Blue Cross and Blue Shield of Nebraska HEDIS & Stars

Quality Improvement Program 
Blue Cross and Blue Shield of Nebraska (BCBSNE) is committed to improving the quality of health care for our Medicare Advantage members. Medicare Advantage maintains a quality improvement program that continuously reviews and identifies the quality of clinical care and services members receive and routinely measure the results to ensure members are satisfied and expectations are met. 

The Medicare Advantage Quality Improvement (QI) unit develops an annual quality improvement program that includes specific quality improvement initiatives and measurable objectives. Activities that are monitored for QI opportunities include:

• Appointment and after-hours access monitoring 
• Quality of care concerns  
• Member satisfaction  
• Chronic care management  
• Utilization management  
• Health outcomes  
• Medical record documentation compliance  
• Chronic care improvement projects  
• Healthcare Effectiveness Data and Information Set (HEDIS^®)  
• Consumer Assessment of Healthcare Provider and Systems Survey (CAHPS) and Health Outcomes Survey (HOS) 
• Regulatory compliance  

Healthcare Effectiveness Data and Information Set  
Healthcare Effectiveness Data and Information Set (HEDIS) is a set of nationally standardized measures commonly used in the managed care industry to measure a health plan’s performance during the previous calendar year. Medicare Advantage follows HEDIS reporting requirements established by the National Committee for Quality Assurance (NCQA) and the Centers for Medicare & Medicaid Services (CMS). Audited HEDIS rates are used to identify quality improvement opportunities and develop quality related initiatives. 

The HEDIS measures that Medicare Advantage focuses on include (but are not limited to):

• Acute hospital utilization 
• Adults access to preventive/ambulatory health services  
• Adult immunizations  
• Antidepressant medication management  
  • Effective acute phase treatment  
  • Effective continuation phase treatment 
• Breast cancer screening  
• Colorectal cancer screening (members 45–75 years of age)  
• Controlling high blood pressure (members 18-85 years of age)  
• Emergency department utilization  
• Eye exam for patients with diabetes (members 18-75 years of age)  
• Fall risk management  
• Follow-up after emergency department visit for substance abuse  
• Follow-up after emergency department visit for mental illness (within seven and 30 days)  
• Follow-up after emergency department visit for people with high-risk chronic conditions (within seven and 30 days)  
• Follow-up after hospitalization for mental illness (within seven and 30 days)  
• Frequency of selected procedures  
• Glycemic control for patients with diabetes (members 18-75 years of age)  
• Hospitalization for potentially preventable complications  
• Inpatient utilization – general hospital/acute care 
• Kidney Evaluation for Patients with Diabetes  
• Non-recommended prostate-specific-antigen based screening in older men  
• Osteoporosis management in women who had a fracture (women age 67–85)  
• Pharmacotherapy management of chronic obstructive pulmonary disease exacerbation 
  • Plan all-cause readmissions  
• Potentially harmful drug-disease interactions in the elderly  
• Statin therapy for patients with cardiovascular disease  
• Statin therapy for patients with diabetes  
• Tobacco cessation – medical assistance  
• Transitions of care  
• Use of high-risk medications in older adults (at least two dispensing events)  
• Use of opioids at high dosage  
• Use of opioids from multiple providers  
• Use of spirometry testing in the assessment and diagnosis of COPD  

What is the CMS Quality Star Ratings Program?  
CMS evaluates Medicare Advantage health insurance plans and issues Star ratings each year; these ratings may change from year to year. The methodology used by CMS is subject to change and final guidelines are released each spring after the measurement year. The CMS plan rating uses quality measurements widely recognized within the health care and health insurance industry to provide an objective method for evaluating health plan quality. The overall plan rating combines scores for the types of services that the BCBSNE Medicare Advantage plans offer. CMS compiles its overall score for quality of services based on measures such as:  

• How BCBSNE helps members stay healthy through preventive screenings, tests and vaccines and how often they receive preventive services to help them stay healthy  
• How BCBSNE helps members manage chronic conditions  
• Member satisfaction with BCBSNE and their experience with their provider  
• How often members filed a complaint against BCBSNE  
• How well BCBSNE handles calls from members  

In addition, because BCBSNE Medicare Advantage plans offer prescription drug coverage, CMS also evaluates these prescription drug plans for the quality of services covered such as:  

• Medication use and/or adherence for certain diabetes, hypertensive and cholesterol-lowering medications 
• Concurrent use of opioids and benzodiazepines  
• Concurrent use of 2 or more anticholinergic medications 
• Drug plan member complaints and Medicare audit findings 
• How easy it is to obtain prescription medications 
• Drug pricing and patient safety  

How are star ratings derived? 
Star measurement is comprised of approximately 40 measures and is assessed across clinical, member perception and operational measures.  

Performance is converted to star ratings based on CMS specifications as one through five stars, where five stars indicates higher performance. This rating system applies to all Medicare Advantage lines of business: health maintenance organizations, preferred provider organizations and prescription drug plans. In addition, the ratings are posted on the CMS consumer website, Medicare.gov to help beneficiaries choose a Medicare Advantage plan offered in their area. 

Star Clinical Performance
For most measures, Star performance is determined by who in the eligible population received appropriate services/care as defined by the measure. 

Numerator: Eligible population that met the criteria
Denominator: Eligible population for the measure

CMS determines the thresholds of performance required to achieve a star rating.  

Administrative: Transaction data or other administrative data is used to identify the eligible population and the numerator. The reported rate is based on all members who meet the eligible population and who are found through administrative data to have received the service required.