CMS 5 STARS
PROGRAM
MedPOINT Management
Planning for the Future
 Healthcare Reform will require significant change to Medicare
Advantage plans transforming them into an integrated health
delivery system concentrating on quality of care outcomes
within the next 1-5 years.
 What are the consequences??
 There will be pressure to correctly screen, document and perform
precise coding or chronic disease along with exceeding quality
performance measures related to HDIS and national survey
instruments (HOS and CAHPS).
 The federal government will essentially be paying for quality
outcomes based on STARs/HEDIS ratings.
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WHAT ARE THE CMS STARs??
 CMS created the 5-STAR Quality Rating System for Medicare
Advantage plans to compare Medicare Advantage plans more
easily, and to help identify areas about which they may want to
ask questions.
 The STARS are a quality rating system that gives each plan a
rating of between 1 and 5 stars. Plans with 5 stars are considered
to be highly above average in quality, and plans with 1 star are
considered to be very below average in quality.
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WHAT ARE THE CMS
STARS?? (CONTINUED)
 STAR RATINGS are CMS Ratings for Part C and D Medicare Plans
 The original purpose of STAR ratings was to enable Medicare
beneficiaries to compare quality among Medicare Advantage Plans on
the Medicare Prescription Drug Plan Finder (MPDPF).
 As part of Health Care Reform, CMS will begin a quality bonus
payment in 2012 for MA Plans based on the Five Star Ratings.
 In the fall of 2006, CMS posted Plan ratings based on a 3 star scale
 For 2008, Annual Enrollment Period (AEP), CMS introduced a 5 Star
scale. [5=highly above average; 1=very below average]
WHY
IS
STARS
RATING
 STAR Ratings are updated annually during the AEP
SIGNIFICANT?
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HOW ARE STAR RATINGS MEASURED?
Health Plans receive an overall STAR rating and ratings by domain
PART C
Domain I: Staying Healthy: Screenings, Tests and Vaccines
Domain II: Managing Chronic (Long Lasting) Conditions
Domain III: Rating of Health Plan Responsiveness and Care
Domain IV: Member Complaints, Appeals and Choosing to Leave the Health Plan
Domain V: Customer Service
PART D
Domain I: Drug Plan Customer Service
Domain III: Member Experience with the Health Plan
Domain IV: Drug Pricing and Patient Safety
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CMS STAR RATINGS – DATA
SOURCES
 HEDIS: A widely used set of performance measures in the managed care industry, developed and maintained by
NCQA
 CAHPS (Consumer Assessment of Healthcare Providers and Systems): Comprehensive family of surveys that ask
consumers and patient to evaluate interpersonal aspects of health care.
 HOS (Health Outcomes Survey): Patient reported outcomes measure used in Medicare managed care. All managed
care organizations with MA contracts must participate.
 CTM (Complaints Tracking Module): Complaint rates per 1,000 are adjusted to a 30-day basis
 CMS Audit: Findings of CMS audits, ad hoc and compliance actions that occurred during the 14-month past
performance review period
 MBDS (Medicare Beneficiary Database Suite of Systems) A collection of individual applications and services that
access a single source for Medicare beneficiary demographic data
 IRE: Independent Review Entity: An independent entity contracted by CMS to review Medicare health plans’ adverse
reconsideration of organization determinations
 Phone Monitoring: Call center data collected by CMS
 PDE Data: Prescription Drug Event Data: Data was obtained from PDE data files submitted by drug plans to Medicare
for the reporting period
 MARx: Medicare Advantage Prescription Drug System: This data presents the percentage of new enrollment requests
from beneficiaries that the plan submitted to Medicare within 7 days of the application date.
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BASIS FOR THE STAR RATINGS
The ratings are based on Part C
& D Measures. Star rating based
on average of 53 measures
which are continually updated.
36 Part C measures
17 Part D measures
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DATA SOURCES BY WEIGHT
 DATA SOURCE
DOMAINS WT VALUE % STARS
 HEDIS
Part C: I & II
24.5
30.82%
 PDE Data
Part D: IV
16
20.13%
 CAHPS
Part C: I & III
14
17.61 %
 HOS
Part C: I & II
9
11.32%
 IRE
Part C: V
6
7.55%
 Phone Monitoring
Part C: V
4.5
5.66%
 CTM
Part C: IV
1.5
1.89%
 CMS Audit
Part C: IV
1.5
1.89%
 MBDS
Part C: IV
1.5
1.89%
 MARx
Part D: I
1
1.26%
79.5
100%
 TOTAL
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HEDIS MEASURES
 Breast Cancer Screening
 Colorectal Screening
 CV Colorectal Screening
 Monitoring of Long Term Patient’s Medication
 Diabetes-Colorectal Screening
 Diabetes-Kidney Monitoring
 Diabetes-Blood Sugar Control
 Diabetes-Cholesterol Control
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HEDIS MEASURES (CONTINUED)
 Glaucoma Testing
 Access to Primary Care Doctor Visits
 Osteoporosis Management
 Diabetes Eye Care
 Controlling Blood Pressure
 Rheumatoid Arthritis Management
 Testing to Confirm COPD
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CAHPS MEASURES
 Annual Flu Vaccine
 Pneumonia Vaccine
 Ease of Getting Needed Care and Seeing Specialists
 Doctors Who Communicate Well
 Getting Appointments and Care Quickly
 Overall rating of Health Care Quality
 Overall rating of the Health Plan
 Customer Service
 Member complaints
 Appeals
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HEALTH OUTCOMES SURVEY
 Improving Bladder Control (Physicians need to initiate discussion)
 Reducing the Risk of Falling (Discuss balance problems, trouble walking and other
risk factors)
 Monitoring Physical Activity (Advise patient how to start, increase or maintain)
 Improving or Maintaining Physical Health (Gauge status at each visit)
 Improving or Maintaining Mental Health (Gauge status at each visit)
---------------------------------------------------------------------------------------------------------USE THE ANNUAL WELLNESS VISIT AS A VEHICLE TO SET THE STAGE.
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