As GOP's Kamikaze Culture War Continues, the Senate Slips from Its Grasp
The Wall Street Journal reported on what we've been speculating on: that the GOP's renewed culture war is calling into question the party's ability to recapture the United States Senate this year. "The GOP is facing a tougher fight on a landscape that hasn't stopped changing. In states such as Maine, Nebraska and North Dakota, Senate races that had once looked like slam-dunks for the GOP have become far more competitive. Democrats may not win all those states, and they are still at serious risk of losing their majority. But they are forcing Republicans to fight on a much broader and more expensive battlefield. The result is that the campaign for the Senate, which was already promising to be one of the fiercest fights of the year, is beginning to resemble the topsy-turvy GOP presidential primary, characterized by sudden shifts in fortune among candidates."
Since the 2010 midterms, Democrats have worried about their grip on the Senate, an institution that is crucial for both parties given the current political alignment in Washington. Democrats hold a 53-47 majority. Of the 33 Senate seats up for re-election, 21 are Democratic and two are independents who caucus with the party—and many are in conservative states. The party's standing was further eroded by a string of retirement decisions. Incumbents in swing states including Wisconsin, New Mexico and Virginia said they wouldn't seek new terms, turning what would have been safe Democratic seats into competitive races.
The Journal examines 4 prominent races that have recently taken turns in the Democrats' favor, especially last week's shocker that centrist Republican Senator Olympia Snowe wouldn't seek reelection after all. In Maine, that virtually clinches the seat for popular former governor Angus King, a left-leaning independent.
The biggest question to my mind is how the eventual Republican nominee effects the down-ticket races like Senate seats. It's now obvious that the race will now stretch well into May -- and possibly the convention itself in August in Tampa -- before a nominee becomes clear. In the interim we're likely to hear more culture war fodder as Santorum tries to force Gingrich from the race and further differentiate himself from Romney. If the nominee is Santorum, I'll say it here: not only will the GOP lose the Presidential race, they'll snatch defeat from the jaws of victory in the Senate too. And if it's Romney, the enthusiasm gap will strongly favor the President and incumbent Democrats defending those 21 seats.
Garry Trudeau, the genius behind the comic strip Doonesbury, cited the biggest reason for the Republican's loosening grip on the Senate best: "For some reason, the GOP has chosen 2012 to re-litigate reproductive freedom, an issue that was resolved decades ago. Why Santorum, Limbaugh et al. thought this would be a good time to declare war on half the electorate, I cannot say...I thought reproductive rights was a settled issue. Who knew we had turned into a nation of sluts?"
Stressed? Tell me about it
The Society of Corporate Compliance and Ethics and the Health Care Compliance Association conducted a survey and released their results in a report entitled Stress, Compliance, and Ethics. The survey results address leading causes of stress among compliance and ethics officers. When three of every five respondents agree that they have considered leaving their job, and over half consider their relationship with colleagues to be adversarial or isolated, it is a strong message to take action.
There exists a small pool of Medicare Advantage and Part D Compliance professionals in the country. Of those charged with the responsibilities of the Medicare Compliance Officer, they know full well what CMS has focused on over the past few years: compliance program effectiveness and performance reviews based on data.
CMS expects plans to demonstrate the effectiveness of the Medicare Compliance Officer by way of communication efforts, transparency throughout the organization, and effective training programs, among other things. We know total effectiveness is near impossible when you are not a true partner in the C-suite. Common barriers to compliance program success include:
• Barriers to leadership: Communication becomes a game of "Operator" when the chain is Compliance Officer to Director to Assistant Vice President to Executive Vice President to General Counsel to Audit Committee to CEO… surely the original message got through;
• Insufficient resources: Compliance divisions often do not have the trained staff or the right tools in order to perform the tasks of a well-oiled compliance machine; lots of manual processes, too little automation;
• Operational pushback: Delay, resistance or refusal to maintain compliance standards will have you seeing stars, and not in a good way.
As a true officer of the company, it is CMS' expectation that your role is meaningful and effective. When the title of Medicare Compliance Officer is given to someone without a seat at the table, the effectiveness of the compliance program is at risk. Next week we'll talk some real-life examples that make up a day in the life of these compliance warriors.
Oregon Leads the Way on End-of-Life Planning
Kaiser Health News is out with a terrific story today on Oregon's progress with end-of-life planning for its seniors. The secret to its success has been a simpler-than-expected solution that a number of states have already adopted or are considering, and it's one of the most encouraging signs of progress in the field since the dark days of "Death Panels" during the 2008 campaign.
