February 20, 2019
Seema Verma, Administrator
Centers for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244
Dear Administrator Verma:
Thank you for the opportunity to respond to your Request for Information (RFI) on Medicare Accreditation Organizations Conflict of Interest and Consulting Services. The National Committee for Quality Assurance (NCQA) accredits health plans, including Medicare Advantage, Marketplace and Medicaid plans. We take very seriously the importance of avoiding conflicts of interest, or any perceptions of conflicts, and greatly appreciate your interest in this.
Accreditation provides a common process and common measures for assessing compliance with the same quality requirements for different entities. We know that the landscape for quality regulations and measurements is rapidly developing and that different populations may need different standards or measures. Nevertheless there is often considerable overlap between accreditation and requirements of government, employers and other purchasers, and accreditation helps to minimize redundancy.
NCQA does not provide consultative services to health plans we accredit to avoid any perceived or real conflict of interest with our role as an independent evaluator of health care performance. To further guard against conflicts, our Review Oversight Committee (ROC) makes final decisions on whether entities earn our accreditation. The ROC is comprised of volunteer physicians with extensive plan survey expertise and strong commitments to quality and integrity. We individually vet each ROC member for any potential conflicts of interest with the entity they review. We have some health plan representatives on our Board of Directors to get their essential perspectives, but the vast majority (16 out of 18) of Board members do not represent insurers. We provide education programs on our accreditation program requirements, but this education is broad-based, not tailored to any specific plan and not factored into scoring that determines whether plans achieve accreditation.
External Quality Review Organizations (EQRO)
In 2016 rulemaking, Section §438.354(c) of the Medicaid Managed Care rule – External Quality Review Organization and Subcontractor Qualifications, CMS excluded accreditors from all EQRO work over concern that financial relationships between plans and accrediting bodies could unduly influence EQR results.
The rule also allowed EQROs to assist with quality ratings, an area in which NCQA is a national leader with unparalleled, specific expertise.
We proposed in our Medicaid Managed Care rule comments that accreditors be eligible to serve in a subcontracting role for non-mandatory EQR-related activities, such as quality ratings and performance measure development support. We understand the unique nature of designing a quality rating system and currently support both state and federal agencies on a contractual basis.
Finally, state EQRO RFPs continue to include tasks that go well beyond mandatory and optional EQR-related activities, such as measurement methodologies and standards. Ohio, for example, recently included such tasks in its EQRO RFP. NCQA maintains cutting-edge experience, particularly in measure development including managed long-term services and supports, behavioral health and eMeasures, that could greatly benefit states. We believe states want to include such tasks in EQRO contracts because of the higher 75% federal matching rate. Letting experienced accreditors subcontract on these issues would enhance state efforts to advance value-based initiatives without conflicts.
We therefore encourage you to update the across-the-board ban on accreditors in EQRO work to let accreditors serve as subcontractors for non-mandatory activities.
States would greatly benefit from enhanced matching that lets them select the most qualified contractors for such tasks without sacrificing much-needed matching dollars. The National Association of Medicare Directors suggested this in 2015 Medicaid managed care rule comments:
CMS should provide enhanced FFP for EQR activities performed by entities other than EQROs.
The rule envisions the use of non-EQROs to conduct some EQR activities, and states believe this is an important flexibility to promote quality in the program. However, the rule does not ensure equal support in federal funding for ERQ activities performed by these other entities; it does not extend the 75 percent FMAP to them. This creates inconsistency in CMS’ policy goals and support for quality improvement activities.
This enhanced match would also support states in conducting the variety of new quality requirements under the proposed rule—many of which will increase costs to the state. For example, the new EQR activity to perform network adequacy monitoring, such as secret shopper calls, will be expensive. Federal support for this quality activity, whether conducted by the EQRO or another entity will be necessary to offset this burden.
We agree that states would benefit from an enhanced match letting them select optimal contractors for such tasks without sacrificing much-needed matching dollars.
We therefore make these recommendations regarding EQROs:
Recommendation 1: Amend Medicaid Managed Care Rule section §438.354(c) on EQRO qualifications to allow accreditors to serve as subcontractors for non-mandatory EQRO-related activities like development and support of quality ratings and performance measures.
Recommendation 2: Increase the enhanced match for EQR activities performance by entities other than EQRO’s from 50% to 75%.
Thank you again for the opportunity to respond to this RFI. If you have any questions, please contact NCQA Director of Federal Affairs, Paul Cotton, at (202) 955-5162 or firstname.lastname@example.org.
Margaret E. O’Kane