2016 Quality Improvement Trends. Free Webinar Series: January 7, 2016

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1 2016 Quality Improvement Trends Free Webinar Series: January 7, 2016 Richard Lieberman Chief Data Scientist Mile High Healthcare Analytics Copyright 2015 Oracle and/or its affiliates. All rights reserved.

2 TODAY S AGENDA 30 Days in 30 Seconds Industry Performance Overview How are plans handling Star ratings Changes to selected measures Quality measurement in Medicaid and on the Exchanges

3 RELEVANT BIO FOR RICHARD LIEBERMAN One of the nation's leading experts on financial modeling and risk adjustment in the managed care industry Combines unique expertise in provider profiling, risk adjustment, case-mix measurement, and provider reimbursement strategies Developer of integrated decision-support platforms coalescing quality measurement, risk adjustment, and utilization reporting Actively involved in the development of risk adjustment systems for over 20 years Johns Hopkins ACG Development Team, Designed the risk-adjusted payment system for Maryland Medicaid 3

4 30 DAYS IN 30 SECONDS The new Governor of Kentucky will not dismantle the Medicaid Expansion or other key elements of the ACA. Instead, Governor Bevin insists he will reform Medicaid in the image of the Indiana Medicaid expansion CMS Details Network Adequacy Standards For 2017 Exchange Plans: CMS, outlined time and distance standards states need to adopt to keep control of their own network adequacy determinations for exchange plans in 2017, and described an exceptions process states can use if they believe certain counties are too rural for the standards to work. States that do not meet the threshold must defer to HHS for network adequacy determinations. HHS touted numbers showing about 84,000 people selected plans in the ninth week of open enrollment and the total number of selections from Nov. 1 through Jan. 2 reached about 8.6 million

5 30 DAYS IN 30 SECONDS CMS has released an RFI describing its initial proposal for Medicare-Advantage RACs! The White House Office of Management and Budget entered 2016 with 10 CMS rules and notices under its review, ranging from Medicaid home health face-to-face requirements to revised benchmarking methodology for Accountable Care Organizations. The past year was an active one for Medicaid expansion, with both Montana and Michigan expanding their programs in the last few months and joining 29 other states that have already done so. Alaska has had 7,700 people enroll in its Medicaid expansion program that started on September 1 st.

6 30 DAYS IN 30 SECONDS CMS finalized its proposal to relax the two-midnight hospital admissions policy and recognize some hospital stays shorter than two-midnights as legitimate inpatient stays CMS is lowering Medicare physician pay rates next year, instead of paying doctors a 0.5 percent pay increase as called for in the law that replaced the Sustainable Growth Rate formula Quiet bipartisanship continues in Congress- changes are being made to the ACA, even by avowed opponents of the ACA Will the gubernatorial election in Kentucky this week mean that people will have health care benefits taken away from them?

7 THE FINANCIAL STATUS OF THE INDUSTRY Based on a (2015) report from MedPAC (derived from plan BPT submissions), MA plans in 2012 had a margin of 4.9 percent. About 91 percent of enrollment was in companies reporting a positive margin. Employer group plans had higher margins than plans for individual Medicare beneficiaries For-profit plans had higher margins than nonprofit plans Special needs plans (SNPs) had higher margins than non-snp plans, except that nonprofit SNP plans reported a slight negative margin. Source: Medicare Payment Advisory Commission. Report to Congress: Medicare Payment Policy. March

8 THE ACA IS IMPACTING THE COST-EFFECTIVENESS OF MA MedPAC estimates that 2015 MA benchmarks (including quality bonuses): Benchmarks will average 107 percent of fee-for-service (FFS) Bids will average 94 percent of FFS Payments to MA Plans will be at 102 percent of FFS spending 8

9 THE STICKINESS OF MEMBER ENROLLMENT CMS data show that in 2012, about 10 percent of beneficiaries voluntarily changed their MA plan Of that number, 80 percent chose another MA plan The remaining 20 percent went to FFS Medicare Only 2 percent of MA enrollees left MA for FFS Among the switchers who faced changes in plan premiums, the large majority switched to a plan with a lower premium Source: Medicare Payment Advisory Commission. Report to Congress: Medicare Payment Policy. March

10 SPECIAL NEEDS PLANS CONTINUE TO GROW Between January 2015 and December 2015 (not including results from 2016 AEP), SNP plans grew by 7.8 percent Currently (December 2015) there are 2.15 million MA members in SNPs, up from 1.99 million in January 2015 We do not have 2016 AEP results available to us yet 10

