measuring quality performance in medicare advantage where we ve been where we are where we re going
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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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measuring quality performance in medicare advantage where we ve been where we are where we re going

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

quality and performance measurement at cms
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
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
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
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
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
Current Quality and Performance Metrics
  • HEDIS
  • HOS
  • CAHPS
  • Independent Review Entity data
  • Part D Performance Measures
  • More detail on these measures today and tomorrow from CMS staff
quality and performance measurement goals
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
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
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 Medicare.gov
    • Domain & measure level ratings
    • 5-star rating system
    • Accessible, comprehensible information
slide13

www.medicare.gov

www.medicare.gov

slide14

www.medicare.gov

www.medicare.gov

domain and measure level ratings
Domain and Measure Level Ratings

Example Domain: Managing Chronic Conditions

Measures:

  • 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
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
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
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
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
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
Measurement Categories
  • Benefit design
  • Risk assessment and care planning
  • Coordination of services
  • Caregiver engagement
  • Internal measurement of performance
  • Beneficiary & caregiver experience
slide22

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
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
need to improve current quality measurement initiatives
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
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 list1
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 list2
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 Medicare.gov and other portals
    • Underway: continuing consumer testing of Medicare Options Compare and Prescription Drug Plan Finder
other ways forward pqa
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
questions
Questions?

Abby L. Block

Director, Center for Beneficiary Choices

[email protected]

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