2023-07115.pdf

to outcome measures and to avoid creating an imbalance between the two most important measure groupings. A commenter noted that having patient experience and outcome measures weighted equally ensures that the patient voice is heard but would help assuage concerns that it is overweighted. A commenter recommended CAHPS measures that they believe are subjective survey questions receive a weight of 2 and measures related to health plan operations and access maintain the current weight of 4. Response: Outcome measures reflect improvements in a beneficiarys health and are central to assessing quality of care. Although patient experience measures have been linked to improved clinical outcomes and are important aspects of health care, we believe a weight of 2 more appropriately balances the value these measures contribute to achieving high quality care without weighting them higher than clinical outcome measures and better aligns the total contribution of patient experience and outcome measures with other CMS quality reporting programs. If we used a weight of 3 for CAHPS measures of patient experience, nearly one third of an MAPDs overall rating would be from CAHPS patient experience of care measures, which we believe is still too high. We also believe it is appropriate to continue to weight patient experience, complaints, and access measures equally. Further, CAHPS surveys focus on matters that patients themselves say are important to them and for which patients are the best and/ or only source of information, so we do not agree that CAHPS measures are subjective. Comment: A commenter stated that it was unable to reach a consensus among its diverse set of patient, provider, payer, and purchaser members on a specific weight for patient experience measures in the Star Ratings program and encourages CMS to continue finding ways to incorporate the beneficiary experience into Star Ratings. Response: We understand the differing viewpoints and agree that patient experience is a critical component of the Star Ratings program. We will continue to work to enhance the measures focused on patient VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00157 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222276 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations 151Quigley DD, Elliott MN, Setodji CM, Hays RD. (2018) Quantifying Magnitude of Group-Level Differences in Patient Experiences with Health Care. Health Services Research, 53: 30273051. experience. As noted in other responses to comments and in the proposed rule, we believe that a weight of 2 for the patient experience measures appropriately balances the importance of these measures with other measures that address health outcomes, plan processes, and improvement. Comment: A couple of commenters recommended that CMS not make significant methodological changes year-over-year in the Star Ratings program since it makes it more difficult for payers and providers to make stable, strategic investments in targeted quality improvement efforts. A commenter suggested waiting to reduce the patient experience/complaints and access measure weights in half until there is compelling evidence of the policy effects of the current methodology. A commenter noted that reducing the weight is not aligned with CMSs commitment to achieve person-centered care across its programs and there have been recent drops in the national averages for CAHPS measures, as well as the Members Choosing to Leave the Plan and Call CenterForeign Language Interpreter and TTY Availability measures. Response: CMS is committed to listening to feedback from stakeholders and providing advance notice of methodological changes. As stated in the April 2018 final rule, the methodology for the Star Ratings program was codified in regulation to give Part C and D sponsors more predictability as the rulemaking process creates a longer lead time for all changes and measure changes are announced several years in advance. (83 FR 16519 20). Any changes to the Star Ratings methodology are finalized prior to the measurement year so Part C and D sponsors can adapt their investments and focus. The weight change we are finalizing here will be effective for the 2024 measurement year and 2026 Star Ratings. We note that from the 2021 to 2022 MA and PDP CAHPS surveys, two MAPD CAHPS national average measure scores changed by less than 2 points, a small change, and seven changed by less than 1 point, a trivial amount.151These small changes are unlikely to persist at the time the new weights will be applied. We believe that we should not wait until there is additional evidence for the need for this change since multiple stakeholders have expressed concern over the increase of the weight to 4 and it is taking away the focus of plans on improving clinical care. As part of CMSs Strategic Plan, CMS serves the public as a trusted partner and steward, dedicated to advancing health equity, expanding coverage, and improving health outcomes. With the weight of 4 for patient experience/complaints and access measures, we are diverting attention away from improving health outcomes. The most recent Star Ratings show there is a need for sponsors to refocus efforts on clinical care measures, as multiple clinical measures performances have declined over the last few years. Given the pandemics impacts on health care, we believe better balancing the proportion of the different measure types in the Star Ratings will encourage Part C and D sponsors to also balance their investments on patient experience/ access as well as clinical care. Comment: A commenter raised concerns about the CAHPS surveys ability to adequately and appropriately capture and measure patient experiences. This commenter encouraged CMS to focus on improving the quality and representativeness of the data itself by making it more representative of all racial and ethnic groups. Response: CMS agrees that it is important to hear the voice of all beneficiaries. CAHPS surveys follow scientific principles in survey design and development. The surveys are designed to reliably assess the experiences of a large sample of patients. The MA and PDP CAHPS surveys use standardized protocols to collect data from random samples of contract enrollees. Extensive quality control mechanisms are employed to collect valid, reliable survey data. The implementation protocols are designed to increase the likelihood of survey participation and achieve as high a response rate as possible. For the MA and PDP CAHPS survey, we currently require a mixed mode survey (mail with telephone follow-up) since telephone outreach helps improve response rates for some groups. In the Advance Notice of Methodological Changes for Calendar Year (CY) 2024 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies published on February 1, 2023 and the Announcement of Calendar Year (CY) 2024 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies published on March 31, 2023, we announced that starting with the 2024 survey administration we will be adding the web mode of data collection to the mixed mode methodology. Offering the survey