2023-07115.pdf

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 and quality of care provided to enrollees with SRFs. We explained in the proposed rule that there would be no changes to the current CAI with the implementation of the HEI reward. We proposed to replace the current reward factor described at  422.166(f)(1) and 423.186(f)(1) with the new HEI reward at proposed  422.166(f)(3) and 423.186(f)(3) starting with the 2027 Star Ratings; the HEI reward for the 2027 Star Ratings would be calculated using data collected or used for the 2026 and 2027 Star Ratings (2024 and 2025 measurement years). As discussed in the preamble to the proposed rule, the current reward factor was included in the Part C and Part D Star Ratings program beginning with the 2009 Star Ratings with the purpose of creating additional incentives for high and stable relative performance across measures by discouraging contracts from having a lot of variation in performance across measures (that is, a mix of low performance and high performance across measures). We proposed that the removal of the current reward factor would be contingent on finalizing the addition of the proposed HEI reward. CMS proposed to add the HEI reward as a methodological enhancement to the Part C and Part D Star Ratings program starting with the 2027 Star Ratings because, similar to the current reward factor, it provides a summary of how performance varies across existing Star Ratings measures. However, our proposed HEI reward is intended to be a methodological enhancement using data from existing Star Ratings measures rather than a new measure with additional burden for contracts. In the case of the HEI reward, however, this summary of performance would be based on performance related to a subset of enrollees with specified SRFs. Adding the HEI as a reward also would allow for the methodology to include a performance threshold below which contracts will not be eligible for the HEI reward, which would incentivize improved performance by contracts for their enrollees with the specified SRFs and help reduce disparities. CMS could also potentially increase this performance threshold over time to incentivize continued efforts to reduce disparities in care. In developing the proposed HEI reward, we considered a number of goals to ensure the incentives of the HEI and the associated reward were in line with our intent. We aim to improve health equity by incentivizing MA plans, cost plans, and Part D plan sponsors to perform well among enrollees with certain SRFs. These goals include the following: Avoiding rewarding large contracts over small contracts that may be providing high quality care for enrollees with the SRFs included in the HEI but lack the number of enrollees needed to reliably calculate the HEI. Avoiding rewarding contracts that may do well among enrollees with the SRFs included in the HEI but serve very VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00159 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222278 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations 153https://www.aspe.hhs.gov/sites/default/files/ migrated_ legacy_ files/171041/ ASPESESRTCfull.pdf?_ga=2.49530854.1703779054.1662938643- 470268562.1638986031. few enrollees with those SRFs, making it easier to do well. Only rewarding contracts that have high relative performance among enrollees with the SRFs included in the HEI compared to other contracts to incentivize high performance for enrollees with the SRFs included in the HEI. Ease of use and understanding for contracts and other interested parties. Minimizing the number of years of data needed to calculate the HEI and HEI reward such that the data used are as current as possible. Allowing for updates to the measure set included in the HEI and updates to accommodate the addition of other SRFs to the HEI over time. Promoting improvement in performance among individuals with certain SRFs and enrollment of individuals with certain SRFs in high quality MA plans, cost plans, and Part D plans. Accurately reflecting true performance among contracts serving enrollees with certain SRFs and minimizing sensitivity to measurement error. The proposed HEI would summarize contract performance in relation to enrollees with certain SRFs across multiple existing Star Ratings measures into a single score using data from the most recent 2 measurement years. We proposed at  422.166(f)(3)(i)(A) and 423.186(f)(3)(i)(A) to initially include LIS/DE or having a disability as the group of SRFs used to calculate the HEI. Prior research has shown that dual eligibility for Medicare and Medicaid is one of the most influential predictors of poor health outcomes, and disability is also an important risk factor linked to health outcomes.153The SRFs included in the HEI may be expanded over time. For purposes of the HEI, we proposed to define an LIS/DE beneficiary as one who was designated as a full-benefit or partial-benefit dually eligible individual or who received a low-income subsidy (LIS) at any time during the applicable measurement period, as we do currently for the calculation of the CAI. If a person meets the criteria for only one of the two measurement years included in the HEI, the data for that person for just that year are used. We proposed to use the original reason for entitlement to the Medicare program to identify enrollees with a disability for purposes of the HEI as we do for the calculation of the CAI. We solicited feedback on potential