CMS Medicare Proposed Rule and Changes to Star Measure Program
This Briefing is brought to you by AHLA’s Payers, Plans, and Managed Care Practice Group.
- March 27, 2020
- Whitney Dockrey , Christensen Law Group PLLC
On February 5, 2020, the Centers for Medicare and Medicaid Services (CMS) released the Advance Notice of Methodological Changes for Calendar Year (CY) 2021 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies – Part II (Advance Notice).
Also, on February 5, 2020, CMS released the Contract Year 2021 and 2022 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicaid Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (Proposed Rule).
Proposed Rule comments must be received by 5:00 p.m. on April 6, 2020, to be assured consideration.[1] Comments may be submitted online.[2]
The final 2021 MA capitation rates and payment policies will be released on April 6, 2020.
The proposed and updated Star measures reflect CMS’ priority for beneficiaries to receive value through health plan coverage and provider delivery of healthcare services. Process standardization, evidence-based practices and treatments, strategic coverage of supplemental benefits to improve health, with data analytics to evaluate performance and identify outliers seem to be the foundation of the recent CMS Medicare Advantage (MA) Star measures proposals, updates, and additions. Proposed changes for MA Plans and Star Measures emphasize beneficiary satisfaction, preventive care measures, population health strategies, dignified care at the end of life, and measured success through data integrity, patient safety, improved care transitions, and price transparency.
CMS expects MA plans currently below a Four Star Rating will continue to decline in Star Ratings, particularly because of the new Tukey Outlier Methodology change. Health plans must strategically develop defined, efficient, and effective processes through clinical partnerships to meet Star measurements to achieve a Four Star Rating or above, and attain Quality Bonus Payments (QBPs), and shared savings. MA plans may consider how supplemental benefits and the use of remote patient monitoring could promote quality and expanded access to care with proposed telehealth and remote monitoring changes, all of which are likely to help meet current and proposed Star measurements. Accurate documentation of hierarchical condition categories (HCCs) for patient risk adjustment factors (RAFs) remains a critical quality and financial strategy to reflect the patient population a health plan serves. Education and the facilitation of efficient processes for providers are likely necessary for MA plans to get providers to conduct services required to meet Star measurements. Additionally, education and incentives for beneficiaries are likely necessary to get beneficiaries to visit their providers and play an active role in their health.
CMS emphasized its responsibility to ensure MA and Part D contracts are stable enough to appropriately serve patients.[3] To do so, CMS may deny applications based on past contract performance that it determines pose “a high risk to the success and stability of the MA and Part D programs and their enrollees.”[4] CMS proposes to use three factors, each of which is sufficient to result in denial of an application: (1) “imposition of civil money penalties or intermediate sanctions,” (2) “low Star Ratings scores,” and (3) “the failure to maintain a fiscally sound operation.”[5] Given CMS anticipates many plans will experience a Star Ratings decline, and CMS’ proposal to adopt “failure to achieve at least a three-star Part C or Part D summary rating in the set of Star Ratings CMS issue[s] . . . as a basis for denying an application based on past performance,” a plan’s achievement of at least a Four Star Rating is increasingly important for plan viability.
Additionally, MA plans and contracted providers must understand and develop processes for risk adjustment to meet CMS’ documentation expectations for HCCs, coding, claims, and risk adjustment scores. CMS continues to move toward using encounter data, and proposes to continue phasing in the 2020 CMS-HCC model. The 2020 CMS-HCC model calculates 75% of the total risk adjustment score based on encounter data risk scores, and the remaining 25% of the score based on the 2017 RAPS based risk score model.[6] CMS also proposes to maintain “the statutory minimum MA coding pattern adjustment of 5.90 percent” to “offset the effects on MA risk scores of higher levels of coding intensity” compared to Fee-For-Service (FFS).[7] CMS will use risk score data from 2015-2019 to calculate normalization factors to set the average beneficiary risk score at 1.0.[8]
Selected components of the proposed and updated Star measures are discussed below. Additional comprehensive and specific guidance is available in the Proposed Rule, Advance Notice, and CMS’ website.
