U.S. patent application number 13/294381 was filed with the patent office on 2013-05-16 for health plan rating system improvement program.
The applicant listed for this patent is DEBRA THESMAN. Invention is credited to DEBRA THESMAN.
Application Number | 20130124217 13/294381 |
Document ID | / |
Family ID | 48281472 |
Filed Date | 2013-05-16 |
United States Patent
Application |
20130124217 |
Kind Code |
A1 |
THESMAN; DEBRA |
May 16, 2013 |
HEALTH PLAN RATING SYSTEM IMPROVEMENT PROGRAM
Abstract
Methods and training programs for improving the level of quality
of care within a healthcare plan. The methods include obtaining
medical data from a population of patients within the plan, storing
such data in electronic medical records embodied on a computer
readable medium, evaluating at least one metric within the data via
a computer capable of interpreting said electronic medical records,
and presenting a notification if the metric is found to be below a
standard for the metric. The training includes evaluating the
healthcare plan's current practices, training the healthcare
provider in improved practices, providing a system for recording
medical documents, and training the healthcare provider in use of
the system.
Inventors: |
THESMAN; DEBRA; (Garden
City, NY) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
THESMAN; DEBRA |
Garden City |
NY |
US |
|
|
Family ID: |
48281472 |
Appl. No.: |
13/294381 |
Filed: |
November 11, 2011 |
Current U.S.
Class: |
705/2 |
Current CPC
Class: |
G16H 10/60 20180101;
G16H 50/20 20180101; G16H 20/10 20180101; G06Q 10/10 20130101 |
Class at
Publication: |
705/2 |
International
Class: |
G06Q 50/24 20120101
G06Q050/24 |
Claims
1. A method of improving the level of quality of care within a
healthcare plan comprising: (a) obtaining medical data from a
population of patients within the plan; (b) storing such data
obtained in step (a) in electronic medical records embodied on a
computer readable medium; (c) evaluating at least one metric within
said data stored in step (b) via a computer capable of interpreting
said electronic medical records; and (d) presenting a notification
if the at least one metric evaluated in step (c) is found to be
below a standard for said metric.
2. The method of claim 1, wherein the at least one metric includes
providing a disease screening.
3. The method of claim 1, wherein the at least one metric includes
providing a vaccination.
4. The method of claim 1, wherein the at least one metric includes
managing a chronic condition.
5. A method of training healthcare plans to improve the level of
quality of care within the plan, said method comprising the steps:
(a) evaluating the healthcare plan's current practices; (b)
training the healthcare provider in improved practices; (c)
providing a system for recording medical documents, wherein the
system comprises: (i) a computer readable medium capable of storing
medical data obtained from a population of patients; (ii) a
computer with software capable of evaluating at least one metric of
the data stored on the computer readable medium in comparison with
a standard for the at least one metric; and (iii) a notification
system capable of presenting to the user of the system a warning if
the at least one metric is found to be below the standard for such
metric; and (d) training the healthcare provider in use of said
system.
6. The method of claim 5, wherein the training provided in step (b)
comprises instructing the healthcare plan to preemptively contact
potential at-risk patients.
7. A system for recording medical documents comprising: (a) a
computer readable medium capable of storing medical data obtained
from a population of patients; (b) a computer with software capable
of evaluating at least one metric of the data stored on the
computer readable medium in comparison with a standard for the at
least one metric; and (c) a notification system capable of
presenting to the user of the system a warning if the at least one
metric is found to be below the standard for such metric.
8. The system of claim 7, wherein the notification system presents
a warning if the metric is the percentage of patients within a
population receiving a disease screening and the percentage is
below a standard assigned for screening said disease.
9. The system of claim 7, wherein the notification system presents
a warning if patients within a population are determined to be
at-risk for medical complications based upon the patients' medical
data.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] Not Applicable
STATEMENT RE: FEDERALLY SPONSORED RESEARCH/DEVELOPMENT
[0002] Not Applicable
BACKGROUND
[0003] The present invention is directed toward improved systems
and methods for improving and/or maintaining a high level of
performance for healthcare plans. More particularly, the present
invention comprises training programs and software systems useful
by healthcare plans to improve their Centers for Medicare and
Medicaid Services' (CMS) Five-Star Quality Rating.
[0004] The Centers for Medicare and Medicaid Services (CMS) rates
the relative quality of the private plans that are offered to
beneficiaries enrolled in Medicare Advantage programs. CMS rates
Medicare Advantage plans on a one to five star scale, with five
stars representing the highest quality.
[0005] The summary score provides an overall measure of a plan's
quality, and is a cumulative indicator of the quality of care,
access to care, responsiveness, and beneficiary satisfaction of
services provided by the plan.
