Covid-19, CMS-4190-F, and Stars: Impacts During Uncertain Times-June 2020

Background

On April 6, 2020, the Centers for Medicare & Medicaid Services (CMS) issued Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC) as an interim final rule with comment period.1  In addition to outlining waivers and flexibilities for individuals and entities that serve Medicare members to respond to the COVID-19 public health emergency (the “PHE”), the interim final rule also addressed the PHE’s effect/impact on the Part C and D quality rating systems.

On June 2, 2020, CMS issued the final rule for Contract Year 2021 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, and Medicare Cost Plan Program (CMS-4190-F). 2

The following white paper will first address the adjustments to the 2021 and 2022 overall Star Ratings due to the expected disruption in data collection as a result of the PHE.  Additionally, the paper will discuss changes to Star Ratings as result of the finalization of CMS-4190-F.  Finally, the paper will discuss actions that plan sponsors should take to mitigate possible decreased performance in Star Ratings.

Changes to the 2021 and 2022 Part C and Part D Star Ratings1,2

2021 HEDIS and CAHPS Data Collection

Collection of HEDIS and CAHPS data for the 2021 Star Ratings should have occurred during the first half of 2020.  However, in order to account for the impact of COVID-19 on plan sponsors’ ability to safely collect data, CMS-1744-IFC suspended the collection of this data.  Therefore, CMS will utilize the values from the 2020 Star Ratings to replace the 2021 Star Ratings measures calculated based on HEDIS and CAHPS data.

CMS currently expects that plans will submit HEDIS data in June 2021 and to administer the CAHPS survey in 2021 for the 2022 Star Ratings.

Calculation of the 2021 Star Rating Measures

CMS-1744-IFC also included a provision that allows it to use the scores from the 2020 Star Ratings for 2021 Star Ratings for any measures on which CMS experiences data issues or is otherwise unable to perform the necessary activities to determine a 2021 rating for the particular measure.  Specifically, CMS will “substitute the score and star for the measure used in the 2020 Star Ratings in the calculation for the 2021 Star Ratings when there is a systemic data quality issue for all plans as a result of the PHE for the COVID-19 pandemic.”  Note that these adjustments are specific to the non-HEDIS and non-CAHPS 2021 Star Ratings measures.

2020 HOS Data Collection Adjustments

In response to the PHE, CMS-1744-IFC postponed the collection of this data for the 2022 Star Ratings until late summer.  Should conditions persist that prevent the HOS from being administered for the 2022 Star Ratings, CMS will utilize the Star Ratings and measure scores from the 2021 Star Ratings to address any corresponding gaps in HOS data.

2022 Star Ratings Guardrail Removal

CMS previously announced that guardrails would be implemented for the 2022 Star Ratings (based on contract year 2020 data).  The guardrails are intended to introduce a level of predictability around the Star Rating cut points.  These guardrails apply to measures that have been in the program more than 3 years and do not allow non-CAHPS measures’ cut points to increase or decrease more than 5 percentage points year over year.  CMS recognizes that the PHE may have a negative impact on plan performance across the industry and that implementing the guardrail policy for measures based on contract year 2020 data could result in plans focusing more on non-urgent care and administrative efforts as opposed to the urgent care situations that arise as a result of the PHE.  To that end, CMS is delaying the implementation of the guardrails until the 2023 Star Ratings (based on contract year 2021 data).

Expansion of the Part C and D Improvement Measures Hold Harmless Provision

Current calculations of Star Ratings include a hold harmless provision for the overall rating.  If the inclusion of the Part C and/or Part D improvement measures in the overall Star Rating calculation for a contract with 4 or more stars will decrease its overall Star Rating, the improvement measures are excluded from the overall Star Ratings calculations.  Because CMS expects an overall decline in performance across the industry due to the PHE, CMS-1744-IFC expands the hold harmless rule to include all contracts at the overall and summary rating levels.  This expansion of the hold harmless rule only applies to the 2022 Star Ratings.

Increase in Measure Weights

In CMS-4190-F, CMS finalized its proposal to increase the measure weight for the patient experience/complaints and access measures from a 2 to a 4 beginning in measurement period 2021 (for the 2023 Star Ratings), further emphasizing the importance of the member’s voice on quality of care. The following measures evaluate the member’s experience with not only their health plan and the benefits they receive but also their access to care: member experience of care measures collected through the CAHPS survey, Members Choosing to Leave the Plan, Appeals, Call Center, and Complaints measures.

Reclassification of the Statin Use in Patients with Diabetes (SUPD) Measure

Based on feedback from Pharmacy Quality Alliance (PQA), the organization responsible for developing and testing Part D measures, CMS finalized in CMS-4190-F the reduction in weight of this measure down from a weight of three and back to one for the 2023 (2021 measurement year) Star Ratings.

Finalization of Use of Tukey Outlier Deletion

In CMS-4190-F, CMS also finalized the use of Tukey outlier deletion, but announced it will delay implementation until the 2024 Star Ratings (2022 measurement year).  Tukey outlier deletion is a standard statistical methodology for removing outliers.  CMS stated it believes use of Tukey outlier deletion will increase the stability and predictability of the Star measure cut points.

Removal of the Rheumatoid Arthritis Management Measure

Also in CMS-4190-F, CMS removed the Rheumatoid Arthritis Management Part C measure for the 2023 (2021 measurement year) Star Ratings.  This is because the measure is being retired from the HEDIS measurement set in 2021.

Strategies to Address Part C Performance During the PHE

While CMS annual surveys have been delayed/suspended, it does not suspend the need to ensure members are satisfied and receiving the care and services they need. It does mean that your strategies may have to be modified depending on the current COVID restrictions in your service areas.  Plans still need to focus on members receiving care and services.

