The Mihalik Blog

Introduction to Accreditation

I'll be teaching at NCQA's upcoming program on Introduction to Accreditation in Washington, DC in May.  There are only a few seats left.  If you're interested in attending, you can look here. 

Medicare Stars: Improvement Strategies

This is the last post of the series on Medicare Stars.  Today we address some ideas for actually implementing the improvement process.

How could a plan start the improvement process?

According to the Institute for Healthcare Improvement (IHI), the Model for Improvement “has been used very successfully by hundreds of health care organizations in many countries to improve many different health care processes and outcomes.”  The Model for Improvement attempts to answer three basic questions:

• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in an improvement?

The following are the steps that the Associates in Process Improvement, developers of the Model for Improvement, recommend:

1. Form a Team:  Be sure that the team includes members familiar with all the different parts of the process — managers and administrators as well as those who work in the process
2. Set Goals:  Improvement requires setting aims.  The aim should be time-specific and measurable.  It should also define the specific population of patients or other system that will be affected.
3. Establish Measures:  Measurement is a critical part of testing and implementing changes.  Measures tell a team whether the changes they are making actually lead to improvement.
4. Select Changes:  Ideas for change may come from the insights of those who work in the system, from change concepts or other creative thinking techniques, or by borrowing from the experience of others who have successfully improved.
5. Test Changes:  The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting — by planning it, trying it, observing the results, and acting on what is learned.  This is the scientific method adapted for action-oriented learning.
6. Implement Changes:  After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team may implement the change on a broader scale — for example, for an entire pilot population or on an entire unit.
7. Spread Changes:  After successful implementation of a change or package of changes for a pilot population or an entire unit, the team can spread the changes to other parts of the organization or in other organizations.

What are some of the analytical tools a plan could use to improve ratings?

Plans should collect data related to the star measures at frequent intervals and develop reporting systems that integrate the data into a “dashboard” style report that provides a summary of all star measure results.  The dashboard report should include not only the actual star ratings, but also raw scores, and cut points, making it easy to identify improvements necessary to reach goals.  The report could be used to drill into poor-performing sub-populations such as individual markets, provider groups, or measures.

The Mihalik Group's performance improvement experts are available to help you improve your stars rating.

Medicare Advantage: Improve Stars to Improve Revenue

In a prior blog, we discussed the delayed effect that performance has on Stars ratings and bonus payments.  Today we look at how to start the Stars improvement process.

How should a plan go about selecting measures to improve in order to increase its star rating?

 Although it’s easy for a plan to want to focus on all measures to improve star ratings, plans will do better to target improvement efforts on measures with the most opportunity for improvement to achieve the best results.

In order to identify measures with the best chance for improvement, plans should:

• Understand the star measures:  Plans need to be familiar with all the measures included in the 5 domains as well as definitions of measures.
• Know historical results for star measures:  Historical performance for measures and where they fall within the CMS threshold cut points is needed to identify the measures with the greatest opportunity for improvement and also those closest to the next cut point (low hanging fruit).
• Emphasize quality and outcome measures:  Star Rating methodology gives the greatest weight to measures that track quality and outcomes.
• Leverage current quality improvement efforts:  Plans should be aware of all QI activities taking place in the organization so that stars improvement efforts are coordinated with other projects. 

How does a plan demonstrate return on investment based on improved star ratings?

Beginning in 2012, a Medicare Advantage organization can increase its CMS revenue by demonstrating quality to earn a benchmark revenue bonus.  CMS will use each MA organization’s star rating to award these bonuses to eligible organizations.  All organizations with a star rating of 3.0 or higher will receive a revenue bonus in 2012.  The bonuses can be significant, as 3-star, 4-star, and 5-star rated plans in 2012 will earn bonuses of 3%, 4%, and 5% respectively on the portion of the benchmark revenue based on the new payment methodology. 

Stars	2012 Bonus	2013 Bonus	2014 Bonus	2015 Bonus	Rebate
<3	0.0%	0.0%	0.0%	0.0%	50%
3	3.0%	3.0%	3.0%	0.0%	55%
3.5	3.5%	3.5%	3.5%	0.0%	65%
4	4.0%	4.0%	5.0%	5.0%	65%
4.5	4.0%	4.0%	5.0%	5.0%	70%
5	5.0%	5.0%	5.0%	5.0%	70%

Each Medicare Advantage organization will need to evaluate its star rating and the Medicare Advantage payment reform in its service area to determine the impact these changes will have on its future revenue. In addition to the bonus payments, a limited number of counties qualify for double bonuses.  Approximately 6% of counties determined with criteria by the Patient Protection and Affordable Care Act will get to double their star bonus payment.

