Comment and Recommendations for CMS-10209 - Medicare Advantage Quality Improvement Project Reporting Template and Chronic Care Improvement Program Reporting Template

March 14, 2007

Carolyn Lovett

OMB Human Resources and Housing Branch

Fax: 202-395-6974

Subject: Comment and Recommendations for CMS-10209 - Medicare Advantage Quality Improvement Project Reporting Template and Chronic Care Improvement Program Reporting Template

CMS has received and responded to industry comments received during the public comment period for approval of CMS-10209 (Quality Improvement Project reporting template and Chronic Care Improvement Program reporting template).

Eleven (11) comments were received for the QIP reporting template. CMS’ response to each comment and subsequent action is provided in attachment 1.

While no official comments were received during public comment for the CCIP reporting template, some minor clarifications were added to the template. These changes are provided in attachment 2.

If you have questions about these changes, please contact Shaheen Halim, Ph.D. at (410) 786-0641, or via e-mail at Shaheen.halim@cms.hhs.gov

Attachment 1:

Comments received on reporting template for Quality Improvement Projects

Comment 1

Submitted by: IPRO, Delmarva, Lumetra

Page 2 , #5 - Project Focus Area Type: add “… and describe” to directions. In the past, at times, it was difficult for the reviewers to determine how the project topic related to the selected focus area. An explanation would help the reviewers better understand the project focus.

CMS Response to Comment 1: CMS agrees with the comment, and has made these changes accordingly.

Comment 2

Submitted by: IPRO, Delmarva, Lumetra

Page 2, #6&7 - Delete “Aspect of Clinical Care” and “Non Clinical Focus Area” items: . In the past, these did not add any value or information to the project report, and were sometimes confusing. (This assumes a description would be added above) .

CMS Response to Comment 2: CMS agrees with the comment, and has deleted these two items. Subsequent items were renumbered.

Comment 3

Submitted by: IPRO, Delmarva, Lumetra

Page 2, #8 - Delete “Describe Target Population”: This appears to be repetitive of the information in the indicator description.

CMS Response to Comment 3: CMS disagrees with the comment, and has chosen to keep this item. CMS believes that the item provides a validity check for the indicators. A description of the Target Population provides insight into whether the MAO accomplished measuring what they intended to measure with the indicators chosen.

Comment 4

Submitted by: IPRO, Delmarva, Lumetra

Page 3 & 4: Reorder D & E - Better reflects the natural order of project conduct – indicators selected/developed. Then data collection begins.

CMS Response to Comment 4: CMS agrees with the comment, and has reordered these two sections.

Comment 5

Submitted by: IPRO, Delmarva, Lumetra

Page 3: Under Data Sources and Collection Methodology, Add check boxes for HEDIS, CAHPS and HOS collection methodologies. Rationale: For review, if the plan uses only audited HEDIS, CAHPS, HOS data and methodology, the documentation requirements are less, and the data is automatically scored as valid.

CMS Response to Comment 5: CMS agrees with the comment, and has added checkboxes for these standardized collection methodologies. The following language was also added to the instructions for the item: “(skip section if indicators used are from standard HEDIS, CAHPS and HOS collections).”

Comment 6

Submitted by: IPRO, Delmarva, Lumetra

Page 3: Describe Changes in Data Collection Methodology: Precede this with “describe baseline data collection methodology”. Rationale: In order to effectively evaluate the project, it is important for the reviewers to understand the baseline methodology, as well as any changes during remeasurement.

CMS Response to Comment 6: CMS agrees with the comment, and has made these changes accordingly.

Comment 7

Submitted by: IPRO, Delmarva, Lumetra

Page 4: Quality Improvement Indicators : Add check boxes for HEDIS, CAHPS and HOS collection methodologies. Rationale: For review, if the plan uses only audited HEDIS, CAHPS, HOS data and methodology, the documentation requirements are less, and the data is automatically scored as valid.

CMS Response to Comment 7: CMS agrees with the comment, and has made these changes accordingly. The following wording was also added to the instructions for the item: “If HEDIS, CAHPS or HOS is checked, plans do not need to complete items #2 through #5 for the indicator.”

Comment 8

Submitted by: IPRO, Delmarva, Lumetra

Page 4: On the “Results” table, include columns for eligible population and exclusions. Rationale: It is important to know the eligible population, as well as the number exclusions, when assessing the validity and reliability of the reported rates.

CMS Response to Comment 8: Recommendation Accepted. Columns for “eligible population size” and “number of exclusions” have been added to the Results table.

Comment 9

Submitted by: IPRO, Delmarva, Lumetra

Page 5 – Section F #2: Indicate that this item is optional. Rationale: In the prior, QAPI version, this item was optional, as it was not required by QISMC standards.

CMS Response to Comment 9: Recommendation Accepted. The item is now designated as optional.

Comment 10

Submitted by: IPRO, Delmarva, Lumetra

Page 5: External Consultation/Delegation – remove plural ‘s’ from Quality Improvement Organization(s). Rationale: There is only one CMS designated QIO assigned to each state

CMS response to Comment 10: Recommendation Accepted. The change was made.

Comment 11

Submitted by: IPRO, Delmarva, Lumetra

Page 7: Make the Lessons Learned section Optional. Rationale: In the prior, QAPI version, this item was optional, as it was not required by QISMC standards.

CMS Response to Comment 11: Recommendation Accepted. The section is now designated as optional.

Attachment 2:

Edits & Clarifications incorporated into the reporting template for Chronic Care Improvement Programs

1) On Page 2, Section C, items 3 & 4, the following clarifying text was added at the end of each item to assist in evaluation of the program:

Specify numbers (including percentage of population) for each of your targeted chronic diseases/conditions. Also specify whether these numbers reflect unique enrollees, or whether enrollees with multiple conditions may be counted more than once.

2) On Page 2, Section C, item 5 the following clarifying words were added: “… new and existing …”

3) On Page 2, Section C, item 7: the following table was added to make the descriptions more uniform and systematic:

Complete the table below for each of your targeted chronic diseases/conditions.

Chronic Disease/Condition	Prevalence Rate in your MA population	Brief rationale for targeting the Chronic Disease/Condition

4) The following new item was added under Section C, as item #8 in order to assist reviewers evaluating the program with additional detail:

List and Describe the data sources used to determine that a CCIP was needed for the conditions selected (e.g., rates of inpatient utilization, ER utilization, clinical performance measures such as HbA1c levels , etc.).

5) In section D, what was previously item 1 was split into two items in order to avoid confusion.:

1. Describe each intervention/strategy used in this program to improve the coordination of care of participants. Indicate dates of initiation and completion/expected completion for each intervention or whether the intervention is ongoing. Describe any barriers that the interventions are meant to address.

2. Describe each intervention/strategy used in this program to improve the health status of participants. Indicate dates of initiation and completion/expected completion for each intervention or whether the intervention is ongoing. Describe any barriers that the interventions are meant to address.

6) For Section E item 2, and Section F items 1 & 2, the following clarifying text was added: “Do this for each of your targeted chronic conditions/diseases.”