March 1, 2019
March 1, 2019
Demetrios Kouzoukas
Principal Deputy Administrator & Director
Center for Medicare
Centers for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244
Attention: CMS-2018-0154
Dear Deputy Administrator Kouzoukas:
Thank you for the opportunity to comment on the 2020 Medicare Advantage Advance Notice of Methodological Changes, Payment Policies and draft Call Letter.
Thank you as well for tracking new and changing HEDIS®[1] measures in the Medicare Advantage Star Ratings pay-for-performance system, and for discussing in the Call Letter NCQA’s effort to develop digital HEDIS measure specifications.
We believe digital measures can reduce provider reporting burden, improve the accuracy of results and tap into the much richer clinical data in EHRs, registries and other electronic sources.
We strongly support development of additional Patient-Reported Outcomes Measures (PROM) —another NCQA priority.
We also urge you to provide as much flexibility as possible on implementing Bipartisan Budget Act provisions allowing plans to offer to chronically ill enrollees broader supplemental benefits that are not primarily health related or offered uniformly.
Please see our detailed comments on these and other issues below.
Star Ratings Measures
Thank you for proposing to add the Follow-Up After Emergency Department Visit for Patients with Multiple Chronic Conditions measure to the display page. This new HEDIS measure tracks the percentage of ED visits by adults with multiple high-risk chronic conditions who had a follow-up service within 7 days. Given the great need to improve the quality of care for such patients, we encourage you to add this measure to the Stars measures as early as is feasible.
We appreciate your proposal to move our Transitions of Care measure to the display page and add it to the Stars measures in the future. We feel this is appropriate, given that we removed the requirement to document medication allergies under the Receipt of Discharge Information indicator.
We also appreciate your proposal to move our Plan All-Cause Readmissions measure to the display page and return it to the Stars measures for 2023, with a weight of 1 in the first year and 3 thereafter. This is appropriate, given that we added observation stays as discharges and readmissions and removed individuals with high-frequency hospitalizations. We support your proposal to include enrollees 18–64 years of age and 65 and older, and to use NCQA’s minimum denominator of 150 enrollees.
We appreciate your proposal to use Medicare Reconciliation Post-Discharge data collected under Transitions of Care, instead of the standalone HEDIS Medication Reconciliation measures. We understand that you will put Transitions of Care on the display page, and NCQA will not retire Medicare Reconciliation Post-Discharge until HEDIS® 2021.
Thank you for considering how to incorporate NCQA stratification by socioeconomic status (SES) for Breast Cancer Screening, Colorectal Cancer Screening, Comprehensive Diabetes Care—Eye Exam Performed and Plan All-Cause Readmissions. These HEDIS measures show persistent SES-related disparities on average, although it is important to note that some plans do well on them despite large populations of low-SES enrollees. Stratification helps increase transparency, target plan efforts to address disparities and highlight disparities rather than mask them.
We also thank you for mentioning in the Call Letter our ongoing work to
- Expand exclusions for advanced illness;
- Develop new measures assessing the use of non-opioid therapies for pain;
- Expand our Adherence to Antipsychotic Medications for Individuals with Schizophrenia measure to Medicare;
- Expand three existing HEDIS measures that focus on the most common acute respiratory conditions for which inappropriate antibiotic prescribing occurs in the ambulatory care setting to include Medicare; and
- Explore development of a new measure assessing overtreatment in clinically complex, older patients with type 2 diabetes.
Measure Digitalization
We appreciate the discussion in the Call Letter of our development of digital specifications for additional HEDIS measures. This is a top priority that can reduce provider reporting burden, improve the accuracy of results and allow measures to utilize the much richer electronic clinical data available in EHRs, registries and other electronic sources.
This effort will also help to:
- Align measures across the health care system to allow quality comparison between practices, hospitals, health plans and a multitude of other settings.
- Provide greater flexibility by providing modified specifications that meet state, local or system needs without affecting the validity of the measure result. This creates opportunities for payers and other stakeholders to examine customized member cohorts and adjust things like age spans and measurement periods.
- Improve accuracy and specificity while reducing costs to implement and update measures, by providing vendors and health systems downloadable specifications that remove the need for manual coding while increasing reliance on data already in electronic systems.
- Enhance value for patients, clinicians, payers, plans, electronic system vendors and government by reducing cost and effort while allowing for more patient-specific, meaningful measurement.
- Create opportunities to develop meaningful outcome measures that leverage clinically relevant information about a patient well beyond what is available from claims.
We released the first six next generation HEDIS electronic clinical quality measures (eCQMs) in 2018. Our goal is to convert an additional 50 measures into machine and human-readable “digital measure packages” over the next three years, while allowing a period of transition from traditional reporting for organizations that are not ready to fully adopt electronic reporting.
