CMS Evaluation of the Financial Alignment Demonstration and Special Considerations for Serving Special Needs Beneficiaries Valerie Wilbur Co-Chair, The SNP Alliance, Vice President, National Health Policy Group 8th Annual Leadership Forum November 1, 2012

Topics Considerations for FAD Evaluation. Considerations for Special Needs Performance Measurement. Specialty Care Measurement Challenges. CMS Preferred Standards for Quality. Overview of FAD Evaluation Framework.

Evaluation of Financial Alignment Demonstration: Key Considerations National comparative analysis. State specific components. Core measurement set. Potential Comparison Groups: FFS, MA, SNP, Medicaid MC, PACE, MLTC. Opportunity to develop new performance evaluation framework, test population and plan specific measures.

Key Considerations for Special Needs Performance Measurement Do measures evaluate whether plans are meeting special needs mandate or do they measure performance for standard Medicare population? Are measures and methods aligned with targeted subgroups served? Are measures streamlined within and across programs? Are performance measures aligned with Model of Care Requirements?

SNP Quality/Oversight SNP Approval: NCQA Model of Care Review Process. All standard MA measures (e.g., HEDIS, HOS, CAHPS). 16 SNP HEDIS measures reported at PBP level, including Care of Older Adults SNP Structure & Process Measures. Medicare and Medicaid Quality Improvement Measures (Medicare Clinical Quality Improvement Program and Quality Improvement Projects; SNP S&P Clinical Quality Improvement measure; Medicaid Performance Improvement Projects). Medicaid HEDIS, CAHPS, Functional Measures Medicaid Long Term Support Services

Unique SNP Identifiers MOC vs. S&P Measures Model of Care Defined population Measure-able goals Staff structure & care mgt roles Specialty networks Health Risk Assessment Individual Care Plan Interdisciplinary Care Team Communication network Model of Care network training Care Management for vulnerable enrollees Performance & health outcome measurement Structure and Process Complex Case Management Improving Member Satisfaction Clinical Quality Improvements Care Transitions ISNP Relationship with Facility Medicare/Medicaid Coordination from Duals

Measurement Challenges for SNPs and Special Needs Populations Disconnect between MOC, S&P, MA ratings Appropriateness of existing measures Bias of Star ratings Need for new, population-specific measures Validity and Reliability of self-report Validity of CAHPS satisfaction discounting Duplication between Medicare/Medicaid and across quality improvement requirements Inadequate risk-adjustment of metrics Lack of Benchmarks

CMS FAD Preferred Standards Quality Reporting: Strong, consistent quality oversight and monitoring requirements with core set of measures, including some current M&M measures. Quality Improvement: Integrated QI program, single entity receiving and reviewing report and measures. Quality Incentives: Plans not eligible for star bonuses. Plan payment withhold of 1%, 2% and 3% will create pool for bonus payments to earn back withholds.

CMS FAD Preferred Standards Model of Care (SNP requirements) Unified MOC attestations to 250 elements on 11 domains. Evidence-based model of care Annual comprehensive assessment of physical, functional, psychosocial health for all enrollees. Individual care plan with beneficiary/family input for all enrollees. Interdisciplinary care teams for all enrollees.

CMS Evaluation of Financial Alignment Demonstration CMS evaluation led by RTI Both state-specific analyses & meta-analysis are planned; states are encouraged to complement with monitoring and state evaluation. Multiple uses for measures in the evaluation and monitoring of demonstrations: Quality and performance measures in state-CMS demonstrations of Financial Alignment Models for Medicare-Medicaid Enrollees. CMS evaluation of the Medicare-Medicaid demonstrations.

CMS Evaluation of FAD Topics Include: Beneficiary health status and outcomes. Quality of care provided across care settings. Beneficiary access to and utilization of care across care settings, satisfaction and experience. Administrative and systems changes and efficiencies. Overall costs or savings for Medicare and Medicaid.

Quality Measures in Demos: Mass MOU gives a hint! Quality and Performance Measures for capitated model states will include measures that address: Access and availability Care coordination/transitions Health and well-being Mental and behavioral health Patient/caregiver experience Screening and prevention Quality of Life

Massachusetts MOU: Measures Tied to Withhold Year 1 Encounter Data Assessments conducted within 90 days Tracking demographic data Documentation of care goals Access to an IL-LRSS coordinator Consumer governance board Ensuring physical access Access to Care Customer Service Years 2 & 3 Plan all cause readmissions Annual flu vaccine FU after hospitalization for Mental Illness Screening for clinical depression/FU Initiation and engagement of Alcohol Drug Dependent Care Controlling blood pressure Reducing fall risk Part D medication adherence for oral diabetes meds Timely transmission of transition record Quality of life measure TBD

Preliminary Quality Measures in Massachusetts MOU NCQA SNP Structure and Process Complex care management, coordination of benefits, care transitions. Member Experience & Satisfaction Indicators Members choosing to leave the health plan CAHPS rating questions of plan & quality of care HOS question on improvement/maintenance of mental health Measures that include LTSS settings: Medication reconciliation; and Pressure ulcers among residents of LTC facilities.

Massachusetts MOU: State Specific Measures States will have opportunity to specify measures. MA preliminary state-specific measures include: Screening for dementia Tobacco use assessment and intervention BMI screening and follow-up Multiple psychotropic medications Unhealthy alcohol use screening & brief counseling Use of HIT at the point of care Care transition measure (3-item CTM) Pain assessment

RTI Evaluation Methods RTI team will have access to plan-reported measures and encounter data to calculate additional measures. Methods used in evaluation include qualitative and quantitative approaches: Site Visits; qualitative analysis of program data; focus group and key informant interview data. Tracking changes in utilization, cost, quality measures. Evaluating impact of demonstration on cost, quality and utilization measures; and Calculating savings attributable to the demo.

For Further Conversation Valerie Wilbur, Vice President National Health Policy Group Co-Chair, SNP Alliance Phone: 202-624-1508 Email: vswilbur@nhpg.org National Health Policy Group 750 9th Street, NW Suite 600 Washington DC 20001 www.nhpg.org