[0006] The ratings are posted on the CMS website to provide
beneficiaries with additional information to help them select the
best Medicare Advantage plan for them from the plans offered in
their service area. The quality rating results are also used by CMS
to evaluate a plan's performance and is a method for CMS to reward
the high-quality plans for performance excellence. Starting in
2012, the Patient Protection and Affordable Care Act introduces
Medicare Advantage bonuses and rebate levels ties to the CMS
five-star quality rating. As such, there is a need for healthcare
plans to maximize, and maintain, a high quality rating.
[0007] CMS defines the star ratings as five stars being excellent
performance, four stars being above average performance, three
stars being average performance, two stars being below average
performance, and one star being poor performance. Healthcare plans
receive both a summary score and an overall score. The summary
score for Medicare Advantage plans: 1) is used under the health
reform law to provide quality-based payments; 2) provides an
overall measure of a plan's quality, based on indicators of the
quality of care, access to care, responsiveness, beneficiary
satisfaction, and customer service; and 3) does not include the
plan's Part D (prescription drug plan) ratings. In contrast, the
overall score for Medicare Advantage plans differs from the summary
score because it combines a plan's summary score with its Part D
rating. CMS uses the overall score for the 2011 ratings, and
proposes to use the overall score into the future.
[0008] The five-star quality scores for Medicare Advantage plans
are based on 36 standard performance measures that are derived from
four sources: 1) the Healthcare Effectiveness Data and Information
Set (HEDIS); 2) the Consumer Assessment of Healthcare Providers and
Systems (CAHPS); 3) the Health Outcomes Survey (HOS); and 4) the
CMS administrative data, including information about beneficiaries'
satisfaction, plans' appeals processes, audit results, and customer
service.
[0009] Accordingly, there is a need in the art for a program
designed to train and support healthcare plans to identify areas of
deficiency, thereby finding and driving specific behaviors to
improve their star rating and/or to maintain a high star
rating.
BRIEF SUMMARY
[0010] One aspect of the present invention is directed toward
methods of improving the level of quality of care within a
healthcare plan. The methods include obtaining medical data from a
population of patients within the plan, storing such data in
electronic medical records embodied on a computer readable medium,
evaluating at least one metric within the data via a computer
capable of interpreting said electronic medical records; and
presenting a notification if at least one metric is found to be
below a standard for the metric. Examples of metrics that may be
evaluated include, but are not limited to, whether a disease
screening has occurred, whether a vaccination has been
administered, and whether a chronic condition is being managed.
[0011] Another aspect of the present invention is directed toward
methods of training healthcare plans to improve the level of
quality of care within the plan. This training includes evaluating
the healthcare plan's current practices, training the healthcare
provider in improved practices, providing a system for recording
medical documents, and training the healthcare provider in use of
said system. The system includes a computer readable medium capable
of storing medical data obtained from a population of patients, a
computer with software capable of evaluating at least one metric of
the data stored on the computer readable medium in comparison with
a standard for the metric, and a notification system capable of
presenting to the user of the system a warning if the metric is
found to be below the standard for such metric.
[0012] In particular, the training provided may include instructing
the healthcare plan to preemptively contact potential at-risk
patients.
[0013] Yet another aspect of the present invention contemplates a
system for recording medical documents. The system includes a
computer readable medium capable of storing medical data obtained
from a population of patients, a computer with software capable of
evaluating at least one metric of the data stored on the computer
readable medium in comparison with a standard for the metric, and a
notification system capable of presenting to the user of the system
a warning if the metric is found to be below the standard for such
metric.
[0014] For example, the notification system may present a warning
if the metric is the percentage of patients within a population
receiving a disease screening and the percentage is below a
standard assigned for screening the disease, or if patients within
a population are determined to be at-risk for medical complications
based upon the patients' medical data.
BRIEF DESCRIPTION OF THE DRAWINGS
[0015] These and other features and advantages of the various
embodiments disclosed herein will be better understood with respect
to the following description and drawings, in which like numbers
refer to like parts throughout, and in which:
[0016] FIG. 1 is a flowchart depicting the steps for practicing the
present invention as it relates to training healthcare plans in
improving, or maintaining a high, CMS Star Score.
DETAILED DESCRIPTION
[0017] The detailed description set forth below is intended as a
description of the presently preferred embodiment of the invention,
and is not intended to represent the only form in which the present
invention may be constructed or utilized. The description sets
forth the functions and sequences of steps for constructing and
operating the invention. It is to be understood, however, that the
same or equivalent functions and sequences may be accomplished by
different embodiments and that they are also intended to be
encompassed within the scope of the invention.
