Medicare Advantage Star Ratings

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1 Medicare Advantage Star Ratings December 2017 The Star Rating System measures how well Medicare Advantage (MA) and its prescription drug plans perform for consumers. As an integrated health system, Presbyterian proactively manages quality improvement projects and initiatives that directly impact MA Star measures and the resulting ratings. The Essentials The MA Star Rating is a reflection of the quality of care provided to Medicare Advantage members. The quality bonus payment awarded for a MA Star Rating of 4.0 or higher depends on the overall collective Star Rating calculated from as many as 44 measures. The bonus payment can be significant and is used to further improve members care. Presbyterian Health Plan (PHP) monitors each of the MA Star measures and collaborates with care teams in Presbyterian Delivery System (PDS) as well as community Providers to address gaps in care with their Medicare patients. Success and Impact In 2016, Presbyterian received an MA Star Rating of 4.5 for PHP s Presbyterian Senior Care (HMO) plan, which resulted in a quality bonus payment. While the MA Star Rating for 2017 dipped to 3.50, it improved to 4.0 for 2018, which will impact revenue in (See page 8 for trends in Presbyterian s MA Star Ratings.) What We Know About Medicare Star Rating System The Medicare Advantage (MA) program gives Medicare beneficiaries the option to enroll in a private health plan rather than receiving benefits in the traditional fee-for-service (FFS) system. Virtually all beneficiaries have access to such plans and may enroll when newly eligible for Medicare or during an open enrollment period. Every year the Centers for Medicare & Medicaid Services (CMS) publish Star Ratings as an evaluation of quality and service of MA and prescription drug plans. These ratings are meant to assist beneficiaries in choosing the best plan for them, as well as to award additional payments to plans that meet high standards. These payments are used by plans to provide additional benefits to members or to reduce cost sharing which may then factor into a beneficiary s choice of MA plans. The Star Ratings program is also meant to drive improvements in the quality of plans. As a result, CMS continues to see increases in the number of Medicare beneficiaries enrolled in high-performing MA plans. For more information, contact: Furthermore, CMS has extended Star Ratings to hospitals, nursing homes, and dialysis facilities, to support improvement in the quality of care provided by those facilities. The focus of this summary is on Star Ratings awarded to the Medicare Advantage Organization (MAO), which administers one or more MA contracts. Tom Rothfeld, MD VP, Chief Medical Officer, PHP trothfeld@phs.org Beth Tibbs Chief Operating Officer, PMG etibbs@phs.org 2017 Presbyterian Healthcare Services 1

2 Medicare Advantage contracts with prescription drug coverage (MA-PD) are rated on as many as 44 unique quality and performance measures. These measures span five broad categories including outcomes, intermediate outcomes, patient experience, access, and process. Measures are categorized and weighted. Altogether, the weighted measures are used to calculate a relative quality score using a 5-star rating system, with 5 being the highest and 1 being the lowest score Figure 1. Average Star Ratings for MA-PD Contracts Since 2013, there has been year-to-year increase in average star ratings, together with reduced incidence of low ratings, suggesting that many plans have put considerable effort into improving performance on the range of measures. 2 1 MA Star Ratings are based primarily on data collected on performance measures drawn from five sources: HEDIS (Healthcare Effectiveness Data and Information Set), HOS (Health Outcomes Survey), Health Plan CAHPS (Consumer Assessment of Healthcare Providers and Systems), CMS administrative data, and Prescription Drug Event (PDE) measures for MA-PD plans. MA Star Ratings are not without controversy. Analysts have raised questions about how differences among beneficiary characteristics and demographics affect Star Ratings. In addition, from year to year, CMS has redefined performance benchmarks by changing thresholds on some measures, making it difficult for Health Plans to plan for and achieve successful outcomes. Star Ratings are published each October prior to the open enrollment period in the Medicare & You handbook and on the Medicare website. These publicly reported results help beneficiaries choose a Medicare health and/or prescription drug plan, and allow the public and research community to assess Medicare program performance. MA plans have a keen interest in the Star Ratings they receive and the measures used to determine them not only because these ratings measure how well they are serving their members, but also because the results can directly affect how much Medicare pays them, and in turn how much they can offer their enrollees. MA plans receive a monthly capitated payment from CMS, which is intended to cover beneficiaries Part A and Part B services. This amount reflects the relationship between a benchmark established by CMS and the amount bid by the plan. Plans that bid below the benchmark set by CMS for a beneficiary population retain a share of the savings, termed a rebate, which must be used to provide additional benefits or reduced cost sharing to beneficiaries. The rebate percentage varies from 50% for plans with fewer than 3.5 Stars to 70% for plans with 4.5 or more Stars. Under a provision of the Affordable Care Act (ACA), plans with Star Ratings of 4.0 or higher earn a quality bonus payment (QBP). While the amount may vary depending on the county involved, the predominant QBP is 5%. In 2017, 170 of the 384 active MA-PD contracts (approximately 73% of total MA enrollees,) scored 4.0 or higher, and thus they were eligible for the bonus. Fifteen plans achieved 5 Stars in While there is no additional 2017 Presbyterian Healthcare Services 2

