News and Updates for Healthcare Professionals

Dr. David Meyers, M.D., AHRQ’s chief medical officer, recognizes the importance of February as Heart Health Month while highlighting important contributions made by AHRQ’s EvidenceNow initiative. AHRQ is working with more than 1,500 primary small- and medium-size care practices to help improve the delivery of services proven to prevent heart attacks and strokes. These include the “ABCS” of heart health – Aspirin use by high-risk individuals,Blood pressure control, Cholesterol management, and Smoking cessation. Dr. Meyers’ blog post describes examples of project successes, including expanded use of medications to prevent heart disease, more effective use of blood pressure measurement among patients at risk for heart attack or stroke, and increased use of smoking cessation counseling. AHRQ’s contributions to heart health are in alignment with the Million Hearts® initiative, a national effort to control risk factors for heart disease, the nation’s number one killer.

Azar: Plans to reduce high drug costs reflect President’s deep commitment to issue

Health and Human Services Secretary Alex Azar issued the following statement today on President Trump’s Fiscal Year 2019 Budget:

“The President’s budget makes investments and reforms that are vital to making our health and human services programs work for Americans and to sustaining them for future generations. In particular, it supports our four priorities here at HHS: addressing the opioid crisis, bringing down the high price of prescription drugs, increasing the affordability and accessibility of health insurance, and improving Medicare in ways that push our health system toward paying for value rather than volume.

“This budget supports the hard work the men and women of HHS are already doing toward these goals. In particular, the budget’s efforts to reduce the high cost of prescription drugs, especially for America’s seniors, are a reflection of President Trump’s deep commitment to addressing this important issue.”

National Institutes of Health scientists developing a rapid, practical test for the early diagnosis of prion diseases have modified the assay to offer the possibility of improving early diagnosis of Parkinson’s disease and dementia with Lewy bodies. The group, led by NIH’s National Institute of Allergy and Infectious Diseases (NIAID), tested 60 cerebral spinal fluid samples, including 12 from people with Parkinson’s disease, 17 from people with dementia with Lewy bodies, and 31 controls, including 16 of whom had Alzheimer’s disease. The test correctly excluded all the 31 controls and diagnosed both Parkinson’s disease and dementia with Lewy bodies with 93 percent accuracy.

The Human Genome Project has been awarded the 2017 Prince Mahidol Award for ground-breaking advances in the field of medicine. The award will be received on behalf of the project by Eric Green, M.D., Ph.D., director of the National Human Genome Research Institute (NHGRI), part of the National Institutes of Health, and the institute responsible for leading NIH’s effort in the project.

COPD, a progressive disease that makes it hard to breathe, is the fourth leading cause of death in the United States.

Diet helps people prevent and treat high blood pressure, lower blood cholesterol.

NIH-supported study could lead to better approaches for treating insomnia, other sleep disorders.

Today, the Centers for Medicare & Medicaid Services (CMS) finalized the cancellation of the mandatory hip fracture and cardiac bundled payment models that were to be operated by the CMS Innovation Center and implemented changes to the Comprehensive Care for Joint Replacement (CJR) Model. These changes will offer greater flexibility and choice for hospitals in providing care to Medicare patients.

“While CMS continues to believe that bundled payment models offer opportunities to improve quality and care coordination while lowering spending, we believe that focusing on developing different bundled payment models and engaging more providers is the best way to drive health system change while minimizing burden and maintaining access to care. We anticipate announcing new voluntary payment bundles soon,” said CMS Administrator Seema Verma.

In the final rule, CMS is reducing the number of mandatory geographic areas participating in CJR from 67 areas to 34 areas. As part of the agency’s ongoing commitment to addressing the unique needs of rural providers, CMS is also making participation voluntary for all low volume and rural hospitals participating in the model in all 67 geographic areas. This regulation also includes an Interim Final Rule with Comment Period, in which CMS is establishing and seeking comment on a final policy to provide flexibility in determining episode costs for participant hospitals located in areas impacted by extreme and uncontrollable circumstances, such as the major hurricanes of 2017.

