Letter to NCQA on HEDIS in Medicaid Expansion States

The purpose of this letter is to bring to your attention an issue concerning HEDIS and the impact on Medicaid health plans operating in expansion states. ACAP health plans that are serving the expansion population are seeing significant year-over-year swings in their HEDIS scores.

As you know, ACAP is an association of 60 nonprofit and community-based Safety Net Health Plans (SNHP). Our member plans, located in 24 states, provide coverage to more than 15 million individuals enrolled in Medicaid, the Children’s Health Insurance Program (CHIP), Medicare Special Needs Plans for dually-eligible individuals and Qualified Health Plans. ACAP plans currently serve approximately one-third of Medicaid and CHIP enrollees who receive coverage through risk-based managed care. ACAP plans are members of their communities, partnering with states through good times and bad to improve the health and well-being of their members who rely upon the Medicaid and CHIP programs.

In many cases, there has been a dramatic drop in HEDIS scores especially in some of the measures related to preventive services. Based on initial analysis, there appears to be different reasons for these declines. For example, cervical cancer screening looks at activity over the last three (3) years. With such a large influx of new members who have either not had access to services or have changed providers, it has been difficult to determine if and when the service was done prior to enrollment or to access the relevant medical records. For other measures, the impact appears to be related to the significant educational effort that plans had to undertake in order to encourage a large number of members to access necessary preventive care. Moreover, unlike a large influx of new members into commercial plans, the Medicaid health plans are serving a population that has greater challenges related to social determinants that plans must overcome upon enrollment.

It should be noted that in some cases, there have also been significant increases for certain HEDIS scores in plans serving the expansion population. For example, individuals with diabetes 2 who are eligible under the expansion have higher rates for HbA1c testing than members eligible under the traditional program. This may be related to the pent up demand for services. The issue is not just whether the swing was up or down, but the fact that health plans in non-expansion states are not seeing these wild swings in any measures.

More importantly, the issue is that the comparison between a plan in an expansion state and a plan in a non-expansion state is now an apples-to-oranges comparison. This will impact HEDIS scores, accreditation status, and health plan ratings due to a dramatic influx of new members, not because the quality of the health plan has changed dramatically. Because the swings are bidirectional, it could impact both health plans serving the expansion population and those that are not.

Therefore, we ask for NCQA to consider taking the following actions. First, complete an analysis of the variation in HEDIS gains and losses in expansion states versus non-expansion states in advance of the release of the final Medicaid health plan ratings. Second, determine if a temporary stratification is warranted to ensure a like comparison. Third, at a minimum, institute some type of transition factor to smooth the HEDIS and accreditation scoring to ensure a fair comparison during this period of rapid growth.

In closing, we are concerned about a skewed analysis of quality scores across health plans, especially in the first two years of participating in a Medicaid expansion. Most importantly, we do not want to see plans penalized or possibly rewarded in the HEDIS scoring for both the ratings and accreditation based solely on their opportunity and willingness to serve this population in need.

Thank you for considering this request. Please let us know if you wish to discuss this issue in more detail with more specific health plan examples. If you wish do with to discuss the issue, you may contact me at dkilstein@communityplans.net or by telephone at 202-341-4101.

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