Oregon has been in the forefront of trying to make sure a person has as much control over the end of his or her life as possible. The state pioneered a form known as a POLST, for Physician Orders for Life-Sustaining Treatment, that has been adopted by 14 states and is being considered in 20 more. The form offers many more detailed options than a simple "do not resuscitate" directive.
The Oregon legislature set up a database several years ago to deal with the problem of inaccessible POLST forms.Now EMTs and doctors can access the state database to see if someone wants to be resuscitated. That database is beginning to generate some interesting facts about the medical interventions people want as they die, according to Dr. Susan Tolle of the Oregon Center for Ethics in Health Care. "We have really learned that this is not a black and white process," Tolle says. "Less than 10 percent of people wanted to refuse all treatment. A majority want some things and not other things." Tolle avoids the topic of whether these detailed end-of-life instructions save money; she is wary of starting another "death panels" debate. But the database has allowed the state to quantify the policy by some measures.
"What we found was that if people marked 'comfort measures only' and 'do not resuscitate' and did not want to go back to the hospital...there was a 67 percent reduction in life sustaining treatments, primarily hospitalization and emergency room visits," says Tolle.
As we've long said, there can be no hope of long-term Medicare solvency without more rational policy and assistance to seniors as they decide how they want to die -- not when Medicare spends 1 in 4 dollars today on care in the last 6 months of life. The POLST solution -- a standardized document with physician support and an accessible database -- is cheap, effective, and should be encouraged by CMS and the Administration. And it's heartening that Senator Ron Wyden is from Oregon and deeply enmeshed in these issues -- Oregon's approach should be embodied in his work with Rep. Paul Ryan on Medicare reform next year.
Word for the day: Volatile
Volatile. n. Fickle, inconsistent, easily vaporized.
Thanks to the Affordable Care Act, Medicare Advantage finances are going to be volatile. Unwary actuaries may be easily vaporized.
The new benchmarks, the "specified amount" under the ACA, are based on which quartile a given county is in. Quartiles are defined by average FFS costs. ACA benchmarks range from 95% to 115% of local anticipated Medicare FFS spending in the county, depending on which quartile a county is in. Every time CMS rebases the FFS calculations, a county can change quartiles. The preliminary list of quartile-jumpers for 2013 moves 27% of all US counties, with about 27% of MA beneficiaries, from one quartile to another. Depending on which quartile you start in and where you end up, that's a change in payment of 5% to 7.5% -- or more in the few counties that move more than one quartile. That's a lot of money to have to cut, if you go the wrong direction. Or a lot to have to quickly absorb in new benefits if you go the other way -- since, with the 85% loss ratio floor coming up in 2014, a plan can't simply stash the extra cash in profit.
We won't have the final list of the new quartiles until April 2. And bids are due June 4! That's a scant 2 months to figure out how to either (a) cut 5% or more out of your bid, or (b) add new benefits to absorb the windfall.
When adding benefits, plans will need to keep in mind that the process can reverse with the next rebasing -- in 3 years or less. Added benefits need to be planned like chess moves. What can we add that will help us now, but which won't hurt too much if we have to withdraw them later?
Plans should be doing some serious contingency planing, so they are ready when the rates and quartiles get recalculated. For 2013, the time to start planning is immediately after reading this blog. The preliminary list of county quartiles is a start, but remember that it's subject to change. Any plan with a significant number of members in counties close to the bubble between quartiles should be getting ready now, in case they have to make some quick decisions when preparing their bids.
To add to the fun, double bonus counties can change, too, based on their newly re-based FFS costs relative to the national average. For some plans that qualified for a double bonus in 2012, the rebasing of FFS could make half the bonus disappear in 2013 in some counties. Or, your bonus could double in 2013 in counties that newly qualify for the double bonus. That's more chaos in the bid building process.
The more i think about the quartile system, the more I'm beginning to like competitive bidding as an alternative. Works for part D, after all.
Glass Half Full on Medicare Reform Prospects
Former CMS Administrator and friend of the firm Gail Wilensky, MD is out with a great op-ed piece in the New England Journal of Medicine today on directions for bipartisan Medicare reform. She echoes many of our recent thoughts on the improving prospects for Medicare reform, not in this hotly-contested election year, but as part of deficit reduction in 2013. Her piece covers the gathering momentum behind the Ryan/Wyden reform proposal, as well as structural changes previously thought unthinkable, such as increasing the eligibility age for the program, further means testing, and a targeted growth rate for our favorite entitlement program. We can thank both President Obama and Speaker Boehner for enabling discussion of these reforms since broaching them during the disastrous debt-ceiling debate last summer.
