November 28, 2017
Seema Verma, Administrator
Centers for Medicare & Medicaid Services
U.S. Department of Health & Human Services
7500 Security Boulevard
Baltimore, MD 21244
ATTENTION: CMS–5522–FC
Dear Administrator Verma:
The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to comment on the final rule for Quality Payment Program Year 2.
We strongly support the final 50% threshold established for the proportion of site recognitions within a Tax Identification Number (TIN) in order for all clinicians within that TIN to receive Patient-Centered Medical Home (PCMH) and Patient-Centered Specialty Practice (PCSP) auto-credit. We believe this is consistent with Congressional intent. However, we urge CMS to accept data feeds from accreditors to validate PCMH and PCSP attestation. Once established, CMS will be able to ensure that only those clinicians who achieve recognition receive credit for it.
We are also pleased that you finalized NCQA’s Patient-Centered Connected Care (PCCC) Program as an Improvement Activity in the Merit-Based Incentive Payment System (MIPS), with Advancing Care Information (ACI) credit for its use of Health IT. We encourage you to consider increasing the activity to a high weight in future years of the program.
However, it’s inconsistent to offer ACI credit for individual Improvement Activities and not offer some ACI credit to PCMHs and PCSPs. PCMHs and PCSPs have rigorous standards for use of Health Information Technology (Health IT). In fact, NCQA’s programs have even more stringent requirements than those in ACI. Offering at least partial credit or bonus points would significantly reduce the burden associated with MIPS reporting. We are happy to arrange time to meet with CMS staff to talk about what further alignment may be necessary to make ACI credit available for the more than 60,000 clinicians recognized through NCQA.
We also urge you to address the low-volume threshold that would prohibit small practices from participating in a Virtual Group. Congress specifically intended for this provision to encourage, not prevent, small practice participation in MIPS. Current implementation of this provision seems counter-intuitive to Congress’ original intent. Without this opportunity, clinicians in small practices also risk falling behind on the path to the type of joint accountability inherent in Alternative Payment Models (APMs). Although we support exclusions for clinicians with a low volume of Medicare, we strongly believe that those clinicians should have a path to participation in Virtual Groups and eventually APMs.
Further, if these small practices are unable to participate in the MIPS whatsoever, they are not eligible for the annual adjustment for inflation. Small practices will therefore receive a zero percent adjustment under current regulation. We believe a minor adjustment to regulatory language, such as making low volume practices ineligible for MIPS “except in the case where such practices elect to participate in a Virtual Group,” would fix this inconsistency.
Thank you again for inviting our comments. If you have any questions about our thoughts, please contact Paul Cotton, Director of Federal Affairs, at cotton@ncqa.org or (202) 955-5162.
Sincerely,
Margaret O’Kane,
President
Appendix A
Advancing Care Information & NCQA PCMH
| Advancing Care Information Measure | NCQA PCMH Standard |
| Security Risk Analysis | Team-Based Care & Practice Organization – Standard 5: The practice uses an EHR system (or modules) that has been certified and issued an ONC Certification ID, conducts a security risk analysis, and implements security updates as necessary correcting identified security deficiencies. |
| e-Prescribing | Knowing and Managing Your Patients – Standard 19: Systematically obtains prescription claims data in order to assess and address medication adherence. |
| Provide Patient Access | Patient-Centered Access and Continuity – Standard 5: Documents clinical advice in patient records and confirms clinical advice and care provided after-hours does not conflict with patient medical record. – Standard 7: Has a secure electronic system for patient to request appointments, prescription refills, referrals and test results. |
| Send a Summary of Care | Care Coordination and Care Transitions – Standard 4 (A-C): The practice systematically manages referrals by: A. Giving the consultant or specialist the clinical question, the required timing and the type of referral; B. Giving the consultant or specialist pertinent demographic and clinical data, including test results and the current care plan; C. Tracking referrals until the consultant or specialist’s report is available, flagging and following up on overdue reports. – Standard 15: Shares clinical information with admitting hospitals and emergency departments. – Standard 18: Exchanges patient information with the hospital during a patient’s hospitalization. – Standard 21 (C): Demonstrates electronic exchange of information with external entities, agencies and registries: C. Summary of care record to another provider or care facility for care transitions. |
| Request/Accept Summary of Care | Care Coordination and Care Transitions – Standard 18: Exchanges patient information with the hospital during a patient’s hospitalization. – Standard 19: Implements a process to consistently obtain patient discharge summaries from the hospital and other facilities. – Standard 21 (C): Demonstrates electronic exchange of information with external entities, agencies and registries: C. Summary of care record to another provider or care facility for care transitions. |
| Patient-Specific Education | Knowing and Managing Your Patients – Standard 8: Evaluates patient population demographics/communication preferences/health literacy to tailor development and distribution of patient materials. – Standard 16: Assesses understanding and provides education, as needed, on new prescriptions for more than 50 percent of patients/families/caregiver. – Standard 21: Uses information on the population served by the practice to prioritize needed community resources. – Standard 22: Provides access to educational resources, such as materials, peer-support sessions, group classes, online self-management tools or programs. |
| View, Download and Transmit (VDT) | Patient-Centered Access and Continuity – Standard 5: Documents clinical advice in patient records and confirms clinical advice and care provided after-hours does not conflict with patient medical record. – Standard 7: Has a secure electronic system for patient to request appointments, prescription refills, referrals and test results. |
| Secure Messaging | Patient-Centered Access and Continuity – Standard 5: Documents clinical advice in patient records and confirms clinical advice and care provided after-hours does not conflict with patient medical record. – Standard 8: Has a secure electronic system for two-way communication to provide timely clinical advice. |
