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Improvement Of Underperforming CMS Star Quality Ratings
This document provides guidance to sales representatives on improving Medicare Advantage plan star ratings and exploiting opportunities. It outlines 6 areas of focus to enhance based on CMS categories. The areas include screening and prevention of diseases, access to care, care management, drug formularies, member satisfaction, and complaint resolution. Consulting, IT, and business process improvements are mapped to the opportunities. Revenue potential for each area is estimated. Initial due diligence and targeting procedures are described to qualify leads and plans rated 2-3 stars.
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Improvement Of Underperforming CMS Star Quality Ratings
- 1. IMPROVEMENT OF UNDERPERFORMING CMSSTAR RATINGS Timothy R. Roe AVP - Life Sciences Solutions Company and Client Confidential
- 2. 2/27/2013 3:21:42 PM 2 Content • Document Purpose • Understanding The Ratings • Specific Confidential Co. Opportunities • Sales Pre-work Guidance • Investigative Probes For Identified Accounts • Detail-level Of Opportunities • Case Studies (Incomplete) • Ratings Source Information And Statistics
- 3. 2/27/2013 3:21:42 PM 3 Document Purpose Exploit regulatory changes which are creating unmet challenges in the marketplace relative to CMS Medicare Advantage Quality “Star Ratings” • Areas of opportunities include • Business Process Re-engineering • Information Technology Enhancements • Healthcare Consulting - Clinical, Promotion And Regulatory/Compliance
- 4. 2/27/2013 3:21:42 PM 4 Understanding the Ratings
- 5. 2/27/2013 3:21:42 PM 5 Medicare Plan Quality Improvements (Background Information) • This proposed rule implements provisions of the Patient Protection and Affordable Care Act and the Health Care Education and Reconciliation Act of 2010 (the Affordable Care Act) that are related to the Medicare Advantage (MA, or Part C) and Prescription Drug Benefit (Part D) Programs. • Key Provisions • Strengthen Medicare beneficiary protections • Remove consistently poor performers and set requirements for fiscal solvency • Codify statutory changes to close the Part D coverage gap • • Plans Receive Star Ratings on a 5 –Scale • 5 Categories worth one star each • 2011 – 53 Measures contributing to fractional stars in each category • 2011 Star rating 5-3 are eligible for quality bonuses • 2012 only 5-4 rated plans are eligible for bonus, 3 and under plans will be branded “Low Performer” icon on the Medicare website • 75% of plans fall into a below “4” rating depicting the current seriousness of CHS to eliminate the garbage plans from top performers • After 2014, plans will need four or five stars to get bonuses. And if they have fewer than three stars, they won't be allowed to enroll beneficiaries through Medicare's website, and risk being booted from Medicare altogether • Members and beneficiaries will select plan with a top performance rating icon next to the plan name and cautioned to avoid those with 3 and under with a poor performing icon attached • All plans automatically enrolled in 2012-2015 national demonstration project to test the hypothesis that moving the scaled rating system from 4-5 star bonus system to a 3.5 – 5 system would reduce the amount of plan failures. A county benchmark comparison will set average FFS cost at a specific % level. • Some or all or the PPACA could be overturned
- 6. 2/27/2013 3:21:42 PM 6 Appearance Of Ratings Healthy Plan Underperforming Plan Too New To Be Rated
- 7. 2/27/2013 3:21:42 PM 7 Repeating Cycle - Decline In Ratings Drives Decline In Membership Accelerating Cycle Lost membership due to highly visible public quality rating comparisons CMS fulfills objective of Rating declines on CMS eliminating “garbage” and membership metrics underperforming plans in favor of quality plans (Retention, Attrition and Attraction) Internal “Plan Inertia” diminishes Financially weak plans become as employees, providers and weaker while stronger plans support becomes increasingly attract higher membership & deflated and unmotivated higher rebates/bonuses Anti-Selectivity increase patients with co-morbidities, thus more Higher rated plans enjoy 11- difficult to manage and higher month enrollment period vs. cost patients only 45-day enrollment period Accelerating complaint volume Lower-rated plans have limited and unanswered surveys further marketing and promotion spends perpetuate negative ratings to attract enrollees Until the 2010 healthcare law and the inclusion of sizeable performance bonuses, plans did not focus as much on quality ratings.
