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STAR RATINGS:

MOVING THE NEEDLE

LISA ERWIN

SENIOR CONSULTANT

APRIL 2016

MELISSA SMITH

SENIOR CONSULTANT

Copyright © 2016 Gorman Health Group, LLC

Government Programs

Leading enterprise of national consulting services and software solutions

for payers and providers.

Our Mission

Our mission, as the industry’s most active professional services consultancy and

provider of technology-based solutions, is to empower health plans and providers

to deliver higher quality care to beneficiaries at lower costs, while serving as

valued, trusted partners to government health agencies.

Washington, DC

Headquartered in Washington, DC, with more than 200 staff and contractors

nationwide with over 2,000 combined years of Government Programs experience.

Leadership

Deep payer and provider knowledge coupled with Centers for Medicare & Medicaid

Services (CMS) regulatory expertise.

Privately Owned

Founded in 1996

Gorman Health Group is the leading solutions and consulting firm

for government-sponsored health programs.

WHO IS GORMAN HEALTH GROUP?

2


Our clients have one-stop access to expert advice, guidance, and support,

in every strategic and operational area for government-sponsored programs, across seven verticals.

CLINICALChanging how you approach Medical Management,

Quality and Stars.

PROVIDER INNOVATIONSSupporting network design and medical

cost control implementation.

OPERATIONSBringing excellence to every aspect of your

implementation from enrollment to claims payment.

COMPLIANCEOffering guidance and support in every strategic and

operational area to ensure alignment with CMS.

PHARMACYLeading experts in Part D, PBM, formulary

and pharmacy programs.

HEALTHCARE ANALYTICS & RISK

ADJUSTMENT SOLUTIONSImplementing cross-functional risk adjustment

programs for medical trend management and quality

improvement.

STRATEGY & GROWTHDriving profitable growth and member retention

through strategic marketing, sales, and product

development.

BROAD SERVICES

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• Capturing the Impact of Dual Eligibles

• Compliance, Data Integrity, and Star Ratings

• Evolution of the Bell Curve

• Measure Updates

o New Measures

o Removals and Retirements

o Specification Changes

• Innovation at Work: Clinical and Pharmacy

Integration

• Star Ratings and the Retail Pharmacy Network

TODAY’S AGENDA

4


MEDICARE ADVANTAGE

QUALITY RATINGS IN

GOVERNMENT HEALTHCARE

5

• Celebrating 10th anniversary

• Up to ~5% of revenue available

through quality bonuses

• Often drives design of

member/provider engagement

strategies

• Measures are commonly (and

retrospectively) modified, added,

or removed from program

COMMERCIAL/MARKETPLACE

• Initial ratings to be published in

Fall 2016

• Not currently tied to revenue

• Often postponed by plan

leaders for future consideration

• Very few measure changes to

date


State-of-the-Art Membership Accounting

Risk Adjustment Adaptation

Proactive Member Service

Collaborative, Accountable

Providers

“Make It Work” Care

Management

Star Ratings Mastery

BRINGING IT ALL TOGETHER

6

Analytics

Compliance


• A Categorical Adjustment Index (CAI) factor will be applied

to reflect performance disparity caused by service to Dual

Eligible (DE)/LIS and disabled beneficiaries

o The CAI factor will be added to (or subtracted from) the Overall,

Part C Summary, and Part D Summary Ratings

o The CAI factor varies based on the proportion of DE/LIS and

disabled beneficiaries

o The CAI effectuates a case mix adjustment for DE/LIS and

disability status

o Additional adjustments will be made for Puerto Rican contracts

• Measures to be adjusted include:

o Part C: Breast & Colorectal Cancer Screening, Diabetic HbA1c

Controlled, Osteoporosis Mgmt in Women Who Had a Fracture,

Rheumatoid Arthritis Mgmt, and Reducing the Risk of Falling

o Part D: Medication Adherence for Hypertension

STAR RATINGS & DUAL ELIGIBLES:

THE WAIT IS OVER!

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AND…this is only an INTERIM solution while measure stewards continue their

comprehensive review of their measures and as ASPE continues its work.

