High Performance Health Plan Networks
A Milliman report commissioned by AHIP finds that narrower, high value provider networks can help reduce premiums from 5 to 20 percent when compared to broad network plans. A high value network is one selected on the basis of not only fee schedules, but also overall efficiency and quality metrics. Health plans can make these judgments in ways individual consumers cannot.
It is ironic that ObamaCare has created the structure and incentives for a truly competitive health care market, something long sought by Republicans as an alternative to government regulation of prices and medical practice.
The Exchanges offer consumers an opportunity to compare plans on cost and (when the data are accurate and up to date) on networks. Now that insurance companies cannot manage costs by waiting periods and exclusions, they have more incentive to high performance networks as their main competitive advantage. This leaves excluded providers with the option to improve, and qualify for high performance networks, or lose business. Maybe, just maybe, we'll see some improvement in the mismatch between what we pay for health care and what we get.
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On Wednesday, July 23, join GHG to discuss the 2015 Medicare Advantage Marketing guidelines and how to plan for the upcoming changes. Register now >>
If you've just submitted your HEDIS data, now is the time to analyze that data for gaps and identify interventions for your health plans, providers and members. On July 17 join John Gorman, Executive Chairman at GHG, Jane Scott, Senior Vice President of Clinical Services and Anita McCreavy, Senior Consultant, for a webinar on HEDIS reporting, the new measures and what's next. Register now >>
Hobby Lobby and Corporate Person-hood
The Supreme Court ruled on Monday, in the Hobby Lobby case, that requiring family-owned corporations to pay for insurance coverage for contraception under the ACA violated a federal law protecting religious freedom. This essentially means that some corporations now have religious rights. Although the majority tried to make this ruling as narrow as possible, it does open the door to future suits claiming exemption from other laws that are deemed by the owners of closely held corporations to infringe on the free exercise of their religion. An initial concern for insurance issuers is whether religious exceptions will proliferate, requiring an increase in benefit design variation. More benefit options means increased operating costs, and more difficult premium calculations.
Beyond this, the logic that a family-owned corporation is indistinguishable from its owners when it comes to religious rights may poke holes in the corporate veil in other ways. Corporations are created by state governments to protect their owners from personal liability. They are fictitious persons, endowed by their creator (the state) with certain specific rights and privileges. The tendency of this Supreme Court to see corporations as extensions of their owners, or of their donors in the Citizens United case, seems to violate this notion of limited rights as well as limited liability, all as determined by state incorporation law. If corporations enjoy freedom of speech and protecting under the federal Religious Freedom Restoration Act, are they also people for purposes of voting and holding public office? Isn't this train of thought leading into some weird and nonsensical places?
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On Wednesday, July 23, join GHG to discuss the 2015 Medicare Advantage Marketing guidelines and how to plan for the upcoming changes. Register now >>
If you've just submitted your HEDIS data, now is the time to analyze that data for gaps and identify interventions for your health plans, providers and members. On July 17 join John Gorman, Executive Chairman at GHG, Jane Scott, Senior Vice President of Clinical Services and Anita McCreavy, Senior Consultant, for a webinar on HEDIS reporting, the new measures and what's next. Register now >>
Part D and Hospice Rules Mucking Up Beneficiaries' Last Days
Last week the Centers for Medicare and Medicaid Services (CMS) met with 30 hospice & healthcare organizations about suspending a new rule intended to avoid duplicate payments for hospice medications. This is a very big deal and the new rule is mucking up many beneficiaries' last days. The National Hospice and Palliative Care Organization described the meeting as "an important first step at righting the wrongs being faced by dying Medicare patients."
Previously, hospice (under Medicare Part A) paid only for the drugs that patients needed for palliation and management of the terminal illness and related conditions, and Medicare Part D covered drugs for hospice patients' unrelated conditions. Under the new rule, CMS requires a beneficiary level prior authorization process for all hospice and Part D providers to determine responsibility of drug coverage, and hospice must cover medications related only to the hospice diagnosis.
