Capital Health Plan CMS Star Ratings Strategies for Improvement

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1 Capital Health Plan CMS Star Ratings Strategies for Improvement ESTRELLITA REDMON, MD, MBA MEDICAL DIRECTOR

2 The Ultimate Goal

3 Outline Current 5 Star Plans CHP History Importance of Ratings Part C and Part D Measures Know the measures Prioritize Design Interventions Assess Results Benchmark Keep thinking

4 2011 Ratings SENIOR ADVANTAGE COLORADO AND ARIZONA 5

5 Capital Health Plan Tallahassee, Florida -- Capital of Florida Non profit HMO Mixed model: both staff and community components Delivery system health plan 118,000+ members (local market 360,000) 29 year history 7 counties in Northwest Florida Deep South demographics

6 Purpose Capital Health Plan s purpose as a nonprofit HMO is to provide the people in Leon and surrounding counties with high quality, affordable health care.

7 Capital Health Plan Focuses on delivery of evidence based medical care under the direction of primary care physicians in an effective timely and cost efficient manner. Emphasizes low administrative costs and ethical business practices. Is proactive and innovative in its quest to continually improve the health of the community.

8 Capital Health Plan Culture Primary care focus Assist the primary care physicians to deliver on our promise of quality care. Design and implement our own programs. Trusted local health plan

9 CMS 5 Star Rating Why CHP? Our purpose is to deliver high quality affordable healthcare. Company wide strategic quality goals. Sustained effort on NCQA accreditation standards positioned CHP to do well on CMS 5 star ratings. Collaboration through the Alliance of Community Health Plans (ACHP).

10 Quality Bonus Payment Stars Rating QBP % for 2012/2013 QBP % for 2014 Less than 3 Stars 0% 0% 3 Stars 3% 3% 3.5 Stars 3.5% 3.5% 4 Stars 4% 5% 4.5 Stars 4% 5% 5 Stars 5% 5%

11 How do we do it? K N O W T H E M E A S U R E S P R I O R I T I Z E D E S I G N I N T E R V E N T I O N S A S S E S S R E S U L T S B E N C H M A R K K E E P T H I N K I N G

12 RATINGS RATINGS

13 Prioritize Effort Review all measurement scores What is feasible in your clinical network? Where can you make the largest impacts to improve quality and patient satisfaction? What measures have impacts in areas such as reduction of rescue care?

14 CHP s Approach Evaluate the measure Not doing well? Set high goals. Benchmark. Re-measure Design an intervention

15 QI Annual Work Plan Prioritize the measures Results CMS Score levels Improvement activities

16 Name of Measure CHP Results for 2011 Rating Star Rating 2011 CHP Results for 2012 Rating Star Rating 2012 Star Threshold Levels Status of Improvement Activities 2011 Part C: Overall Rating of Health Plan Quality Part C Domain: Staying Healthy - Screenings, Tests and Vaccines Staying Healthy: Screenings, Tests and Vaccines (composite) n/a Improving or Maintaining Mental Health(HOS) 79% 2 75% (April - Aug 2010) 2 Min. 4 star: 85% (1-4 star only, no 5 star) Member Education provided prior to 2011 HOS survey through new Medicare 5 Star Brochure, newsletter and Savvy Senior presentations. Gap to next Star: 2 points Monitoring Physical Activity (HOS) 53% 3 55% (Apr - Aug 2010) 3 Min. 4 star: 60% (1-4 star only, no 5 star) Member Education provided prior to 2011 HOS survey through new Medicare 5 Star Brochure, newsletter and Savvy Senior presentations. Gap to next Star: 7 points

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18 Annual Report Card Measure: Breast Cancer Screening Parameters: Women ages Denominator for practice Numerator for practice Percentage Plan averages

19 Commercial and Medicare Combined Rate Track, Trend, Report 100% Breast Cancer Screening 90% 80% 83.8% 79.1% 79.5% 82.5% 85.1% 70% 60% 50% HEDIS 2006 HEDIS 2007 HEDIS 2008 HEDIS 2009 HEDIS 2010

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22 2011 Part C Measures [2012 Changes] 36 Part C individual measures with 5 Domains Staying Healthy (13) [12] Screenings, Tests and Vaccines HEDIS, CAHPS, HOS Ratings of Health Plan Responsiveness & Care (6) [5] CAHPS Chronic Condition Management (10) [13] HEDIS Administrative (4) [3] Complaints, IRE Cases, CMS Audit, Contractor Customer Service (3) [3] Contractor

23 2011 Part D Measures [2012 Changes] 17 Part D individual measures with 4 Domains Customer Service (7) [5] CHP, PBM Administrative (3) Complaints, Members Leaving, Audit Member Experience (3) Drug Pricing and Patient Safety (4) [6]

24 2012 Call Letter Part C and D Ratings Implemented for 2012 Weighting of Measures Reducing the ratings for serious compliance issues All-cause readmissions Body Mass Index SNP-specific Measures: 3 rates Voluntary Disenrollment Medication Adherence: 3 Rates Delayed Rewarding contracts for quality improvement Controlling for concentration of providers in a geographic area Measures from Hospital IQR Transition Process Advising Smoker and Tobacco Users to Quit not implemented (reliability issues)

25 2012 New Measures Measures Average Stars CHP Plan All-Cause Readmissions Care for Older Adults Medication Review Care for Older Adults Functional Status Assessment 3.54 (SNP) (SNP) Care of Older Adults Pain Screening 2.72 (SNP) Adult BMI Assessment Members Choosing to Leave the Plan 3.22 (MA) 3.66 (PDP) Medication Adherence Cholesterol Medication Adherence Diabetes Medication Adherence Blood Pressure

