Understanding the importance of Medicare Stars
Quality Metrics Categories and How They are Measured
Quality metrics categories
Medicare Advantage health plans are rated on how well they perform in the following five categories. The 50+ quality metrics are divided into the following categories:
- Category 1: Staying healthy. Evaluates how often members receive screening tests, vaccines, checkups, and other preventive services to help them stay healthy.
- Category 2: Managing chronic (long-term) conditions. Evaluates how effectively health plans help members manage certain conditions, and receive recommended tests and treatments, with a focus on diabetes and medication management.
- Category 3: Member satisfaction. Evaluates the member experience with their health plan and how they feel about the quality of care they receive from the health plan and their providers.
- Category 4: Customer service. Evaluates how responsive and helpful the plan's customer service is and the accuracy of information given to members.
- Category 5: Pharmacy services. Evaluates customer service, member complaints, the member experience, drug safety and the accuracy of pricing.
The data sources used to create the star ratings include:
- Clinical quality standards
- Health Effectiveness Data and Information Set (HEDIS®)
- Pharmacy Data (Prescription Drug Event (PDE))
- Health Outcomes Survey (HOS)
- Member satisfaction
- Consumer Assessment of Healthcare Providers and Systems (CAHPS®)
- Member Complaint Tracking
- Grievance and Appeals
- Administrative performance and compliance standards
- CMS Audits
- Pharmacy (Part D) Data Integrity
- Call Center Performance
What Florida Blue is Doing to Maintain or Improve Star Ratings
One of our main missions is to ensure our Medicare Advantage and Part D prescription drug plan members continue to have access to high-quality plans with an overall Star rating of four stars or higher. Through our Medicare Advantage plans we aim to help our members maintain or improve their overall health and wellbeing. Some examples of the ways we are working to achieve this mission include:
- Arming providers with timely, actionable patient health information. This includes the latest care gaps report and availability of Census and Coding Opportunities. This valuable information is made available in Provider LinkTM, our electronic population health management platform where providers manage their Florida Blue Medicare Advantage patients.
- Notifying members via tasks focused on closing their care gaps in MyHealthLinkTM, our electronic member-facing health management platform.
- Providing a dedicated team focused on improving our Star ratings for the quality care measures with room for Star score improvement. We continuously evaluate our Star ratings and the individual quality measures that comprise them.
- Work with our Care Management, Health Care Quality, and our network providers to help our members stay healthy by evaluating how often members receive screenings, vaccines, checkups, and other preventive services and helping them to close their care gaps.
- Offer incentives to providers where they are rewarded for their performance based on a number of Quality (HEDIS/Star) measures. For more information about provider performance incentives, see the “Quality Bonus Program Terms & Conditions” located under the “Resources Links” in Provider Link.
How the Provider Can Help Improve Star Ratings
It's more important than ever that we work with you to achieve four Star or higher ratings. Doing so not only means we are achieving positive performance and member' health outcomes, it also means lower costs and enhanced benefits for members.
To get to where we need to be requires focused attention on mastering all the right HEDIS®, pharmacy, and CAHPS® experience measures. We will continue to work with our Florida Blue providers, our BlueMedicareSM members, network pharmacies, and related vendors to ensure that evidence-based care is provided as assessed through star ratings measures.
We count on you and appreciate your willingness to collaborate with us to share information, collect medical records, and engage your patients in obtaining preventive screenings and managing their chronic conditions. In return, we want to be able to provide you with clinical resources, financial incentives, and practice-based support to help us improve health outcomes and achieve 4+ Star ratings.
Opportunities for you (the provider) to help us achieve our targeted and health outcomes include:
- Increase the number of BlueMedicare members/patients who receive timely preventive tests and screenings (e.g., wellness visits, breast cancer screening, colorectal screening, flu vaccine, BMI assessment)
- Improve management of chronic conditions:
- Track hemoglobin A1c (HbA1c) tests for diabetic members and adjust therapy as needed to achieve a HbA1c of less than 9.
- Ensure your patients with diabetes receive their retinal eye exams. Have you received and reviewed the results and documented this in your records?
- Perform annual nephropathy screenings to identify potential kidney complications by doing a urine analysis, urine micro albumin test, or having your patient on an ACE Inhibitor or ARB.
- Optimize the anti-hypertensive medications in your patients with hypertension. If their BP is elevated, continue to treat and monitor until it comes down to the normal range.
- Ensure positive health care experiences and outcomes for BlueMedicare patients:
- Ensure that members discharged from the hospital are scheduled to see a Primary Care Physician (PCP) within 7-10 days of discharge to prevent possible readmissions.
- Transitions from care settings should be closely monitored and coordinated through the PCP practices to ensure the best health outcomes.
- Does your access model support patients needing urgent care during and after-hours? Are members getting care coordination services from their providers (i.e., follow-up appointments, tests, referrals to specialists)?
- Safeguard satisfaction levels for BlueMedicare patients:
- Refer all member complaints about Florida Blue directly to the health plan for timely resolution.
- Make customer service the highest priority within your practice setting.
- Address members' mental and physical health during the office visit.
- Ensure BlueMedicare patients know the importance of taking their medications to maximize the benefits of their treatment:
- Assist members with their medication adherence goals to support the treatment of diabetes, hypertension, and cholesterol control.
- Help to identify barriers to adherence.
- Encourage members with multiple conditions and medications to participate in our Pharmacist-led program for Medication Therapy Management (MTM). If a pharmacist contacts you about recommendations as a result of a MTM review, please review the suggested recommendations.
- Ensure members that are discharged from the hospital or skilled facilities have their current medications reconciled against their discharge medications within 30 days of discharge.
