evekhm/cms_iom_500 huggingface dataset:
2023-07115.pdf
that may do well among enrollees with SRFs but serve very few enrollees in this population, although the tiered HEI reward structure goes further in aligning with this goal. The non-tiered HEI reward structure aligns better with the goal of ease of use and understanding for contracts and other stakeholders. We proposed at  422.166(f)(3)(vii) and 423.186(f)(3)(vii) that the contract percentages of enrollees with SRFs included in the HEI would be based on enrollment in the most recent of the 2 years of data used to calculate the HEI. For example, if the HEI includes data from measurement years 2024 and 2025, the enrollment used would be from 2025. We recognize DSNP only contracts would meet the enrollment thresholds under either the tiered or non-tiered HEI reward structure; however, other plans that do not initially meet the thresholds can also work to increase enrollment of people with SRFs to meet the enrollment thresholds. DSNP only contracts would also need to perform sufficiently well among enrollees with the specified SRFs to qualify for a reward based on the HEI. One consideration in developing the proposed thresholds for the minimum percentages of enrollees with SRFs included in the HEI needed to qualify for an HEI reward was that higher thresholds could potentially create geographic barriers in certain parts of the country to qualifying for the HEI reward because there is variation by State in the percent of enrollees who are LIS/DE or disabled. Both the tiered HEI reward and non-tiered HEI reward structures account for this as all states have percentages of LIS/DE/disabled enrollees that are greater than one-half the contract-level median based on 2019 data, although the non-tiered structure goes further in addressing this concern, as many states do not have percentages of LIS/DE/disabled enrollees that are greater than the contract-level median. 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 would be calculated and assessed separately for MA (that is, Part C) and standalone Part D (that is, PDP) contracts. Because enrollees in Puerto Rico are not eligible
2023-07115.pdf
the contract-level median and half of the contract-level median would be calculated and assessed separately for MA (that is, Part C) and standalone Part D (that is, PDP) contracts. Because enrollees in Puerto Rico are not eligible for LIS, we believe that a different approach is necessary for contracts with services areas wholly located in Puerto Rico. We proposed at  422.166(f)(3)(vii)(A) and (B) and 423.186(f)(3)(vii)(A) and (B) to use a modified calculation to determine the percentage of enrollees with SRFs included in the HEI for contracts with service areas wholly located in Puerto Rico. We proposed to limit this treatment to contracts with service areas wholly in Puerto Rico because our analysis indicates that for plans with service areas that include Puerto Rico and other locations, only a small portion of the enrollment is in Puerto Rico. We proposed to estimate the number of enrollees with the specified SRFs in these contracts differently. We would start with the percentage of DE/disabled enrollees calculated from administrative data, and then add the estimated percentage LIS by taking the LIS/DE percentage calculated for the CAI for contracts with service areas wholly in Puerto Rico as described at  422.166(f)(2)(vi) and (vii) and 423.186(f)(2)(vi) and (vii) and subtracting the percentage of DE enrollees. We need to estimate the number of LIS enrollees because LIS is not available in Puerto Rico; we would use the estimated LIS/DE information from the CAI calculations since these are the only data available on the estimated percentage of enrollees in Puerto Rico contracts that would qualify for LIS. We would then add the estimated LIS percentage to the DE/ disabled percentage calculated from administrative data to get the LIS/DE/ disabled percentage of enrollees in Puerto Rico. This calculation could result in a slight overestimate since some disabled enrollees may also be captured in the estimated LIS percentage; therefore, contracts with service areas wholly in Puerto Rico would be excluded from our calculations to determine one-half of the contract-level median and the contract- level median of enrollees with SRFs included in the HEI. We believe that this approach would ensure equitable treatment of contracts with service areas outside of Puerto Rico. In our simulations of
2023-07115.pdf
of the contract-level median and the contract- level median of enrollees with SRFs included in the HEI. We believe that this approach would ensure equitable treatment of contracts with service areas outside of Puerto Rico. In our simulations of the HEI, we found that the slight overestimate had little impact on whether contracts with service areas wholly in Puerto Rico met the one-half of the contract-level median or contract- level median thresholds. We also proposed that contracts would need to have an HEI score greater than zero on the HEI calculated for the given rating (overall or summary rating) to qualify for a reward for that rating. We proposed at  422.166(f)(3)(i) and 423.186(f)(3)(i) that the HEI score for the overall rating would include the applicable Part C and D measures, the HEI score for the Part C summary rating would include only the applicable Part C measures, and the HEI score for the Part D summary rating would include only the applicable Part D measures. An HEI score of greater than zero means that the contract on average scored in the middle third or better across measures included in the HEI for enrollees with the SRF(s). HEI scores closer to 1.0 indicate better performance for enrollees with the SRFs included in VerDate Sep<11>2014 22:37 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00163 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ER12AP23.010</GPH>ddrumheller on DSK120RN23PROD with RULES222282 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations 154Since data collections for HEDIS and CAHPS were curtailed for the 2021 Star Ratings due to the COVID19 pandemic (CMS1744IFC), these simulations used HEDIS and CAHPS measure data from the 2019 and 2020 Star Ratings. the HEI. While we proposed to require a minimum HEI score of greater than zero for contracts to receive an HEI reward, we may consider increasing this minimum score over time to continue to encourage improved contract performance for enrollees with SRFs included in the
