Top Quality Improvement Trends for 2016

Quality Management Trends | Mile High Healthcare Analytics

In recent years both providers and plans have placed increasing emphasis on quality improvement. CMS Star ratings can have a major impact on financial performance with significant incentives delivered to programs receiving 4-stars or more. The “rules of the game” for quality ratings continue to shift as CMS gains more insight on which measures drive the most positive consequences. As we kick-off 2016, we thought it would be useful to outline some of the most important trends for QI managers to monitor in the coming year:

1. The number of measures comprising CMS Star Rating System continues to fall
Industry-wide performance on HEDIS process measures continues to improve, and historically CMS has dropped measures from Stars once industry performance appears to have topped out. There are currently 47 measures in the system including 32 Part C measures and 15 Part D measures across clinical, administrative and survey categories. All of the measures that have been dropped have been 1.0 weighted which increases the importance of the 3.0 rated measures in the system. Similarly there is a shift underway towards composite measures such as the “improvement score” weighted at 5.0. CMS is likely to replace high-performing measures from the list of Display Measures in the near future.

2. Financial incentives will be limited to Medicare Advantage plans
While much of the focus for quality improvement has been on surpassing the bonus threshold, there will be increasing emphasis on how ratings impact reputation and market share. As healthcare consumerism slowly begins to take hold, more providers and patients are using quality ratings as a factor when making medical decisions. Commercial exchanges and Medicaid quality ratings will be reported publically but will not be linked to financial incentives. In an effort to increase healthcare transparency, public reporting for Medicaid managed care organizations will be available on state Medicaid websites.

3. Drive towards higher performance – beyond 4-stars
Many in the industry have expressed frustration that quality measurement targets are continually shifting. In fact, CMS’ research indicates that quality improves faster in the absence of the fixed cut points. Overtime, we are becoming smarter about both the positive and unintended consequences of various measures which has led CMS to make changes. For instance, the 4-Star threshold for Statin Use went from 76-83% in 2014 and from 73-79% in 2015. Similarly, the 5-Star threshold decreased from 83% to 79% compliance.

4. CMS is coordinating measure sets across sites and providers
There will be roughly a 50% overlap between Medicare Advantage, Commercial and Medicaid measure sets. Aligning, where appropriate, quality standards for Medicaid managed care with that of MA and the Marketplace would result in a simplified and integrated approach to quality measurement and improvement.

5. No resting on your laurels
There is continual shifting on quality measures among providers that were rated both above and below the 4-star threshold. Fifty-three of the contracts that had been rated below 4-stars last year, rose above the threshold in 2015 while 32 of those contracts that had been above the threshold in 2014 dropped below.

6. Potential adjustments to address the impact of socio-economic variation
Multiple Medicare Advantage (MA) organizations and Prescription Drug Plan (PDP) sponsors believe that enrollment of a high percentage of dual eligible (DE) enrollees and/or enrollees who receive a low income subsidy (LIS) disadvantages their plan’s ability to achieve high MA or Part D Star Ratings. CMS has been trying to provide the scientific evidence to prove or disprove this hypothesis. The research to-date has provided scientific evidence that there exists an LIS/Dual/Disability effect for a small subset of the Star Ratings measures. The size of the effect is small in most cases and not consistently negative. CMS is exploring options for possible interim analytical adjustments to the Star ratings system to address the LIS/DE/disability effect.

In an evolving quality improvement environment those QI teams should focus on those things they can control. Based on our experience supporting both plans and providers with their quality improvement strategies, we recommend the following focus areas for 2016:

  • Quality Data Management – if you can’t accurately measure quality, you can’t actually improve it. The first step to any meaningful QI effort is to complete an end-to-end assessment of data integrity.
  • QI Strategy Development – with so many measures and potential impacts, where to start. Developing a sound strategy requires a clear visibility on the impact that moving specific measures will have on overall ratings as well as practical understanding of what it will take to move individual metrics.
  • Actionable Reporting – often QI teams are awash in metrics but lack actionable information. Quality scorecards should be limited to the measures that need the provider’s focus, and they should be dynamic; able to measure variations by provider and compliance status.