ANALYSIS OF THE CMS PROPOSED RULE FOR THE MEDICARE SHARED SAVINGS PROGRAM AND ACCOUNTABLE CARE ORGANIZATIONS (2011)

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1 Occupational Therapy: Living Life To Its Fullest ANALYSIS OF THE CMS PROPOSED RULE FOR THE MEDICARE SHARED SAVINGS PROGRAM AND ACCOUNTABLE CARE ORGANIZATIONS (2011) The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule regarding the Medicare Shared Savings Program: Accountable Care Organizations (76 Federal Register [March 31, 2011]). The proposal would implement section 3022 of the Affordable Care Act, which contains provisions relating to Medicare fee-for-service payments under Parts A and B, including the ability of certain specified providers and suppliers to participate in Accountable Care Organizations (ACOs). Comments are due June 6, 2011, and CMS will respond to comments in the final rule, which is expected later this calendar year. The policies adopted in the final rule are slated to take effect January 1, ACOs are one mechanism established in the Accountable Care Act to improve the system of care under Medicare. If successful, ACOs would spread to the private sector in coming years. An ACO is an umbrella organization made up of providers (combinations of hospitals, physician groups, and other health care facilities) that agree to be accountable for the quality, cost, and overall care of their assigned fee-for-service Medicare beneficiaries. Although the focus is on primary care, an ACO takes responsibility for a beneficiary s entire continuum of care. The purpose is to incentivize the provision of coordinated, quality care with better outcomes by sharing cost savings with providers. The ACO is a new, more developed approach that follows many other ways to organize health care (e.g., original HMOs). Other separate approaches to address cost growth while assuring appropriate services will be piloted over the next several years by the Center for Medicare and Medicaid Innovation, another part of the Medicare Shared Savings Program. I. STATUTORY BACKGROUND Section 3022 of the Affordable Care Act amended Title XVIII of the Social Security Act (SSA) (42 USC 1395 et seq.) by adding a new section 1899 requiring CMS to establish a Shared Savings Program that promotes accountability, coordinates items and services under Medicare Parts A and B, and encourages a commitment to high quality and efficient service delivery. Under the Shared Savings Program, groups of specified providers and suppliers will work together in ACOs to manage and coordinate fee-for-service care to Medicare beneficiaries. The ACOs may share in realized savings and receive financial incentives provided they meet certain quality performance standards. Section 1899(a)(1) requires the program to be established by January 1, The American Occupational Therapy Association, Inc Montgomery Lane Bethesda, MD Fax TDD

2 II. ACO ELIGIBLE PROVIDERS Eligibility requirements for ACOs are established by SSA 1899(b). Only certain types of providers and suppliers are statutorily eligible to form ACOs: ACO professionals and hospitals. An ACO professional is narrowly defined in statute as a physician (a doctor of medicine or osteopathy, SSA 1899(h)(1); 1861(r)(1)) or a practitioner (physician assistant, nurse practitioner, or clinical nurse specialist, SSA 1899(h)(1); 1842(b)(18)(C)(i)). The statutory definition of hospitals for purposes of ACO formation includes only acute care hospitals paid under the hospital inpatient prospective payment system (SSA 1899(h)(2); 1886(d)(1)(B)). The following combinations of providers may form ACOs: ACO professionals (physicians, physician assistants, nurses) in group practice arrangements Networks of individual practices of ACO professionals Partnerships or joint venture arrangements between hospitals and ACO professionals Hospitals employing ACO professionals Such other Medicare providers and suppliers as determined by the Secretary SSA 1899(b)(1). Notably, occupational therapists and rehabilitation hospitals, long-term care hospitals, skilled nursing facilities, and nursing homes are excluded from the list of providers that can form an ACO. The Secretary, however, has exercised her discretion under SSA 1899(b)(1)(E) to propose an expansion to the program that would allow certain other Medicare-enrolled providers and suppliers including post-acute care facilities who would not be able to form ACOs independently to participate in established ACOs. The stated purpose of this proposed change is to increase collaboration and innovation and to ensure that care within an ACO is truly comprehensive. Thus, although occupational therapists and post-acute settings may not independently form an ACO, they may participate as an integral part of an ACO and share in any savings. CMS is soliciting comments on this proposal, specifically: (1) the kinds of providers and suppliers that should or should not be included as potential ACO participants; (2) the potential benefits or concerns regarding including or not including certain provider or supplier types; (3) the administrative measures that would be needed to effectively implement and monitor particular partnerships; (4) other ways in which CMS could employ the discretion provided to the Secretary to allow the independent participation of providers and suppliers not specifically mentioned in the statute; and (5) any operational issues. III. ACO FORMATION ACOs must meet the following statutory requirements in order to be accepted into the Shared Savings Program: 2

