Transcript What are the CMS Stars?

CMS 5 Stars and
Health Survey
1
What are the CMS Stars?
• CMS created the Five-Star Quality Rating System for Medicare
Advantage plans to compare Medicare Advantage plans more
easily, and to help identify areas about which they may want to ask
questions.
• The Stars are a quality rating system that gives each plan a rating of
between 1 and 5 stars. Plans with 5 stars are considered to be
highly above average in quality, and plans with 1 star are
considered to be very below average in quality.
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What are the CMS Stars?
What are Star Ratings?
Star Ratings are CMS ratings for Part C and D Medicare Plans
What are they used for?
• The original purpose of Star Ratings was to enable Medicare
beneficiaries to compare quality among Medicare Advantage Plans on the
Medicare Prescription Drug Plan Finder (MPDPF).
• As part of Health Care Reform CMS will begin a quality bonus payment in
2012 for MA Plans based on the Five Star Ratings.
When did they start?
• In the fall of 2006, CMS posted Plan ratings based on a 3 star scale
• For 2008 Annual Enrollment Period (AEP), CMS introduced a 5 star scale.
[5= highly above average; 1 = very below average]
• Star Ratings are updated annually (during AEP)
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What are the CMS Stars?
Plans receive an overall Star rating and ratings by domain
Part C
Domain I: Staying Healthy: Screenings, Tests and Vaccines
Domain II: Managing Chronic (Long Lasting) Conditions
Domain III: Rating of Health Plan Responsiveness and Care
Domain IV: Member Complaints, Appeals and Choosing to Leave the Health
Plan
Domain V: Customer Service
Part D
Domain I: Drug Plan Customer Service
Domain III: Member Experience with the Health Plan
Domain IV: Drug Pricing and Patient Safety
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What are the CMS Stars?
• The Star ratings are drawn from various
data sources, and each measure is given
a “weight” from 1 to 3. This means that
some measures affect plan ratings more
than others.
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CMS Star Ratings – Data Sources
Healthcare Effectiveness Data A widely used set of performance measures in the managed care industry, developed and maintained by
the National Committee for Quality Assurance (NCQA).
HEDIS and Information Set
Consumer Assessment of
Healthcare Providers and
CAHPS Systems
HOS Health Outcomes Survey
CTM
CMS
Audit
MBDS
Data were obtained from the CTM based on the contract entry date (the date that complaints are
assigned or re-assigned to contracts; also known as the contract assignment/reassignment date) for the
Complaints Tracking Module reporting period specified. Complaint rates per 1,000 enrollees are adjusted to a 30-day basis.
Findings of CMS audits, ad hoc and compliance actions that occurred during the 14 month past
CMS Administrative Data
performance review period between January 1, 2010 and February 28, 2011.
Medicare Beneficiary Database A collection of individual applications and services that access a single, enterprise-wide authoritative
Suite of Systems
source for Medicare beneficiary demographic data.
An independent entity contracted by CMS to review Medicare health plans’ adverse reconsiderations of
Independent Review Entity
organization determinations.
IRE
Phone
Monitori
Call Center
ng
PDE
data
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MARx
CAHPS refers to a comprehensive and evolving family of surveys that ask consumers and patients to
evaluate the interpersonal aspects of health care. CAHPS surveys probe those aspects of care for which
consumers and patients are the best and/or only source of information, as well as those that consumers
and patients have identified as being important. CAHPS initially stood for the Consumer Assessment of
Health Plans Study, but as the products have evolved beyond health plans, the acronym now stands for
Consumer Assessment of Healthcare Providers and Systems.
The first patient reported outcomes measure used in Medicare managed care. The goal of the Medicare
HOS program is to gather valid, reliable, and clinically meaningful health status data in the Medicare
Advantage (MA) program for use in quality improvement activities, pay for performance, program
oversight, public reporting, and improving health. All managed care organizations with MA contracts must
participate.
Prescription Drug Event Data
Medicare Advantage
Prescription Drug System
Call center data collected by CMS
Data were obtained from PDE data files submitted by drug plans to Medicare for the reporting period.
This data used for this measure is from the Medicare Advantage Prescription Drug System (MARx). It
presents the percentage of new enrollment requests from beneficiaries that the plan submitted to
Medicare within 7 days of the application date.
