ACAP Comment Letter on 2018 Advance Notice and Draft Call Letter

March 3, 2017

Liz Richter, Acting Principal Deputy Administrator
Centers for Medicare and Medicaid Services
Director, Center for Medicare United States
Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington, D.C. 20201

Submitted via e-mail to: AdvanceNotice2018@cms.hhs.gov

Re: Advance Notice of Methodological Changes for Calendar Year (CY) 2018 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2018 Call Letter

Dear Ms. Richter:

The Association for Community Affiliated Plans (ACAP) greatly appreciates the opportunity to provide comments to the Centers for Medicare & Medicaid Services (CMS) on the 2018 Advance Notice and Draft Call Letter.

ACAP is an association of 59 not-for-profit, community-based Safety Net Health Plans located in 28 states. Our member plans provide coverage to over seventeen million individuals enrolled in Medicaid, Children’s Health Insurance Program (CHIP) and Medicare Advantage Dual-Eligible SNPs. Nationally, ACAP plans serve approximately one-third of all Medicaid managed care enrollees. Twenty of our plans are D-SNPs and 14 of our plans participate in the Financial Alignment Demonstration.

Summary of ACAP’s Comments
Please find below a list of ACAP’s comments. ACAP has chosen to respond to a subset of proposals in the Advance Notice that are particularly relevant to Safety Net Health Plans. We submit comments on the following areas: SNP Specific Networks, Star Ratings and Social Risk Factors, Opioid Utilization Standards, and Encounter Data.

The positions summarized below are explained in greater detail later in the letter.

  • Encounter Data and Risk Adjustment Data Rates We want to thank CMS for avoiding changes and increases in the encounter (25%) versus risk adjustment (75%) designated percentages. We, however, are concerned about how this method disproportionately affects SNPs.
  • Opioid Use. While we are happy that CMS has decided to incorporate the CDC guidelines we still believe there is a potential disconnect. ACAP recommends that CMS first move to ensure alignment of all three standards, the CDC guidelines, the PQA measures and the NCQA measures before they move forward with these changes.
  • Network Adequacy Guidelines Specific for SNPs. ACAP supports the implementation of SNP specific networks. As CMS begins to prepare for this model, we ask that SNP specific networks should not have more network adequacy requirements than general MA plans. The purpose of the SNP specific networks should be to tailor SNP networks to their target population.
  • Quality Measures and STARS. ACAP appreciates CMS’ recognition of the ASPE report to Congress, published in December 2016, with its findings showing that dual status is a significant predictor of poor Star Ratings, independent of plan or provider performance. The current Star Rating system fails to adequately account for socioeconomic and disability status, producing a structural disadvantage for plans that serve dual-eligible beneficiaries. We request that CMS develop a meaningful, long-term solution that accurately measures and compares quality of care for plans that disproportionately serve dual-eligible beneficiaries. ACAP believes that stratification could provide a framework for a long-term solution, by ensuring that D- SNPs are compared against other D-SNP plans enrolling a similar population.

Encounter Data and Risk Adjustment

ACAP wants to thank CMS for creating administrative simplification by offering one system versus two for reporting purposes.

We also want to thank CMS for avoiding changes and increases in the encounter (25%) versus risk adjustment (75%) designated percentages. We are concerned, however. about how this method disproportionately affects SNPs. According to a recent study by Milliman, 2016 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. However, 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. A similar study by Avalere found that the average risk scores from EDS were 16% lower in the 2016 payment year compared to RAPS. Average risk scores of dual eligible members were also significantly lower compared to non-duals as a result of up to 40% fewer HCC diagnoses identified in EDS compared to RAPS.

To address the operational concerns of the ACAP plans, ACAP has been holding a series 3 of networking calls with our plans to improve their encounter data processes and ensuring all relevant information is captured for risk adjustment.. Although this series focuses on Medicare, we expect there will be lessons learned applicable to the Medicaid and Marketplace lines of businesses.

We request that CMS continue to work with ACAP and its plans to help them improve encounter data submissions and recommend that CMS continue to review the gaps between EDS and RAPS and its impact on SNPs, in particular.

