Cms-10451

Response to Comments, 60-day Comment Period, Evaluation and Development of Outcome Measures for Quality Assessment in Medicare Advantage and Special Needs Plans (CMS-10451)

#	Commenter	General Description	Comment	CMS Response s
1	BARBARA SACHAU	Part D Premium	A Commenter is concerned about payment for their Part D premiums.	The purpose of this collection request is to test the use of new tools available to CMS to measure care pertinent to vulnerable beneficiaries. Although this comment is not pertinent to this data collection request, CMS is always concerned about beneficiary satisfaction. The commenter may contact 1-800 MEDICARE (1-800-633-4227) regarding this complaint. The commenter’s concern was also forwarded to the appropriate staff at CMS.
2	jean public	Part D Premium	A Commenter is concerned about payment for their Part D premiums.	The purpose of this collection request is to test the use of new tools available to CMS to measure care pertinent to vulnerable beneficiaries. Although this comment is not pertinent to this data collection request, CMS is always concerned about beneficiary satisfaction. The commenter may contact 1-800 MEDICARE (1-800-633-4227) regarding this complaint. The commenter’s concern was also forwarded to the appropriate staff at CMS.
3	Aetna	Use Existing Hospital Readmission Measures	The commenter suggested CMS consider using the existing hospital readmissions measure for this evaluation area. However, the hospital readmissions measure should be expressed as readmissions per 1,000 lives to reflect the successful work of MA plans to reduce avoidable admissions.	CMS recognizes that the Hospital Readmission Measure is important. The Transitions of care measure adds to the readmission measure by identifying aspects of care to be improved. The MA Readmissions measure is one reflection of the quality of continuity care, however the components of the proposed measure will evaluate aspects of care that are distinct from the Readmissions measure and these can be linked to reasons for readmission.
4	Aetna	Continuity of Care	The commenter agreed that the Continuity between Mental Health Provider and Primary Care Provider measure is important, but suggested that such continuity is prevented by federal and state laws. The commenter suggested that the data collection assess the impact of laws and regulations that inhibit information sharing about patients with substance use disorders such as the Federal Confidentiality of Alcohol and Drug Abuse Patient Records law. Concern was also raised about state laws and provisions under the Health Insurance Portability and Accountability Act to request that providers not share information about their mental illness.	The comments raise potentially valuable aspects of care that also deserve attention. We agree that limited data sharing may inhibit care coordination and patient outcomes, and this is the focus of the proposed measure. However these comments reflect a misconception that clinical information about mental health cannot be shared among providers of care. Such concerns likely impede high quality coordination of care and encourage discontinuous care that harms patients. A medical record notation that a patient does not want medical information to be shared with another provider will be collected. Such documentation will confer credit for continuity because it indicates that the provider aimed to carry out continuous care but that patient preference interfered with communication. These items were added to the mental health continuity medical record abstraction in the Supporting Statement Part B on pages 62, 68, and 75. Data collection concerning laws affecting transmission of information between providers about mental conditions is important, but outside the scope of the proposed measure. The Validation Study focuses on sharing information between mental health provider and primary care physician; therefore, the data collection process to include patients with substance abuse disorders is also outside the scope of this study.
5	Aetna	Additional Items to the CAHPS	The commenter expressed concern about adding items to the CAHPS survey and suggested CMS consider removing other questions to encourage beneficiaries to complete the survey.	The purpose of the current data collection is to test new survey items that may ultimately be included in a CAHPS survey. Should these items be included, CMS will devise a strategy to ensure that the overall CAHPS survey is not unduly lengthy to complete.
6	Aetna	Develop Measures that Focus on Improvement of Beneficiary Outcomes	With regards to the Transitions of care measure, the commenter indicated that integrated health systems and staff model organizations have enhanced capability to influence coordination between hospitals and outpatient settings compared to national network organizations. The commenter also noted that process measures should be linked to outcome measures as much as possible.	While process measures do not always reflect beneficiary outcomes, they do have value for guiding quality improvement interventions. We agree that greater integration across care venues is a goal of the coordination of MA plans and particularly SNPs. Some organizational structures may have advantages in achieving these processes of care; these organizational structures offer models that can be emulated to enhance continuity across transitions. The proposed measure incorporates process of care components linked to outcomes of adequate care transition approaches, such as readmission, that are important to patients.
7	Aetna	Include Modification of the MA Readmission Measure, The STAR Rating System and Other Measures	The commenter made suggestions concerning other CMS measurement efforts including modification of the MA Readmission measure, the STAR rating system, CAHPS measurement, the quality bonus demonstration and the SNP Structure and Process measures.	The commenter’s suggestion is beyond the scope of the proposed data collection.
8	Aetna	Assess Barriers to Sharing Data between Mental Health and Primary Care Providers.	The commenter points out an additional area that should be captured in the medical record abstraction: documentation in the mental health provider record that the patient refused communication with the primary care provider or documentation in the primary care record of refusal to permit communication.	There are many barriers to continuity of information between mental health providers and primary care physicians. This comment underscores the importance of this mental health continuity measure. Items to collect documentation about refusal to permit communication between the mental health provider and the primary care provider were added to the medical record abstraction form in the Supporting Statement Part B on pages 62, 68, and 75.
