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8/7/2019 Analysis on ACOs
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Occupational Therapy:Living Life To Its Fullest
The American Occupational TherapyAssociation, Inc.
4720 Montgomery LaneBethesda, MD 20814-3425
301.652.2682301.652.7711 Fax
800.377.8555 TDDwww.aota.org
___________________________________________________________
ANALYSIS OF THE CMS PROPOSED RULE FOR
THE MEDICARE SHARED SAVINGS PROGRAM ANDACCOUNTABLE CARE ORGANIZATIONS (2011)
___________________________________________________________
The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule
regarding the Medicare Shared Savings Program: Accountable Care Organizations (76 Federal
Register19528 [March 31, 2011]). The proposal would implement section 3022 of theAffordable Care Act, which contains provisions relating to Medicare fee-for-service payments
under Parts A and B, including the ability of certain specified providers and suppliers to
participate in Accountable Care Organizations (ACOs). Comments are due June 6, 2011, and
CMS will respond to comments in the final rule, which is expected later this calendar year. Thepolicies adopted in the final rule are slated to take effect January 1, 2012.
ACOs are one mechanism established in the Accountable Care Act to improve the systemof care under Medicare. If successful, ACOs would spread to the private sector in coming years.
An ACO is an umbrella organization made up of providers (combinations of hospitals, physician
groups, and other health care facilities) that agree to be accountable for the quality, cost, andoverall care of their assigned fee-for-service Medicare beneficiaries. Although the focus is on
primary care, an ACO takes responsibility for a beneficiarys entire continuum of care. The
purpose is to incentivize the provision of coordinated, quality care with better outcomes by
sharing cost savings with providers. The ACO is a new, more developed approach that follows
many other ways to organize health care (e.g., original HMOs). Other separate approaches toaddress cost growth while assuring appropriate services will be piloted over the next several
years by the Center for Medicare and Medicaid Innovation, another part of the Medicare SharedSavings Program.
I. STATUTORY BACKGROUND
Section 3022 of the Affordable Care Act amended Title XVIII of the Social Security Act
(SSA) (42 USC 1395 et seq.) by adding a new section 1899 requiring CMS to establish aShared Savings Program that promotes accountability, coordinates items and services under
Medicare Parts A and B, and encourages a commitment to high quality and efficient service
delivery. Under the Shared Savings Program, groups of specified providers and suppliers willwork together in ACOs to manage and coordinate fee-for-service care to Medicare beneficiaries.The ACOs may share in realized savings and receive financial incentives provided they meet
certain quality performance standards. Section 1899(a)(1) requires the program to be established
by January 1, 2012.
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Accept accountability for the quality, cost, and care for assigned Medicare fee-for-servicebeneficiaries
Agree to participate for a 3-year period
Adopt a formal legal structure that would allow the organization to receive and distributepayments for shared savings
Include a sufficient number of primary care physicians to meet the primary care needs ofassigned beneficiaries
Care for at least 5,000 assigned beneficiaries
Provide CMS with necessary information regarding participating professionals
Have in place administrative and clinical organization and leadership
Define processes to promote evidence-based medicine and patient engagement, report onquality and cost measures, and coordinate care (such as through the use of telehealth,
remote patient monitoring, and other such enabling technologies)
Be patient-centered, as shown by the use of patient and caregiver assessments or the useof individualized care plans
SSA 1899(b)(2)(A-H)
Legal Structure
CMS states in the proposed rule that it has attempted to balance its requirement of a
formal legal structure with other agency goals of flexibility, cost minimization, and programparticipation by nonprofit, community-based organizations. CMS has thus proposed that ACOs
must only satisfy applicable state laws and be capable of performing all ACO functions
including: (1) receiving and distributing shared savings and repaying any shared losses, and (2)establishing, reporting, and ensuring compliance with program requirements including quality
performance standards. CMS proposes that ACOs each have a tax identification number (TIN)
(or a set of TINs from all the practices constituting the ACO), but does not propose to haveACOs enroll in the Medicare program, in contrast to this requirement for each ACO participant.
CMS also proposes requiring ACOs to have a shared governance structure that providesall ACO participants (not just those professionals and hospitals involved with formation) withproportionate control over decision making. ACO participants directly providing health care
services must have at least 75% control of the ACOs governing body, and the governance
mechanism must include some Medicare patient representatives.