…BUT KEEP IN MIND…

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• Use increased risk-

adjusted revenue to

invest in: Measures needing the

most lift

High-touch tactics with

greatest ROI among

duals

To support/incent

where needed to meet

social needs of duals


• CMS can reduce a measure to 1 star if:

o Biased or erroneous data is submitted

o An underlying compliance issue exists in the data

• Automatic assignment of a 2.5 star overall rating

suspended pending CMS’ reevaluation of the impact

of sanctions, audits, and CMPs on Star Ratings

• Important areas to monitor:

o HEDIS, CAHPS, HOS, MPF, and PDE data

requirements

o ODAG and CDAG processes

o Coverage disputes and complaints

o MTM programs

• CMS’ search for new vulnerabilities continues!

COMPLIANCE, DATA INTEGRITY

& STAR RATINGS

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• CMS is now terminating contracts who have earned their third

consecutive Part C or Part D summary rating below 3 stars.

o 3 contracts are receiving a Low Performer Icon (LPI) for 3 consecutive

low Part C ratings and are eligible for termination.

o 3 contracts are also receiving an LPI for low Part C or D ratings.

• By the time a plan learns of its first “miss,” >75% of the 2nd

measurement year is complete. Time is of the essence!

• The risk is very real:

o 6 contracts earned the LPI

o 29 more MA-PDs earned a 2016 Part C or Part D summary rating <3 stars

o 9 PDPs earned a 2016 Part D summary rating <3 stars

THE ULTIMATE PENALTY:

CONTRACT TERMINATIONS

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2015 2016 2017 2018


EVOLUTION OF THE BELL CURVE

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2016 overall rating

<3 stars:

12 MA-PDs

2016 overall rating of

3 or 3.5 stars:

178 MA-PDs

2016 overall rating

≥4 stars:

179 MA-PDs

3 MA-PDs eligible for

termination

3 MA-PDs earned an LPI

369 MA-PDs earned a

2016 Star Rating.

260 MA-PDs are in play.

64 MMPs will be star rated or

removed from MA Star Ratings

program

124 MA-PDs met too few

measures or were too new to be

rated in 2016

5 MA-PDs predicted to increase

½ star with Puerto Rican

LIS/adherence accommodations

11 MA-PDs predicted to

increase ½ star with CAI factor

44 MA-PDs owned by Humana

and Cigna being acquired by

industry giants

6 1876 Cost plans converting to

MA plans for 2017-2019


2017

NEW MEASURES UNDER CONSIDERATION:

None

RETIRED MEASURES:

Improving Bladder Control measure to be temporarily moved to Display Page

POTENTIIAL UPDATES:

Slight methodology changes for several measures

2018


Medication Reconciliation Post Discharge & Hospitalizations for Potentially Preventable Conditions

RETIRED MEASURES:

High Risk Medication measure to be temporarily moved to Display Page. Others TBA

POTENTIAL UPDATES:

MPF Price Accuracy; NCQA to evaluate Colorectal Cancer Screening & Fall Risk Mgmt based on USPTF recommendations

2019


Statin Therapy measures (Part C and D), potentially Asthma and Depressionmeasures (Part C)

RETIRED MEASURES:

TBA

POTENTIAL UPDATES:

TBA

MEASURE UPDATES:

THE AGILITY TEST CONTINUES

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HOW DO YOU WIN THE RACE

WITHOUT KNOWING THE COMPETITION…

13

…OR THE TEST?


Process

• Tools, Data, and Dashboards

• Case/Disease/Medication Mgmt

• Delegation Oversight

• Regular Audits and Remediation

• Proactive Service

Engagement

• Executives and Leaders

• Internal Managers and Staff

• Vendor Managers and Staff

• Providers and Pharmacies

• Enrollees and Caregivers

Leadership

• Engaged Leadership

• Chief Performance Officer

• Focused, Strategic Action Plan

• Aligned QI and RA Strategies

• Key Providers

A STRATEGIC FOUNDATION FOR SUCCESS

14


THE RIGHT INTERVENTION.

THE RIGHT PERSON. THE RIGHT TIME.

