: 

Replacing the faulty formula that led to inequity in kidney care

Widely used test kept Black people from getting kidney transplants sooner. Now that's changing.

The American Medical Association (AMA) has significant concerns with this measure and believes that revisions to the specifications and additional field testing are necessary. First, any measure that is submitted for consideration in the Merit-Based Incentive Payment System (MIPS) must be tested at the individual clinician level; yet, we note that only clinician group is selected as the level of analysis. It is not clear whether this indicates that CMS only intends to report this measure at the group level and if the intent is to also attribute these costs to individual clinicians, then we request that the Clinician Committee evaluate the measure’s appropriateness for MIPS using the TIN-NPI testing data. 

Similar to the kidney-related issues, prostate cancer has many racial disparities that are present at every stage of the cancer continuum. Black men in the U.S. have 60 percent greater incidence, a higher proportion diagnosed at advanced stage, and two times the prostate cancer mortality than white men. Factors such as increased exposure to neighborhood deprivation and carcinogens, less access to care, lower prevalence of PSA screening, and lower quality care are related to Black men being diagnosed at a later stage and experiencing higher mortality. These exposures, delays, and missteps could lead to higher cost of care for advanced cancer or complications compared to non-Black patients. MIPS may incentivize physicians to prioritize patients expected to have better outcomes and avoid patients or services expected to cost more, which would exacerbate existing prostate cancer inequities. At the same time, the policy could discourage physicians from spending more time discussing options with patients who have historically been mistreated by the healthcare system and/or addressing social factors that are barriers to care. 

Stratifying cost measures separately within groups with local or metastatic cancer may be helpful in avoiding discrimination against Black men who are more likely to present with advanced disease, as long as the payments for caring for metastatic disease are sufficient to avoid incentivizing physicians to shift their care predominantly toward patients with local disease. In addition, research has found that physicians who care for Black patients often have fewer resources, making the administrative burden of MIPS reporting less feasible, or have limited access to the specialists needed to complete assessments to get on the transplant list, in all of these cases putting any incentive payments out of reach It is unclear how the disparate resource issue is addressed in this cost measure and the up-front supplement based on an administratively determined neighborhood stress score or similar alternative could serve as a model.

When reviewing the performance gap at the TIN level, we note that there is a roughly $9,000 difference between the 10^th and 90^th percentiles with some clear outliers and this limited variation when distributed across the current MIPS benchmarking deciles will result in the achievement or loss of points based on small differences in costs. 

In addition, the minimum reliability at the TIN level with at least 20 attributed episodes was 0.365, which falls well below what the AMA considers to be acceptable. Measures must achieve a minimum reliability of at least 0.7 or higher in order to be considered for inclusion in MIPS. 

In addition, the AMA believes that the validity testing with only correlations to other costs (e.g., associated with adverse events) is insufficient. Evaluating costs within the context of the quality of care provided is imperative, particularly as CMS continues to move toward additional MIPS Value Pathways (MVPs) where some association between quality and cost is at a minimum implied. 

We ask that this measure only be considered for MIPS once these additional conditions are provided; specifically, ensuring that the minimum reliability be 0.7 or higher, completing testing to address the low r-squared of the model and adjusting for social risk factors in the risk adjustment model as well as how the risk model performs at the TIN-NPI level if this measure is applied to individual clinicians, completing an evaluation of the costs within the context of the quality of care provided, exploring different benchmarking approaches for cost measures (e.g., outliers) and removing Part D prescription drug costs.

References:

Racial disparities in prostate cancer among black men: epidemiology and outcomes

Association of Neighborhood Deprivation With Prostate Cancer and Immune Markers in African American and European American Men

The American Medical Association (AMA) has significant concerns with this measure and believes that revisions to the specifications and additional field testing are necessary. First, any measure that is submitted for consideration in the Merit-Based Incentive Payment System (MIPS) must be tested at the individual clinician level; yet, we note that only clinician group is selected as the level of analysis. It is not clear whether this indicates that CMS only intends to report this measure at the group level and if the intent is to also attribute these costs to individual clinicians, then we request that the Clinician Committee evaluate the measure’s appropriateness for MIPS using the TIN-NPI testing data. 

When reviewing the performance gap at the TIN level, we note that there is a roughly $3,000 difference between the 10^th and 90^th percentiles with some clear outliers and this limited variation when distributed across the current MIPS benchmarking deciles will result in the achievement or loss of points based on small differences in costs. 

In addition, the minimum reliability at the TIN level with at least 20 attributed episodes was 0.536, which falls well below what the AMA considers to be acceptable. Measures must achieve a minimum reliability of at least 0.7 or higher in order to be considered for inclusion in MIPS. 

In addition, the AMA believes that the validity testing with only correlations to other costs (e.g., associated with adverse events) is insufficient. Evaluating costs within the context of the quality of care provided is imperative, particularly as CMS continues to move toward additional MIPS Value Pathways (MVPs) where some association between quality and cost is at a minimum implied. 

