July 3, 2023
Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Ave. SW
Washington, DC 20201
Attention: CMS-2439-P
Dear Administrator Brooks-LaSure:
The National Committee for Quality Assurance (NCQA) appreciates the opportunity to provide feedback on the proposed rule for Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality.
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 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 is to improve the quality of health for all Americans, with an intentional focus on health equity and support for meaningful value-based payment models.
We are pleased to provide comments in the following areas:
- Making it easier for states to use accreditation and HEDIS®[1] for external quality review (EQR). We applaud CMS’s efforts to standardize quality evaluation and access standards across state Medicaid programs.
- Aligning with existing standards, practices and strategies. We support aligning access and quality standards and reporting requirements with predominant standards and practices that ensure valid and reliable comparison across programs.
- Leveraging new data sources and financing authorities to improve access to care and health outcomes. We are encouraged by the flexibility for health plans to invest in social determinants of health using “in lieu of” services and encourage accreditation to improve outcomes for enrollees.
Making it easier for states to use accreditation and HEDIS for external quality review (EQR)
Streamlining use of non-duplication. We are delighted to see removal of the requirement to achieve Medicare Advantage deeming authority. This simplifies the option for states to use accreditation reviews for non-duplication. We believe this proposal will bolster the rule and profoundly reduce the oversight burden for states, health plans and providers. This change will expand the efficiencies and benefits of non-duplication in state Medicaid programs. Currently, 36 states use Health Plan Accreditation in their Medicaid programs. Of those, 15 states reference using NCQA for non-duplication in their quality strategies. Each year, our Medicaid Managed Care Toolkit supports state adoption of non-duplication, and in 2022, our Access to Care standards showed a 92% equivalency rate with CMS regulations.
Aligning EQR Report Submission Deadline. We agree with the proposed new annual submission date of December 31, which aligns with the HEDIS performance measurement timeline and process. The change will allow 42 states and Puerto Rico, which use HEDIS for its performance management platform, to incorporate the most recent performance rates into their submitted reports, leading to better comparability across states.
The integrity of NCQA’s HEDIS measurement and Health Plan Accreditation programs are equivalent to the rigor of EQR. States increasingly use NCQA Accreditation to meet oversight requirements for compliance review and performance measure validation. For quality reporting alone, that represents more than 65 million Medicaid covered lives in audited Medicaid health plan HEDIS results.
As Medicaid continues to evolve, NCQA looks forward to further aligning with CMS to promote improvement in access to high-quality health care and reducing the administrative burden of states with regard to quality reporting and monitoring.
Aligning with existing standards, practices and strategies.
Recognize access standards as performance benchmarks to pursue. We applaud the establishment of the access to care standard for Medicaid, and we recommend that CMS view the standard as a performance benchmark. Access to care can be nuanced, and missing the target for a certain geography or subpopulation during a given period necessitates an ongoing quality improvement process. NCQA has a long history of establishing and monitoring access to care standards and improvement efforts. For decades, our Health Plan Accreditation program has required Accredited organizations to establish these standards and enact performance activities to pursue them. Accredited organizations in Medicaid use state-specific access to care standards required by Medicaid agencies. Accredited organizations then align monitoring and improvement activities with a regulatory-required access to care standard.
NCQA’s primary care access and utilization measures have been one of the industry’s predominant thresholds for access to care. We are delighted that access continues to be a high priority for CMS, and we are actively exploring new metrics for quantifying and improving network adequacy and access to care—focusing specifically on behavioral health and primary/preventive care. We welcome the opportunity to partner with CMS to develop new and innovative measurement methods.
Align enrollee experience survey requirements with existing Core Set options. We support requiring states to conduct enrollee experience surveys as a component of evaluating access to care. Access to care is multi-faceted, and enrollee experience survey results can complement other assessment methods, such as network adequacy standards and utilization measures. NCQA has worked with nearly every state and territorial Medicaid agency in the country. We understand their use of enrollee experience surveys to quantify access to care. Many states use survey results to incentivize health plan performance on enrollee satisfaction.
We recommend that CMS ensure alignment between enrollee experience survey requirements and the forthcoming Core Set reporting mandates—such as survey instruments, time periods and populations—to reduce survey and reporting burden and prevent duplicate responses.
Align quality measurement requirements to maximize comparability and advance digital quality.
Create motivation to incorporate clinical data. NCQA has supported standardized quality measurement and nationally reliable benchmarking for decades. Standardized and audited health plan reporting has created a powerful policy tool for state Medicaid agencies. Recently, NCQA expanded its use of Electronic Clinical Data System (ECDS) measurement into the goal of creating a standardized national health plan dataset for this growing set of clinical measures. Leveraging these measures and benchmarks for state rulemaking will motivate state Medicaid programs to incorporate clinical data into measurement, validate clinical data streams for reporting purposes and invest state/federal matching dollars into technological upgrades focused on valid/reliable digital quality measurement systems. Aligning quality measure reporting requirements (such as the Quality Rating System [QRS]) in the proposed rule with the Digital Quality Measure Strategic Roadmap will enhance a state Medicaid agency’s role in supporting the transition to digital quality measures, and will expand the use of state/federal matching funds in pursuing that aim.
Validating supplemental data from the source. We recognize the credibility of claims data, given the legal and financial parameters supporting the data’s integrity. NCQA is committed to promoting the same level of credibility for clinical data. In 2020, we launched our Data Aggregator Validation program, which verifies clinical data for use by payers, including Medicaid MCOs for HEDIS reporting. Twenty-six organizations have successfully completed this program and can now share validated clinical data with payers. This work highlights improvements in data transformation and management practices to continuously enhance the credibility of clinical data for reporting. Increasing the use of clinical data—which guide provider application of evidence-based medicine—in evaluating health care system performance will enhance the rigor of evaluation and the influence of policy interventions such as value-based purchasing and payment.