CMS' expectations are unrealistic. Putting prior authorizations on everything adversely impacts beneficiary access to drug therapies and causes agonizing delays at the point of service. Consider this: first, it has to be determined if the drug in question is covered under Part A or D. If Part A, then you have to figure out if it's even covered under the hospice formulary and beneficiary refuses to try formulary equivalent first or drug is not reasonable or necessary per the hospice provider if not and the beneficiary wants the drug, it will be self-pay. If it's neither Part A nor D, then the beneficiary must self-pay. If covered under Part D and the prescriber is not hospice affiliated, the sponsor has to jump through hoops, including what to do if the prescriber is unable or unwilling to coordinate with the hospice provider.Then, if the drug has prior authorization on Part D it would have to satisfy those requirements. Plans have to be able to accept and save proactive determinations from hospice. It's an administrative nightmare. For 2014 only, CMS is universally allowing Plans to treat hospice coverage determinations as exceptions. That in and of itself shows that they are not sure how best to handle this mess.
With end-stage patients (the only kind you get in hospice), it is often difficult to discern which drugs are used for symptom management and what drugs are really for chronic conditions that if in hospice should not be treated, such as diabetes or hypertension meds. The hospice industry has reported widespread confusion and disputes that have made it harder for patients to get their drugs.
Seventy senators signed onto a letter circulated by Sens. Jay Rockefeller (D-WV) and Pat Roberts (R-KS), calling for CMS to suspend the rule. "We ask that CMS immediately suspend the Guidance and begin a process to develop an alternative approach which will ensure both that the right individual or entity pays for the hospice patient's medications and that the patient get the medication that he or she requires without interruption," they write.
We agree and hope CMS goes back to the drawing board on this rule. Calm and freedom from pain should define a beneficiary's last days, not administrative hoops and preauthorizations.
Resources
If you've just submitted your HEDIS data, now is the time to analyze that data for gaps and identify interventions for your health plans, providers and members. On July 17 join John Gorman, Executive Chairman at GHG, Jane Scott , Senior Vice President of Clinical Services and Anita McCreavy, Senior Consultant, for a webinar on HEDIS reporting, the new measures and what's next. Register now >>
The rapid changes to Part D regulations make the tracking and implementation of these CMS requirements exceptionally difficult — to say nothing of actually managing to them. Contact us today to learn how we can help >>
Further Evidence That PBMs are Failing on Government Programs
At CMS' oversight and enforcement conference last week Jonathan Blanar, the agency's Deputy Director of Compliance Enforcement, presented the following slide. In this slide, you will see actions CMS has imposed against Medicare health plans in the last two years, and for what reasons. It's further evidence that pharmacy benefit managers (PBMs) are failing Medicare beneficiaries and the plans enrolling them.
PBMs have a big hand in the first category, coverage determinations, though they're not entirely culpable. What's maddening about that tally is the fact that appeals and grievances rules in Medicare haven't changed much in the 17 years since they were first issued, and PBMs and plans are still screwing it up. To CMS, appeals are the most important consumer protection at the point of service, so they dish those findings out regularly.
It's the second category, formulary administration, that's most disturbing. The numbers speak for themselves. But Blanar added this color, the most frequent findings, which included the following and are a damning indictment of PBMs as the Keystone Kops of government programs:
- Unapproved quantity limits
- Unapproved utilization management practices
- Failure to properly administer the CMS transition policy
- Improperly effectuating a prior authorization or exception request
- Failure to provide a transition supply of a non-formulary medication
Resources
If you've just submitted your HEDIS data, now is the time to analyze that data for gaps and identify interventions for your health plans, providers and members. On July 17 join John Gorman, Executive Chairman at GHG, Jane Scott , Senior Vice President of Clinical Services and Anita McCreavy, Senior Consultant, for a webinar on HEDIS reporting, the new measures and what's next. Register now >>
The rapid changes to Part D regulations make the tracking and implementation of these CMS requirements exceptionally difficult — to say nothing of actually managing to them. Contact us today to learn how we can help >>
4 Points to Ponder from CMS' Oversight and Enforcement Conference
On June 26, CMS hosted their MA-PD Oversight and Enforcement conference. Not one of the topics was less relevant to the audience than another — they prepared ahead of time to present current, critical information related to their data-driven approach to oversight, best practices and common findings, preparing for an audit and enforcement actions. I was glad to see CMS invite plan sponsor staff to share their experiences. They included Todd Meek of SilverScript Insurance Company; Margaret Drakeley of Kelsey Care Advantage; Shannon Trembley of Martin's Point Health Care; Marcella Jordan of Kaiser Permanente, and Jenny O'Brien of UnitedHealthCare. Their first-hand accounts are worth your full attention.