2023-07115.pdf
While we proposed to require a minimum HEI score of greater than zero for contracts to receive an HEI reward, we may consider increasing this minimum score over time to continue to encourage improved contract performance for enrollees with SRFs included in the HEI. Any such increase to the minimum HEI score would be proposed through subsequent notice- and-comment rulemaking. We proposed at  422.166(f)(3)(viii) and 423.186(f)(3)(viii) that the HEI reward would vary from 0 to 0.4 on a linear scale for contracts that meet the threshold for the median percentage of enrollees with SRFs included in the HEI, with a contract receiving 0 reward if the contract received a score of 0 or less on the HEI and a 0.4 reward if the contract received a score of 1 on the HEI. Similarly, the HEI reward would vary from 0 to 0.2 on a linear scale for contracts that meet the threshold for one-half of the contract-level median percentage of enrollees with SRFs included in the HEI, but do not meet or exceed the contract-level median percentage of enrollees with SRFs included in the HEI. Contracts that cannot have an HEI score calculated (that is, contracts that do not have reliable measure scores or do not meet the denominator criteria for at least half of the measures included in the HEI or contracts that do not have at least 500 enrollees) would not receive an HEI reward. As an example, if a contract meets the contract-level median percentage of LIS/ DE/disabled enrollees and receives an HEI score of 0.722325, this would translate on a linear scale to a reward of 0.288930. That is, the size of the HEI reward would equal 0.4 times the difference between the HEI score and the threshold, divided by the difference between the maximum HEI score and the threshold. In this example, this would be 0.4*(0.7223250)/(10), which equals 0.288930. As another example, if a contract meets one-half the contract-level median percentage of LIS/ DE/disabled enrollees but does not meet the contract-level median percentage of LIS/DE/disabled enrollees and receives an HEI score of
2023-07115.pdf
example, if a contract meets one-half the contract-level median percentage of LIS/ DE/disabled enrollees but does not meet the contract-level median percentage of LIS/DE/disabled enrollees and receives an HEI score of 0.722325, this would translate on a linear scale to a reward of 0.144465. That is, the size of the HEI reward would equal 0.2 times the difference between the HEI score and the threshold, divided by the difference between the maximum HEI score and the threshold. In this example, this would be 0.2*(0.7223250)/(10), which equals 0.144465. The HEI reward would be rounded and displayed with 6 decimal places similar to how the CAI values are displayed. As we proposed at  422.166(f)(3)(ix) and 423.186(f)(3)(ix), once each of the HEI rewards are calculated, the applicable HEI reward would be added to the unrounded overall and Part C and D summary ratings after the addition of the CAI and the application of the improvement measures described in  422.166(g)(1) and 423.186(g)(1) and before the final overall and Part C and D summary ratings are calculated by rounding to the nearest half star. For example, if the HEI reward was 0.288930, as previously described in the example, and the unrounded overall rating was 4.234210 after the addition of the CAI and the application of the improvement measure hold harmless rule, the unrounded overall rating would be 4.523140 (4.234210 + 0.288930) resulting in a final, rounded overall rating of 4.5. We also proposed changes in the following sections to revise references to the existing reward factor or to limit application of the current reward factor to the Star Ratings through the 2026 Star Ratings:  422.166(c)(1), 422.166(d)(1) 422.166(f)(1), 422.166(f)(2)(i), 422.166(g)(1), 423.186(c)(1), 423.186(d)(1)
2023-07115.pdf
422.166(f)(2)(i), 422.166(g)(1), 423.186(c)(1), 423.186(d)(1) 423.186(f)(1), 423.186(f)(2)(i), and 423.186(g)(1). We proposed that the new HEI reward would be implemented for the 2027 Star Ratings covering primarily the 2024 and 2025 measurement years. The existing reward factor would continue to be calculated through the 2026 Star Ratings. We simulated the impact of removing the current reward factor and adding the proposed HEI reward and summarized those results in the proposed rule. In simulations using data from the 2020 and 2021 Star Ratings,154the median percentage of LIS, DE, and disabled enrollees was 41.645 percent and one- half the median was 20.822 percent for MA and cost contracts. Half of MA and cost contracts were at or above the median, 33 percent were at or above one-half the median up to but not including the median, and 17 percent were below one-half the median. In the simulations, 88 percent of MAPD contracts that received an overall rating received an HEI score, 42 percent received an HEI score greater than zero, and 34 percent received an HEI reward. The range of HEI scores among MAPD contracts for the overall rating was 0.888889 to 1.000000. The average reward for the overall rating among MAPD contracts with an HEI score greater than zero was 0.109. When simulating the removal of the current reward factor and addition of the proposed new HEI reward, 7 (1.7 percent) MAPD contracts gained one- half star on the overall rating and 54 (13.4 percent) MAPD contracts lost one-half star on the overall rating compared to the 2021 Star Ratings. Among PDP contracts, the median percentage of LIS, DE, and disabled enrollees was 13.848 percent and one- half the median was 6.924 percent. Fifty-one percent of PDP contracts were at or above the median, 39 percent were at or above one-half the median up to but not including the median, and 11 percent were below one-half the median. Among PDP contracts that received a Part