11 STARS PERFORMANCE MEASUREMENT CONTINUES TO EVOLVE The number of measures comprising Stars continues to fall There are now 47 measures All of the dropped measures have been 1x-weighted, accentuating the role of the 3x-weighted measures on the overall Star-rating Expect to see some promotions from AAA (aka the Display Measures) While the bonuses for achieving 4-Stars in Medicare-Advantage are substantial, no other line of business will incorporate financial incentives Commercial and Medicaid are adopting a public reporting paradigm Plans will compete on quality in exchange for recognition and presumably market share

12 QUALITY MEASUREMENT CONTINUES TO EVOLVE There is a shift toward composite measures The improvement score now has the highest weight (5.0) Drive toward higher performance Elimination of fixed 4-star thresholds CMS will be harmonizing measure sets across sites and providers There will be roughly a 50 percent overlap between Medicare- Advantage and commercial Medicaid is following commercial s lead

13 STABILITY/INSTABILITY OF STAR RATINGS OVER TIME Year-over-Year Change ( ) 1 Star increase 12 Contracts 3.0% 0.5 Star increase 66 Contracts 16.7% No Star increase 199 Contracts 50.4% 0.5 Star decrease 91 Contracts 23.0% 1 Star decrease 21 Contracts 5.3% >1 Star decrease 2 Contracts 0.5% >1 Star increase 4 Contracts 1.0% All Contracts 395 Contracts 100% 13

14 PERFORMANCE IMPROVEMENT: DO NOT REST ON YOUR LAURELS Among the contracts that were below 4-stars last year (2014), 53 of them increased to at least 4-stars this year But.. 32 contracts that were at or above 4-stars last year, dropped below the 4-star threshold this year The financial implications of being below 4-stars are tremendous 14

15 NO FAIR! CMS KEEPS MOVING THE CHEESE! CMS has eliminated all of the fixed 4-star cut points In reality, most of the measures no longer had a fixed 4-star cut point CMS research indicates that quality improves faster in the absence of the fixed cut points It s never as bad as it seems: 4-Star threshold for Statin Use went from 76-83% in 2014 to 73-79% in Star threshold decreased from 83% to 79% compliance

16 INDUSTRY-WIDE PERFORMANCE ON HEDIS MEASURES Performance on HEDIS process measures continues to improve CMS in the past has dropped measures from Stars once industry performance appears to have topped out CMS is likely to replace topped-out measures from the list of Display Measures Measure Name Compliance Percent Rate Change Osteoporosis Management in Women who had a 35% 27% 8% Fracture Care for Older Adults Functional Status 75% 70% 5% Assessment Controlling Blood Pressure 70% 65% 5% Care for Older Adults Pain Assessment 86% 82% 4% Colorectal Cancer Screening 67% 64% 3% Adult BMI Assessment 92% 89% 3% Care for Older Adults Medication Review 85% 83% 2% Diabetes Care Kidney Disease Monitoring 92% 91% 1% Diabetes Care Eye Exam 69% 69% 0% Rheumatoid Arthritis Management 78% 78% 0% Plan All-Cause Readmissions 10% 10% 0% Annual Flu Vaccine 72% 73% -1% Diabetes Care Blood Sugar Controlled 75% 76% -1%

17 INDUSTRY-WIDE PERFORMANCE ON MEDICATION USE MEASURES Much different results for the medication use measures High-risk medication use is improving nationwide Other measures are barely changing Have they topped out? Impact of guideline change on the use of statins Measure Name Compliance Rate Percent Change High Risk Medication 7% 11% 4% Medication Adherence for Hypertension (RAS (RAS antagonists) 79% 78% 1% Medication Adherence for Cholesterol (Statins) 75% 74% 1% Medication Adherence for Diabetes Medications 77% 77% 0%

18 NEW AHA/ACC GUIDELINES ON STATIN USE Historically, the clinical objective for patients with high serum cholesterol was to reduce LDL-C to < 100 mg/dl In 2013, the ACC/AHA changed the standard to focus on treating everyone with a statin who met certain clinical criteria 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

19 WHO IS SUPPOSED TO GET A STATIN PRESCRIPTION NOW? Clinical ASCVD, including acute coronary syndromes, history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin Primary Prevention, LDL-C 190 mg/dl Patients with diabetes years of age and LDL-C mg/dl Patients without diabetes years of age and LDL-C mg/dl Estimate 10-y ASCVD risk using the Risk Calculator 7.5% 10-y ASCVD risk: Moderate- or high-intensity statin 5 to <7.5% 10-y ASCVD risk: Consider moderate-intensity statin

