Overview of the Medicare Advantage Quality Strategy Vanessa Duran Director, Division of Policy, Analysis and Planning

1. Overview of the Medicare Advantage Quality Strategy Vanessa DuranDirector, Division of Policy, Analysis and PlanningMedicare Drug & Health Plan Administration GroupSeptember 20, 2011 

2. Purpose Describe the current Quality Improvement (QI) program for the Medicare Advantage (MA) plans Provide an update on future directions for the QI program

3. Presentation Overview Background on the Development of the QI Strategy Defining Quality MA QI Program Components of the QI Strategy Resources and Program Enhancements

5. Foundations of the QI Strategy 42 Code of Federal Regulations (CFR) � 422.152 2001 Institute of Medicine Report Triple AIM Health and Human Services (HHS) National Quality Strategy 2011 HHS National Prevention Strategy 2011

6. 42 CFR �422.152 Contains description of the requirements for the QI program for MA Organizations (MAOs) Separate section for Special Needs Plans (SNPs)

7. Triple AIM Improve the individual experience of care Improve the health of populations Reduce the per capita costs of care for populations Source: Berwick, D., Nolan,T.W., and Whittington, J. The Triple Aim: Care, Health, and Cost. Health Affairs, 27, no 8 (2008): 759-769.

8. HHS National Quality Strategy (NQS) Mandated under the Affordable Care Act Released in March 2011 Will require all agencies within HHS to develop their strategy

9. HHS National Quality Strategy: National Aims and Priorities Three National Aims Better care Healthy people/healthy communities Affordable care

10. HHS National Quality Strategy: Priorities Six Priorities Make care safer by reducing harm caused in the delivery of care Ensure that each person and family are engaged as partners in their care Promote effective communication and coordination of care Promote the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular diseases Work with communities to promote wide use of best practices to enable healthy living Make quality care more affordable by developing new health care delivery models

11. HHS National Prevention Strategy (NPS): Strategic Directions Also mandated under the Affordable Care Act Builds on the principles of the HHS NQS Focus is to improve health care quality and quality of life through increased access to preventive services

12. HHS National Prevention Strategy (NPS): Strategic Directions Four strategic directions Healthy and safe community environments Clinical and community prevention services Empowered people Elimination of health disparities

13. HHS NPS Priorities Seven Priorities Tobacco free living Preventing drug abuse and excessive alcohol use Healthy eating Active living Injury and violence free living Reproductive and sexual health Mental and emotional well-being

15. Defining Quality Complex Contains multiple dimensions May have different meanings depending on the context Dr. Berwick has defined quality during his trainings as: � Meeting and exceeding the needs and expectations of our customers�

16. Defining Quality: Our Goals for MA We want the industry to compete on quality We want MAOs to provide leadership and innovation in delivering quality health care Our MA QI Strategy is the framework to guide the MA program

17. Defining Quality

18. Quality is Multidimensional

19. Quality for MA System Benefits Access Provider Network Well-trained Coordinated care Patient Health status and health outcomes Satisfaction

20. Quality for SNPs System C-SNP D-SNP I-SNP Provider Model of Care: Interdisciplinary Care Team Patient Model of Care: Health Risk Assessment

22. Quality Improvement (QI) Program Applies to all MAOs, including SNPs Seven components of the QI program Chronic care improvement program (CCIP) Meets the requirements of 42 CFR �422.152(c) Addresses populations identified by CMS based on a review of current quality performance Quality improvement projects (QIP) Meet the requirements of 42 CFR �422.152(d) Expected to have a favorable effect on health outcomes and enrollee satisfaction Address areas identified by CMS Develop and maintain a health information system

23. QI Program (continued) Encourage providers to participate in CMS and HHS QI initiatives Contract with an approved Medicare CAHPS� vendor to conduct the Medicare CAHPS� satisfaction survey of Medicare enrollees Include a program review process for formal evaluation of the QI program that addresses at least the following areas on an annual basis: Impact Effectiveness Correct problems for the plan

24. SNP QI Program Model of care (MOC) Eleven elements: Description of the SNP-specific target population Measurable goals Staff structure and care management goals Interdisciplinary care team (ICT) Provider network having specialized expertise and use of clinical practice guidelines and protocols MOC training for personnel and provider network Health risk assessment (HRA) Individualized care plan Communication network Care management for the most vulnerable subpopulations Performance and health outcome measurement

26. QI Strategy Components Vision Mission Core Values Goals Objectives Define specific objectives for our goals Develop metrics to monitor objectives and measure progress Implementation or Action Plan Comprehensive Designed to assess, develop, and implement the best possible standards of care to assure that the health care systems deliver the highest quality of care across all plan types

28. QI Program Resources Code of Federal Regulations (CFR) Central Office and Regional Office Staff CMS website Medicare Managed Care Manual Chapter 5 Refer plans with specific or technical plan rating questions to: PartCRatings@cms.hhs.gov or PartDMetrics@cms.hhs.gov

29. Resources by Topics General MA and SNP QI program, Medicare Managed Care Manual Chapter 5, QIPs/CCIPs, SNP performance measures Margot Blige Holloway Jaya Ghildiyal Vanessa Sammy Dr. Marsha Davenport Plan Ratings; HEDIS�; CAHPS� Dr. Elizabeth Goldstein Health Outcome Survey (HOS) Jason Petrowski Sonya Bowen

30. QI Program Enhancements Improve methods for reporting the CCIPs and QIPs Provide technical assistance early in the process Provide ongoing technical assistance

31. Expand QI Program Resources CMS website pages Will be developed and updated regularly Other areas being developed to support the QI program: Guidance Training Outreach materials for plans

32. Summary Quality is a focus for the MA program Achieve quality health care through a strong QI strategy and program Continue to develop better clinical outcomes measures to demonstrate the impact the MA program has on improving health and health outcomes for our beneficiaries

33. Contact Marsha Davenport, MD, MPH CAPT, USPHS Chief Medical Officer Medicare Drug and Health Plan Contract Administration Group (MCAG) Division of Policy, Analysis and Planning (DPAP) Marsha.davenport@cms.hhs.gov 410-786-0230