We ask that this measure only be considered for MIPS once these additional conditions are provided; specifically, ensuring that the minimum reliability be 0.7 or higher, completing testing to address the low r-squared of the model and adjusting for social risk factors in the risk adjustment model as well as how the risk model performs at the TIN-NPI level if this measure is applied to individual clinicians, completing an evaluation of the costs within the context of the quality of care provided, exploring different benchmarking approaches for cost measures (e.g., outliers) and removing Part D prescription drug costs.

The American Medical Association (AMA) has significant concerns with this measure and believes that revisions to the specifications and additional field testing are necessary. First, any measure that is submitted for consideration in the Merit-Based Incentive Payment System (MIPS) must be tested at the individual clinician level; yet, we note that only clinician group is selected as the level of analysis. It is not clear whether this indicates that CMS only intends to report this measure at the group level and if the intent is to also attribute these costs to individual clinicians, then we request that the Clinician Committee evaluate the measure’s appropriateness for MIPS using the TIN-NPI testing data. 

Research has shown that disparities in patients with Rheumatoid Arthritis (RA) affect outcomes, prognosis, and management of the disease. Access to care is a major concern for many physicians, no matter the area of practice, but with RA this is often related to lack of access to a nearby rheumatologist and/or inadequate access due to narrow networks in coverage prior to eligibility for Medicare among many other things that could lead to delayed diagnoses and care. Just like many other conditions, delays in RA diagnosis can lead to more severe disease manifestations and irreversible bony destruction, disability, and loss of function. According to an NIH study, “Caucasians” with RA have the least amount of disability (HAQ-DI 1.24) compared with African Americans (HAQ-DI 1.28). This could result in greater need for physical, occupational, or speech therapy for Black patients relative to others, which is problematic with regard to Black patients and their physicians often having less access, which would affect quality scores, and having higher costs if they are able to access services needed at a higher level, which would adversely affect cost scores. Pain was also reported as higher in African Americans (39.3/100) versus “Caucasians” (33.3/100). Again, this could lead to far worse, more expensive outcomes for Black patients. The same study saw high opioid prescriptions with more than 66 percent of Medicare/Medicaid beneficiaries receiving chronic opioids, which could suggest that Black RA patients present with more pain and joint deformities, subsequently having an increased need/reliance on pain medications. This is particularly problematic in the Part D measure that seeks to standardize costs. If this disparity in need for medication is not taken into account, then physicians taking care of Black patients could be penalized for providing appropriate care based on higher relative costs. 

When reviewing the performance gap at the TIN level, we note that there is a roughly $10,000 difference between the 10^th and 90^th percentiles with some clear outliers and this limited variation when distributed across the current MIPS benchmarking deciles will result in the achievement or loss of points based on small differences in costs. 

In addition, the minimum reliability at the TIN level with at least 20 attributed episodes was 0.489, which falls well below what the AMA considers to be acceptable. Measures must achieve a minimum reliability of at least 0.7 or higher in order to be considered for inclusion in MIPS. 

In addition, the AMA believes that the validity testing with only correlations to other costs (e.g., associated with adverse events) is insufficient. Evaluating costs within the context of the quality of care provided is imperative, particularly as CMS continues to move toward additional MIPS Value Pathways (MVPs) where some association between quality and cost is at a minimum implied. 

We ask that this measure only be considered for MIPS once these additional conditions are provided; specifically, ensuring that the minimum reliability be 0.7 or higher, completing testing to address the low r-squared of the model and adjusting for social risk factors in the risk adjustment model as well as how the risk model performs at the TIN-NPI level if this measure is applied to individual clinicians, completing an evaluation of the costs within the context of the quality of care provided, exploring different benchmarking approaches for cost measures (e.g., outliers) and removing Part D prescription drug costs.

References:

Health disparities in rheumatoid arthritis

Socioeconomic Disparities in Functional Status in a National Sample of Patients With Rheumatoid Arthritis

Care Disparities Persist Among White, Minority Patients With Rheumatoid Arthritis

The American Medical Association (AMA) continues to have concerns with this measure and strongly encourages CMS to clarify its numerator. Specifically, this numerator defines the vaccination status as whether a patient is up-to-date on his or her COVID-19 vaccinations as defined by the CDC but does not provide any additional guidance on how to determine “up-to-date.” This vague definition could negatively impact the reliability and validity of the measure and a standardized way to collect this information must be made available. Until testing of the measure with precise specifications is completed, we believe that this measure should not be implemented in the Merit-Based Incentive Payment System (MIPS). 

While physicians are responsible for educating their patients on the importance of vaccination, we do not support a measure that holds physicians accountable for patient vaccine hesitancy or refusal.  