The webinars and materials are all available to the public and I encourage you to watch them and encourage your staff to watch. Of all of the things said, the following should be enough to kick your compliance efforts into high gear:
- Jerry Mulcahy shared that the improvement is not what CMS had hoped, and that organizations are still not testing effectively. That should warrant a hard look in the mirror to ensure your "trust but verify" methods are working. Put another set of eyes on your validation. Leverage staff with auditor experience. If the improvement is not what CMS has expected, especially after having shared their protocol and numerous best practice/common findings memos over the past few years, then consider this a red flag.
- Statutes and regulations expect nothing but 100% timeliness. Too often we are asked for the acceptable threshold for compliance of a measure. Unless otherwise published, the expectation is 100%. Kady Flannery stressed this while explaining the 2014 method for checking CDAG and ODAG universe timeliness.
- LCDR Lorelei Piantedosi communicated an additional best practice that didn't make the slides, and that's a 100% rejected Part D claims look-back. Seeing as how all five of the Formulary Administration common findings have been common findings published in the past, it is a wonder when an organization does not dedicate resources to this activity. (She also communicated a best practice near and dear to our hearts, but I'll leave that for another blogger.)
- "Be transparent!" Todd Meeks says he would often times get asked about how transparent to be. Based on the fact that he shared how collaborative CMS was in aiding his organization, at times providing easier, cleaner ways to correct something, then the answer should be simple.
Think about it this way: if you draw the short straw this year for a CMS Program Audit (and I use ‘short straw' in the most lovingly way possible, CMS), then everything you add to your Self-Assessment Questionnaire should already be known by your Account Manager. We can be broken-record about this, but a Medicare Compliance Officer should know what's going on well before CMS does — it's arguably just as important to your organization that your Account Manager knows about it before Central Office.
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From a simple gap analysis to a comprehensive, deep-diving Part C and D audit, our team can help you minimize your compliance risk and maximize your time and resources. Learn more >>
Taking the time needed to regularly assess the risk exposure of operations can be both disruptive and costly — if not impossible. Let us augment your efforts by conducting your required annual risk assessment. Visit our website to learn more >>
PBMs are the Health Plan Industry's Achilles Heel
In this Golden Age of government programs, the health plan industry has never had more exposure to the generally poor performance of pharmacy benefit managers (PBMs). Performance metrics in Medicare, Medicaid and ObamaCare are directly tied to PBM execution, and the recent track record of these companies means they are the Achille's Heel of insurers.
PBMs historically made most of their money on commercial insurance and have lagged on government programs, a trend exacerbated by a brain-drain of talent following a wave of PBM consolidation. The danger has never been greater for health plans, and their choice of vendor has never been more important.
First, Medicare's Star Ratings system has several critical performance measures directly tied to PBM performance, notably those related to drug plan service, formulary administration, patient adherence to drug therapies for chronic diseases like hypertension, and readmission prevention (many hospital readmits are due to drug over/underdose post-discharge). The numbers don't lie: Medicare Part D Star ratings and formulary administration were the two leading reasons for CMS-mandated corrective action plans dropped on insurers in the last year. Of plans scoring less than 2 Stars by performance domain, Drug Plan Customer Service came up worst in CMS's last review cycle -- followed by Member Experience with the Drug Plan, and Member Complaints, Problems Getting Care, and Improvement in the Drug Plan's Performance. It's a dismal record and getting worse.
Then consider that the two critically-important health plan quality improvement measures -- C33 and D07 -- are now weighted 5, a first for CMS and a huge development. The concern here is that PBMs are often terrible at data management, and under these measures a plan can be reduced to 1 Star where mishandled data resulted in bias or error, or where appeals and grievances handling is in question. With that 5-weighting, this has come as a rating killer for several plans and a major vulnerability for the rest, as most don't keep good logs of non-compliance issues or audit results.
