HRS Submits Comments to Inform CMS 2021 Quality Programs

HRS commented that the inclusion of the Hospital-Wide, 30-Day, All-Cause Unplanned Readmission Rate for the Merit-Based Incentive Payment Program (MIPS) may be useful at the community or population level but is not appropriate to attribute this utilization to an individual physician or practices. The Society's comments are:

Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment Program (MIPS) Eligible Clinician Groups

The Heart Rhythm Society (HRS) does not support inclusion of the Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment Program (MIPS) Eligible Clinician Groups measure in the MIPS program. While these administrative claims measure may be useful at the community or population level, it is not appropriate to attribute this utilization to an individual physician or practices. HRS expressed several concerns regarding this measure during the recent NQF endorsement review. There is insufficient evidence provided to support attribution of the measure to physicians or practices in the absence of some coordinated program or targeted intervention led by the health system or hospital. Assignment of responsibility of the reduction of readmissions to multiple physicians and practices in MIPS is not appropriate and there is insufficient information to support the attribution of this measure to up to three physicians or practices.

Furthermore, the measure score reliability results were too low when based on the minimum case number of 25 patients, and higher minimum acceptable thresholds such as 0.80 should be required. The conceptual basis used to explain which social risk factors were tested was inadequate and additional testing is needed to evaluate clinical factors in conjunction with social risk factors, as well as the impact that the inclusion of these factors had on the absolute change of the rates. Further testing also is needed to demonstrate how the measure would perform under the MIPS benchmark methodology and Physician Compare Star Ratings as CMS utilizes two different methodologies for ranking and profiling physicians. This measure has not yet been endorsed by NQF due to concerns over the reliability of the measure as specified. Considering these concerns, HRS recommends that the highest level of MAP recommendation should be “Do Not Support”.