While the American Medical Association (AMA) supports the intent of this measure, we do not believe that the implementation in the Medicare Shared Savings Program (MSSP) is appropriate, particularly since the Screening for Social Drivers of Health (SDOH) measure has never been include on the Measures Under Consideration (MUC) List for that program. Considering a measure that requires the results of that screening is premature.  We also question the relevance of the measure as specified to an accountable care organization (ACO) given not every ACO has an established relationship with a hospital nor is it clear why the measure would be solely limited to that population. 

In addition, measures must be evidence-based and facilitate improvements in patient care. Unfortunately, the developer did not provide any evidence to support the five social needs nor did they sufficiently justify the requirement that an ACO must connect a patient with a community services provider on at least one need within 60 days following hospital discharge. The measure must be supported by evidence and should align with the work of the Health Level 7 Gravity Project and the United States Core Data for Interoperability (USCDI). In addition, the measure itself is not yet tested to demonstrate reliability and validity since only data for two screening tools (which are not required) were provided and most of the information outlined is based on CMMI’s Accountable Health Communities project, which involved community health centers/health systems and therefore does not provide any information on how this measure would perform at the ACO level. 

The concerns with the narrowed focus of the measure, prioritization of this process over the initial screening, as well as the questions on this measure’s feasibility, reliability, and validity must be addressed prior to even considering it for this program. As a result, we believe that the PRMR recommendation should be “Do Not Recommend.”

While the American Medical Association (AMA) supports the intent of this measure, we do not believe that the implementation in the Medicare Shared Savings Program (MSSP) is appropriate, particularly since the Screening for Social Drivers of Health (SDOH) measure has never been include on the Measures Under Consideration (MUC) List for that program. Considering a measure that requires the results of that screening is premature.  We also question the relevance of the measure as specified to an accountable care organization (ACO) given not every ACO has an established relationship with a hospital nor is it clear why the measure would be solely limited to that population. 

Measures must be evidence-based and facilitate improvements in patient care. Unfortunately, the developer did not provide any evidence to support the five social needs nor did they sufficiently justify the requirement for an ACO to resolve at least one health-related social need within a twelve month timeframe after discharge from an inpatient stay. The measure must be supported by evidence and should align with the work of the Health Level 7 Gravity Project and the United States Core Data for Interoperability (USCDI). In addition, the measure itself is not yet tested to demonstrate reliability and validity since only data for two screening tools (which are not required) were provided and most of the information outlined is based on CMMI’s Accountable Health Communities project, which involved community health centers/health systems and therefore does not provide any information on how this measure would perform at the ACO level. 

The concerns with the narrowed focus of the measure, prioritization of this outcome over the initial screening, as well as the questions on this measure’s feasibility, reliability, and validity must be addressed prior to even considering it for this program. As a result, we believe that the PRMR recommendation should be “Do Not Recommend.”

The American Medical Association (AMA) does not support inclusion of this measure in the Hospital Inpatient Quality Reporting (IQR) program given our concerns with the underlying evidence for the expansion to 30 days post-discharge and scientific acceptability of this measure. We were unable to identify any evidence provided by the developers to support broadening this measure to 30 days following hospital discharge as the studies cited in the submission are limited to inpatient stays. In addition, testing demonstrated that reliability is 0.231 using the measure’s case minimum of 25 patients and it required roughly 600 patients to achieve a high level of reliability (0.70 at a minimum). Information around the rationale on why social risk factors were also not included in the risk model was not sufficient to justify their omission. As a result, the AMA believes that the PRMR recommendation should be “Do Not Recommend.”

The American Medical Association (AMA) has significant concerns with this proposed index and does not support its inclusion in the Hospital Inpatient Quality Reporting (IQR) program. The index only includes the seven readmission and two mortality measures, which does not provide a full picture of the care provided by a hospital. We do not believe that there is sufficient evidence to support the apparent assumption that readmissions and mortality alone can serve as indicators of disparities in care. Other measures could serve as better indicators of the degree to which there are disparities in the care provided by a hospital and as a result, we believe that further work is needed to answer this question. We appreciate that imputed race/ethnicity variable is no longer used but caution CMS on using the Area Deprivation Index given the emerging concerns around its limitations in discerning differences in some communities and for some social risk factors. Furthermore, no reliability or validity testing of the index using a scoring approach of the Within and Across Disparity Method results has been completed and testing results must be made available prior to implementation in any CMS program. As a result, the AMA believes that the PRMR recommendation should be “Do Not Recommend.”

The American Medical Association (AMA) supports the ongoing refinement of HCAHPS but also encourages CMS to ensure that implementation of multiple PROs does not result in survey fatigue. For example, does the collection of this survey lead patients to be less likely to complete other surveys? Should some of these questions replace existing items to reduce data collection burden? We believe that it is critical to understand the potential impact and burden that could be experienced from the patient’s perspective. While the data collection process and burden may seem reasonable for one measure, what is the potential long-term impact on patients, facilities, clinicians, and practices as more and more PRO-PMs are implemented?

