Quality Improvement Interview: Fallon Community Health Plan

Fallon Community Health Plan has established itself at the top of the charts for the past three years on the Centers for Medicare and Medicaid Services’ Medicare Advantage Star Ratings.  This year, the plan once again received 4.5 stars, an indicator of its commitment to – and success at – providing high quality health care to its members.

We spoke with Beth Foley, senior director of Quality Services at Fallon, about the health plan’s performance, including its strengths, areas of improvement and measures on which it is focusing.

Because of the plan’s history as an integrated staff model, in which preventive medicine is integral to patient care, Fallon has traditionally done very well on preventive and screening measures. A substantial portion of the health plan’s Medicare membership is seen by a provider network with which Fallon has a close working relationship.

It is due in part to this connection, along with a robust electronic medical record, that screening and preventive measures have remained a particular strength of Fallon’s. As Foley says, it is second nature to make sure members are getting their screenings. “That’s what we’re all about.”

Fallon also performed highly on the Care for Older Adults measure of the Star Ratings, pertaining to Medicare Advantage Special Needs Plan (SNP) enrollees (vulnerable populations who include dual-eligibles and those with chronic conditions). Foley attributes the plan’s significant improvement to supplemental data sources, more vigorous outreach to physicians and better documentation of medications and functional status assessments.

Fallon’s quality in this area is particularly significant to their members, as most of its members are in their 80s and 90s.

One of the most valuable aspects to the Star Ratings is the ability to benchmark data and set goals for improvement. There are always areas in which plans can improve, and the quality data facilitates these efforts. Currently, Fallon is focusing on the readmissions measure, which needs to be at 5 percent to receive top marks.

The plan is looking to bring the “navigator model,” used for its SNP NaviCare, into their general Medicare Advantage plan.

NaviCare, as Foley explains, is a highly successful care model that employs a comprehensive care team to look after patients. She expects that this will help to coordinate care, resulting in better medication adherence, better health outcomes and fewer readmissions.

Because of the ability to see how current performance stacks up against prior performance – as well as the ratings of other organizations – Fallon is able to set informed, attainable goals and focus on achieving them.

New Report: NCQA State of Health Care Quality 2012

Earlier this week, the National Committee for Quality Assurance released its annual State of Health Care Quality Report for 2012.

The report synthesizes quality data collected by the Healthcare Effectiveness Data Set (HEDIS®), one of the industry’s most widely-used performance improvement tools, according to NCQA’s press release.

The report finds that clinicians are placing increased emphasis on health and wellness promotion, and particularly on fighting obesity. The Adult Body Mass Index Assessment – a HEDIS® measure released in 2009 – was the most improved measure in 2012 of more than 40 quality measures.

The greatest gains were seen among Medicare plans, with an increase of 18 percentage points for HMOs and almost 26 percentage points for PPOs.

Medicare Advantage plans also had larger overall improvements than commercial or Medicaid plans, the report found.

View the entire report for a summary of significant changes in HEDIS® and Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures, as well as an overall assessment of health plan performance on each HEDIS® measure.

Quality Improvement Interview: Scott & White Health Plan

For 2012-2013, Scott & White Health Plan received five stars – the highest rating possible – on the Centers for Medicare and Medicaid Services’ (CMS) Medicare Advantage Star Ratings for their Part D plan. The Medicare Part D plan includes prescription drug coverage and is rated on measures such as customer service, member complaints, member experience with the drug plan and patient safety.

According to Charlotte Luebbert, director of Pharmacy Medicare Part D Services at Scott & White, the health plan is excelling in the areas of customer service, member experience and resolving member complaints. Scott & White is an integrated health system, meaning that in addition to a health plan, the organization includes a hospital and clinical provider network. Introducing new initiatives works well in this structure, as there are built-in lines of communication with members and providers.

Communication is integral to efficiency, coordinated efforts and physician buy-in. The plan corresponds with primary care physicians on a quarterly basis, with clinical messaging related to all lines of business. The method is well-received by all providers, Luebbert affirms.