9	Aetna	Substance Abuse Disorders	The commenter suggested that patients with substance abuse disorders should be included in the Continuity between Mental Health Provider and Primary Care Provider measure.	The diagnosis codes for identification of cases do not include substance use codes, CMS will not revise the visit codes to expand the measure to patients with primary substance use disorders because this may distract from the focus on continuity among patients receiving consultation for primary mental health disorders. However, patients with substance use disorders will be included in the study sample by virtue of the relationship of substance use with mental health disorders. The commenter’s suggested changes provide a valuable suggestion for subsequent testing of this measure.
10	Aetna	Transition Record Continuity	One commenter suggests adding all diagnoses in the transition record, including behavioral health diagnoses, to the abstraction instrument in order to evaluate continuity of this information into the outpatient setting.	Collecting data about the specific principal diagnosis and other secondary diagnoses from the hospitalization would add considerably to the data collection burden. CMS concurs that there is value in recording all diagnoses in the transition record, including behavioral health diagnoses, and measuring continuity into the outpatient setting. However, the “principal diagnosis” is required in the transition document based on the technical specifications of NQF endorsed measure #0647 (Transition Record Continuity). The proposed abstraction will determine only if the principal diagnosis was listed in the transition documents.
11	Aetna	Behavioral Health Inpatient Stays	One commenter suggested that patients with new Behavioral Health inpatient stays should be included in the Continuity between Mental Health Provider and Primary Care Provider measure. The comment suggests that inpatient mental health admissions would be a trigger for identification of mental health cases for evaluation of continuity.	The continuity with both mental health and primary care clinicians after an inpatient behavioral health admission is critically important. However, including these patients would increase the complexity and thus the burden of collection of medical records and is beyond the scope of the proposed Validation Study.
12	Aetna	Include a Depression Screening Measure	One commenter suggested that a depression screening measure be developed.	The proposed measures in this data collection do not address screening for depression. Developing such a measure is outside the scope of the proposed data collection.
13	Aetna	Advanced Illness Care Planning	One commenter suggested that measures be developed to address advanced illness care and advance care planning. A second commenter suggested benchmarking unmet care needs, preventive services, a set of geriatric conditions, under-prescribed medications, or integrating SAHMSA measures.	The proposed suggestion to develop additional measures would add considerably to the data collection burden. This suggestion cannot be considered at this time.
14	Aetna	Culturally Competent Care is Important to Beneficiary Outcomes.	The CAHPS beneficiary satisfaction survey is an important component of the MA plan evaluation process. We applaud CMS' recommendation to include new questions that assess the cultural competence of providers.	CMS appreciates this comment.
15	Aetna	Cultural competence. .	The commenter suggested adding an additional item to the proposed CAHPS item on cultural competence.	We appreciate the suggested item, which would further assess physicians’ sensitivity to personal values and beliefs, however we are sensitive to minimizing the number of questions being asked of beneficiaries and will not add this item to the CAHPS.
16	Aetna	Reversing the Order of Question 30 and 31	One commenter suggested reversing the order of questions 30 and 31 in the proposed CAHPS items that evaluate access to an interpreter.	We appreciate the suggestion to reverse the order of these two questions. We will reorder questions 30 and 31 in the Spanish language CAHPS survey. This change was made on page 117 of the revised PRA materials.
17	Aetna	Concern Regarding Length of CAPHS	Remove some questions to ensure that beneficiaries will not be deterred from responding to an extensive survey.	The purpose of the current data collection is to test new survey items that may ultimately be included in a CAHPS survey. CMS will devise a strategy to ensure that the overall CAHPS survey is not unduly lengthy to complete.
18	Aetna	Medical Record Abstraction is Costly	Two commenters note that detailed medical record abstraction is costly. One respondent suggested that CMS hire a nationwide HEDIS/medical record review agency to perform the proposed medical record abstractions and that the proposed data collection not be performed in conjunction with the annual HEDIS audit (December-June).	CMS recognizes that the proposed data collection is more complex than the usual HEDIS medical record abstraction. This is necessary because continuity is complex to measure. The goal is for health plans to carry out the medical record abstraction with a small number of cases. The data collection aims to be completed outside the annual HEDIS audit timeframe so as not to interfere with that process.
19	Aetna	HEDIS Measurement Period	CMS is requesting a one-year clearance for this pilot program. What HEDIS measurement period will CMS target?	The medical record audit of the Validation study aims to avoid overlap with the HEDIS measurement period; this is dependent upon plan participation.
20	Aetna	Health Plan Selection for Validation Study	Commenters request guidance on how plans will be selected to participate in the data collection and whether participation costs will be covered.	CMS will identify plans to participate based on plan interest and the need to include diverse types of participating plans. CMS is developing a sampling strategy to identify plans. In the Pilot study, plans were not compensated, but technical assistance was provided. The same is planned for the Validation study implementation.
21	Aetna	Promote Stability In The Medicare Star Ratings Program	The commenter discussed several issues regarding the Medicare Star Ratings Program, and the three year quality demonstration.	CMS appreciates these comments however; these issues cannot be addressed since they are beyond the scope of this Validation Study.
