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    AAFP Says Proposed Core Set Requirement Must Not Add Burden

    Practices Seeing Medicaid, CHIP Patients Would Be Affected

    October 24, 2022, 5:33 p.m. News Staff — The AAFP is calling on CMS to consider the already high administrative pressures physicians face ahead of new rule-making that would govern core set measurement. 

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    The proposed rule would require states and territories to report annually on the Child Core, Health Home and certain adult behavioral health core set measures. Its mandate could provide meaningful data and quality metrics to inform future practice enhancements, but it also has strong potential to negatively affect clinicians, the AAFP reminded CMS in its Oct. 6 letter.

    “The AAFP urges CMS to consider the impact of these proposals on the clinicians caring for Medicaid and CHIP beneficiaries and ensure the final regulations do not worsen their administrative workload,” the Academy wrote. “Previous experience indicates that state Medicaid agencies and managed care plans will pass on quality measure reporting requirements to participating clinicians. Family physicians continue to cite administrative burdens as their biggest challenge, with quality measure reporting being one major contributor.”

    Instead, CMS could use the new rule to “meaningfully streamline administrative requirements by aligning quality measures across payers,” the AAFP said, adding that family medicine practices contract with an average of 10 payers each. “Keeping track of and successfully reporting different measures for each of these payers creates confusion and additional reporting burden and can actually undermine meaningful practice improvements.

    “Aligning measures across payers will also help to identify disparities in care quality (and, in some cases, utilization and access) across different payers, states and lines of service. Greater alignment will also drive improvements in data collection automation, which will reduce reporting burden on family physicians and other clinicians. Primary care practices should not have to spend their limited resources tracking down data in order to provide what is required for a state Medicaid agency to report on the core measures.”

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    Responding to the proposed rule’s plan to phase in survey measures, the Academy voiced strong support for adding the Person-Centered Primary Care Patient Reported Outcome Performance Measure to the Adult and Child Core Sets. That 11-item, patient-reported assessment — endorsed by the National Quality Forum in 2021 and now available as a quality measure in the Merit-based Incentive Payment System — focuses on accessibility, continuity, comprehensiveness, coordination, advocacy, family and community context and goal-oriented care, among other data the AAFP said are “valued by patients and physicians and unique to primary care.” Adopting the PCPCM PRO-PM would improve evaluation of certain primary care elements “associated with better population health, lower costs, equity and higher quality,” the letter said.

    The Academy was responding to a proposed rule (“Mandatory Medicaid and Children’s Health Insurance Program [CHIP] Core Set Reporting,” published Aug. 22 in the Federal Register) that reflects guidance the AAFP shared with CMS earlier this year. The AAFP’s April letter pointed out that requiring states to annually report performance on a standardized set of measures was likely to “advance CMS’ and the AAFP’s shared goals of improving access to person-centered care and advancing health equity in Medicaid and CHIP.”

    Under the rule proposed in August, CMS would provide annual guidance to Medicaid agencies to set attribution rules, requirements for stratifications across demographic characteristics and delivery types, and other issues. States would be required to submit stratified data for 25% of the measures on each of the required core sets by the second year of annual reporting, 50% of measures for the third and fourth years, then 100% of measures beginning in the fifth year of reporting.

    “The AAFP supports the requirement for states to stratify certain measures by demographics, delivery types and other characteristics to enable better care comparisons and identification of health disparities,” the October letter said.

    After annual Core Set reporting and stratification commence, the letter added, CMS should “assist states in using these data to identify and address health disparities among their Medicaid and CHIP beneficiaries” and “require states to submit plans for mitigating persistent disparities and regularly report on their progress to close access and quality gaps for beneficiaries of color, those with limited English proficiency, LGBTQ+ beneficiaries and other populations experiencing systemic barriers to care.” The Academy further recommended that the agency “pursue strategies for supporting states in these efforts,” reiterating its April advocacy.

    In line with the Academy’s work to improve behavioral health care integration for primary care practices, the letter also expressed support for the proposed rule’s required reporting of behavioral health measures but reminded regulators that the existing behavioral health care infrastructure, including a lean workforce, demands improvement.

    Primary care practices treating a high proportion of Medicaid beneficiaries “often operate on thin financial margins and do not have the capital they need to hire behavioral health professionals or invest in tools and trainings to meet their patients’ behavioral health needs,” the letter said. “Existing fee-for-service payment systems do not sufficiently support behavioral health integration in the primary care setting. Further, primary care practices are generally not equipped to treat serious mental illness, and ongoing behavioral health workforce shortages make referrals to other mental health professionals difficult and often untimely.” Taken together, the letter warned, these barriers “are likely to create challenges for states in reporting or demonstrating progress on behavioral health access and outcomes.”

    “Meaningful improvements in behavioral health outcomes will require additional investments from state and federal policymakers. Primary care practices should not be penalized by state Medicaid agencies, managed care plans or other stakeholders for these systemic failures.”

    Additionally, the Academy said CMS should

    • ensure that Core Sets are streamlined to reduce duplicative reporting and “focus on aspects of health care that are important to patients,”
    • align the Medicaid and CHIP Core Sets with the Core Quality Measures Collaborative Core Measure Sets
    • remove measures that have lost the National Quality Forum’s endorsement, and
    • ensure that the standardized measurement “motivates or incentivizes positive change in health care delivery to improve outcomes.”