Posted in: Government Outreach

Dear Administrator Brooks-LaSure,

The Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) appreciates the opportunity to submit comment to the Centers for Medicare & Medicaid Services (CMS) regarding the recently proposed CY 2024 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program.

AAAHC is a private and independent 501(c)(3) non-profit accreditation organization formed in 1979. Since its inception, AAAHC has promoted a voluntary, peer-based, and educational survey process to advance patient care. These values hold true today, as embodied in our mission statement: Improving health care quality through accreditation. With more than 6,700 accredited organizations in a variety of ambulatory health care settings, AAAHC is a leader in developing Standards to advance and promote patient safety, quality care, and value for ambulatory health care through its accreditation programs, education, research, and other resources. Currently, more than 1,000 ASCs are committed to excellence through AAAHC accreditation under the deemed status program, making AAAHC the leading Medicare- approved, non-hospital accreditation organization in the country. Additionally, 180 AAAHC clients have achieved either Ambulatory Accreditation with Medical Home or achieved Patient-Centered Medical Home recognition through our certification program, demonstrating high-quality care in an environment that promotes patient safety and providing accessible, comprehensive, team-based continuity of care.

AAAHC also provides accreditation services to the United States Coast Guard (USCG) ambulatory health centers, Federally Qualified Health Centers (FQHCs) that receive funds from United States Health Resource and Services Administration (HRSA), Indian Health Services (IHS) funded health centers, and Correctional Healthcare units under the United States Federal Bureau of Prisons (BOP). Other AAAHC-accredited organizations include Community Health Centers, Indian Health Centers, Student Health Centers, Medical Group Practices, and office-based surgery centers.

Direct Supervision via Use of Two-way Audio/Video Communications Technology (88 FR 52301)

AAAHC supports the proposal to maintain this provision through 2024 in alignment with similar provisions covered by the CAA and continued CMS review of the virtual presence flexibility for direct supervision.

Telephone Evaluation and Management (E/M) Services (88 FR 52305)

AAAHC supports the proposal to maintain this provision through 2024 in alignment with similar provisions covered by the CAA and continued CMS review to determine the appropriateness of telephone E/M services.

Reasonable and Necessary Caregiver Training Services (CTS) (88 FR 52324)

AAAHC supports allowing payment for reasonable and necessary CTS. AAAHC also encourages CMS to allow for reimbursement of CTS more than once per year where such services are medically indicated, as caregivers may have different levels of comprehension that require further education or require additional support once the caregiver or provider recognize changes or clarifications are needed to support previous training sessions. AAAHC Patient Centered Medical Home (PCMH) Standards support this expansion, requiring:

  • inclusion of the patient’s family in patient care decisions and education, as appropriate, and
  • effective communication, including assessing and addressing the needs of personal caregivers to the extent they impact the care of the patient.

Services Addressing Health-Related Social Needs (Community Health Integration services, Social Determinants of Health Risk Assessment, and Principal Illness Navigation Services) (88 FR 52325)

AAAHC continues to support additions to covered services where such services are clinically appropriate, including payment for Social Determinant of Health (SDOH) evaluations, Community Health Integration (CHI) services, and Principal Illness Navigation (PIN) services via telehealth and otherwise. AAAHC PCMH Standards require that:

  • providers address patient risk factors and ask about the patient’s concerns, worries, and stressors,
  • a Medical Home be knowledgeable of community resources that support the needs of the patient,
  • referrals and consultations receive tracking and follow-up, and
  • transitions of care are proactively planned and coordinated.

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) (88 FR 52395)

AAAHC continues to support consistency across programs, including for RHC and FQHC facilities, as a means of improving access to equitable, quality care for all persons served by CMS programs.

Proposal (88 FR 52550)

AAAHC supports the CMS proposal that reimbursement be allowed for SDOH assessments with the Annual Wellness Visit (AWV) where appropriate. Similar to other efforts currently being implemented by the Agency, AAAHC requests that CMS publish resources related to SDOH Risk Assessments that are standardized, evidence-based, and furnished in a manner that lowers the burden of ensuring that the cultural and linguistic needs of the patient are met and that communication with the patient is appropriate for the beneficiary’s educational, developmental, and health literacy level.

AAAHC PCMH Standards address cultural competency and language preferences. For example, organizations demonstrate how they:

  • treat patients with cultural sensitivity,
  • explain information in a manner that is easy to understand,
  • provide patient literature in appropriate languages and literacy levels, and
  • perform quality improvement studies that address patient understanding/provider-patient collaboration and accessibility of care.

AAAHC also supports allowing the AWV to be completed over multiple visits and days (or in advance of the AWV) based on patient circumstances, such as limited availability of time or suffering from increased needs which require more in-depth review and assistance.

