CMS Star Ratings Sink or swim and the water is rising! Jane Scott, Senior Vice President Professional Services

Transcription

1 CMS Star Ratings Sink or swim and the water is rising! Jane Scott, Senior Vice President Professional Services

2 Introduction Compliance guidelines are in a perpetual state of flux and seemingly increase in complexity every year. Staying abreast of new requirements can severely stress the resources of a health plan. The following is offered as a resource to plans eligible for the 2016 Star rating program administered by CMS. Before we take a detailed look at the new measures and how they should be shaping Star strategies, following are a few headlines. 1. New Players on the Field. Welcome to the big leagues! Contracts with 500 or more enrollees as of July 2014 will be included in the 2016 ratings. Their ratings will be displayed on the Medicare Plan Finder and used for the calculation of their bonuses. There is no time to waste if your plan does not yet have a systemic approach to managing Stars. 2. Higher s. Hope is not a strategy! In almost all cases, performance levels that earned plans 5 Star ratings in 2015 will only merit between 2 and 3 Stars in The level of performance improvement needed to offset this will not happen by itself. Plans need precision empowered interventions zeroed in on just enough of the membership and provider base to yield breakthrough results. 3. New Screening and Prevention Measures. Close the loop! Plans need to manage appropriate facilitation and intervention with both members and providers to move the needle on these HEDIS measures. That will require careful barrier-to-care analysis. 4. Health Outcomes Survey (HOS). Perceptions matter! There is no risk-based adjustment for the HOS, so your highest-need and most vulnerable members will rate you differently than other members. They will do so based on their declining health rather than on your quality interventions. Plans actively managing these members perceptions with precision outreach will help members recall your plan s quality support at survey time Star Ratings Technical Specs As stated in the 2016 Advanced Notice, more commonly known as the CMS Call Letter, many changes to the Star ratings have recently been discussed and finalized. 2

3 The number of enrollees in a plan will affect how the plan is evaluated. Contracts with 500 or more enrollees as of July 2014 will be included in the 2016 ratings. Their rating will be displayed on the Medicare Plan Finder and will be used for calculation of their bonus. Plans with fewer than 500 enrollees will have their HEDIS data published on the display page located at CMS Display Page. The heaviest lifting for plans in 2016 will lie in key threshold changes for Medicare Part C. Measure C01: Breast Cancer Screening Breast cancer screening is a new preventive health measure that will present challenges for plans in influencing members to make appointments and receive the screenings. Plans should be mindful of barriers to care when tackling preventive services. Plans continue to push the accountability for this to providers, yet are disappointed when the HEDIS results are in mid- to low ranges. It is vital to conduct a barrier-to-care analysis to support improvement of preventive screening measures. In my experience with assisting health plans, screening measures require more than mass mailings or education. Tailored messaging to the target group of patients who have yet to receive mammograms, as well as issuing reminders to providers urging better test rates will produce better results. Providers often omit recommending a screening or asking when the patient last had a mammogram. Measure C02: Colorectal Cancer Screening Plans will have to rethink their efforts when it comes to colorectal cancer screening because of a shift in this measure corridor of ratings. For 2016, the ratings have changed as follows: Measure CO2 Year Over Year (YOY) Changes 1 Star < 51% < 41% 2 Stars 51% to < 63% 41% to < 52% 3 Stars 63% to < 71% 52% to < 58% 71% 58% s 71% to < 78% 58% to < 65% 5 Stars 78% 65% As this measure shows, higher is better. Plans should focus on an average 11 percent increase over previous years. A 5 Star performance in 2015 will fall to just 3 Stars in

4 Measure C04: Improving or Maintaining Physical Health With the Health Outcomes Survey (HOS) as its data source, this measure represents members perception of their own health. Even when members receive each of their preventive screenings and adhere to their medication regimens, they may still believe their overall health has not improved, or has even declined, because they need new or more medication or testing. This measure is most challenging since it is subjectively reported. Without an accurate picture of what members believe about their own health, reminding them to complete the survey will drive higher ratings. This is where the link between member behavioral/mental health is so often missed. This truly requires a refocus on the part of plans and their provider communities. CMS has now made it more challenging by changing thresholds, as highlighted below: Measure C04 YOY Changes 1 Star < 63% < 58% 2 Stars 63% to < 67% 58% to < 59% 3 Stars 67% to < 69% 59% to < 60% 69% 60% s 69% to < 72% 60% to < 68% 5 Stars 72% 68% The changes reflect an increase of 4 9 percent, with the mid-range 3 s moving the most. Plans will need to rethink their HOS management strategy if they measured in at a 4 or 5 Star, which will now show up only as 2 or 3 Stars. This may be an opportunity to begin internal surveys to measure what the patient population believes about its overall health, or conducting campaigns targeted to more challenging provider types/populations. The goal would be to ensure the behavioral or mental health piece is indeed considered or included in the overall picture. 4

