In Part I of this three-part series, I discussed the evaluation of a health plan Model of Care (MOC) and a few data points plans might want to consider. Carrying this idea forward, I would like to discuss how CMS evaluates SNP plans when it comes to plan performance and how that fits into your plan’s annual MOC evaluation.
CMS has set up a great structure through the audit protocol for plans that have not completed an evaluation to their model of care. The first question CMS asks about performance monitoring is, “Did the sponsor (plan) collect, analyze and evaluate the MOC (e.g., specific data sources, specific performance and outcome measures, etc.)? This should prompt plans to ask themselves: Did we really think about this step when we drafted the MOC? Or were we just writing it to meet the application submission deadline? Many plans seek outside consulting help to draft or complete their MOCs; I know because I have been on both sides of this equation. Sometimes the exercise of vetting the data a plan can collect and report on gets missed.
I have audited many plans that have written MOC goals or data metrics for measuring performance improvement ̶ the good old “MOC 4.” At audit time, they discover they have not done what they committed to on paper and, worse, cannot do it. What to do? There are several helpful steps for plans that are the newest to the market, as well as those that have never completed an evaluation.
Get a List Going
Step one is to review what your MOC 4 says your plan will measure, collect and analyze. Remember that managing your plan’s data and the collection process is a critical part of performance improvement. The essential components of this are collecting, tracking, analyzing, interpreting and acting on what the data presents. Quite simply, those are the criteria CMS will use to measure your plan. The whole point of MOC 4 is to help your plan identify and implement improvements to the current model for care delivery, and to monitor your progress as you make improvements.
Next? Make a list of the goals and the associated data sources you said you would collect. Place that list into a work plan, just as you would for your quality improvement work plan. That should help you identify whether or not you have a baseline for your data.
What if you have no baseline data or your external consultant wrote data points you cannot collect? Don’t panic! Start with creating a list of data gaps. This will include all of the measures your plan said it would collect, the data parameters and what if any baseline was mentioned.
There are some common ways that plans fall short in their data collection. Many plans say they will complete all initial health risk assessments within 90 days of the member enrollment date and will do so for 95 percent of their SNP population. This is a great metric, but what if you find that your care management system (which is only a year old) does not report completion rates this way for either individuals or a total population?
Another example: Suppose your plan promised that the MOC would demonstrate how SNP beneficiaries met all preventive screening measures in accordance with member needs and their care plans. After review, you discover that your care management system cannot report individual intervention types or any care plan goals that were met. Suppose only some of the HEDIS data measures for preventive screening fit the profile or attributes of your population and its needs? Imagine that your care management systems cannot identify every HEDIS gap that would show closure. If this is the case for your plan and the system you use for care plan development, it is time to sit down at the reconfiguration table to discuss changes.
Rely on Proxy Measures
Your critical step now is to immediately document the status of your data metrics, what your written measurement was and should be, what barriers to data collection exist (e.g. system capability), and what impact these have on your MOC evaluation. Then determine whether there are any proxy measures that could still be used to collect the data. If so, get going! If your system does not run real-time staff performance reports on HRA completion rates, is there a chance you could run a universe (as described in the SNP Audit Protocol by CMS)? That data could be used in place of a system report.
Next action: Present the gaps in data/metric findings to your executive sponsor for the MOC. This could be your vice president of quality improvement, medical director or even your chief executive officer. If your plan does not have a designated owner for your MOC, this role defaults to your plan CEO. Should that be the case, is this person aware that this is their responsibility?
Once the review has been done by the responsible executive sponsor, make a decision about doing one of the following:
- Using the proxy data as your data source and ensuring that this data mapping/collection continues into the next plan year.
- Redlining the MOC to adjust for the appropriate data reporting source. This identifies a new baseline while providing chronological documentation for your decision and rationale. Make sure your committee meeting minutes present the same information to your stakeholders.
- Discussing new measures for the overall MOC performance and documenting the discussions, rationale and final decisions.
Focusing on evidence-based measures that your plan is able to collect also helps your plan focus on adherence to evidence-based guidelines and drives better provider practices. It also helps guide your benchmarks and insight into where you stand relative to other national and state goals.
Many plans are tempted by too much enthusiasm when listing measures for MOC 4. This leads to metrics that cannot be mapped or reported by the current care management system. The result is further frustration and failure. Prioritizing work with meaningful data leads to improved outcomes. And that, after all, is the entire point of caring for the SNP population.
Check back in the first week of February for the final installment of Rock the MOC!
Jane Scott is senior vice president of Professional Services at Health Integrated.