[0018] Referring now to FIG. 1, there is schematically illustrated
the various steps by which a method of the present invention
operates to train healthcare plans in improving their, or
maintaining an already high, CMS Stars Score. In particular, there
is a first step 100 of evaluating the healthcare plan's current CMS
five-star score. For example, a team consisting of physicians,
nurses, and financial auditors may conduct a two day on-site
evaluation of the client's current five-star score and activities
that determine the client's current score.
[0019] A written report may be given to the client outlining the
team's findings and recommendations that may include staffing
requirements, system requirements, and/or a program training and
implementation work plan.
[0020] The second step 200 includes a comprehensive educational
training program. For example, the training program may be offered
as a five day class with overhead presentations, case studies, and
reference material, with topics including an overview of the
Medicare Advantage Part C and Part D Five-Star rating system,
improved beneficiary outreach, category and measure details,
strategies for improving five-star quality scores, and training on
systems for recording medical documents. The training section 200
may include a ninety day post-implementation follow-up with
client's staff to evaluate program progress and/or quarterly
updates to apprise the client of changes in the CMS Five-Star
Quality Rating System.
[0021] The third step 300 is providing to the healthcare provider a
system for recording medical documents, wherein the system includes
at least a computer readable medium capable of storing medical data
obtained from patients; a computer with software capable of
evaluating the data stored on the computer readable medium; and a
notification system capable of compiling the patient medical data
and presenting an overall summation of the medical data to the user
of the system, thereby indicating steps that may be taken to
improve their CMS five-star score. Examples of data to be recorded
and information that may be presented by the system are discussed
in greater detail below.
[0022] In particular, the Affordable Care Act of 2010 mandates that
CMS make quality bonus payments (QBPs) to Medicare Advantage (MA)
plans that achieve at least four stars in the five-star quality
rating system. The star rating scores will be used by CMS to
determine if a plan qualifies for bonus payments, as well as being
posted on the CMS website to assist beneficiaries in making
informed choices when selecting a Medicare Advantage plan. As such,
there is a large incentive for healthcare plans to achieve and
maintain a high star score.
[0023] In order to achieve and maintain a high CMS star score, one
must be aware of from where the scores are derived and what steps
might be taken to improve the scores. However, for plans offering
both Part C and D services, there are total of 9 category areas
comprised of 53 individual measures utilized in deriving the score.
As such, it can be seen that analyzing and adjusting all of these
areas on one's own can be difficult, if not impossible. In
particular, for plans covering Part D drug services, the overall
score for quality of those services covers 17 different measures in
4 categories: 1) drug plan customer service (including how well the
drug plan handles calls and makes decisions about member appeals),
2) drug plan member complaints and Medicare audit findings
(including how often members filed a complaint about the drug and
findings from Medicare's audit of the plan), 3) member experience
with drug plan (including member satisfaction information), and 4)
drug pricing and patient safety (including how well the drug plan
prices prescriptions and provides updated information on the
Medicare website and how often members with certain medical
conditions get prescription drugs that are considered safer and
clinically recommended for their condition). For Part D coverage,
the quality of drug services information comes from the results of
Medicare's regular monitoring activities, reviews of billing and
other information that plans submit to Medicare, and member surveys
conducted by Medicare.
[0024] For plans covering Part C health services, the overall score
for quality of those services covers 36 different measures in 5
categories: 1) staying healthy as evidenced by screenings, tests,
and vaccines (including how often members got various screening
tests, vaccines, and other checkups that help them to stay
healthy), 2) managing chronic conditions (including how often
members with different conditions got certain tests and treatments
that help them to manage their condition), 3) ratings of health
plan responsiveness and care (including ratings of member
satisfaction with the plan), 4) health plan member complaints and
appeals (including how often members filed a complaint against the
plan), and 5) health plan telephone customer service (including how
well the plan handles calls from members). For Part C coverage, the
quality of health services information comes from member surveys
administered by Medicare, information from clinics, information
submitted by the plans, and results from Medicare's regular
monitoring activities.
[0025] In particular, for Part C coverage, the measures for each
category are shown below in Table 1.