Promoting Continuous Improvement in MIPS (88 FR 52557)

AAAHC implemented its transformational 1095 Strong, quality every day philosophy, a call-to-action that equips ambulatory organizations with the best of what is needed to operationalize quality practices. The 1095 Strong initiative centers on providing accreditation tools, resources, and relevant education to bring meaningful value to organizations and promote compliance with AAAHC Standards, all 1,095 days of the accreditation cycle. From the time an organization submits the application to the time of the survey and beyond, AAAHC provides high-quality health care through accreditation with its 1095 Strong drivers based on the AAAHC drive for continuous improvement. Any organization pursuing and maintaining AAAHC Accreditation is expected to assess its own ongoing compliance with AAAHC Standards and alignment with local, state, federal statutory or regulatory requirements and its own policies. AAAHC asserts that each organization is responsible to investigate and implement corrective action to maintain compliance with AAAHC Standards in order to receive or maintain AAAHC Accreditation. Failure to implement effective correction action may result in denial of accreditation or revocation of the organization’s accreditation term.

In line with the shared mission between CMS and AAAHC, AAAHC supports CMS in the promotion of continuous improvement within the MIPS program, although a caution for burden is necessary. In line with this caution for burden and as supported by AAAHC’s 1095 Strong, quality every day philosophy, AAAHC proposes that providers who offer their services from within a AAAHC-accredited facility be granted an exception from (or be granted automatic compliance with) the Promoting Continuous Improvements in MIPS requirements, if such requirements are implemented by the Agency.

AAAHC Standards for Quality Management and Improvement require:

  • a written quality improvement program (which is reviewed annually for effectiveness and to determine if the program’s purposes and objectives continue to be met),
  • ongoing data collection activities to measure quality, perform benchmark comparisons, and identify quality-related concerns,
  • demonstrate through at least one annual quality improvement study that improvement has occurred and has been sustained, and
  • participation in external benchmarking activities that compare key performance measures with other similar organizations, with recognized best practices, and/or with national or professional targets or goals.

Quality Improvement measurement is implemented with the purpose of identifying underperforming areas in need of improvement and it is important for organizations and providers to examine clinical care measures beyond those in which they perform well. If CMS moves forward with this proposal, AAAHC encourages implementation to be done in a manner that does not penalize providers for reporting measures that need improvement but instead supports and encourages the process of quality improvement.

Quality Performance Category (88 FR 52562)

AAAHC supports the need for all patient communications, including CAHPS surveys, to be provided in the patient’s preferred language and to ensure effective patient communications with consideration for language preferences and literacy levels, as evidenced by AAAHC Standards that require:

  • interpretation services are available,
  • communication in the language or manner primarily used by the patient, and
  • effective communication, including that information be explained in a way that is easy to understand.

Data Completeness Criteria (88 FR 52565)

AAAHC proposes that the proposed changes at 88 FR 52557 related to Promoting Continuous Improvement in MIPS would be more meaningful than increasing the current Data Completeness Criteria. Based on statistics provided by CMS within this proposal, these changes to Data Completeness Criteria would have the most detrimental impact on providers who are currently in need of the greatest support, such as small practices and individual eligible clinicians.

Based upon the increased efficiencies and other benefits offered by Electronic Health Record (EHR) systems, alongside the Agency’s push for EHR adoption over the past decade, it is likely that EHR has already been implemented by those providers for whom it was reasonable to do so. Providers who have not yet adopted EHRs are likely facing the highest burdens in doing so, and these burdens still have not been sufficiently addressed or reduced. Therefore, increasing the Data Completeness Criteria threshold comes across as a continued attempt to force struggling and burdened physicians into EHR adoption within a medical system that has continued to reduce investment in primary care services for at least a decade. (see

Increasing the number of physicians who are unable to fulfill MIPS requirements after effectively pausing the program throughout the PHE seems to create additional unfair penalty, especially within the sphere of primary care. AAAHC encourages CMS to work with Congress to allow for the implementation of changes within the MIPS program that address the programs fundamental problems, such as undue burdens, disproportionate harm upon rural and small/independent practices, exacerbated inequities in health care, and difficulties in supporting meaningful clinical outcomes.

Promoting Interoperability Performance Category Performance Period (88 FR 52578)

If evidence exists to suggest that the 90-day performance reporting is not representative of year-round practices, AAAHC would support year-round reporting, in line with the AAAHC 1095 Strong principle. Additionally, AAAHC proposes that CMS consider exempting organizations who are accredited and/or who hold PCMH certification from the year-round reporting requirement in an effort to ease administrative and expense burdens for facilities and providers who demonstrate their commitment to continuous improvement through their voluntary participation in the accreditation/certification process.

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