Reach for the STAR(s): RaDngs, Bundled Payment and Your Customer. Faculty Disclosures

Transcription

1 Reach for the STAR(s): RaDngs, Bundled Payment and Your Customer Irene Fleshner, RN, MHSA Marylee Grosso, BSPharm Jeanne Manzi PharmD, CGP, FASCP 1 Faculty Disclosures The speakers have no actual or potendal conflicts of interest to report in reladon to this program. 2 At the compledon of this applicadon- based acdvity, the pardcipant should be able to: Describe the Centers for Medicare & Medicaid Services (CMS) STAR radngs system and how it works DifferenDate between STAR measures for Long- Term Post Acute Care (LTPAC) and Medicare plans List the measures for both LTPAC and plans that can be affected by pharmacists IdenDfy inidadves that consultant and dispensing pharmacists can implement to assist their customers to improve STAR radngs for LTPAC and/or Part D plans 3

2 Five Star RaDng System for Long Term Post Acute Care (Nursing Homes) 4 Five- Star Quality RaDng System Created by CMS to help consumers compare LTPAC facilides more easily Began in 2009 Each LTPAC facility is given a new Star radng every year and the website data updated monthly Total radng is based on 3 domains: Health inspecdons Staffing Quality measures (QM) There is a radng for each domain and an overall composite radng Source: h^p:// Enrollment- and- CerDficaDon/CerDficaDonandComplianc/FSQRS.html 5 LTPAC FaciliDes RaDngs Range From 1 to 5 Stars ***** Much Above Average **** Above Average *** Average ** Below Average * Much Below Average Source: h^p://

3 Health InspecDons Health, quality care, and pharmacy services deficiencies RaDngs include 3 most recent annual inspecdons and 3 years of substandated complaints Points assigned by scope and severity of citadons RaDngs based on state specific, fixed distribudon Source: h^p:// Enrollment- and- CerDficaDon/CerDficaDonandComplianc/Downloads/consumerfactsheet.pdf 7 Staffing Staffing informadon Self- reported by facility for 2 week period prior to the survey Two staffing measures equally rated Adjusted RN staffing rado Adjusted total staffing rado Risk adjusted using CMS staffing study to consider differences in levels of care Based upon a nadonal distribudon DistribuDon is not held constant Source: h^p:// Enrollment- and- CerDficaDon/CerDficaDonandComplianc/Downloads/consumerfactsheet.pdf 8 Quality Measures Minimum Data Set (MDS)- based measures STAR radng uses 9 of the 18 total measures Short- Stay (2 measures) Long- Stay (7 measures) Based on nadonal distribudon Except AcDviDes of Daily Living (ADL) decline DistribuDon is not held constant Source: h^p:// Enrollment- and- CerDficaDon/CerDficaDonandComplianc/Downloads/consumerfactsheet.pdf 9

4 Short- Stay Measures 1. % of padents that self- report moderate- to- severe pain 2. New or worsened pressure ulcers Source: h^p:// stay- residents.html 10 Long- Stay Measures 1. % whose need for help with ADLs has increased 2. % who self- report moderate- to- severe pain 3. % with pressure ulcers 4. % who have/had a catheter inserted and lek in their bladder 5. % with a urinary tract infecdon (UTI) 6. % who were physically restrained 7. % experiencing one or more falls with major injury Source: h^p:// Stay- Residents.html 11 Self- Assessment Ques.on #1 What are the 3 domains that comprise the Five- star radng system for LTPAC facilides? 12

5 Trends in Overall RaDngs % received 4 or 5 star radng, by 2013 increased to 49% Quality measure radngs increased since transidon to MDS 3.0 Trends have raised quesdons about the validity of self reported QM and staffing data NYT ardcle Medicare Star RaDngs Allow Nursing Homes to Game the System highlighted self reported staffing data Abt and CMS unable to conclusively determine real improvements in quality vs. coding changes 13 Next Steps CMS, Abt and Technical Expert Panel (TEP) are considering: Rebasing the measures and changes the scoring rules Adding addidonal measures Re- hospitalizadons AnDpsychoDc MedicaDon use Discharge to community MDS and staffing data audits Improving Medicare Post- Acute Care TransformaDon (IMPACT) Act Improving Medicare Post- Acute Care TransformaDon Act $11 million to set up electronic payroll repordng system for staffing beginning in Why LTPAC ExecuDves Care About the Five Star RaDng System Hospital Value Based Purchasing (VBP) hospital readmission penaldes ACO, bundled payment demonstradons Medicare/Medicaid Managed Care 15

