Get your money's worth
When I was a kid, we would jump on those tiny merry-go-arounds outside of stores or those little goofy race cars in Toys R Us and my dad would shake them. Yes, it is true.
He refused to put the 25 cents in to move them mechanically. He would just shake them and after a while we'd jump out. It wasn't worth the 25 cents to him.
Well, what would my dad (or your dad for that matter) say if he knew you were paying $300, $400, or even $500 for a member evaluation and not linking it to gaps in care to improve your HEDIS, STARS, and member plan of treatment, or using they to trigger medical management? In a recent webinar we asked health plans the following questions:
Question #1: Does your health plan use your member evaluation findings to do member outreach to reduce gaps in care?
The Answer: 30% Yes
70% No
Question #2: Do you utilize your member evaluation findings to trigger referral to complex, case, or disease management?
The Answer: 60% Yes
40% No
The member evaluation is a great way to collect clinical, demographic, administrative, and quality of care information. You are paying for it; make sure you are getting your money's worth. We hope next time we asked this question the answers are 100% Yes.
Note: CenseoHealth CEO Jack McCallum is speaking on September 13th on a webinar hosted by MCOL that addresses this topic even further. Register here to join us for this event: Integrating Risk Adjustment and Quality of Care Initiatives
GHG hosting Revenue Forum Oct 6-7 in Las Vegas
Your payment is coming down. Your blood pressure is going up.
• How are you planning to mitigate the coming payment reductions?
• Can we make the difference up through efficiencies alone or do we need to look to top-line solutions, too?
• What strategy have you developed to integrate revenue management into operations?
• When will we know if what we're doing is working?
Join Gorman Health Group Oct 6-7 in Las Vegas, for an exclusive event for MA health plan senior leadership, with responsibilities for finance, revenue management, and risk adjustment. We will share the best ideas we've heard from around the industry as well as our own thoughts for practical strategies for driving revenue.
This forum will offer actionable insight regarding:
• Performance optimization and efficiency
• Must-have investments in your STARS programs (that are often overlooked)
• A redesigned risk adjustment program that drivers higher, more compliant revenue
• A moving target: The components of capitation
This program is designed for senior-level finance decision makers with leadership responsibilities for Medicare Advantage programs. This event will be advanced, but highly practical and action-oriented. As with our previous events, this program is open to health plans only.
The cost of this event is $995; Space is limited for this exclusive event. Pre-register now to secure your plan's attendance.
Click here to pre-register
Click here to view the preliminary agenda
Using What You Know to Improve Care for Your Members
In the current issue of the New England Journal of Medicine , a group of physicians from Harvard Medical School describe an unfortunate and instructive case.[1] One of the system's patients had her spleen removed after an automobile accident. I would venture to guess that just about every sophomore medical student knows that people without a spleen are more likely to have infections, especially with streptococcus pneumonia, and that those infections can lead to death or, as in this poor lady's case, severe, permanent complications. Anyone who has had a splenectomy should be vaccinated against pneumococcus. So far so good, but the vaccine was never given in this case because the problem list in her electronic medical record was never updated to include the fact that her spleen had been removed.
When these doctors looked at the records in their practice (over 1.7 million of them), they found 7125 patients who had had their spleens removed and only 5028 (29%) had the diagnosis on their problem list. And it gets worse from there. Of the ones who had the diagnosis on their problem list, only 54% had been vaccinated; of those without the diagnosis, only 17% had been vaccinated. (Remember, the guideline is vaccination for 100 %.) And this is at one of the very best medical care delivery systems in the United States (probably in the world) and these patients all have electronic medical records. You can guess what the numbers would be like out in the real world where solo practitioners are working with paper charts.
So we have two problems. First, the list of diagnoses was incomplete. Second, there was a clear and unaddressed gap in care. How do you fix a problem like that? The first impulse would be simply to better educate the doctors. These authors conclude (and I agree with them) that "education alone is not a highly reliable intervention." Remember, these are some of the best doctors we have and they are using some of our best clinical tools. The solution has to be in redesigning the system. And that is where Medicare Advantage plans have something really important to offer.
