The Centers for Medicare & Medicaid Services (CMS) strives to make information available to all. Nevertheless, portions of our files including

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1 The Centers for Medicare & Medicaid Services (CMS) strives to make information available to all. Nevertheless, portions of our files including charts, tables, and graphics may be difficult to read using assistive technology. Persons with disabilities experiencing problems accessing portions of any file should contact CMS through at

2 Measuring Quality & Performance in Medicare Advantage Where We ve Been, Where We Are, & Where We re Going Abby L. Block Director, Center for Beneficiary Choices Centers for Medicare & Medicaid Services April 8, 2008

3 History of Quality and Performance Measures in Medicare Advantage 2

4 Quality and Performance Measurement at CMS Staff from HCFA/CMS and HHS have long been involved in developing and refining health plan quality and performance metrics, even before they were used in the Medicare + Choice and Medicare Advantage Programs For example, CMS staff serve on the CPM for HEDIS measures 3

5 Measuring Quality and Performance among Medicare plans In early 1990s, some states required Medicaid programs to collect this data on Medicaid managed care programs In late 1990s, following the Balanced Budget Act (BBA), CMS began collecting HEDIS, CAHPS, and later HOS data from Medicare managed care plans Plans to begin data collection preceded BBA 4

6 Motivation to Measure The decision to begin quality and performance data collection was motivated by several factors Need for accountability to oversight bodies and beneficiaries Desire to make evaluation of managed care plans more objective Desire to improve value in government purchasing 5

7 Early Uses of Quality and Performance Data Reporting Year 1997 was first year of data collection Data was used in various agency initiatives Medicare Compare website in bar chart form (1999) Medicare & You Handbook (2000) First consumer education efforts Reports to plans for use in quality improvement programs HHS Government Performance and Results Act (GPRA) goals 6

8 Towards a Performance Assessment System By , CMS had enough data to create a plan rating system, which eventually became the Performance Assessment System Incorporated various data sources into one swing database in HPMS Generated plans ranking based on performance relative to other plans, using individual and composite measures Allowed CMS to reward high performing plans, i.e. with audit exemptions 7

9 Current Quality and Performance Metrics HEDIS HOS CAHPS Independent Review Entity data Part D Performance Measures More detail on these measures today and tomorrow from CMS staff 8

10 Current Quality and Performance Measurement in Medicare Advantage 9

11 Quality and Performance Measurement Goals Over time, metrics and measurement systems have expanded and evolved Goals remain largely the same Accountability Value-based purchasing Objectivity in program evaluation 10

12 Current Quality and Performance Measurement Objectives To provide performance and quality-based information to beneficiaries to make enrollment decisions Example 1: MA and Prescription Drug plan ratings Demonstrate value and performance Example 2: Special Needs Plan quality measures 11

13 Example 1: Plan Ratings Previously, limited plan performance information was available on Medicare website In 2007, CMS significantly revamped MA and Part D plan ratings on Medicare.gov Domain & measure level ratings 5-star rating system Accessible, comprehensible information 12

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16 Domain and Measure Level Ratings Example Domain: Managing Chronic Conditions Measures: Osteoporosis Management Diabetes Care Eye Exam Diabetes Care Kidney Disease Monitoring Diabetes Care Blood Sugar Controlled Diabetes Care Cholesterol Controlled Antidepressant Medication management (6 months) Controlling Blood Pressure Rheumatoid Arthritis Management Testing to Confirm Chronic Obstructive Pulmonary Disease Continuous Beta-Blocker Treatment 15

17 Five-Star Rating System Real innovation of the 2007 plan ratings was the establishment of a 5-star rating system Not only showed comparison of plans, but placed them in a framework of comparison to agreed-upon standards Unique for Medicare Advantage and Prescription Drug Programs Not yet available for Hospitals or Nursing Homes 16

18 Significance of Plan Ratings Plan ratings improve CMS ability to identify high performing plans and plans that need improvement Also substantially expand information available to beneficiaries for selecting highquality heath and prescription drug plans 17

19 Example 2: Special Needs Plans Quality Measures Since their inception, there has been the expectation that SNPs provide more meaningful health service choices for beneficiaries than other MA plans Yet, neither the statute nor our regulations provided specific guidance on how to specialize clinical programs Lack of quality and performance data hampered ability to demonstrate how plans are special Tremendous growth in SNPs and SNP enrollment further justified need for quality metrics 18

20 Special Needs Plans Quality Measures CMS and the Geriatric Measurement Panel (GMAP) of the NCQA worked collaboratively to develop initial recommendations for SNP quality measures In November 2007, the GMAP finalized their measure recommendations from existing measures: Thirteen HEDIS measures Set of Structure and Process measures 19

21 SNP Quality Measures Measures were on display for public comment through January 2008 HEDIS measures remained the same, but minor modifications were made to structure & process measures based on public comment SNP measures will be collected for Contract Year 2009 Training for health plans on reporting requirements currently underway 20

22 Measurement Categories Benefit design Risk assessment and care planning Coordination of services Caregiver engagement Internal measurement of performance Beneficiary & caregiver experience 21

23 Innovation: Plan-Level Measurement Currently, CMS only measures plans at the contract level, not at the plan benefit package level, and only for contracts with 1,000 members For the SNP specific measures, CMS will collect them from every SNP at the plan benefit package level 22

24 Beginning of a Multi-Stage Process The HEDIS measures and structure and process standards to be used in 2008 are part of a three-year strategy proposed by NCQA For 2009 and 2010, some of these measures will be further refined for SNP-specific use and additional measures will be developed and collected 23

25 Future of Quality and Performance Measures in Medicare Advantage 24

26 Need to Improve Current Quality Measurement Initiatives While current initiatives achieve some of CMS quality and performance measurement objectives, they are constrained by Sources and types of data gathered Plan monitoring and compliance infrastructure Limitations of consumer tools 25

27 Quality Measurement and Performance Assessment Wish List Sources and Types of Data Next stages of SNP measures Part C Performance Measures MA Utilization Data Improvements to HEDIS measures * Some already underway 26

28 Quality Measurement and Performance Assessment Wish List Plan Monitoring & Compliance Integrated plan for how to use plan rating information for purposes of plan monitoring and compliance; plan improvements 27

29 Quality Measurement and Performance Assessment Wish List Consumer Information Research and monitoring to determine if an how consumers are using quality and performance data through Medicare.gov and other portals Underway: continuing consumer testing of Medicare Options Compare and Prescription Drug Plan Finder 28

30 Other Ways Forward: PQA The PQA, a pharmacy quality alliance, was launched at a CMS Open Door Forum CMS is a member of the PQA Steering Committee and an active member on PQA Workgroups CMS supports the promotion of high-value pharmacy services, including measurement approaches, through a stakeholder-led pharmacy quality alliance The measures being developed by PQA and its stakeholders for pharmacy quality and patient satisfaction will be considered for use by CMS in the Part D Plan Ratings 29

31 Questions? Abby L. Block Director, Center for Beneficiary Choices 30