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1 Jeanne Manzi PharmD, CGP, FASCP Clinical Advisor, CVS/Caremark Dr. Manzi is a CVS/Caremark employee Any views or opinions mentioned in this presentation are solely those of the author and do not necessarily represent those of CVS/Caremark or their employees Discuss the CMS STAR rating system, why it was created and how it works. Describe the differences between STAR measures for nursing homes and Medicare D plans. List the rating measures for both nursing homes and plans that can be affected by consultant and dispensing pharmacists. Identify initiatives that pharmacists can implement to assist with improving STAR ratings for nursing homes and plans. Created by CMS to help consumers compare nursing homes more easily Each nursing home is given a new Star rating every year Website data updated monthly Total rating is based on 3 areas: Health inspections Staffing Quality measures Can search by: Location City Zip code or Nursing home name Source: 1

2 Nursing Home Compare was created to: a. Monitor staffing for nursing homes b. Rate nursing home quality every 5 years c. Allow consumers to compare nursing homes via computer d. Compare quality measure ratings for nursing homes that don t participate in Medicare/Medicaid Five tabs for each nursing home: General information Inspection results Staffing Quality measures Penalties Plus overall rating, fines and payment denials Source: %20NY&lat= &lng= &name=HEBREW%20HOME%20FOR%20THE%20AGED%20AT %20RIVERDALE Number of Certified Beds Participates in : Medicare and/or Medicaid? Ownership : For profit or not-for-profit- Corporation? Automatic Sprinkler Systems in All Required Areas: Yes or No Is it located in a Continuing Care Retirement Community (CCRC)? Is it located in a Hospital? Has a Resident and Family Council? Includes overall rating plus rating for each of 3 separate categories Source: %20NY&lat= &lng= &dist=5&ratings=50&AspxAutoDetectCookieSupport=1 Health and mistreatment deficiencies Contains information from onsite inspections from last 3 years, including annual visits and complaint investigations Can click on inspection report for details Lists average number of nursing home health deficiencies in that state and in the U.S. Many different deficiencies possible (ex. background check for staff) Source: Environmental deficiencies examples: Working call bells in resident bathrooms Areas are free from accident hazards and risks to prevent avoidable accidents Adequate room size Source: profile.html#proftab=1&id=335780&dist=5&lat= &lng= &loc=BRONX%2C%20NY&ratings=50 Fire safety deficiencies Also lists average number of nursing home deficiencies in that state and in the U.S. Complaints and facility-reported incidents ex. Coordinate assessments with the preadmission screening and resident review program for mentally-ill and mentally-retarded patients Source: profile.html#proftab=1&id=335780&dist=5&lat= &lng= &loc=BRONX%2C%20NY&ratings=50 2

3 Staffing Information Self-reported by home a few weeks before survey Average number of hours of care given to each resident every day Considers differences in levels of care Several news reports on Star ratings in August 2014 show how nursing homes are gaming the system by hiring extra staff just prior to survey This results in falsely elevated Star ratings Source: Total Number of Residents Total number of licensed nurse staff hours per resident per day RN Hours per Resident per Day Nursing Home State Average National Average hour and 8 1 hour and 35 1 hour and LPN/LVN Hours per Resident per Day CNA Hours per Resident per Day 2 hours 2 hours and 23 2 hours and 28 Physical Therapy Staff Hours per Resident per Day Source: %20NY&lat= &lng=- Five-star ratings use 17 total measures Information collected for all residents Short stay (5 measures) Long stay (12 measures) Ratings are based on resident assessment data that show how well the nursing home cares for residents needs Separate ratings for short- and long-stay residents Source: Source: %20NY&lat= &lng= &name=HEBREW%20HOME%20FOR%20THE%20AGED%20AT%20RIVERDALE Data is collected from the Minimum Data Set (MDS 3.0) Assessment done regularly for residents in a Medicare- or Medicaid-certified nursing home Current data collection period is from 10/1/2013 to 9/30/2014 short-stay 1/1/2014 to 9/30/2014 long-stay Percent of residents 1. that self-report moderate to severe pain 2. with new or worsened pressure ulcers 3. assessed and given flu vaccine 4. assessed and given pneumococcal vaccine 5. who newly received an antipsychotic medication Source: Source: 3