15

• Complex/acute co-morbidities

• Medication effectiveness

• Complex medication regimens

• Medication side effects

• Cost constraints

• Lack of transportation

• Reliance on caregivers

• Lack of motivation/interest

• Lack of disease understanding

• Lack of trust in provider(s)

• Cultural sensitivities

• Poor mental health status

• Decreased cognitive function

• Poor decision-making

• Forgetfulness

• Misguided peer support

Clinical Factors

Socioeconomic & Logistical Factors

Social & Behavioral Factors

Lifestyle & Literacy Factors

Strategy + Execution = Success

Healthcare ecosystem Alignwithbusinessstrategy

Accountable Analytics Definestakeholders’dimensionality

Manage withanalyticsDrive changeinto theorganization

Validate andrealignaccording tobusinessdirection


6. Make it easy and understandable.

7. Strategically use data to:

o Interact holistically and contextually during each

member touch.

o Develop and manage carefully designed

programs.

o Include members in the right program(s) at the

right time.

8. Conduct prioritized, actionable, member

targeting for high-touch, holistic, and well-

coordinated interactions.

9. Develop a personal relationship between

carefully-selected members and a care

coordinator.

10. Support the physician-patient relationship

through all interactions.

WITH PROVIDERS:

1. Make it easy and understandable.

2. Strategically mine data to:

o Provide actionable information.

o Incorporate targeted clinical and HRA

insights.

o Show your value proposition for the effort

you’re requesting.

3. Strategically design and leverage

incentives for targeted improvements.

4. Provide helpful insights and targeted

data to support provider’s care for,

and interactions with, patients.

5. Align strategies, tactics, measures,

and incentives across products (MA,

Medicaid, MMP, Marketplace).

WITH MEMBERS:

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6. Make it easy & understandable.

7. Strategically use data to:o Conduct holistic discussions during each member touch.

o Develop and manage carefully designed programs.

o Include members in the right program(s) at the right time.

8. Conduct prioritized, actionable, member

targeting for high-touch, holistic, and

well-coordinated interactions.

9. Develop a personal relationship between

carefully-selected members and a care

coordinator.

10. Interact with patients, providers &

caregivers to support the physician-

patient relationship.

WITH PROVIDERS:

1. Make it easy & understandable.

2. Strategically mine data to: o Provide actionable information.

o Incorporate targeted clinical & HRA insights.

o Show your value proposition for the effort you’re

requesting.

3. Strategically design & leverage

incentives for targeted improvements.

4. Provide helpful insights & targeted

data to support provider’s care for,

and interactions with, patients

5. Align strategies, tactics, measures,

and incentives across products (MA,

Medicaid, MMP, Marketplace).

WITH MEMBERS:

17

Remember:

“Best Practices” are

only best practices

until they’re

“industry standard.”


• CMS’ use of dual eligible and disability status to determine the CAI factor

introduces new data elements into Star Ratings.

o Enrollment departments must reconcile data and resolve discrepancies.

o Both new data elements routinely contain inaccuracies on the TRR; resolution often

requires coordination with government agencies.

o Reintroduce Enrollment leaders back into your Star Ratings team and work groups!

• CMS’ increased reliance on encounter data for risk adjustment:

o May improve real-time visibility and support proactivity on certain HEDIS measures

(e.g., screenings, controlling blood pressure and diabetic HbA1c control).

o May allow more effective member targeting for more precisely-predicted interventions.

o May strengthen real-time reporting of, and impact from, P4Q/VBC contracts, population

health strategies, and health and wellness programs.

• Effective, strategically-designed data governance processes have never

been more important.

DATA: THE DEVIL IS IN THE DETAILS

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• Of the 9 triple-weighted ratings, 7 are directly or indirectly related to medication therapy.

• Pharmacy and Medical organizational and data silos still exist.

• The MTM CMMI model is bringing medication management into the mainstream, even in PDPs, and relying heavily on retail pharmacists to deliver care coordination.

More and More Medication-Related Metrics on the Horizon: Encompassing Both C and D Ratings

MEDICATION-RELATED

ISSUES TO PONDER

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STAR RATINGS IS A BIG PUZZLE –

WHOSE PIECE IS WHOSE?