20 STATIN INTOLERANCE CAN IMPACT ADHERENCE Fortunately, statins are generally very well tolerated with a very low risk of serious adverse outcomes. The most common presentation of statin intolerance is muscle aches, pains, weakness, or cramps, often called myalgias these can occur in up to 15% of treated patients. In most instances, the symptoms are mild and are rarely associated with muscle inflammation (myositis) and markers of muscle injury (creatine kinase). The symptoms are completely reversible shortly after the statin is stopped. The first two PCSK9 inhibitors, alirocumab and evolocumab, were approved by the U.S. FDA in 2015 for lowering cholesterol where statins and other drugs were insufficient 20

21 The High Risk Medication (HRM) measure will be removed from Star ratings Conceptually, an HRM measure is a good idea. But in practice, many of the prescription drugs on the list were not intended to be avoided in all instances LIKELY GOOD NEWS FOR 2017 Elavil (Amitriptyline) is indicated for use in the elderly in small doses CMS has proposed removing the HRM measure for

22 IMPACT OF NEW AHA/ACC GUIDELINES ON QUALITY MEASUREMENT NCQA has retired all measures that required achievement of a numerical threshold for LDL-C Cholesterol Management for Patients With Cardiovascular Conditions (CMC) Comprehensive Diabetes Care: NCQA removed two indicators of quality from this measure: LDL-C Screening, LDL-C Control (<100 mg/dl) These aforementioned three measures were all single-weighted (1x) Star-rating measures As CMS continues to drop the low-weighted (1x) measures, the tripleweighted measures have a greater impact on overall Star ratings

23 IMPACT OF NEW AHA/ACC GUIDELINES ON A KEY PART D MEASURE The Part D measure, Medication Adherence for Cholesterol (Statins) is even more important Percent of plan members with a prescription for a cholesterol medication who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication Overall performance by MA Plans improved from 2013 to 2014: 2013 Statin compliance: 74% (3.3 Stars) 2014 Statin compliance: 75% (4.0 Stars)

24 MEMBER EXPERIENCE COMPONENTS OF STARS (PART C) C20 Getting Needed Care C21 - Getting Appointments and Care Quickly C22 - Customer Service C23 - Rating of Health Care Quality C24 - Rating of Health Plan C25 - Care Coordination

25 INDUSTRY-WIDE PERFORMANCE ON MEMBER EXPERIENCE Over time, the member experience measures are where the plans will distinguish themselves from each other Most members like their MA Plan s service Small shifts in public opinion are likely to dramatically move Star-ratings There is no way that CMS will retire these measures, even if they topout Many plans struggle with the member experience measures Measure Name Compliance Rate Getting Appointments and Care Quickly 75% 76% -1% Quickly Customer Service 87% 88% -1% Rating of Health Care Quality 85% 86% -1% Rating of Health Plan 84% 86% -2% Care Coordination 85% 85% 0% Complaints about the Health Plan 6% 12% 6% Getting Needed Prescription Drugs 90% 91% -1% Percent Change

26 A HOT TOPIC: THE IMPACT OF SOCIO-ECONOMIC VARIATION Multiple Medicare Advantage (MA) organizations and Prescription Drug Plan (PDP) sponsors believe that enrollment of a high percentage of dual eligible (DE) enrollees and/or enrollees who receive a low income subsidy (LIS) disadvantages their plan s ability to achieve high MA or Part D Star Ratings CMS has been trying to provide the scientific evidence as to whether MA or Part D sponsors that enroll a disproportionate number of vulnerable beneficiaries are systematically disadvantaged by the Star Ratings 26

27 WHERE THE NATIONAL QUALITY FORUM OPINION LIES The National Quality Forum (NQF) recommends assessing performance measures to determine if they should be adjusted for socio-demographic factors, including socioeconomic status (SES), particularly when used for accountability and payment applications. Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Health Outcomes Survey (HOS) are already adjusted for SES characteristics of patients, including education, LIS, DE, and health status. 27

28 EVIDENCE OF STAR RATING ISSUES FOR DUALS The research to-date has provided scientific evidence that there exists an LIS/Dual/Disability effect for a small subset of the Star Ratings measures. The size of the effect is small in most cases and not consistently negative. CMS is exploring two options for possible interim analytical adjustments to address the LIS/DE/disability effect revealed in our research: Categorical Adjustment Index (CAI) Indirect Standardization (IS) 28

