December 22, 2022
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 comment on the List of Screening Instruments for Housing Stability, Food Security, and Transportation Questions on Health Risk Assessments.
NCQA is a private, 501(c)(3) not-for-profit, independent organization dedicated to improving health care quality through our Accreditation, clinician quality 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 their journey toward an equitable, digitally enabled health care system. 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 is pleased to provide comments on the requirements outlined in the memorandum describing social needs screening in Special Needs Plan (SNP) health risk assessments (HRA).
Requirements for Social Needs Screening in SNP HRAs
NCQA applauds CMS’s efforts to advance health equity for SNP enrollees through identification of social needs and implementation of individualized care plans. NCQA believes social needs screening and intervention is critical to advancing equitable care and outcomes, and we support CMS’s requirement for integrating such screening into SNP HRAs. NCQA supports the focus on food insecurity, housing instability and transportation access: These are known high-priority, actionable social needs, and are likely to represent substantial barriers to health, well-being and independence if not addressed. These three domains also align with NCQA’s recently released Healthcare Effectiveness Data and Information Set (HEDIS®) measure, Social Need Screening and Intervention (SNS-E) for measurement year 2023, specified for reporting by Medicare Advantage plans (including SNPs).
SNS-E assesses screening for unmet food, housing and transportation needs, and referral to intervention after a positive screen. These measure domains were selected based on their contribution to access, outcomes and equity, as well as on the maturity of associated electronic data standards. The measure is specified for Electronic Clinical Data System (ECDS) reporting, and aligns with the Gravity Project’s data standards for documentation and interoperable exchange of data on social determinants of health. Social needs data can be captured in a variety of electronic data sources (e.g., EMRs, resource referral platforms, case management systems), allowing effective coordination of patient social needs between multiple health systems and community entities involved in care delivery.
NCQA is committed to expanding measures to address social determinants of health as data standards advance and make measurement possible. Most recently, NCQA has begun developing a measure focused on social connections: Social Connection Screening and Intervention. This measure will assess the percentage of members who were screened for social isolation, loneliness or inadequate social support, and received a corresponding intervention after a positive screen. Research has linked social isolation and loneliness to a higher prevalence of poor clinical outcomes related to morbidity, physical and mental health, and even death, in older adults. The measure (planned for MY 2024) is specified for members 65+ and for the Medicare product line. It is undergoing testing, and is anticipated to be released for public comment in early 2023. We encourage CMS to consider expanding the required social needs domains to include social connections and other high-priority social needs that are likely to impact the health of SNP enrollees.
Instruments for Screening for Housing Stability, Food Security, and Access to Transportation
NCQA supports CMS allowing validated, health IT-encoded screening instruments to meet HRA social needs screening requirements. NCQA underscores that standardized terminology enables exchange of social needs data, in and between health systems and community entities that share responsibility for addressing social needs. We support CMS’s specified list of health IT-encoded screening instruments and the criteria CMS applied to generate the list. Specifically, we applaud CMS’s efforts to align the list with Gravity Project data standards, and CMS’s emphasis on screening instruments that facilitate collection of standardized, quantifiable and actionable data for SNPs. We further support CMS’s allowing and encouraging cultural and linguistic adaptation of such screening instruments, under appropriate consultation with instrument developers.
NCQA supports CMS’s intent to reduce burden and prevent duplication of screening. We understand that allowing SNPs to use state-required Medicaid screening instruments that include questions on housing stability, food insecurity and access to transportation to meet the HRA requirement may alleviate the need to implement multiple instruments. We emphasize, however, that nonstandardized screening tools lacking interoperable terminology may be a barrier to social needs data sharing and exchange. To promote greater capability for exchanging data between entities involved in identifying, coordinating and addressing patient needs, NCQA’s Social Need Screening and Intervention measure is currently limited to screening questions that document and share screening results using standardized terminology. We encourage CMS to urge states to ensure that appropriate terminology exists to support standardized documentation and interoperable exchange of data, especially where Medicaid plans are required to use specific social needs screening instruments or questions. (States that require screening questions or instruments that do not have currently available terminology may want to submit a terminology request to the Regenstrief Institute.)
NCQA supports CMS’s stated guidelines for use of state-required screening questions in HRAs, including the allowance for C-SNPs and I-SNPs that operate in states with a Medicaid social needs screening requirement but that are not directly subject to such requirements to use state-required social need questions in their HRAs. We urge CMS to clarify how this requirement applies to SNPs in multiple neighboring states, where one state has state-required social needs screening questions and a neighboring state does not. In these instances, CMS should state whether a health plan may use one HRA that incorporates state-required screening instruments across all SNPs it operates, even in states that do not have specific social needs screening requirements.
