September 11, 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-1784-P
Dear Administrator Brooks-LaSure,
The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to provide feedback on the CY 2024 Physician Fee Schedule 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 in the CY 2024 Physician Fee Schedule proposed rule.
Health Equity and Person-Centered Care
NCQA applauds CMS’s ongoing commitment to health equity, and to promoting equitable care for all through the collection and use of standardized health equity data across programs. NCQA is proud of our work to bring transparency and accountability for health equity through our national accreditation standards, HEDIS quality measures and research with public and private partners. Several proposals in the CY 2024 Physician Fee Schedule will contribute to advancing equity and promoting person-centered care, and they have our support.
The addition of an SDOH Risk Assessment as a reimbursable element of the Annual Wellness Visit will enhance patient-centered care and support providers in understanding and addressing the needs of the whole patient. In February, the standard-setting bodies of the Sync for Social Needs Coalition (NCQA, The Joint Commission, the National Quality Forum) released a Joint Statement on Digital Health Data Exchange of Social Determinants of Health Assessments. We look forward to supporting advancing this important work.
While we applaud reimbursement of social needs screening, we recommend that results be documented in the clinical record via LOINC code, to capture that screening was based on a validated standardized data collection instrument. A list of instruments with standard LOINC codes has been established. This would discourage the use of home-grown tools, which may not accurately reflect the intent of SDOH screening.
NCQA developed the HEDIS measure Social Need Screening and Intervention—which assesses screening for unmet food, housing and transportation needs, and includes referral to intervention after a positive screen—to hold health plans accountable for assessing and addressing their members’ social needs. We look forward to working with CMS to align social needs measures across reporting quality reporting programs.
NCQA also supports reimbursement for Community Health Integration Services, Principle Illness Navigation and caregiver training services. If HCPCS codes are required to be documented in the patients medical record in relationship to SDOH need(s) they are intended to address, NCQA recommends for data standardization that practitioners be required to also record the associated Z-code in the medical record and on the claim. Although NCQA supports the use of Z-codes for billing, they should be accompanied by the appropriate LOINC codes to better capture the social needs data collection and intervention process mentioned previously. Recognition of these critical services highlights the importance of person-centered care, which requires intentional focus on a person’s goals. NCQA, with support from The John A. Hartford Foundation and The SCAN Foundation, developed, implemented and tested three Person-Centered Outcome measures. These 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.
We are encouraged to see CMS recognize community-based organizations in addressing health-related social needs. Our Health Equity Accreditation programs—particularly Health Equity Accreditation Plus—underscore the value of engaging with community-based organizations in meaningful partnerships to help health systems continuously prioritize and improve health equity for the communities they serve.
We are also pleased that this year’s proposed rule recognizes community health workers (CHW) and the role of other auxiliary personnel in providing high-quality, equitable care for Medicare beneficiaries, although we disagree with CMS’s proposal of an individual training requirement for auxiliary personnel. Research on the contributions of CHWs has long been a focus of NCQA; our white paper Critical Inputs for Successful Community Health Worker Programs identified how organizations can support CHWs in their work, including training and workforce development.
An alternative to individual certification requirements is program-level accreditation for organizations employing CHWs. An accreditation based on best practices for hiring, training and supervising CHWs would ensure that community health integration services are high quality, and consistent with evidence-based best practices, without imposing barriers that may eliminate trusted community members who share lived experiences with beneficiaries but may not meet individual training requirements. NCQA is interested in furthering research and standards in this area, and we have begun work with a state Medicaid agency on a CHW organization-level certification program. We would welcome the opportunity to support CMS in defining and promoting national best practices.
Expansion of Behavioral Health Services
We support CMS’s efforts to advance access to much-needed behavioral health services. The expansion of eligible provider types, and the proposed changes to allow provision of integrated behavioral healthcare as part of primary care settings, will contribute to strengthening behavioral healthcare for people with Medicare. NCQA’s measures and programs have long provided a roadmap for practitioners to assess and provide high-quality behavioral healthcare, and they can be leveraged by CMS as newer provider types and integrated services are offered through the Medicare program.