22	Julie Quist	Extend the Comment Period	One commenter asked for an extension of the comment period for 60 days.	The comment period was extended to January 2, 2013 to ensure a full 60- day period for public comment.
23	Cigna/HealthSpring	Align the Proposed Measures with the Reports of the SNP Structure and Process Measures.	We would like to emphasize the importance of not only developing SNP quality outcomes measures but also aligning all frameworks used to hold SNPs accountable: Model of Care elements, NCQA SNP Structure and Process Measures, HEDIS measures and Star measures, etc. Currently, much data and administrative documentation is submitted to CMS and NCQA each year by SNP plans as evidence of plan quality. This data and documentation is not well aligned and we support the addition of SNP outcome measures that reduce the administrative burden of "process" measures and better align the existing SNP data and document submission requirements.	CMS acknowledges these comments; however, these issues do not address the proposed data collection.
24	Cigna/HealthSpring	Too Small Sample Size	One commenter noted that some data collected at the Plan Benefit Package level have samples that are too small to be meaningful and that data should be collected at the regional or contract level.	The proposed data collection will inform decisions about the minimum plan benefit package size required for meaningful data at the plan benefit package level.
25	Cigna/HealthSpring	SNPs should be scored for HEDIS and CAHPS measures against different benchmarks than those for regular Medicare Advantage plans	One commenter noted that Special Needs Plans care for a particularly vulnerable population and that their scores on the proposed measures should not be compared to regular Medicare Advantage plans.	The proposed data collection is designed to include SNP and regular MA plans to inform whether adjustments are needed in making comparisons among plans.
26	Cigna/HealthSpring	ACOVE Measures Applying to all Medicare Beneficiaries	Two commenters ask whether the proposed measures apply to all beneficiaries or a selected group of “vulnerable elders.”	The measures apply to all Medicare beneficiaries. The particular ACOVE measures included will apply to an MA beneficiary population.
27	Cigna/HealthSpring	Proposed Measures and Medical Record Extraction Process	One commenter suggested that the proposed measures not be added to the existing SNP Structure and Process measure set. Two commenters suggest specific outcomes measures that might be considered for addition to the Structure and Process measures. We recommend that you consider the following SNP outcome measures: • Fewer readmissions • Fewer ER visits • Fewer adverse drug events • Shorter stays in post-hospital settings	The proposed measures are not intended to be added to the SNP Structure and Process measure set. The proposed measures are intended to be applicable to all MA types and will be incorporated into existing data collection tools. Further, the recommendations on the SNP outcome measures to include fewer readmissions; fewer ER visits; fewer adverse drug events; shorter stays in post-hospital settings do not apply to this data collection.
28	Cigna/HealthSpring	Proposed Data Collection Too Burdensome	One commenter stated that the proposed measures are too burdensome to repeat annually for SNP plans.	The proposed implementation of medical record measures aims to evaluate the level of burden and value of these measures in order to inform decisions to be made regarding data collection process.
29	Cigna/HealthSpring	Underestimation of Burden between Mental Health Provider and Primary Care Provider Measure	One commenter suggests that the burden estimate is too low for the medical record abstraction for the Continuity between Mental Health Provider and Primary Care Provider measure.	The burden estimate for the mental health continuity measure is based on effort required during a pilot study of the medical record abstraction process for this measure.
30	Cigna/HealthSpring	Underestimation of Burden for Travel	The burden estimate does not take into account travel to PCP offices, hospitals and facilities, copying and/or postage to obtain member records. We would propose increasing the cost and time estimate for the proposed process to account for the time and expense of manually obtaining records.	The burden estimate for travel is based on effort required during a pilot study of the medical record abstraction process for this measure.
31	Cigna/HealthSpring	Mental Health Continuity Measures	One commenter notes that mental health continuity is complicated by potential flux among providers and patients, including beneficiaries moving between providers and having multiple providers, making data collection difficult.	This measure evaluates communication from the vantage point of both the mental health professional and the primary care provider. An effort at communication from either clinician can be interpreted as satisfying continuity. Pilot implementation of this measure did not find multiple providers or provider switching to be a problem, but an aspect of the proposed implementation is to evaluate if this is a complication to be considered in this measure.
32	Cigna/HealthSpring	Clinical review teams of the type sought in this proposal are expensive.	Clinical review teams of the type sought in this proposal are expensive	The measure requires medical record abstraction, but only a delimited number of cases per plan. Once the medical records are obtained, the abstraction can be completed with reasonable effort.
33	Cigna/HealthSpring	SNP Locus of Control and Evaluating SNP Plan Quality	One commenter asked whether the proposed measures fall within SNP locus of control and whether the data collected can truly be used to evaluate SNP plan quality or whether the proposed measures better evaluate the administrative processes in place at PCP offices, hospitals and mental health providers.	The proposed measures focus on continuity of transition and mental health care, cultural awareness, interpreter availability and caregiver strain. These are all important areas for SNP enrollees and choice of these areas was guided by a Technical Expert Panel that included plan quality of care representatives. Because in many cases, MA plans (including SNPs) control the relationship between mental health providers and primary care physicians, these plans are appropriately situated to assume considerable accountability for mental health and primary care continuity.
