secrets to star ratings success - gorman health group€¦ · cynthia pawley-martin senior...

CYNTHIA PAWLEY-MARTIN

Senior Consultant

MELISSA SMITH

Senior Vice President, Sales, Marketing, Strategy & Stars

SECRETS TO STAR RATINGS SUCCESS:

What’s Working (And What’s Not) In The Pursuit Of 5 Stars

Copyright © 2018 Gorman Health Group2

SETTING THE STAGE: 2019 STAR RATINGS PROPOSALS

PROPOSED NEW MEASURES

Statin Use in Persons with

Diabetes

(Part D)

Statin Therapy for Patients with

Cardiovascular Disease

(Part C)

MEASURES FOR REMOVAL

Beneficiary Access and Performance Problems (BAPP)

NEW METHODOLOGY FOR REDUCTIONS TO APPEALS MEASURES

Scaled reduction policy using

statistical criteria to reduce a

contract’s Star Rating for data

that is incomplete or lacks integrity

PROGRAM METHODOLOGY

Codifying principles for

adding, retiring measures

Minimizes financial

opportunities of cross-walking

during contract consolidations

DISASTER IMPLICATIONS

Excludes impacted plans from many cut

point and Reward Factor

calculations


KEEPING CONTEXT:STAR RATINGS 2020 AND BEYOND

CMS convening the first ever Star Ratings Technical Expert Panel in 2018 for feedback on Star Ratings policies, structure and operation.

New hypertension treatment guidelines which would expand

denominator under evaluation by NCQA; Controlling Blood Pressure may be temporarily retired to the display

page for the 2020 Ratings.

NCQA exploring revisions to Plan All-Cause Readmissions measure which

impact definition of both numerator and denominator and combine the

rates for ages 18-64 and 65+; revised measure may be a 2020 display

measure.

NCQA evaluating enhanced measure exclusions for persons with certain

advanced illnesses, recognizing certain HEDIS® measures may not be

clinically appropriate for all members; changes could be

incorporated into HEDIS® 2019.

CMS proposes introduction of NCQA’s Transitions of Care measure as a 2020

display measure; since Medication Reconciliation Post-Discharge measure is 1 of 4 indicators used in this new

measure, Star Ratings may adjust use of Medication Reconciliation Post-

Discharge as a stand-alone measure.

Medication Adherence measures may be risk adjusted for various socio-

demographic characteristics beginning with the 2018 calculations.

MPF Price Accuracy measure changes will be implemented through the

display page for the 2020 and 2021 ratings.


PROPOSED NEW CLINICAL MEASURES

4

Statin Therapy for Patients with Cardiovascular Disease (SPC; Part C)

• Percent of males aged 21-75 and females aged 40-75 with clinical atherosclerotic cardiovascular disease who were dispensed at least one high or moderate-intensity statin during the measurement year

• Allows for exclusion of certain conditions and symptoms that may indicate statin intolerance (e.g., myalgia, myositis, myopathy, or rhabdomyolysis)

• Measure to be included as process measure since it is based on one fill

Statin Use in Persons with Diabetes (SUPD; Part D)

• Percent of patients aged 40-75 who received at least two diabetes medication fills and also received a statin during the measurement period.

• Excludes members in hospice and with ESRD

• Does not currently allow exclusion of statin intolerant patients

• Measure to be 1x-weighted in 2019 ratings and 3x-weighted beginning in 2020 ratings

• As many as one-third of older adults may meet denominator criteria for SPC measure.

• Many members will be in both measures, but only a high or moderate intensity statin meets SPC measure requirements.

• Careful, integrated, provider-driven outreach is most likely to be successful and supportive of physician-patient relationships.

• Many physicians and patients focus on lifestyle changes (such as diet and exercise) prior to prescribing medications.

• Don’t forget! As soon as the member fills the second statin prescription, s/he will be in the adherence denominator!


What’s Working? What Sometimes Works? What Isn’t Working?