5 Measure C06: Monitoring Physical Activity This measure is the percentage of senior plan members who discussed exercise with their doctor and were advised to start, increase or maintain their physical activity during the year. A counterpart to the measure discussed above also experienced measure threshold changes: Measure C06 YOY Changes 1 Star < 44% < 45% 2 Stars 44% to < 49% 45% to < 53% 3 Stars 49% to < 55% 53% to < 60% 55% 60% s 55% to < 62% 60% to < 63% 5 Stars 62% 63% Here we see that the largest percentage changes occurred in the 2 3 Star ranges, where many plans land with this measure. CMS is giving plans some breathing room with this measure by reducing the percentages overall. This easing also occurred with the body mass index (BMI) measure, allowing plans with a 2 or 3 Star for 2015 to actually show improvement for 2016 if they followed the same successful strategy. 5

6 Measure C08: SNP Care Management The four SNP plan measures underwent changes as well. C08 defines the percent of eligible Special Needs Plan (SNP) enrollees who received health risk assessments (HRA) during the measurement year. The following corridor changes have taken place: Measure C08 YOY Changes 1 Star < 35.8% < 32.7% 2 Stars 35.8% to < 51.9% 32.7% to < 49.7% 3 Stars 51.9% to < 74.0% 49.7% to < 60.0% 74.0% Not predetermined s 74.0% to < 93.9% 60.0% to < 78.4% 5 Stars 93.9% 78.4% CMS validated through 2015 SNP plan audits that many SNP plans fell short on conducting HRAs in a timely manner, or at all, so this change in measure percentage corridors is valid. SNP plans are specially designed to care for a designated population having the HRA as a beginning point for the care and treatment plan. If SNPs cannot show evidence that they conducted the assessments, they need to revamp both their system reporting and their processes. Remember, this measure is plan-reported and many plans struggle with their care management systems even reporting accurately on performance at any point in the care cycle for HRAs, care plans or interdisciplinary care team meetings. If a plan performed at a level in 2015, they will have to work even harder to maintain that for If plans were barely squeaking by at 4 or 5 Stars, their climb will now need to accommodate a 14 percent and 15 percent change. Measure C09: Medication Review This measure reflects the percentage of plan members whose doctor or clinical pharmacist has reviewed a list of everything members take (prescription and non-prescription drugs, vitamins, herbal remedies, other supplements) at least once a year. This measure shows the following changes: 6

7 Measure C09 YOY Changes 1 Star < 47% < 53% 2 Stars 47% to < 60% 53% to < 71% 3 Stars 60% to < 77% 71% to < 80% 77% Not predetermined s 77% to < 87% 80% to < 87% 5 Stars 87% 87% Plans will experience positive changes with some reduction in the percentages, most notably, in the 2 and 3 Star corridors. Plans will need to be reminded not to rest on old practices, however, as plan populations increase, formularies change for If medication adherence slips, this measure may slip, too. Measure C10: Care for Older Adults Functional Assessment This measure cites the percentage of plan members whose doctor has done a functional status assessment to see how well they are able to perform activities of daily living (such as dressing, eating and bathing). This is a HEDIS measure for which CMS is giving plans a huge break by reducing the 1 and 2 Star corridors 25 percent, as outlined below: Measure C10 YOY Changes 1 Star < 24% < 49% 2 Stars 24% to < 54% 49% to < 59% 3 Stars 54% to < 67% 59% to < 73% 67% Not predetermined s 67% to < 86% 73% to < 83% 5 Stars 86% 83% SNP plans that were performing at a 1 or 2 Star level for 2015 may come in at a 2 or 3 Star rating for Keep in mind that even though the corridors were favorably increased, it does not 7

