TMG STARS 2018 1
2 STARS Program Implemented in 2008 by CMS. Tool to inform beneficiaries of quality of various health plans 5-star rating system Used to adjust payments to health plans (bonus to plans and rebates passed to members). Not all measures are weighted equally (HA1C <9 is a triple weighted measure ) Five star plans allowed to sign up new members all year long without restriction
STARS SYSTEM 5 CATEGORIES Staying healthy: screening tests and vaccines. Includes whether members got various screening tests, vaccines, and other check-ups to help them stay healthy. Managing chronic (long-term) conditions: Includes how often members with certain conditions got recommended tests and treatments to help manage their condition. Member experience with the health plan: Includes member ratings of the plan. Member complaints and changes in the health plan s performance: Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan s performance has improved (if at all) over time. Health plan customer service: Includes how well the plan handles member appeals. 3
STARS RATING Performance is not weighted by plan enrollment; a contract performing well with many enrollees does not receive any extra credit for providing highquality care to more people than a contract with lower enrollment. For the majority of measures in the Stars Rating program, performance is not adjusted for patient characteristics or socioeconomic status. 4
BONUS PAYMENT Bonus payments are awarded for contracts receiving 4 or more stars. 5
4.5 4.0 3.5 4.0 2.5 4.0 3.0 6
AHC WAKE COUNTY PERFORMANCE METRICS AHC Wake Performance Metric 2015 2016 2017 YTD STARS (HEDIS) N/A 4.0 In progress 2017 Goal: 4.5 2018 Goal: 5.0
REWARDS FOR STARS ARE TWO-PART Direct bonus payments to the plan operator Alignment Rebates which must be returned to the beneficiary in the form of additional or enhanced benefits, such as reduced premiums or copayments, expanded coverage 8
BONUS PAYMENTS Paid per enrollee and are calculated as a share of the MA benchmarks, which vary by county Bonus payments vary by county. Bonuses for 4-star plans or higher are 5 percent of the area s benchmark 9
REBATES In past MA plans have received a rebate equal to a percentage (previously 75 percent) of the difference between the plan s bid and the benchmark for that area if the bid is below the benchmark Plans bidding above the benchmark receive no rebate and are only paid the benchmark amount per beneficiary by CMS plan beneficiaries selecting that plan have to pay an additional premium to make up the difference. 10
STAR REPORT 11
STARS Program Plan Rating 4.5 & 5 Stars Bonus Payment 5% 4 Stars 5% New Plans 3.5% New Benchmark 105% of Benchmark 105% of Benchmark 103.5% of Benchmark Rebate Payment 70% 65% 65% 3.5 Stars None Benchmark 65% 3 or Fewer Stars Plans Not Reporting None Benchmark 50% None Benchmark 50% 1
TMG BONUS Must hit thresholds for 4 stars or above in several categories TMG Bonus potential increases if plan has 4 or more stars Bonus is part of payment from Medicare from which cost of patient care is deducted to determine bonus. 13
TMG STARS PERFORMANCE METRICS BONUS FOR 2018 Measure Weight BMI Assessment BMI yearly documented in chart 1 Breast Cancer Screening Mammogram every 2 years age 50-74 1 Colorectal Cancer Screening-Colonoscopy every 10 years, sigmoidoscopy every 5 years, or stool guaic yearly 1 Comprehensive Diabetes Care - Blood Sugar Controlled 9 3 Comprehensive Diabetes Care - Eye Exam retinal eye exam every year (OK every two years if documented negative) 1 Comprehensive Diabetes Care Nephropathy-yearly urine protein or diagnosis/treatment for diabetic nephropathy 1 Disease-Modifying Anti- Rheumatic Drug Therapy for Rheumatoid Arthritis 1 Osteoporosis Management- DEXA or treatment for osteoporosis within six months of fracture 1 Plan All-Cause Readmissions-30 days readmission 3 Medication Adherence for Cholesterol (Statins) 3 Medication Adherence for Hypertension (ACEI or ARB) 3 Medication Adherence for Oral Diabetes Medications 3 Medication Reconciliation Post-Discharge-Medicine reconciliation within 30 days of discharge from acute care facility 1
