Proposed Changes to MA and Part D Prescription Drug Program Quality Rating System from the  2021 and 2022 Policy and Technical Changes Proposed Rule

In the 2021 and 2022 Policy and Technical Changes Proposed Rule, CMS is proposing routine measure updates and an increase in the weight of patient experience/complaints and access measures. It is also proposing some technical clarifications of the current rules for the Quality Bonus Payment (QBP) ratings methodology. CMS also proposes the use of Tukey outlier deletion, which is a standard statistical methodology for removing outliers, to increase the stability and predictability of the star measure cut points.

If finalized by CMS, these proposed changes, both to data collected and performance measured, would apply for the 2021 measurement period and the 2023 Star Ratings. CMS is proposing to increase the Star Rating weights from the current 2 to a 4 to further emphasize the importance of patient experience/complaints and access issues.  Given this, Sponsors should begin strategically planning for an increased focus on patient experience/complaints and access measures.

For the Star Ratings, CMS is proposing to:

• Remove outliers for non-CAHPS measures
• Increase weight of patient experience/complaints and access measures
• Remove the Rheumatoid Arthritis Management (Part C) measure from the Star Ratings
• Implement substantive updates to the specifications of the Health Outcomes Survey (HOS) outcome measures
• Add two new Part C measures to the Star Ratings program
• Clarify the rules around consolidations when data are missing due to data integrity concerns
• Add several technical clarifications
• Codify additional existing rules for calculating MA QBP ratings

CMS is proposing to change the following definition:

• Change the definition for “New MA Plans” for QBP purposes to be a plan that:
  • (1) is offered under a new MA contract; and
  • (2) is offered under an MA contract held by a parent organization that has not had an MA contract in the prior three years.

Measure-level Star Rating

CMS is requesting comments on refining the methodology for calculating the Star Ratings for non CAHPS measures by:

• Adding Tukey outer fence outlier deletion to the clustering methodology as an additional step prior to hierarchal clustering.
• In the first year that this would be implemented, the prior year’s thresholds would be rerun, including mean resampling and Tukey outer fence deletion, so that the guardrails would be applied such that there is consistency between the years.
• Plans should be aware that removal of low clustering outliers could exert downward pressure on overall star ratings and
• CMS estimates the effect of Tukey outlier deletion would create a savings of $808.9 million for 2024, increasing to $1,449.2 million by 2030 with savings likely meaning lesser Quality Bonus Payments to plans

Contract Consolidations

For contract consolidations, CMS is proposing to:

• Add a rule to account for instances when the measure score is missing from the consumed or surviving contract(s) due to a data integrity issue.
• Assign a score of zero for the missing measure score in the calculation of the enrollment-weighted measure score.
• Address how the Timeliness Monitoring Project (TMP) or audit data are handled when two or more contracts consolidate, by adding that the TMP or audit data will be combined for the consumed and surviving contracts before carrying out the methodology.

Adding, Updating, and Removing Measures

For measure changes, CMS is proposing to:

Removal:

• Remove the “Rheumatoid Arthritis Management” measure from the Part C Star Rating

Updates:

• For the Health Outcome Measures (HOS) measures:
  • Improving or Maintaining Physical Health (PCS) and Improving or Maintaining Mental Health (MCS)
    • Change the case-mix adjustment
    • Increase the minimum required denominator from 30 to 100
  • Modify the classification of the “Statin Use in Persons with Diabetes” (SUPD) measure category from an intermediate outcome classification to be a process measure

Additions:

• Add the HEDIS “Transitions of Care” measure*
• Add the HEDIS “Follow-up after Emergency Department Visit for Patients with Multiple Chronic Conditions” measure*

*These measures will be on the display page for three years prior to adding them to the Star Ratings program.

Measure Weights

• Further increase the weight of patient experience/complaints and access measures from 2 to 4 to further emphasize the importance of patient experience/complaints and access issues:
  • CAHPS survey
  • Members Choosing to Leave the Plan
  • Appeals
  • Call Center
  • Complaints

Extreme and Uncontrollable Circumstances

• CMS is soliciting additional feedback on the disaster policy for contracts impacted across multiple years.

Quality Bonus Payment Rules

• Add rules for contracts that do not have sufficient data to calculate and assign ratings and do not meet the definition of low enrollment or new MA plans.
• Add that any new contract under an existing parent organization that has other MA contracts with numeric Star Ratings in November would be assigned the enrollment-weighted average of the highest Star Rating of all other MA contracts under the parent organization that will be active as of April the following year.
  • If a new contract is under a parent organization that does not have any other MA contracts with numeric Star Ratings in November, CMS would look at the MA Star Ratings for the previous 3 years. The QBP rating would be the enrollment-weighted average of the MA contracts’ highest Star Ratings from the most recent year that had been rated for that parent organization.

Plans should note that, at this time, the changes outlined above are only proposed and not yet final.  CMS is accepting comments on the proposed rule through 5 p.m. ET on April 6, 2020.  CMS will review comments and may adjust provisions of the proposed rule prior to issuing a final rule. To read “The top 10 things plans need to know about the 2021 and 2022 Policy and Technical Changes Proposed Rule” click here.