34	Cigna/HealthSpring	CAHPS Survey Question: Beneficiaries with+ Mental Illness	Two commenters asked whether mental illness and cognitive impairment were considered in SNP enrollees’ ability to answer the proposed CAHPS survey items.	Mental illness and cognitive impairment have been considered by CMS in the process of developing the CAHPS survey items. CMS believes that this issue has been accounted for in the Validation Study. CAHPS allows for a proxy respondent to complete the survey. The cultural awareness, healthy living and interviewer items underwent cognitive interview testing in an older sample of MA patients.
35	Cigna/HealthSpring	Health Plan Participation in the Validation Study	The commenter relayed that the health plan would like to participate in the proposed data gathering and SNP outcome measure development process.	CMS appreciates the commenter’s offer to participate in the validation study. For the transition of care measure, up to six MAO contracts will be recruited by CMS for participation. CMS envisions plans of varying size that include two MA coordinated care plans, two D-SNPs and two C-SNPs. The same will apply for the measure of continuity between mental health provider and the PCP.
36	Kaiser Permanente	Continuity of Information	The commenter supports CMS' testing of the standard: continuity of information and care from hospital discharge to the outpatient setting.	We acknowledge and appreciate the commenter’s support for this effort to evaluate post-discharge continuity of care.
37	Kaiser Permanente	Continuity of Information	The commenter agrees that integrated care is critical to member well-being. However, communication between mental health providers and PCPs will present many challenges. The biggest challenge will be disclosing (between provider types) this information because of the restrictions under various state and federal medical privacy laws and regulations that require consent or authorization for use or disclosure of very sensitive protected mental health information. Finally, not all MA or SNP members are willing to share this very sensitive mental health information with their other health care providers, including PCPs.	The comments raise potentially valuable aspects of care that also deserve attention. We agree that limited data sharing may inhibit care coordination and patient outcomes, and this is the focus of the proposed measure. However these comments reflect a misconception that clinical information about mental health cannot be shared among providers of care. Such concerns likely impede high quality coordination of care and encourage discontinuous care that harms patients. A medical record notation that a patient does not want medical information to be shared with another provider will be collected. Such documentation will confer credit for continuity because it indicates that the provider aimed to carry out continuous care but that patient preference interfered with communication. These items were added to the mental health continuity medical record abstraction in the Supporting Statement Part B on pages 62, 68, and 75. Data collection concerning laws affecting transmission of information between provides about mental conditions is important, but outside the scope of the proposed measure.
38	Kaiser Permanente	Continuity of Information	The commenter reiterates the legal, ethical, and personal challenges that present barriers to open communication.	Measurement of discontinuity can lead to recognition of perceived legal barriers to continuity of information. The proposed measure does not select cases that have diagnosis codes involving substance use, although we recognize substance use may play a role in mental health problems.
39	Kaiser Permanente	Items Added to the CAHPS Survey Addressing Language Centered Care, Cultural Competence, Physical Activity, Healthy Eating, and Caregiver Strain,	One commenter acknowledged the importance to the CAHPS items addressing language centered care, cultural competence, physical activity, healthy eating, and caregiver strain. This commenter suggested testing items to measure health literacy.	We appreciate this suggestion and will consider additional testing for health literacy mentioned by the commenter for future studies.
40	Kaiser Permanente	Items Added to the CAHPS Survey Addressing Language Centered Care, Cultural Competence, Physical Activity, Healthy Eating, and Caregiver Strain,	One commenter noted that CAHPS items to be tested concerning physical activity and healthy eating evaluate efforts that may be too weak to elicit a change in behavior for these activities. The questions can be expanded to cover Plan Sponsor efforts (directly and through provider networks} to improve both physical activity and nutrition of members. They propose that these questions might fit better in the Health Outcomes Survey.	The proposed items will be tested in a CAHPS survey format. If health plans are found to already be performing these tasks aimed at physical activity and healthy eating at a high level, then these questions can be modified to cover other activities. Yes we agree that these new items may be appropriate for inclusion in the Health Outcomes Survey, but will make that determination after the validation study is completed.
41	Kaiser Permanente	Care Giver Strain Index	Two commenters note that the Caregiver Strain questions proposed to be tested in CAHPS focus on the effects of giving care to others, rather than member experiences with the care and service received through their health plan. One commenter states that “Although one could argue that Plan Sponsors could help their members mitigate the emotional and physical stress from care giving, no such questions are included in this proposal.” Two commenters suggest adding these questions to the Health Outcomes Survey because these questions are more in line with the purpose of the Medicare Health Outcome Survey.	CMS seeks to perform a needs assessment of the burden of caregiving among plan enrollees. Based on the findings of the Caregiver Strain Index, plans may choose to carry out quality improvement activities to help members who are caregivers. Different questions could subsequently be considered for inclusion in a survey or other evaluation instrument to address the commenters’ concerns, based on these initial findings from this data collection.
