Submitted electronically via MMCOcapsmodel@cms.hhs.gov
December 21, 2015
Tim Engelhardt, Director
Medicare-Medicaid Coordination Office
Centers for Medicare and Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244
Re: Medicare-Medicaid Plan Quality Ratings Strategy
Dear Director Engelhardt,
The Center for Medicare Advocacy (Center) greatly appreciates the opportunity to provide comments on the Medicare-Medicaid Plan Quality Ratings Strategy.
The Center, founded in 1986, is a national, non-partisan education and advocacy organization that works to ensure fair access to Medicare and to quality healthcare. We draw upon our direct experience with thousands of individuals and their families to educate policymakers about how their decisions affect the lives of real people. Additionally, we provide legal representation to ensure that beneficiaries receive the health care benefits to which they are legally entitled, and to the quality health care coverage and services they need.
We support and appreciate the Centers for Medicare and Medicaid Services (CMS) and the Medicare-Medicaid Coordination Office (MMCO) efforts to develop a Quality Ratings Strategy for Medicare-Medicaid Plans (MMPs). All consumers should have access to quality information before enrolling in a health care plan and the Quality Ratings Strategy is an important step in cultivating and sharing medical, administrative, and LTSS quality information.
The Center supports the criteria for Medicare-Medicaid Plans (MMPs) “at maturity,” as defined at pages 1-2. However, many of the specific proposals do not reflect or implement these criteria. The Center understands that CMS is using existing measures during an interim period, but urges CMS not to use measures that contradict the criteria, even during an interim period. Flawed interim measures not only give poor and misleading information, but they are also likely to become entrenched and permanent. If CMS cannot identify sufficient measures that meet CMS’s criteria, it may be premature for CMS to publish a comprehensive rating system for Medicare-Medicaid Plans and more appropriate to report a limited number of measures that more fully meet CMS’s criteria.
The criterion calling for validated data is important, but some of the interim measures are not consistent with this criterion. For example, while the Safety of Care Provided domain suggests the inappropriate use of antipsychotic drugs could be considered a possible measure (Safety of Care Provided, page 2), the data would likely be derived from self-reported Long-Term Care Minimum Data Set (MDS) information.
Inaccurate MDS data are the primary reason that nursing homes’ scores on Nursing Home Compare improved so dramatically between 2009 and 2015. CMS’s contractor Abt Associates prepared an analysis, “Six Year Trends from the Nursing Home Compare 5-Star Quality Rating System,” (Sep. 2015), which showed a sharp increase in high star ratings, and a sharp decline for low star ratings, for quality measure ratings between 2009 and 2015, based on self-reported and unaudited resident assessment data:
Slide 15, which includes the following Note, “Note: In February 2015, we reset the quality measure scale, increasing the standard for nursing homes to receive a high rating.”
In contrast, the distribution of health inspection ratings remained constant over the same six-year period:
Slide 13 of Abt PowerPoint.
These official findings are similar to the findings in an investigative report in The New York Times – which led CMS to announce recalibration of the nursing home ratings and a commitment, in the future, to rely less on self-reported measures and more on claims-based measures.
In the interim and at maturity, the Medicare-Medicaid Plan Quality Ratings Strategy should similarly focus on reporting measures and data that are claims-based or otherwise reliable, to the fullest extent possible, and not subject to excessive gaming. If measures are based on self-reported data, CMS must conduct sufficient auditing to assure their accuracy before posting the data as measures.
The domain Community Integration/LTSS focuses on keeping dually eligible beneficiaries out of nursing facilities. This goal is too narrow. There will always be some individuals who will need the level of care that only a nursing facility can legally provide. Measures should not be written in a way that discounts this reality. Plans should not be jeopardized for providing care to people in nursing facilities, if that care is necessary and appropriate and chosen by them.
The Center also recognizes that some people needing residential care will live in congregate care settings other than nursing facilities. While rebalancing the long-term care system to reduce its exclusive reliance on nursing homes is an important goal that both expands beneficiaries’ options (a goal of person-centered and person-directed care) and is strongly favored by many older people, it is also important to assure high quality of care in the “non-nursing home” congregate settings where beneficiaries may live. Moving older people from poor quality nursing homes to poor quality residential care facilities is no improvement; it is a meaningless distraction from the goal of assuring that people receive good care in whatever congregate living setting they choose.
Many dually eligible beneficiaries are currently living in non-nursing home congregate settings. In its June 15, 2015 report, the Assistant Secretary for Planning and Evaluation (ASPE) reported that the National Survey of Residential Care Facilities, which did not include nursing facilities, found, “nearly 20 percent of residents [in residential care facilities] were Medicaid beneficiaries.” 
