PAM Section 4: Quality Management
On this page:
- Regulatory Requirements
- Healthcare Effectiveness Data and Information Set (HEDIS®)
- What are Medicare Star Ratings?
- Program Goals
- Program Activities
- Risk Management/Quality Concern Reporting
- Outcomes, Evaluations and Member-Based Studies
- Access and Availability
- Member and Provider Satisfaction
Regulatory Requirements
An effective Quality Management (QM) program must comply with the applicable federal and state standards. Compliance requires the collaborative efforts of Mount Carmel MediGold Health Plan and all network providers. Mount Carmel MediGold Health Plan must meet all regulatory requirements of the MA program, including required quality improvement projects, Stars and HEDIS, enrollee satisfaction surveys and surveys to assess enrollees’ understanding of their health outcomes.
The requirements Mount Carmel MediGold Health Plan must comply with regarding quality are published in the Medicare Managed Care Manual, Chapter 5. This chapter describes how Mount Carmel MediGold Health Plan must operate and perform quality measurement and improvement related to the delivery of health care and enrollee services. The chapter’s purpose is to assist MA organizations in developing quality assurance and performance improvement programs, as well as to provide CMS with a road map for monitoring the MA Plan’s Quality Management program.
The requirements in Chapter 5 include:
- Formal QM program with participation by network providers.
- Chronic Care Improvement Program (CCIP).
- Minimum performance levels in studies.
- Annually reported standard quality-related measures including Healthcare Effectiveness Data & Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Health Outcome Survey (HOS).
- Maintenance of a health information system that integrates all data necessary to implement the QM program.
- Identification and correction of significant systemic problems.
- Contract with the independent Quality Improvement Organization (QIO)
Healthcare Effectiveness Data and Information Set (HEDIS®)
HEDIS is a set of standardized performance measures. The purpose of HEDIS is to provide members with a means to assess the value they receive for their health care dollar and to hold health plans accountable for their performance. As a network provider, you may, at times, be required to assist in medical record data collection.
Currently, there are 91 measures across seven (7) domains of care. These domains are:
- Effectiveness of care
- Accessibility/availability of care
- Experience of care
- Relative resource use
- Utilization and risk-adjustment utilization
- Health plan descriptive information
- Measures collected using electronic clinical data systems
What are Medicare Star Ratings?
The CMS uses a 5-Star quality rating system to measure how well providers and Medicare Advantage health plans are delivering care to members. Successful collaboration with our providers and quality patient care for our members is very important to us. Ratings range from 1 to 5 stars, with 5 being the highest and 1 being the lowest.
The Star measures are made up of performance measures from HEDIS, CAHPS, HOS (measures comparison of members health plan assessment over 2 years), prescription drug program and CMS administrative data.
Star Ratings include measures applied to the following five (5) broad categories:
- Outcomes: Measures that reflect improvements in a member’s health.
- Intermediate outcomes: Measures that reflect actions taken with patients that assist in improving a member’s health status, i .e . controlling blood pressure.
- Patient experience: Measures that reflect the member’s perspectives of the care they receive.
- Access measures: Measures that reflect processes and issues that could create barriers to receiving needed care, i .e ., Plan makes timely decisions about appeals.
- Process measures: Those that capture the health care services provided to members who can assist in maintaining, monitoring or improving their health status.
Star Measures
The menu below provides a detailed breakdown of the HEDIS-related Star Measures. Select a star measure to view:
- Measure definition
- CMS weighting
- Eligible members
- Cut points to receive a 4-5 star rating in 2023 and 2024
Cut points are established by the Centers for Medicare and Medicaid Services and are updated annually.* For a complete copy of 2024 Stars (CY22) cut points for star ratings 1-5, please refer to the following spreadsheet: 2024 Stars Cut Points.
Measure Definition: % of women aged 50 to 74 years of age who had a mammogram to screen for breast cancer between October 1st two years prior to the measure year and Dec. 31 of the measure year.
CMS Weight: 1
Eligible Members: Women age 50 to 74.
2023 Stars (CY21) Cut Points
- 4 Star: ≥ 70% – <77%
- 5 Star: ≥ 77%
2024 Stars (CY22) Cut Points
- 4 Star: ≥ 71% – < 79%
- 5 Star: ≥ 79%
Measure Definition: >% of members 50 to 75 years of age who received either:
- A fecal occult blood test conducted in the measurement year;
- FIT DNA within 3 years;
- Sigmoidoscopy or CT Colonography within 5 year period;
- Colonoscopy within 10 year period
CMS Weight: 1
Eligible Members: Adults age 50 to 75.
