#63
PROJECT NAME: Partnering with a Medicare Advantage Plan to
Enhance Value Added Patient and Family Centered Care Delivery
Institution: UT Health Northeast
Primary Author: Brenda Lee, MSN, RN
Secondary Author: Dr. Jonathan MacClements
Project Category: Medical Homes/Reform
Purpose:
Health Plans and Federal programs are progressively requiring evidence of quality performance with
reimbursement tied to that evidence. The Triple Aim for the future of health care encompasses;
improved health, improved care, and lower cost. “Integrators” of health will be the organizations
which will move healthcare in the direction of this destination.”1 Three integrators are: Medicare
Advantage, Medical Home, and Accountable Care Organizations. All three of these programs have a
defined set of quality measures which are required in order to participate and in order to receive the
maximum reimbursement. There is significant overlap to these requirements as evidenced in
comparison of the measurement groups – HEDIS, Meaningful Use, PCMH, NQF, PQRS, etc.
As our organization re-engineered for Patient Centered Medical Home designation, partnering with
the Medicare Advantage (MA) plan representing our largest number of beneficiaries became a
strategic tactic. Centers for Medicare and Medicaid (CMS) posts quality ratings of MA plans to
provide beneficiaries with additional plan information. All MA plans are rated on a 1 to 5 star scale,
with 1 star representing poor performance, 3 stars average, and 5 stars excellent. In 2012, MA plans
began to receive bonus payments based on quality ratings. “The plans receiving bonus payments
are required to use the additional dollars to provide “extra benefits” (such as eye glasses or
transportation to and from the doctor) for the plans’ enrollees. “Therefore plans with higher quality
ratings should be able to provide a more attractive set of benefits than their competitors, which in turn
may lead to higher enrollment in plans with higher quality ratings.” 2 The bonus payments may affect
market share if beneficiaries begin to shift to plans with higher ratings.
“Medicare is accelerating plans to peg a portion of doctors’ pay to the quality of their care.”3 The
federal health law requires large physician groups to start getting bonuses or penalties based on their
performance by 2015 with all physicians treating Medicare patients by 2017. Groups are at risk for
1% of their pay in 2015, doubled to 2% in 2016 year under draft regulations. The bonuses and
penalties would be calculated on their patients cost on average as well as the quality of care
provided. Because the provider-performance-dependent metrics are HEDIS measures, the MA Star
program metrics should have been readily accessible by our organization. However, HEDIS results
were not being reported in a consistent, structured manner. We believe particular focus on the star
rated subset of HEDIS measures will assist us in discerning where performance falls short and to
implement improvement strategies.
2013 Deadlines for 4 Star Rates
June 30





Diabetes Kidney Testing
Diabetes A1c Testing
Diabetes LDL Testing
Diabetes Eye Exam
Cardio LDL Testing
September 30





BMI Assessment
Glaucoma Testing
SNP Med Review
SNP Pain Screening
SNP Functional Status
October 31




Breast Cancer Screen
Colorectal Cancer Screen
Rheumatoid Arthritis
Osteoporosis
Management
Aim:
Achieve a 4 STAR rating on all CMS Medicare Advantage clinical measures by January 1, 2014. The
key stakeholders are HealthSpring Key Council members. Our patients are to be considered
stakeholders as this initiative meets the triple aim for improved population health, the right cost, and
of high quality.
Tools and Measurement:
The table below was provided by HealthSpring in March, 3013. This would serve as baseline data
and assist with targeting 5 of 13 HEDIS measures. All outstanding metrics would be eligible for a
$100 incentive bonus if completed by June 30, 2013. The Diabetes related indicators would need to
be completed by June 30, 2013 per the plan established deadline (table 1 above). After the June
deadline, all metrics would be reduced to a $50 incentive bonus.
HEALTHSPRING MEDICARE ADVANTAGE STAR PROGRAM
LSS REPORTS
MEDICARE ADVANTAGE PLAN
Not receiving incentive $$
Inaccurate
Low patient risk scores
No process for completion of elements
Missing Codes
Not capturing all Dx codes
Lack of education regarding plan elements
Coding not reviewing clinic notes
No ZYNX Upgrades
Missing connection between contracting & clinical
Physician Codes incomplete
Over-Customized Build
Clinical not involved in
Contract negotiation
Misunderstood consequences of customization
Knowledge & time
Missing labs results
No reminders / alerts
< 4 STAR RATING FOR
HEALTHSPRING
CLINICAL MEASURES
No LOINC codes loaded
Not built/activated/accurate
Upgrade not taken
Unaware of requirement
timeline
Misunderstood requirements
Inexhaustible external &
internal demands
No priority plan
LSS HEALTH MAINTENANCE
HEDIS DATA
A cause and effect diagram was used to identify root causes for not achieving a 4 or 5 star rating on
HEDIS measures. Highlighted components were determined to be priority items for action planning.
Non-highlighted items are related to EMR functional capability. The EMR Leadership team would be
apprised and delegate(s) included on the HealthSpring Key Council.
