1. How to effectively
manage the
CMS “5 STAR” Rating System
Wayne Pan, MD, MBA
Health Access Solutions

2. Agenda
• The basics
• The approach
• The roll-out
• The demo
• Q&A

3. The basics
• Communication link among all
contracted providers
• Easy to use
• Integrated into the office workflow
• HIPAA-secure
• Web-based

4. The basics
• Dashboard of actionable items
• Who needs something done?
• What is it that they need?
• When do I need to do it?
• Why do I need to do it?
• How can my office reach them?

5. The basics
• Dashboard also functions as:
• Feedback on progress of to-do list
• Compare my office progress with the
rest of my peers
• Link to office data entry portal
• Display of bonus achieved thus far

6. The approach
• Involvement of multiple stakeholders
• Primary care physicians
• Specialty physicians
• Ancillary professionals
• Office staff
• Patient

7. What does this mean?
• Involvement of multiple stakeholders
• Provider portal
• Office staff portal
• Patient portal

8. The roll-out
• Stages of a program roll-out
• Level 1: manual process
• Level 2: electronic, provider-centric
process
• Level 3: electronic, patient- and
provider-centric process

9. Level 1
• Periodic production and distribution of
encounter/lab data in a paper-based
physician dashboard (quarterly)
• Manual collection of provider-based data
• Manual entry of provider data into
tracking database
• Letters to patients to remind them of
missing items

10. Level 1
• Asynchronous data exchange
• Resource-intensive
• Not scalable
• Still with positive ROI, if done well
• Need provider buy-in

11. Level 2
• Use of electronic tools to push
information to providers and office staff
• Goals
• Patients needing contact/services
• Provide near-realtime feedback
regarding progress towards goals
• Tying bonus to achieving goals

12. Level 2
• Two audiences
• Office staff
• Providers
• Create a team-based approach to
achieving goals
• Provide simple-to-use tools

13. Level 2
• Office staff portal
• Provides communication link
• Reactive approach: when patient
shows up in the office
• Proactive approach: when providing
patient outreach

14. Level 2
• Office staff portal: reactive approach
• Incorporate into existing workflow
• Eligibility and patient co-pay
information
• Pop-up messaging for missing
items in provider quality workplan
• Use of portal traceable through
auditing

15. Level 2
• Office staff portal: proactive approach
• Generates patient list to support office
staff outreach efforts
• Office staff to call patients to schedule
appointments for missing items
• MSO member services staff could
assist smaller offices to do outreach
calls

16. Level 2
• Office staff portal: proactive approach
• Data entry by provider office staff
• Automated IVR outbound
appointment reminder calls

17. Level 2a
• Involving the provider through his/her
work environment/workflow
• Paper-based
• Integration with EMR
• Provide electronic tools to help provider
track his/her progress towards goals

18. Level 2a
• Physician portal: reactive approach
• Dashboard driven data presentation
• Fully integrated within physician work
portal (e.g., EHR)
• Auto creation of necessary referral
auths based on missing items
• Auto generation of patient clinical
information sheets

19. Level 3
• Involving the patient in addition to the
physician
• Providing self-service patient portal
• Pull - in addition to the push from the
provider end

20. Level 3
• Patient portal: proactive approach
• Provide patients with their own clinical
data (engage with patients)
• Remind patients of preventive care items
that still need to be completed

21. Level 3
• Patient portal: proactive approach
• Reinforce provider messages regarding
preventive care (e.g., daily exercise,
smoking cessation, need for DXA, etc.)
• Survey patients routinely after physician
office visits

22. The demo

23. Scenario 1 - Reactive

24. Sample workflow
1
Patient
arrives
at office

25. Sample workflow
1 2
Patient Office staff
arrives checks
at office patient in

26. Sample workflow
1 2 3
Patient Office staff Office staff
arrives checks checks
at office patient in eligibility

27. Sample workflow
1 2 3 4
Patient Office staff Office staff Pop-up
arrives checks checks member
at office patient in eligibility questionnaire

28. Sample workflow
1 2 3 4
Patient Office staff Office staff Pop-up
arrives checks checks member
at office patient in eligibility questionnaire
5
Collect
questionnaire,
give patient info

29. Sample workflow
1 2 3 4
Patient Office staff Office staff Pop-up
arrives checks checks member
at office patient in eligibility questionnaire
5
Collect
questionnaire,
give patient info
6
Office staff
puts reminder(s)
on patient chart

