evekhm/cms_iom_500 huggingface dataset:
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has had an opportunity to review and comment on the HEI reward methodology, including the rules for determining which measures are included in the calculation of the HEI. As specified at  422.166(f)(3)(iii) and 423.186(f)(3)(iii), the measures being evaluated for inclusion in the HEI will 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) will 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. Comment: A commenter suggested adjusting the Star Ratings to account for SRFs by setting different cut points for contracts with higher levels of enrollees who are dually eligible. Another commenter recommended risk-adjusting the Star Ratings thresholds (cut points) VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00168 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222287 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations to account for high numbers of dually eligible enrollees. Response: CMS does not believe it would be appropriate to set different cut points for contracts based on the proportion of dually eligible enrollees. We do not want to set lower standards of care for treating underserved populations. Comment: A commenter recommended ensuring additional resources, such as payments from the HEI reward, flow through to providers that serve higher proportions of dually eligible individuals and ensuring funds earned from the HEI reward are directly allocated to patient care. Response: CMS cannot require that sponsoring organizations pay their contracted providers or pharmacies how the commenter suggested. Section 1854(a)(6)(B)(iii) of the Act prohibits the Secretary (and CMS) from require[ing] any MA organization to contract with a particular hospital, physician, or other entity or individual to furnish items and services under this title or require[ing] a particular price structure for payment under such a contract to the
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from require[ing] any MA organization to contract with a particular hospital, physician, or other entity or individual to furnish items and services under this title or require[ing] a particular price structure for payment under such a contract to the extent consistent with the Secretarys authority under this part. There is a similar, but broader, prohibition on interference with the negotiations between drug manufacturers and pharmacies and Part D sponsors in section 1860D11(i) of the Act. Comment: A commenter suggested that it may be useful to include performance benchmarks in calculating the HEI reward rather than distributing performance into thirds to ensure that equity performance does not lag. Response: CMS believes that contracts will continue to be incentivized to improve performance among populations with SRFs because contracts will continue to strive to earn a sufficiently high score on the HEI to be eligible for a reward. A contract that is in the top third of the distribution in one year will not know how well other contracts will perform from year to year and therefore will be incentivized to continue to improve in order to stay in the top third of the distribution. Comment: A commenter suggested including SNP-only measures in the calculation of the HEI reward because these measures are important for health equity goals. The commenter noted that leaving the measures out of the HEI reward reduces their importance and does not provide an opportunity to recognize excellence. Response: CMS thanks this commenter for this suggestion and will take this comment into consideration. We proposed and are finalizing the exclusion of SNP-only measures, however, because they apply only to a subset of contracts. Additionally, based on our simulations, we do not believe that addition of these measures would have a significant impact on the HEI reward distribution. However, if SNP- only measures were to be added to the calculation of the HEI reward, we would first propose this change through notice- and-comment rulemaking. Comment: A commenter stated CMS should look for opportunities to encourage plans to serve enrollees with SRFs and that they were not aware of any new incentives to serve this population. Response: The HEI reward provides an incentive to serve this population, since to be eligible for the full HEI reward contracts must meet the median percentage threshold of enrollees with the specified SRFs, and to be eligible for one-half of the reward, contracts must meet the one-half
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to serve this population, since to be eligible for the full HEI reward contracts must meet the median percentage threshold of enrollees with the specified SRFs, and to be eligible for one-half of the reward, contracts must meet the one-half median percentage threshold of enrollees with the specified SRFs. Comment: A commenter suggested that CMS incorporate historical data in the HEI reward methodology prior to the 2024 measurement year to account for equity efforts already undertaken by some health plans that opted to care for historically underserved populations prior to the implementation of the HEI reward. A couple of commenters recommended CMS implement the HEI reward beginning with the 2026 Star Ratings rather than the 2027 Star Ratings. Response: We appreciate these suggestions; we propose substantive and methodological changes to the Part C and D Star Ratings and finalize them prior to the measurement year. This approach ensures that sponsoring organizations are aware of the quality measures that will be used and have an opportunity to change or improve performance before the contract