2012 CMS 5-STAR PERFORMANCE MEASURES by DATA SOURCE

HEDIS:

Healthcare Effectiveness Data and Information Set. Measures health plan performance on health care and service. HEDIS data are collected through surveys; medical chart reviews; and insurance claims for hospitalizations, medical office visits, and procedures. The measurement year is typically a calendar year, but will vary by measure. Each year, NCQA will collect HEDIS data for services covered in the previous year.

This means the measures you are impacting now will be collected the following year AND will not be reflected in iCares 5-Star HEDIS scores until TWO YEARS LATER!

1. MEASURE: Breast Cancer Screening

2. MEASURE: Colorectal Cancer Screening 3. MEASURE: Cholesterol Screening 4. MEASURE: Glaucoma Testing

NUMERATOR: % of Denominator that had a mammogram during the measurement year or the year prior to the measurement year. DENOMINATOR: Number of female enrollees aged 42 to 69 NUMERATOR: % of denominator that had an appropriate screening for colorectal cancer DENOMINATOR: Number of enrollees aged 51 to 75 NUMERATOR: % of denominator who had LDL-C test during year (and for diabetics the year prior) DENOMINATOR: Enrollees with either ischemic vascular disease or diabetes

5. MEASURE: Access to Primary Care Doctor Visits 6. MEASURE: Diabetes Care Eye Care

NUMERATOR: % of denominator who had at least 1 glaucoma exam by an eye Dr. during year or year prior DENOMINATOR: Enrollees aged 67 or older without a prior diagnosis of glaucoma NUMERATOR: % of denominator that had an ambulatory/preventive care visit during year DENOMINATOR: All enrollees NUMERATOR: % of denominator who had a retinal or dilated eye exam by an eye care professional DENOMINATOR: Diabetic enrollees NUMERATOR:

7. MEASURE: Diabetes Care Kidney Disease Monitoring

8. MEASURE: Diabetes Care Blood Sugar Controlled

NUMERATOR:

% of denominator who either had a urine microalbumin test during the measurement year, or who had received medical attention for nephropathy during the measurement year DENOMINATOR: Diabetic enrollees % of denominator whose most recent HbA1c level is greater than 9, or who were not tested during the measurement year. DENOMINATOR: Diabetic enrollees

9. MEASURE: Diabetes Care Cholesterol Controlled 10. MEASURE: Diabetes Care Cholesterol Screening

NUMERATOR: % of denominator whose most recent LDL-C level during the measurement year was 100 or less DENOMINATOR: Diabetic enrollees NUMERATOR: MA enrollees 18-75 with diabetes (type 1 and type 2) who had an LDL-C screening test performed during the measurement year DENOMINATOR: MA enrollees 18-75 with diabetes (type 1 and type 2) NUMERATOR: % of denominator whose most recent chart notation of systolic BP was 140 or less and diastolic BP was 90 or less during the measurement year th DENOMINATOR: Sampled MA enrollees with hypertension on or before June 30 of the measurement year.

11. MEASURE: Controlling Blood Pressure

12. MEASURE: Rheumatoid Arthritis Management

NUMERATOR: % of denominator who received at least one prescription for a disease modifying anti-rheumatic drug (DMARD) DENOMINATOR: Enrollees diagnosed with rheumatoid arthritis during year

13. MEASURE: Osteoporosis Management NUMERATOR: Female MA enrollees 67 and older who suffered a fracture during the measurement year, and who subsequently had either a bone mineral density test or were prescribed a drug to treat or prevent osteoporosis in the six months after the fracture. DENOMINATOR: Female MA enrollees 67 and older who suffered a fracture during the measurement year

14. MEASURE: Adult BMI Assessment [Checking to See if Members are at a Healthy Weight]
NUMERATOR:

15. MEASURE: Care for Older Adults Medication Review [Yearly Review of All Medications and Supplements Being Taken] NUMERATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older who received at least one medication review (Table COA-B) conducted by a prescribing practitioner or clinical pharmacist during the measurement year and the presence of a medication list in the medical record. DENOMINATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older. 16. MEASURE: Care for Older Adults Functional Status Assessment [Yearly Assessment of How Well Plan Members Are Able to Do Activities of Daily Living] NUMERATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older who received at least one functional status assessment during the measurement year. DENOMINATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older. 17. MEASURE: Care for Older Adults Pain Screening [Yearly Pain Screening or Pain Management Plan] NUMERATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older who received at least one pain screening or pain management plan during the measurement year. DENOMINATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older 18. MEASURE: Plan All-Cause Readmissions [Readmission to a Hospital within 30 Days of Being Discharged] (Lower percentages are better because it means fewer members are being readmitted) NUMERATOR: Senior plan members discharged from hospital stays who were readmitted to a hospital within 30 days, either for the same condition as their recent hospital stay or for a different reason. DENOMINATOR: Plan enrollees 66 years and older

Members 18-74 years of age who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior the measurement year. DENOMINATOR: Members 18-74 years of age

CAHPS:

19. MEASURE: Annual Flu Vaccine

Consumer Assessment of Health Providers and Systems. CAHPS is an annual member survey conducted in February to June asking members to report on and evaluate their experiences with health care which means it measures not only their satisfaction with iCare but their doctors and other health care providers as well.

