GHG Advisors | GHG Advisors

Where did your organization fall with CMS' estimates for 2016 & what's next?

In September, the Centers for Medicare & Medicaid Services (CMS) estimated the average Medicare Advantage (MA) premium will decrease by $0.31 next year, from $32.91 on average in 2015 to $32.60 in 2016. The majority of MA enrollees (59 percent) will face no premium increase. Sounds great, but the reality is most MA and Part D plan sponsors are finding it more challenging than ever to keep premiums low and still maintain attractive benefit packages and viable business/financial models. $0 premium plans in some markets are now the anomaly. Do you keep premiums low, pare down supplemental benefits, and increase copays, or take the hit for another year and hang on, hoping you will make up the financial loss next year or when those risk adjustment scores and Star Ratings align?

According to CMS, about 65 percent of MA enrollees are currently enrolled in plans with 4 or more Stars for 2016, a significant increase from an estimated 17 percent of enrollees in such plans in 2009.

So, the question is, where did your organization fall with CMS' estimates for 2016? Now that competitive premium and benefit information are available for review, I am sure your organization is among the many updating competitive analyses to see what the real situation is. If not, you need to. "Gorman Health Group (GHG) receives a number of requests for benefit analyses as soon as benefits are publicly released," stated Charro Knight-Lilly, Senior Vice President of Client Services. "It is truly the only way an organization can understand their benefit differentials and make the appropriate changes to marketing and sales strategies."

So what's next? For the short-term, it is time to pull your Sales and Marketing teams back together to review where you actually fall in line for 2016 against your competitors and refine or, in some cases, rework the strategies put in place based on competitive assumptions. Ask yourself:

Will my marketing dollar garner the projected return on investment under our original strategy, or should I shift my dollar spend?
Should my messaging change based on competitive product and benefit differentials?
Should my sales distribution strategy change in order to meet close ratios?

With the Annual Election Period (AEP) for Medicare health and drug plans now underway, there is no time to lose.

Have questions or need information? Contact Charro Knight-Lilly, Senior Vice President of Client Services at cknightlilly@ghgadvisors.com, or contact me directly at nlennig@ghgadvisors.com.

Resources

Design and implement a comprehensive data analysis to guarantee you have the right products, programs, and capabilities in place to compete and ensure you are go-to-market ready. Contact us to learn more >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

2016 Star Ratings are Working, and the Bar is Rising

The Centers for Medicare & Medicaid Services (CMS) released the 2016 Medicare Advantage (MA) Star Ratings early this year, on Thursday morning. The usual practice is to wait until Friday after the close. It was a shift designed to move markets, and the news was mixed. Overall, Star Ratings are working to improve quality in many areas of health plan performance, but insurers and their provider and pharmacy benefit partners are struggling on a similar number of metrics. What is clear is that Star Ratings are now the fulcrum of competition in government health programs — and man, this stuff is hard and getting tougher.

There are clear winners and losers in this release. There is a "Divine Dozen" of 5-Star-rated plans, including a couple of new arrivals to the 5-Star world. CIGNA traded its 5 Stars in FL (the legacy HealthSpring plan at the legendary Leon Clinic) for its Arizona plan. Sierra (9 states), Tufts (MA), Group Health of MN, and Essence (IL and MO) made it into the Pantheon. Repeat 5-Star rock stars include Kaiser in 8 states, Martin's Point (ME and NH and will soon own Medicare in Northern New England), and Gunderson in IA and WI.

The half-dozen "walking dead" — plans scoring below 3 Stars for 3 consecutive years —included Wellcare of LA, Sierra Health, Touchstone, Cuatro, Windsor, and GHS (owned by HCSC). Three will be terminated by CMS at the end of 2016.

Star Ratings are proving to be tremendously effective in moving markets and forcing industry investments in population health and the member experience and are driving big improvements in Medicare quality. Roughly half of MA plans (179 contracts) earned 4 Stars or higher for their 2016 overall rating, a nearly 9% increase in a year and the first time a majority scored over 4. On an enrollment-weighted basis, over 70% of MA enrollees are in contracts with 4+ Stars, a nearly 11% increase year over year.