2023 Stars (CY21) Cut Points
- 4 Star: ≥ 71% – < 79%
- 5 Star: ≥ 79%
2024 Stars (CY22) Cut Points
- 4 Star: ≥ 71% – < 80%
- 5 Star: ≥ 80%
Measure Definition: % of members who are 18 to 75 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90 mm Hg) during the measurement year.
CMS Weight: 3
Eligible Members: Hypertensive adults age 18 to 75.
2023 Stars (CY21) Cut Points
- 4 Star: ≥ 73% – < 80%
- 5 Star: ≥ 80%
2024 Stars (CY22) Cut Points
- 4 Star: ≥ 74% – < 82%
- 5 Star: ≥ 82%
Measure Definition: % of members who are 18 to 75 years of age with diabetes (Type 1 and/or Type 2) whose most recent HbA1c test is less than 9% in the measurement year.
CMS Weight: 3
Eligible Members: Diabetic adults age 18 to 75.
2023 Stars (CY21) Cut Points
- 4 Star: ≥ 75% – < 83%
- 5 Star: ≥ 83%
2024 Stars (CY22) Cut Points
- 4 Star: ≥ 80% – < 87%
- 5 Star: ≥ 87%
Measure Definition: % of members who are 18 to 75 years of age with diabetes (Type 1 and/or Type 2) who have received a comprehensive diabetic eye exam in 2020. Diabetic eye exams from 2019 will count to close the measure if the result was negative for diabetic retinopathy.
CMS Weight: 1
Eligible Members: Diabetic adults age 18 to 75.
2023 Stars (CY21) Cut Points
- 4 Star: ≥ 71% – < 79%
- 5 Star: ≥ 79%
2024 Stars (CY22) Cut Points
- 4 Star: ≥ 73% – < 81%
- 5 Star: ≥ 81%
Measure Definition: % of emergency department (ED) visits for members 18 years and older who have multiple high-risk chronic conditions who had a follow-up service within seven days of the ED visit.
CMS Weight: 1
Eligible Members: Members age 18 and older who are discharged from an emergency department.
2023 Stars (CY21) Cut Points
- 4 Star: N/A§
- 5 Star: N/A§
2024 Stars (CY22) Cut Points
- 4 Star: ≥ 60% – < 68%
- 5 Star: ≥ 68%
Measure Definition: % of members with a RX for cholesterol medications (statin) who fill their RX often enough to cover 80% or more of the measurement year.
CMS Weight: 3
Eligible Members: Members age 18 and older who receive two or more RX for statin.
2023 Stars (CY21) Cut Points
- 4 Star: ≥ 88% – < 92%
- 5 Star: ≥ 92%
2024 Stars (CY22) Cut Points
- 4 Star: ≥ 88% – < 91%
- 5 Star: ≥ 91%
Measure Definition: % of members with a RX for diabetes medications who fill their RX often enough to cover 80% or more of the measurement year.
CMS Weight: 3
Eligible Members: Members age 18 and older who receive two or more RX for diabetes medications.
2023 Stars (CY21) Cut Points
- 4 Star: ≥ 88% – < 92%
- 5 Star: ≥ 92%
2024 Stars (CY22) Cut Points
- 4 Star: ≥ 88% – < 90%
- 5 Star: ≥ 90%
Measure Definition: % of members with a RX for blood pressure medications who fill their RX often enough to cover 80% or more of the measurement year.
CMS Weight: 3
Eligible Members: Members age 18 and older who receive two or more RX for a RAS medications.
2023 Stars (CY21) Cut Points
- 4 Star: ≥ 89% – < 91%
- 5 Star: ≥ 91%
2024 Stars (CY22) Cut Points
- 4 Star: ≥ 89% – < 91%
- 5 Star: ≥ 91%
Measure Definition: % of plan members who had a follow up visit to their PCP to reconcile discharge and current medications within 30 days from being discharged from an acute/nonacute facility.
CMS Weight: 1
Eligible Members: Members discharged from an acute or non-acute inpatient facility.
2023 Stars (CY21) Cut Points
- 4 Star: ≥ 69% – < 82%
- 5 Star: ≥ 82%
2024 Stars (CY22) Cut Points
- 4 Star: ≥ 68% – < 82%
- 5 Star: ≥ 82%
Measure Definition: Evaluates the accuracy of drug prices posted on the MPF tool.
CMS Weight: 1
Eligible Members: N/A, plan measure.
2023 Stars (CY21) Cut Points
- 4 Star: ≥ 93% – < 97%
- 5 Star: ≥ 97%
2024 Stars (CY22) Cut Points
- 4 Star: ≥ 98% – < 99%
- 5 Star: ≥ 99%
Measure Definition: % of Medication Therapy Management (MTM) program enrollees who received a Comprehensive Medication Review (CMR) during the reporting period.
CMS Weight: 1
Eligible Members: Members who had a pharmacist (or other health professional) help them understand and manage their medications.
2023 Stars (CY21) Cut Points
- 4 Star: ≥ 82% – < 89%
- 5 Star: ≥ 89%
2024 Stars (CY22) Cut Points
- 4 Star: ≥ 85% – < 92%
- 5 Star: ≥ 92%
Measure Definition: % of women 67-85 years of age who suffered a fracture between July 1 of the prior year and June 30 of the measure year. And who had a bone mineral density test or prescription for a drug to treat osteoporosis in the six months following the fracture date.
CMS Weight: 1
Eligible Members: Women age 67 to 85.
2023 Stars (CY21) Cut Points
- 4 Star: ≥ 55% – < 73%
- 5 Star: ≥ 73%
2024 Stars (CY22) Cut Points
- 4 Star: ≥ 55% – < 71%
- 5 Star: ≥ 71%
Measure Definition: % of acute inpatient stays during the measurement year were followed by an unplanned acute readmission for any diagnosis within 30 days, for members 65 years of age and older.
CMS Weight: 1†
Eligible Members: Acute inpatient stays for members age 65 and older.
2023 Stars (CY21) Cut Points
- 4 Star: N/A§
- 5 Star: N/A§
2024 Stars (CY22) Cut Points
- 4 Star: > 8% – < 10%
- 5 Star: < 8%
Measure Definition: % of males 21 to 75 years of age and females 40 to 75 years of age, who were identified as having clinical atherosclerotic cardiovascular disease (ASVCD) and were dispensed at least on high or moderate-intensity statin medication during the measurement year.
CMS Weight: 1
Eligible Members: Male adults age 21 to 75; Female adults age 40 to 75.
2023 Stars (CY21) Cut Points
- 4 Star: ≥ 85% – < 89%
- 5 Star: ≥ 89%
2024 Stars (CY22) Cut Points
- 4 Star: ≥ 86% – < 90%
- 5 Star: ≥ 90%
Measure Definition: % of members who were dispensed medications for diabetes and received a statin medication.
CMS Weight: 1
Eligible Members: Adults age 40 to 75 with at least two fills with unique dates of service in the targeted drug class(es) during the measurement period.
2023 Stars (CY21) Cut Points
- 4 Star: ≥ 86% – < 90%
- 5 Star: ≥ 90%
2024 Stars (CY22) Cut Points
- 4 Star: ≥ 88% – < 92%
- 5 Star: ≥ 92%
Measure Definition: % of discharges for members 18 years of age and older who had each of the following:
- Notification of Inpatient Admission: Documentation of receipt of notification of inpatient admission on the day of admission through two days after the admission (three total days).
- Receipt of Discharge Information: Documentation of receipt of discharge information on the day of discharge through two days after the discharge (three total days).
- Patient Engagement After Inpatient Discharge. Documentation of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days after discharge.
- Medication Reconciliation Post-Discharge. Documentation of medication reconciliation on the date of discharge through 30 days after discharge (31 total days).
CMS Weight: 1
Eligible Members: Members that are discharged from an acute and nonacute inpatient facility.
2023 Stars (CY21) Cut Points
- 4 Star: N/A§
- 5 Star: N/A§
2024 Stars (CY22) Cut Points
- 4 Star: ≥ 64% – < 78%
- 5 Star: ≥ 78%
*CY23 cut points to be released in October 2024.
§ New measure, cut points to be released October 2023.
† Star weight increases to 3 in CY23.
Program Goals
The Mount Carmel MediGold Health Plan QM program is a comprehensive program designed to comply with regulatory requirements to monitor the quality of care and services provided by the Mount Carmel MediGold Health Plan delivery system. This includes administrative activities of the Plan and its contracted providers.
The program’s purpose is to pursue opportunities for improving medical care, service and the well-being of our members. The focus is on continuous quality improvement with a constant eye on how care and services can be provided at a higher level of quality. Dedicated Mount Carmel MediGold Health Plan resources are allocated to conduct ongoing quality assessment of performance toward goals with problem resolution, as necessary.
