Demonstrating Performance Under the Parts C

1
Demonstrating Performance Under the Parts C
DCMS Measures

• Vikki Oates, M.A.S.
• May 1, 2007

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Presidents Agenda

• On 8/22/06, The President signed an Executive
  Order to ensure that health care programs
  administered by the Federal Government promote
  quality and efficient delivery of health care
  through the use of health information technology,
  transparency regarding health care quality and
  price, and better incentives for program
  beneficiaries, enrollees, and providers.
• The implementation date is January 1, 2007.

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Presidents Agenda (continued)

• The directives for the Agencies were the
  following
• Health Information Technology
• Transparency of Quality Measurements
• Transparency of Pricing Information
• Promoting Quality And Efficiency of Care

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CMS Strategic Plan

• The performance and quality metrics initiative
  supports CMS Strategic Plan
• Confident Informed Consumers Provide
  beneficiaries with personalized tools and
  information to make informed decisions
• True Collaborative Partnerships Work with Plans
  to help improve performance and quality
• High Value Health Care To provide high quality,
  cost effective health care to all beneficiaries

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Goal of Performance and Quality Metrics

• To support the Presidents Agenda on health care
  transparency
• To support the CMS Strategic Plan
• To ensure that Medicare beneficiaries receive the
  best healthcare and prescription drug coverage
  available and that they have the data necessary
  to make informed decisions.

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Current Part D Metrics

• Performance measures ready for 2007 open
  enrollment
• Displayed on the Medicare Prescription Drug Plan
  Finder (MPDPF)
• Some measures will be updated on 4/26/07
• Measures are grouped in five domains
• Customer Service
• Complaints
• Exceptions/Appeals
• Data Systems
• Pricing

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Current Part D Metrics - Continued

• CMS is using the current performance metrics data
  to identify specific areas for plan improvement
• Currently there is not significant variance among
  plan performance since many measures did not have
  established standards
• Baseline data were not available for the first
  year
• Only plans that were statistically the highest
  outliers were rated less than three stars

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The Power of Part D Performance Metrics

• Establishes performance benchmarks
• CMS long-term goal is to establish performance
  benchmarks based on historical experience with
  Part D
• Once benchmarks are established, CMS will work
  with plans to improve performance
• If high performance in an area becomes standard
  for all plans then a measure may be retired
• CMS is working towards the development of
  composite scores for monitoring purposes
• Creates a feedback loop

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Continuous Improvement Opportunities Using
Performance Metrics Case Study

• Identified outliers (plans with less than 3
  stars) on the Appeals measure
• Reviewed individual cases where the IRE
  overturned plan decisions
• Identified the basis for the IRE decisions
• Met with plans to discuss changes to their review
  process

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Performance and Quality Metrics Next Phase

• Expansion of the number of Part D measures
• Making measures more accessible to users of the
  tools
• Measures will be evaluated and rated at a domain
  and measure level

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Performance and Quality Metrics Integrated with
the Plan Finder and Medicare Options Compare

• Beneficiaries will have the opportunity to view
  the measures at three levels
• The highest level is the domain level, which
  summarizes all measures in that area into a
  single rating.
• From each domain, beneficiaries can drill down to
  the summary level. This level will provide a
  rating for each measure.
• Within each measure, a beneficiary can view
  details. This level will show a rate, time, or
  statistic for each measure.
• Both the domain and summary level ratings will be
  based on a five-star scale

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Illustrative Example of 5 Stars for Select Domains
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Proposed Measure Domains

• Part D
• Customer Service
• Access to Prescription Drugs
• Drug Pricing and Utilization
• Part C domains are similar

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Data Sources Supporting Part D Performance Metrics

• Call center monitoring
• Complaint tracking information
• Plan-reported data
• IRE data
• Data systems processing
• Medicare Prescription Drug Plan Finder data
• Part D CAHPS
• PDE

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Part D - Customer Service Measures

• Customer service wait time
• Customer service disconnect rate
• Pharmacy help desk average wait time
• Pharmacy help desk average disconnect rate
• Beneficiary understanding of drug costs and
  coverage
• Beneficiary ability to get help from the plan
• Beneficiary rating of plan
• Total customer service complaints

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Part D- Access to Prescription Drugs Measures

• Rate of Cases forwarded to the IRE because
  decision timeframe was missed
• Percent of IRE confirmation (upholding) of plans
  decisions
• Benefits/Access complaints per 1,000 enrolled
  beneficiaries
• Enrollment/Disenrollment complaints per 1,000
  enrolled beneficiaries

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Part D- Access to Prescription Drugs Measures
(continued)

• Completeness of 4Rx for current enrollees
• LIS Match Rate
• Part D Disenrollment Rate
• Beneficiaries Ability to Get Drugs

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Part D - Drug Pricing and Utilization Measures

