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RFP Responses – Amendment #3 as of May 11, 2011
| Comment No. |
| Document Section & Title |
| Question and/or Comment Recv'd |
| CMS Response/Comment |
| 1 |
| J-1 |
| Will CMS consider a dollar threshold under which pre-approval of paid media is not required? |
| This question applies only to one QIO. The QIO will receive info directly from the CO regarding this issue. |
| 2 |
| J.10 10th SOW Measures and Targets |
| For C.8, one of the measures is signed community coalition charters within three months. Three months from when? Along the same lines, what is the point at which a community is considered ‘recruited’? |
| Recruited communities will have signed agreements. Charters must be sigend within 3 months of recruitment. |
| 3 |
| J.10 10th SOW Measures and Targets |
| Is learning collaborative the same as learning network? |
| Yes. |
| 4 |
| J.10 10th SOW Measures and Targets |
| For the percentage of communities that can demonstrate 4 time series graphs showing positive trending data, how is the final 75% final target determined? Is it from time point 1 compared to time point 4? |
| CMS will evaluate this measure on the percentage of communities that can demonstrate 4 time series graphs that (each) show positive trending data for 4 unique interventions over 4 quarters. The selected quarters are those that are appropriate for assessment of the specific intervention. |
| 5 |
| J.10 10th SOW Measures and Targets |
| Are statewide readmission rates based on a 30 day readmission timeframe, similar to the collaborative measure? |
| The numerator for the percentage of state-wide readmissions per 1,000 Medicare beneficiaries includes the number of state-wide hospital readmissions to an acute care hospital within 30 days of an acute care hospital discharge. |
| 6 |
| J.10 10th SOW Measures and Targets |
| What claims variables will be used to calculate reduction in Medicare FFS costs among community beneficiaries participating in the learning network? |
| CMS is currently investigating use of both Parts A & B claims for this measure. CMS will provide more detailed technical specifications in the future. |
| 7 |
| J-10 Measures and Targets |
| For Num/Den for High-Risk Nursing Home Pressure Ulcer, says stages 3 and 4 for percent of high risk resident with pressure sores-is this intended to be stages 2, 3, and 4? |
| PrU will utilize the new MDS 3.0 measure which includes stages 2, 3, and 4. |
| 8 |
| J-10 Measures and Targets |
| Final target for Nursing Home Physical Restraint is <=3%; is that 3% for each recruited nursing home or an aggregate average? |
| CMS will calculate an aggregate rate for this measure. |
| 9 |
| J-10 Measures and Targets |
| CAUTI measures-If the measure is catheter-acquired urinary tract infections, why isn’t the measurement inclusive of UTIs? The NQF endorsed measure is the percent of residents with a urinary tract infection. Should we be measuring UTIs instead of residents with an indwelling catheter? |
| 25% is an aggregate relative rate of improvement (reduction in CAUTI rate from baseline) |
| 10 |
| J-10 Measures and Targets |
| CAUTI final target: Is the 25% absolute reduction an aggregate absolute reduction or is it per individual provider? |
| 25% is an aggregate relative rate of improvement (reduction in CAUTI rate from baseline) |
| 11 |
| J-10 Measures and Targets |
| Consistent Assignment final target- is the 85% final target an aggregate target or is it per individual provider? |
| CMS is reviewing the calculation for this measure. |
| 12 |
| J-10 Measures and Targets |
| Staff Turnover final target-is the 60% final target an aggregate target or is it per individual provider? |
| CMS is reviewing the calculation for this measure. |
| 13 |
| J-10 Measures and Targets |
| Staff Turnover- is the 60% final target for admin/RN/LPN/CNA combined or for each job category separately? |
| CMS is reviewing the calculation for this measure. |
| 14 |
| J-10 Measures and Targets |
| SSI reduction: When it says that we need to get a certain percentage of HAI participants to agree to participate in SSI reduction projects, do QIOs use CDI participants as well as CLABSI and CAUTI participants? |
| Can use any participants working in HAI reduction project(s)-CLABSI, CAUTI and/or CDI |
| 15 |
| J-10 Measures and Targets |
| For Q6, we need to have at least 1 newly formed team so does it has to happen between November 1, 2012 and January 31, 2013? |
| Please refer to the revised J-10. |
| 16 |
| J-10 Measures and Targets |
| For Q9, we need to have at least 2 newly formed team so does it have to happen between August 1, 2013 and October 31, 2013? |
| Please refer to the revised J-10. |
| 17 |
| J-10 Measures and Targets |
| For Q9, it says we need to have a total of 7 teams formed. However, page 39 (C.7.3.B.2a) of the RFP says we need to have five to ten community teams. Will 5 or 6 be enough? |
| Please refer to the revised J-10. |
| 18 |
| J-10 Measures and Targets |
| The Num/Den for CAUTI Measure is the percentage of long-stay residents with an indwelling catheter in the last five days. However, the NQF endorsed measure captures the percentage of long-stay residents who had an indwelling catheter in the last 7 days on the most recent MDS 3.0 assessment. Shouldn’t the two be aligned? |
| Thank you for raising the issue of alignment. CMS will consider this input. |
| 19 |
| Attachment J-10 Measures and Targets |
| Is it true the general task evaluation measures will be based on claims-based PQRI rates, where as EP evaluation measures will be based on EHR-derived rates? Please describe the rationale for this decision. |
| Yes. The general task evaluation measures use claims-based PQRI/PQRS rates. PQRS reporting via EHRs just started with the 2010 year; the PQRS reporting via claims is more established, with greater number of eligible professionals reporting by this method. |
| 20 |
| J-10 Measures and Targets |
| For OQR measures, which measures are included? Specifically, are the Imaging measures part of this work? |
| CMS will utilize OP-1 through OP-7 to evaluate Quality Improvement and CAH/non subsection (D) hospital reporting work |
| 21 |
| J-10 Measures and Targets |
| For OQR measures, what is meant by the word “eligible” in “% eligible Hospitals…? What makes a hospital eligible? |
| Subsection (d) hospitals that have not signed an OQR withdrawal form |
| 22 |
| Attachment J-10 Table 2 Measure Detail Table |
