SECRETS TO STAR RATINGS SUCCESS - Gorman Health Group · 2018. 5. 24. · MELISSA SMITH Senior Vice...

MELISSA SMITH

Senior Vice President, Sales, Marketing, Strategy & Stars

SECRETS TO STAR RATINGS SUCCESS:

Using the Right Data to Drive Your Star Ratings Strategy

Copyright © 2018 Gorman Health Group2

DATA & ANALYTICS

What’s Working?

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

What Sometimes Works?

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

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

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


5-STAR DATA INTEGRATION REQUIRES 5-STAR DATA

Pharmacy Data

Enrolled Days, Covered Days, Days Needed for 80% PDCDays to nonrecoverable, last day for InterventionDrug-drug interactions, opioid use

Provider Data

Credible PCP Attribution/AssignmentsMembers not assigned to providersEngaged/unengaged providersCAHPS proxy dataProviders requesting suppressionMembers receiving episodic care from non-PCPs

“5-star” Data

Onboarding response dataHRA responses

CDC, RWJF, KFF, Healthy People 2020, CHNAsMember call data (CS, CM, MM, Rx)

Clinical Data

Rising risk indicators, members in health crisisMembers newly diagnosed with impactful conditions

Unengaged and “never numerator” membersHEDIS IDSS dataHOS proxy data

Enrollment and Demographic Data

Accurate addresses and phone numbersLanguage and literacy

Do not call/ preferred communication channelsProgram enrollment data (CM, DM, fitness, etc)


CONTRACT-LEVEL MONITORING

4

Is the source of your data current enough to allow you to adjust priorities?

Are you disclaiming your basis for cut point predictions?

If available, are you using CAHPS/HOS proxy survey data?

Are you looking for outlier measures which could prevent you from earning Reward Factor?

Are you factoring in potential new, removed and changed measures?

Are your executives using this as “directionally reasonable” rather than as a precise measure of performance?


CASE STUDY: USING PERFORMANCE TO SET PRIORITIES

5

20

18

PE

RFO

RM

AN

CE

INCREASING RISK (weight, distance to next star, etc)


CASE STUDY: PREDICTING PERFORMANCE AMIDST UNCERTAINTY

6

SEQUENTIAL SCENARIO

2017 CUTPOINTS

(NO ADJUSTMENTS)

W/1 RATING DROP ON

ANY MEASURE W/IN 1%

OF NEXT LOWER

CUTPOINT

MEASURE TREND

CUTPOINT MODEL

INDIVIDUAL

CUTPOINT TREND

MODEL

2016 STAR

RATINGS

2015 STAR

RATINGS

2014 STAR

RATINGS

1. Use of validated measure rates √ √ √ √ √ √ √

2. Addition of Post-Discharge Medication Reconciliation (4) and Bladder Control (2) √ √ √ √ √ √ √

3. Removal of 2 topped out measures

- 1x-weighted 5 star measures

- 1.5x-weighted 5 star measures √ √ √ √ √ √ √

- 3x-weighted 5 star measures √ NO √ √ √ √ √

2018 SENSITIVITY ANALYSIS

# 3x-weighted incremental ratings away from dropping below 4 star rate (from #3)

# of measures management has assumed performance equal to prior year

# of measures management has provided no source data to validate rate

# of new measures for which no data exists to support predictions

2019 Rollforward: From worst case 2018 Scenario

4. Add 3 single-weighted new measures

- with 2 star performance

- with 3 star performance √ NO √ √ √ √ √

5. Removal of 3 additional topped out measures

- 1x-weighted 5 star measures

- 1.5x-weighted 5 star measures √ NO NO √ √ √ √

- 3x-weighted 5 star measures √ NO NO √ √ √* √*

2019 SENSITIVITY ANALYSIS

# 3x-weighted incremental ratings away from dropping below 4 star rate (from #5)

# of measures management has assumed performance equal to prior year

# of measures management has provided no source data to validate rate

# of new measures for which no data exists to support predictions

* No additional 5 star measures available to remove. Modeled based on removal of next highest performing 3x-weighted measure.