6 Hospital VBP As hospitals are being penalized for excess readmissions, they are turning to Skilled Nursing FaciliDes (SNFs) with reputadons for high performance and track records for lowering hospitalizadon rates via clinical readiness and enhanced capabilides 16 Accountable Care OrganizaDons The Affordable Care Act (ACA) established the ACO model within the Medicare program A voluntary program where providers can join together to manage and coordinate care for a populadon of padents, and accept responsibility for the quality and cost of that care ACOs are centered around primary care Hospitals pardcipadng in ACO or bundled payment demonstradons can only achieve savings by reducing re- hospitalizadon rates 17 Where They Are Medicare Shared Savings and Pioneer ACOs in the United States January 2014 Source: The Advisory Board Company 18

7 Medicare/Medicaid Become Managed Care Goal encourage coordinated care Reward providers that meet three aims: 1. Safe, efficient and effecdve transidons 2. Excellent outcomes - Five Star 3. Low re- hospitalizadon rates 19 Hospitals, Managed Care OrganizaDons (MCOs) and ACOs Use Five- Star for Network development and narrowing Discharge referrals Quality monitoring Payment incendves/disincendves 20 LTPAC ExecuDves Need to Demonstrate Quality Outcomes Quality measures Nursing Home Compare Five- Star radng FuncDonal Independence Measure (FIM) scores Customer sadsfacdon Re- hospitalizadon rates 21

8 And.Manage High Acuity Admit 24/7 from hospital, emergency department, doctors office Physician/Advanced Registered Nurse PracDDoner (ARNP) management Higher rado of RNs with advanced clinical experdse Leadership development of directors of nursing (DONs) to convert their role to that of execudve manager Care protocols and pathways that extend from hospital to subacute and subacute to home health Minimal hospital admissions and readmissions, and no emergency room visits 22 Self- Assessment Ques.on # 2 True or False: ACO and Bundled Payment means the same thing. 23 Pharmacists Role Food for Thought How Does the Pharmacist Get Involved? How Can You Provide Value to Your Customer? 24

9 Nursing Home Compare Website h^p:// Can search by: LocaDon City Zip code or Nursing home name

10 Nursing Home (LTPAC) Profile Five tabs for each LTPAC: General informadon InspecDon results Staffing Quality measures PenalDes Plus overall radng, fines and payment denials Source: h^p:// %20DE&lat= &lng= &name=SEAFORD%20CENTER&Distn= General InformaDon Tab Number of CerDfied Beds ParDcipates in: Medicare and/or Medicaid? Ownership: For profit or not- for- profit- CorporaDon? AutomaDc Sprinkler Systems in All Required Areas: Yes or No Is it located in a ConDnuing Care ReDrement Community (CCRC)? Is it located in a Hospital? Has a Resident and Family Council? Includes overall radng plus radng for each of 3 separate domains Source: h^p:// %20DE&lat= &lng= &name=SEAFORD%20CENTER&Distn= InspecDon Results Tab Health, quality care, and pharmacy services deficiencies Contains informadon from onsite inspecdons from last 3 years, including annual visits and complaint invesdgadons Can click on inspecdon report for details Lists average number of nursing home health deficiencies in that state and in the U.S. Scope and severity descripdon Important Source: h^p:// Enrollment- and- CerDficaDon/CerDficaDonandComplianc/Downloads/consumerfactsheet.pdf 30

11 Quality Measures Tab IdenDfies overall and quality measures star radngs Allows drill down to review short- stay and long- stay quality measures Includes percentages of padents self repordng or measured in 2 short stay and 7 long stay categories Source: h^p:// Enrollment- and- CerDficaDon/CerDficaDonandComplianc/Downloads/consumerfactsheet.pdf 31 Self- Assessment Ques.on #3 Nursing Home Compare website can be used to learn: 1. Overall, survey, staffing and quality measures star radngs 2. Results and detailed survey reports 3. Percentages for short- and long- stay quality measures 4. Comparisons to state and nadonal averages 5. All of the above 32 CMS Five- Star RaDng System Overall RaDng STEP 1 STEP 2 STEP 3 Health Inspection Rating Staffing Rating Quality Measures Rating = Overall Rating Start with Health Inspection Rating Add 1 star for 4 or 5 Star Staffing Rating Subtract 1 star for a 1-Star Staffing Rating Add 1 star for a 5-star QM Rating Subtract 1 star for a 1- Star QM Rating 33