I thought the most compelling part of Dr. Wilensky's argument is her assertion that we have turned the corner on recognizing that the traditional fee-for-service paradigm of Medicare is unsustainable. She notes "growing agreement that a fee-for-service system like Medicare's, which reimburses physicians for some 7000 discrete services, is inconsistent with achieving the care coordination needed by seniors with multiple chronic conditions or complex acute care needs. To me, this growing disillusionment with the incentives and rewards of fee-for-service medicine is the most surprising evolution in thinking of the past quarter century and offers the greatest promise for success in developing a replacement, whatever its parameters."
We agree, and would add that the experience of Medicare Advantage and Part D show the only true path to securing the fiscal solvency of the program is through capitation and care coordination of the chronically ill. It's encouraging to hear a policy luminary like Gail point out that we're closer than we may think to some consensus on new approaches to preserving Medicare for the long haul.
Solving your claims-based HCC conundrum
Everybody knows that 37% of claims-based HCCs fail in a RADV audit, but no one ever talks about how to fix the problem.
How to fix the high failure rate of claims based HCCs?
1. Filter your claims and tier into confidence levels (high, moderate and low). (We call our filtration, tiering, and resolution tracking solution CareCurrent.) We recommend you filter on frequency, site of service, provider of service, clinical significance, plus CMS compliance and clinical condition alignment.
2. Audit your medical groups with both the highest member density plus your providers consistently in your low confidence coding tier.
3. Note the diagnoses or most common conditions inaccurately recorded.
4. Meet with physicians and staff to create an evaluation to billing process improvement workflow for your top three most common inaccurate codes. Repeat this education and communication with other medical groups.
5. Re-stratify your claims and note improvements using CareCurrent if you have no internal system.
6. Audit the new dates of service stratified and glean if the education and new workflow aided in more specificity or accuracy in coding.
7. Create clinical and coding initiatives as appropriate to compliment your coding areas of improvement.
If you note that previous codes were inaccurately billed in claims and submitted to CMS, delete the codes prior to final sweeps to ensure appropriate payment and audit success.
It's Super Tuesday and Romney Still Gets No Respect
Today is Super Tuesday, the biggest event thus far in the Presidential race, with more delegates at stake for the GOP candidates than any other primary or caucus to date. Mitt Romney was supposed to have the nomination locked up by now; instead, as today's Wall Street Journal points out, he's more like the Rodney Dangerfield of politics: he just can't get no respect. Don't get me wrong, I'm still convinced it's Romney vs. Obama in November -- but after months of campaigning, the enthusiasm gap that's evident only favors the incumbent President.
Romney will likely have a strong showing today in Massachusetts, Vermont, and Virginia, where he has only Rep. Ron Paul as competition. But the biggest delegate yields are in Ohio (63 delegates), Tennessee (55), and Oklahoma (40), where Rick Santorum has a strong lead. In Georgia, Gingrich's home state, there are 76 delegates at stake. None of these contests are winner-take-all -- each candidate has the opportunity to compete for delegates in parts of each state where they are strong.
Today's new Journal/NBC News poll shows the primary process has worn away the overall enthusiasm edge that Republicans, desperate to oust President Obama, were supposed to have:
![[CAPJOURN]](http://si.wsj.net/public/resources/images/NA-BP702_CAPJOU_NS_20120305162703.jpg)
The new survey shows that both parties' registered voters are virtually even in members expressing great interest in the election -- and the share of Republicans excited about the race has dropped 10 percentage points since January. The big concern for Romney has to be the trend line on the independents, who are being turned off by the renewed culture war ignited by Santorum, Gingrich, and the right wing of the party. Weeks of gunfights on birth control, pre-abortion invasive ultrasounds in Virginia, gay marriage, whether the President is a "snob" for wanting Americans to have the opportunity to go to college, and anything-but-the-economy shows that 40 percent of American adults think less of the party after watching its transformation this electoral season -- especially independent women.
Driven by an intensifying ideological purity test that brings to mind a white, working-class, ultra-religious "American Taliban" (as the Journal points out, Democrats don't require their presidential candidates to declare repeatedly that they are liberals, thereby pushing themselves away from the center of the political spectrum), the GOP has come to stand for "God's Own Party" in these last few months, and likely voters are tuning out as a result. A notable casualty: centrist Republican Senator Olympia Snowe of Maine decided not to run this week after all -- a big loss for her party, both for her deal-making skills and the likelihood her seat will go to an Independent, popular former Governor Angus King.
As the Journal pointed out today, "Mr. Romney has a tough job, for the Republican party is a hard one to lead right now. Any party that is trying to simultaneously win over Wall Street money managers and the tea-party movement, and to win Hispanic votes while championing the tough immigration laws of Arizona and Alabama, has laid out a tough task indeed...So Mr. Romney would have to raise sagging numbers among independents, light a fire beneath an underenergized party base and confront a president whose approval ratings are moving higher."
