IMPROVEMENT OF UNDERPERFORMING CMS STAR RATINGS

Timothy R. Roe

AVP - Life Sciences Solutions

Company and Client Confidential

Content• Document Purpose• Understanding The Ratings• Specific Confidential Co. Opportunities• Sales Pre-work Guidance• Investigative Probes For Identified Accounts• Detail-level Of Opportunities• Case Studies (Incomplete)

• Ratings Source Information And Statistics

04/10/2023 03:24:35 AM 2

04/10/2023 03:24:35 AM

3

Document Purpose

Exploit regulatory changes which are creating unmet challenges in the marketplace relative to CMS Medicare Advantage Quality “Star Ratings”

• Areas of opportunities include• Business Process Re-engineering• Information Technology Enhancements • Healthcare Consulting - Clinical, Promotion And Regulatory/Compliance

04/10/2023 03:24:35 AM

4

Understanding the Ratings

04/10/2023 03:24:35 AM

5

Medicare Plan Quality Improvements(Background Information)

• This proposed rule implements provisions of the Patient Protection and Affordable Care Act and the Health Care Education and Reconciliation Act of 2010 (the Affordable Care Act) that are related to the Medicare Advantage (MA, or Part C) and Prescription Drug Benefit (Part D) Programs.

• Key Provisions • Strengthen Medicare beneficiary protections• Remove consistently poor performers and set requirements for fiscal solvency• Codify statutory changes to close the Part D coverage gap•

• Plans Receive Star Ratings on a 5 –Scale • 5 Categories worth one star each• 2011 – 53 Measures contributing to fractional stars in each category• 2011 Star rating 5-3 are eligible for quality bonuses• 2012 only 5-4 rated plans are eligible for bonus, 3 and under plans will be branded “Low Performer” icon on the

Medicare website• 75% of plans fall into a below “4” rating depicting the current seriousness of CHS to eliminate the garbage plans from

top performers• After 2014, plans will need four or five stars to get bonuses. And if they have fewer than three stars, they won't be

allowed to enroll beneficiaries through Medicare's website, and risk being booted from Medicare altogether• Members and beneficiaries will select plan with a top performance rating icon next to the plan name and cautioned to

avoid those with 3 and under with a poor performing icon attached

• All plans automatically enrolled in 2012-2015 national demonstration project to test the hypothesis that moving the scaled rating system from 4-5 star bonus system to a 3.5 – 5 system would reduce the amount of plan failures. A county benchmark comparison will set average FFS cost at a specific % level.

• Some or all or the PPACA could be overturned

04/10/2023 03:24:35 AM

6

Appearance Of RatingsHealthy Plan

Underperforming Plan

Too New To Be Rated

04/10/2023 03:24:36 AM

7

Repeating Cycle - Decline In Ratings Drives Decline In Membership

Lost membership due to highly visible public quality

rating comparisons

Rating declines on CMS membership metrics(Retention, Attrition and

Attraction)

Financially weak plans become weaker while

stronger plans attract higher membership & higher

rebates/bonuses

Higher rated plans enjoy 11-month enrollment period vs. only 45-day enrollment

period

Lower-rated plans have limited marketing and

promotion spends to attract enrollees

Accelerating complaint volume and unanswered

surveys further perpetuate negative ratings

CMS fulfills objective of eliminating “garbage” and underperforming plans in

favor of quality plans

Anti-Selectivity increase patients with co-morbidities,

thus more difficult to manage and higher cost

patients

Internal “Plan Inertia” diminishes as employees,

providers and support becomes increasingly

deflated and unmotivated

Accelerating Cycle

Until the 2010 healthcare law and the inclusion of sizeable performance bonuses, plans did not focus as much on quality ratings.

04/10/2023 03:24:37 AM

8

Example of Allowed 5-Star Plan Promotion Higher-rated Plans Have Greater Ability To Attract New Members, Grow Rebates And Bonuses And Have Longer Enrollment Periods

04/10/2023 03:24:37 AM

9

Specific Confidential Co. Opportunities

04/10/2023 03:24:37 AM

10

Opportunity

• Focus Area 1: Organizations with Star Ratings of 2 and 3 are prime for targeting

• Focus Area 2: Organizations with a “Too New to Rate” or “Not Enough Membership” should be second-tier targets and must be watched as they become ratings-eligible

• Organizations with Star Ratings of “1” should not be focused on as they will likely be eliminated as a CMS plan host

Distribution of Overall Plan Ratings for MA-PD Contracts (2011)

• Half-star ratings are rounded down for these distributions

• These ratings summarize all Part C and Part D measures combined.

