Featured Health Business Daily Story, Aug. 25, 2011

CMS Unveils Specific Star-Rating Measures To Add, ‘Retire’; Changes May Cut Scores

Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in MA and Medicaid managed care.

By James Gutman, Managing Editor
August 18, 2011Volume 17Issue 16

Following up on indications it had given earlier, CMS late last month unveiled plans to “retire” some star-rating quality measures and institute others for 2012 Medicare Advantage plan ratings. While no plan executives or consultants queried by MAN questioned the agency’s intent in the changes, some pointed out that the measures slated for retirement are ones in which MA plans usually are doing well or in which ratings among the plans tend to be very similar.

Conversely, the new measures are likely to yield lower ratings, which could lead to overall lower scores — and thus to lower quality bonus payments under the new CMS demonstration program (MAN 2/24/11, p. 1) and the health reform law.

Despite that, two executives and two consultants tell MAN they generally welcome the changes, which move away from “process measures” of quality and toward actual outcomes measures. MA Special Need Plans, which long have pushed for SNP-specific measures, were especially pleased that CMS is proposing three of them that one plan calls “appropriate,” although it would like to see additional measures that also reflect the different characteristics of SNP members. The new and retired measures aren’t final yet but are likely to be soon unless there is adamant opposition from stakeholders.

The new details on potential star-rating changes came from Liz Goldstein, Ph.D., director of CMS’s Division of Consumer Assessment & Plan Performance, in the Part C & D User Group Call July 27. The proposed standards, she said, take into account the responses it received from MA plan sponsors on the agency’s request for comments in both the 2012 call letter (MAN 4/7/11, p. 1) and CMS’s spring conference (MAN 4/21/11, p. 1) on which measures should be used to gauge quality improvement, how measures should be weighted (MAN 5/19/11, p. 1) and which measures should be retired. Another call on related subjects is scheduled for Aug. 24.

The plan comments, according to Goldstein, showed substantial support for using objective measures of quality improvement and “some support” for including just measures in which “performance is low or variation is high.” She said that some commenters had recommended retiring use of self-reported data. Moreover, there was support in the comments for “weighting objective/clinical measures more than subjective or administrative/process measures” and for giving more weight to measures that plans directly influence, she added.

As a result of the comments and the agency’s own goals, Goldstein said, CMS intends to retire for the 2012 rankings measures related to doctor communication, monitoring of patients taking long-term medications, testing for osteoporosis and chronic obstructive pulmonary disease (COPD), call-center hold time and information accuracy, and timeliness in submitting 4Rx change transactions for CMS-generated enrollment.

Proposed New Measures Stress Clinical Issues

She then outlined “additional potential measures” for the 2012 ratings for both MA and Part D. On the MA side, noted Goldstein, those include “all-cause” hospital readmissions; smoking-cessation counseling; adult body mass index (BMI) measurement; medication adherence — based on proportion of days covered — for diabetes, cholesterol and high blood pressure; “enrollment timeliness” — based on the percentage of time drug plans transmitted enrollment information to CMS within seven days — and three SNP-specific measures involving care for older adults. The SNP measures are medication review, functional-status assessment and pain screening. For all MA and Part D plans, CMS also intends to measure the percentage of plan members who chose to leave the plan in 2010, other than members who left due to factors beyond the plans’ control, Goldstein said.

Industry executives and consultants generally gave positive reviews to the proposed changes. “CMS is demonstrating the star ratings will be dynamic and evolving,” says consultant Maureen Miller, vice president, Medicare services, at Visante Inc. Miller emphasizes that the items getting retired are mainly process measures and that even they stand to go on a “watch list” rather than necessarily disappear forever.

“I think it’s very smart on CMS’s part to be changing these,” she tells MAN, adding that “it’s a message to the industry to not get comfortable.”

But one industry executive, who asks not to be identified and also compliments the CMS approach, says there are complications for MA plans in some of the measures being retired.

The new measures, the executive tells MAN, almost by definition will be in areas where plans don’t do as well as in the retired measures and therefore could lead to lower scores and quality bonuses. There is no “ill intent,” however, in CMS’s changes, he stresses. The measures to be introduced, according to the executive, generally make sense, although they raise specific concerns. MA plans should want to get measured on all-cause readmissions, for instance, he contends, but there could be “misinterpretation” in how the data are reported. Similarly, medication-adherence measures are significant, and CMS is using the only measures it has available, but they show just prescriptions that are refilled, he says. They don’t reflect whether patients actually use the refilled prescriptions, nor do they take into account reselling of prescriptions — a particularly big problem in Medicaid, the executive adds.

Enrollment timeliness, he says, is another justifiable measure, but there are times when lack of timeliness is not an MA plan’s fault. If the largest plan in an area doesn’t renew its MA contract, for example, or if there are extreme weather conditions in an MA plan area, there may be delays in enrollment, and CMS should take such circumstances into account, the executive asserts.

Measuring members choosing to leave a plan also poses concerns, he tells MAN. He congratulates CMS for making specific exceptions for certain things, such as out-of-area moves and employer-group decisions. However, this still leaves the issue of markets in which people tend to move a lot for other reasons and therefore where MA plans lose a lot of members, the executive says, and he recommends that CMS confirm this will not be held against plans, nor will any kind of service-area reduction.

CMS Seeks to Gauge ‘Beneficiary Experience’

CMS in this measure is basically just looking to gauge the “beneficiary experience” in the MA plan, Corey Ford, a manager in the health reform practice of consulting firm Avalere Health LLC, tells MAN. While a figure for voluntary departures by members is just a process measure, it’s an important one for assessing member satisfaction, he maintains.

Overall, says Ford, the star-rating changes were pretty much expected based on the 2012 call letter. However, he agrees that the measures to be retired are ones that plans have done well on. Ford also concurs that there’s no reason to believe CMS selected the new measures for any reason other than feeling significant improvements in quality can be made through them.

All-cause readmissions fit with CMS’s goals for outcomes-based measures, and adult BMI measurement, while it’s a process measure, does fit with CMS’s expanded clinical focus and is an area that can stand improvement since the average plan performance on it is about 36%, according to Ford. Medication adherence also isn’t necessarily outcomes based, he notes, but it too is a clinical indicator.

Perhaps the organizations most satisfied with the planned changes are SNPs, which long have pushed for measures that recognize the special needs of their populations. XLHealth Corp., one major SNP operator, is “really encouraged” that CMS has responded to those requests, says Laurie Russell, vice president of quality strategy and outcomes. Russell tells MAN the proposed SNP standards are “a good first step,” although she adds that they don’t “go far enough.” That’s because, she explains, there are only three measures, and there are other significant ones available. She notes that SNP models of care, along with structure and process (e.g., complex case management), are measured by outside organizations and therefore could be used in star ratings.

Omissions notwithstanding, Russell lauds the measures CMS chose for SNPs. Medication review is “appropriate,” she says, especially since medication problems are a big reason for hospital admissions and readmissions for SNP members. While there is difficulty for SNPs in getting providers to document that they’ve done these medication reviews, XLHealth uses house calls and clinical pharmacist reviews and expects to do well on this measure, Russell says.

Functional-status assessment also is “very appropriate” for SNPs, and can be done via use of SF-36 or other comprehensive standardized forms, she says. Similarly, pain screening is a suitable measure but often doesn’t appear in administrative data, and XLHealth has been focusing on it for a long time, according to Russell.

However, she adds that some SNPs will have difficulties with all three collecting and reporting requirements.

View the planned star-rating changes by visiting the Aug. 18 From the Editor entry at http://aishealth.com/newsletters/medicareadvantagenews.

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