Significant Star Measure Weight Changes
Patient Experience, Complaints, and Access Measures
CMS continues to emphasize the beneficiary’s voice as a leading quality indicator. Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures focus “on critical aspects of care from the perspective of patients such as access and care coordination issues.”[9] Just as hospitals and providers are evaluated by patients through Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys and scores, MA plans are evaluated through the Star Ratings CAHPS survey.
Patient Experience, Complaints, and Access Measures will increase from a weight of one and a half to a weight of two for 2021 Star measures.[10] More notably, the Proposed Rule would “further increase the weight of patient experience/complaints and access measures from a weight of 2 to 4” for 2023 Star Ratings.[11]
Beneficiary satisfaction is measured by all non-flu CAHPS measures of beneficiary surveys, access and care coordination issues, Members Choosing to Leave the Plan, appeals, disenrollment, the call center, and complaints measures.[12] CMS uses the results to evaluate patient “perceptions of care as well as ensure that [patients] have access to needed care.”[13] Complaint changes are designed to emphasize measurement, transparency, and data integrity. CMS explained plans “must use the CMS complaint tracking system to address and resolve complaints received by CMS against the plan.” [14] CMS will also require specific content on health plan websites, including the electronic complaint form at Medicare.gov for streamlined accessibility.[15]
CMS is confident in its methodology to rate plans based on patient experience, explaining that it has identified statistical reliability between a plan’s CAHPS measures and “meaningfully better performance.”[16] Plans should anticipate another increase to the measurement weight in the future. The Advance Notice explains CMS’ use of the Net Promoter Score (NPS) as a “measurement of predicted consumer loyalty (likelihood to recommend the organization to a friend or colleague using a 0 – 10 scale).”[17] CMS asked for feedback on the addition of “a related question to the NPS or customer loyalty to [the] MA and PDP CAHPS survey to use to develop a measure in the future for the Part C and D program.”[18]
Tukey Outlier Deletions and Savings
Contracts currently below a Four Star Rating are at risk of a further reduction.
The new patient experience/complaints and access weight measurements are estimated to increase most plans’ Star Ratings, identified by CMS as a measurement on which most plans tend to do well. Therefore, the increase in Ratings will be balanced with the Tukey Outlier Methodology outlier deletions to generate an aggregate savings of $4.9 billion for the Medicare Trust Fund over 2024 – 2030.[19] The net reduction is principally by contract reductions from Star Ratings, as the Tukey Outlier’s statistical methodology creates reductions through outlier deletions in measurement cut points.[20]
According to CMS, since “more outliers tend to be at the low end of the distribution (worse performers), directly removing outliers causes some shifting downward in overall Star Ratings.”[21] Consequently, many plans can expect reduced amounts paid in Quality Bonus Payments (QBPs) and shared savings.[22] Nevertheless, CMS expects the Tukey Outlier methodology “to increase the stability and predictability of the star measure cut points.”[23]
Past Performance and Quality Bonus Payments (QBPs)
CMS proposed a change to prevent organizations from “evading” the consequences of past performance of “parent organizations” with the creation of new MA contracts. [24] CMS proposes “to consider the performance of contracts held by the applicant’s parent organization or another organization controlled by the same parent and ascribe that performance to the applicant.” [25] One of CMS’ goals with this change is to “force organizations responsible for a poor past performance record to direct their attention away from acquiring new Medicare business when their focus should be on bringing their current Medicare contract performance up to an acceptable level.” [26]
MA plans with a Four Star Rating qualify “for a QBP that is capped at 5 percent (or 10 percent for certain counties).”[27] Since changes to the outlier methodology are likely to impact QBPs, as some plans’ Star Ratings fall, lower rated plans may lose enrollees to plans with higher ratings, because of the additional QBPs and incentives Four Star and Five Star rated health plans can offer beneficiaries. CMS stated, “The rebate share of savings amounts to 50 percent for plans with a rating of 3.0 or fewer stars, 65 percent for plans with a rating of 3.5 or 4.0 stars, and 70 percent for plans with a rating of 4.5 or 5.0 stars.”[28]
Network Adequacy