Total Attention

76%Focus #28.1%

Focus #167.6%

68% of 2011 plans represent an immediate opportunity.8% of 2011 plans represent a future potential opportunity.

Focus Area 1 = 319 Plans Focus Area 2 = 164 Plans

04/10/2023 03:24:38 AM

11

Specific Areas of Focus

# Confidential Co. Areas of Focus

Screening, Monitoring And Prevention Of Costly Acute And Chronic Disease

Access To Care

Care Management

Drug Formulary Information And Prescription Tracking System

Member Comfort Ratings: Enrollment, Retention And Attrition

Complaint Tracking And Resolution Process

(CMS Category)

• Confidential Co. Life Science and Healthcare Solutions has identified six “Areas of Focus” which are within our scope of expertise and potentially high revenue drivers.

• By enhancing the determined “Areas of Focus”, Confidential Co. will enable broad improvements in quality ratings over the nine CMS category set.

Confidential Co. Expertise Mapped To CMS Categories

1

1

1

1

1

1

1

2

3

4

5

6

53

• Staying Healthy

• Managing Chronic Conditions

• Plan Responsiveness

• Members’ Complaints and Appeals

• Telephone Customer Service

CMS 5-Point Consolidation

04/10/2023 03:24:38 AM

12

Confidential Co.’s Journey To Business Outcomes

Business Outcomes

• Improved Screening, Monitoring And Prevention Of Costly Acute And Chronic Disease

• Improved Access To Care

• Improved Care Management

• Improved Drug Formulary Information And Prescription Tracking System

• Improved Member Comfort Ratings: Enrollment, Retention And Attrition

• Improved Complaint Tracking And Resolution Process

Quality Improvement Roadmap

Phases: 1-Assessment, 2- Interim Enhancements, 3- Business Outcomes Model

Less Clarity In Scope & Specification

Technical Understanding

Simulate Process Improvements

“To-Be” Solution & Business Case Accepted

Joint Management & Governance Model

Complete Member Record with Action Indicator

Changing Requirements

Solution DesignBusiness Model

Reduce WorkflowInefficiencies

Typical Enhanced Productivity Gains

Average Productivity Gain

Business Operations

Understanding

IT Environment Member Data Integration (MDM)

Confidential Co. Technology

Layer

Impact of Inaction

Lack of “ground truth” – agreed upon current state capabilities

Reactive software development activities

Multi site, multi-vendor collaboration challenges in design & implementation of improvements

Knowledge retention dependent on people and experience

Multiple Technologies, hosting environments, resources

“As-Is” ModelBaseline

ImprovementInitiatives

Knowledge Management Framework

PHASE 1

-------- +1.5-------- +1.0---------- +0.5-------- 0--------- -0.5------------ -1.0

Transformational Benefits

Transformation Initiatives Will

Lead To An Outcomes-based

iTOPS Model.

(Trusted Partner = Shared Risk)

PHASE 2 PHASE 3

(Representative)

Growing Members and Products without Complete Member Record and Member Master Data

Consulting – Assessment Execution – Building the Technology and Ops Components

Project Execution Framework

Business OutcomesImpact of Confidential

Co. Enablers

A Path To Business Outcomes (Star Rating Improvement)

INACTION Repeating Downward

Cycle

Star Rating Improvements

04/10/2023 03:24:39 AM

14

Confidential Co. Healthcare Consulting Approach*

1. System Discovery And Assessment

2. Assessment Workshops

3. Findings And Recommendations

4. Build And Install Improvements

5. Monitor And Report On Performance

6. Adapt Solutions Based On Lessons Learned

Phase I

Phase II

Phase III

*Approach is standard to each potential area of improvement

04/10/2023 03:24:39 AM

15

Opportunities Tableau

11

12

13

14

15

16

Opportunities Matrix by “Area of Focus” and Confidential Co. Vertical

# Confidential Co. Identified “Areas of Focus”

Confidential Co. Opportunity

IT Enhancemen

t

BPO Consulting

Screening, Monitoring And Prevention Of Costly Acute And Chronic Disease

• Increase management oversight in critical performance areas • Predictively measure quality deviation• Introduction of IVR technology to reach out proactively to membership • Train Staff that pain is 4th vital sign and should be documented• Establish disease-specific protocols for providers – consistently educate

and remind

✔✔✔

✔

✔✔✔✔

Access To Care • Evaluate system-wide ease of member to obtain timely care • Development of a more robust appointment management system• Determination if candidate areas exist for the appropriate application of

process improvement

✔✔✔✔

✔✔

✔

Care Management • Care management for the treatment of specific chronic conditions • Quality slippage monitoring system • Establish disease-specific protocols for providers – consistently educate

and remind

✔ ✔✔✔✔

Drug Formulary Information And Prescription Tracking System

• Creation of member intranet or links to established drug information portals (i.e. WebMD or Mayo) for those drugs on the formulary list

