medicare advantage 5-star rating of california physician … · • angeles ipa • applecare...

December 2017

Medicare Advantage 5-Star Rating of California Physician Organizations Results & Highlights Measurement Year 2016

© 2017 Integrated Healthcare Association. All rights reserved. 2

Program Overview


• Centers for Medicare & Medicaid Services (CMS) publicly reports performance of Medicare Advantage (MA) health plans on a variety of clinical quality, member experience, and customer service measures through a 5-star rating system.

• Building on the MA plan rating system, IHA measures performance and awards star ratings at the physician organization (PO) level in California using a subset of CMS clinical quality measures.

• PO-level performance measurement allows IHA to aggregate data across participating MA plans to identify performance variations and help plans and POs target quality improvement efforts.

• IHA publicly reports PO-level star ratings to help Medicare beneficiaries identify high-performing POs.

IHA Medicare Advantage 5-Star Reporting of Physician Organizations


Program Evolution

2003

2008

2011

2012

2016

First year IHA measurement—commercial only

CMS publicly reports clinical quality and patient experience using a 5-star

rating system for MA health plans

IHA, using a subset of CMS measures for MA plans,

expands measurement to MA & publicly reports star ratings for California POs

CMS pays bonuses of up to 5% to MA health

plans with at least 4 stars

IHA partners with the California Office of the Patient Advocate to

publicly report PO MA star ratings

© 2017 Integrated Healthcare Association. All rights reserved. 5Copyright © 2015 Integrated Healthcare Association. All rights reserved. 5

5© 2017 Integrated Healthcare Association. All rights reserved.

Why Measure Medicare Advantage?

1 Jacobson, et al., “Medicare Advantage 2017 Spotlight: Enrollment Market Update”. Kaiser Family Foundation. Jun 2017. http://kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update/2 Congressional Budget Office, “Medicare – Congressional Budget Office’s January 2017 Baseline,” January 24, 2017. https://www.cbo.gov/sites/default/files/recurringdata/51302-2017-01-medicare.pdf/


Enrollment in California

• 27 health plans cover 2.3 million California MA beneficiaries

• POs contract with many MA plans for relatively small populations, making valid performance measurement and targeted quality improvement difficult

• Aggregation of results valuable for producing a single, valid summary of performance


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Physician organizations contracting with more than one health plan

Aggregated and Plan-Specific Rates for Colorectal Cancer Screening

Aggregated Rate Min Plan-Specific Rate Max Plan-Specific Rate

Given a fragmented Medicare Advantage health plan market, aggregation of PO performance across plans creates a single summary of performance more credible than individual health plan estimates of PO performance.

Aggregation Strengthens Quality Performance Signal

For example, the identified PO’s aggregated performance across contracted plans is 75.94%. On plan-specific basis, the PO’s performance ranges from 40 to 87.8% – plan-specific results are more sensitive to variation in small numbers and reflect uncertainty about the PO’s actual performance.


Program Elements

Common Measure Set & Methodology

Public Report Card

PO Recognition

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Number of Physician Organizations

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POs by Number of Medicare Advantage Health Plan Contracts

Kaiser Permanente Non-Kaiser

Measurement Includes Majority of MA Enrollees

• Five health plans with over 81% of MA enrollees in CA participate in IHA PO star rating program in MY 2016:

o Blue Shield of California

o Health Net

o Kaiser Permanente

o SCAN Health Plan

o UnitedHealthcare

• 181 participating physician organizations

Department of Managed Healthcare Financial Summary Data, 2016http://www.dmhc.ca.gov/DataResearch/FinancialSummaryData.aspx#.WhSukUqnGHu


Measure Set

Measurement focuses on CMS MA Star domains that relate directly to PO care delivery performance. Of 21 PO-relevant measures in the three domains, IHA collects all 12 measures that do not require patient survey results or chart review.

Staying Healthy: Screenings, Tests

& Vaccines

Managing Chronic Conditions

Drug Safety

1. Adult BMI Assessment2. Breast Cancer Screening3. Colorectal Cancer Screening

4. All-cause Readmissions5. Diabetes Care – Eye Exam6. Diabetes Care – Blood Sugar Controlled7. Diabetes Care – Kidney Disease Monitoring8. Osteoporosis Management in Women Who Had a Fracture9. Rheumatoid Arthritis Management

10. Medication Adherence for Cholesterol (Statins)11. Medication Adherence for Diabetes Medications12. Medication Adherence for Hypertension (RAS

Antagonists)


As MACRA expands performance measurement into the Medicare fee-for-service realm, measure alignment is an imperative. Participants in IHA measurement initiatives are ahead of the curve – the measures collected are well-aligned.