• Pricing/Co-Insurance Complaints per 1,000
  enrollees
• Percent of Data File Submissions Without Errors
• Price Changes Over Time
• Correlation Between Pricing at Point of Sale and
  What is Displayed on Plan Finder
• Generic Dispensing Rate
• Identification of MTM Eligible Beneficiaries
• Percent of beneficiaries with a high risk
  medication

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Expansion in 2008 Part D Proposed Quality
Measures

• CMS plans to use only validated quality measures
• CMS intends to parallel the efforts of the
  Pharmacy Quality Alliance and hopes to adopt some
  of the measures that will undergo validation and
  testing by NCQA
• Areas under consideration focus on therapeutic
  duplication and overutilization

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Part D Proposed Patient Safety Measures for 2008

• Therapeutic duplication
• Beta-blockers
• ACEI or ARBs
• Calcium-Channel Blockers
• Overutilization
• gt2 Beta-agonist inhaler canisters per 30 days
• Exceeding average daily dosage for specific
  medications

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Part C
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Current Display of Part C Metrics

• HEDIS and CAHPS data currently displayed on
  Medicare Options Compare

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Part C Quality Metrics

• First released on Medicare Compare (now called
  Medicare Options Compare) January 1999
• Current measures
• Beneficiary Satisfaction
• Getting Care without Long Waits
• Getting Needed Care
• Overall Rating of Health Plan
• Overall Rating of Health Care
• Doctors who Communicate Well
• Seeing a Specialist
• Helping You Stay Healthy
• Flu Shots
• Diabetes (eye exams, glucose control tests, lipid
  (cholesterol) tests)
• Beta blockers after heart attack
• Access to Providers
• About Providers
• Providers who stayed in the plan for at least 1
  year

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Data Sources Supporting Part C Quality and
Performance Metrics

• Health Plan Employer Data and Information Set
  (HEDIS)
• Consumer Assessment of Healthcare Providers and
  Systems (CAHPS) Survey
• Maximus

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Proposed Measure Domains

• Part C
• Customer Service
• Access to Healthcare
• Effective Treatment for Chronic Conditions
• Preventing Illnesses and Complication

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Part C Customer Service Measures (proposed)

• Adult access to preventive/ambulatory health
  services
• Getting Needed Care CAHPS composite
• Getting Care Quickly CAHPS composite
• Antidepressant medication management optimal
  practitioner contacts
• Initiation of Alcohol and other Drug Dependency
  Treatment
• Access to specialists (CAHPS)
• Getting care for illness/injury right away
  (CAHPS)

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Part C Access to Healthcare Measures (proposed)

• Follow up after hospitalization for mental
  illness within 7 and 30 days of discharge (2
  separate measures)
• Controlling blood pressure
• Diabetes care HbA1c poor control
• Diabetes care LDL-C controlled
• Beta blocker treatment after AMI
• Persistence of beta blocker treatment after AMI
• Osteoporosis in woman who had a fracture
• DMARD therapy for rheumatoid arthritis
• Antidepressant medication management effective
  acute phase and continuation phase treatment (2
  separate measures)
• Engagement of alcohol and drug dependency
  treatment

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Part C Effective Treatment for Chronic Conditions
Measures (proposed)

• Doctors who Communicate Well CAHPS composite
• Customer Service CAHPS composite
• Courteous Office Staff CAHPS composite
• Overall Rating of Health Plan (CAHPS)
• Overall Rating of Health Care (CAHPS)
• Call Abandonment
• Call Answer Timeliness

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Part C Preventing Illnesses and Complication
Measures (proposed)

• Drugs to be avoided in the elderly exposure to
  1 and 2 drugs (2 measures)
• Annual monitoring for patients on persistent
  medications
• Spirometry testing for COPD
• Breast cancer screening
• Colorectal cancer screening
• Diabetes care
• LDL-C screening
• Eye exam
• Kidney disease monitored
• HbA1c screening
• Annual flu shot
• Pneumonia vaccination

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Part C Appeals

• Independent Review Entity agrees with plans
  decision
• Plan makes timely decisions on appeals

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Rollout Strategy for bothPart C D

• Industry Calls April 2007
• Final Call Letter April 2007
• User Group Call May 9, 2007
• Comments May 18, 2007
• Consumer Testing of Language and Content
  June/July 2007
• Additional Industry Calls Summer 2007
• Preview of Information for Plans in HPMS
  September/October 2007
• New Information and Displays available on
  www.Medicare.gov November 2007

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Summary

• The expanded measures reflected in the Part C D
  report cards will
• Improve CMS ability to identify high performing
  plans
• Help CMS identify plans that we need to work with
• More importantly, will substantially improve
  information available to beneficiaries for
  selecting high-quality heath and prescription
  drug plans

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Contact Information
Vikki Oates, M.A.S. Director, Division of
Clinical and Economic Performance Medicare Drug
Benefit Group vikki.oates_at_cms.hhs.gov 410-786-3652