But below the water line, at the metric level, the news was mixed and cautionary:

The good news: Average Star Ratings increased for 10 Part C measures and 5 Part D measures. We saw significant improvements in several challenging, longitudinal Health Outcomes Survey (HOS) measures: Improving/Maintaining Mental Health, Monitoring Physical Activity, Part D Appeals Autoforwards, and High Risk Medications. There were smaller improvements on many other measures, where removal of the 4-Star thresholds helped plans improve ratings.
The bad news: Average Star Ratings DROPPED for 16 Part C measures and 6 Part D measures. We saw significant decreases in several screening measures (colorectal cancer screening, diabetes kidney disease monitoring) and the HOS measure of improving/maintaining physical health. And there was a big drop on the Medicare Plan Finder (MPF) Price Accuracy measure, where the cut points have gotten so small that 97% accuracy only gets 3 Stars, 99% results in 4 Stars, and it literally takes a perfect 100% to earn 5 Stars.

We knew the removal of the 4-Star thresholds would produce a tremendous amount of fluctuation in the measure cut points, and that's exactly what happened. It's like playing "Pin the Tail on the Donkey" during an earthquake, making it really hard for health plan leaders to predict where their ratings will ultimately land while they still have time to influence them. For example:

The average rating on the Diabetic A1c Control measure increased from 3.3 in 2015 to 3.9 in 2016. But there was no change whatsoever in the average performance rate for this measure — in both 2015 and 2016, the average compliance rate was 76%. The improvement on this measure can be entirely attributed to CMS relaxing the cut points once the predetermined threshold was removed.
In contrast, the Controlling Blood Pressure measure rating dropped from 3.7 in 2015 to 3.4 in 2016. The compliance rate actually increased from 65% in 2015 to 71% in 2016. This is an example of where the removal of the predetermined thresholds tightened the pressure on this measure — in fact, the 4-Star threshold increased 12% upon removal of the predetermined thresholds.

The Star Ratings data for 2016 pretty much emasculated industry arguments for relaxing metrics for Special Needs Plans (SNPs). SNPs saw improvement in their quality scores roughly equal to that of HMOs and PPOs: MA plans operating SNPs averaged a 3.61 rating in 2016 (up from 3.47 in 2015), while plans with HMO/PPO-only contracts averaged 3.87 in 2016 (up from 3.79 in 2015).

Non-profit MA plans are pounding for-profits into the sidewalk on quality. About 70% of non-profit MA plans received 4+ Stars vs. 39% of the for-profits. Much of that discrepancy is due to culture. Non-profits tend to be far more focused on the all-important member experience measures and are more collaborative with their provider networks.

Methodological changes by CMS ensure the Star Ratings bar will continue to rise. 2016 is the first year plans with 500-999 members were rated. Only 369 Medicare Advantage Prescription Drug Plans (MA-PDs) were rated in 2016. 188 more plans weren't rated, but may be in 2017 — and this dilution will warp the bell curve plans are graded on, especially when considering most of those 188 are provider-sponsored, and strong performers will emerge. 4+-Star plans have the most to lose in this environment, and no one can afford to get comfortable.

Some takeaways:

Stars must be managed as a program and a corporate priority, not as a group of measures. The effort must be directed by dedicated executive leadership and support. No plan improves Star Ratings doing it off the side of their desks.
The removal of the remaining predetermined thresholds means there is no way for plans to "pick and choose" a subset of measures to focus on. It has to be improvement across the board.
The bar continues to rise fast among Part C Star Ratings measures. The "low hanging fruit" has been eaten. Part C Star Ratings success is no longer easily influenced by slick reports provided to physicians. Plans need to help providers execute on gaps in care plans and eliminate barriers to care for the vulnerable. There's a reason the 5-Star plans are mostly provider-sponsored, vertically integrated, collaborative, and member-centric by nature.
Star Ratings measures need to be woven into every department's work streams. This includes not only quality, care management, health services, and pharmacy, but also risk adjustment, network operations, and compliance.
Lagging SNPs need to work harder and smarter and assume no CMS help on the measures for the low-income and disabled. To the contrary, recent draft measures for dual eligibles from the National Quality Forum focus on mental and behavioral health and will prove an enormous challenge.

