February 10, 2017
Tim Engelhardt, Director
Centers for Medicare & Medicaid Services
U.S. Department of Health & Human Services
The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to comment on your Request for Information on the Programs of All‐Inclusive Care for the Elderly (PACE). Providing comprehensive, coordinated Medicare and Medicaid benefits to additional populations through PACE‐ like models will accelerate the transition to paying for value for those with the greatest need. Below we offer in‐depth feedback on ways to improve your proposal.
Potential Elements of the P3C Model
We strongly encourage you to consider adjusting the payment methodology from the original PACE program to share more savings with state Medicaid programs. Historically states have limited enrollment in PACE programs because the largest share of savings is achieved by reducing Medicare expenditures and is therefore directed back to the federal government. You could maximize access to new PACE‐like models such as Person Centered Community Care (P3C) if savings were better shared with state Medicaid programs and organizations delivering the services.
We strongly support the additional benefits offered within the P3C model, specifically the social and employment support services and the adaptive home equipment. We support allowing beneficiaries to retain their primary care and specialist providers, but suggest you also allow beneficiaries to retain Support Services Providers with whom they have an established relationship.
We are particularly encouraged to see the flexibility offered in the P3C model. We strongly support reconfiguration of PACE Center requirements to support the principles of the Medicaid Home & Community Based Services (HCBS) rule. This flexibility will encourage person‐centered care planning with an emphasis on keeping patients in delivery settings that best fit their needs. Permitting rural community centers, adult foster care, and other HCBS settings to deliver comprehensive care will maximize options and access to this model.
However, increased flexibility will increase the administrative burden involved in oversight of the program. NCQA can help greatly reduce the need for oversight through accreditation of organizations delivering these services. For example, once a PACE or P3C organization has demonstrated high quality, patient‐centered care by achieving NCQA accreditation, you could deem it as low priority for audit.
We have two existing programs that could be adapted to meet the precise needs of the PACE and P3C models:
- Accreditation of Case Management for Long‐Term Services and Supports provides a framework for organizations delivering high‐quality, person‐centered long‐term services and supports. The program prioritizes keeping people in their preferred setting of care. Other requirements include conducting comprehensive assessments, coordinating care transitions, and managing critical incidents. This program is ideal for organizations such as area agencies on aging, centers for independent living, and other home and community‐based organizations.
- Long‐Term Services and Supports Distinction offers a similar set of standards but is designed for NCQA‐accredited organizations that offer comprehensive medical benefits and manage LTSS. This includes NCQA‐accredited managed care organizations, managed behavioral health organizations and organizations providing clinically‐focused case management.
Both of these programs set a high bar for quality in the delivery of long term care. Accountability will be critical to the success of any model that offers flexibility to participants. Meeting NCQA program requirements can provide that accountability, reducing the burden of federal oversight. We look forward to working with you on potential ways to adapt these programs to fit the models’ needs.
Proposed Quality Outcomes for Evaluation of P3C Model
Regarding the quality outcomes under consideration for evaluation of the P3C model, we believe there are a number of important aspects of care that need greater focus than what is currently proposed. Importantly, any survey‐based measure should require that a certified interviewer conduct the survey to improve accuracy and validity of responses.
We believe the following quality measures, which we developed and are now testing for CMS, should be included in the model:
- Falls Risk Assessment
- Falls: Plan of Care
- Patient‐Reported Access to Care
- Medication Reconciliation Post‐Discharge
- Use of High‐Risk Medications in the Elderly
- Potentially Harmful Drug‐Disease Interactions in the Elderly
- Depression Remission or Response for Adolescents and Adults
We strongly encourage inclusion of additional patient‐reported outcome measures (PROMs) as they become available. NCQA is working to develop PROMs that engage patients in their own care and self‐ management and believe this work could be useful for PACE and P3C.
More specifically, we are exploring development of prioritized person‐reported outcome measurement and goal attainment measurement. The first method assesses a patient’s progress on standardized outcomes associated with their individualized goals. Patients and their care teams first identify one or more personal health goals, such as pain management or better sleep. The care team then selects a standardized PROM questionnaire addressing a domain that best aligns with the goal identified by the patient. Over time, the team will assess the patient on improvement toward that selected PROM domain.
The second method helps measure individual patients’ goal attainment progress using quantitative scales. Care teams and patients first identify specific short‐term goals. They then define the expected outcome, as well as the “better” or “worse” than expected outcomes, and assign numerical weights to each. Over time, they assess whether the outcomes are better, worse or as expected. One patient may want to improve mobility to work in their garden or play with grandchildren. Another may wish to improve independence so they can travel or attend events in the community. This approach measures the degree to which each individual achieves their goal.
Although each patient has an individualized goal, at the population level, you can assess whether a care team is helping patients to improve or maintain on the identified outcome. These methods are thoughtful, innovative approaches to outcome measures that engage patients in their own care. We look forward to exploring ways that this work could be used as part of PACE, P3C, or the Financial Alignment Demonstrations across the country.
Thank you for the opportunity to comment on this Request for Information. We look forward to working with CMS as you develop new models for integrated long term care. Please contact Joe Castiglione, Federal Affairs Manager, at 202‐955‐1725 or firstname.lastname@example.org if you have any questions.
Margaret O’Kane President