Data Sources by Weight
Data Source
Domains
HEDIS
PDE Data
CAHPS
Part C: Domains I&II
Part D: Domain IV
Part C: Domain I&III; Part D: Domain
III
HOS
Weighted % Total Stars
Value
Ratings
24.5
16
30.82%
20.13%
14
17.61%
Part C: Domains I&II
9
11.32%
IRE
Part C: Domain V; Part D: Domain I
6
7.55%
Phone Monitoring
CTM
CMS Audit
MBDS
MARx
Total:
Part C: Domain V; Part D: Domain I
Part C: Domain IV
Part C: Domain IV
Part C: Domain IV
Part D: Domain I
4.5
1.5
1.5
1.5
1
79.5
5.66%
1.89%
1.89%
1.89%
1.26%
100.00%
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2010-2012 Ratings CA Plans
Ove ra ll Sta r Ra ting s
CA Org a niza tio n_Ma rke ting _Na me
Ka ise r Pe rma ne nte Se nio r Ad va nta g e
Inte r Va lle y He a lth Pla n
SCAN He a lth Pla n
SCAN He a lth Pla n
One Ca re
Pa rtne rship He a lthPla n o f Ca lifo rnia
Blue Shie ld o f Ca lifo rnia
Ca re Mo re He a lth Pla n
GEMCARE He a lth Pla n
He a lth Ne t o f CA
SCAN He a lth Pla n - Sa n Jo a q uin
Se cure Ho rizo ns b y Unite d He a lthca re
Ae tna Me d ica re
Chine se Co mmunity He a lth Pla n
He a lth Pla n o f Sa n Ma te o
Citize ns Cho ice He a lthp la n
IEHP Me d ica re Dua lCho ice
Bra nd Ne w Da y
Anthe m Blue Cro ss
Ca re 1st Me d ica re Ad va nta g e Pla n
MD Ca re Inc
Ce ntra l He a lth Me d ica re Pla n
Mo lina He a lthca re o f Ca lifo rnia
2010
4
3
3.5
3.5
3
3
3
3.5
3.5
3
3
3
3
3
2.5
3
2.5
3
2.5
2.5
2
2.5
2
2011
4.5
4
3.5
3.5
3.5
3.5
3
3.5
3.5
3.5
3.5
3.5
3
3
3
3.5
3.5
3
3
3
3
2.5
2.5
2012
5
4
4
4
4
4
4
3.5
3.5
3.5
3.5
3.5
3.5
3.5
3.5
3
3
3
3
3
2.5
2.5
2.58
2010-2012 CA Ratings
12
10
8
6
4
2
0
2
2.5
3
3.5
4
4.5
No. CA Plans
CA Plan Ratings 2010-2012
2010
2011
2012
5
SCAN H9104 & H5425
Star Rating
77th percentile nationally
Star 2
6
Star 2.5
66
Star 3
144
Star 3.5
119
Star 4
50
Star 4.5
46
Star 5
9
440
1%
15%
33%
27%
11%
10%
2%
R a te d P la ns Ca lifornia
0
5
6
0%
19%
22%
9
33%
6
22%
0
0%
1
4%
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74th percentile in CA
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HOS Survey
 Member-reported survey
April - July
 Measures patient reported
functional status and quality
of patient/doctor interaction
 Knowing what to ask
patients can improve scores
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5 Star HOS Questions
5 key measures
1. Improving or maintaining physical health3
2. Improving or maintaining mental health3
3. Monitoring physical activity
4. Reducing risk of falling
5. Improving bladder control
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5 Star HOS Questions
Improving or Maintaining
Physical & Mental Health
 “Compared to one year ago,
how would you rate …?”
 Gauge patients’ physical and
mental status at each visit
 Consider how the following
measures can impact these
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5 Star HOS Questions
Monitoring Physical Activity
 Find out how much they’re
getting
 Advise them how to start,
increase or maintain
 One of best all-around
“prescriptions” for improving
physical and mental health
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5 Star HOS Questions
Reducing Risk of Falling
 Leading cause of fatal injury,
non-fatal injury and hospital
admissions
 Discuss balance problems,
trouble walking and other risk
factors
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5 Star HOS Questions
Improving Bladder Control
 Can be treated or improved in 8
of 10 cases
 Urinary Incontinence linked to:
 increased fall risk
 decline in mental health
 Physicians need to initiate
discussion
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SCAN Contacts for 5 Stars
For additional information, please contact us by e-mail:
 [email protected]
 [email protected]
“Geriatric toolkit” currently in development
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Break for Pfizer
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What Can You Do?
 Ask your patients about their physical and mental health
 Ask your patients about their physical activity and how it
can be improved
 Your medical staff are key for setting the stage for
improved patient/doctor interaction
 Use the Annual Wellness Visit as a vehicle to set the
stage
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What Can You Do?
Distribute this presentation and consider posting an excerpt
on your web site. Please refer to the following web sites for
additional resources:
 www.scancme.com: learn more about SCAN’s
Continuing Medical Education (CME PIE) Program
featuring guidelines and CMS Star relevant courses
 www.scanhealthplan.com/qip: learn more about the
CMS 5 Star Ratings, CAHPS, HOS, and Initial Health
Assessment (“HQ”)
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What Can We Do?