2023-07115.pdf
percent of PDP contracts were at or above the median, 39 percent were at or above one-half the median up to but not including the median, and 11 percent were below one-half the median. Among PDP contracts that received a Part D summary rating, 91 percent received an HEI score, 47 percent received an HEI score greater than zero, and 40 percent received an HEI reward. The range of HEI scores among PDP contracts was 1.000000 to 1.000000. The average reward among PDP contracts with an HEI score greater than zero was 0.160. Compared to the 2021 Star Ratings, 3 (5.3 percent) PDP contracts gained one-half star on the Part D summary rating and 7 (12.3 percent) PDP contracts lost one-half star on the Part D summary rating. We solicited comments on these proposals. Comment: Nearly all commenters supported advancing health equity, and a majority of commenters supported the HEI reward as proposed, including replacing the current reward factor. A few commenters also specifically endorsed the tiered threshold structure for the percentage of enrollees with the specified SRFs that we proposed contracts must meet to qualify for the HEI reward. Some commenters provided reasons for supporting the HEI reward, such as it is in line with CMSs goal of advancing health equity, it will help to shed light on deep-seated disparities in the health care system, and it will drive reductions in disparities in care and result in better health outcomes for populations with SRFs. Other commenters noted that the HEI will allow for clearer comparisons among and between plans and remove any disincentives plans may have for serving populations with SRFs, and adding the HEI to the Star Ratings will help make health equity part of the fabric of quality programs. Response: CMS thanks these commenters for their support of the HEI reward. Comment: A commenter stated they do not believe that the HEI aligns with CMSs health equity definition or the ultimate goal of improved and more VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00164 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with
2023-07115.pdf
259001 PO 00000 Frm 00164 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222283 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations 155HHS Finalizes Physician Payment Rule Strengthening Access to Behavioral Health Services and Whole-Person Care | CMS. equal health outcomes. The commenter suggested that CMS create a more wholistic and systemic approach to improving health equity, including accurately capturing data, aligning incentives not just for MA organizations but across other demonstrations, and providing mechanisms to address at-risk populations through benefits and plan design. Response: CMS developed the HEI reward to further incentivize Part C and D plans, as part of the Star Ratings, to focus on improving care for enrollees with specified SRFs and reward contracts for excellent care for these populations with the goal of reducing disparities in care. As such, CMS believes the HEI reward aligns with CMSs health equity definition. We agree that it is important to capture accurate data to identify beneficiaries with SRFs, and there are ongoing efforts to improve data accuracy, as well as efforts across multiple CMS programs to create similar incentives to improve care for more vulnerable enrollees. For example, starting in 2023, a health equity adjustment to an accountable care organizations quality score as part of the Medicare Shared Savings Program (MSSP) was added to incentivize improvement in the care for vulnerable beneficiaries.155In addition, proposals to address improved access to benefits for MA enrollees and require MA coordinated care plans ensure that services are provided in a culturally competent manner are addressed in sections II.A.2. and III.A. of this rule. Comment: A commenter recommended CMS not proceed with the HEI reward proposal and instead release a white paper describing a range of possible methodologies and approaches for addressing health equity for stakeholders to react to. This commenter also requested CMS to detail the relationship between the HEI and the Health Equity Summary Score (HESS) and to illustrate exactly how the HEI is calculated using specific examples. Response: CMS first requested feedback on a possible HEI reward in the spring of 2022 through the Advance Notice of Methodological Changes for Calendar Year
2023-07115.pdf