| On the table it is stated as Measure: Staff turnover- Num/Den (Inclusion & Exclusion) 'Rate of improvement in Admin/RN/LPN/CNA turnover in NH from the prior year. Baseline Q4-2012.' However, at this time the Advancing Excellence Staff Turnover Data Tracker only tracks RN, LPN and CNA turnover. Will this change to include Administrator by 2012? |
| CMS will strive to ensure the inclusion of Administrator. |
| 23 |
| Attachment J-10 Table 2 Measure Detail Table |
| For the measure "Percentage of communities that can demonstrate 4 time series graphs showing positive trending data (to meet the intervention improvement objective) for 4 unique interventions over four quarters": Does this measure refer to four different interventions for each community? Do the four quarters include a baseline quarter as the first quarter, or would this measure look at a full year of data after a baseline quarter? Given that many measures are affected by seasonality, how is "positive trending" being defined over a four quarter period of time? |
| Please refer to Q 4. |
| 24 |
| Attachment J-10 Table 2 Measure Detail Table |
| Percentage of eligible Hospitals improving CMS QIO Hospital Inpatient Quality and Experience of Care Performance Score (CQIHIQECPS); How is the score determined? Is this providers' HCAHPS score or something else? |
| Please review the Hospital VBP performance score discussion in the Hospital VBP rule for a detailed discussion of the methodology used to calculate this score. |
| 25 |
| Attachment J-10 Table 2 Measure Detail Table |
| Reduction in the cases of CDI for a targeted facility as compared to the baseline number of CDI cases for same facility expressed as a percentage for a baseline of 7/1/2012-12/31/2012. A percentage is not specified However, on pg 31, it notes a 36th month relative improvement rate of 10% or greater. Please clarify. |
| The outcome measure, relative rate of improvement pertains only to the end of the contract @ the 36th month given the shorter time for that initiative. The 27th month target is a process measure |
| 26 |
| Section J10 - Improve Health for Populations and Communities - PQRS-EHR Reporting Assisting Offices/EPs - Outcome 2 |
| Please clarify the requirements of this target? It specifies the reporting of Offices Assisted, but the recruitment is by EP. |
| For the PQRS-E.HR Reporting task, QIOs are required to recruit offices & eligible professionals (EPs) such that they meet the agreed-upon recruitment target of EPs. |
| 27 |
| Attachment J-10; Improve Individual Patient Care: Quality Reporting and Improvement |
| Is CMS QIO Hospital Inpatient Quality and Experience of Care Performance Score (CQIHIQECPS) part of Value Based Purchasing? |
| Yes. Please review the Hospital VBP performance score discussion in the Hospital VBP rule for a detailed discussion of the methodology used to calculate this score. |
| 28 |
| Attachment J-10; Integrate Care for Populations and Communities |
| The 50% target for the percentage of eligible communities recruited that submit applications to a Care Transitions Program is higher than our minimum state target in Attachment J-19 Estimated Level of Effort. Which of these targets should the QIO identify as our number of communities to work with? |
| The QIO should ensure that they work with a sufficient number of communities to successfully meet the minimum performance thresholds. |
| 29 |
| Attachment J-10; Improve Health for Populations and Communities |
| The 1.25* state specific number for the 27th month evaluation measure is higher than our minimum state identified target in Attachment J-19 Estimated Level of Effort. Which of these numbers should be used to target our recruitment efforts? |
| Please see Q 573 & 587. |
| 30 |
| Attachment J-10 Improve Health for Population and Communities: PQRS-HER Reporting - Outcome 2 |
| How will CMS evaluate zero baseline scenario (0 EP participation in PQRI/PQRS by direct HER-reporting)? |
| The PQRS-E.HR reporting task requires that QIOs recruit and assist eligible professionals (EPs) in starting to report to PQRS via E.HR - and do so successfully (so that they earn an incentive for participation). There is no issue related to "zero baselines" for these EPs. |
| 31 |
| Attachment J-10 Improve Health for Population and Communities: General Task Evaluation |
| Does "as reported via claims" mean evaluated by utilization measure (claim-based measure)? |
| No. Please see the PQRI/PQRS website for additional information. |
| 32 |
| Attachment J-10 |
| Recruitment of Offices: Does not contain any target counts. Section C (Page 56) clearly identifies July 31, 2012 as the target date. Is this correct or does J-10 indicate that recruitment is always open? |
| For the PQRS-E.HR reporting task, the deadline to recruit eligible professionals (EPs) is July 31, 2012. There are interim (quarterly) recruitment targets for the first year, listed in Attachment J-10, table 3. These are based on a percentage of the agreed-upon recruitment target. QIOs must recruit a sufficient number of offices for PQRS-E.HR reporting to achieve the agreed-upon threshold for the number of EPs. |
| 33 |
| Attachment J-10 |
| Are the improvement percentages absolute, relative, reduction in failure rate (RFR) or something else? |
| For the HAI project, they are relative rate(s) of improvement (which in those cases would represent a reduction in rates) |
| 34 |
| Attachment J-10 |
| Can an 18 month time period and 27 month time period column be added a populated as needed? The document already contains a baseline time period column. |
| Thank you for this constructive suggestion. |
| 35 |
| Attachment J-10 |
| If the EP did not participate in 2010 PQRI how will baseline data be collected? |
| General evaluation measures are not calculated using EP-specific data. See also Q 572. |
| 36 |
| Attachment J-10 |
| Are CMS QIO Hospital Inpatient Quality & Experience of Care Performance Scores of 0.1 - 0.9 possible? If so, are these scores considered "non-zero"? |
| No, scores in this range are not possible. |
| 37 |
| Attachment J-10 |
| Does time series mean 4 months or 4 quarters or 4 weeks? |
| The QIO should ensure that they work with a sufficient number of communities to successfully meet the minimum performance thresholds. |
| 38 |
| Attachment J-10 |
| Should we assume that the readmission and hospitalization rates refer to are all-cause readmissions and hospitalizations? |
| Yes. Admission & readmission measures consider all-causes. |
| 39 |
| Attachment J-10: 10th SOW Measures and Targets |