2 4 8 5 8N/A

NO

NO

N/A

6

NOTE:

ALL SCENARIOS COMPUTED WITHOUT IMPROVEMENT MEASURES TO EVALUATE LIKELIHOOD OF ATTAINING 4 STAR BASE RATING TO TRIGGER "HOLD HARMLESS" PROVISION.

STRONG PERFORMANCE ON IMPROVEMENT MEASURES AND/OR EARNING OF REWARD FACTOR COULD POSITIVELY IMPACT THESE MODELS

3 N/A 1 3

7

3

1 4

√ √ √ √ √

NO √ √ √ √

ATTAINMENT OF OVERALL 4 STAR CALCULATED RATING USING:

√ √ √ √ √ √

2017 CUTPOINTS 2018 GHG PROJECTED CUTPOINTS HISTORICAL CUTPOINTS:

√

√

14

7

2

14

√


EXAMPLE: PROVIDER PROFILINGFROM 1,300 PCPS TO THE 104 WITH IMPACT

7


EXAMPLE: PROVIDER PROFILINGFROM 1,300 PCPS TO THE 104 WITH IMPACT

8

WHO DO I NEED TO INTERVENE WITH?

WHAT DO I NEED TO ASK?


DATA-DRIVEN INTERVENTION PLANNING “THE ART OF THE POSSIBLE” IN COMPLEX POPULATIONS

9

Healthy Stable At Risk Multiple Chronic Complex

• <3 screening, testing or similar gaps, and

• ≥1 medication adherence denominator(s) with PDC >80% on each, and

• ≥1 compliant intermediate outcomes measure

• 3 screening or testing gaps, or• ≥2 medication adherence

denominators with PDC <80% on ≥1 adherence measure, or

• ≥1 intermediate outcomes measure with 1+ non-compliant test result

• >3 screening or testing gaps, or • >1 intermediate outcomes

measure with >1 current year non-compliant test result, or

• ≥6 medications, or• Members diagnosed with

drug/alcohol dependence, or• Members <65, or• Low-income members (≥75% LIS

coverage), or• ≥2 hospitalizations or emergency

room visits in past year

• ≥3 chronic conditions, regardless of total number of gaps in care

• complex or catastrophic disease states as defined by existing CM program description, regardless of the number/type of Star Ratings measure gaps who are not actively engaged with CM


EXAMPLE: DATA-DRIVEN MICROTARGETING

10

Is member adherent to oral diabetes

meds?

Is member compliant on Diabetes A1c control

measure?

YES

NO

YES NO: NO TEST NO: NO RESULT NO: A1c >9%



11


meds?


measure?

YES

NO

YES

No Action Needed;

suppress A1c

control gap



12


meds?


measure?

YES

NO

NO: NO RESULT

Locate test result;

update

microtargeting



13


meds?


measure?

YES

NO

NO: NO TEST

Locate test result or

schedule appt for

test; update

microtargeting

NO: NO TEST


schedule appt for test

& conduct adherence

intervention



14


meds?


measure?

YES

NO

NO: A1c >9%

MD intervention

requesting review of

medication regimen

NO: A1c >9%

MD and/or member

intervention/

coaching



15


meds?


measure?

YES

NO

YES

No Action Needed;

suppress A1c

control gap

NO: NO TEST


schedule appt for

test; update

microtargeting

NO: NO RESULT

Locate test result;

update

microtargeting

NO: A1c >9%

MD intervention

requesting review of

medication regimen

NO: NO TEST


schedule appt for test

& conduct adherence

intervention

NO: A1c >9%

MD and/or member

intervention/

coaching


LEVERAGING DATA FOR YEAR-ROUND INTERVENTIONS

16

January February March April May June July August September October

November/

December

All MD's

receive P/Y

unclosed Gaps

Stars mtg

w/Top 50 MDs

All MD's receive

Gaps

All MD's receive

Gaps

All MD's receive

Gaps

Schedule

In-home appts

Gaps in Care

Checklist

Member Stars

Focus Groups

Gaps in Care

Checklist

CAHPS Proxy

Srvy

Member Stars

Focus Groups

Schedule

In-home appts

Member

Calendar Newsletter Newsletter Newsletter Newsletter Newsletter

Stars education for all MD's and systems Health Systems receive monthly gaps in care reports/data fi les to allow EMR/care management alignment

1st Quarter

Stars focused mtg w/

Top 50 MD's each month.

