December 21, 2015

Andrew Slavitt, Acting Administrator
Centers for Medicare & Medicaid Services

Thank you for the opportunity to comment on your effort to develop a star rating system for Financial Alignment Initiative Medicare-Medicaid Plans (MMPs). The National Committee for Quality Assurance (NCQA) agrees that there should be a star rating system tailored to the broader scope of benefits and the unique patient needs in these plans. We support your goals and proposed approach for achieving them overall. Our ongoing work to develop more appropriate standards and measures for these very types of plans and populations may provide insights on how to strengthen and refine your effort.

Community Integration/LTSS: We agree that you should include the measures on “Admission to an Institution (Nursing Facility or Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions) from the Community.” We also agree that the “Short Stay NF or ICF/IID Institution Discharge to the Community” and “Long Stay NF or ICF/IID Institution Discharge to the Community” measures hold promise. While these measures can provide valuable utilization information, CMS should not use them for accountability and comparison between plans without appropriate risk adjustment. Differences in state eligibility policies for nursing home level-of-care may significantly impact plan performance on these measures. Standardized data collection methods and definitions will also be essential for these measures to be useful for comparing performance across organizations or states.

We are concerned, however, about inclusion of the “Falls with Injury” measure in the “Adapted NF/Home Health/PACE Outcome Measures.” Falls with injury are important, but very difficult to define, verify, and standardize for measurement purposes across various settings, particularly in the home. In PACE and nursing facility settings with daily patient observation, falls measurement may be more feasible than in homes where falls are not directly observed and are dependent upon patient self-report. An additional concern with falls as an accountability measure is the potential unintended consequence of contributing to under-reporting of falls, as falls tends to be underreported by community-dwelling adults and providers do not regularly ask about falls. Holding plans accountable for the number of falls could adversely incentivize plans to not assess patient self-reports of falls. Pairing a falls with injury measure with a falls screening measure (such as NQF #101 Falls Risk Prevention: Screening, Assessment and Plan of Care) could reduce risk of this unintended consequence.

The MMP “Comprehensive Health Risk Assessment completion and Reassessments” measure needs a clear definition of what constitutes risk assessment. Currently, many programs require assessment but do not specify what domains to include. Risk assessment also needs to include domains beyond health, including assessment of individual patient’s personal goals, such as maintaining independence and getting out to family and social events, so providers develop care plans that help meet them.
In our research, we found that assessment of individual goals and building care plans around them is a hallmark of organizations with the longest histories of successfully integrating Medicare and Medicaid.

We are currently developing and testing two measures of comprehensive risk assessment for older adults with complex care coordination needs (under contract with CMS for Medicare Advantage) and comprehensive risk assessment for adults using Long Term Services and Supports (under contract with CMS for Medicaid Managed Long Term Services and Supports Plan measurement). These measures could be adapted for use in the dual eligible population and provide greater specificity about the elements that should be included in a comprehensive risk assessment measure.

We are updating our Health Plan and Case Management Accreditation programs to more fully address the issues of people using LTSS. This includes a requirement to incorporate individuals’ goals and preferences in care plans. We also are working to develop goal-based outcomes measures that reflect what is most important to people, as well as care coordination measures. This work could be an important part of an MMP star rating system. Our Policy Approaches to Advancing Person-Centered Outcome Measurement paper describes this work, and we would be happy to discuss it with you further.

Management of Chronic Conditions/Health Outcomes
: We agree with most of the proposed measures for this domain. However, this domain also should include patient-reported outcomes measures (PROMs) collected at the point of care to help promote self-care and inform care planning, quality improvement, and plan accountability. We are developing and piloting such measures with support from the Patient-Centered Outcomes Research Institute, John A. Hartford Foundation and The SCAN Foundation.

We also believe the care coordination measures currently under development for the Medicare Advantage star ratings program would be better than the “Care Transition Record Following Inpatient Discharge” measure. The Medicare Advantage measures are more comprehensive in assessing whether primary care providers are notified of admissions and receive a summary of care after discharge, and whether follow-up visits occur for patients with complex care coordination needs.

Prevention: Screenings, Tests & Vaccines: We support inclusion of this critical domain. However, you may want to examine the appropriateness of the proposed measures by subpopulations, as it could well vary. For example cervical cancer screening requires pelvic examination and can be traumatic for individuals with intellectual and developmental disabilities (IDD). Guidelines for IDD populations recommend cervical cancer screening at a less frequent interval than for the general population based on the shared decision making between the provider, individual and their family.

Safety of Care Provided
: This is another important domain to include. The “Use of High-Risk Medications in the Elderly” and “Potentially Harmful Drug-Disease Interactions in the Elderly” measures would help meet its goals. You might also consider evaluating use of physical and chemical restraints, such as inappropriate antipsychotics use in adults with dementia.

Member Experience with Medicare-Medicaid Plan & Service Providers: This domain needs a better way of measuring patient experience than the current CAHPS surveys that are costly to field and so long they yield low very response rates. CAHPS also provides feedback long after care delivery and without needed information on potential differences among subpopulations, which can vary substantially within MMPs and may have significantly different experiences.

A better tool would be shorter, collect information and provide feedback much faster, and in formats that are easier and thus generate higher response rates, perhaps via electronic methods. We would be happy to work with you to develop such a tool. You may also want to use adaptive design to obtain more data from patients with higher clinical needs without increasing overall sample size.

Methodological Issues
: We understand your interest in giving higher weights to outcomes over process measures. However, standard outcomes measures may be difficult to use in MMPs with their diverse and frail populations. For example, improved outcomes for some populations may not be possible and so the goal is to slow decline. Instead, you might again consider using PROMs, patient-generated goal outcomes measures, and process measures that incentivize use of PROMs.

Interim Quality & Performance Information on MMPs
: We support your proposal to not issue overall performance ratings until there are adequate measures to assess the full range of MMP functions, including long term services and supports. Provision of LTSS benefits sharply distinguishes MMPs from traditional Medicare managed care plans. You therefore cannot fairly and comprehensively assess overall MPP performance until adequate measures for these and other essential MMP benefits can be included.

Additional MMP Measures for Public Reporting: Finally, we support most of the measure you are proposing for public reporting. However, the “Utilization of the PHQ-9 to Monitor Depression Symptoms” PROM measure is more effective measure than “Screening for Clinical Depression and Follow-up.” The PHQ-9 measure uses patients’ own rating of their symptoms to not merely screen but also to monitor their progress and indicate when treatment may need to be adjusted.

We also are concerned that the “Care Planning” measure only assesses whether care plans were completed within established timeframes. It is much more important to assess whether care plans are comprehensive and aligned with patient-generated goals. We discuss this important difference in our Policy Approaches to Advancing Person-Centered Outcome Measurement paper and are working to develop such a measure.

Thank you again for inviting our comments. If you have any questions, please contact Paul Cotton, Director of Federal Affairs, at or (202) 955 5162.


Margaret O’Kane,