If you achieved 4+ Stars this year, congratulations, it's an increasingly impressive accomplishment. Now get back to work. There are 178 plans at 3-3.5 Stars who are close on your heels and feeling the urgency. Now add the 188 unrated plans who will smash the bell curve in 2017. A 4-Star plan's equal effort in 2016 only guarantees a score that starts with a 3 the next year. Keep. Moving. Forward.

If you missed your 4^th Star this year, panic a little, but then get it together. Fast. In a competitive market, you're circling the toilet bowl but aren't flushed yet. You still have time to influence your 2017 Star Ratings and must make improvement the focus of your benefit, formulary, and network designs in the months ahead. You have big decisions to make and must invest time and resources wisely and with a sense of urgency.

Once again, the 2016 Star Ratings prove the world's biggest experiment in performance-based payment is working and forcing insurer evolution. And evolution isn't about size, it's about continuous adaptation.

Resources

Whether your plan missed the overall 4-Star Rating necessary to earn Quality Bonus Payments, or whether the new 4-Star cut points have introduced new risks of maintaining your overall 4-Star rating, we can help. Our team of experts understands the Star Ratings program and knows how to influence performance. Contact us to learn more >>

Join us on Friday, October 9, from 1-2 pm ET, as John Gorman, Founder & Executive Chairman at Gorman Health Group (GHG), examines the state of government healthcare programs and outlines proven tactics market leaders are implementing to cut costs, increase member satisfaction, and drive sustainable growth. Register now >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

ACO vs. Value-Based

Earlier this year, the U.S. Department of Health & Human Services (HHS) set a goal of moving 30 percent of payment for traditional Medicare benefits to value-based payment models by the end of 2016 and 50 percent by the end of 2018. The Center for Medicare & Medicaid Innovation's (CMMI's) Accountable Care Organizations (ACOs) have been the largest movement toward that goal to date, yet the most recent financial results highlight some flaws, and organizations should carefully analyze whether an ACO or a Medicare Advantage (MA) structure is a better fit for them.

The results show these ACOs are important building blocks for many organizations and will continue to generate success coupled with tweaks made by the Centers for Medicare & Medicaid Services (CMS) to generate more positive numbers. Organizations having already proven their success in generating savings could easily graduate to MA and be successful. Plans not as successful, or plans not currently possessing the infrastructure needed to succeed in MA, should look to CMS' Next Generation model to alleviate some of the concerns of the previous demonstrations.

CMS applauded the most recent financial and quality results, stating Medicare ACOs continue to improve quality of care while slowing down healthcare costs. Ninety-seven ACOs qualified to share in savings by meeting quality and cost benchmarks. CMS stated the ACOs generated net savings of $411 million in 2014 and improved in most quality measures. CMS also noted additional ACOs are inquiring about participating next year.

Yet these numbers represent one in four generating enough savings to qualify for bonuses. Only 11 Pioneer ACOs earned savings payments of $82 million. Five generated losses, with three owing CMS shared losses of $9 million. Despite CMS reporting Pioneer ACOs improving an average of 3.6 percent compared to 2013 on 28 of the 33 quality measures, most did not see any rewards. Only 27 percent of Medicare Shared Savings Program (MSSP) ACOs earned shared savings payments.

