NAHC, Other Post-Acute Care Consumer and Provider Groups, Express to Congress and CMS Concerns and Principles Regarding IMPACT Act Implementation
March 31, 2016 02:01 PM
On March 18, 2016, the National Association for Home Care & Hospice (NAHC) along with other post-acute care consumer and provider groups sent letters to U.S. Congressional leaders and the Centers for Medicare & Medicaid Services (CMS) expressing concerns about, as well as principles and recommendations pertaining to, the implementation of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. While NAHC and the other groups said they are “strong supporters of the principles and objectives” of the IMPACT Act, they expressed “serious collective concerns” about its implementation process; specifically that CMS “has had a compressed timeframe in which to implement IMPACT Act provisions due to statutory timelines,” which “could create unintended consequences and serious risks to beneficiary safety and access to care.”
For example, the groups stated, the Medicare Spending per Beneficiary for Post-Acute Care (MSPB-PAC) measure is “currently scheduled to be applied far earlier than is prudent.” While CMS has stated that the “measure development process may require up to two years,” the measure was first initiated in summer 2015 and has a specified application date of October 1, 2016, for inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs) and skilled nursing facilities (SNFs), and January 1, 2017 for home health agencies (HHAs). Furthermore, the groups stated, “there is insufficient measure specification information available to permit a thoughtful review of the proposed measure, and little or no opportunity for CMS and its contracted measure developers to adequately review the submitted stakeholder feedback prior to the submission to the National Quality Forum (NQF) for review. This opaque process raises questions regarding the consideration given to providers and lacks adequate opportunity for public input, likely leading to the development of flawed quality and resource use measures.”
The compressed timeframe demonstrates “broader concerns” with other measures in development as well as “unreasonable” comment period timelines that only “exacerbate these issues,” the groups said. “While CMS has occasionally extended the comment periods, such last-minute extensions would be unnecessary and less disruptive if reasonable and realistic comment periods and implementation timelines were initially provided.”
The groups additionally expressed concerns about the proposed specifications of several other IMPACT Act measures, “particularly whether they have been adequately vetted for cross-setting application.” Identified concerns regarding these measures have “created confusion and reporting burdens not foreseen by the law and its implementation timeline.”
To address these concerns, NAHC and the groups requested consideration of the following principles, legislative recommendations, and administrative recommendations:
Fully Specified Measures. The IMPACT Act requires that data on patient assessment, quality measures, and resource use be standardized and interoperable by using common standards and definitions. We encourage the collection of necessary information for measure development purposes through the identified PAC assessment instruments and other sources. Before any use of a cross-setting outcome measure for quality reporting or payment purposes, however, a measure should be subject to endorsement by a consensus-based entity, and only after fully specified and tested measures have been presented.
Validated Measures. Existing measures that have been endorsed for patient characteristics used in one PAC setting may not provide adequate risk-adjustment for those present in another PAC setting. Failure to validate a cross-setting measure could have unintended consequences on patient care and access, particularly in settings where the adjustments do not adequately identify meaningful patient characteristic differences. Any proposed cross-setting outcome measure should be validated within and across each PAC setting and endorsed by a consensus-based entity prior to use for quality reporting or payment purposes.
Aligned Measures. Measures not only serve as benchmarks for quality and cost efficiency purposes, they can also be used as a framework to build clinical redesign processes. Measures that do not align with one another across settings, however, could incentivize care choices favoring the improvement of one patient characteristic or clinical pathway to the detriment of another potentially more appropriate option. Before any new cross-setting outcome measure is implemented, the measure specifications must be fully evaluated for potential care delivery incentive conflicts. In particular, resource use measures in isolation can dis-incentivize care and should not be used unless they include clinical and functional items, or otherwise align with other quality measures within and across settings.
NQF Endorsement: The Secretary shall have PAC measures endorsed by NQF before they can be used for payment, public reporting of quality and resource use, and in Five Star (or similar)Rating Systems.
In instances where there is no NQF-endorsed PAC measure, the Secretary shall obtain said endorsement within 18 months of proposing to use the measure.
Defining Assessment Tool and Data Elements: The Secretary shall inform the public of the measure’s assessment tool and data elements prior to implementation in addition to existing IMPACT Act requirements of informing the public of the measure’s numerator, denominator, exclusions, and any other aspects the Secretary deems necessary.
Study on Applicability of Quality Measures to all Individuals, Regardless of Payer: The Secretary shall examine and provide a report to Congress on the practicality and benefits of extending the quality measure population to reflect the care provided to all patients by a provider.
Prospective Schedule. CMS should provide advance notice in the form of an anticipated timeline for developing all measures required under IMPACT Act rather than release draft measures in different places with limited announcements and no advanced notice.
Adequate Opportunity for Comment. CMS should afford the public a minimum of 30 days to submit comments on proposed measures (including comments submitted to measure development contractors). Shorter time periods, irrespective of last-minute extensions, do not afford the public sufficient time to review and respond to proposed measures and their draft specifications.
Instill Greater Transparency. By allowing its contractors to operate the public comment process, CMS is able to sidestep basic assurances typically afforded to the interested public. In addition to minimum durations for comment periods, CMS should require that all submitted comments be available for public review. While this is standard practice for notice-and-comment rulemaking, the IMPACT Act measurement development process is a “black box” in which stakeholders are not privy to each other’s comments and the Agency is not required to attend to or otherwise acknowledge any comments received. In addition, we urge CMS to use publicly available data sets to test and validate the measures before they are released and make the results of testing available prior to the comment period. If CMS uses data that are not publicly available, such as the PAC-PRD data, we urge CMS to make those data available as soon as possible to permit external review of measure performance.
The letter to Congress is available here, and the letter to CMS is available here.