Equity Summary Score (HESS) and to illustrate exactly how the HEI is calculated using specific examples. Response: CMS first requested feedback on a possible HEI reward in the spring of 2022 through the Advance Notice of Methodological Changes for Calendar Year (CY) 2023 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. CMS considered the feedback received on the Advance Notice as we continued to develop the HEI reward for the proposed rule. Considering the feedback we received on the proposed rule, CMS believes there has been sufficient opportunity for stakeholder input on the HEI reward methodology. We note that, to prepare health plans for implementation of the HEI reward, CMS will calculate the HEI reward beginning with the 2024 Star Ratings and will share the results in confidential contract-level reports in HPMS. The HESS is a quality improvement tool developed by the CMS Office of Minority Health with a similar goal of improving health equity. The HESS differs from the HEI developed for the Part C and D Star Ratings program in that it currently focuses on CAHPS and HEDIS measures, while the HEI focuses on a broader set of measures included in the Part C and D Star Ratings. The HESS examines differences by race and ethnicity and LIS/DE status and assigns each contract composite scores for CAHPS and HEDIS (translated to diamonds, ranging from 15, with 5 being the best) based on a combination of current performance and improvement in performance over a four-year period. The HEI only requires two years of data and focuses on the specified SRFs. The HESS is separate from the Part C and D Star Ratings program and has no link to payment. Comment: A couple of commenters supported including LIS/DE and disability as the SRFs in the HEI reward methodology and supported the proposed definitions of these populations used in the HEI reward. Response: CMS thanks these commenters for their support. Comment: A commenter supported using the proposed methodology to calculate the percentage of LIS/DE enrollees for contracts in Puerto Rico because LIS is not available in Puerto Rico. Response: CMS thanks this commenter for their support. Comment: A commenter requested that CMS provide clarification on whether the HEI reward applies to standalone PDPs or just MAPD plans. Response: The HEI reward applies to both standalone PDP and MAPD contracts as proposed and finalized
2023-07115.pdf
A commenter requested that CMS provide clarification on whether the HEI reward applies to standalone PDPs or just MAPD plans. Response: The HEI reward applies to both standalone PDP and MAPD contracts as proposed and finalized at  422.166(f)(3)(i) and 423.186(f)(3)(i). The HEI is a rating-specific factor added to the summary and overall ratings of contracts that qualify. We proposed and finalized calculating the HEI separately for the Part D summary rating for MA PDs and cost contracts, and PDPs. Comment: A commenter requested that CMS provide clarification on how the HEI reward would impact a contracts Star Rating and whether it would help or harm a contracts Star Rating. Response: The HEI reward is an upside only reward, incentivizing high quality care for underserved populations. Any applicable HEI reward would be added to the unrounded overall and Part C and D summary ratings after the addition of the CAI and the application of the improvement measures described in  422.166(g)(1) and 423.186(g)(1) and before the final overall and Part C and D summary ratings are calculated by rounding to the nearest half star. Since it is an upside only reward, it avoids penalizing contracts. Comment: Several commenters questioned how measure reliability will be calculated. Response: Measure reliability is a measure of the fraction of the variation among the observed measure values that is due to real differences in quality (signal) rather than random variation (noise). In order to calculate this signal to noise ratio for each measure included in the HEI, measure reliability is calculated based on the combined subset of enrollees with the specified SRFs across two years of data. Reliability calculations for MA and PDP CAHPS patient experience measures are provided in the Quality Assurance Protocols & Technical Specifications, available at https://ma-pdpcahps.org/ en/quality-assurance, in section IX Data Analysis and Public Reporting, sub- section Significance Testing, Reliability and Star Assignment. The reliability calculations for all other measures are implemented using SAS PROC MIXED as documented in the report The Reliability of Provider ProfilingA Tutorial, available at
2023-07115.pdf
Public Reporting, sub- section Significance Testing, Reliability and Star Assignment. The reliability calculations for all other measures are implemented using SAS PROC MIXED as documented in the report The Reliability of Provider ProfilingA Tutorial, available at https://www.rand.org/pubs/technical_ reports/ TR653.html, which is consistent with the reliability calculations used to determine inclusion for Part C HEDIS measures in the Star Ratings for low enrollment contracts (500 to <1000 enrollees). Comment: A commenter did not support a measure reliability of 0.7 in the HEI reward. This commenter also did not support requiring that a contract must meet the reliability criteria for at least half the measures in the HEI because measure rates will increase over time with the introduction of the HEI reward, and it may take several years for the measure rates to stabilize such that they can be included in the HEI reward. Response: Measure reliability will be calculated based on the combined two measurement years of data for the subset of enrollees with the specified SRFs. Reliability assesses variability in performance that is attributable to real differences in performance versus measurement error. CMSs intent with VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00165 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222284 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations the introduction of the HEI reward is to incentivize improvements in performance among populations with SRFs. Such performance improvements do not mean that measures are not reliable or that measures should not be included in the HEI reward. Comment: A few commenters suggested that CMS provide clarification on how rates will be calculated for the 2-year combined rate. Response: As specified at  422.166(f)(3)(i)(B) and 423.186(f)(3)(i)(B), measure-level scores for the subset of enrollees with the SRFs of interest included in the HEI will be calculated using a regression model that includes year (that is, an indicator for whether the data are from