JUMP START ASSESSMENT (JSA) A comprehensive whole-person medical and psychosocial assessment provided to eligible health plan members. Outcomes Help drive closure for the following HEDIS measures. - Adult BMI Assessment - Diabetes Care (Blood Sugar Controlled) - Diabetes Care (Kidney Disease Monitoring) - Diabetes Care (Eye Exam) - Controlling Blood Pressure - Colorectal Cancer Screening history of colonoscopy is noted in patient history in members medical record - Breast Cancer Screening history of mammogram is noted in patient history in members medical record Medication Reconciliation Post Discharge - Care for Older Adults - Medication Review - Functional Assessment - Pain Assessment Help develop the following care plans - Care Management - Chronic Disease Management - Home Monitoring 15
CMS QUALITY MEASURES Adult Access to Preventative/Ambulatory Health Services Members must have a preventive care visit at least annually. Influenza Vaccine Members must receive an influenza vaccine annually. Pneumonia Vaccine Members over 65 must receive a pneumonia vaccine once. Breast Cancer Screening Female members ages 50-74 need a mammogram once every 2 years. Colorectal Cancer Screening Members ages 50-75 require one appropriate screening for colon cancer. This requirement can be fulfilled through the following screenings: an annual FOBT test kit, flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years. Diabetes Care (Eye Exam) Patients with a diagnosis of diabetes must receive an annual eye exam by an eye care professional to screen for retinopathy. This requirement may also be fulfilled by evidence of the patient being negative for diabetic retinopathy in the previous year s exam. Diabetes Care (Kidney Disease Monitoring) Diabetics must have a microalbumin test annually. Diabetes Care (Blood Sugar Controlled) Diabetics must have at least 2 HbA1c lab tests during the year. HbA1c should be under 9. Take action if HbA1c value is over 9.. 16
CMS QUALITY MEASURES.Medication Adherence (ACE/ARB or RAS antagonists, Statins, Oral Diabetes Meds) Members should fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medications. Prescribe 90-day fill for the medications above to improve compliance. High Risk Medication (HRM) Management Members 65 and older who have received prescriptions for certain drugs with a high risk of side effects (muscle relaxants, long-acting BZDs), should be converted to safer alternatives. Rheumatoid Arthritis Management Members diagnosed with Rheumatoid Arthritis must receive at least one or more prescription(s) for disease-modifying antirheumatic drug (DMARD). Osteoporosis Management in Women Who Had a Fracture Female members age 67-85 who have had a fracture must have a DEXA scan or begin treatment for osteoporosis within 6 months of fracture 17
CMS QUALITY MEASURES Adult BMI Assessment Annually documented body mass index (BMI) value and weight in patient chart. Controlling Blood Pressure Members 18 85 years of age who had a diagnosis of hypertension and whose BP was adequately controlled (<140/90) for members 18-59 years of age and 60-85 years of age with diagnosis of diabetes or (150/90) for members 60-85 without a diagnosis of diabetes during the measurement year. Care for Older Adults SNP Members age 66 years and older should have the following done annually: a) Medication Review: At least one medication review conducted during the measurement year and the presence of a medication list in the medical record. Both services must be on the same date of service. b) Functional Assessment: At least one functional status assessment during measurement year. c) Pain Assessment: Annually complete and document at least one pain screening. Medication Reconciliation Post Discharge Members 18 and older must have their medication reconciled the date of discharge through 30 days after discharge 18
MEDICATION ADHERENCE FOR HYPERTENSION (RAS ANTAGONISTS) % of plan members with a prescription for a blood pressure medication who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication. ( Blood pressure medication means an ACE (angiotensin converting enzyme) inhibitor, an ARB (angiotensin receptor blocker), or a direct renin inhibitor drug.) Metric: percent of Medicare Part D beneficiaries 18 years and older who adhere to their prescribed drug therapy for renin angiotensin system (RAS) antagonists: angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or direct renin inhibitor medications. 19
