January 9, 2017
Seema Verma, Administrator
Center for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244
Dear Administrator Verma:
Thank you for the opportunity to comment on proposed Medicare Advantage and related program changes for 2019. The National Committee for Quality Assurance (NCQA) strongly supports letting plans limit opioid prescriptions to specific prescribers and pharmacies for at-risk beneficiaries. This closely parallels our new HEDIS® opioid measures that track high dosages and multiple prescribers. We urge you to add these and other behavioral health measures to the Medicare Advantage Stars to emphasize their importance with the powerful Stars bonus and rebate financial incentives.
We also support letting plans reduce cost sharing for certain benefits, tailor supplemental benefits, and vary deductibles for patients with specific medical criteria. Experience with such value-based insurance design in employer plans shows that it can increase use of high-value treatments and providers in ways that lower overall costs and disease burden over time.
We support adding anti-fraud efforts and Medication Therapy Management (MTM) program costs to the medical loss ratio. Both improve quality and should count as other quality efforts do. We do not support, however, letting plans merely report medical loss ratio percentages rather than specific details, as that would limit the ability to track spending on quality improvement and assess its impact.
We further support changing policy on Star ratings when plans consolidate. The proposal to base ratings on enrollment-weighted scores is better than allowing plans to apply a higher rating from a remaining contract to consolidated lower-rated plans in other states. However, it would be much better to issue contract numbers and base ratings at the state level. This would provide a more accurate assessment of actual plan quality that beneficiaries need to make truly informed decisions.
We also have concern about ending the “meaningful difference” requirement for plans offered by the same issuer. This could lead to “choice overload” that makes it difficult for beneficiaries to choose the best plan. It would not encourage innovation, as suggested, since true innovation by definition should provide a meaningful difference.
Detailed comments on these and other issues in the proposed rule are below.
Opioid Limits: We strongly support the proposal to let plans limit opioids to certain prescribers and/or pharmacies for enrollees at risk of addiction. This is an urgently needed policy that can help to address the opioid epidemic sweeping our nation. It also parallels our new HEDIS opioid measures:
· Use of Opioids at High Dosage. This measure assesses the rate of health plan members 18 years and older who receive long-term opioids at high dosage (average morphine equivalent dose >120mg) for 90 consecutive days or longer.
· Use of Opioids from Multiple Providers. This measure assesses the rate of health plan members 18 years and older who receive opioids from 4 or more prescribers and 4 or more pharmacies.
High dosages, along with multiple prescribers and pharmacies, are all risk factors for dangerous overdose and death. Our intent is for these measures to encourage health plans to address the opioid epidemic and track their progress.
These measures are among a growing suite of behavioral measures we have or are now developing because behavioral health conditions are substantially undertreated and strongly associated with increased physical health need. We also have measures addressing the many behavioral and mental health treatments that have significant side effects that require careful monitoring and treatment. We include a list of all these measures in Appendix A. We urge you to add these measures to the Star Ratings to make improving behavioral and mental health care a Medicare Advantage priority.
Value-Based Insurance Design (VBID): We support allowing plans to reduce cost sharing for certain benefits, tailor supplemental benefits, and vary deductibles for patients with specific medical criteria. Experience with such value-based insurance design in employer plans shows that it can increase use of high-value treatments and providers in ways that lower overall costs and disease burden over time.
Reduced cost sharing for highly effective preventive services and chronic care therapies addresses financial barriers that can prevent people from getting needed care and improves adherence to high-value treatments. This in turn can prevent costly complications and yield net savings.
There is already substantial evidence on the powerful benefits of VBID.
· Private employers like Pitney Bowes have found significant savings from reduced cost sharing for essential diabetes treatments.
· The Oregon Public Employee’s and Educators Benefit Board’s extensive VBID program improved HEDIS scores, increased use of preventive services, and provided substantial savings.
· The U.S. Department of Health & Human Services prominently features VBID in its National Quality Strategy.
· And the University of Michigan Center for Value-Based Insurance Design tracks case studies and more at http://www.sph.umich.edu/vbidcenter.
This provides more than sufficient evidence to incorporate VBID throughout the Medicare Advantage program as proposed while the Medicare Advantage-specific VBID demonstration program progresses and develops further evidence on its efficacy.
