NCQA Comments on Medicare Advantage

August 31, 2022

Chiquita Brooks-LaSure
Administrator
Centers for Medicare and Medicaid Services
Department of Health & Human Services
Hubert H. Humphrey Building
200 Independence Ave., S.W.
Washington, DC 20201

Attention: CMS-4203-NC, Feedback on Medicare Advantage

Dear Administrator Brooks-LaSure:

The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to provide feedback on Medicare Advantage.

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 toward an equitable health care system. Our mission to improve the quality of health for all Americans, with an intentional focus on health equity and support for meaningful value-based payment models, propels our daily work.

NCQA agrees with the CMS National Quality Strategy’s aim to create a more equitable, safe, outcomes-based and person-centric health care system. We have developed the tools that Medicare Advantage plans need to improve quality, equity, inclusion, population health, and more. We believe our programs offer CMS the opportunity to improve the performance of Medicare Advantage plans in all of the areas you have outlined. We have commented in detail below, and would welcome the opportunity to work with you in a more in-depth way to drive accountability and improvement in the Medicare Advantage market to align with your priorities.

We are pleased to provide comments in the following areas:

• Advance Health Equity. To drive more equitable care for our nation’s seniors, we encourage CMS to mandate Health Plan Accreditation, and incentivize the achievement of Health Equity Accreditation and Health Equity Accreditation Plus. We also encourage CMS and to consider policy levers to increase collection of race, ethnicity and other demographic data. Finally, we support the adoption of measures addressing social drivers of health, and aligning those measures standardize interoperable social needs data.
• Expand Access: Coverage and Care. We encourage CMS to explore the use of standardized electronic, interoperable processes to digitize prior authorization, and welcome the opportunity to collaborate on this work.
• Drive Innovation to Promote Person-Centered Care. To advance data exchange and drive the move to digital measurement, CMS should consider financial incentives for digital reporting and fund efforts to advance data interoperability. To improve the Medicare Advantage Star Ratings, we encourage CMS to adopt next-general digital measurement to reflect the continuum of care from patient experiences to health outcomes, and to modernize patient experience measurement to include a broader representation of patients and care settings. We also recommend that CMS adopt principles of person-centered outcome measures, to incorporate what matters to patients and caregivers into care planning and quality measurement.

Advance Health Equity

Accreditation Helps Organizations Drive Quality, Value and Equity

We commend CMS’s commitment to advancing health equity, and we support the agency’s Framework for Health Equity across all CMS programs. CMS can use NCQA’s programs to drive innovation and accountability, specifically using our accreditation programs to embed evidence-based practices in Medicare Advantage.

NCQA’s Health Plan Accreditation gives organizations a roadmap for quality improvement that will drive equitable care. It is the most widely recognized accreditation program in the United States. More than 1,100 health plans have earned NCQA Accreditation; 42 states either require or use it. Moreover, every plan offered in the Exchange Marketplace must be accredited, and most choose NCQA’s program. We believe a mandate requiring all health plans in the Medicare Advantage market to be Accredited is essential to protect consumers and drive more equitable care for our nation’s seniors.

Health Plan Accreditation standards evaluate plans on how well they manage population health, implement best practices and quality improvement processes, perform network and utilization management and manage member connections, as well as tasks in other areas. The standards provide a framework for improving key impact areas that keep patients at the center of care: care coordination, access and availability of health resources, such as wellness services, and tools for managing chronic disease.

NCQA has worked hard to ensure that the Health Plan Accreditation program includes a roadmap to achieving health equity. Equity-focused standards require organizations to promote diversity in their recruitment and hiring practices and to offer employee training on cultural competency, bias or inclusion.

Equity is also a focus of population health management. Accredited organizations must demonstrate that they:

• Have a population health management strategy that describes the organization’s commitment to improving health equity and a plan for taking at least one action to promote equity in the management of member care.
• Assess their members’ needs regarding social determinants of health, aspects of disability, race, ethnicity or limited English proficiency.
• Assess their segmentation or stratification methodologies, or algorithms, for the presence of racial bias.
• Make training on implicit bias accessible to network practitioners/providers.

NCQA can also support Medicare Advantage plans in addressing health equity specifically through Health Equity Accreditation and Health Equity Accreditation Plus. CMS can leverage these programs to enhance health equity for enrollees and embed standardized processes, structures and reporting into Medicare Advantage to drive innovation and accountability that is informed by social determinants of health. These programs lay a foundation for organizations to provide culturally sensitive care and deliver high-quality, equitable care. Regional subsidiaries of national health plans (United Healthcare, Elevance, CVS Health, Centene, Molina) participated in the feasibility pilot of both programs to demonstrate that their commitment to health equity benefits their regions and populations.

Health Equity Accreditation guides organizations toward an internal culture that improves diversity, equity and inclusion, and reduces bias. It requires organizations to collect data on race, ethnicity, sexual orientation and gender identity, to identify opportunities to create (and offer) language services, written materials and provider networks that can meet their populations’ cultural and linguistic needs. The program also requires organizations to identify opportunities to reduce disparities in clinical performance and to address inequities in care and services.

