In early April, the Center for Medicaid and Medicare Services shared its Announcement for Medicare Advantage Part C and D plans, incorporating feedback solicited after an Advance Notice was issued in February 2022. Overall, not much has changed since the Advance Notice, however CMS addressed the comments issued by Medicare Advantage stakeholders like MA organizations and prescription drug plan sponsors.

Tori Erxleben Rush, PharmD, Director of Clinical Pharmacy Programs for Mosaic Pharmacy, has reviewed the report and identified three major takeaways from this recent change from CMS:

Efforts to Drive Health Equity

There has been a strong push for increased transparency and equity across all aspects of the healthcare system. Now, CMS seeks to take on these inequities by incorporating policies that emphasize equity in the performance measurement of Medicare Advantage Part C and Part D plans.

CMS reported that there was unanimous support for their efforts to advance equity, and many respondents supported the proposal to bridge the equity gap through future reporting stratification in the Star Ratings program. With stratified reporting, Medicare plans can review quality rating performance by various demographics and patient populations, highlighting potential inequities.

Further, due to a lack of comprehensive SDoH data, CMS proposed using administrative data (e.g., an annual beneficiary self-attestation during enrollment) or a national-level data set already in existence. This effort aims to limit the possibility that organizations will attempt to game the system, which would hinder progress toward health equity. Yet, there are concerns with this method in terms of timing and availability, as national-level datasets can quickly become outdated.

Many respondents supported the Health Equity Index that is being developed by CMS for Star Ratings in risk adjustment, but this method, as well as others mentioned for the procurement of national data, comes with burdensome rollout processes and administrative delays.

The biggest consensus among CMS and stakeholders is the need for additional screening measures for potential social barriers to coverage and care. The screenings are already being implemented, but further screening is needed before any noted health inequities can be addressed.

Risk Adjustment for Adherence Measures

CMS has been testing risk adjustment methodology to account for socioeconomic status and sociodemographic status in medication adherence since 2021. This methodology is in accordance with the PQA measure specifications that were endorsed by the National Quality Forum and recommend all adherence measures be risk adjusted as well as adjusted for age, gender, low-income subsidy status and disability status.

In addition, CMS stated these measures are stratified in the Patient Safety Reports by the beneficiary-level sociodemographic status to allow health plans to identify inequities and understand how differences in patient populations affect their measure performance.

Most stakeholders agree with adjustments for sociodemographic status. However, many expressed concern for how this may impact the Categorical Adjustment Index and potential redundancy that would come as a result of this change. In addition, there was concern over removing inpatient and skilled nursing facility stays from the measurement because of the way it would affect adherence calculations for health plans.

More information will be needed before these changes are made, and CMS must ensure these adjustments allow plans to accurately manage adherence levels of entire patient populations.

Persistence to Basal Insulin

PQA has developed a new measure, Persistence to Basal Insulin, to address the lack of quality measures to assess patients with insulin-dependent diabetes in measurement programs. This measure calculates the adherence rates among diabetic patients, and was tested in 2020 in accordance with PQA’s proposed measurements of continuous enrollment.

There is general agreement about the use of this measure in Part D plans; however, there are concerns about the measure’s methodology since insulin therapy is complex and responses to insulin treatment can vary.

Further tests are in place so CMS can accurately define the best way to account for measurements of persistence to insulin. It will likely take these tests and additional vetting before this measure will be considered for Star Ratings.