Measure Set Aligned with National Quality Priorities

IHA MeasureCMS MedicareAdvantage Plan

Star Rating

NCQA Medicare Plan Accreditation

IHA Value BasedP4P

CMS Merit-Based Incentive Payment

System (MIPS)

Adult BMI Assessment X X

All-Cause Readmissions X X X X

Breast Cancer Screening X X X X

Colorectal Cancer Screening X X X X

Diabetes Care: HbA1c Poor Control >9% X X X X

Diabetes Care: Kidney Disease Monitoring X X X X

Diabetes Care: Eye Exam X X X

Rheumatoid Arthritis Management X

High-Risk Medication (info only) X X X

Osteoporosis Management in Women Who Had a Fracture

X X X

Medication Adherence: Hypertension (RAS Antagonists), Cholesterol (Statins), Diabetes Medications

X X


Calculating PO-Level Medicare Advantage Star Ratings

Collect and report measure results using VBP4P process

• Leverage better of audited PO results or plan-aggregated rates for awards and reporting

• POs review preliminary results prior to finalization

Apply CMS star rating cut points to individual measures

• Stars assigned according to cut points released by CMS in the fall

Calculate Overall star Rating for each PO

• Performance on 12 clinical measures combined to reflect an overall PO Medicare Advantage Star Rating

• Rating calculated by taking weighted average of the measure-level star ratings available for POs

• Consistent with CMS methodology, outcome measures are triple-weighted

Award 4.5 & 5–Star and Most Improved POs

• Overall PO MA star ratings are used to determine high performing and most improved POs

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Program Elements

Standard Measure Set

& Methodology

Public Report Card

PO Recognition

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5 STAR RECOGNITION (10 of 181 participating)

• Kaiser Permanente Northern California Permanente Medical Group:

‒ San Jose Medical Center

‒ San Rafael Medical Center

‒ South San Francisco Medical Center

‒ Vallejo/Vacaville Medical Centers

• Kaiser Permanente Southern California Permanente Medical Group:

‒ Orange County

‒ Woodland Hills

• Sutter East Bay Medical Foundation – Sutter East Bay Medical Group

• Sutter Palo Alto Medical Foundation - Mills-Peninsula Division/Mills-Peninsula Medical Group

• Sutter Palo Alto Medical Foundation – Palo Alto Foundation Medical Group

• UC San Diego Health

High Performing POs (MY 2016)Integrated Healthcare Association and its stakeholder partners recognize the following physician organizations for earning the highest overall star ratings for the quality of care provided to its Medicare Advantage members in Measurement Year 2016.


• AMVI Medical Group

• Central Valley Medical Group

• Desert Oasis Healthcare

• Edinger Medical Group

• Family Practice Medical Group of San Bernardino, Inc.

• Greater Newport Physicians

• HealthCare Partners Medical Group

• Kaiser Permanente Northern California Permanente Medical Group: ‒ Diablo/Antioch Medical Centers‒ Fremont/San Leandro Medical Centers‒ Fresno Medical Center‒ Modesto/Manteca/Stockton Medical Centers‒ Redwood City Medical Center‒ Roseville/Sacramento Medical Centers‒ San Francisco Medical Center‒ Santa Clara Medical Center‒ Santa Rosa Medical Center‒ South Sacramento Medical Center

• Kaiser Permanente Southern California Permanente Medical Group: ‒ Antelope Valley‒ Baldwin Park‒ Downey‒ Fontana/Ontario‒ Kern County‒ Los Angeles‒ Panorama City‒ Riverside‒ San Diego‒ South Bay‒ West Los Angeles

• Northwest Orange County Medical Group

• Physicians Medical Group of Santa Cruz

• Riverside Medical Clinic

• Sansum Clinic

• Scripps Clinic Medical Group

• Sharp Rees-Stealy Medical Group

• Sutter Gould Medical Foundation – Gould Medical Group

• Sutter Medical Foundation – Sutter Medical Group

• Sutter Pacific Medical Foundation – Sutter Medical Group of the Redwoods

• Woodland Clinic Medical Group

• UC Davis Medical Group

High Performing POs (MY 2016)Integrated Healthcare Association and its stakeholder partners recognize the following physician organizations for earning the highest overall star ratings for the quality of care provided to its Medicare Advantage members in Measurement Year 2016.

4.5 STAR RECOGNITION (39 of 181 participating)


MOST IMPROVED RECOGNITION

Most Improved POs (MY 2016)Integrated Healthcare Association and its stakeholder partners recognize the following physician organizations for outstanding improvement between Measurement Year 2015 and 2016 in overall star ratings for the quality of care provided to their Medicare Advantage members.

1.5-Star Improvement• Universal Care Medical Group

1-Star Improvement• Woodland Clinic Medical Group• UC San Diego Health

.5-Star Improvement• Angeles IPA• AppleCare Medical Group St. Francis• Brown & Toland Physicians – Alta Bates Medical Group• Central Valley Medical Group• Chaffey Medical Group• Desert Valley Medical Group Inc.• Dignity Health Medical Group - Inland Empire• Family Practice Medical Group of San Bernardino, Inc.• Genesis Healthcare• Greater Newport Physicians

.5-Star Improvement cont.• Hill Physicians Medical Group - Sacramento Region• John Muir Health• Kaiser Permanente Northern California Permanente Medical

Group:- San Rafael Medical Center- South San Francisco Medical Center- Vallejo/Vacaville Medical Centers

• Kaiser Permanente Southern California Permanente Medical Group - Woodland Hills

• Noble AMA IPA• Northwest Orange County Medical Group• Riverside Medical Clinic• Santa Clara County IPA (SCCIPA)• Sutter East Bay Medical Foundation – Sutter East Bay Medical

Group• Sutter Palo Alto Medical Foundation - Mills-Peninsula

Division/Mills-Peninsula Medical Group• UC Davis Medical Group


Program Elements

Common Measure Set & Methodology

Public Report Card

PO Recognition

1717


• IHA MY 2016 Medicare Advantage PO Star Ratings will be publicly reported via the Office of the Patient Advocate’s Medical Group Medicare Advantage Report Card in early 2018.

