Humana Updates and Resources

Transcription

1 Humana Updates and Resurces Kelsey White and Janna Schmidt Prvider Cnsultants September 28 th 2018

2 Agenda Medicare CMS Stars HEDIS Stars Measures Patient Safety Part D Measures Member Experience CAHPS/HOS Preventative Screen Claims Credentialing Resurces 2

3 Medicare CMS Stars: General framewrk Stars has been created by the Centers fr Medicare & Medicaid Services (CMS) t raise the quality f care fr Medicare enrllees and reduce federal health care expenditures. The prgram hlds health plans accuntable fr the care prvided t enrllees by physicians, hspitals and ther health care prviders. CMS develped the Stars prgram fr Medicare Advantage cnsumers with tw bjectives: Drive health plans tward higher quality and mre efficient care Influence cnsumer plan chices during pen enrllment MA-PD (Medicare Advantage Part D) nly Star ratings are calculated at an verall cntract level (ratings cmbine Part C and D measures) Based n 40-plus weighted measures (measure set reviewed by CMS each year) Ratings published annually (1 Star t 5 Stars) Cnsensus-building entities (e.g., NCQA and PQA) cnsult with CMS fr measure cncept develpment, specificatins and endrsement Ratings at cntract level 3

4 Measures physicians can impact HEDIS Healthcare Effectiveness Data and Infrmatin Set HEDIS 27% weight Imprvement 13% weight CAHPS Cnsumer Assessment f Healthcare Prviders and Systems CAHPS 17% weight Patient safety 13% weight HOS 10% weight HOS Healthcare Outcmes Survey CMS (Centers fr Medicare & Medicaid Services) Administrative data n plan quality/member satisfactin CMS 12% weight IRE 8% weight IRE Independent review entity Physicians directly influence 80 percent f the Stars rating 4

5 Stars BY2021 Measures 1 and Weights 1 HEDIS (measured Jan Dec) ABBR Weight Rheumatid Arthritis Management ART 1x Breast Cancer Screening BCS 1x Osteprsis Management OMW 1x Plan All-Cause Readmissins PCR 3x Clrectal Cancer Screening COL 1x Cntrlling Bld Pressure CBP 3x Diabetes Eye Exam EYE 1x Diabetes Nephrpathy NPH 1x Diabetes Bld Sugar Cntrl HBA 3x Adult BMI Assessment ABA 1x COA 2 Medicatin Review MDR 1x COA 2 Functinal Status Assessment FSA 1x COA 2 Pain Screening PNS 1x Medicatin Recnciliatin Pst- Discharge Statin Therapy fr Cardivascular Disease MRP SPC Patient Safety (Jan Dec) ABBR Weight Medicatin Adherence: Diabetes 3 MAD 3x Medicatin Medicatin Adherence: Hypertensin 3 MAH 3x (ACE/ARB) Medicatin Adherence: Chlesterl (statins) 3 MAC 3x Statin Use in Persns with Diabetes SUPD 3x 1x 1x CAHPS (measured Feb Jun) ABBR Weight Annual Flu Vaccine FLU 1x Getting Needed Care GNC 1.5x Getting Appintments and Care Quickly HOS (measured Feb Jun) ABBR Weight Imprving r Maintaining Physical Health Imprving r Maintaining Mental Health GACQ 1.5x Custmer Service CS 1.5x Overall Rating f Health Care Quality RHCQ 1.5x Overall Rating f Health Plan RHP 1.5x Care Crdinatin CC 1.5x Overall Rating f Drug Plan RDP 1.5x Getting Needed Prescriptin Drugs GNRx 1.5x PCS MCS Mnitring Physical Activity PAO 1x Imprving Bladder Cntrl MUI 1x Reducing the Risk f Falls 1 FRM 1x IRE (measured Jan Dec) ABBR Weight Appeals Aut-Frward (drug plan) AAF 1.5x Appeals Upheld (drug plan) AU 1.5x Timely Decisins abut Appeals PTD 1.5x Reviewing Appeals Decisins RAD 1.5x 3x 3x CMS (measured Jan Dec) ABBR Weight Cmprehensive Medicatin Review CMR 1x Cmplaints abut the Health Plan CHP 1.5x Members Chsing t Leave the Plan MLPC 1.5x Medicare Plan Finder Accuracy MPF 1x Special Needs Plan Care Management 2 SNP 1x Call Center - Freign Language Interpreter & TTY/TDD - Part C Call center - Freign Language Interpreter & TTY/TDD - Part D FLIC 1.5x FLID 1.5x Imprvement Measures ABBR Weight Part C Imprvement HPQI 5x Part D Imprvement DPQI 5x Display Measures (2018) 4 ABBR High Risk Medicatins HRM Patient Safety Opiid Overutilizatin Antipsychtic Use in Persns with Dementia OO APD Patient Safety Patient Safety Patient Frmulary Administratin Analysis FAA Safety Beneficiary Access and Perfrmance Prblems BAPC CMS Hspitalizatin fr Ptentially Preventable Cmplicatins 1 HPC HEDIS Updated: April 9, Prpsed measures and weights reflect latest CMS Call Letter (4/2/2018). Nte HPC will be a display measure fr BY20 and Reducing the Risk f Falls will be a Stars Measure fr BY Measures apply nly t Special Needs Plans (SNP). 3. Per CMS Advanced Ntice guidelines, medicatin adherence measures fr Puert Ric are 0-weight. 4. Display measures are nt part f Star ratings Display measures reflect MY2017 services, displayed n CMS.gv in

