Medicare 2015 QI Program Evaluation

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1 Color Code: Red does not meet 5 star threshold, or target. Green meets or exceeds 5 star threshold/target. Improving or Maintaining Physical Health (HOS) Improving or Maintaining Mental Health (HOS) Diabetes BP Control <140/90 Controlling Blood Pressure (CMS CCIP program Antidepressant Medication Management, Acute Phase Treatment Potentially Harmful Drug- Disease Interaction in Elderly (low score is better) #1 Priority Measures: High Priority Measures Included in NCQA Ratings/CMS Star Ratings C 3 63% 68% 65% 2 stars Removed from NCQA 2016 ratings star threshold for 2016 ratings: 72% (2014: 68%). C 3 78% 78% 81% Removed from NCQA star threshold: 82% (2014: ). 2 stars 2 stars ratings. 69% 71% 75% NCQA weight: 3 points Methodology change for HEDIS C 3 73% 72% 78% Financial incentive for CHP practice nursing staff. NCQA weight: 3 points EMR dashboard report for PCPs. EMR alert to recheck high BP readings. HEDIS 2015: adds age range of with diabetes <150/ star threshold: 82% (2014: 75%). 64% 63% CHP staff contact PCPs when members are identified, and when medications haven't been filled. Statistically significant improvement (z=7.94; p=0.00). 20% 48% 42% Methodology change for 2014 results; list of medications revised. High Risk Medications in the Elderly D 1 3% 11% 9% Financial incentive for staff & affiliate PCPs. NCQA ratings: uses HEDIS measure. NCQA weight: 1 point Prime PBM sends letters to prescribers on a weekly basis after high risk medications are filled. A number of high risk medications have been removed from the formulary star threshold: 6% (2014: 7%). Reducing the Risk of Falling (HOS) C 1 59% 54% 2 stars 53% 2 stars star threshold: 73% (2014: 73%). Rating of Specialist 90% 88.5% NCQA ratings: uses score of 9-10; NCQA weight: 1.5 points Getting Appointments & Care Quickly (CAHPS) C % 78% 76% Questions: Received care as soon as needed; Appt. as soon as needed; Appt. time within 15 minutes of arrival. NCQA weight: 1.5 points star threshold: 79% (2014: 80%). Pharmacotherapy Management of COPD Exacerbation, Bronchodilator (display C 1 82% 80% 80% NQCA weight: 1 point Patients are monitored and contacted to fill medications if necessary. Pharmacotherapy Mgt. of COPD, Corticosteroid (display C 71% 71% 71% Patients are monitored and contacted to fill medications if necessary. 1

2 Advising Smokers to Quit (CAHPS - CMS CCIP program 83% 84% Members are identified and provided educational #1 Priority Measures: High Priority Measures Included in NCQA Ratings/CMS materials Star Ratings during PCP visits (CHP staff practices and TPCA). Priority #2 Measures Included in NCQA Ratings/CMS Star Ratings Osteoporosis Management in Women who had a Fracture C 1 61% 67% 53% CHP Radiology staff contacts and schedules appropriate members for a DEXA scan. HEDIS 2015: adds an age limit of 85, eliminates estrogens & pathologic fractures star threshold: 75% (2014: 76%). Annual Flu Vaccine (CAHPS) C 1 79% Pneumonia Vaccine (HEDIS: CMS display Initiation of Alcohol or Other Drug Tx (HEDIS: CMS display Persistent Beta Blocker Treatment (HEDIS: CMS display 79% 77% CAHPS question revised for flu shot since July since September. NCQA weight: 1 point 73% 80.5% 79% C 58% 63% 63% Barrier: mis-diagnosis and inaccurate coding. NCQA weight: 1 point 95% 95% The Health department and local pharmacies provided documentation of services to CHP star threshold: 78% (2014: 79%). Statistically significant improvement (z= 2.9; p = 0.00). CMS has decided to keep this measure on the display page. HP staff monitor population, promote follow-up visits, and accurate coding. Diabetes Care Blood Sugar Controlled (<8) Non-recommended PSA Screening (HEDIS: low score is better) C 3 90% 53% New HEDIS 2015 Measure NCQA weight: 3 points star threshold: 84% (2014: 86%). Rating of PCP (CAHPS) 93% 93.5% 92% NCQA ratings: uses score of NCQA weight: 1.5 points Rating of Health Plan (CAHPS) Getting Needed Care (CAHPS) C % C % Priority #3 Measures Included in NCQA Ratings/CMS Star Ratings 94% 93% NCQA weight: 1.5 points Questions: Easy to get appt. with specialists; easy to get care, treatment you needed. NCQA weight: 1.5 points Sample size for Medicare CAHPS survey increased from 800 to 1500 since star threshold: (2014: ) star threshold: 86% (2014: ). 2

