ACAP Comment Letter on All Cause Readmission for BCN May 2017

May 12, 2017

To: Whom It May Concern

Re: Quality Measure Development and Maintenance for CMS Programs Serving Medicare-Medicaid Enrollees and Medicaid-Only Enrollees, Contract Number HHSM-500-2013-13011I, Task Order #HHSM-500-T0004. – ACAP Support with Modifications

Submitted via

Measure Name: BCN-2 – All-cause inpatient admission rate for Medicaid beneficiaries with complex care needs and high costs (BCNs)
Level of Support: Support with modifications

The Association for Community Affiliated Plans (ACAP) represents 60 Safety Net Health Plans that cover more than 17 million people through Medicaid, CHIP, Medicare, the Marketplaces and other publicly-sponsored health programs. Our plans cover nearly half of all people in Medicaid managed care, and are on the forefront of innovative efforts to reform health care, especially health care for people with low incomes. We thank you for this opportunity to comment on the proposed measures for dual-eligible individuals entitled “BCN-2 – All-cause inpatient admission rate for Medicaid beneficiaries with complex care needs and high costs (BCNs).”

While we support the use of quality measures to evaluate readmissions for Medicaid beneficiaries with complex care needs and high costs (BCNs) to ensure high-quality care, we do have some concerns with the specifics of the measure and will address each of the issues raised in the request for comment below.

General Questions

  • Is the candidate measure useful for measuring important domains of quality for the Medicaid population?

While we think that a readmission measure is important, we do not support this measure as drafted. First, we think it would be better to wait for the outcome of the NCQA work to develop a risk-adjusted Medicaid HEDIS Readmission measure. If necessary that measure could be further stratified to meet the desire intent to focus on high cost, high need members. This would address the issue without causing more measures that are not aligned or cannot be easily reconciled. Second, there is inconsistency in terms of defining this measure throughout the specifications making it difficult to know if the focus is admissions or readmissions.

  • Does the measure duplicate comparable measures that have already been validated and widely used, are now under development, or will be submitted for consensus-based entity (NQF) endorsement?

As noted above, we believe the focus should be on the Medicaid HEDIS measure for all-cause readmissions now under development for the Medicaid line of business. This is an area where we have gone from having no good measures to having a number of measures focused on readmission. This use of multiple measures will result in reconciliation issuers. Therefore, we do not support the measure as drafted.

  • Are the measure specifications in the MIF clear, for example, the numerator, denominator, and any potential exclusions? What should be more clearly defined?

No. Please see the comment above about the confusion over whether the measure is focused on admissions or readmission.

Additional Measure Specification Questions

  • Should observation stays be included in the numerator?

No, we believe that observation stays are more akin to extended emergency rooms visits and should not be included in the numerator.

  • Should inpatient admissions due to childbirth or maternal diagnosis related group (DRG) codes be excluded from the numerator?

No. While high cost, high need individuals may have maternity stays, they are not the stays that lead to an individual being defined as a high-cost, complex need individual. Therefore, maternity-related stays should not be included.

  • Should the reporting of the measure be stratified? For example, should we consider stratifying inpatient admissions by the original point of entry into the hospital (Emergency Department, observation status, or from the community)? Should the measure be stratified by surgery versus medicine diagnostic categories, as is done for some (but not all) similar existing measures?

We do not support the suggested stratification. If any stratification is considered, it should be based on diagnostic groupings or the number of comorbidities. These are much more important factors than the point of entry or whether the services was medical or diagnostic.

  • Are there special considerations related to potentially pairing the measure with the all-cause emergency department measure that is being developed under this contract?

No comment at this time.


Other Concerns

There is a wide variation in how mental health services are treated in relation to the carve-out of behavioral health services across the states. We support either the exclusion of plans where behavioral health services are carved out or the exclusion of mental health admissions and readmissions from the measure specifications. Otherwise, there would be extreme comparability challenges in terms of the reporting on a national basis.
If you have any questions or comments on this response, please feel free to contact me at




Deborah Kilstein

VP Quality Management and Operational Support