3 Accept accountability for the quality, cost, and care for assigned Medicare fee-for-service beneficiaries Agree to participate for a 3-year period Adopt a formal legal structure that would allow the organization to receive and distribute payments for shared savings Include a sufficient number of primary care physicians to meet the primary care needs of assigned beneficiaries Care for at least 5,000 assigned beneficiaries Provide CMS with necessary information regarding participating professionals Have in place administrative and clinical organization and leadership Define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care (such as through the use of telehealth, remote patient monitoring, and other such enabling technologies) Be patient-centered, as shown by the use of patient and caregiver assessments or the use of individualized care plans SSA 1899(b)(2)(A-H) Legal Structure CMS states in the proposed rule that it has attempted to balance its requirement of a formal legal structure with other agency goals of flexibility, cost minimization, and program participation by nonprofit, community-based organizations. CMS has thus proposed that ACOs must only satisfy applicable state laws and be capable of performing all ACO functions including: (1) receiving and distributing shared savings and repaying any shared losses, and (2) establishing, reporting, and ensuring compliance with program requirements including quality performance standards. CMS proposes that ACOs each have a tax identification number (TIN) (or a set of TINs from all the practices constituting the ACO), but does not propose to have ACOs enroll in the Medicare program, in contrast to this requirement for each ACO participant. CMS also proposes requiring ACOs to have a shared governance structure that provides all ACO participants (not just those professionals and hospitals involved with formation) with proportionate control over decision making. ACO participants directly providing health care services must have at least 75% control of the ACO s governing body, and the governance mechanism must include some Medicare patient representatives. 3

4 Agreement Period CMS is proposing to limit participating agreements in the first round of the Shared Savings Program to 3 years, the minimum allowable by statute. CMS also proposed to require 60 days advance written notice of an intent to terminate the agreement, at which point the ACO will be subject to a 25% withhold of shared savings in order to offset any future losses. Minimum of 5,000 Beneficiaries Under the proposed rule, should an ACO s assigned population fall below 5,000 during the course of the agreement period, CMS would issue a warning and place the ACO on a corrective action plan. The ACO would remain eligible for shared savings over the course of the performance year for which the warning was issued. If the ACO fails to meet the eligibility criterion of having more than 5,000 beneficiaries by the completion of the next performance year, the ACO s participation agreement would be terminated and the ACO would not be eligible to share in savings. CMS is proposing that ACOs be subject to substantial monitoring and reporting requirements, including public reporting of quality data to ensure transparency. ACOs would also be required to provide documentation in their program application describing plans to (1) promote evidence-based medicine, (2) promote beneficiary engagement, (3) report internally on quality and cost metrics, and (4) coordinate care. CMS is seeking comment on whether more prescriptive criteria would be appropriate for future rulemaking. ACO applications must also include a description of processes in place for internal reporting on quality and cost measures. IV. QUALITY PERFORMANCE MEASURES The quality of care furnished by an ACO will be measured using nationally recognized measures in five key domains: patient/caregiver experience, care coordination, patient safety, preventive health, and at-risk population/frail elderly health. CMS is proposing an initial set of 65 measures across these domains (see CMS Table 1, Proposed Measures for Use in Establishing Quality Performance Standards for Shared Savings in the First Year). These measures and reporting mechanisms are intended by CMS to be aligned with the measures in other CMS programs such as the Electronic Health Records (EHR) initiative and the System (PQRS). An ACO that successfully reports the quality measures required under the Shared Savings Program would also be deemed eligible for the PQRS bonus. ACOs must report completely and accurately on all measures within all domains to be deemed eligible for shared savings. The stated purpose of this is to require ACOs to address all domains and be accountable across the continuum of care. CMS also proposes giving a performance score to an ACO for each measure: performance below the minimum attainment 4