6 CMS Stars measure threshlds CMS grades n a curve; therefre, Stars threshlds are based n the tp perfrmers. Because f this, CMS always is raising the bar, and every gap in care is an imprvement pprtunity. Prvider perfrmance may imprve frm mnth t mnth, but physicians may ntice Stars ratings decline due t the grading curve; cnsequently, Humana assciates seek t clse all available gaps in care. Humana s bjective is t be the leader in the industry by imprving quality f care by fcusing n clsing every member gap. Key call-t-actin items: Clse HEDIS gaps based n current Stars Quality Reprt Data submissin (btain evidence f care) CAHPS/HOS cmment screcards Part D (adherence and patient safety) impactables 6

7 Hw Humana supprts quality imprvement Humana cnducts utreaches t physicians and their patients with Humana cverage t d the fllwing: Prvide Star Quality Reprts highlighting patients needing preventive services Facilitate quality visits/relatinships (prvider engagement representatives) Prmte physician Star rewards Encurage use f electrnic medical recrds (EMRs) and lab cnnectins Assist with data cllectin Execute clinical and incentive prgrams t supprt patient well-being 7

8 Methds fr submitting supplemental data 1. Claims/encunters - Mst preferred methd fr gap clsure Lessen the need fr submissin f data by ensuring prper cdes are included n claims. 2. Medical recrds cnnectivity Allw Humana t cnnect electrnically with prvider electrnic medical recrds and exchange clinical data. Send yur Humana-cvered patient s medical recrds autmatically t Humana after each episde f care. 3. Data feeds Enable prviders t extract data frm their electrnic medical recrd int a standardized layut and prvide it n a regular basis t Humana via secure r FTP. Extract data frm EMRs t create the file fr submissin. 4. Attestatins Ensure pen gaps reprts have been cmpleted. Verify that cmpleted reprts are signed by a practitiner with apprved credentials (M.D., N.P., P.A., D.O., R.P.H.). 5. Cpies f medical recrds Submit medical recrds t clse gaps in care. Be sure t include tw patient identifiers and the minimal infrmatin required by the measures. Prvide medical recrds t Humana via uplad, fax r mail. 8

9 HEDIS Stars measures 9

10 HEDIS Stars measures HEDIS Stars measures have an assigned weight. The weight is indicative f the measure s value within the Stars rating scale. Generally, utcme measures are tripleweighted, cmpared t screenings measures that are single-weighted. The cmbined rates f the HEDIS Stars measures cnstitute 27 percent f the Stars scre. Measure Weight Breast cancer screening 1 Clrectal cancer screening 1 Adult BMI assessment 1 Care fr lder adults medicatin review 1 Care fr lder adults functinal status assessment Care fr lder adults pain assessment 1 Osteprsis management 1 Diabetes care eye exam 1 Diabetes care kidney disease mnitring 1 Diabetes care bld sugar cntrlled 3 Cntrlling bld pressure 3 Rheumatid arthritis management 1 Plan all-cause readmissins 3 Medicatin recnciliatin pst-discharge 1 Statin therapy fr patients with cardivascular disease

