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CMS Pushing Hard To Launch Medicare-Medicaid Plan Star Program

CMS Pushing Hard To Launch Medicare-Medicaid Plan Star Program

With its success with the Medicare Advantage Star program and its role as national healthcare shutterstock_206718085_stars_man_thinking.jpgpolicy-maker and czar, the Centers for Medicare and Medicaid Services (CMS) is pushing hard to begin fostering quality attainment in other lines of business.

CMS has long been frustrated with quality outcomes in the Medicaid program and has recently announced two main reform efforts. First, in its proposed Medicaid “Uber rule” (meant to foster overall accountability in the system in general), CMS calls for Medicaid agencies to adopt a quality incentive program in each state. Second, it has published a draft proposal for its Medicare-Medicaid Plan (MMP) Star program (also known as dual demonstration projects).

CMS has already adopted an interim strategy for quality incentive performance in each of the dual demonstration contracts in a number of states. Generally, it focuses on a three-year timeline of quality achievement, with light administrative-based reform metrics early on and growing into a more mature combination of clinical and survey metrics over time.

In its proposed formal Star program for MMP plans, CMS builds on the success of the broader Medicare Advantage program (using existing measures) and will also leverage Medicaid and MMP quality program successes in a number of states. Given the concern about the challenges Special Needs Plans (SNPs) have in attaining high achievement due to the socio-economic and healthcare challenges faced by their populations, the MMP Star program could also be the basis for a better rating system for these plans.

The proposed MMP Star program would focus on a number of overall goals:

  • Foster attainment of the six goals of the CMS Quality Strategy
    • Community Integration/Long-Term Services and Supports (LTSS)
    • Management of Chronic Conditions/Health Outcomes
    • Prevention: Screenings, Tests, and Vaccines
    • Safety of Care Provided
    • Member Experiences with Health Plan and Care Providers
    • Plan Performance on Administrative Measures
  • Measure quality across the full spectrum of Medicare and Medicaid services, including LTSS and treatment of behavioral health and substance abuse
  • Reflect the care and quality-of-life goals of the populations served by MMPs
  • Address the measurement goals for Medicare-Medicaid enrollees identified by stakeholders

CMS notes that it will build measures to stress outcomes over process and minimize plan and provider reporting burdens by limiting the overall number of measures. The use of encounter data and existing reporting mechanisms will be emphasized. But as plans know, the reality is that quality reporting is a burdensome enterprise and the conversion to encounter-data actually raises stakes for plans.

The MMP Star program, too, would seek to measure achievement not only among MMPs, but also against Medicare Advantage Prescription Drug Plans and the traditional fee-for-service (FFS) Medicare environment.

CMS plans on weighting both the Community Integration/LTSS domain and the Management of Chronic Conditions/Health Outcomes domains at about one quarter of the overall MMP star ratings total. The rationale is that the MMP demonstration would integrate and promote quality in the two public programs, ensure community placement for as long as possible, as well as recognize the higher co-morbidity of the dual eligible populations. The other four might be weighted at about 12.5% each.

CMS admits that some challenges remain in crafting an appropriate MMP Star program. Gaps clearly exist in adequately assessing quality outcomes in certain areas. CMS is working with a number of organizations focused on the dual eligible populations to refine both clinical and survey measures to recognize the unique needs and characteristics of dual eligibles and special needs populations. What is known is the following:

  • Health risk assessment engagement and completion will remain a key focus.
  • Care plans and inter-disciplinary care teams (ICTs) will be major priorities.
  • Avoidance of hospital admissions and readmissions will be stressed.
  • Looking at both physical and mental health outcomes is a must.

What is impressive about CMS’ approach is moving from a general focus on quality to assessing unique characteristics of various communities in the healthcare system and seeking to hold providers and plans accountable for care delivery. It will mean challenges ahead for plans, but not doing so will amount to a series of half measures in an American healthcare system in desperate need of cost-efficiency and outcome achievement.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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