The Stars Impact of the CY 2021 Advance Notice (Part II) and the CY 2021 Proposed Rule

The Stars Impact of the CY 2021 Advance Notice (Part II) and the CY 2021 Proposed Rule

On February 5th, CMS released the Advance Notice of Methodological Changes for Calendar Year (CY) 2021 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies – Part II (referred to as Advance Notice, going forward). The entire 83-page document includes important information for Medicare Advantage plans across a variety of topics. This paper will focus solely on the impact on Star Ratings. There is typically a “Draft Call Letter” attached. This year, CMS did not release a call letter, but all of the changes are communicated through the Advance Notice itself.

On the same day, CMS released the Contract Year 2021 and 2022 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicaid Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (referred to as CY 2021 Proposed Rule, going forward). Like the Advance notice, the entire 895-page document includes an enormous amount of valuable MA proposed changes, but this paper will focus solely on the impact on Star Ratings.

This paper summarizes the key points but does not yet dig into the ultimate ramifications of some of these proposed changes, which are still being explored.

Comments on the Advance Notice are due to CMS on March 6th. Comments on the Proposed Rule are due to CMS by April 6th. Please take advantage of your opportunity to influence the future of Stars.

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For simplicity, I’ll break it down by Star Rating year, combining key changes we already knew and proposed changes that were just released. I’ll distinguish between the two. And please realize this is just key changes to Stars, in my opinion. There are many, many pages in the actual documents that need reviewed in their entirety by your organizations.

2021 Stars

Expected/Known

No new measures

CBP on Display (year 2 of 2)

PCR moving to Display (year 1 of 2)

  • PCR also obviously not included in Improvement Measure calculation

Member Experience measures moving from weight of 1.5x to weight of 2x

  • All non-Flu CAHPS measures, Disenrollment, Appeals, Call Center, and Complaints measures

Newly Proposed

SUPD will increase to a weight of 3x for 2021 (and presumably 2022 Stars)

Reviewing Appeals Decisions – CMS now allowing re-openings through June 30

CMS encouraging plans to use and reference digital specifications for HEDIS measures

Some HEDIS measures now allow data from patient-used devices to fulfill numerators (such as home BP machines)

2019 saw only one natural disaster impacting Stars (Puerto Rico earthquake, 12/28/2019), compared to 2018 which included an earthquake, wildfires, a typhoon, and two hurricanes.

New on Display Page (definite future Stars candidates)

  • Concurrent Use of Opioids and Benzodiazepines (COB)
  • Use of Opioids at High Dosage in Persons Without Cancer (OHD)
  • Use of Opioids from Multiple Providers in Persons Without Cancer (OMP)
  • Use of Opioids at High Dosage and from Multiple Providers in Persons Without Cancer (OHDMP)

Updates to other Display measures

  • Antipsychotic Use in Persons with Dementia Overall (APD)
  • Antipsychotic Use in Persons with Dementia, for Community-only Residents (APD-COMM)
  • Antipsychotic Use in Persons with Dementia, for Long-term Nursing Home Residents (APD-LTNH)


2022 Stars

Expected/Known

CBP returning with initial weight of 1x

PCR still on Display (year 2 of 2)

BMI, Appeals Auto-Forward, and Appeals Upheld officially retire from Stars

New mean resampling & guardrails apply to cut-points

Newly Proposed

SUPD will increase to a weight of 3x for 2021 (and presumably 2022 Stars)

Important tweaks to Transitions of Care (still on Display page)

Important tweaks to the CBP denominator

Important changes to COA – Functional Status Assessment Indicator

  • Would move to Display for 2022 and 2023 Stars

New HEDIS cross-cutting exclusions

  • Affecting members who require nursing home level care but do not reside in one
  • Affecting members receiving palliative care

Reevaluation of the Initiation and Engagement of Alcohol and Other Drug Abuse and Dependence Treatment measure

  • No indication of future inclusion in Stars

Updates to Hospitalization for Potentially Preventable Complications

  • No indication of future inclusion in Stars


2023 Stars

Expected/Known

PCR returning with initial weight of 1x

CBP weight increasing back to 3x

Newly Proposed

Adding Transitions of Care (HEDIS) as a new official Stars measure

Adding Follow-Up after Emergency Department Visit for Patients with Multiple Chronic Conditions (HEDIS) as a new official Stars measures