sequentially in multiple modes helps improve response rates and the representativeness of the data. In the CAHPS field test we found that for enrollees with email addresses, the web- mail-phone protocol increased MA response rates by 4 percentage points. We believe that the availability of better email addresses across all contracts will help improve response rates overall. In addition to English, CMS provides survey materials in Chinese, Korean, Spanish, Tagalog, and Vietnamese. Offering the survey in multiple languages helps improve response rates for Asian and Pacific Islander and Hispanic respondents. CMS issues an annual HPMS memo about the Medicare CAHPS survey that includes strategies contracts can use to promote member participation in the survey, including providing survey vendors with language preference data and current phone numbers for all enrollees as well as avoiding fielding other surveys of beneficiaries during or close to the MA and PDP CAHPS survey administration period. Finally, the scoring methodology takes into account reliability, and there are extensive quality control checks to ensure programming is accurate. More information on CMS guidelines for MA and PDP CAHPS and recommendations to achieve high survey response rates is also available at https://ma- pdpcahps.org/. Comment: A commenter recommended the weight change be delayed until marketing complaints decline. Response: With the weight of 4 for patient experience/complaints and access measures, we are diverting attention away from improving health outcomes. A weight of 2 will still incentivize plans to address marketing issues that may be reflected in the complaints measures, but it ensures that the weighting of patient experience/ complaints and access measures is appropriate relative to outcome measures. There are other efforts being made by CMS to address marketing misrepresentation and other marketing issues. Comment: A couple of commenters supported testing of a new CAHPS question about whether an enrollees personal doctor dismisses symptoms that are important to them. Response: CMS appreciates the support for the testing of this CAHPS question. We are continuing to analyze the data from our field test. After considering the comments we received and for the reasons outlined in the proposed rule and our responses to comments, we are finalizing the weight VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00158 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222277 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations 152Social Risk Factors: Definitions and Data | Accounting for Social Risk Factors in Medicare Payment | The National Academies Press | https:// nap.nationalacademies.org/read/23635/chapter/4. change for patient experience/ complaints and access measures at  422.166 at paragraphs (e)(1)(iii) and (iv) and  423.186 at paragraphs (e)(1)(iii) and (iv) as proposed without modification. F. Health Equity Index Reward ( 422.166(f)(3) and 423.186(f)(3)) As discussed in section III.A. of this final rule, advancing health equity is the first pillar of the 2022 CMS Strategic Plan and a goal of the CMS National Quality Strategy. In reports on accounting for social risk factors (SRFs) in value-based purchasing programs, the National Academies of Sciences, Engineering, and Medicine (NASEM) define SRFs as factors related to health outcomes that are evident before care is provided, are not consequences of the quality of care, and are not easily modified by health care providers.152 CMS agrees with the NASEM definition of SRFs because it captures the elements we consider important in defining SRFs. There are often disparities in health care and outcomes between groups with and without SRFs. For example, the within- contract LIS/DE and non-LIS/DE differences in performance for Part C and D Star Ratings measures can be found at: https://www.cms.gov/files/ document/2023-categorical-adjustment- index-measure-supplement.pdf or https://www.cms.gov/files/document/ 2024-categorical-adjustment-index- measure-supplement.pdf. As discussed in the proposed rule, the current approach to addressing SRFs in the Part C and Part D Star Ratings program has focused on adjusting for the average within-contract disparities in performance through the CAI, as described at  422.166(f)(2) and 423.186(f)(2), in order to not inappropriately penalize or reward health and drug plans for factors that are difficult for plans to control. For certain current Star Ratings measures, it may be more difficult for most plans to achieve the same level of care for groups that are socioeconomically disadvantaged, disabled, or more complex due to a variety of issues, including transportation issues, lower health literacy, communication challenges, and residential instability. The CAI is a factor that can be positive or negative and is added to a contracts overall and summary Star Ratings and that adjusts for the average within-contract performance disparity based on a contracts composition of LIS/DE and disability status enrollees. The CAI was implemented in the Part C and Part D Star Ratings program to address SRFs while measure stewards evaluated adjustment on a measure- specific basis. The CAI is a data-driven approach to account for within-contract disparities in performance associated with SRFs in Star Ratings measures that are not already adjusted according to the measure specifications developed by measure stewards. The CAI does not incentivize contracts to focus on reducing disparities. Although all contracts have incentives in the Star Ratings program to improve performance, prior to the proposed HEI reward, there were no methodological adjustments that specifically created incentives to address disparities of care among a contracts enrollees. In addition to adjusting for within- contract disparities through the CAI, we also want to encourage MA organizations, cost plans, and Part D plan sponsors to better identify and then address disparities in care provided to enrollees with a particular SRF, with the ultimate goal of reaching equity by eliminating health disparities or differences in contract performance by SRFs, consistent with CMS efforts to advance health equity. CMS developed a health equity index (HEI) factor that we proposed for use in the Part C and Part D Star Ratings to reward contracts for obtaining high measure-level scores for the subset of enrollees with specified SRFs. Our intent in implementing an HEI reward is to improve health equity by incentivizing MA, cost, and PDP contracts to perform well among enrollees with specified SRFs. The CAI is designed to improve the accuracy of performance measurement, while not masking true differences in performance between contracts; in contrast, our proposed HEI reward is specifically designed to create an incentive to reduce disparities in care. As discussed in the proposed rule, the HEI reward, therefore, would not replace the CAI but rather assist plan sponsors in better identifying and then addressing disparities in care provided to members with a particular SRF, with the ultimate goal of reaching equity in the level