CMS 5 STARS PROGRAM

MedPOINT Management

Healthcare Reform will require significant change to Medicare Advantage plans transforming them into an integrated health delivery system concentrating on quality of care outcomes within the next 1-5 years.

What are the consequences?? There will be pressure to correctly screen, document

and perform precise coding or chronic disease along with exceeding quality performance measures related to HDIS and national survey instruments (HOS and CAHPS).

The federal government will essentially be paying for quality outcomes based on STARs/HEDIS ratings.

Planning for the Future

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CMS created the 5-STAR Quality Rating System for Medicare Advantage plans to compare Medicare Advantage plans more easily, and to help identify areas about which they may want to ask questions.

The STARS are a quality rating system that gives each plan a rating of between 1 and 5 stars. Plans with 5 stars are considered to be highly above average in quality, and plans with 1 star are considered to be very below average in quality.

WHAT ARE THE CMS STARs??

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WHY IS STARS RATING SIGNIFICANT?

STAR RATINGS are CMS Ratings for Part C and D Medicare Plans

The original purpose of STAR ratings was to enable Medicare beneficiaries to compare quality among Medicare Advantage Plans on the Medicare Prescription Drug Plan Finder (MPDPF).

As part of Health Care Reform, CMS will begin a quality bonus payment in 2012 for MA Plans based on the Five Star Ratings.

In the fall of 2006, CMS posted Plan ratings based on a 3 star scale

For 2008, Annual Enrollment Period (AEP), CMS introduced a 5 Star scale. [5=highly above average; 1=very below average]

STAR Ratings are updated annually during the AEP

WHAT ARE THE CMS STARS?? (CONTINUED)

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HOW ARE STAR RATINGS MEASURED?

Health Plans receive an overall STAR rating and ratings by domain

PART CDomain I: Staying Healthy: Screenings, Tests and VaccinesDomain II: Managing Chronic (Long Lasting) ConditionsDomain III: Rating of Health Plan Responsiveness and CareDomain IV: Member Complaints, Appeals and Choosing to Leave the Health PlanDomain V: Customer Service

PART DDomain I: Drug Plan Customer ServiceDomain III: Member Experience with the Health PlanDomain IV: Drug Pricing and Patient Safety

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CMS STAR RATINGS – DATA SOURCES HEDIS: A widely used set of performance measures in the managed care industry, developed

and maintained by NCQA

CAHPS (Consumer Assessment of Healthcare Providers and Systems): Comprehensive family of surveys that ask consumers and patient to evaluate interpersonal aspects of health care.

HOS (Health Outcomes Survey): Patient reported outcomes measure used in Medicare managed care. All managed care organizations with MA contracts must participate.

CTM (Complaints Tracking Module): Complaint rates per 1,000 are adjusted to a 30-day basis

CMS Audit: Findings of CMS audits, ad hoc and compliance actions that occurred during the 14-month past performance review period

MBDS (Medicare Beneficiary Database Suite of Systems) A collection of individual applications and services that access a single source for Medicare beneficiary demographic data

IRE: Independent Review Entity: An independent entity contracted by CMS to review Medicare health plans’ adverse reconsideration of organization determinations

Phone Monitoring: Call center data collected by CMS

PDE Data: Prescription Drug Event Data: Data was obtained from PDE data files submitted by drug plans to Medicare for the reporting period

MARx: Medicare Advantage Prescription Drug System: This data presents the percentage of new enrollment requests from beneficiaries that the plan submitted to Medicare within 7 days of the application date.

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BASIS FOR THE STAR RATINGS

The ratings are based on Part C & D Measures. Star rating based on average of 53 measures which are continually updated.

36 Part C measures17 Part D measures

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DATA SOURCES BY WEIGHT

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HEDIS MEASURES

Breast Cancer Screening

Colorectal Screening

CV Colorectal Screening

Monitoring of Long Term Patient’s Medication

Diabetes-Colorectal Screening

Diabetes-Kidney Monitoring

Diabetes-Blood Sugar Control

Diabetes-Cholesterol Control

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HEDIS MEASURES (CONTINUED)

Glaucoma Testing

Access to Primary Care Doctor Visits

Osteoporosis Management

Diabetes Eye Care

Controlling Blood Pressure

Rheumatoid Arthritis Management

Testing to Confirm COPD

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CAHPS MEASURES

Annual Flu Vaccine

Pneumonia Vaccine

Ease of Getting Needed Care and Seeing Specialists

Doctors Who Communicate Well

Getting Appointments and Care Quickly

Overall rating of Health Care Quality

Overall rating of the Health Plan

Customer Service

Member complaints

Appeals

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HEALTH OUTCOMES SURVEY Improving Bladder Control (Physicians need to initiate discussion)

Reducing the Risk of Falling (Discuss balance problems, trouble walking and other risk factors)

Monitoring Physical Activity (Advise patient how to start, increase or maintain)

Improving or Maintaining Physical Health (Gauge status at each visit)

Improving or Maintaining Mental Health (Gauge status at each visit)

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USE THE ANNUAL WELLNESS VISIT AS A VEHICLE TO SET THE STAGE.

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