Default Enrollments: To ensure quality when allowing passive enrollment into Medicaid plans after non-renewal of a plan serving people dually eligible for Medicare and Medicaid, we urge you to require NCQA performance-based Accreditation. We publicly report on the quality of all NCQA-Accredited plans including Medicaid plans. Most states require or recognize NCQA Accreditation for their Medicaid plans. We also have the only program accrediting plans providing long-term services and supports (LTSS), which some states require in Medicare-Medicaid Financial Alignment demonstrations. These features of NCQA’s Medicaid Accreditation program provide the detailed assessment of quality needed for determining which plans should qualify for default enrollments. NCQA-Accredited plans also perform demonstrably better on key quality indicators such as Medicare Star Ratings.
Medical Loss Ratio: We support adding anti-fraud efforts and Medication Therapy Management (MTM) program costs to what counts as medical spending for the medical loss ratio. Both anti-fraud efforts and MTM programs help to improve quality and should count, as other quality efforts already do. Fraud, for example, can include claims for needed care not delivered and delivery of unnecessary care, both of which have potential to cause physical as well as financial harm to enrollees. MTM programs focus on appropriate drug utilization among patients with complex care needs, for whom inappropriate utilization can be common and especially problematic.
We do not support, however, letting plans merely report medical loss ratio percentages rather than specific details, such as quality improvement activity spending. Doing so would limit the ability to track spending on quality improvement and assess the degree to which the size and type of specific efforts result in better outcomes. If you do let plans simply report percentages, we urge you to conduct random audits to guard against the significant potential for gaming.
Open Enrollment: We appreciate the concern for consumers suggested by the proposal to let beneficiaries make an additional plan switch as late as March 31, rather than February 14 as under current policy. We note, however, that doing so will impact Medicare Advantage Star Ratings, as many measures require more than 9 months of continual enrollment. Enrollees who switch as late as March 31 will not be eligible for inclusion in denominators for several measures. While the number of enrollees who make such changes will likely be small, one result will be a less robust picture of quality.
Improving Measures: Regarding your inquiry on how to improve measures to better reflect the quality of outcomes, we urge you to develop measures and systems to reward plans for reducing disparities in care. Racial, ethnic and other socioeconomic disparities persist throughout our healthcare system. However, our own internal analysis shows that Medicare Advantage plans with high levels of low-income enrollees nonetheless are able to achieve high quality in all parts of the country. It is therefore clearly possible to reduce and ultimately eliminate disparities in Medicare Advantage, and to rate each Medicare Advantage plan on disparities. Doing so would provide a powerful incentive for all plans to achieve the low rates of disparities that we found in our analysis.
To improve Star Ratings overall, you could reward plans for reporting via electronic clinical data systems, such as provider electronic health record data. Electronic health data would allow for measurement of meaningful outcomes that we cannot assess with claims data or without burdensome medical record review. CMS established precedent for this in Medicare Access & CHIP Reauthorization Act Merit-based Incentive Payment System regulations providing end-to-end electronic reporting bonus points. Electronic reporting can enhance the ability to audit and ensure accuracy.
Geographic/Market Area Characteristics: We are skeptical about potentially adjusting Star Ratings for geographic factors such as serving areas that are rural or dominated by provider monopolies. Doing so could dis-incentivize plans from striving to provide the highest quality in all areas they serve. Any such adjustments, if made, should be to payments, as CMS is doing for plans with enrollees who are dually eligible and/or disabled. You should not adjust Star Ratings directly, as that would merely mask without actually addressing any related quality issues.
New Entrants: To level the field on quality between new and experienced Medicare Advantage plans, you could temporarily enhance new entrants’ scores based on NCQA performance-based Accreditation.
NCQA-Accredited plans perform better on many Stars measures, including measures of prevention, appropriate treatment and patient experience. Therefore NCQA Accreditation is a strong proxy for high quality that you could rely on for new plans.
Physician Experience: We believe you should measure and reward plans for the experience they provide to physicians and other clinicians, as plan-clinician relationships are a critical factor in maintaining and improving quality. Clinician experience measures could, for example, assess the frequency and substance of feedback from plans to providers on gaps in care, resource use, and other quality issues on which plans and clinicians achieve the best results when working together as partners.