5 level would earn zero points, while performance at or above the minimum attainment level but less than the performance benchmark will receive points on a sliding scale. V. SHARED SAVINGS Shared savings amounts will be determined based on algorithms tied to an ACO s quality performance score and its savings rate. CMS proposes two models for shared savings: a shared savings model ( one-sided model ) and a shared savings/losses model ( two-sided model ). Under the one-sided model, an ACO would receive a smaller percentage share in savings. Under the two-sided model, an ACO willing to bear risk and repay losses to the Medicare program would receive a greater percentage of any shared savings (see CMS Table 8, Shared Savings Program Overview). CMS proposes that ACOs be required to report quality measures and meet performance criteria for all 3 years within the 3-year agreement period. For the first year of the program, however, CMS proposes requiring only full and accurate reporting to set benchmarks and encourage participation. Scales and standards with a minimum attainment level will be in effect for subsequent years. If an ACO satisfies quality performance criteria and its annual expenditures fall below a certain Expenditure Benchmark, then it is eligible to share in cost savings. The cost savings in which ACOs may share fall within a range between the Minimum Savings Rate (for the onesided model, the Minimum Savings Rate ranges from 2% of the Expenditure Benchmark for ACOs over 60,000 beneficiaries and 3.9% for ACOs of 5,000 beneficiaries; for the two-sided model, the minimum is a flat 2%) and the Maximum Sharing Cap. ACOs using the one-sided model are entitled to receive up to 50% of the net savings beyond the Minimum Savings Rate up to the Maximum Sharing Cap of 7.5% of the Expenditure Benchmark. ACOs using the two-sided model are entitled to up to 60% of the gross savings beyond the Minimum Savings Rate and up to the Maximum Sharing Cap of 10% of the Expenditure Benchmark. ACOs may not participate in any other shared savings program or demonstration under the Center for Medicare and Medicaid Innovation or Independence At Home Medical Practice pilot program, to ensure that savings are not counted twice. VI. IMPLICATIONS FOR PATIENTS A central goal of ACOs is to protect Medicare beneficiaries by providing them with better, patient-centered care and preventing them from having to retell their stories and medical histories to each treating provider. The proposed rule includes a list of criteria for demonstrating patient-centeredness: A beneficiary experience of care survey in place and a description in the ACO application of how the ACO will use the results to improve care over time. Patient involvement in ACO governance. 5

6 A process for evaluating the health needs of the ACO s assigned population, including consideration of diversity in their patient populations, and a plan to address the needs of their population. Systems in place to identify high-risk individuals and processes to develop individualized care plans for targeted patient populations, including integration of community resources to address individual needs. A mechanism in place for the coordination of care. A process in place for communicating clinical knowledge/evidence-based medicine to beneficiaries in a way that is understandable to them. This process should allow for beneficiary engagement and shared decision-making that takes into account the beneficiaries unique needs, preferences, values, and priorities. Written standards in place for beneficiary access and communication and a process in place for beneficiaries to access their medical record. Internal processes in place for measuring clinical or service performance by physicians across the practices, and using these results to improve care and service over time. CMS is also proposing to ensure that Medicare beneficiaries be given notice of provider membership in an ACO, maintain their choice of provider, and retain privacy protections. CMS would require participating ACO providers to notify Medicare fee-for-service beneficiaries at the time they seek services that the provider is participating in an ACO. Providers must offer beneficiaries information about the ACO, including how the ACO would improve the care that they receive, and post signs indicating ACO participation. CMS would also allow beneficiaries to retain their choice of providers even if they receive care from a physician, hospital, or other facility participating in an ACO. CMS proposes to prohibit ACOs from developing any policies that would restrict a beneficiary s ability to seek care from providers and suppliers outside of the ACO, including expressly limiting patients to certain providers, managing utilization, or requiring prior authorization for Medicare services. In this same vein, CMS has also proposed strict restrictions to ACO patient communications and marketing activities that are confusing or misleading and would not forward the goal of patientcenteredness. The agency is proposing that all marketing materials, communications, mailings, calls, or community events that are used to educate, solicit, notify, or contact Medicare beneficiaries or providers/suppliers regarding the ACO and its participation in the Shared Savings Program be pre-approved by CMS. Because Medicare beneficiaries may seek care from their choice of providers, they may receive services over the course of a year from a number of different ACOs and even from professionals who do not participate in the Shared Savings Program at all. For this reason, CMS proposes to assign beneficiaries to an ACO retrospectively at the end of the performance year based upon utilization data. CMS finds that prospective assignment would be plagued 6

