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PUBLIC
FINANCING

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The Healthcare Effectiveness Data Not every domain is weighted equally, however. For 2017 Star
and Information (HEDIS) is one Ratings, outcomes and intermediate outcomes continue to be
such attempt and helps physicians weighted three times as much as process measures, and patient ex-
focus on certain metrics that affect perience and access measures are weighted 1.5 times as much as
payment. process measures. CMS assigns a weight of 1 to all new measures.
Of the 364 health plan contracts that participate in Medicare Ad-
HEDIS is a tool used by more than vantage, there were only 81 with a STAR rating of 4.5 or higher.
90 percent of America's health plans
to measure performance on impor- The lesson in reimbursement for physicians is that that world is
tant dimensions of care and service. getting more complex and there are real opportunities to receive
Many health plans use the HEDIS additional pay for performance. It is not an easy objective to achieve
measurements to highlight their and requires a lot of expertise in this area. Even though the physi-
scores to prospective employers. cian may achieve a higher level of income, there will be costs asso-
HEDIS measures address a broad ciated with achieving the higher reimbursements. Nevertheless, this
range of important health issues. appears to be the direction the government is heading. The
Among them are the following: Medicare Access and CHIP Reauthorization Act of 2015
• Asthma Medication Use (MACRA), is an example where outcome-based performance pay-
• Persistence of Beta-Blocker Treatment after a Heart Attack ment is heading.
• Controlling High Blood Pressure
• Comprehensive Diabetes Care Alan Preston, MHA, Sc.D., is an independent consultant that helps physi-
• Breast Cancer Screening cians navigate through the difficult regulatory framework and helps them achieve
• Antidepressant Medication Management higher reimbursements from insurance companies; skilled with a tremendous
• Childhood and Adolescent Immunization Status background in managed care and Population Health Management, epidemiol-
• Childhood and Adult Weight/BMI Assessment ogy, team building, and biostatistics; strong healthcare professional with a Doctor
of Science (Sc.D.) focused in Public Health, Health Services Research from
For the Medicare Advantage population, CMS has used another Tulane University School of Public Health and Tropical Medicine. Dr. Preston
tracking program called STAR. One of the differences between is involved in risk-sharing contracts, ACOs, Medicare Advantage including
HEDIS and STAR is that HEDIS is responsible for making sure RAP scores, HEDIS, and STAR ratings which helps physicians and health
that providers at least perform the activities of measurement as plans alike in reducing MLR.
required by HEDIS, whereas STAR requires both the perform-
ance of the measurement activity with the additional requirement
of demonstrating improved outcomes. Thus, it is not good
enough that the doctor saw the patient, they also need to make
sure that the prescribed treatment is heading in the right direc-
tions regarding outcomes.

Star Ratings are driving improvements in
Medicare quality. The Star Rating measures
span five broad categories:
• Outcomes
• Intermediate Outcomes
• Patient Experience
• Access
• Process

16 San Antonio Medicine • December 2017