Public Comment Tracker

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Overview

Instructions and Definitions
Comment Tracker

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Sheet 1: Instructions and Definitions

Workbook Title: QIS PRA Comment Tracker

Background:

The Quality Improvement Strategy (QIS) Technical Guidance and User Guide for the 2017 Coverage Year was PRA was released on July 1, 2015 for a 30-day public comment period (until 7/30/15). This document tracks comments received in response to the Technical Guidanceand User Guide.

Overview of the Worksheets:

Worksheet 1: Instructions

Worksheet 2: Comment Tracker: Each row represents a unique comment and contains information on CMS' response to the comment and whether or not the comment could impact the QIS burden estimate.

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Sheet 2: Comment Tracker

Comment Submission ID #	Organization	Date Received	Element	Category	Comment	Response - Disposition	Impact on Burden Estimate (Y/N)
C001-1	BlueCross BlueShield Association	7/20/2015	15	Reporting Requirements	Current Payment Model Description (Element 15) -- QHP issuers must collect information on the amount of FFS payments tied to quality or value or payments in an Alternative Payment Model tied to quality or value across all product lines [emphasis added], not for the QIS in particular. Therefore, this information is not relevant to evaluating issuers' quality improvement strategies for compliance.	CMS agrees that there is no QIS statutory authority to collect information on issuers’ other product lines. We removed all references to payment models used outside of the Marketplace.	N
C001-2	BlueCross BlueShield Association	7/20/2015	16	Reporting Requirements	Data Sources (Element 16) -- QHP issuers must collect information on the data sources used for developing and monitoring their quality improvement strategies. However, given the potentially wide variation across issuers in the different data sources used to inform their strategies - some of which may be proprietary - and the lack of standardized definitions, it is unclear how this will help the agency evaluate the compliance and adequacy of QHP issuers' quality improvement efforts.	CMS clarified that the purpose of collecting issuers’ data sources (Element 16) is to promote transparency; CMS does not intend to publically display issuers’ information that is considered confidential or proprietary.	N
C001-3	BlueCross BlueShield Association	7/20/2015	24	Alignment	Goal(s), Meausure(s), Performance Target(s) (Element 24) -- QHP issuers must collect information on clinical quality measures to monitor progress in meeting performance targets. We believe this detailed information is not necessary for CMS to comply with ACA requirements under section 1311(g) for guidelines to report on QIS implementation, and also duplicates QHP quality information already being collected through the Quality Rating System.	CMS added clarifying language to the QIS User Guide to explain the purpose of collecting this information. CMS added a sentence to the description of Element 24 in the QIS User Guide clarifying that issuers have broad flexibility in selecting the measures used to track progress related to their QIS. A QIS should incentivize quality, tying payments to measures of performance, when providers meet specific quality indicators.	N
C001-4	BlueCross BlueShield Association	7/20/2015	19	Market-Based Incentives Definition	Market-based Incentive Types (Element 19) -- The current definition of market-based incentives offered by CMS is too narrow, and therefore could force issuers to implement programs and collect information that otherwise would not be necessary or may be duplicative of strategies issuers already have in place that address health and health care disparities. CMS should expand the incentives allowed for QIS to include population-directed initiatives.	CMS added language to Section 1 of the QIS Technical Guidance to further clarify the definition of a market-based incentive.	N
C001-5	BlueCross BlueShield Association	7/20/2015	21	Alignment	Targets all Plans Offered Through the Marketplace (Element 21) -- The QIS should not have to apply to the full enrollee population. A QHP issuer serving urban and rural areas, for example, may wish to encourage a payment structure in densely populated urban areas with a high degree of provider competition, but use a different approach in rural areas that does not involve payment structures. A one-size-fits-all approach would unfairly penalize and burden QHPs that operate in rural or underserved areas that lack the infrastructure for robust payer-provider interactions.	CMS added clarifying language to Section 2 of the QIS Technical Guidance that describes how an issuer may submit one or more strategies, to clarify that there must be a QIS for each QHP, but the QIS (or QISs) do not have to cover all of each QHP’s enrollees.	N