7 with inaccuracies and could encourage providers to limit their care improvement activities to a subset of patients who are believed to be assigned to them. CMS would assign beneficiaries to an ACO under a plurality rule : placing responsibility for a patient s care on the ACO where a patient received a plurality of his or her primary care services. To better coordinate care among ACO providers, under the proposed rule an ACO would be permitted to request personal health information (PHI) about a patient from CMS claims data. Before doing so, however, ACOs would be required to provide written notice to beneficiaries during an office visit that it would request the beneficiary s PHI from CMS and allow beneficiaries to opt out. VII. LEGAL ISSUES The expansive ACO and Medicare Shared Savings Programs have broad legal implications. Consequently, as part of a coordinated, inter-agency effort, several federal agencies have issued companion proposals. There will be a 60-day public comment period for these proposals. Self-Referral, Anti-Kickback, and Fraud and Abuse Waivers CMS and the HHS Office of the Inspector General (OIG) jointly issued a Notice on Waivers in Connection with Sections 1899 and 1115A of the Social Security Act. The notice proposes to waive the Physician Self-Referral Law, the federal anti-kickback statute, and certain civil monetary penalties law provisions for specified financial arrangements involving ACOs. The OIG would also waive fraud and abuse laws so that the Center for Medicare and Medicaid Innovation could carry out its mission of testing new payment and service delivery models. Specifically, the notice addresses the application of the following federal laws to participating ACOs: The Physician Self-Referral Law (SSA 1877(a)), which prohibits physicians from making referrals for Medicare designated health services, including hospital services, to entities with which they or their immediate family members have a financial relationship, unless an exception applies. The federal anti-kickback statute (SSA 1128B(b)), which provides criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit, or receive remuneration to induce or reward the referral of business reimbursable under any federal health care program. The civil monetary penalties law (SSA 1128A(b)(1) and (2)), which prohibits a hospital from making a payment, directly or indirectly, to induce a physician to reduce or limit services to Medicare and Medicaid beneficiaries under the physician s direct care. 7

8 CMS and the OIG are proposing to waive the above laws in three specific circumstances: The distribution of shared savings payments by an ACO to its participants. The distribution of shared savings payments to other individuals or entities for activities necessary for and directly related to the ACO s participation in the Shared Savings Program. Financial relationships that are necessary for and directly related to the ACO s participation in the Shared Savings Program and fully comply with an exception to the physician self-referral law (waiver of the anti-kickback statute and civil monetary penalties law only). The notice requests public comments on other areas where this waiver authority might be appropriately exercised, including ACO start-up costs, continuing operating expenses, and nonshared savings relationships between ACO members or outside entities. Antitrust Policy Statement In addition, the Federal Trade Commission (FTC) and Department of Justice (DOJ) jointly issued a Proposed Statement of Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program on antitrust enforcement of ACOs. The proposed antitrust policy would apply to collaborations, not including mergers, among independent providers seeking to participate in the Shared Savings Program (effective for post-march 23, 2010, activities). The policy includes a proposed Safety Zone for ACOs meaning that they will not be challenged by federal agencies for antitrust violations absent extraordinary circumstances. An ACO program applicant with a share above 50% for any common service that two or more ACOs provide to patients in the same area meets a Mandatory Review Threshold. Such an applicant must obtain a letter from one of the federal antitrust agencies stating that competitive concerns are not raised and a challenge is not anticipated. The DOJ and FTC have committed to provide a 90-day expedited review of ACOs that meet the 50% mandatory review threshold. Federal Tax Guidance The Internal Revenue Service (IRS) anticipates that tax-exempt organizations (such as nonprofit hospitals and other health care organizations) will form ACOs and may have questions about the application of federal tax law to the new structures. Accordingly, the IRS has issued a notice soliciting comments as to whether its existing guidance is sufficient or, if not, what additional guidance is needed. Under current federal tax law, a tax-exempt organization must ensure that earnings do not financially benefit organizational insiders or other private parties. Nonprofit hospitals participating in an ACO may receive payment under the Shared Savings Program which, 8