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Agreement Period
CMS is proposing to limit participating agreements in the first round of the Shared
Savings Program to 3 years, the minimum allowable by statute. CMS also proposed to require 60
days advance written notice of an intent to terminate the agreement, at which point the ACO will
be subject to a 25% withhold of shared savings in order to offset any future losses.
Minimum of 5,000 Beneficiaries
Under the proposed rule, should an ACOs assigned population fall below 5,000 during
the course of the agreement period, CMS would issue a warning and place the ACO on acorrective action plan. The ACO would remain eligible for shared savings over the course of the
performance year for which the warning was issued. If the ACO fails to meet the eligibility
criterion of having more than 5,000 beneficiaries by the completion of the next performance
year, the ACOs participation agreement would be terminated and the ACO would not be eligibleto share in savings.
Reporting
CMS is proposing that ACOs be subject to substantial monitoring and reporting
requirements, including public reporting of quality data to ensure transparency. ACOs wouldalso be required to provide documentation in their program application describing plans to
(1) promote evidence-based medicine, (2) promote beneficiary engagement, (3) report internally
on quality and cost metrics, and (4) coordinate care. CMS is seeking comment on whether more
prescriptive criteria would be appropriate for future rulemaking. ACO applications must alsoinclude a description of processes in place for internal reporting on quality and cost measures.
IV. QUALITY PERFORMANCE MEASURES
The quality of care furnished by an ACO will be measured using nationally recognized
measures in five key domains: patient/caregiver experience, care coordination, patient safety,preventive health, and at-risk population/frail elderly health. CMS is proposing an initial set of
65 measures across these domains (see CMS Table 1, Proposed Measures for Use in Establishing
Quality Performance Standards for Shared Savings in the First Year).
These measures and reporting mechanisms are intended by CMS to be aligned with the
measures in other CMS programs such as the Electronic Health Records (EHR) initiative and the
Physician Quality Reporting System (PQRS). An ACO that successfully reports the qualitymeasures required under the Shared Savings Program would also be deemed eligible for the
PQRS bonus.
ACOs must report completely and accurately on all measures within all domains to be
deemed eligible for shared savings. The stated purpose of this is to require ACOs to address all
domains and be accountable across the continuum of care. CMS also proposes giving aperformance score to an ACO for each measure: performance below the minimum attainment
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level would earn zero points, while performance at or above the minimum attainment level but
less than the performance benchmark will receive points on a sliding scale.
V. SHARED SAVINGS
Shared savings amounts will be determined based on algorithms tied to an ACOs qualityperformance score and its savings rate. CMS proposes two models for shared savings: a shared
savings model (one-sided model) and a shared savings/losses model (two-sided model).Under the one-sided model, an ACO would receive a smaller percentage share in savings. Under
the two-sided model, an ACO willing to bear risk and repay losses to the Medicare program
would receive a greater percentage of any shared savings (see CMS Table 8, Shared SavingsProgram Overview).
CMS proposes that ACOs be required to report quality measures and meet performance
criteria for all 3 years within the 3-year agreement period. For the first year of the program,however, CMS proposes requiring only full and accurate reporting to set benchmarks and
encourage participation. Scales and standards with a minimum attainment level will be in effectfor subsequent years.
If an ACO satisfies quality performance criteria and its annual expenditures fall below a
certain Expenditure Benchmark, then it is eligible to share in cost savings. The cost savings inwhich ACOs may share fall within a range between the Minimum Savings Rate (for the one-
sided model, the Minimum Savings Rate ranges from 2% of the Expenditure Benchmark for
ACOs over 60,000 beneficiaries and 3.9% for ACOs of 5,000 beneficiaries; for the two-sided
model, the minimum is a flat 2%) and the Maximum Sharing Cap. ACOs using the one-sidedmodel are entitled to receive up to 50% of the net savings beyond the Minimum Savings Rate up
to the Maximum Sharing Cap of 7.5% of the Expenditure Benchmark. ACOs using the two-sided
model are entitled to up to 60% of the gross savings beyond the Minimum Savings Rate and upto the Maximum Sharing Cap of 10% of the Expenditure Benchmark.
ACOs may not participate in any other shared savings program or demonstration underthe Center for Medicare and Medicaid Innovation or Independence At Home Medical Practice
pilot program, to ensure that savings are not counted twice.