CMS is also finalizing the cancelation of the hip fracture and cardiac bundled payment and incentive payment models – the Episode Payment Models and the Cardiac Rehabilitation Incentive Payment Model – that were scheduled to begin on January 1, 2018. Not pursuing these models gives CMS greater flexibility to design and test innovations that will improve quality and care coordination across the in-patient and post-acute care spectrum.

Moving forward, CMS expects to increase opportunities for providers to participate in voluntary initiatives rather than large mandatory bundled payment models. The changes in the final rule will help position the agency to engage in future voluntary efforts.

For a technical fact sheet on the changes in this final rule and interim final rule with comment period, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-30.html.

For more information on the Comprehensive Care for Joint Replacement Model, please visit: https://innovation.cms.gov/initiatives/cjr.

The final rule and interim final rule with comment (CMS-5524-F and IFC) can be downloaded from the Federal Register at https://www.federalregister.gov/public-inspection.

To determine optimal doses, routes of administration, and dosing strategies of naloxone for suspected opioid overdose in out-of-hospital settings, and whether transport to a hospital following successful opioid overdose reversal with naloxone is necessary.

The new high blood pressure guidelines illustrate the utility and impact of NHLBI scientific studies.

Five primary care practices participating in AHRQ’s EvidenceNOW project have been named as 2017 Million Hearts® Hypertension Control Champions. The award winners – three in New York, one each in Oklahoma and Wisconsin – are among 24 honorees that include primary care practices, individual clinicians and health systems. The honorees were recognized for achieving blood pressure control for at least 70 percent of their patients through innovations in health information technology and electronic health records, patient communication, and teamwork. EvidenceNOW, launched in May 2015, provides support services to 1,500 small and medium primary care practices with the objective of improving patients’ blood pressure and addressing other risk factors to improve heart health.

By: Christopher M. Jones, PharmD, MPH and Vanila M. Singh, MD, MACM

Over the past 15 years, communities across America have been devastated by increasing prescription and illicit opioid abuse, addiction, and overdose.

In 2016, 11 million Americans misused prescription opioids, nearly 1 million used heroin, and 2.1 million had an opioid use disorder due to prescription opioids or heroin. And every day, an estimated 90 Americans die from an opioid overdose—resulting in more than 300,000 deaths since 2000. Meanwhile, an estimated 25 million Americans experience pain every day. For many of these individuals, this pain interferes with their physical and mental health, work productivity, and ability to engage in social activities.

Primary care clinicians are often the first to see older adults with memory loss or other signs of cognitive impairment. Three brief, online guides from NIA can help healthcare providers assess, manage, and support their patients with memory complaints or impairment:

• Assessing Cognitive Impairment in Older Patients: A Quick Guide for Primary Care Physicians — read about the benefits of early screening and learn how to screen quickly and accurately.
• Managing Older Patients with Cognitive Impairment: A Quick Guide for Primary Care Physicians — get practical advice on planning and care strategies for patients with mild cognitive impairment, Alzheimer’s, or a related dementia.
• Now What? Next Steps After a Diagnosis of Alzheimer’s Disease — give this checklist of resources and referrals to newly diagnosed patients. Available in English and Spanish.

The Effective Health Care Program has posted the following on its Web site:

Draft Report
This draft report is available for comment until November 15, 2017.

Final Report
Understanding Health-Systems’ Use of and Need for Evidence To Inform Decisionmaking

Twelve specialized research centers designed to conduct multidisciplinary research, research training, and community engagement activities focused on improving minority health and reducing health disparities will launch. The centers, to be funded by the National Institute on Minority Health and Health Disparities (NIMHD), part of the National Institutes of Health, will share approximately $82 million over five years, pending the availability of funds.

Joint HHS-DoD-VA initiative will award multiple grants totaling $81 million.

The American Diabetes Association (ADA) has released a position statement to update the assessment and treatment of hypertension among patients with diabetes.