| References are made to the “CMS QIO Hospital Inpatient Quality and Experience of Care Performance Score (CQIHIQECPS).” Is this equal to the provider’s Total Performance Score under the proposed Value Based Purchasing program? If so, does this mean CAH providers are not eligible for measures referencing the CQIHIQECPS? |
| For inpatient care, this score is equivalent to the Hospital VBP performance score finalized in the 4/29 Hospital VBP final rule. This is correct that CMS will not calculate this score for CAH and other non-subsection (d) hospitals, and eligible hospitals that do not report a sufficient volume of cases for the minimum number of measures. Please refer to the Hospital VBP NPRM and final rule for a comprehensive description of this score's methodology. |
| 40 |
| Attachment J-10: 10th SOW Measures and Targets |
| For the measure here referencing “% of eligible hospitals reaching BL Yr 1 for 3/5 OQR measures,” what is the criteria for eligibility? Does this include reporting CAH facilities, or only PPS? |
| For OQR, we include only PPS subsection (d) hospitals as eligible and did not submit an OQR withdrawal form |
| 41 |
| Attachment J-10: 10th SOW Measures and Targets |
| For the measure here referencing “% of eligible hospitals improving measure rates for 4 OQR measures (from previous year),” what is the criteria for eligibility? Does this include reporting CAH facilities, or only PPS? |
| Eligible hospitals is interpreted as “Eligible PPS subsection (d) hospitals (i.e., PPS subsection (d) hospitals with no active OQR withdrawal forms)” |
| 42 |
| Attachment J-10: 10th SOW Measures and Targets |
| The fourth measure on this page reads, “% of eligible Hospitals receiving a non-zero CMS QIO Hospital Inpatient Quality and Experience of Care Performance Score (CQIHIQECPS) (FY 2014 Only).” Should the measure read, “% of eligible Hospitals improving CQIHIQECPS (FY 2014 only)”? This would match the Num/Den entry for the fourth measure on page 11. |
| CMS will verify the alignment of the contract language for this Task. Thank you for raising this issue. |
| 43 |
| Attachment J-10: 10th SOW Measures and Targets |
| The Intermediate and Final Targets for Physical Restraints are both to be <=3%. Is this a goal to be reached as an aggregate score for the learning action network, the statewide learning action network, or by each individual nursing home participating in this SOW? OR, is this indicative of 3% relative or absolute improvement over a baseline value either individually or en masse? |
| Please see Q 8. |
| 44 |
| Attachment J-10. 10th SOW Measures and Targets For the measure “Consistent Assignment,” the numerator/ denominator includes the “Rate of consistent assignment of CNAs in the NH”. For the measure “Staff Turnover,” the Num/Den includes the “Rate of improvement in ADMIN/RN/LPN/CNA turnover in the NH from the prior year.” |
| The Final Target is 85%. What does the 85% represent? The Final Target is 60%. What does the 60% represent? |
| CMS is reviewing the calculation for this measure. |
| 45 |
| J-10 10th SOW Measures and Targets |
| Contract statement: Percentage of proposed communities recruited that have signed community coalition charters and within 3 months? - As this is an incomplete statement please clarify what is meant by “and within 3 months”? |
| Please see Q 2. |
| 46 |
| Attachment J-10 – 10th SoW Measures and Target |
| For the % of CAHs reporting IQR and the % of CAHs Reporting OQR, what is the definition of reporting for a CAH? i.e. reporting on all eligible cases and topics vs. reporting on one topic for at least one measure |
| CAH and other non subsection (d) hospital successfully submitting at least one case in at least one topic covering OP-1 through OP-7, however, again, we encourage QIOs to strive for maximum versus minimum expectations. |
| 47 |
| Attachment J-10 Central Line Insertion Practices (CLIP) adherence rate |
| Our state does not require CLIP reporting in NSHN due to high reporting workload of IP’s. Are the goals set too high for the contract requirements? |
| Thank you for sharing your state-specific information. |
| 48 |
| Attachment J-10 CAUTI Relative Improvement Rate |
| Our state does not require CAUTI RIR reporting in NSHN and most hospitals don’t report it. Are the goals set too high for the contract requirements? |
| RIR reporting can be calculated from CAUTI incident rates which is the data to be entered into NHSN |
| 49 |
| J-10: 10th SOW Measures and Targets - Improve Individual Patient Care: Quality Reporting and Improvement/% of Annual Payment Update – IQR Providers |
| In calculating the percentage of APU-IQR providers receiving full APU, would an IPPS provider that elected to withdraw from the public reporting program be included in the denominator? Example: An IHS hospital that has chosen not to participate because they have few Medicare patients, limited resources, and for financial reasons do not want to contract with a vendor for HCAHPS. |
| Eligible hospitals is defined as subsection (d) hospitals that have not signed the applicable (i.e., Iqr, oqr) withdrawal form |
| 50 |
| J-10: 10th SOW Measures and Targets/Improve Individual Patient Care: Quality Reporting and Improvement/% of Annual Payment Update – IQR Providers |
| For CAHs participating in IQR, will they be considered a reporting hospital if they report one measure set? Example: They submit only pneumonia. |
| For nonsubsection (d) hospitals, accepted data into the applicable warehouse for at least one patient episode case in at least one measure in at least one quarter counts in a numerator, however, again, we encourage QIOs to strive for maximum versus minimum expectations. |
| 51 |
| J-10: 10th SOW Measures and Targets/Improve Individual Patient Care: Quality Reporting and Improvement/% of Annual Payment Update – OQR Providers |
| For CAHs participating in OQR, do they need to submit all measures for chest pain and OP surgery to be considered a reporting hospital? |
| For nonsubsection (d) hospitals, accepted data into the applicable warehouse for at least one patient episode case in at least one measure in at least one quarter counts in a numerator |
| 52 |
| J-10: 10th SOW Measures and Targets/Improve Individual Patient Care: Quality Reporting and Improvement/% of eligible Hospitals receiving a non-zero CMS QIO Hospital Inpatient Quality and Experience of Care Performance Score |
