In my column posted on 11/4/22 … PB #29, “Medicare Quality
Measures, Part l” … I wrote about a “quest” I was on to see if Medicare would consider
making a doctor’s referral of an AD patient or caregiver to a support group
qualify as a “quality measure.” To
briefly review, in response to my June article about support groups, a doctor
had suggested that more doctors might refer AD patients and caregivers to
support groups if referrals were considered Medicare “quality measures” …
actions that would result in financial or other incentives for doctors to make
such referrals. I then described my
unsuccessful efforts to reach someone at CMS … Centers for Medicare and
Medicaid Services … who could give me information about this matter. No email address was available for the head
of CMS, Chiquita Brooks-LaSure, and no one contacted at CMS would give me her
email address.
In late December, tired of waiting for a response from Medicare
administrators I was able to email, I decided to try a hunch and sent an email
to the head of CMS by using the same ID characteristics of email addresses for
the lower level CMS administrators … first and last names or initials with periods
and such, followed by the CMS email string of cms.hhs.gov. Much to my surprise, within one day I
received a detailed response from a high ranking CMS official who said my email
to Brooks-LaSure was referred to him.
Aside from being very helpful, the official also provided me with
websites to find additional information and wrote, in part:
“I directed your most recent email to
our group of experts on quality measures, called the Quality Measurement and
Value-Based Incentives Group (QMVIG) within the Center for Clinical Standards
and Quality (CCSQ). You have definitely gotten to the right place to make sure
your input is being submitted and that you’re getting the information from the
best source. I checked before I left for
the holiday last week, and they were about to get back to you. So you should hear from them soon. I’ll follow up there again, and I’m sure they
will respond back more fully with more robust information but … there are
potentially payment incentives for our quality programs.”
I was very excited with this response
and followed up by reading information on websites provided by the senior advisor. However, a month went by with no response
from QMVIG, so I wrote again to the CMS official in Ms. Brooks-LaSure’s office. Within 48 hours I received a detailed
response from an administrator of QMVIG.
Here are excerpts of that response to my email, specifically to three
questions I raised:
“1. Would there be a specific billing or reimbursement advantage for doctors who would report using such a Medicare quality measure? Potentially. Quality measures are commonly used in quality reporting programs or value based purchasing programs which seek to revise our payment systems by focusing on high value care (high quality/low cost). Depending upon the care setting, a program may apply penalties or bonuses based on provider performance on quality metrics. Some areas where Medicare does have payment is on caregiver health risk assessment through CPT code 96161. Additionally, through Medicare’s cognitive assessment and care plan services CPT code 99483, clinicians can refer people with suspected or diagnosed dementia to social services (such as support groups) and determine caregiver willingness to furnish care: https://www.cms.gov/files/document/cognitive-assessment-care-plan-services-cpt-code-99483.pdf
2. Would there be any other
specific advantage to doctors who would report using such a Medicare quality
measure? Other advantages include the
ability to share performance information on measures with the public, which can
be used as consumer tools when selecting a provider and leveraging results of
quality measurement to identify areas where there is room for quality care
improvement.
3. If the answer to
questions 1 and/or 2 is yes, what would be my next step in trying to have
Medicare consider AD support group referrals as "quality measures."
It is a long process to have something be
considered for a quality measure, and usually involves having a measure
developer who has experience developing a measure – as quality measures used in
federal programs require strict definitions, specifications, and testing for
validity and reliability. However any measure by any developer may be submitted
to CMS for consideration. Please see the Measure Blueprint for more information
on this process (https://mmshub.cms.gov/blueprint-measure-lifecycle-overview). The measure would then be submitted to a
consensus-based entity for endorsement, such as the National Quality Forum (https://www.qualityforum.org/what_we_do.aspx). The measure ultimately needs to be submitted to the Measures
Under Consideration list. Information on the pre-rulemaking process can be
found here https://mmshub.cms.gov/Pre-Rulemaking-Resources.”
My initial response to this
administrator’s email, which also included a lot more relevant information, was
that the CMS bureaucratic process for something to become a Medicare “quality
measure” was a navigational process beyond my capabilities. After checking out the websites and
familiarizing myself more with the bureaucratic hoops I’d have to go through to
make my quest successful, my initial response was confirmed. I emailed the QMVIG administrator telling her
that I now planned to contact an advocacy organization with the resources and
expertise to deal with the CMS bureaucracy …perhaps AARP, The Alzheimer’s
Association, or UsAgainstAlzheimer’s … since, as the administrator noted, “it is
a long process to have something be considered for a quality measure, and
usually involves having a measure developer who has experience developing a measure.”
My experience with educational and
non-profit organizations is that they almost always hire or already have on
staff one or more specialized individuals with the precise experience necessary
in order to apply for state or federal grants in their field, and this quality
measure quest seems to be much like a state or federal grant application process. I would expect a large AD advocacy
organization to have people with such experience.
I plan to forward what I have
learned to one or more AD advocacy organizations and hope one of them will
pursue this quest to have CMS recognize doctor referrals to AD support groups
as quality measures. Then, perhaps, more
people with AD and their caregivers will learn more about support groups and
benefit from attending such groups.
