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

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(1)

Shoot For The Stars

Medicare Advantage Plans

(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

(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

(4)

Medicare Star Ratings

The star rating is based on overall

performance in 5 different areas

of quality:

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

Stars

HEDIS®

HOS

CAHPS®

Part D

Pharmacy

Safety

Operational

Performance

(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

.

(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

Quality Scores Drive Participation 7



Excellent Performance



Above Average

Performance



Average Performance



Below Average

Performance

Poor Performance

(8)

BMI

Patients 18-74

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

.

(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

9 Quality Scores Drive Participation

(10)

Controlling High Blood Pressure

Patients with HTN

B/P adequately

controlled (<140/90)

based on the most

(11)

Comprehensive Diabetes Care

Patients 18-75 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

(12)

Cholesterol Management

for patients with Cardiovascular Conditions

Patients 18-75 patients with a

diagnosis of Acute MI, CABG,

PTCA or Diagnosis of ASVD

(13)

Care of Older Adults

SNP members 66 and older

4 separate measures

Medication Review

Functional Status Assessment

Pain Assessment

Advance Care Planning

(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

(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 G/Chair Walker Bed WC Dressing Min Mod Max Transfers Transfer Board Assistance 1 person/2 person Lift Toileting Cont. Bowel

Cont. Bladder Incontinent of Bowel Incontinent of Bladder Colostomy Suprapubic Cath Ileostomy Condom Cath Foley Cath Briefs Feeding Fed PEG NG

TPN

Can the member demonstrate that he/she can stand from a sitting position? Yes No

(16)

Pain Assessment

(Care of Older Adult)

0

2

4

6

8

10

Very

happy,

no hurt

Hurts just a

little bit

Hurts a

little

more

Hurts even

more

whole lot

Hurts a

much as

Hurts as

you can

imagine

(don’t have to be crying to

feel this much pain)

Visual Analog Scale (VAS)

(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

(18)

Colorectal Cancer Screening

Patients 50-75

Colonoscopy in the past 10

years or

Flexible sigmoidoscopy in

the past 5 years or

(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

19 Quality Scores Drive Participation

(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

(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.

(22)

Star Rating Thresholds

Measure

4 Star 5 Star

BMI 77-89 % > 89 % Disease-Modifying Anti-Rheumatic Drug Therapy 77-83 % > 83 % Controlling High Blood Pressure 63-77 % > 77 % DM- HbA1c 80-84 % > 84 % DM-LDL-C screening 85-93 % > 93 % DM-LDL-C Control 53-59 % > 59% Nephropathy screening 85-89 % > 89 % Retinal Eye Exam 64-70 % >70 % Cholesterol Management- Screening 85-89 % > 89 % COA- Medication Review 75-92 % > 92 % COA- Functional Status Assessment 62-87 % > 87 % COA-Pain Assessment 76-91 % > 91 %

(23)

HOS AND CAHPS® SURVEYS

2

nd

Category:

Quality Scores Drive Participation 23

Stars

HEDIS®

HOS

CAHPS®

Part D

Pharmacy

Safety

Operational Performance

(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?

(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)

(26)

PART D

PHARMACY SAFETY MEASURES

3

rd

Category

Stars

HEDIS®

HOS

CAHPS®

Part D

Pharmacy

Safety

Operational Performance

(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)

OPERATIONAL PERFORMANCE

4

th

Category

Stars

HEDIS®

HOS

CAHPS®

Part D

Pharmacy

Safety

Operational Performance

(29)

Operational Performance

(of Health Plan)

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.

(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

(32)

2013 Bonus Payment

HEDIS 2013 CURRENT RATE

BONUS PER COMPLIANT MEMBER HEDIS MEASURE

ELIGIBLE MEMBERS

COMPLIANT

MEMBERS RATE STAR MET

4 STAR 5 STAR 4 STAR 5 STAR

BONUS AMOUNT

Anti-Rheumatic Drug 11 7 64.00% 2 Star 2 3 $125.00 $175.00 $0.00 Colorectal Cancer Screen 346 242 70.00% 5 Star MET MET $30.00 $40.00 $9,680.00 Diabetes LDL-C < 100 209 112 54.00% 4 Star MET 26 $125.00 $175.00 $14,000.00 Diabetic Eye Exam 209 130 62.00% 3 Star 4 23 $70.00 $90.00 $0.00 Functional Assessment 212 190 90.00% 5 Star MET MET $70.00 $90.00 $17,100.00 Glaucoma Screening 368 257 70.00% 4 Star MET 31 $70.00 $90.00 $17,990.00 HbA1c <= 9 209 160 77.00% 3 Star 8 24 $125.00 $175.00 $0.00 Mammogram 123 95 77.00% 4 Star MET 4 $30.00 $40.00 $2,850.00 Medication Review 212 194 92.00% 5 Star MET MET $70.00 $90.00 $17,460.00 Osteoporosis Test 10 5 50.00% 3 Star 1 2 $125.00 $175.00 $0.00 Pain Screening 212 191 90.00% 5 Star MET MET $70.00 $90.00 $17,190.00

P4P Total

. . . . .

(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)

$160.00 per eligible compliant

Medicare SNP (dual-eligible) member per year

Monthly Monthly for each newly

compliant member

(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

$40.00 per eligible

compliant Medicare

member per year

Monthly

Monthly for

each newly

compliant

member

Breast Cancer Screening – achieve a 5.0 quality

rating

$20.00 per eligible

compliant Medicare

member per year

Monthly

Monthly for

each newly

compliant

member

Comprehensive Diabetes Care – Glucose Good

Control – each compliant member Hemoglobin

A1c < 9%

$20.00 per eligible

compliant Medicare

member per year

Monthly

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

(35)

35

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

(36)

Although it is the health plan that is assigned

the score, 95% of the score comes from the

(37)

Health plans that do not achieve a

4

Star rating or better, will take a

substantial payment reduction in

2015.

In 2016, Changes will effect

Straight Medicare

(38)

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