Brain Food | GHG Advisors

MA Plans' Must-Fix: the Member Experience

Now more than ever, it's clear to us health plans and their stakeholders will thrive or die based on the member experience they provide. The member experience, especially with drug benefits, now represents more than half of a health plan's Star Rating in Medicare Advantage (MA), with millions in bonuses and bid rebates hanging in the balance. It also drives member retention and thereby acquisition expense (now averaging $1,200 per/member, or more than an average month's premium), so how members are treated now determines both health plan revenues and costs.

Overall, the member experience in a Medicare plan is defined by an enrollee's ability to get timely appointments, care, and information, how well providers communicate, and whether member-facing health plan and provider staff are helpful, courteous, and respectful. It's driven by the company culture, its commitment to communication, and the empowerment of staff to solve problems. And despite two-thirds of plans saying the member experience is their top investment priority, we are losing ground.

In a few short years, the Star Ratings system has evolved from a crappy consumer information tool to a multi-billion dollar pay-for-performance (P4P) initiative investing in improved processes and outcomes of care in MA. In 2016, the scoring methodology for Star Ratings ensures the member experience measures, especially in Part D, count for more than half of a plan's rating. It also narrows the margin for error, so only a 10% deviation in performance on the critical Consumer Assessment of Healthcare Providers and Systems (CAHPS®) is the difference between a 2-Star Rating and a 4-Star Rating.

On an enrollment-weighted basis, MA averages a 4.03 rating, with 49% of contracts (179) and 71% of members in plans over 4 Stars. But on CAHPS®, the program dropped from 3.45 Stars in 2015 to 3.4 Stars this year. That's a big problem threatening to drag the program back below the all-important 4th Star and, taken in context of other recent data, gets downright scary.

Last week our friends at Deft Research released their latest Seniors Shopping survey on the 2016 open enrollment period. They found that for the first time in recent memory, far more seniors are leaving Medicare Advantage for Medigap than vice-versa.

On virtually every measure, they found declining loyalty to and retention with their health plan. That says a lot about the state of the member experience in MA despite the priority and focus. It says we're missing the point.

Meanwhile, Alegeus Technologies had some incredible findings in their annual health plan consumer survey presented at the recent AHIP conference. First, they found half of members (50%) do not want to "play an active role" in their healthcare. This argues plans' investments in "member engagement" may be backfiring with half their enrollees. And there was widespread confusion in what they're paying for, possibly delineating why appeals and grievances processing remains the top compliance challenge for plans:

66% of members think they're not paying the right amount
56% complain they don't know how much they are spending until after they receive services
45% of members say they simply do not know much they spend even after getting a bill
45% say they never know what is covered

All of this says the way we think of and invest in the "member experience" needs rethinking.

It reminds me of the seminal 2014 behavioral economics study that found that happiness is defined by expectations being exceeded a little bit on a regular basis. Because expectations are variable, everyone can be made happy. That begins during the marketing and sales process and continues throughout the member lifecycle.

Moving to proactive service models is only the beginning. Only half our members want to be involved — the rest are disappointed and confused enough to be leaving in growing numbers to join inferior and more expensive products. They need help navigating provider networks, better understanding of how to use their benefits, and what to expect in out-of-pocket spending in real time. They need in-plan service ninjas empowered to solve their problem on the first call. They need Pharmacy Benefit Managers to get it together and health plans to advocate and agitate for members with their vendors. They need constant improvement in the member experience to be the new normal in government programs.

Resources

For actionable advice and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas. During this year's information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn't. We will share proven tactics to cut costs, increase member satisfaction, and manage 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

Provider Directory & Network Adequacy Highlights in the 2017 Draft Call Letter

The Centers for Medicare & Medicaid Services (CMS) has emphasized the wide-scale monitoring efforts underway with respect to network adequacy and provider directory monitoring and the direct impact it has on not only the plan's ability to provide timely and adequate access to care, but the impact it has on the decision-making ability of the beneficiary and/or their caregiver to select the plan that best meets their needs.

While the new release cycle will affect CMS' ability to have gathered enough feedback and information to finalize the 2017 Audit Protocols, the Provider Network Adequacy (PNA) pilot is still at the forefront for CMS according to the recent release of the 2017 Medicare Advantage (MA) Advance Notice of Methodological Changes and Call Letter. Plans have a key opportunity to do a deep-dive into their provider networks and the policies and procedures governing their network, such as provider terminations, and prepare a monitoring protocol that will not only meet compliance but also take steps towards the future of network management that includes ensuring data integrity for the plan and its members.