CMS Surveys Used to Measure Members' Experiences
CMS develops and administers many different patient experience surveys. Surveys ask patients about their experiences with, and ratings of, their health care providers and plans, including hospitals, doctors, drug plans, and others.
CAHPS Survey
The Consumer Assessment of Healthcare Providers and Systems (CAHPS®)survey is a mandated regulatory survey sent to a select number of Medicare members annually. CAHPS results are an integral part of the CMS Star ratings. CAHPS collects information on consumers' experiences with their health plan, personal doctor, specialists, and health care in general and is used for CMS Star ratings. It has become the national standard for measuring and reporting on consumers' experiences with their health plans.
HOS Survey
The Medicare Health Outcomes Survey (HOS), utilized for CMS Star ratings, is a patient-reported outcomes measure used in Medicare managed care. According to CMS, the goal of the HOS program is to gather valid and reliable clinically meaningful data that have many uses, such as targeting quality improvement activities and resources, monitoring health plan performance and rewarding top-performing health plans; helping the Medicare-covered make informed health care choices; and advancing the science of functional health outcomes.
For more information, see the Tips to Success and the Pre-visit Checklist materials below: click here:
- You can influence your patient’s perception of the care received by talking with them about CAHPS and HOS and printing out a pre-visit checklist (English), (Spanish) or (Haitian-Creole) for them to complete before their office visit.
- You may also print the or CAHPS and HOS Quality Measures’ Tips to Success.
CMS Star Ratings Performance
Provider Quality Bonus Program
Our Florida Blue Medicare Provider Quality Bonus Program (“Bonus Program”) is closely aligned with the Centers for Medicare & Medicaid Services’ (CMS) Five-Star Quality Rating System. The program rewards eligible provider groups with an annual incentive for ensuring their Florida Blue Medicare Advantage HMO and PPO patients receive quality care.
Central to this bonus program are the Healthcare Effectiveness and Data Information Set (HEDIS®1) and Pharmacy Quality Alliance (PQA2) measures. These are used to evaluate the care and services provided to the Medicare Advantage population including health outcomes, preventive screenings and overall treatments for chronic conditions.
Providers will have tools to keep them informed of their performance in the applicable components of the Bonus Programs via the Florida Blue Medicare provider platform, Provider LinkTM.
Provider Link is accessed via the Provider Portal in the Florida Blue Payer Space on availity.com. Your practice administrator for Availity®3 can grant access to the tool by checking the Provider Portal box in the user profile.
Provider Link educational material, including Frequently Asked Questions and a user’s guide, are located in the Florida Blue Learning Center in the Florida Blue Payer Space on availity.com.
Member Incentives
- QR Code to HealthyBlue Rewards Brochure – print for patients
Provider Communications
Identifying Patients' Care Gaps
Provider LinkTM
The Care Gaps report in Provider Link, our population health management web application for providers, is updated frequently to allow you to monitor the status of your members' care gaps and even permits you to provisionally close care gaps from within the platform.
Provider Link is accessed via the Provider Portal in the Florida Blue Payer Space on availity.com. Your practice administrator for Availity®1 can grant access to the tool by checking the Provider Portal box in the user profile.
Provider Link educational material, including Frequently Asked Questions and a user's guide, are located in the Florida Blue Learning Center in the Florida Blue Payer Space on availity.com.
Member At-Home Care Closure Options
Convenient Bone Density Screening Options for Members
To assist our members, your patients, in achieving better overall health outcomes we're offering our Medicare Advantage female members choices to help them complete their bone density screening (bone mineral density or BMD test). Members who need this screening and meet the requirements for the Osteoporosis HEDIS Stars measure are offered the following option for receiving a bone density screening for no additional charge:
QUS (Quantitative Ultrasound) – Bone Density screening is available to patients from our contracted vendor, POPHealthcare, is conveniently conducted in our member's home.
If you have a Florida Blue Medicare patient with a bone density screening care gap, it is likely you'll receive a copy of their test results since we're asking our members who test to provide us with their provider information so we may share the results with them.
When your patient closes this gap, you and the member may be eligible to receive an incentive. Check the Quality Incentives page for more information.
Thanks for encouraging your patients with this care gap to make an appointment today!
Florida Blue Centers
We know convenience is important to our members. That's why we offer a variety of events at area Florida Blue Centers for our Medicare Advantage members to receive screenings and services that may support care gap closure. Screening and service offerings vary by location.
To learn more about events and services available virtually and in-person, please visit floridablue.com/find-a-floridablue-center and share this link with your patients as well.
Diabetic Retinopathy Screenings*
Diabetic retinal exams can detect diabetic retinopathy and lower the risk of vision loss for patients diagnosed with diabetes.
A vision vendor we trust conducts exams at our Florida Blue Center locations during the latter part of the year as needed. To learn more about these events to share with your patients, contact carole.wright@bcbsfl.com for more information.
Mobile Care Gap Closure Options
Diabetic Retinopathy Screenings* at Your Door
Diabetic retinal exams (DRE) can detect diabetic retinopathy and lower the risk of vision loss for patients diagnosed with diabetes.
If you have 10 or more patients with a DRE care gap, a vision vendor we trust can come to your office and conduct mobile retinal eye screening. Just schedule our members to come to your office and they will receive the screening. There is no cost to you or the member. Contact Starsoutreachreporting@bcbsfl.com for more information.
iCare HEDIS Diabetic Retinal Screening Brochure
iCare HEDIS Diabetic Retinal Screening Scheduling Guide
iCare HEDIS Diabetic Retinal Screening Preparation Guide
1Availity, LLC is a multi-payer joint venture company. For more information or to register, visit availity.com.
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