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
AdvantageWhere Weve Been, Where We Are,
Where Were Going

• Abby L. Block
• Director, Center for Beneficiary Choices
• Centers for Medicare Medicaid Services
• April 8, 2008

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• 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

• 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
www.medicare.gov
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www.medicare.gov
www.medicare.gov
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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 high-quality 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
• 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
• abby.block_at_cms.hhs.gov