Because CMS has not provided sufficient information on whether these new sub-measures should be added to the HCAHPS Survey measure for the Hospital Inpatient Quality Reporting (IQR) and Hospital Value-Based Purchasing (HVBP) Programs, we are unable to adequately comment on their potential inclusion. In previous years when new or replacement sub-measures were proposed (e.g., MUC16-263), CMS included details on the changes that would be made to the survey items and resulting sub-measures. On the December 15 Hospital Measures Listening Session, CMS staff indicated that changes beyond the inclusion of these three sub-measures were planned but that this information would not be made available until the next rulemaking cycle. We believe that this information is needed and should be shared with the Hospital Committee and publicly during this review.

The American Medical Association (AMA) supports the ongoing refinement of HCAHPS but also encourages CMS to ensure that implementation of multiple PROs does not result in survey fatigue. For example, does the collection of this survey lead patients to be less likely to complete other surveys? Should some of these questions replace existing items to reduce data collection burden? We believe that it is critical to understand the potential impact and burden that could be experienced from the patient’s perspective. While the data collection process and burden may seem reasonable for one measure, what is the potential long-term impact on patients, facilities, clinicians, and practices as more and more PRO-PMs are implemented?

Because CMS has not provided sufficient information on whether these new sub-measures should be added to the HCAHPS Survey measure for the Hospital Inpatient Quality Reporting (IQR) and Hospital Value-Based Purchasing (HVBP) Programs, we are unable to adequately comment on their potential inclusion. In previous years when new or replacement sub-measures were proposed (e.g., MUC16-263), CMS included details on the changes that would be made to the survey items and resulting sub-measures. On the December 15 Hospital Measures Listening Session, CMS staff indicated that changes beyond the inclusion of these three sub-measures were planned but that this information would not be made available until the next rulemaking cycle. We believe that this information is needed and should be shared with the Hospital Committee and publicly during this review.

The American Medical Association (AMA) supports the ongoing refinement of HCAHPS but also encourages CMS to ensure that implementation of multiple PROs does not result in survey fatigue. For example, does the collection of this survey lead patients to be less likely to complete other surveys? Should some of these questions replace existing items to reduce data collection burden? We believe that it is critical to understand the potential impact and burden that could be experienced from the patient’s perspective. While the data collection process and burden may seem reasonable for one measure, what is the potential long-term impact on patients, facilities, clinicians, and practices as more and more PRO-PMs are implemented?

Because CMS has not provided sufficient information on whether these new sub-measures should be added to the HCAHPS Survey measure for the Hospital Inpatient Quality Reporting (IQR) and Hospital Value-Based Purchasing (HVBP) Programs, we are unable to adequately comment on their potential inclusion. In previous years when new or replacement sub-measures were proposed (e.g., MUC16-263), CMS included details on the changes that would be made to the survey items and resulting sub-measures. On the December 15 Hospital Measures Listening Session, CMS staff indicated that changes beyond the inclusion of these three sub-measures were planned but that this information would not be made available until the next rulemaking cycle. We believe that this information is needed and should be shared with the Hospital Committee and publicly during this review.

The American Medical Association (AMA) supports the ongoing refinement of HCAHPS but also encourages CMS to ensure that implementation of multiple PROs does not result in survey fatigue. For example, does the collection of this survey lead patients to be less likely to complete other surveys? Should some of these questions replace existing items to reduce data collection burden? We believe that it is critical to understand the potential impact and burden that could be experienced from the patient’s perspective. While the data collection process and burden may seem reasonable for one measure, what is the potential long-term impact on patients, facilities, clinicians, and practices as more and more PRO-PMs are implemented?

Because CMS has not provided sufficient information on whether these new sub-measures should be added to the HCAHPS Survey measure for the Hospital Inpatient Quality Reporting (IQR) and Hospital Value-Based Purchasing (HVBP) Programs, we are unable to adequately comment on their potential inclusion. In previous years when new or replacement sub-measures were proposed (e.g., MUC16-263), CMS included details on the changes that would be made to the survey items and resulting sub-measures. On the December 15 Hospital Measures Listening Session, CMS staff indicated that changes beyond the inclusion of these three sub-measures were planned but that this information would not be made available until the next rulemaking cycle. We believe that this information is needed and should be shared with the Hospital Committee and publicly during this review.

While the American Medical Association (AMA) supports the intent of this measure to begin to address the social drivers that can also impact an individual’s health outcomes, we do not believe that the implementation of this process measure in the Hospital Outpatient Quality Reporting (OQR) program, in the absence of any resources or tools that would be widely and readily available to hospitals, should be pursued at this time. Measures must be actionable and facilitate improvements in patient care. While all hospitals can identify and facilitate addressing social needs, they cannot and should not be held responsible for resolving them. Other strategies such as stratification of populations by race, ethnicity, and social drivers of health should be employed. 

