United States: Star Ratings And Future Measurement Concepts In The CY 2019 Final Call Letter

Medicare Part C and Part D Star Ratings are used by CMS to measure the quality of and reflect the experiences of beneficiaries in Medicare Advantage ("MA") and Prescription Drug Plans ("PDPs"). Below is a summary of CMS' proposed enhancements to the 2019 Star Ratings set forth in the 2019 Final Call Letter (issued by CMS on April 2, 2018) , as well as possible enhancements to the 2020 Star Ratings.

Changes to Measures

CMS will add two new measures for 2019, including "Statin use in Persons with Diabetes" (Part D) and "Statin Therapy for Patients with Cardiovascular Disease" (Part C). CMS is also removing a measure from the Star Ratings, "Beneficiary Access and Performance Problems" ("BAPP") (Part C and D). The BAPP measure, intended to reflect information about problematic plan behaviors leading to government action, is currently based on CMS sanctions and civil monetary penalties imposed against a plan, as well as "Compliance Activity Module" ("CAM") data including notices of non-compliance, warning letters, and ad-hoc corrective action plans. The BAPP measure, however, has faced years of methodological concerns. The measure was first removed from the Star Ratings calculation in 2015 based particularly on concerns about the effect of including audit results in the measure. It was then returned to active status in 2016, with audit results removed from the calculation to reduce unfairness.

This 2016 adjustment, however, did not resolve methodological concerns around the BAPP measure and its incorporation of audit outcomes, including through sanctions and civil monetary penalties that may arise from audits. Based on these concerns, CMS proposed additional revisions in its CY2018 Advance Notice/draft Call Letter. Many commenters supported revising the BAPP measure, citing methodological difficulties associated with score components that depend on audit outcomes, including differences in methodologies and goals, the subjective nature of audits, and the absence of audit information for each plan each year. Other commenters, however, raised concerns about CMS' proposed BAPP measure revisions, leading CMS to retain the BAPP measure in the 2018 Star Ratings. However, CMS signaled in its 2018 Call Letter that it intended to remove all enforcement actions and reductions for plans under sanction due to audit findings from the BAPP measure, to retire the current measure, and to introduce a new displace page letter.

In the 2019 Final Call Letter, CMS carried through with this intention, retiring the current BAPP measure in the entirety for next year. The new BAPP measure will include only CAM data and will be included on the display page for 2019. Currently, the BAPP measure receives a weight of 1.5 and is classified as an access measure. Every contract begins with a BAPP measure of score of 100. A contract's score is then reduced contingent on their sanction status, CAM score and each CMP related to beneficiary access. The CAM portion of the BAPP score combines information on notices of non-compliance, warning letters, and ad-hoc Corrective Action Plans and their severity. The CAM score per contract is calculated and then converted to deductions ranging from 0 to 80 in increments of 20. This change will remove a source of substantial unpredictability and unjustified variation from Star Ratings scores, at least for the upcoming year. While CMS may certainly reintroduce some form of BAPP measure to the Star Ratings calculation in the future, its experience with the current BAPP measure may well inform selection of a more consistent and relevant set of metrics.

Data Integrity

CMS continues to be concerned about the integrity of data used for Star Ratings given the financial and marketing incentives associated with higher performance in ratings. Like in the past, CMS has signaled that it will continue to conduct reviews to identify incomplete or biased measure data and will modify measure-specific ratings due to data integrity issues.

