2023-07115.pdf

SRFs in rural communities will likely perform lower than similar members in non-rural locations due to the general disparities in care. These commenters expressed concern that contracts that consist mainly of metropolitan areas with many forms of accessible transportation and robust provider networks will find remaining in the top third of industry contracts to receive their HEI reward much more achievable compared to contracts in rural areas with limited transportation and provider options. These commenters were concerned that rural Medicare beneficiaries report lower satisfaction with their care than their urban counterparts. They also raised a concern that any changes to benefits may worsen patient experiences and cause less favorable health outcomes. Response: We do not see significant differences in quality scores for urban versus rural beneficiaries, which suggests that any potential differences in provider networks or transportation do not impact quality scores. For CAHPS measures, in fact, we see the opposite, with scores in rural locations being slightly higher than urban locations.156We have also seen significant improvements for rural residents on HEDIS scores when comparing performance from 2009 to 2018. By 2018, most of the large inequities we had previously observed were eliminated on the measures analyzed.157Further, we understand that rural areas may have different transportation challenges relative to urban areas and that contracts serving rural populations may need to have different approaches for addressing transportation needs, such as ride sharing and volunteer driver models.158 Comment: A commenter stated that many plans will need to increase the number of enrollees with SRFs after the current reward factor is removed in order to qualify for the HEI reward, even in rural areas where this may not be a possibility, and that this consequence is not aligned with CMSs goal to close the Star Ratings performance disparity among existing membership. Response: In our simulations using data from the 2021 Star Ratings, no contracts lost QBPs when the HEI reward replaced the current reward factor. Contracts may earn the highest rating of 5 stars without qualifying for the HEI reward. Further, the minimum percentage enrollment threshold to qualify for the HEI reward is one-half the median percentage of contract-level enrollees with SRFs. This is a relatively low bar and is intended to accommodate areas and circumstances which may make it more difficult to enroll individuals with the specified SRFs. In our simulations using data from the 2021 Star Ratings, only 17 percent of MA and cost contracts and 11 percent of PDPs did not meet this threshold. Comment: A few commenters stated the HEI reward would drastically change the current reward factor so that it becomes a two-sided, net-zero approach. A commenter recommended that CMS not finalize the HEI reward and instead propose an improved framework that continues to take a reward-only approach. Response: CMS does not agree with this characterization of the HEI reward. The HEI reward is an upside only reward. Contracts that perform well across the Star Ratings measures included in the HEI reward and that serve a minimum percentage of enrollees with the specified SRFs will be eligible for the reward. Contracts that do not qualify for the reward will not be penalized and can still earn the highest rating of 5 stars without the current reward factor. Comment: A commenter recommended the HEI reward methodology include a subset of measures initially, such as HEDIS measures, and gradually expand to include other measures. Another commenter recommended that CMS allow for notice and public comment on the exact measures that will be used in the HEI reward to ensure there is an opportunity for stakeholders to prioritize measures that are most meaningful to achieving equitable care among beneficiaries with SRFs. A commenter did not support including HOS measures in the HEI reward. Another commenter recommended that SRF researchers, community leaders, and patients be engaged to determine which subset of Star Ratings measures should be included in the HEI. Response: CMS believes it is appropriate to incentivize high performance among enrollees with the specified SRFs across all of the Star Ratings measures included in the HEI reward rather than only a subset of measures since there are interactions across measurement sets. For example, improving care coordination as measured through CAHPS will impact other more clinical measures. CMS proposed, and is finalizing, the criteria that will be used to determine which Star Ratings measures are included in the HEI reward. Therefore, the public has had an opportunity to review and comment on the HEI reward methodology, including the rules for determining which measures are included in the calculation of the HEI. As specified at  422.166(f)(3)(iii) and 423.186(f)(3)(iii), the measures being evaluated for inclusion in the HEI will be announced annually in the process described for changes in and adoption of payment and risk adjustment policies in section 1853(b) of the Act. These announcements (of the measures being evaluated for inclusion in the HEI) will not include the final list of measures used in the HEI for the upcoming Star Ratings because the data to determine that final set will not yet be available. Comment: A commenter suggested adjusting the Star Ratings to account for SRFs by setting different cut points for contracts with higher levels of enrollees who are dually eligible. Another commenter recommended risk-adjusting the Star Ratings thresholds (cut points) VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00168 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222287 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations to account for high numbers of dually eligible enrollees. Response: CMS does not believe it would be appropriate to set different cut points for contracts based on the proportion of dually eligible enrollees. We do not want to set lower standards of care for treating underserved populations. Comment: A commenter recommended ensuring additional resources, such as payments from the HEI reward, flow through to providers that serve higher proportions of dually eligible individuals and ensuring funds earned from the HEI reward are directly allocated to patient care. Response: CMS cannot require that sponsoring organizations pay their contracted providers or pharmacies how the commenter suggested. Section 1854(a)(6)(B)(iii) of the Act prohibits the Secretary (and CMS) from require[ing] any MA organization to contract with a particular hospital, physician, or other entity or individual to furnish items and services under this title or require[ing] a particular price structure for payment under such a contract to the extent consistent with the Secretarys authority under this part. There is a similar, but broader, prohibition on interference with the negotiations between drug manufacturers and pharmacies and Part D sponsors in section 1860D11(i) of the Act. Comment: A commenter suggested that it may be useful to include performance benchmarks in calculating the HEI reward rather than distributing performance into thirds to ensure that equity performance does not lag. Response: CMS believes that contracts will continue to be incentivized to improve performance among populations with SRFs because contracts will continue to strive to earn a sufficiently high score on the HEI to be eligible for a reward. A contract that is in the top third of the distribution in one year will not know how well other contracts will perform from year to year and therefore will be incentivized to continue to improve in order to stay in the top third of the distribution. Comment: A commenter suggested including SNP-only measures in the calculation of the HEI reward because these measures are important for health equity goals. The commenter noted that leaving the measures out of the HEI reward reduces their importance and does not provide an opportunity to recognize excellence. Response: CMS thanks this commenter for this suggestion and will take this comment into consideration. We proposed and are finalizing the exclusion of SNP-only measures, however, because they apply only to a subset of contracts. Additionally, based on our simulations, we do not believe that addition of these measures would have a significant impact on the HEI reward distribution. However, if SNP- only measures were to be added to the calculation of the HEI reward, we would first propose this change through notice- and-comment rulemaking. Comment: A commenter stated CMS should look for opportunities to encourage plans to serve enrollees with SRFs and that they were not aware of any new incentives to serve this population. Response: The HEI reward provides an incentive to serve this population, since to be eligible for the full HEI reward contracts must meet the median percentage threshold of enrollees with the specified SRFs, and to be eligible for one-half of the reward, contracts must meet the one-half median percentage threshold of enrollees with the specified SRFs. Comment: A commenter suggested that CMS incorporate historical data in the HEI reward methodology prior to the 2024 measurement year to account for equity efforts already undertaken by some health plans that opted to care for historically underserved populations prior to the implementation of the HEI reward. A couple of commenters recommended CMS implement the HEI reward beginning with the 2026 Star Ratings rather than the 2027 Star Ratings. Response: We appreciate these suggestions; we propose substantive and methodological changes to the Part C and D Star Ratings and finalize them prior to the measurement year. This approach ensures that sponsoring organizations are aware of the quality measures that will be used and have an opportunity to change or improve performance before the contract is rated on specific performance measures. Since the HEI reward includes two years of data, the earliest measurement year data it can use is from 2024 and 2025, and the earliest it can be implemented is the 2027 Star Ratings. Comment: A commenter suggested that CMS could adjust the HEI reward relative to the change in LIS/DE enrollee percentages in the 2024 and 2025 measurement years compared to a baseline in order to limit health plans seeking to benefit from the new rewards of the HEI from crowding out health plans that currently serve underserved populations. Response: CMS appreciates this suggestion; however, we do not believe it would be appropriate. With the HEI reward, CMS aims to improve health equity by incentivizing all MA plans, cost plans, and Part D plan sponsors to perform well among enrollees with certain SRFs. Any plans that enroll more members who are LIS, DE, or disabled will also have to perform well among these enrollees to be eligible for the HEI reward. The HEI reward methodology focuses on performance in the measurement years when contracts are actually serving LIS/DE or disabled enrollees. The HEI reward would not create the same incentives if we adjusted for changes in LIS/DE and disabled enrollment compared to a baseline before the HEI was implemented. Comment: A commenter recommended CMS implement a temporary approach for the 2025 Star Ratings to account for plans that have already been working to reduce disparities by taking the better of a plans measure-level Star Rating or the HESS for those measures for which there is overlap between the two programs, or by incorporating the HESS as a bonus component to account for plans that scored well on the HESS. Another commenter recommended adding the HESS to the Star Ratings as soon as possible beginning with the 2026 Star Ratings. Response: We appreciate these suggestions; however, we make such substantive and methodological changes to the Part C and D Star Ratings through rulemaking and generally finalize them prior to the measurement year. At this time, we are not considering adding the HESS to the Star Ratings program as a basis for a reward factor since it is methodologically complex to calculate HESS scores within the tight timeframes for producing the Star Ratings. The HESS also requires 4 years of data, which would exclude a number of newer contracts from a reward based on the HESS. Additionally, given the 4 years of data needed, it would be more complex to implement as measure specifications are updated. Comment: Some commenters suggested adding additional SRFs to the HEI such as race and ethnicity, gender, language, gender identity, sexual orientation, enrollee self-reported social needs, cultural context, social relationships, residential and community context, rurality, and enrollees with housing, food, or transportation needs identified using data from the NCQA Social Need Screening and Intervention measure. A commenter stated that the SRFs proposed to be included in the HEI reward do not adequately capture the population of members included in CMSs health equity definition and VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00169 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222288 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations 159https://www.aspe.hhs.gov/sites/default/files/ migrated_ legacy_ files/171041/ ASPESESRTCfull.pdf?_ ga=2.49530854.1703779054.1662938643-470268562.1638986031. 160Beckett MK, Martino SC, Agniel D, Mathews M, Hudson Scholle S, James C, Wilson-Frederick S, Orr N, Darabidian B, Elliott MN. (2021). Distinguishing neighborhood and individual social risk factors in health care Health Services Research: 114. 161https://www.govinfo.gov/content/pkg/FR- 2022-11-18/pdf/2022-23873.pdf. 162Social deprivation index (SDI). Robert Graham CenterPolicy Studies in Family Medicine & Primary Care. (2018, November 5). Accessed 2/23/ 23, from https://www.graham-center.org/rgc/maps- data-tools/sdi/social-deprivation-index.html. 163Goodman DC, Mick SS, Bott D, et al. Primary care service areas: