By Troy Jelinek December 21st, 2022
Reducing Star Ratings from 4 to 2 for patient experience
measures is one of 5 key takeaways for the 2024 CMS Proposed Rule. Read here
for a deeper dive into the proposed changes, their impact, and next steps.
On December
14, 2022, CMS released policy and technical changes through a proposed rule for
the Contract Year (CY) 2024, to be officially published on
December 27, 2022. One notable and significant change includes reducing weight
across patient experience measures for the Star Ratings program from 4
to 2. We’ll cover this in more detail, along with 4 other crucial
aspects that you’ll want to know about.
1. Strengthening Quality: Star Ratings Program
What:
CMS has
proposed reducing the weight across patient experience/complaints from 4 to 2
for 2026 Stars Ratings, along with several other key proposed measure removals,
updates, and additions.
Why:
While CMS
agrees that these measures still play a crucial role in reflecting patient
voice and experience of care, CMS wants to align the Stars program with their
Quality Strategy—fostering a healthcare system that promotes quality health
outcomes, safety, equity, and accessibility.
What To Do:
Accounting
for 58% of the overall 2023 Star Ratings, patient experience would decrease
to 41% of the overall 2024 rating for the proposed change in measure
weight. The proposed change would refocus plans to prioritize health
outcomes, screenings, and preventive care while doing so in a manner
that balances patient experience within the journey.
With the
refocus on member health outcomes, a good place to start is to ensure members
receive annual wellness visits (AWVs) because they’ve been proven to help drive
other health actions, including breast cancer or colorectal
screenings.
An analysis
of CMS’s 2023 Medicare Advantage and Part D
Star Ratings Fact Sheet shows that the national average measure
scores for breast cancer and colorectal screenings declined YOY following the
COVID-19 PHE. With roughly 70% of Medicare members and 81% of Medicaid members
completing an AWV before completing any other high-value
activity, AWVs are an untapped resource that can positively impact overall
quality scores, risk adjustment, and member satisfaction for plans.
In addition,
getting data-driven insights from members—through mock surveys and other
tools—will be critical to prioritize operational and member experience
improvements that directly impact plan performance.
Here is a
quick hit summary of the proposed measure removals, updates, and
additions:
Proposed Measure
Updates Summary
|
Proposed Measure Removals |
Diabetes
Care – Kidney Disease Monitoring (Part C) |
|
Proposed Measure
Updates |
Colorectal Cancer Screening (Part
C) |
|
Proposed Measure Additions |
Kidney
Health Evaluation for Patients with Diabetes (Part C) |
More details
on these proposed measure updates can be found on pages 518 – 539 of the proposed rule.
Advancing Health Equity: Digital Health
Literacy & HEI
Addressing digital health literacy—the
superdeterminant of health.
What:
CMS proposes
that MA organizations develop and maintain procedures to identify and offer
digital health education to enrollees with low digital health literacy to
assist with accessing any medically necessary covered telehealth
benefits.
Why:
Telehealth
has always been critical, yet there is an assumption that everyone has access.
For populations experiencing health disparities, additional barriers, such as
reduced digital literacy, continue to worsen care gaps.
What To Do:
80% of
low-income households that
qualify for reduced-rate broadband access don’t realize it.
The good
news is that Icario’s Digital Bridge Program is designed to
promote digital access by connecting members to devices, broadband access,
digital support, and education services. By providing information to members on
the availability of free or low-cost devices, broadband internet service,
hotspots, and the education and technical support they need to use these tools
to close gaps in care, plans can help address this major social determinant of
health. Additionally, connecting members to digital
resources helps combat loneliness and promote connection.
Further
Reading: Beginning in 2024, D-SNP HRAs will require screening for food, house, and
transportation as part of the 2023 Final Rule. See how one
plan increased their HRA completions by
2x+.
HEI incentive structure addresses health
disparities.