VI. IMPLICATIONS FOR PATIENTS
A central goal of ACOs is to protect Medicare beneficiaries by providing them with
better, patient-centered care and preventing them from having to retell their stories and medicalhistories to each treating provider. The proposed rule includes a list of criteria for demonstrating
patient-centeredness:
A beneficiary experience of care survey in place and a description in the ACOapplication of how the ACO will use the results to improve care over time.
Patient involvement in ACO governance.
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A process for evaluating the health needs of the ACOs assigned population, includingconsideration of diversity in their patient populations, and a plan to address the needs oftheir population.
Systems in place to identify high-risk individuals and processes to develop individualized
care plans for targeted patient populations, including integration of community resourcesto address individual needs.
A mechanism in place for the coordination of care.
A process in place for communicating clinical knowledge/evidence-based medicine tobeneficiaries in a way that is understandable to them. This process should allow for
beneficiary engagement and shared decision-making that takes into account the
beneficiaries unique needs, preferences, values, and priorities.
Written standards in place for beneficiary access and communication and a process in
place for beneficiaries to access their medical record.
Internal processes in place for measuring clinical or service performance by physiciansacross the practices, and using these results to improve care and service over time.
CMS is also proposing to ensure that Medicare beneficiaries be given notice of provider
membership in an ACO, maintain their choice of provider, and retain privacy protections.
CMS would require participating ACO providers to notify Medicare fee-for-servicebeneficiaries at the time they seek services that the provider is participating in an ACO.
Providers must offer beneficiaries information about the ACO, including how the ACO would
improve the care that they receive, and post signs indicating ACO participation.
CMS would also allow beneficiaries to retain their choice of providers even if they
receive care from a physician, hospital, or other facility participating in an ACO. CMS proposesto prohibit ACOs from developing any policies that would restrict a beneficiarys ability to seek
care from providers and suppliers outside of the ACO, including expressly limiting patients to
certain providers, managing utilization, or requiring prior authorization for Medicare services. In
this same vein, CMS has also proposed strict restrictions to ACO patient communications andmarketing activities that are confusing or misleading and would not forward the goal of patient-
centeredness. The agency is proposing that all marketing materials, communications, mailings,
calls, or community events that are used to educate, solicit, notify, or contact Medicare
beneficiaries or providers/suppliers regarding the ACO and its participation in the SharedSavings Program be pre-approved by CMS.
Because Medicare beneficiaries may seek care from their choice of providers, they may
receive services over the course of a year from a number of different ACOs and even from
professionals who do not participate in the Shared Savings Program at all. For this reason, CMSproposes to assign beneficiaries to an ACO retrospectivelyat the end of the performance
yearbased upon utilization data. CMS finds that prospective assignment would be plagued
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with inaccuracies and could encourage providers to limit their care improvement activities to a
subset of patients who are believed to be assigned to them. CMS would assign beneficiaries to anACO under a plurality rule: placing responsibility for a patients care on the ACO where a
patient received a plurality of his or her primary care services.
To better coordinate care among ACO providers, under the proposed rule an ACO wouldbe permitted to request personal health information (PHI) about a patient from CMS claims data.
Before doing so, however, ACOs would be required to provide written notice to beneficiariesduring an office visit that it would request the beneficiarys PHI from CMS and allow
beneficiaries to opt out.
VII. LEGAL ISSUES
The expansive ACO and Medicare Shared Savings Programs have broad legal
implications. Consequently, as part of a coordinated, inter-agency effort, several federal agencieshave issued companion proposals. There will be a 60-day public comment period for these
proposals.
Self-Referral, Anti-Kickback, and Fraud and Abuse Waivers
CMS and the HHS Office of the Inspector General (OIG) jointly issued a Notice onWaivers in Connection with Sections 1899 and 1115A of the Social Security Act. The notice
proposes to waive the Physician Self-Referral Law, the federal anti-kickback statute, and certain
civil monetary penalties law provisions for specified financial arrangements involving ACOs.
The OIG would also waive fraud and abuse laws so that the Center for Medicare and MedicaidInnovation could carry out its mission of testing new payment and service delivery models.
Specifically, the notice addresses the application of the following federal laws toparticipating ACOs:
The Physician Self-Referral Law (SSA 1877(a)), which prohibits physicians frommaking referrals for Medicare designated health services, including hospital services,to entities with which they or their immediate family members have a financial
relationship, unless an exception applies.