42	Kaiser Permanente	CAHPS Survey Burden on Respondents and Cost Burden	The commenter notes that CMS consider the burden on respondents if the proposed questions are added to the complete current MAPD version of the Medicare CAHPS questionnaire. Increasing the number of questions will impact on respondent burden and response rates. Furthermore, the cost to Plan Sponsors for fielding the survey will likely increase because the questionnaire will require extra pages-- resulting in higher printing costs and possibly higher postage fees.	The purpose of the current data collection is to test new survey items that may ultimately be included in a CAHPS survey. Should these items be included, CMS will devise a strategy to ensure that the overall CAHPS survey is not unduly lengthy to complete.
43	Health Partners	Health Plan Sampling	One commenter suggested that all Coordinated Care plan types, including HMO, HMO-POS and PPO, be included in the implementation because they have different network rules and restrictions.	CMS will develop a sampling plan that endeavors to include all plan types. Please refer to the Supporting Statement Part B on page 10.
44	Health Partners	Transitions of Care collection – Dual Eligibles	One commenter notes that the Transitions of care measure data collection may not be evident in the EMR/EHR information pulls and may miss D-SNP care management efforts and members’ experience because these may not be reflected in the clinical care processes.	The proposed Transitions of care measure focuses on two areas of post-discharge care: transition of pertinent patient information by the hospital and completion of pending/ordered post-discharge clinical activities. The completion of pending/ordered post-discharge activities could be facilitated by case management. Case management activities are specifically captured in item 20 of the medical record abstraction form.
45	Health Partners	CAHPS Survey Length and Validity of Caregiver Strain Section .	The commenter is concerned about the length of the CAPHS and also questioned the validity of the responses that will be provided for the Caregiver sections.	The purpose of the current data collection is to test new survey items that may ultimately be included in a CAHPS survey. Should these items be included, CMS will devise a strategy to ensure that the overall CAHPS survey is not unduly lengthy to complete. The Caregiver strain items were developed to reflect aspects of caregiver strain measured by validated longer instruments. In this implementation, the full Caregiver strain index is being collected to validate the 4-item version among MA plan beneficiaries.
46	SNP Alliance	SNP Alliance Support for Development of Outcome Measures	One commenter suggested that population specific outcomes are needed, particularly for C-SNPs.	CMS agrees that population specific outcome measures will be useful, particularly for C-SNPs, but also for common conditions in D-SNPs. However this consideration cannot influence the proposed measures for testing in the Validation study as these aim to be applicable to all MA plan types.
47	SNP Alliance	Clarifications Regarding Measurement Development Initiative	One commenter noted that the measures are process measures rather than outcome measures and that the commenter prefers development of outcome measures.	Caregiver strain is an outcome measure. The continuity measures and the other items to be tested in CAHPS are process measures that may lead to development of outcome measures in the future. The inpatient to outpatient transition measures are a combination of process and outcome measures. CMS believes that both process and outcome measures are important in the evaluation of care provided to vulnerable patients.
48a	SNP Alliance	ACOVE Measures	The commenter states that the understanding of ACOVE measures is that they were developed for a vulnerable elder population which Rand defined in the development of the ACOVE measures.	CMS believes that the ACOVE measures included apply to the MA beneficiary population, which includes SNP beneficiaries and are particularly applicable to SNP enrollees.
49	SNP Alliance	Existing Benchmarks	The commenter asks whether implementation of the Transitions in care measure aims to establish existing benchmarks as the basis for identifying improvement goals.	The sorts of outcomes described by the commenter are clearly relevant to the MAO population and particularly beneficiaries enrolled in SNPs. However, the purpose of the inpatient to outpatient transition measures is to implement measures of the process of transition as well as the outcome of completion of testing and follow up after discharge. The care processes in the Transitions in Care measure are linked to outcomes of importance to patients such as post-discharge health status and readmission. Implementation of the proposed measure could establish benchmarks and be linked to measured outcomes.
50	SNP Alliance	Definition of Outcome Measures	The commenter requests clarification of CMS’ definition of outcome measures and how they will be developed as a result of ACOVE data collection.	This project aimed to develop outcome measures for MA enrollees including SNP enrollees. The project was guided by a Technical expert panel that identified areas for measure development. Many of these outcome measures are in development outside of this PRA package. Others covered areas that are more amenable to process measurement at this time that aim to evolve into outcome measurement in the future.
51	SNP Alliance	Clarify the Target Population for ACOVE Measurement.	The commenter requests that CMS clarify the target population for ACOVE measurement.	The particular ACOVE measures included apply to all MA beneficiary populations, including the SNP populations.
52	SNP Alliance	Core Set of Outcome Measures	The commenter recommends the use of the following outcome measures for evaluating plan performance in the care of vulnerable populations: • Inpatient admissions and readmissions • Emergency room visits • Long-term stays in nursing facilities (e.g., in excess of 90 days) • Adverse drug events • Medication Compliance	CMS agrees that measures focused on these topics are important and can be developed in future studies, although they will likely require risk adjustment. However, these outcome measures are not the subject of the measures to be tested in this validation study.
53	SNP Alliance	SNPs – Measures Should be Risk Adjusted and CMS Establish Benchmarks.	One commenter suggested that outcome measures should be risk adjusted to reflect population characteristics and that CMS establish benchmarks for evaluating SNP beneficiary’s health outcomes against FFS providers.	This Validation study will include evaluation of the need for risk adjustment based on patient factors for each measure. Benchmarking of the measures to be implemented will be based on findings from the Validation study.