Aided by an in-house customer service department, Scott & White is demonstrating success in improving customer service and keeping member complaints low. Service representatives are well educated on the plan’s Medicare Part D product, and provide members with efficient, accurate and personalized attention.

Another advantage to the plan’s pharmacy customer service department is the background of the representatives: All pharmacy call service agents are pharmacy technicians, meaning they possess a comprehensive understanding of pharmaceutical issues. Luebbert repeatedly emphasizes the importance of understanding to the representatives – the need to understand benefits, how to help members and alternatives at the point of service.

For example, member complaints are routed to specialized agents who are well versed in dealing with Medicare complaints, and who work with members to identify the roots of the issues. With such personalized service complaints are addressed efficiently and quickly.

In the Patient Safety domain, Scott & White has earned five stars on all of the medication adherence measures. These measures relate to Part D benefit design; Scott & White offers a generous maintenance benefit in which members are eligible for reduced copays for 90-day supplies of maintenance medications. Vice President of Pharmacy John Chaddick believes that this serves as an incentive for adherence. The plan’s clinical initiatives focus on making sure benefit designs are cost-conscious and give seniors benefits that encourage compliance.

Chaddick and Luebbert also highlight the plan’s focus on the High Risk Medication (HRM) measure, on which Scott & White’s rating improved from 2012 to 2013. A new initiative identifies and addresses the use of HRMs in the Medication Therapy Management (MTM) population, and provides targeted member and physician education to encourage use of alternative medications. Thanks to the plan’s direct communication with pharmacists, primary care physicians and patients, the initiative will be fully implemented in the next one to two months.

Effective communication is key to a quality member experience, emphasizes Luebbert. It is especially important to make sure that people have access to ample information during the open enrollment period, in which seniors can switch Medicare coverage options.

Quality Improvement Interview: Capital Health Plan

Since 2009, Tallahassee-based Capital Health Plan has been ranked among the top five commercial plans by NCQA. Capital came in as the third-highest ranked commercial plan in the nation for 2012-2013, continuing its trend of consistently exceptional quality performance. The health plan is also demonstrating marked quality improvement on the Medicare side:  It has been ranked among the top ten Medicare plans since 2008.

Nancy Van Vessem, M.D., Capital’s chief medical officer, attributes the plan’s performance to a range of factors, one of the most important being the maintenance of a focused and coordinated approach.

A health plan must have the desire to strive for high quality as measured by the NCQA standards,” and this focus must be written into a strategic plan, she says.

Every year, Capital staff and physicians reprioritize their performance strategy, focusing on measures that are most important to the health of their members. Many of these measures, relating to conditions such as diabetes and ischemic vascular disease, focus on disease management. The health plan’s extensive attention to these measures is evidenced in its performance – among diabetes measures, the plan is at or above the 90th percentile.

Chronic disease registries have been instrumental in maintaining adherence to quality measures by facilitating consistent screenings, leading to early detection and disease avoidance and ensuring that the most relevant, up-to-date information is available to physicians and specialists.

These registries — accessible through CHPConnect, Capital’s electronic portal — provide detailed lab information on patients, enabling physicians to coordinate care and monitor patients’ statuses. Thirty-five percent of patients are seen within Capital’s staff model, while the electronic medical record provides further assistance in reminding staff about needed care – both during the course of office visits and reminders between visits.

If patients are not getting the advised labs and have not responded to reminders, Capital will directly contact the patients with a letter, followed by a lab slip. If the patients use the lab slip and have their testing done, both the member and the primary care physician receive the results of the tests. This type of intervention, exhibiting a level of engagement unusual for a health plan, is central to keeping patients’ chronic conditions under control and preventing serious complications.

Many of these processes were already in play when NCQA started publishing their rankings in 2005, says Dr. Van Vessem. The plan has been highly-ranked since then on a variety of measures, including colorectal cancer screening, for which Capital has been ranked number one for all but one year that measure has been used. The colorectal cancer screening program started in 2002 – several years before the actual HEDIS® screening measure was developed – when physicians and staff noticed that screening rates were low (NCQA rankings are based upon HEDIS measures).