Cut point predictions Multi-variate intervention

evaluation Denial of CAHPS and HOS data Uncoordinated data infrastructure Leveraging EMR extracts, customer

service notes, medical record notes Insistence on evidence-based ROI

as justification for initiatives

DATA & ANALYTICS

Right member. Right intervention. Right setting. Right timing.







DATA & ANALYTICS

Integrating medical and pharmacy measures and data

Marriage of adherence and disease control measure data to target interventions

Contract-level monitoring/modeling Provider profiling and prioritization Member profiling and segmentation Monthly adjustment of focus areas








DATA & ANALYTICS

Integrating medical and pharmacy measures and data

Marriage of adherence and disease control measure data to target interventions

Contract-level monitoring/modeling Provider profiling and prioritization Member profiling and segmentation Monthly adjustment of focus areas


Predictive modeling Leveraging non-standard data

sources (HRAs, proxy surveys) Bidirectional data exchanges with

sophisticated provider partners Data-driven focus on outcomes Narrow selection of measures and/or

focus areas Data-driven retail pharmacy targeting


PROVIDER ENGAGEMENT & STRATEGIES


Standard contract terms Managing the network with no field

presence Interacting only with highest volume,

engaged and “pleasant” providers Expecting 4+ star performance

without delivering 4+ star service

Providers are vital. Achieving 4+ star ratings requires their alignment and support.



What’s Working?

Data-driven targeting Partnerships with the right providers Support for provider preferences Contracts that support Star Ratings

needs Investments into providers Prioritizing actionable requests Spending time in provider settings Focus on members under 65 Star Ratings team on JOCs

What Sometimes Works? What Isn’t Working?








What’s Working?

Data-driven targeting Partnerships with the right providers Support for provider preferences Contracts that support Star Ratings

needs Investments into providers Prioritizing actionable requests Spending time in provider settings Focus on members under 65 Star Ratings team on JOCs

What Sometimes Works?

Provider incentive programs Provider incentives to support

adherence measures Capitation/risk as the incentive to

improve health outcomes Gap reporting Electronic tools to communicate and

support gap closure

What Isn’t Working?







VENDORS

It’s blackjack,

not poker.


Targeting logic and algorithms held as proprietary information

Misaligned incentives Full/heavy reliance on PBM Heavily outsourced service model Low-cost, low-touch, and single-

purpose vendors Trust without validation


VENDORS

It’s blackjack,

not poker.

What’s Working?

Inclusion of CAHPS and HOS needs in contracts, dashboards, reports

Expanding services from successful single-purpose vendors

Partner-based monitoring and education programs inclusive of Star Ratings needs

Star Ratings team on JOCs






VENDORS

It’s blackjack,

not poker.

What’s Working?

Inclusion of CAHPS and HOS needs in contracts, dashboards, reports

Expanding services from successful single-purpose vendors

Partner-based monitoring and education programs inclusive of Star Ratings needs

Star Ratings team on JOCs


Risk-based payment terms Outsourcing of critical business

functions







CARE, CASE & DISEASE MANAGEMENT

People are not their problems. But their problems are real.And many of our members are very ill and clinically complex.

What’s Working? What Isn’t Working?

Failure to account for health episodes in pursuit of Star Ratings needs

Single-purpose interventions Disease-specific DM programs,

particularly for members with MCCs Programs focused only on high-cost

members Heavy use of mail and IVR UM-heavy cost containment





What’s Working?

Empathy, compassion, and support, particularly of members with MCCs

Risk-based stratification Star Ratings Case Management Multipurpose higher-touch intervention Targeted intervention suppression Team-based care (social, pharmacy, BH)

with an assigned “team captain” Motivational interviewing/active listening SDOH support and resolution








In-home clinical care Clinical investments in members focused

on the long term Integrating mental/behavioral health

into primary care Palliative care programs Non-traditionally focused programs such

as depression, loneliness, dementia, SMI, etc.



What’s Working?

