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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 Advantage Where We ve Been, Where We Are, & Where We re Going Abby L. Block Director, Center for Beneficiary Choices – PowerPoint PPT presentation

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Title: Measuring Quality & Performance in Medicare Advantage Where We’ve Been, Where We Are, & Where We’re Going

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

  • History of Quality and Performance Measures in
    Medicare Advantage

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

Measuring Quality and Performance among Medicare
  • 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
  • The decision to begin quality and performance
    data collection was motivated by several factors
  • Need for accountability to oversight bodies and
  • Desire to make evaluation of managed care plans
    more objective
  • Desire to improve value in government purchasing

Early Uses of Quality and Performance Data
  • Reporting Year 1997 was first year of data
  • 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
  • HHS Government Performance and Results Act (GPRA)

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
  • HOS
  • Independent Review Entity data
  • Part D Performance Measures
  • More detail on these measures today and tomorrow
    from CMS staff

Current Quality and Performance Measurement in
Medicare Advantage
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
  • To provide performance and quality-based
    information to beneficiaries to make enrollment
  • Example 1 MA and Prescription Drug plan ratings
  • Demonstrate value and performance
  • Example 2 Special Needs Plan quality measures

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
  • Domain measure level ratings
  • 5-star rating system
  • Accessible, comprehensible information

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
  • Continuous Beta-Blocker Treatment

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
  • Unique for Medicare Advantage and Prescription
    Drug Programs
  • Not yet available for Hospitals or Nursing Homes

Significance of Plan Ratings
  • Plan ratings improve CMS ability to identify
    high performing plans and plans that need
  • Also substantially expand information available
    to beneficiaries for selecting high-quality heath
    and prescription drug plans

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
  • 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
  • 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
  • Training for health plans on reporting
    requirements currently underway

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

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

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

Future of Quality and Performance Measures in
Medicare Advantage
Need to Improve Current Quality Measurement
  • 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
  • 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 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 List
  • Consumer Information
  • Research and monitoring to determine if an how
    consumers are using quality and performance data
    through and other portals
  • Underway continuing consumer testing of Medicare
    Options Compare and Prescription Drug Plan Finder

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
  • 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

  • Abby L. Block
  • Director, Center for Beneficiary Choices