March 7, 2022
Ms. Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue SW, Room 445-G
Washington, DC 20201
Re: Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs
Dear Administrator Brooks-LaSure:
America’s Physician Groups (APG) appreciates the opportunity to comment on the Contract Year (CY) 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs. MA is instrumental to the transformation of our nation’s health care system from volume to value. We know that MA provides better quality care for seniors and our members’ value-based payment arrangements in MA create incentives for: (1) a team-based approach that emphasizes primary care; (2) physician organizations to provide the right care at the right time in the most appropriate setting; and (3) a care team that addresses the patient’s total care needs, including mental health, behavioral health, and home environment.
About America’s Physician Groups
APG is a national professional association representing over 300 physician groups that employ or contract with approximately 195,000 physicians that provide care for nearly 45 million patients. Our tagline, “Taking Responsibility for America’s Health,” represents our members’ vision to move away from the antiquated fee-for-service (FFS) reimbursement system where clinicians are paid “per click” for each service rendered rather than on the outcomes of the care provided. Our preferred model of accountable, risk based, and coordinated care avoids incentives for the high utilization associated with FFS reimbursement. APG member organizations are also working diligently to rise to the challenge presented by the COVID-19 pandemic, and we appreciate the flexibilities and waivers CMS has afforded us during this time of crisis.
Summary of APG’s Comments
Amend MA Network Adequacy Rules by Requiring a Compliant Network at Application
• CMS should consider the far-reaching implications of making these changes before implementations, such as inadvertently driving MA plans to add organizations with poor RAF and Star Ratings to their networks, the definition of network advocacy in a time where an increasing number of services are provided virtually, and the potential impact on rural areas
Standardizing Housing, Food Insecurity, and Transportation Questions on Health Risk Assessment
• Standardizing the questions asked of beneficiaries and targeting those aspects that most directly affect health outcomes could be a good first step in making the necessary improvements in tracking social determinants of health and compiling standardized data on the issue
Past Performance Methodology to Better Hold Plans Accountable for Violating CMS Rules
• APG is in support of this change in methodology
2023 Part C Star Ratings Calculations for Certain Measures Given Impacts of the COVID-19 Public Health Emergency (PHE)
• Both the CAHPS survey and HOS survey have outsized impacts on Star Ratings
• The CAHPS survey has an adverse effect on the revenue and reimbursement of providers
• The HOS surveys do not seem to be improving outcomes, nor measuring process improvement
• The HOS survey sample size and response rates are too small to adequately capture process improvement and we would prefer this data to be captured by either encounter/hybrid administrative data capture (CPT II’s)
Background
Amend MA Network Adequacy Rules by Requiring a Compliant Network at Application
CMS proposes to require that, as part of the application process, MA plan applicants demonstrate that they meet network adequacy standards for the service area and to allow for denial of an application if the network is inadequate. CMS proposes including a 10-percentage
point credit towards the percentage of beneficiaries residing within the published time and distance standards for new and expanding service area applicants since it may be difficult for MA plans to have a full network in place a year ahead of the contract start date. The change would apply to applications submitted in 2023 for the 2024 contract year.
While we are largely supportive of any effort to increase network adequacy and ensure that applicants are adequately prepared to serve MA beneficiaries, there are some issues with this proposal that CMS should take into consideration before finalization. Firstly, the agency should weigh whether making this change could inadvertently result in MA plans adding organizations to their networks that would potentially detract from RAF & Stars ratings just to ensure that they meet the network adequacy requirements. Sacrificing the quality of care extended to beneficiaries in order to just get your foot in the door would make for an uneven tradeoff that would hurt the overall quality of MA. We also have questions regarding how network advocacy is being defined in a time where an increasing number of services are provided virtually. If the definition is too restrictive it could eliminate plans that can provide services but relies on virtual services. Perhaps a small ratio of requirements than would historically be considered may be appropriate. This also potentially could have a larger impact on more rural areas who have challenges on fulfilling the parameters of a full, robust network. The far-reaching implications and how they could impact different applicants in different locations should be explored more deeply before CMS commits to wholesale change.
Standardizing Housing, Food Insecurity, and Transportation Questions on Health Risk Assessment
CMS proposes requiring that all MA organizations offering special needs plans include social determinants of health (SDOH) questions related to housing stability, food security, and access to transportation as part of their health risk assessments in order to better meet the needs of members and help connect members to needed services.
APG and its members have been strong supporters of better tracking and accounting for social determinants of health in treating patients and MA beneficiaries, with many APG member organizations already having included these questions in correspondence to beneficiaries for years. One way of doing this would be in making improvements on standardized data surrounding SDOH and ensuring that any questions asked of beneficiaries are standardized and target those aspects that most directly affect health outcomes could be a good first step in making the necessary improvements in tracking on this issue.
Past Performance Methodology to Better Hold Plans Accountable for Violating CMS Rules
CMS proposes to include an organization’s record of Star Ratings, bankruptcy issues, and compliance actions in its past performance methodology for determining whether an
organization may enter into or expand an existing contract. This expands past performance methodology from only negative net worth and intermediate sanctions during the performance timeframe. CMS is also considering whether civil monetary penalties should be included in the methodology. Each violation would incur a number of compliance action points at which time reaching a total of 13 compliance action points would be grounds for denial of a new contract application or service area expansion, equating to about two percent of plans.
APG recognizes the need for CMS to address a number of complaints from MA beneficiaries regarding plan performance recently. While past performance methodology as currently constituted includes both solvency and certain compliance actions, we recognize that further action expanding on what already exists may be appropriate. We support this new proposal in order to better support beneficiaries.
2023 Part C Star Ratings Calculations for Certain Measures Given Impacts of the COVID-19 Public Health Emergency (PHE)
CMS has proposed removing the 60 percent rule for affected contracts so that it can calculate the 2023 Star Ratings cut points for the three HEDIS measures derived from the HOS survey (Monitoring Physical Activity, Reducing the Risk of Falling, and Improving Bladder Control) and include these measures in the determination of the performance summary and variance thresholds for the reward factor for the 2023 Star Ratings.
We would like to take this opportunity to comment not only on the HOS survey measures, but also the same outsized effect that CAHPS measures have on the MA Star Ratings program. As currently constructed, the CAHPS survey has a large rate of services that are sent to patients and inundates their mailboxes. As time has gone on, the response rate for these services has lessened and become and less accurate. The responses to these surveys are not captured on claims data and are not necessarily process-based. Despite these downsides, the CAHPS survey has too large of an impact. Among APG members, we have found that the CAHPS survey has an adverse effect on the revenue of providers located in the western United States. In fact, the quadruple weighting of the CAHPS survey has a larger downstream effect on reimbursement, for some providers totaling up to 6-7 percent.
In regard to the outsized influence of the HOS survey, from a provider perspective, the HOS surveys do not seem to be actually improving outcomes, nor measuring process improvement. The questions are written in a way that is more a test of patient memory to a conversation, rather than actually capturing data. Further, some APG members have reported not seeing actual improvement in outcomes data shown due to implementation of HOS survey measures in STAR ratings. We believe that the sample size and response rates are too small to adequately capture process improvement and would prefer this data to be captured by either encounter/hybrid administrative data capture (CPT II’s).
Conclusion
Thank you for your attention to the above comments. Again, we reiterate our robust support for MA. It is important that CMS continues to work with stakeholders to encourage value in MA. Please feel free to contact Valinda Rutledge, Executive Vice President, Federal Affairs, (vrutledge@apg.org) if you have any questions or if America’s Physician Groups can provide any assistance as you consider these issues.
Sincerely,
Donald H. Crane
President and CEO
America’s Physician Groups
Please click here to download a copy of the letter.
