6 strategies to improve HEDIS scores and Star ratings

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1 Transforming healthcare through innovative digital engagement 6 strategies to improve HEDIS scores and Star ratings By Chuck Rolfsen, Chief Revenue Officer, Healthx Proven strategies to help move the needle on member and provider behavior Tips to improve your performance in member and provider surveys In recent years, achieving high scores on HEDIS measures and Medicare Star ratings has taken on greater importance for health plans. What was once a nice-tohave for marketing purposes has become a must-have for operating in certain lines of business.

2 6 strategies to improve HEDIS scores and Star ratings Introduction The challenge for health plans is that many performance measures are tied to data extracted from claims and medical records. In the words of the Centers for Medicare & Medicaid Services: Sponsors are accountable for the care provided by physicians, hospitals, and other providers to their enrollees. * Some health plans point out that s not fair. It s one thing to judge them based on access to providers and appeals processes; it s another to judge them based on which services provider recommendations and member follow-through. As controversial as that topic is, I m not going to address it in this guide. Fair or not, the standards exist and they re not going away anytime soon. Instead, I m going to give you some proven strategies to help move the needle on member and provider behavior, as well as tips to improve your performance in member and provider surveys. Even if your improvements are incremental, these strategies can deliver huge benefits for your bottom line and your members health. *Source: Medicare Part C & D Star Ratings: Update for 2016 In recent years, NCQA accreditation has shifted from a nice-tohave to a must-have. Whether it is actually required depends on the line of business. 2

3 Setting the stage: HEDIS What is HEDIS? HEDIS, the acronym for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for Quality Assurance (NCQA). HEDIS is a performance measurement tool for health plans. The standard set of measures related to care and service is organized in categories including: Effectiveness of care Access/availability of care Experience of care Utilization and risk-adjusted utilization Health plan descriptive information 3

4 6 strategies to improve HEDIS scores and Star ratings Why is HEDIS so important? HEDIS measures are a significant component of the NCQA accreditation process about one-third of the overall score. Whether accreditation is required or not depends on the line of business: For commercial group coverage NCQA accreditation is not required. However, many groups (especially large companies and organizations) will only consider an accredited health plan. For Medicare Advantage plans The Centers for Medicare & Medicaid Services (CMS) has made NCQA an approved accreditor. Medicare Advantage plans that go through NCQA s MA Deeming Module are deemed meaning they are considered by Medicare to meet certain requirements. These requirements include quality assurance programs, antidiscrimination, access to services, confidentiality and accuracy of records, information on advance directives, and provider participation rules. In addition, NCQA is contracted with CMS to evaluate Medicare Advantage Special Needs Plans (SNPs). For Medicaid plans Most states have modeled their standards for managed Medicaid plans on the NCQA accreditation standards (in full or in part). Like with Medicare, some states deem plans if they have met some or all of the NCQA accreditation requirements. Others specifically require NCQA accreditation for managed Medicaid plans. There are now a number of Medicaid payers currently gearing up for NCQA s look-back period that starts July 1 so they can go through the accreditation process. (View the state-specific Medicaid requirements here. Note that this list is as of November 2015, but updates are issued regularly so check the NCQA website for the latest information.) For Exchange plans, including co-ops: Some states require plans to be NCQA certified to be sold on the Exchange. In other states, the Exchange regulations do not specifically require NCQA accreditation, but they call for Exchange plans to follow standards that align with NCQA making NCQA accreditation a quasi-regulatory requirement. 4

5 Alignment of NCQA and Marketplace requirements Requirement Required by NCQA Required to participate in Marketplace Local performance on clinical quality measures such as HEDIS Patient experience ratings on a standardized CAHPS survey Consumer access Utilization management Quality assurance Provider credentialing Complaints and appeals Network adequacy and access Patient information programs that help enrollees find a doctor 5

6 6 strategies to improve HEDIS scores and Star ratings How is HEDIS data collected? The data is collected by health plans, submitted to NCQA, and audited according to standards set by NCQA. The data comes from three sources: Administrative data The plan s claims database Hybrid data Claims database and review of medical records* Survey data Provider and member surveys The specific source for key measures is illustrated in the following table. When is the data collected and released? HEDIS data is collected and released according to a timeline set by NCQA. The most important date is the May 15 deadline to gather data for the reporting period. The HEDIS timeline January 1 - May 15 June July September - October Plans gather Plans report NCQA NCQA data for the results to releases releases previous NCQA Quality Quality measurement Compass Compass year (MY) results results ending (Commercial) (Medicare Dec 31 and Medicaid) 6

