NCMS Morning Rounds 10-28-21

Happy Thursday! Enjoy your NCMS Morning Rounds!

October 28, 2021

Public Comment for Clinical Quality Measures in Development: Depression and All-Cause Mortality

The Centers for Medicare & Medicaid Services (CMS) has contracted with Mathematica to develop two new measures for potential use in the Inpatient Psychiatric Facility Quality Reporting (IPFQR) program. Mathematica invites comments on draft measure specifications for the two measures currently under development:

  1. Improvement in Depression Symptoms during the Inpatient Psychiatric Facility (IPF) Stay
  2. 30-day Risk Standardized All-Cause Mortality Following Inpatient Psychiatric Facility (IPF) Discharge

Clinical experts and a multistakeholder technical expert panel were consulted throughout the measure development process. CMS is requesting that stakeholders review and comment on the draft measure specifications. We welcome all comments and are particularly interested in comments that address the following:

  • The extent to which measure scores indicate quality of care in IPFs
  • The extent to which IPFs can effect change in measure performance
  • The feasibility of implementing the measure in the IPF setting
  • The usability of measure scores to improve quality
  • Unintended consequences that might result from implementing the measure
  • The accuracy and reasonableness of the draft measure specifications, including denominator exclusions and potential risk adjustors

Review the draft measure specifications.

Instructions for providing comments:

  • The public comment period opens at 9:00 a.m. (EST) on October 27, 2021, and closes at 11:59 p.m. (EST) on November 26, 2021.
  • Please email your comments to
  • To be considered, comments must be submitted by 11:59 p.m. (EST) on November 26, 2021.

If you have any questions, please email

REMINDER: WCC Funding and Leadership Training Opportunity Ending Soon

Whole Community Connection (WCC), a joint initiative of Interprofessonal Education and Practice and UNC Rural, both under the Office of the Provost, is launching in Edgecombe and Robeson counties.

WCC invites applications from community-academic collaborations advancing health and well-being in Edgecombe or Robeson County, NC. Selected teams from each county will receiving funding and leadership training to implement their approaches.

Deadline is November 1.

Learn more and apply here.

Medicare: Provider Performance and Experiences under the Merit-based Incentive Payment System

The Government Accountability Office (GAO) released a report examining the distribution of the Merit-based Incentive Payment System (MIPS) performance scores and related payment adjustments as well as stakeholders’ perspectives on the strengths and challenges of the MIPS program. GAO analyzed MIPS data for performance years 2017 to 2019 and interviewed officials from the Centers for Medicare & Medicaid Services (CMS) and 11 selected professional organizations that represent MIPS-eligible physicians of various specialties. Key highlights from the report are outlined below:

  • Final scores for MIPS physicians were generally high and at least 93% of physicians earned a small positive adjustment, with the largest payment adjustment in any year being 1.88%.
  • Median final scores were well above the performance threshold across each of the 3 years.
  • About 72 to 84% of physicians earned an exceptional performance bonus, depending on the year.
  • Two of the eleven stakeholders stated that bonus points, such as those that may be added to the final scores for small practices, helped increase scores for certain physicians who might otherwise be disadvantaged.
  • Eight stakeholders questioned whether the program helps to meaningfully improve quality of care or patient health outcomes.

In the News

3 takeaways from the emergence of the ‘Delta Plus’ coronavirus variant, STAT, 10-27-21

Learning Opportunity 

Today with Macrae, Tuesday, November 9, 3:00-4:00 p.m. ET

The webcast will include a segment with Peter Marks, MD, PhD, the director of FDA’s Center for Biologics Evaluation and Research, who will provide the latest guidance for health centers on COVID-19 vaccines and other updates on vaccine safety and efficacy.

Join the day of the session


If you have policies you’d like your NCMS Board of Directors to consider, please complete the Board input form here. Thanks for reading!


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