September 11, 2023
Chiquita Brooks-LaSure, Administrator
Centers for Medicare & Medicaid Services
Department of Health & Human Services
Hubert H. Humphrey Building
200 Independence Ave. SW
Washington, DC 20201
Dear Administrator Brooks-LaSure:
The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to provide feedback on the Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems Proposed Rule.
NCQA is a private, 501(c)(3) not-for-profit, independent organization dedicated to improving health care quality through our Accreditation and measurement programs. We are a national leader in quality oversight and a pioneer in quality measurement. Leveraging our strengths as a trusted third party, we are committed to helping organizations navigate the challenges associated with moving to an equitable health care system. Our mission to improve the quality of health for all Americans, with a focus on health equity and support for meaningful value-based payment models, propels our daily work.
We are pleased to provide comments in the following areas:
- Advancing Health Equity through OPPS and ASC. We applaud CMS’s efforts to advance equity across all payment programs and encourage the use of health equity accreditation programs to strengthen ongoing efforts.
- Behavioral Health Services in Medicare. We support expansion of intensive outpatient services to more organizations and integration of behavioral health services in primary care settings.
- Changes to Quality Reporting. We encourage alignment of quality measures with the Universal Foundation and a continued transition to digital quality measures to improve quality for patients while decreasing the burden of measurement and reporting.
Advancing Health Equity through OPPS and ASC
As CMS weighs development of an impact analysis for OPPS and ASC populations, we encourage the use of Advancing Health Equity: A Measurement Framework for Accountability in Medicaid, a white paper published by NCQA’s Research team, as a guide. Through review of over 300 existing measure concepts across 6 domains—social interventions, access, clinical care, experience of care, structures of care, overall well-being—we detail how organizations can monitor to ensure that payment adjustments do not worsen health disparities or produce unintended results.
In our previous comments, we shared that the area deprivation index, the social deprivation index and the social vulnerability index are useful tools for adjusting payment to providers that participate in models of care and operate in communities with greater social needs and health inequities. However, we do not believe that such tools should be used for adjustment of outcome measures, because that can mask disparities. Stratification and reporting of results based on these indices is a better approach.
We strongly encourage CMS to require health equity plans in future OPPS and ASC rules.
NCQA agrees with the CMS National Quality Strategy’s aim to create a more equitable, safe, outcomes-based and person-centric health care system. We recommend CMS require health equity plans in the Conditions of Participation for hospitals, ambulatory surgical centers, and Community Mental Health Centers, and other Medicare and Medicaid participating providers. Additionally, CMS should exercise “deeming” for CMS-approved accrediting organizations, since many health care organizations use accreditation to create standardized, measurable health equity plans. NCQA believes accreditation can be a primary lever to advance health equity and create the necessary data collection and quality improvement processes to measure, report and improve patient outcomes. To date, over 150 organizations have earned Health Equity Accreditation (or its predecessor, Multicultural Healthcare Distinction) and 15 states have leveraged NCQA’s Health Equity Accreditation in some capacity.
Health Equity Accreditation is designed to guide health care organizations toward an internal culture that improves diversity, equity and inclusion, and reduces bias. Among other activities, the accreditation requires organizations to collect race, ethnicity, sexual orientation and gender identity information using standardized methods, and to identify opportunities to create (and offer) language services, written materials and networks that can meet their populations’ cultural and linguistic needs.
In 2021 and 2022, two health care systems (Novant Health, Hennepin Healthcare) joined seven health plans as inaugural participants to achieve NCQA’s Health Equity Accreditation Plus. This program builds on Health Equity Accreditation, its prerequisite, by requiring organizations also collect data on social needs and upstream social risks of the communities they serve, and to make data-driven decisions to improve members’ access to and experience with community-based partnerships and resources. Health Equity Accreditation and Health Equity Accreditation Plus are designed to incentivize improved health outcomes for all and alignment across the care continuum—they are available to provider groups, health systems, hospitals, ACOs, health plans and more.