The position statement, published in Diabetes Care, includes advances in care since the ADA last published a statement on this topic in 2003. The ADA notes that antihypertensive therapy is shown to reduce atherosclerotic cardiovascular disease (ASCVD) events, heart failure, and microvascular complications in patients with diabetes. There have also been reductions in ASCVD morbidity and mortality in patients with diabetes since 1990, which are likely due to improvements in blood pressure control.

“Treatment should be individualized to the specific patient based on their comorbidities; their anticipated benefit for reduction in ASCVD, heart failure, progressive diabetic kidney disease, and retinopathy events; and their risk of adverse events,” according to the ADA. “This conversation should be part of a shared decision-making process between the clinician and the individual patient.”

The ADA has made the following recommendations:

Screening and diagnosis

• Clinicians should measure blood pressure at every routine clinical care visit. Patients with elevated blood pressure ?140/90 mmHg should have blood pressure confirmed with multiple readings to diagnose hypertension (Grade B recommendation).
• Hypertensive patients with diabetes should have home blood pressure monitoring to identify white-coat hypertension (Grade B recommendation).
• Orthostatic measurement of blood pressure should be performed during initial evaluation of hypertension and periodically at follow-up, or when symptoms of orthostatic hypotension are present, and regularly if orthostatic hypotension has been diagnosed (Grade E recommendation).

Blood pressure targets

• The systolic blood pressure goal should be <140 mmHg, and the diastolic blood pressure goal should be <90 mmHg for most individuals with diabetes and hypertension (Grade A recommendation).
  Lower systolic and diastolic blood pressure targets may be appropriate for those with high risk of cardiovascular disease if they can be achieved without excessive treatment burden (Grade B recommendation).

Lifestyle management

• Lifestyle intervention for those with systolic blood pressure >120 mmHg or diastolic blood pressure >80 mmHg consists of weight loss if overweight or obese; a Dietary Approaches to Stop Hypertension (DASH)-style dietary pattern; increased fruit and vegetable consumption; moderation of alcohol intake; and increased physical activity (Grade B recommendation).

Pharmacologic antihypertensive treatment

• Patients with confirmed blood pressure ?140/90 mmHg should have timely titration of pharmacologic therapy to achieve blood pressure goals, in addition to lifestyle therapy (Grade A recommendation).
• Patients with confirmed blood pressure ?160/100 mmHg should have prompt initiation and timely titration of 2 drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes, in addition to lifestyle therapy (Grade A recommendation).
• Treatment should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes. These include ACE inhibitors, angiotensin receptor blockers (ARBs), thiazide-like diuretics, or dihydropyridine calcium channel blockers. Multiple-drug therapy is generally required to achieve blood pressure targets (Grade A recommendation).
• An ACE inhibitor or ARB is the recommended first-line treatment for hypertension in patients with diabetes and urine albumin-to creatinine ratio ? 300 mg/g creatinine (Grade A recommendation) or 30–299 mg/g creatinine (Grade B recommendation). If one class is not tolerated, the other should be substituted. (Grade B recommendation).
• Serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored in patients treated with an ACE inhibitor, ARB, or diuretic (Grade B recommendation).

The following new item has been posted: Providing a State-by-State Picture of the Nation’s Opioids Crisis

The following new item has been posted: Advances in Patient Safety and Medical Liability.

Today, as part of our continuing commitment to greater data transparency, Centers for Medicare & Medicaid Services (CMS) unveiled the Hospice Compare website. The site displays information in a ready-to-use format and provides a snapshot of the quality of care each hospice facility offers to its patients. CMS is working diligently to make healthcare quality information more transparent and understandable for consumers to empower them to take ownership of their health. By ensuring patients have the information they need to understand their options, CMS is helping individuals make informed healthcare decisions for themselves and their families based on objective measures of quality.

