Crash Course for Submitting Comments to CMS

#HPM Crash Course in Submitting Comments to CMS | Matthew Cortland on Patreon – Feb 2018 – by Matthew Cortland

Mr. Cortland gives excellent advice for the best way to write your comments on opioid policy. Though his words are aimed at Hospice & Palliative Medicine (HPM) clinicians, I believe many of us chronic pain patients have just as much knowledge and experience with this subject.

CMS has published their proposed changes to Medicare for 2019.

Here are the changes that, in my view, may be the most concerning to Hospice & Palliative Medicine (HPM) clinicians:  

  1. Starting to crack down on opioid ‘potentiator’ drugs – like gabapentin and pregabalin.
  2. Limiting opioids to 90 MME per day.
  3. Making it more difficult for patients to fill two or more long-acting opioids.   

Why Comment on These Changes?

These changes are not final, yet. Before CMS issues the final rules for 2019, it must accept and respond to feedback.  

Comments from HPM clinicians [and pain patients! -zyp] are incredibly important – CMS might actually listen to you.

Comments are due by March 5th 2018, at 11:59 PM ET.

Here are the main sources that inform my approach to commenting:

  1. The Art of Commenting: How to Influence Environmental Decisionmaking With Effective Comments, 2d (support of patrons allowed me to purchase my own copy)
  2. HHS Regulations Toolkit
  3. Tips for Submitting Effective Comments – [pdf]
  4. I’ve also spent several hours reading through the 2019 Advance Notice Part I [pdf] and Part II [pdf].

III. How to Comment Effectively

This post is rather narrowly aimed at HPM clinicians commenting on the “Improving Drug Utilization Review Controls in Medicare Part D” provisions of the CMS proposal. We’re going to focus on 17 pages of this pdf out of a total of 218. And we’re going to focus on the kinds of arguments HPM clinicians are best positioned to make.

Organizational Tips

Logistics – How do you actually submit a comment?

  1. Go to
  2. Click on “Comment Now”
  3. Either enter your comment in the text box (must be fewer than 5000 characters)
  4. Or upload your comments as a pdf (this is the option I recommend)
  5. Complete the form and “Continue.” Keep in mind comments are public.

Facts Matter

  1. Facts matter. As HPM clinicians you’re factual experts – you are experts in the medical facts of your specialty.
  2. I’m going to point out the places where CMS is asking for your factual expertise or making factual assertions/conclusions that seem suspect to me.  
  3. I’ll go in order through the document, page-by-page, highlighting areas where I think your factual expertise as a HPM clinician can do the most good. Pound the facts.

Mr. Cortland has done the hard work of picking apart this document page by page. On his web page, you’ll find screenshots of the parts are most relevant to pain care, the document page numbers where to find them, and questions to consider for your comment.

For instance, he gives specific suggestions for how to address the proposed 90MME limit in this example from his page:

Page 203 – Introduction, cont. 

“Over time, CMS has modified the OMS opioid overutilization criteria based on stakeholder feedback and on the CDC Guideline for Prescribing Opioids for Chronic Pain. 31 With regard to the latter, the OMS criteria incorporate a 90 morphine milligram equivalent (MME) threshold cited in the CDC Guideline, which was developed by experts as the level that prescribers should generally avoid reaching with their patients.”

Later in the document, CMS will explain how they’re going to use the 90 MME threshold (i.e. it will become more difficult to fill scripts above 90 MME per day), and we’ll get to that section.

But here CMS tells us how they are using the CDC Guidelines as the rationale and basis for the 90 MME per day threshold for their overutilization criteria. Here are some points to possibly comment on:

  • In your opinion as a HPM clinician, is CDC using the Guidelines appropriately? If they aren’t, explain how they’re being misused.
  • Does using the CDC Guidelines in this way burden (make more difficult) patient access to medically necessary drug regimens?
  • Is it the consensus of HPM experts that the patients HPM clinicians take care of should “generally avoid” 90 or more MME per day?
    Or are there entire patient populations (e.g. folks with cancer or folks on hospice) for which it is not actually the case that there’s an expert consensus to “generally avoid reaching” 90+ MME per day?
    In other words, is CMS making an incorrect factual assertion?

Original article: #HPM Crash Course in Submitting Comments to CMS | Matthew Cortland on Patreon – Feb 2018 – by Matthew Cortland

(nb. If you have questions or would like feedback on a draft of your comment before submitting it to CMS, please leave a comment here and I’ll be happy to get back to you.
I can also be reached on twitter
And if my work is helpful, consider
becoming a patron.)

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