The federal anti-kickback statute (SSA 1128B(b)), which provides criminal penaltiesfor individuals or entities that knowingly and willfully offer, pay, solicit, or receive
remuneration to induce or reward the referral of business reimbursable under any federal
health care program.
The civil monetary penalties law (SSA 1128A(b)(1) and (2)), which prohibits a hospitalfrom making a payment, directly or indirectly, to induce a physician to reduce or limit
services to Medicare and Medicaid beneficiaries under the physicians direct care.
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CMS and the OIG are proposing to waive the above laws in three specific circumstances:
The distribution of shared savings payments by an ACO to its participants.
The distribution of shared savings payments to other individuals or entities for activities
necessary for and directly related to the ACOs participation in the Shared SavingsProgram.
Financial relationships that are necessary for and directly related to the ACOsparticipation in the Shared Savings Program and fully comply with an exception to thephysician self-referral law (waiver of the anti-kickback statute and civil monetary
penalties law only).
The notice requests public comments on other areas where this waiver authority might be
appropriately exercised, including ACO start-up costs, continuing operating expenses, and non-
shared savings relationships between ACO members or outside entities.
Antitrust Policy Statement
In addition, the Federal Trade Commission (FTC) and Department of Justice (DOJ)jointly issued a Proposed Statement of Enforcement Policy Regarding Accountable Care
Organizations Participating in the Medicare Shared Savings Program on antitrust enforcement of
ACOs. The proposed antitrust policy would apply to collaborations, not including mergers,among independent providers seeking to participate in the Shared Savings Program (effective for
post-March 23, 2010, activities).
The policy includes a proposed Safety Zone for ACOsmeaning that they will not be
challenged by federal agencies for antitrust violations absent extraordinary circumstances. AnACO program applicant with a share above 50% for any common service that two or more
ACOs provide to patients in the same area meets a Mandatory Review Threshold. Such anapplicant must obtain a letter from one of the federal antitrust agencies stating that competitive
concerns are not raised and a challenge is not anticipated. The DOJ and FTC have committed to
provide a 90-day expedited review of ACOs that meet the 50% mandatory review threshold.
Federal Tax Guidance
The Internal Revenue Service (IRS) anticipates that tax-exempt organizations (such as
nonprofit hospitals and other health care organizations) will form ACOs and may have questions
about the application of federal tax law to the new structures. Accordingly, the IRS has issued anotice soliciting comments as to whether its existing guidance is sufficient or, if not, whatadditional guidance is needed.
Under current federal tax law, a tax-exempt organization must ensure that earnings do notfinancially benefit organizational insiders or other private parties. Nonprofit hospitals
participating in an ACO may receive payment under the Shared Savings Program which,
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although not expected by the IRS to result in such prohibited inurement or impermissible private
benefit, may create confusion.
* * * * *
AOTA is currently analyzing the implications of the proposed rule for therapy anddrafting comments. Please email us at [email protected] with your thoughts.