- 8. 2/27/2013 3:21:42 PM 8 Example of Allowed 5-Star Plan Promotion Higher-rated Plans Have Greater Ability To Attract New Members, Grow Rebates And Bonuses And Have Longer Enrollment Periods
- 9. 2/27/2013 3:21:42 PM 9 Specific Confidential Co. Opportunities
- 10. 2/27/2013 3:21:42 PM 10 Opportunity 68% of 2011 plans represent an immediate opportunity. 8% of 2011 plans represent a future potential opportunity. Distribution of Overall Plan Ratings for MA-PD Contracts (2011) Focus #1 Total 67.6% Attention Focus #2 76% 8.1% • Half-star ratings are rounded down for these distributions • These ratings summarize all Part C and Part D measures combined. Focus Area 1 = 319 Plans Focus Area 2 = 164 Plans • Focus Area 1: Organizations with Star Ratings of 2 and 3 are prime for targeting • Focus Area 2: Organizations with a “Too New to Rate” or “Not Enough Membership” should be second-tier targets and must be watched as they become ratings-eligible • Organizations with Star Ratings of “1” should not be focused on as they will likely be eliminated as a CMS plan host
- 11. 2/27/2013 3:21:42 PM 11 Specific Areas of Focus Confidential Co. Expertise Mapped To CMS Categories (CMS Category) # Confidential Co. Areas of Focus Screening, Monitoring And Prevention Of 11 Costly Acute And Chronic Disease 21 Access To Care 31 Care Management Drug Formulary Information And Prescription 41 Tracking System Member Comfort Ratings: Enrollment, 51 Retention And Attrition 61 Complaint Tracking And Resolution Process 53 • Confidential Co. Life Science and Healthcare Solutions CMS 5-Point Consolidation has identified six “Areas of Focus” which are within our scope of expertise and potentially high revenue drivers. • Staying Healthy • Managing Chronic Conditions • By enhancing the determined “Areas of • Plan Responsiveness Focus”, Confidential Co. will enable broad improvements • Members’ Complaints and Appeals in quality ratings over the nine CMS category set. • Telephone Customer Service
- 12. 2/27/2013 3:21:42 PM 12 Confidential Co.’s Journey To Business Outcomes
- 13. Quality Improvement Roadmap APath To Business Outcomes (Star Rating Improvement) Consulting – Assessment Execution – Building the Technology and Ops Components Improvement Transformation Initiatives Will Star Rating Initiatives Confidential Co. Lead To An Outcomes-based Improvements Technology iTOPS Model. “To-Be” Solution & Business Layer (Trusted Partner = Shared Risk) -- Case Accepted Complete Member Record -- with Action Indicator Transformational -- Joint Management & Benefits Governance Model -- +1.5 -- Knowledge Management -- Business Framework -- Operations Business Outcomes Understanding Impact of Confidential -- +1.0 Simulate Process Co. -- Improvements Project Execution Enablers -- Framework -- Typical Enhanced “As-Is” Model IT Environment Member Baseline Reduce Workflow Productivity Gains -- Data Integration (MDM) Solution Design Inefficiencies -- +0.5 Technical Business Model -- Understanding -- -- -- 0 Average Productivity Gain --- -- Changing Reactive software Knowledge retention -- development activities Requirements dependent on people and -- -0.5 experience Impact of Inaction Less Clarity In Scope -- & Specification (Representative) -- Growing Members and Products -- Lack of “ground truth” without Complete Member Record -- – agreed upon current and Member Master Data state capabilities Multi site, multi-vendor collaboration -- challenges in design & INACTION -- -1.0 implementation of improvements Multiple Technologies, hosting Repeating environments, resources Downward Cycle PHASE PHASE PHASE 3 1 2 Phases: 1-Assessment, 2- Interim Enhancements, 3- Business Outcomes Model