These authors recommend "tools such as reminders and patient-level reports about guideline compliance" as the best way to change the system. I would suggest that carefully designed and targeted member evaluations of Medicare Advantage members organized by the plans can bring together a wealth of clinical information from claims with directed face to face evaluations to yield accurate and complete diagnostic information and to identify gaps in care. If that information is collected in a proper open access data base, actionable reminders can be generated for the member, for the member's treating physician, and for plan case management—just the sort of tool the authors recommend.
And, once again, we have an impact that cannot be replicated by fee for service Medicare.
Note: You can join Jack at a MCOL-hosted webinar event on September 13th, as he discusses further more powerful ways of addressing gaps in care, and integrating risk adjustment and medical management. Click here for details on that event.
[1] Gandhi, Tejal K., Zuccotti, Gianna, and, Lee, Thomas, "Incomplete Care—On the Trail of Flaws in the System" New England Journal of Medicine, 365:486-488, August 11, 2011.
Law of Averages: How does it add up to a complete health picture of your members?
I attend a number of industry conferences, and at a recent event hosted by Opal in San Diego, I heard the following:
- The average 75 year old has three chronic conditions and takes five medications
- The average 75 year old Medicare Advantage (MA) member spends 12 hours a year in doctor visits
- The average amount of time a patient actually spends with the doctor during one of his visits is only 13 minutes
- The average 75 year old Medicare members sees between five to seven different doctors a year (whether primary care, covering physicians, urgent care, hospitalists, or specialists)
- To conduct a comprehensive health assessment, a physician needs to spend between 45 to 65 minutes with a MA member
This highlights the need for EMR, collaborative care models, and medical homes. It also illustrates the need for annual comprehensive exams and an engaged model around medical management.
If you do the math, a MA member is spending a mere 156 minutes with physicians each year. And 55 of those minutes should be spent with some clinician who will collect and record an accurate and updated health picture. Whether it's a primary care physician, a specialist acting as a primary care physician, or a physician evaluator in the home, some clinician has to collect this information for each health plan MA member each year. The challenge is the time differential.
How does the physician morph 13 minutes into 55 minutes? This is probably not a case for efficiency, but a change in scheduling or approach. Whether in the home or in the office, we need to create an environment at least once a year that allows Physicians to do that complete wellness exam or health status evaluation in which they ask questions about everything, from activities of daily living to nutrition to chronic condition to medications to behavioral health.
The next step in beating the averages is using this picture. This health status report needs to be integrated, not only with all the member's doctors' plan of treatment, but also with health plan medical management or perhaps even in the member services department. We need to find new ways to help the member navigate the healthcare system to survive the law of averages.
Note: You can join CenseoHealth September 13th to hear more thoughts on integrating risk adjustment and quality of care initiatives during an MCOL-hosted webinar event. Click here for more details.
Do Stars Matter?
I have occasionally made the point that MA can have a positive impact on members' lives in a way that fee for service Medicare can never replicate. Over the weekend, I was catching up on old journals and ran across a nice case in point. If you are like me, you have wondered from time to time whether there was a real point in some of the Stars and HEDIS data you collect (particularly some of the survey questions) or whether it was just filler to make a bureaucrat feel more useful. Well, here is a reassuring answer to that question:
You are probably aware that one of the HEDIS/HOS indicators is "the percent of sampled Medicare enrollees 65 years of age or older who had a doctor's visit in the past 12 months and who received advice to start, increase, or maintain their level of exercise or physical activity." (It takes at least a 60% positive from the sample to get a plan to four stars.) Another requirement (HEDIS) is that you measure BMI at least yearly in members less than 74 years old. Does all that really matter?
It will probably come as no surprise to you that 20% of adults over 65 are obese (BMI>30) and that the number is rising every year. What you may not have thought about is that obesity is now one of the major causes of frailty in the elderly. The archetypal "little old lady" slowly maneuvering across the room with her cane has been replaced by the very big old lady (or old man) maneuvering through a grocery store on a scooter.