What:
To advance
health equity, CMS has put forward efforts in the Stars program through the
Health Equity Index (HEI) incentive structure that rewards plans for specific
measure-level scores for members with specific social risk factors (SRFs), such
as receiving a low-income subsidy (LIS), being dually eligible, or having a
disability.
Why:
While not
deemed a Star measure, the HEI reward incentive structure would be geared to
specifically address health disparities within care of an MA plan’s membership.
The proposed rule suggests the HEI reward structure begins for 2027 Star
Ratings, leveraging data from measurement years 2024 and 2025.
For certain
current Star Ratings measures, it may be more difficult for most plans to
achieve the same level of care for groups that experience social determinants
of health (SDoH), including lack of transportation, lower health literacy,
communication challenges, and housing instability.
The proposed
rule aims to eliminate health disparities in plan performance by SRFs,
consistent with CMS efforts to advance health equity.
What To Do:
Table 5 is a
high-level summary of the steps CMS is proposing to take to calculate the
HEI.
Table 5: Steps To
Calculate The HEI
|
Steps |
High-Level Description
of Steps to Calculate the HEI |
|
Step 1 |
Measure-level scores
for each measure included in the HEI are calculated for each contract using
data from the two most recent measurement years based on enrollees with the
specified SRFs using a modeling approach that accounts for year. |
|
Step 2 |
Measures that are case-mix adjusted in the Star Ratings
would employ all standard case-mix adjustors except for adjusters that are
the same as the SRFs included in the HEI, are strongly correlated with the
included SRFs, or are conceptually similar to the included SRFs. |
|
Step 3 |
A contract would need
to meet the reliability and minimum denominator criteria for at least half of
the measures included in the HEI based on data from the two most recent
measurement years and have at least 500 enrollees at the contract level in
the most recent measurement year to have the HEI calculated. |
|
Step 4 |
For each measure using all contract-level scores
calculated in Step 1/Step 2 that have at least 0.7 reliability and meet the
minimum denominator criteria, points would be assigned as follows: 1 point to
those contracts that score in the top third of all contracts, 0 points to
those that score in the middle third of all contracts, and 1 negative point
to those that score in the bottom third of all contracts. |
|
Step 5 |
For each contract,
the HEI would be calculated as the weighted average of the points assigned in
Step 4 using the Star Ratings measure weights and including only measures for
which the contract met all inclusion criteria. |
The full
breakdown of HEI proposals, calculations, and reward structure can be found
on pages 549 – 566.
3. Expanding Coverage: Language
Accessibility
What:
The proposed
rule suggests plans must provide ongoing materials in all languages spoken by
5% or more of their served population by delivering fully translated materials
or offering an equivalent experience in a different manner. It suggests once a
plan learns of an enrollee’s preferred language, whether through an individual
request, health risk assessment (HRA), or an additional member touchpoint, the
plan must provide required materials in that identified language as long as the
enrollee: 1) remains with the plan, or 2) requests another
language.
Why:
CMS noticed
two things:
1.
Across dually eligible members, MA
plan materials are not captured in a full suite of languages as compared to
Medicaid managed care organizations (MCOs)
2.
MA members have had to file separate
requests to obtain materials in their preferred language
What To Do:
Numerous
studies have tried to figure out why members leave health plans. One key reason
that pops up regularly is dissatisfaction with the communication members
receive from their plan.
Personalizing
healthcare is a proven way to boost Star Ratings and keep members engaged with
your health plan. But more importantly, personalized outreach that leverages the right language can
be one of the most effective ways to break down Social Determinants of Health (SDoH) barriers and
move members who need it the most to take the right health actions.
Furthermore, CMS also emphasizes the opportunity to reward members for updating
their language preferences, as it promotes improved health and the efficient
use of healthcare resources.
Additionally,
CMS is calling for this proposed rule to expand towards individualized care
plans (ICPs) for Special Needs Plans (SNPs), showing their focus on breaking
down language barriers in the healthcare experience.