- 14. 2/27/2013 3:21:42 PM 14 Confidential Co. Healthcare Consulting Approach* 1. System Discovery And Assessment Phase I 2. Assessment Workshops 3. Findings And Recommendations Phase II 4. Build And Install Improvements 5. Monitor And Report On Performance Phase III 6. Adapt Solutions Based On Lessons Learned *Approach is standard to each potential area of improvement
- 15. 2/27/2013 3:21:42 PM 15 Opportunities Tableau Opportunities Matrix by “Area of Focus” and Confidential Co. Vertical # Confidential Co. Identified Confidential Co. IT BPO Consulting “Areas of Focus” Opportunity Enhancement • Increase management oversight in critical performance areas Screening, Monitoring And • Predictively measure quality deviation ✔ ✔ Prevention Of Costly • Introduction of IVR technology to reach out proactively to membership ✔ 11 • ✔ ✔ Acute And Chronic Train Staff that pain is 4th vital sign and should be documented ✔ • Establish disease-specific protocols for providers – consistently educate ✔ ✔ Disease and remind • Evaluate system-wide ease of member to obtain timely care ✔ • Development of a more robust appointment management system ✔ ✔ 21 Access To Care • Determination if candidate areas exist for the appropriate application of ✔ ✔ ✔ process improvement ✔ • Care management for the treatment of specific chronic conditions ✔ • Quality slippage monitoring system 31 Care Management • Establish disease-specific protocols for providers – consistently educate ✔ ✔ ✔ and remind ✔ • Creation of member intranet or links to established drug information Drug Formulary portals (i.e. WebMD or Mayo) for those drugs on the formulary list ✔ • Introduction of high risk SAE indicators within a monitoring framework ✔ Information And ✔ 41 that flags safer alternatives ✔ ✔ Prescription Tracking • ✔ Enable ease and speed of medication access ✔ • May require formulary system overhaul, including the creation of ✔ System member drug utilization DBMS • Segment and predict early tendency toward specific areas of Member Comfort Ratings: membership abandonment for proactive outreach ✔ ✔ • Retrain all customer service staff or contractors on bedside manner ✔ 51 Enrollment, Retention And • Introduction of intelligent IVR technology for Customer Service ✔ ✔ ✔ Attrition improvement ✔ ✔ • Institute new SOP with 3-day standard for handling enrollment requests • Assess and recommend system changes for complaint resolution ✔ process ✔ 6 Complaint Tracking And ✔ 1 • Implement technology layer that will enable predictive, logic-based ✔ ✔ Resolution Process ✔ action to alert management of probable complaints so that they may be ✔ proactively addressed ✔
- 16. 2/27/2013 3:21:42 PM 16 Monetizing The Opportunity Plans representing an immediate opportunity. Focus Area #1: 2 and 3 Star Plans Percentage of Confidential Co. Invoicing Range of Revenue Opportunity* Year One 61 $250k to $3MM 51 $750k to $3MM 41 $250k to $2MM 31 $500k to $1MM 21 $500k to $3MM 11 $500k to $3MM *Based on detail-level scrutiny Opportunities could present as a combination of IT, Business Process Re-engineering or Consulting
- 17. 2/27/2013 3:21:42 PM 17 What Makes Confidential Co.’s Solution Unique? Three Primary Differentiators Exist • iTOPS – No other IT consulting firm has more experience with “pay for performance” than Confidential Co.. Our business outcomes methodology of invoicing was a first in industry and we are the only firm that does it from a leadership position. • Healthcare and Life Sciences Consulting – Confidential Co.’s specialty staff are former industry executives who offer clients the most robust “fire-power” in the market • We address each CMS category individually and determine those areas which will provide an optimized solution to increase quality more meaningfully and more rapidly • Assessment • Management Workshops • Consideration of Commercial, Legal, Regulatory and Compliance Factors • Simulation Through An Optimization Tableau
