Risk-Adjusted Adherence Measures

PQA announced on Monday that the National Quality Forum has endorsed three PQA risk-adjusted adherence measures. These measures are used in the Centers for Medicare & Medicaid Services (CMS) Medicare Part D Star Ratings Program, and they evaluate adherence to medications for diabetes, hypertension and cholesterol.

The updated measures include a valid risk adjustment methodology for sociodemographic status factors. Accounting for these factors may impact patient health outcomes is important for ensuring that quality measures are applied fairly.

NQF recommends that performance-based measures be risk-adjusted for sociodemographic factors if there is scientific evidence that such factors affect the quality outcome measured. That recommendation is detailed in the Measure Developer Guidebook for Submitting Measures to NQF (PDF), which was last updated in September 2019. NQF’s rationale is supported in part by an earlier technical report: Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors (PDF).

CMS addressed this in the Announcement of Calendar Year (CY) 2021 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies, which was released April 6. On pages 97-98, CMS discussed PQA’s measures and noted NQF’s recent endorsement, saying:

The risk-adjusted adherence measures were endorsed by the National Quality Forum (NQF) in the 2019 Spring cycle (NQF endorsed #0541). CMS will consider implementation of the PQA recommendations in the future for these Star Ratings measures (i.e., for the 2022 measurement year or beyond). Substantive measure changes must be proposed and finalized through rulemaking.

As discussed in the 2020 Call Letter and the April 17, 2019 HPMS memo, UPDATES - 2019 Medicare Part D Patient Safety and Overutilization Monitoring System Reports, CMS included stratifications by age, gender, dual eligibility/LIS status, and disability status in the Medication Adherence Patient Safety Reports to Part D sponsors for the 2019 measurement year.

The majority of commenters strongly supported the risk adjustment for SDS characteristics of the adherence measures. However, commenters have requested more information on how the adherence measures will be risk adjusted and how the changes could impact the Star Ratings. Such details would be provided through the rulemaking process if CMS proposes a rule to add the measure adjustments to the Star Ratings system. CMS will continue to work with the PQA to incorporate the risk adjustment specifications into the adherence measures under development. We appreciate the comments and will consider them as we make decisions about future measures. 

In PQA’s comment letter to CMS on the 2021 Advance Notice, we said we “support CMS considering implementation of PQA’s sociodemographic status (SDS) risk adjustment recommendations for the 2022 measurement year or beyond for PQA’s three adherence measures.” PQA will continue to work with our members and CMS on this issue.

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