2023-07115.pdf

and 423.184(e)(1)(iii) as proposed without modification. E. Patient Experience/Complaints and Access Measure Weights ( 422.166(e)(1)(iii) and (iv), 423.186(e)(1)(iii) and (iv)) CMS proposed to lower the weight of patient experience/complaints and access measures to 2 beginning with the 2026 Star Ratings covering the 2024 measurement period. The weight for the patient experience/complaints and access measures is codified at  422.166(e)(1)(iii) and (iv) and 423.186(e)(1)(iii) and (iv). Process measures receive a weight of 1, outcome measures receive a weight of 3, and the Part C and D improvement measures receive a weight of 5. In the April 2018 final rule, we finalized an increase in the weight of patient experience/ complaints and access measures from 1.5 to 2, starting with the 2021 Star Ratings. (83 FR 1657577). These measures include the patient experience of care measures collected through the CAHPS survey, Members Choosing to Leave the Plan, Appeals, Call Center, and Complaints measures. We also stated in the April 2018 final rule (83 FR 1657516576) that, given the importance of hearing the voice of patients when evaluating the quality of care provided, CMS intended to further increase the weight of patient experience/complaints and access measures in the future. In the June 2020 final rule, CMS finalized an additional increase in the weight of patient experience/complaints and access measures from 2 to 4 for the 2023 Star Ratings. At that time, we stated we were putting more weight on this category of measures that primarily reflect patient experience of care measures to put patients first and to emphasize CMSs goal of listening to the voice of the patient to identify opportunities to improve care delivery (85 FR 33837). We still believe these measures focus on critical aspects of care such as care coordination and access to care from the perspective of enrollees, but taking into consideration additional stakeholder feedback we have received and the effect of the policy on the 2023 Star Ratings, we have reconsidered our position from the June 2020 final rule and now believe these measures currently receive an undue weight in the Star Ratings program. One of the guiding principles of the Part C and Part D Star Ratings program is to align with the CMS Quality Strategy (83 FR 16521). As part of the current CMS Quality Strategy, CMS is trying to create a resilient, high-value health care system that promotes quality outcomes, safety, equity, and accessibility for all individuals, as described at https://www.cms.gov/ Medicare/Quality-Initiatives-Patient- Assessment-Instruments/Value-Based- Programs/CMS-Quality-Strategy. One of the goals of the CMS Quality Strategy is to increase alignment across the CMS quality programs to improve value. Currently, the measure weight of 4 for the patient experience/complaints and access measures is not consistent with the contribution of these types of measures in the overall performance scores for other CMS quality measurement programs. For example, in the hospital value-based purchasing program, person and community engagement measures, which are measures collected through the Hospital CAHPS Survey, account for 25 percent of the total performance score for hospitals (https://www.cms.gov/ medicare/quality-initiatives-patient- assessment-instruments/ hospitalqualityinits/hospital-value- based-purchasing-). As another example, one-sixth of the global score for the Quality Rating System for QHPs is based on enrollee experience (https:// www.cms.gov/files/document/2022-qrs- and-qhp-enrollee-survey-technical- guidance.pdf). In contrast, for the 2023 Star Ratings, with a weight of 4, the patient experience/complaints and access measures account for approximately 58 percent of the overall rating for MAPDs. For the Part C and Part D Star Ratings, we include a broader set of measures related to person and community engagement relative to other CMS quality programs. For example, we include appeals measures given the importance of access to care and services for Part C plan enrollees. However, if the patient experience/complaints and access measures had a weight of 2, these measures would account for 41 percent of the overall rating. Reducing the weighting to 2 for this category of measures would align the patient experience/complaints and access measures more closely with other programs, without exactly matching the lower influence measures of this type have on the overall (that is, total performance or global) score in these other programs. We did not propose to reduce the weight further than 2 given the important link between patient experience, adherence, and health outcomes. We stated that reducing the weight for these measures from 4 to 2 is a significant change and a more extensive change may be too much to adopt at this time. Prior to the April 2018 final rule, the weight of 1.5 given to the patient experience/complaints and access measures in the Part C and Part D Stars Ratings had been in place since the 2012 Star Ratings, so we have extensive experience with how using a weight lower than 2 for these categories of measures influences plan behavior. We stated that we continue to believe that a weight higher than 1.5 is appropriate. The weighting of measures within the Star Ratings program is important as not all measures contribute equally to the goals of the program. Patient experience, complaints, and access to care have been linked to improved clinical outcomes and are important aspects of health care. For example, patient experience is associated with better patient adherence to recommended treatment, better clinical processes, better hospital patient safety culture, better clinical outcomes, reduced unnecessary health care use, and fewer inpatient complications (Anhang Price et al., 2014; Anhang Price et al., 2015; Quigley et al., 2021).147We also VerDate Sep<11>2014 22:35 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00154 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222273 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations PD, Zaslavsky, AM, & Hays, RD (2015). Should health care providers be accountable for patients care experiences? Journal of General Internal Medicine, 30(2), 253256. Quigley DD, Reynolds K, Dellva S, & Anhang Price, R (2021). Examining the business case for patient experience: a systematic review. Journal of Healthcare Management, 66(3), 200224. 