Comment On Proposed Medicare/Medicaid Electronic Clinical Quality Measures Changes

Patients, caregivers, employer and other health plan sponsors and consultants, health care providers, lawmakers hear a lot about health care quality; however, few understand the quality data and measures relied upon by parties making health care quality claims.

While quality measures and meanings take many forms drawn for various sources, Medicare, Medicaid and many other health plans, health quality assessors rely upon the Department of Health and Human Services Office of the National Coordinator for Healthcare Information (“ONC”) electronic clinical quality measures (“eCQMs”).

As part of its quality initiatives, the Centers for Medicare & Medicaid Services (“CMS”) requires many Medicare and Medicaid participating health care providers to report to maximize reimbursement eligility or other purposes.

Every Fall, health care providers, health plans and insurers and other stakeholders concerned about these eCQMs can review and comment on changes to the eCQM specifications and supporting resources proposed by ONC as part of ONC’s annual Change Review Process (CRP) for the ONC Project Tracking System. Interested stakeholders must monitor the posting of issues and act quickly to share their feedback, however, as stakeholders have only two weeks to comment after a ONC posts a new proposed eCQm change.

eCQMs As Measure of Health Care Quality

Electronic clinical quality measures or “eCQMs” are tools that ONC develops with stakeholder input to help Medicare and Medicaid measure and track the quality of health care services that eligible hospitals and critical access hospitals (CAHs) provide, as generated by a provider’s electronic health record (EHR). CMS Measuring and reporting eCQMs helps to ensure that our health care system is delivering effective, safe, efficient, patient-centered, equitable, and timely care. CMS’ eCQMs measure many aspects of patient care, including:

  • Patient and Family Engagement
  • Patient Safety
  • Care Coordination
  • Population/Public Health
  • Efficient Use of Healthcare Resources
  • Clinical Process/Effectiveness

To successfully participate in the Medicare and Medicaid Promoting Interoperability Programs, the Centers for Medicare and Medicaid Services (“CMS”) requires eligible providers, eligible hospitals, critical access hospitals and dual-eligible hospitals electronically to report on eCQMs determined by CMS that require the use of data from the provider’s certified electronic health record (“EHR”) technology (CEHRT) or other health information technology systems to measure and report quality measures in a standardized manner. For calendar year (CY) 2022, Medicare Promoting Interoperability Program participants are required to report on three self-selected eCQMs and the Safe Use of Opioids – Concurrent Prescribing eCQM from the set of nine available for at least three self-selected quarters of CY 2022 data. To report eCQMs successfully, health care providers must use an EHR and adhere to the requirements identified by the CMS quality program. Failing to meet these eCQM reporting requirements can prevent the provider from meeting meaningful use requirements and trigger reductions in reimbursements for care.

Health care quality, credentialing, accreditation, and other provider, health plan and other organizations also use the eCQMs data alone or with other quality measures and tools to set standards and assess and enforce quality goals and performances.

As the proposed changes on a relevant eCQM could materially impact the reporting responsibilities of the reporting providers, the quality and meaning of a proposed data measure, or both, impacted stakeholders should monitor the system for possible changes impacting the eCQMs used or applicable to their organizations and its activities and if appropriate, comment promptly.

2022 eCQMs Updates

Each year, CMS makes updates to the eCQMs approved for CMS programs to reflect changes in:

  • Evidence-based Medicine
  • Code Sets
  • Measure Logic

Conducted annually as part of OCN’s eCQM Issue Tracker project, the CRP provides eCQM users the opportunity to review and comment on draft changes to the eCQM specifications and supporting resources under consideration by the measure stewards. The goal of the CRP is for eCQM implementers to comment on the potential impact of draft changes to eCQMs so CMS and measure stewards can make improvements to meet CMS’s intent of minimizing provider and vendor burden in the collection, capture, calculation, and reporting of eCQMs. 

Stakeholders with an account on the ONC Project Tracking System can monitor, review and comment on proposed eCQM changes through the eCQM Issue Tracker project during the two week period following the date the issue is posted in the eCQM Issue Tracker. To participate in the CRP, users must have an ONC Project Tracking System account. New users can create an account via the ONC Project Tracking System website.

The following table reflects the eCQM issues open on the eCQM Issue Tracker as of September 14, 2022 and their scheduled comment closing dates

Issues Open for Public Comment As of 9/14/2022

CMS eCQM Identifier and Measure TitleCRP Issue TitleIssue Number and LinkIssue TypeGoal of ReviewPublic Comment Open DatePublic Comment Close Date
Multiple measuresIncorporate ‘Diagnosis’ datatype to capture Hospice CareCQM-5561Logic; Value SetObtain clinical and technical feedback09/07/202209/21/2022
CMS128: Anti-depressant Medication Management; CMS136: Follow-Up Care for Children Prescribed ADHD Medication (ADD); CMS156: Use of High-Risk Medications in Older AdultsUpdate Cumulative Medication Duration function to calculate maximum daily frequencyCQM-5562LogicObtain technical feedback09/07/202209/21/2022
Multiple measuresExpand codes using ‘Diagnosis’ datatype to capture Palliative CareCQM-5563Logic; Value SetObtain clinical and technical feedback09/07/202209/21/2022
Multiple measuresRequire 2 indications of frailty to meet exclusionCQM-5564Header; Logic; Measure Intent ClarificationObtain clinical feedback09/07/202209/21/2022
CMS127: Pneumococcal Vaccination Status for Older AdultsExpand numerator to allow for pneumococcal vaccination since 19 years of ageCQM-5565Header; Logic; Measure Intent ClarificationObtain clinical feedback09/07/202209/21/2022

eCQM Issue Tracker Open Issues As Of September 14, 2022

As proposed eCQM changes are posted for public comment as CRP issues. ONC informs eCQM accountholders of the proposed change or eCQM issue by posting for review in the ONC Project Tracking System. Accountholders only have two weeks after ONC posts a proposed eCQM to comment on the posted issue. Stakeholders interested in commenting on a particular issue must submit their comment in accordance with the directions within this two-week period.

Parties interested in providing input that miss the required time for response should plan ahead to respond during the next annual comment period. Other avenues of input also sometimes are available. However, responding through the designated procedure is the best way to ensure your input receives consideration.

More Information

We hope this update is helpful. For more information about the these or other health or other legal, management or public policy developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297

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About the Author

Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for 30+ years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications.

A Fellow in the American College of Employee Benefit Counsel, Vice Chair of the American Bar Association (“ABA”) International Section Life Sciences and Health Committee, Past Chair of the ABA Managed Care & Insurance Interest Group, Scribe for the ABA JCEB Annual Agency Meeting with HHS-OCR, past chair of the the ABA RPTE Employee Benefits & Other Compensation Group and current co-Chair of its Welfare Benefit Committee, Ms. Stamer is most widely recognized for her decades of pragmatic, leading edge work, scholarship and thought leadership on health and managed care industry legal, public policy and operational concerns. 

Ms. Stamer’s work throughout her 30 plus year career has focused heavily on working with health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns. 

For more information about Ms. Stamer or her health industry and other experience and involvements, see or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here

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