12 CMS Five- Star RaDng System Health InspecDon Scoring (LTPAC) Each deficiency scored by scope & severity More points for higher scope, higher severity Weighted scores summed for: 3 Most Recent Standard Surveys 3 Years of SubstanDated Complaints Added Points for: (a) substandard quality, (b) revisits needed beyond first revisit Most Recent Surveys Weighted More (50% % %) Survey results compare to centers within the state 34 IMMEDIATE JEOPARDY to resident health and safety Scope and Severity J Required: Cat 3 Optional: Cat 1,2 K Required: Cat 3 Optional: Cat 1,2 L Required: Cat 3 Optional: Cat 1,2 ACTUAL HARM that is not immediate jeopardy G Required: Cat 2 Optional: Cat 1 H Required: Cat 2 Optional: Cat 1 I Required: Cat 2 Optional: Cat 1 NO ACTUAL HARM with POTENTIAL FOR MORE THAN MINIMAL HARM that is not immediate jeopardy D Required: Cat 1 Optional: Cat 2 E Required: Cat 2 Optional: Cat 1 F Required: Cat 2 Optional: Cat 1 NO ACTUAL HARM with POTENTIAL FOR MINIMAL HARM Substandard Quality of Care F , F , F Only A B C ISOLATED PATTERN WIDESPREAD Substantial Jeopardy and Compliance SQOC SQOC = Substandard Quality of Care Cat = Category 35 36

13 Top 10 Health (F- Tag) Deficiencies YTD Tag Deficiency DescripDon YTD F323 Accident Hazards 6,639 6,464 3,572 F441 InfecDon Control 6,128 6,095 3,503 F371 Food Storage 5,002 5,373 2,954 F309 Quality of Care 5,207 5,175 2,928 Comprehensive Care Plan - F279 Content 3,617 3,624 1,817 F329 Unnecessary MedicaDons 2,952 3,771 1,959 F514 Maintaining Clinical Records 3,011 3,037 1,681 Proper Labeling of Drugs/ F431 Biologicals 2,837 3,107 1,732 F241 Dignity and Respect 2,805 2,845 1,494 Comprehensive Care Plan - F281 Quality of Services 2,882 2,770 1,483 Source: CMS Nursing Home Compare Database dated 9/18/14 37 Pharmacist Involvement Be Part of the Team Ideas for assis.ng LTPAC in the new business world: 1. ReducDon of Unnecessary Meds and AnDpsychoDcs Clinically appropriate documentadon of indicadons for psychotropic medicadons 2. Non- Pharmacological IntervenDons Measures for Behavior Management 3. Pain Management Protocols 4. Wound Care Management 5. Falls Risk Assessments and PrevenDon 6. InfecDon Control Measures and AnDbioDc Therapies for UTI 38 Pharmacist Involvement Be Part of the Team Ensure Readiness with Pharmacy Related F- tags F- 329 unnecessary medicadons F- 332 and medicadon errors (should be <5%) F- 429 drug regimen review report, if response not documented by PCP, follow up with medical director F431 labeling and storage Understand the reladonship with other F- tags 39

14 Pharmacist Involvement Be Part of the Team Pharmacists can assist in improving padent care and medicadon safety: ImplemenDng a program to report/reduce medicadon errors and avoid high risk medicadon (HRM) use Ensuring Dmely delivery of medicadon Providing medicadon educadon in- services for nursing staff ParDcipaDng in coordinadon care teams Becoming knowledgeable about MDS 3.0 quality indicators Meet survey team and provide your contact informadon for any medicadon related issues that may need clarificadon 40 Self- Assessment Ques.on #4 Which of the following tabs on the Nursing Home Compare website provides pharmacists the best opportunity to impact Star radngs? 1. Health & fire safety inspecdons 2. Staffing 3. Quality measures 4. 1 & 3 above 41 State OperaDons Manual and F- tags Appendix PP of the State OperaDons Manual link: h^p:// Enrollment- and- CerDficaDon/GuidanceforLawsAndRegulaDons/Downloads/ som107ap_pp_guidelines_ltcf.pdf 42

15 MEDICARE PLANS MA- PD, MA and PDP 43 Medicare Plans (MA, PDP & MA- PD) CMS website to compare plans: h^p:// RaDngs consist of about 50 measures from: HEDIS (Healthcare EffecDveness Data and InformaDon Set) CAHPS (Consumer Assessment of Healthcare Providers and Systems) CMS (Centers for Medicare and Medicaid Services) HOS (Health Outcomes Survey) IRE (Independent Review EnDty) Goal is to: Educate consumers on quality, compare muldple plans Make quality data more transparent and accessible 44 Types of Plans MA Medicare Advantage Plan 5 domains/51 measures Part C only PDP PrescripDon Drug Plan 4 domains/15 measures Part D only **Does not qualify for bonus payments MA- PD Medicare Advantage- PrescripDon Drug 9 domains/48 measures Parts C and D Source: Medicare Part C & D Star RaDng Technical Notes. Updated 4/2/