The results indicate ACOs need time to adjust to the model and show improvement over time. Thirty-seven percent of the MSSP ACOs launching in 2012 generated savings in the third performance year, compared to 27 percent of MSSPs beginning in 2013 and 19 percent beginning in 2014. However, these numbers do not account for the ACOs dropping out of the program, potentially skewing the earlier success rates. The results also highlight the complexity of participating in CMS' alternative payment models. Many ACOs not as successful initially likely lacked or underestimated the investment needed for new infrastructure and systems. Plans and providers need to understand the need to set up more sophisticated information technology (IT) infrastructure and how to successfully utilize data. As potential ACOs evaluate whether to participate, they should consider how much of an investment is needed in order to succeed.

The major concern over CMS' use of benchmarks is also still evident. In order for an ACO to qualify for shared savings, the ACO must beat a benchmark calculated by CMS. The year-to-year trend in this benchmark is a mix of the national percentage growth rate in Medicare and the absolute dollar value of the annual per member per month (PMPM) increase in the average Fee-for-Service (FFS) per capita costs. Because of this, ACOs in high-cost areas consistently achieving lower costs are not rewarded because their improvements in financial and quality performance are not accurately captured. The current program also lacks a full and up-to-date risk adjustment to accurately account for beneficiaries' health status. Thus, ACOs that may generate savings for CMS still miss the benchmark.

Despite concerns with methodology, there are now approximately 7 million beneficiaries served by more than 400 ACOs. At the same time, CMS has shown it is focused on issues that develop and is working on options which will tweak the program to better fit future participants (the Next Generation ACO, for example). Despite the challenges, ACOs are currently the biggest initiative succeeding in enticing and exposing large numbers of providers and beneficiaries in its effort to coordinate services. The program is still receiving strong interest from both new applicants and existing ACOs seeking to continue the program, and CMS plans to announce new and retiring ACOs by the end of the year.

Resources

We understand Medicare ACOs: We have helped launch eight over the past two years. But we also understand that this is just a first step toward taking greater control over the Medicare revenue stream by "moving up the food chain." Our team of veteran executives can help your ACO evaluate the options, manage the workflow to achieve either a Medicare Advantage contract with CMS or a risk contract with an existing MA plan, and continue to achieve improved outcomes. Visit our website to learn more >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

The MA-VBID Model: Key Takeaways

Now that you have digested the Centers for Medicare & Medicaid Services' (CMS) announcement on the proposed demonstration for high-value benefit designs, the clock is ticking on determining an optimal set of benefits prior to the CMS deadline of November 15, 2015.

Over 37 organizations are eligible to consider this opportunity, which is based on member value and not competition. As John Gorman, Founder & Executive Chairman at Gorman Health Group, and I discussed at length on our recent Medicare Advantage Value-Based Insurance Design Model (MA-VBID) webinar on Monday, a multi-faceted approach within the health plan operation will be needed to quickly put together a review and proposal. Operational "must haves" include high-value, narrow networks which understand the eligible populations, high-quality disease management programs, solid Star Ratings programs, and predictable membership. A strong foundation in claims processing and configuration, product design (including supplemental benefits), return on risk adjustment, efficient organization staffing, and excellent communications (electronically) with providers are needed to support the required capabilities.

Although marketing to the target populations will take place post-enrollment to limit adverse selection, the concept of a target condition is based on two key triggers. Realistically, the target condition is marked on a claim with several months' run-out, even if a need already exists such as follow-up visits to specialists or prescription drugs. Good Electronic Medical Record (EMR) communication can shortcut that process to activate benefits. Fortunately, drugs can be targeted for benefits, but Pharmacy Benefit Manager (PBM) coordination is critical.

GHG has been preparing for this shift in the industry and is already working with clients to assist in the assessment of current providers, referral patterns, and populations within the eight chronic conditions (diabetes, congestive heart failure, chronic obstructive pulmonary disease (COPD), past stroke, hypertension, coronary artery disease, mood disorders, and various International Classification of Diseases (ICD) combinations). Understanding the cost and utilization as well as referral patterns for these members (medical and pharmacy) will help a plan maximize the potential for success. A team of subject matter experts from Gorman Health Group will deliver actionable results, driven by data analysis of current capabilities and benefit designs, to achieve quality care for the target populations.