11 Osteprsis management in wmen wh had a fracture (OMW) Percentage f wmen 67 t 85 years ld wh suffered a fracture and had either a bne mineral density (BMD) test r prescriptin fr a drug t treat r prevent steprsis in the six mnths after the fracture. Ntes: A patient wh had a BMD test 24 mnths befre the fracture r a prescriptin t treat r prevent steprsis within 12 mnths befre the fracture is excluded frm the denminatr. A cpy f the radilgy reprt shuld be btained and filed in the patient s medical recrd. 11

12 Cmprehensive diabetes care (CDC) Percentage f patients 18 t 75 years ld with diabetes (Type 1 r Type 2) wh had each f the fllwing: Bld sugar cntrlled (CDC-HbA1c) measure Result must be recrded and 9 percent r less fr Medicare Advantage Star reprting fr cmpliance. The last reading/result f the measurement year will be used fr HEDIS reprting, and perfrmance rating fr a care pprtunity may repen with a nncmpliant r missing result. Eye exam (dilated r retinal) (CDC-eye) A cmprehensive eye exam by an eye care prfessinal shuld be perfrmed and read during the measurement year fr cmpliance. A negative eye exam by an eye care prfessinal in the year prir t the measurement year can clse the care pprtunity (ICD-10 cde submissin required). Diabetic nephrpathy screening (CDC-neph) T be cmpliant, a patient must have had a nephrpathy screening, nephrlgy cnsult r dispensed prescriptin fr angitensin-cnverting enzyme (ACE) inhibitr/angitensin receptr blcker (ARB) therapy. 12

13 Hw t address the HbA1c care pprtunity Ensure the patient has taken the test Ensure crrect cding fr HbA1c result n a claim (CPT II) Wrk with the patient t achieve an HbA1c within acceptable limits Accurately dcument the result in the medical recrd, including date f service Use lab and supplemental data feeds 13

14 Best practices fr CDC-eye measure Review and use apprpriate CPT II cdes t indicate review f eye exam results. Refer patients t cvered eye care prfessinals and schedule appintments fr patients, if necessary. Ensure use f prper diagnsis cdes t reprt negative test results fr retinpathy. Utilize mbile eye exam units using fundus phtgraphy t capture image f the retina. 14

15 Best practices fr diabetic nephrpathy screening Use Medicare Stars checklist fr reference and place n tp f chart as a reminder t discuss with patient. Review diabetes services needed at each ffice visit. Order labs prir t appintments fr diabetic patients.. Prvide a test ptin in ffice. Send reminders t patients with either Type 1 r Type 2 diabetes regarding required testing. Cnnect patients t cmmunity and/r health plan resurces. 15

16 Cntrlling bld pressure (CBP) Percentage f patients diagnsed with hypertensin whse bld pressure (BP) was adequately cntrlled during the measurement year: Patients years ld whse BP was less than 140/90 mmhg Patients years ld with a diagnsis f diabetes whse BP was less than 140/90 mmhg Patients years ld withut a diagnsis f diabetes whse BP was less than 150/90 mmhg The last reading/result f the measurement year will be used fr HEDIS reprting and perfrmance rating. Ntes: CBP is a chart chase measure ( chart chase is the term used fr recrds cllectin seasn); therefre, the fllwing medical recrd dcumentatin is required: Hypertensin diagnsis dcumented n r befre June 30 f the measurement year Actual bld pressure reading (t pass, the mst recent adequately cntrlled bld pressure reading f the year must be dcumented) 16

17 Medicatin recnciliatin pst-discharge (MRP) Percentage f discharges frm Jan. 1 Dec. 1 f the measurement year fr patients 18 years ld and lder fr whm medicatins were recnciled frm the date f discharge thrugh 30 days. Ntes: Medicatin recnciliatin is the prcess f reviewing medicatins given in the hspital with thse taken regularly t prevent duplicatin r interactins. Medicatin recnciliatin must be cnducted by a prescribing practitiner, clinical pharmacist r registered nurse, as dcumented thrugh either administrative data r medical recrd review. Ensure dcumentatin n the encunter includes sme mentin f the inpatient/snf stay and/r that they were recently discharged. 17