A current state value stream map was created which demonstrated the need for a future state value
stream map which would enhance reliability of accomplishing whole person delivery of care.
CURRENT STATE VALUE STREAM MAP
Transfer to
Scheduling
Call main number
for appointment
ing
erform
RN p s vs.
task
ing
teach
Patient to Exam
Room
Registration
Check In Clerk
Delay
Fills out history
Insurance Verified
Co-payment
Exam Room
RN/MA Assessment
Delay
Paged to booth
Time for
patient
education/
teaching
Checkout
Provider
Delay
Checkout Clerk
Delay
Vitals taken
Referral info
Patient Assessment
Verified meds
Prescription info
Treatment
Question on any
problems
Discussion
(Meds, etc.)
Undress and gown
No health
maintenance
alerts in EMR
Next appointment
scheduling
Intervention and Improvement:
1) The organization began to partner with HealthSpring, a Medicare Advantage plan, to educate
staff and physicians regarding the Star Rating Program. An in-service was provided to
physicians, nursing and the entire coding department. A Key Council; comprised of UT Tyler
PCP’s, HealthSpring representatives, senior leadership, one specialist, managed care
contractor, and quality department was established. The council meeting is scheduled to meet
ten times per year. The focus of the council meetings is to review the plan financial report and
discuss specific requirements and barriers to implementation. There is on-going dialogue with
HealthSpring clarify questions/concerns regarding reports.
2) We changed the hand delivery of “hot reports” by the HealthSpring representative from the
contracting office to the Quality Department. The ‘hot reports” detail missing HEDIS
measures. In addition to “hot reports”, a patient missing a Health Management Report (HMR)
was included. The HMR is intended to support physicians in the management of their patients
by alerting them to pertinent conditions diagnosed during the past two years. This prevented
the information from literally being thrown away by providers or staff because they did not
understand the value.
3) EMR issues were discussed with the Co-Chief Information officer and at a HealthSpring on-site
meeting with laboratory representatives present. Missing LOINC codes were contributing to 1
(one) STAR HEDIS compliance. Iatric was contracted with to build LOINC code reporting for
HealthSpring patients as an interim solution, pending an upgrade to the laboratory reporting
system.
4) Health Maintenance issues identified; Glaucoma testing and Colon screening missing
elements, lack of reminders or alerts, inaccurate reports, and not all HEDIS measures in
active. These issues were addressed with the EMR Leadership committee. Corrective actions
began in July and are to be completed by December 31, 2013. Thus, a manual process for
capturing HEDIS and HMR requirements was implemented
5) The future state Value Stream Map was constructed.
FUTURE STATE VALUE STREAM MAP
Transfer to
Scheduling
Inaccurate
reports
Pre-Visit
Patient to Exam
Room
Check In Clerk
Delay
Planning for
upcoming visit:
ft in
not le
EMR
room
exam
Registration
MA
Delay
Exam Room
MA
Delay
Exam Room
Provider
Delay
Paged to booth
Fills out history
Verified meds
Insurance Verified
Co-payment
Question on any
problems
Patient Assessment
Treatment
Discussion
(Meds, etc.)
Education
Self Management
Support
Managing Group
Visits
No health
maintenance
alerts in EMR
Group visit
process to be
designed
Between Visits
Checkout Clerk
Delay
Undress and gown
Protocols to be
developed
Checkout
RN
Delay
Patient EMR opened
on computer
Vitals taken
1. Health
Maintenance
outstanding
2. Protocol ordering
of “needed” care
management
Call main number
for appointment
Patient
Delay
Referral info
Entry of Clinical Care
labs/results
Prescription info
Next appointment
scheduling
Portal access for
medications
Management of
disease
Intervention Results:
Breast Cancer Screening (HEDIS)
**Colorectal Cancer Screening (HEDIS)
**Cardio Care - LDL Screen (HEDIS)
**Comprehensive Diabetes Care - LDL Screen (HEDIS)
Glaucoma Testing (HEDIS)
**Adult BMI Assessment (HEDIS)
Osteoporosis Fracture Management (HEDIS)
**Comprehensive Diabetes Care - Eye Exam (HEDIS)
**Comprehensive Diabetes Care - Kidney Disease
(HEDIS)
**Comprehensive Diabetes Care (HBA1C < 9 (HEDIS)
**Comprehensive Diabetes Care - LDL < 100mg/DL
(HEDIS)
Rheumatoid Arthritis Management (HEDIS)
Plan all Cause Readmissions (HEDIS)
4 Star
Rating
Threshold
5 Star
Rating
Threshold
Previous
Rate
Current
Rate
74%
58%
85%
85%
70%
61%
60%
64%
83%
67%
91%
90%
78%
80%
67%
81%
50%
60%
100%
92%
86%
80%
NA
62%
67%
55%
89%
100%
85%
85%
NA
52%
85%
80%
90%
88%
92%
0%
86%
90%
53%
78%
11%
66%
86%
3%
0%
0%
0%
60%
NA
28%
1) Key Council and ongoing dialogue has heightened awareness regarding the need to change
our patient flow and related EMR functioning. Errors in both HealthSpring and internal reports
are of high priority to resolve. Star Rating reports from HeatlhSpring do not match with internal
manual audit metric scores. HealthSpring is addressing reliability of their reports. It is
therefore, not realistic at this point in the project to determine if our aim has been met.