| The identified “Final Target” is 95% of eligible hospitals receiving a non-zero score. It appears hospitals will be scored twice, once for point in time performance and once for improvement between two points in time, keeping the higher of the two scores. In both instances hospitals below the median will receive a score of zero. In an example of 100 hospitals, 50 will have non-zero scores on the point in time measure. In order to achieve the identified “Final Target” of 95%, 45 of these 50 hospitals will have to be below the median on the improvement measure so 45 that received a zero score on the point in time measure can have non-zero scores for improvement. In addition, if hospitals in some states perform well on both measures, by default, hospitals in other states are forced to fail the Final Target, as there will always be hospitals that fall below the median and receive a zero score. Therefore, it would appear that all QIOs will not have equal opportunity to pass this measure. Please clarify. |
| Higher of achievement and improvement in each domain is statutorily mandated for this score. Please review the Hospital VBP performance score discussion in the Hospital VBP rule for a detailed discussion of the methodology used to calculate this score. CMS intends to use this score for CQIHIHQECPS. CMS will explore releasing code used to calculate the Hospital VBP performance score regulatory impact to QIO's, but cannot guarantee release by August 1, 2011. |
| 53 |
| J-10 |
| Metric: PrU prevention and care: Final target 100%. Does the 100% represent the facilities in the state or the facilities recruited for the Learning and Action Network? |
| Recruited facilities, however, please consider how you will work with your LAN and what mechanism you might implement to track your progress internally. |
| 54 |
| J-10 |
| Metric: Best practices to prevent and treat PrU’s. Final target 100%. Does the 100% represent the facilities in the state or the facilities recruited for the Learning and Action Network? |
| Trends depicting the success of interventions may use appropriate methods to adjust for seasonality. Please also see Q 4. |
| 55 |
| J-10, Measure and Targets |
| There is a requirement of 7% relative improvement for communities in learning collaborative and 5% for communities in the learning network. What is the distinction between the collaborative and the network? |
| Relative. |
| 56 |
| Attachment J-10, Table 2: Measure Detail Table |
| Are the evaluation measures for cardiac and EHR 6% absolute or 6% relative improvement? Are the evaluation measures for expected improvement statewide or just for EPs? |
| Relative improvement. CMS is seeking statewide improvement as this is a part of a larger HHS Departmental effort to improve the cardiac health of the populations. QIOs are encouraged to participate in the national efforts conducted by other HHS components and the private sector as this initiative is released in the near future. |
| 57 |
| Attachment J-10, Table 2: Measure Detail Table |
| How will PQRS EHR reporting data be utilized if the general task evaluation measure is claims based reporting? |
| The PQRS-E.HR reporting task will be evaluated based on PQRS-E.HR Reporting Outcome Measures 1 & 2. Please note that Outcome measure 1 requires that at least 90% of the eligible professionals (EPs) assisted by the QIO successfully report to PQRS via E.HRs for program year 2012, such that they receive incentive payments for their participation. |
| 58 |
| Attachment J-10: 10th SOW Measures and Targets |
| Given the strong emphasis on participant interaction, feedback, and collaborative innovation, will CMS allow for the posting of questions on social media platforms such as LinkedIn and Facebook? For example, a question posted in anticipation or observance of National Health Information Technology Week might be: “What growing pains have you experienced in EHR implementation? What advice do you have to share with other physician practices?” Or is this in violation of the QIO Communications Handbook guideline regarding Collecting Information (Surveys)? If such activity (as described above, on social media platforms) is permitted, will the QIO Communications Handbook be updated to reflect this exception? |
| CMS is working on guidance for QIOs about the use of social media under the auspices of the 10th SOW tasks. We will share this guidance through our usual communications mechanisms, including TOPS/SDPS memos, the Communications ListServ, the QIO Communications Handbook, and our regular calls/meetings between CMS and the QIO community. |
| 59 |
| Attachment J-10 :10th SOW Measures and Targets |
| Measures #201 Blood Pressure, #203 LDL-C Control, and #204 Aspirin Therapy are not measures that can be reported via the EHR for PQRS. Will these measures need to be reported via claims or a registry? |
| Please see Q 542. |
| 60 |
| Attachment J-10 |
| The measure "Reduction in Medicare FFS costs among community beneficiaries participating in the Learning Network” data source does not specify the type of claims to be used in the measure. Will this only be inpatient costs, or outpatient costs as well, including ER visits and observation stays? |
| Please see Q 6. |
| 61 |
| Attachment J-10 |
| The RFP states, "Increase to at least 1.25* state specified number (as noted in J-18) of eligible professionals participating in PQRS via EHR reporting (in 2012, compared with 2010 baseline)." How soon prior to the 07/31/12 deadline for recruiting the state specified number of EPs, can the QIOs expect to receive the data from CMS on the number of 2010 EHR reporting EPs to determine the goal for increased participating EPs? |
| The CMS-proposed target number is specified in J-18. This number will be reviewed and agreed upon during contract negotiations. Please see question/comment #573. |
| 62 |
| Attachment J-10 |
| Evaluation Measure attachment notes two readmission measures- one statewide and the other for communities participating in the Learning Collaborative Since the Learning and Action Networks are statewide-is the measure looking at Coalition readmission metrics or is this for members of the Learning Action Network (which could be state-wide)? |
| One set of measures is statewide; the other is focused on specific community (ies) that have been recruited. |
| 63 |
| Attachment J-10 |
| Please clarify what is meant by "Demonstration of continuous improvement and member engagement with a goal of no pADEs in Learning Network." Will the QIOs be held to a target of 0 (zero) pADEs in the Learning Network for this evaluation component? |