• Introduction of high risk SAE indicators within a monitoring framework that flags safer alternatives

• Enable ease and speed of medication access • May require formulary system overhaul, including the creation of member

drug utilization DBMS

✔✔✔✔

✔✔✔

✔

Member Comfort Ratings: Enrollment, Retention And Attrition

• Segment and predict early tendency toward specific areas of membership abandonment for proactive outreach

• Retrain all customer service staff or contractors on bedside manner• Introduction of intelligent IVR technology for Customer Service

improvement• Institute new SOP with 3-day standard for handling enrollment requests

✔✔✔✔

✔✔✔

✔

Complaint Tracking And Resolution Process

• Assess and recommend system changes for complaint resolution process

• Implement technology layer that will enable predictive, logic-based action to alert management of probable complaints so that they may be proactively addressed

✔✔✔✔

✔✔✔

✔

04/10/2023 03:24:39 AM

16

Monetizing The Opportunity

Plans representing an immediate opportunity.Focus Area #1: 2 and 3 Star Plans

Opportunities could present as a combination of IT, Business Process Re-engineering or Consulting

Percentage of Confidential Co. Invoicing Opportunity*

12

13

14

15

16

11

*Based on detail-level scrutiny

Range of Revenue Year One

$250k to $3MM

$750k to $3MM

$250k to $2MM

$500k to $1MM

$500k to $3MM

$500k to $3MM

04/10/2023 03:24:40 AM

17

What Makes Confidential Co.’s Solution Unique?

• iTOPS – No other IT consulting firm has more experience with “pay for performance” than Confidential Co.. Our business outcomes methodology of invoicing was a first in industry and we are the only firm that does it from a leadership position.

• Healthcare and Life Sciences Consulting – Confidential Co.’s specialty staff are former industry executives who offer clients the most robust “fire-power” in the market

• We address each CMS category individually and determine those areas which will provide an optimized solution to increase quality more meaningfully and more rapidly• Assessment

• Management Workshops

• Consideration of Commercial, Legal, Regulatory and Compliance Factors

• Simulation Through An Optimization Tableau

Three Primary Differentiators Exist

04/10/2023 03:24:40 AM

18

Sales Pre-Work Guidance

04/10/2023 03:24:40 AM

19

Initial Due Diligence Procedure• Go to www.medicare.gov/find-a-plan• Enter a zip code for the geographic areas of sales for

which you are responsible.• Enter “I do not have a plan” and “I do not know for all

answers” to avoid report limitations• Enter “I am not on any drugs”• Enter “View 100” plans to get the large list• Sort by plan rating• Begin to qualify leads

• (a place to start may be the “low hanging fruit” or current clients. Humana, UAM and United Healthcare all have pockets geographically that are at 3 or below)

http://www.m2details.com/fileshare/Confidential Co./Sample%20CMS%20Plan%20Ratings%20Report%20for%20Hartford_%20CT%20Area.pdf

Click To Download Sample Report

04/10/2023 03:24:40 AM

20

Targeting• Organizations

• Determination made by running CMS Plan rating reports for geographic location

• Download ratings detail for individual plans• Create list of organizational targets• Create plan of entry targeting IT Executives, QC/QA Executives, Lead

Clinicians• Review with and utilize Healthcare Consulting for help and approach

• Internal Leadership• Plan Brand Directors, Product Development Directors• CIO, COO and other Corporate Leaders• Most information is publically available

• Yahoo Finance is a fantastic and robust source• http://finance.yahoo.com/

04/10/2023 03:24:40 AM

21

Resources

Perform Due Diligence (Samples)

Marketplace Facts(Minimum Educational Requirements)

Research every area of the organizations financials,quarterly and annual statements, news, PR…

http://www.m2details.com/fileshare/Confidential Co./UAM%202011%20Star%20Rating%20-%20Unsorted.xlsx

http://www.m2details.com/fileshare/Confidential Co./CMS%20Fact-Sheet-2011-Landscape-for-MAe-and-Part-D-FINAL111010.pdf

http://www.m2details.com/fileshare/Confidential Co./CMS%20Ratings%20Analysis.pdf

http://www.m2details.com/fileshare/Confidential Co./CMS%20Sanctions%20on%20UAM.pdf

http://www.m2details.com/fileshare/Confidential Co./Universal%20American%20Goes%20Red%20-%20DailyFinance.pdf

http://www.m2details.com/fileshare/Confidential Co./redp3975-1.pdf

CMS Fact Sheet Star Rating and Bonus Plan by

Kaiser

Sample Analysis of Poor Performance

Mid-Market Selling Guide Example

CMS Tech Notes

http://www.m2details.com/fileshare/Confidential Co./2012_Tech_Notes_2011_10_11.pdf