| Patient-Generated Health Data | Care Management and Support – Standard 7: Identifies and discusses potential barriers to meeting goals in individual care plans. – Standard 8: Includes a self-management plan in individual care plans. – Standard 9: Care plan is integrated and accessible across settings of care. |
| Clinical Information Reconciliation | Knowing and Managing Your Patients – Standard 14: Reviews and reconciles medications for more than 80 percent of patients received from care transitions. Care Coordination and Care Transitions – Standard 20: Collaborates with the patient/family/caregiver to develop/implement a written care plan for complex patients transitioning into/out of the practice (e.g., from pediatric care to adult care). |
| Immunization Registry Reporting
| Care Coordination and Care Transitions – Standard 21 (B): Demonstrates electronic exchange of information with external entities, agencies and registries: B. Immunization registries or immunization information systems. |
Appendix B
Advancing Care Information & NCQA PCSP
| Advancing Care Information Measure | NCQA PCSP Domain & Element |
| Security Risk Analysis | Measure and Improve Performance – Element E: Use Certified EHR Technology. The practice uses a certified EHR system: o The practice attests to conducting a security risk analysis of its EHR system (or modules) and implementing security updates as necessary and correcting identified security deficiencies. |
| e-Prescribing | Plan and Manage Care – Element C: Use Electronic Prescribing. The practice uses an electronic prescription system with the following capabilities: o At least 75 percent of eligible prescriptions are generated using the electronic prescription system. o More than 50 percent of eligible prescriptions written by the practice are compared to drug formularies and sent to pharmacies electronically. o More than 60 percent of medication orders are entered into the medical record. |
| Provide Patient Access | Provide Access and Communication – Element B: Electronic Access. The practice provides the following information and services to patients/ families/caregivers through a secure electronic system: o More than 50 percent of patients have timely access to their health information. o The capability to view, download or transmit their health information to a third party. |
| Send a Summary of Care | Working with Primary Care and Other Referring Clinicians – Element D: Assessing Initial Referral Response. The practice has a written process and monitors against it to ensure a timely response to PCPs and referring clinicians that includes: o Electronic transmission of a summary of care record to another provider, for more than 10 percent of referrals. – Element F: Connecting Patients With Primary Care. The practice implements a documented process for connecting self-referred patients with primary care clinicians that includes: o For self-referred patients with a primary care clinician, providing a summary of care report to the primary care clinician. Track and Coordinate Care – Element B: Referral Tracking and Follow-Up. The practice coordinates referrals to other (secondary) specialists by: o Demonstrating its capability to provide an electronic summary-of-care record to another provider following a referral. o Electronically transmitting a summary-of-care record to another care provider, for more than 10 percent of care referrals. – Element C: Coordinate Care Transitions. The practice supports patients who have an ongoing relationship with a specialist during acute care transitions. For these patients, the practice systematically: o Demonstrates its capability to provide an electronic summary of care record to another facility following a transition of care. o Electronically transmits a summary of care record to another care setting for more than 10 percent of care transitions. |
| Request/Accept Summary of Care | Track and Coordinate Care – Element B: Referral Tracking and Follow-Up. The practice coordinates referrals to other (secondary) specialists by: o Following up to obtain the specialist’s report. o Asking patients/families/caregivers about self-referrals and requesting reports from clinicians. – Element C: Coordinate Care Transitions. The practice supports patients who have an ongoing relationship with a specialist during acute care transitions. For these patients, the practice systematically: o Demonstrates its process for consistently obtaining patient discharge summaries from the hospital and other facilities. |
| Patient-Specific Education | Plan and Manage Care – Element A: Care Planning and Support Self-Care. The practice provides the following care management and self-care support for practice-specific conditions: o Uses an EHR to identify and provide patient-specific education resources to more than 10 percent of patients. |
| View, Download and Transmit (VDT) | Provide Access and Communication – Element B: Electronic Access. The practice provides the following information and services to patients/ families/caregivers through a secure electronic system: o More than 50 percent of patients have timely access to their health information. o The capability to view, download or transmit their health information to a third party. |
| Secure Messaging | Provide Access and Communication – Element B: Electronic Access. The practice provides the following information and services to patients/ families/caregivers through a secure electronic system: o The capability to send a secure message. o Two-way communication between patients/families/caregivers and the practice. o Requests for appointments, prescription refills, referrals and test results. |
| Patient-Generated Health Data | No analogous standard at this time. – With approval from CMS, we can develop this as a part of an ACI deeming module for PCSP. |
| Clinical Information Reconciliation | Plan and Manage Care – Element B: Medication Management. The practice has a process and demonstrates that it systematically manages medications prescribed by the practice in the following ways: o Reconciles medications for more than 50 percent of patients received from another care setting or at a relevant visit. Working With Primary Care and Other Referring Clinicians – Element C: Assessing Initial Referral Content. The practice sets expectations and monitors against those expectations to confirm receipt of information needed in referrals from clinicians: o Clinical questions to be answered by the referral. o Type of referral. o Urgency of referral. o Patient demographics. o Clinical information. o Current primary practice care plan, treatment, test results and procedures. o Which clinician is responsible for communicating with patient/family/ caregiver. |
| Immunization Registry Reporting | Measure and Improve Performance – Element E: Use Certified EHR Technology. The practice uses a certified EHR system: o The practice demonstrates the capability to submit electronic data to immunization registries or immunization information systems. |