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HRMs CMRs Med Rec

Post

Discharge

Statins

for CV

Disease

Statin Use

in Persons

with

Diabetes

Asthma

Measures

2018 and Beyond

PQA making

changes-

Hospice

patients

removed,

dosage calcs

modified for

several drugs

Under discussion at

PQA this year −

MTM Patient

Survey: Patient

satisfaction/

experience with

MTM services

MTM-Part D: Drug

Therapy Problem

Resolution• HPMS detail file

• Data integrity

• MTM Audits

NCQA

expanded

both the

coverage to

all of MA, and

the age range

to members

18 years and

older

NCQA also

added

diabetes

and statin

measure,

duplicate

with PQA

New PQA

measure

NCQA,

includes 2

measures for

older adults

• Med Mgmt

• Asthma

medication

ratio

• Care Coordination,

including Part D data

• Depression measures,

Part C

• Pain Mgmt, Part C

• Opioids, Part D

• Antipsychotics in

dementia, Part D

• Big DDI changes

coming

Part D Part D Part C Part C Part D Part C Parts C and D

Moved to

display for

2017, may be

revised and

back in 2019

but based on

2017 data

Greater emphasis

on outcomes

coming

2017 display,

then rating in

2018

2017

display, at

least 2

years

2017 display

using 2015

data, 2 years

TBA in 2019

2017 display 2018 and beyond

MEDICATION METRICS: SILO BUSTERSMetrics Developed Across Channels

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• Depression Measures

o NCQA has adapted a provider-level depression outcome measure

developed by Minnesota Community Measurement for use in HEDIS.

Depression Remission or Response in Adolescents and Adults (DRR)

uses a patient-reported outcome measure, the PHQ-9 tool, to assess

whether patients with depression have achieved remission or have an

improvement in their symptoms.

o This measure also uses a new data collection methodology for HEDIS,

relying on data coming from electronic clinical data systems (e.g.,

Electronic Health Records (EHRs), clinical registries, case management

records).

o If approved, the new measure would be published in HEDIS 2017.

BEYOND 2018

Look for Increasing Measure Sophistication

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• The Part D Enhanced Medication Therapy Management (MTM)

model will test whether providing Part D sponsors with additional

payment incentives and regulatory flexibilities will engender

enhancements in the MTM program, leading to improved therapeutic

outcomes, while reducing net Medicare expenditures.

• Draft specifications for the Enhanced MTM model encounter data

elements out for public comment until 5:00 p.m. ET, Tuesday, April

26, 2016.

INNOVATION

As MTM Moves from Process to Outcomes

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• A bipartisan group of congressional representatives is urging that

retail pharmacists play a part in a new initiative designed to improve

the use of MTM in Medicare.

• 44 members of the House of Representatives — 24 Republicans

and 20 Democrats — signed a letter to Secretary of Health and

Human Services (HHS) Sylvia Burwell, according to the National

Association of Chain Drug Stores.

o “We believe the proposed enhanced MTM model to be a positive step

forward in improving the Part D MTM program,” the House members

wrote. “However, we also believe that without participation of retail

community pharmacists, the testing of enhanced MTM models will fall

short of achieving the maximum potential in terms of positive outcomes

and impact on beneficiary health.”

NEAR-TERM & FUTURE IMPACT OF CMMI

How Will this Change the Current MTM Program?

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The motivation of health plans and PBMs in forming preferred pharmacy networks is clear: to control costs and increase profitability.

To participate in a preferred network, pharmacies must typically be willing to accept reduced reimbursement, thereby helping health plans, PBMs, and employers control costs.

THE PBM STICK

Preferred Status for Reduced Reimbursement

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• Health plans are rewarding top-performing physicians through Pay-

for-Performance (P4P) models.

• A few health plans have started to venture into P4P for pharmacies,

such as HealthPartners, Humana, and Inland Empire Health Plan

(IEHP).

• IEHP, a non-profit managed Medicaid health plan covering 720,000

lives in southern California, has started one of the first large P4P

programs for community pharmacies in the country. Special needs

plan’s (SNP’s) network encompasses nearly 720 pharmacies, split

between chains and independents.

• March 2016 ‒ IEHP received the Excellence Award from the

Pharmacy Benefit Management Institute (PBMI) for its Pharmacy

P4P Program.

