These comments are being submitted by the Association for Community Affiliated Plans (ACAP). ACAP represents 58 nonprofit Safety Net Health Plans in 24 states, which collectively serve more than twelve million people enrolled in Medicaid, Medicare, the Children’s Health Insurance Program (CHIP), and other public health programs.
As noted in the introduction to the NCQA proposal, plans will now be scored on all measures regardless of where they are in the accreditation cycle. In addition, this is the first year with the complete elimination of the adjustment for sampling variation. This will be coupled with NCQA’s move from rankings to ratings with a move to emphasize value and outcome-based measures.
Most importantly, many Medicaid health plans have been addressing issues surrounding the steep member growth associated with Medicaid expansion. In states that have expanded, this influx includes significant members that have been previously uninsured with no access to care, are heavily impacted by social issues such as homelessness, and are still being educated on accessing health care. Because many states have not expanded the Medicaid program, it is a very real possibility that noted variation among the plans will not be associated with the quality of care under the plan, but the variation in the membership.
As a result, we are concerned that it will be impossible to discern the impact of membership and NCQA changes versus the impact of quality improvement activities on the part of the plans. Therefore, we question whether this is an appropriate time to add additional measures to the scoring set and do not support this action without further study. Alternatively, the addition of new measures to the scoring se should be delayed until 2018 to allow the market variations to settle. In addition, we also strongly urge NCQA to consider reinstating a sampling adjustment during this unprecedented transitional period if necessary to smooth this variation that is beyond the control of an individual health plan.
Finally, we have one concern with the addition of measures that are only administrative. Based on input from our member plans, it appears there is significant geographic variation on the lift that chart review has on a measure based on the reliability of the data. Therefore, we are concerned that only adding administrative measures for scoring will adversely impact plans in some geographic areas. We would ask that NCQA measure this impact prior to adding additional measures to the scoring set.
Our remaining comments are specific to the measures proposed for addition to the HEDIS scoring set.