Tags:

Transcription

Medicare STARS ProgramThe Centers for Medicare and Medicaid Services (CMS) works with MedicareAdvantage Plans like GlobalHealth (HMO) and Generations Healthcare HMO toimprove the quality, performance and cost effectiveness of services provided toMedicare beneficiaries. The Medicare STARS program determines how well plansand providers perform across a section of quality measures using information frommember satisfaction (both plan and providers), health outcomes and planoperations. A plan can get a rating from one to five stars. A 5-STAR rating isconsidered excellent. The measures are divided into the following categories: Staying Healthy- Includes how often members received various screeningtests, vaccines, and other assessments to help them stay healthy. Managing chronic conditions- Includes how often members with differentlong-term conditions completed certain tests and treatments that helpmanage their conditions; appropriateness of medication and medicationadherence. Member Satisfaction- Includes ratings of member satisfaction with the planand how they feel the quality of their care, the plan and providers. Customer Service- Includes how responsive and helpful the plan’s customercare is and if the information provided is accurate; includes grievances andappeals. Plan Operations- Includes how the plan makes decisions aboutdeterminations and appeals; formulary pricing; prescription dug safety andfindings from CMS audits.A Plan’s STAR ratings are ranked 1-5 in each category, and then used todetermine a Plan’s overall rating. Excellent PerformanceAbove Average PerformanceAverage PerformanceBelow Average PerformancePoor Performance2015 Stars Webpage info

The STAR rating measures the Plan’s performance in over 30 measures covering: Clinical quality standardsMember satisfactionHealth plan administrative performanceCompliance with CMS operational standardsData sources used to measure the performance include: Clinical quality standards: Health Effectiveness Data and Information Set (HEDIS )(HEDISSTARS Measures Link (please see below) Pharmacy Data (Prescription Drug Event-PDE), includes medicationadherence Laboratory data Health Outcome Survey (HOS)http://www.hosonline.org/Content/Default.aspx Member experience, satisfaction and complaints with Plan: Consumer Assessment of Healthcare Providers and Systems (CAHPS )https://cahps.ahrq.gov/about-cahps/index.html Medicare Advantage (MA) and Prescription Drug Plan (PBP) CAHPS tems/Research/CAHPS/mcahps.html Complaint Tracking Module Grievances and Appeals Administrative performance and compliance standards CMS Audits Pharmacy (Part D) drug safety and drug pricing accuracy Customer Care PerformanceWhat is GlobalHealth doing to enhance quality and improve Star ratings?GlobalHealth’s goal is to support our members in maintaining and improving theirphysical and mental health; effectively manage long-term conditions; and providehigh quality, cost effective health care.We utilize Case and Disease Management, Care Coordination, Quality Improvementand our network providers to encourage our members’ healthy choices bymonitoring how frequently members receive screenings, vaccines, and otherpreventive services. Please see GlobalLinkTM for referral forms.

We have a team dedicated to quality and improving our Star ratings, with a goal ofimproving the health of our members; attracting new members to our high qualityplans and offering competitive reimbursement to our providers. GlobalHealthconstantly assesses the Star ratings and the measures that they encompass.GlobalHealth is also working with specific provider groups in Shared Savings (SSP)agreements, where providers are rewarded for their performance on a number ofquality measures, including HEDIS and Stars.What you can do to continue to provide high quality, timely, appropriate service to ourmembers: Ensure your patients receive routine screenings and preventative services,including labs; Help your patients manage their long- term conditions, including high bloodpressure, diabetes, high cholesterol and arthritis; Refer to GlobalHealth Case and Disease Management and Behavioral Health CareCoordination as indicated; Help members choose safe medications (a link to the High Risk Medications list isprovided below); Ensure patients are taking their medications as prescribed (principally oraldiabetic, cholesterol, HTN, ACE/ ARB); Submit claims and document all services timely, thoroughly and accurately; Understand the impact that you and your staff have on your patient’s (ourmember’s) health and satisfaction with their health plan and care, which isreflected in CAHPS and HOS surveys.

GlobalHealth and Generations Medicare Advantage PlansHEDIS/CAHPS STAR Measures (2015)Bolded items are GlobalHealth & Generations focus for 2015 StarsMeasureDescription of Measure4 StarBenchmarkColorectal Cancer ScreeningMedicare members age 50-75 should have a 1)Fecal Occult Blood (gFOBT or iFOBT) within thelast year or: 2) flexible sigmoidoscopy within thelast 5years or; 3) colonoscopy within the last 10years. Documentation must include the datetest was completed.Female Medicare members ages 50- 74 shouldhave a mammography every 2 years.Medicare members ages 18-75 (male andfemale) who were discharged after an AcuteMyocardial Infarction, Coronary Artery BypassGraft (CABG) or Percutaneous CoronaryInterventions (PCI) within the past year, or whohave been diagnosed with Ischemic VascularDisease (IVD) within the past year, should havean LDL-C screening and an LDL-C control ( 100mg/dL) annually.Medicare members ages 18-75 (male andfemale) with a diagnosis of diabetes with aCholesterol Screening Test LDL-C, annually.Medicare members (male and female) who hada flu shot annually prior to flu season.Medicare members (male and female) whostate their physical health was the same orbetter than expected after two years.Medicare members (male and female) whostate their mental health was the same orbetter than expected after two years.Medicare members age 65 and older (male andfemale) who discuss exercise with their doctorand were advised to start, increase or maintaintheir physical activity during the year.Medicare members ages 18-74 (male andfemale) should visit with their primary physicianand have a body mass index (BMI) documentedevery 2 years. Calculate from the member'sheight and weight.Female Medicare members age 67- 85 years ofage who suffered fracture and received bonemineral density (BMD) test or were prescribed adrug to treat or prevent osteoporosis within 6months of the fracture. Excludes fractures offingers, toes, face, and skull. (Refer to Drug listlink below) 58%Breast Cancer ScreeningCholesterol Screening forPatients with Heart DiseaseDiabetes Care- CholesterolScreeningAnnual Flu VaccineImproving or MaintainingPhysical HealthImproving or MaintainingMental HealthMonitoring Physical ActivityAdult BMI AssessmentOsteoporosis Management inWomen who had a Fracture 74% 85% 85% 75% 60% 85% 60% 87% 60%