It was previously anticipated the PNA would drive the sample of providers used to evaluate directory compliance. The 2017 Draft Call Letter indicates the opposite, noting specifically the data collected during the monitoring process could drive additional reviews of network adequacy as well as future monitoring and/or audit-based activities. CMS has given plans the ability to develop innovative pathways to ensure directory accuracy. Plans will need to close the loop and ensure interoperability between all systems, including those such as Health Services Delivery (HSD) tables and programs used to formulate both online and printed directories, to have a true impact on the data integrity presented to CMS and to their members.

Additionally, CMS continues to move in the direction of a uniform evaluation for both PNA and provider directories across all government-sponsored health plans. Given the fact Medicare Advantage (MA) plans currently have the fewest data elements required for provider directories and the least restrictive reporting requirements for network adequacy, plans should anticipate the need to augment the information they collect on providers, and, as with the requirement to submit your entire network during a service area expansion, gear up for more stringent network review requirements.

At Gorman Health Group, we have experts who have worked directly with managing provider networks and adequacy for over 20 years, including detailed analytics such as specialty code mapping and software, which is critical in building the infrastructure needed to fully support the quality and financial goals the network brings to your health plan.

If you have questions regarding the recent regulations proposed in the 2017 Draft Call Letter for MA and Part D around provider and network adequacy, please contact me directly at emartin@ghgadvisors.com.

Resources

GHG's renowned team of experts collaborated to provide the key features and implications of the 2017 Advance notice and Draft Call Letter for your organization in 2017 and beyond. Download our full summary and analysis >>

Listen to John Gorman's recent podcast on his top line observations from the 2017 Draft Call Letter.

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: Moving the Needle

Now more than ever before, plans must streamline their Star Ratings programs to meet member expectations while encompassing all aspects of care delivery and breaking down internal silos. This requires innovation amidst a backdrop of the ever-changing Centers for Medicare & Medicaid Services (CMS) landscape. CMS continues to treat Star Ratings as an ever-evolving, dynamic measurement program that is consistently expanding to include challenging new clinical areas, the impact of socio-economic status on Star Ratings, and operational evolution within the risk assessment processes.

As CMS continues to introduce more medication-related measures into Star Ratings, as both Part C and Part D ratings, and evolves Medication Therapy Management from its current status as a process measure to a more impactful outcomes measure, highly-rated plans will continue to set a high bar for seamless, integrated, and holistic care management and coordination. Earning 4 stars will become more difficult without fully breaking down organizational and data-related silos and effectively communicating and engaging with providers.

Join my colleague, Lisa Erwin, and me at our annual Gorman Health Group Forum next month as we share best practices around optimizing the relationship of medication management (either in-house or via Pharmacy Benefit Manager delegation) with the "medical side of the house" for a more holistic approach to achieving Star Ratings success.

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

Operations Mistakes Will Be Costly — Highlights of the 2017 Draft Call Letter

There was a time when operational areas were shooting for 98% accuracy as the "golden" number. In today's age of data and focused audits, even 99% may not be enough. The Call Letter doesn't have many surprising new risk areas for Operations. No new crazy regulations to ponder how we can possibly implement them. Instead, they have something worse: the addition of teeth to the new regulations. Why is this worse? Because the focus is on areas Operations and plans often struggle with and eventually accept status quo as good enough. How many times have you heard or possibly said, "What are our peers doing?" and used them as the measuring stick.

Some of the key focuses to keep operational eyes on are:

