Mr. Andy Slavitt Acting Administrator Centers for Medicare & Medicaid Services Department of Health & Human Services Hubert H. Humphrey Building 200 Independence Ave., S.W. Room 445-G Washington, DC 20201 Submitted electronically via http://www.regulations.gov File Code: RIN 0938-AS82 Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Organ Procurement Organization Reporting and Communication; Transplant Outcome Measures and Documentation Requirements; Electronic Health Record (EHR) Incentive Programs; Payment to Certain Off-Campus Outpatient Departments of a Provider; Hospital Value-Based Purchasing (VBP) Program Dear Mr. Slavitt: Thank you for the opportunity to comment on the Hospital Outpatient Prospective Payment (OPPS) Proposed Rule. AHIP is the national trade association representing health insurance plans. AHIP s members provide health and supplemental benefits through employer-sponsored coverage, the individual insurance market, and public programs such as Medicare and Medicaid. AHIP advocates for public policies that expand access to affordable health care coverage to all Americans through a competitive marketplace that fosters choice, quality, and innovation. AHIP appreciates CMS efforts to refine its quality measurement and reporting programs across diverse care settings using a variety of approaches, including expansion of the existing Hospital Outpatient Quality Reporting (OQR) Program s measure set as well as continued implementation of quality measurement in the ambulatory surgical setting through the Ambulatory Surgical Centers Quality Reporting (ASCQR) Program. Our comments focus on the following components of the proposed rule: - Site Neutral Payments,
Page 2 - CAHPS Survey Proposals, - Measure additions for the 2020 OQR and ASCQR programs, - EHR Incentive Program changes, and - Medicare s Inpatient Only List Site Neutral Payments Provision Currently, Medicare pays for services at a higher rate if those same services are provided in a hospital outpatient department rather than a physician s office. Section 603 of the Bipartisan Budget Act of 2015 specified that, as a general matter, applicable items and services furnished by certain off-campus outpatient provider-based departments (off-campus PBDs) will not be paid for under the OPPS beginning in 2017 and instead will be paid under the applicable payment system under Medicare Part B. CMS is proposing that, for items and services for which payment can be made to a billing physician or practitioner under the Medicare Physician Fee Schedule (PFS), the physician or practitioner furnishing such services in the off-campus PBD would bill under the PFS at the non-facility rate. This would be a one-year transitional policy while CMS explores additional operational changes for 2018. We strongly support the implementation of site neutral payments for office visits and ambulatory services provided in physician s offices and hospital outpatient departments. As noted by MedPAC, price differentials based on site of service create distortions in provider incentives. For example, MedPAC has observed that when hospital outpatient department payments are not aligned with rates paid for the same services in a physician s office, hospitals have an incentive to acquire physician practices and bill for these services at a higher hospital outpatient rate, increasing program spending and out-of-pocket costs for beneficiaries. As CMS explores the additional operational changes that will be needed going forward, one possible approach would be to establish a single outpatient payment fee schedule to align payments for outpatient services for similar patients regardless of whether they are furnished in a physician s office or hospital outpatient department. Should CMS consider this approach, we suggest that CMS refer to MedPAC discussions and methodology for aligning payments across post-acute care (PAC) settings. 1 The Commission has recommended that patient assessment data be collected in order for Medicare to develop a common PAC payment system where payments can be based on patient characteristics rather than site of service. Collection of patient assessment data across sites of care will enable a more complete comparison of providers costs 1 MedPAC. Chapter 7 - Medicare s Post-Acute Care: Trends and Ways to Rationalize Payments. March 2015.
