Abby L. Block Director, Center for Beneficiary Choices Centers for Medicare & Medicaid Services

1. Measuring Quality & Performance in Medicare AdvantageWhere We’ve Been, Where We Are, & Where We’re Going Abby L. Block Director, Center for Beneficiary Choices Centers for Medicare & Medicaid Services April 8, 2008

2. History of Quality and Performance Measures in Medicare Advantage

3. Quality and Performance Measurement at CMS • Staff from HCFA/CMS and HHS have long been involved in developing and refining health plan quality and performance metrics, even before they were used in the Medicare + Choice and Medicare Advantage Programs • For example, CMS staff serve on the CPM for HEDIS measures

4. Measuring Quality and Performance among Medicare plans • In early 1990s, some states required Medicaid programs to collect this data on Medicaid managed care programs • In late 1990s, following the Balanced Budget Act (BBA), CMS began collecting HEDIS, CAHPS, and later HOS data from Medicare managed care plans • Plans to begin data collection preceded BBA

5. Motivation to Measure The decision to begin quality and performance data collection was motivated by several factors • Need for accountability to oversight bodies and beneficiaries • Desire to make evaluation of managed care plans more objective • Desire to improve value in government purchasing

6. Early Uses of Quality and Performance Data • Reporting Year 1997 was first year of data collection • Data was used in various agency initiatives • Medicare Compare website in bar chart form (1999) • Medicare & You Handbook (2000) – First consumer education efforts • Reports to plans for use in quality improvement programs • HHS Government Performance and Results Act (GPRA) goals

7. Towards a Performance Assessment System • By 2000-2001, CMS had enough data to create a plan rating system, which eventually became the Performance Assessment System • Incorporated various data sources into one swing database in HPMS • Generated plans ranking based on performance relative to other plans, using individual and composite measures • Allowed CMS to reward high performing plans, i.e. with audit exemptions

8. Current Quality and Performance Metrics • HEDIS • HOS • CAHPS • Independent Review Entity data • Part D Performance Measures • More detail on these measures today and tomorrow from CMS staff

9. Current Quality and Performance Measurement in Medicare Advantage

10. Quality and Performance Measurement Goals • Over time, metrics and measurement systems have expanded and evolved • Goals remain largely the same • Accountability • Value-based purchasing • Objectivity in program evaluation

11. Current Quality and Performance Measurement Objectives • To provide performance and quality-based information to beneficiaries to make enrollment decisions • Example 1: MA and Prescription Drug plan ratings • Demonstrate value and performance • Example 2: Special Needs Plan quality measures

12. Example 1: Plan Ratings • Previously, limited plan performance information was available on Medicare website • In 2007, CMS significantly revamped MA and Part D plan ratings on Medicare.gov • Domain & measure level ratings • 5-star rating system • Accessible, comprehensible information

13. www.medicare.gov www.medicare.gov

14. www.medicare.gov www.medicare.gov

15. Domain and Measure Level Ratings Example Domain: Managing Chronic Conditions Measures: • Osteoporosis Management • Diabetes Care – Eye Exam • Diabetes Care – Kidney Disease Monitoring • Diabetes Care – Blood Sugar Controlled • Diabetes Care –Cholesterol Controlled • Antidepressant Medication management (6 months) • Controlling Blood Pressure • Rheumatoid Arthritis Management • Testing to Confirm Chronic Obstructive Pulmonary Disease • Continuous Beta-Blocker Treatment

16. Five-Star Rating System • Real innovation of the 2007 plan ratings was the establishment of a 5-star rating system • Not only showed comparison of plans, but placed them in a framework of comparison to agreed-upon standards • Unique for Medicare Advantage and Prescription Drug Programs • Not yet available for Hospitals or Nursing Homes

17. Significance of Plan Ratings • Plan ratings improve CMS’ ability to identify high performing plans and plans that need improvement • Also substantially expand information available to beneficiaries for selecting high-quality heath and prescription drug plans

18. Example 2: Special Needs Plans Quality Measures • Since their inception, there has been the expectation that SNPs provide more meaningful health service choices for beneficiaries than other MA plans • Yet, neither the statute nor our regulations provided specific guidance on how to specialize clinical programs • Lack of quality and performance data hampered ability to demonstrate how plans are “special” • Tremendous growth in SNPs and SNP enrollment further justified need for quality metrics

19. Special Needs Plans Quality Measures • CMS and the Geriatric Measurement Panel (GMAP) of the NCQA worked collaboratively to develop initial recommendations for SNP quality measures • In November 2007, the GMAP finalized their measure recommendations from existing measures: • Thirteen HEDIS measures • Set of Structure and Process measures

20. SNP Quality Measures • Measures were on display for public comment through January 2008 • HEDIS measures remained the same, but minor modifications were made to structure & process measures based on public comment • SNP measures will be collected for Contract Year 2009 • Training for health plans on reporting requirements currently underway

21. Measurement Categories • Benefit design • Risk assessment and care planning • Coordination of services • Caregiver engagement • Internal measurement of performance • Beneficiary & caregiver experience

22. Innovation: Plan-Level Measurement • Currently, CMS only measures plans at the contract level, not at the plan benefit package level, and only for contracts with 1,000 members • For the SNP specific measures, CMS will collect them from every SNP at the plan benefit package level

23. Beginning of a Multi-Stage Process • The HEDIS measures and structure and process standards to be used in 2008 are part of a three-year strategy proposed by NCQA • For 2009 and 2010, some of these measures will be further refined for SNP-specific use and additional measures will be developed and collected

24. Future of Quality and Performance Measures in Medicare Advantage

25. Need to Improve Current Quality Measurement Initiatives • While current initiatives achieve some of CMS’ quality and performance measurement objectives, they are constrained by • Sources and types of data gathered • Plan monitoring and compliance infrastructure • Limitations of consumer tools

26. Quality Measurement and Performance Assessment Wish List • Sources and Types of Data • Next stages of SNP measures • Part C Performance Measures • MA Utilization Data • Improvements to HEDIS measures • * Some already underway

27. Quality Measurement and Performance Assessment Wish List Plan Monitoring & Compliance • Integrated plan for how to use plan rating information for purposes of plan monitoring and compliance; plan improvements

28. Quality Measurement and Performance Assessment Wish List Consumer Information • Research and monitoring to determine if an how consumers are using quality and performance data through Medicare.gov and other portals • Underway: continuing consumer testing of Medicare Options Compare and Prescription Drug Plan Finder

29. Other Ways Forward: PQA • The PQA, a pharmacy quality alliance, was launched at a CMS Open Door Forum • CMS is a member of the PQA Steering Committee and an active member on PQA Workgroups • CMS supports the promotion of high-value pharmacy services, including measurement approaches, through a stakeholder-led pharmacy quality alliance • The measures being developed by PQA and its stakeholders for pharmacy quality and patient satisfaction will be considered for use by CMS in the Part D Plan Ratings

30. Questions? Abby L. Block Director, Center for Beneficiary Choices abby.block@cms.hhs.gov