8 mean plans should omit focus on new provider engagement strategies for this measure. Having SNP members miss out on functional assessments as part of their care plans is similar to missing the fundamental basis for addressing barriers to care. Think about it. If a plan misses identifying a member who cannot perform basic activities of daily living, why would you expect that member to be adherent to preventive health screenings or a medication regimen? This is where a SNP s care management staff communication with the PCP and/or predominant provider becomes crucial. Staff must pass along information about the initial assessment and care plan progress, as well as sentinel changes to a member s health. C11: Pain Assessment The situation is the same for this measure, with the 1 and 2 Star corridors experiencing a change of 25 percent in favor of plans. Members will need pain assessments at least once during the year, reported through HEDIS data, but ultimately, these should be part of the overall care management process on an ongoing basis. These should be identified through the care plan and reassessments as well. Many plans struggle with knowing when to conduct proper assessments beyond HRAs, or as part of HRAs. Plans should be sure to educate staff and their provider community about the desired algorithm, or about opportunities for additional assessments and screenings as a part of the care management process. Measure C13: Eye Exams The diabetic measures also underwent percentage corridor changes that will require new strategies from plans to manage this often difficult and high-cost population. This measure experienced the following percentage changes: Measure C13: Eye Exams 1 Star < 53% < 53% 2 Stars 53% to < 65% 53% to < 60% 3 Stars 65% to < 75% 60% to < 64% 75% 64% s 75% to < 82% 64% to < 77% 5 Stars 82% 77% Plans that came in at s for plan year 2015 will now have to work harder to bridge that 11 percent increase and to hold their position. 8

9 This measure requires frequent educational information to be sent to the targeted population denominator, citing the importance of eye exams and how diabetes retinopathy can go undetected, as it often does not present with objective symptoms until damage has occurred. For improvement, plans may wish to target both Type I and Type II populations for improved overall outcomes. Measure C14: Kidney Disease Monitoring Kidney disease monitoring is undergoing similar percentage changes and requires improved plan population management. Measure C14 YOY Changes 1 Star < 85% < 82% 2 Stars 85% to < 89% 82% to < 83% 3 Stars 89% to < 93% 83% to < 85% 93% 85% s 93% to < 97% 85% to < 94% 5 Stars 97% 94% Plans who were pleased with their 2015 performance will now need to re-strategize, as the changes move them to be rated at 3 Stars. This population can be very challenging because it is often simply beyond most people to understand their disease state, manage their medications and lifestyle changes, and to think about future complications. Providers who do not perform the required tests in their offices create an additional task for the member to fulfill in visiting another place of service and possibly making an additional copay. Measure C15: Blood Sugar Control This measure is defined as the percentage of diabetic Medicare Advantage enrollees between 18 and 75 years of age (denominator), whose most recent HbA1c levels were greater than 9 percent, or who were not tested during the measurement year (numerator). 9

10 Measure C15 YOY Changes 1 Star < 49% < 61% 2 Stars 49% to < 60% 61% to < 70% 3 Stars 60% to < 71% 70% to < 80% 71% 80% s 71% to < 84% 80% to < 86% 5 Stars 84% 86% CMS gave plans a measure break here, changing cut points to allow for more favorable ratings. Does this mean, however, those outcomes are improved? Remember, getting an A1C does not indicate a well-managed, educated diabetic member. Plans need to focus on improved outcomes outside of the Star rating measures to fulfill their care model design. Measure C16: Controlling Blood Pressure This measure is defined as the percentage of plan members with high blood pressure who were treated and able to maintain healthy pressure. Key words here are adequately controlled, or those members who were actually treated. Again, since Star measures are designed to increase quality overall, influencing bonus payments for which a plan may be eligible, does not necessarily mean patients are experiencing more favorable health outcomes or complying with treatment regimens. This measure percentage changed as follows: Measure C16 YOY Changes 1 Star < 47% < 42% 2 Stars 47% to < 62% 42% to < 53% 3 Stars 62% to < 75% 53% to < 63% 75% 63% s 75% to < 82% 63% to < 75% 5 Stars 82% 75% What was a 5 Star performance for 2015 is now a performance with the 4 and 5 Star ranges experiencing a 12 percent change. 10

11 Measure C18: Reducing Risk of Falling The measure underwent an 8 percent change, presenting even greater challenge to the plans for the HEDIS/HOS measure: Measure C18 YOY Changes 1 Star < 53% < 50% 2 Stars 53% to < 60% 50% to < 55% 3 Stars 60% to < 67% 55% to < 59% 67% 59% s 67% to < 73% 59% to < 73% 5 Stars 73% 73% CMS tightened up the ranges, so if a plan was a 4 or 5 Star performer in 2015, that plan could become a 3 Star for As if this measure weren t hard enough to improve as it is! Here again, is a huge opportunity for plan care managers to share with providers the discoveries made in the HRA, changes to care plans, or caregiver/home situations, so this measure can be effective with the population. Plans often fail to connect the dots between diet/proper nutrition and the risk of falling. If a member does not have good nutrition and it goes undetected or reported, their risk of falling greatly increases. Yet, educational materials provided to members or doctors often focus just on home hazards or assist devices. 11