3 Customer Service (CAHPS) C % 94% 91% NCQA weight: 1.5 points Member Services staff meetings are held weekly #1 Priority Measures: High 5 Priority stars Measures Included in NCQA Ratings/CMS to Star discuss Ratings issues and provide education star threshold: 90% (2014: 97%). Rating of Health Care Quality (CAHPS) 7 Day Follow-up after Hosp. for Mental Illness (HEDIS: CMS display Osteoporosis Testing (HOS: CMS display C % Question: Rating of health 5 star threshold: (2014: ). care. NCQA ratings: uses score of NCQA weight: 1.5 points C 74% 70% 84% Local hospital's BH Center continues to coordinate follow-up visits. Statistically significant improvement (z=4.76; p=0.00). C 87.5% 88.5% Diabetes Care Eye Exam C 1 90% 83% 84% Eye Care staff contact appropriate members for testing & provide exams in affiliate PCP offices. Eye coupons discontinued in Statistically signficant decrease (z=2.56; p=0.01) 5 star threshold: 82% (2014: 77%). Diabetes Care Kidney Disease Monitoring Breast Cancer Screening C 1 C 1 N.A. 84% star threshold: 97% (2014: 94%). Moved to a display measure in 2014 due to a methodology change. Has been moved back in 2015 to the Star 5 star threshold: 80%. Adult BMI Assessment C 1 94% 99% 97% Statistically signficant improvement (z=2.07; p=0.038). 5 star threshold: (2014: 93). Colorectal Cancer Screening C 1 92% 91% 90% CHP's Colon Screening Program tracks members & provides screening procedures. 5 star threshold: 78% (2014: 65%). HEDIS and CAHPS Measures: Not in the NCQA or Star Ratings Use of Aspirin (CAHPS: CMS CCIP Members Who Smoke Cigarettes or Use Tobacco (CAHPS: CCIP Antidepressant Medication Management, 6 months 53% 53.5% 55% 7.7% 8.7% 7.3% Members are identified and provided educational materials during PCP visits (CHP staff practices and TPCA). 53% 51% 51% Barrier: mis-diagnosis and inaccurate coding. CHP staff contact PCPs when members are identified, and when antidepressant medications haven't been filled. 3

4 Engagement of Alcohol or Other Drug Tx (HEDIS: CMS display Diabetes BP Control <140/80 Monitoring of Patients on Long Term Meds (HEDIS: CMS display Cardiac Care LDL Screening (HEDIS: CMS CCIP program Testing to Confirm COPD Diabetes A1c Testing (HEDIS: CCIP Diabetes Care LDL Screening (HEDIS: CCIP Cardiac Conditions: LDL Level <100 (HEDIS: (CCIP Diabetes Care LDL Control < 100 (HEDIS: CCIP C 5% 8.5% 8% Barrier: mis-diagnosis and #1 Priority Measures: High Priority Measures Included NCQA Ratings/CMS Health inaccurate coding. NCQA Star Ratings Promotions staff monitor the population, promote scheduling of follow-up visits. weight: 1 point 58% 61% 62% Measure has been retired from HEDIS. D 94% 94% 94% 95% 94% Measure has been retired from HEDIS and the Star 62% 68.5% 69% Health Promotions (HP) staff contact appropriate members and provide the testing. 95% 98% 97% Measure has been retired from HEDIS and the Star 77% 77% 72% Measure has been retired from HEDIS. 75% 69% 71% Measure has been retired from HEDIS and the Star Additional Star Rating and CMS Display Measures Medication Adherence for Hypertension D 3 76% 79% 81% Financial incentive for staff & affiliate PCPs. Prime sends quarterly mailings to prescribers and provides CHP with a detailed adherence report. Statistically significant improvement (p=2.72; p=0.01) star threshold: 81% (2014: 85%). Medication Adherence for Cholesterol (Statins) D 3 69% 74% 75% Financial incentive for staff & affiliate PCPs. Prime sends quarterly mailings to prescribers and provides CHP with a detailed adherence report. Statistically significant improvement (p=2.98; p=0.00) star threshold: 79% (2014: 83%). Diabetes Medication Adherence Plan All-Cause Readmission (HEDIS: CMS QIP) D 3 71% C 3 9% 73% 9% 74% 8% Financial incentive for staff & affiliate PCPs. Measure revised in 2015 to exclude planned readmissions. Prime sends quarterly mailings to prescribers and provides CHP with a detailed adherence report star threshold: 82% (2014: 81%). Interventions revised in 2015: interventions are customized, and target the population of members at highest risk for readmissions star threshold: 6%. (2014: 2%). 4

