Presbyterian Health Plan Issues Public Comment on Centers for Medicare & Medicaid Services Rule

Targeted News Service

WASHINGTON, May 25 -- Brandon Fryar, president of Presbyterian Health Plan, Albuquerque, New Mexico, has issued a public comment on the Centers for Medicare and Medicaid Services rule entitled "Medicare and Medicaid Programs: Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency". The comment was written on May 20, 2020, and posted on May 21, 2020:

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The following is a response to CMS Interim Final Rule from Presbyterian Health Plan (PHP) in New Mexico. Presbyterian appreciates the efforts outlined within the ruling to reduce the burden upon providers by putting patients and their safety before paperwork, especially during this unprecedented public health emergency. We also appreciate the opportunity to provide feedback and requests for consideration regarding the changes within this ruling.

The STAR rating Program has provided a great standard of quality which health plans utilize to drive improvement in the health of their Medicare Members year over year. It has proven to be an extremely informative tool for these same Members to make decisions when choosing the best plan to meet their health needs. In addition to the Stars Program providing accurate and current information on a health plan's quality performance for consumers, it also incentivizes health plans to continuously strive to improve this quality performance. While changing the calculation of the 2021 Star Rating holds good intentions to focus on the current care of patients amidst the COVID-19 crisis without burden of chart collection and survey administration, it negatively impacts the ability of plans to show their improvement to potential consumers and diminishes the opportunity to position themselves among top quality performers, increase membership and continue to offer better benefits to their Members.

Over the past 2 years, Presbyterian Health Plan has made substantial investments to improve our Star rating, and these investments began to show in our last year's Star rating, where we scored at a raw, unrounded 3.74, as theoretically close to 4-Star performance that we could get without actually receiving a 4.0STAR score. While this marked significant improvement for us, our scores were negatively impacted by low CAHPS scores, that largely reflected our members dissatisfaction with their experience with using their pharmacy benefit. Last year, we continued our investments to improve the experience of our members, and we invested not only monetarily in performance improvement but within creased focus, manpower, energy and time to improve provider relationships, expand incentive programs, strengthen member relationships, create community engagement activities, and integrate approaches to member engagement in preventive and overall care. We placed special focus on areas related to pharmacy, and for example, included an investment in a zero cost share preferred generic drug benefit, and invested in automation of data feeds with provider partners allowing them at point of care to not only validate coverage of a drug but also determine the member cost share of their prescriptions. We also invested in a specialized pharmacist unit within our call center to take all calls related to a member's pharmacy benefit, allowing us to provide members with tailored education and guidance on their pharmacy benefit.

The improvements we have made are having an impact. Our most recent CAHPS-like quarterly member experience surveys are showing strong improvement, including an 8% increase in our members overall scoring of their prescription drug plan, and further, our administrative rates in all but 3 of our HEDIS measures have increased. These results give us strong confidence that Presbyterian Health Plan would have earned a 4.0 STAR rating in the results announced this fall.

CMS's plan to use last year's CAHPS and HEDIS scores has the unintended effect of penalizing plans like Presbyterian Health Plan, as we were highly likely to have scored 4.0 Stars this fall. As we sit here today, we are readying our 2021 bids and with our very high confidence in a 4.0 Star rating, we were planning additional investment in our plans, including reduction of premiums to our members and added supplemental benefits. Ultimately, a 4.0 STAR rating determines the amount of benefits we can offer to our members, and CMS' proposed approach will result in our being able to offer less benefits to our members. Presbyterian is also facing a market that is dominated by national insurers, most of whom that have 4.0 STAR ratings and have the advantage of having multi-state plans. New Mexico is a very rural state, which presents unique challenges in ensuring timely and sufficient access to health care. In our market, Presbyterian will be disadvantaged for another year relative to these large national plans.

We're hopeful that CMS will consider our suggestions below to help mitigate the potential negative impact on not only our plan but other health plans in similar situations.

Suggestion #1:

To ensure plans have the opportunity to more closely represent their 2020 quality improvement and to provide members the highest quality benefits, we request CMS consider the following suggested changes below. This will also help to mitigate the possibility of double penalizing or rewarding plans for their 2018 efforts around HEDIS measures while maintaining a submission route for those plans unable to complete 2020 data collection.

HEDIS

Accepting 2020 HEDIS submissions towards the 2021 STAR rating and allowing plans the option to rotate their submitted measures between 2019 final rates and 2020 final rates. Along with this, holding cut points for the HEDIS measures at the Stars 2020 levels so two different HEDIS measure cut points are not required. Presbyterian, and many other plans, were able to complete HEDIS data collection for 2020 and will be submitting our complete IDSS. The plans that were unable to complete data collection due to COVID could be covered as proposed in the Interim Ruling.