CALCULATION FOR ADHERENCE Member Year = (# months patient enrolled in plan)/12 Example 12/12 = 1 member year 8/12 =.75 member year Medication adherence % = (Goal > = 80%) # of pills taken in a given time period # of pills prescribed by the physician in that same time period % adherence = # member years beneficiaries taking their medications 80% or more of the time # of member-years for all patients with at least 2 fills of same medication 20
MEDICATION ADHERENCE FOR DIABETES MEDICATIONS Percent of plan members with a prescription for diabetes medication who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication. ( Diabetes medication means a metformin, a sulfonylurea drug, a TZD, a DPP-IV inhibitor, an incretin mimetic drug, a meglitinide drug, or an SGLT2 inhibitor. Plan members who take insulin are not included.) Metric: This measure is defined as the percent of Medicare Part D beneficiaries 18 years and older who adhere to their prescribed drug therapy across classes of diabetes medications: biguanides, sulfonylureas, thiazolidinediones, and (DPP)-IV Inhibitors, incretin mimetics, meglitinides, and (SGLT2) inhibitors. % = # member years taking 80% or more/ # member years filling same rx 2 or more times 21
MEDICATION ADHERENCE FOR CHOLESTEROL (STATINS) Percent of plan members with a prescription for a cholesterol medication (a statin drug) who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication. Metric: This measure is defined as the percent of Medicare Part D beneficiaries 18 years and older who adhere to their prescribed drug therapy for statin cholesterol medications. % = # number of member-years taking statins at 80 percent or more of the time / # of member years of patients prescribed statin 2 or more times in same time period 22
DIABETES CARE (BLOOD SUGAR CONTROLLED) Diabetics must have at least one HbA1c lab tests during the year. HbA1c should be under 9. Take action if HbA1c value is over 9 and repeat test before year end if > 9 How to improve your quality performance? Ensure members have an HbA1c done quarterly and medication is prescribed appropriately 23
DIABETIC NEPHROPATHY Nephropathy screening testing on all diabetic members : - Timed, spot or 24 hour urine for microalbumin - 24-hour urine for total protein - Urine for microalbumin/ creatinine ratio - Random urine for protein/ creatinine ratio OR Documented evidence of nephropathy with -Any urine macroalbumin test -Medical attention for nephropathy OR Nephrology consult in 2017 (include if primary care physician also is a nephrologist) OR A dispensed prescription for angiotensin converting enzyme (ACE) inhibitor/angiotensin receptor blockers (ARB) therapy 24
DIABETIC EYE EXAM All diabetic patients must receive a diabetic eye exam to check for retinopathy (damage from diabetes) by an eye care professional, at least annually. How to improve your quality performance? - Always document negative or positive retinopathy results in the patients medical record. - Prior year to the measurement year results can be utilized as long as eye exam results were negative. Patient Self-Reported - Documentation of retinopathy in patients medical history and recorded in the medical record can be utilized as long as the following requirements are met: date of service (month/year), rendering physician and eye exam results. 25
RHEUMATOID ARTHRITIS Members diagnosed with Rheumatoid Arthritis must receive at least one or more prescription(s) for diseasemodifying antirheumatic drug (DMARD). How to improve your quality performance? Avoid coding errors: Confirm RA diagnosis with appropriate testing or medical record review. Ensure that patients with a diagnosis of rheumatoid arthritis are on an appropriate DMARD medication to slow the progression of the disease. Do not diagnose member with RA if they have osteoarthritis. The following diagnosis may be more appropriate and holds the same RAF score: M06.4 Inflammatory Polyarthropathy Rheumatologist Visit: If you suspect rheumatoid arthritis, schedule a follow-up with a rheumatologist 26
COLORECTAL CANCER SCREENING Members ages 50-75 require one appropriate screening for colon cancer. This requirement can be fulfilled through the following screenings: an annual FOBT test kit, flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years. How to improve your quality performance? 9 years prior to the measurement year results can be utilized for colonoscopy. 4 years prior to the measurement year results can be utilized for sigmoidoscopy. Ensuring member completes an FOBT kit during measurement year. Patient Self-Reported - Documentation of colonoscopy or sigmoidoscopy in patients medical history and recorded in the medical record can be utilized as long as the following requirements are met: date of service (month/year) 27
