Response to Comments

2014 60 day comments for HPMS Level I and Level II Data Entry for PACE
Comment Number	Source of Comment: (Company Name)	HPMS Level I and Level II HPMS Data Entry 60 day	HPMS Level I	HPMS Level II	Description of the Issue or Question	Comments & Recommendation(s) from Source	Type of Suggestion (Insertion Deletion, or Revision)	CMS Decision (Accept, Accept with Modification, Reject, Clarify)
60 Day Comments
1	National PACE Organization	60 day	ü		HPMS System Functionality	Under the immunization category, POs are driven to enter numbers in unrelated fields for participants for whom immunization status is not available as the system does not accept the data unless all the numbers entered in the various fields in this category equate to the "total number of participants at the end of the quarter" in the header. (Recommendation) To alleviate this, POs have suggested that an additional field be provided to enter the number for participants for whom the immunization status is not available in the current quarter.	Revision	Accept with modification - CMS is aware that the HPMS system needs functionality upgrades and process data entry improvements. CMS has assessed the current HPMS system and is preparing to make data entry, process and content changes. This PRA package is meant to address Level I and Level II data entry and process changes that will include the redesign of the current Level I and the total development of Level II HPMS monitoring module. CMS will consider the proposed revisions and suggestions during the HPMS Level I and Level II redesign and development.
2	National PACE Organization	60 day	ü		HPMS System Functionality	HPMS data is not collected in retrievable fields for analysis. The commenter is recommending that HPMS is updated with the functionally to retrieve data.	Revision	Accept with modification - CMS is aware that the HPMS system needs functionality upgrades and data entry improvements. CMS has assessed the current HPMS system and is preparing to make data entry, process, and content changes. This PRA package is only meant to address Level I and Level II data entry and process changes. At this time, it does not propose revisions associated with redesign and development. Consequently, CMS will save the comment and will consider the suggestions during the HPMS Level I and Level II redesign and development phase. If subject to the public comment requirements of the Act, the redesign and development will be made available for public review and comment through the regular PRA process.
3	National PACE Organization	60 day	ü		HPMS System Functionality	HPMS only allows for quarterly entry which is retrospective. (Recommendation) Commenter is recommending that HPMS data be entered in real-time data reporting.	Revision	Accept with modification - CMS is aware that the HPMS system needs functionality upgrades and data entry improvements. CMS has assessed the current HPMS system and is preparing to make data entry, process and content changes. This PRA package is meant to address Level I and Level II data entry and process changes that will include the redesign of the current Level I and the total development of Level II HPMS monitoring module. CMS will consider the proposed revisions and suggestions during the HPMS Level I and Level II redesign and development.
4	National PACE Organization	60 day	ü		HPMS System Functionality	The commenter states that HPMS Level I data reporting should be organized in a systematic and quantitative method in order to identify trends, gaps, areas for improvement and/or outlier incidents.	Revision	Accept with modification - CMS intends on making the HPMS Level I and II data entry more streamlined, qualitative and organized. This PRA package is meant to address Level I and Level II data entry and process changes that will include the redesign of the current Level I and the total development of Level II HPMS monitoring module. CMS will consider the proposed revisions and suggestions during the HPMS Level I and Level II redesign and development.
5	CalPACE	60 day	ü		HPMS System Functionality	The commenter is recommending that HPMS data entry for Level I monitoring should be more streamlined and offer more quality metrics and the data entry should focus on aggregate measures. For example, readmission and emergency room care are entered as narrative text rather than as boarder percentages or rates.	Revision	Accept with modification - CMS intends to make HPMS Level I and II data entry a more streamlined, qualitative and organized. This PRA package is meant to address Level I and Level II data entry and process changes that will include the redesign of the current Level I and the total development of Level II HPMS monitoring module. CMS will consider the proposed revisions and suggestions during the HPMS Level I and Level II redesign and development.
6	1)CalPACE 2)Center for Elders' Independence	60 day	ü	ü	HPMS System Functionality	Commenters are recommending updates to the HPMS system so that PACE organizations can upload an Excel template rather than manual data entry into the system.	Revision	Clarification - Currently, HPMS has limited Excel upload functionality. CMS plans to extend this upload functionally to PACE. This PRA package is meant to address Level I and Level II data entry and process changes that will include the redesign of the current Level I and the total development of Level II HPMS monitoring module. CMS will consider the proposed revisions and suggestions during the HPMS Level I and Level II redesign and development.