Effective Measurement for Care Informed by Social Determinants of Health
We are encouraged by CMS’s recent efforts to include social needs screening measures in quality programs, and we believe patient-level, health-related social needs data are essential to meaningful collaboration between health care payers, providers and community-based organizations. NCQA supports aligning all such measures with the Gravity Project’s work to standardize interoperable social needs data, and we encourage CMS to do the same.
We welcome the opportunity to work with CMS to ensure that measures of social needs are reliable and valid, and that they ease the burden of collection and strive for alignment across programs. We encourage CMS to align Screening for Social Drivers of Health and Screen Positive Rate for Social Drivers of Health with the Gravity Project’s efforts before making them mandatory in other CMS programs or considering them for use in Medicare Advantage. We further encourage CMS to consider the importance of combining a positive screening rate and a screening rate in a single measure, to minimize unintended incentives associated with targeting patients who are likely to result in a low positive screen rate, as well as the importance of assessing intervention for patients with identified needs, to ensure that they receive the benefits of screening (and not only the burden).
Equitable Quality Measurement
Advancing health equity requires transparent, inclusive approaches to quality measurement and improvement. It is critical to leverage appropriate data and quality measures to assess plan performance on providing equitable care. To that end, in addition to implementing measures of social need, NCQA has implemented efforts to stratify HEDIS measures by race and ethnicity. To date, we have added race and ethnicity stratifications to 13 HEDIS measures:
- Colorectal Cancer Screening
- Controlling High Blood Pressure
- Hemoglobin A1c Control for Patients With Diabetes
- Prenatal and Postpartum Care
- Child and Adolescent Well-Care Visits
- Immunizations for Adolescents
- Asthma Medication Ratio
- Follow-Up After Emergency Department Visit for Substance Use
- Pharmacotherapy for Opioid Use Disorder
- Initiation and Engagement of Substance Use Disorder Treatment
- Well-Child Visits in the First 30 Months of Life
- Breast Cancer Screening
- Adult Immunization Status
These measures represent areas prioritized by stakeholders (including patients), and received strong support during NCQA’s public comment process. We plan to expand stratifications over several years, to help identify disparities in care among patient populations.
NCQA has also implemented efforts to address disparities in care for transgender and gender diverse members, who disproportionately experience disparities in care for preventive services and access to gender-affirming care. We have revised HEDIS measures to ensure appropriate inclusion of these members in measures that assess pregnancy care and various preventive services (e.g., breast and cervical cancer screening).
In pursuit of equitable quality measurement and reduction of disparities in care, we encourage CMS and other federal stakeholders to consider policy levers to increase collection of race, ethnicity and other demographic data. We recently published recommendations with Grantmakers in Health (Federal Action Is Needed to Improve Race and Ethnicity Data in Health Programs), and we encourage CMS to compel reporting of complete data on race, ethnicity, gender identity and sexual orientation, people living with disability and marginalized populations.
Accountability through measurement can also help drive improvement in quality of care and promote equity. NCQA recently developed a health equity measurement framework that can be used by payment programs for accountability in health plan managed-care contracting. The framework articulates six domains of equitable care: social needs, access, clinical care, experiences, structures and well-being. Although it focuses on Medicaid use cases, many elements can be applied across the health care ecosystem, including SNPs. We encourage CMS to work with states to adopt this framework (or elements of the framework) to promote accountability for equity in Medicaid managed care programs, or beyond.
Integrate Person-Centered Measurement, Informed by Historically Marginalized Communities
Efforts to advance health equity must ensure that the voice of the person and care partners are consistently represented. NCQA’s three Person-Centered Outcome Measures (two process measures, one outcome measure) work in tandem with clinical care to help people living with complex health needs make progress toward a health outcome goal that matters to them. This approach improves the care planning process, and provides valuable data on a range of goals.
To address equity and care alignment, NCQA is developing and disseminating messages about these measures using information, data and stories that resonate with, and demonstrate value to, a variety of populations and viewpoints.
It is essential that CMS leverage stakeholders from marginalized communities and those with lived experience when creating a national strategy for health equity measurement.
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 Eric Musser, NCQA Assistant Vice President of Federal Affairs, at (202) 955-3590 or at firstname.lastname@example.org.
Margaret E. O’Kane
 McGinty, Emma E., Rachel Presskreischer, Hahrie Han, and Colleen L. Barry. 2020. “Psychological Distress and Loneliness Reported by US Adults in 2018 and April 2020.” JAMA 324(1): 93–94. https://doi.org/10.1001/jama.2020.9740.