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SHM Comments on CMS' Measure Development Plan for MACRA

March 01, 2016

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ATTN: Eric Gilbertson
Health Services Advisory Group, Inc.
3133 East Camelback Road, Suite 240
Phoenix, AZ 85016-4545


RE: CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs)


Dear Mr. Gilbertson:

The Society of Hospital Medicine (SHM), on behalf of the nation’s nearly 50,000 hospitalists, appreciates the opportunity to provide comments on CMS’ draft Measure Development Plan. As CMS begins to implement the Medicare Access and CHIP Reauthorization Act (MACRA), the role of quality measures in physician payments will only continue to increase.

Hospitalists are the front-line inpatient providers in America’s hospitals, providing care for millions of hospitalized patients each year, many of whom are Medicare and Medicaid beneficiaries. In their role, hospitalists manage the clinical care of acutely ill, hospitalized patients, while working to enhance the performance of hospitals and healthcare systems. This unique position of hospitalists within the healthcare system affords a distinctive perspective both in individual physician-level and facility-level value-based purchasing and alternative payment models. However, this position also creates a myriad of challenges for hospitalists in participating fully in quality measurement and pay-for-performance programs as currently structured.

Hospitalists are eager to participate in pay for performance programs and believe there is a significant potential in measuring and assessing quality and costs as a means for quality improvement. At the same time, hospitalist experiences with the current programs (PQRS, value-based payment modifier, Meaningful Use) indicate a very real need for CMS to evaluate its ability to ensure providers are assessed in a transparent way that promotes both quality improvement and trust in these programs. SHM concurs with the sentiments offered by Robert Wachter recently in the New York Times: “Measurement cannot go away, but it needs to be scaled back and allowed to mature. We need more targeted measures, ones that have been vetted to ensure that they really matter.”1 We encourage CMS to refine the Measure Development Plan to ensure the following three principles are met:

1.  Measures are fair and reasonable proxies of the provider’s scope of practice;

2.  Measurement should not cause undue administrative and reporting burden and disrupt physician workflow; and

3.  Measures and reporting methodologies must be tailored to the specific needs of each specialty.

SHM offers the following specific comments on the Measure Development Plan:

III. CMS Strategic Vision

CMS General and Technical Principles

SHM agrees, in general, with the General and Technical Principles outlined in the Measure Development Plan. However, a critical aspect of fairly measuring providers is noticeably absent from the plan. In order to assess providers accurately, they must be compared against providers who have similar practice patterns and settings. Failing to do so penalizes those providers who are facility-based, who by virtue of working exclusively in facilities, are seeing many of the sickest and frailest patients. Without sufficient risk adjustment and accurate comparison pools, quality assessment of providers does not take into account the significant differences between providers and the nature of their practice. It is not, for example, meaningful or even productive for hospitalists to be compared to providers who practice predominantly or exclusively in the outpatient setting, as that would result in their being evaluated as low quality and high cost in comparison. This undermines provider trust in these programs and is contrary to the intent of quality measurement and pay-for-performance.

CMS must prioritize the creation of fair comparison pools for quality measures as part of its Measure Development Plan. We appreciate the recent approval of a hospitalist Medicare specialty billing code and encourage CMS to incorporate this into their plans for comparison pools. CMS should also consider site-specific adjustments, such as using Place of Service codes where appropriate, to further ensure fair comparisons between providers. 

IV. Operational Requirements of the Quality Measure Development Plan

CMS indicates their intention to continue developing new patient experience surveys as part of improving the range of options for patients to provide feedback about their providers. SHM agrees that it is critical for a patient-centered healthcare system to provide ample opportunities for patients to share their experiences and incorporate that feedback into quality improvement and physician assessment. However, we harbor reservations about the proliferation of patient surveys and low response rates as part of CMS’ implementation of MACRA. It is unreasonable to ask hospitalized patients to fill out surveys for every provider who interacts with them. This is especially true in light of the fact that the hospital will send a similar survey with many of the same questions. We request that more information be included in the Measure Development Plan about how CMS intends to balance the need to have patient input with the limitations of survey instruments and survey fatigue.

Gap Analysis

Although SHM agrees that there are significant condition-based, population health, and patient safety gaps in the measure field, we are concerned this focus will continue to deprive many providers of a meaningful set of quality measures that accurately reflect their clinical work and care goals. Since the quality measures used in programs under MACRA are expressly meant to be part of physician performance assessment, SHM strongly urges CMS to focus first on the lack of actionable measures for all providers and other provider issues either in the context of or before addressing other broader priorities.

Under the policies in PQRS, CMS has artificially exacerbated the scarcity of measures for many providers by requiring the reporting of at least nine measures across three National Quality Strategy domains. As part of addressing this lack of measures for providers, SHM recommends CMS consider developing a more flexible set of requirements under the MIPS to ensure providers are reporting relevant and meaningful measures both for themselves and for their patients, not simply reaching towards an arbitrary number of measures or domains that must be reported.

Applicability of Measures across Healthcare Settings

SHM is encouraged by the discussion in the Measure Development Plan to consider measures across settings of care and types of clinicians. The statutory language of MACRA authorizes CMS to move towards better integration of measures and goals between providers and the settings in which they practice. The lack of measures for facility-based providers indicates a significant gap for those providers and should be treated as a high priority for CMS to address. There are nearly 50,000 hospitalists nationwide whose clinical work is not adequately accounted for in the existing pay-for-performance programs. Hospitalists work in a team-oriented and shift-based facility environment that does not lend itself towards the individualized outpatient-focused approach these programs have taken to date.

We acknowledge CMS intends to seek comment on options for facility alignment for hospitalists through the rulemaking process. As CMS considers the implementation of the Measure Development Plan, we strongly urge action on facility alignment as a short-term goal for CMS. SHM has been a leading proponent of this option for the past three years. In the current pay-for-performance programs, hospitalists face a variety of barriers, leaving them unfairly vulnerable to increasing penalties and little to no recourse. For many hospitalists, a facility alignment option would capitalize on the harmony between facility and hospitalist goals and significantly reduce the irrelevance that PQRS represents to most hospitalists. SHM is ready to work with CMS on developing this option.

V. Challenges in Quality Measure Development and Potential Strategic Approaches

1 Wachter, R. M. “How Measurement Fails Doctors and Teachers.” New York Times. Jan. 16, 2016.