CAHPS

Staying true to the intention of the Stars Program, Presbyterian, as did other plans, heavily invested in improvement to our overall member satisfaction in 2019. Our mock surveys showed marked improvement across several measures and we anticipated this to reflect positively on our survey scores. We are now not allowed to accurately demonstrate that improvement this year but wish to avoid being additionally penalized by the rollover of the previous year's rates along with an increase in weighting for these measures. We suggest CMS also delay the weight increase from 1.5 to 2 on CAHPS measures or hold plans harmless if the increased weighting combined with the previous year's rates results in significant changes to the overall rating.

Improvement Measures

The theme to all our suggestions is to ensure outcomes are reflective of our plan's true performance including our overall improvement. Utilizing prior year data to calculate the Improvement Measures is not a true reflection of improvements instituted in 2019. The request here is that all plans are held harmless and these measures be set to the greater of their 2020 (based on 2018 data) or 2021 (based on 2019 data) results.

Suggestion #2:

HEDIS and CAHPS

If the ruling is not adjusted and the previously submitted rates for HEDIS and CAHPS are carried over as outlined in the ruling without any of the above considerations; Presbyterian asks CMS to consider creating an optional demonstration project. This project would allow plans who believe they were positioned prior to COVID to achieve the QBP and enrollment benefits, the option to showcase their improvement in 2019 by providing to CMS the descriptions of efforts taken in 2019 to improve quality and the data reflecting the outcome of those improvements (outside the official submission process). The review and approval from CMS would award an adjusted Bonus payment and enrollment option for the plans able to show improvement. Additionally, the results of these demonstrations would be included in documentation shared with consumers to represent the improvements since the assigned ratings would not reflect this.

The ideal demonstration program would include a review of HEDIS administrative rates (because they are less likely to be directly impact by COVID) and performance on individual health plan non-CAHPS member surveys to serve as an approximation for performance change year to year. If this were not feasible, then the fairest path would be for CMS to allow plans to submit their 2020 HEDIS and CAHPS results as normal if they so choose and assign measure-level star ratings using those results relative to 2020 star cut points. This is not a perfect methodology, but at least give plans that have worked for significant improvement a chance to reach 4 Stars. It would be reasonable to assume that plans that overcome the COVID-19 impacts enough to achieve a 4.0 Star rating under 2020 cut points have demonstrated that they reasonably deserve that rating.

Suggestion #3:

Overall STAR Rating

We recognize that CMS' very ability to calculate 2021 STAR ratings is at risk during the current crisis. In this event, Presbyterian suggests that CMS temporarily disconnect the Star Rating from payment levels and offer a one-time Quality Bonus across all Medicare Advantage Plans as well as open enrollment to all. Not only will this limit burden of calculation on CMS, it will help to support continued improvement amongst the quality measures in this time of shared need and open the accessibility and options to accommodate the consumers in search of quality programs to improve and maintain their health especially benefiting our rural or underserved populations. One possible method for consideration here is to allow plans who were in a reasonable range of the overall Star rating cutoff in the past few years (such as 3.0 or 3.5 and above) to receive the standard "too new to rate" payment bonus at a minimum for plan years 2022 and 2023. This would not perfectly solve for the artificially frozen achievement gap for plans right on the cusp, but it would at least make the playing field more level.

Finally, we hope that CMS will continue to be open to considerations moving forward regarding the 2021 submission of 2020 data. Like many other plans we were already deep into our medical record review process and survey preparations when the announcement of change was released. While the public health emergency response impacted our 2020 HEDIS season data collection, we feel like the bigger impact from COVID-19 will be in the 2021 HEDIS rates when 2020 measurement year will be reflected.

New Mexico is mostly classified by CMS as rural, even frontier in some counties. Due to the high distances between urban populated areas, the limited resources available both outside and within those urban areas, and the high instances of poverty experienced across the state, we have already witnessed independent provider and clinic closures as a result of social distancing/stay at home orders, further impacting our already limited access to care. We anticipate this severely impacting our state's ability to immediately provide the necessary specialty and regular care visits associated with most of our performance measures once the stay at home orders are lifted. As none of us can predict at this point in the year when COVID restrictions will relax and allow for the return to normal operations, we have no idea what the overall impact to the 2020 measurement year COVID will have on our state and the HEDIS measures.

As we've stated, Presbyterian appreciates the guidance and drive for continuous improved quality that CMS provides through the Stars Rating Program. It helps us as a plan stay focused on the importance of achieving the highest quality of care for our Membership. We appreciate your consideration of our suggestions allowing us to remain on that path of improvement.

Thank you,

Brandon Fryar

President

Presbyterian Health Plan

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The rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0032-0013

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