Dr. Van Vessem emphasizes that Capital follows a logical approach of monitoring HEDIS® measures throughout the year, identifying potential areas of improvement and communicating priorities to staff. By using EHRs to monitor patients, pull relevant data and follow up with patients, Capital has organized a work plan that prioritizes members’ health and wellness.

The evidence of its success is in the numbers.

Photograph courtesy of Capital Health Plan.

ACHP Members Rated Among Top Medicare Plans in the Country

Today, the Centers for Medicare and Medicaid Services (CMS) released its annual Medicare Advantage Star Ratings, a program intended to provide Medicare beneficiaries with additional information about health plans in their area and make quality data more transparent. Twenty-five percent of Medicare enrollees are enrolled in Medicare Advantage plans, which are rated on more than 50 quality measures, derived from multiple sources of data: CMS administrative data on plan quality and member satisfaction; the Consumer Assessment of Healthcare Providers and Systems (CAHPS®); the Healthcare Effectiveness Data and Information Set (HEDIS®); and the Health Outcomes Survey (HOS).

There are 580 Medicare Advantage plans, 46 of which are ACHP members. All Medicare Advantage plans are rated on a one- to five-star scale, with five stars representing excellent performance on the quality measures. Each year, ACHP member plans demonstrate superior performance on the ratings: Of the 11 plans that are rated five stars, eight of them are ACHP members. Thirty Medicare plans operated by ACHP members received five, 4.5 and four stars in the combined 2013 Medicare Advantage and Medicare Part D Star Ratings.

Patricia Smith, ACHP president and CEO, states that “by providing high-quality care and service to millions of Medicare beneficiaries, ACHP members are making sure the federal government – and American taxpayers – are getting the value they demand from Medicare Advantage plans.”

For more information, look to the CMS stars technical guide, released in early September, which includes measure thresholds with which plans can interpret raw scores. A blog post by Health Dialog offers some useful, distilled information on the six key points from the technical guide – in case you would prefer not to read the entire 113-page document. CMS released their latest version in conjunction with the Star Ratings release today.

We will also be releasing additional blog posts in the coming weeks that will focus on specific plans’ performances and other elements of the Star Ratings.

Putting the Patient in the Center: Star Ratings Congress for Medicare Advantage Plans

As I like to say, Medicare Advantage (MA) is one of the best kept secrets in Washington.  When it comes to creating better health, providing better health care, and lowering costs, MA plans are on a path to creating value, and a model for the future of our health care system.

Let’s start with some basics.

Today, one in four people with Medicare are enrolled in a Medicare Advantage plan.  In fact, as of January of this year, 12.8 million beneficiaries were enrolled in an MA plan. The number of seniors enrolling in MA plans is rising at a rate of 5 to 10 percent a year.  And the number of plans participating in the program is also rising.

Improving the quality of care and rewarding value in MA has long been a goal of Medicare policy experts.  And the drive toward these goals began nearly a decade ago when Congress began to consider policies to move MA – and the rest of the Medicare program — in this direction, including:

  • Under the Medicare Modernization Act of 2003, the Institute of Medicine (IOM) was directed to evaluate ways to improve quality and value. The IOM issued a 2006 report, “Rewarding Provider Performance: Aligning Incentives in Medicare,” that recommended Medicare begin to test pay for performance in the MA program.
  • Beginning in 2004, the Medicare Payment Advisory Commission (MedPAC) recommended that Congress establish a quality incentive payment policy for Medicare Advantage (MA) plans, reflecting its view that “one of Medicare’s most important goals is to ensure that beneficiaries have access to high quality health care.” With their history of measurement and accountability, private plans were a logical starting point for quality-based payments.
  • The Affordable Care Act (ACA) incorporated significant changes to the MA program, including a quality incentive program based on established quality metrics and a star ratings system, to start in 2012. At the same time, Congress established or extended quality reporting and payment requirements for hospitals, physicians, and other providers serving Medicare patients.

