February 27, 2018
Demetrios Kouzoukas
Principal Deputy Administrator & Director, Center for Medicare
Centers for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244
Attention: CMS-2017-0163
Thank you for the opportunity to comment on the Medicare Advantage (MA) Advance Notice and 2019 draft Call Letter. The National Committee for Quality Assurance (NCQA) thanks you for proposing to add our HEDIS®[1] measure, Statin Therapy for Patients with Cardiovascular Disease, to Star Ratings. However, this measure does not involve medical record review, as the call letter suggests; it looks at claims for statins dispensed to patients.
We also strongly support letting plans limit opioid prescriptions to specific prescribers and pharmacies for at-risk beneficiaries. This parallels our new opioid measures that track high dosages and multiple prescribers. We thank you for citing one of our opioid measures and additional HEDIS behavioral measures as potential future Medicare Advantage Star Ratings.
We support letting plans provide a wider array of supplemental benefits, including non-medical services that address health needs. This is wise policy, as many non-medical services can improve enrollees’ quality of life while reducing disease burden and total health care spending.
We support letting plans include completion of health risk assessments (HRAs) as a permitted health-related activity in a Rewards & Incentives Program. This can help to increase HRA completion, and subsequently lead to better detection and treatment of health care conditions. However, you should require plans to demonstrate that they address HRA results if they offer such incentives.
We support prioritizing technical assistance to states on more robust D-SNP Model of Care submissions that incorporate information on integrating Medicare & Medicaid managed long-term services and supports (MLTSS). Two states already require NCQA’s new LTSS Accreditation programs for plans providing MLTSS, and our program can help to facilitate better LTSS integration.
Detailed comments on these and other issues in the proposed rule are below.
Medicare Advantage Star Ratings
Statin Therapy for Patients with Cardiovascular Disease: Thank you for proposing to add this important measure to the Star Ratings. This measure looks at the percentage of males age 21-75 and females age 40-75 diagnosed with clinical atherosclerotic cardiovascular disease who received at least one high or moderate-intensity statin medication. We developed it from 2013 guidelines from the American College of Cardiology and the American Heart Association.[2] They based the guidelines on scientific evidence that statin therapy reduces the risk for cardiovascular events by significantly lowering low-density lipoprotein cholesterol (LDL-C). Adding this to the Star Ratings will provide strong incentives for plans to ensure that patients with atherosclerotic cardiovascular disease get effective treatment. Of note, we are now considering additional exclusions for people 65 or over with an advanced illness or frailty.
Also, importantly, the draft call letter incorrectly suggests that the measure is based on medical record review. The measure relies solely on claims and assesses whether patients actually received statins, not whether a clinician prescribed them.
Opioid Limitations: We strongly support letting plans limit opioid prescriptions to specific prescribers and pharmacies for at-risk beneficiaries. There is an urgent need for this policy to address the widespread, lethal opioid epidemic. The policy also parallels our new opioid measures that track high dosages and multiple prescribers:
- Use of Opioids at High Dosage. Members who received prescription opioids for 15 days or more at a high dosage (>120 mg morphine equivalent dose).
- Use of Opioids from Multiple Providers. Members who received prescription opioids for 15 days or more from multiple providers, reported by three rates:
- Multiple Prescribers: Members receiving prescriptions for opioids from four or more different prescribers during the measurement year.
- Multiple Pharmacies: Members receiving prescriptions for opioids from four or more different pharmacies during the measurement year.
- Multiple Prescribers and Multiple Pharmacies: Members receiving opioids from four or more different prescribers and four or more different pharmacies during the measurement year.
High dosages, along with multiple prescribers and pharmacies, are all risk factors for dangerous overdose and death. Our intent is for these measures to encourage health plans to address the opioid epidemic and track their progress.
Our new opioid measures are among several new behavioral health measures we have or are developing, which together can help to promote urgently needed improvement in this critical area. We thank for you referencing three of these as potential future Medicare Advantage Star Ratings measures:
- Opioid Overuse,
- Depression Screening, and
- Follow-Up, and Unhealthy Alcohol Use Screening and Follow-Up).