ASPE reported, “In federal fiscal year 2012, Medicaid LTSS spending was $140 billion, representing 34.1 percent of all Medicaid spending. Expenditures on HCBS – which include those provided in residential care settings – accounted for 49.5 percent of total LTSS spending.”
Although ASPE’s report indicates that many Medicaid beneficiaries receive residential care services, including assisted living services, under Medicaid home and community-based waivers (§1915(c)), §1115 research and demonstration waivers, §1915(b) waivers, and personal care services under state plans, the Medicare-Medicaid Plan Quality Ratings Strategy does not include residential care or assisted living. CMS recognizes that there are no valid, endorsed survey-based measures for outcomes for assisted living or other residential settings. The Center supports CMS in identifying measures that reach this large and growing population of dually-eligible beneficiaries.
The National Core Indicators – Aging and Disability tool is still in early stages of development. Since its focus is assessing state performance and person-centered goals, rather than health and safety, it may not be a sufficient measure, by itself, of the adequacy of the quality of care provided by congregate living facilities other than nursing facilities. 
Management of Chronic Conditions/Health Outcomes
We agree with the measurement vision of this domain. In particular, we strongly support the HOS measurement of improving or maintaining mental health, under the Management of Chronic Conditions domain.
This domain includes two measures related to hospitalization and rehospitalization. The measures need to recognize that many hospitalized patients are called outpatients, even though they may occupy a bed for multiple nights, receiving care and services that are identical to the care and services received by patients who are classified as inpatients. Ignoring outpatient status or observation status for hospitalized patients voids the validity of hospitalization/rehospitalization measures. 
Prevention: Screenings, Tests, and Vaccines
The Center recommends that this domain be expanded to consider measures of broader applicability, such as falls, heart disease, flu vaccines, and screenings for cancers in addition to cervical cancer.
Nursing Home Compare does not include a pneumonia vaccination as a measure; it includes measures for seasonal influenza vaccine and pneumococcal vaccine. It is not clear why CMS is proposing the pneumonia vaccination for Medicare-Medicaid Plans. The flu vaccine is more generally applicable to the nursing home population.
We also recommend adding measures on falls prevention. MMCO might want to consider a measure that was recommended by the NQF MAP Dual Eligible Beneficiary Workgroup in its February 28, 2014 report (NQF Endorsed Measure Number 101). This is a process measure that assesses the following three areas:
- Screening for Future Fall Risk
- Multifactorial Risk Assessment for Falls
- Plan of Care to Prevent Future Falls
While this measure has been primarily used for individuals 65 and older, the NQF Duals Workgroup suggested that this measure be expanded and tested for anyone at risk for falls, including younger individuals with disabilities.
We support measures on pressure ulcers (rate and prevention). While these measures have been used in home health and nursing home settings, they are also relevant to acute and post-acute settings. While a case can be made for inclusion in the area of LTSS quality, they may conceptually fit better in the category of Health Outcomes.
We seek clarification on why Cervical Cancer Screening is listed as the sole cancer screening measure. We are unclear if this would serve as a proxy for other cancer screenings. If not, we urge inclusion of additional cancer screenings in the measure.
Safety of Care Provided
The Center supports use of a measure to reduce inappropriate use of antipsychotic drugs in nursing home residents, but urges CMS to ensure that the measure is sufficiently broad to include (1) both atypical and conventional antipsychotic drugs, (2) drugs given to short-stay and long-stay residents, and (3) drugs given to residents, regardless of the payer (Medicare Part A or Medicare Part D). The different definitions of antipsychotic drug use yield highly varying conclusions about the rate of inappropriate antipsychotic drug use in nursing facilities. The broadest possible definition is appropriate to assure that all inappropriate antipsychotic drug use is recorded and reported.
A critical measure of safety in nursing facilities is nurse staffing levels, particularly registered nurse staffing levels. The Inspector General’s 2014 report documenting adverse events and other harm to Medicare beneficiaries within, on average, 15.5 days of their admission to a skilled nursing facility in August 2011 found nurse staffing failures ("failure by SNF staff to monitor residents or staff delay in providing necessary care") as a key cause. 
CMS is now in the process of developing a payroll-based system, as required by the Affordable Care Act, to replace the self-reported staffing information that nursing facilities provide at the time of the annual survey. A valid nurse staffing measure would give the public important information about the quality of care provided by a nursing facility.
Plan Performance on Administrative Measures
The Center supports the development of measures related to timeliness and accuracy of appeals.
As noted above, the Center urges CMS not to report measures that are based on self-reported, unaudited, and unvalidated data, including the Long-Term Care MDS. It is a disservice to the public to report measures that can be easily gamed by providers and fail to accurately reflect actual performance.