The QM program focuses on three dimensions of health care delivery:
- Delivery system structure itself
- Processes involved in delivering health care
- Results of care delivery
By continuously monitoring and evaluating these three dimensions of health care delivery, Mount Carmel MediGold Health Plan constantly strives to provide the highest quality care in the most appropriate setting in the most efficient manner to attain the utmost satisfaction of Mount Carmel MediGold Health Plan members.
Program Activities
A variety of activities are involved in implementing the Mount Carmel MediGold Health Plan QM program including, but not limited to, the following:
- Risk management/quality concern reporting.
- Monitoring of member service activities, including complaints, appeals and grievances.
- HEDIS data collection/monitoring.
- Member satisfaction surveys.
- Member-based performance improvement projects/studies.
- Provider-based performance improvement.
- Physician access and availability surveys.
- Review of quality concerns for each physician at the time of recredentialing.
- Required data reporting to CMS, such as hospital acquired conditions and serious reportable adverse events.
Risk Management/Quality Concern Reporting
The goal of Risk Management, a component of the QM program, is to control and minimize possible risks arising in the direct provision of care, as well as risks associated with administration of the Plan. The Risk Management/Quality Concern Reporting Form provides a reporting mechanism for contracted providers to report risk management cases or quality concerns. This reporting mechanism is used to identify cases/incidents with potentially serious, undesirable and/or unexpected occurrences that may include loss of life, limb or function or has the potential to adversely affecMount Carmel MediGold Health Plan’s reputation. If there is a risk management or quality concern issue in your office regarding a member, please contact Mount Carmel MediGold Health Plan England’s QM Department at the email listed in the Contact Us section of this manual.
Outcomes, Evaluations and Member-Based Studies
The outcomes of clinical care are measured in the following terms: improved health, illness and death reduction, whether the treatment or therapy improved outcome as planned, whether the medical action positively altered the course of the disease’s natural history and whether clinical actions taken provided positive outcomes. Outcomes evaluation identifies potentially adverse events resulting from quality issues. Adverse outcomes identified in significant number or scope are investigated and member-based studies are conducted to improve measurable outcomes.
Access and Availability
An additional measure of quality is the access to care and availability for our members. Access means that medically necessary care is available in a timely manner and that members are able to schedule appointments and obtain any required referrals, as indicated, based on clinical needs. Availability means that Mount Carmel MediGold Health Plan has made arrangements for the provision of all covered services to members by the proper types, mix and number of network providers. The standards for measuring the adequacy of access and availability are stipulated in the Mount Carmel MediGold Health Plan Provider agreement and Mount Carmel MediGold Health Plan’s Network Practitioner’s Access and Availability Standards.
The access and availability requirements which have been approved by Mount Carmel MediGold Health Plan’s Quality Management Committee are as follows:
- Telephone coverage service 24 hours a day, seven (7) days a week.
- Member calls returned within 24 hours. This includes attempts made to members by leaving voice mail messages, leaving verbal messages with other relatives, etc.
- Urgent appointments scheduled with the PCP or a network PCP acting on your behalf within three days of the request. Urgent appointments are identified as any convolution of persistent symptoms which are perceived urgent by a prudent layperson or that may endanger members not seen within 48 hours.
- Routine appointments are scheduled by the PCP or a network PCP acting on your behalf within ninety (90) days of request.
- Members with a concern they view as needing medical attention prior to routine appointments, under the assistance of health plan case management, may be requested for access within the 90-day timeframe.
- Covered services are provided in a culturally competent manner to all members including those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds and physical or mental disabilities.
- Members have timely access to copies of pertinent information from their medical records.
- Compliance with standards is evaluated by reviewing medical records, claims and encounter history, scheduling systems and records, complaints and grievances, and member satisfaction and disenrollment surveys.
Member and Provider Satisfaction
Mount Carmel MediGold Health Plan monitors members’ perceptions of the quality of care and services received. Member satisfaction is considered an indicator of the success of an organization in providing quality care.
Mount Carmel MediGold Health Plan assesses member satisfaction using the following sources of information: member complaints and grievances, PCP change requests, and random sampling by CMS through use of standardized disenrollment surveys and member satisfaction surveys. Mount Carmel MediGold Health Plan may also periodically conduct independent provider and member satisfaction surveys to assess provider access and availability, members’ perception of access to care and services, wait times, referrals, explanations of care, members’ education and members’ participation in the decision-making process to meet their health care goals.
Mount Carmel MediGold Health Plan also monitors providers’ perceptions of the quality of administrative services provided by Mount Carmel MediGold Health Plan. Network provider surveys are periodically conducted to evaluate provider satisfaction and identify areas for improvement.