Shoot For The Stars. Medicare Advantage Plans. Quality Scores Drive Participation 1

Transcription

1 Shoot For The Stars Medicare Advantage Plans Quality Scores Drive Participation 1

2 Stars Rating System CMS rates Medicare Advantage Plans (HMO, PPO, and PFFS) on a 1 to 5 Star scale. Star ratings can be used as an incentive to reward high quality health plans with additional benefits, bonuses and rebates. Excellent Performance Above Average Performance Average Performance Below Average Performance Poor Performance Quality Scores Drive Participation 2

3 Examples of Medicare Advantage Plans in Florida Florida Blue ( Blue Cross/Blue Shield of Florida) Florida Healthcare Plus Aetna Wellcare Coventry Highmark United Healthcare Preferred Care Partners Freedom Optimum Humana Amerigroup Florida Care Plus Simply Physicians United Plan Quality Scores Drive Participation 3

4 Medicare Star Ratings The star rating is based on overall performance in 5 different areas of quality: HEDIS 1. Staying Healthy: Screenings, tests and vaccines 2. Managing chronic conditions 3. Member experience with the health plan 4. Member complaints, problems with obtaining services 5. The Health Plans Customer Service These 5 areas are broken down into 4 different categories Operational Performance Stars Part D Pharmacy Safety HOS CAHPS Quality Scores Drive Participation 4

5 HEDIS HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET A set of standardized performance measures designed to help purchasers and consumers compare the performance of health plans on an apples-to-apples basis. Quality Scores Drive Participation 5

6 CMS STAR Measures May Change Annually 6

7 2014 Star Rated HEDIS measures 1. BMI 2. Disease-Modifying Anti- Rheumatic Drug Therapy 3. Controlling High Blood Pressure 4. Comprehensive Diabetes Care 5. Cholesterol Management 6. Care of Older Adults 7. Colorectal Cancer Screening 8. Use of High-Risk Meds in Elderly 9. Osteoporosis Management 10. Plan All Cause Readmission Excellent Performance Above Average Performance Average Performance Below Average Performance Poor Performance Quality Scores Drive Participation 7

8 BMI Patients Documentation in the medical record must include: Height/Weight Calculated BMI value & the date it was performed. Documentation of height and weight ONLY does not meet HEDIS criteria. 8

9 DMARD Disease-Modifying Anti-Rheumatic Drug Therapy Patients with Rheumatoid Arthritis Diagnosis Filled at least one prescription for a DMARD Hydroxychloroquine (Plaquenil) Sulfasalzine (Azulfidine) Methotrexate (Rheumatrex, Trexall) Azathioprine (Imuran) Cyclophosphamide (Cytoxan) Biologics (Actemra, Cimzia, Embrel,, Humira, Kinerat, Orencia, Remicade, Rituxan, Simponi) NSAIDS/Steroids Do not Meet Criteria 2 exclusions: Dx of HIV or pregnancy Quality Scores Drive Participation 9

10 Controlling High Blood Pressure Patients with HTN B/P adequately controlled (<140/90) based on the most recent blood pressure. Quality Scores Drive Participation 10

11 Comprehensive Diabetes Care Patients with Diabetes HbA1c < 9.0% LDL-C screening LDL-C control <100mg/dl Nephropathy screening/urine Microalbumin Retinal eye exam* * or a negative retinal exam from the year prior Quality Scores Drive Participation 11

12 Cholesterol Management for patients with Cardiovascular Conditions Patients patients with a diagnosis of Acute MI, CABG, PTCA or Diagnosis of ASVD LDL-C screening Quality Scores Drive Participation 12

13 Care of Older Adults SNP members 66 and older 4 separate measures Medication Review Functional Status Assessment Pain Assessment Advance Care Planning Quality Scores Drive Participation 13

14 Medication Review (Care of Older Adults) Current list of medications in the medical record AND Evidence of a medication review by a practitioner with the date it was performed Quality Scores Drive Participation 14

15 Functional Assessment (Care of Older Adults) FUNCTIONAL STATUS Unable to obtain due to mental status (If selected, was the information obtained from a family member/caregiver? If yes, Name: ADL Skill Independent Dependant Supporting Diagnosis Ambulation Cane Walker WC G/Chair Bed Dressing Min Mod Max Transfers Transfer Board Lift Assistance 1 person/2 person Toileting Cont. Bowel Incontinent of Bowel Cont. Bladder Incontinent of Bladder Feeding Fed PEG NG TPN Colostomy Ileostomy Foley Cath Suprapubic Cath Condom Cath Briefs Can the member demonstrate that he/she can stand from a sitting position? Yes No Quality Scores Drive Participation 15