One-Third Financial Audit Results — Don't skip this section thinking this is Finance and doesn't involve Operations. One-third financial audits are full of operational reviews with direct member impact. The Draft Call Letter is indicating, beginning with 2017, one-third financial audits for plan year 2015 will have potential enforcement action like civil money penalties (CMPs) assessed for findings with adverse beneficiary impact. The Centers for Medicare & Medicaid Services (CMS) specifically calls out increased or incorrect cost-sharing or copayments as items of concern. Reviewing your benefit setup and claims processing to ensure controls are in place for adequate application of copays is a fundamental process but one in which CMS is seeing discrepancies year after year. Plans should review their controls or Medicare Secondary Payer (MSP) processes, their provider fee schedule process, and their benefit setup processes to ensure beneficiaries are protected and benefit designs are operationalized each year as filed with CMS.
Timely Processing of Coverage Determinations and Redeterminations — Your plan may delegate coverage determinations and possibly redeterminations, but whether delegated or processed in house, the plan is responsible. CMS is seeing a continued high volume of auto-forwards of coverage determinations and redeterminations to the Independent Review Entity (IRE) when these functions are not processed within required time frames. CMS is indicating they will be taking action against plans with high volumesâ€”no waiting for an audit and a review of the results. CMS has the data to know there is a problem. Have you looked at your numbers? Do you know your auto-forward volumes? Better yet, do you know the root causes and mitigations to ensure there are no auto-forwards and no negative beneficiary impact?
Data Integrity — Once again a misleading title that has big operational impacts. CMS is raising concerns CMS program audits are identifying issues that may impact Star Ratings data used for Star Ratings. CMS is indicating they are looking at tying audit findings to data submitted for Part C and Part D reporting and Star Ratings where the audit may have raised concerns. CMS is indicating finding issues within other reviews, such as program audits, may result in review of submitted data for Star Ratings. They are rightâ€”it is a holistic approach health plans should be using to get ahead of this curve. If during an internal audit at the health plan a finding occurred indicating grievances were under-reported, is there follow-through to reconcile that under-reporting and revise Part C and Part D grievance reports? In our often-siloed departments and processes, that type of follow through doesn't often occur.

We are all busy. Few of us in Operations have the luxury of focusing on one product or function. We are all trying to keep multiple balls in the air. But if we don't take time to evaluate, stabilize, and set up good controls, we won't survive unscathed. The last thing any of us want is an enforcement action that will take time and energy to resolve and will ultimately impact our members, resulting in most or all of the balls crashing down. Our multi-disciplinary team of consultants has been in your shoesâ€”we have juggled the same balls and are ready to partner with you. Contact us to get started >>

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

The Good, the Bad, and the Ugly!

Regarding the New Proposed Medicare Marketing Guidelines (MMG)

Taking a quick read of the proposed 2017 MMG, our marketing team had some initial thoughts about the proposed changes we would like to share.

The Good

It's only February, and we have the proposed 2017 MMG. This is great for us "Marketers" since we can plan now and won't get sucker-punched at the last moment with changes we weren't expecting.
The proposed MMG state you no longer have to put the disclaimer about "Availability of Non-English Translations" on print ads and postcards except in the language in which the ad is printed. With so little space to work with on ads and postcards, this change is very welcome.
Although already released in previous guidance, CMS now includes the following key provider directory updates in the MMG:
- CMS includes more specific guidance on timely updating of directories. Hard copy directories are proposed to be updated monthly; using addendums for the updates is acceptable. Online directories are expected to be completed within 30 days of notification. Although updating directories monthly or within 30 days is very difficult, it is better than real time, which was stated last year.
- CMS states all providers and/or pharmacies represented in the directory have a current contract in effect to participate in a Plan's network. At a minimum, any provider and/or pharmacy listed in the hard copy or online directory for the upcoming plan year should have a contract in effect for the first full month of the plan year. This greatly helps those of us in Marketing and Sales as nothing derails a sale better than stating a provider is in the network only to find out later the provider is not in the network.
- Last year the MMG stated Plans needed to contact their providers on a monthly basis to update their information. CMS has updated the previous language to state the provider contact is required quarterly.
CMS is clarifying when it is acceptable to use the term "free" in marketing materials. CMS states the term "free" may be used when describing mandatory supplemental benefits that are provided at $0 cost sharing for all enrollees.

The Bad

Unfortunately, CMS has also proposed Plans cannot use the term "free" to describe $0 premium plans, Part B premium buy-downs, low-income subsidy, or dual-eligibility.
CMS has clarified guidance from last year to state if an agent is conducting a one-on-one appointment telephonically, the agent must follow the Scope of Appointment guidance.

The Ugly

CMS includes language stating it will no longer generate Summaries of Benefits (SBs), and Plans will be required to develop their SBs based on their bid data in the Health Plan Management System (HPMS) and required data elements provided in an SB guidance memo. First-year changes like this are always ugly since there are always interpretation issues, and timing on these documents is already tight. However, we fully expect CMS to provide additional guidance around the implementation of this change in the months to come.

Not a BIG deal but Worth Mentioning:

There is a proposed fifth mailing statement to be utilized for the Annual Notice of Changes (ANOC) mailing only: "Important information about the changes to your Medicare drug and health plan."
CMS has included what they stated in a memo last year: the ANOC/Evidence of Coverage (EOC), directories, formulary, Utilization Management documents, and Multi-Language Insert must be on the website by September 30, with some exceptions.