3 financial incentive for achieving 5 Stars, five-star plans have the advantage of accepting beneficiary enrollment at any time during the year, rather than only during the annual open enrollment period. For plan year 2017, Presbyterian achieved MA Star Ratings of 3.5 for Presbyterian Senior Care (HMO) and 3.5 for Presbyterian MediCare PPO. The reporting/rewarding schedule for Medicare Star Ratings follows a three-year cycle. For example: For services provided during all of: MA Star measures are reported in: which sets the overall Star Rating for all of: which impacts the premiums in: For services provided in 2016, Presbyterian s 2018 MA Star Ratings are 4.0 for Presbyterian Senior Care (HMO) and 3.0 for Presbyterian MediCare PPO. The HMO Contract qualifies for a 5% bonus, which will impact premiums in (See page 6 for more about the process of MA Star data reporting; see page 7 for trends in Presbyterian s MA Star Ratings.) The MA Star system is not a typical pay-for-performance program. Since CMS does not directly pay the Providers, but instead pays insurers offering private coverage to Medicare beneficiaries, the reward is actually paid to intermediaries in the provision of care. Thus, in order to earn a reward, the intermediary MAOs must inform the Providers who see the MA enrollees as to the specific quality and performance measures being evaluated. Presbyterian Health Plan proactively manages initiatives around each MA Star measure, to provide tools and to promote interventions that Providers may use to engage in quality improvement processes Presbyterian Healthcare Services 3

4 How PHS Manages Medicare Star Measures Presbyterian is committed to providing quality care and services that meet or exceed CMS quality measures. In order to monitor MA Star measures, the PMG Quality Improvement team organizes the measures according to the data sources. Medicare Star Measures by Source Adult BMI Assessment (ABA) Disease Modifying Anti-Rheumatic Drug (DMARD) therapy for Rheumatoid Arthritis (ART) Breast Cancer Screening (BCS) Colorectal Cancer Screening (COL) Comprehensive Diabetes Care (CDC) A1C Poor Control - >9.0% Nephropathy Screening Retinal Eye Exam Controlling Blood Pressure (CBP) Osteoporosis Management in Women who had a fracture (OMW) Medication Reconciliation after Discharge (MRP) Plan All Cause Readmission (PCR) Improving or Maintaining Physical Health Improving or Maintaining Mental Health Monitoring Physical Activity (PAO) Reducing the Risk of Falling (FRM) Improving Bladder Control Getting Needed Care Getting Care Quickly Customer Service Rating of Health Care Quality Rating of Health Plan Care Coordination Annual Flu Vaccine Rating of Drug Plan Getting Needed Prescription Drugs Members Choosing to the Health Plan Complaints about the Health Plan Plan Makes Timely Decision about Appeals (Part C) Appeals Auto-Forward (Part D) Reviewing Appeals Decisions (Part C) Appeals Upheld (Part D) Beneficiary Access and Performance Problems Call Center Foreign Language Interpreter and TTY Availability (separate measures for Part C and Part D) Medicare Price Finder Price Accuracy Medication Adherence for Diabetes Medications Medication Adherence for Hypertension (RAS Antagonists) Medication Adherence for Cholesterol (Statins) Medication Therapy Management (MTM) completion rate for Comprehensive Medication Review (CMR) HEDIS HOS CAHPS Survey CMS Administrative Prescription Drug Event (PDE) In addition to the measures listed above, two additional Quality Improvement Measures are assigned a Star rating. One is for Part C (Medical) measures, and the other is for Part D (Pharmacy) measures. These highly weighted measures are based on year over year improvement for selected measures Presbyterian Healthcare Services 4