20. MEASURE: Pneumonia Vaccine

NUMERATOR: % of denominator who reported receiving a flu vaccine between Sept-Dec DENOMINATOR: Sampled enrollees NUMERATOR: % of denominator who reported ever receiving a pneumococcal vaccine. DENOMINATOR: Sampled enrollees Mean of CAHPS Composite converted to a scale from 0 to 100 that includes the following questions:

21. MEASURE: Ease of Getting Needed Care and Seeing Specialists

22. MEASURE: Getting Appointments and Care Quickly

In the last 6 months, how often was it easy to get appointments with specialists? In the last 6 months, how often was it easy to get the care, tests, or treatment you needed through your health plan?

Mean of CAHPS Composite converted to a scale from 0 to 100 that includes the following questions:

23. MEASURE: Overall Rating of Health Care Quality

In the last 6 months, when you needed care right away, how often did you get care as soon as you thought you needed? In the last 6 months, not counting the times when you needed health care right away, how often did you get an appointment for your health care at a doctor's office or clinic as soon as you thought you needed?

Mean of CAHPS Composite converted to a scale from 0 to 100 that includes the following questions:

24. MEASURE: Overall Rating of Health Plan

your health plan?

Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate your health care in the last 6 months?

Mean of CAHPS Rating converted to a scale from 0 to 100 for the following question: Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate

25. MEASURE: Customer Service

Mean of CAHPS Composite converted to a scale from 0 to 100 that includes the following questions:

In the last 6 months, how often did your health plans customer service give you the information or help you needed? In last 6 months, did your health plans customer service treat you with courtesy and respect? In the last 6 months, how often were the forms for your health plan easy to fill out?

HOS:

Medicare Health Outcomes Survey - conducted annually from April to August. Questions focus on members personal assessment of their health as well as their satisfaction with their health care providers. HOS is unique in that the same people surveyed every two years, and the data from the initial survey is compared to the second one.

26. MEASURE: Improving or Maintaining Physical Health 27. MEASURE: Improving or Maintaining Mental Health

NUMERATOR: % of denominator whose physical health status was better than expected or remained the same DENOMINATOR: Sampled enrollees NUMERATOR: % of denominator whose mental health status was better than expected or remained the same. DENOMINATOR: Sampled enrollees

28. MEASURE: Monitoring Physical Activity

NUMERATOR:

29. MEASURE: Improving Bladder Control

NUMERATOR:

% of denominator who had a Drs visit in the past 12 months and who received advice to start, increase, or maintain their level exercise or physical activity DENOMINATOR: Sampled enrollees 65 years of age or older % of Percentage of denominator who reported having a urine leakage problem in the past 6 months and who received treatment for their current urine leakage problem. DENOMINATOR: Members 65 years or older

30. MEASURE: Reducing the Risk of Falling

NUMERATOR:

% of denominator seen by a practitioner in the past 12 months who received fall risk intervention from current practitioner DENOMINATOR: Members 65 years of age or older who had a fall or had problems with balance or walking in the past 12 months.

CMS DATA

Data collected directly by CMS about iCare.

31. MEASURE: Complaints about the Health Plan

32. MEASURE: Plan Makes Timely Decisions about Appeals

CALCULATION: [(Number of complaints logged into the Complaint Tracking Module (CTM)) Average Medicare enrollment)] x 1,000 x 30 (Number of Days in Period) NUMERATOR: % of appeals timely processed by the plan DENOMINATOR: All the plans appeals cases decided by the IRE (excluding dismissed cases and cases with unknown timeliness) NUMERATOR: % of appeals cases where a plans decision was upheld by the IRE DENOMINATOR: All the plans cases (upheld & overturned cases only) that the IRE reviewed NUMERATOR: The number of members who chose to leave the plan anytime during the measurement period. DENOMINATOR: All members enrolled in the plan at any time during the measurement period. Percent of the time a foreign language interpreter or TTY/TDD service was available to callers who spoke a foreign language or were hearing impaired. The calculation of this measure is the number of successful contacts with the interpreter or TTY/TDD divided by the number of attempted contacts.

33. MEASURE: Fairness of Health Plans Denials to Members Appeal, Based on IRE 34. MEASURE: Members Choosing to Leave the Health Plan

35. MEASURE: Availability of TTY/TDD and Foreign Language Interpretation

36. MEASURE: Beneficiary Access and Performance Problems [Problems Medicare Found in Members Access to Services and in the Plans Performance]

Findings of CMS audits, ad hoc, and compliance actions that occurred during the 14 month past performance review period. This measure is based on CMS performance audits of health and drug plans, sanctions, civil monetary penalties (CMP) as well as Compliance Actions Module (CAM) data (this includes: notices of non-compliance, warning letters, and ad-hoc corrective action plans (CAP) and the CAP severity).