9 although not expected by the IRS to result in such prohibited inurement or impermissible private benefit, may create confusion. * * * * * AOTA is currently analyzing the implications of the proposed rule for therapy and drafting comments. Please us at with your thoughts. Resources Proposed Rule: Medicare Shared Savings Program: Accountable Care Organizations, 76 Federal Register (March 31, 2011) CMS Fact Sheet: Improving Quality of Care for Medicare Patients: Accountable Care Organizations (March 31, 2011) CMS Fact Sheet: What Providers Need to Know: Accountable Care Organizations (March 31, 2011) CMS Fact Sheet: What Patients Need to Know About Accountable Care Organizations (March 31, 2011) Federal Agencies Address Legal Issues Regarding ACOs Participating in the Medicare Shared Savings Program (March 31, 2011) Notice: Self-Referral and Anti-Kickback Legal Waivers (CMS and OIG, Display Copy, March 31, 2011) Proposed Rule: Statement of Antitrust Enforcement Policy Regarding ACOs (FTC and DOJ, Display Copy, March 31, 2011) Notice: Guidance on Tax-Exempt Providers Participating in ACOs (IRS, March 31, 2011) Attachments CMS Table 1. Proposed Measures for Use in Establishing Quality Performance Standards for Shared Savings in the First Year CMS Table 8. Shared Savings Program Overview 9

10 CMS-1345-P 174 Table 1. Proposed Measures for Use in Establishing Quality Performance Standards that ACOs Must Meet for Shared Savings AIM: Better Care for Individuals 1. Patient/Care Giver Experience Clinician/Group CAHPS: Getting Timely Care, Appointments, and Information 2. Patient/Care Giver Experience Clinician/Group CAHPS: How Well Your Doctors Communicate 3. Patient/Care Giver Experience Clinician/Group CAHPS: Helpful, Courteous, Respectful Office Staff 4. Patient/Care Giver Experience Clinician/Group CAHPS: Patients' Rating of Doctor 5. Patient/Care Giver Experience Clinician/Group CAHPS: Health Promotion and Education 6. Patient/Care Giver Experience Clinician/Group CAHPS: Shared Decision Making 7. Patient/Care Giver Experience Medicare Advantage CAHPS: Health Status/Functional Status 8. Care Coordination/Transitions Risk-Standardized, All Condition Readmission: The rate of readmissions within 30 days of discharge from an acute care hospital for assigned ACO beneficiary population. NQF #5 Survey Patient Experience of Care NQF #5 Survey Patient Experience of Care NQF #5 Survey Patient Experience of Care NQF #5 Survey Patient Experience of Care NQF #5 Survey Patient Experience of Care NQF #5 Survey Patient Experience of Care NQF #6 Survey Patient Experience of Care CMS Claims Outcome

11 CMS-1345-P Care Coordination/Transitions 30 Day Post Discharge Physician Visit CMS 10. Care Coordination/Transitions Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility Percentage of patients aged 65 years and older discharged from any inpatient facility (eg, hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days following discharge in the office by the physician providing ongoing care who had a reconciliation of the discharge medications with the current medication list in the medical record documented. 11. Care Coordination/Transitions Care Transition Measure: Uni-dimensional self-reported survey that measures the quality of preparation for care transitions. Namely: 1. Understanding one's self-care role in the post-hospital setting 2. Medication management 3. Having one's preferences incorporated into the care plan NQF #554 NQF #228 or alternate Survey or Group Practice Patient Experience of Care