“The Hospice Compare website is an important tool for the American people and will help empower them in a time of vulnerability as they look for information necessary to make important decisions about hospice care for loved ones,” said CMS Administrator Seema Verma. “The CMS Hospice Compare website is a reliable resource for family members and care givers who are looking for facilities that will provide quality care.”

Hospice facilities offer specialized care and support to individuals with a terminal illness and a prognosis of six months or less if the illness runs its normal course. Once a patient elects hospice care, the focus shifts from curative treatment to palliative care for relief of pain and symptom management, and care is generally provided where the patient lives. Additionally, caregivers can get support through the hospice benefit, such as grief and loss counseling. Hospice Compare helps patients and caregivers find hospice providers in their area and compare them on quality of care metrics.

Section 1814(i)(5) of the Social Security Act authorizes a quality reporting program for hospices. The Act requires hospice providers to report data to CMS on a number of quality measures selected through notice and comment rulemaking. The Hospice Quality Reporting Program (HQRP) includes both quality data from the Hospice Item Set (HIS) and Hospice Consumer Assessment of Healthcare Providers and Systems (Hospice CAHPS®).

The Hospice Compare site allows patients, family members, caregivers, and healthcare providers to compare hospice providers based on important quality metrics, such as the percentage of patients that were screened for pain or difficult or uncomfortable breathing, or whether patients’ preferences are being met. Currently, the data on Hospice Compare is based on information submitted by approximately 3,876 hospices.

The Hospice Compare website will reflect current industry best practices for consumer-facing websites and will be optimized for mobile use. For more information, please visit https://www.medicare.gov/hospicecompare/ to view the new Compare site.

The Effective Health Care Program is pleased to announce the launch of its newly redesigned Web site today, Friday, August 11, 2017. The Web site’s address remains the same: https://effectivehealthcare.ahrq.gov. All of your bookmarks will continue to work.

The new design offers streamlined menus, clear navigation, improved search capabilities, and a responsive layout that works on all your devices.

The Web site offers these new navigation features –

• “Health Topics” – organizes EHC Program products by categories such as demographic groups and condition.
• “Consumers” – lists all of the consumer summaries and patient decision aids on one page.
• “Products & Tools” – offers quick access to EHC Program reports, shared decisionmaking tools, and professional education resources.
• “Research Methods” – provides guidance, methods, and tools to support systematic reviews as well as research using registries.
• “Get Involved” – presents ways to participate in EHC Program research by suggesting topics, commenting on research in development, and submitting scientific data.
• “Product Search” – helps to more easily find reports using faceted searching.

On July 24, the Centers for Medicare & Medicaid Services (CMS) distributed an email update with an explanation for its special status calculation for the Quality Payment Program. The message incorrectly stated that clinicians considered to have “special status” would be exempt from the Quality Payment Program.

Special status affects the number of total measures, activities, or entire categories that an individual clinician or group must report. Individual clinicians or groups with special status are not exempt from the Quality Payment Program because of their special status determination.

To determine if a clinician’s participation should be considered special status under the Quality Payment Program, CMS retrieves and analyzes Medicare Part B claims data. Calculations are run to indicate a circumstance of the clinician’s practice forwhich special rules would apply. These circumstances are applicable for clinicians in: Health Professional Shortage Area (HPSA), rural, non-patient facing, hospital-based, and small practices.

For more information, please visit the Quality Payment Program website.

Join CMS for an office hours session on Wednesday, August 16 on the draft provisions included in the Quality Payment Program Year 2 Notice of Proposed Rulemaking (NPRM). CMS will provide a brief overview of the Quality Payment Program and address questions from attendees on the Year 2 NPRM.

Webinar Details

Title: Quality Payment Program Year 2 NPRM Office Hours Session
Date: August 16
Time: 12 – 1 pm ET

Space for this webinar is limited. Register now to secure your spot. After you register, you will receive a follow-up e-mail with step-by-step instructions about how to log-in to the webinar.

For More Information

CMS encourages participants to review the proposed rule,
press release, and fact sheet prior to the webinar. Additional resources are also available on the website.

