NCQA Comments on Patients over Paperwork

August 12, 2019

Seema Verma, Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services

Attention: CMS-6082-NC

Dear Administrator Verma:

Thank you for the opportunity to respond to your RFI on ways to reduce administrative burden. The National Committee for Quality Assurance (NCQA) supports the Patients Over Paperwork initiative and suggests three areas for burden reduction.

First, NCQA is working diligently to reduce the burden of reporting clinical quality measures by automatically extracting data needed for measures from electronic health records (EHR), health information exchanges (HIE), registries and other electronic sources. This also allows development of more meaningful measures using the richer clinical data found in electronic sources. You can help this effort by increasing bonus points in value-based payment systems for end-to-end electronic reporting and by developing and disseminating best practices for moving to automated electronic reporting.

Automated clinical quality measure reporting can help improve the accuracy and validity of measurement results if systems used for reporting undergo rigorous testing. NCQA’s eCQM testing program is the only one that reviews 100% of the logic in each measure to ensure accurate results. You can promote better eCQM results accuracy by encouraging/requiring certification through our system.

Second, NCQA’s Patient-Centered Medical Home (PCMH) program includes standards that align with “Promoting Interoperability” measures in Medicare’s Merit-based Incentive Payment System (MIPS). We could reduce burden by sending data feeds of PCMH clinicians who meet these standards. You can support this by accepting data feeds from PCMH sponsors.

Third, we can reduce burden by maximizing and adjusting external quality review policies for state Medicaid programs and plans. There are three ways to do this.

1. Increase use of private sector health plan accreditor requirements for nonduplication of Medicaid mandatory external quality review (EQR) activities. You can support this by increasing assistance to states so that more may take advantage of this opportunity.
2. Let private accreditors serve as subcontractors for nonmandatory EQR-related activities such as developing and supporting quality ratings and performance measures. You can support this by amending Medicaid managed care rules to allow this.
3. Increase matching funds for EQR activities by non-EQR organizations. You can support this by increasing the match to 75% from 50%.

Below, we provide more detailed comments on these suggestions to reduce regulatory burden.

Reducing Burden, Adding Value

As stewards of HEDIS®¹, the most widely used and respected clinical quality measures, NCQA is acutely aware of the urgent need to reduce the burden of reporting clinical quality measures. Through our Digital Measures Roadmap (DMR) initiative, we are working on many steps called for in your RFI. The DMR aims to make quality measurement and reporting as effortless as possible via automated data extraction that physicians/clinicians collect during the normal course of patient care.

This data-inclusive approach also addresses workflow concerns by reducing the need to produce clinician documentation solely for quality measurement. EHRs and electronic data repositories such as registries and HIEs provide a more robust picture of quality than data gathered from claims. As the DMR leads us to the next generation of HEDIS, it will let us make these additional improvements:

• Align NCQA measure specifications throughout the health care system to allow comparison across practices, hospitals, clinically integrated networks, health plans and other settings.
• Provide greater flexibility by allowing appropriate adjustments to some specifications that assist specific state or local programs or healthcare systems in the pursuit of quality improvement.
• Improve accuracy and validity while reducing costs to implement and update measures by letting vendors and health care systems digitally download specifications, reducing manual data entry and relying more on data already in electronic systems.
• Enhance the value for patients, clinicians, payers, plans, electronic system vendors and government by reducing costs and efforts while allowing more meaningful measurement.
• Build the digital foundation for designing future outcome-based measures by leveraging access to the rich clinical data found in electronic sources other than claims.

You can support this effort by increasing bonus points in VPB systems for end-to-end electronic reporting and by developing and disseminating best practices for moving to automated electronic reporting.

You could also develop a measure to rate how well electronic systems support automatic clinical quality measure data extraction for incorporation into Promoting Interoperability measures. NCQA would be happy to work with you to develop such a measure.

Testing for eCQM Reporting

Improving the accuracy of eCQM results is essential for addressing the wide variation in results, which skews and undermines confidence in VBPs determined by measurement. All parties must trust metrics used for VBP, particularly patients and providers.

NCQA’s eMeasure Certification Program assesses both the reliability and the validity of target systems’ measure algorithms and data processing. Reliability means that primary sources are verified. This is largely based on data processing to extract, translate and load data.

Validity means testing whether reported data are correct, based on measure specifications. Auditors certify that data accurately represent source data, to ensure decreased variation in the accuracy of results and increased confidence in VBPs.

Our program is more rigorous that the Office of the National Coordinator for Health IT’s Project Cypress certification tool, which until recently covered only 80% of each measure’s logic and still covers just 95%, which still leaves room for error. Systems certified at 80% do not have to recertify or retest to the upgraded system, nor do they have to validate for new measure specification releases that affect rates. Most eCQM Authorized Testing Laboratories (ATL) approved by ONC also rely on the Project Cypress tool.

This is a serious problem, given that measurement results will redirect billions of payment dollars in VBP systems and inform the Physician Compare website. Failure to ensure greater accuracy and validity of measurement results could misdirect vast sums of money and severely undermine confidence in the nationwide movement toward paying for value rather than for volume.