HEDIS digital measures specify the use of electronic data from a combination of sources for use in both measurement and decision support. We use international data standards to build standardized measure formats including:
- Quality Data Model (QDM), a common data model, defines standardized elements that make up quality measures (diagnoses, primary care encounter, screening test for a specific condition). Medicare requires QDM as the standard for eCQMs in the Merit-Based Incentive Program (MIPS).
- Fast Healthcare Interoperability Resources (FHIR) specification, a standard for exchanging health care information electronically, designed to simplify implementation without sacrificing information integrity.
- Clinical Quality Language (CQL), the standard logic used to associate measure data elements to produce quality scores. CQL is a standard that is compatible with both eCQMs and clinical decision support systems. CQL logic does much of the “heavy lifting” of measure calculation for end users—a marked departure from each site having to develop its own interpretation from a text description. It also removes the need to create measure specifications that require clinicians to check boxes to meet quality requirements and eliminates the need for burdensome manual record review.
There are many challenges in achieving these ambitious goals, but we believe the effort is essential and greatly appreciate your interest and support.
Patient-Reported Outcomes Measures (PROM)
PROMs are another top priority for NCQA, as they are for the CMS Meaningful Measures initiative. Patients can be the ultimate—and ideal—source of information on how treatment affects their symptoms, functioning and overall quality of life.
HEDIS includes PROMs such as our PHQ-9 measures for depression screening and follow-up, symptom monitoring and remission or response. This suite of measures maximizes patient reporting through a validated, easy-to-administer tool to identify a condition, monitor symptom progress and adjust treatment. We specified these measures only for electronic reporting, which allows for richer, more accurate quality measurement with less reporting burden. However, some systems are not yet able to benefit from the electronic measure specification as their systems are still capable of only claims-based reporting.
Person-Driven Outcomes Measures: Perhaps our most ambitious PROMs effort focuses on “person-driven outcomes measures” to improve the lives of adults with complex care needs for whom traditional quality measures may not apply. This ongoing work, supported by The SCAN Foundation and the John A. Hartford Foundation, aims to create quality measures that reward clinicians and health systems for helping individuals achieve self-defined goals. Individuals with complex care needs may prioritize personal goals over more traditional care goals; for example, being able to play with grandchildren, work in their garden or avoid hospitalization. Helping them meet these goals improves their quality of life and engages them in their health and in their health care.
We are testing the person-driven measure approach across four organizations, including tools for implementing the approach and a digital platform for collecting, monitoring and sharing data on person-driven outcomes. We also will develop a paper on how other quality measures may conflict with individual goal measurement, and develop options for mitigating such conflicts.
PROMs Challenges: These include concerns about the time required to administer PROMs. Some practices address this by having patients fill out PROM questionnaires on tablets in the waiting room and having nonphysician team members review results. There is a trade-off, however: It saves clinician time but decreases the opportunity for enhanced patient engagement. There also are concerns that results are not actionable if they identify needs that clinicians or health systems lack the capabilities to address. However, these concerns should subside as more practices and health systems understand the need and responsibility to address disparities and social determinants of health.
Special Supplemental Benefits for the Chronically Ill
We strongly support Bipartisan Budget Act of 2018 provisions to expand supplemental benefits that plans may offer to chronically ill enrollees, but that are not primarily health related or offered uniformly. The law allows these benefits, which may include transportation for nonmedical needs and food, when there is a reasonable expectation of improving or maintaining health or overall function.
We urge you to give plans broad flexibility to determine what chronic conditions meet the statutory standard, what types of enrollee needs should qualify and what benefits to include. Limiting supplemental benefits to specific diagnoses, needs or services could inhibit optimal care for enrollees who could gain from these benefits. Letting plans consider financial need is particularly important, given the extent to which unmet financial need drives a wide range of social determinants of health. Medicare Advantage’s capitated payments should guard against potential improper use of this flexibility, as will objective criteria and detailed documentation for benefit eligibility.
We support letting plans contract with community-based organizations (CBO), such as Area Agencies on Aging and Centers for Independent Living, to provide and determine eligibility for supplemental benefits. Some plans already contract with CBOs for home meal delivery and transportation services.
Many CBOs have achieved NCQA’s Long-Term Services and Supports (LTSS) Accreditation, which allows them to provide delegated services to an NCQA-Accredited Medicare Advantage plan. LTSS Accreditation lets CBOs demonstrate their ability to coordinate LTSS benefits, which include many of the new supplemental benefit services Medicare Advantage plans may now cover. Accredited CBOs are ideally suited to help plans coordinate LTSS and other supplemental benefits for the chronically ill. We urge you to allow these CBOs to serve as a specialty provider type to MA plans for these benefits and to encourage plans to look for CBOs that have demonstrated their commitment to care coordination and quality by earning NCQA LTSS Accreditation.
Thank you again for the opportunity to comment on the draft. If you have any questions, please contact Paul Cotton, NCQA Director of Federal Affairs, at 202-955-5162 or at cotton@ncqa.org.
Sincerely
Margaret E. O’Kane
President
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