The patient-centered medical home (PCMH) model is ubiquitous, and it continues to be used in the CMS MIPS/MVP program. Clinicians in NCQA-Recognized PCMHs or PCSPs (patient-centered specialty practices) automatically get full credit in the MIPS Improvement Activities category. NCQA also offers a Distinction in Behavioral Health Integration for PCMH practices. The Distinction helps practices incorporate behavioral health providers at the site of care, use independent behavioral health providers and train care teams to address patients’ mental health and substance use concerns. We encourage CMS to consider how PCMH practices that have achieved Distinction can be rewarded in previous or newly proposed MVPs (e.g., Quality Care in Mental Health, Substance Use Disorder MVP).
While expanding access to behavioral healthcare services is critical, we must also ensure that care is high quality and that we can measure and compare provider performance. NCQA researchers, with support from the California Health Care Foundation, recently released Behavioral Health Care Integration: Challenges and Opportunities for Quality Measurement, an issue brief that highlights current challenges to behavioral health quality measurement and how solutions such as practice level resources, data infrastructure, data standards and the shift to digital quality measurement can improve measurement and reporting of integrated behavioral healthcare services.
Digital Transformation
NCQA recognizes the concerns about requiring ACOs to report all payer/all patient eCQMs and MIPS CQMs due to the reporting cost and administrative burdens. We understand that the proposed Medicare Clinical Quality Measure (Medicare CQM) data collection type is intended to be transitional and a stepping stone until all payer/all patient electronic reporting is feasible. The proposal is aligned with NCQA’s HEDIS Electronic Clinical Data Systems (HEDIS ECDS) reporting standard, which gives health plans a method to collect and report structured electronic clinical data for HEDIS quality measurement and improvement from a variety of sources, not just from EMRs. We welcome the opportunity to work with CMS and its partners on the collection, validation and eventual transition of this reporting method to future all-digital reporting.
The need for this new data collection type reinforces the challenges with eCQMs, which cannot be readily aggregated with other necessary data to accurately measure quality across all payers or validated against other data sources. These challenges highlight the need to incentivize and accelerate dQM development and adoption across federal programs and the private sector.
Medicare providers should be able to use tools for quality reporting that are fully digitized and pull data from EHRs, clinical registries, case management systems and similar electronic clinical data systems (which could include HIEs). That is why, in 2022, NCQA launched a pilot program for Digital Content Services to help advance digitized quality measurement and to maximize flexibility and transparency in HEDIS performance measurement.
The Digital Content Services product will be available to the public in 2024. This May, NCQA announced upcoming publication of requirements and open-source software for interpreting and executing Clinical Quality Language so any organization or software developer can use HEDIS Digital Content Services—making it easy for developers to understand digital requirements and test capabilities for working with NCQA’s digital measure content. These efforts allow the industry to both advance quality measurement through new electronic data sources and reduce the burden and cost associated with reporting for quality payment programs.
High-Value, High-Quality Care
NCQA fully supports the evolution of MIPs to MVPs, and we are encouraged by the proposed MVPs. We also support the proposal to consolidate Promoting Wellness and Optimizing Chronic Disease MVPs into a single primary care MVP that aligns with the adult Universal Core set of quality measures. We encourage CMS to align the measures in MVPs with the Universal Foundation, where possible. We look forward to continuing our collaboration with CMS to reach our shared goals of burden reduction, health equity and transitioning to digital quality reporting through the Universal Foundation.
We commend CMS’s focus on diabetes prevention and screening. The flexibilities proposed for the Medicare Diabetes Prevention Program should allow more beneficiaries to access this benefit. Expanding access to diabetes screenings will get more people the right care at the right time. NCQA has long been a leader in assessing and promoting diabetes management, and we are in the process of updating our own Diabetes Recognition Program, including developing new diabetes measures that align with evolving data collection and technology. We are interested in further developing our standards and measures to encompass diabetes prevention and screening, and would welcome collaboration with CMS on this important topic.
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