| The goal is to demonstrate improvement moving towards zero events. The zero is not an absolute target. Please review the revised J10 |
| 64 |
| Attachment J-10 |
| For the INR in controlled range evaluation component, does the final target of "70% of patients having INRs in the controlled range" pertain to the state (as stated in the RFP), or does it pertain to the PoF within the community teams? |
| This is statewide and also indicated in the measure detail table. |
| 65 |
| Attachment J-10 |
| Please clarify what is meant by "Improvement each quarter. Maintenance level of 90%" |
| Please review the revised J10 and the revisions to tables 2 and 3 for the ADE aim. |
| 66 |
| Attachment J-10: 10th SOW Measures and Targets |
| RFP states the "baseline time period is based on 2010 PQRI claims data." The QIOs are charged with assisting providers to successfully submit EHR data. Can CMS provide a definition of "claims data"? |
| This refers to a method of reporting to PQRS; eligible professionals may report to PQRS via claims; a qualified E.HR; a qualified registry; or group-reporting method. Please refer to the CMS PQRS website for additional information. |
| 67 |
| Attachment J-10: 10th SOW Measures and Targets |
| How will CMS calculate the 6% improvement when comparing claims data to EHR data? |
| Claims data is not being compared with E.HR data. Please see question/comment #575 and question/comment #661. |
| 68 |
| Attachment J-10: 10th SOW Measures and Targets |
| How will CMS take into account those patients under 65 that do not have Medicare or available claims data, but still fall into the targeted population for PQRS reporting and measurement? |
| These measures are based on analysis of PQRI/S claims-based data. |
| 69 |
| Attachment J-10: 10th SOW Measures and Targets |
| How and when will CMS be sharing the EHR reported PQRS 2010 data? |
| The General Task Evaluation measures are based on the eligible professionals in the state that report quality data codes to PQRS via Medicare claims. Patients that are not Medicare beneficiaries or whose providers are not participating in PQRS will not be included. See also question/comment #608. |
| 70 |
| Attachment J-10: 10th SOW Measures and Targets |
| The RFP states, "the final target for the PQRS measures is 6% improvement from baseline." If the recruited EPs have not previously reported to PQRI and therefore have a zero baseline, how will that effect the measurement of 6% improvement? |
| The 6% improvement expectation is for the General Task Evaluation Measures. These are not specific to the QIO-recruited-&-assisted eligible professionals. Please see question/comment #575. |
| 71 |
| Attachment J-10: 10th SOW Measures and Targets |
| The RFP states, "the final target for the PQRS measures is 6% improvement from baseline." Is it CMS' intent to have the QIOs recruited EPs that have participated in the 2010 reporting for comparison? |
| No. Please see question/comment #70, question comment #575 and question/comment #661. |
| 72 |
| Attachment J-10: 10th SOW Measures and Targets |
| The RFP states, "the final target for the PQRS measures is 6% improvement from baseline." Is the 6% improvement from baseline a relative improvement rate or absolute improvement rate? |
| Relative improvement. |
| 73 |
| Attachment J-10: 10th SOW Measures and Targets |
| The RFP states, "the final target for the PQRS measures is 6% improvement from baseline." Can CMS provide to the QIOs, a list of PQRS participating providers by state and reporting methodology used by the start of the contract? |
| No, CMS will not be providing this information. |
| 74 |
| Attachment J-10: 10th SOW Measures and Targets |
| The measures # 204 (Aspirin Therapy) and #203 (LDL-C Control) are not able to be submitted via EHR. Will the re-measurement be based on claims data for these measures? How will CMS capture those patients that fall outside the Medicare population? How can aspirin therapy be captured on claims if it is an over-the-counter drug? |
| Please see question/comment #514. |
| 75 |
| Attachment J-10: 10th SOW Measures and Targets, Table 1. – Qualitative and Quantitative Evaluation Metrics, Quality Improvement Activities and Outcomes |
| It states, “The QIO must constantly asses the value of the Learning Networks and technical assistance using the best method as determined by the QIO.” Will the QIO be able to use survey methodology for the assessment? If so, will the current restrictions/requirements regarding surveys continue? |
| QIOs may use any appropriate means to achieve success for this Task. |
| 76 |
| Attachment J-10: 10th SOW Measures and Targets, Table 1. – Qualitative and Quantitative Evaluation Metrics, Valuing Innovation |
| “The QIO is expected to demonstrate solicitation and/or creation of new ideas…. This includes designing a mechanism by which all entities the QIOs work with and/or have contact with are able to contribute ideas…. It may also include leading to a new product, service, or feature for the benefit of the participants.” This sounds like the development of knowledge management/sharing mechanisms – for example, a website, etc. Is this to what the metric is referring? |
| This metric does not anticipate any one specific mechanism the QIO should use to demonstrate how its work embodies the spirit of “valuing innovation.” For instance, we expect that under the auspices of the CRISP piece of the SOW, QIOs will continually re-evaluate stakeholder needs through barrier analysis throughout the course of the project, recognizing that communications needs evolve as providers and facilities make clinical gains and need to maintain them. Thus, based on particular stakeholder needs and analyses of the barriers that confront individual projects, websites may or may not be an appropriate mechanism (e.g., low technical literacy groups or nursing home staff who lack regular PC access may find a website less helpful than would state policymakers). |
| 77 |
| Attachment J-10: 10th SOW Measures and Targets, Table 2 – Measure Detail Table, Improve Health for Populations and Communities, General Task Evaluations |
| If the 2010 baseline is reported in claims and all of our work is through PQRS (clinical data), will the CMS Clinical Data Warehouse be able to count the clinical measures AND the claims data in the clinical outcome measures? |
| CMS is not using claims-based utilization measures (a secondary data source for the 9th SOW) for evaluation of this Task. |
| 78 |
| Attachment J-10: 10th SOW Measures and Targets, Table 2 – Measure Detail Table, Improve Individual Patient Care: Quality Reporting and Improving |
| For the % of eligible Hospitals reaching BL Yr 1, what are the 3 and 5 OQR measures that will be used in the QIO evaluation? For the % of eligible Hospitals reaching improving measure rates, what are the 4 OQR measures (from previous year) that will be used in the QIO evaluation? Will there be any measure exclusions? |
| We will use the 7 chart abstracted OQR measures (OP-1 through OP-7) for evaluating QIO performance in this component. |
| 79 |
| Attachment J-10: 10th SOW Measures and Targets, Table 2 – Measure Detail Table, Improve Individual Patient Care: PrU, PR and Systemic Changes |
| Under the Nursing Home Physical Restraint measure, does the target number (<=3%) represent an aggregate average? |
| Please see Q 8. |
| 80 |
| Attachment J-10: 10th SOW Measures and Targets, Table 2 – Measure Detail Table, Improve Individual Patient Care: PrU, PR and Systemic Changes |
| Under the CAUTI Measure, it states: “Percentage of residents who have had an indwelling catheter in the last five days noted on the annual, quarterly, significant change, or significant correction during the selected quarter (three month period).” It does not indicate the denominator or that UTI be noted on the above assessments. Is this measure calculated by indwelling catheter, rather than by whether the indwelling catheter caused UTI? |
| NHSN asks for all of the data elements to be entered to calculate this measure. Facilities will be expected to enter data into NHSN so that this metric can be obtained. |
| 81 |
| Attachment J-10: 10th SOW Measures and Targets, Table 2 – Measure Detail Table, Improve Individual Patient Care: PrU, PR and Systemic Changes |
| Under the CAUTI measure, the target is looking at tracking the catheter utilization ratio. How does this target measure UTI infections given that there is no target measure that looks at the % of residents with a UTI infection? |
| Please see Q 80. |
| 82 |
| Attachment J-10: 10th SOW Measures and Targets, Table 2 – Measure Detail Table, Improve Individual Patient Care: PrU, PR and Systemic Changes |
| Under the Consistent Assignment measure, what does the final 85% target represent and from where did this number come? |
| CMS is reviewing the calculation for this measure. |
| 83 |
| Attachment J-10: 10th SOW Measures and Targets, Table 2 – Measure Detail Table, Improve Individual Patient Care: PrU, PR and Systemic Changes |
| Under the Staff Turnover measure, does the target number (60%) represent an aggregate average? What does this number represent and from where did this number come? |
| CMS is reviewing the calculation for this measure. |
| 84 |
| Attachment J-10: 10th SOW Measures and Targets, Table 2 – Measure Detail Table, Integrate Care for Populations and Communities |
| For the percentage of “proposed communities recruited that have signed community coalition charters and within 3 months,” is 3 months an interim report? Please clarify. |
| Please see Q 2. |
| 85 |
| Attachment J-10: 10th SOW Measures and Targets, Table 2 – Measure Detail Table, Integrate Care for Populations and Communities |
| Does the readmission/admission improvement rate apply to EACH hospital in the community? Or does it apply to the rate of the combined hospitals in the community? |
| CMS will calculate readmission/admission based on the number of Medicare FFS beneficiaries living in the specified community (ies) that have been recruited by the end of Quarter 4. |
| 86 |
| Attachment J-10: 10th SOW Measures and Targets, Table 2 – Measure Detail Table, Integrate Care for Populations and Communities |
| For the statewide readmission/admission improvement rates, do they include both tracks of communities (accepted into a formal care transition program and those that are not accepted)? |
| CMS will calculate state-wide readmission/admission based on the number of Medicare FFS beneficiaries living in the state. |
| 87 |
| Attachment J-10: 10th SOW Measures and Targets, Table 2 – Measure Detail Table, Integrate Care for Populations and Communities |
| How will costs associated with the measures be determined? Will SAS methodology be provided for monitoring? |
| Please see Q 6. |
| 88 |
| J.10 10th SOW Measures and Targets |
| If the 2010 baseline is reported in claims and all of our work is through PQRS (clinical data), will the CMS clinical data warehouse be able to count the clinical measures and the claims data in the clinical outcome measures? |
| Please see question/comment #31 and question/comment #76. |
| 89 |
| J.10 10th SOW Measures and Targets |
| Please provide more detail on the PrU process measure regarding the number of nursing homes using an interdisciplinary and collaborative approach to PrU prevention and care. When is this task expected to be completed? |
| This Task must be completed by the 18th month. |
| 90 |
| J.10 10th SOW Measures and Targets |
| Please provide more detail on the PrU process measure regarding the number of nursing homes using evidence-based practices for the prevention and treatment of PrUs. When is this task expected to be completed? |
| Please see Q 89. |
| 91 |
| J.10 10th SOW Measures and Targets “Percentage of proposed communities recruited that signed community coalition charters and within 3 months” |
| In the statement, “percentage of proposed communities recruited that have signed community coalition charters and within 3 months,” does “within three months” mean within three months of initiation of the contract or within three months of recruitment of the community? |
| Please see Q 2. |
| 92 |
| J 10 attachment |
| How will data be tracked for Pressure Ulcer prevention? |
| CMS is working to provide QIOs and CMS staff with access to PrU rates. |
| 93 |
| J-10 Attachment |
| For NH PR the 18 month target and end target are both </= 3%. Will there be a re-measurement at the end of the project (7-31-14) or is the end target 18 months? |
| QIOs are expected to meet the minimum satisfactory performance threshold for this measure at the 18th month. As with other projects it is expected that improvement will be sustained. |
| 94 |
| J-10, C.7.2.A “Background: Reduce HAIs by 40%” |
| CAUTI 18 month measurement (2-1-13) is tracking of catheter utilization but recruitment for any-cause HAC doesn’t end until 1-31-13. |
| CMS is reviewing this issue. |
| 95 |
| Attachment J-10-Table 2 PQRS - Learning and Action Network Invitation. |
