TEMPLATE COMMENT LETTER ONDevelopment, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) – Stream 2

November XX, 2017

General Instructions for the comment letter (delete the text below prior to sending your letter)

We recommend includingthe following items in your comment letter:

-Name of your organization and a contact person

-Mailing address

-E-mail address

-Phone number

Indicate whether you are a current PACE organization, other provider type, state Medicaid agency, other state agency, provider or advocacy organization, or other entity.

Please Note: Any submitted comments may be made publicly available by CMS. All comments must be submitted electronically (PDF form) to CMS () by 12:00 am EST, Thursday, November 30, 2017. In the document’s title, please indicate the organization or individual submitting the comments—and, put “Development, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) – Stream 2” in the subject line.

Re: Development, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) – Stream 2

NAME OF ORGANIZATIONappreciates the opportunity to submit comments on the Development, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) – Stream 2documents released by the Centers for Medicare and Medicaid Services(CMS) on Monday, October 30, 2017.

Include a brief description of your organization and additional information. For example:

  • If your organization is a PACE organization, provide information on when it initiated operations, number of participants you serve, the role you play in your state’s long-term services and supports system, etc.
  • Discuss your organization’s current performance measurement and quality improvement activities to emphasize the existence of internal programs geared toward improving the quality of care and outcomes of those served, while highlighting any activities specific to the proposed measures.

NAME OF ORGANIZATION is a member of the National PACE Association (NPA)/state agency/provider organization/other and, like NPA, appreciatesCMS’ efforts to develop, adapt, and implement quality measures for PACE. We support in full the comments submitted by NPA and, in particular,want to emphasize our support for NPA’s recommendationsrelated to the following(Please include those issues of greatest importance to you and/or include other issues identified in NPA’s comment):
Referring to NPA’s comment letter on which NAME OF ORGANIZATION had significant opportunity to provide input, we believe that measuring the quality of health care is a necessary step in the process of improving health care quality. We support the utilization of performance indicators, as it is a critical component of continuous performance measurement and improvement. We anticipate that the implementation of PACE quality measures will support initiatives specifically targeted to improve PACE participant outcomes and would expect that CMS will be transparent in communicating the intended purposes of measure reporting.

NAME OF ORGANIZATIONcautions CMS and its contractors as they seek to adapt existing quality measuresto PACE given the variability in POs’ size, PACE participants’ needs and abilities, and programmatic differences between PACE andother providers of care (e.g., nursing facilities). It is vital to consider the unique characteristics of PACE in considering the potential to make comparisons between POs, as well as, other service delivery options (e.g., managed care).

We reinforce the point that currently PACE lacks a common assessment instrument and data standard. As referenced in NPA’s comment letter, NPA has developed a common data platform across all PACE Organizations referred to as the Common Data Set (CDS). We encourage Econometrica to seek alignment with those efforts currently underway to address these limitations.

We encourage CMS to harmonize the measure definitions of the proposed measure set with the definitions and reporting requirements associated with current PACE Quality Monitoring reporting requirements (i.e., Level I and Level II reporting) to mitigate the use of varying definitions for the same data element, assure consistency amongst data reporting requirements, and eliminate duplication in reporting.

Include a paragraph(s) emphasizing your concerns with any of the proposed measures. You may consider modifying the following text related each measure to explain your organization’s specific concerns and/or recommendations.

While we understand the overall intent, and are in support of the proposed measures, we offer the following general concerns and/or recommendations.

Feasibility of Data Collection

We request that further consideration be given to the data collection and reporting burden that POs will incur in implementing these measures. Currently, many POs have significant limitations on the ability to effectively, and efficiently, abstract many of the data elements required for the proposed measures. Please include details of anticipated challenges your organization will encounter specific to data collection and reporting. We strongly encourage CMS to provide adequate time for POs to establish a

strategy to accommodate implemented quality measures and applicable reporting requirements.

The rationale for the reporting of many required data elements is unclear and appears to provide no meaningful information as it relates to the applicable measures. This includes “participant residence” for Percentage of Participants with an Advance Directive or Surrogate Decision-Maker, Percentage of Participants with an Annual Review of Their Advance Directive or Surrogate Decision-Maker, and Percentage of Participants with Depression Receiving Treatmentmeasures. We believe that this data element does not provide meaningful information as it relates to these measures and should be removed as it creates an undue administrative burden. If the determination is made to adapt this data element, we recommend that the descriptions be modified as outlined in NPA’s comment letter.

We suggest that it is also the case with many of the data elements requested for the Percentage of Participants with Depression Receiving Treatmentmeasure. We therefore recommend that “Depression screening”, “Depression screening tool used” and “Type of treatment” data elements be eliminated from data collection and reporting requirements for this measure.

Calculation Methodology

Within the supplemental documents distributed with the CMS call for comment, it is noted that initially risk stratification will be used rather than risk adjustment, and that stratification will be based on PACE organization characteristics. We request that CMS specifically delineate what specific PACE organization characteristics will be considered and the anticipated methodologyto be utilized.We also encourage CMS to consider the use of participant characteristics for stratification purposes, while it further examines risk adjustment and alternative adjustment methodologies.

If you’d like, include additional details emphasizing one or more issues of most importance to you for each of the noted measures.

Percentage of Participants with an Advance Directive or Surrogate Decision-Maker and Percentage of Participants with an Annual Review of Their Advance Directive or Surrogate Decision-Maker

The exclusionary criteria for this measure requires clarification, specifically as it relates to a participant’s inability to provide an advance directive or identify a surrogate decision maker. It is unclear what criteria CMS expects POs to consider for exclusionary purposes.

We request clarification on data reporting requirements for participants meeting the exclusionary criteria for these measures. According to the exclusion criteria noted, participants with written documentation in the medical record that reflects that the participant did not wish or was unable to provide an advance directive or identify a surrogate decision-maker are excluded from both the numerator and denominator. Furthermore, the “Auto-Generated Participant Number” is reflected as the total number of non-excluded participants. This appears to conflict with the available responses for “Participant has documentation of an advance directive or surrogate decision-maker, or meets exclusionary criteria”, specifically #5 #6, and #7.

Percentage of Participants Not in Nursing Homes

While the expectation is that PACE participants residing in nursing homes should be low, natural age progression may require a long-term nursing home stay—as a result, we recommend exclusion criteria that considers the naturalprogression of chronic conditions and the related impact on the participant’s functional status.

We also recommend, for measure stratification and risk adjustment purposes, that consideration be given to participant characteristics, as well as POs access and use of alternative residential settings, which may be limited due to geographic area, state specific guidelines, or other uncontrollable factors.

Percentage of Participants with Depression Receiving Treatment

Based on the current measure definitions, the participants’ Dementia diagnosis does not have an impact on the measure. We recommend that this measure be limited to the evaluation of the diagnosis and treatment of depression.

We appreciate the opportunity to provide comments to the Development, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) –

Stream 2. If you have any questions, please do not hesitate to contact NAME and TITLE, at EMAIL ADDRESS and PHONE NUMBER.

Sincerely,

NAME

TITLE