CMS seemed to acknowledge the difficulty of providing MA coverage and developing networks in challenging and rural areas. CMS proposes to “strengthen network adequacy rules for MA plans by codifying [the] existing network adequacy methodology and standards (with some modifications)” and seeks feedback “on refining standards related to telehealth.”[29] Network adequacy and access, as key components to beneficiary health outcomes and satisfaction, may be improved through CMS’ efforts to expand telehealth coverage, particularly if expansion helps “to increase plan choice in more rural counties.”[30] CMS proposed and requests feedback on efforts “to modify the current network adequacy standards by codifying a reduced standard for the percentage of beneficiaries that must reside within the maximum time and distance standards in non-urban counties . . . for an MA plan to comply with the network adequacy standards.”[31] CMS requests feedback on other proposed network adequacy strategies plans which serve or are considering contract coverage in rural areas could provide valuable feedback.[32]
CMS proposed to “allow MA plans to receive a 10 percent credit towards the percentage of beneficiaries residing within published time and distance standards when they contract with telehealth providers in the following provider specialty types: dermatology, psychiatry, cardiology, otolaryngology and neurology.”[33] CMS also asked for feedback “. . . regarding whether [they] should expand this credit to other specialty provider types, such as nephrology for home dialysis, and if this percentage ‘credit’ should vary by county type.”[34] Again, seeming to show acknowledgement of the difficulties to meet Star measures and profitability in certain areas and provider shortages.
Supplemental Benefits
MA plans may “use rebates to fund mandatory supplemental benefits and/or to buy down beneficiary premiums for Part B and/or Part D prescription drug coverage.”[35] MA plans could consider how to leverage supplemental benefits to meet Star measure requirements and improve patient satisfaction to increase Star Ratings.
Plans could provide feedback to strengthen and expand supplemental benefits and telehealth coverage for remote and rural areas to help plans expand remote monitoring opportunities and access to care. Wearable and remote monitoring items could help provide close care monitoring for expanded access to care through telehealth and virtual services. Expanded access to care through virtual access and monitoring could help patients who may be difficult to reach or unable or unlikely to return for a follow-up visit due to distance. Remote monitoring may also help identify complications sooner or more effectively than a case management phone call to help plans meet many current and proposed Star measures.
CMS proposes to codify its definition of “primarily health related” and also provides examples of “supplemental benefits.”[36] CMS’ interpretation of “primarily health related benefits,” “is used as a criteria for supplemental benefits, has been changed to include services or items used to diagnose, compensate for physical impairments, ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization,” effective as of January 1, 2019. [37]
Under CMS’ interpretation, MA plans have “flexibility in designing and offering supplemental benefits that may enhance beneficiaries’ quality of life and improve health outcomes” [38] which can improve Star Ratings and help develop population health strategies.
MA supplemental benefits, listed by CMS in the Proposed Rule, included:[39]
Dental, vision, adult day health services, home-based palliative care, in home support services, support for caregivers of enrollees, stand-alone memory fitness, expanded home & bathroom safety devices & modifications, wearable items such as compression garments and fitness trackers, over-the-counter items, and expanded transportation.
CMS also noted, a “supplemental benefit is not primarily health related under this definition if it is an item or service that is solely or primarily used for cosmetic, comfort, general use, or social determinant purposes.”[40] Plans could offer feedback on CMS’ definitions and examples of supplemental benefit options to promote MA beneficiary health improvement strategies and note, particularly, how examples may relate to Star measurements for which plans are rated.
However, CMS did propose to codify that the definition of Special Supplemental Benefits for the Chronically Ill (SSBCI) also include non-primarily health related SSBCI benefits. [41] Examples of SSBCI benefits, originally listed in the 2019 HPMS memo, as non-primarily health related SSBCI benefits MA plans could offer include: “meals, food and produce, transportation for non-medical needs, pest control, indoor air quality and equipment and services, non-fitness club memberships, community or social clubs, park passes, services supporting self-direction, structural home modifications,”[42] in addition to many more.