C001-6	BlueCross BlueShield Association	7/20/2015		Eligibility	CMS should require all QHP issuers, not only QHP issuers who have been participating in an Exchange for two or more consecutive years, to submit a QIS implementation plan for the 2017 coverage year.	CMS added clarifying language to Section 5.1 of the Technical Guidance, citing Final Rule language, “[CMS] believes that two years is an appropriate time period for issuers to understand their populations who have enrolled through Exchanges, and develop relevant quality improvement strategies to meet the needs of that population.”	N
C001-7	BlueCross BlueShield Association	7/20/2015		Public Reporting	CMS should clarify that if QIS information is eventually displayed publicly, it will display the same information for all QHPs (e.g., no QHP will be allowed to display information for three QISs when other QHPs have the one QIS).	CMS added clarifying language to Section 5.2 of the QIS Technical Guidance that for the 2017 coverage year, there are no plans for public reporting.	N
C001-8	BlueCross BlueShield Association	7/20/2015	15	Reporting Requirements	Delete this element (Element 15, Current Payment Model(s) Description) from the form as it is outside of the scope of the Quality Improvement Strategy, as defined in 1311(c)(1)(E) of the Affordable Care Act.	CMS added clarifying language to the QIS User Guide noting that these payment model categories reflect the goals of HHS’ Better, Smarter, Healthier initiative which has set a goal of linking 30 and 50 percent of current Medicare fee for service payments to alternative payment models by 2016 and 2018, respectively. CMS noted that the information in Element 15 is collected for the purpose of broader health care delivery understanding, is intended to support overall health care system innovation, and is in no way meant to discourage innovation. Additionally, Element 15 is intended to reflect an issuers' overall payment models, not just the payment models in a specific QIS.	N
C001-9	BlueCross BlueShield Association	7/20/2015	16	Reporting Requirements	Delete this element (Element 16, Data Sources) from the form, as its value for evaluating compliance with the QIS is unclear.	CMS clarified that the purpose of collecting issuers’ data sources (Element 16) is to promote transparency; CMS does not intend to publically display issuers’ information that is considered confidential or proprietary.	N
C001-10	BlueCross BlueShield Association	7/20/2015	19	Market-Based Incentives Definition	Expand the incentives allowed for a QIS to include population-directed initiatives such as grants to community organizations or direct outreach to populations in need.	CMS added clarifying language to Section 1 of the QIS Technical Guidance to further clarify that a QIS that includes population- or community-based activities must also link those activities to a market-based incentive.	N
C001-11	BlueCross BlueShield Association	7/20/2015	21	Alignment	BCBSA recommends that HHS clarify that a QIS does not have to apply to the full enrollee population – a QHP issuer serving urban and rural areas, for example, may wish to make heavy use of a particular payment structure in densely populated urban areas with a high degree of provider competition, but use a different approach in rural areas that does not involve payment structures.	CMS added clarifying language to Section 2 of the QIS Technical Guidance that describes how an issuer may submit one or more than one QIS, to clarify that there must be a QIS for each QHP, but the QIS (or QISs) do not have to cover all of each QHP’s enrollees.	N
C001-12	BlueCross BlueShield Association	7/20/2015	21	Market-Based Incentives Definition	BCBSA recommends that if a QHP serves an area where improvement strategies, that are not based on payment, are likely to be more cost-effective and successful than strategies that do not fit neatly into the market incentives orientation (e.g., rural, underserved, or provider shortage areas), that QHP should be excluded from the QIS requirements – unless HHS recognizes population-based, or community-oriented initiatives of the sort described above as QIS	CMS added clarifying language to Section 2 of the QIS Technical Guidance that describes how an issuer may submit one or more than one QIS, to clarify that there must be a QIS for each QHP, but the QIS (or QISs) do not have to cover all of each QHP’s enrollees.	N
C001-13	BlueCross BlueShield Association	7/20/2015	22	Health and Health Care Disparities	BCBSA recommends that HHS provide further guidance on what is meant by “reducing health and health disparities” (including clarifying that activities may not necessarily include market-based incentives – see discussion under Element 23), and give QHP issuers flexibility in focusing on those disparities of greatest importance to the markets and covered populations.	CMS revised the content of Element 22 (Rationale for QIS) of the Implementation Plan and Progress Report form to include examples of quality improvement activites as cited in the Affordable Care Act. CMS revised the QIS Technical Guidance to include language clarifying that the statutory requirements related to the QIS require the use of market-based incentives (either increased provider reimbursement or other incentives) to improve the quality and value of health care and services specifically for Marketplace enrollees. Activities related to reducing health and health care disparities – such as data analysis, consumer engagement, navigation tools or cultural competency training – must be tied to an incentive in order to comply with the QIS.	N