5 Plan All-Cause Readmission Diabetes Treatment 86% Rheumatoid Arthritis Management Quality Improvement (CMS composite) 10.3% 10.7% 9.7% Measure revised in 2015 to Interventions revised in 2015: interventions are #1 Priority Measures: High Priority Measures Included exclude in planned NCQA Ratings/CMS customized, Star Ratings and target the population of readmissions. members at highest risk for readmissions. C 1 86% C % % Measure has been removed from the Star Ratings for Improvement score is based on significant change in measures collected over 2 years using the same specifications. Letters are sent to the diagnosing physicians asking them to evaluate the patient for correct diagnosis and to start patients on appropriate medications star threshold: 86% (2014: ) star threshold: (2014: 0.408). Quality Improvement (CMS composite) D Improvement score is based on significant change in measures collected over 2 years using the same specifications star threshold: (2014: 0.5). Appeals Auto-Forward D Rate of appeals autoforwarded to IRE due to exceeding time requirements (low # better) 3 appeal cases auto-forwarded to IRE in 2014; one case has been submitted to CMS for a decision for exclusion. 1 case: due to an issue with CTS system that has been resolved. 1 case due to late notification star threshold: 5.0 (2014: 0.7). Prime has auto-forwarded 2 appeal cases in Reviewing Appeals Decisions C % % of appeals upheld by the Independent Review Entity (IRE) Total # of Part C appeals sent to IRE in 2014: 29 # upheld: 21; # overturned: 3; # dismissed: 4; # withdrawn: star threshold: 94% (2014: 95%). Plan Makes Timely Appeals Decisions C % 94% 100% % of appeals processed timely out of appeals decided by IRE Appeals Upheld D 1.5 Data not reported for plans with fewer than 10 cases. Foreign Language & TTY/TTD C % N.A. 94% Measure not reported by CMS in 2014 due to methodology issues. 2015: Prime is involved in appeal procedures; appeals staff monitor the timeliness of reviews and notifications star threshold: 98% (2014: 95%). CHP had 6 appeals upheld for Part D in star threshold: (2014: 84%). Member Services staff track and review all test calls, and provide training for staff on an ongoing basis star threshold: 93%. 5

6 Foreign Language & TTY/TTD Care Coordination (CAHPS) C 1.5 Complaints about Plan C/D Members Choosing to Leave C/D 1.5 1% Beneficiary Access and Performance Problems Getting Needed Prescription Drugs (CAHPS) D % N.A. 92% Measure not reported by star threshold: 93%. #1 Priority Measures: 1 star High Priority Measures Included CMS in in 2014 NCQA due Ratings/CMS to Star Ratings methodology issues. C D % Rating of Drug Plan (CAHPS) D % Improving Bladder Control (HOS) Monitoring Physical Activity (HOS) MPF Pricing Accuracy Enrollment Timeliness (CMS display 41% C 1 57% D 1 98% C/D % % 40% 55% 99% 85% % % 42% 59% 98% 97% Questions: Dr. has medical records and other patient information; enrollee receives timely test results; Dr. provides information on medications; enrollee receives help managing care; Dr. is informed about care from specialists. NCQA weight: 1.5 points Measures problems found during audit. No problem or NA is = 100%;. Questions: Easy to get meds; easy to fill prescriptions; easy to prescriptions by mail Measure has been revised, and removed from the Star Measure revised to included only price accuracy star threshold: (2014: ) star threshold: 0.08 (2014: 0.17). The Enrollment department monitors disenrollment data on a monthly basis. 5 star threshold: 10 (2014: 9) star threshold: star threshold: 92% (2014: 92%) star threshold: 86% (2014: ) star threshold: 62% (2014: 63%) star threshold: 100% (2014: 99%). Atypical Antipsychotic Use by the Elderly in Nursing Homes Timely Receipt of Case Files for Appeals (CMS display Appeals - Timely Effectuation (CMS display D 50% 50% 42% Prime's Guided Health sends quarterly prescriber mailings targeting antipsychotic use in dementia. D 2/2 1/1 Data period Jan - June Very small # of appeals are sent to IRE. D Data period Jan - June Dismissed appeals excluded - very small # of appeals are sent to IRE. 6

7 Drug-Drug Interactions Diabetes Medication Dosing (CMS display measures) D 7% 7% 6% Methodology change for 2014 results; list of #1 Priority Measures: High Priority Measures Included in NCQA Ratings/CMS medications Star Ratings revised. D 1.8% 1.1% 0.6% The Medicare formulary requires quantity limits on most of the diabetes drugs. Report Date: 11/3/2015 Health Delivery Committee Review: 11/4/2015 7

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