04/10/2023 03:24:42 AM

22

Yahoo Finance Sample Report

04/10/2023 03:24:42 AM

23

Investigative Probes for Identified Accounts

04/10/2023 03:24:42 AM

24

Four Initial Questions For Account1. What has been your member growth or decline over the

past two years?  Is this an accelerating growth or decline? What were the primary drivers?  

2. What is the most troublesome aspect of your quality ratings as they stand now? What category and more specifically, measures, are you most focused on improving?  Which have proven to be the most difficult to overcome and why?

3. What have you implemented in the past 6 months to improve your quality ratings?  Where have your attempts been successful and where have they not been successful and why?

4. How is your MA book of business distributed geographically? What percent is south of the Mason-Dixon line, and deep South? Do you have a breakout of performance measures geographically? 

04/10/2023 03:24:42 AM

25

Subsequent Questions for Account1. Which measures are considered out of your control? Example:

measurement for flu vaccines, but the CMS survey done outside of flu season 

2. Have you performed an evaluation (internally or externally) resulting in a remediation strategy accounting for

• Category/Measure

• Ease of recovery (financially and/or within your immediate control)

• Speed of recovery

• Communication/Messaging to provider network and members

3. How important is, or what value do you place on, monitoring quality rating slippage?  How proactive do you want to be in warding off quality slippage predictively?

4. How receptive are you to either and IT, business process or communications/commercial consulting solution to achieve the outcomes you will require?

5. Are you interested in the Confidential Co. outcomes (iTOPS) approach?

04/10/2023 03:24:42 AM

26

Several Organizations Are Having Success In This Space

Health Data Vision Silver Link

04/10/2023 03:24:43 AM

27

In Summary• A primary provision of the CMS quality star ratings is to

eliminate plans with poor quality of care and reward plans with high quality of care

• Significant opportunities exist for Confidential Co. in helping organizations achieve higher performance quality ratings

• The consequences of poor-performer inaction is an accelerating decline in membership, partnerships and quality ratings in a repeating cycle until financial insolvency occurs

• Confidential Co. has a detailed approach to assess, design and implement a myriad of solutions

• There are companies making money in this space so the opportunities are “real”

04/10/2023 03:24:43 AM

28

Detailed-Level of Opportunities

04/10/2023 03:24:43 AM

29

Screening, Monitoring And Prevention Of Costly Acute And Chronic Disease

Annual Flu VaccineBreast Cancer ScreeningChecking to See if Members Are at a Healthy WeightCholesterol Screening for Patients with DiabetesCholesterol Screening for Patients with Heart DiseaseColorectal Cancer ScreeningEye Exam to Check for Damage from DiabetesGlaucoma TestingKidney Function Testing for Members with DiabetesMonitoring Physical ActivityPneumonia VaccineReducing the Risk of FallingYearly Pain Screening or Pain Management Plan

• Address monitoring and tracking to increase management oversight in critical performance areas under direct organizational control.

• Enhancements to technology, current business rules and logic to predictively measure quality deviation• Introduction of IVR technology to reach out proactively to membership base as pre-chronic condition flags

present• Train staff on new guidance that pain assessment is the 4th vital sign that always must be measured, documented

and treated appropriately – ensure fields exist in current system and implement reporting capability for CMS review

• Establish disease-specific protocols for providers – educate and remind consistently

13 CMS Measures Impacted

1

Opportunities for Confidential Co.

04/10/2023 03:24:43 AM

30

Access To Care2

Ease of Getting Needed Care and Seeing SpecialistsGetting Appointments and Care QuicklyProblems Medicare Found in Members’ Access to Services and in the Plan’s Performance Readmission to a Hospital within 30 Days of Being Discharged

• Evaluate system-wide ease of member ability to obtain timely care • Development of a more robust member appointment management system• Determination if candidate areas exist for the appropriate application of process improvement

4 CMS Measures Impacted

Opportunities for Confidential Co.

