2023-07115.pdf

fabric of quality programs. Response: CMS thanks these commenters for their support of the HEI reward. Comment: A commenter stated they do not believe that the HEI aligns with CMSs health equity definition or the ultimate goal of improved and more VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00164 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222283 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations 155HHS Finalizes Physician Payment Rule Strengthening Access to Behavioral Health Services and Whole-Person Care | CMS. equal health outcomes. The commenter suggested that CMS create a more wholistic and systemic approach to improving health equity, including accurately capturing data, aligning incentives not just for MA organizations but across other demonstrations, and providing mechanisms to address at-risk populations through benefits and plan design. Response: CMS developed the HEI reward to further incentivize Part C and D plans, as part of the Star Ratings, to focus on improving care for enrollees with specified SRFs and reward contracts for excellent care for these populations with the goal of reducing disparities in care. As such, CMS believes the HEI reward aligns with CMSs health equity definition. We agree that it is important to capture accurate data to identify beneficiaries with SRFs, and there are ongoing efforts to improve data accuracy, as well as efforts across multiple CMS programs to create similar incentives to improve care for more vulnerable enrollees. For example, starting in 2023, a health equity adjustment to an accountable care organizations quality score as part of the Medicare Shared Savings Program (MSSP) was added to incentivize improvement in the care for vulnerable beneficiaries.155In addition, proposals to address improved access to benefits for MA enrollees and require MA coordinated care plans ensure that services are provided in a culturally competent manner are addressed in sections II.A.2. and III.A. of this rule. Comment: A commenter recommended CMS not proceed with the HEI reward proposal and instead release a white paper describing a range of possible methodologies and approaches for addressing health equity for stakeholders to react to. This commenter also requested CMS to detail the relationship between the HEI and the Health Equity Summary Score (HESS) and to illustrate exactly how the HEI is calculated using specific examples. Response: CMS first requested feedback on a possible HEI reward in the spring of 2022 through the Advance Notice of Methodological Changes for Calendar Year (CY) 2023 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. CMS considered the feedback received on the Advance Notice as we continued to develop the HEI reward for the proposed rule. Considering the feedback we received on the proposed rule, CMS believes there has been sufficient opportunity for stakeholder input on the HEI reward methodology. We note that, to prepare health plans for implementation of the HEI reward, CMS will calculate the HEI reward beginning with the 2024 Star Ratings and will share the results in confidential contract-level reports in HPMS. The HESS is a quality improvement tool developed by the CMS Office of Minority Health with a similar goal of improving health equity. The HESS differs from the HEI developed for the Part C and D Star Ratings program in that it currently focuses on CAHPS and HEDIS measures, while the HEI focuses on a broader set of measures included in the Part C and D Star Ratings. The HESS examines differences by race and ethnicity and LIS/DE status and assigns each contract composite scores for CAHPS and HEDIS (translated to diamonds, ranging from 15, with 5 being the best) based on a combination of current performance and improvement in performance over a four-year period. The HEI only requires two years of data and focuses on the specified SRFs. The HESS is separate from the Part C and D Star Ratings program and has no link to payment. Comment: A couple of commenters supported including LIS/DE and disability as the SRFs in the HEI reward methodology and supported the proposed definitions of these populations used in the HEI reward. Response: CMS thanks these commenters for their support. Comment: A commenter supported using the proposed methodology to calculate the percentage of LIS/DE enrollees for contracts in Puerto Rico because LIS is not available in Puerto Rico. Response: CMS thanks this commenter for their support. Comment: A commenter requested that CMS provide clarification on whether the HEI reward applies to standalone PDPs or just MAPD plans. Response: The HEI reward applies to both standalone PDP and MAPD contracts as proposed and finalized at  422.166(f)(3)(i) and 423.186(f)(3)(i). The HEI is a rating-specific factor added to the summary and overall ratings of contracts that qualify. We proposed and finalized calculating the HEI separately for the Part D summary rating for MA PDs and cost contracts, and PDPs. Comment: A commenter requested that CMS provide clarification on how the HEI reward would impact a contracts Star Rating and whether it would help or harm a contracts Star Rating. Response: The HEI reward is an upside only reward, incentivizing high quality care for underserved populations. Any applicable HEI reward would be added to the unrounded overall and Part C and D summary ratings after the addition of the CAI and the application of the improvement measures described in  422.166(g)(1) and 423.186(g)(1) and before the final overall and Part C and D summary ratings are calculated by rounding to the nearest half star. Since it is an upside only reward, it avoids penalizing contracts. Comment: Several commenters questioned how measure reliability will be calculated. Response: Measure reliability is a measure of the fraction of the variation among the observed measure values that is due to real differences in quality (signal) rather than random variation (noise). In order to calculate this signal to noise ratio for each measure included in the HEI, measure reliability is calculated based on the combined subset of enrollees with the specified SRFs across two years of data. Reliability calculations for MA and PDP CAHPS patient experience measures are provided in the Quality Assurance Protocols & Technical Specifications, available at https://ma-pdpcahps.org/ en/quality-assurance, in section IX Data Analysis and Public Reporting, sub- section Significance Testing, Reliability and Star Assignment. The reliability calculations for all other measures are implemented using SAS PROC MIXED as documented in the report The Reliability of Provider ProfilingA Tutorial, available at https://www.rand.org/pubs/technical_ reports/ TR653.html, which is consistent with the reliability calculations used to determine inclusion for Part C HEDIS measures in the Star Ratings for low enrollment contracts (500 to <1000 enrollees). Comment: A commenter did not support a measure reliability of 0.7 in the HEI reward. This commenter also did not support requiring that a contract must meet the reliability criteria for at least half the measures in the HEI because measure rates will increase over time with the introduction of the HEI reward, and it may take several years for the measure rates to stabilize such that they can be included in the HEI reward. Response: Measure reliability will be calculated based on the combined two measurement years of data for the subset of enrollees with the specified SRFs. Reliability assesses variability in performance that is attributable to real differences in performance versus measurement error. CMSs intent with VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00165 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222284 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations the introduction of the HEI reward is to incentivize improvements in performance among populations with SRFs. Such performance improvements do not mean that measures are not reliable or that measures should not be included in the HEI reward. Comment: A few commenters suggested that CMS provide clarification on how rates will be calculated for the 2-year combined rate. Response: As specified at  422.166(f)(3)(i)(B) and 423.186(f)(3)(i)(B), measure-level scores for the subset of enrollees with the SRFs of interest included in the HEI will be calculated using a regression model that includes year (that is, an indicator for whether the data are from year 1 or year 2) as an adjustor or independent variable to account for potential differences in performance across years and to adjust the data to reflect performance in the second of the two years of data used. Through this modeling approach, data can be combined across the two years for each contract and can be adjusted to account for situations where mean scores were, for the average contract, different in the two years. Comment: A commenter questioned how the HEDIS hybrid measures will be addressed. Response: The HEI reward is calculated using patient-level data. The HEDIS hybrid measures combine administrative claims data with data abstracted through medical record review. The patient-level data submitted for these patients correspond to the summary-level data from administrative claims and medical record review. In order to calculate the HEI reward, no additional steps are necessary for HEDIS hybrid measures compared to HEDIS administrative measures. Comment: A commenter questioned how survey measures will be addressed since LIS/DE stratification reports do not include calculated values for CAHPS measures. Response: The CAHPS measures included in the Star Ratings are currently adjusted for DE and LIS status. For the HEI reward, case-mix adjustment is recalculated without adjustment for DE and LIS when calculating the CAHPS measure scores for the purposes of the HEI over the 2- year period as described at  422.166(f)(3)(i)(A) and 423.186(f)(3)(i)(A). Case-mix adjustment of the CAHPS measures used for the measure-level Star Ratings is not affected. Comment: A commenter questioned how enrollees in a health plan for one year will be handled. Response: As proposed and finalized at  422.166(f)(3)(B) and 423.186(f)(3)(B), the HEI is calculated by combining data across the two most recent measurement years. Data from enrollees in a health plan for one of the two measurement years will be included for the year in which they are enrolled in the plan. Comment: A commenter requested that CMS provide clarification on which measures are included and why certain measures are removed from the calculation. Response: As proposed and finalized, CMS will take five steps to analyze the measure-level scores for each contract and to roll up to the HEI scores in order to assess when an adjustment is available for a contracts ratings. As proposed and finalized in  422.166(f)(3)(ii) and 423.186(f)(3)(ii), all Star Ratings measures would be included in the HEI unless a measure meets one or more of the four exclusion criteria listed in paragraphs (f)(3)(ii)(A) through (D): (A) the focus of measurement is not the enrollee but rather the plan or provider; (B) the measure is retired, moved to display, or has a substantive specification change in either year of data used to construct the HEI; (C) the measure is applicable only to SNPs; or (D) at least 25 percent of contracts do not meet the measure- level denominator and reliability criteria. These exclusion criteria ensure we have enrollee-level data for most contracts to include these measures in the HEI. For a contracts HEI score, measures are included if the two criteria in paragraphs (f)(3)(iv)(A) and (B) are met. To meet the measure-level denominator and reliability criteria, a measure for a contract must have a reliability of at least 0.7 and meet the measure denominator requirement when calculated for the subset of enrollees with the specified SRFs across the two years of data. These criteria for determining when a measure would be used for a contracts HEI score are necessary to ensure the HEI is reliably calculated for each contract. Comment: A commenter questioned if the data layout used for presenting information about the HEI reward will be the same layout used in the Part C and D Star Ratings Stratified Reports shared through the May 11, 2022 HPMS memo titled, Stratified Reporting for Part C and D Star Ratings Measures, and whether data from the stratified reports will be used to determine which third of the distribution a contract is in for each measure. Response: The stratified reports are for quality improvement purposes and are not used in calculating Star Ratings or otherwise used in the Star Ratings methodology. Both the HEI reward methodology and the stratified reports use data from measures included in the Star Ratings program. The stratified reports may be useful to sponsoring organizations for identifying opportunities for improvement for the Star Ratings measures included in the HEI because the data are stratified by LIS/DE and disability status and the reports provide national performance scores to help inform and target quality improvement initiatives. Comment: A commenter questioned how the percentage of enrollees with SRFs will be calculated for the tiered HEI reward structure. Response: As proposed and finalized,  422.166(f)(3)(vii) and 423.186(f)(3)(vii) address this. The contract percentages of enrollees with SRFs