12 CMS-1345-P Care Coordination Ambulatory Sensitive Conditions Admissions: Diabetes, short-term complications (AHRQ Prevention Quality Indicator (PQI) #1) All discharges of age 18 years and older with ICD-9-CM principal diagnosis code for short-term complications (ketoacidosis, hyperosmolarity, coma), per 100,000 population. 13. Care Coordination Ambulatory Sensitive Conditions Admissions: Uncontrolled Diabetes (AHRQ Prevention Quality Indicator (PQI) #14) All discharges of age 18 years and older with ICD-9-CM principal diagnosis code for uncontrolled diabetes, without mention of a short-term or long-term complication, per 100,000 population. 14. Care Coordination Ambulatory Sensitive Conditions Admissions: Chronic obstructive pulmonary disease (AHRQ Prevention Quality Indicator (PQI) #5) All discharges of age 18 years and older with ICD-9-CM principal diagnosis code for COPD, per 100,000 population. NQF #272 Claims Outcome NQF # 638 Claims Outcome NQF #275 Claims Outcome

13 CMS-1345-P Care Coordination Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8 ) NQF #277 Claims Outcome All discharges of age 18 years and older with ICD-9-CM principal diagnosis code for CHF, per 100,000 population. 16. Care Coordination Ambulatory Sensitive Conditions Admissions: Dehydration (AHRQ Prevention Quality Indicator (PQI) #10) All discharges of age 18 years and older with ICD-9-CM principal diagnosis code for hypovolemia, per 100,000 population. 17. Care Coordination Ambulatory Sensitive Conditions Admissions: Bacterial pneumonia (AHRQ Prevention Quality Indicator (PQI) #11) NQF # 280 Claims Outcome NQF # 279 Claims Outcome All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for bacterial pneumonia, per 100,000 population.

14 CMS-1345-P Care Coordination Ambulatory Sensitive Conditions Admissions: Urinary infections (AHRQ Prevention Quality Indicator (PQI) #12) NQF # 281 Claims Outcome All discharges of age 18 years and older with ICD-9-CM principal diagnosis code of urinary tract infection, per 100,000 population. 19. Care Coordination/Information Systems % All Physicians Meeting Stage 1 HITECH Meaningful Use Requirements CMS / EHR Incentive Program 20. Care Coordination/Information Systems % of PCPs Meeting Stage 1HITECH Meaningful Use Requirements CMS / EHR Incentive Program

15 CMS-1345-P Care Coordination/Information Systems % of PCPs Using Clinical Decision Support CMS Program Core Measure / EHR Incentive Program 22. Care Coordination/Information Systems % of PCPs who are Successful Electronic Prescribers Under the erx Incentive Program CMS Program Core Measure / erx Incentive Program 23. Care Coordination/Information Systems Patient Registry Use CMS Program Menu Set Measure

16 CMS-1345-P Patient Safety Health Care Acquired Conditions Composite: Foreign Object Retained After Surgery Air Embolism Blood Incompatibility Pressure Ulcer, Stages III and IV Falls and Trauma Catheter-Associated UTI Manifestations of Poor Glycemic Control Central Line Associated Blood Stream Infection (CLABSI) Surgical Site Infection AHRQ Patient Safety Indicator (PSI) 90 Complication/Patient Safety for Selected Indicators (composite) o o o o o o o o Accidental puncture or laceration Iatrogenic pneumothorax Postoperative DVT or PE Postoperative wound dehiscence Decubitus ulcer Selected infections due to medical care (PSI 07: Central Venus Catheter-related Bloodstream Infection) Postoperative hip fracture Postoperative sepsis CMS (HACs), NQF #531 (AHRQ PSI) Claims or CDC National Healthcare Safety Network Outcome

17 CMS-1345-P Patient Safety Health Care Acquired Conditions: NQF #298 CLABSI Bundle AIM: Better Health for Populations 26. Preventive Health Influenza Immunization: Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February). System Measure #110 Claims or CDC National Healthcare Safety Network 27. Preventive Health Pneumococcal Vaccination: Percentage of patients aged 65 years and older who have ever received a pneumococcal vaccine. NQF #41 System Measure #111 NQF #44