C001-14	BlueCross BlueShield Association	7/20/2015	19	Market-Based Incentives Definition	Clarify that market-based activities include a wider range of incentives, as recommended for Element 19 (Market-based Incentive Type(s)).	CMS added clarifying language to Section 1 of the QIS Technical Guidance to further clarify that a QIS that includes population- or community-based activities must also link those activities to a market-based incentive.	N
C001-15	BlueCross BlueShield Association	7/20/2015	24	Reporting Requirements	BCBSA recommends that HHS not require clinical quality measures and performance targets to monitor strategy progress, as that is neither necessary nor useful for the agency to perform its functions.	CMS added a sentence to the description of Element 24 in the QIS User Guide clarifying that issuers have broad flexibility in selecting the measures used to track progress related to their QIS. A QIS should incentivize quality, tying payments to measures of performance, when providers meet specific quality indicators.	N
C001-16	BlueCross BlueShield Association	7/20/2015	24	Reporting Requirements	If CMS keeps the requirement to set performance targets, it should clarify the length of the “initial years” period so that issuers can determine the amount of time they have to tweak or redesign their strategies.	CMS did not revise the content in the Technical Guidance and User Guide. The Technical Guidance already specifies that issuers will not be penalized for failure to meet performance targets during the initial years of QIS implementation.	N
C001-17	BlueCross BlueShield Association	7/20/2015	24	Reporting Requirements	If CMS keeps the requirement to set performance targets, it should provide further clarification for Element 24c regarding how QHP issuers should calculate the baseline, especially if QHP issuers are reporting on a new product or changing population, or if the strategy itself is brand new.	CMS added a sentence to the description of Element 24 in the QIS User Guide clarifying that while issuers have broad flexibility in selecting the measures used to track progress related to their QIS, CMS encouraged issuers to use national, state, or regional benchmarks when establishing performance targets.	N
C001-18	BlueCross BlueShield Association	7/20/2015	24	Reporting Requirements	CMS encourages the use of national benchmarks for QIS performance targets, but should clarify that QHP issuers that utilize regional benchmarks will not be penalized	CMS added a sentence to the description of Element 24 in the QIS User Guide clarifying that while issuers have broad flexibility in selecting the measures used to track progress related to their QIS, CMS encouraged issuers to use national, state, or regional benchmarks when establishing performance targets.	N
C001-19	BlueCross BlueShield Association	7/20/2015	26	General Support	BCBSA supports this element (Element 26).	Supportive statement - CMS did not revise the content of Element 26 (Risk Assessment) of the Implementation Plan and Progress Report form.	N
C001-20	BlueCross BlueShield Association	7/20/2015	27	QIS Evolution	Provide flexibility for QHP issuers in responses provided in this section [Element 27: Addition of Health Plans to the Issuer's QIS].	Supportive statement - CMS did not revise the content of Element 27 of the Implementation Plan and Progress Report form.	N
C001-21	BlueCross BlueShield Association	7/20/2015	28	QIS Modifications	Further clarify whether issuers may change goal(s) and performance target(s), or whether the goal(s) must remain the same while the target(s) may change.	CMS added clarifying language to Section 7 of the QIS Technical Guidance indicating what changes issuers are able to make to modify their quality improvement strategies, when these changes can be made, and what changes require a new QIS.	N
C002-1	AHIP	7/17/2015		General Support	We support the annual submission of a Reporting Template beginning one year after the submission of the Plan Template.	Supportive statement - CMS did not revise the content of the Implementation Plan and Progress Report form.	N
C002-2	AHIP	7/17/2015		Alignment	We recommend aligning Quality Reporting Strategy and QIS requirements wherever possible across both Federal and State based exchanges to avoid the use of disparate requirements and timelines that would add to cost and burden.	The QIS is designed to provide SBMs with flexibility to establish the timeline, format, validation, and other requirements related to the annual submission of QIS data by issuers that participate in their respective Marketplaces. CMS revised the QIS Technical Guidance to include language specifying that issuers offering Multi-State Plan (MSP) options should contact the Office of Personnel Management (OPM) to confirm the requirements and timing associated with QIS implementation.	N
C002-3	AHIP	7/17/2015		QIS Evaluation	QHP issuers would benefit from additional training and resource materials similar to what is offered for the Chronic Care Improvement Program (CCIPs) and the Quality Improvement Project (QIP) for Medicare Advantage.	CMS anticipates conducting issuer training sessions, including a demonstration of the evaluation and scoring tool, which will address the comment regarding how the “must-pass” and minimum score thresholds/partial credit is operationalized.	N