• Report card features overall star ratings, as well as individual measure rates and star ratings.

Public Reporting of PO-Level Performance

http://reportcard.opa.ca.gov/rc/MedicareMGCounty.aspx


Measurement Year 2016 Results & Highlights


Enrollment Advantage

PO Performance Drives Health Plan Clinical Quality Performance

CMS MA Plan Financial Incentives

0% 1%

3%

8%

18%

24%

18%

22%

6%

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5%

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25%

30%

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Overall MA Star Ratings

CMS MA Plan Financial Disincentives

Overall PO performance on largely clinical subset of CMS measures in IHA’s Medicare Advantage Stars program contributes to overall health plan star ratings, which are tied to strong CMS financial and enrollment incentives.


Participating California Health Plans Outperform National Plan Average on Quality MeasuresThe average health plan star rating for program participants is higher than the national plan average for 11 of the 12 measures collected.

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Adult BMI Assessment

Plan All-Cause Readmissions

Rheumatoid Arthritis Management

Medication Adherence for Diabetes Medications

Diabetes Care – Blood Sugar Controlled

Diabetes Care – Eye Exam

Medication Adherence for Cholesterol

Diabetes Care - Kidney Disease Monitoring

Colorectal Cancer Screening

Medication Adherence for Hypertension

Osteoporosis Management in Women who had a Fracture

Breast Cancer Screening

Health Plan Average Star Rating

IHA Participating HP Average National HP Average


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Medications Adherence forHypertension (RAS

Antagonists)

Medical Adherence forDiabetes Medications

Medical Adherence forCholesterol (Statins)

Diabetes Care: HbA1c PoorControl >9.0%

All-Cause Readmissions

PO

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%)

MY 2015 MY 2016

Marked Gains on Outcome Measures

Higher-is-better measure Lower-is-better measure

Five measures collected by IHA are CMS triple-weighted outcome measures. Overall physician organization performance in MY 2016 improved on all five outcome measures, with statistically significant gains on 3 measures (denoted by *).

+2.9%*+2.2%* +3.2%*

-0.6% -0.4%


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Adult BMIAssessment

Rheumatoid ArthritisManagement

Breast CancerScreening

Diabetes Care: EyeExam

Colerectal CancerScreening

Diabetes Care:Medical Attention for

Nephropathy

OsteoporosisManagement in

Women Who had aFracture

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%)

MY 2015 MY 2016

Process Measures Steady or Improving

+3.1% -0.1%

+2.7%

+4.9%* +1.5%

+0.1%

+2.7%

Seven measures collected by IHA are CMS single-weighted process measures. Physician organization performance in MY 2016 improved on 6 of the 7 measures and 1 measure saw statistically significant improvement (denoted by *).


Comparing results for POs participating in VBP4P and Medicare Advantage star ratings measurement suggests measure performance across populations and products is closely related; the correlation between PO performance in commercial VBP4P and Medicare Advantage Stars ranges from 0.56 to 0.84 for measures collected in both populations except readmissions (not shown).

Performance in Commercial HMO Correlated to Medicare Advantage Performance

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Commercial HMO/POS Rate

Diabetes Care - Blood SugarControlled

Breast Cancer Screening

Medication Adherence forHypertension (RAS Antagonists)

Medication Adherence forDiabetes Medications

Medication Adherence forCholesterol (Statins)

Colorectal Cancer Screening

Diabetes Care - MedicalAttention for Nephropathy


• Health Plan Medicare Advantage star ratings tied to significant financial & enrollment incentives

• PO performance on quality measures drives plan ratings

• IHA Medicare Advantage star ratings aggregate PO performance across plans, increasing validity and amplifying performance improvement signal to POs

• PO performance improvement impacts all lines of business, not just Medicare Advantage

• IHA participating health plans and POs ahead of the curve, both on performance and measure alignment

Implications


• Program Fact Sheet: Medicare Advantage 5-Star Reporting of Physician Organizations

• Press Release: California Medical Groups Honored for High-Quality Care of Medicare Advantage Patients

• Measure Specifications: Measurement Year 2016 VBP4P Manual

• Measure Set: Measurement Year 2016 Measure Set

Additional Resources

http://www.iha.org/sites/default/files/resources/medicare_stars_fact_sheet_december_2017.pdf

http://www.iha.org/pr/california-medical-groups-honored-high-quality-care-medicare-advantage-patients-0

http://www.iha.org/sites/default/files/resources/my_2016_value_based_p4p_manual_1.pdf

http://www.iha.org/sites/default/files/resources/my_2016_measure_set.pdf


Contact [email protected]

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