A group led by the geriatricians at Washington University in Saint Louis looked at the problem: they did a one year controlled study of the effects of diet and exercise in the obese elderly.[1] One study group did what they had always done (or not done), a second group dieted, a third group exercised, and a fourth group dieted and exercised. Each group that did something did better than the group that did nothing but the fourth group did best of all. Their strength went up 35%; their gait speed increased 23%; the rate at which they lost bone decreased; their peak oxygen consumption (a reflection of the ability to be active) increased; their balance improved and their risk of falling decreased.
We are accustomed to thinking about weight loss and exercise programs in younger adults as ways to prevent hypertension, diabetes, and other chronic illnesses. It is a different matter in the elderly. For them it is a way to directly and significantly improve the quality of life.
So should MA plans take pride in the fact that they are collecting data about exercise and weight loss and that the good ones are finding better ways to use that data to help their members get thinner and more active? You bet they should.
[1] Villareal, Dennis et al, "Weight Loss, Exercise, or Both and Physical Function in Obese Older Adults" NEJM:364, 1218-1229, March 31, 2011
Alternatives to the Individual Mandate
Kaiser Health News is doing some tremendous reporting these days. Today they offered some perspectives from a number of experts on alternatives to the individual mandate, recognizing the unlikely chance the US Supreme Court will strike it down when it considers the issue next year. We think the mandate will be upheld given other precedents that allow the Congress to regulate interstate commerce and tax economic inactivity like refusing to buy health insurance.
Granted, if the Supremes kill the individual mandate, legislative prospects for these alternatives may be slim. Democrats are in peril of losing both the White House and the US Senate in 2012 (see the current futures markets outlook on these outcomes at InTrade.com here). Still it's encouraging to see so many potential options, and even the perspectives that ACA implementation could proceed without it.
Medicaid Managed Care = Risky (BIG) Business
The Washington Post printed a recent expose on the coming explosion in Medicaid managed care opportunities, coupled with the tremendous challenges of caring for lower-income, vulnerable beneficiaries, especially dual eligibles.
Texas is moving some 425,000 beneficiaries into health plans this year. California began moving 380,000 older and disabled patients into private plans in June. Louisiana debuted managed-care contracts in July, affecting 875,000 enrollees. In October, New York plans to begin moving about 1.5 million patients into managed care. Florida is negotiating with the federal government to move most of its 3 million Medicaid enrollees into private plans. With the expansion of Medicaid managed care underway in at least 20 states and the surge of enrollment in 2014, thanks to the ACA, insurers expect $60 billion in new annual revenue.
We've long said that by 2015 we expect the entire TANF population (Temporary Assistance to Needy Families -- the "moms and kids") population to be in health plans, with millions of dual eligibles to follow suit. With a new office in the CMS Innovation Center dedicated to Federal/state collaboration on the duals, that segment will transition to managed care quickly as states desperately try to reduce the #1 item in every state budget: long-term care for the elderly and disabled. The "A/B/Ds" (Aged/Blind/Disabled) are the "final frontier" for health plans, and worth upwards of $300B annually -- but not without their perils in this climate of austerity.
America's Hospital Patient Safety Problem in 1 Awesome Graphic
The graphics geniuses at MedicalBillingandCodingCertification.net have come out with another of their charticles examining the American health-care system. The quick takeaway? "The United States ranks dead last out of 19 developed nations in preventable deaths at hospitals." The problem is preventable and the solutions pretty straightforward. The charticle is fascinating and scary. Enjoy.
And the Survey Says... Claims based submissions are scary
During our September 1st webinar, Risk Adjustment: Vulnerabilities in Claim Based HCC Codes, we asked our health plan attendees a few questions about claims-based HCC codes. Here are the answers.
What percentage of your HCC submissions comes from claims?