18 Methds t address the MRP clinical care pprtunity Submit Current Prcedural Terminlgy (CPT ) cdes*: (days 1-7 pst-discharge) (days 8-14 pst-discharge) 1111F (within 30 days pst-discharge); Include Natinal Prvider Identifier (NPI) Cmplete an electrnic attestatin frm and/r Star Quality Reprt. Ensure medical recrd is submitted shwing cmpletin. *A medical cder reviews the patient s medical recrd and assigns the pertinent cde based n qualifying dcumentatin f medicatin recnciliatin. These cdes are transmitted t Humana via supplemental data feed by uplading electrnic medical recrds directly t Humana s secure prtal r faxed t Humana Recrd Retrieval. If the clinical pprtunity remains pen by the end f the year, Humana will cnduct a chart review t identify MRP cmpletin. 18

19 Plan all-cause readmissin (PCR) Percentage f patients 65 years ld and lder discharged frm a hspital stay and readmitted t a hspital within 30 days, either fr the same cnditin r a different reasn Ntes: Effrts frm the plan and physicians supprting crdinatin f care and preventin f readmissins imprve this rate. This is a highly leveraged measure and ne f the mst difficult t cntrl. 19

20 Best practices fr addressing the PCR measure Prmte health plan services (e.g., transitin f care, care crdinatin, hme health, etc.). Be aware f the daily discharge census. Manage scheduling capacity t be able t see patients wh have been discharged frm a hspital stay within seven days. Cnduct medicatin recnciliatin during first pst-discharge visit with patient. Discuss with patients if they have issues accessing the resurces necessary t prevent a readmissin (e.g., transprtatin fr fllw-up appintments and necessary medicatins). Cnnect patient t cmmunity resurces and/r health plan care management services t help remve barriers t care and/r access t resurces. 20

21 Statin therapy fr patients with cardivascular disease (SPC) Percentage f men years ld and wmen years ld, identified as having clinical athersclertic cardivascular disease (ASCVD) and dispensed at least ne high- r mderate-intensity statin medicatin during the measurement year. Ntes: A patient is excluded if there is a diagnsis f: - Pregnancy - Drugs administered fr in vitr fertilizatin r dispensed with clmiphene medicatin - End-stage renal disease - Mysitis - Myalgia - Cirrhsis - Mypathy - Rhabdmylysis Patients are identified fr the eligible ppulatin in tw ways: Event (during prir year): Mycardial infarctin (inpatient), crnary artery bypass grafting (CABG), percutaneus crnary interventin (PCI), ther revascularizatin Diagnsis: At least ne acute inpatient r utpatient visit with ischemic vascular disease (IVD) diagnsis in current and previus year 21

22 Patient safety Stars measures 22

23 Patient safety measures Patient safety Stars measures have an assigned weight. The weight is indicative f the measure s value within the Stars rating scale. Because medicatin adherence measures heavily influence patient utcmes, mst are tripleweighted. * SUPD was single-weighted as an intrductry measure, but will nw be triple-weighted. Measure Medicatin adherence: diabetes medicatin Medicatin adherence: hypertensin (ACE/ARB) Medicatin adherence: chlesterl (statins) Cmprehensive medicatin review (CMR) Statin use in persns with diabetes (SUPD) Weight * The cmbined rates f the patient safety Stars measures cnstitute 13 percent f the Stars scre. 23

24 Medicatin adherence (Part D) measures Percentage f patients 18 years ld r lder wh fill a prescriptin 80 percent r mre f the time fr the fllwing: Diabetes: - Biguanides - Sulfnylureas - Thiazlidinedines - DPP-IV inhibitrs - Incretin mimetics - Meglitinides Nte: Patients wh take insulin are nt included. Bld pressure: - ACE inhibitr - ARB drug - Direct renin inhibitr drug Chlesterl - Statin drugs 24