18 CMS-1345-P Preventive Health Mammography Screening: Percentage of women aged 40 through 69 years who had a mammogram to screen for breast cancer within 24 months. System Measure # Preventive Health Colorectal Cancer Screening: Percentage of patients aged 50 through 75 years who received the appropriate colorectal cancer screening. NQF #31 System Measure #113 NQF #34

19 CMS-1345-P Preventive Health Cholesterol Management for Patients with Cardiovascular Conditions: The percentage of members years of age who were discharged alive for AMI, coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year, who had each of the following during the measurement year.ldl-c screening LDL-C control (<100 mg/dl) 31. Preventive Health Adult Weight Screening and Followup: Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside parameters, a follow-up plan is documented. Parameters: Age 65 and older BMI 30 or < 22; Age BMI 25 or < 18.5 NQF # 75 System Measure #128 NQF #421 & Outcome

20 CMS-1345-P Preventive Health Blood Pressure Measurement: Percentage of patient visits with blood pressure measurement recorded among all patient visits for patients aged > 18 years with diagnosed hypertension. System #TBD 33. Preventive Health Tobacco Use Assessment and Tobacco Cessation Intervention: Percentage of patients who were queried about tobacco use. Percentage of patients identified as tobacco users who received cessation intervention. NQF #13 System #TBD 34. Preventive Health Depression Screening: 35. At Risk Population - Diabetes Percentage of patients aged 18 years and older screened for clinical depression using a standardized tool and follow up plan documented. Diabetes Composite (All or Nothing Scoring): Hemoglobin A1c Control (<8%) Low Density Lipoprotein (<100) Blood Pressure <140/90 Tobacco Non Use Aspirin Use NQF #28 System #134 NQF #418 NQF #575*, 64*, 61*, 28*, TBD & Outcome

21 CMS-1345-P At Risk Population Diabetes Diabetes Mellitus: Hemoglobin A1c Control (<8%) Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1c less than 8.0%. 37. At Risk Population Diabetes Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus 38. At Risk Population - Diabetes Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg/dl). Diabetes Mellitus: Tobacco Non Use Tobacco use assessment and cessation NQF #575 System Measure #2 NQF #64 System #TBD Outcome Outcome 39. At Risk Population - Diabetes Diabetes Mellitus: Aspirin Use Daily aspirin use for patients with diabetes & cardiovascular disease NQF #28 NQF TBD

22 CMS-1345-P At Risk Population - Diabetes Diabetes Mellitus: Hemoglobin A1c Poor Control(>9%): Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1c greater than 9.0%. System Measure #1 Outcome 41. At Risk Population - Diabetes Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus: Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent blood pressure in control (less than 140/90 mmhg). NQF #59 System Measure #3 Outcome 42. At Risk Population - Diabetes Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients Percentage of patients aged 18 through 75 years with diabetes mellitus who received urine protein screening or medical attention for nephropathy during at least one office visit within 12 months. NQF #61 System Measure #119 NQF #62

23 CMS-1345-P At Risk Population - Diabetes Diabetes Mellitus: Dilated Eye Exam in Diabetic Patients Percentage of patients aged 18 through 75 years with a diagnosis of diabetes mellitus who had a dilated eye exam. System Measure # At Risk Population - Diabetes Diabetes Mellitus: Foot Exam The percentage of patients aged 18 through 75 years with diabetes who had a foot examination. NQF #55 System Measure # At Risk Population - Heart Failure Heart Failure: Left Ventricular Function (LVF) Assessment Percentage of patients aged 18 years and older with a diagnosis of heart failure who have quantitative or qualitative results of LVF assessment recorded. NQF #56 System Measure #198 NQF # 79

24 CMS-1345-P At Risk Population - Heart Failure 47. At Risk Population - Heart Failure 48. At Risk Population - Heart Failure 49. At Risk Population - Heart Failure Heart Failure: Left Ventricular Function (LVF) Testing Percentage of patients with LVF testing during the current year for patients hospitalized with a principal diagnosis of heart failure (HF) during the measurement period. Heart Failure: Weight Measurement Percentage of patient visits for patients aged 18 years and older with a diagnosis of heart failure with weight measurement recorded. Heart Failure: Patient Education Percentage of patients aged 18 years and older with a diagnosis of heart failure who were provided with patient education on disease management and health behavior changes during one or more visit(s) within 12 months. Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Percentage of patients aged 18 years and older with a diagnosis of heart failure who also have LVSD (LVEF < 40%) and who were prescribed beta-blocker therapy. System Measure #228 CMS System #227 NQF # 85 System #199 NQF # 82 System Measure # 8 NQF #83