PBMs are generally good at managing the drug benefits of commercial members, but the complexity of seniors and the low-income and the previously uninsured continues to confound these companies. Gorman Health Group ran 15 solicitations for government program PBM services for its clients in the last 12 months, and we wouldn't wrap fish in one of the responses we received. All varying degrees of suck.
In this last round of contract and service area expansions for 2015 Medicare Advantage and Part D, in our 18 years we have never seen more rejections due to PBM failings like pharmacy and home infusion network adequacy -- literally dozens this cycle, due both to PBM sloppiness and a new resolve at CMS to directly address it.
As PBMs continue to consolidate, plans need to protect themselves from weak execution by bringing renewed focus on PBM-directed Star ratings measures and most importantly, inspecting what they expect. The delegation oversight plan for this vendor is the most important document in compliance right now. Payers are now literally at the whim of the government programs sophistication of their PBM account manager, and that is not a comfortable place to be with literally billions of dollars and millions of seniors and the vulnerable hanging in the balance.
PBMs need to awaken to the new reality of the primacy of government programs today, and make a serious commitment to catching up.
Resources
If you've just submitted your HEDIS data, now is the time to analyze that data for gaps and identify interventions for your health plans, providers and members. On July 17 join John Gorman, Executive Chairman at GHG, Jane Scott , Senior Vice President of Clinical Services and Anita McCreavy, Senior Consultant, for a webinar on HEDIS reporting, the new measures and what's next. Register now >>
The rapid changes to Part D regulations make the tracking and implementation of these CMS requirements exceptionally difficult -- to say nothing of actually managing to them. Contact us today to learn how we can help >>
The state of enrollment: Lessons learned in connecting Americans to coverage
Enroll America issued a 92 page report on the lessons learned and best practices from the initial open enrollment on the new Affordable Care Act (ACA) Exchanges. According to the report, 8 million people enrolled in the new qualified health plans (QHPs) and an additional 4.8 million people enrolled in Medicaid and CHIP. The report was followed by a conference featuring analysis by health policy leaders and reports from Navigators and Assisters who were on the front lines during the open enrollment. The report highlighted many findings including:
- Repeated contact is needed for hard to reach populations. African Americans, Latinos and young people were twice as likely to enroll after the third contact.
- People were twice as likely to enroll when helped by in-person assisters. 87 percent of partners surveyed by Enroll America reported that help from an assister was the top factor that led to a successful enrollment.
- Affordability has been the biggest barrier to insurance coverage. Informing people that financial assistance was available was the biggest motivator to enroll. Combined digital messages and email messages emphasizing affordability and access to personalized tools, such as calculators greatly increased uptake.
What will this November look like? See expected changes below.
- Enrollees need to be educated on payment of premiums and the need to re-enroll.
- 2015 outreach will target Latinos who have a low level of literacy and low enrollment levels.
- Messaging on financial assistance and examples with data are critical.
- Mobile matters since 85 percent of the target population have cell phones and one-half are smart phones.
- Personalizing the message is critical and testimonials where real individuals share real experiences are effective outreach efforts.
- Messaging about penalties is more effective when combined with the benefits of insurance.
- While data driven outreach helped drive successful campaigns in 2013-14, the effort in 2014-15 will be expanded to include predictive modeling and updating models and data to adjust for the newly insured.
The lack of insurance and health coverage literacy in the target population is very high, e.g. 50 percent did not know what an exchange was; 40 percent did not understand a deductible; and there was a poor understanding of the Medicaid expansion or availability of subsidies. HHS through the "Coverage to Care" Campaign, Exchanges and partners will continue outreach and education leading up to and during the second open enrollment.
The new campaign "From Coverage to Care" (C2C) is a national initiative to help new QHP enrollees and Medicaid and CHIP enrollees use their new health care coverage. The program includes an 8-step roadmap which describes coverage basics such as steps to accessing care, benefits of coverage, and define terms, e.g. in and out of network coverage. Topics covered in the roadmap include: Understanding Your Coverage, Using Prevention to Stay Healthy, Understanding Primary vs. Emergency Care, How to Select a Provider, Preparing for and Follow-Up After Appointments. A diagram of the roadmap and videos are available here. A marketplace 800 number is available 24/7 (800-318-2596) or consumers can contact their insurer or Medicaid or state CHIP agency. The C2C program is an ongoing program. Separate resources are available for partners and providers to help their patients' access covered care.