16 Pain Assessment (Care of Older Adult) Hurts just a Hurts even Hurts a little bit more whole lot Very happy, no hurt Hurts a little more Hurts as much as you can imagine (don t have to be crying to feel this much pain) Visual Analog Scale (VAS) Quality Scores Drive Participation 16

17 Advance Care Planning (Care of Older Adults) Copy of an Advance Care Planning in the record or Documentation of a discussion with member and the date it occurred or Notation that member previously executed an Advance Care Plan Quality Scores Drive Participation 17

18 Colorectal Cancer Screening Patients Colonoscopy in the past 10 years or Flexible sigmoidoscopy in the past 5 years or FOBT (X3) annually exclusion: diagnosis of colorectal cancer or total Colectomy Quality Scores Drive Participation

19 Use of High-Risk Medication in the Elderly Patients Age 66 and older One or more high-risk medications prescribed and filled in measurement year Quality Scores Drive Participation 19

20 Osteoporosis Management in Women who had a Fracture Women 67 years and older AND who suffered a fracture A Bone Mineral Density test or a prescription for a drug to treat or prevent osteoporosis in the 6 months after the fracture exclusions: fracture of finger/toe/face/skull Quality Scores Drive Participation 20

21 Plan All-Cause Readmission 18 and older Readmission within 30 days; either for the same or different condition. May be the same or different hospital No specific reporting for the providers. Star rating is generated from health plan data. Quality Scores Drive Participation 21

22 Star Rating Thresholds Measure 4 Star 5 Star BMI % > 89 % Disease-Modifying Anti-Rheumatic Drug Therapy % > 83 % Controlling High Blood Pressure % > 77 % DM- HbA1c % > 84 % DM-LDL-C screening % > 93 % DM-LDL-C Control % > 59% Nephropathy screening % > 89 % Retinal Eye Exam % >70 % Cholesterol Management- Screening % > 89 % COA- Medication Review % > 92 % COA- Functional Status Assessment % > 87 % COA-Pain Assessment % > 91 % COA- Advance Care Planning N/A N/A Colorectal Cancer Screening % > 65% Use of High-Risk Medication 3-5 % < 3 % Osteoporosis Management % > 70% Plan All-Cause Readmission 9-11 % < 9 % Quality Scores Drive Participation 22

23 HEDIS Operational Performance Stars HOS CAHPS 2 nd Category: Part D Pharmacy Safety HOS AND CAHPS SURVEYS Quality Scores Drive Participation 23

24 Health Outcomes Survey (HOS) Monitors physical activity, mental health, risk of falls and improving bladder control patient-reported outcomes measure Patients are contacted by a 3 rd party vendor The patients are asked. Did your Provider Discuss strategies for your risk of falling? Discuss strategies to improve Urinary Incontinence? Discuss your current level of physical activity? Is your physical health the same, better or worse? Is your mental health the same, better or worse? HOS is weighted 3 times more than health plan operations

25 Consumer Assessment of Healthcare Providers and Systems (CAHPS ) Survey that measures the members SATISFACTION with their provider along with their current health plan. Getting Needed Care: ease of getting appointment, care, tests and treatments believed necessary. (15 minutes from check-in to being seen by the provider!) Getting Care Quickly Coordination of Care from Doctor s Office Doctor had Medical correspondence Staff follow up with test results ( including specialist consults) Doctor discussed prescriptions Satisfaction with help to coordinate care ( any assistance needed) Patient satisfaction is weighted 1.5 times more than health plan operations

26 HEDIS Operational Performance Stars HOS CAHPS 3 rd Category PART D Part D Pharmacy Safety PHARMACY SAFETY MEASURES Quality Scores Drive Participation 26

27 Medication Management (Part D) Annual Monitoring for Patients on Persistent Medication Adherence to: Statins Diabetes Medications High Blood Pressure medications (ACE/ARB) Anti-Retroviral Medications Quality Scores Drive Participation