Star Measures Removals for 2022
Three measurements will be removed for 2022 Star Ratings, including: (1) the Part C Adult Body Mass Index (BMI) assessment measure; and two Part D measurements, (2) Appeals Auto-Forward measure, and the (3) Appeals Upheld measure.[43] Considering the ease of meeting the BMI measurement compared to some measures, health plans should consider what could replace the BMI measurement as a similarly easy measurement to attain to maintain overall Star Ratings. Plans which have not focused on clinical documentation for risk adjustment and HCCs, like BMI documentation, should note risk adjustment continues to grow in importance for Star Ratings and plan financial viability.
Proposed Rheumatoid Arthritis Management Measure Removal
CMS proposed the removal of the Rheumatoid Arthritis Management measure from Star Ratings for the 2021 measurement year and 2023 Star Ratings.[44] The NCQA is “retiring” the HEDIS measure for the 2021 measurement year “due to multiple concerns,”[45] including that the measurement “may not reflect the rate at which members get anti-rheumatic drug therapy because sometimes these medications are covered by Patient Assistance Programs, which do not generate claims.”[46]
Other measurement barriers include questionable continued patient adherence and the determination that effectiveness was “unclear, based on the evidence, whether patients in remission should remain on these medications.”[47]
Similarly, the Advance Notice announced the NCQA is retiring the HEDIS Osteoporosis Testing in Older Women measure, through the Health Outcomes Survey (HOS), due to concerns similar to the Rheumatoid Arthritis measurement, including data validity from patients’ abilities to recall past screenings and an emphasis on claims generated outcomes data.[48] CMS seems to be raising the bar for measurement evaluation criteria for Star measurements focusing on evidence-based effectiveness and high reliability, and documented processes for beneficiaries versus allowing plans to use limited or “completion” actions, to meet Star requirements.
Proposed Measure Updates
Updates to the Improving or Maintaining Physical Health Measure and Improving or Maintaining Mental Health Measure From the HOS
CMS welcomes comments on proposed substantive updates for two HOS measures: (1) Improving or Maintaining Physical Health Measure; and (2) Improving or Maintaining Mental Health Measure.[49] The change for both measures reflects CMS’ direction to continue analyzing data based upon risk adjustment (RA) and case-mix adjustments (CMA) to ensure patient populations are appropriately measured and compared.[50]
CMS explains, “Case-mix adjustment (CMA) is critical to measuring and comparing longitudinal changes in the physical and mental health of beneficiaries across MA contracts through the PCS and MCS measures.”[51] CMS proposed to adjust CMA differences by “providing a case-mix adjuster if one does not exist through the replacement of the mean value for that adjuster for other beneficiaries in the same contract who also supply data for the PCS/MCS measures.”[52] This departs from the current practice, which “results in a reduced number of case-mix variables used for a beneficiary because it does not use any of the case mix variables in a group of adjusters if one is missing from the group.”[53] The second proposed change for the measurements includes increasing the minimum required denominator from 30 to 100 for the two measures to better align with the HEDIS denominator for the HOS survey for increased statistical reliability.[54]
The changes highlight CMS’ efforts to use risk adjustment and valid data collection strategies to evaluate success. Plans could comment on how CMS does not seem to account for uncontrollable and unpreventable patient circumstances which can affect short-term mental and physical health when the beneficiary completes the survey.
For example, a broken bone or grief due to the loss of a loved one during the survey could affect how the patient feels about the patient’s personal physical or mental health status when the survey is conducted, yet not be entirely reflective of the beneficiary’s and plan’s efforts and progress to improve physical and mental health throughout the overall year.