Finally, the Center urges CMS to develop strong regulatory oversight of all health care providers. The reporting of quality measures is a market-based approach to quality assurance. Public reporting does not, by itself, assure quality across-the-board from providers who are reimbursed by the federal government.
Member Experience with Medicare-Medicaid Plan
The QRS draft indicates the Member Experience domain will be comprised of measures based on CAPHS surveys.
This raises concerns as the CAPHS health plan survey is limited to seven domains that omit several essential elements of MMP plan delivery: person centered care planning, access to services without discrimination, and LTSS care coordination.
We are also concerned about the lack of measures relating to nondiscrimination protections in health care programs. The current CAHPS Survey lacks any measures to help CMS understand plan compliance with the ACA’s 1557 nondiscrimination protection. At a minimum, the survey should query the individual on MMP and/or provider discrimination on the basis of race, color national origin, sex, disability or age. To help CMS and consumers understand the MMP’s compliance with 1557 protections, the questions should explore:
- potential MMP and provider communication barriers for people who are limited English proficient;
- potential MMP and provider access and care challenges on the basis of sex, sexual orientation and /or gender identity; and
- potential MMP and provider access and care challenges to people with a disability.
We would like to emphasize the importance of cultural competency in care. The 2012 National HealthCare Disparities Report released by the Agency for Healthcare Research and Quality (AHRQ) found that disadvantaged patients were more likely to receive poor quality care. “We find that racial and ethnic minorities and poor people often face more barriers to care and receive poorer quality of care when they can get it.” 
The IOM Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care had similar findings in its 2002 report regarding lower quality care for low income and minority patients. The report found that several factors may undergird this result, such as language and cultural barriers, potential provider bias, and the possibility that minorities are disproportionately enrolled in lower-cost health plans that place greater per-patient limits on healthcare expenditures and available services. “Three mechanisms might be operative in healthcare disparities from the provider’s side of the exchange: bias (or prejudice) against minorities; greater clinical uncertainty when interacting with minority patients; and beliefs (or stereotypes) held by the provider about the behavior or health of minorities.” Therefore, we urge CMS to recognize that dual eligible enrollees face additional challenges in obtaining high quality care and outcomes. We encourage CMS to consider how plans are addressing these barriers as any new quality rating system is developed. It is essential to examine innovations aimed at countering barriers unique to the duals population in order to accurately reflect the quality of care.
The Center greatly appreciates the opportunity to provide information for this request for information.
Senior Policy Attorney
 Katie Thomas, “Medicare Star Ratings Allow Nursing Homes to Game the System,” The New York Times (Aug. 25, 2014), http://www.nytimes.com/2014/08/25/business/medicare-star-ratings-allow-nursing-homes-to-game-the-system.html
CMS, “CMS Announces Two Medicare Quality Improvement Initiatives” (News Release, Oct. 6, 2014), http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-10-06.html. The recalibration led to the changes in July 2015 in Slide 15.
 Paula Carder, PhD, Janet O'Keeffe, Dr.PH, RN, and Christine O'Keeffe, RTI International, Compendium of Residential Care and Assisted Living Regulations and Policy: 2015 Edition, https://aspe.hhs.gov/basic-report/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition#public.
 See Center for Medicare Advocacy, https://www.medicareadvocacy.org/?s=observation+status&op.x=0&op.y=0.
See Center for Medicare Advocacy, “Antipsychotic Drugs and Nursing Home Residents: What Do the Different Numbers Mean?”, CMA Alert (Mar. 12, 2015), https://www.medicareadvocacy.org/antipsychotic-drugs-and-nursing-home-residents-what-do-the-different-numbers-mean/.
 Inspector General, Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries, OEI-06-11-00370, page 28 (Feb. 2014, http://oig.hhs.gov/oei/reports/oei-06-11-00370.pdf.
 Medicare Advantage and Prescription Drug Plan CAHPS Survey, About the Survey, available at: http://ma-pdpcahps.org/content/homepage.aspx.
 National Healthcare Disparities Report, Agency for Healthcare Research and Quality (last modified Nov. 3, 2014), available at http://www.ahrq.gov/research/findings/nhqrdr/nhdr12/highlights.html.
Unequal Treatment: What Healthcare Providers Need to Know About Racial and Ethnic Disparities in Healthcare, Institute of Medicine 1 (March 2002), https://www.iom.edu/~/media/Files/Report%20Files/2003/Unequal-Treatment-Confronting-Racial-and-Ethnic-Disparities-in-Health-Care/Disparitieshcproviders8pgFINAL.pdf.
 Id. at 3.