HOS Survey Outcomes

Regardless of delay or suspension, health outcomes remain an important area of focus in ensuring on-going quality of care. Plans need to explore implementing interventions such as targeted call campaigns and personal check-in calls to members which include dialogue around COVID-19 concerns or barriers to health and raising awareness of telehealth opportunities.

Plans may also consider administration of their own similar survey to identify trends of member concerns to address, and ensuring that care plans include detailed information to assist members in maintaining their physical health despite the changing healthcare landscape in light of COVID-19.

CAHPS

CAHPS is a member perception survey, which is administered to a large, random sample of members.  Because of this randomization, Plans cannot take proactive, targeted action to address concerns at a member level.  This presents an age-old challenge of how to successfully impact CAHPS survey scores.  ITo improve overall member satisfaction,  Plans need to ensure that the organization is focused on member satisfaction and access every day, in every area of the Plan.  Plans can use activities such as post-call satisfaction surveys, annual surveys and provider satisfaction surveys as tools to evaluate their performance during the year.

Given the major disruption the pandemic has had on access to care, it is more important than ever for Plans to monitor and attempt to influence member satisfaction.  Careful attention should be given to grievances and grievance resolution, call handling times, appeal timeliness and advocating use of telehealth services when appropriate. Plans should also continue communications with contracted providers to gain insight into and develop strategies to address new concerns or challenges members may be experiencing due to the pandemic.

HEDIS

Regardless of suspension of HEDIS data collection for this year, it is incumbent upon Plans to continue to deploy interventions to close gaps in care and ensure members are receiving the care and services needed. Many members have likely delayed routine screenings due to office closures or reluctance to go to health care centers. Plans should continue to target and communicate with members who have missed screening opportunities and ensure that the outreach includes tips on safely navigating routine care in light of COVID-19.

Plans should work with contracted providers to ensure they are using telehealth visits with the members and that they are communicating available telehealth opportunities.

Strategies to Address Part D Performance During the PHE

Although CMS-1744-IFC revised the calculations of the 2022 Star Ratings by delaying the implementation of cut point guardrails as well as expanding the hold harmless provision, it is imperative that Plans not lose sight of their Part D Star measure performance and continue efforts to ensure members receive timely and appropriate access to medications.  Similarly, despite CMS reducing the SUPD measure weight for the 2021 measurement year, it is important to finish strong in 2020 on this measure and continue closing this gap in care.

Adherence Measures3

So, what can Plans continue to do to maximize adherence during these uncertain times?

  • Day Supply Conversion – Proportion of days covered looks at exactly that: the number of days during the measurement period that the member has medication. Therefore, by converting members from 30 day supplies to 90 day supplies, the member will have more days with medication on hand and fewer opportunities for missed refills.
  • Refill Reminders – Refill reminders are a great method to help members remember to fill their adherence medications. Currently, most pharmacies have their own refill reminder programs that members can opt into.  However, it is more personal and impactful for the plan to identify members and reach out to them personally to not only remind them to refill their medications, but also to assess any barriers to adherence and discuss the importance of continued therapy.
  • Provider Outreach – Provide actionable lists of non-adherent members to providers so they can perform necessary outreach and education.
  • Home Delivery – Many members prefer to obtain their prescriptions from their local retail pharmacies. However, for members who have transportation issues, home delivery is an excellent option to ensure that their medications are filled timely.

Medication Therapy Management3

The Part D measure Medication Therapy Management (MTM) Completion Rate for Comprehensive Medication Review (CMR) shows how many members in the program had an assessment of their medications from the plan.  At the completion of the one-on-one medication assessment, the member is provided a written summary of the discussion that includes an action plan as well as a personal medication list.  There are typically three different MTM models used to engage members: (1) telephonic, (2) in-person, and (3) hybrid.  Even as communities begin to reopen after the COVID-19 quarantine, persons aged 65 years and older and those with underlying health concerns are still being encouraged to stay home to reduce their chances of contracting the virus.  While perhaps a necessary step to help prevent the continued spread of the virus, this may have the unexpected result of lowering CMR performance for Plans, especially those who utilize an in-person or hybrid model.  These sponsors should look for ways to transition their engagement to a telephonic process that will allow them to continue to successfully work towards their CMR goal.

Statin Use in Persons with Diabetes3

The Statin Use in Persons with Diabetes measures the percent of plan members with diabetes who take the most effective cholesterol-lowering drugs.  Strategies that Plans can use to target this measure include the following:

  • Perform claims analysis to identify members with diabetes, coupled with provider outreach, to close the gap in care
  • Utilize telehealth for provider visits to initiate statin therapy, as appropriate
  • Utilize pharmacists within doctor offices to assist with initiating therapy, as appropriate
  • Ensure the Plan’s MTM program addresses this gap in care

Conclusion

Although Plans – like the entire nation – may currently find themselves in a time of uncertainty, it is imperative to continue to put effort and resources into programs that support quality of care for your members.  Plans should evaluate the available flexibilities and waivers to determine whether any can be levied to enhance quality measure interventions.  Now perhaps more than ever, members need Plans to be innovative and committed to providing high quality care.

 


REFERENCES

  1. Centers for Medicare & Medicaid Services. Medicare and Medicaid Programs – Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC). March 31, 2020.
  2. Centers for Medicare & Medicaid Services. Contract Year 2021 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, and Medicare Cost Plan Program (CMS-4190-F). June 2, 2020.
  3. Centers for Medicare & Medicaid Services. Medicare 2020 Part C & D Star Ratings Technical Notes. October 1, 2019.
  4. Centers for Medicare & Medicaid Services. Memorandum: Information Related to Coronavirus Disease 2019 – COVID-19. April 21, 2020.