16 Categories of RaDngs Examples of domains: 1. Staying healthy via prevendve services ex. screenings, tests and vaccines 2. Managing chronic condidons 3. RaDngs of plan responsiveness and care 4. Complaints, appeals, and voluntary disenrollment 5. Telephone customer service 46 PaDent ProtecDon and Affordable Care Act of 2010 Ties federal reimbursement rates for Medicare Advantage plans to performance as measured by the Star radngs system Bonus payments are determined by Star radngs PotenDal revenue increasing annually with maximum bonus opportunity in 2014 Congressional Budget Office (CBO) projects this scoring system will save billions of dollars in federal health care spending Source: h^p:// 47 How Can Medicare Beneficiaries UDlize The Star RaDngs? Quick overview of health plans performance Easy comparison for enrollment choices CMS encourages beneficiaries to see if plan improved performance over recent years Enrollees can switch to a 5- STAR rated plan at any $me and do not have to wait for open enrollment Consumer website: h^ps:// a- plan/quesdons/ home.aspx 48

17 Bonus Payments Payments are available to MA and MA- PD plans who have received 4 or more stars Certain plans are unrated by CMS Too new Too few enrollees Bonus payments are calculated as a percentage share of the Medicare Advantage benchmarks ( benchmark) Will vary from state to state and county to county and are determined each year 49 Examples of Measures MedicaDon adherence calculadons Diabetes, HTN, cholesterol (stadns) Breast cancer screening Call Center foreign language interpreter and TTY availability (new for 2014) High risk medicadons Annual flu vaccine Complaints about the health plan Timely decision about appeals Diabetes care Eye exam Kidney disease monitoring Blood sugar controlled Cholesterol controlled DiabeDc hyptetensive treatment ACE inhibitor/arb therapy Source: Medicare Part C & D Star RaDng Technical Notes. Updated 4/2/ Pharmacists Role - Plans Performance and quality measures High risk medicadons for padents 65 years and older who received 2 or more rx fills for the same HRM Diabetes treatment one oral hypoglycemic rx and 1 BP med, should be ACE/ARB Blood pressure controlled: < 140/90 mmhg Rheumatoid arthrids management padents with diagnosis of RA who got rx for 1 or more DMARD Source: Medicare Part C & D Star RaDng Technical Notes. Updated 4/2/

18 MedicaDon Adherence CMS was only reviewing PDEs for 30- day claims but is now including 60- and 90- day fills Compliant marker is >80% of propordon of days covered padent can refill up to 6 days late for a 30- day prescripdon and sdll be compliant Check every refill rx for dates filled/refilled Perform sure- up fills and call plan for refill- too- soon overrides so all of padents rx s are due for refill on the same day Adherent vs. compliant Just because a pa.ent fills their prescrip.on regularly one cannot assume that they are taking it correctly or taking it at all! Source: Medicare Part C & D Star RaDng Technical Notes. Updated 4/2/ Addressing MedicaDon Non- adherence Implement a medicadon adherence program Reminders - postcards, phone calls, etc. If padent is non- compliant with refills, counsel to determine barriers to compliance and address those issues Cost/formulary Access/travel/distance Forge~ulness EducaDon/misunderstanding of medicadon Meds monitored by CMS for adherence Diabetes meds biguanides, sulfonylureas, TZDs, DPP- IV inhibitors, meglidnides and GLP- 1 agonists HTN ACE- inhibitors/angiotensin receptor blockers (ARBs) Cholesterol stadns 53 Self- Assessment Ques.on #5 What are some examples of barriers to medicadon adherence? 54

19 High Risk MedicaDon (HRM) If prescripdon for a HRM is presented by a padent > 65 years old, contact prescriber to change to a safer alternadve Beers list link: h^p:// documents/beers/2012beerscriteria_jags.pdf CMS will condnue to use Pharmacy Quality Alliance (PQA) list of medicadons Source: h^p:// Enrollment- and- CerDficaDon/GuidanceforLawsAndRegulaDons/Downloads/ som107ap_pp_guidelines_ltcf.pdf 55 Plan RaDngs Range From 1 to 5 Stars STAR RATINGS ***** Excellent **** Above Average *** Average ** Below Average * Poor Quality Bonus Payments STAR Ra.ng 2015 QBP Percentage Less than 3 stars 0% 3 stars 0% 3.5 stars 0% 4 stars 5% 4.5 stars 5% 5 stars 5% Source: h^p:// Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2015.pdf 57

20 Summary The CMS Star radng system (LTPAC) combines survey results with staffing and quality measures Star radngs for LTPAC and plans are similar but different, both a measure of quality of care LTPAC measures (all survey results and quality measures) as well as medicadon related plan measures may be affected by pharmacists Pharmacists can play an integral role in working with LTPAC and Medicare plans to support the changing business dynamics and acuity of the populadon served MulDple inidadves can be implemented by pharmacists to help improve Star radngs for both LTPAC and/or Part D plans 58 QuesDons 59 Thank you! 60