by Advanced Plan for
Health
Apr 19, 2018
Apr 19, 2018
Guest blog contributor:
Rex Wallace - Principal, Rex Wallace Consulting, LLC
On April 2nd, the Centers for Medicare and Medicaid Services (CMS) released the Announcement of Calendar Year (CY) 2019 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter. The entire document is a behemoth which includes important information about CY2019 for Medicare Advantage plans across a variety of topics. This post will focus solely on the impact on Star Ratings.
The release of the Final Call Letter is one of a series of key
milestone dates leading up to October 11, 2018, when CMS releases Star Ratings
for each Medicare Advantage organization to the public.
IMPACT ON THE 2019 STAR RATINGS
NEW MEASURES FOR 2019 STARS
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New!
|
New!
|
|
Statin User in Persons with Diabetes (SUPD)
(Part D)
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Statin Therapy for Patients with
Cardiovascular Disease (Part C)
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NEW: Statin Use in Persons with Diabetes (SUPD) (Part D)
CMS will add SUPD to the 2019 Star Ratings with a weight of 1.
Beginning with the 2020 Star Ratings, CMS proposes that this PQA intermediate
outcome measure will have a weight of 3. The Holy Trinity of triple-weighted
Part D measures has officially become the Mt. Rushmore.
NEW: Statin Therapy for Patients with Cardiovascular
Disease (Part C)
This NCQA HEDIS measure is currently included as a display
measure. CMS is adding it to the 2019 Star Ratings as a process measure with an
ongoing weight of 1.
REMOVAL OF MEASURES FOR 2019 STARS
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REMOVAL!
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Beneficiary Access and Performance Problems
(BAPP) (Part C & D)
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REMOVAL: Beneficiary Access and Performance Problems (BAPP)
(Part C & D)
Although CMS received mixed responses from advocacy groups
(opposed to removing BAPP) and health plans (supportive of removing BAPP), it
will proceed in retiring the current BAPP measure for 2019 Stars. A revised
BAPP measure including only CAM data (CAM score will be the only deduction)
will hit the display page for 2019. No official word on when this measure will
become an official Stars measure again.
|
NOTE:
Reducing the Risk of Falling (Part C)
Is staying.
Vacation was officially cancelled for this HOS measure which was
scheduled to be removed temporarily for 2019.
Responders convinced CMS to leave it on. And note only is it
staying on, it will continue impacting the all-important Part C
Improvement Measure for 2019.
|
CHANGES TO MEASURES FOR 2019 STARS
CHANGING: Improvement Measures (Part C & D)
Below are the changes regarding which measures are included in
the Improvement Measures for 2019 Stars as compared to 2018 Stars. Some of this
is elementary regarding the treatment of measures new to Stars or being
removed, but I’ll err on the side of overcommunicating. One change from the
Advance Notice is that – as mentioned above – the HOS measure, Reducing the
Risk of Falling, which was originally proposed to be removed from the 2019 Star
Ratings and thus, Improvement Measure inclusion, is now staying.
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2019 MEASURE CHANGES IMPACTING THE
IMPROVEMENT MEASURE
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2018 STARS
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2019 STARS
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Improving
Bladder Control
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No
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Yes
|
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Reducing
the Risk of Falling
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Yes
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Yes
|
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Beneficiary
Access and Performance Problems
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No
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No (Removal)
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Medication
Reconciliation Post- Discharge
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No
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Yes
|
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Getting
Appointments and Care Quickly
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No
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Yes
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Customer
Service
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No
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Yes
|
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Care
Coordination
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No
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Yes
|
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Statin
Therapy for Patients with Cardiovascular Disease
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No (Was Not Official Measure)
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No (1st Year as Official
Measure)
|
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Statin
Use in Persons with Diabetes
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No (Was Not Official Measure)
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No (1st Year as Official
Measure)
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CHANGING: Medication Adherence (ADH) for Hypertension (RAS
Antagonists), Medication Adherence for Diabetes Medications (Part D)
For 2019 Stars, CMS will expand its data sources for identifying
all Part D enrollees with ESRD for exclusion from the measures to include
ICD-10-CM codes found in both Part A & B claims and Risk Adjustment
Processing System (RAPS) RxHCCs.
CHANGING: Medication Adherence (ADH) for Hypertension (RAS
Antagonists), Medication Adherence for Diabetes Medications, and Medication
Adherence for Cholesterol (Statins) (Part D)
CMS will implement a simpler approach to count the day of
discharge in the PDC adjustment for 2019 Stars.
CHANGING: Members Choosing to Leave the Plan (Part C &
D)
CMS is expanding the exclusions to include plan benefit package
(PBP) service area reductions (SARs).
