Seeing Stars in Puerto Rico

Transcription

1 Seeing Stars in Puerto Rico Stephen Wood Senior Vice President, Development Universal American March 6,

2 What s in the Stars? 2014 Stars scores have improved na<onwide, but Puerto Rico plans remain in the boaom 14% of all plans na<onwide 2014 Overall Star Ra<ng PR Plans Humana Medicare y Mucho Mas Preferred Medicare Choice Triple S Salud* MCS Classicare First Medical Health Plan American Health Medicare Na#onwide, 43% of plans have 4 or more Stars up from 27% in 2013** 18% of all low performing plans are in PR * Triple S Salud has one plan rated 2 ½ stars; ** Avalere analysis of CMS data. 2

3 Payment rates are a challenge to investment % lower cost than US Average Average Monthly Spending for Full Benefit Dual Eligible Beneficiaries (Based on Medicare- Medicaid Coordination Office Profiles, MedPac June 2013 Report and Medicare Platino estimates for PR) $4,500 $4,000 $3,500 $3,000 $2,500 $2,000 $1,500 $1,000 $500 $0 $4,004 $2,956 $2,433 New York Florida National Average in 2009 $950- $1,000 Puerto Rico Poses a challenge for PR Plans to support 4- Star performance 3

4 BUT, MA Plans will be more in demand as the number of seniors and duals increase Today, nearly 16% of the PR popula<on is over age 65 The Puerto Rico populafon is aging faster than the mainland (18% of total by 2025) The PR Medicaid expansion adds 76,000 new Medicaid beneficiaries Growth of the 65+ Popula<on in Puerto Rico % 15.8% 18 % 4

5 PR Plans Lag Behind in All Domains Average of All PR Plan Stars Performance By Domain Customer Service Member Complaints Member Experience In 2015, plans need 4 or more Stars to receive quality bonuses Managing Chronic Condi<ons 2.9 Staying Healthy 3.6 5

6 On average, Plans are performing best in the Staying Healthy Domain - - process measures Average ra<ngs for Puerto Rico plans ( 4 stars or greater) Improving/Maintaining Physical Health Diabetes Cholesterol Screening Cardiovascular Cholesterol Screening Colon Cancer Screening Breast Cancer Screening Problem Areas: Flu vaccine (1 Star) Glaucoma tes#ng ( 2.6 Stars) Improving/ maintaining mental health (1.9 Stars) 6

7 Nearly half of all Chronic Condi<on measures are rated below 3 stars These chronic Chronic Condi<ons Management condi#on Measures Averaging< 3 Stars measures are a Rheumatoid Arthri<s 1.6 mixture of Management process and Controlling Blood Pressure 2.4 outcomes Diabetes Cholesterol Controlled 1.8 measures. Outcomes Diabetes Blood Sugar Control 1.5 measures are Osteoporosis Management 2.3 weighted at 3 Medica<on Review (older adults) 2.7 #mes the value. 7

8 Average Star ra<ngs for Member Experience Measures vary widely in PR Average Ra<ng of PR Plans on Member Experience Measures Care Coordina<on 1.2 Ra<ng of Plan 4 Ra<ng of Care Quality 4.3 Customer Service 3.5 Gedng Appointments and Care Quickly 1.5 Gedng Needed Care 3.6 8

9 In the Member Complaints and Customer Service domain, no service is rated at the 4 Star level Average Ra<ng of Low Rated Complaints and Customer Service Measures Reviewing Appeals Decisions Choosing to Leave Plan Beneficiary Access and Performance Problems Complaints About Plan Some areas perform a bit bever Quality Improvement (3.5 Stars) Timely Appeals (3.6 Stars) Call Center (3.6 Stars) 9

10 2014 Medica<on Adherence Measures a Big Problem Distribution of all Part D Contracts by Average Medication Adherence STAR Rating Number of Contracts 105 Puerto Rico Contracts Less than 2 2 X < 3 3 X < 4 4 X < 5 5 Not enough data or too new 73% of the rated contracts average 3.0 STARs or more in MedicaFon Adherence measures. 10

11 The Road Ahead: The intersection of Part D, Medicare, and Public Health - - circa 2011 Part D is driving down Medicare stars scores in PR Average part D summary score Average part D summary score Decline of 0.54 stars for part D Medication adherence is the driver 3 new measures rated at 3x Drives part D scores 28% of raw scores (9/32 part D points) Adherence measures explain 64% of statistical variance in part D summary score Drives part C also 20% of controlling blood pressure scores 20% of controlling blood sugar scores Adherence is issue for entire island 3 adherence measures 12 plans star scores

12 Radical Focus on Adherence Data Member reports Provider reports Member engagement Understand why? Disease management/wellness Communication Provider engagement Education/reports Payment Health plan collaboration Community collaboration Pharmaceutical Association of Puerto Rico Retail pharmacy Public Entities Non- pronit entities Single minded focus on drug adherence is most important activity plans can do

13 2014: Improving adherence has huge returns: The STORY of HALF a STAR Current Scenario (Medication Adherence at 1.11 STARs vs 3.67 National Level) At 3.5 STARs Rebate for Benefits Estimated PMPM Impact Aggregate Impact in 2015 Benefits 0 50% $0 0 Hypothetic Scenario (Medication Adherence at 3.67 National Level) 459,000 (assuming 85% of members) 65% $24 $132,192,000 13

14 Bright spots Over the Average 19 of 36 in Part C 4 of 15 in Part D STAR Rating by Measure (Sorted by Percentage Difference between PR and National Rates) Measure National PR PR- Nat % Diff C22: Reducing the Risk of Falling % C28: Rating of Health Plan % C09: Monitoring Physical Activity % C21: Improving Bladder Control % C01: Breast Cancer Screening % Part C Average % Measure National PR PR- Nat % Diff D12: Diabetes Treatment % D08: Rating of Drug Plan % D07: Drug Plan Quality Improvement % D04: Complaints about the Drug Plan % D14: Medication Adherence for Hypertension (RAS antagonists) % D13: Medication Adherence for Diabetes Medications % D15: Medication Adherence for Cholesterol (Statins) % Part D Average % 14

15 4 Stars or No Bonus in 2015 Star Ra<ng Financial Impact of Stars Performance QBP Percent 2014 Rebate Percent < 3 Stars 0% 50% 3 Stars 3% 65% 3.5 Stars 3.5% 65% 4 Stars 5% 65% 4.5 Stars 5% 70% 5 Stars 5% 70% The CMS demo expires in 2015, and plans with fewer than 4 Stars will not be eligible for bonuses 15

16 Focus, Focus, Focus Outcomes measures are weighted three <mes higher than process measures in calcula<ng a Stars score Outcomes Measures Weight PR Plan Average Stars Improving or Maintaining Physical Health Improving or Maintaining Mental Health Diabetes Care Blood Sugar Controlled Diabetes Care Cholesterol Controlled PR Plan Average % 4 Star Threshold Comment (PR Plans) % > 60% All Plans above % > 85% No plan above % > 80% Range 38-70% % > 53% Range 19-50% Controlling Blood Pressure % > 63% Range 41-67% Plan All Cause Readmissions Not predetermined Health Plan Quality Improvement Not predetermined 16

17 Essen<als for making do with less... Cri<cal Success Factors Improve Stars Performance to Improve Payments Manage Chronic Conditions Improve Care Coordination Focus on the Customer The future is not completely beyond our control. It is the work of our own hands. Robert Kennedy Redesign the provider-payer relationship Manage Performance with systems and processes 17