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Richard Lieberman

Chief Data Scientist

Mile High Healthcare Analytics

2016 Quality Improvement Trends

Free Webinar Series: January 7, 2016

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

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, 1991-2005

– Designed the risk-adjusted payment system for Maryland Medicaid

• 3

“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

“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 1st.

“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?

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.

7

Source: Medicare Payment Advisory Commission. Report to Congress: Medicare Payment Policy. March 2015.

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

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

9

Source: Medicare Payment Advisory Commission. Report to Congress: Medicare Payment Policy. March 2015.

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

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

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

STABILITY/INSTABILITY OF STAR RATINGS OVER TIME

Year-over-Year Change (2013-2014)

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

PERFORMANCE IMPROVEMENT: DO NOT REST ON YOUR LAURELS

14

• 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

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 2015

– 5-Star threshold decreased from 83% to 79%

compliance

INDUSTRY-WIDE PERFORMANCE ON HEDIS MEASURESMeasure Name Compliance

Rate

Percent

Change

2014 2013

Osteoporosis Management in Women who had a

Fracture

35% 27% 8%

Care for Older Adults – Functional Status

Assessment

75% 70% 5%

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%

• 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

INDUSTRY-WIDE PERFORMANCE ON MEDICATION USE MEASURES

Measure Name Compliance

Rate

Percent

Change

2014 2013

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%

• 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

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”

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 40–75 years of age and LDL-C 70–189 mg/dL

• Patients without diabetes 40–75 years of age and LDL-C 70–189

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

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

LIKELY GOOD NEWS FOR 2017

• 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

– Elavil (Amitriptyline) is indicated for use in the

elderly in small doses

• CMS has proposed removing the HRM

measure for 2017

21

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 triple-

weighted measures have a greater impact on overall Star ratings

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)

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

INDUSTRY-WIDE PERFORMANCE ON MEMBER EXPERIENCE

Measure Name Compliance

Rate

Percent

Change

2015 2014

Getting Appointments and Care Quickly

Quickly

75% 76% -1%

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%

• 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 “top-

out”

• Many plans struggle with the

member experience measures

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

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 socio-

economic 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

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

• 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

16 CANDIDATE MEASURES FOR POTENTIAL ADJUSTMENT

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

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

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

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

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 2016

34

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

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

MEASURES COMMON TO COMMERCIAL AND MEDICAID

Measure ProgramAdolescent Well-Care Visits QRS and Medicaid

Adult BMI Assessment QRS, MA-Stars, and Medicaid

Annual Monitoring for Patients on Persistent MedicationsQRS, MA-Stars, and Medicaid

Antidepressant Medication Management QRS, MA-Stars, and Medicaid

Breast Cancer Screening QRS, MA-Stars, and Medicaid

Cervical Cancer Screening . QRS, MA-Stars, and Medicaid

Childhood Immunization Status QRS and Medicaid

Chlamydia Screening in Women QRS and Medicaid

Controlling High Blood Pressure QRS, MA-Stars, and Medicaid

Diabetes Care: Hemoglobin A1c (HbA1c) Control QRS, MA-Stars, and Medicaid

Diabetes Care: Hemoglobin A1c Testing Medicaid Only

Follow-Up Care for Children Prescribed ADHD

MedicationQRS and Medicaid

Follow-Up After Hospitalization for Mental Illness: 7 daysQRS, MA-Stars, and Medicaid

37

MEASURES COMMON TO COMMERCIAL AND MEDICAID (CONT’D)

Measure ProgramHPV 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 AdolescentsQRS and Medicaid

Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of LifeQRS and Medicaid

38

SELECTED MEASURES SPECIFIC TO COMMERCIAL

Measure ProgramColorectal Cancer Screening QRS and MA-Stars

Diabetes Care: Eye Exam (Retinal) Performed QRS and MA-Stars

Annual Dental Visit QRS only

Appropriate Testing for Children With Pharyngitis QRS only

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Bronchitis QRS only

Relative Resource Use for People with Cardiovascular Conditions

ConditionsQRS only

Relative Resource Use for People with Diabetes—Inpatient Facility

FacilityQRS only

Use of Imaging Studies for Low Back Pain QRS only

Adults’ Access to Preventive and Ambulatory Health Services QRS and MA-Display

39

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

QISim OverviewPowerful Tool for Strategic Planning

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

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

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

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

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

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 http://www.healthcareanalytics.expert/news-

and-events/free-webinar-series/ to learn about our

webinar topics

CONTACT INFORMATION

Richard Lieberman

rlieberman@healthcareanalytics.expert

720-446-7785 (voice)

www.healthcareanalytics.expert

THANK YOU FOR JOINING US!!

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