- 25% of the health plans answered 45-60%
- 21% of the health plans answered 61-80%
- 44% of the health plans answered 81-100%
Studies indicate that between 60-80% of all HCCs comes from claims submissions. However, we also know that between 17-44% of all claims-based HCCs fail a CMS RADV audit. We must verify the validity and accuracy of health plans' claims-based submissions. How can we do that?
CenseoHealth's CareCurrent provides continuous data analysis, reporting and production management designed to mitigate HCC risk. This analysis not only supports a health plan in determining the confidence levels of the ICD-9s that trigger HCCs; the service also indicates how to remediate high-risk codes with chart review or a member evaluation.
Next we asked —
Do you filter your claims based HCCs?
- 50% answered yes and 50% answered no
That is a little scary and the health plan's next RADV audit may be even scarier. Scrubbing your claims based HCCs is a critical part of the mock RADV audit process and the foundation of RADV "proofing" your risk adjustment program.
Finally we asked —
How frequently would you or should you scrub your claims based HCCs?
- 55% of the health plans answered monthly
- 45% of the health plans answered quarterly
Both are good answers. We recommend running a claims based filter in late September so you can resolve any low confidence codes with chart review or member evaluations prior to the end of the calendar year. We also suggest running a claims based code analysis at the end of December to ensure the health plan deletes any unsubstantiated codes before the January 2012 sweeps.
Debt Crisis Hangover: 'Scary Erosion in Confidence'
Politico had a terrific story last week on the lingering hangover from the debt crisis. New data from The Conference Board suggest that the bitter debt ceiling debate in DC not only drove the US to the edge of default and cost the nation its triple-A credit rating, but crushed American confidence like few recent events and may tip the economy back into recession.
The Conference Board this week reported the biggest monthly decline in consumer confidence since the height of the financial crisis in 2008, its consumer confidence index falling from a reading of 59.2 to 44.5, the lowest in two years. Nearly every poll shows Americans lacking any confidence in the ability of political leaders to agree on significant steps to boost the economy or deal with other significant legislative matters.
GOP pollster Bill McInturff suggested that we are now "entering a new phase of the American political dialogue that has been irrevocably shifted in a way that will prove difficult to predict" and is likely to lead to "unstable and unpredictable political outcomes."
We're indeed sailing into some very scary uncharted partisan waters, to McInturff's point. We got the worst monthly jobs report in years this week, possibly indicating a "double-dip" recession. This will further weaken the President and his standing. Obama and Speaker Boehner can't even agree on the timing of a Presidential address to Congress on another stimulus package, much less what should be in it. Stimulus is usually comprised of some combination of infrastructure spending and tax cuts. Republicans in this Congress will never agree to the former, and Democrats will never agree to the latter. So I'm not expecting much progress on that front, and the economy will continue to stagger along.
Next up in intractable issues: the Congressional "supercommittee" that's supposed to figure our way out of the debt crisis. 7 of its 12 members must agree on recommendations to Congress, which must vote up or down. A simple majority in the House and Senate can send those recommendations to the President. But 7 out of 12 seems a stretch, as does even getting a simple majority in either this House or Senate. That means "sequestration": across the board cuts, including 2% to Medicare provider payments, likely on top of the 29% cut physicians will take in Medicare payments at year end due to the continued inability of Congress to fix the Sustainable Growth Rate methodology. And that's likely a better scenario than any specific cuts the Supercommittee may come up with. That all adds up to a horrible, no good, very bad day for our favorite program.
Listen to me, it sounds like my confidence is eroded, and I just got back from vacation. It is. I get it that Americans voted for divided government in the 2010 midterms, but I don't think they voted for dysfunctional government. Like McInturff said, we're sailing into some very big "unpredictable political outcomes." And the stakes for Medicare couldn't be higher.
I'll be speaking on this and related topics at AHIP's Medicare conference here in DC on September 13, and again September 26-27 at the Opal Events 3rd Annual Medicare Advantage Strategic Business Symposium. For more information, click here. Hope to see you there.