5 Each of these measures is assigned to an owner who proactively manages initiatives around the measure. The owner works with partners (PMG Providers, community Providers, vendors, etc.) as necessary to improve/maintain measure outcomes. For example, to improve the prevalence of colorectal cancer screening among patients and members, PHP uses a HEDIS report to identify members who are imputed to PMG Providers and who may be due for screening. The PMG care teams can use these imputed member lists to verify potential gaps in care. Using the resources of the Patient-Centered Medical Home, PMG care teams encourage patients to get the recommended screening test and follow up with patients showing a positive test result. All workflows related to MA Star Measures are monitored by The Performance Improvement Steering Committee, which includes measure owners from both PHP and the Presbyterian Delivery System, along with analysts and key leaders. This committee meets monthly to coordinate performance improvement for both MA Star and Centennial Care performance measures. It reports to the Presbyterian Integration Leadership Team (PILT). SERVICES TECHNOLOGY PEOPLE Epic EHR: used by the delivery Process Owners: system to document patient care, Director, Performance provide order sets and standard Improvement, The Quality protocols (and supporting tools), Department of PHP; and collect quality data including Chief Operating Officer PMG HEDIS; the Healthy Planet module (Beth Tibbs) helps to identify patients with gaps in care Compile and report data related to MA Star measures Identify patients with gaps in care; share this information with Providers Identify stakeholders in patient care (e.g., care teams, pharmacy, claims processors); determine their impact on quality of care Make Providers aware of MA Star measures; recommend interventions to impact performance Develop interventions to improve specific MA Star measures: Provider outreach/incentives Member outreach/rewards Improved data management Other systems improvements Facets system: a care management tool used by PHP to identify patient-members with gaps in care, or in need of care interventions HEDIS and Star Program Director (Elaine Haemmerle) Analysts HEDIS Program Managers PMG Nursing Directors Providers Care Managers 2017 Presbyterian Healthcare Services 5

6 Process There is a complex process for compiling, reporting, and forecasting outcomes data for MA Star measures. Some data sources (such as HEDIS) can be monitored throughout the calendar year (CY) while others (i.e., Health Plan CAHPS survey and HOS) are reported once per year, and just one month before Star Ratings are assigned, making it more difficult to track progress and predict results. Moreover, HOS evaluates a cohort of members over a two-year time span, which makes its results asynchronous with the rest of the measure sources. For example: Used to calculated Star Rating assigned in: Determines Star Rating for: Source: Measure performance data collected during: Are submitted to CMS: HEDIS CY 2016 Jun 2017 Oct HOS May-Aug 2016 Sep 2017 Oct CAHPS Feb-May 2017 Sep 2017 Oct CMS Admin. CY 2016 Jun 2017 Oct PDE Measures CY 2016 Jun 2017 Oct For Payment during: Given the difficulty in predicting Star Rating performance for both HOS and CAHPS Survey, analysts have found it significantly challenging to forecast accurately an overall Star Rating Presbyterian Healthcare Services 6

7 Measures of Success Objective Measures Aligns with Aim Maintain MA Star Rating Weighted Star Overall Star Rating Better Health, 4.0 Weighted composite, according to data source: Exceptional Experience o HEDIS Measures o HOS Measures o CAHPS Measures o CMS Administrative Measures o PDE Measures The forecast of the Weighted Overall MA Star ratings (for both HMO and PPO contracts) is reported monthly on both PHP and PDS Board scorecards. Only 23 measures (out of 44) those that have outcomes data reported on a regular basis are included in this forecast calculation. Current forecasting methods account for less than 53% of the overall weighted Star rating. In addition, individual measures are grouped according to data source, and scores are weighted according to CMS formulas. These composite scores, as well as individual measure scores, are shared regularly with the Performance Improvement Steering Committee. Trends in MA Star Ratings For the 2018 MA Star Ratings, Presbyterian saw an increase in MA Star Ratings for several measures, including: Diabetes Care Kidney Disease Monitoring (HEDIS) Improving or Maintaining Mental Health (HOS) Customer Service (CAHPS Overall Rating of Healthcare Quality (CAHPS) Getting Needed Prescription Drugs (CAHPS) Plan Makes Timely Decisions about Appeals Part C (Administrative) Foreign Language Interpreter Availability (Administrative) Part C Quality Improvement Although the individual Star Rating did not change, Presbyterian saw improved results for several measures. This improvement contributed to the Part C Quality Improvement measure. This highly weighted measure is assigned a Star based on year over year improvement for selected measures. Measures showing improved results include: Colorectal Cancer Screening Osteoporosis Management in Women who had a Fracture Diabetes Care Eye Exam Complaints about the Health Plan Page 8 shows trends in MA Star Ratings for both Presbyterian Senior Care (HMO) and Presbyterian MediCare PPO over the last five years Presbyterian Healthcare Services 7

8 Weighted Star - Overall Rating HMO PPO The PHP HMO contract achieved 4.0 or higher for services provided in 2014 and Weighted Star - HEDIS Measures HEDIS measures are designed to assess a plan s clinical effectiveness, accessibility to members, and use of resources. Weighted Star - HOS Measures HOS asks the member to self-report their health status. Weighted Star - CAHPS Measures Weighted Star - CMS Administrative Measures Weighted Star - Pharmacy Event Measures The Health Plan CAHPS survey assesses the patient s satisfaction with both their health plans and their network providers. These measures reflect member interactions with CMS such as call center performance, volume of complaints, and beneficiary disenrollment. These measures reflect member experience with drug plan, drug pricing, and pharmacy-related patient safety Presbyterian Healthcare Services 8