7	CalPACE	60 day	ü		HPMS System Functionality	Pneumococcal Immunization Current practice: Number immunized entered and calculated as a percentage of total participant population. (Recommendation) Keep the measure as a percentage of total participants that are immunized. Revise the criteria to match the Center for Disease Control(CDC) and Prevention’s recommendation – at age 65, individuals receive one more dose and then do not have to be immunized again. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5934a3.htm	Revision	Accept with modification - CMS intends on reviewing the CDC data collection process for the elements in question and will consider aligning the HPMS Level I collection process to the CDC's collection process. This PRA package is meant to address Level I and Level II data entry and process changes that will include the redesign of the current Level I and the total development of Level II HPMS monitoring module. CMS will consider the proposed revisions and suggestions during the HPMS Level I and Level II redesign and development.
8	CalPACE	60 day	ü		HPMS System Functionality	Grievances Current Practice: Narrative text entered for each grievance, including the source of each grievance, date of initiation, date of resolution, and description of the grievance. (Recommendation)Report on percentage of grievances that are resolved within 30 days. Per Title 42 § 460.120, PACE organizations must “must maintain, aggregate, and analyze information on grievance proceedings” for quality improvement purposes, and the current reporting practice is not conducive to aggregation and analysis.	Revision	Accept/Clarification for the commenter - CMS is aware that the HPMS system needs functionality upgrades and data entry improvements. CMS plans to remove most of the narrative requirements. This PRA package is meant to address Level I and Level II data entry and process changes that will include the redesign of the current Level I and the total development of Level II HPMS monitoring module. CMS will consider the proposed revisions and suggestions during the HPMS Level I and Level II redesign and development.
9	CalPACE	60 day	ü		HPMS System Functionality	Appeals Current Practice: Narrative text entered for each appeal, including the source of each appeal, date of initiation, date of resolution, and description of the appeal. (Recommendation) Report on percentage of appeals that are resolved within 30 days. Per Title 42 § 460.122, PACE organizations must “must maintain, aggregate, and analyze information on appeal proceedings” for quality improvement purposes, and the current reporting practice is not conducive to aggregation and analysis.	Revision	Accept/Clarification for the commenter - CMS is aware that the HPMS system needs functionality upgrades and data entry improvements. CMS plans to remove most of the narrative requirements. This PRA package is meant to address Level I and Level II data entry and process changes that will include the redesign of the current Level I and the total development of Level II HPMS monitoring module. CMS will consider the proposed revisions and suggestions during the HPMS Level I and Level II redesign and development.
10	CalPACE	60 day	ü		HPMS System Functionality	Disenrollments Current Practice: Data entered as narrative text for each disenrollment, including date of disenrollment, type (voluntary or involuntary), and reason for disenrollment. (Recommendation) Enter total number of disenrollment's and the breakdown that are voluntary and involuntary. Also report on the total number of disenrollment's due to death, moving out of service area, disruptive or threatening behavior, wishes to access out of network, etc.	Revision	Accept/Clarification for the commenter - CMS is aware that the HPMS system needs functionality upgrades and data entry improvements. CMS plans to remove most of the narrative requirements. This PRA package is meant to address Level I and Level II data entry and process changes that will include the redesign of the current Level I and the total development of Level II HPMS monitoring module. CMS will consider the proposed revisions and suggestions during the HPMS Level I and Level II redesign and development.
11	CalPACE	60 day	ü		HPMS System Functionality	Prospective Enrollees: Current Practice: Data entered as narrative text for each prospective enrollee, including identifier, reason for not enrolling, and date. (Recommendation) Remove this measure as other health plans do not have to report on prospective members who do not enroll. This is an administrative burden that adds little value to the PACE organization.	Revision	Accept/Clarification for the commenter - CMS is aware that the HPMS system needs functionality upgrades and data entry improvements. CMS plans to remove most of the narrative requirements. This PRA package is meant to address Level I and Level II data entry and process changes that will include the redesign of the current Level I and the total development of Level II HPMS monitoring module. CMS will consider the proposed revisions and suggestions during the HPMS Level I and Level II redesign and development.
12	1)CalPACE 2)Center for Elders' independence	60 day	ü		HPMS System Functionality	30-Day Readmission to Hospital Current Practice: Data entered as narrative for each readmission, including dates for initial admission and discharge, and readmission and discharge; diagnosis codes for initial admission and readmission; and dispositions upon discharge for both initial hospital admission and readmission. (Recommendation) Submit data as a percentage of readmissions/total number of admissions by quarter. Hospital-wide All-Cause Unplanned Readmission Measure (HWR) is an industry standard, endorsed by the National Quality Forum (NQF) with CMS as the measure developer and steward, and also recommended by CalPACE and the National PACE Association. http://www.qualityforum.org/QPS/1789	Revision	Clarification - CMS is aware that the HPMS system needs functional upgrades and data entry improvements. We will review and consider national data collection standards and practices. This PRA package is meant to address Level I and Level II data entry and process changes that will include the redesign of the current Level I and the total development of Level II HPMS monitoring module. CMS will consider the proposed revisions and suggestions during the HPMS Level I and Level II redesign and development.
