NY Manual
SHP Manual

New York Provider Manual
14.4 Focused Studies, Surveys and Investigations | 14.6 Quality Evaluation of Providers

14.5 Quality Improvement – Medicare


Healthfirst’s participation in the Medicare Advantage Program requires additional reporting requirements. The Program incorporates the mandatory quality standards for the Medicare program. The Medicare program is operated under the auspices of the U.S. Department of Health and Human Services – Centers for Medicare & Medicaid Services (CMS). It is expected that providers comply with the requirements of Healthfirst, CMS, and the Quality Improvement Organization (QIO) designated as the review agent for CMS, in order to meet these important initiatives that ensure our Medicare members receive the highest quality of care possible.
The Medicare Star Rating system, a program administered by the Centers for Medicare & Medicaid Services (CMS), measures the quality of Medicare Advantage plans and supports CMS efforts to drive improvements in Medicare quality and improve the level of accountability for the care provided by physicians, hospitals, and other providers. CMS publishes the Star Ratings each year to assist beneficiaries in finding the best plan for them and to determine MA Quality Bonus Payments.
The Star Ratings system is consistent with CMS’ Three Aims (better care, healthier people/healthier communities, and lower costs through improvements) with measures spanning the following five broad categories:

1. Outcomes

Outcome measures focus on improvements to a beneficiary’s health as a result of the care that is provided.

2. Intermediate Outcomes

Intermediate outcome measures help move closer to true outcome measures.

3. Patient Experience

Patient experience measures represent beneficiaries’ perspectives about the care they have received.

4. Access

Access measures reflect issues that may create barriers to receiving needed care.

5. Process

Process measures capture the method by which health care is provided.
Medicare members may be asked to provide feedback by answering up to three surveys per year. Not all Medicare members receive these three annual surveys:
1.     Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey: Provided to Medicare members to rate their satisfaction with their doctors and the plan. Members may be asked questions like:
·         In the last 6 months, not counting the times when you needed care right away, how often did you get an appointment as soon as you thought you needed one?
·         In the last 6 months, how often did your personal doctor seem informed and up-to-date about the care you got from specialists?
·         How often did your health plan’s customer service give you the information or help you needed?
2.     Health Outcomes Survey (HOS):  Provided to Medicare members to rate their physical and mental health. Members may be asked questions like:
·         In the past 12 months, did a doctor or other health provider advise you to start, increase, or maintain your level of exercise or physical activity?
·         Has your doctor or other health provider done anything to help prevent falls or treat problems with balance or walking?
·         Have you ever talked with a doctor, nurse, or other healthcare provider about leaking of urine?
3.     Health Risk Assessment (HRA) Survey:  The HRA survey is given to all plan members enrolled in a Special Needs Plan (SNP) once a year. Members are to complete the HRA survey within 90 days of enrolling in a SNP plan, and once a year after that. This survey asks about health status and to identify any health conditions or concerns a member may have.
The following measures are the standard reporting requirements for the Medicare products:
Access/Availability of Care
Access to Primary Care Doctor Visits
Appeals Auto-Forward
Appeals Upheld
Beneficiary Access and Performance Problems
Call Answer Timeliness
Disenrollment Reasons - Financial Reasons for Disenrollment
Disenrollment Reasons - Problems Getting Information about Prescription Drugs
Disenrollment Reasons - Problems Getting Needed Care, Coverage, and Cost Info
Disenrollment Reasons - Problems with Coverage of Doctors and Hospitals
Disenrollment Reasons - Problems with Prescription Drug Benefits and Coverage
Drug Plan Provides Current Information on Costs and Coverage for Medicare’s Website
Engagement of Alcohol or other Drug Treatment
Enrollment Timeliness
Foreign Language Interpreter and TTY Availability
Grievance Rate
Initiation of Alcohol or other Drug Treatment
Medicare Plan Finder – Stability
Plan Makes Timely Decisions about Appeals
Plan Submitted Higher Prices for Display on MPF
Reviewing Appeals Decisions
Timely Effectuation of Appeals
Timely Receipt of Case Files for Appeals
Transition monitoring - failure rate for all other drugs
Transition monitoring - failure rate for drugs within classes of clinical concern
Patient Experience
Aspirin Use and Discussion
Care Coordination
Complaints about the Health Plan
Computer Use Made Talking with Doctor Easier
Computer Used during Office Visits
Computer User by Doctor Helpful
Customer Service
Doctors who Communicate Well
Getting Appointments and Care Quickly
Getting Information from Drug Plan
Getting Needed Care
Getting Needed Prescription Drugs
Medical Assistance With Smoking and Tobacco Use Cessation
Members Choosing to Leave the Plan
Rating of Drug Plan
Rating of Health Care Quality
Rating of Health Plan
Reminders for Appointments
Reminders for Immunizations
Reminders for Screening Tests
Reminders to Fill prescriptions
Reminders to Take Medications
Medicare Plan Finder Price Composite
Medication Therapy Management Program Completion Rate for Comprehensive Medication Review
SNP Care Management
Process/Effectiveness of Care
Adult BMI Assessment
Annual Flu Vaccine
Annual Monitoring for Patients on Persistent Medications
Antidepressant Medication Management
Breast Cancer Screening
Care for Older Adults: Medication Review
Care for Older Adults: Functional Status Assessment
Care for Older Adults: Pain Screening
Colorectal Cancer Screening
Continuous Beta Blocker Treatment
Controlling High Blood Pressure
Diabetes Care: Eye Exam
Diabetes Care: Kidney Disease Monitoring
Diabetes Care: Blood Sugar Controlled
Drug-Drug Interactions
Follow-Up Visit after Hospital Stay for Mental Illness
Medication Reconciliation Post-Discharge
Non-Recommended PSA-Based Screening in Older Men
Osteoporosis Management in Women Who Had a Fracture
Pharmacotherapy Management of COPD Exacerbation
Pneumonia Vaccine
Rate of Chronic Use of Atypical Antipsychotics by Elderly Beneficiaries in Nursing Homes
Rheumatoid Arthritis Management
Testing to Confirm Chronic Obstructive Pulmonary Disease
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
High Risk Medication
Intermediate Outcome/
Effectiveness of Care
Medication Adherence: Diabetes
Medication Adherence: Hypertension
Medication Adherence: Cholesterol
Reducing the Risk of Falling (HOS)
Management of Urinary Incontinence in Older Adults (HOS)
Monitoring Physical Activity (HOS)
Osteoporosis Testing (HOS)
Improving or Maintaining Mental Health (HOS)
Improving or Maintaining Physical Health (HOS)
Plan All-Cause Readmissions
Health Plan Quality Improvement
Drug Plan Quality Improvement