- 18. 2/27/2013 3:21:42 PM 18 Sales Pre-Work Guidance
- 19. 2/27/2013 3:21:42 PM 19 Initial Due Diligence Procedure • Go to www.medicare.gov/find-a-plan • Enter a zip code for the geographic areas of sales for which you are responsible. • Enter “I do not have a plan” and “I do not know for all answers” to avoid report limitations • Enter “I am not on any drugs” Enter “View 100” plans to get the large list http://www.m2details.com/fileshar • e/Confidential Co./Sample%20CMS%20Plan%2 0Ratings%20Report%20for%20H artford_%20CT%20Area.pdf • Sort by plan rating Click To Download • Begin to qualify leads Sample Report • (a place to start may be the “low hanging fruit” or current clients. Humana, UAM and United Healthcare all have pockets geographically that are at 3 or below)
- 20. 2/27/2013 3:21:42 PM 20 Targeting • Organizations • Determination made by running CMS Plan rating reports for geographic location • Download ratings detail for individual plans • Create list of organizational targets • Create plan of entry targeting IT Executives, QC/QA Executives, Lead Clinicians • Review with and utilize Healthcare Consulting for help and approach • Internal Leadership • Plan Brand Directors, Product Development Directors • CIO, COO and other Corporate Leaders • Most information is publically available • Yahoo Finance is a fantastic and robust source • http://finance.yahoo.com/
- 21. 2/27/2013 3:21:42 PM 21 Resources Marketplace Facts (Minimum Educational Requirements) http://www.m2details.com/ http://www.m2details.com/files http://www.m2details.co http://www.m2details.com/ hare/Confidential http://www.m2details.com/fil fileshare/Confidential m/fileshare/Confidential fileshare/Confidential Co./2012_Tech_Notes_2011_ eshare/Confidential Co./CMS%20Fact-Sheet- Co./CMS%20Ratings% Co./redp3975-1.pdf 10_11.pdf Co./UAM%202011%20Star 2011-Landscape-for-MAe- 20Analysis.pdf %20Rating%20- and-Part-D- %20Unsorted.xlsx FINAL111010.pdf CMS Fact Sheet CMS Tech Notes Star Rating and Mid-Market Selling Sample Analysis of Bonus Plan by Guide Example Poor Performance Kaiser Perform Due Diligence (Samples) Research every area of the organizations financials, quarterly and annual statements, news, PR… http://www.m2details.co http://www.m2details.com m/fileshare/Confidential /fileshare/Confidential Co./CMS%20Sanctions Co./Universal%20Americ %20on%20UAM.pdf an%20Goes%20Red%20 -%20DailyFinance.pdf
- 22. 2/27/2013 3:21:42 PM 22 Yahoo Finance Sample Report
- 23. 2/27/2013 3:21:42 PM 23 Investigative Probes for Identified Accounts
- 24. 2/27/2013 3:21:42 PM 24 Four Initial Questions For Account 1. What has been your member growth or decline over the past two years? Is this an accelerating growth or decline? What were the primary drivers? 2. What is the most troublesome aspect of your quality ratings as they stand now? What category and more specifically, measures, are you most focused on improving? Which have proven to be the most difficult to overcome and why? 3. What have you implemented in the past 6 months to improve your quality ratings? Where have your attempts been successful and where have they not been successful and why? 4. How is your MA book of business distributed geographically? What percent is south of the Mason- Dixon line, and deep South? Do you have a breakout of performance measures geographically?
