1

Using Data to Improve Quality and Performance

CMS Personnel

Jennifer Clark, RN, BSN

2

Objectives

Recognize the applicability of performance assessment data for quality improvement by CMS

Recognize opportunities of partnering with stakeholders to improve performance and quality

Outline data that can be used for cost containment, improve member outcomes and satisfaction, and increased compliance

3

Overview

Ramifications of low performance scores for for health plans and providersOverall ratings were related to

voluntary disenrollment ratesDecreased market credibility Poor health outcomesUltimately cost implications

4

Regional Utilization

Perspectives for RO considerationInternal trends for pre audit Regional trends for low composite

percentile rank nationally

5

Purpose

Purpose of using performance to improve quality:Measurement and reporting

performance dataPayment incentivesQuality Improvement initiativesConsumer comparative shopping

6

Trending for Pre-site Audit

Pre-site preparation for routine audit • Correlate performance scores with

potential worksheet audit review findings, operational areas, and interdepartmental areas (Medicare Advantage Manual, Chapter 5)

7

Regional Trends

Regional trends for lower or below composite percentile rank nationally Internal collaboration with

organizational components Collaboration with other stakeholders

• Regional Office Plan Managers • Quality Improvement Organizations • Accrediting Organizations.• State Agencies

8

Internal component collaboration

Examples of referencesCAHPS Improvement Guide Medicare Advantage Chapter 5NCQA Bridge of Excellence Tools

9

Example of CIG Responsibility Roster

10

Example of Organization Response

11

Example of collaborative alternatives

Collaborative efforts may be with all stakeholdersCMSQuality Improvement Plans StateAccrediting Organizations

12

Example of collaborative alternatives

State RO

QIO & AO

MAO

13

Conclusion

Recap of objectives Business & clinical outcomes

Appropriate care/cost containmentServices/Resource allocationCustomer Service/Consumer

Satisfaction

Cost containment will follow the quality of services

14

Questions

15

References

Levitan, S.E.; Shaller, D; McInnes, K.; Joyce, Coltin, K.L.; and Cleary, P.D. (2003).The CAHPS Improvement Guide: Practical Strategies for Improving Guide.