What we have seen is steady improvement on a wide range of quality measures year after year.  In a number of key clinical areas, Medicare Advantage plans perform at a higher level than their commercial counterparts.

I have the honor of working with a group of health plans that embraced the challenge Medicare laid out by providing high quality care to hundreds of thousands of seniors.  Some 98 percent of Medicare beneficiaries enrolled in an MA plan that received a 5-star quality rating from CMS (the highest possible rating) are in ACHP member plans.  In 2011, the National Committee for Quality Assurance (NCQA) ranked 17 ACHP Medicare plans among the top 25 in the country.

But instead of merely reiterating our successes, I’d like to share some of the things that we have learned over many years of pursuing higher quality care, even when the system didn’t provide any financial incentives.  Essentially, putting the patient at the center of care is critical; leadership and systems should be built around this central feature.

This commitment starts at the very top of an organization, meaning that CEOs and their leadership teams must send a clear message to staff, partners and communities that they hold themselves and their organizations accountable to better experiences of care for their patients.  Higher quality also requires systemic thinking, such as building new systems and processes that support safe, effective, patient-centered, timely, efficient and equitable care.  One aspect of this systemic thinking is building a close relationship between health plans and their provider partners – and once again, putting patients at the center.  A commitment to training and culture growth can pull an entire health care system toward a new organizational DNA – one that is all about better health, better health care and lower costs.

There has been some criticism recently about the ACA’s MA star ratings program, which links payment to quality and therefore creates incentives for the Medicare program to actually buy value.  I could offer a slew of statistics reaffirming the benefits of MA and paying for quality, but I think it would be more effective to share a story from one of our member plans, Priority Health in Grand Rapids, Michigan.

“Michael” is a member of Priority Health, and, like many Medicare beneficiaries, Michael suffers from multiple chronic conditions.  In fact, his health history includes diabetes, back pain, congestive heart failure, depression, and chronic obstructive pulmonary disease, among other conditions.

Before he joined an MA plan, Michael did not have a primary care physician, and was socially isolated and experiencing frequent hospitalizations. At the time, he was on a ventilator and his doctors were doubtful that he would recover.

Once he was enrolled in Priority Health’s MA plan, he chose a primary care physician, and a complex care management team worked to address barriers to Michael’s care.  They provided him with counseling on how to manage his chronic conditions. They taught him what he needed to know about his medications, and set up a home telemonitoring program.  As a result, Michael has avoided readmission for nearly ten months. He better understands how to manage his multiple conditions, and is enjoying a much better quality of life.  He even has a girlfriend now.

Health plans like Priority Health focus on quality outcomes, care coordination, and patient engagement. Instead of a long litany of uncoordinated services that run up a huge bill and deteriorate the patient’s quality of life, people like Michael – and there are millions of them in our country today – get the care they need, when they need it, from trained professionals who put the patient at the center of care.

-Patricia Smith
President and CEO, ACHP

Carrots, not Sticks: Focusing on Quality Performance

While policymakers in both parties argue over how to reshape Medicare for the future, the Medicare Advantage (MA) program is quietly and effectively getting the job done.

Consider these facts:

  • Today, nearly 1 in 4 Medicare beneficiaries have chosen to enroll in a MA plan — 12.8 million of Medicare’s 49 million beneficiaries.  I’m proud of the fact that ACHP member plans that offer Medicare Advantage enroll about 15 percent of the almost 13 million MA members.   MA plans are doing a better job at preventing unnecessary readmissions to hospitals by improving coordination of care and care transitions (also see ACHP’s recent Transitions of Care report);[1]
  • Beneficiaries with chronic conditions often get better care if they are enrolled in an MA plan —  for example, diabetics who are enrolled in MA plans see their doctors more often and go to the hospital less frequently than those who are in traditional fee-for-service Medicare;[2]
  • The number of beneficiaries enrolling in MA plans is rising at a rate of five to ten percent a year and the number of plans participating in the program is also rising.