25 Medicatin therapy management (MTM) Cmpletin rate fr cmprehensive medicatin review (CMR) - Measures the percent f Medicare Part D beneficiaries 18 years ld r lder enrlled in the MTM prgram fr at least 60 days wh received a CMR MTM eligibility criteria: - Patients have three f the fllwing five chrnic diseases: cngestive heart failure (CHF), diabetes mellitus, dyslipidemia, hypertensin r bne disease arthritis steprsis - Minimum f eight Part D medicatins - Anticipated Part D drug cst f mre than $3,967 25

26 Statin use in persns with diabetes (SUPD) Percentage f Medicare Part D beneficiaries 40 t 75 years ld dispensed medicatin fr diabetes wh receive a statin medicatin Ntes: - A patient is excluded if in hspice. - Prescriptin claims data are used as a prxy fr diabetes diagnsis in this measure. - This measure uses nly prescriptin claims as a surce f data. 26

27 Member experience verview 27

28 CAHPS and HOS survey timelines January 2018 February March April May June July CAHPS survey Prentificatin letter First paper questinnaire mails Secnd paper questinnaire mails Telephnic utreach begins Telephnic utreach cntinues (three ttal attempts) Fllw-up calls end Cutff date fr phne and mail surveys Final data files due t CMS HOS survey HOS baseline chrt survey begins HOS fllw-up chrt survey begins HOS baseline chrt survey ends HOS fllw-up chrt survey ends Blackut perid: Late February thrugh June. Health plans are prhibited frm asking their members any CAHPS-related questin that culd influence fficial survey respnses. Physicians, hwever, may discuss CAHPS and HOS quality tpics with patients during this perid. 28

29 Why are CAHPS and HOS imprtant? Stars categry weight 13% 13% 10% 17% HOS CAHPS HEDIS IRE 11% 8% 27% CMS Patient safety Imprvement measures At 27 percent, CAHPS and HOS make up the secnd largest cmbined slice f the verall CMS Star rating. At a 4-Star level r abve, each plan is eligible fr a bnus based n membership. 29

30 Cnsumer Assessment f Healthcare Prviders and Systems (CAHPS) survey Survey assesses cnsumers experiences with the quality f their health care and ther plan services. Medicare Advantage and prescriptin drug plan versin f the survey asks 68 questins. 800 members are randmly selected frm each health plan annually. Five attempts are made t survey the health plan member: tw by paper and three telephnically. 30

31 CAHPS survey questin dmains Weight Measure 1.5 Getting care quickly 1.5 Getting needed care 1.5 Care crdinatin 1.5 Custmer service 1.5 Getting needed prescriptin drugs 1 Annual flu vaccine 1.5 Rating health care quality 1.5 Rating the health plan 1.5 Rating the drug plan Cmpsite Single item Overall 31

32 Health Outcmes Survey (HOS) This tl assesses the ability f a Medicare Advantage Organizatin t maintain r imprve its patients physical and mental health. Survey asks 68 questins. Between 1,200 and 2,000 members are randmly selected frm each plan annually. Patients are selected t receive a baseline survey and a fllw-up survey tw years apart. Up t 11 attempts are made t survey the member: tw by paper and six t nine telephnically. 32

33 HOS measure dmains Weight Measure 3 Physical health 3 Mental health 1 Bladder cntrl* 1 Fall risk 1 Physical activity Imprvement Discussin *Bladder cntrl is included in verall HOS scring as f Feb. 1, 2017, accrding t directin frm the Centers fr Medicare & Medicaid Services (CMS). 33

34 Surces Medicare 2018, Part C & D, Star Rating Technical Ntes HEDIS 2018, Vlume 2, Technical Specificatins fr Health Plans The infrmatin in this presentatin is nt a cmplete r cmprehensive descriptin f HEDIS r the Stars prgram. The presentatin serves as an intrductin t HEDIS, Stars and crrespnding clinical measures. 34

35 CAHPS/HOS materials The materials belw can assist with imprving yur CAHPS and HOS scres. CAHPS/HOS measures CAHPS/HOS guide CAHPS/HOS ne-pager Let's Talk pads Physical activity prescriptin pads Specialist appintment reminder pads Prvider screcard Happy pster Bladder/ falls pster Getting needed care Getting care quickly Care crdinatin Overall rating f health care quality Overall rating f health plan Flu vaccine Physical health Mental health Physical activity Bladder cntrl Risk f falling. 35