29 16 CANDIDATE MEASURES FOR POTENTIAL ADJUSTMENT Adult BMI Assessment Rheumatoid Arthritis Management Breast Cancer Screening Controlling Blood Pressure Diabetes Care Blood Sugar Controlled Diabetes Care Eye Exam Diabetes Care Kidney Disease Monitoring Colorectal Cancer Screening Osteoporosis Management in Women who had a Fracture Plan All-Cause Readmissions Annual Flu Vaccine Monitoring Physical Activity Reducing the Risk of Falling Medication Adherence for Diabetes Medications Medication Adherence for Hypertension Medication Adherence for Cholesterol. 29

30 THE STATE OF MEDICAID MANAGED CARE There are currently 275 Medicaid Managed Care Organizations (MCOs) in the United States As of March 2015, 39 states had Medicaid contracts with comprehensive MCOs Tracking enrollment in Medicaid managed care is complicated because we are reliant on public reporting by states 30

31 EVOLUTION OF QUALITY MEASUREMENT PARADIGM Quality measurement for government-regulated health plans and issuers began with Medicare-Advantage Stars Significant bonus payments (5 percent premium increase) to encourage plans to invest Public reporting limited to beneficiary website used during open enrollment Demonstration program in first three years that gave bonus to > 90 percent of plans Quality measurement in the Marketplaces No payments for quality measurement or improvement Quality measurement is a requirement of participation Significant public reporting requirement 31

32 ELEMENTS OF THE MEDICAID MANAGED CARE QUALITY PARADIGM Transparency Public reporting on information of quality of care On State Medicaid websites Common set of measures, aligned with Medicare-Advantage and Marketplace Alignment with other systems of care Aligning, where appropriate, quality standards for Medicaid managed care with that of MA and the Marketplace would result in a simplified and integrated approach to quality measurement and improvement Consumer and Stakeholder Engagement Useful tool is consumer participation in the development of state strategies for improving care and quality of life 32

33 CMS ROLE IN MEDICAID QUALITY IMPROVEMENT The Center for Medicaid and CHIP Services partners with states to share best practices and provide technical assistance to improve the quality of care. CMS s efforts are guided by the overarching aims of the CMS Quality Strategy: better health, better care, lower cost through improvement. The CMS Quality Strategy is built on the foundation of the CMS Strategy and the HHS National Quality Strategy. Working with states and other partners to eliminate disparities and improve patient safety are key aspects of achieving these aims. 33

34 THE PROPOSED MEDICAID MEGA-RULE On May 26, 2015, CMS issued the first regulatory changes to Medicaid managed care in 13 years The proposed rule seeks to: Support states efforts to encourage delivery system reform initiatives within managed care programs that aim to improve health care outcomes and beneficiary experience while controlling costs; and Strengthen the quality of care provided to beneficiaries by strengthening transparency and measurement, establishing a quality rating system, and broadening state quality strategies and consumer and stakeholder engagement; Improving consumer experience in the areas of enrollment, communications, care coordination, and the availability and accessibility of covered services We expect the rule to be finalized in the Spring of

35 THE PROPOSED MEDICAID MEGA-RULE (CONT D) Implementing best practices identified in existing managed long term services and supports programs; Aligning Medicaid managed care policies to a much greater extent with those of Medicare Advantage and the private market; Strengthening the fiscal and programmatic integrity of Medicaid managed care programs and rate setting; Aligning the CHIP managed care regulations with many of the proposed revisions to the Medicaid managed care rules strengthen quality and access in CHIP managed care programs. 35

36 QUALITY IMPROVEMENT REPORTING IS NOT SUFFICIENTLY ACTIONABLE Most plans and issuers have some variation on a quality measurement scorecards For the Stars measures, most entities can tabulate and report on members eligible (denominators), members compliant (numerators), and compliance rates Oftentimes, too many measures are reported, but only Star-rating measures Quality scorecards should be limited to the measures that need the provider s focus Dynamic scorecards the measure composition varies by provider, based on compliance status Now that CMS has eliminated the fixed 4-Star cut points, Star rating thresholds will float from year-to-year It is harder to hold providers or plans accountable for Star-rating improvements if the cut points can change somewhat arbitrarily 36

37 MEASURES COMMON TO COMMERCIAL AND MEDICAID Measure Adolescent Well-Care Visits Adult BMI Assessment Annual Monitoring for Patients on Persistent Medications Antidepressant Medication Management Breast Cancer Screening Cervical Cancer Screening. Childhood Immunization Status Chlamydia Screening in Women Controlling High Blood Pressure Diabetes Care: Hemoglobin A1c (HbA1c) Control Diabetes Care: Hemoglobin A1c Testing Follow-Up Care for Children Prescribed ADHD Medication Follow-Up After Hospitalization for Mental Illness: 7 days Program QRS and Medicaid QRS, MA-Stars, and Medicaid QRS, MA-Stars, and Medicaid QRS, MA-Stars, and Medicaid QRS, MA-Stars, and Medicaid QRS, MA-Stars, and Medicaid QRS and Medicaid QRS and Medicaid QRS, MA-Stars, and Medicaid QRS, MA-Stars, and Medicaid Medicaid Only QRS and Medicaid QRS, MA-Stars, and Medicaid 37