13	1)CalPACE 2)Center for Elders' Independence	60 day	ü		HPMS System Functionality	Emergency care: Current Practice: Data entered as narrative for each emergency care visit. CMS has requested the following in the narrative text: date of ER care, discharge diagnosis, disposition, and follow-up action. (Recommendation) Submit data as a rate for each month or quarter – number of ER visits (that do not result in hospitalization) per 1000 participants. Also, the current definition of emergency care is “PACE participants seen in the hospital emergency room or an outpatient department/clinic emergency.” Clarify that emergency care is defined as when a patient is seen and discharged from the ER (http://kff.org/other/state-indicator/emergency-room-visits/). When patients are admitted to the hospital, this is considered an inpatient stay. Hospitals bill accordingly, and it would be double counting for PACE organizations to be asked to reclassify inpatient stays as ER care	Revision	Accept - CMS will consider the recommended definition, as it is clear and offers the opportunity to collect aggregate data for more meaningful use.
14	1)CalPACE 2)Center for Elder's Independence	60 day		ü	HPMS System Functionality	Unusual incident: Current Practice: Level 1 events are entered as narrative for each incident, regardless of level of injury. For example, for falls, the following information is included in the narrative text: participant identifier, date of fall, description of fall, level of injury, follow-up action, and whether a fall resulted in an ER visit. Similar information is entered for medication errors, vehicle accidents, etc. Level 2 events, which are more severe – when there is injury or adverse medical outcomes – are reported within two days of occurring/determination to CMS, both the central and regional office, as well to the Department of Health Care Services (DHCS). PACE organizations submit and intake summary, perform a root cause analysis, and then share the findings for each Level 2 event with the regional CMS team and DHCS in a teleconference. (Recommendation) Eliminate Level 1 reporting. PACE organizations already report on the events that result in harm or an adverse medical outcome through the Level 2 reporting process.	Revision	Accept with modification - CMS does not plan to eliminate Level I reporting. However, we will streamline the data collection process and make necessary changes in HPMS to eliminate duplication and narrative requirements. This PRA package is meant to address Level I and Level II data entry and process changes that will include the redesign of the current Level I and the total development of Level II HPMS monitoring module. CMS will consider the proposed revisions and suggestions during the HPMS Level I and Level II redesign and development.
15	1)CalPACE 2)Center for Elder's Independence	60 day		ü	HPMS System Functionality	Participant deaths: Current practice: Information entered as narratives for each participant who has expired, including date of death, setting, and primary cause of death. (Recommendation) Fold this into the measure on disenrollment's and report on deaths in the aggregate.	Revision	Accept with modification - CMS is aware that the HPMS system needs functionality upgrades and data entry improvements. This PRA package is meant to address Level I and Level II data entry and process changes that will include the redesign of the current Level I and the total development of Level II HPMS monitoring module. CMS will consider the proposed revisions and suggestions during the HPMS Level I and Level II redesign and development.
16	National PACE Organization	60 day	ü	ü	Meaningfulness of Information	Commenter states, Level I and Level II needs more standard definitions for Level I and Level II reporting categories i.e. falls, emergency care and grievances. (Recommendation) CMS should standardized definitions in order to reduce subjectivity develop quality controls with HPMS, and disseminate data. Level II regional and national trend data can be used to develop educational and best practice resources, and for peer-to peer quality improvement activities.	Revision	Clarification - CMS has updated and provided standard definitions for "Falls" via the 2014 Level II Reporting Guidance for PACE participants. CMS has reviewed the standardized "fall" definitions and have adopted the definition from the Department of Veterans Affairs, 1996, p. 4 for PACE participants, as it best applies to the PACE population.
17	National PACE Organization	60 day	ü	ü	Meaningfulness of Information	The commenter is requesting for CMS to send out aggregate HPMS data reports.	Revision	Clarification - CMS will consider this recommendation, however, our initial focus is to upgrade HPMS so that the data is meaningful.
18	On Lok Senior Health Services	60 day	ü	ü	Meaningfulness of Information	The commenter is recommending that HPMS Level I data reporting should be organized in a systematic and quantitative method in order to identify trends, gaps, areas for improvement and/or quilter incidents. Revise HPMS Level I reporting mechanism to support aggregate reporting including enabling PACE organization to upload data in spreadsheets similar to Medicare Advantage Plans. The current HPMS also lacks the ability to track and trend data for internal quality improvement purposes. Ex. data cannot be sorted or merged from one quarter to the next quarter.	Revision	Accept with modification - CMS has plan to allow for more data retrieval and entry in a aggregated format. This PRA package is meant to address Level I and Level II data entry and process changes that will include the redesign of the current Level I and the total development of Level II HPMS monitoring module. CMS will consider the proposed revisions and suggestions during the HPMS Level I and Level II redesign and development.