| At least 95% of the REC recruited, installed offices will be invited to participate in learning collaborative (network). Please clarify, 95% of all RECs recruited practices, or from the 22/28 EPs to be recruited by the QIO? |
| For the REC-recruited installed Network task, to meet the minimum satisfactory threshold for this measure, at least 95% of the REC-recruited, installed offices will be invited to participate in a learning collaborative (network) within 3 months of installation (Go-Live date). Additionally, QIOs must successfully meet the minimum performance threshold for the PQRS-E.HR reporting task, which includes a recruitment target which CMS has proposed in J-18 and will be agreed upon during contract negotiation. |
| 96 |
| Attachment J-10 |
| According to information submitted by First Coast Services Options (Medicare Administrative Contractor for the territory of Puerto Rico and U.S. Virgin Islands) to CMS PR Office, by December 2010 in Puerto Rico there are no physicians and or providers participating in PQRS. Can we suggest using meaningful use data to report the measures instead of PQRS in the proposal or do we have to submit a Special Innovation Project Proposal? |
| QIOs with special concerns, such as no or limited PQRI/S EHR reporting may wish to discuss this issue with Contracts in advance. |
| 97 |
| Attachment J-10 |
| Based on our uniqueness, we have the following question: Puerto Rico does not have hospitals currently using the NHSN data collection system. Therefore, we do not have baseline data for CLABSI and CAUTI. Can we change the baseline period in the proposal or do we have to submit a Special Innovation Project to request a change in the baseline period? |
| If your state has CLABSI and/or CAUTI data in another data repository where the measure definitions are compatible with NHSN, that data can be used and entered retrospectively into NHSN |
| 98 |
| J-10, Table 2 |
| Will the denominator for satisfaction surveys for beneficiary complaints and appeals be limited to those complaints and appeals that were referred from the NCC to the local QIO? |
| Yes. |
| 99 |
| J-10, Table 2 |
| Regarding “Percent of communities that can demonstrate 4 time series graphs showing positive trending data (to meet the intervention improvement objective) for 4 unique interventions over 4 quarters.” – Is the denominator for the measure (“The number of communities participating in the Care Transitions learning collaborative.”) the same as the number of target communities stated in Attachment J-23a, “Estimated Level of Effort Assumptions”? |
| Please see Q 4. |
| 100 |
| Attachment J.10 – Improve Health for Populations & Communities |
| Are QIOs expected to go back in time and include all of the REC practices that installed more than 3 months prior to the contract start? |
| Please see question/comment #539. |
| 101 |
| J.10 |
| Who is the target audience for the CAUTI measure? Who is the target for the consistent assignment and staff retention measure? The assumptions we were given is for 51 minimum for nursing home and restraints. Is this the outcomes of the learning an action network? |
| CMS is reviewing this issue. |
| 102 |
| Attachment J-10 |
| Where will the QIO get cost information? |
| Please see Q 6. |
| 103 |
| Attachment J-10 |
| Is cost going to be based on submitted claims or actual paid amounts. |
| Please see Q 6. |
| 104 |
| J-10 |
| As there is no publically reported or other known measure of “administrative turnover,” what is the source of and/or the basis for the baseline and ongoing measures? |
| Please see Q 12 and 22. |
| 105 |
| J-10- 10th SOW Measures and Targets, Table 1. Qualitative and Quantitative Evaluation Metrics |
| Please confirm that the qualitative and quantitative measures delineated in Table 1 apply to the Beneficiary and Family Centered Care Aim, in addition to the measures delineated in Table 2, Measure Detail Table. |
| Some of the measures may not apply. Example, commitments, secured participants engagements while others certainly apply such as having a customer focus and commitment to boundarilessness. |
| 106 |
| Attachment J-10 – Table 1 – Qualitative and Quantitative Evaluation Metrics |
| The table lists several qualitative metrics. Who determines whether a QIO has passed a qualitative metric? Will the QIO have an opportunity to summarize to that evaluator how it has made midcourse adjustments, addressed sustainability, solicited new ideas, used customer feedback, used rapid cycle improvements, and shared unconditionally with other QIOs? |
| CMS will review all documentation submitted by the QIO related to all qualitative metrics. |
| 107 |
| Attachment J-10 – Table 2 – Measure Detail Table |
| The table indicates that the satisfaction metric in the 10th SOW is satisfaction with beneficiary complaints and appeals. Appeals satisfaction has not been evaluated previously. Has CMS considered splitting these into two separate metrics to better understand satisfaction with complaints, and satisfaction with appeals? Has CMS considered whether a 90% final target is realistic for appeals, or particularly reflective of the QIO’s performance? The encounter with the patient/family will begin with the NCC’s centralized intake staff, and the interaction with the QIO’s staff will be quite brief, given the lack of an intake role and rapid timelines. Appeals do not have the same opportunity as quality of care complaints for staff to establish a longitudinal relationship with the patient/family representative. It may be difficult for the patient/family to separate their dissatisfaction with the decision regarding readiness for discharge to a lower setting of care, which has immediate financial and logistic implications for them, from their perception of customer service in the process. |
| Yes, CMS wants to assess beneficiary satisfaction across all review types as well as to eventually assess the cost per review. You are correct that the NCC may be the first point of contact (as always, Beneficiaries may enter the process from different referral points including the QIO itself) and as such plays an integral role in meeting the beneficiaries’ expectations. As unconditional teamwork and boudarilessness is an expectation for both the QIO and the NCC, it is expected that both entities will work together to ensure a satisfactory experience for the beneficiary. CMS sets a 90% target for the satisfaction measure. |
| 108 |
| Attachment J-10 – Table 2 – Measure Detail Table |