12 Measure C19: Plan All Cause Readmits This measure experienced a smaller change than those highlighted elsewhere in this paper. Measure C19 YOY Changes 1 Star > 17% > 13% 2 Stars > 11% to 17% > 11% to 13% 3 Stars > 9% to 11% > 9% to 11% Not > 6% predetermined s > 6% to 9% > 2% to 9% 5 Stars 6% 2% Plans will definitely have to refocus their readmission management tactics, especially in light of the end to the All Cause Readmit Quality Improvement Plan. Measure C27: Members Choosing to Leave the Plan Plans will also need to think about this measure. Measure C27 YOY Changes 1 Star > 31% > 46% 2 Stars > 23% to 31% > 29% to 46% 3 Stars > 16% to 23% > 16% to 29% > 10% Not predetermined s > 10% to 16% > 9% to 16% 5 Stars 10% 9% Because a lower percentage indicates better performance, plans performing in the 2 or 3 Star ranges for 2015 will need to improve even more to maintain those ratings for Plans often struggle with capturing accurate disenrollment data or reason codes, especially in SNP plans, as members move frequently and can be difficult to represent accurately on some plan enrollment systems. Now is a great time to re-evaluate your plan s internal disenrollment tracking capabilities ahead of closing the annual enrollment period. A thoughtful retention strategy will be in order for many plans, especially when the member acquisition cost keeps rising in today s market environment. 12

13 C30: Timely Decisions About Appeals Plans making timely decisions about appeals will be an increased challenge. The percentage cut points were not favorable to plans in the 2016 tech specs. Measure C30 YOY Changes 1 Star < 53% < 47% 2 Stars 53% to < 76% 47% to < 66% 3 Stars 76% to < 91% 66% to < 85% 91% 85% s 91% to < 98% 85% to < 95% 5 Stars 98% 95% As with many measures discussed, plans that performed at a in 2015 will be at a 3 Star for

14 Measure C31: Reviewing Appeal Decisions This will also present an opportunity to re-strategize operational processes. The changes are as follows. Measure C31 YOY Changes 1 Star < 73% < 67% 2 Stars 73% to < 85% 67% to < 77% 3 Stars 85% to < 89% 77% to < 87% 89% 87% s 89% to < 94% 87% to < 95% 5 Stars 94% 95% The biggest new struggle will be for the 3 Star performers of If plans were on the low end of a 3 Star performance, they could now easily drop to 1 Star. This measure expresses how often an independent reviewer thought a health plan s denial decision was fair. This applies to appeals made by plan members and out-of-network providers. (This rating is not based on how often the plan denied appeals, but rather how fair the plan was perceived to be when the appeal was denied.) Application of clinical practice guidelines has been a CMS audit focus in recent years, as plans have at times made organizational determinations too quickly, without adequate information, or with incorrect application of the guidelines as found on appeal. Plans will need to be sure their education in the use of clinical guidelines is correct and that they have the job aids or tools needed to make the most accurate decisions. Medicare, Part D Measure D01: Call Center The first measure to the Part D Domain One is new for This measure cites the percentage of time TTY services and foreign language interpretations were available when needed during calls by prospective members to the drug plan s customer service phone number. Plans need to be ready to secret shop and monitor their own processes and outcomes before CMS does. 14

15 Measure D02: Appeals Auto Forwarded As with Part C, Part D has cut point changes from This measure is defined as the rate of cases auto-forwarded to the Independent Review Entity because the plan exceeded decision timeframes for determinations or redeterminations of coverage. Measure D02 YOY Changes: 1 Star > 60.3 > Stars > 38.5 to 60.3 > 8.3 to Stars > 14.2 to 38.5 > 1.3 to 8.3 > s > 5.0 to 14.2 > 0.7 to Stars As this measure uses the lower is better methodology, plans are getting a break from CMS with these changes. Despite the positive cut point changes for plans, this has historically been something of a trouble spot for plans. It will require focus. 15

16 Measure D5: Members Choosing to Leave the Plan This also experienced positive cut point changes for plans. Measure D05 YOY Changes 1 Star > 31% > 46% 2 Stars > 23% to 31% > 29% to 46% 3 Stars > 16% to 23% > 16% to 29% > 10% Not predetermined s > 10% to 16% > 9% to 16% 5 Stars 10% 9% Using the same lower is better methodology as the measure discussed above, plans that were 2 or 3 Stars in 2015 will catch a break. Measure D06: Beneficiary Access and Performance Problems Each year, Medicare checks each plan for any problems, such as whether members are having problems being served and whether plans are following Medicare s rules. Medicare gives plans scores between 0 and 100. Plans get lower scores when Medicare finds problems, the severity of the problems, their number or whether they directly affect members. A higher score is better, because it means Medicare found fewer problems. Given industry performance with regard to Part D audits, many plans will want to assure their internal monitoring and auditing practices are solid so there will be no surprises with either this measure or any compliance-related issues. Some plans are experiencing reductions to 1 Star on certain measures because of audits or data. Make no mistake, performance issues can cost you. 16

