February 13, 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-4201-P
Dear Administrator Brooks-LaSure:
The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to provide feedback on the Contract Year 2024 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs Proposed Rule.
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.
We are pleased to provide comments in the following areas:
- Advancing Health Equity in Medicare Advantage. We applaud CMS’s efforts to advance equity in Medicare Advantage, and we encourage adoption of NCQA’s Health Equity Accreditation programs to support this goal.
- Ensuring Timely Access to Care: Utilization Management Requirements. We encourage CMS to mandate Health Plan Accreditation to enhance utilization management and quality oversight.
- Changes to the Medicare Advantage Quality Ratings System. We support inclusion of a Health Equity Index (HEI) in Medicare Advantage to incentivize plans to reduce disparities, but we have concerns that omitting race and ethnicity from the index may mask or exacerbate existing inequities.
- Behavioral Health in Medicare Advantage. We support extending primary care appointment wait times to behavioral health services provided to Medicare Advantage enrollees.
Advancing Health Equity in Medicare Advantage
NCQA agrees with the CMS National Quality Strategy’s aim to create a more equitable, safe, outcomes-based and person-centric health care system, and we are encouraged by the inclusion of “Advancing Equity” as the first pillar of the 2022 CMS Strategic plan. We strongly encourage CMS to require NCQA Health Equity Accreditation for Medicare Advantage plans to help achieve this goal. Accreditation is a set of standards that organizations, such as Medicare Advantage plans, can use as an actionable framework for improving quality. NCQA’s Health Equity Accreditation programs—Health Equity Accreditation and Health Equity Accreditation Plus—focus on the foundation of health equity work, and can support Medicare Advantage plans’ internal culture and external efforts to advance equity and embed standardized processes, structures and reporting into sustainable business practices. We believe Accreditation can be a primary lever to advance health equity and create the necessary data collection and quality improvement processes to measure, report and improve outcomes for all Medicare Advantage enrollees.
We know there is a high level of disparities in Medicare Advantage, and we are seeing greater enrollment of racial and ethnic minorities and other traditionally marginalized groups into the program. With over 50 percent of the eligible Medicare population expected to enroll in Medicare Advantage within the next year, it is imperative that CMS include requirements to meet the increasingly diverse needs of enrollees. We applaud the proposed enhancements to Medicare Advantage and the Medicare Prescription Drug Benefit program to address these needs, and we agree with CMS that existing quality improvement (QI) programs are optimal vehicles to advance health equity. Medicare Advantage plans can leverage NCQA’s Accreditation programs to embed equity into these programs. At the very least, health plans should be rewarded for their commitment to advancing health equity through Accreditation, and should be deemed for the new expectations outlined in the proposed rule if they achieve NCQA’s Health Equity Accreditation.
Health Equity Accreditation guides health plans and other health care providers toward an internal culture that improves diversity, equity and inclusion, and reduces bias. Among other activities, it requires organizations to collect race, ethnicity, sexual orientation and gender identity information using standardized methods, and to identify opportunities to create (and offer) language services, written materials and provider networks that can meet their populations’ cultural and linguistic needs. For example, as part of the Practitioner Network Cultural Responsiveness element, organizations collect and publish information in their physician directory about providers’ race, ethnicity, languages in which they are fluent and available language services. Organizations also demonstrate that they have programs to improve culturally and linguistically appropriate services (CLAS), including setting and monitoring against measurable goals.
To achieve this Accreditation, organizations also identify opportunities to reduce disparities in clinical performance and address inequities in care and services. They analyze measures of clinical performance and patient experience to determine if disparities exist; identify and prioritize opportunities to reduce disparities, improving the cultural and linguistic appropriateness of care and services; and implement and evaluate the effectiveness of at least one intervention. Health Equity Accreditation can help Medicare Advantage organizations incorporate disparity reduction activities into their QI programs and implement best practices for provider directories to improve network adequacy, increase access to care and advance equity, as outlined in the proposed rule.