25 CMS-1345-P At Risk Population - Heart Failure 51. At Risk Population - Heart Failure Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Percentage of patients aged 18 years and older with a diagnosis of heart failure and LVSD (LVEF < 40%) who were prescribed ACE inhibitor or ARB therapy. Heart Failure: Warfarin Therapy for Patients with Atrial Fibrillation Percentage of all patients aged 18 and older with a diagnosis of heart failure and paroxysmal or chronic atrial fibrillation who were prescribed warfarin therapy. System Measure #5 NQF #81 System Measure #200 NQF #84

26 CMS-1345-P At Risk Population Coronary Artery Disease 53. At Risk Population Coronary Artery Disease Coronary Artery Disease (CAD) Composite: All or Nothing Scoring Oral Antiplatelet Therapy Prescribed for Patients with CAD Drug Therapy for Lowering LDL- Cholesterol Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) LDL Level <100 mg/dl Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD) Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed oral antiplatelet therapy. NQF #67, 74, 70, 64, 66 System Measure # 6 NQF #67 & Outcome

27 CMS-1345-P At Risk Population Coronary Artery Disease 55. At Risk Population Coronary Artery Disease 56. At Risk Population Coronary Artery Disease Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL- Cholesterol Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed a lipid-lowering therapy (based on current ACC/AHA guidelines). The LDL-C treatment goal is <100 mg/dl. Persons with established coronary heart disease (CHD) who have a baseline LDL- C 130 mg/dl should be started on a cholesterol-lowering drug simultaneously with therapeutic lifestyle changes and control of nonlipid risk factors (National Cholesterol Education Program (NCEP). Coronary Artery Disease (CAD): Beta- Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) Percentage of patients aged 18 years and older with a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy. Coronary Artery Disease (CAD): LDL level < 100 mg/dl System #197 NQF #74 System Measure # 7 NQF #70 CMS Outcome

28 CMS-1345-P At Risk Population Coronary Artery Disease Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD) System Measure #118 NQF #66 Percentage of patients aged 18 years and older with a diagnosis of CAD who also have diabetes mellitus and/or LVSD (LVEF < 40%) who were prescribed ACE inhibitor or ARB therapy. 58. At Risk Population Hypertension Hypertension (HTN): Blood Pressure Control Percentage of patients with last BP < 140/90 mmhg System #TBD Outcome 59. At Risk Population Hypertension Hypertension (HTN): Plan of Care Percentage of patient visits for patients aged 18 years and older with a diagnosis of HTN with either systolic blood pressure 140 mmhg or diastolic blood pressure 90 mmhg with documented plan of care for hypertension. NQF #18 System #TBD NQF # 17

29 CMS-1345-P At Risk Population COPD Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry evaluation results documented. 61. At Risk Population COPD Chronic Obstructive Pulmonary Disease (COPD): Smoking Cessation Counseling Received 62. At Risk Population COPD Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy based on FEV1 Percentage of patients aged 18 years and older with a diagnosis of COPD and who have an FEV1/FVC less than 70% and have symptoms who were prescribed an inhaled bronchodilator. 63. At Risk Population Frail Elderly Falls: Screening for Fall Risk Percentage of patients aged 65 years and older who were screened for fall risk at least once within 12 months System Measure # 51 NQF #91 CMS System Measure # 52 NQF #102 NQF #101

30 CMS-1345-P At Risk Population Frail Elderly Osteoporosis Management in Women NQF #53 Who had a Fracture Percentage of women 65 years and older who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the 6 months after the date of fracture 65. At Risk Population Frail Elderly Monthly INR for Beneficiaries on Warfarin Average percentage of monthly intervals in which Part D beneficiaries with claims for warfarin do not receive an INR test during the measurement period *Individual measure within composite measure is used in the Program. NQF #555 Claims

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