1. CMS 5 STARS PROGRAM
MedPOINT Management

2. Planning for the Future
Healthcare Reform will require significant change to Medicare Advantage plans transforming them into an integrated health delivery system concentrating on quality of care outcomes within the next 1-5 years.
What are the consequences??
There will be pressure to correctly screen, document and perform precise coding or chronic disease along with exceeding quality performance measures related to HDIS and national survey instruments (HOS and CAHPS).
The federal government will essentially be paying for quality outcomes based on STARs/HEDIS ratings.
4/17/2017
MedPOINT Management STARs PROGRAM Overview

3. WHAT ARE THE CMS STARs??
CMS created the 5-STAR Quality Rating System for Medicare Advantage plans to compare Medicare Advantage plans more easily, and to help identify areas about which they may want to ask questions.
The STARS are a quality rating system that gives each plan a rating of between 1 and 5 stars. Plans with 5 stars are considered to be highly above average in quality, and plans with 1 star are considered to be very below average in quality.
4/17/2017
MedPOINT Management STARs PROGRAM Overview

4. Why is STARS rating significant?
WHAT ARE THE CMS STARS?? (CONTINUED)
STAR RATINGS are CMS Ratings for Part C and D Medicare Plans
The original purpose of STAR ratings was to enable Medicare beneficiaries to compare quality among Medicare Advantage Plans on the Medicare Prescription Drug Plan Finder (MPDPF).
As part of Health Care Reform, CMS will begin a quality bonus payment in 2012 for MA Plans based on the Five Star Ratings.
In the fall of 2006, CMS posted Plan ratings based on a 3 star scale
For 2008, Annual Enrollment Period (AEP), CMS introduced a 5 Star scale. [5=highly above average; 1=very below average]
STAR Ratings are updated annually during the AEP
Why is STARS rating significant?
4/17/2017
MedPOINT Management STARs PROGRAM Overview

5. HOW are star ratings measured?
Health Plans receive an overall STAR rating and ratings by domain
PART C
Domain I: Staying Healthy: Screenings, Tests and Vaccines
Domain II: Managing Chronic (Long Lasting) Conditions
Domain III: Rating of Health Plan Responsiveness and Care
Domain IV: Member Complaints, Appeals and Choosing to Leave the Health Plan
Domain V: Customer Service
PART D
Domain I: Drug Plan Customer Service
Domain III: Member Experience with the Health Plan
Domain IV: Drug Pricing and Patient Safety
4/17/2017
MedPOINT Management STARs PROGRAM Overview

6. CMS Star Ratings – Data Sources
HEDIS: A widely used set of performance measures in the managed care industry, developed and maintained by NCQA
CAHPS (Consumer Assessment of Healthcare Providers and Systems): Comprehensive family of surveys that ask consumers and patient to evaluate interpersonal aspects of health care.
HOS (Health Outcomes Survey): Patient reported outcomes measure used in Medicare managed care. All managed care organizations with MA contracts must participate.
CTM (Complaints Tracking Module): Complaint rates per 1,000 are adjusted to a 30-day basis
CMS Audit: Findings of CMS audits, ad hoc and compliance actions that occurred during the 14-month past performance review period
MBDS (Medicare Beneficiary Database Suite of Systems) A collection of individual applications and services that access a single source for Medicare beneficiary demographic data
IRE: Independent Review Entity: An independent entity contracted by CMS to review Medicare health plans’ adverse reconsideration of organization determinations
Phone Monitoring: Call center data collected by CMS
PDE Data: Prescription Drug Event Data: Data was obtained from PDE data files submitted by drug plans to Medicare for the reporting period
MARx: Medicare Advantage Prescription Drug System: This data presents the percentage of new enrollment requests from beneficiaries that the plan submitted to Medicare within 7 days of the application date.
4/17/2017
MedPOINT Management STARs PROGRAM Overview

7. Basis for the STAR ratings
The ratings are based on Part C & D Measures. Star rating based on average of 53 measures which are continually updated.
36 Part C measures
17 Part D measures
4/17/2017
MedPOINT Management STARs PROGRAM Overview

8. Data Sources by weight DATA SOURCE DOMAINS WT VALUE % STARS
HEDIS Part C: I & II %
PDE Data Part D: IV %
CAHPS Part C: I & III %
HOS Part C: I & II %
IRE Part C: V %
Phone Monitoring Part C: V %
CTM Part C: IV %
CMS Audit Part C: IV %
MBDS Part C: IV %
MARx Part D: I %
TOTAL %
4/17/2017
MedPOINT Management STARs PROGRAM Overview

9. HEDIS MEASURES Breast Cancer Screening Colorectal Screening
CV Colorectal Screening
Monitoring of Long Term Patient’s Medication
Diabetes-Colorectal Screening
Diabetes-Kidney Monitoring
Diabetes-Blood Sugar Control
Diabetes-Cholesterol Control
4/17/2017
MedPOINT Management STARs PROGRAM Overview

10. HEDIS MEASURES (CONTINUED)
Glaucoma Testing
Access to Primary Care Doctor Visits
Osteoporosis Management
Diabetes Eye Care
Controlling Blood Pressure
Rheumatoid Arthritis Management
Testing to Confirm COPD
4/17/2017
MedPOINT Management STARs PROGRAM Overview

11. CAHPS MEASURES Annual Flu Vaccine Pneumonia Vaccine
Ease of Getting Needed Care and Seeing Specialists
Doctors Who Communicate Well
Getting Appointments and Care Quickly
Overall rating of Health Care Quality
Overall rating of the Health Plan
Customer Service
Member complaints
Appeals
4/17/2017
MedPOINT Management STARs PROGRAM Overview

12. Health Outcomes Survey
Improving Bladder Control (Physicians need to initiate discussion)
Reducing the Risk of Falling (Discuss balance problems, trouble walking and other risk factors)
Monitoring Physical Activity (Advise patient how to start, increase or maintain)
Improving or Maintaining Physical Health (Gauge status at each visit)
Improving or Maintaining Mental Health (Gauge status at each visit)
USE THE ANNUAL WELLNESS VISIT AS A VEHICLE TO SET THE STAGE.
4/17/2017
MedPOINT Management STARs PROGRAM Overview