Posted in: Government Outreach

Dear Administrator Brooks-LaSure,

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-deemed ambulatory surgical accreditation organization in the country.

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 procedure centers.

Update to ASC Covered Surgical Procedure Payment Rates for CY 2024 (88 FR 49750)

AAAHC appreciates the agency’s recognition and acknowledgment of the disparity between payments made to hospital outpatient facilities and ambulatory surgical centers. Medicare patients rightfully expect and deserve the same level of high-quality care across facility types. However, the fiscal policies historically in place preclude the ability of ASCs to offer many needed services to this population due to the imbalance between costs and payment. We look forward to the agency’s continued efforts to neutralize this disparity, ensuring that Medicare beneficiaries have the continuing ability to access services within the ASC setting.

Proposed Changes to the List of ASC Covered Surgical Procedures for CY 2024 (88 FR 49760)

The CY 2022 final rule with comment period implemented the ASC Covered Procedures List (CPL) Nomination Process. According to the final rule and information published online, nominations were to begin being accepted as of the CY 2023 rulemaking cycle. (see All nominated procedures were to be posted to the CMS ASC Payment web page, along with additional guidance on the nomination process. The CY 2023 final rule modified the start date from January 1, 2023, to January 1, 2024. The CY 2024 proposed rule does not further address the nomination/recommendation process and AAAHC has been unable to locate any guidance on participation in this process. In this proposal, CMS again encourages the submission of procedure recommendations, but the lack of additional information related to participation in this process is discouraging. As 2024 quickly approaches and the timeframe for submissions is limited, AAAHC requests that supporting information and guidance be published as promptly as possible, allowing for AAAHC to plan for appropriate and meaningful participation in this process. Furthermore, AAAHC encourages CMS to work with Congress to allow for continued expansion of allowed procedures across all acceptable specialties including, but not limited to, dental procedures, within the Medicare and Medicaid programs.

Proposed Modification of the COVID–19 Vaccination Coverage Among HealthCare Personnel (HCP) Measure Beginning with the CY 2024 Reporting Period/CY 2026 Payment Determination (88 FR 49774)

As of 2023, the Public Health Emergency surrounding COVID-19 has come to an end and CMS has terminated the previously instituted vaccination requirements for CMS providers. AAAHC does not believe that the benefits of having this information outweigh the measure’s associated burdens, particularly for small or rural ASC facilities. Considering the continuing struggles in health care staffing, the limited resources available to collect, track, and store this information, and the fact that personal protective equipment (PPE) and hand hygiene also play a role in source control and infection prevention and control, AAAHC recommends that CMS retire the COVID–19 Vaccination Coverage Among HealthCare Personnel (HCP) Measure as it will divert valuable resources away from factors that hold a heavier weighting related to patient safety and quality of care. Additionally, the burden of collecting data on this measure is only complicated by the continually changing definition of when a vaccination series is considered “up to date” (including the various interpretations of the term as related to personal demographics, such as age and immunocompromised status), the inconsistency of vaccination mandates (or prohibitions/exemptions) between states, and the continuing disparities of vaccination rates in different geographic locations, among races, etc. Should CMS deny the retirement of this measure, AAAHC encourages CMS to decrease the frequency of required data collections to match other vaccination reporting measures, such as that for influenza vaccination reporting.

AAAHC encourages CMS to carefully consider and only implement those measures providing the greatest value to patient safety and quality of care, as additional mandatory measures must be balanced against the potential additional administrative burden increased measure reporting may place on ASCs. While AAAHC supports the value that measures can bring, we also believe it is important to recognize the increased burdens and the consequence of diverting revenue away from patient safety investments by dictating how ASCs must budget by requiring resources for the implementation of new mandatory measures if such measures are not directly related to patient safety.

Proposed Adoption of the Risk Standardized Patient-Reported Outcome-Based Performance Measure (PRO–PM) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) in the HOPD Setting (THA/TKA PRO–PM) Beginning With Voluntary CYs 2025 and 2026 Reporting Periods Followed by Mandatory Reporting Beginning With the CY 2027 Reporting Period/CY 2030 Payment Determination (88 FR 49783)

AAAHC supports meaningful measures that allow for benchmarking, comparison, and quality improvement while ensuring that the total burden placed upon facilities and providers does not detract from the ability to dedicate necessary resources to patient care and safety.

AAAHC’s Advanced Orthopaedic Certification (AOC) program contains rigorous Standards that promote safe, quality care for patients undergoing orthopaedic procedures, such as total joint arthroplasty. The Standards go above and beyond the CMS Conditions for Coverage and accreditation requirements, providing a deep focus on prescreening, admission, and post operative assessments. Rigorous requirements for an integrated risk management and quality improvement program focused on total joint arthroplasty are also incorporated. As a result, the AOC program requires ASCs to engage in a continuous data collection process to measure ongoing quality and identify related problems or concerns, which includes external benchmarking with similar organizations through use of a nationally recognized specialty specific data repository. Imposing set measures for THA or TKA not only increases administrative burden for ASCs that comply with standards necessary to participate in voluntary quality improvement programs, but it also forces ASCs to manage the reporting burden by therefore choosing compliance with imposed measures over those that best serve their patient population. Removing facility autonomy for measure selection further has the potential to limit the selection of data registries available to participating ASCs.

Proposed Modification of the Survey Instrument Used for the Cataracts: Improvement in Patient’s Visual Function Within 90 Days Following Cataract Surgery Measure Beginning with the Voluntary CY 2024 Reporting Period (88 FR 49807)

AAAHC continues to support burden reduction within the CMS programs, including through the use of specified survey instruments. We commend CMS for the incorporation of survey options with a lower burden that also provide similar levels of statistical reliability.

Proposed Modification of Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients Measure Denominator Change to Align with Current Clinical Guidelines Beginning with the CY 2024 Reporting Period/CY 2026 Payment Determination (88 FR 49809)

AAAHC continues to support efforts to align measures across CMS programs when appropriate and feasible, to reduce provider burden when participating across multiple programs. AAAHC also supports updating measures to maintain congruence with current clinical practice guidelines, such as adjusting the applicable age range in this measure based upon evidence that colorectal cancer rates have decreased for people over 50 years old but have increased 51% over the last 30 years in persons under age 502, with the resulting mortality rate in this younger demographic also rising3. To maintain efficacy and meaningfulness, quality improvement efforts and measures should be regularly reviewed and updated to incorporate current clinical evidence and guidelines.

Proposed Re-adoption with Modification of the ASC Facility Volume Data on Selected ASC Surgical Procedures Measure Beginning with the Voluntary CY 2025 Reporting Period Followed By Mandatory Reporting Beginning with the CY 2026 Reporting Period/CY 2028 Payment Determination (88 FR 49811)

AAAHC reiterates its support of the position taken by CMS within the CY 2018 proposed and final rule4 that procedure-type-specific measures will provide patients with more valuable ASC performance data than the ASC-7 measure in selecting an ASC for their care, and that there are other measures available that are more strongly associated with desired patient outcomes for the particular topic. In CY 2018, CMS addressed that the maintenance costs and administrative burden to ASCs associated with retaining the measure was high and that the burdens of the ASC-7 measure outweighed the benefits of keeping the measure in the ASCQR Program.

As expressed in previous comment submissions, AAAHC continues to be concerned related to the impact this measure may have on new and growing ASCs and on ASCs that attend to medically underserved populations, recommending caution that consumers are not led to falsely believe that higher volumes will necessarily result in improved outcomes and facilities are not penalized or perceived in a disadvantageous manner.

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