54	SNP Alliance	Additional Considerations for the Focus of Quality Reporting for Vulnerable Populations.	The commenter recommends that, in addition to developing outcome measures related to the ACOVE process measures proposed for use in this project, that CMS also consider identifying outcome measures related to the four key findings of the original Rand research that produced the ACOVE measures.	CMS recognizes the importance of this idea, but it is outside the scope of this study and data collection.
55	SNP Alliance	Measures Should be Used to Compare SNP Care to Fee for Service Care	The commenter suggested that measures be used to compare SNP care to fee-for-service care.	Consideration of comparing MA plans and SNPs to FFS care is beyond the scope of implementation of the proposed measures within the Validation Study. However, the measures being developed may contribute to future comparisons of MA and FFS care.
56	SNP Alliance	Physician Orientation of ACOVE Measures	One commenter questions whether the proposed measures are appropriate to measure care at the plan level, rather than at the level of the provider, and which providers are responsible for each aspect of each measure. The commenter requests that CMS consider whether any of the proposed ACOVE measures may need to be modified to be applicable to health plans.	The proposed measures (and ACOVE measures in general) are designed to measure quality at the level of the health system that is accountable for care (such as the health plan). Because the responsibility for these measures belongs to the health system (in this case, the plan), it is all providers and the plan itself that bear joint responsibility to fulfill these measures. Prior implementation of ACOVE measures has been largely in the MA plan and SNP environment. Furthermore, the measurement topics were identified by a Technical Expert Panel that included representation from all MA plan types; therefore CMS will use the proposed ACOVE measures without modifications.
57	SNP Alliance	Consideration for Parsimony in Reporting	The commenter states that other, already collected or recently NQF endorsed, measures should be used to measure the care provided to SNP enrollees including S&P measures, Care of Older Adult HEDIS measures and palliative and end-of-life measures. Using these existing small set of core measures in the development of outcome measures for vulnerable populations would increase the value and utility of the SNP S&P data collection effort.	The implementation of the proposed measures does not have implications for the use of SNP S&P measures in rating of SNP performance.
58	SNP Alliance	Use Existing Data Currently Reported	The commenter states that other, already collected or recently NQF endorsed, measures should be used to measure the care provided to SNP enrollees including the S&P measures, Care of Older Adult HEDIS measures and palliative and end-of-life measures.	The proposed set of measures assesses aspects of care that are important for vulnerable persons and are not evaluated by ongoing measurement. These areas were identified as important by the Technical Expert Panel for this project, which included patient advocates, clinicians and representation from plans, including SNPs.
59	SNP Alliance	Develop appropriate benchmarks for measures to enable comparison of FFS outcomes with SNP outcomes for like populations.	The commenter notes that a significant challenge faced by CMS, SNPs and other MA plans is the absence of FFS benchmark data that would allow plans and CMS to evaluate how well SNPs and other MA plans perform in caring for vulnerable populations.	Benchmarking of the measures to be implemented will be based on findings from the Validation study. Comparisons of FFS outcome with SNP outcomes for like populations are outside the scope of this data collection request.
60	SNP Alliance	Transition Measures	While the commenter strongly supports outcome measures to ensure that plans and providers are effectively managing care transitions for vulnerable populations, the commenter states that most of the current transition measures are data intensive process measures that focus on whether and how well a health plan completes its administrative tasks, not on a plan’s clinical performance in managing care transitions and whether the plan’s performance results in positive outcomes. Further the commenter believes CMS and NCQA should consider using outcome measures that evaluate the effectiveness of the transition process. It appears to us that the reporting requirements for the proposed NQF transition measures are even more elaborate and prescriptive than the SNP S&P requirements for measure #4.	CMS does not agree that most of the activities that the proposed transition measures target are administrative. Measure NQF #0648 (Timely Transmission of Transition Record) does target the timeliness (an administrative task) with which a hospital transmits information to the post-discharge care entity. However, other aspects of this measure target the specific content and completeness of the transmitted information. In addition, the proposed ACOVE measures monitor the follow through of selected pending/ordered activities that could pose problems in the post-transition period if not addressed. This would indeed reflect clinical (process) performance, not merely administrative task performance. Reference is made by the commenter to S&P #4, which focuses on administrative tasks related to transition (e.g., identification and notification of transition, contact with the patient, identification of patients at risk, structure and process for care coordination). While we agree that outcome measures are important, process measures can identify specific areas of care that might benefit from quality improvement interventions. Please see response to Comment #4.
61	SNP Alliance	Transition Measures	The commenter suggests revising the SNP Structure and Process measure from a process to an outcome orientation and establish standards for successful transitions, using outcomes that signify effective transitions such as reducing hospital admissions and readmissions rates, ER visits, long-term nursing home admissions, and adverse drug events; improving adherence to medication regimens; and improving member satisfaction with care coordination.	CMS appreciates the suggestions on S&P measures, but they are outside the scope of this data collection request.
62	SNP Alliance	Minimize Additional Data Burden	This commenter suggests using existing data collection to evaluate clinically important aspects of transition care to minimize additional data burden.	We are sensitive to the burden caused by duplicative data measurement requirements. While SNPs have been required to report on post-discharge medication reconciliation, the proposed data collection would be carried out by a larger population that includes other plan types as well.