THE CARROTExtending P4P to the Retail Pharmacy Setting

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https://www.healthpartners.com/ucm/groups/public/@hp/@public/documents/documents/cntrb_041092.pdf

http://www.cedrugstorenews.com/userapp/lessons/page_view_ui.cfm?lessonuid=&pageid=FED2FFF325299FD88461061317854ED5

https://ww3.iehp.org/en/providers/pharmaceutical-services/pharmacy-p4p-program/


• Under IEHP’s Pharmacy P4P Program, launched in October 2013,

pharmacies will be eligible for a bonus payment every 6 months

based on the quality of medication-related care they provide to IEHP

members.

• Participating pharmacies are evaluated on how they perform on

Medicare Part D Star Ratings measures (e.g., medication adherence

and safety) plus asthma and generic dispensing rate compared to

pre-determined standards.

• Each pharmacy in the IEHP network is able to track its performance

via personalized dashboards within PQS’ EQuIPP platform.

• IEHP has publicly-recognized pharmacies that achieved high-quality

scores.

VALIDATING THE ROLE OF THE

COMMUNITY PHARMACISTPromoting Quality

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https://ww3.iehp.org/en/providers/pharmaceutical-services/pharmacy-p4p-program

https://ww3.iehp.org/en/providers/pharmaceutical-services/pharmacy-p4p-program


• Health screenings

• Wellness programs

• Blood pressure, cholesterol

• Immunizations

• Smoking cessation

• Weight loss

RETAIL PHARMACY CLINICS

Delivering More than Just Medications; Parallel C and D Star Silos

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• Annual influenza vaccine

• Cardiovascular Care –

cholesterol screening

• Care for older adults –

medication review

• Care for older adults – pain

screening

• Colorectal cancer screening

• Diabetes care – cholesterol

• Diabetes care – eye exam

• Osteoporosis management

• Reducing the risk of falling

COMMUNITY PHARMACY

Looking Beyond the Medication Measures

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MTM can drive many of these measures but not for enough members.

Are there modified MTM processes that can address the non-qualifiers?


HEALTH PLAN / COMMUNITY

PHARMACY COLLABORATIONRate the Star Performance of the Pharmacies in Your Network

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• Network Pharmacy Report Cards

o Allow for an overlay of the plan member with the

pharmacy they frequent in conjunction with the

Star Ratings performance of the pharmacy

o Enable the plan to act in real time as data

becomes available throughout the plan year

o Provide the opportunity to target specific

members at the pharmacy to close Star Ratings

gaps

o Goal would be to add retail non-pharmacy

related metrics to this, e.g., immunizations,

counseling, other medical services performed


• Transforming from Part D Star Ratings to Medication Management

Team:

o Are the right team(s) designing and leading all medication-related initiatives?

o What staff is conducting medication-related initiatives? What part is your

PBM playing as part of your leadership team ?

o Does your PBM have a quality-based network that includes both Part C

and D related targets?

o Who is responsible for data/analytics for medication-related initiatives?

o Do you have the right outcomes methodology monitoring so you know what

is working (near and long term)?

o How are Part D Star Ratings activities coordinated with providers (including

pharmacies, medical providers) and PBMs?

• Implement frequent, productive communication and monitoring.

• Include clinical and operational experts on the Star Ratings team.

REFINE YOUR STAR RATINGS

MEDICATION GAME PLAN

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Q&A

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Gorman Health Group, LLC (GHG) is a leading consulting and software solutions firm specializing in government health programs, including

Medicare managed care, Medicaid and Health Insurance Marketplace opportunities. For nearly 20 years, our unparalleled teams of subject-

matter experts, former health plan executives and seasoned healthcare regulators have been providing strategic, operational, financial, and

clinical services to the industry, across a full spectrum of business needs. Further, our software solutions have continued to place efficient and

compliant operations within our client’s reach.

GHG offers software to solve problems not addressed by enterprise systems. Our Valencia™ software reconciles membership of more than 10

million members in Medicare, Medicaid and the Health Insurance Marketplace. Over 3,000 compliance professionals use the Online

Monitoring Tool™ (OMT), our complete Medicare Advantage and Part D compliance toolkit, while more than 33,000 brokers and sales agents

are certified and credentialed using Sales Sentinel™. In addition, hundreds of health care professionals are trained each year using Gorman

University™ training courses.

We are your partner in government-sponsored health programs

T

E

T

E

LISA ERWIN

Senior Consultant

33

248.410.3309

[email protected]

MELISSA SMITH

Senior Consultant

615.351.8018

[email protected]

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