Member Experience measures moving from weight of 2x to weight of 4x

  • All non-Flu CAHPS measures, Disenrollment, Appeals, Call Center, and Complaints measures

Removing the Rheumatoid Arthritis measure from Stars

In addition to the mean resampling and guardrails, cut-points would also apply Tukey outer fence outlier deletion, a method of removing outliers that would result in higher 1 and 2 Star thresholds and, combined with the 5% guardrails, would result in 16% of MA contracts decreasing by half a Star (and one contract decreasing by a full Star)

  • Would result in reduced QBP payments of $1.5 billion by 2030

Reclassifying SUPD as a process measure to justify the weight of 1x (will still be 3x for 2021 and presumably 2022 Stars; returning to weight of 1x for 2023 Stars and forward)

Changes to the two 3x-weighted HOS measures (Improving or Maintaining Physical Health; Improving or Maintaining Mental Health)

  • Changing the case mix adjustment methodology to mirror CAHPS
  • Increasing the minimum denominator from 30 to 100

Contract consolidations

  • New rules for when measure scores are missing from either the consumed or surviving contract

Disasters

  • Changes proposed regarding such topics as missing data and the impact of a contract being affected in multiple years by natural disasters

QBP Payments

  • Changes proposed, primarily regarding how QBPs apply to new MA contracts

Important changes to COA – Functional Status Assessment Indicator

  • Would move to Display for 2022 and 2023 Stars

Retiring Osteoporosis Testing in Older Women from Display Page


2024 Stars

Expected/Known

PCR weight increasing back to 3x

Newly Proposed

Proposing that all three Medication Adherence measures are risk adjusted for socioeconomic status (SES) or sociodemographic status (SDS)


Potential New Measure Concepts

ESRD

  • Proposing other measures to replace Diabetes Care – Kidney Disease Monitoring

CMS asking for feedback on including Prior Authorizations as future Stars measure

New HOS measure going on 2021 Display

  • Physical Functioning Activities of Daily Living (PFADL)

Potentially expanding existing HOS measures to under 65 population

Osteoporosis Screening measure (Potential HEDIS measure for CY 2020)

Cardiac Rehabilitation (Potential HEDIS measure for CY 2020)

Diabetes Overtreatment (Potential HEDIS measure for CY 2021)

Home Health Services (Potential HEDIS measure for CY 2021)

Generic Utilization

  • CMS desires to reward plans for high rates of generic utilization

Initial Opioid Prescribing (IOP) measures

  • Initial Opioid Prescribing at High Dosage (IOP-HD) (Still being analyzed)
  • Initial Opioid Prescribing for Long Duration (IOP-LD) (CMS plans to begin reporting this measure on Display for 2023 Stars)
  • Initial Opioid Prescribing for Long-Acting or Extended Release Opioids (IOP-LA) (Still being analyzed)

Net Promoter Score (NPS)

  • CMS considering adding NPS question to CAHPS to include in Stars
Sujata Bajaj

Chief Technology Officer @ Yuvo | Tech enabled value based care start up, ACO, Medicare, Medicaid, ACA

4y

Very useful intel Rex!

Elizabeth Haynes

Executive in Quality, Stars, and Risk Adjustment | Government Programs | Leader | Mentor | Healthcare | CAHPS & Member Experience | Process Improvement

4y

Rex this was a great recap!! Thank you very much!!

Rex Wallace

Founder and CEO, Rex Wallace Consulting, LLC | Quality Improvement Consultant | Host, Rising Stars Podcast

4y

Someone just pointed out an important clarification that was not clear in my debrief. Though the SUPD measure is being reclassified as a process measure (and 1x weight) for 2023 Stars and forward, CMS had already determined to make it a 3x intermediate outcome measure for 2021 Stars (and I assume 2022 Stars). From page 158 of the proposed rule...

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Caroline Spencer

Vice President of Operations at Texas Independence Health Plan

4y

Thank you, Rex!

Kelvin Wursten

Vice President, Business Operations & Data Science at PointClickCare

4y

Thanks Rex!

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