This measure has now been proposed for multiple programs over the last three years and yet no new information on the feasibility, reliability, and validity have been provided, which were some of the conditions placed by the Measures Applications Partnership (MAP). It also remains unclear how CMS plans to address the additional conditions from the MAP around additional details on how potential resources, tools, and best practices map to the individual drivers.   

The developer has not provided any evidence to demonstrate that the collection of these data alone will drive improvements in health outcomes nor is it is clear why the developer selected the specific social drivers of health for this measure. The measure must be supported by evidence and should align with the work of the Health Level 7 Gravity Project and the United States Core Data for Interoperability (USCDI). We believe that many of these discrepancies would be resolved if the measure was fully specified and demonstrated to be evidence-based, feasible, reliable, and valid. 

Because we do not believe that this measure will result in effective change, we believe that the PRMR recommendation should be “Do Not Recommend.”

While the American Medical Association (AMA) supports the intent of this measure to begin to address the social drivers that can also impact an individual’s health outcomes, we do not believe that the implementation of this process measure in the Hospital Outpatient Quality Reporting (OQR) program, in the absence of any resources or tools that would be widely and readily available to hospitals, should be pursued at this time. Measures must be actionable and facilitate improvements in patient care and a measure that only reports the rate of positive screens does not represent the quality of care provided by a hospital. While all hospitals can identify and facilitate addressing social needs, they cannot and should not be held responsible for resolving them. Other strategies such as stratification of populations by race, ethnicity, and social drivers of health should be employed. 

This measure has now been proposed for multiple programs over the last three years and yet no new information on the feasibility, reliability, and validity have been provided, which were some of the conditions placed by the Measures Applications Partnership (MAP). It also remains unclear how CMS plans to address the additional condition from the MAP around how the results of this measure in particular will be shared and contextualized for public reporting.   

The developer has not provided any evidence to demonstrate that the collection of these data alone will drive improvements in health outcomes nor is it is clear why the developer selected the specific social drivers of health for this measure. The measure must be supported by evidence and should align with the work of the Health Level 7 Gravity Project and the United States Core Data for Interoperability (USCDI). In addition, the measure itself is not yet tested. We believe that many of these discrepancies would be resolved if the measure was fully specified and demonstrated to be evidence-based, feasible, reliable, and valid. 

Because we do not believe that this measure will result in effective change, we believe that the PRMR recommendation should be “Do Not Recommend.”

The American Medical Association (AMA) supports the assessment of patient-reported outcomes (PROs) and the focus of this patient-reported outcome performance measure (PRO-PM) but we encourage CMS to ensure that the implementation of multiple PROs does not result in survey fatigue. For example, does the collection of this survey lead patients to be less likely to complete other surveys such as OAS CAHPS? Are these questions better suited to be included as supplemental items on an existing survey to reduce data collection burden? We believe that it is critical to understand the potential impact and burden that could be experienced from the patient’s perspective. While the data collection process and burden may seem reasonable for one measure, what is the potential long-term impact on patients, facilities, clinicians, and practices as more and more PRO-PMs are implemented?

We also encourage CMS to continue to evaluate the feasibility, reliability, and validity of this measure across a diverse set of facilities beyond the 15 testing sites. For example, the current testing produced a minimum reliability level of 0.572 and we believe that a high level of reliability (0.70 at a minimum) should be achieved and additional validity testing beyond correlations against OAS CAHPS is needed. As a result, we believe that the PRMR recommendation should be “Recommend with Conditions.”

While the American Medical Association (AMA) supports the integration of health equity strategies and initiatives throughout an ambulatory surgical center’s leadership and the entity’s overall structure and practices, we do not believe that the development of a structural measure, particularly one that primarily looks for the presence of equity-focused documents, in the absence of any demonstrated linkage to improvement in patient outcomes should be pursued. This approach could increase administrative burden to report a measure that does not drive the improvements we all desire and would be one that will top out quickly. We encourage CMS to shift focus from developing this type of measure and target those measures, initiatives, and activities that prioritize the collection and reporting of additional relevant disparities data and promote interventions that address them. 

We strongly believe that initiatives or programs that are considered to address inequities are best addressed through small pilots and tests and rolled out through a scaled approach and not within national accountability programs. As a part of the AMA’s efforts to reduce health care inequities, we are currently in the process of developing a collaborative with health systems across the country that will leverage data-driven approaches to confront and overcome health disparities. The program design will drive equity in health care by leveraging the foundational concepts of quality and safety improvement practices and making equity improvement an integral part of health care practice. The key objectives cross domains from patient care to operations to quality initiatives to culture and education. The framework to guide the AMA’s work is based on five key drivers: 

• Driver 1: Integrate Equity into all Quality, Safety and Risk Analyses 
• Driver 2: Use Equity-Informed High-Reliability Education 
• Driver 3: Use Data to Support Equity Improvement 
• Driver 4: Leadership Awareness and Engagement 
• Driver 5: Organizational Accountability to Stakeholders 

As we continue to collaborate with health systems to test this framework and determine any unintended consequences, the AMA continues to support efforts to pilot test innovative strategies to improve health equity and reduce disparities. Because we do not believe that a structural measure at the national level will result in effective change, we believe that the PRMR recommendation should be “Do Not Recommend.”

While the American Medical Association (AMA) supports the integration of health equity strategies and initiatives throughout a hospital’s leadership and the entity’s overall structure and practices, we do not believe that the development of a structural measure, particularly one that primarily looks for the presence of equity-focused documents, in the absence of any demonstrated linkage to improvement in patient outcomes should be pursued. This approach could increase administrative burden to report a measure that does not drive the improvements we all desire and would be one that will top out quickly. We encourage CMS to shift focus from developing this type of measure and target those measures, initiatives, and activities that prioritize the collection and reporting of additional relevant disparities data and promote interventions that address them. 

We strongly believe that initiatives or programs that are considered to address inequities are best addressed through small pilots and tests and rolled out through a scaled approach and not within national accountability programs. The AMA continues to support efforts to pilot test innovative strategies to improve health equity and reduce disparities. Because we do not believe that a structural measure at the national level will result in effective change, we believe that the PRMR recommendation should be “Do Not Recommend.”

While the American Medical Association (AMA) supports the ongoing focus of improving patient safety, including targeting a hospital’s leadership and the entity’s overall structure and practices, we do not believe that the development of a structural measure, particularly one that primarily looks for the presence of patient safety-focused documents, in the absence of any demonstrated linkage to improvement in patient outcomes should be pursued. CMS continues to put forward these structural measures that require only “yes/no” attestation that specific requirements are met with the inaccurate assumption that this approach does not increase administrative burden and that there are gaps to be addressed. We believe that there are many activities already integrated into a hospital’s structures and processes including actively engaging patients and families in activities such as a Patient and Family Advisory Council, reporting to a Patient Safety Organization, participating in large-scale learning networks, and tracking progress on safety metrics against external benchmarks. As a result, reporting on this measure will likely lead to overall high performance quickly and it remains unclear the extent to which attesting to these domains has a direct link in increasing the quality and safety of the care delivered within a hospital. We encourage CMS to shift focus from developing this type of measure and target those measures, initiatives, and activities that prioritize the collection and reporting of additional relevant safety data and promote interventions that address them. We believe that the PRMR recommendation should be “Do Not Recommend.”

While the American Medical Association (AMA) supports the intent of this measure, we do not believe that the implementation of this process measure at the hospital level in the Hospital Inpatient Quality Reporting (IQR) program is appropriate, particularly due to the absence of any resources or tools that would be widely and readily available. Measures must be evidence-based and facilitate improvements in patient care. Unfortunately, the developer did not provide any evidence to support the five social needs nor did they sufficiently justify the requirement to connect a patient with a community services provider on at least one need within 60 days following hospital discharge. The measure must be supported by evidence and should align with the work of the Health Level 7 Gravity Project and the United States Core Data for Interoperability (USCDI). In addition, the measure itself is not yet tested to demonstrate reliability and validity since only data for two screening tools (which are not required) were provided and most of the information outlined is based on CMMI’s Accountable Health Communities project, which involved community health centers/health systems and therefore does not provide any information on how this measure would perform at the hospital level. 

Hospitals are actively reviewing the specifications and evaluating the feasibility of implementing the Screening for Social Drivers of Health measure. Many are reporting challenges around its implementation, particularly due to the lack of adequate specifications or assurances that the performance scores that result will be reliable and valid. These challenges as well as the questions on this measure’s feasibility, reliability, and validity must be addressed prior to even considering it for this program. As a result, we believe that the PRMR recommendation should be “Do Not Recommend.”

While the American Medical Association (AMA) supports the intent of this measure, we do not believe that the implementation of this process measure at the hospital level in the Hospital Inpatient Quality Reporting (IQR) program is appropriate, particularly due to the absence of any resources or tools that would be widely and readily available. Measures must be evidence-based and facilitate improvements in patient care. Unfortunately, the developer did not provide any evidence to support the five social needs nor did they sufficiently justify the requirement to resolve at least one health-related social need within a twelve month timeframe after discharge from an inpatient stay. The measure must be supported by evidence and should align with the work of the Health Level 7 Gravity Project and the United States Core Data for Interoperability (USCDI). In addition, the measure itself is not yet tested to demonstrate reliability and validity since only data for two screening tools (which are not required) were provided and most of the information outlined is based on CMMI’s Accountable Health Communities project, which involved community health centers/health systems and therefore does not provide any information on how this measure would perform at the hospital level. 

Hospitals are actively reviewing the specifications and evaluating the feasibility of implementing the Screening for Social Drivers of Health measure. Many are reporting challenges around its implementation, particularly due to the lack of adequate specifications or assurances that the performance scores that result will be reliable and valid. These challenges as well as the questions on this measure’s feasibility, reliability, and validity must be addressed prior to even considering it for this program. As a result, we believe that the PRMR recommendation should be “Do Not Recommend.”

Johnson & Johnson supports meaningful patient-centered care planning measures that promote patient well-being and comprehensive, shared decision making; therefore, we agree with the implementation of this measure to improve appropriate and timely inpatient treatment of malnutrition.   

Johnson & Johnson believes in equitable care for all patients. Patient self-reported surveys represent a valuable tool for patients to properly communicate about the quality of their experience. J&J encourages the use of measures that capture patient goals, especially in areas of high clinical acuity. This measure is necessary for patients to properly convey and document their life goals with dialysis care providers, as well as goals outside of health and safety related to the patient’s quality of life. 

Johnson & Johnson supports this measure, as it enables hospitals to better identify and work toward closing gaps in health equity. 

Johnson & Johnson supports this measure for inclusion in MIPS.  We concur that appropriate biomarker testing prior to the initiation of therapy leads to better therapeutic approaches, with appropriate agents being selected more frequently, leading to better patient outcomes.  

Johnson & Johnson encourages the development and implementation of additional metrics that encourage evidence-based cancer care. For example, we recommend future measures aligned to National Comprehensive Cancer Network Oncology Guidelines which advocate for broad molecular profiling as a key component in the improvement of care of patients with non-small cell lung cancer and recommend completing biomarker assessment prior to therapy initiation, when clinically feasible. (Ettinger DS, Wood DE, Aisner DL, et al. NCCN guidelines insights: non‐small cell lung cancer. J Natl Compr Canc Netw. 2021;19:254‐266). 

Johnson & Johnson supports meaningful patient-centered experience and care planning measures that promote patient well-being and comprehensive shared decision making. Therefore, we support the concepts and direction of these patient experience hospital performance sub-measures on care coordination, restfulness of hospital environment, responsiveness of hospital staff, and information about symptoms. These measures are an important addition to hospital quality programs because they align with CMS’ goal of fostering engagement and bringing patient voices to the forefront. 

Johnson & Johnson supports meaningful patient-centered experience and care planning measures that promote patient well-being and comprehensive shared decision making. Therefore, we support the concepts and direction of these patient experience hospital performance sub-measures on care coordination, restfulness of hospital environment, responsiveness of hospital staff, and information about symptoms. These measures are an important addition to hospital quality programs because they align with CMS’ goal of fostering engagement and bringing patient voices to the forefront. 

Johnson & Johnson supports meaningful patient-centered experience and care planning measures that promote patient well-being and comprehensive shared decision making. Therefore, we support the concepts and direction of these patient experience hospital performance sub-measures on care coordination, restfulness of hospital environment, responsiveness of hospital staff, and information about symptoms. These measures are an important addition to hospital quality programs because they align with CMS’ goal of fostering engagement and bringing patient voices to the forefront. 

Johnson & Johnson supports meaningful patient-centered experience and care planning measures that promote patient well-being and comprehensive shared decision making. Therefore, we support the concepts and direction of these patient experience hospital performance sub-measures on care coordination, restfulness of hospital environment, responsiveness of hospital staff, and information about symptoms. These measures are an important addition to hospital quality programs because they align with CMS’ goal of fostering engagement and bringing patient voices to the forefront. 

Johnson & Johnson is supportive of expanding the use of this measure to the ASCQR; Hospital OQR Program; REHQR programs. CMS has successfully implemented this measure within other programs. For example, CMS’ Enhancing Oncology Model (EOM) guides participants to collect data for health-related social needs with tools such as the Accountable Health Communities Health-Related Social Needs Screening Tool and the National Comprehensive Cancer Network’s Distress Thermometer and Problem List. Unmet social needs impact the health and well-being of many Medicare beneficiaries. Social needs contribute to and often exacerbate health disparities if not identified and mitigated (1,2). We concur that reducing health disparities and advancing health equity requires addressing the underlying health-related social needs such as challenges in obtaining proper nutrition during chemotherapy treatment, access to transportation for infusion appointments, and financial toxicity in chemotherapy cost, and we support this measure.  

1. AACR Cancer Disparities Progress Report. (2020). American Association for Cancer Research. Retrieved from: https://cancerprogressreport.aacr.org/wp-content/uploads/sites/2/2020/09/AACR_CDPR_2020.pdf  
2. Anderson, J.K.E., Jain, P., Wade, A., Morris, A.M, Slaboda, J.C., Norman, G.J. (2020). Indicators of Potential Health-Related Social Needs and the Association with Perceived Health and Well-Being Outcomes Among Community-Dwelling Medicare Beneficiaries. Quality of Life Research.  