Changes and Adjustments with Opioid Use Quality Measures

In the 2017 Call Letter CMS introduced consideration with altering the overutilization standard of opioids, however, the proposed criteria was not consistent with CDC guidelines. While we are happy that CMS has decided to incorporate the CDC guidelines we still believe there is a potential disconnect. ACAP recommends that CMS first move to ensure alignment of all three standards, the CDC guidelines, the PQA measures and the NCQA measures before they move forward with these changes. In addition, the use of a 6 month versus 12 month measurement period could potentially bring in too many members with short-term pain management issues which does not align with the PQA measures that use 12 months.

While we do support alignment with the CDC guidelines, that support was dependent on further alignment with the quality measures. The PQA measures that CMS has adopted are still based on 120 MED.

ACAP further recognizes that while the use of group number instead of individual prescribers will limit false positives, just looking at the number of prescribers alone will probably result in a number too high for plans to address and does not take into account the role of a pharmacy of choice to monitor this.

SNP Specific Network Adequacy Standards

ACAP supports the implementation of SNP specific networks. As CMS begins to prepare for this model, we ask that SNP specific networks should not have more network adequacy requirements than general MA plans. The purpose of the SNP specific networks should be to tailor SNP networks to their target population. More flexibility and tailoring for networks is needed, particularly the recognition in the provider type requirements and exceptions process. Not all providers accept Medicaid and therefore there is a high likelihood that these providers will not accept duals.

The time and distance standards for SNP networks should vary based on characteristics and needs of SNP enrollees, including prevailing patterns of care. The requirements on 4 which provider types and the number of providers that must be included in a network should vary and be tailored to the SNP target population. CMS should also change the minimum provider ratio and the beneficiaries required to cover, as appropriate to meet the needs of the target SNP population.

CMS should also permit additional health care delivery modalities, such as telemedicine and mobile units, be included in the exceptions process. Where possible, CMS should look at how states work through exception processes to promote continued alignment.

STAR Ratings and Social Risk Factors

ACAP appreciates CMS’ recognition of the ASPE report to Congress, published in December 2016, with its findings showing that dual status is a significant predictor of poor Star Ratings, independent of plan or provider performance. The current Star Rating system fails to adequately account for socioeconomic and disability status, producing a structural disadvantage for plans that serve dual-eligible beneficiaries. ACAP is pleased that CMS recognizes the problem and is working on interim and long-term solutions.

We recognize that there are many challenges to developing a quality measurement system for MA plans, and one that is not biased by social risk factor. We supported the implementation of the Categorical Adjustment Index (CAI) for 2017. We feel the CAI was a positive step in the right direction. That said, as CMS has acknowledged, CAI is an interim fix and is not a long-term solution. We request that CMS develop a meaningful, long-term solution that accurately measures and compares quality of care for plans that disproportionately serve dual-eligible beneficiaries. ACAP believes that stratification could provide a framework for a long-term solution, by ensuring that D- SNPs are compared against other D-SNP plans enrolling a similar population. We look forward to hearing from CMS about proposed long-term solutions regarding adjustment for socioeconomic status in the Star Rating system. All Medicare Advantage consumers are best served when their plans are evaluated on a level playing field.

The characteristics of the special needs populations should drive quality measures and improvement. ACAP strongly urges a more robust approach to adjust for social risk factors than what is being proposed for the 2018 plan year. When developing a methodology to account for social risk factors in the Star Ratings program, CMS should be guided by the ASPE research findings, as the report provides robust testing and offers methodological options to address social risk factors in Stars.

CMS should use the exceptions and exclusions of individual measures to tailor them to dual-eligible beneficiaries. CMS should also use geographic data at the most granular 5 level possible to adjust for social risk factors and should require measure developers to use this geographic data in measure retesting.

Conclusion

ACAP is prepared to assist with additional information, if needed. If you have any questions, please do not hesitate to contact Christine Lynch at (202) 204-7519 or clynch@communityplans.net.

Sincerely,

/s/

Margaret A. Murray
Chief Executive Officer

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