7 Data source for selected 2016 HEDIS measures Measure Data source Required for Commercial Required for Medicaid Required for Medicare Adult BMI assessment Hybrid data Weight assessment and counseling for nutrition and physical activity for children/adolescents Hybrid data Immunizations for adolescents Hybrid data Breast cancer screening Administrative data Cervical cancer screening Hybrid data Colorectal cancer screening Hybrid data Care for older adults Hybrid data (Special Needs Plans only) Medication management for people with asthma Administrative data Controlling high blood pressure Hybrid data Comprehensive diabetes care Hybrid data Osteoporosis management in women who had a fracture Administrative data Fall risk management HOS survey data* Management of urinary incontinence in older adults HOS survey data* Osteoporosis testing in older women HOS survey data* Physical activity in older adults HOS survey data* Flu shots for adults ages CAHPS survey data** Medical assistance with smoking and tobacco use cessation CAHPS survey data** Flu shots for adults ages 65 and older CAHPS survey data** Pneumococcal vaccination status for older adults CAHPS survey data** Prenatal and postpartum Care Hybrid data Call answer timeliness Administrative data Frequency of ongoing prenatal care Hybrid data Well-child visits in the first 15 months of life Administrative data for commercial, hybrid data for Medicaid Well-child visits in the third, fourth, fifth and sixth years of life Administrative data for commercial, hybrid data for Medicaid Adolescent well-care visits Administrative data for commercial, hybrid data for Medicaid * HOS = Medicare Health Outcomes Survey ** CAHPS = Consumer Assessment of Healthcare Providers and Systems survey 7

8 6 strategies to improve HEDIS scores and Star ratings Setting the stage: Star ratings What are Star ratings? The Five-Star Quality Rating System, often called the Medicare Star ratings, is a tool used by the Centers for Medicare & Medicaid Services (CMS) to evaluate the performance of Medicare Advantage Organizations (MAOs) that administer Medicare Part C and Medicare Part D coverage. Ratings are presented on a scale from 0 stars to 5 stars. For Medicare Advantage (MA) plans that cover medical services only not prescription drugs the measures include five categories: Staying healthy Whether members get certain screenings, tests, and vaccines. Managing chronic conditions How often members with long-term conditions get certain tests and treatments that help them manage their condition. Member experience with the health plan Member satisfaction ratings. Member complaints and changes in the health plan s performance Problems with the plan found by Medicare or reported by members. Customer service How the plan handles member appeals. For stand-alone Medicare Prescription Drug Plans (PDPs), the measures include four categories: Customer service How the plan handles member appeals. Member complaints and changes in the drug plan s performance Problems with the plan found by Medicare or reported by members. Member experience with plan s drug services Member satisfaction ratings. Drug safety and accuracy of drug pricing Accuracy of the plan s pricing information, plus how often members with certain medical conditions are prescribed drugs in a way that is safer and clinically recommended for their condition. For MA-PD plans that cover both medical services and prescription drugs, all of the categories above apply. As of 2016, only plans with 500 or more enrollees are included in the Star rating programs. The number of enrollees is determined at the contract level, not the plan level. 8

9 Why are Star ratings so important? When CMS first started collecting data for the Star ratings and reporting it publicly, the primary goal was to help beneficiaries choose from the plans available in their area. I should mention that among Healthx customers, we have seen little correlation between Star ratings and enrollment so far. For example, one of our clients is the only 5-Star plan in New York City. They ve done really well but they still didn t attract as many members as a less expensive plan with lower Star ratings. Early on, attaining a high Star rating was mainly a marketing win, but it had little value otherwise. That all changed when the Affordable Care Act (ACA) included a provision attaching financial incentives to Star ratings. Early on, attaining a high Star rating was mainly a marketing win. That all changed when the Affordable Care Act included a provision attaching financial incentives to Star ratings. 9