Adding these and additional behavioral health measures to the Star Ratings system will emphasize their importance and incentivize much-needed improvement through the powerful Stars bonus and rebate financial incentives.
Reducing the Risk of Falling: We support temporarily removing this NCQA measure from Star Ratings. As you note, changes we made to this measure require revisions to the Health Outcomes Survey from which we derive the measure’s results. We changed its denominator to include all beneficiaries age 65+, instead of just those 75+ or 65-74 with balance or walking problems or falls. We also removed the phrase “Check your blood pressure lying down or standing” to align with the United States Preventive Services Task Force. We agree on adding it to 2020 display page and back into the Star Ratings for 2021.
Socio-economic Status: We thank you for including a discussion of NCQA’s decision to stratify measures for which there are differences based on enrollee socio-economic status. These measures include Breast Cancer & Colorectal Cancer Screening, Comprehensive Diabetes Care – Eye Exam Performed, and Plan All-Cause Readmissions. We are stratifying results for these measures based on whether enrollees have
- A disability;
- Dual Medicaid/Medicare enrollment and/or receive the Part D Low-Income Subsidy (LIS);
- A disability and dual Medicaid/Medicare enrollment and/or receive LIS;
- Neither a disability or dual Medicaid/Medicare enrollment and/or receive LIS; and
- The Total rate.
This will highlight disparities, help target improvement efforts, and support comparison among plans.
Hospitalizations for Potentially Preventable Complications: We support keeping this measure on the display page, as we are considering incorporation of observation stays. We agree that you should move it into the Star Ratings for 2022.
Initiation and Engagement in Alcohol or Drug Dependence Treatment: You are correct that we have added Medication Assisted Treatment (MAT) to this measure. However, we are no longer considering whether to add specific behavioral health codes, such as self-harm, asphyxiation, overdose or poisoning.
Telehealth and Remote Access Technologies: We thank you for seeking comment on the feasibility and strategies for applying telehealth and remote access technologies to several Star and display measures, which we are actively considering.
We are conducting a comprehensive review of measures for which we should incorporate these technologies that greatly improve access and timeliness of care. CMS requires Medicare Advantage reporting for several measures in this review:
- Use of Spirometry Testing in the Assessment and Diagnosis of COPD
- Osteoporosis Management in Women who had a Fracture
- Adults’ Access to Preventive/Ambulatory Health services
- Ambulatory Care
- Comprehensive Diabetes Care
- Statin Therapy for Patients with Diabetes
- Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis; and
- Statin Therapy for Patients with Cardiovascular Disease.
Other Issues
Managed Long-term Services & Supports: We support prioritizing technical assistance to states on more robust D-SNP Model of Care submissions that incorporate information on integrating Medicare & Medicaid MLTSS. NCQA launched an LTSS Accreditation programs in 2016 to support the growing movement toward better LTSS coordination. Pennsylvania and Virginia quickly required it for plans participating in the Financial Alignment Initiative for Medicare-Medicaid Enrollees, and other states are considering the same. As of January 2018, 24 entities have earned NCQA MLTSS accreditation.
Health Risk Assessment Incentives: We support letting plans include completion of HRAs as a permitted health-related activity in an Rewards & Incentives Program. This can help to increase HRA completion, and subsequently lead to better detection and treatment of health care conditions. However, we recommend that you require plans to demonstrate that they address HRA findings with referral to appropriate care or population health programs in order to provide such incentive. This will prevent recurrence of situations in which plans collected additional patient diagnoses to increase risk adjustment scores but did not manage those diagnoses.
Thank you again for the opportunity to share comments. If you have questions, please contact Paul Cotton, Director of Federal Affairs, at (202) 955-5162 or cotton@ncqa.org.
Sincerely,
Margaret O’Kane,
President
[1] HEDIS – the Healthcare Effectiveness and Data Information Set, is a registered trademark of NCQA.
[2] Stone, et al, 2013. “ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults.” Journal of the American College of Cardiology.