Contract Consolidations: We, like the Medicare Payment Advisory Commission (MedPAC) and others, believe it is urgently important to change current policy that lets plans apply a higher rating from a remaining contract to lower-rated plans in other states when issuers consolidate contracts. However, using enrollment-weighted averages of scores among consolidating plans would still give lower-rated parts of consolidated contracts higher scores than they have earned. This would mislead enrollees and unfairly skew quality-based bonuses and rebates intended to drive enrollees to genuinely higher-rated offerings.
A better approach would be to issue contract numbers and base Star ratings at the state level. This would provide a more accurate quality assessment to help beneficiaries make informed choices and better ensure that quality bonuses and rebates drive enrollment to the highest quality offerings.
Adding, Updating & Removing Measures: We appreciate interest in moving measure updates from sub-regulatory methods to the Federal Register, and related changes in the timeline for changing measures. We also agree it is critically important to continue allowing some sub-regulatory changes, such as for updated clinical guidelines or reliability issues. However, you should not put measures on the Display Page for two years when measure stewards decide to update rather than remove them. This will lead to unnecessary gaps in measurement for critically important issues for which plans need to be accountable.
We recommend moving the Plan All-Cause Readmission measure to the display page for measurement year 2019 due to significant changes we are considering. We plan to publish these changes in 2018 and then to apply them in measurement year 2019.
Additional measures for which we plan revisions in the next two years include:
- Care for Older Adults Medication Review, Functional Status Assessment and Pain Assessment: We are developing a new measure – Health Assessment for People with Multiple High-Risk Chronic Conditions – that would potentially replace the Care for Older Adults measure for HEDIS 2020 (measurement year 2019). If approved, we plan to publish these changes in 2018 and to apply them in measurement year 2019 to all Medicare Advantage Plans.
- Controlling Blood Pressure: We are updating this measure based on new guidelines published in late 2017 and the changes could be substantial. If approved, we plan to publish the changes in 2018 as part of the HEDIS 2019 publication.
- Osteoporosis Management in Women who had a Fracture: We are planning to re-evaluate this measure for potentially substantial revisions that we would publish in 2019.
- Rheumatoid Arthritis Management: We are planning to re-evaluate this measure for potential revisions or retirement that we also would publish in 2019.
- Medication Reconciliation Post-Discharge: We plan to retire this measure pending first-year analysis of an identical indicator in the Transitions of Care measure, which should replace it.
- Risk of Chronic Opioid Use: We are developing this measure for HEDIS 2020 (measurement year 2019). If approved, we will publish it in 2019 and it would apply to all Medicare Advantage Plans.
- We also are developing a measure specified for electronic reporting to assess receipt of recommended adult immunizations. It will incorporate Pneumococcal Vaccination Coverage for Older Adults, which would cease to be a stand-alone measure.
Patient Experience, Complaints & Access Measures: We appreciate your interest in potentially increasing the weight for such measures from the current 1.5 to 3. These measures are critically important and could benefit from greater attention from plans that increased weighting generates. However, we encourage you to not move forward on this until we have better measures in these areas. The Consumer Assessment of Health Plans Survey (CAHPS) is long and has low responses and long lags in feedback that does not target which enrollees are having what types of problems. Complaint measures also merely assess raw numbers and do not yet differentiate between low-level issues, multiple calls from the same enrollee, and other important distinctions. Once we have better measures in these areas, it would make sense to consider increasing the weights.
Meaningful Difference: We do not support the proposal to repeal the “meaningful difference” requirement for plans offered by the same issuer. Allowing issuers to offer plans in the same locations that do not provide substantially different benefit packages could lead to “choice overload” and make it difficult for beneficiaries to choose the best plan. Removing the meaningful difference requirement will not enhance competition, as choices lacking meaningful difference only foster confusion. It also will not encourage innovation, since true innovation by definition should provide a meaningful difference.
Thank you again for inviting our comments. If you have questions, please contact Paul Cotton, Director of Federal Affairs, at firstname.lastname@example.org or (202) 955-5162.