4. Cash Equivalent Clarification: Rewards
& Incentives
What:
CMS is
looking to learn how MA plans interpret and implement the current R&I programs
guidance and whether stakeholders believe further framework and definition
around cash equivalents is needed.
Why:
CMS is
requesting continued feedback on rewards and incentives (R&I) “cash
equivalent” rules in the MA program.
Previously,
the Office of Inspector General (OIG) had put forth in a December 2020 rule that “gift
cards offered by large retailers or online vendors that sell a wide variety of
items (e.g., big-box stores) could easily be diverted…we would consider such
gift cards to be cash equivalents.” However, Icario believes that recent prohibitions
on larger retailers such as Walmart and Target (and potentially others similar
such as Dollar General, CVS, Home Depot, etc.) is in direct conflict with CMS’s
strategic plan to address health equity. In addition, restricting access to a
network of retailers disadvantages MA members without steady transportation,
limited accessibility or mobility, or those that may be low income and reliant
upon these rewards to help purchase necessities.
What To Do:
To comply
with the current rules while still providing members with easy access to
benefits, including OTC medication, nutrition, hearing, fitness, and vision,
plans are offering flexible benefits care cards to their
members. These cards allow MA plans to tailor restrictions to meet specific
program goals while offering members benefits and incentives via a retail
network covering more than 62,000 locations—including those hardest to reach in
most rural areas.
A benefits
care card ensures that plans comply with CMS guidelines while promoting
improved member satisfaction by delivering a variety of plan benefits and
compliant rewards on a single, easy-to-use card. The capability enables plans
to encourage and incentivize healthy behaviors among members by offering them
rewards that match the plan’s specific goals, including closing gaps in care.
5. Proposed Star Calculation Changes
In addition
to the previous 4 proposed rules, here is a quick hit of the proposed Stars
calculation changes:
1.
Removal of
bi-directional guardrails caps, which
restricts upward, and downward movement of a measure’s cut points compared to
the prior year when determining measure-specific thresholds for CAHPS
measures.
a.
This significantly reduces the
predictability of cut points and allows for better alignment to keep pace with
industry-driven movements. Previously, guardrails in place ensured non-CAHPS
measure’s cut points did not increase or decrease more than 5% from one year to
the next.
2.
Tukey
Outlier deletion was instated. Prior modeling from
CMS shows outliers are more common in the lower end leading to 1- or 2-star
thresholds often being bumped higher.
a.
Lower Star Ratings would reduce
bonus payments, rebates, and supplemental benefits offered to beneficiaries.
For plans serving the most vulnerable, lower bonuses and rebate dollars could
make it even harder to address disparities. At the high end of the spectrum,
this may also raise the 4- and 5-Star cut points.
3.
Modifying
the Improvement Measure to
only apply for 5-star plans may drag down performance for others.
a.
If this protection is removed, the
improvement measures can once again drag down the ratings of plans with lower
Star Ratings.
4.
Proposal for
removal of Star Ratings measures when
a measure steward other than CMS (such as NCQA or PQA) retires the
measure.
a.
This proposal will allow CMS to
respond more quickly to measure removals by external measure stewards to ensure
that measures included in Star Ratings are clinically meaningful, reliable, and
up to date.
b.
For example, when a measure steward
such as NCQA retires a measure, they go through a process that includes
extensive review by their various measurement panels. In addition, they solicit
public comment regarding proposed measure retirements, so health plans,
purchasers, consumers, and other stakeholders can weigh in on the relevance and
scientific soundness of any changes to the HEDIS measurement set.
5.
Remove the
60 percent rule that is part of the adjustment
for extreme and uncontrollable circumstances, as the Tukey outlier deletion to
alleviate the impact of any extreme outliers.
The proposed
rules highlight CMS’s focus on its strategic pillars: advancing health equity,
expanding coverage, and improving health outcomes. Looking ahead into next
year, comments are due on the above details, among others, by February 13,
2023. Sign up for CMS News Alerts, as Icario
will issue a summary of the 2024 Advanced Notice that will drop in early
2023.
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