148Cohen, Marc A, Hwang, Ann and Hawes, Frances M (July 13, 2022). Could Person-Centered Care Be The Secret To Achieving the Triple Aim? Health Affairs Forefront. recognize that whether clinicians acknowledge patient preferences148 may be another factor that is important to measure and include in the Star Ratings program; consequently, we tested a question for the CAHPS survey related to whether an enrollees personal doctor dismisses symptoms that are important to them for potential incorporation in the survey and Star Ratings in the future. CMS continues to believe, as we stated in the April 2018 final rule at 83 FR 16576, that we must listen to the perceptions of care from people with Medicare, as well as ensure they have access to needed care. While focusing on patient experiences of care and ensuring that care is person-centric are critical, health and drug plans also have a responsibility to consider and work toward improving clinical outcomes. Improving clinical outcomes is an important goal for the Part C and Part D programs to meet the CMS Quality Strategy goal of promoting the highest quality outcomes and safest care for all individuals. High-value care does not always align with patient experiences of care, and we must take this into consideration as we consider how to weight the different Star Ratings measures. Clinical quality measures, for example, are also important in that they measure health outcomes, clinical processes, and adherence to clinical guidelines. They measure whether plans are following the best practices for health care delivery, including providing preventive care such as immunizations and cancer screenings and caring for enrollees with ongoing health problems such as diabetic enrollees who need blood sugar tests, eye exams, and blood pressure monitoring. It is also important to create incentives for health and drug plans to continuously focus on quality improvement by giving sufficient weight to the Health Plan Quality Improvement and Drug Plan Quality Improvement measures relative to the patient experience/access and complaints measures. In the proposed rule, we stated that we believe the weight given to measures in the Part C and Part D Star Ratings program should be in line with how the measures are linked to health care and the value they have in improving health care. Subsequent to finalizing the weight of 4 for patient experience/complaints and access measures in the June 2020 final rule, we have received significant stakeholder feedback on this issue through the Part C and D Advance Notices, the 2023 Part C and D proposed rule (CMS4192P), the COVID19 interim final rules (CMS1744IFC and CMS 3401IFC), letters sent to CMS, and meetings with plans. A number of concerns have been raised by stakeholders related to a weight of 4, including devaluing measures of health outcomes, encouraging plans to abandon efforts to drive clinically appropriate care, sending the message that preventive care such as cancer screenings are not important, and not balancing appropriately clinical excellence and patient experience. Stakeholders have also raised concerns around disproportionately overweighting patient experience measures, which in turn diminishes the importance of other measures. MedPAC noted in their response to the CY 2021 and 2022 proposed rule (CMS4190P) that the increased weight would give disproportionate weight to patient experience measures relative to outcome measures and create an imbalance between the two most important measure groupingsoutcome and patient experience measures. Stakeholders have continued to raise concerns about the disproportionate weight given to patient experience/ complaints and access measures. Stakeholders have continued to suggest that clinical outcomes should count more than patient experience of care measures. Additionally, we have received feedback that cancer screenings, medication reconciliation, and other Star Ratings measures are critical areas of focus in particular in underserved communities but have a diminished role in the Star Ratings program due to the high weight of patient experience/complaints and access measures. Given these concerns, as well as the impact of the weighting policy on the 2023 Star Ratings, CMS re-evaluated its decision to weight these measures higher than outcome measures. We were concerned that the higher weight of 4 may create incentives for plans to not focus as much on patient outcomes, screenings, and preventive care. This could lead to ineffective or inappropriate care and increased costs if providers primarily focus on patient experiences. Although patient experience/complaints and access to care measures have been linked to improved clinical outcomes and are important aspects of health care, we proposed to move back to a weight of 2 to more appropriately balance the value these measures contribute to achieving high quality care without weighting them higher than clinical outcome measures and to better align the total contribution of patient experience and outcome measures with other CMS quality reporting programs. To better align the Part C and Part D Star Ratings with the current CMS Quality Strategy and other CMS quality programs and to better balance the contribution of the different types of measures in the Star Ratings program, we proposed to modify  422.166 at paragraphs (e)(1)(iii) and (iv) and  423.186 at paragraphs (e)(1)(iii) and (iv) to decrease the weight of patient experience, complaints, and access measures from 4 to 2 beginning with the 2026 Star Ratings. At a weight of 2, the patient experience, complaints, and access measures would be weighted higher than process measures but not as high as outcome measures. This is in line with the value these measures add to achieving high quality care without weighting them higher than clinical outcome measures. In addition, this would align more closely with the weight these types of measures are given in other CMS quality programs. We solicited feedback on this proposed change. Comment: The majority of commenters strongly supported CMSs response to stakeholder concerns regarding the overemphasis on patient experience/complaints and access measures in the Part C and D Star Ratings program. Commenters noted that by lowering the weight from 4 to 2, CMS will continue to emphasize patient experiences in the Star Ratings, but the Star Ratings will also highlight preventive care and clinical outcomes more and be more in line with other quality programs. There was concern that undue weight for patient experience/complaints and access measures may shift payer priorities and lessen emphasis on clinical outcomes. Some commenters noted that they recognize the importance and value of patient experience/complaints and access measures, but agree that they should not account for more than half of the overall Star Ratings. A commenter noted that bringing patient experience, complaint, and access measures back to their prior weight of 2 rebalances the impact of different measure types, signals the critical importance of clinical outcome and process measures, which had been underweighted when the weighting was doubled, and ensures VerDate Sep<11>2014 22:35 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00155 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222274 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations that the Quality Rating System reflects the continuum of care from patient experiences to health outcomes. A commenter noted that access to care, care coordination, and health care quality cannot be measured solely through a member perception survey, and plan performance related to members receiving timely preventive screenings and care for chronic conditions should