Page 3 and outcomes and facilitate the development of a cross-cutting outpatient payment system. Additionally, CMS may wish to explore ways to phase-in implementation of site neutral payments to give off-campus PBDs time to adjust their cost structures. CAHPS Survey: Hospital Value-Based Purchasing CMS adopted the HCAHPS Survey in the Hospital VBP Program beginning with the FY 2013 program, with assistance from the Agency for Healthcare Research and Quality (AHRQ). The current HCAHPS survey consists of 9 dimensions, each containing related questions, and are distributed to patients within 6 weeks after discharge. CMS is proposing to remove the Pain Management dimension (consisting of 3 questions) from the hospital value-based purchasing program for the 2018 program year, due to extensive feedback from stakeholders regarding concerns about incentives on hospital staff to prescribe more opioids in order to achieve high scores on this dimension. AHIP is supportive of this proposed change and, given the current opioid crisis, we understand efforts need to be taken to discourage the use of these medications as the only source of pain management. AHIP recommends that even though the pain management questions would no longer factor into HVBP payments from Medicare, hospitals should continue to survey patients about their inpatient pain management experience, as management of pain is an important aspect of high quality inpatient care. Also, collection of these data will allow continued investigation into the relationship between these pain management questions and use of opioids. CAHPS Survey: Hospital Outpatient Quality Reporting (OQR) Program and Ambulatory Surgical Center Quality Reporting (ASCQR). The Hospital Outpatient Quality Reporting (OQR) program and the Ambulatory Surgical Center Quality Reporting (ASCQR) program have been developed to promote high quality care for patients receiving services in either a hospital outpatient setting or ambulatory surgical setting. We applaud CMS for continuing to promote higher quality and more efficient healthcare through implementation of these quality reporting programs, focusing on measures that have high impact to Medicare beneficiaries and support national quality priorities. Under these programs, hospitals and ambulatory surgical centers (ASC) report data using standardized measures of care to receive the annual update to their Outpatient Prospective Payment System (OPPS) payment rate. Although CMS is not proposing any changes to the CY 2018 or 2019 measure sets for either of the quality reporting programs, changes for 2020 payment determination and subsequent years are being considered. In addition to claims based measures discussed below, CMS is proposing
Page 4 to adopt 5 Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey (OAS CAHPS) measures, including pain management communication questions. Unlike the HCAHPS pain management questions, which directly address the adequacy of the hospital s pain management efforts, CMS believes the OAS CAHPS pain management communication questions focus more on information provided to patients regarding different methods of pain management and not the facilities efforts to manage the patients pain. AHIP supports CMS s proposal to include the additional 5 OAS CAHPS questions in the 2020 payment determination for both the OQR and ASCQR programs, as it is important to collect and analyze data about healthcare providers performance from a patient s or consumer s perspective. However, we have some concerns with relying too heavily on the survey results for reimbursement determinations, and emphasize the need to secure an adequate response rate to ensure reliable measurement. Additionally, while we support the removal of the Pain Management Dimension and related questions from HVBP due to concerns about incentives on hospital staff to prescribe more opioids in order to achieve high scores on this dimension, we are not confident that simply including communication questions regarding pain management will reflect the true perception the patients have of their experience relative to pain management. We encourage CMS to continue to explore ways to ensure better measurement of patient s experience with pain management. Hospital Outpatient Quality Reporting (OQR) and Ambulatory Surgical Center Quality Reporting (ASCQR). CMS continues to promote higher quality and more efficient healthcare for Medicare beneficiaries, through implementation of quality reporting for multiple settings, including the Hospital Outpatient Quality Reporting (OQR) and Ambulatory Surgical Center Quality Reporting, with both areas focused on measures that have high impact to Medicare beneficiaries and support national quality priorities. Although CMS is not proposing any changes to the CY 2018 or 2019 measure sets or current policies regarding measure retention, measure retirement or topped-out measure criteria, CMS is considering changes for the 2020 payment determination measurement period. CMS is proposing to add two claims based quality measures to the Hospital OQR and two additional quality measures to the ASC quality reporting criteria. The new measures being proposed are: Hospital Outpatient Quality Reporting