Stars focused mtg w/

Top 50 MD's each month.

Implement market-customized, targeted CAHPS CQI Activities

Provide clinical services to patients

30/60/90 Outreach for HRA Completion Schedule Gap Closure Adherence/Outcomes Coaching

Adherence Coaching for any member exceeding pro-rate share of Gap Days

Member outreach for in-home BMD screening post-fracture.

DM/Health & Wellness Coaching Gap Closure by DM/Health and Wellness

Gap Closure in RA & MM home visits

Schedule Gap Closure Appts

Gap Closuere via MTM-like Retail Rx visits

Star Gap coaching in RA home visits Star Gap closure in RA home visits

Pre-HEDIS Data Collection

Welcome Calls

Gap discussion during member calls with Concierge

Stars-focused On-hold Messaging

Member Appreciation Events/CAHPS Campaign

CAHPS Outreach for Red Alerts

Ca

re

Mgm

t

Sta

rsP

hys

icia

ns

Dis

ease

/Sta

rsM

gmt

Ma

rket

ing

Pro

vid

erR

ela

tio

ns

Calendar 2016Calendar 2018 Calendar 2019

Op

era

tio

ns

RA


Coordinated efforts with the Risk Adjustment team will yield higher results and less provider abrasion

RISK AND QUALITY TIMELINES


QUALITY TOOL BOX

Member Level Reports Provider Level Reports Plan Oversight

Output Files• All Members-All Gaps• PCP information • Quality and Risk information • Non Compliant and Compliant indicators• Financial indicators • Multiple and weighted measure indicators

Chase Ranking Criteria• Filtering criteria that allows customized

prioritization by measure, provider, impact or risk factors

• Identifies high priority/high risk members• Contains both Quality and Risk Gaps

Multiple Measure/High Impact Reports • CDC and Cardiovascular measures • Med Adherence Measures

Measure & PDE Performance

Provider Prioritization: • Measure, Group, or Within a Health Plan• High Priority Providers

Provider Report Cards

Provider Gap Identification:• Member/Patient Profile • Gaps Open by %• Quality & RA gaps• Ranking of Provider• Low-Performing Providers

Data oversight that allows filtering at: • Plan (All LOB)• Contract• LOB• Provider Entity • Within a Quality Metric

Measure benchmarking and Trending data• Year over Year/Month over Month• Multiple Benchmarks

5-Star

• Reward Factor

• Improvement Measures

• CAI Calculations

• Threshold Performance


PROVIDER ALERT EXAMPLE: Provide data that is Actionable• Address gaps at the

Member level-including Risk Adjustment

• When possible integrate into providers workflow system such as EMR or provider portal

• Ability for Provider to give feedback or upload medical record data

• Gap list should contain more than compliant/non compliant information

• Suppress or indicate if Gap is non-closeable

• Give Date of Service, Lab detail, or RX claim information when possible

• Start early on providing gaps for new and anticipated measures


COMPLEX/OVERLAPPING MEASURES REQUIRE DATA ANALYTIC REPORTS THAT ARE ACTIONABLE

Several members cross multiple measures including:

• C13 Comprehensive Diabetes Care (CDC)-Eye Exam-weight of 1

• C14 Comprehensive Diabetes Care (CDC)-Kidney Disease- weight of 1

• C15 Comprehensive Diabetes Care (CDC)-Blood Sugar controlled -weight of 3

• D11 Medication Adherence for DM-weight of 3

• D12-Medication Adherence for Hypertension-weight of 3

• D13- Medication Adherence for Cholesterol -weight of 3

• Display Measure- Statin Use in Persons with Diabetes (SUPD)

• Display Measure- Statin Therapy for Patients with Cardiovascular Disease

Complex Overlap:

• CDC drug list does not overlap with Medication Adherence for Diabetes

• CDC Members must have 2 outpatient visits or RX

• Metformin is not on the RX list for CDC denominator, but is on the list for Medication Adherence for DM

• Insulin is not in the Medication Adherence for DM, but it is on the list for CDC denominator

• SUPD- allows for low impact statin, SPC –must be on Mod/High impact statin


MULTIPLE MEASURE HIGH IMPACT SAMPLE REPORT

Members Across CDC, Med-Adherence Measures, SPC, and SUPD to assist in identifying High Impact/high target prescribers and members


UNDERSTANDING OVERLAPPING DENOMINATORS

CDC2 Outpatient Visits

with DX for DM or 1 Prescription for DM

D11

2 Prescriptions for DM

D13

2 Prescriptions for Statin

SUPD

2 or More Prescriptions for DM

and 1 Statin

SPC

Atherosclerotic

Cardiovascular

Disease (ASCVD)


EXAMPLE PLAN A: COMPREHENSIVE DIABETES CARE AND D11-MEDICATION ADHERENCE FOR DM

CDC Denominator

=1395

Members in CDC not in D11= 817

Med Adherence Measure Diabetes

Denominator (*Age 18-75)= 880

Members in D11 not in CDC=302

In Both CDC and Med Adherence

for DM =578

Compliant (80%) for D11 and CDC =355

NON Compliant for D11 and in

CDC=223


EXAMPLE PLAN A: CDC AND D11-MEDICATION ADHERENCE FOR DM

In Both CDC and D11=578

Compliant (80%) for D11 and CDC =355

NON Compliant for

D11 and in CDC=223

Compliant HbA1C Less <9

195=55%

Non Compliant HbA1c

160=45%

Missing

Test

23= 14%

Missing

Lab Value

131=82%

Greater than >9 6=4%

Compliant HbA1C Less <9

77=35%

Non Compliant HbA1c

146=65%

Missing

Test

13= 8%

Missing Lab Value 124=85%

Greater than >9 9=6%


KEY TAKEWAYS=TAKING ACTION

• Lab Result (MRR) and Lab Test

154 Members Compliant for D11 and

Missing HbA1c

• Medication Adherence Intervention

• Rx review for members not in CDC denominator

366 Members

Not Compliant for D11

• Medication Adherence Intervention/RX review

• Provider Performance/Trending

• Disease/Case Management possible target

817 CDC Members

not in D11

• Review members for Exclusions

• Disease/Case Management possible target

• RA Coding Patterns

302 D11 Members

not in CDC


EXAMPLE PLAN A-D13 MEDICATION ADHERENCE FOR STATINS, CDC, SPC, AND SUPD

SPC Denominator=91

CDC Denominator =1395

CDC and D13=686

CDC and SUPD=768

CDC and SPC=51

D13=2887

D13 and SUPD=638 SPC and D13=56Lower number of Members (686) in both CDC/D13 vs

Members in CDC/SUPD (768).

56% of SPC Members (i.e.

have AVSCD) also in CDC

Denominator.

KEY TAKAWAYS


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

E

T

E

Melissa Smith

Senior Vice President, Sales, Marketing, Strategy & Stars

202.420.1346

[email protected]

Kari Hadley

Senior Director, Medicaid and Quality Products

509.939.1332

[email protected]

https://www.gormanhealthgroup.com/subscribe/

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SECRETS TO STAR RATINGS SUCCESS - Gorman Health Group · 2018. 5. 24. · MELISSA SMITH Senior Vice...

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Transcript of SECRETS TO STAR RATINGS SUCCESS - Gorman Health Group · 2018. 5. 24. · MELISSA SMITH Senior Vice...