- 25. 2/27/2013 3:21:42 PM 25 Subsequent Questions for Account 1. Which measures are considered out of your control? Example: measurement for flu vaccines, but the CMS survey done outside of flu season 2. Have you performed an evaluation (internally or externally) resulting in a remediation strategy accounting for • Category/Measure • Ease of recovery (financially and/or within your immediate control) • Speed of recovery • Communication/Messaging to provider network and members 3. How important is, or what value do you place on, monitoring quality rating slippage? How proactive do you want to be in warding off quality slippage predictively? 4. How receptive are you to either and IT, business process or communications/commercial consulting solution to achieve the outcomes you will require? 5. Are you interested in the Confidential Co. outcomes (iTOPS) approach?
- 26. 2/27/2013 3:21:42 PM 26 Several Organizations Are Having Success In This Space Health Data Vision Silver Link
- 27. 2/27/2013 3:21:42 PM 27 In Summary • A primary provision of the CMS quality star ratings is to eliminate plans with poor quality of care and reward plans with high quality of care • Significant opportunities exist for Confidential Co. in helping organizations achieve higher performance quality ratings • The consequences of poor-performer inaction is an accelerating decline in membership, partnerships and quality ratings in a repeating cycle until financial insolvency occurs • Confidential Co. has a detailed approach to assess, design and implement a myriad of solutions • There are companies making money in this space so the opportunities are “real”
- 28. 2/27/2013 3:21:42 PM 28 Detailed-Level of Opportunities
- 29. 2/27/2013 3:21:42 PM 29 1 Screening, Monitoring And Prevention Of Costly Acute And Chronic Disease 13 CMS Measures Impacted Annual Flu Vaccine Breast Cancer Screening Checking to See if Members Are at a Healthy Weight Cholesterol Screening for Patients with Diabetes Cholesterol Screening for Patients with Heart Disease Colorectal Cancer Screening Eye Exam to Check for Damage from Diabetes Glaucoma Testing Kidney Function Testing for Members with Diabetes Monitoring Physical Activity Pneumonia Vaccine Reducing the Risk of Falling Yearly Pain Screening or Pain Management Plan Opportunities for Confidential Co. • Address monitoring and tracking to increase management oversight in critical performance areas under direct organizational control. • Enhancements to technology, current business rules and logic to predictively measure quality deviation • Introduction of IVR technology to reach out proactively to membership base as pre-chronic condition flags present • Train staff on new guidance that pain assessment is the 4th vital sign that always must be measured, documented and treated appropriately – ensure fields exist in current system and implement reporting capability for CMS review • Establish disease-specific protocols for providers – educate and remind consistently
- 30. 2/27/2013 3:21:42 PM 30 2 Access To Care 4 CMS Measures Impacted Ease of Getting Needed Care and Seeing Specialists Getting Appointments and Care Quickly Problems Medicare Found in Members’ Access to Services and in the Plan’s Performance Readmission to a Hospital within 30 Days of Being Discharged Opportunities for Confidential Co. • Evaluate system-wide ease of member ability to obtain timely care • Development of a more robust member appointment management system • Determination if candidate areas exist for the appropriate application of process improvement
- 31. 2/27/2013 3:21:42 PM 31 3 Care Management 12 CMS Measures Impacted Controlling Blood Pressure Improving Bladder Control Improving or Maintaining Mental Health Osteoporosis Management Plan Members with Diabetes whose Blood Sugar is Under Control Plan Members with Diabetes whose Cholesterol Is Under Control Rheumatoid Arthritis Management Taking Blood Pressure Medication as Directed Taking Cholesterol Medication as Directed Taking Oral Diabetes Medication as Directed Using the Kind of Blood Pressure Medication That Is Recommended for People with Diabetes Yearly Assessment of How Well Plan Members Are Able to Do Activities of Daily Living Opportunities for Confidential Co. • Care management process for the treatment of specific chronic conditions measured • The design and implementation of a quality slippage monitoring system (aka CIGNA) with insertion of technology layer and logic-based action indicator lamp enabling highest degree of proactive care response from the first touch point • Establish disease-specific protocols for providers – educate and remind consistently an Confidential Co.-developed communications and CMS tool