Sadly, Medicare Advantage is often a political football, tossed and kicked in different directions by both parties. But such political contentiousness belies the true value of the program. By creating the combination of quality and payment incentives for patients and their providers to get the right care at the right time, Medicare Advantage has helped to manage costs and improve quality.  Health plans have led the way in the movement toward value-based purchasing by adding preventive health care and care coordination for high risk patients to the typical array of benefits.

The Medicare Advantage program’s  capitated payments promote cost savings and allow for flexibility to manage chronic disease and complex patient cases.  In addition, Medicare Advantage allows health plans to provide social supports and to fill in gaps where patients need care.

The benefits to patients are clear: with Medicare Advantage, beneficiaries’ total out-of-pocket costs are much more predictable and typically less than they would be using fee-for-service.  Moreover, MA members have guaranteed access to a network of qualified providers.  In an MA plan the problems that some fee-for-service patients face, such as limited access to providers, simply don’t exist.

And there’s another important difference between Medicare Advantage and traditional fee-for-service Medicare:  quality measurement.  Since 1997, MA plans have collected and reported data on their performance and the performance of their providers using evidence-based quality measures. This information helps to guide plans’ quality improvement efforts and provides Medicare consumers with detailed data about the performance of MA plans. That data forms the basis for Medicare’s “Five-Star” quality rating system that provides consumers with summary information about plans and their providers’ performance, as well as detailed drill-down data.  As a result, beneficiaries and the general public have robust information about the quality of the care delivered by MA plans and can choose the plan that best suits their health care needs.  This stands in stark contrast with traditional Medicare, which until recently has collected very little information about quality and customer service and provides consumers with much less comparative data.

The Affordable Care Act established a new program to reward plans that consistently provide high-quality care and service to their Medicare members. Under the law, MA plans that achieve either four or five stars for their performance are eligible for additional payments that reflect their investment in quality and service.  These quality incentives must be spent directly on enrollees to expand benefits, making it clear that the additional funding ultimately is intended to improve the health of members.  To incentivize more plans to improve, a demonstration program that provides incentive payments to Medicare Advantage plans with a star rating of three stars or above is in place for 2012, 2013 and 2014.

ACHP member plans have performed extremely well under this ratings system:  Seven of the MA plans offered by our members received 5 stars in 2012.  In fact, 98 percent of Medicare beneficiaries enrolled in a 5-Star Medicare Advantage plan are in an ACHP member plan.  And 70 percent of beneficiaries in plans with a star rating of 4.5 or better are members of an ACHP plan.

Medicare’s quality payments address three of the toughest problems in health care today:  by tracking performance on clinical measures that matter to consumers, such as consistent  care for diabetes patients, health and health care are improved; by grouping these clinical ratings with customer service ratings, consumers can make choices about where they will get the care and service they need; and by aligning payment with higher performance on clinical, satisfaction and access measures, we’re spending our Medicare dollars more wisely.

In short, health plans in Medicare Advantage have an incentive to provide high-quality services and to do so efficiently.  These quality-over-quantity incentives promote better care; they also give patients clear, evidence-based information about their health plans and providers.  Medicare beneficiaries can use the star system to help them select a high-quality plan that also emphasizes customer service.

What’s more, highly rated plans can, and should, be used as learning laboratories for Medicare innovation and program reform. Medicare Advantage provides a model for reform of traditional fee-for-service Medicare, transforming the way in which patients and providers access and deliver health care.  Let’s use it.

– Patricia Smith
President and CEO, ACHP


[1] “Hospital Readmission Rates in Medicare Advantage Plans.” American Journal of Managed Care. 2012; 18(2):96-104.

[2] “Medicare Advantage Chronic Special Needs Plan Boosted Primary Care, Reduced Hospital Use Among Diabetes Patients.”  Health Affairs, January 2012 31:1110-119.

(Image courtesy of Green Growth Cascadia)