________
Resources
Proposed Rule: Medicare Shared Savings Program: Accountable Care Organizations, 76 Federal
Register19528 (March 31, 2011)
CMS Fact Sheet: Improving Quality of Care for Medicare Patients: Accountable CareOrganizations (March 31, 2011)
CMS Fact Sheet: What Providers Need to Know: Accountable Care Organizations (March 31,
2011)
CMS Fact Sheet: What Patients Need to Know About Accountable Care Organizations (March
31, 2011)
Federal Agencies Address Legal Issues Regarding ACOs Participating in the Medicare Shared
Savings Program (March 31, 2011)
Notice: Self-Referral and Anti-Kickback Legal Waivers (CMS and OIG, Display Copy, March
31, 2011)
Proposed Rule: Statement of Antitrust Enforcement Policy Regarding ACOs (FTC and DOJ,
Display Copy, March 31, 2011)
Notice: Guidance on Tax-Exempt Providers Participating in ACOs (IRS, March 31, 2011)
________
Attachments
CMS Table 1. Proposed Measures for Use in Establishing Quality Performance Standards for
Shared Savings in the First Year
CMS Table 8. Shared Savings Program Overview
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CMS-1345-P 174
Table 1. Proposed Measures for Use in Establishing Quality Performance Standards
that ACOs Must Meet for Shared Savings
Domain Measure Title & Description CMS Program,
NQF Measure
Number, Measure
Steward
Method of Data
Submission
Measure Type
AIM: Better Care for Individuals1. Patient/Care Giver Experience Clinician/Group CAHPS:Getting Timely Care, Appointments, and
Information
NQF #5 Survey Patient
Experience of
Care
2. Patient/Care Giver Experience Clinician/Group CAHPS:How Well Your Doctors Communicate
NQF #5 Survey Patient
Experience of
Care
3. Patient/Care Giver Experience Clinician/Group CAHPS:Helpful, Courteous, Respectful Office
Staff
NQF #5 Survey Patient
Experience of
Care
4. Patient/Care Giver Experience Clinician/Group CAHPS:Patients' Rating of Doctor
NQF #5 Survey Patient
Experience of
Care
5. Patient/Care Giver Experience Clinician/Group CAHPS:Health Promotion and Education
NQF #5 Survey Patient
Experience of
Care
6. Patient/Care Giver Experience Clinician/Group CAHPS:Shared Decision Making
NQF #5 Survey PatientExperience of
Care
7. Patient/Care Giver Experience Medicare Advantage CAHPS:Health Status/Functional Status
NQF #6 Survey Patient
Experience of
Care
8. Care Coordination/Transitions Risk-Standardized, All Condition
Readmission:The rate of readmissions within 30 days
of discharge from an acute care hospital
for assigned ACO beneficiary population.
CMS Claims Outcome
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CMS-1345-P 175
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
9. Care Coordination/Transitions 30 Day Post Discharge Physician Visit CMS Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Process
10. Care Coordination/Transitions Medication Reconciliation:Reconciliation After Discharge from an
Inpatient Facility
Percentage of patients aged 65 years and
older discharged from any inpatient
facility (eg, hospital, skilled nursing
facility, or rehabilitation facility) and seen
within 60 days following discharge in the
office by the physician providing on-
going care who had a reconciliation of the
discharge medications with the current
medication list in the medical record
documented.
NQF #554 Group PracticeReporting
Option (GPRO)
Data Collection
Tool
Process
11. Care Coordination/Transitions Care Transition Measure:Uni-dimensional self-reported survey that
measures the quality of preparation for
care transitions. Namely:1. Understanding one's self-care role in
the post-hospital setting
2. Medication management3. Having one's preferences incorporated
into the care plan
NQF #228 or
alternate
Survey or Group
Practice
Reporting
Option (GPRO)Data Collection
Tool
Patient
Experience of
Care
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CMS-1345-P 176
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
12. Care Coordination Ambulatory Sensitive ConditionsAdmissions:
Diabetes, short-term complications(AHRQ Prevention Quality Indicator
(PQI) #1)
All discharges of age 18 years and olderwith ICD-9-CM principal diagnosis code
for short-term complications
(ketoacidosis, hyperosmolarity, coma),
per 100,000 population.
NQF #272 Claims Outcome
13. Care Coordination Ambulatory Sensitive ConditionsAdmissions:
Uncontrolled Diabetes(AHRQ Prevention Quality Indicator
(PQI) #14)
All discharges of age 18 years and older
with ICD-9-CM principal diagnosis code
for uncontrolled diabetes, without
mention of a short-term or long-term
complication, per 100,000 population.
NQF # 638 Claims Outcome
14. Care Coordination Ambulatory Sensitive Conditions
Admissions:Chronic obstructive pulmonary disease(AHRQ Prevention Quality Indicator
(PQI) #5)
All discharges of age 18 years and older
with ICD-9-CM principal diagnosis code
for COPD, per 100,000 population.
NQF #275 Claims Outcome
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CMS-1345-P 177
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
15. Care Coordination Ambulatory Sensitive ConditionsAdmissions:
Congestive Heart Failure(AHRQ Prevention Quality Indicator
(PQI) #8 )
All discharges of age 18 years and older
with ICD-9-CM principal diagnosis code
for CHF, per 100,000 population.
NQF #277 Claims Outcome
16. Care Coordination Ambulatory Sensitive Conditions
Admissions:Dehydration(AHRQ Prevention Quality Indicator
(PQI) #10)
All discharges of age 18 years and older
with ICD-9-CM principal diagnosis code
for hypovolemia, per 100,000 population.