Quality Bonus Payments are required to be used towards providing additional services to their members, further boosting quality of plan services.

The Mihalik Group has a dedicated team ready to help you manage your Stars performance.  Feel free to contact us here.

NCQA Case Management Certification

NCQA has announced that it will be releasing a new certification program, for Case Management, in summer 2012.

The draft standards are available for public comment here. 

With the continued evolution of disease management, “traditional” disease management programs are becoming more scarce.  Disease management programs are looking more like case management programs with a focus on a specific condition.

The new case management standards will look very familiar to anyone who knows the disease management standards.  What is quite different however, is that the interventions are quite fluid and not really pre-planned based on stratification or assessment as is the case with traditional disease management programs.  Some disease management programs that are finding the disease management standards a challenge may find a comfortable home in the new case management certification standards. 

There are a few other twists and turns that make the case management standards distinct from the disease management standards…like a standard for “care transitions” adopted from the SNP structure and process measures…but, all-in-all, very similar. 

I encourage you to review the proposed case management standards and respond to the public comment which expires on March 27, 2012.

Medicare Advantage Stars Primer: Part 2

Last time we discussed the basics of the Medicare Advantage Stars Program.  We continue that discussion today. 

What Data Submissions Comprise the Annual Star Ratings and Bonus Payments?

There is a delayed impact of the measure results on the Star Ratings and on the Bonus payments.  Here’s how it works.

2013 Star Rating is based on:

• HEDIS 2012
• CAHPS 2012
• HOS 2011
• CMS Data 2011/2012

2013 Star Rating affects the 2014 bonus payment.

It is important to work on improving performance NOW to ensure the highest bonus payments in future years. 

What is the integration factor?

In order to reward plans that produce consistent results across all measures, CMS calculates an integration factor.  The integration factor is based on the average variance within plans and among measures.  Plans with low variance compared to the variance of all other plans are rewarded.  The integration factor is designed to assist plans that more consistently perform at higher levels as opposed to plans that rate high for some measures but not for others.

What are some of the benefits of being at 5 stars?

Besides receiving the highest possible rebates and bonuses, CMS announced that beneficiaries would be granted a special election period allowing them to enroll in 5-Star plans at any point during the year.

CMS has also created a high performing contract icon identifying 5-Star plans that will be displayed in the Medicare.gov Plan Finder.

Medicare Advantage Stars Primer: Part 1

I recently spent some time chatting with our Performance Measurement Improvement consulting staff about the Medicare Advantage Stars Program. In this and then next few posts I'll cover the basics of the Stars Program, its impact on the revenue of a health plan, and how to start the improvement process.

What is the Medicare Advantage Stars Quality Rating System?

The Centers for Medicare and Medicaid Services (CMS) rates the relative quality of the private plans that are offered to Medicare beneficiaries through the Medicare Advantage program to aid beneficiaries who are considering enrolling in a private plan. Medicare Advantage plans are rated on a one to five-star scale, with five stars representing the highest quality.

Medicare health and prescription drug plans get an overall rating that summarizes all categories and measures into a single “star” rating. A plan’s star rating is reviewed each year and results are available each fall. A plan can get ratings between one and five stars.

★★★★★ = “Excellent”

★★★★ = “Above Average”

★★★ = “Average”

★★ = “Below Average”

★ = “Poor”

How does the Stars Program financially impact Medicare Advantage health plans?

Beginning in 2012, Medicare Advantage plans will see a 10% reduction in premiums. However, CMS has also created the opportunity to earn bonus revenue if the plans achieve a 3, 4, or 5-Star rating. In 2012 the new bidding rebates will begin to phase in, with the new rebates phased in at one-third of the total in 2012, two-thirds of the total in 2013 and fully in 2014. Bonus payments will also begin in 2012 for plans that have an overall score of at least 3 stars.

Additionally, plans receiving 5 stars in 2012 will be able to enroll and market to Medicare beneficiaries throughout 2012, not just during the annual enrollment period.

How are Stars Ratings Calculated?