4 Percent of residents: 1. whose need for help with ADLs has increased 2. who self-report moderate to severe pain 3. that are high-risk with pressure ulcers 4. who have/had a catheter inserted and left in their bladder 5. with a UTI 6. who were physically restrained Source: 7. who received an anti-psychotic medication 8. who lose too much weight 9. who have depressive symptoms 10. were assessed and given flu vaccine 11. were assessed and given pneumococcal vaccine 12. are low-risk who lose control of their bowels or bladder Source: Assist nursing home to be compliant with Federal Regulations Ex. When a HRM is prescribed for a nursing home patient, 1 st month is F-tag 329, subsequent fills are F-tag 428 Falls risk assessment and prevention medications Particular F-tags of interest to pharmacists F-329 unnecessary medications F-332 and -333 medication errors (should be <5%) F-428 drug regimen review report F-441 infection control (insulin pens, glucose meters) Appendix PP of the State Operations Manual link: GuidanceforLawsAndRegulations/Downloads/ som107ap_pp_guidelines_ltcf.pdf Updates SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter pdf Pharmacists can assist in improving patient care and medication safety by: Implementing a program to report/reduce medication errors and avoid HRM use Ensuring timely delivery of medication Providing medication education in-services for nursing staff Participating in coordination care teams especially for hospice and dialysis patients Becoming knowledgeable about MDS 3.0 quality indicators Meet survey team and provide them with contact information for any medication related issues that may need clarification Educate nurses about infection control policies ***** Much Above Average **** Above Average *** Average ** Below Average * Much Below Average Source: 4

5 Beginning in 2015, nursing homes will no longer be able to report falsely elevated staffing information. a. True b. False MA-PD, MA and PDP CMS website to compare plans: Ratings consist of about 50 measures from: HEDIS (Healthcare Effectiveness Data and Information Set) CAHPS (Consumer Assessment of Healthcare Providers and Systems) CMS (Centers for Medicare and Medicaid Services) HOS (Health Outcomes Survey) IRE (Independent Review Entity) Goal is to: Educate consumers on quality, compare multiple plans Make quality data more transparent and accessible MA Medicare Advantage Plan 5 domains/with up to 33 measures Part C only PDP Prescription Drug Plan 4 domains/13 measures Part D only **Does not qualify for bonus payments MA-PD Medicare Advantage-Prescription Drug 9 domains/44 measures Parts C and D Source: Medicare Part C & D Star Rating Technical Notes. Updated 10/3/ Examples of domains: Ø Staying healthy via preventive services Ø ex. screenings, tests and vaccines Ø Managing chronic conditions Ø Ratings of plan responsiveness and care Ø Complaints, appeals, and voluntary disenrollment Ø Telephone customer service Ties federal reimbursement rates for Medicare Advantage plans to performance as measured by the Star ratings system Bonus payments are determined by Star ratings Potential revenue increasing annually with maximum bonus opportunity in 2014 Congressional Budget Office (CBO) projects this scoring system will save billions of dollars in federal health care spending Source: 5

