March 3, 2023
Chiquita Brooks-LaSure, Administrator
Centers for Medicare & Medicaid Services
Department of Health & Human Services
Hubert H. Humphrey Building
200 Independence Ave. SW
Washington, DC 20201
Attention: CMS-2023-0010
Dear Administrator Brooks-LaSure:
The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to provide feedback on the Advance Notice of Methodological Changes for Calendar Year (CY) 2024 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies.
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 quality measurement. Leveraging our strengths as a trusted third party, we are committed to helping organizations navigate the challenges associated with moving toward an equitable health care system. Our mission to improve the quality of health for all Americans, with a 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.
Establishment of the Universal Foundation
We celebrate the establishment of the Universal Foundation across CMS. This ambitious and much needed initiative will support both CMS and NCQA in our shared goals of reducing measurement burden, enhancing health equity and transitioning to digital quality reporting. Nearly 70% of the measures in the Universal Foundation are NCQA HEDIS measures. We are proud HEDIS is the “foundation of the Universal Foundation.”
For more than 30 years, NCQA has stewarded HEDIS measures and ensured they are rigorously validated and continuously adjusted to represent quality in the ever-changing health care landscape. Moving forward with CMS into the digital quality measurement era, we remain steadfast in our commitment to measuring quality and improving health care for all.
We are honored that our colleagues at CMS selected so many of our measures for inclusion in the Universal Foundation, and we look forward to continuing to work with CMS to reach pivotal goals in Medicare Advantage and across CMS programs.
The Universal Foundation advances health equity by helping CMS, health plans and others track disparities in care. NCQA is committed to advancing health equity in a number of ways, including through measure stratification. Half of the HEDIS measures in the Universal Foundation are either currently stratified by race and ethnicity or are scheduled to be so by 2024. Stratification brings transparency to gaps in care, and CMS can leverage stratified data to hold its partners accountable for disparities in care and outcomes and highlight those that reduce those disparities.
Focusing on a smaller group of measures also supports CMS’s Digital Quality Measurement Strategic Roadmap by allowing measure developers, providers, health plans and other stakeholders to transition to digital reporting for these measures first. NCQA remains committed to making measurement more accessible, actionable and closer to the point of care, to help better manage populations, support more equitable care and drive outcomes. Five of the 24 measures in the Universal Foundation are part of NCQA’s Digital Content Services Early Adopter program, and all 17 HEDIS measures in the set are either currently specified as digital quality measures or are in development for 2024.
We are proud to see alignment between CMS’s efforts and our work to promote high-quality, equitable care by moving to next-generation digital measurement and measuring what matters across the continuum of care.
Changes to Star Ratings Measures for the 2023 Measurement Year and Beyond
NCQA supports aligning Medicare Advantage Star Ratings Measures with the Universal Foundation. We believe it is appropriate to include Adult Immunization Status, Screening for Depression and Follow-Up Plan and Screening for Social Drivers of Health/Social Need Screening and Intervention in Medicare Advantage Star Ratings, which would align with the Universal Foundation.
We are pleased to see the inclusion of a social needs screening measure in the Universal Foundation, and we support its inclusion in Medicare Advantage. We request that CMS clarify which measures for social needs/drivers screening will be used across CMS programs. We welcome the opportunity to work with CMS and with industry partners to harmonize the Universal Foundation’s Screening for Social Drivers of Health, a provider level measure, with the Social Needs Screening and Intervention measure we recently added to HEDIS.
Measure Updates
NCQA supports CMS’s consideration of including updates to Diabetes Care—Eye Exam and Diabetes Care—Blood Sugar Controlled. NCQA is reviewing these two measures for potential updates to existing specifications that leverage standardized electronic clinical data. NCQA’s HEDIS Electronic Clinical Data Systems (HEDIS ECDS) reporting standard gives health plans a method to collect and report structured electronic clinical data for HEDIS quality measurement and improvement. These changes would also apply to the Kidney Health Evaluation for Patients With Diabetes measure, currently on the display page and proposed for the 2026 Star Ratings. We also support CMS’s consideration of incorporating a glucose management indicator as an additional test that meets numerator requirements for Diabetes Care—Blood Sugar Controlled. NCQA is considering these updates as we launch our refreshed Diabetes Recognition Program later this year and work to better leverage digital measurement in diabetes care.
Display Measures
NCQA supports adding the Depression Screening and Follow-Up for Adolescent and Adults measure to the 2026 Star Ratings display page and eventually in Star Ratings. Major depressive disorder is the second leading cause of disability worldwide, affecting an estimated 120 million people. We are encouraged that CMS included Screening for Depression and Follow-Up Plan in the Advance Notice.
We also support adding the Initiation and Engagement of Substance Use Disorder (SUD) Treatment measure (currently on the display page) to Star Ratings in the future. Behavioral health measures are an important component of whole-person care; their inclusion in the Universal Foundation and the Medicare Advantage Star Ratings will incentivize focus on this critical area.
NCQA also supports adding the Adult Immunization Status measure to the 2026 display page.
This measure also uses the HEDIS ECDS reporting standard, which allows expanded sources (administrative claims, immunization registries and EHRs, among others) to capture receipt of vaccinations. We believe incorporating this measure in the Universal Foundation will continue to increase vaccination rates.
Potential New Measure Concepts and Methodological Enhancements for Future Years
As highlighted in recent comment letters, NCQA applauds CMS’s efforts to advance equity in Medicare Advantage, which is in line with our own efforts, including our Health Equity Accreditation programs and the continued expansion of race and ethnicity stratification in HEDIS measures. We offer the following comments on the proposals for potential new measure concepts and methodological enhancements described in the Advance Notice.
- Stratified Reporting. We applaud CMS for providing confidential stratified reports to Parts C and D sponsors to help identify disparities in care by low-income subsidy, dual eligibility and disability status for most Star Ratings measures. We also commend CMS’s 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 stratified data by race and ethnicity, where available, and in the Medicare.gov Plan Finder in the future. Although not all measures may be appropriate for stratification, NCQA is currently seeking public comment (open through March 13) on an additional 15 measure candidates, adding to the 13 measures already stratified in Measure Years 2022 and 2023.
- Cross-cutting updates to HEDIS measures. We support CMS’s consideration of approaches to update applicable HEDIS measure specifications where eligible populations are currently defined using gendered language. We are conducting an ongoing effort to ensure that HEDIS measures are inclusive and gender affirming, and address care for all populations. We also support reevaluating how people with chronic conditions are characterized across HEDIS measures, which will simplify identification of conditions for various measures.
- Other measure concepts under exploration. We support CMS’s consideration of other measure concepts NCQA is currently exploring. We look forward to hearing feedback on these potential new measures and eventually including them as display or Star Ratings measures. Concepts under development include measures of chronic pain assessment, new blood pressure control measures, kidney health management and screening for social connections.
- Addressing Unmet Health-Related Social Needs on HOS. We support CMS’s efforts to ensure that enrollee health-related social needs are met. We encourage CMS to consider opportunities to minimize duplication of screening on topics covered in other quality measures in Medicare Advantage. We also encourage CMS to prioritize screening in settings that provide timely, actionable and shareable data. Social needs identified through the HOS survey may not be communicated back to plans that could act on the information.
Thank you for the opportunity to comment. We remain committed to working with CMS to build a more equitable, sustainable and responsible American health care system. We welcome a discussion on our experience and recommendations to continue to strengthen Medicare Advantage. If you have any questions, please contact Eric Musser, Assistant Vice President of Federal Affairs, at (202) 955-3590
or at musser@ncqa.org.
Sincerely,
Margaret E. O’Kane
President