Maqro

To: Bonnie L Harkless
Room C4-26-05
7500 Security Boulevard
Baltimore, Maryland 21244-1850
Per instructions from Shaheen Halim, I have enclosed a copy of Comment and Recommendations for
CMS-10209 submitted to OMB from the MAQRO teams.
This document has also been sent to Carolyn Lovett via fax: 202-395-6974.
Thank you,
Laura Stewart
Lumetra
415-677-2131

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Quality Review Organization

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January 5,2007

To: OMB Human Resources and Housing Branch
Attention: Carolyn Lovett
Delivered via Fax: 202-395-6974
Subject: Comment and Recommendationsfor CMS-10209 - Medicare Advantage Quality
lmprovement Project ReportingTemplate and Chronic Care lmprovement Program Reporting
Tern plate

The Medicare Advantage Quality Review Organization (MAQRO) is pleased to provide comments to
the Centers for Medicare & Medicaid Services (CMS) on CMS-10209.
MAQRO is contracted by CMS to provide evaluation and consultation expertise to assess the quality
and outcomes of the Medicare Advantage (MA) quality improvement projects (QIP)and chronic care
improvement programs (CCIP). Additionally, MAQRO is charged with supporting CMS in the
development and implementation of QIP/CCIP tools and protocols. MAQRO consists of teams from
three Quality lmprovement Organizations (QlOs)- Delmarva, IPRO, and Lumetra. These QlOsfirst
began work under the MAQRO (formerly Medicare+Choice Quality Review Organizations (M+CQROs),
contract in 2000: the comments below are based on their experience developing tools and
protocols, and evaluating over 600 MA quality improvement project reports.
MAQROoffers recommendations pertaining to the following specific areas:
Medicare Advantage Quality lmprovement Project Reporting Template OMB #0938
Item and Suggested Edit
Comments/Rationale
Page
#
In the past, at times, it was difficult
B - #5 - Project Focus Area Type
2
for the reviewers to determine how
(Select all that apply)
the project topic related to the
Add "...and describe"
selected focus area. An explanation
would help the reviewers better
understand the project focus.
2
B - #6 Aspect of Clinical Care
In the past, these did not add any
value or information to the project
B - #7 Non-Clinical Focus Area
report, and were sometimes
Delete these items
confusing. (This assumes a
description would be added above)
This appears to be repetitive of the
2
B - #8 Describe target population
information in the indicator
Delete this item
description.
3
Better reflects the natural order of
D. Data Sources and Collection Methodology
project conduct - indicators
4
E. Quality Improvement Indicators
selected/developed, then data
Reorder these collection begins.
D. Quality Improvement Indicators
E. Data Sources and Collection Methodolorn

Medicare Advantage Quality lmprovement Project Reporting Template OMB #0938
Page
Item and Suggested Edit
Comments/Rationale
#
D. Data Sources and Collection Methodology
For review, if the plan uses only
3
audited HEDIS, CAHPS, HOS data and
Above item #1, Add check boxes for:
methodology, the documentation
HEDIS (Administrative) Yr:requirements are less, and the data
HEDIS (Hybrid) Y r : , CAHPS YR:-,
is
automatically scored as valid.
HOS YR:-,
OTHER
Also add: Plans do not have to complete
questions 1-4 of this section if HEDIS, CAHPS or
HOS is checked.
D - # 4 - Describe changes in data collection
methodology
Change # 4 to "Describe the baseline data
collection methodology, collection periods,
sampling, sample size, and efforts to assure
reliability and validity"
Renumber the current # 4 to #5 "Describe any
changes in data collection methodology..."
E. Quality- Improvement
Indicators
.
Above #1, add check boxes for:
HEDIS (Administrative) HEDIS (Hybrid), CAHPS,
HOS, OTHER

4

F Results
Include columns for "Eligible Population" and
"Exclusions"

5

F-#2
Indicate that this item is optional

5

H. External Consultation and Delegation
Typo - "the Quality Improvement
Organization(s)/QIO in your state?
Remove plural (s)
I. Lessons Learned
Indicate that this item is optional

7

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.

For review, if the plan uses only
audited HEDIS, CAHPS, HOS data and
methodology, the documentation
requirements are less, and the data
is automaticallv scored as valid.
It is important to know the eligible
population, as well as the number
exclusions, when assessing the
validity and reliability of the reported
rates.
In the prior, QAPl version, this item
was optional, as it was not required
by QlSMCstandards.
'There is only one CMS designated
QIO assigned to each state

In the prior, QAPl version, this item
was optional, as it was not required
by QlSMC standards.

Medicare Advantage Chronic Care lmprovement Program Reporting Template (CCIP) OMB #0938
Page #

Suggested edit
No suggestions

Comments/Rationale

Submitted by: Marci Kramer, Delmarva - kramerm@dfmc.org;Janice Acar, IPRO - jacar@ipro.org;
Laura Stewart, Lumetra - Istewart@caaio.sd~s.org
CC: Bonnie L. Harkless
CMS, Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development - C; Room C4-26-05
7500 Security Boulevard, Baltimore, MD 21244-1850