NCQA Comments on CMS’s CY 2024 Home Health Prospective Payment System Proposed Rule

August 29, 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–1780–P

Dear Administrator Brooks-LaSure:

The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to provide feedback on the CMS Calendar Year (CY) 2024 Home Health Prospective Payment System 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 to 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 for the CMS CY 2024 Home Health Prospective Payment System Proposed Rule.

Incorporating Health Equity in the HHVBP Model and HH QRP Measures

NCQA appreciates CMS’s health equity considerations for the Home Health Value-Based Purchasing (HHVBP) Model and Home Health Quality Reporting Program (HH QRP) measures. NCQA is committed to enhancing measure stratifications to identify and address inequitable health outcomes. We have stratified 13 HEDIS measures, spanning 7 measure domains, a mix of populations and conditions and points along the care continuum. NCQA also recently launched the Race and Ethnicity Stratification Learning Network, an interactive, online tool that offers data and best practices to help health plans improve how they collect race and ethnicity data on their members. We encourage CMS and other federal stakeholders to consider policy levers to increase collection and reporting of race, ethnicity and other demographic data across CMS quality programs.

CMS should also require health equity strategies in the Conditions of Participation for Home Health Agencies and other Medicare and Medicaid participating providers, and exercise “deeming” for CMS-approved accrediting organizations, since many health care organizations use accreditation to create standardized, measurable health equity plans. NCQA believes 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 patient outcomes. To date, over 150 organizations have earned Health Equity Accreditation (or its predecessor, Multicultural Healthcare Distinction) and 15 states have leveraged NCQA’s Health Equity Accreditation in some capacity.

Health Equity Accreditation guides health care organizations toward an internal culture that improves diversity, equity and inclusion, and reduces bias. Among other activities, the accreditation 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 networks that can meet their populations’ cultural and linguistic needs.

In 2021 and 2022, two health care systems (Novant Health, Hennepin Healthcare) joined seven health plans as inaugural participants to achieve NCQA’s Health Equity Accreditation Plus. This program builds on Health Equity Accreditation, its prerequisite, by requiring organizations to also collect data on social needs and upstream social risks of the communities they serve, and to make data-driven decisions to improve members’ access to and experience with community-based partnerships and resources. Health Equity Accreditation and Health Equity Accreditation Plus encourage improved outcomes and alignment across the care continuum—they are available to provider groups, health systems, hospitals, ACOs, health plans and more.

Measures and Measure Concepts Recommended for Use in the HH QRP

NCQA strongly supports CMS in its efforts to streamline quality measures across its quality programs (including Home Health) to promote the best, safest and most equitable care for individuals. A key pillar of the CMS National Quality Strategy (NQS) is “alignment,” and NCQA is energized by CMS’s effort to align quality measures across care settings through the Universal Foundation. We are honored that nearly 70% of the measures in the Universal Foundation are HEDIS measures NCQA has developed and stewarded for more than 30 years, making HEDIS “the foundation of the Universal Foundation.” We look forward to our continuing collaboration with CMS to reach our shared goals of burden reduction, health equity and interoperable digital quality measures to allow cross-comparison across programs and identify measurement gaps.

NCQA recommends the Social Need Screening and Intervention HEDIS measure for the HH QRP because, unlike eCQMs for clinician programs, this measure is designed to collect social needs data from sources in addition to the EMR. The measure assesses screening for unmet needs for food, housing and transportation, and includes referral to intervention after a positive screen. NCQA supports aligning all such measures with the Gravity Project’s work to standardize interoperable social needs data, and we encourage CMS to do the same. Because social needs data can be captured in a variety of electronic data sources (e.g., EMRs, resource referral platforms, case management systems), this HEDIS measure is specified for Electronic Clinical Data System (ECDS) reporting.

Although the measure is not currently used in the Home Health domain, we welcome the opportunity to work with CMS to adjust and align quality measures across programs. We look forward to supporting CMS, CMMI and additional federal partners in onboarding more electronic clinical data sources, which will result in a more holistic picture of American health outcomes.

HH QRP Measurement Gaps

We are encouraged by CMS’s commitment to tackling the mental health challenges addressing our nation—measurement plays an important role in identifying needed interventions and coordination. We appreciate CMS’s interest in addressing this measurement gap in the
HH QRP, particularly with regard to depression. NCQA believes Depression Screening and Follow-Up for Adolescents and Adults (DSF) can be collected using existing tools (e.g., the Outcome and Assessment Information Set [OASIS]).

The DSF measure has two parts:

1. Depression Screening. The percentage of members who were screened for clinical depression using a standardized instrument.
2. Follow-Up on Positive Screen. The percentage of members who received follow-up care within 30 days of a positive depression screen.

Because OASIS currently includes items from the PHQ 2 and PHQ 9, a standardized screening tool for depression, a screening measure would be feasible for DSF part 1. For part 2, the OASIS administration schedule allows completion at home for every 60 days of a home health episode and at discharge from acute care. Because a home health stay typically averages 56 days, it would be feasible to determine if the patient received follow-up care within the 30-day period. Additional enhancements of OASIS may be needed to assess referral or access to follow-up behavioral care.

NCQA recommends that CMS incorporate person-centered care measures into HH QRP. We have long supported advancement of person-centered outcomes, and we have led efforts to reach the next generation of patient reported outcomes.

NCQA’s person-centered outcome measures are the result of 10 years of collaboration between NCQA, individuals and their families, clinicians, researchers and 13 health care organizations. Person-Centered Outcome (PCO) measures work in tandem with clinical care to help people living with complex health needs make progress toward a health outcome goal that matters to them. The measures were developed, implemented and tested with support from The John A. Hartford Foundation and The SCAN Foundation, and are ready for immediate use.

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. 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