is rated on specific performance measures. Since the HEI reward includes two years of data, the earliest measurement year data it can use is from 2024 and 2025, and the earliest it can be implemented is the 2027 Star Ratings. Comment: A commenter suggested that CMS could adjust the HEI reward relative to the change in LIS/DE enrollee percentages in the 2024 and 2025 measurement years compared to a baseline in order to limit health plans seeking to benefit from the new rewards of the HEI from crowding out health plans that currently serve underserved populations. Response: CMS appreciates this suggestion; however, we do not believe it would be appropriate. With the HEI reward, CMS aims to improve health equity by incentivizing all MA plans, cost plans, and Part D plan sponsors to perform well among enrollees with certain SRFs. Any plans that enroll more members who are LIS, DE, or disabled will also have to perform well among these enrollees to be eligible for the HEI reward. The HEI reward methodology focuses on performance in the measurement years when contracts are actually serving LIS/DE or disabled enrollees. The HEI reward would not create the same incentives if we adjusted for changes in LIS/DE and disabled enrollment compared to a baseline before the HEI was implemented. Comment: A commenter recommended CMS implement a temporary approach for the 2025 Star Ratings to
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reward would not create the same incentives if we adjusted for changes in LIS/DE and disabled enrollment compared to a baseline before the HEI was implemented. Comment: A commenter recommended CMS implement a temporary approach for the 2025 Star Ratings to account for plans that have already been working to reduce disparities by taking the better of a plans measure-level Star Rating or the HESS for those measures for which there is overlap between the two programs, or by incorporating the HESS as a bonus component to account for plans that scored well on the HESS. Another commenter recommended adding the HESS to the Star Ratings as soon as possible beginning with the 2026 Star Ratings. Response: We appreciate these suggestions; however, we make such substantive and methodological changes to the Part C and D Star Ratings through rulemaking and generally finalize them prior to the measurement year. At this time, we are not considering adding the HESS to the Star Ratings program as a basis for a reward factor since it is methodologically complex to calculate HESS scores within the tight timeframes for producing the Star Ratings. The HESS also requires 4 years of data, which would exclude a number of newer contracts from a reward based on the HESS. Additionally, given the 4 years of data needed, it would be more complex to implement as measure specifications are updated. Comment: Some commenters suggested adding additional SRFs to the HEI such as race and ethnicity, gender, language, gender identity, sexual orientation, enrollee self-reported social needs, cultural context, social relationships, residential and community context, rurality, and enrollees with housing, food, or transportation needs identified using data from the NCQA Social Need Screening and Intervention measure. A commenter stated that the SRFs proposed to be included in the HEI reward do not adequately capture the population of members included in CMSs health equity definition and VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00169 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222288 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations 159https://www.aspe.hhs.gov/sites/default/files/
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RULES222288 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations 159https://www.aspe.hhs.gov/sites/default/files/ migrated_ legacy_ files/171041/ ASPESESRTCfull.pdf?_ ga=2.49530854.1703779054.1662938643-470268562.1638986031. 160Beckett MK, Martino SC, Agniel D, Mathews M, Hudson Scholle S, James C, Wilson-Frederick S, Orr N, Darabidian B, Elliott MN. (2021). Distinguishing neighborhood and individual social risk factors in health care Health Services Research: 114. 161https://www.govinfo.gov/content/pkg/FR- 2022-11-18/pdf/2022-23873.pdf. 162Social deprivation index (SDI). Robert Graham CenterPolicy Studies in Family Medicine & Primary Care. (2018, November 5). Accessed 2/23/ 23, from https://www.graham-center.org/rgc/maps- data-tools/sdi/social-deprivation-index.html. 163Goodman DC, Mick SS, Bott D, et al. Primary care service areas: a new tool for the evaluation of primary care services. Health Services Research 2002; 38(1 Pt 1):287309. doi: 10.1111/1475 6773.00116. 164Herb J, Dunham L, and Stitzenberg K. A comparison of area-level socioeconomic status indices in colorectal cancer care. J Surg Res 2022; 280:304311. 165Social deprivation index (SDI). Robert Graham CenterPolicy Studies in Family Medicine & Primary Care. (2018, November 5). Accessed 2/23/ 23, from https://www.graham-center.org/rgc/maps- data-tools/sdi/social-deprivation-index.html. those who experience SRFs. A commenter stated that focusing on limited SRFs ignores other SRFs where there are disparities and requested a timeline for the inclusion of additional SRFs in the