Diabetes- Retinal Eye ExamDiabetes- Kidney DiseaseMonitoringDiabetes Care- Blood SugarControlledDiabetes Care- CholesterolControlledControlling High BloodPressureRheumatoid ArthritisManagementImproving Bladder ControlMedicare members ages 18-75 (male andfemale) with diabetes (Type 1and Type 2) whohad a dilated or retinal eye exam by an eye careprofessional to check for damage from diabetesduring the year. Results need to indicate dateand result.Medicare members ages 18-75 (male andfemale) with diabetes who had nephropathyscreening test performed every year. a)Macroalbumin – Any of the following tests donein measurement year: Urinalysis positive(random, spot or timed) for protein, Positiveurine dipstick, Positive tablet reagent for urineprotein, Positive result for albuminuria, Positivefor macroalbuminuria, Positive for proteinuria,Positive for gross proteinuria Note: “trace”urine macroalbumin test results are notconsidered positive. b) Microalbuminuria –Anyof the following tests in measurement year: 24hour urine for microalbumin Timed urine formicroalbumin, Spot urine for microalbumin,Urine for microalbumin/ creatine ratio, 24-hoururine for total protein, Random urine forprotein/creatinine ratio or c) hasdocumentation of nephropathy in the recordduring the past year.Medicare members ages 18-75 (male andfemale) with diabetes who had an HBA1c test inthe measurement year documented in therecord with date and results indicating 8.0%.Medicare members ages 18-75 (male andfemale) with diabetes who had a cholesteroltest in the in the measurement yeardocumented with a LDL-C 100 mg/ dL)Medicare members (male and female)diagnosed with HTN, ages 18-59 and allmembers diagnosed with diabetes, with BP of 140-90 mmHg during the measurement year.Medicare members (male and female)diagnosed with HTN, ages 60 and older; with BPof 150/90 mmHg during the measurementyear.Medicare members (male and female) whowere diagnosed with rheumatoid arthritisduring the measurement year and weredispensed at least one prescription for diseasemodifying anti- rheumatic drug (DMARD) filled.Medicare members 65 years and older (maleand female) who reported having a urineleakage problem in the last six months and whoreceived treatment for the current urineleakage problem. 64% 85% 80% 64% 63% 78% 60%

Reducing the Risk of FallingPlan All-Cause ReadmissionsEase of Getting Needed Careand Seeing SpecialistsGetting Appointments andCare QuicklyHigh Risk MedicationDiabetes TreatmentMedication Adherence- OralDiabetes MedicationsMedication AdherenceHypertensionMedication AdherenceCholesterol (Statins)Statin Use in Diabetes(new)Medicare members 65 years and older (male 59%and female) who had a fall, problems withbalance or walking in the past 12 months andwho received fall risk intervention from currentpractitioner. Review of falls and balanceannually. Interventions may include recommenduse of cane or walker; check BP lying andstanding; recommend exercise or physicaltherapy program; or suggest vision or hearingtesting.Medicare members discharged from hospital 9%stays who were readmitted to a hospital within30 days of discharge, either for the samecondition as the recent admission or for adifferent reason.Medicare member report of ease of access to 85%providers, tests and treatment when needed,including care from specialists.Medicare member report of ease of access toproviders when needed/ wanted; received care assoon as they thought it was needed and seen within15 minutes of appointment time.Medicare members age 65 and older, who filled 2 ormore prescriptions for certain medications with ahigh risk of serious side effects when safer meds areavailable. Refer to High Risk Medication List- linkbelow.Medicare members ages 18 and older with HTN andDiabetes who are prescribed and filled at least oneprescription for the recommended BP med (ACEinhibitor, ARB DRI therapy) during measurementyear.Medicare members with diabetes andprescribed an oral diabetic medication, whofilled that prescription often enough to covergreater than or equal to 80% of the time theyare supposed to be taking the medication.Medicare members with HTN and treated withan ACE/ ARB or DRI medication, who filled thatprescription often enough to cover greater thanor equal to 80% of the time they are supposedto be taking the medication.Medicare members treated with a statincholesterol mediations, who filled thatprescription often enough to cover greater thanor equal to 80% of the time they are supposedto be taking the medication.Medicare members (male and female) ages 1875 years of age, diagnosed with HTN anddiabetes, who filled at least 2 prescriptions fordiabetic medications and at least oneprescription for a statin medication during themeasurement period. 75% 9% 86% 77% 81% 76% 76%

High Risk Medication RM%20Measure%202013website.pdfNote: The National Committee for Quality Assurance (NCQA) has a comprehensive list of medicationsand National Drug Code (NDC) codes posted FinalNDCLists.aspx

Medicare STARS Program The Centers for Medicare and Medicaid Services (CMS) works with Medicare Advantage Plans like GlobalHealth (HMO) and Generations Healthcare HMO to improve the quality, performance and cost effectiveness of services provided to Medicare beneficiaries. The