Thursday, February 13,
2020
As we reported last
week, the Centers for Medicare & Medicaid Services (CMS) recently
released a proposed rule (the Medicare and Medicaid
Programs: Contract Year 2021 and 2022 Policy and Technical Changes to the
Medicare Advantage Program, Medicare Prescription Drug Benefit Program,
Medicaid Program, Medicare Cost Plan Program and Programs of All-Inclusive Care
for the Elderly) (the Proposed Rule), the 2021 Medicare Advantage and
Part D Advance Notice of Methodological Changes for Medicare Advantage
Capitation Rates and Part C and Part D Payment Policies (Part II) (the
Advance Notice), and supplemental Health Plan Management System (HPMS)
memos that propose several significant changes to Medicare Advantage (MA)
and Part D policies. This blog post highlights the key details of the proposed
changes to the star rating system and past performance methodology and their
potential impact on MA and Part D plans.
Star Rating Proposed Changes
The Proposed Rule
includes several changes to CMS’s star rating system. If finalized, these
changes would impact data collection for the 2021 measurement period and the
star ratings for 2023. Below are some of the key changes proposed by CMS.
Modifying Cut Point Methodology for Non-CAHPS Measures
CMS is proposing to
modify how it identifies cut points for star measures that are not part of
the Consumer Assessment of Healthcare Providers & Systems
(CAHPS) survey by changing the methodology it uses to identify and
remove outliers. Modifying the cut points has been an ongoing process by
CMS, which first solicited comments on this issue in November 2018 through the
proposed rule entitled Policy and Technical Changes to
the Medicare Advantage, Medicare Prescription Benefit, Programs for
All-inclusive Care for the Elderly (PACE), Medicaid Fee-for-Service, and
Medicaid Managed Care Programs for Years 2020 and 2021.
Building on past
comments, CMS proposes to use a statistical methodology known as the Tukey
outer fence methodology to identify and delete outliers. Under this
methodology, outliers are defined as “measure scores below a certain point
(first quartile - 3.0 x (third quartile - first quartile)) or above a certain
point (third quartile + 3.0 x (third quartile - first quartile)).” Values
that meet this definition are deleted as outliers. Based on its analysis,
CMS found that this methodology would delete more outliers on the lower end of
measure scores, thus increasing the 1-star and 2-star thresholds. CMS
anticipates that this deletion methodology would create a savings of over $800
million for 2024 and increasing to $1.45 billion in savings by 2030.
Increasing the Weight of Patient Experience/Complaints and Access
Measures
Under the current
regulations for star ratings, CMS will be weighting patient
experience/complaints and access measures by 2 when calculating a plan’s
overall star rating beginning in 2021. In the Proposed Rule, CMS is
proposing to increase that weight to 4 for the 2023 star ratings.
The measures affected by
this increased weight would include the patient experience of care measures
collected through the CAHPS survey, Members Choosing to Leave the Plan,
Appeals, Call Center, and Complaints measures. The increased weighted
value would not change the calculation of the stars at the measurement level;
rather, it would impact the calculation of the overall and summary
ratings. CMS decided to increase the weight of these measures given the
growing importance of “hearing the voice of patients when evaluating the
quality of care provided” and to further emphasize the importance of patient experience/complaints
and access issues.
Adding and Deleting Star Measures
CMS proposes to remove
the Rheumatoid Arthritis Management measure from the MA star ratings for the
2021 measurement year because the National Committee for Quality Assurance
(NCQA) is retiring this measure from the Healthcare Effectiveness Data and
Information Set (HEDIS) measurement set. In terms of additions, CMS proposes to
add the following measures:
·
Transitions
of Care: Percentage of
discharges for members 18 years of age and older who had each of the following:
1) notification of admission and post-discharge; 2) receipt of discharge
information; 3) patient engagement; and 4) medication reconciliation.
·
Follow-up
after Emergency Department (ED) Visit for Patients with Multiple Chronic Conditions: Percentage of ED visits for members 18
years old and older who have multiple high-risk chronic conditions who had a
follow-up service within 7 days of an ED visit.
·
Statin
Use in Persons with Diabetes: Percentage of plan members 40 to 75 years old who were
dispensed at least two diabetes medication fills and received a statin
medication fill.
Updating the Definition of "New MA Plan" and Codifying
Existing Guidance on QBP Ratings
CMS states that it is
“proposing to codify current policy (for how we have historically assigned
[Quality Bonus Payment (QBP)] ratings) without any changes.”
Specifically, this codification involves clarifying how CMS assigns QBP
ratings for new contracts under existing parent organizations and amending the
definition of “new MA plan.” CMS is proposing the following definition
for "new MA plan":
[A] plan that meets
the following: (1) is offered under a new MA contract; and (2) is offered under
an MA contract that is held by a parent organization defined at [42 C.F.R.] § 422.2
that has not had an MA contract in the prior 3 years.
These changes have the
ability to impact plans’ star ratings and payments under QBP ratings.
Suspension of Past Performance Methodology
Under 42 C.F.R. §§
422.502(b) and 423.503(b), CMS has the authority to deny a MA or Part D
application submitted by an organization that has failed to comply with the
requirements of a previous MA or Part D contract. Historically, CMS would
release Past Performance Review Methodology each application cycle to evaluate
past performance. (For example, the 2019 Past Performance Review
Methodology can be found here.)
In an HPMS memo dated
February 6, 2020, CMS stated that it was suspending the use of the Past
Performance Methodology but will continue to consider past performance of
organizations in making contracting decisions, as set out in the applicable
regulation. In the Proposed Rule, CMS is seeking to amend the regulation
text by adding the criteria that it will use to deny an application based on
prior contract performance. Specifically, CMS is proposing to add the
following three factors that could serve as a basis for denying an MA or Part D
application:
·
The imposition of civil
money penalties or intermediate sanctions;
·
Low star ratings scores;
and
·
The failure to maintain
a fiscally sound operation.
Under the Proposed Rule,
CMS may deny an application due to the presence of any one of these factors.
For those applicants with no recent MA or Part D contracting history, CMS is
proposing that it would continue to consider the performance of contracts held
by the applicant’s parent organization or another organization controlled by
the same parent. Although the suspension of the detailed Past Performance
Methodology may come as a relief to plans, the proposed regulations would
provide CMS with wide latitude to deny new applications.
CMS is accepting
comments on these proposals through April 6, 2020.
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