0. 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

1. 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.

2. 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.

3. 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?

4. 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

5. 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

6. 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

7. 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.

8. 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.

9. 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.

10. 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.

11. 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

12. 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

13. 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.

14. 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

15. 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.

16. For Further Conversation
Valerie Wilbur, Vice President
National Health Policy Group
Co-Chair, SNP Alliance
Phone:
National Health Policy Group
750 9th Street, NW
Suite 600
Washington DC 20001