August 17, 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-0938-AV19
Dear Administrator Brooks-LaSure:
The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to provide feedback on the Request for Information (RFI): Episode-Based Payment Model.
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 a focus on health equity and support for meaningful value-based payment models, propels our daily work.
We are pleased to provide comments in the following areas:
- Care Delivery and Incentive Structure Alignment: Use existing standards to ensure alignment and integration between specialty and primary care. Defining standards and responsibilities is essential for episode-based payment models to succeed.
- Quality Measures, Interoperability and Multi-Payer Alignment: Align models to the Universal Foundation and available FHIR resources.
- Health Equity: Leverage industry partners and research to align health equity goals across models.
Care Delivery and Incentive Structure Alignment
We agree with CMS that the role of clinical episodes will evolve as more patients are cared for by providers in accountable care arrangements, and we agree that CMS’s goal to have all Medicare beneficiaries in an accountable relationship by 2030 is ambitious, but worthy. We recommend CMS support existing patient-centered models to reduce burden for providers participating in federal efforts to bring a more integrated patient journey to the American health care consumer.
How can CMS structure episodes of care to increase specialty and primary care integration and improve patient experience and clinical outcomes?
We appreciate CMS’s acknowledgment that episode-based payment incentives must be aligned across models to encourage intentional overlap, promote coordination and facilitate seamless transition back to primary care. National recognition programs help align primary care and specialty care incentives and promote the coordination and integration outlined in this RFI. We ask CMMI to build on these programs in designing future models for specialty and primary care integration.
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.
The PCMH model and its family of NCQA Recognition programs continues to be the gold standard for patient-centered care. But we can’t rest on a job well done; we need to advance our patient-centered mission. That’s why we have recruited organizations and providers for a Virtual Care Accreditation Pilot. We hope to engage with partners, like CMMI, to draft standards, define measures and provide a structure to align incentives that thoughtfully integrate virtual care across the patient journey.
How can CMS promote person-centered care in episodes, which includes mental health, behavioral health, and non-medical determinants of health?
Person-centered care requires intentional focus on the goals of the person. Quality measures in action can change the experience of people and families experiencing acute and prolonged clinical episodes. NCQA, with support from The John A. Hartford Foundation and The SCAN Foundation, developed, implemented and tested Person-Centered Outcome measures. These measures (two process measures and one outcome measure) 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. These measures are now being tested in behavioral health settings, and will make a strong contribution to advancing person-centered quality measurement. Clinicians across the care continuum—from primary care, to specialty care, to home- and community-based services—can use this measurement approach to elicit what is important to the person.
What should CMS consider in the design of this model to effectively incorporate health information technology (health IT) standards and functionality, including interoperability, to support the aims of the model?
We are enthused that CMMI is leveraging FHIR APIs and the Minimal Common Oncology Data Elements (mCODE) for reporting in the Enhancing Oncology Model. We urge CMS to find additional opportunities to accelerate adoption of FHIR and standardized data in future models.
Additionally, upfront incentive payments for model participants to adopt and maintain certified electronic health record technology (CEHRT) is essential to advancing CMS’s mission to evolve to all-digital quality measures by 2030, and future models should advance this goal. As CMS develops an episode-based model, it should provide upfront infrastructure payments that will allow access to certified technology for providers who were left out of Meaningful Use (e.g., behavioral health and long-term care providers).
NCQA applauds CMS’s proposal, in the Making Care Primary Model, to accelerate USCDI adoption through USCDI v3. This step will help ensure that certified vendors can identify and respond to the inequities plaguing American health care. USCDI v3 is important for spurring the industry to capture and respond to health equity data (beyond USCDI v1, which includes only race/ethnicity data).
We caution that continuing to build a national measurement system focused on eCQM reporting, and additional investments into eCQM reporting (and not dQMs), will limit the potential value of electronic clinical data and hinder the nation’s ability to leverage digital health data for multiple use cases (e.g., public health reporting, prior authorization). We appreciate CMS outlining this concern in the CMS Digital Quality Measurement Strategic Roadmap: “While eCQMs meet the definition for dQMs in many respects, limitations in data standards, requirements, and technology have limited their interoperability and continue to levy a significant administrative cost for implementation beyond that required for the provision of clinical care.”
We believe these limitations, and challenges aggregating QRDA files, have constrained eCQM adoption in value-based contracts—this is one reason why we are working to deliver the next generation of dQMs as configurable, modular software applications that can integrate relevant data via FHIR and other standard-based APIs. We look forward to partnering with CMS to capitalize on these technological advancements to enable more dynamic value-based care arrangements and enhance patient safety.
Quality Measures, Interoperability, and Multi-Payer Alignment
NCQA commends CMS for its review of 21 Medicare models from 2012–2020, and for examining performance by cost and health outcomes. We were, however, disheartened that analysis showed most models had no significant improvement in patient experience or mortality. For that reason, we believe the CMS National Quality Strategy (NQS) is well timed, and is a needed addition to national health policy reform.