04/10/2023 03:24:43 AM

31

Care Management3

Controlling Blood PressureImproving Bladder ControlImproving or Maintaining Mental HealthOsteoporosis ManagementPlan Members with Diabetes whose Blood Sugar is Under ControlPlan Members with Diabetes whose Cholesterol Is Under ControlRheumatoid Arthritis ManagementTaking Blood Pressure Medication as Directed Taking Cholesterol Medication as Directed Taking Oral Diabetes Medication as Directed Using the Kind of Blood Pressure Medication That Is Recommended for People with DiabetesYearly Assessment of How Well Plan Members Are Able to Do Activities of Daily Living

• Care management process for the treatment of specific chronic conditions measured• The design and implementation of a quality slippage monitoring system (aka CIGNA) with insertion of

technology layer and logic-based action indicator lamp enabling highest degree of proactive care response from the first touch point

• Establish disease-specific protocols for providers – educate and remind consistently an Confidential Co.-developed communications and CMS tool

12 CMS Measures Impacted

Opportunities for Confidential Co.

04/10/2023 03:24:43 AM

32

Drug Formulary Information And Prescription Tracking System

4

• Creation of member intranet or links to established drug information portals (i.e. WebMD or Mayo) for those drugs on the formulary list

• Introduction of high risk SAE indicators within a monitoring framework that flags if a safer alternative formulary-approved drug exists

• Enable ease and speed of medication access through IT and process reengineering• After assessment, may require formulary system overhaul, including the creation of member drug utilization

DBMS

Drug Plan Provides Information or Help When Members Need ItMembers’ Ability to Get Prescriptions Filled Easily When Using the Plan

Plan Members 65 and Older Who Received Prescriptions for Certain Drugs with a High Risk of Side Effects When There May Be Safer Drug Choices Yearly Review of All Medications and Supplements Being Taken

4 CMS Measures Impacted

Opportunities for Confidential Co.

04/10/2023 03:24:43 AM

33

Member Comfort Ratings: Enrollment, Retention And Attrition

5

Customer ServiceMembers Choosing to Leave the Plan Members’ Overall Rating of Drug PlanMembers’ Overall Rating of Health PlanOverall Rating of Health Care QualityPlan Handles New Enrollment Requests within 7 Days

• Implement process improvement and predictive modeling technology to segment and depict early tendency toward specific areas of membership abandonment for proactive outreach

• Retrain all customer service staff or contractors on bedside manner similar to current medical school mandates – creates environment of warmth, caring and genuine interest in each member

• Introduction of intelligent IVR technology to increase speed and ease of members obtaining customer service through both process and system re-engineering

• Institute new SOP with 3-day standard for handling enrollment requests

6 CMS Measures Impacted

Opportunities for Confidential Co.

04/10/2023 03:24:44 AM

34

Complaint Tracking And Resolution Process

6

Complaints about the Drug PlanComplaints about the Health PlanDrug Plan Makes Timely Decisions about AppealsFairness of Drug Plan’s Denials to Member Appeals Based on an Independent ReviewerHealth Plan Makes Timely Decisions about Appeals

• Assess and recommend system changes or overhaul that will speed the complaint resolution process

• Implement technology layer that will enable predictive, logic-based action to alert management of probable complaints so that they may be proactively addressed

5 CMS Measures Impacted

Opportunities for Confidential Co.

04/10/2023 03:24:44 AM

35

Case Studies

04/10/2023 03:24:44 AM

36

Case Studies

• UAM• Others

To Be Added. Please Submit Success And Failure As Learnings And Best Practices

04/10/2023 03:24:44 AM

37

Rating Source Information and Statistics

04/10/2023 03:24:44 AM

38

Star-Ratings Source Data and National Average Scores

• HEDIS• HOS• NCQA• CAHPS • CAM - Compliance Actions Module • CTM• IRE• Plan Call Center• Others

• PDE - Prescription Drug Event • MPF Pricing Files• HPMS approved formulary extracts• First DataBank and Medispan

2012 National Averages for Part C Measures

04/10/2023 03:24:44 AM

39

Source Data Statistics• The CMS Star Rating measures a broad array of clinical quality, customer

satisfaction and other beneficiary experience areas. • There are 33 measures taken from multiple sources which include two surveys,

one measure set and a variety of administrative sources, which include:• CAHPS Survey (8)• HOS Survey (6)• HEDIS Measurement Set (11)• Administrative Sources (8)

• These 33 Star Rating Measures are broadly grouped into five domains, These domains include:• Staying Healthy• Managing Chronic Conditions• Ratings of Care and Responsiveness• Complaints, Appeals, and Choosing to Leave• Customer Service

• There are 185 possible stars. • A plan needs 158 stars to get the maximum bonus at 4.5 stars overall, while the

4 star threshold is at 139 stars out of the possible 185 stars