Statin Use in Persons with Diabetes (Part D)
CMS welcomes comments on its proposal to modify the classification of the Statin Use in Persons with Diabetes (SUPD) measure to change from an intermediate outcome measure to a process measure starting with the 2023 Star Ratings in response to opposing commentary of SUPD as an intermediate outcome measure.[55] The SUPD measure did not increase in weight for the 2020 Star Ratings.[56]
Proposed Measures Additions
Transitions of Care, Readmissions, and Follow-Up
Health plans can influence quality and meet Star measures through coverage of services and days in the hospital, post-discharge medications, skilled nursing care, and supplemental benefit coverage tools, such as devices for remote patient monitoring, to help reduce readmissions through improved transitions of care.
CMS proposes to add two new Part C measures to the Star Ratings program to improve continuity and transitions of care, including the HEDIS Transitions of Care (TRC) measure and the HEDIS Follow-up after Emergency Department Visit for Patients with Multiple Chronic Conditions (FMC) measures.[57] CMS stated it is “working with NCQA to expand efforts to better evaluate a plan’s success at effectively transitioning care from a clinical setting to home.”[58] Both measures will be added to the 2023 Star Ratings and Display Page for three years before its addition to the Star Ratings program.[59]
Plan All-Cause Readmissions
CMS Star measures largely focus on preventive care to prevent costly hospitalizations. However, the measures will soon likely also focus on addressing costly readmissions based on CMS’ stated intent for the Transitions of Care Star measure.[60] The Plan All-Cause Readmissions (PCRs) Star measure may reflect CMS’ efforts to penalize health plans for readmissions similar to how hospitals are penalized for readmissions through CMS’ Value Based Purchasing (VBP) programs. While CMS’ financial penalties for readmissions have not largely forced hospitals and health plans to focus on strategic initiatives to reduce readmissions, MA health plans could evaluate how a high readmission rate could affect Star Ratings, particularly when combined with the new Transitions of Care and ER Follow-Up measures.
If transitions of care and ER follow-ups are effectively conducted, plans could help ensure patients receive a higher quality of care while Star Ratings improve and capitated Per Member Per Month (PMPM) savings increase.
Transitions of Care
CMS’ “intent of [the Transitions of Care] measure is to improve the quality of care transitions from an inpatient setting to home, as effective transitioning will help reduce hospital readmissions, costs, and adverse events.”[61] Currently, the HEDIS Transitions of Care measure requires four steps: “(1) notification of inpatient admission and discharge; (2) receipt of discharge information; (3) patient engagement after inpatient discharge; and (4) medication reconciliation post discharge.”[62] The NCQA is considering three non-substantive transitions of care measure changes that will likely increase ways health plans can meet measure requirements to demonstrate compliance.[63]
The first proposed change, “for all measure indicators, is to broaden the forms of communications from one outpatient medical record to other forms of communication such as admission, discharge, and transfer record feeds, health information exchanges, and shared electronic medical records.”[64] The second proposal clarifies the timeline for inpatient admission notifications and receipt for discharge information “to ‘on the day of admission or discharge or within the following two calendar days.’” [65] The third proposal changes the requirement for the Receipt of Discharge Information indicator from giving instructions to “the primary care providers or ongoing care provider for patient care,” to instead, “instructions for patient care post-discharge.”[66]
Notably, the measure “excludes members in hospice and is based on the number of discharges, not members.”[67] Health plans may consider how to educate appropriate patients on potential benefits of hospice care, to allow interested patients a dignified end of life care experience, based on informed decision making, which may better meet their personal needs and wishes for comfort.[68]
The proposed changes reflect CMS’ efforts to standardize expectations and timelines for care. CMS’ acknowledgement of how interoperability challenges affect demonstrated completion of Star measurements with its proposed response to broaden accepted forms of communication could also be helpful for health plans.
HEDIS Follow-Up after Emergency Department Visit for Patients with Multiple Chronic Conditions
The HEDIS Follow-up after Emergency Department Visit for Patients with Multiple Chronic Conditions measure includes adult patients with two or more specified chronic conditions receiving “a follow-up service within 7 days of the ED visit between January 1 and December 24 of the measurement year.”[69]
Notably, the requirement is a service, not necessarily a follow up visit, and includes services like telehealth services, telephone calls, case management visits, complex patient management, behavioral health visits, as well as an “outpatient visit (with or without telehealth modifier)” to address “complex care needs” and “help prevent the development of more severe complications.”[70]
Plans have time to begin developing processes to effectively reach out to MA beneficiaries after ED visits through innovative leveraging of resources and technology to reach patient populations, who can sometimes be challenging to contact after discharge. Moreover, plans also can begin developing ways to meet other Star measures during the follow up service to improve Ratings, such as asking about past due preventive screenings.