- 32. 2/27/2013 3:21:42 PM 32 4 Drug Formulary Information And Prescription Tracking System 4 CMS Measures Impacted Drug Plan Provides Information or Help When Members Need It Members’ Ability to Get Prescriptions Filled Easily When Using the Plan Plan Members 65 and Older Who Received Prescriptions for Certain Drugs with a High Risk of Side Effects When There May Be Safer Drug Choices Yearly Review of All Medications and Supplements Being Taken Opportunities for Confidential Co. • Creation of member intranet or links to established drug information portals (i.e. WebMD or Mayo) for those drugs on the formulary list • Introduction of high risk SAE indicators within a monitoring framework that flags if a safer alternative formulary- approved drug exists • Enable ease and speed of medication access through IT and process reengineering • After assessment, may require formulary system overhaul, including the creation of member drug utilization DBMS
- 33. 2/27/2013 3:21:42 PM 33 5 Member Comfort Ratings: Enrollment, Retention And Attrition 6 CMS Measures Impacted Customer Service Members Choosing to Leave the Plan Members’ Overall Rating of Drug Plan Members’ Overall Rating of Health Plan Overall Rating of Health Care Quality Plan Handles New Enrollment Requests within 7 Days Opportunities for Confidential Co. • Implement process improvement and predictive modeling technology to segment and depict early tendency toward specific areas of membership abandonment for proactive outreach • Retrain all customer service staff or contractors on bedside manner similar to current medical school mandates – creates environment of warmth, caring and genuine interest in each member • Introduction of intelligent IVR technology to increase speed and ease of members obtaining customer service through both process and system re-engineering • Institute new SOP with 3-day standard for handling enrollment requests
- 34. 2/27/2013 3:21:42 PM 34 6 Complaint Tracking And Resolution Process 5 CMS Measures Impacted Complaints about the Drug Plan Complaints about the Health Plan Drug Plan Makes Timely Decisions about Appeals Fairness of Drug Plan’s Denials to Member Appeals Based on an Independent Reviewer Health Plan Makes Timely Decisions about Appeals Opportunities for Confidential Co. • Assess and recommend system changes or overhaul that will speed the complaint resolution process • Implement technology layer that will enable predictive, logic-based action to alert management of probable complaints so that they may be proactively addressed
- 35. 2/27/2013 3:21:42 PM 35 Case Studies
- 36. 2/27/2013 3:21:42 PM 36 Case Studies To Be Added. Please Submit Success And Failure As Learnings And Best Practices • UAM • Others
- 37. 2/27/2013 3:21:42 PM 37 Rating Source Information and Statistics
- 38. 2/27/2013 3:21:42 PM 38 Star-Ratings Source Data and National Average Scores 2012 National Averages for Part C Measures • HEDIS • HOS • NCQA • CAHPS • CAM - Compliance Actions Module • CTM • IRE • Plan Call Center • Others • PDE - Prescription Drug Event • MPF Pricing Files • HPMS approved formulary extracts • First DataBank and Medispan
- 39. 2/27/2013 3:21:42 PM 39 Source Data Statistics • The CMS Star Rating measures a broad array of clinical quality, customer satisfaction and other beneficiary experience areas. • There are 33 measures taken from multiple sources which include two surveys, one measure set and a variety of administrative sources, which include: • CAHPS Survey (8) • HOS Survey (6) • HEDIS Measurement Set (11) • Administrative Sources (8) • These 33 Star Rating Measures are broadly grouped into five domains, These domains include: • Staying Healthy • Managing Chronic Conditions • Ratings of Care and Responsiveness • Complaints, Appeals, and Choosing to Leave • Customer Service • There are 185 possible stars. • A plan needs 158 stars to get the maximum bonus at 4.5 stars overall, while the 4 star threshold is at 139 stars out of the possible 185 stars