BPN Primary Care Physicians Are HEDIS Stars
By Brenda Radke, Brevard Physicians Network CEO // April 14, 2012
BREVARD PHYSICIANS NETWORK UPDATE
BREVARD COUNTY, FLORIDA – As health care costs continue to skyrocket, health plans, employers and consumers want to know: Are we getting the most return from our health care dollars?
The National Committee for Quality Assurance is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality. Since its creation in 1990, NCQA has been a central force in driving improvement throughout the health care system, helping to elevate the issue of health care quality to the top of the national agenda.
The NCQA seal is a widely recognized symbol of quality. Organizations incorporating the seal into advertising and marketing materials must first pass a rigorous, comprehensive review and must annually report on their performance. For consumers and employers, the seal is a reliable indicator that an organization is well-managed and delivers high quality care and service.
NCQA’s programs seek to Measure. Analyze. Improve. Repeat. NCQA makes this process possible in health care by developing quality standards and performance measures for a broad range of health care entities. The annual reporting of performance against such measures has become a focal point for the media, consumers, and health plans, which use these results to set their improvement agendas for the following year.
NCQA did not create the field of health care performance measurement, but they have refined the process and led the development of objective measures since the mid-1990s when the standardized measurement tool, the Healthcare Effectiveness Data and Information Set (HEDIS), was broadly adopted by the industry.
Since then, NCQA has constantly improved, expanding the scope of what was measurable from a narrow list of preventive process measures (e.g., what percentage of children were immunized?) to a broad range of overuse, underuse, value, process and outcome measures that address public health issues ranging from smoking cessation to overuse of antibiotics to cancer, heart disease, diabetes and asthma.
Medicare currently uses three systems to measure and compare quality across Medicare Advantage (MA) plans:
• Healthcare Effectiveness Data and Information Set (HEDIS®)
• Consumer Assessment of Healthcare Providers and Systems (CAHPS®)
• Health Outcomes Survey (HOS)
Results for each of the above systems are reported at the MA contract level for the entire Medicare population covered under the contract.
HEDIS includes performance measures related to dozens of important health care issues.
Selected measures include, but are not limited to:
• Advising smokers to quit
• Antidepressant medication management
• Breast cancer screening
• Cervical cancer screening
• Children and adolescent access to primary care physician
• Children and adolescent immunization status
• Comprehensive diabetes care
• Controlling high blood pressure
• Prenatal and postpartum care
HEDIS consists of health care process measures and outcome measures that are based on administrative data (medical provider claims data (including pharmacy claims), encounter data, laboratory results, and electronic health records), supplemented in some cases by information obtained from individuals’ medical records.
Performance measurement isn’t just for health plans. Physicians are increasingly participating in performance measurement activities, especially in the context of pay-for-performance initiatives that are taking shape across the country. Measurement at all levels of the system is fast becoming the norm in health care.
The Centers for Medicare and Medicaid Services (CMS) rates the relative quality of the private plans that are offered to Medicare beneficiaries through the Medicare Advantage program. CMS rates Medicare Advantage plans on a one to five-star scale, with five stars representing the highest quality.
The summary score provides an overall measure of a plan’s quality, and is a cumulative indicator of the quality of care, access to care, responsiveness, and beneficiary satisfaction provided by the plan.
Primarily PCPs are the driving force behind the members obtaining their annual health screening as part of preventative medicine. PCPs are then given a star rating based upon a calculation of the following:
The number of assigned Medicare Advantage Members with Medicare Health Plan (times (x) # of HEDIS screenings based upon members age/sex/health condition (times(x) # of completed HEDIS screenings submitted to Health Plan over a period of 12 months (divided) by total base of required screenings on said population.
- 1 STAR= PCP completed 49.99% of required HEDIS screenings based upon his/her membership panel with Health Plan.
- 2 STARS = PCP completed between 50.0% and 74.99% of required HEDIS screenings based upon his/her membership panel with Health Plan
- 3 STARS = PCP completed between 75.0% and 84.99% of required HEDIS screenings based upon his/her member panel with Health Plan.
- 4 STARS = PCP completed between 85.0% and 94.99% of required HEDIS screenings based upon his/her member panel with Health Plan.
- 5 STARS = PCP completed more than 95.0% of required HEDIS screenings based upon his/her member panel with Health Plan.
CMS passes a “quality bonus” to each Medicare Plan that achieves an overall Star rating of at least 3.0 Stars. This “quality bonus” is a direct pass through to the PCPs who are servicing the membership base for the Health Plan and based upon the PCPs assigned panel of members.
If the Health Plan fails to meet the required Star rating they may face financial penalties and could potentially lose their Medicare Advantage Contract with CMS. By 2013 each Medicare Advantage Plan must meet a 4 Star rating or they will not receive any quality bonuses to pass along to the PCPs in the panel.
It is the goal of Brevard Physicians Network to achieve a 3.5 Star Rating by the end of 2011 and a 4 Star Rating by the end of 2012, one year ahead of the mandated 4 Star rating of the health plan.
Every month, BPN receives reports from each contracted Medicare Advantage Plan. These reports provide a listing by PCP of those assigned members that have “missing” HEDIS screenings that have not been reported to date.
BPN generates a letter directly to the member reminding the member of the identified missing HEDIS screenings and how it is important to keep them healthy and to please contact their PCP office to obtain those preventative screenings.
BPN sends a copy of these letters to the PCP and we ask the PCP office to call the member for a follow up and to place the letter in the medical record so when the patient comes in, the PCP will coordinate the completion of the HEDIS screenings.
We have found that patient outreach is a vital component in achieving a high star rating. BPN’s goal is to remove a significant portion of this administrative burden from the PCP office, allow the physician to achieve a high star rating and to potentially receive a quality bonus paid directly to the provider by the health plan.
On these pages of SpaceCoastDaily.com, Brevard Physicians Network recognize all its STAR providers.
Brenda Radke is CEO of Brevard Physicians Network, the not-for-profit organization that acts as liaison between insurance companies and 300 Network member physicians in Brevard and Indian River Counties. She has an impressive background in all aspects of the health insurance field. For more than two decades, Radke has been immersed in some of the largest health care groups in the state, including Humana Health Care of Florida, Wellcare of Florida, United Healthcare of Florida and Accountable Health Plans. She served as director of finance for Humana as well as the corporation’s director of wholly owned affiliated physicians clinics. Radke was also regional director of provider operations for Care Plus, executive director of Wellcare of Florida, finance manager for United Healthcare and director of provider operations for Accountable Health Plans. She holds degrees in business administration and healthcare management, and is very active in supporting many community causes.