Page 5 OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, and OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687) Ambulatory Surgical Center Quality Reporting ASC-13 (not NQF-endorsed): Normothermia Outcome, and ASC-14 (not NQF-endorsed): Unplanned Anterior Vitrectomy We support inclusion of these additional quality measures in the Hospital OQR for the 2020 payment determination measurement period and beyond, as cancer treatment and overall hospital re-admissions continue to be high focus areas and we agree it is important to identify unmet needs in the care provided to these patients. We also support adding the proposed ASCQR measures given the fact that cataracts are a leading cause of blindness in the United States and ambulatory surgical centers should make every effort to minimize complications from cataract surgery. Lastly, AHIP supports CMS efforts to ensure consumers have adequate information with which to make informed healthcare decisions, by publicly displaying measurement data on the Hospital Compare Web site, or other CMS Web site, as soon as possible. This will not only help consumers make decisions about where to get their care but will also encourage hospitals to ensure high quality of care. Electronic Health Record (EHR) Incentive Program In 2015 CMS published a final rule titled Medicare and Medicaid Programs; Electronic Health Record Incentive Program Stage 3 and Modifications to Meaningful Use. In that rule efforts were made to align the Modified Stage 2 measures with Stage 3 measures, align the required reporting periods with the calendar year, as well as align parts of the Incentive Program with other CMS quality reporting programs. CMS is now considering a number of additional process changes as it relates to the EHR incentive program. CMS is proposing changes to both the objectives and applicable measures for meaningful use for Modified Stage 2 and Stage 3, starting with the electronic health record (EHR) reporting period for calendar year 2017. For both the Modified Stage 2 in 2017 and Stage 3 in 2017 and 2018, CMS is proposing to eliminate both the Clinical Decision Support (CDS) and Computerized Provider Order Entry (CPOE) objectives and measures for those attesting under the Medicare EHR Incentive Program, as it is believed the measures in these objectives are topped out. In
Page 6 addition to the above, CMS is proposing to lower the reporting thresholds for a subset of the remaining objectives and measures. CMS acknowledges that statute requires the Secretary to seek to improve the use of EHRs and subsequently intends to continue to evaluate the program requirements and seeks input from eligible hospitals and CAHs on how the measures could be made more stringent in the future. AHIP does not support the above mentioned proposed changes to the EHR incentive program. We believe it is important to continue to emphasize measures that accurately gauge the level of EHR usage and facilitation of data collection and data transfer. If CMS finds measure thresholds are being consistently met, we would recommend CMS raise those specific measure thresholds so as not to diminish EHR use. Additionally, our member organizations as well as provider groups, have already invested significant resources to ensure that their EHR systems meet the required standard. CMS is also proposing to change the EHR reporting period in 2016 for all returning EPs, eligible hospitals and CAHs that have previously demonstrated meaningful use in the Medicare and Medicaid EHR Incentive Programs. CMS is proposing to change the reporting period from the full calendar year to any continuous 90-day period within the calendar year for 2016. AHIP supports this proposal. Changing the reporting requirement to a consecutive 90-day period allows practices and health systems to continue the progress they have made in EHR systems implementation and investment in technology that helps support numerous payment and delivery models. Lastly, CMS proposes to implement a one-time significant hardship exception from the 2018 payment adjustment for certain eligible professionals who are new participants in the EHR Incentive Program in 2017 and are transitioning to the Merit-Based Incentive Payment System (MIPS) in 2017. We support the implementation of this one-time exception from the 2018 EHR Incentive Program payment adjustment. Due to the overlap in the 2017 reporting and performance periods and the different measures and requirements between the EHR Incentive Program and the Advancing Care Performance Category under MIPS, this one-time exception will enable providers new to certified EHR technology to focus on their transition to MIPS.
Page 7 Inpatient Only List The Medicare Inpatient Only (IPO) list includes procedures that are typically provided only in an inpatient setting and, therefore, are paid under the Inpatient Prospective Payment System (IPPS) rather than under the OPPS. While CMS is not proposing to remove total knee arthroplasty (TKA) from the IPO list for 2017, CMS is requesting comments on whether TKA should be removed from the IPO list in a future year. The criteria upon which CMS bases its decisions regarding removal from the IPO list include: most outpatient departments are equipped to provide the services; the simplest procedure described by the code may be performed in most outpatient departments; the procedure is related to codes already removed from the IPO list; or a determination is made that the procedure is already being performed in numerous hospitals on an outpatient basis. We support removal of TKA from the IPO list. Recent innovations have enabled surgeons to safely perform TKA on an outpatient basis in the commercial market. Stratification based upon risk, appropriately trained and skilled surgeons, and selective approval of this procedure on an outpatient basis are the key determinants to whether this procedure can be safely and appropriately performed on an outpatient basis. Thank you for the opportunity to comment on these important issues. Sincerely, Carmella Bocchino Executive Vice President