Regulatory Reminder

In the final days of 2020, CMS posted a list of Measures Under Consideration or MUCs. CMS is required by statute to do this every December as a pre rulemaking process. This pre rulemaking process provides CMS with the vehicle to hear from stakeholders for early consideration of measures.  It lists the measures that CMS is considering adopting for certain Medicare quality programs in the forthcoming year’s rulemaking cycle.

As we have discussed in prior Broad River communications, CMS is continuing to align newly adopted measures across programs whenever possible with the goal of moving payment toward value, improving outcomes for patients and reducing regulatory burden for providers through focusing their efforts on the same quality areas. CMS is accomplishing this through the Meaningful Measures Framework. This initiative is aimed at identifying the highest priority areas for quality measurement and quality improvement to assess the core areas most vital to patient outcome improvement.

In the December 2020 MUC list, CMS has posted the following 2 measures under consideration specifically for  the Skilled Nursing Facility Quality Reporting Program or SNF QRP. The full document, linked above, also provides tables with a summary of the technical specifications for each measure.

MUC ID Measure Title Description Measure Type Measure Steward CMS Program(s)
MUC20-0002 Skilled Nursing Facility Healthcare-Associated Infections Requiring Hospitalization This measure will estimate the risk-adjusted rate of healthcare-associated infections (HAIs) that are acquired during skilled nursing facility (SNF) care and result in hospitalizations. The measure is risk adjusted to “level the playing field” and to allow comparison of measure performance based on residents with similar characteristics between SNFs. It is important to recognize that HAIs in SNFs are not considered “never-events.” The goal of this risk-adjusted measure is to identify SNFs that have notably higher rates of HAIs that are acquired during SNF care and result in hospitalization, when compared to their peers. Outcome Centers for Medicare & Medicaid Services SNF QRP
MUC20-0044 SARS-CoV-2 Vaccination Coverage among Healthcare Personnel This measure tracks SARS-CoV-2 vaccination coverage among healthcare personnel (HCP) in IPPS hospitals, inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), inpatient psychiatric facilities, ESRD facilities, ambulatory surgical centers, hospital outpatient departments, skilled nursing facilities, and PPS-exempt cancer hospitals. Process Centers for Disease Control & Prevention ASCQR; ESRD QIP; Hospital IQR Program; Hospital OQR Program; IPFQR; IRF QRP; LTCH QRP; PCHQR; SNF QRP

If you are not aware, a draft of the technical specifications for MUC20-0002 was posted earlier this year as a heads up to SNFs relate to future QRP measures dealing with infection control. SNFs also received a Healthcare Associated Infections Confidential Dry Run Report in their CASPER folders based on the new measure specifications. These were posted so that facilities could begin to understand how they are performing related to this new measure. It would be advantageous to access your facility specific report in CASPER. See example report below.



Recently it has also been reported that prominent lawmakers are urging the federal government to provide ongoing data updates about the progress of its COVID-19 vaccination program at long-term care facilities in a push for more transparency. They indicated, “These data should, in turn, be included in the weekly COVID-19 reports issued by CMS. Going forward, COVID-19 vaccination data should be included in Minimum Data Set reporting requirements and Nursing Home Compare — similar to flu and pneumonia vaccines,”.

We expect to see these measures show up in the rule making cycle for 2021. The first will be the SNF PPS proposed rule that is usually posted in late April. Stay tuned for more on these measures. Sign up for our BLOG and participate in our monthly Broad River Reflections web presentations. We will address these measures as they appear in rulemaking and final policy in these venues throughout 2021.   

Here’s to a 2021 that is full of hope and promise! Happy New Year!