Regarding data completeness, currently there are four Star Ratings appeal measures that rely on data submitted to the Independent Review Entity ("IRE").   Of these, two are Part C measures – "Plan Makes Timely Decisions about Appeals" and "Reviewing Appeals Decisions" and two are Part D measures – "Appeals Auto-Forwarded" and "Appeals Upheld." Regarding these measures, CMS has principally relied on the use of audit findings and targeted reviews – if issues with data completeness are identified, appeal measures can be reduced to one star. Stakeholders have argued that reductions based solely on audit findings are unfair since only a subset of contracts of audited each year. In addition, if a reduction due to IRE data integrity was applied, it resulted in a measure-level Star Rating of one star. In response, CMS will adopt its proposal to use statistical criteria to reduce a contract's Star Rating for data that are not complete or lack integrity using Timeliness Monitoring Project ("TMP") or audit data. CMS recognized that due to varying degrees of data issues, it will use a methodology for reductions that reflects the degree of the data accuracy issue for a contract instead of a one-size-fits-all approach. For example, contracts with the most severe data quality issues will receive the largest reduction, while contracts with minor data quality issues will receive the smallest reductions.

Categorical Adjustment Index

Based upon CMS's research regarding within-contract disparity in performance associated with a contract's percentages of beneficiaries with low income subsidiary and dual eligible (LIS/DE) and disability status, CMS implemented the Categorical Adjustment Index ("CAI") in the 2017 Star Ratings Program. The CAI is used to address the impact socio-economic status ("SES") upon Star Ratings. In this call letter CMS stated that "[t]here continues to be additional work in the research community on both identifying the impact of social risk factors on health outcomes and how to best address the impact on clinical quality measurement..." For 2018, the adjustment resulted in plans moving up in ratings – 11 plans' ratings improved, while 1 plan's rating decreased. For the 2019 Star Ratings Program, CMS will continue to use the CAI unchanged, but signaled that it would consider modifying the selection of measures rules for 2020.

2020 and Beyond

The Call Letter asks for feedback regarding several new proposed measures for 2020 and beyond. Notably one of the new measures addresses opioid overuse. For HEDIS 2018, NCQA is collecting data on use of opioid at high doses, as well as opioid use from multiple providers. In 2019, NCQA will test a concept involving members who were not prescribed opioids, but who become long-term or chronic users. CMS also signaled that it will continue to focus on Part C organization determinations and reconsiderations and Part D coverage determination and redeterminations by sponsors as these are critical areas.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Authors
Events from this Firm
20 Feb 2019, Seminar, Orange, United States

The annual seminar addressing changes and developments in state and federal wage and hour laws is a unique one-day program and hundreds of California employers, personnel managers, controllers, attorneys, payroll managers, and supervisors attend each year.

21 Feb 2019, Seminar, Orange, United States

The seminar is designed to provide a guide to Human Resource Officials, Personnel Specialists, Consultants, Supervisors and other management officials through the ever-increasing maze of state and federal employment discrimination laws.

26 Feb 2019, Seminar, Pasadena, United States

The annual seminar addressing changes and developments in state and federal wage and hour laws is a unique one-day program and hundreds of California employers, personnel managers, controllers, attorneys, payroll managers, and supervisors attend each year.

Similar Articles
Relevancy Powered by MondaqAI
 
In association with
Related Topics
 
Similar Articles
Relevancy Powered by MondaqAI
Related Articles
 
Related Video
Up-coming Events Search
Tools
Print
Font Size:
Translation
Channels
Mondaq on Twitter
 
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
 
Email Address
Company Name
Password
Confirm Password
Position
Mondaq Topics -- Select your Interests
 Accounting
 Anti-trust
 Commercial
 Compliance
 Consumer
 Criminal
 Employment
 Energy
 Environment
 Family
 Finance
 Government
 Healthcare
 Immigration
 Insolvency
 Insurance
 International
 IP
 Law Performance
 Law Practice
 Litigation
 Media & IT
 Privacy
 Real Estate
 Strategy
 Tax
 Technology
 Transport
 Wealth Mgt
Regions
Africa
Asia
Asia Pacific
Australasia
Canada
Caribbean
Europe
European Union
Latin America
Middle East
U.K.
United States
Worldwide Updates
Registration (you must scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions

Mondaq.com (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of www.mondaq.com

To Use Mondaq.com you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.

Disclaimer

The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.

General

Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions