2023-07115.pdf

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 included in the HEI will be based on enrollment in the most recent of the two years of data used to calculate the HEI. For example, if the HEI includes data from measurement years 2024 and 2025, CMS would use enrollment from 2025. The percentage of enrollees with SRFs would include any enrollees who are LIS/DE or have a disability. This is treated as one group of enrollees with SRFs. As specified at  422.166(f)(3)(vii) and 423.186(f)(3)(vii), the contract-level median and half of the contract-level median enrollment percentages will be calculated and assessed separately for contracts that offer Part C and standalone Part D contracts. Comment: A commenter suggested that CMS provide clarification regarding whether the three specified SRFs would be treated independently and thus the HEI score would be calculated separately for each SRF or, alternatively, if they would be combined in a manner similar to the calculation of the CAI. This commenter also recommended that CMS clarify whether the weights of selected measures would be used when calculating the final HEI reward. A commenter stated that CMS did not specify which SRFs would be included in the HEI. Response: As described in the proposed rule, all enrollees who are DE, LIS, or disabled would be combined into one group as described at  422.166(f)(3)(i)(A), 422.166(f)(3)(i)(B), 423.186(f)(3)(i)(A), and 423.186(f)(3)(i)(B). See also 87 FR 79628. We believe combining the enrollees with these specified SRFs into one group will help ensure that measure-level contract performance can be reliably measured for most contracts. The measure weights will be used when VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00166 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222285 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations calculating the final HEI as described at  422.166(f)(3)(v) and 423.186(f)(3)(v). Comment: A commenter questioned whether a contracts measure-level score will be included for purposes of the performance thresholds to determine if a contracts measure score is in the bottom third, middle third, or top third if the contract does not meet the minimum enrollment percentage of enrollees. Response: For all contracts, the scores meeting the criteria in  422.166(f)(3)(iv) and 423.183(f)(3)(iv) will be included in the calculations to determine the distribution of contract performance for each eligible measure. Similarly, only the scores for each contracts performance that meet those criteria will be used to determine the contracts HEI score. Comment: Another commenter noted that there are no Z-codes to identify issues around social determinants of health and recommended that the HEI reward should not be implemented until data collection improves. Response: While there are no Z-codes to identify issues around social determinants of health, CMS administrative data (that is, the Medicare Advantage Prescription Drug System (MARx)) currently includes data about DE, LIS, and disability status for the specified SRFs we proposed and finalized for the HEI. As more data are available to identify beneficiaries with additional SRFs, we will explore adding other SRFs to the HEI reward methodology through future notice-and- comment rulemaking, but in the meantime, we believe it is important to start incentivizing improved care with the data we have to identify beneficiaries with SRFs. Comment: While a majority of commenters supported replacing the current reward factor with the HEI reward, some did not support removing the current reward factor even if they supported adding the HEI reward. A handful of commenters stated that removing the reward factor would penalize and lower Star Ratings for high-performing plans and adversely impact Medicare enrollees by reducing funding for supplemental benefits offered by plans or increasing cost- sharing requirements. A few commenters recommended combining the HEI reward and the reward factor, with each reward having a maximum value of 0.2, and several commenters recommended a transition period before fully removing the reward factor. A couple of commenters recommended including both the HEI reward and the current reward factor in the Star Ratings in order to reward contracts for overall positive performance. A couple of commenters suggested taking the better of the HEI reward and the current reward factor. Response: Contracts are already rewarded for high and consistent performance when they do well on the measure-level Star Ratings and the Part C and D improvement measures. We believe contracts will still have incentives to perform well and improve on all measures if the reward factor is removed because high performance on individual Star Ratings measures, as well as the improvement measures that incentivize improvements in performance from the prior year (Health Plan Quality Improvement and the Drug Plan Quality Improvement), translate into better overall and summary ratings. 