Healthcare.gov will be better for next open enrollment period given the short time frame between April and November and will include improved back-end functions, a small business portal and a simplified application that can be used by applicants with uncomplicated financial situations.
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The launch of the Health Insurance Exchanges is the most challenging implementation in our industry's history with a patchwork of eligibility, new systems and numerous regulations. GHG can help, find out how >>
The Impact of Tax Subsidies in the Federally Facilitated Marketplaces (FFM)
A recent report released by the Department of Health and Human Services (HHS) found that four out of five persons who qualified for tax credits in the Federally-facilitated Marketplaces paid an average of $82 a month in premiums after tax subsidies for their health coverage.
69 percent of individuals selecting plans with tax credits in the FFM have premiums of $100 or less while nearly half had premiums of $50 or less. The tax subsidies averaged $264 per month and reduced enrollee premiums an average of 76 percent.However, the analysis shows wide variations among states in the premiums that people are paying for their new insurance, the amount the government is picking up and the proportion who qualify for the subsidies. For example, enrollees in Mississippi paid an average of $23 in monthly premiums after subsidies while enrollees in New Jersey had the highest post-subsidy premiums averaging $148. Cost sharing expenses, such as deductibles and coinsurance, are additional beneficiary costs and were not included in the report. In addition, the report did not analyze premiums in State-based Exchanges, such as California, which had by far the most people sign up.
On average, the federal exchanges provided a choice of 47 health plans offered by an average of five insurers. New York had the highest number of issuers with 16. Florida and Wisconsin had the largest choice as measured by number of plans. However one in five enrollees had a choice of two or fewer insurers, for example there was only one issuer in New Hampshire and West Virginia. New issuers, including CO-OPs, represented almost 26 percent of all state issuers. The majority of new issuers had Medicaid experience. On average, an increase of one issuer in a rating area reduced the second lowest cost silver plan premium by four percent.
Nearly half of enrollees chose the lowest cost silver plan and two-thirds chose one of the two lowest cost silver plans. The HHS report provides analysis of enrollee selection of plans at all metal levels and analyzes premiums by age group in FFMs as compared to State-based marketplaces and Medicaid expansion states.
What does this mean for you if you are participating in the FFM?
- According to the analysis above, the Americans who qualify for tax credits through the new federal insurance exchange are paying an average of $82 a month in premiums for their coverage — about one-fourth the bill they would have faced without the government's help.
- The government has previously reported that 87 percent of the 5.4 million Americans who chose a health plan through the federal health exchange qualified for some financial help.
- Be careful: As of June 1, the government will need to verify eligibility of subsidies by additional documents to verify their income, citizenship, immigration status and Social Security numbers, as well as any health coverage that they may have from employers. People who do not provide the information risk losing their subsidized coverage and may have to repay subsidies next April.
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The launch of the Health Insurance Exchanges is the most challenging implementation in our industry's history with a patchwork of eligibility, new systems and numerous regulations. GHG can help, find out how >>
Integration of MMP Requirements
MA-PD plans have plenty to worry about with CMS requirements, regulator's issue of the day, or Central Office determining what issue to hang their hat on today, seemingly changing with the shift of the wind. It is a challenge to keep track of it all, but it's a necessity we promote and support.
Running like a drippy faucet is the constant stream of sub-regulatory guidance being issued on CMS' Medicare-Medicaid Integration office web page on the Financial Alignment Initiative. We already know that this population is high-touch, with just about every service requiring preauthorization. Operational areas have to keep up with this guidance and also ensure that they are meeting state and Federal requirements for the care of their membership. Generally, they are getting that guidance from the organization's regulatory knowledge center: Compliance.