NQF # 280 Claims Outcome
17. Care Coordination Ambulatory Sensitive Conditions
Admissions:
Bacterial pneumonia
(AHRQ Prevention Quality Indicator(PQI) #11)
All non-maternal discharges of age 18
years and older with ICD-9-CM principal
diagnosis code for bacterial pneumonia,
per 100,000 population.
NQF # 279 Claims Outcome
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CMS-1345-P 178
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
18. Care Coordination Ambulatory Sensitive ConditionsAdmissions:
Urinary infections(AHRQ Prevention Quality Indicator
(PQI) #12)
All discharges of age 18 years and older
with ICD-9-CM principal diagnosis code
of urinary tract infection, per 100,000
population.
NQF # 281 Claims Outcome
19. Care Coordination/Information Systems % All Physicians Meeting Stage 1HITECH Meaningful Use
Requirements
CMS Group Practice
Reporting
Option (GPRO)
Data Collection
Tool / EHR
Incentive
Program
Reporting
Process
20. Care Coordination/Information Systems % of PCPs Meeting Stage 1HITECH
Meaningful Use Requirements
CMS Group Practice
Reporting
Option (GPRO)Data Collection
Tool / EHR
Incentive
Program
Reporting
Process
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CMS-1345-P 179
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
21. Care Coordination/Information Systems % of PCPs Using Clinical DecisionSupport
CMS
EHR Incentive
Program Core
Measure
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool/ EHR
IncentiveProgram
Reporting
Process
22. Care Coordination/Information Systems % of PCPs who are Successful
Electronic Prescribers Under the eRxIncentiveProgram
CMS
EHR Incentive
Program Core
Measure
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool / eRx
Incentive
Program
Reporting
Process
23. Care Coordination/Information Systems Patient Registry Use CMS
EHR Incentive
Program MenuSet Measure
Group Practice
Reporting
Option (GPRO)
Data CollectionTool
Process
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CMS-1345-P 180
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
24. Patient Safety Health Care Acquired ConditionsComposite:
Foreign Object Retained AfterSurgery
Air Embolism Blood Incompatibility Pressure Ulcer, Stages III and IV Falls and Trauma Catheter-Associated UTI Manifestationsof Poor Glycemic
Control
Central Line Associated BloodStream Infection (CLABSI)
Surgical Site Infection AHRQ Patient Safety Indicator
(PSI) 90 Complication/Patient
Safety for Selected Indicators
(composite)
o Accidental puncture orlaceration
o Iatrogenic pneumothoraxo Postoperative DVT or PEo Postoperative wound
dehiscence
o Decubitus ulcero Selected infections due to
medical care (PSI 07: Central
Venus Catheter-relatedBloodstream Infection)
o Postoperative hip fractureo Postoperative sepsis
CMS (HACs), NQF
#531 (AHRQ PSI)
Claims or CDC
National
Healthcare
Safety Network
Outcome
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CMS-1345-P 181
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
25. Patient Safety Health Care Acquired Conditions:CLABSI Bundle
NQF #298 Claims or CDC
National
Healthcare
Safety Network
Process
AIM: Better Health for Populations
26. Preventive Health Influenza Immunization:Percentage of patients aged 50 years and
older who received an influenzaimmunization during the flu season
(September through February).
Physician Quality
Reporting SystemMeasure #110
EHR Incentive
Program Clinical
Quality Measure
NQF #41
Group PracticeReporting
Option (GPRO)Data Collection
Tool
Process
27. Preventive Health Pneumococcal Vaccination:Percentage of patients aged 65 years and
older who have ever received a
pneumococcal vaccine.
Physician Quality
Reporting System
Measure #111
EHR Incentive
Program ClinicalQuality Measure
NQF #44
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Process
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CMS-1345-P 182
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
28. Preventive Health Mammography Screening:Percentage of women aged 40 through 69
years who had a mammogram to screen
for breast cancer within 24 months.
Physician Quality
Reporting System
Measure #112
EHR IncentiveProgram Clinical
Quality Measure
NQF #31
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Process
29. Preventive Health Colorectal Cancer Screening:Percentage of patients aged 50 through 75
years who received the appropriate
colorectal cancer screening.