Health Equity Accreditation Plus supports health care organizations that are more advanced in their health equity journey. It builds on Health Equity Accreditation, its prerequisite, by requiring organizations to also collect data on social determinants of health 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, with the goal of improving outcomes.

We recommend that CMS require Medicare Advantage plans to achieve Health Plan Accreditation, which will drive quality, value and equity and improve care for enrollees. We also encourage CMS to incentivize achieving Health Equity Accreditation and Health Equity Accreditation Plus. With these programs in place CMS can have confidence that Medicare Advantage plans operate under standardized guidelines and are accountable for improving equity for their workforce, communities and enrollees.

Advancing Equity Requires Appropriate Data

It is critical that CMS also leverage appropriate data and quality measures to assess plan performance on providing equitable care. We applaud the Center for Medicare for publicly reporting stratified HEDIS rates for Medicare Advantage plans for over a decade. And we are committed to stratifying our HEDIS measure set; to date, we have added race and ethnicity stratifications to 13 HEDIS measures and plan to expand stratifications over the next several years to help identify disparities in care among patient populations.

We encourage CMS and other federal stakeholders to consider policy levers to increase collection of race, ethnicity and other demographic data, and we recently published relevant recommendations with Grantmakers in Health (Federal Action Is Needed to Improve Race and Ethnicity Data in Health Programs). We believe CMS should use its authority under Section 4302 of the Affordable Care Act to require Medicare Advantage payments to be linked to specific performance levels for reporting race, ethnicity and language data, beginning with the HEDIS measures Race/Ethnicity Diversity of Membership and Language Diversity of Membership. We also encourage CMS to compel reporting of complete data on race, ethnicity, gender identity and sexual orientation, people living with disability and marginalized populations.

Effective Measurement for Care Informed by Social Determinants of Health

We are encouraged by CMS’s proposal to include social needs screening measures in quality programs, and we believe patient-level, health-related social needs data are essential to meaningful collaboration between health care payers, providers and community-based organizations. NCQA supports aligning measures with the Gravity Project’s work to standardize interoperable social needs data, and we encourage CMS to do the same.

NCQA released the Social Need Screening and Intervention measure (for MY 2023) that assesses screening for unmet food, housing and transportation needs, and referral to intervention after a positive screen. Measure domains are based on maturity of electronic data standards and can be expanded as data standards advance. Because social needs data can be captured in a variety of electronic data sources (e.g., EMRs, resource referral platforms, case management systems), NCQA’s measure is specified for Electronic Clinical Data System (ECDS) reporting. The measure also aligns with the Gravity Project’s standards and will be subject to the traditional HEDIS audit to ensure validity of results.

We welcome the opportunity to work with CMS to ensure that measures of social needs are reliable and valid, and that they ease the burden of collection and strive for alignment across programs. We encourage CMS to align Screening for Social Drivers of Health and Screen Positive Rate for Social Drivers of Health with the Gravity Project’s efforts before making them mandatory in other CMS programs or considering them for use in Medicare Advantage. Currently they do not align with the Gravity Project’s timeline for harmonizing social risk factor data for interoperable electronic exchange, or account for screening outcomes.

Expand Access: Coverage and Care

Reducing the Burden of Prior Authorization

Current prior authorization policies are based on administrative data and guidelines, and there is broad desire to align them more closely with clinical best practices and treatment guidelines. Like payer-driven quality and value-based payment programs, they can be a source of administrative burden on providers, interrupt physician workflows and negatively impact patient experience and access. We believe that digitizing prior authorization – much like the move to digital quality measures – may offer an opportunity to improve the experience for providers and patients alike.

NCQA recently convened key industry stakeholders to address the burden of prior authorization and utilization management. Stakeholders agreed that standardization and technology solutions will help reduce burden. Establishing common tools, infrastructure, standards and implementation is important for relieving the burden of prior authorization, and allows payer prior authorization decisions to be made more quickly, to meet patient needs.

We encourage CMS to explore the use of standardized electronic, interoperable processes focused on transparency of utilization management requirements and real-time decisions at the point of care. Using standardized content and format to make medical necessity determinations would support electronic interface, ease provider burden and improve members’ timely access to care. Other potential opportunities to consider include eliminating the prior-authorization requirement for specific services that meet a consistent approval threshold.

Specific data and measures that may be meaningful for Medicare Advantage enrollees, clinicians and organizations include:

• Percentage of services approved, by transaction type.
• Percentage of denials and appeals.
• Percentage of overturned denials and appeals.
• Percentage of reasons for denial and appeal determinations.
• Percentage of retrospective decisions, and associated outcomes.
• Decision turnaround time by decision type.
• Clinician-specific denial and approval rates, by service category.
• Level of electronic prior authorization automation (and amount of provider burden reduction).
• Measures stratified by race, ethnicity and other health equity elements.

We welcome the opportunity to collaborate with CMS to develop solutions for tackling this important issue.