The benefits must be approved with November submissions and certified by the plan's actuaries with the 2017 bid in June 2016, so they are binding. Gorman Health Group is prepared to help with individual plan assessments and partner with clinically-effective benefit designs that deliver financial and quality results.

Resources

GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you're keeping pace with CMS expectations in both compliance and health care outcomes. Visit our website to learn more >>

Download a copy of the recording from Monday's Medicare Advantage Value-Based Insurance Design Model (MA-VBID) webinar, hosted by John Gorman.

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

New Part D Medication Therapy Management Model: Is It Right For you?

Drum roll, pleaseâ€¦beginning January 1, 2017, the Centers for Medicare & Medicaid Services (CMS) will pay Medicare Prescription Drug Plans (PDPs) to play in Medication Therapy Management (MTM)â€”and it's all about the money. Where before MTM costs were administrative, there will be two additional payments for plans approved for participation in the model program. The "model test performance period" will actually span seven total years (2017-2023) because payments will be made for two additional years after the five-year model performance period. There will be a prospective payment for "more extensive MTM interventions to members and providers" and a performance payment "in the form of an increased direct premium subsidy for plans that successfully achieve a certain level of reduction in fee-for-service expenditures and fulfill quality and other data reporting requirements through the model." The final approved prospective payment will be on a per member per month (PMPM) basis and will be paid per enrollee in the plan regardless of how many enrollees are receiving enhanced MTM services.

As of August 2015, there are 24 million enrollees in Medicare PDPs. Enrollees sign up because the PDP premiums are usually less expensive than MAPD plan premiums. However, these plans usually provide minimal MTM services meant to meet the letter of CMS compliance, not the intent. For example, provider interventions may have no feedback loop to ascertain whether or not the provider agreed or disagreed with or accepted the recommendations. And, therefore, any cost avoidance or actual cost savings data are missing or suspect.

This new enhanced MTM performance model has the potential to move the needle, but PDPs in the eligible regions will have to complete an accurate risk analysis for their members to determine what a viable program consists of and how new and innovative MTM endeavors will positively impact the CMS MTM goals of "optimized therapeutic outcomes through improved medication use, and reduced risk of adverse events, including adverse drug interactionsâ€”while reducing net Medicare expenditures."

"Gorman Health Group is ready to help work with PDP plans in identifying the cohort populations that would benefit from this demonstration," explained a Senior Consultant in Risk Adjustment & Healthcare Analytics at Gorman Health Group. "The successful MTM programs will leverage pharmacy costs and utilization to achieve savings in medical costs. CMS is looking for this savings, and participating plans need to monitor their effectiveness with new MTM programs."

Resources

Click here to download Gorman Health Group's whitepaper on the Part D Enhanced Medication Therapy Management (MTM) Model, written by Celia Girard, Director of Policy & Training and Caron Wingerchuck, Senior Director of Pharmacy Solutions.

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

Recommendations Made by the National Quality Forum on Medicaid Measures

The National Quality Forum (NQF) is a non-profit organization working to evaluate and endorse standardization of healthcare performance measures. Recently, NQF submitted a series of reports to the U.S. Department of Health and Human Services (HHS) outlining recommendations on new measures aimed at improving Medicaid beneficiary quality of care. For the last four years, NQF started providing strategies to HHS on improving care for dual eligibles, adults, and children in the Medicaid program. These new quality measures were created to improve healthcare quality for more than 70 million adults and children. The key area of concentration was the beneficiaries' behavioral health and how it affects diabetic and cardiovascular care delivery.

