Association for Community Affiliated Plans Issues Public Comment on Centers for Medicare & Medicaid Services Notice

WASHINGTON, March 17 -- Margaret A. Murray, CEO of the Association for Community Affiliated Plans, has issued a public comment on the Centers for Medicare and Medicaid Services' notice entitled "Updates for Part C and D Star Ratings of the Advance Notice of Methodological Changes for Calendar Year 2021 for Medicare Advantage Capitation Rates and Part C and Part D Payment Policies - Part II". The comment was written on March 6, 2020, and posted on March 13, 2020:

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The Association for Community Affiliated Plans (ACAP) greatly appreciates the opportunity to provide comments to the Centers for Medicare & Medicaid Services (CMS) on Parts 1 and 2 of the Advance Notice of Methodological Changes for Calendar Year (CY) 2021. ACAP is an association of 74 not-for-profit, community-based Safety Net Health Plans located in 29 states. Our member plans provide coverage to over twenty million individuals enrolled in Medicaid, Children's Health Insurance Program (CHIP) and Medicare Advantage Dual-Eligible SNPs. Twenty of our plans are D-SNPs and nationally, ACAP plans serve approximately one out of every four Medicaid managed care enrollees.

We submit the following comments for CMS' consideration.

* Star Ratings and Socioeconomic Status: Some ACAP plans have identified a potential issue with the placement of full dual D-SNPs into final adjustment categories for the CAI. CMS should evaluate why CMS' data sources do not indicate that all beneficiaries enrolled in a full dual D-SNP/contract are dually eligible; provide D-SNPs with a way to notify CMS when they are miscategorized for the CAI and allow for a redetermination; and, if necessary, change the methodology for the categorization of either the LIS/DE initial groups or the final adjustment categories so that D-SNPs for full duals are correctly placed into the 6th final adjustment category. Further, in order to level the playing field for D-SNPs, CMS should evaluate peer grouping the Star Ratings so that D-SNPs are compared to each other in the Star Rating system.

* CMS-HCC Risk-Adjustment Model: ACAP is concerned that, relative to the 2017 CMS-HCC model, the 2020 CMS-HCC model underpredicts costs for some demographic groups, such as gender. CMS must evaluate the predictive accuracy of the 2020 CMS-HCC model for demographic categories and for all dual eligibles; identify why the model is underpredicting costs for certain demographic categories; and implement any changes necessary to improve the accuracy of the model.

* Encounter Data: ACAP is concerned over the dual impact of a further phase in of the 2020 CMS-HCC model, which seems to be underpredicting costs for some demographic groups, and a further phase in of EDS, which has been shown to incorrectly reduce payments to DSNPs. ACAP recommends that CMS hold off on further phasing in EDS until the agency has ensured the accuracy of the 2020 CMS-HCC model for all demographic groups and dual eligibles.

Star Ratings and Socioeconomic Status

ACAP believes in the need for an accurate quality measurement system for all MA plans, including those who exclusively serve dual-eligible beneficiaries. As CMS is aware, the Star Rating system is currently not a level playing field for D-SNPs, because the ratings do not adjust for the impact of dual-eligible status or other social risk factors. This results in a structural disadvantage for plans serving dual-eligible beneficiaries. As CMS also knows, the December 2016 ASPE Report to Congress found that dual status is a significant predictor of poor-quality ratings, independent of plan or provider performance. However, an effective adjustment has still not been made to the Star Rating system to remove the effect of dual status and other social risk factors on D-SNPs quality scores.

Our comments on CMS' specific proposals are below.

Categorical Adjustment Index

ACAP plans are concerned that there may be a problem with the placement of full dual D-SNPs into final adjustment categories for the CAI. Some of our members only operate D-SNPs for full-benefit dual eligibles, therefore, all the beneficiaries under their contract are dually eligible. These plans should be placed into the L10 LIS/DE group and should fall under the 6th final adjustment category. However, these plans are falling into the 5th final adjustment category because CMS' data does not capture that 100 percent of their enrollees are dually eligible. Furthermore, since the overall CAI value for the 5th category decreased relative to last year, these plans are estimating a similar impact on their overall Star Rating.

Given that the purpose of the CAI is to serve as an interim adjustment for SES in the Star Ratings, it should be a priority that plans/contracts for full duals are correctly categorized. The intent of the CAI will not be realized if D-SNPs are miscategorized and their Star Ratings are negatively affected as a result. To that end, ACAP requests the following:

1. Evaluate why CMS' data sources do not indicate that all beneficiaries enrolled in a full dual D-SNP/contract are dually eligible;

2. Provide D-SNPs with a way to notify CMS when they are miscategorized for the CAI and allow for a redetermination;

3. If CMS determines that it is not possible to correctly identify all members of a full dual DSNP/contract as dually eligible due to data limitations, then CMS must change the methodology for the categorization of either the LIS/DE initial groups or the final adjustment categories so that these plans are correctly placed into the 6th final adjustment category.

Permanent adjustment to Stars to address SES

As CMS has acknowledged, the CAI was intended to be an interim fix rather than a long-term solution to address the impact of SES in the Star Ratings. ACAP supports a meaningful, long-term adjustment to the Star Rating system to level the playing field for D-SNPs.

We ask CMS to evaluate peer grouping the Star Ratings for D-SNPs as a long-term strategy to address the impact of dual-eligible enrollment on Star Ratings. There is already a precedent for CMS using peer grouping in a quality rating system. The agency currently uses peer grouping in the hospital quality rating system by placing hospitals into quintiles based on their proportion of dual-eligible patients. We ask that CMS maintain consistency in its approach to quality measurement by using peer grouping for D-SNPs in the Star Rating system. We note that for this to occur, Star Ratings will likely have to be reported at the plan level.

In addition to peer grouping, we also ask CMS to evaluate using measures that are appropriate for the dual-eligible population. The Star Rating system should incorporate measures that consider the unique needs of dual-eligible beneficiaries with complex health, behavioral, and cognitive conditions and whose care is affected by socioeconomic challenges.

Finally, ACAP is highly supportive of PQA's recommendation to stratify Medication Adherence for Hypertension, Medication Adherence for Diabetes, and Medication Adherence for Cholesterol by beneficiary-level sociodemographic status characteristics. We are glad that CMS is considering these changes for future Star Ratings and we encourage CMS to evaluate stratifying more Star Rating measures by sociodemographic status.

CMS-HCC Risk-Adjustment Model

Over the past few years, CMS has made significant improvements to the predictive accuracy of the CMS-HCC model for dual-eligible beneficiaries. The introduction of the six-segment model and the inclusion of more categories for behavioral health conditions have improved the ability of the model to predict costs for dual-eligible beneficiaries.

With respect to the 2020 CMS-HCC model, ACAP supports the inclusion of dementia in the model and the model's accounting for the number of chronic conditions. However, we are concerned that, relative to the 2017 CMS-HCC model, the 2020 CMS-HCC model underpredicts costs for some demographic groups. Some of our member plans are currently seeing that for CY 2020, the phased-in portion of the 2020 CMS-HCC model underpredicts the costs by gender. ACAP is supportive of further phasing in the 2020 CMS-HCC model. At the same time however, CMS must also evaluate the predictive accuracy of the 2020 CMS-HCC model for demographic categories and for all dual eligibles; identify why the model is underpredicting costs for certain demographic categories; and implement any changes necessary to improve the accuracy of the model.

Lastly, we note that the CMS-HCC model does not eliminate the need for the frailty adjuster. We are glad that CMS permits FIDE-SNPs in addition to PACE organizations to apply for the frailty adjuster. However, we feel that MMPs should also be eligible for the frailty adjuster. MMPs also enroll frail LTSS beneficiaries, and for the purposes of payment accuracy, equity, and consistency in payment methodologies for the same enrollees, CMS should allow MMPs to be eligible for the frailty adjuster.

Encounter Data as a Diagnosis Source for 2021

Historically, the use of encounter data has disproportionality affected the accuracy of payments to SNPs. According to a 2017 study by Milliman, median EDS risk scores were lower than RAPS risk scores by 4 percent which translated to an approximate reduction of $40/per member per year. The difference between EDS and RAPs was more pronounced for SNPs, with EDS scores that were 8.4 percent lower than RAPs at the 20th percentile and 5.1 percent lower at the 50th percentile.

ACAP remains concerned about the impact of EDS on the accuracy of risk-adjusted payments to D-SNPs for full duals. Our concerns over the accuracy of risk-adjusted payments to D-SNPs for CY 2021 are amplified by the dual impact of a further phase in of the 2020 CMS-HCC model which seems to be underpredicting costs for some demographic groups, and a further phase in of EDS, which has been shown to incorrectly reduce payments to D-SNPs. While CMS is statutorily obligated to further phase-in the 2020 CMS-HCC model, the agency can hold off on further phasing in EDS. As such, ACAP recommends that CMS hold off on further phasing in EDS until the agency has ensured the accuracy of the 2020 CMS-HCC model for all demographic groups and dual eligibles.

Conclusion

ACAP is prepared to assist with additional information, if needed. If you have any questions, please do not hesitate to contact Christine Aguiar Lynch at (202) 204-7519 or [email protected].

Sincerely,

Margaret A. Murray

Chief Executive Officer

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The notice can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0003-0002

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