30. Sample workflow
1 2 3 4
Patient Office staff Office staff Pop-up
arrives checks checks member
at office patient in eligibility questionnaire
5
Collect
questionnaire,
give patient info
7 6
Physician sees Office staff
patient with puts reminder(s)
reminder(s) on patient chart

31. Sample workflow
1 2 3 4
Patient Office staff Office staff Pop-up
arrives checks checks member
at office patient in eligibility questionnaire
5
Collect
questionnaire,
give patient info
8 7 6
Physician sees Office staff
Patient receives patient with puts reminder(s)
appropriate care reminder(s) on patient chart

32. Sample workflow
1 2 3 4
Patient Office staff Office staff Pop-up
arrives checks checks member
at office patient in eligibility questionnaire
5
Collect
questionnaire,
give patient info
9 8 7 6
P4P/HCC/5STAR Physician sees Office staff
metrics achieved Patient receives patient with puts reminder(s)
for this patient appropriate care reminder(s) on patient chart

33. SMITH, MARY
8/15/1945
F
123 MAIN STREET
SANTA CLARA, CA 95051
4085551212
SCCIPA
ROBERT NORMAN, MD
1/1/2000
Check eligibility
1234567890
Quality Measures MAMMOGRAPHY, CRC, CARDIO CARE, DIABETES CARE, HYPERTENSION
CMS 5 STAR GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD

34. SMITH, MARY
8/15/1945
F
123 MAIN STREET
SANTA CLARA, CA 95051
4085551212
SCCIPA
ROBERT NORMAN, MD
1/1/2000
1234567890
Quality Measures MAMMOGRAPHY, CRC, CARDIO CARE, DIABETES CARE, HYPERTENSION
CMS 5 STAR GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD

35. SMITH, MARY
8/15/1945
F
123 MAIN STREET
SANTA CLARA, CA 95051
4085551212
SCCIPA
ROBERT NORMAN, MD
1/1/2000
1234567890
Quality Measures MAMMOGRAPHY, CRC, CARDIO CARE, DIABETES CARE, HYPERTENSION
CMS 5 STAR GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD

36. SMITH, MARY
8/15/1945
F
123 MAIN STREET
SANTA CLARA, CA 95051
4085551212
SCCIPA
ROBERT NORMAN, MD
1/1/2000
1234567890
Quality Measures MAMMOGRAPHY, CRC, CARDIO CARE, DIABETES CARE, HYPERTENSION
CMS 5 STAR GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD

37. Pop-up
SMITH, MARY
8/15/1945
message
F
123 MAIN STREET
SANTA CLARA, CA 95051
4085551212
CLOSE x
SCCIPA
ROBERT NORMAN, MD
1/1/2000
MEDICARE PATIENT
1234567890
QUESTIONNAIRE
HCC
Quality Measures MAMMOGRAPHY, CRC, CARDIO CARE, DIABETES CARE, HYPERTENSION
CMS 5 STAR GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD

38. SMITH, MARY
8/15/1945
F
123 MAIN STREET
SANTA CLARA, CA 95051
4085551212
CLOSE x
SCCIPA
ROBERT NORMAN, MD
1/1/2000
MEDICARE PATIENT
1234567890
QUESTIONNAIRE
Click to
HCC print
Quality Measures MAMMOGRAPHY, CRC, CARDIO CARE, DIABETES CARE, HYPERTENSION
CMS 5 STAR GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD

42. SMITH, MARY
8/15/1945
F
123 MAIN STREET
SANTA CLARA, CA 95051
4085551212
CLOSE x
SCCIPA
ROBERT NORMAN, MD
1/1/2000
MEDICARE PATIENT
1234567890
QUESTIONNAIRE
HCC
Click to
Quality Measures MAMMOGRAPHY, CRC, CARDIO CARE, DIABETES CARE, HYPERTENSION
print
CMS 5 STAR GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD

44. SMITH, MARY
8/15/1945
F
123 MAIN STREET
SANTA CLARA, CA 95051
4085551212
SCCIPA
ROBERT NORMAN, MD
1/1/2000
1234567890
Click on
measures
Quality Measures MAMMOGRAPHY, CRC, CARDIO CARE, DIABETES CARE, HYPERTENSION
CMS 5 STAR GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD

45. MARY SMITH
1234567890

47. x
x

48. SMITH, MARY
Medicare Dashboard
8/15/1945 Complete? DOC Measure
F
x 25FEB11 Mammography
123 MAIN STREET
SANTA CLARA, CA 95051 x 1MAR11 Colorectal Cancer Screening
4085551212 x 25FEB11 Cardio Care
SCCIPA x 25FEB11 Diabetes Care
ROBERT NORMAN, MD x 1MAR11 Hypertension
1/1/2000 x 15FEB11 Glaucoma
x 1MAR11 Chronic Meds Monitoring
x 8FEB11 Flu Vaccine
x 1MAR11 Pneumo Vaccine
x 25FEB11 Bone Density Testing
x 8FEB11 Rheumatologic Medication
1234567890 x 1MAR11 Spirometry for COPD
x 1MAR11 Urine leakage counseling
x 1MAR11 Falls counseling
x 1MAR11 Exercise counseling
x 1MAR11 Appointment ease
x 1MAR11 Physical/emotional health
Quality Measures MAMMOGRAPHY, CRC, CARDIO CARE, DIABETES CARE, HYPERTENSION
CMS 5 STAR GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD

49. Scenario 2 - Proactive

50. Sample workflow
1
Office staff
opens
dashboard

51. Sample workflow
1 2
Office staff Prints list of
opens patients
dashboard needing care

52. Sample workflow
1 2 3
Office staff Prints list of Outreach to
opens patients patients on
dashboard needing care list

53. Sample workflow
1 2 3 4
Office staff Prints list of Outreach to Office staff
checks eligibility
opens patients patients on and prints
dashboard needing care list questionnaire

54. Sample workflow
1 2 3 4
Office staff Prints list of Outreach to Office staff
checks eligibility
opens patients patients on and prints
dashboard needing care list questionnaire
5
Collect
questionnaire,
give patient info

55. Sample workflow
1 2 3 4
Office staff Prints list of Outreach to Office staff
checks eligibility
opens patients patients on and prints
dashboard needing care list questionnaire
5
Collect
questionnaire,
give patient info
6
Office staff
puts reminder(s)
on patient chart

56. Sample workflow
1 2 3 4
Office staff Prints list of Outreach to Office staff
checks eligibility
opens patients patients on and prints
dashboard needing care list questionnaire
5
Collect
questionnaire,
give patient info
7 6
Physician sees Office staff
patient with puts reminder(s)
reminder(s) on patient chart

57. Sample workflow
1 2 3 4
Office staff Prints list of Outreach to Office staff
checks eligibility
opens patients patients on and prints
dashboard needing care list questionnaire
5
Collect
questionnaire,
give patient info
8 7 6
Physician sees Office staff
Patient receives patient with puts reminder(s)
appropriate care reminder(s) on patient chart

58. Sample workflow
1 2 3 4
Office staff Prints list of Outreach to Office staff
checks eligibility
opens patients patients on and prints
dashboard needing care list questionnaire
5
Collect
questionnaire,
give patient info
9 8 7 6
P4P/HCC/5STAR Physician sees Office staff
metrics achieved Patient receives patient with puts reminder(s)
for this patient appropriate care reminder(s) on patient chart

62. Click on
measure

63. ANDREW SMITH
MARY SMITH
PAULA SMITH
SANDRA SMITH

64. ANDREW SMITH
MARY SMITH
PAULA SMITH
SANDRA SMITH
Click on
patient

65. MARY SMITH
1234567890

66. ANDREW SMITH
MARY SMITH
PAULA SMITH
SANDRA SMITH
Click to
download

67. SMITH ANDREW M
SMITH MARY F
SMITH PAULA F
SMITH SANDRA F

68. SMITH ANDREW M
SMITH MARY F
SMITH PAULA F
SMITH SANDRA F

69. SMITH ANDREW M
SMITH MARY F
SMITH PAULA F
SMITH SANDRA F

70. MARY SMITH

71. SMITH, MARY
8/15/1945
F
123 MAIN STREET
SANTA CLARA, CA 95051
4085551212
SCCIPA
ROBERT NORMAN, MD
1/1/2000
1234567890
Quality Measures MAMMOGRAPHY, CRC, CARDIO CARE, DIABETES CARE, HYPERTENSION
CMS 5 STAR GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD

72. Alice Smith
Betty Smith
Charles Smith
David Smith
Edward Smith
Frank Smith
Georgette Smith
Henry Smith
Illana Smith
Jackie Smith
Kelly Smith
Lori Smith
Mary Smith
Nancy Smith
Octavia Smith
Paul Smith
Quincy Smith
Robert Smith
Samantha Smith
Tom Smith

73. Discussion

74. Thank you

75. How to effectively
manage the
CMS “5 STAR” Rating System
Wayne Pan, MD, MBA
Health Access Solutions
wpan@hasinc.com
650.358.5820