In the reports, NQF tracked the effects behavioral health has on diabetics and the domino effect it has on a beneficiary's overall health. Many providers are seeing that therapies used on patients with serious behavioral health issues are causing significant health problems. An example is weight gain as a side effect of the medications given to treat mental health illnesses. They saw this turn into health issues, such as diabetes, in these patients. The report continues to state that not addressing the behavioral health problems of a beneficiary has led to higher glycated hemoglobin (A1C) which then resulted in cardiovascular issues. This problem of addressing both the physical and mental health needs of the Medicaid population has been in the forefront of the American Psychiatric Association and U.S. Psychiatric and Mental Health Congress.

NQF has made recommendations for the working age population of adults, which are also the most rapidly-growing population relating to controlling and monitoring cardiovascular health (e.g., high blood pressure) and medication management in those individuals who have serious behavioral health illnesses. NQF has also made recommendations for children and dual eligibles. Due to the complex needs of the dual-eligible population, the amount of measures was increased, many concentrating on behavioral health and comorbidities. They also concentrated on making changes to the care coordination and readmission rate monitoring.

Resources

Gorman Health Group can perform an analysis on your current quality programs and provide expert advice on benefit designs, as well as conduct a risk analysis to determine what a viable program consists of and expected outcomes. Contact us to learn more >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

Healthcare Implications Post Boehner Exit

House Speaker John Boehner announced last Friday he will resign his seat at the end of October. Following this announcement, House and Senate members immediately announced plans to pass a spending bill preventing a government shutdown by scrapping plans to block Planned Parenthood funding for the time being. Boehner's resignation makes this move possible because he no longer faces the threat of being ousted by the House Republicans if the bill he brings forward to the floor does not have Republican majority.

While the most imminent government shutdown has currently been averted, the threat of everything coming to a halt mid-December, at which point the spending bill funding would run out, is much more likely to materialize. The next funding bill will need to work out the funding levels for the rest of budget year 2016 in order to prevent a government shutdown. In an attempt to put the continual nightmare of annual shutdown threats off until the next administration, Senator McConnell just announced potential talks with President Obama to negotiate a 2-year budget, and cover fiscal year 2016 and 2017.

So what does this all mean for healthcare and the Affordable Care Act (ACA)?

Planned Parenthood aside, Boehner was actually quite a critical opponent of Obamacare and fought it to the very end, even bringing lawsuits against the administration. His only move seen as a positive in the healthcare industry is the support to repeal the flawed Sustainable Growth Rate (SGR) formula earlier this year. Because House Republicans are likely celebrating the win of the resignation, however, we will likely see many more attacks on the ACA despite all of them being unlikely to work, just as under Boehner's leadership.

Reconciliation bills are one likely tactic — House Ways and Means Committee already approved one today — to repeal portions of the ACA, such as employer and individual mandates, medical device tax, and the Independent Payment Advisory Board. The House and Energy Committee also introduced a reconciliation bill to defund Planned Parenthood. However, although Boehner stepping down may mean such bills could make it through both the House and Senate, they will certainly meet their end on the President's desk.

Unfortunately, this also puts any potential good bipartisan agreements at bay for the time being. Bipartisan bills to repeal the "Cadillac Tax," for example, will likely see much more punting around. Repealing the tax would create an $87 million budget deficit, and, with what is shaping up to be an aggressive fight in December, such a move is unlikely.

Under the new speaker's leadership, likely a more conservative pick, the Planned Parenthood fight may also stick around until December 2015. While Boehner was more willing to work across party lines on this issue, the current Republican majority is celebrating the resignation and may be much more emboldened in their fight in December.

The big issue is, of course, the 2016 budget. While the current spending bill will deal with emergency issues such as the imminent expiration of the transportation funding, the bill in December will need to tackle the FY 2016 budget as a whole. One huge one is Part B premiums — if Social Security is not adjusted and stopgap funding is not provided, this fund could run dry, and Medicare recipients under Part B will see significant premium increases. Another example is the temporary funding created by the repeal of the SGR, for example, funding for ambulance rides and physical therapy. These programs will face cuts if funding is not agreed upon in December.

