Shoot For The Stars
Medicare Advantage Plans
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
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
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
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
.
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
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
.
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
Controlling High Blood Pressure
Patients with HTN
•
B/P adequately
controlled (<140/90)
based on the most
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
Cholesterol Management
for patients with Cardiovascular Conditions
Patients 18-75 patients with a
diagnosis of Acute MI, CABG,
PTCA or Diagnosis of ASVD
Care of Older Adults
SNP members 66 and older
4 separate measures
Medication Review
Functional Status Assessment
Pain Assessment
Advance Care Planning
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
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
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)
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
Colorectal Cancer Screening
Patients 50-75
•
Colonoscopy in the past 10
years or
•
Flexible sigmoidoscopy in
the past 5 years or
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
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
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.
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 %
HOS AND CAHPS® SURVEYS
2
nd
Category:
Quality Scores Drive Participation 23
Stars
HEDIS®
HOS
CAHPS®
Part D
Pharmacy
Safety
Operational Performance
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?
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)
PART D
PHARMACY SAFETY MEASURES
3
rd
Category
Stars
HEDIS®
HOS
CAHPS®
Part D
Pharmacy
Safety
Operational Performance
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 ParticipationOPERATIONAL PERFORMANCE
4
th
Category
Stars
HEDIS®
HOS
CAHPS®
Part D
Pharmacy
Safety
Operational Performance
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.
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
2013 Bonus Payment
HEDIS 2013 CURRENT RATEBONUS 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
. . . . .
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
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