2023-07115.pdf

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 receive substantial weighting in the Star Ratings program. By reducing the weight of CAHPS measures back to a weighting of 2, a commenter stated that the Star Rating program will return to a more balanced framework that extends relatively equal weighting across domains. In doing so, this commenter noted that CMS will positively impact population health- based quality measures, such as cancer screenings, chronic condition management, and medication adherence that are the ultimate path to health equity. Another commenter noted that patient experience and access measures are critical to evaluating plan quality; however, the weights should not be higher than clinical outcomes. Weighted at 2, patient experience measures will still play a critical part in rating a plan. Response: We appreciate and agree with these comments. As we noted, this weight reduction further aligns efforts with other CMS quality programs and the current CMS Quality Strategy, and better balances the contribution of the different types of measures in the Star Ratings program. Comment: Multiple commenters stated that the weight reduction appropriately accounts for the value these types of measures contribute to achieving high quality care and better aligns the total contribution of patient experience/complaints and outcome measures within the Star Ratings program. Another commenter supported this change and noted that while enrollees perspectives and experiences with the plan are critical components of a plans Star Ratings, and highly rated plans should have reasonably satisfied enrollees, enrollee satisfaction should not overshadow a plans obligations to the quality of care and health outcomes it delivers or ability to meet clinical and operational performance standards. Response: We agree and note that concerns from interested parties after the weight was increased to 4, including concerns about disproportionately overweighting patient experience measures and subsequently diminishing the importance of other measures, are what led to our proposal to reduce the weight to 2. Comment: Some commenters strongly encouraged that CMS make the weight change sooner than the 2026 Star Ratings to correct the current weighting imbalance and ensure plans are also focused on patient outcomes, screenings, and preventive care. Response: In the June 2020 final rule, CMS finalized an increase in the weight of patient experience/complaints and access measures from 2 to 4 for the 2023 Star Ratings and since then we have not proposed further changes to the measure weights. Any changes to the weights need to be proposed and finalized through rulemaking to amend  422.166 and 423.186. The 2026 Star Ratings is the soonest this change can be implemented to ensure adequate notice to plans about this change in advance of the performance period. We do not intend for this change to rebalance the weight of the patient experience/ complaints and access measures to unfairly surprise plans or undermine efforts during the 2023 performance period to improve performance consistent with measure weights in place at the start of the year. Comment: A commenter recommended that the weight be decreased further so that there is not a negative impact on preventive care and patient outcomes. This commenter further suggested we might want to evenly weight CAHPS/HOS, HEDIS, and Part D measures. Another commenter stated that patient experience of care measures should receive a weight of 1 and outcome measures should be weighted more heavily. Response: 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. We believe this is in line with the value these measures add to achieving high quality care without weighting them higher than clinical outcome measures. Prior to the 2012 Part C and D Star Ratings, all measures were weighted equally. Beginning with the 2012 Star Ratings, CMS has placed greater weight on outcome measures compared to process measures; at that time, patient experience/complaints and access measures were weighted higher than process measures, but not as high as outcome measures. This differential weighting was implemented to create incentives to drive improvement in clinical outcomes, patient experience/ complaints, and access measures. Patient experience of care measures are related to positive clinical outcomes so receive a higher weight than process measures. Assigning all measures within HEDIS with the same weight, for example, would weight process measures the same as outcome measures in the set of Star Ratings measures derived from HEDIS. This would no longer place greater weight on outcome measures and would assume that all measures within a group, whether HEDIS, CAHPS/HOS, or Part D, are equally important. One of the primary goals of the MA and Part D Star Ratings system is to encourage improved health outcomes (83 FR 16520) and the weighting of individual measures in the program reflects this goal. Comment: A handful of commenters encouraged CMS to continue efforts to modernize the CAHPS surveys and appreciated CMSs efforts to test the web mode and other updates to the survey. Response: We thank these commenters for their support. Comment: A commenter recommended regular patient satisfaction surveys around network access questions such as how many clinicians the patient contacted before finding an appointment and how long a patient had to wait for an appointment. Response: There are two existing Star Ratings measures, Getting Needed Care and Getting Appointments and Care Quickly, that are collected through the CAHPS survey and focus on issues related to accessing care. Contracts are permitted to add a limited number of supplemental questions to the MA and PDP CAHPS questionnaire so long as they do not contain content similar to existing MA and PDP CAHPS survey items or affect responses. In this case, contracts can add additional survey items if the added questions capture different aspects of patient experiences getting appointments and care. Comment: Some commenters opposed the weight decrease and noted that the patient experience, complaints, and access measures are critical indicators of plan quality and important factors for a beneficiary making plan decisions. A commenter noted that complaints against plans can include issues regarding terminated coverage and denied authorization requests that impact beneficiaries health and care and should be given significant weight in the Star Ratings. Another commenter suggested that patient experience is underweighted in other CMS quality programs. A commenter also stated that there is a positive association between various aspects of patient experience, such as good communication between providers and patients, and several important health care processes and outcomes. A commenter noted that CAHPS patient experience of care and access measures help support an age-friendly health system that encourages age- VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00156 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222275 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations 149Age-Friendly Care (johnahartford.org). 150https://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment-Instruments/Value- Based-Programs/HVBP/Hospital-Value-Based- Purchasing. friendly care.149This commenter noted that the 4x weighting of the CAHPS experience of care and access measures has shifted the clinical and operational discussions within their organization more than any payment innovation in recent organizational history since it created incentives for an adaptive approach to the evolving and variable needs of Medicare enrollees. The commenter noted that while HEDIS measures have drawbacks since they are limited to the eligible populations, CAHPS measures include more of the enrollee population and help drive interventions to address social needs to improve access to care. This commenter also noted that plans can influence CAHPS scores to a greater degree than many currently recognize. They stated that examining grievances, appeals, and call center statistics can also reveal gaps in member education, delays, or process issues in utilization management, as well as provider abrasion that is communicated to members. This commenter further noted that MA is sufficiently unique such that CAHPS weightings in other programs are not directly relevant. Response: We appreciate these comments but remain 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. 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. We agree with the commenters that patient experience/complaints and access measures are critical aspects of care, and with the weight change to 2, these measures will account for approximately 40 percent of the overall rating for MAPD contracts, 45 percent of the Part C summary rating for MA- only contracts, and 37 percent of the Part D summary rating for PDPs so they will still have a significant contribution to a contracts overall rating. We acknowledge the commenters position that other programs are underweighting patient experience of care measures. However, similar to our approach here to tailor the weights to reflect an overall balance for the Part C and Part D Quality Star Ratings program, other CMS programs are trying to balance creating incentives for facilities, providers, or plans to ensure Medicare beneficiaries get high quality care across different domains of quality in each of the programs. For example, the hospital value-based purchasing program has multiple goals focused on improving the quality, efficiency, patient experience, and safety of care that Medicare beneficiaries receive during an inpatient stay and must balance the weights across these different goals.150While we believe consistency and alignment across programs is important and a consideration for alignment with the CMS Quality Strategy, the specific goals and circumstances of each program also need to be taken into account. The change in weights for patient experience/complaints and access measures will not be implemented prior to the 2026 Star Ratings to allow adequate notice to plans in advance of the 2024 measurement period. This will allow any efforts during the 2023 performance period to be reflected in the 2025 Star Ratings. Comment: A commenter does not support the reduction in the weight for access measures, noting that the current four access measures are the only quality measures in the program that specifically address, and hold plans accountable for, a timely appeals process and adequate interpreter services. Another commenter suggested that Members Choosing to Leave the Plan (a measure of ultimate plan satisfaction) and the Call Center Foreign Language Interpreter and TTY Availability measures (which support CMSs health equity goals) be weighted as 4. Response: We agree access measures and Members Choosing to Leave the Plan remain critical measures given the importance of access to care and services for Part C plan enrollees. We also agree that the Call CenterForeign Language Interpreter and TTY Availability measures are important in measuring the operational performance of a plan and, as a result, for an MA PD, we include both a Part C measure and a Part D measure. Since there are already two measures focused on call center monitoring, we do not agree that these measures should be weighted a 4. We remain concerned that a weight of 4 for access, disenrollment, and call center measures devalues measures of health outcomes and encourages plans to abandon efforts to drive clinically appropriate care. We also note that CMS has other means to evaluate compliance by plans with the regulatory requirements for appeal processes and interpreter services, and CMS can take action as necessary to address deficiencies in performance (including issuing notices of non-compliance). Comment: A few commenters recommended a weight of 3 for CAHPS measures so there would be proportionate weighting between patient experience measures relative 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