The Quality Payment Program Hardship Exception Application for the 2017 transition year is now available on the Quality Payment Program website.

MIPS eligible clinicians and groups may qualify for a reweighting of their Advancing Care Information performance category score to 0% of the final score, and can submit a hardship exception application, for one of the following specified reasons:

• Insufficient internet connectivity
• Extreme and uncontrollable circumstances
• Lack of control over the availability of Certified EHR Technology (CEHRT)

There are some MIPS eligible clinicians who are considered Special Status, who will be automatically reweighted (or, exempted in the case of MIPS eligible clinicians participating in a MIPS APM) and do not need to submit a Quality Payment Program Hardship Exception Application.

About the Hardship Exception Application Process

In addition to submitting an application via the Quality Payment Program website, clinicians may also contact the Quality Payment Program Service Center and work with a representative to verbally submit an application.

To submit an application, you’ll need:

• Your Taxpayer Identification Number (TIN) for group applications or National Provider Identifier (NPI) for individual applications;
• Contact information for the person working on behalf of the individual clinician or group, including first and last name, e-mail address, and telephone number; and
• Selection of hardship exception category (listed above) and supplemental information.

If you’re applying for a hardship exception based on the Extreme and Uncontrollable Circumstance category, you must select one of the following and provide a start and end date of when the circumstance occurred:

• Disaster (e.g., a natural disaster in which the CEHRT was damaged or destroyed)
• Practice or hospital closure
• Severe financial distress (bankruptcy or debt restructuring)
• EHR certification/vendor issues (CEHRT issues)

Please note: Once an application is submitted, you will receive a confirmation email that your application was submitted and is pending, approved, or dismissed. Applications will be processed on a rolling basis.

NIH-funded study suggests role for specific immune cells in brain disease.

On July 13, 2017, the Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2018 Physician Fee Schedule (PFS) proposed rule that would make additional proposals to implement the Medicare Diabetes Prevention Program (MDPP) expanded model starting in 2018. The MDPP expanded model was announced in early 2016, when it was determined that the Diabetes Prevention Program (DPP) model test through the Center for Medicare and Medicaid Innovation’s Health Care Innovation Awards met the statutory criteria for expansion. Through expansion of this model test, more Medicare beneficiaries will be able to access evidence-based diabetes prevention services, potentially resulting in a lowered rate of progression to type 2 diabetes, improved health, and reduced costs.

The Medicare Diabetes Prevention Program expanded model is a structured intervention with the goal of preventing progression to type 2 diabetes in individuals with an indication of pre-diabetes. The clinical intervention, the result of National Institutes of Health-funded research, consists of a minimum of 16 intensive “core” sessions of a Centers for Disease Control and Prevention (CDC) approved curriculum furnished over six months in a group-based, classroom-style setting that provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control. After completing the core sessions, less intensive follow-up meetings furnished monthly will help ensure that the participants maintain healthy behaviors. The primary goal of the expanded model is at least 5 percent weight loss by participants.

The CY 2017 Medicare PFS final rule, published in November 2016, established the expansion and aspects of the expanded model policy framework. The CY 2018 PFS proposes additional policies necessary for suppliers to begin providing MDPP services nationally in 2018, including the MDPP payment structure, as well as additional supplier enrollment requirements and supplier compliance standards aimed to ensure program integrity. Services provided under the expanded model would largely be furnished in-person. We present a new proposal on beneficiary engagement incentives. We also include in this proposed rule amendments on previous policies finalized in the CY 2017 PFS regarding MDPP services and beneficiary eligibility.

CMS will accept comments on the proposed rule until September 11, 2017, and will respond to comments in a final rule. The proposed rule will appear in the July 13, 2017 Federal Register and can be downloaded from the Federal Register (PDF).

