The following information impacts APP Physicians with Medicare Advantage (MA) members.
Medicare Advantage (MA) Background
MA is a contracted Medicare plan offered by private insurers to provide Part A and B benefits. CMS rates each plan annually on how it performs in quality, utilization and patient experience on a scale of 1-5 stars, with 5 stars being the highest. The star ratings help members choose a high performing plan and determines the MA Quality Bonus Payment for systems and providers in the network. The star rating scale promotes the delivery of appropriate chronic care, preventative services and health outcomes.
Importance of Stars Performance
As the provider network in select MA plans, we submit quality data based on national guidelines. Results are publicly reported and members can access them to assist in selecting a high performing plan and provider. Financial incentives earned contribute to the Single Incentive Fund. Higher star ratings highlight quality care and potential to earn more incentives for distribution.
Performance Measures include:
- Breast Cancer Screening
- Colorectal Cancer Screening
- Osteoporosis Management in Women who had a Fracture
- Diabetes Care (Glycemic Status Assessment for Patients with Diabetes, Eye Exam, Kidney Health Evaluation)
- Controlling Blood Pressure
- Statin Therapy for Patients with Cardiovascular Disease
- Medication Adherence for Diabetes, Hypertension, and Statin Medications
- Statin Use in Persons with Diabetes (SUPD)
- Patient Experience: Getting Needed Care, Care Coordination, Provider/Patient Conversations, Access to Care
- Care of Older Adult: Functional Status Assessment, Medication Review, Pain Assessment
- Follow up After ED Visit for Patients with Multiple Chronic Conditions
- Plan All Cause Readmission
- Transition of Care: Aggregate-Notification of Inpatient Admission, Receipt of Discharge Information, Patient Engagement Post Discharge, Medication Reconciliation
Patient Experience and Health Outcome Surveys are also used to determine star ratings.
Opportunities for Improvement
- Encourage all patients to have an annual exam
- Capture all applicable Condition Mangement & Documentation coding
- Encourage patients to have all appropriate yearly screenings
- Ensure that medical record documentation is up to date and outside reports are stored in the EMR
- Outreach to patients for missing/out of date services and follow up
- Use of CPT II codes when appropriate
- Mammography screening: Advocate offers same day mammograms with same day results
- Colon Cancer Screenings: encourage FIT tests or the Direct Access Screening Colonoscopy program through Advocate hospitals, as appropriate
- Diabetes Care: encourage annual retinal screenings, diet and medication adherence, and Hemoglobin A1C control
- Controlling High Blood Pressure: encourage patients to monitor their own blood pressures, encourage diet and medication adherence, encourage follow up appointments for blood pressures that are out of control.
- Transition of Care: contact patients to schedule a follow up appointment, ideally within seven days of discharge, but before 30 days, in order to ensure a complete review of medications.
- Osteoporosis Management in Women with a Fracture: encourage women who have had a fracture to schedule a bone mineral density (DEXA) test to monitor for osteoporosis.
- Medication Adherence: encourage 90 day refills