October 21, 2022
Centers for Medicare and Medicaid Services
Department of Health & Human Services
Hubert H. Humphrey Building
200 Independence Ave., S.W.
Washington, DC 20201
Dear Administrator Brooks-LaSure:
The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to provide feedback on the proposed rule for Medicaid Core Set Reporting.
We applaud CMS’s efforts to standardize measurement and stratifications across state Medicaid programs, and we appreciate the intense effort it will take to support states in their endeavor to achieve a valid and reliable measurement approach across delivery systems, demographic make-up, and Medicaid coverage.
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 digital quality measurement. Leveraging our strengths as a trusted third party, we are committed to helping organizations navigate the challenges associated with transitioning to a digital future. Our mission to improve the quality of health for all Americans, with an intentional focus on health equity and support for meaningful value-based payment models, propels our daily work.
NCQA has a unique, and longstanding perspective on standardizing measurement at a national level. We receive audited Medicaid health plan HEDIS® results from 42 states and Puerto Rico, representing 65 million Medicaid covered lives. In addition, our Measure Certification program validates measure logic used to calculate results for non-plan level reporting and adjusted HEDIS measures used by health systems and providers. We appreciate the opportunity to share our decades of experience in designing and improving a valid and reliable measurement system that can evolve and maintain its integrity.
NCQA is pleased to offer our comments of support and recommendations for how to evolve the Medicaid Core Set reporting requirements to ensure that CMS can promote improvements in quality and reductions in disparities across the country.
Summary of Public Comment
We support CMS’s policy goals and the historic efforts embodied in the Core Set Measure reporting process, and we respectfully submit comments regarding:
- Aligning Core Set measure reporting requirements with predominant measurement system practices that ensure valid and reliable comparison.
- Leveraging the Core Set Measure reporting mandate to promote the current transition to digital measurement.
- Supporting states through technical assistance, learning collaboratives, and pilot programs as they build capacity to meet reporting requirements.
Aligning With Digital Transformation
As we evolve our measure portfolio to drive toward a digital future, we believe aligning NCQA’s measure roadmap and the Core Set Measure reporting process can be a critical pathway for states to support:
- Measuring and aggregating quality data across all levels of the delivery system.
- Adopting multiple measures in addition to HEDIS and other use cases (not limited to reporting).
- Enhancing data quality, validation and administration of targeted quality improvement programs.
- Developing new measures, such as patient-reported outcomes, that can promote patient engagement, interact with clinical support guidelines, and return real-time insights.
Below we offer comments and recommendations for ways to support states on their journey to reporting for the Core Set:
Aligning with Existing measurement systems
Continue allowing states to report using audited MCO HEDIS rates. The proposed CMS Core Set measure lists many HEDIS measures. Many states use audited HEDIS rates reported by their Medicaid managed care organizations to report Core Set measures. We encourage CMS to allow states to continue this practice because it is an efficient method for reporting performance rates that support comparability across Medicaid MCOs and managed care states. In addition, states can immediately meet the reporting mandate without duplicating efforts or cost, while providing CMS with comparable performance rates.
Align stratified HEDIS reporting requirements. NCQA began phasing in stratification of HEDIS measures by race and ethnicity for measurement year 2022. All plans reporting these measures must use the stratification, thus yielding a standardized national health plan dataset on a growing set of clinical measures, which is anticipated to support benchmarking.
The table below includes the measures and timeline for reporting by race and ethnicity. NCQA will continue adding measures in subsequent HEDIS releases. We welcome the opportunity to work with CMS to ensure alignment between NCQA HEDIS stratifications by race and ethnicity and the CMS Core Set measure stratification requirements.
Alignment will maintain the efficiency gains of leveraging the HEDIS process, as well as the integrity of comparison across Medicaid MCOs and managed care states. Leveraging stratified HEDIS measures will provide valid, reliable data on inequities, which CMS can use immediately to pilot policy solutions to address identified disparities.
HEDIS Measures Stratified by Race and Ethnicity, by HEDIS Measurement Year
|HEDIS Measure||First MY of HEDIS Stratification||Adult FFY 2023 Core Set||Child FFY 2023 Core Set 2023|
|Child and Adolescent Well Care Visits||HEDIS MY 2022||ü|
|Colorectal Cancer Screening||HEDIS MY 2022||ü|
|Controlling High Blood Pressure||HEDIS MY 2022||ü|
|Hemoglobin A1c Control for Patients With Diabetes (indicators for A1C >9 and|
|HEDIS MY 2022||ü|
|Prenatal and Postpartum Care||HEDIS MY 2022||ü||ü|
|Adult Immunization Status||HEDIS MY 2023||Recommended for addition to|
FFY 2023 Core Set
|Asthma Medication Ratio||HEDIS MY 2023||ü||ü|
|Breast Cancer Screening||HEDIS MY 2023||ü|
|Follow-Up After Emergency Department Visits for Substance Use||HEDIS MY 2023||ü||ü|
|Immunizations for Adolescents||HEDIS MY 2023||ü|
|Initiation and Engagement of Substance Use Disorder Treatment||HEDIS MY 2023||ü|
|Pharmacotherapy for Opioid Use Disorder||HEDIS MY 2023|
|Well-Child Visits in the First 30 Months of Life||HEDIS MY 2023||ü|
We acknowledge that HEDIS does not yet stratify measures by other categories in the proposed rule, such as disability, age, gender and language. We have received stakeholder feedback on incorporating these additional stratifications—building on our work to promote reduction in racial and ethnic disparities. We welcome the opportunity to coordinate with CMS to add these stratifications.