28 HEDIS Operational Performance Stars Part D HOS CAHPS 4 th Category Pharmacy Safety OPERATIONAL PERFORMANCE Quality Scores Drive Participation 28

29 Operational Performance Health Plan Customer Service including member complaints and satisfaction survey reviews Health Plan overall performance such as making timely decisions about appeals and reviewing appeal decisions. (of Health Plan) Quality Scores Drive Participation

30 Quality Scores Drive Participation 30

31 Benefits of the Stars Program Benefits to the provider: Improved relations between you and your patient Increased awareness of patient safety issues Greater focus on preventive medicine Financial incentives based on individual provider s performance Quality Scores Drive Participation 31

32 2013 Bonus Payment HEDIS MEASURE ELIGIBLE MEMBERS HEDIS 2013 CURRENT RATE BONUS PER COMPLIANT MEMBER COMPLIANT MEMBERS RATE STAR MET 4 STAR 5 STAR 4 STAR 5 STAR BONUS AMOUNT Anti-Rheumatic Drug % 2 Star 2 3 $ $ $0.00 Colorectal Cancer Screen % 5 Star MET MET $30.00 $40.00 $9, Diabetes LDL-C < % 4 Star MET 26 $ $ $14, Diabetic Eye Exam % 3 Star 4 23 $70.00 $90.00 $0.00 Functional Assessment % 5 Star MET MET $70.00 $90.00 $17, Glaucoma Screening % 4 Star MET 31 $70.00 $90.00 $17, HbA1c <= % 3 Star 8 24 $ $ $0.00 Mammogram % 4 Star MET 4 $30.00 $40.00 $2, Medication Review % 5 Star MET MET $70.00 $90.00 $17, Osteoporosis Test % 3 Star 1 2 $ $ $0.00 Pain Screening % 5 Star MET MET $70.00 $90.00 $17, P4P Total..... $96, Quality Scores Drive Participation 32

33 2014 Potential Bonus Payment 2014 Quality Measure Bonus Payment Amount Results Evaluated Payment Frequency Payment will be made when all 4 measures are completed by submitting the required 5 Category II CPT Codes. Achievement will be verified by Claim Submission on the CMS 1500 Form. Care of Older Adults (COA) submission of a combination of all five (5) CPT II codes is required for 4 measures: - Advanced Care Planning: 1157F OR 1158F (one code) - Medication Review: 1159F AND 1160F (two codes) - Functional Status: 1170F (one code) - Pain Screening: 1125F OR 1126F (one code) $ per eligible compliant Medicare SNP (dualeligible) member per year Monthly Monthly for each newly compliant member 33

34 Payment will be made when the measure is achieved. Achievement will be verified by the Monthly Quality Review Report distributed by the Coventry Quality Department. Rheumatoid Arthritis Management achieve a 3.0 or higher quality rating Breast Cancer Screening achieve a 5.0 quality rating Comprehensive Diabetes Care Glucose Good Control each compliant member Hemoglobin A1c < 9% $40.00 per eligible compliant Medicare member per year $20.00 per eligible compliant Medicare member per year $20.00 per eligible compliant Medicare member per year Monthly Monthly Monthly Monthly for each newly compliant member Monthly for each newly compliant member Monthly for each newly compliant member Comprehensive Diabetes Care Cholesterol Good Control each compliant member LDL < 100 $20.00 per eligible compliant Medicare member per year Monthly Monthly for each newly compliant member Osteoporosis Management in Women (OMW) Osteoporosis testing and management each compliant member BMD test and/or osteoporosis medicine to manage post fracture $40.00 per eligible compliant Medicare member per year Monthly Monthly for each newly compliant member 34

35 How can YOU improve Star/HEDIS rates? Educate patients regarding the importance of screenings (mammograms and Colonoscopies), appropriate to their sex and age. Focus on identified care gaps and encourage patients to schedule appointments for screenings. Have time to discuss patient s health concerns. Assist patients in the management of chronic conditions such as diabetes and high blood pressure by having appropriate lab tests and/or procedures. Engage support staff in the process 35

36 Although it is the health plan that is assigned the score, 95% of the score comes from the physician/patient experience. Quality Scores Drive Participation 36

37 Health plans that do not achieve a 4 Star rating or better, will take a substantial payment reduction in In 2016, Changes will effect Straight Medicare Quality Scores Drive Participation 37

38 THANK YOU Quality Scores Drive Participation 38