Re-Evaluating Your Plan’s QI Evaluation and the Process Behind It.

This is the time of year when most plans have either completed, or are in the process of completing, their annual evaluation of their Quality Improvement (QI) Program Description and Work Plan for operating year 2014.  In the 12+ years I have worked for Gorman Health Group (GHG), I have seen a range of evaluations — from great evaluations to those that are just a couple of pages without content.  Let’s examine some mistakes and discuss some industry happenings that are often missed in the overall QI world.  Before we go on to discuss, let’s remind ourselves what the Centers for Medicare & Medicaid Services (CMS) is looking for in a QI Program Description, which is based upon the regulation 42 CFR § 422.152:

For each plan, a Medicare Advantage Organization must:

  1. Develop and implement a chronic care improvement program (CCIP) 42 CFR §422.152(c);
  2. Develop and implement a quality improvement project (QIP) 42 CFR §422.152(d);
  3. Develop and maintain a health information system (42 CFR §422.152(f)(1));
  4. Encourage providers to participate in CMS and HHS QI initiatives (42 CFR §422.152(a)(3));
  5. Implement a program review process for formal evaluation of the impact and effectiveness of the QI Program at least annually (42 CFR §422.152(f)(2));
  6. Correct all problems that come to its attention through internal surveillance, complaints, or other mechanisms (42 CFR §422.152(f)(3));
  7. Contract with an approved Medicare Consumer Assessment of Health Providers and Systems (CAHPS®) vendor to conduct the Medicare CAHPS® satisfaction survey of Medicare enrollees (42 CFR §422.152(b)(5)); and,
  8. Measure performance under the plan using standard measures required by CMS and report its performance to CMS (42 CFR §422.152(e)(i)).
  9. Develop, compile, evaluate, and report certain measures and other information to CMS, its enrollees, and the general public. Responsible for safeguarding the confidentiality of the doctor-patient relationship and report to CMS in the manner required cost of operations, patterns of utilizations of services, and availability, accessibility, and acceptability of Medicare-approved and covered services (42 CFR §422.516(a)).

Mistakes often seen:

Develop and maintain a health information system: Many plans have multiple platforms that make reporting — the validity and accuracy of — a nightmare! When a plan implements a new care management system, for example, the overall analysis of its performance is often not reported in the QI Work Plan or at the plan’s QI Committee. Yet, this is a vital piece to overall operational and quality success.  Ask yourselves: Did your plan implement a new system or module upgrade in plan year 2014, and do we know if it has improved our overall reporting and impacted any quality measures or our providers?

Recommendation: As part of a system upgrade or new system implementation project plan, include overall success reporting to the QI Committee.  This can include major milestones success or failure during implementation as well as a narrative summary of changes the plan and/or providers will experience upon completion of the project. Will there be new requirements for claims submission? A new clearinghouse?  A new provider portal sign-in process? Don’t forget all of your external and internal customers and the impact they may experience.

Plan goals for HEDIS: I often see goals set for middle-of-the-road success at or below the 50th percentile. While I am not encouraging setting unrealistic goals, many plans miss aligning their HEDIS goals with a 4 or 5 Star Rating corridor.  Now that CMS will be eliminating pre-determined benchmarks for plan year 2016, it will be even more important for HEDIS goals to be realigned with your plan’s Star strategy.  I also see many plans not include an improvement process or overall data analytics in their QI Work Plan showing how HEDIS measures actually improve overall population outcomes.  We really don’t want providers just checking a box that a test was completed — we want to understand if and how the HEDIS measures have possibly improved the overall health of our membership, and, if the outcomes are positive, how did this occur? Health plans often share data with providers regarding gaps in care but miss sharing any overall improved health outcomes so providers can see the successes of their efforts.

Recommendation: Consider adding true outcomes measures to specific HEDIS measures, especially those measures that affect your Medicare Advantage Prescription Drug (MA-PD) Plan or Special Needs Plan (SNP) population as a whole.  The goal of the evaluation is to effect improvement changes both in plan operations as well as clinical outcomes.

Correct all problems that come to its attention through internal surveillance, complaints, or other mechanisms: Many plans recognize they have multiple issues or problems which may come to their attention through internal monitoring and auditing, inter-rater reliability processes, or dashboard reporting.  These problems/issues, however, often do not make it to the QI process cycle.

Recommendation: Remember, when your plan discovers a risk area through internal monitoring or a high volume of complaints/Complaints Tracking Module complaints (CTMs) for a defined reason/category, it is the plan’s responsibility to institute a process which identifies a root cause, implements a corrective action, and measures the success of the corrective action.  Clinical and non-clinical activities are part of the overall QI process.

Lastly, let’s discuss the pay for performance or provider incentive plan process.  Many plans have instituted an incentive program designed to improve health outcomes, prevent acute readmissions, improve medication adherence, or improve preventive health services measures which reward physicians financially when goals are achieved.  Yet, many of the goals within a provider incentive program do not align with the goals for Star Ratings, goals within a Model of Care (MOC) for SNPs, nor do these payments align with improved overall outcomes for a population.

Recommendation: Overlay the benchmarks from your current provider incentive program to be sure they align with desired goals defined within your QI Work Plan and your Star Rating strategy.  Also evaluate your population health outcomes to determine if your incentive program is driving the results your plan desires.

If your plan is still an outlier in the completion of your program’s annual evaluation, GHG is ready to assist!



GHG’s clinical team of experts can assess your current quality program, and develop integrated strategies to build a new foundation focused on the areas that matter to you most: cost, quality and revenue. Visit our website to learn more >>

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Jane Scott
Jane Scott

Jane Scott is Senior Vice President of Population Health Management and Clinical Innovations at Gorman Health Group (GHG). In this role, she is responsible for leading GHG’s Clinical Innovations practice area. Jane brings GHG clients 37 years of experience in healthcare as one of the industry leaders on the topics of the Centers for Medicare & Medicaid Services (CMS) Special Needs Plans (SNPs), development and implementation of Models of Care (MOCs), as well as the Star Ratings Quality Bonus Payment Program. Her experience expands to the areas of quality improvement (QI), utilization and medical management, claims operations, and provider/associate education.

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