Partnering to Improve CMS Star Ratings and Chronic Care Management

May 1, 2019

Partnering to improve CMS star ratings and chronic care management

Access to chronic care management, care coordination and avoidable hospitalizations are proven benefits of eConsults. These factors directly tie into CMS patient satisfaction star ratings and improving patient satisfaction, which are imperative for providers and healthcare organizations as patients select membership plans.

The Star Rating System

The Centers for Medicare & Medicaid Services (CMS) created a Five-Star Quality Rating System to help the healthcare consumer population, their families, and caregivers measure Medicare beneficiaries’ experience with their health plans and the healthcare system. The rating identifies areas the healthcare consumer needs to be reviewed in detail and queried.

Medicare plans are rated on a 1 to 5 scale. A 5-star rating represents the highest score. Higher star ratings signify better performance and quality—a more desirable plan.

  • 5-star rating: Excellent
  • 4-star rating: Above Average
  • 3-star rating: Average
  • 2-star rating: Below Average
  • 1-star rating: Poor

We will focus on Medicare plans providing health coverage that are evaluated within the following categories according to CMS:

  • Staying healthy: This rating is based on patient access to preventive services to promote continued health, including physical examinations, vaccinations like flu shots, and preventive screenings.
  • Chronic care management: Plans are rated for care coordination and how frequently members receive services for long-term health conditions.
  • Member experience: Overall satisfaction with the health plan.
  • Member complaints: A rating on how frequently members submitted complaints or left the plan, whether members had issues getting needed services, and whether plan performance improved from one year to the next.
  • Customer service: Plans are rated for quality of call center services (including TTY and interpreter services) and promptly processing appeals and new enrollments.

Immediate access to necessary care leads to improved patient outcomes and plan satisfaction. Curious as to how eConsults are improving patient satisfaction to increase Star ratings?

Ways eConsults Impact CMS Patient Satisfaction and Chronic Care Management

1. Star Measures C22 (Getting Needed Care) and C23 (Getting Appointments and Care Quickly)

General primary care process of scheduling regular specialist consultations for patient health issues.

Traditional care delivery system: A patient typically has to find an in-network specialist, make an appointment, wait for an appointment (often long wait times), travel to the specialist visits, then follow up with their PCP, which takes several weeks as well. The patient finally visits their PCP for follow-up guidance and treatment plan—at which point several weeks have passed.

Result: This patient received a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and is disappointed with the time it took to get the specialist visit they believed they needed based on the PCP referral. They give the health plan low marks due to the time it took to see the specialist, resulting in poor star scores and the loss of star bonus funds.

A contrast with the AristaMD eConsult care delivery system: The PCP will reach out to a specialist on the day of the patient encounter, then be able to follow up with the patient the next day, at the latest, with the next steps for their care and treatment. The appointment is scheduled for 1 to 2 weeks when the patient discusses a care plan with their PCP.

Result: This patient receives a CAHPS survey and is pleased that what used to take three months has taken a week or two. Their expectations are exceeded, giving the health plan high patient satisfaction scores. Star bonus dollars result from the star rating.

2. Star Measure C27 [Care Coordination (CAHPS)]

We are ensuring the closed loop for specialty referrals and patients receiving chronic care management.

Case highlight: A PCP needs assistance managing a patient with atrial fibrillation (AF) but wants to avoid losing the patient in referrals to specialists.

Traditional care delivery system: A patient waits 2 to 6 weeks to see a local cardiologist for an appointment referred by their PCP to manage the AF. At the meeting, necessary diagnostic tests are run. A follow-up appointment to discuss test results is then scheduled four weeks out. When the patient returns, their tests have come back, and a simple medication regimen is initiated.

Results: Care plan development took 8 to 11 weeks from referral to treatment. The PCP may not know about the patient’s treatment, have no idea if the specialist ordered tests for the patient, or changed the patient’s prescribed medications. This exhibits little and suboptimal care coordination, repeated tests, and multiple office visits resulting in increased cost.

A contrast with the AristaMD eConsult care delivery system: The PCP determines if the patient would benefit from the input of a cardiologist to ensure the condition is treated appropriately. The PCP reviews the eConsult checklist for AF and orders the recommended diagnostics test(s) such that the patient has a preliminary diagnostic profile for the cardiologist. The eConsult is submitted to a cardiologist who reviews the case details and diagnostic results and then recommends the patient be placed on a mild rhythm control medication and return to the PCP in 4 weeks for a follow-up check.

Result: In less than a week, the PCP obtained the input from a cardiologist that was needed to treat the patient’s AF condition and maintain coordination of the patient’s care. This was far less costly for the patient and payer due to avoiding multiple unnecessary tests and specialist visits.

3. Star Measure C21 [Plan All-Cause Readmissions Healthcare Effectiveness Data and Information Set (HEDIS)]

We are mitigating hospital readmissions.

Case highlight: A recently discharged patient is confused about how to best manage her new diagnosis of hepatitis C following multiple specialists and hospital visits, as well as new prescriptions and increasing symptoms.

Traditional care delivery system: The patient schedules a visit with her PCP two weeks after discharge. The PCP is surprised to learn she was hospitalized and listens as she explains the diagnosis given to her at the hospital. The PCP recommends she visit a gastroenterologist she saw while in the hospital to suggest the best treatment options.

Results: The specialist visit is scheduled relatively quickly—two weeks after the primary care visit. However, one week after the visit, the patient experiences severe abdominal pain and nausea, go back to the ER and is then readmitted to the hospital.

A contrast with the AristaMD eConsult care delivery system:  After seeing their patient newly diagnosed with hepatitis C, the PCP decides they would like specialist guidance to manage the patient. The PCP reviews the hepatitis C and chronic abdominal pain referral checklist and notes that the hospital recently performed tests. The PCP determines he has enough information based on the checklist and discussion with the patient to submit an eConsult. The eConsult is returned later that day. A specific drug regimen is recommended, as well as an immediate follow-up with the PCP to understand the short-term treatment plan.

The PCP meets with the patient two days later and carefully reviews her condition, the treatment plan, and return precautions for the PCP should she experience any problems or have any questions.

Results: The patient is reassured with the treatment plan and medication that is communicated to her and adheres to it, allowing her to manage symptoms and reduce the risk of readmission. In contrast, long-term treatment plans are made for her hepatitis C.

AristaMD’s eConsults replace 73% of Specialist Visits and Positively Impact Patient Care Plans >92% of the Time

This means PCPs can better manage patients by improving access to timely care and reducing the number of unnecessary specialist appointments that cause additional missed work, travel time, and out-of-pocket costs.

“Being able to use AristaMD for eConsults has been a game changer for our clinicians and patients.  Clinicians can maximize their skill set by having access to enhanced knowledge through the eConsults and simultaneously save patients the time and inconvenience it takes to go to a specialist’s office. Even in cases where a face-to-face with the specialist is still necessary, our clinicians can often initiate some treatments or order additional tests prior to the specialist visit based on the eConsultant’s recommendations.”

— Dr. Kelly Motadel, Child Health Officer at County of San Diego

There are many onboarding options, from same-day setup to customized organization workflows. eConsults fit within any existing patient referral workflow, with any EHR. Get in touch with us to discuss the best options to improve chronic care management at your organization.