17 Measure D12: Adherence for Diabetics The next hurdle plans face is the ever-challenging medication adherence. This measure experienced the following cut point changes. Measure D12 YOY Changes 1 Star < 60% < 69% 2 Stars 60% to < 69% 69% to < 73% 3 Stars 69% to < 75% 73% to < 77% Not 75% predetermined s 75% to < 82% 77% to < 81% 5 Stars 82% 81% Plans will experience a bit of a break here. If your plan performed on the cusp of the upper end of a 3 Star performance, you can now slide in as a performer this year. Measure D13: Medication Adherence Measure for Hypertension This measure also has cut point changes with another positive change for plans. If your plan was performing at the high end of 2 Stars in 2015, you will be happy to see your ratings move to the 3 Star range. The performers in 2015 could move to 5 Stars with this change. Measure D13 YOY Changes 1 Star < 58% < 72% 2 Stars 58% to < 73% 72% to < 76% 3 Stars 73% to < 77% 76% to < 81% Not 77% predetermined s 77% to < 81% 81% to < 85% 5 Stars 81% 85% 17

18 Other Points of Consideration There are other considerations for plans relative to 2016 Star rating technical specs. Plans should adjust operational and data tracking/reporting to reflect the changes that CMS describes on page 9 of the tech specs. For example, if HEDIS measures are used for your plan s physician incentive plan payments, your plan will need to adjust the performance measure calculation to recognize changes in measure C16, as well as measures that have been retired. CMS continues to emphasize the importance of data integrity, as well as assuring best practices in adhering to HEDIS requirements, and processing organizational determinations and appeals, to name just a few. Don t be caught by surprise. CMS will act against plans with improper practices that impact data reporting. Make sure your plan is conducting internal audits, monitoring the data validation process, and working with your plan s HEDIS vendor/auditor to ensure data is correct. Having inaccurate data or following processes lacking data integrity open the door to unnoticed compliance risks in other operational areas. It may astonish you to learn that some plans have missed deadlines for HEDIS or other data submissions altogether. Don t become one of the plans that makes a simple but stunning mistake that reduces them to a 1 Star rating. Such an error can cost a plan millions of dollars. Plans may want to focus on their provider network contracting strategy and how it affects overall performance. Do you have the best possible partners at the table with you to achieve Star rating success? Finally, it may seem obvious, but it bears repeating: have a strong Star rating project work plan and accountable/responsible people within your organization to navigate these changes. The right approach and your well-executed tactical efforts can bring your plan the success it truly deserves. 18

19 About Jane Scott Jane Scott joined Health Integrated in 2015 as senior vice president of professional services. Scott is a recognized leader in health care for her expert knowledge of Medicare requirements, Star ratings, special needs plan population management and models of care. She has more than 33 years of industry experience, and most recently served with Gorman Health Group in Washington, DC, where she was senior vice president of clinical and provider innovations. Scott counsels health plan clients on quality measures affecting revenue and care model design, the quality bonus program (Star ratings) and regulatory compliance requirements. While at Gorman, Scott was responsible for leading the Star ratings optimization program, facilitating assessments and strategic plans to drive plan scoring. Exceptionally knowledgeable about the Centers for Medicare and Medicaid Services (CMS) quality bonus payment program, Scott also guided plans in developing model of care and quality improvement programs. Prior to joining Gorman in 2003, she served as the Medicare compliance officer at Health Net of Arizona, and later as their director of Medicare program management for government programs from 1996 and Under her leadership, Health Net increased its total Medicare program revenue by more than 6 percent annually. To complement her managed care expertise, Scott has more than two decades of clinical nursing experience, including in case management and utilization management. She earned her nursing degree at St. John s Hospital in Red Wing, Minn. About Health Integrated Health Integrated leads the industry with Precision Empowered Care Management, enabling health plans to precisely manage their most vulnerable members. By combining actionable big data with a proven biopsychosocial model, we address the physical, psychological and social drivers impacting member health and satisfaction. As a result, plans enhance quality, achieve compliance and strengthen their financial performance, while empowering members to achieve better outcomes. 19