Transcript Slide 1

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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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
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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
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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
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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
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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
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Current Quality and Performance
Metrics
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HEDIS
HOS
CAHPS
Independent Review Entity data
Part D Performance Measures
• More detail on these measures today and
tomorrow from CMS staff
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Current Quality and
Performance Measurement
in Medicare Advantage
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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
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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
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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
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www.medicare.gov
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www.medicare.gov
www.medicare.gov
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www.medicare.gov
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
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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
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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 highquality heath and prescription drug plans
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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
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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
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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
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Measurement Categories
• Benefit design
• Risk assessment and care planning
• Coordination of services
• Caregiver engagement
• Internal measurement of performance
• Beneficiary & caregiver experience
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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
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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
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Future of Quality and
Performance Measures
in Medicare Advantage
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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
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Quality Measurement and
Performance Assessment Wish List
Sources and Types of Data
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Next stages of SNP measures
Part C Performance Measures
MA Utilization Data
Improvements to HEDIS measures
* Some already underway
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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
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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
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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
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Questions?
Abby L. Block
Director, Center for Beneficiary Choices
[email protected]
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