Health Equity Accreditation Plus is designed for organizations progressing to the next step of their health equity journey. It builds on Health Equity Accreditation, its prerequisite, and requires organizations to address the root causes of inequities by collecting data on social needs and upstream social risks of the communities they serve, and to make data-driven decisions that improve members’ access to and experience with community-based partnerships and resources. The Accreditation aligns with CMS’s efforts to improve health equity and invest in community-based organizations and local support agencies to transform the environments where members live, work and play. It requires organizations to collect social needs information for a core set of domains, in alignment with the Gravity Project and NCQA’s Social Needs Screening and Intervention HEDIS measure, and gives them the flexibility to choose an additional domain that reflects their unique priorities for members. Several organizations that participated in NCQA’s feasibility pilot chose “access and literacy for technology-based services” as the additional domain, highlighting how the industry, NCQA and CMS align on the domain’s importance.
Nine organizations, including five regional subsidiaries of national health plans (UnitedHealthcare, Elevance, CVS Health, Centene, Molina), two payviders (UPMC, Geisinger) and two health systems (Novant Health, Hennepin Healthcare) participated in the feasibility pilot of both Health Equity Accreditation and Health Equity Accreditation Plus. To date, over 100 organizations have earned Health Equity Accreditation (or its predecessor, Multicultural Healthcare Distinction). Eleven states have already mandated Health Equity Accreditation for one or more product lines or ACOs.
As the Medicare Advantage program continues to grow and become more diverse, CMS can leverage NCQA’s Health Equity Accreditation programs to improve quality, value, equity and care for all enrollees. We encourage CMS to require the base program, Health Equity Accreditation, as CMS finalizes proposals to advance health equity, as many states have already done. At a minimum, CMS should give credit (deeming) to organizations that achieve the Accreditation, and prominently display the Accreditation on the Medicare Plan Finder. Plans achieving NCQA’s Health Equity Accreditation programs already meet the equity enhancements in the proposed rule, and should be rewarded for doing so.
Ensuring Timely Access to Care: Utilization Management Requirements
NCQA supports CMS’s proposal to strengthen utilization management processes and procedures for Medicare Advantage plans. Additional transparency and oversight of utilization management is critical to advancing accountability in a growing Medicare Advantage market. We recommend that CMS leverage approved Accrediting Organizations to enhance oversight of utilization management by requiring Accreditation. We responded to CMS’s recent Medicare Advantage RFI and described the opportunities for Health Plan Accreditation to bring additional accountability and advance health equity for Medicare Advantage enrollees. NCQA’s Health Plan Accreditation is the most widely recognized accreditation program in the United States, leveraged by many states and other CMS programs. More than 1,100 health plans have earned NCQA Accreditation, and 42 states either require or use it. Every plan offered in the Exchange Marketplace must be accredited, and most choose NCQA’s program. We believe Medicare Advantage organizations would benefit from the program’s utilization management and other quality improvement standards.
Changes to the Medicare Advantage Quality Ratings System
Health Equity Index
NCQA supports CMS’s proposal to include an HEI in Star Ratings scoring. Explicitly including an equity component that dictates quality bonus payments for Medicare Advantage plans further signals CMS’s commitment to advancing health equity by incentivizing plans to perform well among enrollees with specified social risk factors, and reduce disparities in care. The proposed HEI is an important first step, and a potentially promising approach, but we have questions about the methodology and how it will reward plans for providing equitable care (or hold accountable those who do not).
It will be challenging to fully understand and address disparities in the Medicare Advantage population without including race and ethnicity in a measure of health equity. For example, while the initial proposed social risk factors are enrollees who receive a low-income subsidy (LIS), are dually eligible (LIS/DE) or have a disability (all known drivers of disparities), NCQA believes that other risk factors, such as race and ethnicity, should be included, and we are pleased to see that allowing for future addition of other social risk factors is included among CMS’s goals. Most notably, we know that people of color have faced long-standing disparities in health and have experienced disparate outcomes across many measures of health status. It will be important for CMS to address these disparities head on in order to achieve health equity for all Medicare Advantage enrollees. We look forward to seeing the HEI evolve over time to fully align with CMS’s strategic vision.
Other demographic information, such as income, education level and geographic location, can provide information about disparities, but race and ethnicity are important factors that shape experiences and outcomes in unique ways. Measuring equity without race and ethnicity may provide a limited picture and overlook important differences and disparities that need to be addressed. By limiting the social risk factors to only enrollees with LIS, LIS/DE and disability status, the proposed HEI risks ignoring—and even perpetuating—inequities in these groups. Inequities and disparities in health outcomes are deeply tied to both place and racial and ethnic identity, which was demonstrated by disparities in COVID-19 outcomes that persisted even after accounting for socioeconomic disparities. Therefore, we encourage CMS to consider including race and ethnicity, so these inequities are not masked within the social risk factors currently included in the HEI.