The NCQA is considering an update to the HEDIS measure for “Hospitalization for Potentially Preventable Complications,” including the removal of “hospitalizations without an overnight stay” from the [ ] numerator and aligning the value sets with . . . related AHRQ Prevention Quality Indicators and . . . updates to the risk adjustment model used for the measure.”[71] Processes to prevent unnecessary readmissions, with appropriate documentation to increase risk adjustment scores, could help meet these quality indicators.
Care for Older Adults – Functional Status Assessment Indicator
CMS proposes to remove the fourth option to complete and document a Functional Status Assessment from the “Care for Older Adults” measurement based on the NCQA’s removal of the fourth option.[72] The proposed change will display for 2022 and 2023 Star Ratings and be in future rulemaking.[73] NCQA’s choice is based on the “clinical field” . . . “moving toward agreement” on standardization of the clinical assessment.[74]
The Functional Status Assessment change is similar to the removal of the Rheumatoid Arthritis Management measure as CMS seems to be proposing to eliminate measures that do not represent standardized, evidence-based practices.[75] The measure is on the Display Page for 2022 and will be in future rulemaking for 2023 Star Ratings.[76]
Reviewing Appeals Decisions
CMS, in the Advance Notice, changed the deadline for Star Ratings appeals and the Complaints Tracking Module (CTM) measure data submissions, from May 1 to June 30,[77] noting the change was in consideration of feedback from plans. Overturned reopenings of IRE decisions could improve Star Ratings, although changes are expected to be minimal, “as reopenings are infrequent.”[78]
Controlling High Blood Pressure
The proposed change for the Controlling High Blood Pressure measure will likely better evaluate and demonstrate sustained improvement of controlled blood pressure through the incorporation of set time parameters.[79] “A minimum six-month window for interventions that might assist in bringing members’ blood pressure under control” would be used to evaluate progress, “effectively narrow[ing]” the denominator of patients covered by the measure.”[80]
Patients with a diagnosis of “hypertension in the first six months of the measurement year or prior year” would be included in the denominator.[81] This change would exclude patients receiving treatment for short periods of time from influencing scores as part of the denominator the same way patients on treatment for months affect the measurement.[82] Notably, the weight for Controlling High Blood Pressure will increase from a weight of one for the 2022 Star measure to a weight of three for the 2023 Star measure.[83]
Other Measurement Areas
Extreme and Uncontrollable Circumstances
CMS acknowledges natural disasters can affect performance measurement in the Star Ratings program and intends to use the “same policy as used for adjustments to 2020 Star Ratings based on extreme and uncontrollable circumstances”[84] for CY 2021. CMS welcomes feedback “for contracts impacted across multiple years.”[85]
Potential Future Star Measurements and Changes
Pharmacy Agreements, Performance, and Opioids
CMS stated it may propose Part D Star Ratings through the “assessment of a Part D plan sponsors’ uptake of a standard set of pharmacy performance measures or [measures] that evaluate the percent of high-performing pharmacies in the sponsors’ pharmacy network.”[86] Required disclosures for measures used to evaluate pharmacy performance according to “the plan’s network pharmacy agreement,” may also be used to set future Star Ratings measurements.
The following Part D opioid related measures are likely to become future Star measurements and will be added to the Display Page for 2021:[87]
- Concurrent Use of Opioids and Benzodiazepines;
- Use of Opioids at High Dosage in Persons Without Cancer;
- Use of Opioids from Multiple Providers in Persons Without Cancer;
- Use of Opioids at High Dosage and from Multiple Providers in Persons Without Cancer.