38 MEASURES COMMON TO COMMERCIAL AND MEDICAID (CONT D) Measure Program HPV Vaccination for Female Adolescents QRS and Medicaid Immunizations for Adolescents QRS and Medicaid Medication Management for People With Asthma QRS and Medicaid Plan All-Cause Readmissions QRS, MA-Stars, and Medicaid Prenatal and Postpartum Care: Postpartum Care QRS and Medicaid Prenatal and Postpartum Care: Timeliness of Prenatal Care QRS and Medicaid Weight Assessment and Counseling for Nutrition and Physical Physical Activity for Children and Adolescents QRS and Medicaid Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life QRS and Medicaid 38

39 SELECTED MEASURES SPECIFIC TO COMMERCIAL Measure Colorectal Cancer Screening Diabetes Care: Eye Exam (Retinal) Performed Annual Dental Visit Appropriate Testing for Children With Pharyngitis Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Bronchitis Relative Resource Use for People with Cardiovascular Conditions Conditions Relative Resource Use for People with Diabetes Inpatient Facility Facility Use of Imaging Studies for Low Back Pain Adults Access to Preventive and Ambulatory Health Services Program QRS and MA-Stars QRS and MA-Stars QRS only QRS only QRS only QRS only QRS only QRS only QRS and MA-Display 39

40 COMMON DEFICIENCIES IN QUALITY REPORTING Most reporting shows year-to-date measurement, e.g., how many members are compliant as of the date the report was generated Some reports also show the compliance rate for the last year Beware of specification changes that can make year-over-year comparisons difficult to interpret In recent years, Breast Cancer Screening and Osteoporosis Management populations have been redefined Prior year data should be run against current year NCQA specifications But there are more useful metrics to report: Compliance rates for the same time interval, but one year earlier This captures the temporal nature of compliance some measures are more likely to close at different times of the year 40

41 QISim Overview Powerful Tool for Strategic Planning

42 QISim: SCENARIOS REVIEW Flexible Grids: user can work with up to 4 different scenarios easily comparing them. Columns can be easily added as a copy of previous one and removed Save scenarios: Any changes in scenarios are stored immediately. This approach helps user to concentrate on data, without distractions. After playing with numbers, user can review all the versions, and save best ones Inline details: By clicking on row, user will get more details that stand behind the scenes. This will help to understand what efforts needed to get one more star 42

43 QISim : MEASURES Application provides set of features that help user to manage a long list of measures, so you can quickly find the important information Collapse groups: each group of measures can be collapsed, but still have summary scores visible. This helps to see the high-level view of the scenarios Quick Filter: there are lots of important information presented on screen, and sometimes it is difficult to find some piece. This filter will help to figure out Emphasis: sometimes not all measures can be improved at the moment. With checkboxes user can emphasize those that have higher priority 43

44 QISim : SNAPSHOTS In addition to automatic saving of any scenario, QISim provides the ability to take a snapshot of the whole system state Checked rows Selected scenarios 44

45 POPULATING QISim MHHA has an NCQA-certified quality measures engine that calculates compliance rates for all measures Can be run in real-time Static data can be also be used CMS-supplied HEDIS public use files NCQA s Quality Compass data Users can also populate the application directly using their own numerator and denominator counts 45

46 SO WHAT IS THE NEXT GENERATION? With regards to quality measurement, some skeptics may argue that absent financial incentives that quality measurement will ramp up very slowly But quality measurement, along with risk adjustment and utilization measurement are the key elements of the migration toward value-based payments The next generation is utilization reporting merged with multiple years of quality profiling and multiple years of risk score profiles The key to achieving this kind of reporting is: good data governance Comprehensive ETL process Reporting across the silos, not within them 46

47 NEXT WEBINAR Mile High Healthcare Analytics will continue our free webinar series. We will continue to present key risk adjustment and performance improvement topics to health plans and provider groups. Our next three webinars will be held on: Thursday February 11, 2016: PARTICIPANT S CHOICE! Thursday, March 3, 2016: the 45-Day Notice Thursday April 7, 2016: the Final Notice for MA Plans Please watch to learn about our webinar topics

48 CONTACT INFORMATION Richard Lieberman (voice)

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