36 Preventative Screen/Humana Prgrams 36

37 Annual Wellness Visit (AWV) Medicare Advantage Members are eligible fr a Welcme T Medicare visit when they becme Medicare eligible and then Annually there after The visit is an pprtunity t have a sit dwn planning meeting t assess: Brain health, memry and depressin Overall physical, jint and emtinal health B/P check Bdy Mass Index calculatin Keep track f dctrs Keep track f medicatins Manage chrnic prblems Plan fr screenings/shts Review Medical Histry Frequency Welcme t Medicare Visit nce per lifetime w/in first 12 mnths f Medicare Part B enrllment Initial AWV nce per lifetime at least 12 mnths after Medicare Part B enrllment Subsequent AWV annually after the initial AWV 37

38 Annual Physical/In Hme Wellness Assessment Annual Physical Medicare Advantage Members are eligible fr 1 physical every 12 mnths in the years fllwing the Welcme t Medicare Visit Services assessed may include: Reviewing medical histry Cnducting a physical exam t identify risk status and manage any interventins as needed B/P check Cunsel n diet, exercise, substance abuse, injury preventin Recrding height, weight and intervals accrding t prvider s clinical discretin Screening visin at prvider s discretin Screening hearing at prvider s discretin The physical can be prefrmed in the same 12 mnths as the AWV and is reimbursable n the same day as an AWV 38

39 In Hme Wellness Assessment IHWA A licensed physician r nurse practitiner will perfrm a min assessment in the patient s hme Services assessed may include: Brief exam including vitals Active/inactive/chrnic medical cnditins with assciated medicatins Functinal status/fall risk assessment Persnal/scial histry, drug/tbacc/alchl screenings Diabetes/cancer assessments Depressin screen/mental status exam Preventative/chrnic disease care recmmendatins The IHWA des nt take the place f a visit with the members Primary Care Prvider. All IHWA are sent t the prvider by the vendr nce they are cmpleted and prcessed 39

40 Clinical prgrams 1Member evaluatin New member assessments Predictive mdeling Transitin f care Well-being and lifestyle Health and wellness educatin Member assistance prgram Smking cessatin Health caching Humana fitness: SilverSneakers G Guidance and supprt Analysis and feedback Acute, episdic events Lng-term health Utilizatin management Clinical review Radilgy review services Therapeutic review services Onclgy quality management HumanaFirst: Urgent advice Senir case management Humana At Hme Transitins Well Dine SM Transplant management Acrss all levels f health Humana At Hme Chrnic Care Prgram (HCCP) Humana At Hme Stay Healthy End-stage renal disease (ESRD)/chrnic kidney disease (CKD) management Humana Behaviral Health Retrspective Current Prspective HumanaFirst: Health Planning and Supprt Humana health alerts Humana guidance centers Welvie shared decisin-making tl Availity care prfile Member Summary In-hme health and wellbeing assessments 40

41 Claims/Credentialing 41

42 Claims Prvider Payment Integrity Humana has a prcess t address claims cncerns Inquiries can be submitted by: Calling r cntactppi@humana.cm Custmer Service will research the issue and respnd within 3 business days Unsatisfactry reslutin can by escalated by send a secure t helpppi@humana.cm Yu will receive an acknwledgement f the submissin but need t allw 7 business day fr review/respnse t the inquiry Cding Questins If yu have specific cding questins they can be submitted thrugh Availity if yu have access r Sign int Humana.cm and g t Claims Tl and select Cde Edit Simulatr Humana ffers MRA Webinars Mnthly/Quarterly free f charge fr thse interested in additinal educatin 42

43 Credentialing Prvider Updates Yu can submit changes and terminatins f prviders via /fax t: NCRNETWORKOPS@humana.cm FAX:

44 Resurces 44

45 Resurces Available - MRP Flyer - OMW Flyer - Clinical Prgrams Flyer - CAHPS/HOS Package - Outcmes MTM Flyer fr CMR Cmpletin - SPC Flyer - SUPD Flyer - Humana Pharmacy Flyer - Cver My Meds Flyer - Availity Flyer and Webinar Schedule - Medicare Preventative Services Tip Sheet - Well Dine Flyer - Transitins f Care Flyer - Claims Escalatin Flyer - MRA Webinar Schedule Prvider HEDIS Guide 45