Empathy, compassion, and support, particularly of members with MCCs

Risk-based stratification Star Ratings Case Management Multipurpose higher-touch intervention Targeted intervention suppression Team-based care (social, pharmacy, BH)

with an assigned “team captain” Motivational interviewing/active listening SDOH support and resolution







CORPORATE CULTURE & STRUCTURE


HEDIS as “the driver” of Star Ratings New plans assuming their “next

magic MA solution” will be 4+ stars Presuming commercial or Medicaid

success portends 4+ star ratings Part D measures addressed only by

the Rx team; Part C measures addressed only by clinical teams

Silo’ed Part D teams Longevity as criteria for leadership Functional departments unaware of

Star measure nuances

Culture matters. It is hard to strive for service excellence and best practices if staff are focused on day-to-day survival.



What’s Working?

Accountability, empowerment, trust Focus on members under 65 Allowing the freedom to fail Focus on better, faster, smarter – not

perfection Stars hardwired into daily operations Passion, commitment, and empathy

for seniors and disabled adults Mission as the foundation for NFPs Business plans aligned with service

area











What’s Working?

Accountability, empowerment, trust Focus on members under 65 Allowing the freedom to fail Focus on better, faster, smarter – not

perfection Stars hardwired into daily operations Passion, commitment, and empathy

for seniors and disabled adults Mission as the foundation for NFPs Business plans aligned with service

area


Reliance on heroic actions by individuals

Use of non-MA business levers to drive success in MA (commercial, Medicaid)

Supplemental benefits as tools to overcome Star Ratings barriers

Simulation for senior centricity, living on low income, managing multiple chronic conditions and episodes

Embedding staff in provider settings










Our clients have one-stop access to expert advice, guidance, and support, in every strategic and operational area for government-sponsored programs, across eight verticals

CLINICALPairing clinical teams with innovation to provide patient-centered care

.

PROVIDER STRATEGIESSupporting 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, Pharmacy Benefit Manager, formulary, and pharmacy programs

HEALTHCARE ANALYTICS &

RISK ADJUSTMENT SOLUTIONSImplementing cross-functional risk adjustment programs for medical trend management and quality improvement

SALES, MARKETING & STRATEGYDriving profitable growth and member retention through strategic marketing, sales, and product development

BROAD SERVICES

STAR RATINGS & QUALITY INNOVATIONSStrategic innovations to drive quality and improve

performance


Gorman Health Group (GHG) is a leading consulting and software solutions firm specializing in government health programs, including Medicare managed care, Medicaid and Health Insurance

Exchange opportunities. Since 1996, 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. Our mission is to empower health plans and providers, through a compliant, member-centric

focus, to deliver higher quality care to members at lower costs while serving as valued, trusted partners.

Further, our software solutions have continued to place efficient and compliant operations within our clients’ reach. Our Valencia™ software provides rigorous, compliant, and transparent

workflow controls that ensure your operational processes – and the resulting payment– are as accurate as possible. Sentinel Elite™ is our module-based software solution designed to assist

government managed care organizations onboard agents, provide training, manage ongoing oversight activities, and pay commissions effectively and compliantly. Our Online Monitoring Tool™

(OMT) is the complete Medicare Advantage and Part D compliance toolkit, designed to perform ongoing monitoring and auditing, manage regulatory notices, document corrective actions, and

streamline member material review. CaseIQ™ brings clarity to appeals and grievances and offers a new way to ensure your cases come to a compliant resolution. We also offer training courses

on a variety of industry topics designed to meet the unique needs of your organization through Gorman University™, and our exclusive daily digest, The Insider, provides in-depth analysis and

expert summaries of the most critical legislative and political activities impacting and shaping your organization.

Stay connected to industry news and gain perspective on how to navigate the latest issues by subscribing to our weekly newsletter, and follow us on LinkedIn, Facebook, and Twitter.

We are your partner in government-sponsored health programs.

T

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Melissa Smith

Senior Vice President, Sales, Marketing, Strategy & Stars

202.420.1346

[email protected]

Cynthia Pawley-Martin

Senior Consultant

305.962.4455

[email protected]

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secrets to star ratings success - gorman health group€¦ · cynthia pawley-martin senior...

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