TABLE-US-00001 TABLE 1 Category 1 Category 2 Category 3 Category 4
Category 5 Breast Cancer Osteoporosis Getting Needed Complaints
Call Center - Screening Management in Care About the Health Hold
Time Women Who Plan Have Had a Fracture Colorectal Diabetes Care -
Doctors Who Plan Makes Call Center - Cancer Eye Exam Communicate
Timely Information Screening Well Decisions About Accuracy Appeals
Cardiovascular Diabetes Care - Getting Reviewing Call Center - Care
- Kidney Disease Appointments Appeals Foreign Cholesterol
Monitoring and Care Decisions Language Screening Quickly
Interpreter and TTY/TDD Availability Diabetes Care - Diabetes Care
- Customer Corrective Cholesterol Blood Sugar Service Action Plans
Screening Controlled Glaucoma Diabetes Care - Overall Rating
Testing Cholesterol of Health Care Controlled Quality Appropriate
Controlling Overall Rating Monitoring for Blood Pressure of Plan
Patients Taking Long Term Medications Annual Flu Rheumatoid Vaccine
Arthritis Management Pneumonia Testing to Vaccine Confirm Chronic
Obstructive Pulmonary Disease Improving or Improving Maintaining
Bladder Control Physical Health Improving or Reducing the
Maintaining Risk of Falling Mental Health Osteoporosis Testing
Monitoring Physical Activity Access to Primary Care Doctor
Visits
[0026] As can be seen from reviewing the contents of Table 1, while
there are many factors in determining a plan's five-star score, the
bulk of the data is derived from Categories 1 and 2 in relation to
staying healthy and managing long-term conditions. Thus, one can
more readily improve their score by ensuring these measures are at
a high level. For example, the second measure in Category 1, i.e.,
colorectal cancer screening, is measured based upon the percentage
of plan members aged 50-75 who have had the appropriate screening
for colorectal cancer. One star is given if less than 36% of these
plan members have received the appropriate screening, two stars is
given if between 36% and 48% of these plan members have received
the appropriate screening, three stars is given if between 48% and
58% of these plan members have received the appropriate screening,
four stars is given if between 58% and 70% of these plan members
have received the appropriate screening, and five stars is given if
70% or more of these plan members have received the appropriate
screening. Similar metrics are utilized for the other measures.
However, differing methodologies are utilized for calculating the
star rating of various measures, including 1) relative distribution
and clustering, 2) relative distribution and significance testing,
and 3) a standard, relative distribution, and clustering.
Furthermore, these measures, ranges, and methodologies for
determining scores are subject to change. Accordingly, it can be
seen that it can be exceedingly difficult to predict on one's own
what changes to be made within a plan will have a significant
change in a plan's overall five-star score. Some of the objects of
the present invention are to compile the medical data of plan
members, analyze the organized data, and present areas of
improvement that will likely result in a higher overall five-star
score.
[0027] The compilation, organization, analysis, and presentation of
data is performed by a software platform (herein referred to as
iCode, and additionally disclosed in U.S. patent application Ser.
No. 13/167,976, titled Hierarchical Condition Categories Program
filed on Jun. 24, 2011, the teachings of which are herein
incorporated by reference in their entirety).
[0028] iCode allows for the enhanced care of Medicare Advantage
enrollees, provides valuable information to the caregiver at the
point of care, reduces duplicate and costly services by providing a
comprehensive clinical history for each patient, and assists with
capturing qualifying HEDIS codes.
[0029] In particular, iCode is capable of importing data from a
caregiver's current medical records, billing files, health plan
claim files, and the like. iCode then auto-populates each field
from the data import to create new electronic medical records,
analyzes the data, and creates reports of the analyzed data.
Examples of such reports include, patient demographic information,
health plan eligibility history, outstanding tests/procedures
affecting performance per HEDIS measurements, summary of reported
chronic conditions, list of potential unreported HEDIS measures,
list of three year medical history by ICD-9 and CPT
classifications, last six months of pharmacy data, and notes and
comments. All captured data fields can be output as an iCode
report.
[0030] Of particular relevance, however, is the ability of iCode to
collect and analyze patient records, and further present to the
user areas of deficiency that may be corrected to improve a
healthcare plan's five-star score. For example, iCode may warn the
user that a particular screening test has not been performed on a
sufficient number of patients within a given population (for
example an age range or gender), thereby providing an avenue for
potential improvement that may raise a plan's five-star score.
[0031] Similarly, iCode may identify beneficiaries, based upon
disease markers, that may be at-risk and would benefit from
increased frequency of visits and intensity of services, enrollment
in complex care management, chronic care programs, and/or
transitional care programs when appropriate--all designed to ensure
the best possible clinical outcome for patients and improved
efficiency for healthcare plans. Examples of such other programs
are described in U.S. Pat. Nos. 7,657,442 and 7,464,041 and U.S.
patent application Ser. Nos. 11/352,028 and 12/834,767, the entire
teachings of which are collectively incorporated by reference
herein. By identifying these potentially at-risk patients, the
healthcare plan may preemptively reach out to these beneficiaries
thereby more effectively maintaining their health and/or managing
their long-term conditions.
[0032] Additional modifications and improvements of the present
invention may also be apparent to those of ordinary skill in the
art. Thus, the particular combinations of parts and steps described
and illustrated herein is intended to represent only certain
embodiments of the present invention, and is not intended to serve
as limitations of alternative devices and methods within the spirit
and scope of the invention.
* * * * *