CMS Memo to OMB re: PQRS ICR package

To: OMB

From: CMS/CCSQ

Re: 2013 PRA Package for the PQRS (CMS-10276, OCN 0938-1059)

Date: July 25, 2014

PRA Package for the PQRS:

Revisions based on the Requirements Established in the CY 2014 PFS Final Rule

On Thursday, July 17, 2014, a conference call occurred to discuss the PQRS PRA package related to the CY 2014 PFS Final Rule. OMB requested the following additional information to aid in its review of the PRA package.

1. Public comments that do not specifically address the PRA package but nonetheless relate to changes we are making in the PRA package due to changed reporting criteria:

We reviewed the CY 2014 PFS final rule and believe the following comments address the changes we discuss in the PRA package. These comments can be found starting on 78 FR 74458:

The majority of commenters opposed our proposal to increase the number of measures to be reported via registry from 3 measures covering 1 NQS domain to 9 measures covering 3 NQS domains. Several of these commenters generally opposed any proposal that would increase the number of measures to be reported via registry from 3 measures covering 1 NQS domain. Some of these commenters noted that they have been successful at meeting the criteria for satisfactory reporting in the PQRS in the past, and increasing the number of measures to be reported would make it more difficult for these eligible professionals to meet the criteria for satisfactory reporting for the 2014 PQRS incentive. Other commenters urged CMS not to increase the criteria for satisfactory reporting until participation in PQRS increases, as the commenters feared that increasing the criteria for satisfactory reporting in PQRS would discourage eligible professionals from participating in the PQRS. Still some of these commenters opposing this proposal noted that certain eligible professionals did not have 9 measures covering 3 NQS domains for which to report.

While several commenters generally supported our proposal to increase the number of measures to be reported, the commenters urged CMS to provide a more gradual approach to increasing the number of measures that must be reported via registry. These commenters suggested requiring the reporting of either 4 measures covering at least 1 NQS domain, 5 measures covering at least 2 NQS domains, or 6 measures covering at least 2 NQS domains.

CMS Response: We finalized our proposal to require the reporting of 9 measures covering 3 domains despite these comments, as we believed the reporting of more measures would provide a better picture of the overall quality of care being provided to a patient. We are, however, allowing those EPs who cannot find at least 9 measures covering 3 domains to report less than 9 measures and still meet the criteria for satisfactory reporting, provided that these EPs report on as many measures as are applicable to their practice. To check to see whether these EPs reported on as many measures as can be reported, we implemented a Measure Application Validation (MAV) process for registry, which is similar to the MAV process we used for claims. This MAV process allows us to check to see if there are any other measures for which an EP could have reported.

2. Information related to incorporation of measures in the PQRS:

We reviewed the CY 2014 PFS final rule and believe the following comments address our considerations for the selection of PQRS quality measures (beginning on 78 FR 74487):

Sections 1848(k)(2)(C) and 1848(m)(3)(C)(i) of the Act, respectively, govern the quality measures reported by individual eligible professionals and group practices reporting under the PQRS. Under section 1848(k)(2)(C)(i) of the Act, the PQRS quality measures shall be such measures selected by the Secretary from measures that have been endorsed by the entity with a contract with the Secretary under section 1890(a) of the Act (currently, that is the National Quality Forum, or NQF). However, in the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the NQF, section 1848(k)(2)(C)(ii) of the Act authorizes the Secretary to specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary, such as the AQA alliance. In light of these statutory requirements, we believe that, except in the circumstances specified in the statute, each PQRS quality measure must be endorsed by the NQF. Additionally, section 1848(k)(2)(D) of the Act requires that for each PQRS quality measure, ‘‘the Secretary shall ensure that eligible professionals have the opportunity to provide input during the development, endorsement, or selection of measures applicable to services they furnish.’’

The statutory requirements under section 1848(k)(2)(C) of the Act, subject to the exception noted previously, require only that the measures be selected from measures that have been endorsed by the entity with a contract with the Secretary under section 1890(a) of the Act (that is, the NQF) and are silent for how the measures that are submitted to the NQF for endorsement were developed. The basic steps for developing measures applicable to physicians and other eligible professionals prior to submission of the measures for endorsement may be carried out by a variety of different organizations. We do not believe there needs to be any special restrictions on the type or make-up of the organizations carrying out this basic process of development of physician measures, such as restricting the initial development to physician-controlled organizations. Any such restriction would unduly limit the basic development of quality measures and the scope and utility of measures that may be considered for endorsement as voluntary consensus standards for purposes of the PQRS.

In addition to section 1848(k)(2)(C) of the Act, section 1890A of the Act, which was added by section 3014(b) of the Affordable Care Act, requires that the entity with a contract with the Secretary under section 1890(a) of the Act (currently, that is the NQF) convene multi-stakeholder groups to provide input to the Secretary on the selection of certain categories of quality and efficiency measures. These categories are described in section 1890(b)(7)(B) of the Act, and include such measures as the quality measures selected for reporting under the PQRS. Under section 3014 of the Affordable Care Act, the NQF convened multi-stakeholder groups by creating the Measure Applications Partnership (MAP).

Section 1890(A)(a) of the Act requires that the Secretary establish a prerulemaking process in which the Secretary must make publicly available by December 1st of each year a list of the quality and efficiency measures that the Secretary is considering for selection through rulemaking for use in the Medicare program. The NQF must provide CMS with the MAP’s input on selecting measures by February 1st of each year. The list of measures under consideration for 2013 is available at http://www.qualityforum.org/map/. As we noted above, section 1848(k)(2)(C)(ii) of the Act provides an exception to the requirement that the Secretary select measures that have been endorsed by the entity with a contract under section 1890(a) of the Act (that is, the NQF). We may select measures under this exception if there is a specified area or medical topic for which a feasible and practical measure has not been endorsed by the entity, as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary. We requested that stakeholders apply the following considerations when submitting measures for possible inclusion in the PQRS measure set:

• High impact on healthcare.

• Measures that are high impact and support CMS and HHS priorities for improved quality and efficiency of care for Medicare beneficiaries.

• Measures that address gaps in the quality of care delivered to Medicare beneficiaries.

• Address Gaps in the PQRS measure set.

• Measures impacting chronic conditions (chronic kidney disease, diabetes mellitus, heart failure, hypertension and musculoskeletal).

• Measures applicable across care settings (such as, outpatient, nursing facilities, domiciliary, etc.).

• Broadly applicable measures that could be used to create a core measure set required of all participating eligible professionals.

• Measures groups that reflect the services furnished to beneficiaries by a particular specialty.

In addition to these comments, we note that OMB may reference our 2014 PQRS measures list, available at http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2014_PQRS_IndClaimsRegistry_MeasureSpecs_SupportingDocs_12132013.zip.