63	SNP Alliance	Structure and Process Measures on Care Transitions	The commenter offered several recommendations regarding SNP Structure and Process #4 Element 3A	This comment refers to several recommendations related to S&P #4. CMS appreciates the suggestions however; they are unrelated to our proposed measures to be validated in this data collection request.
64	SNP Alliance	Structure and Process Measures on Care Transitions	The commenter suggests that CMS ensure that transition measures are appropriate to the population being served and link the measures to the nature of the condition and/or target population. While some transition measures are common to all Medicare subsets, others may not be.	All of the proposed measures are appropriate for all patient populations and generalizable to all MA plan types. They represent the basic transition requirements that should be met for all patient transitions from hospital to home: transition information given to the patient, transition information given in a timely fashion to the post-discharge care entity, and the completion of all pending/ordered post-discharge activities.
65	SNP Alliance	Structure and Process Measures on Care Transitions .	Update hospital conditions of participation to require all Medicare licensed hospitals to provide plans with discharge summaries in a timely fashion so that plans can comply with care transition requirements and timeframes, such as updating care plans when a beneficiary moves from one setting to the next.	This comment refers to several recommendations related to S&P #4. CMS appreciates the suggestions however; they are unrelated to our proposed measures to be validated in this data collection request.
66	SNP Alliance	Newly proposed NQF and ACOVE Measures	The commenter expressed concerns that the newly proposed NQF and ACOVE measures will only exacerbate challenges and add to the data collection burden without improving outcomes. The commenter suggests using the data reported by SNPs for S&P measure 4 and other data relevant to care transitions instead of initiating a new, expanded data collection effort, and to carry out the recommendations above in the process.	The data collection request pertains to all MA health plans as well as SNPs. MA health plans are not required to submit S&P measures. The transitions of care measure adds to the readmission measure by identifying aspects of care to be improved. The MA Readmissions measure is an important reflection of the quality of continuity care; however, the components of the proposed measure will evaluate aspects of care that are distinct from the Readmissions measure and these can be linked to reasons for readmission.
67	SNP Alliance	Newly proposed NQF and ACOVE Measures	The commenter asks for clarification regarding some of the ACOVE measures. For example, who would be responsible for implementing the interventions/tasks identified by the “then” statements in the ACOVE measures? ACOVE Continuity #7 (PCP Notification) would be the responsibility of the marker hospital or emergency department. ACOVE Continuity #10-12 (Serum Level, Post-Hospitalization Pending Tests, Post-Hospitalization Appointments) fall into the responsibilities that are the focus of the case manager/coordinator, that is, post-hospitalization transition follow-up (S&P #4, B. Supporting Members Through Transitions). The commenter stated that, in general, because the responsibility for these measures belongs to the health system, it is all providers, including the plan, that bear joint responsibility to fulfill the measures.	The proposed measures (and ACOVE measures in general) are designed to measure at the level of the health system that is accountable for care (such as the health plan). Because the responsibility for these measures belongs to the health system (in this case, the plan), it is all providers including the plan who bear joint responsibility to fulfill these measures. Prior implementation of ACOVE measures has been largely in the MA plan and SNP environment.
68	SNP Alliance	Timeframe for Recording Changes for Post-Hospitalization Medications.	One commenter asks about the timeframe for recording post-hospitalization medication changes after the inpatient to outpatient transition and whether this is limited to chronic disease medication.	This measure supports the need for medication continuity between providers. The proposed data collection measures continuity between the discharging hospital and the post-discharge care provider as measured at the first post-discharge visit. Since the proposed data collection is limited to the continuity between discharge and post-discharge sources of care, all discharge medications would be reviewed and there would be no limitation to “chronic disease medication.”
69	SNP Alliance	Clarification on ACOVE Measure # 9 Chronic Disease Medication	The commenter seeks clarification for ACOVE Continuity #9 about how “chronic disease medication” is defined and why this item is limited to chronic disease medications instead of all prescription drugs.	This measure supports the need for medication continuity between providers. The proposed data collection measures continuity between the discharging hospital and the post-discharge care provider as measured at the first post-discharge visit. Since the proposed data collection is limited to the continuity between discharge and post-discharge sources of care, all discharge medications would be reviewed and there would be no limitation to “chronic disease medication.”
70	SNP Alliance	Clarification on ACOVE Measure # 9	[See 56] The commenter questions whether CMS plans to use the data collection effort to establish a threshold regarding current practice and an improvement goal, such as a percentage improvement within a certain period of time, consistent with SNP requirements for measureable goals Is part of the goal of data collection to identify best practices about information sharing regarding prescribed medications among physicians treating the same patients so that this information can be shared among plans with the goal of reducing adverse drug events? Clarification of these types of issues would be helpful.	While SNPs are required to report on post discharge medication reconciliation, the proposed data collection will be carried out by a larger population that includes all MA health plans. Therefore, the data collection effort pertains not only to the SNP population or SNP requirements for measureable goals. The goal of this data collection is to test and validate these measures, including continuity of medications at the inpatient to outpatient transition, to determine if the additional measures are appropriate to implement.
