What’s New in CMS Quality Programs

The 2022 PQA Annual Meeting hosted a general session to discuss recent changes across Centers for Medicare & Medicaid (CMS) quality programs and future implications.   

The May 4 session, “What’s New in CMS Quality Program,” welcomed Sharon Jhawar, PharmD, MBS, Chief Pharmacy Officer of SCAN Health Plan; Chris Powers, PharmD, Vice President of Part D Stars at Cigna; and Nate Lucena, MA. Rex Wallace, Principal of Rex Wallace Consulting LLC, and Mick Twomey, CEO of Hyperlift Logic, moderated this session.  

The panel focused on the April 29, 2022, CMS final rule announcement, which will apply the Tukey method and affect Star Rating cutoff points. Jhawar predicts alternate performance programs, such as bonus pools or health plan outcomes programs, will emerge. Some beneficiaries may need to change their pharmacy to continue getting lower co-pays.  

Powers concurred, adding that CMS will consider star ratings when they look at past performance. Plans performing at 2.5 stars or less will be penalized for past performance, reducing their ability to expand. Lucina expands that the new methodological change can impact the current star ratings of health plans based on past performance and predicts more plans will be rated lower after the final rule goes into effect. Twomey agreed that all plans would be affected. 

The panel agreed that mitigating strategies would be crucial to balance the drop in star ratings to help organizations maintain a positive rating. While CMS has guard rails to stabilize cutoff points, they predict the shift may be more than 5% in either direction annually. Wallace expects these changes to be more predictable in the long-term but could be dramatic in the first year. CMS estimates that by the end of 2024, the program will save approximately $935,000,000.  

The group anticipates that patient care measures will have more weight after CMS implements the Tukey method. Jhawar recommends bolstering patient care measures through collaboration with medical groups, member outreach and assistance with empathy and expertise. Powers suggests looking at patient experience data holistically to identify system-wide issues. He cautions against overweighting patient experience measures over clinical outcomes and advocates for a balance.  

Additionally, the final rule will require stratified reporting on members race and language data to address healthy inequities. Jhawar detailed the SCAN Health Plan program, which analyzed measure data by race and identified that Black and Latinx members had 3-5% lower adherence than white counterparts. She elaborated that SCAN Health Plan “tied our energy to every employee’s compensation last year to reduce that inequity.” She and Powers advocate for expansion and proactive utilization of translator services for members.  

The panel agreed that pharmacies are critical to gather data on social determinants of health (SDOH) as one of the most frequent touch points for patients in the healthcare system. Lucina expands that understanding health equity and SDOH as a framework will help drive the “right initiative in the right location at the right time to impact that disparity.” Jhawar concludes that the solutions are not systematic but instead will require more time, energy and creativity.  

You can listen to the full recording of this general session from the 2022 PQA Annual Meeting at the Rising Stars Podcast YouTube Channel.   

Fay Hussain, a Class of 2024 Doctor of Pharmacy student from the University of South Carolina, is a PQA Summer Executive Intern sponsored by Pharmacy Quality Solutions. 

Share this post:

Comments on "What’s New in CMS Quality Programs "

Comments 0-5 of 0

Please login to comment