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those who experience SRFs. A commenter stated that focusing on limited SRFs ignores other SRFs where there are disparities and requested a timeline for the inclusion of additional SRFs in the HEI reward. Another commenter recommended including additional SRFs beginning with the 2027 Star Ratings or as soon as possible. Response: CMS appreciates these suggestions and will consider including additional SRFs with data readily available at this time, such as rurality and gender, in the HEI reward methodology in the future. Other SRFs will be considered over time as data become available to measure the specified SRFs. The addition of SRFs would be proposed through notice-and- comment rulemaking. While it is true that not all populations with SRFs are captured in the HEI reward we proposed and are finalizing in this rule, CMS does not believe this biases the HEI reward. Health plans should strive to perform well among all populations with SRFs regardless of whether they are included in the HEI reward. We see differences in performance for the SRFs included in the HEI reward. For example, prior research has shown that dual eligibility is one of the most influential predictors of poor health outcomes, and disability is also an important risk factor linked to health outcomes.159 Comment: Several commenters suggested using the ADI, the Social Vulnerability Index (SVI), or the Social Deprivation Index (SDI) in the HEI instead of LIS/DE and disabled status. A commenter recommended that CMS continue to monitor different indices that measure socioeconomic status and adopt them if they are found to be more accurate measures than the ADI. Response: We will continue to consider additional SRFs for the HEI reward over time through notice-and- comment rulemaking. As we noted in the preamble to the proposed rule, consistent with literature on the ADI, and other neighborhood-based indices,160our analyses showed that for the Part C and D Star Ratings measures, the ADI explains very little of the variation in the quality of care received beyond enrollee-level LIS/DE and disability information. The ADI is more useful in situations where there is a lack of beneficiary-level quality performance data, which is the case for the MSSP, for example. The MSSPs health equity adjustment applies to Accountable Care Organizations (ACOs) that report the all- payer/patient electronic clinical quality measures (eCQMs) or
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data, which is the case for the MSSP, for example. The MSSPs health equity adjustment applies to Accountable Care Organizations (ACOs) that report the all- payer/patient electronic clinical quality measures (eCQMs) or Merit-based Incentive Payment System (MIPS) CQMs; these measures are reported in aggregate, so beneficiary-level data are not readily available. The MSSP adopted a health equity adjustment that will upwardly adjust an ACOs quality performance score to reward ACOs that report all-payer eCQMs/MIPS CQMs, and are high performing on quality and serve a high proportion of underserved beneficiaries. The health equity adjustment adds up to 10 bonus points to the ACOs MIPS quality performance category score based on the percentage of the ACOs assigned beneficiaries who are LIS and/or DE and reside in census blocks with high ADI as described at 87 FR 69781.161Since the MSSP does not have Medicare-only beneficiary-level data linked to the quality performance data, CMS does not stratify the quality measure data by LIS/DE and disability status and analyze performance like we can for the Part C and D Star Ratings program. In the CY 2023 Advance Notice, we solicited feedback on the use of the ADI in the HEI reward methodology. At that time there was limited support for adding the ADI to the index. A number of concerns were raised, including that the ADI does not always reflect some of the more deprived areas; it does not adequately distinguish between areas that have both extreme poverty and extreme wealth; and it is not fully representative of systemic disparities for historically marginalized communities. There was also concern that including the ADI may create incentives for plans to focus on certain geographic areas versus focusing on improving care for those with the greatest needs. The SVI was designed to identify communities at increased risk of negative impacts from natural disasters and infectious disease outbreaks that require community-level response and is calculated at both the census tract and county level. Similar to other geography-based measures of social risk, the SVI is constructed using census data on socioeconomic status, household composition and disability, minority status and language, and housing and transportation characteristics. The Social Deprivation Index (SDI) was developed to identify the extent of disadvantage in small geographic areas and assess the association
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is constructed using census data on socioeconomic status, household composition and disability, minority status and language, and housing and transportation characteristics. The Social Deprivation Index (SDI) was developed to identify the extent of disadvantage in small geographic areas and assess the association of level of disadvantage with health outcomes and health inequities. The SDI is a composite of sociodemographic characteristics, including poverty, education, unemployment, housing characteristics, household composition, and car ownership.162It is constructed at the county, census tract, aggregated Zip Code Tabulation Areas, and Primary Care Service Area163levels using 5-year estimates from the American Community Survey. Studies have shown that different geography-based measures of social risk have very similar associations with measures of quality of care and health outcomes.164However, for the Part C and D Star Ratings measures, geography-based indices of social risk do not substantively explain variation in care received beyond beneficiary-level SRFs such as dual- eligibility for Medicare and Medicaid, receipt of the Part D LIS, and disability as the original reason for Medicare eligibility,165which are used in the HEI. Comment: A commenter questioned why CMS decided against using the ADI in the HEI reward but is using the ADI as a factor in calculating the health equity adjustment in the MSSP. Response: The ADI is more useful in situations where there is a lack of beneficiary-level quality performance data, which is the case for the MSSP. Unlike for the Part C and D Star Ratings program, the MSSPs health equity adjustment is only available to those ACOs that report aggregate quality data for all-payer eCQMs/MIPS CQMs. For the HEI reward, CMS has access to beneficiary-level data on each quality measure included in the HEI and can match that beneficiary-level information to dual eligibility, LIS, and disability status. As we noted in the proposed rule, our analyses suggest that ADI explains little variation in care received beyond beneficiary-level LIS/DE and disability information for the Part C and D Star Ratings measures. VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00170 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM
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VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00170 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222289 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations 166https://www.aspe.hhs.gov/sites/default/files/ migrated_ legacy_ files/171041/ ASPESESRTCfull.pdf?_ ga=2.49530854.1703779054.1662938643-470268562.1638986031. Similar to our goals for the HEI reward in terms of creating incentives for MA plans, cost plans, and Part D plan sponsors to perform well among enrollees with certain SRFs, the MSSP adopted a health equity adjustment that will upwardly adjust an ACOs quality performance score to reward high quality performance across all populations served by an ACO; encourage all ACOs to treat underserved populations; provide an incentive for ACOs to provide high quality care to all of the populations they serve; and ensure there are not incentives for ACOs to avoid underserved populations as CMS transitions to all-payer eCQMs/ MIPS CQMs as described at 87 FR 69839. Comment: A commenter raised concerns about using dual eligibility, LIS, and disability as the SRFs including in the HEI reward. The commenter stated there is mixed evidence on the effectiveness of these variables as indicators for health equity and noted issues with comparability given state-by-state differences in Medicaid eligibility criteria. Response: The HEI reward methodology we proposed not only includes dual eligibility (which could differ by state), but it also includes enrollees who apply for an LIS subsidy (which allows us to capture enrollees whose income and resources are limited) and disability status. Prior research has shown that dual eligibility is one of the most influential predictors of poor health outcomes, and disability is also an important risk factor linked to health outcomes.166Further, we set the minimum percentage of enrollees with the specified SRFs at the relatively low bar of one-half the contract-level
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predictors of poor health outcomes, and disability is also an important risk factor linked to health outcomes.166Further, we set the minimum percentage of enrollees with the specified SRFs at the relatively low bar of one-half the contract-level median in part to address geographic variation in enrollment. Comment: Some commenters stated that large plans may serve many enrollees with SRFs but not meet the percentage of enrollees with the specified SRFs thresholds to qualify for the HEI reward, and some commenters recommended including thresholds for both the total number of enrollees as well as the percentage of enrollees. A commenter stated that larger plans not meeting the enrollment thresholds set for the HEI for enrollees with specified SRFs may be disincentivized from improving health equity even if they have a significant number of members experiencing SRFs, and another commenter stated that enrollees with SRFs will be overlooked if they are in plans that serve a significant SRF population but do not meet the thresholds. A commenter believes that an unintended consequence of our proposed methodology is that plans will not be eligible for an HEI reward due to the limited number of beneficiaries with those SRFs, and recommended that all plans be eligible for an HEI reward even if the proportion of their members with the specified SRFs is low. This commenter also stated that all plans should be working to improve the care for members with SRFs even if the proportion of enrollees with the specified SRFs does not meet the specifications to be eligible for the HEI reward. Response: CMS believes all plans should work to improve health equity regardless of whether they qualify for the HEI reward. Further, improving performance among members with SRFs will improve performance on Star Ratings measures even in the case where plans do not qualify for the HEI reward. One of the goals CMS considered when developing the HEI reward was to avoid rewarding contracts that may do well among enrollees with the SRFs included in the HEI but serve few enrollees with those SRFs relative to their total enrollment, making it easier to do well. If a number, rather than a percentage, of enrollees with the specified SRFs were used as the threshold for qualifying for the HEI reward, this goal would not be met. Larger contracts might be able to meet a minimum number threshold even though they serve a relatively small number of enrollees with the specified SRFs compared to