July 11, 2017 – The U.S. Preventive Services Task Force released today a final recommendation statement on behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults without cardiovascular risk factors. The Task Force recommends that primary care professionals individualize the decision to offer or refer adults without obesity who do not have hypertension, dyslipidemia, abnormal blood glucose, or diabetes to behavioral counseling to promote a healthful diet and physical activity. The final recommendation statement can also be found in the July 11 online issue of JAMA.

The Centers for Medicare & Medicaid Services (CMS) has published the 2017 CMS Quality Reporting Document Architecture Category III (QRDA III) Implementation Guide (IG) Version 1.0 (7/07/2017) for Eligible Clinicians and Eligible Professionals (EPs) Programs with Schematron and sample files. This version replaces the 2017 CMS QRDA III IG for Eligible Clinicians Reporting v0.1 (12/29/2016).

The 2017 CMS QRDA III IG for Eligible Clinicians and EPs provides technical instructions for QRDA III reporting for the following programs:

• Merit-based Incentive Payment System (MIPS)
• Comprehensive Primary Care Plus (CPC+)

The 2017 CMS QRDA III IG for Eligible Clinicians and EPs contains the following high-level changes compared with the reporting specifications in the 2016 CMS QRDA IG:

• The 2017 IG is based on the Health Level Seven (HL7) QRDA Category III R1, Standard for Trial Use R2.1
• For MIPS, Advancing Care Information (ACI) measures and Improvement Activities (IA) can be reported using the two new section templates: ACI Section and IA Section, respectively
• A performance period must now be specified using the Reporting Parameters Act template that is contained within each section template for Quality (electronic clinical quality measures), ACI, and IA

The 2017 CMS QRDA III Schematron provides rules that enforce the conformance statements of the IG. QRDA III submissions to CMS for the 2017 performance period will be submitted through the new Quality Payment Program submissions API or via file upload on the Quality Payment Program website. CMS will provide immediate, clear, and actionable feedback at the time of submission which will enable submitters to be confident that they successfully submitted their data. If there is a problem with the submission, submitters will get the issue specifics right away – and be able to address them immediately. Exact validation feedback provided by the Quality Payment Program may differ, but this Schematron file will validate that a QRDA III file is properly structured and will help with file submission through the Quality Payment Program submission system.

The new Schematron and sample files for this IG replace the 2017 CMS QRDA III Schematrons and Sample Files for Eligible Clinicians Programs v0.1. For more details regarding the changes, visit the “Change Log” sections of the IG.

Additional QRDA-Related Resources:

You can find additional QRDA related resources, as well as current and past implementation guides, on the eCQI Resource Center and the CMS eCQM Library.

Today, only 5% of patients account for nearly half of the nation’s spending on health care. How do we improve care management for these patients while also balancing quality of care and costs?

To advance insights and perspectives on how to improve the care of these high-need patients, the National Academy of Medicine, with the guidance from an expert planning committee, convened three workshops to explore opportunities for improving care and outcomes for high-need patients.

Summarizing and building upon the workshop discussions, Effective Care for High-Need Patients, identifies key characteristics of the high-needs population and introduces a new patient taxonomy that segments high-need patients based on the care they need and how often they need it to help provide better care management to improve their health. It also includes insights into successful models of care and opportunities for a path forward.

Improving care for high-need patients is not only possible–it also contributes to a more sustainable health system. But progress will take a coordinated effort from policy makers, payers, providers, and researchers, as well as patients and their loved ones.

With the rise of dementia and cognitive impairment as national health concerns, there have been a wide range of programs and products, such as diets, exercise regimens, games, and supplements, which claim to keep these conditions at bay. But, how do we know what actually might prevent or reduce risk of cognitive decline or dementia as we age?

To help sort through the data and to understand the current evidence for possible interventions, NIA commissioned a committee of experts through the National Academies of Sciences, Engineering and Medicine to conduct an extensive scientific review and provide recommendations.

The committee did not find sufficient evidence to recommend specific interventions to prevent cognitive decline or dementia. However, they did note “encouraging” evidence for three types of interventions: cognitive training, blood pressure control for people with hypertension, and increased physical activity.