The CMS Star Rating measures a broad array of clinical quality, customer satisfaction and other beneficiary experience areas. There are 36 measures for Medicare Advantage Part C plans taken from multiple sources which include two surveys, one measure set, and a variety of CMS administrative sources. The specific sources are:

• CAHPS Survey
• HOS Survey
• HEDIS
• CMS Administrative Sources

The Star Rating Measures are broadly grouped into five domains:

• Staying Healthy
• Managing Chronic Conditions
• Ratings of Care and Responsiveness
• Complaints, Appeals, and Choosing to Leave
• Customer Service

Here are the domains, measures, and sources of data that are used in the Stars calculations for Medicare Advantage Part C Plans:

Domain	Measure	Source
Staying Healthy: Screenings, Tests and Vaccines	Breast Cancer Screening	HEDIS
	Colorectal Cancer Screening	HEDIS
	Cardiovascular Care – Cholesterol Screening	HEDIS
	Diabetes Care – Cholesterol Screening	HEDIS
	Glaucoma Testing	HEDIS
	Annual Flu Vaccine	CAHPS
	Pneumonia Vaccine	CAHPS
	Improving or Maintaining Physical Health	HOS
	Improving or Maintaining Mental Health	HOS
	Monitoring Physical Activity	HOS
	Access to Primary Care Doctor Visits	HEDIS
	Adult BMI Assessment	HEDIS
Managing Chronic Conditions	Care for Older Adults – Medication Review	HEDIS
	Care for Older Adults – Functional Status Assessment	HEDIS
	Care for Older Adults – Pain Screening	HEDIS
	Osteoporosis Management in Women who had a Fracture	HEDIS
	Diabetes Care – Eye Exam	HEDIS
	Diabetes Care – Kidney Disease Monitoring	HEDIS
	Diabetes Care – Blood Sugar Controlled	HEDIS
	Diabetes Care – Cholesterol Controlled	HEDIS
	Controlling Blood Pressure	HEDIS
	Rheumatoid Arthritis Management	HEDIS
	Improving Bladder Control	HOS
	Reducing the Risk of Falling	HOS
	Plan All-Cause Readmissions	HEDIS
Ratings of Plan Responsiveness and Care	Getting Needed Care	CAHPS
	Getting Appointments and Care Quickly	CAHPS
	Customer Service	CAHPS
	Overall Rating of Health Care Quality	CAHPS
	Overall Rating of Plan	CAHPS
Member Complaints, Problems Getting Services, and Choosing to Leave the Plan	Complaints about the Health Plan	CMS Data
	Beneficiary Access and Performance Problems	CMS Data
	Members Choosing to Leave the Plan	CMS Data
Health Plan Customer Service	Plan Makes Timely Decisions about Appeals	CMS Data
	Reviewing Appeals Decisions	CMS Data
	Call Center – Foreign Language Interpreter and TTY/TDD Availability	CMS Data

Each measure is assigned a star based on several factors including type of measure, performance relative to national percentiles, and other criteria.

A plan’s overall summary score is calculated by averaging the stars for all measures.

• Stability over time is rewarded for those plans showing high and stable performance.
• Summary scores can be at the ‘half-star’ level, e.g. 4.5 stars.
• To receive a summary score, a plan must report at least 18 of the 36 measures (17 for plans that do not offer a SNP).
• Not all measures carry the same weight. In general, outcome measures are weighted more than process measures.

Next time I’ll address how the bonus process works.

 

 

Behavioral Health HEDIS Measures

I remember many, many years ago when NCQA intended, and indeed tried, to create a robust set of behavioral health measures within HEDIS. For numerous reasons, a prominent one being the inconsistent availability of claims data by MBHOs, a major "target" of the behavioral health HEDIS measures, the effort never came to fruition.

In the current HEDIS public comment, NCQA is proposing a number of new measures related to behavioral health. I'm not sure what NCQA's long term plan is, but it wouldn't surprise me if the accreditation decision-making process for MBHOs were to morph in a manner that reserved the highest level of accreditation for those organizations that could submit audited results for the behavioral health subset of HEDIS measures.

In any case, you can find the public comment documents here. You have until close of business on March 14, 2012 to submit your comments to NCQA.

All the new behavioral-health related measures are being proposed for Medicaid only. Here's a brief run-down of the proposed new measures:

