CMS Advance Notice: A Clinical Perspective

CMS Advance Notice: A Clinical Perspective

The Centers for Medicare & Medicaid Services (CMS) has had a busy 2023 already with a flurry of regulatory activity. We saw the CMS RADV Final rule published on Jan 30, 2023 and the CMS Advance Notice for PY 2024 published on February 1st, 2023. Impact to risk adjustment and quality programs were minimal in the past few releases of the CMS Advance Notice, however the CY 2024 Notice has proposed changes to the risk adjustment model. The agency estimates this will lead to a 3.12% reduction to 2024 payments when combined with other changes.

While our recent blog on the RADV Final Rule provides details, impact, and what to do next, this memorandum will help you understand the proposed changes in the Advance Notice for both Risk Adjustment and Quality programs for a MA plan.

Risk Adjustment Changes 

The following provides a high-level overview of the proposed model for Part C:

  • V28 has a total of 115 payment HCCs with 7,770 ICD-10 diagnoses codes mapped to these HCCs. Compare that to V24, which has 86 payment HCCs and 9,797 ICD-10 diagnoses codes mapped.

  • Some of the HCCs in the V28 model are renumbered. In part, this reflects how there is an increase in the number of HCCs in the proposed model relative to the current model due to newly-created HCCs and the splitting of existing HCCs.

  • Revisions in MV 28 are based on the Principle 10 that is used as part of the standard evaluation of all risk adjustment models:
    Principle 10 – Discretionary diagnostic categories should be excluded from payment models. Diagnoses that are particularly subject to intentional or unintentional discretionary coding variation or inappropriate coding by health plans/providers, or that are not clinically or empirically credible as cost predictors, should not increase cost predictions. Excluding these diagnoses reduces the sensitivity of the model to coding variation and coding proliferation.

  • HCC constraints (i.e., hold the coefficients of the HCCs equal such that each HCC carries the same weight) applied to:

    • Constrained all Diabetes HCCs (HCC 36, 37, and 38)
    • Constrained Congestive Heart Failure HCCs (HCCs 224, 225, and 226) with no immediate impact as all relevant diagnosis codes map to the same set of HCCs

  • Changes at HCC Level

    • Certain HCCs have been removed:

      • HCC 47 Protein-Calorie Malnutrition
      • HCC 230 Angina Pectoris
      • HCC 265 Atherosclerosis of Arteries of the Extremities, with Intermittent
      • Claudication
      • HCC 176 Complications of specified implanted device

    • Splitting out Congestive Heart Failure into:

      • Cardiomyopathy / Myocarditis
      • Heart Failure (3 HCCs, all same coefficient for now)
      • End-Stage Heart Failure or Heart Failure w/ Heart Assist Device

    • Adding severe persistent asthma to the Lung Disease Group

    • Peripheral Vascular and Arterial Diseases no longer hold value as they previously mapped to HCC 108 Vascular Disease.

    • Major Depressive Disorder, previously mapping V24 HCC59 have diagnoses codes that no longer maps to an HCC.

Quality and STAR Ratings

  • Star Ratings measures and its focus are undergoing significant changes annually:

    • Universal Foundation

    • Continue adding and updating measures:

      • REVISE:  Breast Cancer Screening (Part C)
      • REMOVE:  Care for Older Adults (COA) – Pain Assessment
      • REVISE:  Diabetes Care – Eye exam and Blood Sugar Controlled (Part C)
      • REMOVE:  NCQA is considering potential removal of HYBRID reporting for MY 2024 and beyond
      • ADD:  NCQA is considering incorporating Glucose Management Indicator (GMI) to assess compliance
      • REVISE:  Statin Use in Persons with Diabetes (SUPD) (Part D)
      • REVISE:  Non-Substantive adherence measures to fully align with PQA
      • REVISE:  Medication Adherence for Diabetes Medication/Medication Adherence for Hypertension (RAS Antagonists)/ Medication Adherence for Cholesterol (Statins) (Part D)

    • Health Equity Index Reward

    • Aligning with NCQA, PQA, and AIR

  • Increased focus to move to digital measures and simplified reporting and reduction of chart review measures.

Advantmed Analysis 

Based on the Advantmed team’s analysis with this new model, CMS is providing an opportunity for MA plans to plan ahead for care management programs as opposed to diagnosis capture – for ex: Managing Diabetes programs to make up for the difference in the loss of the specificity of the HCCs. We also performed specific analysis on certain HCCs or diagnoses codes that were no longer mapped – for example: 90% of members with Vascular Disease (V24 HCC 108) have a diagnosis that no longer maps to an HCC and 50% of members with Major Depressive Disorder (V24 HCC 59) have a diagnosis that no longer maps to an HCC.

The proposed model changes should not affect the type of visit (i.e., telehealth versus face-to-face assessments) since, clinically, the supportive criteria of capturing the diagnosis maintains the same. Although overall the HCCs collected during an in-home assessment are more supported, there are a few exceptions with the limitations of the practitioner to assess them. This includes morbid obesity (if the member has no access to a scale during a telehealth visit), Congestive heart failure (due to the lack of auscultation of heart sounds and inability to test for some of the main symptoms such as pitting edema), and COPD (due to the lack of auscultation of the lungs and inability to perform the spirometry during telehealth). Despite these limitations, the majority of the other HCCs captured during telehealth appointments can still be well supported through the interactive video and audio forum. 

There is a significant opportunity to mitigate any negative impact of the model by preparing ahead through better care coordination, focused programs, and care management.

Keep an eye out for our update following the CMS Announcement on April 3rd, 2023.