9 Changing Thresholds CMS made changes to rating thresholds which impacted the overall Star rating for For example, in three measures (Breast Cancer Screening, Controlling Blood Pressure, and Adult BMI Assessment), Presbyterian s Star Rating decreased by 1 Star, even though the performance rates improved or stayed the same. Future Work Presbyterian s integrated work plan for managing MA Star measures intends to guide the organization towards achieving 4.0 or greater Star Ratings. The work plan articulates both short- and long-term goals. Short-Term Complete interventions during Q4 of 2017 that will impact 2019 MA Star Ratings, specifically: Designate ownership for all MA Star measures, including HEDIS, CAHPS and HOS measures Conduct bi-weekly Performance Improvement Committee meetings with a focus on select priority measures: o Diabetic Measures (Eye Exam, Kidney Screen, A1c<9) o Breast Cancer Screening o ART/Rheumatoid Arthritis Long-Term Implement MA Star activities in CY 2018 in order to impact 2020 MA Star Ratings, including: Identify interventions that can impact key measures. Continue improving in areas where we may already be meeting or exceeding benchmarks, given the nature of the ever-changing thresholds. Devise a methodology for estimating threshold increases. Devise a process for forecasting CAHPS and HOS results, and incorporate in monthly tracking report. Additional Measures In 2017, PHP began offering a Special Needs Plan to Medicare/Medicaid Dual Eligible enrollees, and additional measures will be reported. Data for services provided in 2017 will be reported beginning in 2018 for: Special Needs Plan Case Management Care of Older Adults o Functional Assessment o Pain Assessment o Medication Review 2017 Presbyterian Healthcare Services 9

10 Glossary gap in care HEDIS HOS CAHPS Medicare Star Gap in care (or care gap ) is a term used widely throughout patient health analytics to recognize a disparity between health care needs or recommended best practices and the services that have actually been provided. Gaps in care may be those outstanding office visits, lab tests, procedures, and pharmaceuticals that a patient needs, but have not yet received, usually because there are obstacles. A successful Population Health program gives real-time insights to both clinicians and administrators, allowing them to identify and address gaps in care within the patient population. According to CMS: There is a need for all providers to work actively to continuously monitor and address disparities, and to be accountable for reducing gaps in care and outcomes. All CMS beneficiaries must have access to and receive person-centered, equitable, effective, safe, timely, and efficient care and services. The Healthcare Effectiveness Data and Information Set (HEDIS ) is a tool used by more than 90 percent of America s health plans to measure performance on important dimensions of care and service. Altogether, HEDIS consists of 81 measures across 5 domains of care. The Medicare Health Outcomes Survey (HOS) was designed to gather valid, reliable, and clinically meaningful health status data in the Medicare Advantage (MA) program for use in quality improvement activities, pay for performance, program oversight, public reporting, and improving health. All managed care organizations with Medicare contracts must participate. The HOS is administered annually to a random sample of Medicare beneficiaries drawn from each participating MA plan and surveyed in the spring (i.e., a baseline survey is administered to a new cohort, or group, each year). Two years later, these same respondents are surveyed again (i.e., follow up measurement). The survey asks the member how they have been feeling, both physically and mentally, during the four weeks prior to the survey. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program is a multi-year initiative of the Agency for Healthcare Research and Quality (AHRQ) to support and promote the assessment of consumers experiences with health care. The CAHPS Health Plan Survey is a tool for collecting standardized information on enrollees experiences with health plans and their services. Developed by the Center for Medicare and Medicaid Services (CMS), the Star Rating System (also called MA Star ) measures how well Medicare Advantage (MA) and its prescription drug plans perform for consumers. MA Star ratings serve several purposes: to measure quality in Medicare Advantage and Prescription Drug Plans, to assist beneficiaries in finding the best plan for them, and to award MA quality bonus payments. In addition, CMS has extended Star Ratings to hospitals, nursing homes, and dialysis facilities, to support improvement of the quality of care provided by those facilities. CMS rates MA contracts based on a range of as many as 44 unique quality and performance measures, with data gathered from a variety of data sources, including standard HEDIS, CAHPS, and HOS measures. Altogether, the weighted measures are used to calculate a relative quality score using a 5-star rating system, with 5 being the highest and 1 being the lowest score Presbyterian Healthcare Services 10

11 Additional References Clinical Care Model Colorectal Cancer Screening Patient-Centered Medical Home (PCMH) Resources: PHS login required Medicare Stars - CAHPS Member Experience 2017 Results Additional Resources 2017 Star Ratings (CMS) Medicare & You 2018: Medicare handbook Part C and D Performance Data (cms.gov) The five-star rating system and Medicare plan enrollment (medicareinteractive.org) Star Ratings: Measures and Definitions (medicare.gov) 2017 Presbyterian Healthcare Services 11