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). At the beginning of the Star Ratings program, the distribution of ratings across contracts looked very different, with overall performance much lower than it is today. At that time, 38 percent of MA contracts received less than 3 stars for the Part C summary rating (the overall rating was not implemented yet at that time). Over time, we have established additional methodological enhancements to incentivize performance improvement across measures, such as the addition of the Health Plan Quality Improvement and the Drug Plan Quality Improvement measures as described at  422.164(f) and 423.184(f). MA organizations have also responded to the incentive to perform well across measures as a result of the link between Star Ratings and QBP ratings for MA contracts. As contract performance has improved and stabilized over time, different incentives are needed to continue to drive quality improvement so that all Medicare beneficiaries are receiving high quality care. CMS believes that even with the removal of the current reward factor from the Star Ratings methodology, contracts will still have incentives to perform well and improve because high performance on individual Star Ratings measures, including the Health Plan Quality Improvement and the Drug Plan Quality Improvement measures, translates into better overall and summary ratings. As noted in the April 2018 final rule, the Star Ratings are designed to provide information to beneficiaries that is a true reflection of plan quality and encompasses multiple dimensions of high quality care. The goals of the Star Ratings are to publicly display quality information to inform plan choice, to provide information for public accountability, incentivize quality improvement, provide information to oversee and monitor quality, and accurately measure and calculate scores and stars to reflect true performance. (83 FR 16519). QBPs, as defined in  422.260(b), tie increases in payment benchmarks and rebate percentage to providing high quality care, as reflected in quality ratings and performance data. CMSs goal is to continue to evolve the Star Ratings methodology over time to ensure that the methodology encourages continued improved plan performance across beneficiaries. In simulations using data from the 2023 Star Ratings, even before factoring in the HEI reward, the majority of contracts (80 percent of MA and cost contracts, and 82 percent of PDP contracts) would have no change in their overall rating as a result of taking away the reward factor, and no contracts would lose QBPs. Simulations replacing the current reward factor with the HEI reward using data from the 2021 Star Ratings show that no contracts would lose QBPs and only 9.4 percent of contracts would lose rebate dollars. Further, we note that the reward factor should not be seen as an extra funding source; removing the reward factor supports our efforts to continue to evolve the Star Ratings program to incentivize improved plan performance for all enrollees. We did not consider a transition or blend to use both the current reward and the new HEI reward over a period of time because that approach would dilute the impact of the health equity incentives and be methodologically complex to implement. Based on this, we are finalizing the proposed removal of the current reward factor with additional revisions to the regulation text at  422.162(b)(1) and 423.182(b)(1) and to the definition of highly rated contract in  422.162(a) and 423.182(a) to remove references to the current reward factor. Comment: A couple of commenters suggested that the HEI reward methodology focus on within-contract differences. A commenter stated the HEI reward sets separate and unequal performance benchmarks for different SRF groups. The commenter also stated a contract could widen its internal inequities while doing well on the HEI. VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00167 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222286 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations 156https://www.cms.gov/about-cms/agency- information/omh/research-and-data/stratified- reporting. 157Trends in Racial, Ethnic, Sex, and Rural-Urban Inequities in Health Care in Medicare Advantage: 20092018 (cms.gov). 158https://www.ruralhealthinfo.org/toolkits/ transportation. Response: If the HEI focused on within-contract inequities based on the reduction of disparities between members with and without SRFs within a contract, this would be problematic because disparities could be reduced when performance is poor for both groups. Additionally, rewarding a reduction in disparities for within- contract disparities only would disproportionately reward those contracts with historical inequities. The inclusion of thresholds based on the percentage of enrollees with the specified SRFs is important to ensure that contracts are not being rewarded if they serve relatively few enrollees with the specified SRFs, making it easier to do well among this population. Further, CMS expects contracts to perform well among all enrollees with SRFs; there should be no incentive to perform worse among any groups with SRFs, as that would be detrimental to the contracts measure-level and overall and summary Star Ratings. The HEI reward methodology does not set performance benchmarks. Contracts will be evaluated based on the distribution of performance on each measure in the given measurement years. These distributions may change from year to year and contracts will not know a priori which third of the distribution their performance will be in; therefore, contracts should be incentivized to continue to improve year over year. Comment: A couple of commenters stated the HEI reward would have a disproportionately negative impact on rural beneficiaries, given that members with 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