6 Measure Type Description Weight Outcome Measures Intermediate Outcome Measures Patient Experience Measures Access Measures Process Measures Focus on improvement to a beneficiary s health as a result of the care that is provided Concentrate on ways to help beneficiaries move closer to achieving a true outcome Represent beneficiaries perspectives about the care they receive Reflect processes or structures that may create barriers to receiving needed health care Capture a method by which health care is provided Quick overview of health plans performance Easy comparison for enrollment choices CMS encourages beneficiaries to see if plan improved performance over recent years Enrollees can switch to a 5-Star rated plan at any time and do not have to wait for open enrollment Consumer website: home.aspx Payments are available to MA and MA-PD plans who have received 4 or more stars Certain plans are unrated by CMS Too new Too few enrollees PACE plans are exempt Bonus payments are calculated as a percentage share of the Medicare Advantage benchmarks ( benchmark) Will vary from state to state and county to county and are determined each year Which of the following Medicare plans qualify for bonus payments based on their Star ratings? a. MA b. MA-PD c. PDP d. A and B only Medication adherence calculations Diabetes, HTN, cholesterol (statins) Breast cancer screening Call Center foreign language interpreter and TTY availability (new in 2014) High risk medications Annual flu vaccine Complaints about the health plan, member initiated dis-enrollments Timely decision about appeals Diabetes care Eye exam Kidney disease monitoring Blood sugar controlled Cholesterol controlled Diabetes treatment ACE inhibitor/arb therapy Source: Medicare Part C & D Star Rating Technical Notes. Updated 10/3/ Performance and quality measures High risk medications for patients 65 years and older who received 2 or more rx fills for the same HRM Diabetes treatment one oral hypoglycemic rx and 1 BP med, should be ACE/ARB (note: PQA has retired this measure) Blood pressure controlled: < 140/90 mmhg Rheumatoid arthritis management patients with diagnosis of RA who did/did not have rx for at least 1 DMARD Source: Medicare Part C & D Star Rating Technical Notes. Updated 10/3/

7 CMS was only reviewing PDEs for 30-day claims but is now including 60- and 90-day fills Compliant marker is >80% of proportion of days covered patient can refill up to 6 days late for a 30-day prescription and still be compliant Check every refill rx for dates filled/refilled Adherent vs. compliant Just because a patient fills their prescription regularly one cannot assume that they are taking it correctly or taking it at all Source: Medicare Part C & D Star Rating Technical Notes. Updated 10/3/ Implement a medication adherence program Reminders - postcards, phone calls, texts, s, etc. If patient is non-compliant with refills, counsel to determine barriers to compliance and address those issues Cost/formulary Access/travel/distance Forgetfulness Education/misunderstanding of medication Meds monitored by CMS for adherence Diabetes meds biguanides, sulfonylureas, TZDs, DPP-IV inhibitors, meglitinides and GLP-1 agonists HTN ACE-inhibitors/ARBs Cholesterol statins Pharmacists can improve patient adherence to medication by: a. Automatically refilling rx s when they are due b. Counseling patients when a late refill is noted c. Recommending a daily medication cassette to assist patient with remembering d. B and C only e. All of the above If prescription for a HRM is presented by a patient > 65 years old, contact prescriber to change to a safer alternative Beers list link: documents/beers/2012beerscriteria_jags.pdf CMS will continue to use PQA list of medications Source: som107ap_pp_guidelines_ltcf.pdf STAR RATINGS ***** Excellent **** Above Average *** Average ** Below Average * Poor Barriers to medication adherence are caused by (but not limited to) the following: a. Formulary/coverage/cost issues b. Forgetfulness c. Patient believes the medication should be taken prn but is actually a standing dose d. All of the above 7

8 Star Rating 2015 QBP Percentage Less than 3 stars 0% 3 stars 0% 3.5 stars 0% 4 stars 5% 4.5 stars 5% 5 stars 5% The CMS Star rating system is utilized for both Medicare- and Medicaid-participating nursing homes and Medicare D plans Pharmacists have the potential to be recognized by payers and financial incentives must be implemented to reward them for providing high-quality patient care All measures have a 2-year delay time so what is being done now will reflect in Star ratings for 2017 Source: Plan measures are modified every year with some being deleted and some being added Nursing home Star ratings are published for both nursing homes and plans every year and posted on the Medicare.gov website Pharmacists can positively impact Star ratings for both nursing homes and plans 8

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