Key Takeaways

  • The Center for Medicare and Medicaid Services implements initiatives to assure quality health care for Medicare beneficiaries through accountability and public disclosure.

  • Community-based organizations pursuing contracts with Medicare Advantage plans should know and understand how quality measures can impact plan decision-making.

  • It's important to frame your value proposition for community-based services around common quality measures and your ability to improve beneficiary satisfaction, engagement, and activation.

Community-based organizations pursuing contracts with Medicare Advantage plans should know and understand how quality measures can impact plan decision-making. Here are seven things you should know to improve beneficiary satisfaction, engagement, and activation.

1. Accreditation

Accreditation is a comprehensive evaluation process in which an impartial external organization (an “accrediting body”) reviews a health care organization’s policies, procedures, processes, and performance to ensure that it is conducting business in a manner that meets predetermined criteria and is consistent with national standards.

Medicare rules require that Medicare Advantage Plans are accredited by an approved CMS accrediting body.  Accreditation reviews often reflect the level and intensity of services provided to specialized populations, like those enrolled in Medicare Advantage and Medicaid Managed Care Plans.

Community-based organziations should become familiar with the standards from the two most common health care organization accrediting bodies, the Utilization Review Accreditation Commission (URAC) and the National Committee for Quality Assurance (NCQA).  This information helps identify a health plans’ strengths and deficiencies which, in turn provides service providers with information to tailor their partnership engagement, particularly in addressing the deficiencies.

For example, a Medicare Advantage Plan Part D contractor’s accreditation status could be affected by factors such as poor outcomes for diabetic patients.  In this instance, service providers can offer the Diabetes Self-Management Program as a solution to enhance the health outcomes of those specific patients.

2. Consumer Experience and Satisfaction Surveys

Consumer feedback is considered an essential component of the quality care reviews of Medicare Advantage Plans. CMS requires plans to conduct consumer satisfaction surveys to analyze information about their beneficiaries’ experiences with the plan. The CMS Medicare Advantage and Prescription Drug Plan Consumer Assessment of Health Plan survey (MA & PDP CAHPS) is used for this purpose.

The MA & PDP CAHPS survey is mailed annually to a large sample of plan members. The survey includes topics such as ease of getting needed care and seeing specialists; getting appointments and care quickly; doctors who communicate well; coordination of members’ health care services; ease of getting prescriptions filled; rating of health and/or drug plan; rating of health care quality; and offering of annual flu and pneumonia vaccinations.

The results of the surveys are reported to CMS and accrediting bodies as well as publicly reported in the Medicare & You Handbook. The State Health Insurance Assistance Program also offers consumers information about local heath plan performance and satisfaction ratings. Survey results impact the accreditation scores and Medicare Star Ratings of the Medicare Advantage plans.  The results can be used by beneficiaries to inform their plan selection decisions.  When negotiating with MA Plans, community-based organizatitions can highlight information from studies that address the impact of services (e.g. evidence-based programs) on participants’ satisfaction with their health care delivery.

3. Healthcare Effectiveness Data and Information Set (HEDIS)

HEDIS is another tool created by NCQA and used by health care organizations to measure performance on the various dimensions of care and service. It is comprised of 81 measures across 5 domains of care. In recent years, HEDIS measures have been updated to include program intervention metrics that are oriented to older Americans and people living with disabilities, such as falls prevention.

HEDIS standard measures can be used to compare performance across health plans. HEDIS accounts for nearly 40% of NCQA accreditation scoring and is factored into Medicare Advantage Plan Star Rating evaluations. Community-based organizations offering evidence-based programs should research the HEDIS scores of potential Medicare Advantage Plan partners and be prepared to illustrate how programming can enhance HEDIS performance. 

4. Health Outcomes Survey (HOS)

The HOS is administered to Medicare Advantage Plans with more than 500 enrollees. This comprehensive tool is used to collect and analyze data annually and then report on the selected cohort of beneficiaries two years later. The goal of the Medicare HOS program is to collect valid and reliable health status data from Medicare managed care plans for use in quality improvement activities, plan accountability, public reporting, and support for beneficiary selection of plans. The survey instrument includes:

  • Physical and mental health status
  • Select HEDIS Effectiveness of Care measures
  • CMS specific questions
  • Questions on race, ethnicity, primary language, sex and disability status

As is the case with HEDIS, community-based services providers should become familiar with the HOS survey results of targeted Medicare Advantage plans and be prepared to discuss how programming can impact HOS results.

5. Quality Improvement Programs

All Medicare Advantage plans are required to develop a quality improvement program that is based on care coordination for members. The foundation of the Medicare Advantage Quality Strategy and the Quality Improvement Program is to improve care coordination and encourage provision of health care using evidence-based clinical protocols. Among the tenets outlined in the CMS quality guidance is the requirement for Medicare Advantage plans to develop and implement a chronic care improvement program (CCIP). Medicare Advantage plan quality assurance standards are described in Chapter 5 of the Medicare Manual. Many plans also post summaries of this information on their websites. Community-based services providers should research the manual and the quality improvement program of the targeted Medicare Advantage plan to identify ways they can address initiatives, goals, and needs.

6. Model of Care (MOC) Requirement Unique to Special Needs Plans (SNPs)

There are unique aspects of SNPs that distinguish them from the traditional Medicare Advantage plan. One key distinction is the Model of Care (MOC) requirement.  The MOC is a quality improvement road map used to ensure that the needs of SNP beneficiaries are identified and addressed. The MOC is an important and vital component of SNPs’ Quality Improvement Strategy.  The MOC has 11 clinical and non-clinical elements ranging from detailed descriptions of the target populations to the provision of MOC training for personnel and the provider network.

MOCs are submitted with the annual SNP application.  Per 2012 ACA legislation, MOCs are reviewed and approved by NCQA based on standards and scoring criteria established by CMS. An MOC must achieve a minimum score of 70%.  MOCs that score 75% or higher qualify for multi-year approval of two or three years.  Addressing the use of evidence-based health promotion programs to enhance members’ health outcomes and satisfaction within Medicare Advantage plans could influence MOC proposal scoring.

7. Star Ratings

The star ratings are a quality measurement system utilized by CMS to evaluate Medicare Advantage plans, including those that only cover health services, only cover prescription drugs only, or those that cover both.  Star ratings fall into several categories (varying by type of plan) such as: managing chronic illness, member experience, member complaints/appeals, medication safety, etc.

Star ratings range from 1-5, with 5 being the most positive rating. The scores are publicly reported and used by consumers to evaluate plan selection.  Plans with high scores receive enhanced payment from Medicare. These plans also benefit from year-round enrollment of new beneficiaries, not just during the fall Medicare open enrollment period.

Plans with consistent ratings below 3 are at risk of being placed in corrective action status and could be dismissed from the Medicare program.  Hence, star rating scores have a major impact on premiums, marketing, and plan performance/compliance.  When engaging plans, community-based organizations offering home and community-based services should be ready to demonstrate their ability to support star rating improvement initiatives, such as member satisfaction, prescription drug safety, and other quality measurement outcomes through improved member engagement, education, and activation.