Measuring Quality & Performance in Medicare

AdvantageWhere We’ve Been, Where We

Are, & Where We’re Going

Abby L. BlockDirector, Center for Beneficiary

Choices Centers for Medicare & Medicaid

ServicesApril 8, 2008

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History of Quality and Performance

Measures in Medicare Advantage

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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 measures

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Measuring Quality and Performance among Medicare plans

• 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

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Motivation to Measure

The decision to begin quality and performance data collection was motivated by several factors– Need for accountability to oversight

bodies and beneficiaries– Desire to make evaluation of managed

care plans more objective– Desire to improve value in government

purchasing

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Early Uses of Quality and Performance Data

• Reporting Year 1997 was first year of data collection

• 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

programs– HHS Government Performance and Results Act

(GPRA) goals

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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

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Current Quality and Performance Metrics

• HEDIS• HOS• CAHPS• Independent Review Entity data• Part D Performance Measures

• More detail on these measures today and tomorrow from CMS staff

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Current Quality and Performance

Measurement in Medicare Advantage

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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

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Current Quality and Performance Measurement Objectives

• To provide performance and quality-based information to beneficiaries to make enrollment decisions– Example 1: MA and Prescription Drug

plan ratings

• Demonstrate value and performance– Example 2: Special Needs Plan quality

measures

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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 Medicare.gov• Domain & measure level ratings• 5-star rating system• Accessible, comprehensible information

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www.medicare.gov

www.medicare.gov

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www.medicare.gov

www.medicare.gov

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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 Disease• Continuous Beta-Blocker Treatment

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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 standards

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

Homes

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Significance of Plan Ratings

• Plan ratings improve CMS’ ability to identify high performing plans and plans that need improvement

• Also substantially expand information available to beneficiaries for selecting high-quality heath and prescription drug plans

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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

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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

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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 2009– Training for health plans on reporting

requirements currently underway

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Measurement Categories

• Benefit design

• Risk assessment and care planning

• Coordination of services

• Caregiver engagement

• Internal measurement of performance

• Beneficiary & caregiver experience

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• 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 level

Innovation: Plan-Level Measurement

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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 collected

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Future of Quality and Performance

Measures in Medicare Advantage

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Need to Improve Current Quality Measurement Initiatives

• 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

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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

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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

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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 Medicare.gov and other portals– Underway: continuing consumer testing

of Medicare Options Compare and Prescription Drug Plan Finder

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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 alliance

• 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

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Questions?

Abby L. BlockDirector, Center for Beneficiary

Choicesabby.block@cms.hhs.gov