Although the NQS will allow industry stakeholders to invest time and resources in an informal public-private partnership, we encourage CMS to more formally bring resources to bear, to galvanize partners to implement the NQS.
Which quality measures, currently used in established models or quality reporting programs, would be most valuable for use across care settings?
A key pillar of the NQS is “alignment,” and NCQA is energized by CMS’s effort to align quality measures across care settings through the Universal Foundation. We applaud and fully support this ambitious and much needed initiative. We are honored that nearly 70% of the measures in the Universal Foundation are HEDIS measures that 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 transitioning to digital quality reporting through the Universal Foundation.
What supports can this new model provide for decreasing burden of data collection?
We’re encouraged by the latest model from CMMI, Making Care Primary, which requires use of ONC-certified technology and connection to a state or national health information exchange (HIE). Most important, it allows upfront investment for practices to procure tools to advance health equity and build the infrastructure to share and analyze operational and quality data. We recommend that CMMI continue to support model participants in this way, in future episode-based payment models.
NCQA has validated many state and national HIEs through our Data Aggregator Validation program. This program evaluates clinical data streams to help health plans, providers, government organizations and others trust the accuracy of aggregated clinical data for use in HEDIS reporting and quality programs like CMMI models. We ask CMMI to consider standards for data aggregation vendor partners to increase the conformity of heath care data and decrease the burden collection for model participants.
We also encourage CMS to advance the work of HCP-LAN State Transformation Collaboratives. The recently released Multi-Payer Alignment Blueprint provides a clear roadmap for timely and consistent data sharing, and highlights opportunities that the Bulk FHIR API can have in reducing the burden of data collection. We hope CMMI adopts the Bulk FHIR API in future models, to ensure that participation does not mean performing unnecessary administrative functions.
Model participants should be able to use tools for quality reporting that are fully digitized and that pull data from EHRs, clinical registries, case management systems and similar electronic clinical data systems (which could include HIEs). That’s 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 this year. This past May, NCQA announced the 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. We hope CMMI can support model participants with similar tools and guidance in upcoming models.
Health Equity
NCQA appreciates the Biden administration’s ongoing commitment to health equity, and its desire to close disparate health outcomes for historically marginalized communities. NCQA is proud of our work to bring transparency and accountability for health equity through both our national accreditation standards and our HEDIS quality measures. Additionally, our research arm has spent decades helping private and public partners identify health inequities and making policy recommendations to counteract them. We look forward to supporting CMMI in advancing this important mission.
What other factors could be considered for providers who serve underserved beneficiaries or beneficiaries who experience social risk factors? Can measure stratification among patient subgroups and composite health equity measures improve how CMS identifies and quantifies potential disparities in care and outcomes?
NCQA Researchers, with support from the California Health Care Foundation, released Measuring Health Equity: A Review of Scoring Approaches, an issue brief that can help CMS determine appropriate approaches to identify and quantify disparities in programs. Our review identified four common dimensions that differentiate approaches to rating equitable health care quality: selecting indicators of SDOH; selecting reference groups; selecting health care quality metrics (including whether to use composite approaches); and benchmarking.
What metrics should be used or monitored to adjust payment to assure health disparities are not worsened as an unintended consequence?
NCQA’s Research team published Advancing Health Equity: A Measurement Framework for Accountability in Medicaid. Metrics from all six domains of the framework—social interventions, access, clinical care, experience of care, structures of care, overall well-being—should be monitored to ensure that payment adjustments do not worsen health disparities or produce unintended consequences.
We also agree with CMS that the social deprivation index, the social vulnerability index and the area deprivation index are good indicators for adjusting payment to providers who participate in models and operate in communities with greater social needs and health inequities, but we do not believe that quality outcomes should be adjusted by such indicators, because it would mask disparities. In order to monitor investments/payments distributed by the indices, CMS should stratify quality and cost metrics by demographic factors to understand how payments address individual inequities by race, ethnicity, language, sexual orientation, gender identity and other demographic factors.
Aside from claims data, what data sources would be valuable for evaluation and tracking of health equity?
NCQA believes that collecting, documenting and exchanging interoperable social need data is critical to supporting better patient care, and we recognize that these data are not readily available in claims data. That is why, 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. NCQA urges CMS to use its subregulatory authority to align with the recommendation to accelerate adoption of standards related to social risk in future models.
To reduce burden, state and federal agencies should evaluate available tools for aligning data collection and sharing, and the federal government should encourage alignment with national data standards. The HEDIS measure Social Need Screening and Intervention assesses screening for unmet needs for food, housing and transportation, and includes referral to intervention after a positive screen. Because these data can be captured in a variety of electronic data sources (e.g., EMRs, resource referral platforms, case management systems), this measure is specified for Electronic Clinical Data System (ECDS) reporting. 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.
Thank you again for the opportunity to comment. We remain committed to improving the nation’s health care system, and we welcome a discussion of our recommendations. 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