10 6 strategies to improve HEDIS scores and Star ratings Beginning in 2012, CMS started awarding bonuses to plans receiving 4 or more stars. In addition, CMS is offering larger rebates for highly rated plans that submit bids below the county or regional benchmark. These plans will be able to retain up to 70% of the difference between the benchmark and the plan bid bonus payment and rebate structure Rating % MA-PD Contracts Receiving this Rating ( ) Bonus Payment New Benchmark Rebate Payment 5 Stars 2.46% 5% 105% of Benchmark 70% 4.5 Stars 12.08% 5% 105% of Benchmark 70% 4 Stars 13.87% 5% 105% of Benchmark 65% 3.5 Stars 29.31% None Benchmark 65% 3 or Fewer Stars 42.28% None Benchmark 50% Note: New plans are automatically assigned to a 3.5% bonus payment with a rebate payment of 65% What that means is that there is a lot of potential revenue at stake. Consider the financial impact of going from 3 1/2 to 4 Stars? It could be tens of millions of dollars. In addition, there are penalties associated with low ratings. CMS recently instituted a three strikes rule for plans that fail to achieve at least a 3-Star rating for three consecutive years. Starting in February 2016, these plans are receiving nonrenewal notices meaning they cannot enroll members during the following calendar year. 10

11 How is the data collected? The data for Star ratings is derived from four sources: Administrative data CMS data on plan quality and member satisfaction HEDIS scores CAHPS survey data The Consumer Assessment of Healthcare Providers and Systems (CAHPS ) HOS survey data The Health Outcomes Survey The data time frame varies for each measure. Generally it is the previous calendar year; however, some measures have a different data time frame. For example, the reporting time frame for Measure C03 (Annual Flu Vaccine) is from February 15 to May 31. Medicare releases the Star ratings in October. It s important to note that ratings are grouped at the Medicare Advantage Organization contract level not at the plan level. 11

12 6 strategies to improve HEDIS scores and Star ratings 6 strategies to improve your HEDIS scores and Star ratings 1 Improve member satisfaction by improving engagement with effective self-management Using web-based and mobile tools, you can provide members with self-management tools, information, programs and access to resources. Some ideas: Allow members to track their health, review the results of recent visits, manage their prescriptions and perform other tasks in mobile-friendly web portals and/or mobile apps. Implement online health risk assessments to identify individuals with health risks, and then share that information with providers as well as the members. Provide outreach through the phone, , employer intranets and other tools to communicate care gaps (and reinforce the need to close them). 2 Use incentives to drive usage of self-management tools Use positive or negative incentives to motivate members to change the way they interact with the plan to view the plan as a health resource, not just a claim payer. Some ideas: Use financial incentives or pre-enrollment requirements to drive utilization of the online health assessment. 3 Develop reimbursement strategies to increase provider collaboration Often, plans work hard to convince providers how important it is to address gaps in care. Ultimately, collaborating on how to improve quality is much more effective that convincing when it comes to provider engagement. To do that: Work with providers at the organizational level to develop outcome-based models and value-based reimbursement plans together plans that reflect the realities of all the factors impacting care. 12

13 4 Use technology to extend care plan collaboration If you participate in government-sponsored programs, you have full accountability for managing the capitulated payment to best meet the needs of your members. You are responsible for developing Individual Care Plans that includes the member, primary care provider, specialists, family, community support mechanisms and other providers as appropriate. Utilize technology to make care plans accessible to all members of the members interdisciplinary care team. Allow all of the care team members who have access to review and comment on the care plan. Show more than claims data in the provider portal. Show as much as you can about lab results, prescriptions filled, etc. 5 Improve HEDIS scores by delivering data and tools in an actionable form to reduce gaps in care Providing access to data in an actionable form rather than large data sets or files is key. Your provider portal gives you a way to achieve this: Create a dashboard that highlights quality-related information about current care gaps, such as lab work, immunizations or screenings required. Deliver member-specific messages about gaps in care on the member eligibility screen in your portal. When you send preventive care reminders to physicians, clearly and specifically ask them to engage the member. 6 Tap in to the competitive nature of providers Physicians are, by nature, high performers. They strive to deliver the highest-quality care and they are often competitive. Use this to your advantage by making the financial relationship between payer and provider more transparent: Where you display quality data, create a view of the data that shows how the provider compares to other physicians, practices and medical groups. Show information about the provider s current earnings for value-based reimbursement programs in relation to the provider s potential to collect under those programs. 13