Resources

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

Do More Than Survive AEP

How quickly another Annual Election Period (AEP) is upon us. This time of year is the perfect time to review your new member onboarding activities and AEP strategy. We all know the sale doesn't end when the application is turned in and membership begins. This is where the rubber hits the road.

These are the four questions to consider going into AEP:

Are all plan resource documents updated with the 2016 plan benefits? Picture this: A friend newly eligible for Medicare recently enrolled in a Medicare Advantage plan. He experienced a benefit problem that nearly ended in a sales allegation all because a representative was relying on outdated benefit information. This would have been avoided if everyone at the plan had the new benefit designs.
Does health plan staff see the big picture? It's easy for us to focus on our individual operational components. After all, the number of regulations and processes to manage a compliant Operations Department is significant and takes our full attention, but the big picture allows for cohesive programs and the ability to see what part we play. Does Enrollment know the top issues that Reconciliation experiences? Is there a feedback loop established to catch improvement opportunities early as we move into AEP? Has Sales shared the advertising schedule and advertisements with Customer Service? Customer Service can maintain that strategy and answer member questions about the campaigns for 2016.
Are operational oversight tools in place? Not only should all operational staff know the requirements governing their processes, they should know how to tell they are meeting those requirements. The ability to oversee our own processes and know we are in compliance is empowering. Not only can corrections occur immediately, but staff can be confident and efficient, focusing on the important actions supporting new and existing members.
Is everyone focused on the goal — ensuring a positive member experience? If applications are incomplete, is the Enrollment staff focused on sending a letter to get the application off their plate or focused on reaching out to the member to complete the member enrollment? Are welcome calls in place to answer any lingering questions and ensure new members feel confident and engaged in their plan choice?

AEP was quick to arriveâ€”it will be equally quick to come to an end. Make sure it's the AEP you designed rather than the AEP you survived.

Resources

In Operations, we naturally focus on our own internal processes and efficiencies, but now is the time to invest in making sure staff knows how their contributions impact members and the health plan. Gorman Health Group's experienced Operations team can work with you to set up strategic, efficient, and knowledgeable operations. We've been in your shoes and know how to navigate through AEP. Visit our website to learn more >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

Star Ratings Plan Preview #2

It's hard to believe, but it's that time of year again. Yes, it's football seasonâ€”and it's also the beginning of Star Ratings season.

The Centers for Medicare & Medicaid Services (CMS) annual Star Ratings plan preview periods have become as much an annual ritual for Medicare Advantage (MA) plans as the Advance Notice and Call Letter, and plans throughout the nation are feverishly working to understand their 2016 Star Ratings so they can quickly determine what still needs to be done during the fourth quarter to close out 2015 strong.

Although there were few surprises in the 2016 Star Ratings measure specifications, there was much to be gleaned from the long-awaited removal of the remaining pre-determined 4-Star thresholds. As expected, almost as many 4-Star thresholds were decreased as were increased. The plan preview measure specifications show 4-Star cut points were tightened on 20 measures and relaxed for 13 measures. Measures where the 4-Star cut points were relaxed included those with significant patient lifestyle and perception impacts, such as medication adherence, diabetic blood sugar control, and several Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) measures. In contrast, measures with tightened cut points include many of the Healthcare Effectiveness Data and Information Set (HEDIS^®) process measures, where plans and providers have a long history of focus and attention to gap closure. In contrast, 4-Star cut points were only relaxed for one administrative, or plan-controlled, measure, which demonstrates plans are "controlling the controllables" within the program. Again, no big surprises in these changes. But the absence of surprise does not mean it will be easy for plans to adapt to these changes.

So what can we take away from the plan preview?

CMS continues to use the Star Ratings program to compel health plans to increase their strong focus on quality improvement in their service to beneficiaries.
Plans must continue investing efforts in longer-term strategic relationships with members and providers to continue improving health outcomes, meeting beneficiary expectations, and performing well in the Star Ratings program.
With the increasing competition in MA and full adoption of the bell curve within the Star Ratings program, the definition of success is likely to continue to rise. There is simply no such thing as "good enough" in Star Ratings.

