Key Points about Star Ratings from the CMS 2016 Final Call Letter

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1 News from April 2015 Key Points about Star Ratings from the CMS 2016 Final Call Letter On April 6, 2015 CMS released the Announcement of Methodological Changes for Calendar Year 2016 for Medicare Advantage Capitation Rates and Part C and Part D Payment Policies and Call Letter. TMG put together a summary of the 2016 Draft Call Letter portion of the document, specifically as it related to the Star Ratings. Here is that document with notes explaining if anything significant has changed from what was specified in the Draft Call Letter. Please refer to the full CMS document for complete information and the discussion of comments and responses. Low Performing Plans NO CHANGE CMS plans to terminate those contracts that have failed in three consecutive years to achieve a three star rating for Part C or D (i.e., the 2014, 2015, or 2016 sets of ratings). These contracts will receive nonrenewal notices from CMS in February 2016 with an effective date of December In March 2016, CMS will issue notices to beneficiaries enrolled in non renewed contracts that they must select a new plan during the 2016 open enrollment period. Furthermore, CMS will not calculate 2017 Star Ratings for non renewed contracts, so there will not be another opportunity to show improvement. provides experienced resources, support, and solutions to Medicare Advantage plans across the nation. Contact Us Today Medicare Medicaid Plans (MMPs) NO CHANGE CMS is exploring the development of an integrated Star Rating system for MMPs participating in the capitated Financial Alignment Initiative. The purpose of this effort is to develop a rating system that acknowledges the additional needs of Medicare Medicaid enrollees and measure the performance of the MMPs in integrating the Medicare and Medicaid benefits. More information will be provided in Star Rating Calculation Changes NO CHANGE CMS analyses show that contracts show more significant improvement on measures where there are no pre determined thresholds, as compared to when there are pre set thresholds. They will move forward with the proposal to eliminate all pre determined 4 star thresholds for the 2016 Star Ratings. CMS reports: Stars improvement resources and recommendations Member engagement and outreach MTM program registration and scheduling of Comprehensive Medication Reviews (CMRs) Medicare CAHPS administration with in depth analysis and reporting Appointment scheduling and reminder calls Based on the 2015 simulations of the impact of eliminating predetermined 4 star thresholds, most contracts (83%) would have no change in their overall rating. Approximately 7% of contracts would go

2 News From up 0.5 stars and 10% would go down by 0.5 stars. Simulations found that for contracts with no SNPs and for SNP only contracts, 82% of contracts would not change their overall rating. For contracts with some SNPs as plan benefit packages, 87% of contracts would not change their overall rating. New 2016 Measure NO CHANGE CMS intends to add the following to the 2016 Star Ratings. It will be assigned a weight of 1 since it will be a first year measure. Medication Therapy Management Program Completion Rate for Comprehensive Medication Reviews (Part D) The specifications from the 2015 Display Measure will continue to be used for the 2016 Star Rating. Additional 2016 Measures NO CHANGE CMS intends to return the following to the 2016 Star Ratings. Breast Cancer Screening (Part C) Returning to the Star Ratings after a year on the Display Page because of a measure specification change. Call Center Foreign Language Interpreter and TTY Availability Measures (Part C &D) These were excluded from the 2015 Star Ratings because of concerns about data quality. All contracts will be monitored using the same timeframe this year (March June) and CMS has taken steps to correct the quality issues. Beneficiary Access and Performance Problems (Part C & D) This measure had moved out of the 2015 Star Ratings and into the Display Measures since there were significant methodological changes to the 2013 audit process and scoring. It will return for the 2016 Stars with a weight of 1 and will be weighted 1.5 for 2017 Stars. Changes to Measures for 2016 Star Ratings MINOR CHANGES IN SOME MEASURE SPECIFICATIONS Clarification about how changes to measure specifications impact the Star Ratings: If a specification change to an existing measure is announced in advance of the measurement period, the measure remains in the Star Ratings; it will not be moved to the Display Page. If the change is announced during the measurement period that significantly expands the denominator or population covered by the measure, the measure is moved to the Display Page for at least one year. If the change is announced during the measurement period that does not significantly impact the numerator or denominator of the measure, the measure will continue in the Star Ratings (e.g., when during the measurement period additional codes are added that would increase the number of numerator hits for a measure). 2

3 News From CMS is modifying the methodology for the following measures: Part C Controlling Blood Pressure Plan Makes Timely Decisions about Appeals Plan All Cause Readmissions Osteoporosis Management in Women who had a Fracture Part C & D Complaints about the Health/Drug Plan (CTM) Improvement Measures CAHPS CMS is making minor modifications to permit imprecisely measured low reliability contracts to receive 5 stars or 1 star, if evidence warrants such a designation. Part D Appeals Auto forward and Upheld measures Medication Adherence (for Diabetes Medications and Hypertension (RAS antagonists)) and Diabetes Treatment Medication Adherence (Diabetes Medications, Hypertension (RAS antagonists), and for Cholesterol (Statins)) Obsolete National Drug Codes (NDCs) Retirement of Measures MEASURE ADDED NCQA retired the following measures from HEDIS 2015 so they will no longer be included in the Star Ratings: Cardiovascular Care: Cholesterol Screening Diabetes Care: Cholesterol Screening Diabetes Care: Cholesterol Controlled Appropriate Treatment of Hypertension in Diabetes (NEW) Temporary Removal NO CHANGE Because of changes to the Improving Bladder Control (Part C) measure, there will be no data for the 2016 and 2017 Star Ratings. CMS will discuss the use of data from the revised measures for the 2018 Star Ratings in a future Call Letter. Contracts with Low Enrollment NO CHANGE CMS has determined that contracts with 500 or more enrollees in July of the HEDIS measurement year have sufficient data to reliably report Star Ratings. These contracts in most cases will have sufficient data to produce both overall and Part C and D ratings. Beginning with the 2016 Star Ratings, contracts with 500 or more enrollees as of July 2014 will be included in the 2016 Star Ratings, on the Medicare Plan Finder, and used for QBPs (quality bonus payments). The HEDIS data for contracts with less than 500 enrollees will continue to be posted on the display page. 3