CHANGING: Reducing the Risk of Falling (Part C)
You’d better update your dashboards for 2019 Stars forecasts,
because the “Falls” measure failed to fall off. CMS had planned to remove it
from 2019 and 2020 Stars due to a denominator expansion. However, many
commenters urged CMS to leave it on, fearing that taking it off would send the
signal that falls prevention is not important. CMS will keep it on for 2019 and
2020 Stars.
ADDITIONAL IMPLICATIONS FOR 2019 STARS
Contract Consolidations and Quality Bonus Payments. CMS is proposing rules that would prevent
plans who have taken advantage of the Quality Bonus Payment (QBP) loopholes
which have allowed them to merge large under-performing contracts into tiny
high-performing contracts, reaping huge financial gains and creating – some say
– an unfair playing field.
Proposed Scaled Reductions for Appeals IRE Data Completeness
Issues. CMS proposed a new
process to determine and apply reductions to the four appeals measures based on
findings that the underlying data are inaccurate, biased, or incomplete. CMS
plans to provide plans with a preview of the data before the Star Ratings are
finalized.
Disaster Implications. Natural disasters significantly affected many Medicare Advantage
organizations and their beneficiaries in 2017. The Final Call Letter includes
much information about certain 2019 Stars changes for affected organizations.
Here, I will call out a few key ways these changes are impacting all other
organizations.
§
CMS will exclude
impacted plans from many cut-points and Reward Factor calculations
§
i.e., plans operating
solely in Puerto Rico or with 60% or more of their enrollees in FEMA-designated
Individual Assistance areas at the time of the disaster
§
These contracts will
be excluded to ensure that any impact of the disaster on their measure-level
scores will not have an impact on the cut points for other contracts.
§
CMS examined the data
from the previous year’s Star Ratings; states that this change last year would
have resulted in a “very similar” distribution of 2018 Star Ratings.
NEW 2019 DISPLAY MEASURE
NEW: Plan Makes Timely Decisions about Appeals (Part
C). CMS plans to include a
new appeal measure for the 2019 and 2020 display pages which includes cases
dismissed by the IRE because the plan has subsequently approved
coverage/payment. These cases are currently excluded which could artificially
improve performance. CMS plans to make this a 2021 Stars measure, at which time
the current measure would be retired.
CHANGES TO EXISTING 2019 DISPLAY
MEASURES
CHANGING: Hospitalizations for Potentially Preventable
Complications (Part C). Stakeholder concerns led NCQA to consider updates to this
measure. CMS will retain this measure on the 2019 display page and propose it
as a 2022 Stars measure with a first-year weight of 1 and weight of 3
thereafter.
CHANGING: High Risk Medication (HRM) (Part D). This PQA measure will remain on the 2019
display page with an updated drug list and recent PQA specification change.
CHANGING: Drug-Drug Interactions (DDI) (Part D). Implementing the PQA updated drug list for the
2019 display page.
CHANGING: Antipsychotic Use in Persons with Dementia (APD)
(Part D). On the 2019 display
page, CMS proposes to display the rates for the two population breakouts
(community-only and long-term nursing home residents) as well as the overall
APD rate. CMS will consider making APD a future Stars measure.
CHANGING: Use of Opioids from Multiple Providers and/or at
High Dosage in Persons without Cancer (Part D). PQA has proposed several changes to these
measures. CMS is implementing the changes into the 2017 Patient Safety reports
and adding some of the changes to the 2019 display page. Once PQA finalizes the
updated measure specifications, CMS will consider these as future Stars
measures.
2019 DISPLAY MEASURES BEING RETIRED
RETIRING: Enrollment Timeliness (Part C and D). Due to high performance across most plans, CMS
is removing this measure from the display page. However, they encourage
contracts to continue to perform highly in spite of the fact that public
accountability will no longer exist.
RETIRING: Appropriate Monitoring of Patients Taking
Long-term Medications and Asthma Medication Ratio (Part C). NCQA removed the Medicare population from
these measures, which will result in their removal from the display page
beginning in 2019.
POTENTIAL IMPACT ON THE 2020 STAR
RATINGS
Now, let’s look ahead to the 2020 Star Ratings, which requires
that we also look back, because the measurement period began four
months ago.
POTENTIAL CHANGES TO EXISTING MEASURES FOR 2020 STARS
Controlling High Blood Pressure (Part C). NCQA is exploring modifications to this
heavyweight measure that is currently entirely – and maddeningly – based on
medical records. Fingers are crossed that NCQA finds a way to allow plans
to close this gap with administrative data.