14 6 strategies to improve HEDIS scores and Star ratings Healthx services that help clients improve HEDIS and Star Here s a quick overview of some of the services we offer to help health plans achieve NCQA compliance and improve HEDIS scores and Star ratings: MEM 1 Health appraisals The organization administers a health appraisal to eligible individuals as a means of measuring and improving health What we do: To provide a seamless user experience, Healthx uses SAML 2.0 SSO (single sign-on) to integrate an NCQA-accredited health assessment within the member portal and/ or app. Clients can use any vendor they choose, and we re happy to offer advice to help with the selection process. MEM 2 Self-Management Tools The organization has evidence-based self-management tools available to help members manage their health What we do: Healthx supports clients in meeting this standard through seamless integration with an NCQA-accredited vendor. Integration is typically provided via SAML 2.0 SSO. MEM 3 Functionality of Claims Processing The organization provides members with timely and accurate information about their claims What we do: Healthx member portals and apps give members access to timely and accurate information about their claims. They can track claims throughout the claims process and view information such as amount approved, amount paid, date paid (if applicable), and member cost. MEM 4 Pharmacy Benefit Information The organization provides members with the information they need to understand and use their pharmacy benefit What we do: Healthx supports clients in meeting this standard by seamlessly integrating services and data provided by the client s Pharmacy Benefit Manager, typically using SAML 2.0 SSO. Interested in any of these solutions? Contact us. 14

15 MEM 5 Personalized Information on Health Plan Services The organization provides members with the information they need to easily understand and use health plan benefits What we do: Healthx member portals and apps give members the ability to perform all the functions described in Element A of this standard (website functionality such as ID card requests and PCP selection). To assist clients with Element C (monitoring quality and accuracy of information provided to members on the web), we can provide detailed web utilization reports. To support Element D (related to inquiries from members), monitoring of response time to s originating in the Healthx member portal is a standard feature in our workflow tool. Notes: We do not support the elements of this requirement related Element B (functionality available by phone), nor do we support the monitoring of phone-related information called for in Element C. MEM 6 Member Support The organization uses technology to improve member services What we do: We integrate the client s choice of third-party vendors into online tools and services using SAML 2.0 SSO. For example, we can support functionality such as electronic refill reminders, HSA/FSA calculators, electronic referrals, electronic enrollment in disease management and wellness programs, and online personal health records. MEM 7 Health Information Line The organization offers a health information line to assist members with wellness and prevention What we do: Clients can promote availability of the health information line in our member portals and apps. In addition, if the plan provides an online chat service, we can track members who elect to call or access that service through the portal or app. MEM 8 Encouraging Wellness and Prevention The organization promotes member wellness and prevention of illness, and measures access to wellness and prevention services What we do: We help clients meet the requirements of Element B (targeted follow-up with members) and Element C (encouraging member health) in several ways. For example, our member portals and apps can display relevant information based on data elements contained in the member s eligibility record. Thus, a member who is enrolled or identified as a potential candidate for the plan s disease management program would be able to view relevant information and specific content based upon their condition. In addition, we can display or send reminders about needed care to the member in the portal and app. Note: We do not provide the data analytics as required for Element A (identifying members eligible for wellness activities). 15

16 6 strategies to improve HEDIS scores and Star ratings About Chuck Rolfsen Chuck Rolfsen has over 30 years of managed healthcare experience as a provider, payer and technology consultant. He has assisted over 100 Healthx clients, including regional and managed Medicaid health plans, in developing strategies and solutions to streamline administrative processes and improve the quality of care. About Healthx Healthx provides the healthcare industry s leading digital engagement platform connecting our payer customers to their consumer, provider, employer and broker constituents. As an innovator in cloud-based technology, Healthx supports over 170 payers representing 16 million members and 600,000 providers. Our engagement expertise enables us to guide customers to achieve their business objectives by driving online portal and mobile app utilization and producing measurable ROI. The platform can integrate with over 150 third party applications; customized into a seamless user experience across the consumer engagement ecosystem including shop and enroll, managing benefits, cost transparency, payment processing, wellness, health education and other specialty content. Healthx is a proven and trusted partner, led by healthcare and technology experts passionate about delivering engagement solutions that drive outcomes. Note: This is not a legal document. Although we have made significant effort to ensure the accuracy of the information in this guide, the ultimate responsibility for accurate collection and reporting of data lies with the parties involved. The information in this guide was current at the time of publication (November 2015) and is subject to change. Sources: Measures.pdf https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/mc86c05.pdf https://www.medicare.gov/find-a-plan/staticpages/rating/planrating-help.aspx https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovgenin/ Downloads/2016-Part-C-and-D-Medicare-Star-Ratings-Data-v zip https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovgenin/ Downloads/2016-Star-Ratings-User-Call-Slides-v2015_08_05.pdf https://www.cms.gov/medicare/health-plans/medicareadvtgspecratestats/downloads/ advance2016.pdf Priority Way W Drive, Suite 150, Indianapolis, IN Healthx 11/2015

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