Standardize Measurement With Valid Data Across Medicaid programs and Populations
Ensure comparable rates across populations and delivery systems. Given our experience implementing a standardized set of clinical and patient experience measures nationally for over 30 years, we recognize the importance of standardization and validation for comparability purposes. Comparability is critical to meeting CMS’s policy goals, as outlined in the proposed rule. We encourage CMS to promote standardized reporting across states, including removing the ability for states to make unique adjustments when reporting.
We acknowledge that the current HEDIS reporting process is limited to reporting health plan performance, and it cannot holistically achieve CMS’s goals within the Core Set Measure reporting proposed rule. We are excited about the opportunity presented to CMS, states and Medicaid beneficiaries by the proposal to assess Core Set measures by delivery system and population.
NCQA suggests CMS consider developing a third-party validation process that certifies state measure logic and audits IT/measurement systems in a standardized way. Standardization of these processes encourage valid, reliable comparison to inform CMS’s goal of promoting best practices that improve quality and reduce disparities. NCQA’s Measure Certification, HEDIS Compliance Audit™, and the External Quality Review performance measure validation protocol are examples of best practices. Three States have HEDIS certification agreements with NCQA, and many states are supported by certified vendors. This would be particularly important for states that are predominantly fee for service. Certifying results from FFS states in a similar fashion to managed care states will bolster comparability.
Encourage comprehensive data types for measure reporting. While the proposed rule does not detail CMS’s vision for digital quality measurement or for supplementing measure performance rates with clinical data, we recognize that this is part of the Administration’s Digital Quality Measure Strategic Roadmap. NCQA has a defined measure roadmap and is progressing toward a digital future by establishing the Electronic Clinical Data System (ECDS) reporting method, which standardizes the use of clinical data for HEDIS measure reporting and eliminates the need for chart reviews for measure reporting. Consistent with the recommendation to report audited HEDIS rates for Core Set measures, we recommend CMS consider encouraging states to require their MCOs to use the ECDS reporting method for applicable Core Set measures. We welcome the opportunity to work with CMS to expand the data types used to report these measures. This will continue to reduce the burden of reporting for a subset of measures and will promote CMS’s long-term goal of leveraging interoperable digital health data for quality measurement. Aligning the Core Set measure reporting mandate with the Digital Quality Measure Strategic Roadmap will enhance a state Medicaid agency’s role in supporting the transition to digital quality measures and will expand the use of state/federal matching funds in pursuing that aim.
Validating supplemental data from the source. We recognize the credibility of claims data, given the legal and financial parameters supporting the data’s integrity, and NCQA is committed to promoting the same level of credibility for clinical data. In 2020, we launched our Data Aggregator Validation program, which verifies clinical data for use by Medicaid MCOs for HEDIS reporting.
Twenty-two organizations have successfully completed this program, which also highlights improvements in data transformation and data management practices to continuously enhance the credibility of clinical data for reporting. We encourage CMS consider the opportunities the Data Aggregator Validation program offers to state and federal stakeholders to promote the use of clinical data for reporting while ensuring measurement system integrity. Increasing the use of clinical data—which guide provider application of evidence-based medicine—in evaluating health care system performance will enhance the rigor of evaluation and the influence of policy interventions such as value-based purchasing and payment.
As technologies advance (e.g., FHIR®) and additional aspects contributing to measurement integrity emerge, NCQA will evolve the Data Aggregator Validation program to ensure ongoing, credible use of electronic data sources and clinical data for quality measurement.
NCQA’s Efforts to Reduce Burden and Error in Measure Calculation
This year, NCQA launched a pilot with vendors, health plans and a health system to finalize software development requirements for a digital quality solutions software product. While the initial pilot focused on verifying use of a subset of HEDIS measures, NCQA envisions expanding software capabilities to include non-HEDIS specified measures. The software will alleviate the burden of building and certifying measure logic. We welcome the opportunity to partner with CMS in piloting the software with federal and state stakeholders to support the Core Set measure reporting mandate and policy goals.
Considerations for reporting on behalf of states. While we support CMS’s efforts to use existing data sources to analyze state Medicaid performance, we encourage CMS to exercise caution in translating measures reported on behalf of states into policies without sufficient validation. We value CMS’s policymaking leadership and the advantages for quality improvement and health equity presented by the CMS Core Set measurement process. However, we believe measurement rates calculated at the federal level must be validated and aligned with rates that states can produce themselves, to ensure that CMS’s findings and goals can be implemented and evaluated at the state, health plan and provider levels.
State supports to consider for phasing in reporting guidance. We support a phase-in period that is responsive to state feedback on timelines. Based on our experience, creating a valid, reliable measurement system in the Medicaid landscape involves considerable activity. We also acknowledge that state staff committed to meeting the Core Set measure reporting mandate may also be tasked with developing, executing and evaluating the state Medicaid agency’s quality improvement policies and programs. We ask CMS to consider these factors when establishing the phase-in approach. Supports such as technical assistance, learning collaboratives and pilots to test new technologies can enhance the integrity of the Core Set measurement system and promote state policy innovations. NCQA’s state affinity groups (the State Medicaid Quality Network, and the State Data Quality Network) can serve as sounding boards for topics of interest or value for such supports.
Thank you again for the opportunity to comment. We welcome the chance to discuss our experience and findings, and we remain committed to working with CMS to build a more equitable, sustainable and responsible American health care system.
If you have any questions, please contact Kristine Toppe, NCQA Assistant Vice President of State Affairs, at (202) 955-1744 or at firstname.lastname@example.org, or contact Tom Curtis, NCQA Deputy Director for State Affairs, at (202) 517-8002 or at email@example.com.
Margaret E. O’Kane
National Committee for Quality Assurance
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