Behavioral Health Services in Medicare
NCQA supports CMS’s continuing efforts to expand behavioral health services and ensure their accessibility for Medicare beneficiaries throughout the country. We are encouraged by the expansion of services to hospital outpatient departments, community mental health centers, Federally Qualified Health Centers, rural health clinics and opioid treatment programs. This builds on the goals of the Biden-Harris administration to embed and co-locate mental health and substance use providers into community-based settings. Further, this expansion of services creates consistency for patients as they are stepped down from a more intensive care setting.
As CMS seeks to expand community-based services, we strongly encourage development of a behavioral health quality framework centered on patient goals. We are humbled that CMS’s request for comment recognized the benefits of our report Behavioral Health Quality Framework: A Roadmap for Using Measurement to Promote Joint Accountability and Whole-Person Care. NCQA recently released Behavioral Health Care Integration: Challenges and Opportunities for Quality Measurement, which details current challenges to behavioral health quality measurement, and how solutions such as practice level resources, data infrastructure, data standards and the shift to digital quality measurement can improve measurement and reporting of integrated behavioral healthcare services. These works build on each other to promote availability and access to high-quality care, increase coordination of care, improve the patient experience and enhance patient-centered approaches to care.
To ensure that the patient voice is centered in care and measurement, NCQA with support from The John A. Hartford Foundation and The SCAN Foundation, developed, implemented and tested Person-Centered Outcome Measures. These measures are personalized, structured, measurable goals identified by a person with complex health status (or their caregiver) that can be used for both care planning and quality measurement. These measures are now being tested in behavioral health settings, and will make a strong contribution to advancing person-centered quality measurement. Clinicians across the care continuum—from primary care, to specialty care, to home- and community-based services—can use this measurement approach to elicit what is important to the person.
As CMS continues to transition Medicare beneficiaries to value-based care by 2030, NCQA is exploring ways to support patients, health care organizations, states and federal programs to create alignment and decrease reporting burden. We recognize the need to support patients in the appropriate level of care to improve long-term outcomes. We also understand the need to support alignment of measure reporting. We believe that with the right tools, developed through broad stakeholder engagement and an understanding of clinical assessments, health care organizations can improve patient outcomes and health care quality. This work builds on existing programs; for example, Distinction in Behavioral Health Integration, which helps primary care practices integrate behavioral healthcare, use independent behavioral health providers and train care teams to address patients’ mental health and substance use concerns; and NCQA’s Patient Centered Medical Home (PCMH) program, the most widely adopted PCMH program in the country.
Changes to the Quality Ratings System
Since the release of the CMS’ Universal Foundation, programs across CMS have signaled intent to align measures to decrease reporting burden. We were discouraged CMS did not include any reference to the Universal Foundation in this year’s OPPS rule. NCQA encourages CMS to align measure reporting with the Universal Foundation, where possible, in future OPPS rules. Focusing on a smaller group of measures also supports CMS’s Digital Quality Measurement Strategic Roadmap by allowing measure developers, providers, health plans and other stakeholders to transition to digital reporting for these measures first.
Digital quality measurement will allow CMS, providers and health plans to improve the accuracy and usability of measures and ratings, including outcome measures; tailor measurement to what is important to patients and caregivers; and reduce reporting burden. NCQA is committed to making measurement more accessible and actionable for improvement closer to the point of care, to help better manage populations, support more equitable care and drive improved health outcomes. This work builds on the goals of the CMS Behavioral Health Strategy, and can be used to speed development of increasingly accurate measures of care for chronic pain and suicide prevention.
Thank you for the opportunity to comment. We remain committed to working with CMS to build a more equitable, sustainable and responsible American health care system. We welcome further discussion to advance our shared goal of high-quality health care for all Americans. If you have any questions, please contact Eric Musser, Assistant Vice President of Federal Affairs, at (202) 955-3590 or at email@example.com.
Margaret E. O’Kane