BREAST CANCER SCREENING Women age 50-74 years must complete a mammogram every two years. How to improve your quality performance? - A mammogram in the year prior to the measurement year can be utilized. - Ensure members complete a mammogram screening every 2 years. Patient Self-Reported - Documentation of mammogram in patients medical history and recorded in the medical record can be utilized as long as the following requirements are met: date of service (month/year) 28
ADULT BODY MASS INDEX Annually documented body mass index (BMI) value and weight in patient chart. How to improve your quality performance? - Ensure to document the BMI value in members chart and bill ICD 10 CODE Z68.20 Body mass index (BMI) 20.0-20.9, adult. Z68.21 Body mass index (BMI) 21.0-21.9, adult. Z68.22 Body mass index (BMI) 22.0-22.9, adult. Z68.23 Body mass index (BMI) 23.0-23.9, adult. Z68.24 Body mass index (BMI) 24.0-24.9, adult. Z68.25 Body mass index (BMI) 25.0-25.9, adult 29
OSTEOPOROSIS MANAGEMENT IN WOMEN Women 67-85 years of age who suffered a fracture should receive either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis (Bisphosphonates) within the six months after the fracture. Deadline Measure requires member to either receive BMD/ DEXA scan or osteoporosis medication within 6 months of the fracture date.. 30
Medication Reconciliation Post Discharge (MRP) Percentage of Medicare members > 18 years of age who are discharged from an acute or non-acute inpatient facility for whom medications were reconciled within 30 days of discharge. Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking including drug name, dosage, frequency, and route and comparing that list against the discharge orders, with the goal of providing correct medications to the patient. It helps to assure the quality of care coordination as well as member safety in their transition home. This measure can be met by completing and documenting a medication reconciliation, including a medication list, in the member s medical record within 30 days of discharge. This would generally be done at the time of an office visit after discharge from the hospital. 31
Medication Reconciliation Post Discharge (MRP) CPT Codes that satisfy the MRP Measure 99495 Transitional Care Management Services, Moderate Complexity 99496 Transitional Care Management Services, High Complexity 32
MEDICATION RECONCILIATION POST-DISCHARGE DOCUMENTATION REQUIREMENTS Medication reconciliation that has been completed by a prescribing practitioner, clinical pharmacist or registered nurse on the date of discharge through 30 days after the discharge date. Documentation in the medical record must include evidence of medication reconciliation and the date when the reconciliation was performed. Current and discharge medications have been reconciled by the providers and reconciled with current medications. Current medication list to include a note that the discharge medications have been reviewed or No medications were prescribed or ordered upon discharge. Examples of Documentation No changes in medication since discharge Same medication at discharge Discontinue all discharge medications Evidence that the member was seen for post-discharge hospital follow-up with evidence of medication reconciliation or review. 33
Unacceptable Forms of Documentation Documentation that the discharge medications have been reviewed, but no documentation that they were reviewed or reconciled with the current medications. List of the discharge medications and a list of the current medications are included in the record, but no documentation that they have been reconciled. Discharge medication and current medication reconciled on a date more than 30 days after the discharge date. 34
TMG STARS STRATEGY Encourage all members to have yearly JSA Review health maintenance at every visit Review gap list -will be provided in July Alignment to visit all independent practices in September-October to retrieve records (we ll send staff to retrieve medical records from your EMR) Updated gap list by mid-november for end of year push to meet measure requirements (AHC will also do a concurrent outreach) 35