In our own work, NCQA has expanded race and ethnicity stratification to 13 HEDIS measures, and will continue to stratify more measures in the future as a tool to incentivize equity with benchmarks and performance scoring. We understand the concerns about the completeness and accuracy of demographic data available to CMS. We have identified practical recommendations for federal agencies to improve the collection and use of race and ethnicity data to advance health equity. Our own programs allow indirect imputed data for race and ethnicity stratification while encouraging plans to work toward the “gold standard” of self-reported member data. We are also looking forward to the OMB’s continued process to expand race and ethnicity categories; we see this as an important opportunity to align across governmental programs, including Medicare Advantage, when new categories are finalized.
NCQA also has questions about other details of the HEI, specifically, identifying enrollees with a disability and assigning scores. We are concerned that the current definition of “disability,” which uses the original reason for entitlement to the Medicare program to identify enrollees with a disability, will overrepresent younger populations and exclude enrollees who incur a disability later in life. NCQA has heard from our advisory panels that the Medicare eligibility file significantly underestimates disability and functional status. We encourage CMS to compare disability eligibility data with the Medicare Current Beneficiary Survey data, which includes elements such as number of activities of daily living limitations, to assess the gap left by the current definition.
For HEI scoring, we agree with CMS’s goal of ease of use and understanding, but we have concerns that distributing contract performance into thirds and doing a purely plan-to-plan comparison could disincentivize high performance. We will be interested to see the variability and distribution in performance across contracts to assess the appropriateness of using a top third/middle third/lowest third approach to scoring. It may be beneficial to include benchmarks against which plans are measured, to ensure that equity performance does not lag.
Overall, NCQA is encouraged to see the inclusion of an HEI in the Medicare Stars program. We look forward to understanding its impact on plan performance, particularly how it drives equitable performance. We welcome the opportunity to work with CMS to evolve the methodology.
Measure Weighting
NCQA strongly supports CMS’s proposal to reduce the weighting of patient experience, complaints and access measures in the Star Ratings program. As we have noted in previous comment letters, Star Ratings should reflect all important aspects of health care quality, which include both patient experience and clinical process and outcome measures. Bringing patient experience, complaint and access measures back to their prior weight of 2 rebalances the impact of different measure types and signals the critical importance of clinical outcome and process measures, which had been underweighted when the weighting was doubled. We believe a quality rating system should reflect the continuum of care from patient experiences to health outcomes. To that end, we should focus on adding more outcome measures for use in tandem with patient experience and access measures, and continue to work toward next-generation digital measurement.
Digital quality measurement will allow CMS and health plans to improve the accuracy and usability of measures and ratings, including outcome measures, tailor measurement to what really matters to patients and caregivers and reduce reporting burden for plans. We also support alignment across CMS programs, and we thank CMS for listening to stakeholder feedback and reversing the weighting change to better support that alignment.
Other Updates to the Quality Rating System
NCQA fully supports the proposal that CMS have the authority to remove a measure from the Star Ratings calculation when a measure steward other than CMS retires the measure. As noted in the proposed rule, when NCQA or other measure stewards retire a measure, we conduct an extensive review with expert panels and solicit public comment. We agree that CMS should be able to respond more quickly to measure retirements by external measure stewards; this will ensure Star Ratings are clinically meaningful, reliable and up to date.
NCQA also thanks CMS for updating the measures in Star Ratings to align with updates from the measure stewards, including expanding the age range for the Colorectal Cancer Screening measure, adding Care for Older Adults back to Star Ratings and adding Kidney Health Evaluation for Patients With Diabetes to the 2026 Star Ratings.
Behavioral Health in Medicare Advantage
NCQA supports CMS’s continuing efforts to expand behavioral health services and ensure accessibility to Medicare Advantage enrollees throughout the country. We are encouraged by the proposal to align appointment wait times with existing primary care standards established in the Manual. We believe this can lead to more timely care and improve health outcomes. Further, including prescribers of medications to treat opioid use disorder will support plans as they seek to enhance equity for persons suffering from opioid use disorder. This approach, when coupled with removal of the X-waiver requirement, could greatly expand care for this vulnerable population. We encourage CMS to evaluate the enhancement and development of additional quality measures for this population, to support efforts to integrate physical and behavioral health, and we look forward to supporting CMS in this important work.
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