With approximately five percent of MA plan revenues tied to Star Ratings performance through Quality Bonus Payments, an objective review of a plan's Star Ratings infrastructure, strategy, and performance can be a wise investment.

Resources

Whether your plan missed the overall 4 Star Rating necessary to earn Quality Bonus Payments, or whether the new 4-Star cut points have introduced new risks of maintaining your overall 4 Star rating, we can help. Our team of experts understands the Star Ratings program and knows how to influence performance. Contact us to learn more >>

by GHG Advisors

Medicare Advantage Value-Based Insurance Design: Key Considerations

The Centers for Medicare & Medicaid Services (CMS) recently announced a proposed demonstration that will test varying benefit designs based on health status. The Medicare Advantage Value-Based Insurance Design (MA-VBID) Model will allow organizations to offer targeted supplemental benefits and/or reduced cost sharing to enrollees with specific chronic conditions to further the goal of improving beneficiary health, reducing the utilization of avoidable high-cost care, and reducing costs for plans, beneficiaries, and the Medicare program. The overall goal of this demonstration is to improve clinical outcomes while reducing plan expenditures.

Do you qualify?

This demonstration is proposed for seven states: Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee. According to the announcement, only current MA organizations in good standing in those states will be allowed to participate. The demonstration is aimed at Health Maintenance Organizations (HMOs), Health Maintenance Organization Point of Service (HMO-POS) plans, and local Preferred Provider Organizations (PPOs) in order to determine how it affects beneficiaries and costs in the most common plans. Special Needs Plans (SNPs), Regional PPOs, Medicare-Medicaid Plans (MMPs), Private Fee-for-Service (PFFS) plans, Employer Group Waiver Plans (EGWPs), Health Savings Accounts, and cost plans are not eligible.

The demonstration will waive certain regulations so benefit plans can vary for enrolled members based on their diagnosis, condition, or need for a medical service. Currently, health status distinctions in providing benefits to enrolled beneficiaries are prohibited by regulations.

How we can help:

Applications

The CMS process begins with the submission of a Request for Application (RFA), which is currently due on November 15, 2015. Organizations failing to submit an RFA cannot participate in 2017 but may be allowed at a later date during the five-year demonstration period. Organizations must submit an RFA that has sufficient detail to allow CMS to determine if the benefit plan addresses targeted beneficiaries, will provide measureable results, and is appropriately structured for the demonstration. We can work with your organization through every step of the application process, from gathering the right data and completing the application, to submitting the application and responding to follow-up questions.

Financial Analysis

The key to designing a successful MA-VBID model is to establish programs to simultaneously manage revenue through best-in-class Star Ratings operations and targeted risk adjustment for these prevalent diseases and avoid adverse risk selection as well as an ongoing review of cost and utilization drivers from medical and pharmacy claims. An initial assessment of claims and financials can help highlight existing strengths and weaknesses in medical management (including pharmacy) as well as provider networks. With annual bids as the source of financial truth, targets need to be realistic and timely.

Benefit Design Analysis

Organizations can propose any myriad of combinations of benefits or services provided they are based on the proposed chronic conditions listed in the announcement. Most importantly, CMS notes participating organizations can initiate the demonstration with a limited benefit and can expand their benefit plans during the five-year term of the demonstration. While the benefits will be mandatory supplemental benefits, CMS proposes to prohibit marketing these benefits to non-member beneficiaries.

Resources

We can work with your organization to design and implement a comprehensive data analysis to guarantee you have the right products, programs, and capabilities in place to compete and ensure you are go-to-market ready.

Is this the right opportunity for your organization? Attend our webinar to find out. Join John Gorman, Founder and Executive Chairman at Gorman Health Group, and I on Tuesday, September 29, from 1-2 pm ET, as they outline the MA-VBID plan requirements as well as what you should be doing now to prepare for January 2017. Register now >>

by GHG Advisors