March 4, 2022
Deputy Administrator & Director
Center for Medicare
Centers for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244
Dear Deputy Administrator Seshamani:
The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to comment on the 2023 Medicare Advantage (MA) Advance Notice.
NCQA is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality through our Accreditation and measurement programs. As an independent organization dedicated to improving health care quality through measurement, transparency and accountability, NCQA is 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 is pleased to provide the following comments on the proposals and considerations outlined in the Advance Notice.
Reminders for 2023 Star Ratings
NCQA agrees the patient experience is essential, but, like many stakeholders, we have concerns about the increased weight of patient experience/complaints and access measures (from 2 to 4) finalized in the 2023 Star Ratings. CAHPS surveys have a low—and declining—response rate due to burdensome paper-based surveys, and because surveys go to a random patient sample, it is difficult to identify and act on concerns of a specific group (e.g., racial and ethnic minorities, patients with multiple chronic illness). Clinical process and intermediate outcome measures, like the 14 HEDIS and Health Outcomes Survey measures currently in the Star Rating system, have a significant impact on quality of life and on cost avoidance. As more outcome measures are defined and developed, evidence-based process measures closely tied to outcomes will continue to play a critical role in the interim.
CMS-HCC Risk Adjustment Model for CY 2023
NCQA supports enhancements to the CMS-HCC risk adjustment model to address the impacts of social determinants of health on beneficiary health status. We support accounting for social risk factors as part of payment approaches; this can ensure that plans and organizations serving challenging populations with unmet needs have the financial resources necessary to support care for people with social needs and are not penalized for providing that care.
Changes to Existing Star Ratings Measures in 2023 and Future Years
Thank you for considering how to incorporate NCQA’s HEDIS Electronic Clinical Data Systems (ECDS) Reporting into Star Ratings for Breast Cancer Screening and Colorectal Cancer Screening for measurement year (MY) 2023 or 2024. The HEDIS® ECDS reporting standard gives health plans a method to collect and report structured electronic clinical data for HEDIS quality measurement and improvement. We also appreciate CMS’s consideration of our ongoing work to leverage standardized clinical data for incorporation into future Star Rating measures, including Controlling Blood Pressure, Adult Immunization Status and diabetes care measures. We are currently exploring how electronic clinical data can be leveraged to better assess diabetes outcomes, including HbA1c control over time. We plan to explore incorporating data from continuous glucose monitoring and other glucose management data into future specifications.
NCQA remains committed to supporting industry stakeholders through a Digital Quality System as part of our larger strategy to advance whole-person care and reduce measurement burden. Adopting Digital Quality Measures (dQM) and leveraging electronic clinical data for measurement aligns with the industry’s migration toward greater interoperability of health information. This is an essential first step toward CMS’s goal of fully digital reporting by 2025.
Traditional quality measures rely on arduous manual coding processes and specific expertise to generate accurate and reliable information. HEDIS dQMs offer consistent, reliable representations of quality measurement operations, enabling the use of data from across the entire care continuum (EHRs, clinical registries, care management systems, payer administrative systems) to evaluate health care quality efficiently and effectively. Moving to dQMs is essential to reduce burden, improve accuracy and reliability and produce clinically relevant knowledge that can inform care decisions.
NCQA is committed to providing education and collaboration opportunities through our Digital Measurement Community. Visit our Future of HEDIS webpage for information on how NCQA is evolving measurement for the digital future.
Potential New Measure Concepts and Methodological Enhancements for Future Years
We commend the Biden Administration’s commitment to health equity and CMS’s goal of reaching equity by eliminating health disparities in MA contract performance. We offer the following comments on the proposals outlined for new measure concepts and future methodological enhancement described in the Advance Notice.