Also, Initial Opioid Prescribing for Long Duration (IOP-LD) may be a future Star measurement progressing through the rulemaking process once CMS “gains[s] experience with the measure.”[88]
Medication Adherence (ADH) for Hypertension (RAS Antagonists), Medication Adherence for Diabetes Medications, and Medication Adherence for Cholesterol (Statins)
CMS “will consider implementation of the PQA recommendations in the future for these Star Ratings measures (i.e., for the 2022 measurement year or beyond)”[89] for ADH, RAS Antagonists, and Statin Adherence. The PQA’s recommendations included the three Medication Adherence measures to be risk-adjusted for socioeconomic status (SES) or sociodemographic status (SDS) to account for differences and realistic abilities for patients to be compliant among various SES and SDS populations.[90]
CMS’ acknowledgment of the need for SES and SDS is significant for risk adjustment factors and population health efforts. SES and SDS factors significantly affect medication adherence and affordability, transitions of care, and whether the care provided can be sustained once the patient leaves a hospital facility through compliance with discharge instructions, follow up appointments, and access to nutrition and stable home environments. MA plans could consider how supplemental benefits could help patients within certain SES and SDS thresholds. As SES and SDS factors are considered to identify populations’ true barriers to health, CMS can use documented data to create and enforce reimbursement and incentive structures necessary to reimburse providers and health plans based on risk-adjusted patient populations.
Prior Authorizations
CMS noted its goal to develop a Display Page measure for Prior Authorizations “as a Star Ratings measure to support beneficiary access to necessary and reasonable care” [91] in the Advance Notice. Although CMS acknowledged how prior authorizations help contain costs, CMS stated it “recognizes that when processes are not in place to quickly review and approve requests for tests, services and supplies that may be medically necessary for the beneficiary, this can affect access to needed patient care.” [92] CMS welcomes feedback on quality measures to assess how well plans “administer and automate electronic prior authorizations.”[93]
Cross-Cutting Exclusions for HEDIS
CMS welcomes feedback as the NCQA develops cross-cutting exclusions for HEDIS measures including how to identify and measure the quality of care provided to patients “who require nursing home level care but who reside in the community” and patients electing palliative care.[94] The NCQA emphasize the importance of “clinically appropriate”[95] quality measures so specific quality of care issues are not overlooked for these patient populations as well as similarly unique populations. Given the likelihood of future application, MA plans could contribute ideas on how to measure and identify populations so appropriate patients and quality measures are included in future Star measurements and supplemental benefit options.
Patient-Used Device Data for HEDIS
CMS notes the NCQA’s intent to continue adding CPT codes for technological devices which provide “additional sources of data” to meet measures including the “incorporat[ion] of data from patient-used devices.”[96] An example by CMS is a home blood pressure monitor device, which can digitally send patient readings to providers, to meet the HEDIS Controlling High Blood Pressure numerator measurement.[97]
CMS states, the “NCQA is looking forward to the wider use of other technologies that facilitate the incorporation of patient data into clinical data repositories in the future,” likely signaling CMS’ intent to continue leveraging technology to add to its “data repositories.”[98]
Since MA plans can use supplemental benefits for remote monitoring and devices, plans could comment on needed CPT code coverage and begin strategically developing programs in preparation for CMS’ likely expansion of data collection methods to meet Star measurements in the future.
Digital Specifications for HEDIS
CMS “strongly encourage[s] MA contracts to begin using and referencing [ ] digital specifications.”[99] MA plans can likely expect future digital specification requirements with CMS’ encouragement for MA plans to use and reference HEDIS digital specifications for “greater specificity and standardization of the language used to define the measure data elements,”[100] specifically, since the NCQA continues to develop and add digital specifications for HEDIS measures.[101] According to CMS, “digital specifications are produced using clinical quality language (CQL) and standard terminologies and may reference clinical concepts directly in addition to using claims-based proxies for measure definitions.” [102]
Data Integrity
CMS also clarified “rules around consolidations when data are missing due to data integrity concerns and add[ed] several technical clarifications.”[103]