CMS Five-Star Quality Rating System
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1 CMS Five-Star Quality Rating System Pantea Ghasemi, USC Pharm.D. Candidate of 2015 Preceptor Dr. Craig Stern Pro Pharma Pharmaceutical Consultants, Inc. April 24, 2015
2 Objectives 1. Understand the background on Medicare 2. Understand the Five-Star Quality Rating System 3. Analyze how the Rating is calculated 4. Outcomes of Five-Star Rating 5. Understand strengths and weaknesses of the Five-Star Rating System
3 Background Affordable Care Act (ACA) Centers of Medicaid and Medicare Services (CMS) Improve quality of care Strengthen Medicare by making health plans report to national data bases measurements of their measured quality of care Federal agency that administers Medicare Designed the Five-Star quality rating system in 2007 Five-Star Quality Rating System Allows for patients to select a health plan Allows to compare and measure quality of care among different health plans
4 Background-Medicare Types Part A Part B Part C Part D Description Inpatient Services Outpatient Services Medicare Advantage (Part A+B, Part D optional) Prescription drug Plan
5 Five-Star Quality Rating System It s a quality and performance scoring method for certain plans offered to Medicare beneficiaries Allows patients to compare performance among health plans Scale 5 Excellent 4 Above Average 3 Average 2 Below Average 1 Poor Performance
6 Five-Star Quality Rating System: 5 Star Health Plan Examples 1) Medicare Advantage Plans with Prescription Drug Coverage Kaiser Foundation HP, Inc. (California) CarePlus Health Plan Inc. (Florida) Group Health Plan (Washington) Gundersen HP (Wisconsin) Providence HP (Oregon) Martin s Point Generations, LLC (Maine) Healthspan Integrated Care (Ohio)
7 Five-Star Quality Rating System: Evaluation Ratings combine scores for types of services each plan offers Based on Measures related to 1. Clinical performance 2. Customer Service 3. Member Satisfaction Measure: Specific Characteristic 1. Quality and performance 2. Each assigned a star rating Domain: Categories 1. Each assigned an average star rating
8 Five-Star Quality Rating System: Part C Medicare Advantage 36 Measures in 5 Domains: 1. Staying Healthy: Screenings, Tests, and Vaccines 2. Managing chronic (long-term) conditions 3. Managing responsiveness and care 4. Member complaints, problems getting services, and choosing to leave a plan 5. Health plan customer service
9 Five-Star Quality Rating System: Part D-Prescription Plan 17 Measures in 4 Domains: 1. Drug plan customer service 2. Member complaints, problems getting services, and choosing to leave the plan 3. Member experience with drug plan 4. Drug pricing and patient safety
10 Five-Star Quality Rating System: Data Collection Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare Healthcare Outcomes Survey (HOS) Healthcare Effectiveness Data and Information Set (HEDIS) Data collected from patients as well as physicians CMS administrative data
11 Calculating the Rating Individual Measures Domain Level (Part C and D) Part C and D Summary Ratings Measure Outcome measures Intermediate outcome measure Patient experience measures Weight Average of individual measure Star Ratings Calculated by taking the weighted average of the measure level ratings plus the i-factor Access measures 1.5 Process measures 1
12 Example Calculation Pantea s Health Plan: Overall Star-Rating: 5 Stars!
13 Example Calculation- Bonus Payments 2015
14 Outcomes of Star Rating The average star rating weighted by enrollment last year in 2014 compared to 2013: MA-PD: 3.66 vs 3.44 PDP: 3.30 vs. 2.96
15 2013 Star Rating: MA+PDP
16 2014 Star Rating: MA+PDP
17 Strengths of Five-Star Rating System Creates Accountability for performance and finance for health plans Easy way for patients to compare health plans Sets up a system to provide and improve quality of care With the Quality Bonus Payments creates an incentive for health plans to continue with the process of improving quality of care The rating system ultimately will lower utilization of care
18 Weaknesses of the Star-Rating System Performance can be relative Patient surveys are subjective Variable depending on population and geography Need more outcome measures
19 Summary Star-Rating system allows apple to apple comparison among health plans Measures different domains (outcomes and patient satisfaction) with corresponding weights Shows promise in improving quality of care Contains strengths and weaknesses where there is room for improvement
20 References 1. Clark, A., Piper, B., & Dieguez, G. The Medicare Advantage 5-Star Rating Program and Its Implications for Actuaries. Society of Actuaries: Health Watch, 2012, Centers for Medicare & Medicaid. Fact Sheet 2014 Star Rating. Pp Retrieved April 22, Medicare Advantage Plans. Medicare.gov Retrieved April 19, 2015, from 4. Framework for Improving Medicare Plan Star Ratings. December Retrieved April 19, 2015, from 5. Part C and D Performance Data. Updated March 9, Retrieved April 19, 2015, Coverage/PrescriptionDrugCovGenIn/PerformanceData.html
21 Thank You! Any Questions?
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