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27 2012 Retired Measures Measures Appropriate Monitoring for Pts Taking Long Term Meds Osteoporosis Testing Doctors Who Communicate Well Testing to Confirm COPD Call Center Customer/Beneficiary Hold Time Call Center Information Accuracy Drug Plan Provides Pharmacists with Up-to-Date and Complete Enrollment Information about Plan Members Completeness of the Drug Plan s Information on Members Who Need Extra Help Part C or D C C C C C and D C and D D D

28 Second Plan Preview Period September 8 16, 2011 Part C and D Measure Data Star assignments Domain Summary Overall level Technical notes Cut points for star values 2012 Plan Ratings Go Live October 12, 2011

29 If you are not improving, you are losing ground.

30 Urinary Incontinence Managing Chronic Conditions Domain

31 Urinary Incontinence Chronic Condition Management PART C: Improving Bladder Control (HOS - % Medicare members with leakage problem in past 6 months who received treatment) CHP 2010 results 40% 2 stars CHP 2011 results 42% 3 stars Minimum 4 star 60%

32 Urinary Incontinence Chronic Condition Management What questions on HOS (Health Outcomes Survey)? Q42 Many people experience problems with urinary incontinence, the leakage of urine. In the past 6 months, have you accidentally leaked urine: YES (go to question 43) NO (go to question 46) Q43 How much of a problem, if any, was the urine leakage for you? A BIG PROBLEM (go to question 44) A SMALL PROBLEM (go to question 44) NOT A PROBLEM (go to question 46) Q Have you talked with your current doctor or other health provider about your urine leakage problem: YES NO Q45 - There are many ways to treat urinary incontinence including bladder training, exercises, medication and surgery. Have you received these or any other treatments for your current urine leakage problem? YES NO

33 What is it? Who has it? Urinary Incontinence Chronic Condition Management Why is it important? More than 50% of nursing facility admissions are related to incontinence. Difficulty with bladder control results in higher rates of depression and limited activity levels. Incontinence is expensive both to individuals in the form of bladder control products and to the health care system and nursing home industry.

34 Urinary Incontinence Chronic Condition Management Do you need data for this intervention? The question targets people who are not getting advice or treatment.

35 Urinary Incontinence Chronic Condition Management Design the intervention Figure out what is going on now usual care. Information to members Information to Network providers Give exact instructions on what you want them to do Help them deliver better care Make sure appropriate resources are available

36 Weighting of Measures Plan Preferences Advocate Preferences CMS Decision CMS Weighting Intermediate Outcomes Intermediate Outcomes Intermediate Outcomes 3 Outcomes and Process Patient Experience Outcomes 3 Patient Experience Outcomes and Process Patient Experience 1.5 Access Access Access 1.5 Process 1

37 Intermediate Outcome Measures (3) Part D High Risk Medications Diabetes Treatment Medication Adherence for Oral Diabetes Medications Medication Adherence for Hypertension (ACEI or ARB) Medication Adherence for Cholesterol (Statins) Source: PDE Data

38 Outcome Measures (3) Part C Improving or Maintaining Physical Health Improving or Maintaining Mental Health Plan All-Cause Readmissions (weighed as 1 because first year measure) HEDIS HOS

39 Patient Experience (1.5) Part C Getting Needed Care Getting Appointments and Care Quickly CAHPS Customer Service Overall Rating of Health Care Quality Overall Rating of Health Plan Complaints about the Health Plan CTM Beneficiary Access and Performance Problems CMS Members Choosing to Leave the Plan MBD Plan Makes Timely Decisions about Appeals IRE Reviewing Appeals Decisions Foreign Language Interpreter and TTY/TDD Availability CMS

40 Patient Experience (1.5) Part D Complaints about the Drug Plan Members Choosing to Leave the Plan Getting Information From Drug Plan Rating of Drug Plan CTM MBD CAHPS

41 Access (1.5) Part D Access to Primary Care Visits (Part C) Call Center Pharmacy Hold Time Foreign Language Interpreter and TTY/TDD Availability Appeals Auto-Forward Appeals Upheld HEDIS Beneficiary Access and Performance Problems (includes audits, sanction, civil monetary penalties, compliance actions module [CAM] data) IRE CMS CMS

42 Process Measures (1) Part C Breast Cancer Screening CRC Screening CV Care Cholesterol Screening HEDIS Diabetes Cholesterol Screening Glaucoma Testing Adult BMI Assessment Annual Flu Vaccine CAHPS Pneumonia Vaccine Monitoring Physical Activity HOS SNPs Care for Older Adults (Med Review, FSA, Pain Screening) HEDIS

43 Process Measures (1) Part C Osteoporosis Management in Women who had a Fracture Diabetes Care Eye Exam, Kidney Disease Monitoring, Blood Sugar Controlled, Cholesterol Controlled Controlling Blood Pressure Rheumatoid Arthritis Management Improving Bladder Control Reducing the Risk of Falling HOS H E D I S

44 Process Measures (1) Part D Enrollment Timeliness MARX MPF Composite (Plan provides accurate price information for Medicare s Plan Finder Website and Keeps Drug Prices Stable) PDE

45 Know the Measure Part D: Medication Adherence Oral Diabetes Medications Metric: % of MAPD beneficiaries, 18 years or older, who adhere to their prescribed drug therapy across four classes of oral diabetes medications: biguanides, sulfonylureas, thiazolidinediones, and DPP IV Inhibitors. Source: PDE 1/1/10-12/31/10

46 Discussion of Pitfalls PDE Information PBM Data Formulary Management Enhanced Alternative Drug Plans EGWPs Multiple Sources for Data Reviewing the Data Who has access? Who receives the data? Who reviews the data? If the information exists for plans to review, it can become a measure for the star ratings

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48 Discussion/Questions