Physician Quality
Reporting System
Measure #113
EHR Incentive
Program Clinical
Quality Measure
NQF #34
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Process
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CMS-1345-P 183
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
30. Preventive Health Cholesterol Management for Patientswith Cardiovascular Conditions:
The percentage of members 1875years of age who were discharged
alive for AMI, coronary artery
bypass graft (CABG) orpercutaneous coronary
interventions (PCI) of the year
prior to the measurement year, or
who had a diagnosis of ischemic
vascular disease (IVD) during the
measurement year and the year
prior to the measurement year, who
had each of the following during
the measurement year.LDL-C
screening
LDL-C control (
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CMS-1345-P 184
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
32. Preventive Health Blood Pressure Measurement:
Percentage of patient visits with blood
pressure measurement recorded among all
patient visits for patients aged > 18 years
with diagnosed hypertension.
Physician Quality
Reporting System
#TBD
EHR Incentive
Program ClinicalQuality Measure
NQF #13
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Process
33. Preventive Health Tobacco Use Assessment and Tobacco
Cessation Intervention:Percentage of patients who were queried
about tobacco use. Percentage of patients
identified as tobacco users who received
cessation intervention.
Physician Quality
Reporting System
#TBD
EHR Incentive
Program Clinical
Quality Measure
NQF #28
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Process
34. Preventive Health Depression Screening:
Percentage of patients aged 18 years and
older screened for clinical depressionusing a standardized tool and follow up
plan documented.
Physician Quality
Reporting System
#134
NQF #418
Group Practice
Reporting
Option (GPRO)
Data CollectionTool
Process
35. At Risk Population -
DiabetesDiabetes Composite (All or NothingScoring):
Hemoglobin A1c Control (
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CMS-1345-P 185
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
36. At Risk Population Diabetes Diabetes Mellitus: Hemoglobin A1cControl (
8/7/2019 Analysis on ACOs
22/31
CMS-1345-P 186
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
40. At Risk Population -
DiabetesDiabetes Mellitus: Hemoglobin A1cPoor Control(>9%):Percentage of patients aged 18 through 75
years with diabetes mellitus who had
most recent hemoglobin A1c greater than
9.0%.
Physician Quality
Reporting System
Measure #1
EHR Incentive
Program ClinicalQuality Measure
NQF #59
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Outcome
41.
At Risk Population -
DiabetesDiabetes Mellitus: High Blood Pressure
Control in Diabetes Mellitus:Percentage of patients aged 18 through 75
years with diabetes mellitus who had
most recent blood pressure in control
(less than 140/90 mmHg).
Physician Quality
Reporting System
Measure #3
EHR Incentive
Program Clinical
Quality Measure
NQF #61
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Outcome
42. At Risk Population -
DiabetesDiabetes Mellitus: Urine Screening for
Microalbumin or Medical Attention for
Nephropathy in Diabetic Patients
Percentage of patients aged 18 through 75years with diabetes mellitus who received
urine protein screening or medical
attention for nephropathy during at least
one office visit within 12 months.
Physician Quality
Reporting System
Measure #119
EHR Incentive
Program Clinical
Quality Measure
NQF #62
Group Practice
Reporting
Option (GPRO)
Data CollectionTool
Process
8/7/2019 Analysis on ACOs
23/31
CMS-1345-P 187
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
43. At Risk Population -
DiabetesDiabetes Mellitus: Dilated Eye Exam inDiabetic Patients
Percentage of patients aged 18 through 75
years with a diagnosis of diabetes
mellitus who had a dilated eye exam.
Physician Quality
Reporting System
Measure #117
EHR Incentive
Program ClinicalQuality Measure
NQF #55
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Process
44. At Risk Population -
DiabetesDiabetes Mellitus: Foot Exam
The percentage of patients aged 18
through 75 years with diabetes who had a
foot examination.
Physician Quality
Reporting System
Measure #163
EHR Incentive
Program Clinical
Quality Measure
NQF #56
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Process
45. At Risk Population -
Heart FailureHeart Failure: Left Ventricular
Function (LVF) Assessment
Percentage of patients aged 18 years andolder with a diagnosis of heart failure
who have quantitative or qualitative
results of LVF assessment recorded.