4 News From Data Integrity NO CHANGE CMS will continue to take steps necessary to protect the integrity of the data. If erroneous or biased data has been submitted, it is CMS s policy to reduce the measure rating to 1. For the 2015 Star Ratings, CMS began using validated plan reported data for the SNP Care Management measure. They propose to expand their use of the data validation results as a new method of comprehensively reviewing plan operational systems and verify the validity of the data used for Star Ratings. Duals/LIS CHANGE Multiple MA organizations and PDP Sponsors believe that plans with a high percentage of dual eligible (Dual) and/or LIS enrollees are disadvantaged in the current Star Ratings Program. CMS conducted research and found some differences in measure level performance for LIS/Dual beneficiaries, although for the majority of measures the differences are small. The preliminary analyses revealed evidence for differential outcomes for Dual/LIS beneficiaries for the following six Part C measures: Breast Cancer Screening Colorectal Cancer Screening Diabetes Care Blood Sugar Controlled Osteoporosis Management in Women who had a Fracture Rheumatoid Arthritis Management Reducing the Risk of Falling. Additionally, analyses revealed some evidence of differential outcomes for Dual/LIS beneficiaries for the following Part D Measure which was specific to PDPs: Medication Adherence for Hypertension (RAS antagonists) Therefore, pending further research and investigation, CMS proposes to take the interim step of reducing the weights on this subset of Part C measures for MA and 1876 contracts and one Part D measure for PDP contracts for the 2016 Star Ratings. The reduced weights will target immediate relief to plans with significant Duals/LIS enrollment while maintaining incentives for all plans to improve on these important measures. After consideration of the information collected to date and the comments received in response to the draft Call Letter, CMS has decided not to move forward with the proposed interim step to reduce the weights on a subset of measures for the 2016 Star Ratings Program. CMS is firmly committed to continuing to identify the issue more precisely (i.e., to identify the effect on specific measures) and to build the foundation for a solution that appropriately addresses the issue. Changes for Measures Posted on the CMS Display Page NO CHANGE It is expected that all 2015 display measures will continue to be used for

5 News From Forecasting to 2017 and Beyond CMS is monitoring additional measures being developed by NCQA, including a measure of potentially avoidable hospitalizations and measures of depression screening for inclusion in the Star Ratings. Potential changes to measure specifications or calculations: Medication Reconciliation Post Discharge NCQA is proposing to expand coverage of this measure from SNP plans to all of MA and to expand the age range from adults 65+ to adults 18+. CAHPS 5.0 Changes The current MA & PDP CAHPS survey includes the core CAHPS 4.0 Health Plan Survey. CMS is interested in updating the survey to reflect the new 5.0 version and will conduct and experiment in 2015 to understand if/how performance on CAHPS measures differs between 4.0 and 5.0. MPF Price Accuracy Multiple changes are being considered for the 2017 Ratings. Potential new measures: Care Coordination Measures Current data is largely limited to the CAHPS survey, but CMS is working to develop other measures related to patient assessment of their plans care coordination, encounter data based measures, and medical records based measures. Asthma Measure Suite NCQA tested three asthma measures in the fall of 2014 to evaluate the effects of expanding the measure to include older adults. The three measures under consideration for inclusion of older adults include: Use of Appropriate Medications for People with Asthma Medication Management for People with Asthma Asthma Medication Ratio Depression NCQA is developing a new set of HEDIS measures that would assess depression care along the continuum of care. These measures are intended for all individuals age 12 and older but may be particularly relevant to the population age 65 and older. The measures currently in testing include: Depression Screening and Follow up Utilization of the PHQ 9 for Monitoring of Depressive Symptoms Depression Remission, Response or Treatment Adjustment at 6 Months Hospitalizations for Potentially Preventable Complications Statin Therapy High Risk Medication (HRM) Opioid Overutilization 5

6 News From About is a full service healthcare improvement organization providing healthcare surveys, member engagement/outreach, and performance improvement tools and consultation. Accreditations: NCQA Certified CAHPS Survey Vendor CMS Approved Medicare Health Outcomes Survey (HOS) Vendor CMS Approved Medicare CAHPS Survey Vendor NCQA Certified CAHPS PCMH Survey Vendor CMS Certified Vendor for the CAHPS for ACOs Survey CMS Approved Survey Vendor for the QHP Enrollee Survey URAC HIPAA Security Accreditation delivers valuable member feedback and reliable analysis to support improvement initiatives through survey research, phone outreach, and member engagement programs for healthcare organizations throughout the nation. Regulatory Surveys Complete management of survey requirements Certified Survey Vendor In depth, actionable reporting and analysis Trusted experience for the best results Insight Surveys Comprehensive line of tested, reliable surveys Valuable, in depth insight and feedback Customization and Flexibility Experts in survey design and execution TMG Connect Call Center Services Advanced call center support services Enhanced member outreach/engagement Full service onsite, US based call center Expertise in managing regulatory requirements Performance Improvement Consulting Star/Scores Improvement Experienced guidance and action planning Recommendations for quality improvement Understanding survey results and implications Copyright

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