NCQA is the only ONC-approved ATL with:

• Extensive quality measurement expertise.
• A concentrated focus on eCQM validation with testing via multiple use cases for 100% of measure logic.
• Mandatory annual recertification for HEDIS measures to ensure that systems have the proper updates for code-set changes.
• The Premier healthcare alliance and Oklahoma’s MyHealth Access Network have both endorsed NCQA’s ONC-approved testing.
• Premier stated that NCQA’s program is “considerably more robust and rigorous” and “easier to use” than Project Cypress. NCQA uses industry-standard messaging formats, multiple test decks per measure with automated test results, a web-based interface to conduct testing and streamlined validation of discrepancies found.
• MyHealth Access Network stated that NCQA’s program provides “the assurance of validity and the process controls necessary to detect issues early and communicate clearly with interested parties when issues arise.” NCQA’s program is “highly robust” because of our “locked-box” methodology, which ensures integrity of results; industry-standard messaging formats; multiple test decks per measure with automated results; easy to use web-based interface to test and score results; and streamlined validation with a team of experts for any discrepancies.

Nineteen entities², including health systems, HIEs, vendors and others, have earned or are seeking eCQM certification through NCQA’s rigorous program. You can promote consistent accuracy of eCQM results by encouraging or requiring certification through our testing system.

PCMH Data Streams

NCQA’s PCMH Recognition program includes requirements that align with measures in the MIPS Promoting Interoperability³ category. Reporting burden can be reduced by authorizing for MIPS-qualified PCMH program sponsors to send CMS a data feed of clinicians in Recognized PCMHs who meet specific Promoting Interoperability measures. Doing this would eliminate the need for clinicians to “double report” information to CMS that they have already documented to NCQA.

Using Accreditor Standards for Nonduplication

NCQA supports nonduplication as described in federal requirements 42 C.F.R. § 438.360. As noted below, we agree it is important to identify all potential accreditor requirements that can be used for nonduplication. NCQA’s annual Medicaid Managed Care Toolkit analyzes how our standards align with federal requirements eligible for nonduplication, and when and how they meet or partially meet them.

It is important to note that even when information from a Medicare or private accreditation review does not completely meet requirements, it can still work toward meeting nonduplication requirements. For example, nonduplication might be able to satisfy a subset of the regulatory requirements that are subjects of the compliance review, as is outlined in the draft EQR protocols released in February 2019⁴. The EQRO could use information from the nonduplication source for that subset of requirements, and then the EQR-related activity would only need to be conducted on the remaining requirements to fully assess compliance.

NCQA believes accreditors should not be excluded being able to provide sub-contractual support for nonmandatory EQRO activities. We would like to draw your attention to the potential benefits of allowing accreditors—for example, NCQA—to serve as subcontractors for nonmandatory EQR-related activities such as quality ratings and performance measure development support. In 2016 rulemaking, Section §438.354(c) of the Medicaid Managed Care rule—External Quality Review Organization and Subcontractor Qualifications, CMS excluded accreditors from all EQRO work due to concerns that financial relationships between plans and accrediting bodies could unduly influence EQR results.

The rule also allowed EQROs to assist with quality ratings, an area in which NCQA is a national leader with specific and unparalleled expertise. We understand the unique nature of designing a quality rating system, and currently support both state and federal agencies on a contractual basis. State EQRO RFPs continue to include tasks that go well beyond mandatory and optional EQR-related activities, such as measurement methodologies and standards. Ohio, for example, recently included such tasks in its EQRO RFP.NCQA maintains cutting-edge experience—particularly in measure development, including managed long-term services and supports, behavioral health and eMeasures—that could greatly benefit states.

We believe states want to include such tasks in EQRO contracts because of the higher federal matching rate (75%). We bring the experience of a national accreditor and measure developer which supports use of tested and vetted approaches to driving quality and performance measure development and reporting.

Letting experienced accreditors subcontract to perform EQRO activities would enhance state efforts to advance value-based initiatives without conflict. We therefore encourage you to update the across-the-board ban on accreditors in EQRO work, to allow accreditors to serve as subcontractors for nonmandatory activities.

States would greatly benefit from enhanced matching that lets them select the most qualified contractors for such tasks without sacrificing much-needed matching dollars.

The National Association of Medicaid Directors (NAMD) suggested this in 2015 Medicaid managed care rule comments. We agree with NAMD’s recommendation to give states flexibility to work with organizations that are not EQROs, by increasing available matching funds.

Thank you again for the opportunity to comment on the draft. If you have any questions, please contact NCQA Director of Federal Affairs, Paul Cotton, at (202) 955-5162 or at cotton@ncqa.org.

Sincerely

Margaret E. O’Kane
President

¹ HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
² Please refer to Appendix A for a full list of entities.
³ Please refer to Appendix B for a crosswalk of related Promoting Interoperability measures to NCQA PCMH standards.
⁴ CMS-R-305 https://www.federalregister.gov/documents/2019/02/14/2019-02231/agency-information-collection-activities-proposed-collection-comment-request

Appendix A

* ECQM CERTIFIED: To identify the performance period/reporting year, reference the eCQI Resource Center’s website (https://ecqi.healthit.gov/eligible-professional/eligible-clinician-ecqms) and search by the measure’s version number.

Appendix B