additional ways to identify enrollees who have a disability that could be incorporated over time and whether the same process and standards should be used for the CAI adjustment as well. In particular, we noted our interest in how we could expand the definition to include enrollees who develop a disability after aging into the Medicare program. LIS/DE and disability are the SRFs that have been used in the CAI for many years and are included in the confidential Part C and D Stratified Reports provided to MA and Part D contracts in HPMS as of 2022. We proposed that enrollees with these SRFs would be identified for the HEI the same way they are identified for the CAI at  422.166(f)(2)(i)(B) and 423.186(f)(2)(i)(B). BILLING CODE 412001C We also considered including the Area Deprivation Index (ADI) in the HEI. The ADI is a measure of socioeconomic neighborhood deprivation, including measures of income, employment, housing, education, social environment, and readmissions. As discussed in the preamble to the proposed rule, we will continue to explore the feasibility of adding other SRFs to the HEI over time. As we noted in the proposed rule, the addition of other SRFs or other mechanisms to identify enrollees with one or more of the SRFs that are part of the HEI reward methodology would be proposed through future notice-and- comment rulemaking. We proposed that the HEI would examine performance among those with certain SRFs for all Star Ratings measures unless they meet one of the specified exclusions. As we proposed in  422.166(f)(3)(ii)(A)(D) and 423.186(f)(3)(ii)(A)(D), measures would be excluded from the HEI if one or more of the following criteria are met: The focus of the measurement is not the enrollee but rather the plan or provider (for example, the appeals and call center measures focus on the plan and its operations rather than on the enrollee). Measures meeting this criterion would be excluded because enrollee-level SRF information for these measures is not available for inclusion in the HEI. The measure is retired, moved to display, or has a substantive specification change in either year of data used to construct the HEI. Measures meeting these criteria would be excluded because there are not enough data to calculate the HEI for these measures. The measure is applicable only to SNPs. Measures meeting this criterion would be excluded because these measures are not relevant for all contracts. At least 25 percent of contracts are unable to meet the criteria described at proposed paragraph (f)(3)(iv), which provides that a measure is only included for the HEI for a contract if the measure has a reliability of at least 0.7 for the contract when calculated for the subset of enrollees with the specified SRF(s) and the contract meets the measure denominator requirement when the measure is calculated for only the enrollees with the specified SRF(s) (that is, the SRFs included in the HEI). For Part D measures, these criteria are assessed separately for MAPDs and cost contracts, and PDPs consistent with how the Part D measure cut points and CAI are calculated separately for MA PDs and cost contracts, and PDPs for the Part D summary rating. We proposed to exclude any measures from the HEI that less than 25 percent of contracts can have reliably calculated because scores would be missing for most contracts. We proposed, at  422.166(f)(3)(iii) and 423.186(f)(3)(iii), that the measures being evaluated for inclusion in the HEI would 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) would 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. In general, measures from HEDIS, HOS, and CAHPS would be included unless they meet one of the four exclusion criteria, proposed at  422.166(f)(3)(ii)(A)(D) and 423.186(f)(3)(ii)(A)(D). Additionally, medication adherence, MTM Program Completion for CMR, and Statin Use in Persons with Diabetes measures would be included as long as they meet the requirements for inclusion for more than 25 percent of contracts as proposed at  422.166(f)(3)(i)(B) and 423.186(f)(3)(i)(B). We described in the proposed rule the five steps that CMS would take 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. Step 1: For each measure included in the HEI, measure-level scores calculated for each contract among enrollees with the included SRFs (that is, all enrollees who are DE, LIS, or disabled combined into one group) would be combined over the two most recent measurement years. CMS carefully considered the VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00160 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222279 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations number of years of data needed for the proposed HEI. We believe that using 2 years of data allows for a balance between increasing measure-level reliability so that smaller contracts may still have enough data to have the HEI calculated and minimizing the number of years of data used. As outlined in our goals in designing the HEI, it is important to minimize the number of years of data used to avoid carrying forward very old data in the Star Ratings and to allow new measures and newer contracts to more quickly be included in the HEI. As proposed at  422.166(f)(3)(i)(B) and 423.186(f)(3)(i)(B), the scores for the subset of enrollees with SRFs of interest included in the HEI would be calculated using a modeling approach that includes year (that is, an indicator for whether the data are from year 1 or year 2) as an adjustor to account