Amid the announcement of rulemaking in the Medicare program that was primarily around beneficiary and drug benefit issues for Medicare beneficiaries, CMS (Centers for Medicare and Medicaid Services) Administrator Seema Verma on Monday revealed a few proposed changes to the Medicare Advantage program that could eventually impact clinical and healthcare IT leaders in patient care organizations, in terms of potentially greater flexibility around quality measures for providers, even as the quality measures being spoken of Monday were for payers (Medicare Advantage health plans).
The main focus of the press availability that Administrator Verma conducted by phone was a final rule that updates Medicare Advantage (MA) and the prescription drug benefit program (Part D) “by promoting innovation and empowering MA and Part D sponsors with new tools to improve quality of care and provide more plan choices for MA and Part D enrollees. In addition to creating opportunities for innovation and additional plan choices in MA and Part D, the final changes will result in an estimated $295 million in savings a year for the Medicare program over 5 years (2019 through 2023) – resulting in lower premiums or additional benefits,” CMS stated in a press release published at the time of the press availability Monday afternoon.
As that press release, under the headline “CMS Finalizes Policy Changes and Updates for Medicare Advantage and the Prescription Drug Benefit Program for Contract Year 2019 (CMS-4182-F),” stated, “CMS is committed to supporting flexibility and efficiency throughout the MA and Part D programs. The MA and Part D programs have been successful in allowing for innovative approaches for providing Medicare and Part D benefits to millions of Americans. In Spring 2017, CMS released a Request for Information that solicited ideas to transform Medicare Advantage and the prescription drug benefit so that Medicare beneficiaries have robust options in their health care and prescription drug coverage. CMS received numerous ideas in response to the Request for Information on how to improve Medicare Advantage and the prescription drug benefit from beneficiaries, Medicare Advantage and Part D sponsors, advocacy groups, and other stakeholders. The policies in the final rule are responsive to this feedback.”
While changes to the quality measures used in the Medicare Advantage program will not directly impact IT leaders in patient care organizations, some minor changes revealed Monday may ultimately reverberate across the process evolving around the Quality Payment Program under MACRA/MIPS (the Medicare Access and CHIP Reauthorization Act of 2015 and the Merit-based Incentive Payment System).
That’s because the flexibility being shown by CMS around the Quality Improvement Project (QIP) within the Medicare Advantage program might be conveying greater flexibility overall on the part of federal healthcare officials.
Within the text of the final rule was this section: “Focusing Plans on Improving Chronic Condition Management: CMS is removing the Quality Improvement Project (QIP) from the Quality Improvement (QI) requirements. The QIP is duplicative of activities MA plans are already doing to meet other plan needs and requirements,” the rule’s text states. “The removal of the QIP and the continued implementation of the Chronic Care Improvement Program (CCIP) allows MA plans to focus on one project that supports improving the management of chronic conditions, a CMS priority, while reducing the duplication of other QI initiatives.”
Beginning on page 311 of the proposed rule, CMS officials write this: “Several commenters encouraged CMS to develop measures related to how well the care that is received by beneficiaries reflects the beneficiaries’ concerns, values, and goals. Response: CMS is tracking work by measure developers in this area and thanks the commenters for the suggestion. Comment: Many commenters supported CMS continuing to develop and implement new measure concepts beyond those in current or currently anticipated measure sets. Among the most common suggestions were outcome measures, especially new patient-reported outcome measures, quality of life, and functional status measures (including Healthy Days at Home). Several commenters also encouraged measuring care for cancer, prevention of diabetes and other chronic conditions, long-term management of chronic obstructive pulmonary disease (COPD), as well as advanced care planning, advanced directives and palliative care….”
As the officials note in the text of the final rule, among other things, “[A] few commenters urged CMS to provide quality and performance information about physicians within plans or to measure plans on the engagement of their network of physicians in value-based purchasing designs (that is, payment designs that reward or increase payments based on quality or capitated payments to physicians/practitioners, medical groups and ACOs). Several comments highlighted promoting and measuring network adequacy and potential delays in care or medication related to this, and a few encouraged CMS to reward plans that maintain adequate networks with increased Star Ratings. A number of commenters urged CMS to measure access to medical specialists and subspecialists, such as Mohs surgeons, cataract surgeons, and ophthalmologists, while a couple of commenters supported the assessment of pharmacy networks broken down by specialty drug access.”
Further, the text states, “The two comments about networks of physician and surgeon specialists urged CMS to leverage extant measurement with the MIPS and Quality Payment Program (QPP) to also help measure plan network adequacy. A commenter urged CMS to look beyond simple numbers of physicians and specialists, since contracting and affiliation in medical groups and ACOs may effectively limit the access patients have to the full network. Response: CMS appreciates the breadth of suggestions for new measures and will take these under consideration, including internal discussion and sharing them with the measure developers. We will also study the value and feasibility of deriving additional metrics (such as additional patient-reported outcome measures) from existing data collection efforts, like HOS…. HOS means the Medicare Health Outcomes Survey which is the first patient reported outcomes measure that was used in Medicare managed care. The goal of the Medicare HOS program is to gather valid, reliable, and clinically meaningful health status data in the Medicare Advantage (MA) program for use in quality improvement activities, pay for performance, program oversight, public reporting, and improving health. All managed care organizations with MA contracts must participate.”
In other words, CMS officials essentially hinted both at an alignment of measures that relate to the quality of care being delivered to Medicare Advantage beneficiaries, with some of the measures being required of physicians under MACRA/MIPS, and potentially, the inclusion of more patient-reported outcomes measures under Medicare Advantage—which could also potentially impact how MACRA/MIPS measurement might evolve forward.
Administrator Verma hinted as much when she said, in her initial remarks to the press on Monday, that “CMS is encouraging plans to adopt data-release [strategies] allowing enrollees in Medicare Advantage plans to connect their claims data to prices, etc. We’re seriously considering… adding to this [the current set of data made publicly available to Medicare Advantage enrollees], per the MyHealthEData Initiative,” she said, “empowering them with information they need to make choices.”
