Measuring quality performance in medicare advantage where we ve been where we are where we re going
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Abby L. Block Director, Center for Beneficiary Choices Centers for Medicare & Medicaid Services PowerPoint PPT Presentation

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Measuring Quality & Performance in Medicare Advantage Where We’ve Been, Where We Are, & Where We’re Going. Abby L. Block Director, Center for Beneficiary Choices Centers for Medicare & Medicaid Services April 8, 2008. History of Quality and Performance Measures in Medicare Advantage.

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Abby L. Block Director, Center for Beneficiary Choices Centers for Medicare & Medicaid Services

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Measuring Quality & Performance in Medicare AdvantageWhere We’ve Been, Where We Are, & Where We’re Going

Abby L. Block

Director, Center for Beneficiary Choices

Centers for Medicare & Medicaid Services

April 8, 2008

History of Quality and Performance Measures in Medicare Advantage

Quality and Performance Measurement at CMS

  • Staff from HCFA/CMS and HHS have long been involved in developing and refining health plan quality and performance metrics, even before they were used in the Medicare + Choice and Medicare Advantage Programs

  • For example, CMS staff serve on the CPM for HEDIS measures

Measuring Quality and Performance among Medicare plans

  • In early 1990s, some states required Medicaid programs to collect this data on Medicaid managed care programs

  • In late 1990s, following the Balanced Budget Act (BBA), CMS began collecting HEDIS, CAHPS, and later HOS data from Medicare managed care plans

    • Plans to begin data collection preceded BBA

Motivation to Measure

The decision to begin quality and performance data collection was motivated by several factors

  • Need for accountability to oversight bodies and beneficiaries

  • Desire to make evaluation of managed care plans more objective

  • Desire to improve value in government purchasing

Early Uses of Quality and Performance Data

  • Reporting Year 1997 was first year of data collection

  • Data was used in various agency initiatives

    • Medicare Compare website in bar chart form (1999)

    • Medicare & You Handbook (2000) – First consumer education efforts

    • Reports to plans for use in quality improvement programs

    • HHS Government Performance and Results Act (GPRA) goals

Towards a Performance Assessment System

  • By 2000-2001, CMS had enough data to create a plan rating system, which eventually became the Performance Assessment System

    • Incorporated various data sources into one swing database in HPMS

    • Generated plans ranking based on performance relative to other plans, using individual and composite measures

    • Allowed CMS to reward high performing plans, i.e. with audit exemptions

Current Quality and Performance Metrics


  • HOS


  • Independent Review Entity data

  • Part D Performance Measures

  • More detail on these measures today and tomorrow from CMS staff

Current Quality and Performance Measurement in Medicare Advantage

Quality and Performance Measurement Goals

  • Over time, metrics and measurement systems have expanded and evolved

  • Goals remain largely the same

    • Accountability

    • Value-based purchasing

    • Objectivity in program evaluation

Current Quality and Performance Measurement Objectives

  • To provide performance and quality-based information to beneficiaries to make enrollment decisions

    • Example 1: MA and Prescription Drug plan ratings

  • Demonstrate value and performance

    • Example 2: Special Needs Plan quality measures

Example 1: Plan Ratings

  • Previously, limited plan performance information was available on Medicare website

  • In 2007, CMS significantly revamped MA and Part D plan ratings on

    • Domain & measure level ratings

    • 5-star rating system

    • Accessible, comprehensible information

Domain and Measure Level Ratings

Example Domain: Managing Chronic Conditions


  • Osteoporosis Management

  • Diabetes Care – Eye Exam

  • Diabetes Care – Kidney Disease Monitoring

  • Diabetes Care – Blood Sugar Controlled

  • Diabetes Care –Cholesterol Controlled

  • Antidepressant Medication management (6 months)

  • Controlling Blood Pressure

  • Rheumatoid Arthritis Management

  • Testing to Confirm Chronic Obstructive Pulmonary Disease

  • Continuous Beta-Blocker Treatment

Five-Star Rating System

  • Real innovation of the 2007 plan ratings was the establishment of a 5-star rating system

    • Not only showed comparison of plans, but placed them in a framework of comparison to agreed-upon standards

  • Unique for Medicare Advantage and Prescription Drug Programs

    • Not yet available for Hospitals or Nursing Homes

Significance of Plan Ratings

  • Plan ratings improve CMS’ ability to identify high performing plans and plans that need improvement

  • Also substantially expand information available to beneficiaries for selecting high-quality heath and prescription drug plans

Example 2: Special Needs Plans Quality Measures

  • Since their inception, there has been the expectation that SNPs provide more meaningful health service choices for beneficiaries than other MA plans

  • Yet, neither the statute nor our regulations provided specific guidance on how to specialize clinical programs

    • Lack of quality and performance data hampered ability to demonstrate how plans are “special”

  • Tremendous growth in SNPs and SNP enrollment further justified need for quality metrics

Special Needs Plans Quality Measures

  • CMS and the Geriatric Measurement Panel (GMAP) of the NCQA worked collaboratively to develop initial recommendations for SNP quality measures

  • In November 2007, the GMAP finalized their measure recommendations from existing measures:

    • Thirteen HEDIS measures

    • Set of Structure and Process measures

SNP Quality Measures

  • Measures were on display for public comment through January 2008

  • HEDIS measures remained the same, but minor modifications were made to structure & process measures based on public comment

  • SNP measures will be collected for Contract Year 2009

    • Training for health plans on reporting requirements currently underway

Measurement Categories

  • Benefit design

  • Risk assessment and care planning

  • Coordination of services

  • Caregiver engagement

  • Internal measurement of performance

  • Beneficiary & caregiver experience

Innovation: Plan-Level Measurement

  • Currently, CMS only measures plans at the contract level, not at the plan benefit package level, and only for contracts with 1,000 members

  • For the SNP specific measures, CMS will collect them from every SNP at the plan benefit package level

Beginning of a Multi-Stage Process

  • The HEDIS measures and structure and process standards to be used in 2008 are part of a three-year strategy proposed by NCQA

  • For 2009 and 2010, some of these measures will be further refined for SNP-specific use and additional measures will be developed and collected

Future of Quality and Performance Measures in Medicare Advantage

Need to Improve Current Quality Measurement Initiatives

  • While current initiatives achieve some of CMS’ quality and performance measurement objectives, they are constrained by

    • Sources and types of data gathered

    • Plan monitoring and compliance infrastructure

    • Limitations of consumer tools

Quality Measurement and Performance Assessment Wish List

  • Sources and Types of Data

  • Next stages of SNP measures

  • Part C Performance Measures

  • MA Utilization Data

  • Improvements to HEDIS measures

  • * Some already underway

Quality Measurement and Performance Assessment Wish List

Plan Monitoring & Compliance

  • Integrated plan for how to use plan rating information for purposes of plan monitoring and compliance; plan improvements

Quality Measurement and Performance Assessment Wish List

Consumer Information

  • Research and monitoring to determine if an how consumers are using quality and performance data through and other portals

    • Underway: continuing consumer testing of Medicare Options Compare and Prescription Drug Plan Finder

Other Ways Forward: PQA

  • The PQA, a pharmacy quality alliance, was launched at a CMS Open Door Forum

    • CMS is a member of the PQA Steering Committee and an active member on PQA Workgroups

  • CMS supports the promotion of high-value pharmacy services, including measurement approaches, through a stakeholder-led pharmacy quality alliance

  • The measures being developed by PQA and its stakeholders for pharmacy quality and patient satisfaction will be considered for use by CMS in the Part D Plan Ratings


Abby L. Block

Director, Center for Beneficiary Choices

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