1. Continuity of Antipsychotic Medications for Treatment of Schizophrenia: The percentage of members 25–64 years of age with a diagnosis of schizophrenia who remained on an antipsychotic medication for at least 80 percent of their treatment period.
2. Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications: The percentage of members 25–64 years of age with a diagnosis of schizophrenia or a diagnosis of bipolar disorder, who were prescribed any antipsychotic medication and received a diabetes screening test during the measurement year.
3. Cardiovascular Health Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications: The percentage of members 25–64 years of age who were diagnosed with schizophrenia or bipolar disorder and prescribed any antipsychotic medication, and who received a cardiovascular health screening during the measurement year.
4. Diabetes Monitoring for People with Diabetes and Schizophrenia: The percentage of members 25–64 years of age who were diagnosed with schizophrenia and with diabetes, and received both an LDL-C test and an HbA1c test during the measurement year.
5. Cardiovascular Health Monitoring for People with Cardiovascular Disease and Schizophrenia: The percentage of members 25–64 years of age with a diagnosis of schizophrenia and a diagnosis of cardiovascular disease, who received a cardiovascular health monitoring test during the measurement year.
6. Cervical Cancer Screening for Women with Schizophrenia: The percentage of women 21–64 years of age with a diagnosis of schizophrenia who received one or more Pap tests to screen for cervical cancer.
7. Follow-Up after Hospitalization for Schizophrenia: The percentage of discharges for members 25–64 years of age and older who were hospitalized for treatment of schizophrenia and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: the percentage of discharges for which the member received follow-up within 30 days of discharge and the percentage discharges for which the member received follow-up within 7 days of discharge

Describing Standards Compliance

In my last post, I described the need for organizations seeking NCQA accreditation to present the survey team with carefully thought-out and easy-to-understand documentation of compliance.

This time I want to focus on the Statement of Compliance.

The Statement of Compliance is another component of NCQA’s new Documentation Preparation Guidelines.

The Statement of Compliance is used to “tell your story.” Nobody knows your processes better than you do. While you may think that the documents speak for themselves, trust me, they usually do not!

You need to “pull it together” for the survey team. Tell them what the documents mean and how they fit together as evidence of compliance.

Anticipate questions and address them in the Statement of Compliance. For example, if you include a copy of your practitioner newsletter as evidence of informing practitioners about a specific requirement, you need to tell the surveyors how the newsletter is distributed. Is it in hard copy? Does it get mailed to each and every practitioner? Do some practitioners receive an email version? What if you do not have email addresses for each practitioner?

The important question to answer with the Statement of Compliance is HOW.

How do we comply with the standard? How do the documents demonstrate that compliance?

Do not use the Statement of Compliance to simply say “We do, x, y, or z.” You need to say HOW you do x, y, or z.

With better preparation you just might find that your survey outcome improves.

Documenting Standards Compliance

I know you’ve heard me comment on how it is becoming progressively more difficult to conduct NCQA surveys due to poor documentation preparation.

Starting with surveys conducted in July 2012, NCQA will be enforcing its Document Preparation Guidelines.

The guidelines specify that organizations are expected to provide the necessary documents in an organized and readable format. Documentation should be limited to what is minimally necessary to demonstrate compliance. The organization is also expected to use highlighting, comments, hyperlinks and other software tools to direct the surveyors to the evidence of compliance.

Did you catch that?

You need to know what is required to demonstrate compliance and to present it in an easy-to-understand manner. If you include numerous documents and/or the evidence of compliance is not clear, the surveyors will ask for clarification rather than struggle to read everything that is presented.

NCQA summed up the situation nicely: “The onus is on the organization to demonstrate compliance, not on the team to find compliance.” [Emphasis in original.]

Remember, you have two opportunities provide evidence of compliance after the initial ISS submission. The first is when you respond to NCQA’s outstanding issues form. The second is following the conference call with the survey team. If you do not follow the documentation guidelines and the surveyors ask for clarification, you will have wasted the one of your two opportunities to provide additional documentation.

Are you ready for NCQA 2012? (Part 2)

Last time I discussed the most significant changes to the Health Plan and MBHO UM standards. Today I’ll cover the highlights of the other categories.

Across all standards categories, there must be evidence that the delegation agreement was mutually agreed to before the delegate began performing delegated activities.

For organizations that delegate complex case management, there must be an annual file review of the delegate’s complex case management files. This is a new element scored by the surveyors. A similar element was added to UM. The focus of both is on whether the organization conducted an annual file review and reviewed the appropriate number of files.

Nurse practitioners are now included in the file pull for credentialing. In addition, NCQA clarified that the organization must credential all eligible practitioners regardless of whether they are in the file pull.

There are nine requirements for the QI work plan. All nine elements must be present for the work plan to be considered in compliance.

Practitioner availability must be measured separately for general practitioners/family practitioners; internists; and pediatricians.

If accessibility issues are identified in the organization-wide analysis, practitioner-level analysis is required to determine the cause.

For disease management organizations must identify psychosocial issues that may affect adherence, including: beliefs and concerns about the condition and treatment; perceived
barriers to meeting treatment requirements; access, transportation and financial barriers to obtaining treatment; and cultural, religious, and ethnic beliefs.

As always, if you need assistance with accreditation preparation, just contact us at marketing@themihalikgroup.com