Johnson & Johnson supports this measure for inclusion in MIPS to increase germline testing and ensure that correct therapy is initiated for identified genetic variations.  Approximately 15% of patients with ovarian cancer have a germline BRCA (gBRCA) variation (1), which has important implications, including increased sensitivity to platinum-based chemotherapy and poly(ADP-ribose) polymerase inhibitors and improved survival (2). We support the development and implementation of additional measures that encourage providers to follow evidence-based precision medicine. 

1. Norquist  BM, Harrell  MI, Brady  MF,  et al.  Inherited mutations in women with ovarian carcinoma.   JAMA Oncol. 2016;2(4):482-490. doi:10.1001/jamaoncol.2015.5495  
2. Yang  D, Khan  S, Sun  Y,  et al.  Association of BRCA1 and BRCA2 mutations with survival, chemotherapy sensitivity, and gene mutator phenotype in patients with ovarian cancer.   JAMA. 2011;306(14):1557-1565. doi:10.1001/jama.2011.1456  

Johnson & Johnson supports this measure. COVID-19 continues to be a major driver of hospitalizations and deaths(1), particularly among the elderly and the immunocompromised. Further, recent uptake of the new bivalent boosters in the adult population is significantly below recommended rates. According to a Kaiser Family Foundation report from March 2023, slightly less than a quarter (23%) of adults reported they have received the bivalent booster(2). This measure will encourage health plans and providers to promote uptake of COVID vaccination. 

1. CDC MMWR. https://www.cdc.gov/mmwr/volumes/72/wr/mm7218a3.htm?s_cid=mm7218a3_w%20[cdc.gov]. Accessed, December 14, 2023.  
2. Kaiser Family Foundation: https://www.kff.org/coronavirus-covid-19/dashboard/kff-covid-19-vaccine-monitor-dashboard. Accessed, December 14,2023. 

Johnson & Johnson supports the implementation of this measure across multiple CMS quality and performance programs. J&J supports the implementation of this measure because it encourages providers to identify and close gaps in SDOH to attenuate the health impacts of unmet social needs. 

Johnson & Johnson supports this measure, which encourages facility commitment to improving health equity through substantive changes to infrastructure, policy and capabilities. However, commitment to health equity is evidenced by the actions of the organization, and these may or may not be effectively captured through attestations of those actions through this measure. The evidence for the effectiveness of attestation has an analogue in Meaningful Use (MU) attestation. Researchers have performed validation of attestation using difference in difference analyses that suggest that MU attestation correlates to better care quality and cost efficiency, but does not correlate to PSI-90 scores, suggesting that hospitals did not see improvements in patient safety (1). While J&J is supportive of this measure, we ask CMS to conduct an analysis on the effectiveness of attestation through this measure to actually closing equity gaps to allow for optimal effectiveness.   

1. Trout KE, Chen LW, Wilson FA, Tak HJ, Palm D. The Impact of Meaningful Use and Electronic Health Records on Hospital Patient Safety. Int J Environ Res Public Health. 2022 Sep 30;19(19):12525. doi: 10.3390/ijerph191912525. PMID: 36231824; PMCID: PMC9564815. 

Johnson & Johnson supports this measure, which encourages hospital commitment to improving health equity through substantive changes to infrastructure, policy and capabilities. However, commitment to health equity is evidenced by the actions of the organization, and these may or may not be effectively captured through attestations of those actions through this measure. The evidence for the effectiveness of attestation has an analogue in Meaningful Use (MU) attestation. Researchers have performed validation of attestation using difference in difference analyses that suggest that MU attestation correlates to better care quality and cost efficiency, but does not correlate to PSI-90 scores, suggesting that hospitals did not see improvements in patient safety (1). While J&J is supportive of this measure, we ask CMS to conduct an analysis on the effectiveness of attestation through this measure to actually closing equity gaps to allow for optimal effectiveness.   

1. Trout KE, Chen LW, Wilson FA, Tak HJ, Palm D. The Impact of Meaningful Use and Electronic Health Records on Hospital Patient Safety. Int J Environ Res Public Health. 2022 Sep 30;19(19):12525. doi: 10.3390/ijerph191912525. PMID: 36231824; PMCID: PMC9564815. 

Johnson & Johnson supports meaningful patient-centered experience and care planning measures that promote patient well-being and comprehensive, shared decision making. Therefore, we agree with the implementation of a patient reported outcome measure on chemotherapy related fatigue. However, we also encourage the incorporation of treatment-related risk adjustment accounting for effectiveness of chemotherapy treatment and survey questions to promote care-planning aiming to prevent treatment related fatigue exacerbation. Without these additional components to the measure, the measure may promote treatment decisions focused on fatigue minimization as opposed to treatment effectiveness.  

Johnson & Johnson is supportive of this measure because it helps to address the health-related social needs of beneficiaries and improve health equity. We are also mindful that increasing referral to community service providers should be accompanied by efforts to ensure that communities and providers are adequately resourced to address the social needs of the referrals they receive.