NCQA’s Data Aggregator Validation program is increasingly being adopted by states to reduce provider burden in the HEDIS primary source verification and hybrid abstraction processes, thereby supporting the move to population level measurement. The program validates clinical data streams transmitted for use by health plans in HEDIS reporting. While ECDS measurement creates a standardized program rule to allow clinical data to be used in measurement, Data Aggregator Validation helps reduce provider burden for supporting data validation.
We recommend that CMS adopt this program as an emerging, promising practice by state Medicaid programs to support advancement of a state digital quality measurement framework. New York, Alabama, Rhode Island and North Carolina are leading the way by adopting or promoting Data Aggregator Validation among their Health Information Exchanges, to enable validation and use of clinical data. As technologies advance (e.g., FHIR®) and additional aspects contributing to measurement integrity emerge, NCQA will evolve the program to ensure ongoing, credible use of electronic data sources and clinical data for quality measurement.
Maximizing comparability by building from established certification, auditing and reporting processes. The HEDIS measurement process serves as the foundation for state performance management systems. It encompasses measure specifications, implementation requirements (measure certification and validation), reporting and auditing guidelines and benchmarking methods. Its rigor has made it an institutionalized component of state Medicaid quality programs. Many states use HEDIS to meet Performance Measure Validation EQR requirements. We recognize that most of the proposed Core Set reporting measures are HEDIS, and we strongly support CMS’s modification to the rule to align the QRS with similar CMS quality measurement and rating initiatives. We encourage CMS to also align state directed payment evaluation requirements with the HEDIS process. By leveraging the NCQA’s Measure Certification and HEDIS Compliance Audit™ aspects of the HEDIS process, CMS promotes best practices and improves data quality. This enhances the goal of reducing disparities using valid, reliable data. Alignment will support states in maintaining the efficiency gains of the HEDIS process in other areas, and increase the integrity of comparison across Medicaid MCOs and managed care states.
Leverage new reporting and financing authorities to improve access to care and health outcomes.
Maximize Medicaid investment to address social determinants of health. We believe the “in lieu of” services (ILOS) policy is a tremendous advancement in providing flexibility for states to use Medicaid funding to address social determinants of health. States have long attempted to partner with their Medicaid health plans to address their beneficiaries’ socioeconomic barriers, with limited ability to scale and spread innovative interventions with Medicaid funding. We are delighted to see this new policy innovation.
NCQA has amplified its commitment to addressing health equity and social determinants of health through its Health Equity Accreditation Plus program. While the base Accreditation program focuses on creating organizational and programmatic infrastructure to identify and address systemic disparities based on race, ethnicity, sexual orientation and gender identity, Accreditation Plus guides organizations into authentic community partnerships to address social risk factors in the community.
Health Equity Accreditation Plus promotes an operational model that integrates clinical and social care for Medicaid beneficiaries, including requiring Accredited organizations to develop a budget for the model. To date, some organizations have perceived limitations in their ability to invest in initiatives that address social risk factors due to Medical Loss Ratio constraints. The latest ILOS policy allows Medicaid health plans to use the medical expenditure side of the ratio to address social determinants, rather than finding room in their administrative budgets for these integral and innovative community partnerships. Health Equity Accreditation Plus provides a framework for using data-driven and community engagement methods to plan and implement ILOS investments.
Organizations that have achieved Health Equity Accreditation/Plus are in an ideal position to maximize the intent of equity-centered policies such as ILOS. Thus far, 169 organizations have achieved Health Equity Accreditation. Eleven states require their Medicaid health plans to achieve it, and 2 state-based exchanges requiring it for Qualified Health Plan Certification. Ten organizations have achieved Accreditation Plus, and momentum is growing to commit to health equity and social risk factors in an institutional and structural way. NCQA’s Health Equity Accreditation programs are emerging as another gold standard for the industry.
Utilize payment rate comparison requirements to institute care delivery innovations. We believe the requirements for states to compare Medicaid and Medicare payment rates will motivate them to adopt care delivery innovations, along with fee schedule modifications. In our work with state Medicaid programs, we have seen states adjust Medicaid payment rates to Medicare levels for providers who achieve NCQA Patient-Centered Medical Home (PCMH) Recognition (see Florida’s example). CMS should consider ways to leverage this rule to spark care delivery innovations in state Medicaid programs.
Closing considerations
Support states in implementing the Quality Rating System. Based on our experience, creating a valid, reliable measurement system in the Medicaid landscape involves considerable expertise and resources. We also acknowledge that state staff committed to implementing a QRS mandate may also be tasked with developing, executing and evaluating the state Medicaid agency’s quality improvement policies and programs overall. We recommend that CMS consider providing technical assistance to states through learning collaboratives and pilots to test innovative technologies that can enhance the integrity of the system and promote state policy innovations. NCQA’s experience in engaging states through our affinity groups (the State Medicaid Quality Network, the State Data Quality Network) has proved a valuable approach to idea exchange and solution sharing on such topics.
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 Kristine Toppe, Assistant Vice President of State Affairs, at (202) 955-1744 or at toppe@ncqa.org, or contact Tom Curtis, Director for State Affairs, at (202) 517-8002 or at tcurtis@ncqa.org.
Sincerely,
Margaret E. O’Kane
President
National Committee for Quality Assurance
[1]HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).