71	SNP Alliance	Continuity Between Mental Health Provider and PCP .	The commenter notes that this task will include a number of challenges related to information disclosure due to federal and state restrictions on information sharing in order to protect privacy. Further state and federal laws require various forms of consent and not all beneficiaries are willing to share mental health information with other providers.	The Validation Study focuses on sharing information between mental health provider and primary care physician. A medical record notation that a patient does not want medical information to be shared with another provider will be collected. Such documentation will confer credit for continuity because it indicates that the provider aimed to carry out continuous care but that patient preference interfered with communication. These items were added to the mental health continuity medical record abstraction in the Supporting Statement Part B on pages 62, 68, and 75. Data collection concerning laws affecting transmission of information between provides about mental conditions is important, but outside the scope of the proposed measure. The Validation Study focuses on sharing information between mental health provider and primary care physician.
72	SNP Alliance	Expand the Data Collection to Dual Eligible Beneficiaries under 65 Diagnosed with a Permanent Disability	The commenter recommends that the ACOVE measures not be limited to vulnerable elders, but also be used to collect data for all special needs beneficiaries under and over 65. Many dual eligible beneficiaries enrolled in SNPs are under 65 and became eligible for Medicare as a result of a permanent disability that includes mental or behavioral health issues.	The measures tested for this data collection will apply to persons 65 and older. Expansion of patient eligibility based on age is reasonable and might be considered after this evaluation is complete.
73	SNP Alliance	Continuity Between Mental Health Provider and PCP	The commenter suggests that CMS and Rand consider measures SAMHSA may recommend for persons with mental illness or behavioral health problems in addition to the proposed ACOVE measures. In addition, it was recommended that SAMHSA, NQF and others work together to conduct a gap analysis to identify measurement gaps for persons with mental health and behavioral health problems, consistent with the type of analysis NQF performed in developing its report to HHS on quality measures for dual eligibles.	CMS appreciates these suggestions and will consider them for future projects outside of this data collection request.
74	SNP Alliance	ACOVE Continuity #3: Medication Continuity	The commenter seeks clarification for the ACOVE Continuity #3 and asks about the timeframe for recording medication continuity between mental health provider and PCP and whether this is limited to chronic medication.	This measure evaluates medication continuity between mental health and primary care providers. This is evaluated across outpatient visits. Types of medications are limited as described in the abstraction instructions.
75	SNP Alliance	ACOVE Continuity #7: Communication with PCP:	The commentator asked about the definition of the primary care physician in the Continuity between Mental Health Provider and Primary Care Provider measure.	The continuity physician is the primary care physician according to the health plan.
76	SNP Alliance	Continuity Between Mental Health Provider and PCP	The commenter requests clarification of how these data will be used to establish outcome measures.	This measure is nested within the mental health continuity measure. The goal is for mental health consultations that occur in the emergency room setting to be communicated to the PCP in order to improve care for the MA enrollee and therefore outcomes of mental health treatment.
77	SNP Alliance	Items to be added to CAHPS Survey/ Caregiver Strain	The commenter notes that the proposed questions regarding caregiver strain focus on activities and effects of giving care to others, but not on ways to reduce caregiver strain. The commenters suggest that that if the intent is to measure how well plans meet the health needs arising from emotional and physical stress, that a different set of questions would be needed. The commenters state that it is important to ensure that plans would not inadvertently be penalized for data collected in an area for which they have no benefits and over which they may have limited influence. It is recommended that CMS consider adding these questions to the Medicare Health Outcome Survey	CMS seeks to perform a needs assessment of the burden of caregiving among plan enrollees. Based on the findings of the Caregiver Strain Index, plans may choose to carry out quality improvement activities to help members who are caregivers. Different questions could subsequently be considered for inclusion in a survey or other evaluation instrument to address the commenter’s concerns, based on these initial findings from this data collection.
78	SNP Alliance	Burden on Beneficiaries	The commenters recommend that CMS consider the burden on beneficiaries of adding the proposed questions to the existing survey and should consider deleting other, lower priority items in the current Medicare CAHPS questionnaire prior to adding new items.	The purpose of the current data collection is to test new survey items that may ultimately be included in a CAHPS survey. Should these items be included, CMS will devise a strategy to ensure that the overall CAHPS survey is not unduly lengthy to complete.
79	SNP Alliance	Request Consideration of Issues to improve CAHPS Measurement and Assure Appropriate Administration for Special Needs Beneficiaries.	The commenters requested consideration of several miscellaneous issues including those below: Weighting of satisfaction ratings for duals Appropriateness of self-report measures for persons with cognitive impairment, mental illness or behavioral health problems Performance evaluation for special needs beneficiaries SNP Model of Care (MOC) requirements governing MOCs are not well aligned with SNP S&P measures. Align performance measures with the needs of the SNP’s target population.	CMS is aware of these issues and have engaged in discussion with the commenters during previous conference calls and forums. CMS is always willing to continue these discussions with the SNP Alliance. However, the identified issues are outside the scope of this data collection request. The commenter is most welcome to contact appropriate CMS staff to address these issues outside of this PRA data collection response to commenters.