National Committee for Quality Assurance: CMS star ratings changes may cause 'incredible volatility' 

Frank Micciche is vice president of public policy and external relations at the National Committee for Quality Assurance. He spoke with Becker's to explain why the NCQA believes recent star ratings changes by CMS to the weighting of patient experience measures could have a negative affect on healthcare quality.

Question: This week, CMS released its final 2023 Medicare Advantage capitation and Part C and D rate announcement. What type of effect do you believe the changes to star ratings to more heavily weight patient experiences is going to have?

Frank Micciche: Patient experience is a hugely important factor in determining quality of care. However, we're concerned at the magnitude of the increase in the weighting going from what was 1.5 back in 2018 to four now for 2023. That's a huge jump in the weight of these measures. Medicare stars is a pretty efficient machine, meaning when they incentivize behavior by increasing weighting (and as a result put more money behind performance in those measures), they get the focus and attention and efforts of plans. All of which is good. It's actually a very functional use of incentives, as long as the incentives are right and they're balanced appropriately. That's our concern. Again, patient experience is important. Access measures, which are also weighted at four now, are important. But the attention and time and human capital of the plans is a relatively fixed asset, and it's a zero sum game. So if they are now paying twice as much attention, and the math doesn't work out quite that easily, to patient experience and access measures than they were previously, that attention comes from somewhere. We believe it's going to come from what are very important measures in the clinical area, including what's called process measures and also intermediate outcome measures.

Q: America's Health Insurance Plans released a brief this week that said CMS should maintain the weighting of patient experiences and access measures at two. Do you agree with that?

FM: Yes, that is a very reasonable proposition. It has worked previously. And it avoids exactly what I was describing, which is not only a decrease in attention to the other important measures, but also this incredible volatility. The effect will be that you may see dramatic swings in ratings and stars, based on the fact that these patient experience measures now have such weight. We stand arm and arm with AHIP on the idea of maintaining the patient experience and access measures at a two.

Q: Do you believe that CMS should extend its pandemic disaster relief policies to all measures for this year's ratings?

FM: That's a really difficult question. I think there are certainly plans and measured areas that can make a case for extending those provisions. Even as we see what may be a recent increase in COVID-19, we (the culture at large and the plans in this context of ratings), have to get to that point where we live with COVID. I would hope we're there for the most part, and anything that extends these extraordinary measures to account for all of the very legitimate concerns around COVID and the effect on plans and performance — there has to be an endpoint. It doesn't mean COVID is over, it just means we've adapted and accommodated our measures to reflect the reality of the, if not post-COVID, the late-COVID realities. I'd be reluctant to have a blanket policy that says we're going to extend all those provisions.

Q: Do you agree with CMS deciding to share their stratified Part C and D report going forward?

FM: I think in general transparency is a positive thing; it's certainly a principle we live by at NCQA. While there may be arguments by others that there might be some sort of competitive advantage that's given through this or that intellectual property is being shared, in general, if they have information on the quality of these plans that is of value to consumers and to payers, they should share it.

Q: Final thoughts?

FM: If one believes that patient experience and access measures should be doubled in weighting, and we don't obviously, this is a particularly inopportune time to be making that shift. I say that because the performance they're measuring, and the conditions under which they're measuring it are, to say the least, unique. While the system is beginning to accommodate all of the craziness around COVID, it is a very unstable time. Even the best of plans and systems and providers are facing challenges that they never imagined previously. That's going to have an impact on patient experience and access. It may also have a legitimate impact on the perception of patients as to their experience. I don't know that this is the time to add a ton of weighting in that area. Ideally, if we are in fact coming to the post-pandemic period, or maybe the endemic period of this disease, maybe we need to wait a little longer before we implement these kinds of changes. We don't support the change in general, but certainly the timing I think is even more problematic or adds to the problematic nature of this change. I think the other aspect of this is to see what performance on the clinical measures — if they are (and they are) going to lose proportional value compared to patient experience and access, what's the effect on the loss of that value? Will we see poor performance in those areas? The next logical question is, what's the effect of that poor performance? We would suggest it's significant, because those measures really do ensure that the right things are being done at the right time for the right conditions. That's the bread and butter of high-quality care.

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