Plan All-Cause Readmissions (Part C). NCQA and CMS are exploring several revisions
to this HEDIS measure. The revised measure would be on the display page for
2019 and 2020, then it would become part of 2021 Stars (weight of 1 the first
year; weight of 3 thereafter). The current measure would remain through 2020
Stars.
Initiation and Engagement in Alcohol or Drug Dependence (AOD)
Treatment (Part C). NCQA
made minor modifications to this display page, and CMS is asking for plans to
provide feedback on other potential changes.
Telehealth and Remote Access Technologies (Part C). CMS requests feedback to share with NCQA on
feasibility of and strategies for addressing telehealth services, especially
regarding the following measures:
§
Use
of Spirometry Testing in the Assessment and Diagnosis of COPD
§
Adults’
Access to Preventive/Ambulatory Health Services
§
Controlling
High Blood Pressure
§
Comprehensive
Diabetes Care
Cross-Cutting Exclusions for Advanced Illness (Part C). NCQA is evaluating the clinical
appropriateness and feasibility of excluding individuals with advanced illness
from selected HEDIS measures. NCQA is exploring which specific illnesses and
healthcare utilization may warrant an exclusion and to which measures the
exclusion should be applied. If approved, updates to HEDIS measures for any
additional exclusions would be incorporated in HEDIS 2019.
Medication Adherence (ADH) for Cholesterol (Statins) (Part
D). CMS plans to apply the
ESRD exclusion to 2020 Stars that PQA implemented for this measure for 2018.
Medication Therapy Management (MTM) Program Completion Rate for
Comprehensive Medication Reviews (CMR) Measure (Part D). CMS plans to apply a new denominator exception
to 2020 Stars that PQA implemented for this measure for 2018.
MPF Price Accuracy (Part D). CMS will implement the following changes for
the 2020 and 2021 display page, potentially including it in 2022 Stars:
§
Factor both how much
and how often prescription drug event (PDE) prices exceeded the prices
reflected on the MPF.
§
Increase the claims
included in the measure.
Center for Medicare and Medicaid Innovation Model Tests. Some stakeholders have expressed concern
regarding the potential for improvements resulting from VBID and Enhanced MTM
participation to adversely influence the Star Ratings of contracts that are
ineligible to participate. CMS is considering excluding VBID and Enhanced MTM
participants from cut-point calculations for relevant measures, or possibly
establishing different cut-points for participants.
POTENTIAL NEW MEASURES FOR 2020
STARS AND BEYOND
STARS AND BEYOND
Transitions of Care (Part C). CMS plans to include this measure on the 2020
display page and potentially include in 2022 Stars.
Follow-up after Emergency Department Visit for Patients with
Multiple Chronic Conditions (Part C). CMS plans to include this measure on the 2020 display page and
potentially include in 2022 Stars.
Care Coordination Measures (Part C). CMS has identified potential new care
coordination measures and is currently testing them for possible future
implementation.
Opioid Overuse (Part C). Measures still being developed; no current plans to add these to
the display page or Star Ratings.
Assessment of Care for People with Multiple High-Risk Chronic
Conditions (Part C). The
measure concept is currently undergoing testing to assess feasibility,
alignment with current practice, and gaps in care.
Depression Screening and Follow-Up for Adolescents and Adults
(Part C). Depending on the
results during the first year of implementation, CMS may consider this measure
for the display page and Star Ratings in the future.
Unhealthy Alcohol Use Screening and Follow-Up (Part C). CMS may consider this measure for the display
page and Star Ratings in the future.
Readmissions from Post-Acute Care (Part C). If approved, the new measure or revisions to
the current PCR measure would be included in HEDIS 2019.
Adult Immunization Measure (Part C). If approved, the new measure would be included
in HEDIS 2019. Depending on results of implementation, CMS will determine the
use of this new composite measure for the display page and Star Ratings for the
future.
Anxiety (Part C). Any new anxiety quality measures or changes for the depression
measures would be included in HEDIS 2020 at the earliest.
Polypharmacy Measures (Part D). PQA developed three measures that identify
potentially harmful concurrent drug use or polypharmacy. CMS is reviewing these
measures for potential inclusion in Patient Safety reporting, display page, or
Star Ratings in the future.
Additional PQA Medication Adherence Measures (Part D). CMS evaluated two additional PQA endorsed
medication adherence measures but will not add them to the Patient Safety
reports, the display page, or Star Ratings at this time.
Rex Wallace is
Principal at Rex Wallace Consulting, LLC. His firm is dedicated to helping Medicare Advantage plans improve Star
Ratings. Prior to founding Rex Wallace Consulting, Rex held Consumer Experience
and Star Ratings leadership roles at Cambia Health Solutions and Universal
American. He is an esteemed expert in the Medicare space.
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