Medicare Advantage - Stride Quality Program NH Medical Director Meeting March 2015

Transcription

1 Medicare Advantage - Stride Quality Program 2015 NH Medical Director Meeting March 2015

2 Medicare Membership New Hampshire has 1000 Medicare Advantage Stride members Counties currently in contracts include Hillsborough Merrimack Rockingham New Hampshire Value Rx 777 New Hampshire Value Rx Plus 242 New Hampshire TOTAL 1,019 2

3 CMS Stars measures Medicare Advantage plans are graded on a 1 to 5 star rating by the Centers for Medicare & Medicare Services (CMS) based on a range of quality metrics, including HEDIS CMS originally developed MA Star Ratings as a system to help consumers compare quality among competing Medicare Advantage plans. The Stars system currently consists of 53 measures that are weighted 1, 1.5 or 3. CMS has also announced plans to add additional measures and redistribute the weighting of current measures in the coming years 3

4 Star Ratings Star Ratings are based on measures of health plan s rating across five categories known as Domains Staying Healthy: Screenings, tests and vaccines (such as annual PCP visits, and colorectal cancer screening). Managing Chronic Conditions (such as diabetes, COPD, etc). Plan responsiveness, care and quality (such as getting needed care as well as getting appointments and care quickly). Member complaints, problems getting services and choosing to leave the plan (such as complaints about the health plan). Customer Service (such as timely appeal decisions) 4

5 Quality Program CMS Stars Measure Set for measures from the 3 domains Members currently enrolled will be eligible for the 2 year measures in 2016 Choosing measures with wt of 3 to maximize HPHC rating Domain: 1 - Staying Healthy: Screenings, Tests and Vaccines Domain: 2 - Managing Chronic (Long Term) Conditions Domain: 4 - Patient Safety and Accuracy of Drug Pricing 5

6 Full 2015 Quality Program CMS Stars Measure Set Colorectal Cancer Screening (1) Annual Flu Vaccine (1) Monitoring Physical Activity - MD talked to member re physical activity (1) Adult BMI Assessment - documented height, weight, and BMI in record (1) Diabetes Care Eye Exam (1) Diabetes Care Kidney Disease Monitoring (1) Diabetes Care Blood Sugar Controlled- Poor control (100-rate, higher better) (3) Controlling Blood Pressure - (3) Rheumatoid Arthritis Management - Rx for DMARD (1) Improving Bladder Control of % with issue what % had conversation & tx (1) Reducing the Risk of Falling % w/ fall who had conversation about prevention (1) High Risk Medication (3) Diabetes Treatment (3) use recommended BP Rx for people with Diabetes 6

7 Measuring LCU Performance Performance for 2015 will be determined by attestations submitted by LCU Participating Providers certifying compliance with the Measures for each of their Medicare Advantage Members, The Plan will calculate performance based on the attestation of compliance of each LCU Participating Provider on the Measures attributed to their Medicare Advantage Members HPHC retains the right to request applicable medical records as necessary to validate such compliance. 7

8 2015 Quality Program Payment Providers will receive per member, annual payment for each measure based on provider's attestation of compliance. Assumption that 7/1/2015 membership threshold will permit HPHC specific Stars reporting in Measure sample size likely to still be small due to continuous membership requirements assessed at January 1 of measurement year, so each member likely to count for a significant percentage of the measure score. 8

9 Member Identification By March 30 of the current year (e.g. 2015), the Plan will provide a Medicare Advantage Member roster to each LCU that identifies: the LCU s Medicare Advantage Members, the LCU Primary Care Provider for such Members the list of Measures requiring attestation. Currently working on the language for this communication Expect questions on membership by providers By July 15 th, of the current year (e.g. 2015), the Plan will provide an updated Medicare Advantage Member Roster ( Final Roster ) to each LCU 9

10 Medicare Stride Information Harvard Pilgrim Health Care - Medicare Advantage Stride (HMO) Plans 10