2) The HMR is a CMS driven manual paper process. Coding is aware of the low patient coding
assigned risk score. HealthSpring’s coding representative will provide education regarding the
HMR by end of August, 2013. Each coder assigned to a particular physician will then review
the prepopulated HMR for accuracy. Deadline for all HMR review is December, 2013.
3) The Iatric HealthSpring interim report does not appear to be accurate in the July, 2013 report.
A manual audit of “hot reports” demonstrated 85% - 90% compliance with HGA1c (diabetics)
and LDL (cardio & diabetics) being obtained and in control. Manual audit will continue until the
lab computer update in October, 2013, is completed.
4) Nurse Managers are actively involved in obtaining missing HEDIS measures and annual
HMR’s. Going forward, all HealthSpring patients will be scheduled for visits in the first 90
days. The pre-visit work will accomplish as many of the HEDIS measures prior to the HMR
office visit. Pre-authorization required items will be scheduled in advance of the HMR visit as
pertinent. Coordination of measures will be accomplished by the RN/MA and scheduling.
Protocols will allow for automatic ordering of HEDIS required measures during the pre-visit
review. EMR decision support based alerts/needed items will be based on patient condition(s).
5) The future state Value Stream Map aligns with the Family Medicine Clinics’ PCMH model. The
Internal Medicine Clinic began working toward PCMH in July. Observation will be performed
on the new value stream map to further eliminate non-value steps and reduce waste. A3
methodology will then be utilized to address “red storm clouds” on the map. The most value
added time to this new model depends on the patient time spent working toward their health.
Revenue Enhancement /Cost Avoidance / Generalizability:
HEALTHSPRING MEDICARE ADVANTAGE
POTENTIAL REVENUE INCENTIVE PROGRAM
HMR
Physician
MacClements
Menard
Davis
Belt
Karaki
Holm
Bosworth
Powell
Olusola
Andrews
Tompkins
Shafer
Total
Eligible
Patients
1st Qtr
16
7
26
30
67
22
14
15
7
32
19
32
287
3200.00
1400.00
5200.00
6000.00
13400.00
4400.00
2800.00
3000.00
1400.00
6400.00
3800.00
6400.00
57400.00
1st Qtr. Potential Revenue:
2nd Qtr. Potential Revienue:
3rd Qtr. Potential Revenue:
4th Qtr. Potential Revenue
2nd Qtr
HEDIS MEASURES
3rd/4th
Qtr
1600.00 1600.00
700.00
700.00
2600.00 2600.00
3000.00 3000.00
6700.00 6700.00
2200.00 2200.00
1400.00 1400.00
1500.00 1500.00
700.00
700.00
3200.00 3200.00
1900.00 1900.00
3200.00 3200.00
28700.00 28700.00
$64,500.00
$35,800.00
$32,250.00
$32,250.00
Eligible
3rd/4th
1st Qtr 2nd Qtr
Patients
Qtr
5
2
9
5
16
4
6
2
2
8
4
8
71
500.00 500.00 250.00
200.00 200.00 100.00
900.00 900.00 450.00
500.00 500.00 250.00
1600.00 1600.00 800.00
400.00 400.00 200.00
600.00 600.00 300.00
200.00 200.00 100.00
200.00 200.00 100.00
800.00 800.00 400.00
400.00 400.00 200.00
800.00 800.00 400.00
7100.00 7100.00 3550.00
AMT. RECEIVED
Received
Number
Through
Completed
June 30
5
500.00
1
100.00
5
500.00
3
300.00
8
800.00
1
100.00
3
300.00
0
0.00
1
100.00
0
0.00
4
400.00
2
200.00
33
3300.00
Potential ROI
$64,500 vs. Actual
ROI $3,300 to date
Lessons learned from this project are related to patient’s willingness to accomplish the requirements.
This finding supports the future state value stream map of planned, coordinated pre-visits to
accomplish as many items with the least amount of face time. As our Medicare Advantage patient
base increases, the potential for lost revenue will increase. The loss of revenue may be tied to CMS
revenue in the form of value based purchasing. Going forward, it will be essential to monitor whether
quality ratings and bonus payments are associated with better care and improved health outcomes
for MA enrollees.
This project is applicable to all providers contracting with Medicare patients.
REFERENCES
1. STARs Tutorial: Medicare Advantage Plan Star Ratings and Bonus Payments in 2012, A tutorial for utilizing
SETMA’s Deployment of the STARS MA Program.
2. Jacobson G, Neuman T, Damico A, Huang J. Medicare Advantage Plan Star Ratings and Bonus Payments in 2012.
November 2011
3. Rau J. Medicare Announces Plans to Accelerate Linking Doctor Pay to Quality. Kaiser Health News, July 20.