C002-4	AHIP	7/17/2015	15	Reporting Requirements	We caution HHS when evaluating Element 15: Current Payment Model(s) descriptions that there is no consistent recognized methodology to measure the percentage of provider's payments tied to quality or value.	CMS added clarifying language to the QIS User Guide noting that these payment model categories reflect the goals of HHS’ Better, Smarter, Healthier initiative which has set a goal of linking 30 and 50 percent of current Medicare fee-for-service payments to alternative payment models by 2016 and 2018, respectively. CMS noted that the information in Element 15 is collected for the purpose of broader health-care delivery understanding, is intended to support overall health care system innovation, and is in no way meant to discourage innovation.	N
C002-5	AHIP	7/17/2015		Alignment	Given that QHPs will benefit from greater flexibility in designing and implementing QIS, we recommend that QIS reporting be broad and flexible and reporting be focused at the strategy level.	CMS added clarifying language to the QIS Technical Guidance and User Guide. CMS revised Section 2 of the QIS Technical Guidance to indicated that issuers may use existing strategies, and those may include payment methodologies and other incentives such as those used under accountable care contracts. CMS added a sentence to the description of Element 24 in the QIS User Guide clarifying that issuers have broad flexibility in selecting the measures used to track progress related to their QIS. A QIS should incentivize quality, tying payments to measures of performance, when providers meet specific quality indicators.	N
C002-6	AHIP	7/17/2015	22	QIS Evaluation	We ask for clarification around expectations for reporting on activities to reduce health and health care disparaties.	CMS revised the content of Element 22 (Rationale for QIS) of the Implementation Plan and Progress Report form to include examples of quality improvement activites as cited in the Affordable Care Act. CMS revised the QIS Technical Guidance to include language clarifying that the statutory requirements related to the QIS require the use of market-based incentives (either increased provider reimbursement or other incentives) to improve the quality and value of health care and services specifically for Marketplace enrollees. Activities related to reducing health and health care disparities – such as data analysis, consumer engagement, navigation tools or cultural competency training – must be tied to an incentive in order to comply with the QIS. CMS revised the description of Element 22 in the QIS User Guide to include a call-out box describing options for gathering data to identify health and health care disparities.	N
C002-7	AHIP	7/17/2015	16	Reporting Requirements	We recommend the deletion of Element 16: Data Sources.	CMS added clarifying language to the QIS User Guide to explain the purpose of collecting this information.	N
C002-8	AHIP	7/17/2015	24	Alignment	Further clarification is needed to accurately report the information requested under Elements 24c: Baseline results, 24d: Performance period, and 24e: Performance target.	CMS did not revise the content of Element 24 of the Implementation Plan and Progress Report form. CMS added clarifying language to the QIS User Guide to explain the purpose of collecting this information. CMS added a sentence to the description of Element 24 in the QIS User Guide clarifying that issuers have broad flexibility in selecting the measures used to track progress related to their QIS. A QIS should incentivize quality, tying payments to measures of performance, when providers meet specific quality indicators.	N
C002-9	AHIP	7/17/2015	28	QIS Modifications	We recommend issuers have the opportunity to modify performance goals in addition to the allowable modifications listed under Element 28a.	CMS added clarifying language to Section 7 of the QIS Technical Guidance indicating what changes issuers are able to make to modify their quality improvement strategies, when these changes can be made, and what changes require a new QIS.	N
C002-10	AHIP	7/17/2015		Public Reporting	We recommend that HHS looks to the QRS to give consumers information on a standardized set of measures regarding quality of care and enrollee experience.	CMS added clarifying language to Section 5.2 of the QIS Technical Guidance that for the 2017 coverage year, there are no plans for public reporting.	N
C002-11	AHIP	7/17/2015		Public Reporting	Should HHS choose to move forward with public reporting of QIS information, we request that HHS provide a future public comment period to provide input on making this information publicly available.	CMS added clarifying language to Section 5.2 of the QIS Technical Guidance that for the 2017 coverage year, there are no plans for public reporting.	N
C002-12	AHIP	7/17/2015		QIS Evolution	We recommend that HHS consider the development of a glide path for new QHP issuers and established QHP issuers when reporting on a Quality Improvement Strategy.	Supportive statement - no changes necessary.	N