- Stratified Reporting. NCQA supports CMS’s proposal to report differences in contract performance on additional Star Ratings measures for subgroups of beneficiaries with social risk factors (e.g., stratified reporting by disability, low-income subsidy status, dual eligibility status) and we commend its long-standing commitment to transparency through MA contract-level race and ethnicity stratification reports available on the Office of Minority Health’s website. We believe CMS should also include stratification data in the Medicare.gov Plan Finder and were encouraged to see it considered in the Advance Notice. We agree that not all measures can be stratified, but we are exploring stratification of additional HEDIS measures, as well as additional variables for stratification, as part of our broader commitment to health equity. For MY 2022 we introduced race and ethnicity stratification to five HEDIS measures across key areas covering multiple product lines and domains with known disparities. Based on feedback from expert panels and external stakeholders, we developed a list of candidate measures for public comment (through March 11) to expand stratification for MY 2023. We welcome feedback from CMS and the broader public.
- Health Equity Index. NCQA supports CMS’s proposal to develop a health equity index that summarizes contract performance into a single score. We believe this could supplement the current reward factor to incentivize contracts to reduce disparities in care; however, we urge CMS to consider how to ensure transparency and action on specific inequities. With input from state Medicaid programs, NCQA published a white paper, Evaluating Medicaid’s Use of Quality Measurement to Achieve Equity Goals (December 2021). Our findings can provide insight and considerations for use of a health equity index in Star Ratings. For example, some stakeholders expressed concern that an index could mask health equity information at the component or subgroup level. This could be mitigated with a commitment to transparency through interactive public reporting that allows drill-down to individual subgroups. This would most likely require additional technical resources and education of stakeholders. We also thank CMS for referencing the Health Equity Summary Score developed through the Office of Minority Health—NCQA proudly supported that work. CMS could leverage that information, including development of a dashboard to provide confidential health equity index data back to health plans.
- Measure of Contracts’ Assessment of Beneficiary Needs. In general, NCQA supports a performance measure that evaluates assessment of health-related social needs for MA enrollees. We agree with CMS’s position to not require use of a specific assessment tool, which is consistent with the work of the Gravity Project. However, inclusion of interpersonal safety does not align with the Gravity Project’s timeline for harmonizing social risk factor data for interoperable electronic health information exchange, and the measure concept as described does not align with the proposed 2023 CMS rule to require all SNPs to include standardized questions on housing stability, food security and transportation as part of their health risk assessment. Nor does the measure account for screening outcomes. And we question the appropriateness of transforming a clinician-level measure into a health plan-level measure for Star Ratings. In our view, the measure concept outlined in the Advance Notice is not the best approach.
- Screening and Referral to Services for Social Needs. NCQA supports including a measure on the display page, and eventually in Star Ratings, that brings transparency to the unmet social needs of Medicare members and actions taken to address them. Such a measure would recognize the significant impact of social needs on health outcomes, the efficacy of health care interventions and the tools MA plans have to address those needs. There are currently no national health plan measures that address social needs. NCQA sees this as a critical quality measurement gap to fill and we are developing a measure for MY 2023 that assesses screening for unmet food, housing and transportation needs and referral to intervention after a positive screen. Domains included in the measure were selected based on maturity of electronic data standards, and the measure has the ability to expand to additional domains as data standards advance. Because social needs data can be captured in a variety of electronic data sources (e.g., EMR, resource referral platforms, case management systems), to ensure consistent evaluation and reduce the burden of chart abstraction, NCQA supports aligning measures with the Gravity Project’s work to standardize interoperable social needs data. NCQA’s measure aligns with the Gravity Project’s standards and will be ECDS reported. Given CMS’s other considerations of ECDS in this Advance Notice, we believe a social needs measure of this type is appropriate for Star Ratings.
- Kidney Health. NCQA supports including a measure on the display page (and eventually in Star Ratings) that assesses appropriate kidney health evaluation and management. We are proud to be developing measures to help stakeholders improve the quality of kidney care. Our goal is to help patients and care teams navigate CKD diagnosis, monitoring and management through measurement and educational resources like our recently released Kidney Health Toolkit.
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 Director of Federal Affairs, at (202) 955-3590 or at firstname.lastname@example.org.
Margaret E. O’Kane