Not a pretty picture for the GOP, and with every day the Republicans' internecine and cultural warfare continues, the further victory drifts from their grasp. The big question to my mind now is whether the renewed culture war from the far right has cost the GOP not only the White House, but the US Senate as well...and with it, any prospect of stopping health reform before it launches in 2014.
Preaching to the Converted on Medicare Reform
Politico is out with a great op-ed today from centrist thought leader Will Marshall on why the Ryan/Wyden Medicare reform plan deserves a fair hearing -- especially among Democrats. He's preaching to the converted here at GHG -- the Wall Street Journal noted our support for the plan last week in Fred Barnes' column.
I agree with Will (as I usually do; Will and I are both former Clintonians and he is the longtime leader of the Progressive Policy Institute, one of my favorite centrist think tanks) -- we like the concessions Ryan's made to his plan in order to get Senator Wyden (D-OR) to support it, and remain hopeful (though not delusional) that both parties can put aside "Mediscare" tactics this election year for a thoughtful discussion about it. More likely it'll be next year, after the dust has settled from this messy race and the deficit reduction debate begins again in earnest.
Integration around chronic conditions, such as chronic kidney disease
Many of our clients have requested customized mapping and integration which electronically links the findings from the Advanced Evaluation into their medical management system. Health plans and medical groups both appreciate the in-depth reporting, plus electronic connection that triggers or flags particular members for placement into unique case management programs, whether it is a COPD, CHF, frail and fall reduction, or chronic kidney disease referral.
This is an easy workflow to ensure the data is transformed from a picture in time to an integrated care support tool.
One of the diagnoses we focus on a great deal is Chronic Kidney Disease. We have built a specific module around the clinical guideline statement from the National Kidney Foundation regarding Chronic Kidney Disease and have engaged experts to ensure our clinical analytics, detection, and evidence based findings are easily understood by the members, interact with the health plan's platform, and are simply formatted for community physician plan of treatment development.
Dr. Dambro, CMO and Dr. McCallum, CEO of CenseoHealth will be sharing more information about our chronic disease modules and clinical outcomes in future conferences and blogs. Stay tuned.
When Worlds Collide: ACOs and Risk Adjustment
By John Nimsky & RaeAnn Grossman
As we enter the era of ACOs, we have to be aware of all the clinical and operational essentials that are needed to make the ACO a viable health care solution for members, plus the elements needed to support the ACO as an engaged and intelligent communicator with CMS.
If you have a shared cost saving ACO you must have an accurate picture of the member's health status at Day 1. This detailed clinical picture will help you as an ACO:
1) engage the member in appropriate care programs
2) understand their cost today and project cost for next year, and
3) calculate the risks and benefits of treatment.
In traditional Medicare, it is well substantiated that over 75% of the members may have undocumented HCCs or gaps in care. However, as an ACO your primary concern is wellness and cost saving, and so you want to push toward 100% member evaluation completion for each calendar year. Why? Your members really should be evaluated to ensure there is a documented, compliant health status profile of of each member who starts with your ACO, and each year thereafter.
If you stratify the patient population within the ACO for relative health status, your plan for future treatment intervention will include identification of those members who can benefit from:
• referrals to case management;
• inclusion in disease registries;
• and other target services on a one to one basis.
Effective population stratification and risk assessment produces a complete health profile, a tool that can help reduce:
• admits;
• re-admits;
• acute utilization;
• ER visits;
• and other avoidable costs found in today's fragmented approach to health services delivery
Specifically, a robust risk assessment approach for a defined populations will
a) identify ACO members who will benefit from treatment but are currently missed by the system and thus are more likely to develop more serious pathologies later;
b) give physicians and members/patients quantitative information about the risks of adverse events and the benefits of treatment;
c) identify priorities for appropriate outreach programs; and
d) assist in calculating appropriate benchmarks and shared savings incentives for physicians.
An in-office or in-home assessment of the patient's medical history and current health status, when appropriately employed at the time of member assignment to an ACO, is a powerful tool that must be ready to launch Day 1 of ACO implementation. Because members are likely to join the ACO throughout the year, the stratification for those new members must occur monthly and integration into the care pathway must be timely and seamless. Timely integration of the member into standardized clinical treatment approaches will lessen the burden on care givers and will ensure that services are provided efficiently and in the appropriate setting. This is not a time for a long implementation phase, lags in data refreshes, or delays in re-stratifying members.
One of the tools available to assist in the process of identifying member current health status and treatment planning is offered by CenseoHealth, which has ACO Advanced Evaluation modules for Medicare, Medicaid, and commercial members. These populations' clinical conditions differ, and so their outreach, analytics, and engagement strategies are also dissimilar.