What to Expect from CMS in 2024

As the healthcare industry continues evolving and keeping pace with changing attitudes toward health and wellness, the Centers for Medicare and Medicaid Services (CMS) has shifted its focus toward Social Determinants of Health (SDoH) and associated care costs to address population health.

This seismic industry shift will have far-reaching implications for healthcare providers of all sizes. Although these changes are merely anticipated at this time, it is typical for CMS to adopt them, especially given the significant scale of the anticipated amendments. 

What are Social Determinants of Health (SDoH)?

The Centers for Disease Control and Prevention (CDC) defines social determinants of health as “conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes.” 

These conditions have real-life consequences, as they can affect the health outcomes of a wide swath of any given population at any given time. 

CMS has renewed its focus on adopting an equity-based treatment model to address the shortcomings of existing policies, programs, and procedures that create roadblocks for underserved populations nationally.

What you should anticipate in 2024

Starting in January 2024, CMS will significantly change to the following:

  1. Hierarchical Condition Categories (HCCs) model
  2. Star Rating System
  3. Healthcare Effectiveness Data and Information Set (HEDIS)

These changes will impact the current systems in place at the CMS, and patients can expect higher quality healthcare as a result.

Definition of Hierarchical Condition Categories (HCC)?

HCCs are sets of medical codes that link to specific clinical diagnoses and have been used by the CMS since 2004 as part of a risk-adjustment model. The model identifies individuals with serious acute or chronic conditions to project the expected risk and future annual cost of care. 

They are commonly used to calculate payments to healthcare organizations for patients insured by Medicare Advantage, Accountable Care Organizations, Affordable Care Act coverage and more.  

How is the Star Rating System measured?

The Star rating system measures the experiences Medicare beneficiaries have with both their health plan and the healthcare system. 

What is a Healthcare Effectiveness Data and Information Set (HEDIS)

Developed by the National Committee for Quality Assurance (NCQA), the Healthcare Effectiveness Data and Information Set (HEDIS) is a comprehensive set of standardized performance measures in the managed care industry.

According to NCQA, over 200 million people are enrolled in plans that report HEDIS results, making it one of health care’s most widely used performance improvement tools. 

CMS Proposed 2024 Changes

To summarize the changes proposed for 2024, CMS has added 29 HCCs and has removed 2,027 diagnoses that map to HCCs. 

Additionally, all Disease Management (DM) will map to one diagnosis and manifestation(s) will not need to be spelled out, all coefficients are changed, and HEDIS will include a two-part SDoH screen. 

The HCCs removed from the list are as follows:

  • Protein-Calorie Malnutrition, Cachexia
  • Angina Pectoris (unstable only)
  • Atherosclerosis of Arteries of the Extremities, with Intermittent Claudication (PAD)
  • Aortic Atherosclerosis, AAA, TAA, Renal Artery, Ecstasia
  • Sickle Cell Trait
  • Chemo-Induced Pancytopenia
  • Thrombocytopenia
  • Neutropenia
  • Immunodeficiency 2/2 Drugs, External Causes (Radiation), DS Elsewhere (RA, SLE)
  • Sarcoidosis of Lung
  • Hyperparathyroidism, Adrenal
  • Drug-Induced Neuropathy, Radiation, and ETOH Neuropathy
  • Cardiomyopathy 2/2 Drug
  • Sjorgen’s, PR, Inflammatory Spondylopathy
  • Amputation of Toes
  • No HD, PD

Patients and healthcare providers can both expect increased transparency from CMS, an equity-based operation model nationwide, and higher quality health outcomes. 

Full list of proposed 2024 changes are available in the CMS Advance Notice of Methodological Changes for Calendar Year (CY) 2024 for Medicare Advantage.

For more in-depth guidance on how these proposed changes may affect your business, reach out to Harmony Healthcare today.

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