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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
Copyright © 2016 Gorman Health Group, LLC
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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Copyright © 2016 Gorman Health Group, LLC
• 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
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MEDICARE ADVANTAGE
QUALITY RATINGS IN
GOVERNMENT HEALTHCARE
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• 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
Copyright © 2016 Gorman Health Group, LLC
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
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Analytics
Compliance
Copyright © 2016 Gorman Health Group, LLC
• 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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Copyright © 2016 Gorman Health Group, LLC
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
Copyright © 2016 Gorman Health Group, LLC
• 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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Copyright © 2016 Gorman Health Group, LLC
• 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
Copyright © 2016 Gorman Health Group, LLC
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
Copyright © 2016 Gorman Health Group, LLC
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
NEW MEASURES UNDER CONSIDERATION:
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
NEW MEASURES UNDER CONSIDERATION:
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
12
Copyright © 2016 Gorman Health Group, LLC
HOW DO YOU WIN THE RACE
WITHOUT KNOWING THE COMPETITION…
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…OR THE TEST?
Copyright © 2016 Gorman Health Group, LLC
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
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Copyright © 2016 Gorman Health Group, LLC
THE RIGHT INTERVENTION.
THE RIGHT PERSON. THE RIGHT TIME.
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• 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
Copyright © 2016 Gorman Health Group, LLC
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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Copyright © 2016 Gorman Health Group, LLC
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.”
Copyright © 2016 Gorman Health Group, LLC
• 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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Copyright © 2016 Gorman Health Group, LLC
• 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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Copyright © 2016 Gorman Health Group, LLC
STAR RATINGS IS A BIG PUZZLE –
WHOSE PIECE IS WHOSE?
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Copyright © 2016 Gorman Health Group, LLC
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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Copyright © 2016 Gorman Health Group, LLC
• 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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Copyright © 2016 Gorman Health Group, LLC
• 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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Copyright © 2016 Gorman Health Group, LLC
• 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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Copyright © 2016 Gorman Health Group, LLC
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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Copyright © 2016 Gorman Health Group, LLC
• 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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Copyright © 2016 Gorman Health Group, LLC
• 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
Copyright © 2016 Gorman Health Group, LLC
• 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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Copyright © 2016 Gorman Health Group, LLC
• 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?
Copyright © 2016 Gorman Health Group, LLC
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
Copyright © 2016 Gorman Health Group, LLC
• 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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Copyright © 2016 Gorman Health Group, LLC
Q&A
32
Copyright © 2016 Gorman Health Group, LLC
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
lerwin@gormanhealthgroup.com
MELISSA SMITH
Senior Consultant
615.351.8018
msmith@gormanhealthgroup.com
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