| PQRS-EHR Reporting Outcome 2 states that the number of eligible professionals that participate in PQRS by direct EHR-reporting will increase by 1.25*[QIO state target], as compared to 2010 PQRI participation. To be clear, can CMS confirm that the goal is to increase the number of organizations reporting by the EHR method from 2010 to 2012? If so, since the EHR-based reporting did not begin until 2011, would it be correct that the baseline number of eligible professionals reporting via the EHR-based method for all states from 2010 is 0? If that is not correct, please explain. |
| CMS is proposing for evaluation of PQRS-EHR Reporting outcome 2, the QIO achieve at least 1.25*minimum state target in J-18 as the number of eligible professionals that participate in PQRS by EHR-reporting in 2012. It is expected that the baseline will be a very low number for each state. |
| 109 |
| Attachment J-10 – Table 2 – Measure Detail Table |
| The General Task Evaluation metrics for C.9 appear to compare 2010 PQRI claims-based reporting in a given state to the 2012 PQRS EHR-based reporting. Is that correct? Or, is it possible that the intent is to compare the 2010 PQRI claims-based reporting to the 2012 PQRS claims-based reporting? If so, that would come from an entirely different group of practices than the QIO has been working with to support EHR-based reporting. Or, to compare the metric for all organizations who reported it, regardless of how it is submitted? What data is being compared to PQRI 2010 claims-based reporting for a given measure? It is very important to clarify which professionals’ performance will be included in the overall task evaluation. |
| For the General Task Evaluation measures, QIOs will be evaluated using the PQRS (PQRI) claims-based reporting. Different eligible professionals may report during the baseline than during the remeasurement time periods. See also question/comment #661. |
| 110 |
| Attachment J-10 – Table 2 – Measure Detail Table |
| Will the QMHAG/contractor (the named data source for the General Task Evaluation metrics for C.9) provide monthly or quarterly reports to the QIO to indicate which organizations are reporting via claims, via a registry, or via the EHR, and the baseline performance and performance in subsequent periods? When and how will the baseline data be shared? |
| CMS (and its contractors) will not be providing reports on which organizations are reporting via which methods. State-specific performance rates of the General Task Evaluation measures (baselines) will be shared as soon as they are available. |
| 111 |
| Attachment J-10 – Table 2 – Measure Detail Table |
| J-10 Table 2 indicates that it is a contract target that 90% of CAHs report IQR and OQR data by the 18th month, and 95% by the final evaluation. Please define “report”. Is the goal that they report at least one measure, of their choosing, in at least one quarter? If they select a measure, but ultimately have less than 5 cases to report, would that still count? Could the CAH document that it does not wish to report, and exclude itself from the denominator for this measure? Is the fact that the data source is the preview file an indication that the hospital can report, but choose not to suppress after preview? |
| At least one successfully submitted case in at least one of the chart abstracted measures in at least one quarter |
| 112 |
| Attachment J-10 – Table 2 – Measure Detail Table |
| The three metrics related to reaching baseline year national median for OQR on p.12 and 13 – are these for PPS hospitals only? The first measure of this kind appears to identify the proportion of hospitals who reach (or exceed) the baseline median for at least 5 measures of OQR, with a target of 40% for CY 2011. The second measure of this kind appears to identify the proportion of hospitals who reach (or exceed) the baseline median for at least 3 measures of OQR, with a target of 20% for CY2011. Are these two versions of the same metric (with the second less stringent) that CMS is still evaluating? Please clarify the purpose of these measures, and how they are different. |
| These are three distinct metrics for eligible PPS subsection (d) hospitals rewarding (1) achievement of national median, (2) achievement of national high benchmark performance levels, and (3) improvement at all baseline levels of performance. |
Achieving national median performance rewards performance for more hospitals achieving median levels of performance (i.e., increasing number of hospitals achieving and surpassing baseline national median of hospitals, thereby improving median of quality curve forward)
Achieving national benchmark performance rewards performance for more hospitals achieving exceptionally high levels of performance (i.e., more hospitals pushing frequency of hospitals in high tail end of quality curve forward)
Improving performance rewards all hospitals, regardless of baseline position on the quality curve for improving quality of care.
In tandem, these three metrics strive to reward QIO’s for improving quality of care for all eligible hospitals in their state, regardless of baseline performance level.
| 113 |
| Attachment J-10 – Table 2 – Measure Detail Table |
| For the ADE metrics, the goal appears to be to improve above a baseline (established between Nov 1, 2011 and April 30, 2012). However, Section C.7.3.B (p.40) indicates that recruitment is to occur on a rolling basis throughout the scope of work. Must all participants be recruited by Nov 1, 2011 so that they can begin collecting their baseline? J-10 table 3 (p. 35) suggests that by Jan 31, 2013 the QIO needs one newly QIO-formed community team, and a total of 5 teams (including teams not formed by the QIO). What are the actual recruitment targets? Is the evaluation only conducted on those teams joining by Nov 1, though the QIO is expected to continue to recruit? Are teams that join after April 30, 2012 required to construct a retrospective baseline for Nov 11 – Apr 12? |
| CMS understands there are existing community teams. Therefore, the QIO is expected to form at least one new team on its own by the 18th month evaluation. By the 27th month evaluation, the QIO is expected to have formed two new teams by the 27th month. |
| 114 |
| Attachment J-10 – Table 2 – Measure Detail Table |
| The table lists the baseline time period for the CLABSI and CAUTI metrics. What are the re-measurement time periods that will be used to calculate the intermediate and final evaluations? |
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