Imagine you are a large, multi-state plan jumping off the springboard into this pool of Medicare-Medicaid Plans, and you need to ensure you are speaking the right language (i.e. Fully Integrated Duals Advantage, One Care, Healthy Connections Prime, Integrated Care Organization, Integrated Care Demonstration Project, and so forth). The fact that the states are on different timelines in terms of implementation doesn't make it any easier. In this first half of June, for example, the Texas Memorandum of Understanding was posted; one Spanish-language chapter of the Ohio MMP Member Handbook was posted; three separate chapters of the NY MMP Member Handbook were posted, and the reporting requirement templates for Ohio were posted.
I've seen plenty of ways that Compliance tracks new rules, memoranda and plan-specific notices, from extremely effective to non-existent. Sometimes the right tool exists but not the right players — sometimes the right staff is in place but with no effective tool. Whatever the state of affairs, this new guidance has to be reviewed, addressed, and if it pertains to reporting or pulling universes, practiced. I can't stress that enough. CMS gives you the tools and templates; they expect you to be well-versed in how to use them when they come calling.
We are keeping our eyes open in terms of Medicare-Medicaid coordination, in addition to the regularly expected updates from CMS. It should be an interesting next six months as organizations move further ahead in their MMP initiatives, and chances are good that this program won't look the same a couple years down the road.
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Many plans have not yet adapted the way they monitor their business to minimize compliance risk. The Online Monitoring ToolTM (OMTTM) is a complete compliance toolkit designed to help organizations track the compliance of their operations. Learn more about how OMTTM can help bring transparency to performance monitoring, including the required oversight of the delegated entities >>
Most, if Not All, States Will Be on the Federal Exchange by 2020
Correction: June 20, 2014
An earlier version of this article misidentified the state of Washington as preparing to enter into the Federal Exchange. Though the state of Washington is having trouble with its enrollment website, Washington Health Benefit officials have clarified that Washington state has no intention of becoming part of the federal marketplace.
As ObamaCare launched last fall you'll recall 16 states started their own exchanges, 7 were State/Federal partnerships (effectively operated by the Federal exchange for most functions), and 27 states were supported purely by the Federal Exchange.
Ironically, most of these were in red states where Congressional delegations and governors and state legislatures wailed about a "Federal takeover of healthcare," and that's exactly what they got by their inaction. We knew at least 3 would have no choice but to drop out after the first year and go Federal. As preparations continue for ObamaCare's second enrollment period in October, it's now clear at least half of the state-based exchanges are going Federal in 2015.
I'll say it: I think most states, if not all, will be on the Federal exchange by the end of the decade. The only holdouts will be states where the politics necessitate it, like Kentucky's KYNect, home of Senate Minority Leader Mitch McConnell (R-KY). KYNect has been wildly successful, signing up over 420,000 Kentuckians, many gaining health insurance for the first time in their lives, and it's giving McConnell fits in his midterm reelection bid.
The technology to run an exchange at state and Federal is duplicative, basically the same black box web-commerce architecture from over a decade ago, made wildly complex by the many state and Federal agencies involved in eligibility and enrollment. In the last several months we've seen multiple states crash and burn trying to stand it up, just as healthcare.gov did last fall. Oregon is preparing to sue Oracle for its botched system. Maryland's goat rodeo of an exchange launch has become a wedge issue in the governor's race. Now, Politico reports that Washington state is dealing with "back end" problems on its enrollment website, and the ObamaCare launch actually went relatively well there.
Then there's the issue of cost. The Affordable Care Act requires state-based exchanges to be self-sufficient in 2015. Those that went their own way had the buildout — or meltdown — largely paid for with Federal funds in 2011-2012. It was a vendor's Full Employment Act, with extremely mixed results. Next year's a whole different matter. State-based exchanges costs hundreds of millions of dollars annually to operate, and that won't last long in cash-strapped legislatures. The only ones left standing at the end of the decade may be Kentucky — and only as a middle finger to McConnell, as long as he may be in office — and California. Because it's California.
So for those health plans operating in states already under the Federal exchange: steady as she goes and stay current as pregame festivities begin for the second open enrollment period. If you're operating in a state doing it's own thing that's not KY or CA, you may want to consider re-speccing your systems for Federal functionality. It's only a matter of time in my opinion.
Resources
The launch of the Health Insurance Exchanges is the most challenging implementation in our industry's history with a patchwork of eligibility, new systems and numerous regulations. GHG can help, find out how >>