Drive Innovation to Promote Person-Centered Care

Data Exchange and the Move to Digital Measurement

NCQA has invested heavily in building a digital quality ecosystem to create more efficient data collection and reporting, and better accountability at all levels. The launch of our inaugural Digital Quality Solutions Pilot will move the industry toward realizing the full potential of digital quality measures, and can be a prototype for CMS’s considerations for measure calculation tools (as outlined in its Digital Quality Measurement Strategic Roadmap). We are encouraged by CMS’s commitment to requiring that all quality measures be reported as digital quality measures in the near future. CMS can support organizations and facilitate the transition by incentivizing and rewarding those that transition to digital quality measurement. For Medicare Advantage, CMS should consider bonus payments for digital reporting through the Star Ratings system or other programs.

We also believe CMS should fund efforts to advance data interoperability, and focus on making tooling and guidance freely available, to enable uptake. Collaborations like Georgia Tech’s Fast Healthcare Interoperability Resources and Observational Medical Outcomes Partnership (OMOPonFHIR), which developed tools to convert from one data model to another, are examples of advancing data standards but not requiring a “one-size fits all” approach. Mapping among a variety of data models can accelerate progress, provide the most value and ease the burden of transitioning to digital measurement.

We encourage CMS to continue to incentivize standardized data exchange under the Trusted Exchange Framework and Common Agreement (TEFCA) through other CMS programs and value-based payment models. This will greatly enhance our ability to automatically extract data for quality measurement from health information exchanges and other non-EMR clinical data sources.

Improving Medicare Advantage Star Ratings to More Accurately Reflect Care and Outcomes

Although patient experience and access measures are a critical component of a quality ratings system, we disagree with the recent change that doubled the weight of patient experience, complaints and access measures in the Stars Ratings methodology. We do not believe these measures should be weighted more than clinical measures (especially at a ratio of 2:1). The methodology should instead balance all important aspects of health care quality. The move to increase weight for patient experience, complaints and access measures decreases the relative weight of clinical measures in the overall ratings, and while actions such as stratifying data will shine a light on inequities, the reduced relative weighting of clinical measures may mean plans have less incentive to close those gaps.

The Star Ratings program is an example of how appropriate financial incentives, aligned with transparent quality measurement, can drive improved health outcomes and provide consumers with tools to choose a plan that best fits their needs. Requiring that plans report using consistent methods on a set of rigorously defined measures ensures meaningful benchmarking and comparison. Rigorous auditing gives stakeholders confidence that results are accurate and valid. The process measures in the program—such as evidence-based cancer screening—are closely tied to outcomes, and we have seen that screening for things like colorectal cancer has increased significantly over time. Process and intermediate outcome measures improve health, health plan performance and cost, and measures related to wellness, prevention and chronic disease management have a significant impact on quality of life, as well as on cost.

Improvements to the Medicare Advantage Star Ratings program could, however, enable a more accurate reflection of the quality of care enrollees receive, reduce the reporting burden and improve the holistic measurement of patient experience. For example, NCQA applauds CMS’s efforts to test a web-based mode for fielding the CAHPS survey and its plan to test new survey topics that address language, experience with remote care and perceived discrimination, and collect sexual orientation and gender identity data. But we also believe more can be done to modernize inclusion of the patient voice in the Star Ratings. A quality rating system should reflect the continuum of care from patient experiences to health outcomes. Moving to next-generation digital measurement offers opportunities to improve the accuracy and usability of measures and ratings, and the ability to tailor measurement to what really matters to patients and caregivers, and can also reduce reporting burden.

A digital approach to patient experience can improve response rates by providing convenience and accessibility and more targeted and actionable results, and can improve identification of populations from whom feedback is most needed (such as high utilizers, people with multiple chronic conditions and those negatively impacted by social risks). We encourage CMS to explore the measurement of experience across care settings, such as in the home, because where and how care is delivered is changing rapidly. Finally, the Stars Ratings system would benefit from the addition of person-centered measures, described below. All of these steps would improve the holistic measurement of patient experience.

Person-Centered Measurement to Help Achieve Equitable Outcomes

Accumulating evidence suggests that care based on what matters to people, particularly those with complex health status, leads to increased patient engagement and decreased resource utilization. We encourage CMS to adopt principles of person-centered outcome measures, which can help achieve equitable outcomes with next-generation measures designed around the concept of incorporating what matters to patients and caregivers into care planning and quality measurement. NCQA’s person-centered outcome measures integrate, drive and assess that care across the care continuum. The Star Ratings system could benefit from the addition of such measures.

NCQA is preparing for two measure-testing collaboratives that will help develop and finalize measures for widespread dissemination—we hope this includes their eventual use in federal programs. Participating sites include primary care practices, organizations that offer long-term services and supports and behavioral health organizations. Widespread use of person-centered outcome measures that can standardize tracking and achieving patient-centered goals would drive care based on patient goals.

Thank you again for the opportunity to comment. We are eager to work with CMS to advance health equity and drive person-centered care in Medicare Advantage through the use of evidence-based standards and next-generation quality measurement. If you have any questions, please contact Eric Musser, NCQA Assistant Vice President of Federal Affairs, at (202) 955-3590 or at musser@ncqa.org, or Olivia Umoren, NCQA Federal Affairs Manager, at (202) 827-9450 or at oumoren@ncqa.org.

Sincerely,
Margaret E. O’Kane