Physician Quality
Reporting System
Measure #198
NQF # 79
Group Practice
Reporting
Option (GPRO)
Data CollectionTool
Process
8/7/2019 Analysis on ACOs
24/31
CMS-1345-P 188
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
46. At Risk Population -
Heart FailureHeart Failure: Left VentricularFunction (LVF) Testing
Percentage of patients with LVF testing
during the current year for patients
hospitalized with a principal diagnosis ofheart failure (HF) during the
measurement period.
Physician Quality
Reporting System
Measure #228
CMS
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Process
47. At Risk Population -
Heart FailureHeart Failure: Weight Measurement
Percentage of patient visits for patients
aged 18 years and older with a diagnosis
of heart failure with weight measurement
recorded.
Physician Quality
Reporting System
#227
NQF # 85
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Process
48. At Risk Population -
Heart FailureHeart Failure: Patient Education
Percentage of patients aged 18 years and
older with a diagnosis of heart failure
who were provided with patient education
on disease management and health
behavior changes during one or more
visit(s) within 12 months.
Physician Quality
Reporting System
#199
NQF # 82
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Process
49. At Risk Population -
Heart FailureHeart Failure: Beta-Blocker Therapy
for Left Ventricular Systolic
Dysfunction (LVSD)
Percentage of patients aged 18 years and
older with a diagnosis of heart failure
who also have LVSD (LVEF < 40%) and
who were prescribed beta-blocker
therapy.
Physician Quality
Reporting System
Measure # 8
EHR Incentive
Program Clinical
Quality Measure
NQF #83
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Process
8/7/2019 Analysis on ACOs
25/31
CMS-1345-P 189
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
50. At Risk Population -
Heart FailureHeart Failure: Angiotensin-ConvertingEnzyme (ACE) Inhibitor or
Angiotensin Receptor Blocker (ARB)
Therapy for Left Ventricular SystolicDysfunction (LVSD)
Percentage of patients aged 18 years and
older with a diagnosis of heart failure and
LVSD (LVEF < 40%) who were
prescribed ACE inhibitor or ARB
therapy.
Physician Quality
Reporting System
Measure #5
EHR Incentive
Program ClinicalQuality Measure
NQF #81
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Process
51. At Risk Population -
Heart FailureHeart Failure: Warfarin Therapy for
Patients with Atrial Fibrillation
Percentage of all patients aged 18 and
older with a diagnosis of heart failure and
paroxysmal or chronic atrial fibrillation
who were prescribed warfarin therapy.
Physician Quality
Reporting System
Measure #200
EHR Incentive
Program Clinical
Quality Measure
NQF #84
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Process
8/7/2019 Analysis on ACOs
26/31
CMS-1345-P 190
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
52. At Risk Population Coronary Artery
DiseaseCoronary Artery Disease (CAD)Composite: All or Nothing Scoring
Oral Antiplatelet Therapy Prescribedfor Patients with CAD
Drug Therapy for Lowering LDL-Cholesterol
Beta-Blocker Therapy for CADPatients with Prior Myocardial
Infarction (MI)
LDL Level
8/7/2019 Analysis on ACOs
27/31
CMS-1345-P 191
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
54. At Risk Population Coronary Artery
DiseaseCoronary Artery Disease (CAD): DrugTherapy for Lowering LDL-
Cholesterol
Percentage of patients aged 18 years and
older with a diagnosis of CAD who wereprescribed a lipid-lowering therapy
(based on current ACC/AHA guidelines).
The LDL-C treatment goal is
8/7/2019 Analysis on ACOs
28/31
CMS-1345-P 192
Domain Measure Title & Description CMS Program,NQF Measure
Number, Measure
Steward
Method of DataSubmission
Measure Type
57. At Risk Population Coronary Artery
DiseaseCoronary Artery Disease (CAD):Angiotensin-Converting Enzyme
(ACE) Inhibitor or Angiotensin
Receptor Blocker (ARB) Therapy forPatients with CAD and Diabetes and/or
Left Ventricular Systolic Dysfunction(LVSD)
Percentage of patients aged 18 years and
older with a diagnosis of CAD who also
have diabetes mellitus and/or LVSD
(LVEF < 40%) who were prescribed ACE
inhibitor or ARB therapy.
Physician Quality
Reporting System
Measure #118
NQF #66
Group Practice
Reporting
Option (GPRO)
Data Collection
Tool
Process
58. At Risk Population Hypertension Hypertension (HTN): Blood Pressure
Control
Percentage of patients with last BP