 SCAN/Pfizer will present to your staff the “Big Picture” on
how they can impact your groups star rating
 Present to your staff the questions that will be asked on
the HOS and how they can positively impact the results
 Educate your staff on the AWV and how it can impact the
overall star ratings
 Develop a comprehensive “geriatric tool kit” with
forms/checklist and guidelines on improving patient
satisfaction and overall quality of care
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SCAN Initiatives
 Member GuideBook – Multiple mailings and incentives
throughout the year
 Annual Wellness Visit – April, 2012
 Medication Adherence – June, 2012
 Diabetes – June, 2012
 Annual Flu Vaccinations – September, 2012
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SCAN Initiatives
 Medication Adherence – Reminder letters for those
members who have a history of not refilling their
prescriptions as prescribed – April, 2012
 Automated Calls – For those members who have a gap
in care for one of the following conditions – Quarterly
starting April, 2012
 Osteoporosis
 Rheumatoid Arthritis
 COPD
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REFERENCE
Following are HOS questions used for Star
Ratings
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HOS – Physical Health
Improving or Maintaining Physical Health
1. In general, would you say your health is:
a. Excellent
b. Very Good c. Good
d. Fair
e. Poor
2. The following are items about activities you might do during a typical day. Does your health now limit you in these activities? If so,
how much?
a. Moderate activities , such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
a. Yes, limited a lot
b. Yes, limited a little
c. No, not limited at all
b. Climbing several flights of stairs
a. Yes, limited a lot
b. Yes, limited a little
c. No, not limited at all
3. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your
physical health?
a. Accomplished less than you would like
a. No, none of the time
b. Yes, a little of the time
c. Yes, some of the time
d. Yes, most of the time
e. Yes, all of the time
b. Were limited in the kind of work or other activities
a. No, none of the time
b. Yes, a little of the time
c. Yes, some of the time
d. Yes, most of the time
e. Yes, all of the time
5. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
a. Not at all
b. A little bit
c. Moderately d. Quite a bit
e. Extremely
8. Compared to one year ago, how would you rate your physical health in general now?
a. Much better
b. Slightly betterc. About the same
d. Slightly worse
d. Much
worse
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HOS – Mental Health
Improving or Maintaining Mental Health
4. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any
emotional problems (such as feeling depressed or anxious)?
a. Accomplished less than you would like
a. No, none of the time
b. Yes, a little of the time
c. Yes, some of the time
d. Yes, most of the time
e. Yes, all of the time
b. Didn’t do work or other activities as carefully as usual
a. No, none of the time
b. Yes, a little of the time
c. Yes, some of the time
d. Yes, most of the time
e. Yes, all of the time
6. How much of the time during the past 4 weeks:
a. Have you felt calm and peaceful?
a. All of the timeb. Most of the time
c. A good bit of the time
d. Some of the time
e. A little of the time
f. None of the time
b. Did you have a lot of energy?
a. All of the timeb. Most of the time
c. A good bit of the time
d. Some of the time
e. A little of the time
f. None of the time
c. Have you
felt downhearted and blue?
a. All of the timeb. Most of the time
c. A good bit of the time
d. Some of the time
e. A little of the time
f. None of the time
7. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like
visiting with friends, relatives, etc.)?
a. All of the timeb. Most of the time
c. A good bit of the time
d. Some of the time
e. A little of the time
f. None of the time
9. Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) in general now?
a. Much better
b. Slightly betterc. About the same
d. Slightly worse
e. Much worse
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HOS – Physical Activity and UI
Monitoring Physical Activity
46. In the past 12 months, did you talk with a doctor or health provider about your level of exercise or physical activity?
For example, a doctor or other health provider may ask if you exercise regularly or take part in physical exercise.
a. Yes
b. No
47. In the past 12 months, did a doctor or other health care provider advise you to start, increase or maintain your level
of exercise or physical activity ? For example, in order to improve your health, your doctor or other health care provider
may advise you to start taking the stairs, increase walking from 10 to 20 minutes every day or maintain your current
exercise program.
a. Yes
b. No
Improving Bladder Control
42. Many people experience problems with urinary incontinence, the leakage of urine. In the past 6 months, have you
accidentally leaked urine?
a. Yes (go to question 43) b. No (go to question 46)
43. How much of a problem, if any, was the urine leakage for you?
a. A big problem (go to question 44)
b. A small problem (go to question 44)
c. Not a problem (go to question 46)
44. Have you talked with your current doctor or other health provider about your urine leakage problem?
a. Yes
b. No
45. There are many ways to treat urinary incontinence including bladder training exercises, medication and surgery.
Have you received these or any other treatments for your current urine leakage problem?
a. Yes
b. No
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HOS – Reducing Risk of Falling
Reducing the Risk of Falling
48. A fall is when your body goes to the ground without being pushed. In the past 12 months, did your
doctor or other health provider talk with you about falling or problems with balance or walking?
a. Yes
b. No
c. I had no visits in the past 12 months
49. Did you fall in the past 12 months?
a. Yes
b. No
50. In the past 12 months, have you had a problem with balance or walking?
a. Yes
b. No
51. Has your doctor or other health provider done anything to help prevent falls or treat problems with
balance or walking? Some things they might do include:
-Suggest that you use a cane or walker
-Check your blood pressure lying or standing
-Suggest that you do an exercise or physical therapy program
-Suggest a vision or hearing testing
a. Yes
b. No
c. I had no visits in the past 12 months
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