19	Center for Elders' Independence	60 day	ü	ü	Meaningfulness of Information	The commenter is recommending CMS to adopt measures that have been validated(e.g. Endorsed by the National Quality Forum or the National Committee for Quality Assurance), which would allow PACE organizations to benchmark with others in healthcare, trend data, and drive improvement within the organization.	Revision	Accept with Modification - CMS will review the latest and most appropriate validated measures when updating the HPMS data entry process. This PRA package is meant to address Level I and Level II data entry and process changes that will include the redesign of the current Level I and the total development of Level II HPMS monitoring module. CMS will consider the proposed revisions and suggestions during the HPMS Level I and Level II redesign and development.
20	National PACE Organization	60 day		ü	Reporting Burden	The commenter urges CMS to examine the impact to the current 2014 Level II Reporting Guidance minimal threshold criteria on PO reporting. Example of burden reporting Example of Adult Protective Services (APS) calls that often are just with suspicion of neglect or abuse are already reported to the local agency so reporting a Level II often means that this event is in some states reported three times to different agencies (i.e., APS, Area Agency on Aging and CMS).	Revision	Reject of portions the commenter's comment - CMS notes that this PRA is only meant to address Level I and Level II HPMS data entry and process changes. CMS is not responsible for State and other agencies' requirements. CMS does not consider reporting "abuse" as a burden. CMS accepts the commenter's suggestion regarding HPMS structure changes for the "Fall" and "Unusual Incident" sections.
21	On Lok Senior Health Services	60 day		ü	Reporting Burden	Commenter concurred with NPA that all Level II incidents do not need a RCA and urges CMS to examine the impact of the revised minimum thresholds. Level II threshold revision.	Revision	Rejection - CMS rejects this comment. CMS notes that this PRA is only meant to address Level I and Level II HPMS data entry and process changes.
22	On Lok Senior Health Services	60 day	ü	ü	Reporting Burden	The commenter is recommending to monitor trends for both Level I and Level II through their quality improvement process and submits this information to their Quality Assurance and Improvement Committee (QAIC) as part of our quality improvement process. The commenter believes monitoring trends within their own QAIC is the appropriate level of oversight for the incident not meeting the Level II reporting threshold. The rigor involved in HPMS data entry takes time away from more valuable quality improvement studies and activates.	Revision	Rejection of the commenter's comment - CMS PRA burden is only accounting for Level I and Level II data entry. CMS is not incorporating other required data collections that are required from other entities. Monitoring for trends that do not meet the Level II guidance within the commenter's organization is not a violation. However, the organization must continue to complete CMS monitoring requirements. This PRA is only focused on the Level I and Level II data entry requirements.
23	CalPACE	60 day			Reporting Burden	Commenter does not believe the proposed burden estimate take into account supplemental reporting requirements that are imposed by CMS Regional Offices. (Recommendation) In region 9 supplement this by requiring PACE organization in California to submit narrative information in addition to the data/information that is entered in the HPMS system. This is very time consuming and cumbersome for PACE organization, and requires them in essence to re-enter information that the have already entered in the HPMS system a different, narrative format. Commenter is recommending that CMS provide guidance to its regional offices that additional reporting requirements beyond those in the HPMS system reporting are not necessary and must be approved by CMS.	Revision	Rejection - CMS PRA burden only accounts for Level I and Level II HPMS data entry. CMS is not incorporating other required data collections from other entities.
24	Center for Elders' Independence	60 day	ü	ü	Reporting Burden	The time burden is significant for Level I reporting – almost 100 hours of work for CEI per year. • 16 hours/quarter for data entry, composing narratives, and validating/review the data • 2 hours/quarter to enter the data • 6 hours/quarter to respond to CMS Region 9 request for follow-up information in addition to what CEI reports via HPMS (see attachment, “CEI-Qtr. 1 2014 CMS Questions”). For 100 PACE organizations, this would be close to 100,000 hours, far exceeding the estimated total annual hours of 1,575 cited in the document.	Revision	Rejection of the commenter's comment - This PRA is only Level I and Level II reporting requirements. CMS is not incorporating data collections from other entities in the burden hours (i.e. regional office or PACE a organizations). In addition, it appears the commenter made a calculation error (i.e.100 PACE times 100 hours per year is 10,000 not 100,000).