Changes to the MMG are never wanted, unless it makes our lives easier, but having a "heads up" related to potential changes in February is a great way to get started for the upcoming Annual Election Periodâ€•thank you, CMS!

Resources

Gorman Health Group's marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. We will work with you to understand your market, mining demographic data for opportunity and finding the gaps in the competitive field into which your plan can fit. Visit our website to learn more >>

Register your team for the 2016 GHG Forum! For more details around the event and agenda, download the full conference brochure or visit our website. 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

CMS Releases New Medicaid Rule, OMB in Final Review

Last week, the Centers for Medicare & Medicaid Services (CMS) finalized the new Medicaid rule — a 653-page proposal requiring Medicaid managed care organizations (MCOs) to enhance their network adequacy, establish quality ratings, set a medical loss ratio (MLR) threshold of 85%, and develop a robust managed long-term care program. The new Medicaid rule has now been sent to the Office of Management and Budget (OMB) for final review. This means the new Medicaid rule could be published by mid- to late May. There are 39 states and the District of Columbia that currently outsource their Medicaid programs and about 46 million lives that will be affected by this new change.

Some of the proposed changes that were up for consideration:

Medical Loss Ratio — CMS proposed an MLR of 85% for Medicaid managed care plans, the industry standard for Medicare Advantage (MA) plans. CMS proposed to mostly use commercial rules in calculating and reporting MLR due to the "need for consistency" between plans in the Marketplace and in Medicaid.
Appeals and Grievances — The proposed rule made a few updates to the appeals and grievances process to align with MA plans. For example, the rule seeks to shorten the time frame in which MCOs and Prepaid Inpatient Health Plans (PIHPs) have to make a decision about a standard appeal from 45 days to 30 days, the same as MA plans. The expedited appeal time frame would be shortened from 3 days to 72 hours, also the same as MA.
Beneficiary Protections — Under current regulations, coordination and continuity of care focus on primary and acute medical care. The proposed rules aim to reduce coordination issues beneficiaries with chronic and complex conditions face. The proposed rule also seeks to align enrollment practices between Medicaid fee-for-service, Medicaid managed care, and Marketplace coverage.
Create standards to evaluate network adequacy and ensure beneficiaries are receiving accurate network information.
Medicaid Managed Care Quality Rating System — Align with existing MA and Marketplace rating systems. Standardize quality metrics among states and plans.
Updates to rate development standards and actuarial soundness of capitation rates, with a focus on federal oversight and a more detailed process to ensure actuarial soundness.
Calls on states to update quality strategies at least once every three years. Currently, some states are operating on strategies drafted more than five years ago. States are called on to develop a description of quality metrics and performance targets the state will use to assess Medicaid managed care quality.

Let the team of experts at Gorman Health Group (GHG) help you prepare for the upcoming changes that could impact your organization. GHG's risk adjustment experts can help analyze the financial impact, develop feasibility models to help with meeting the new MLR requirements, and provide guidance on streamlining operations. GHG's Compliance Solutions can assist in the development and monitoring of these new contract requirements, and our clinical team can assist with reviewing and developing integrated care models to provide quality initiatives that are effective and efficiently managed to get optimal results.

For more information, contact me directly at sjanicek@ghgadvisors.com.

Resources

Register your team for the 2016 GHG Forum! For more details around the event and agenda, download the full conference brochure or visit our website. 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

Noteworthy Evolution for Star Ratings in 2017 MA Draft Call Letter

Last week's release by the Centers for Medicare & Medicaid Services (CMS) of the 2017 Medicare Advantage (MA) Advance Notice of Methodological Changes and Call Letter ended the mystery surrounding potential policy and payment changes on the horizon. As our Founder and Executive Chairman, John Gorman, recently noted: "There's a lot to like — and much to fear." Although CMS is proposing higher-than-expected rates for 2017 and has introduced both payment and Star Ratings relief for plans serving dual-eligible beneficiaries, this positive news was counterbalanced somewhat by a number of factors, including proposals to increase compliance scrutiny in challenging areas such as network adequacy, provider directory accuracy, and medication therapy management programs.

As anticipated from a Star Ratings perspective, there were few surprises but quite a bit of noteworthy evolution for MA this year. CMS' proposals include:

Accounting for the Star Ratings Impact of Dual-Eligible and Disabled Beneficiaries:

After a lengthy research process and significant pressure from the industry, CMS proposes moving forward with an interim analytical solution to account for the Star Ratings impact of dual-eligible and disabled beneficiaries. Despite the fact only a handful of plans would likely gain or lose a full half-star in their rounded overall Star Rating, this is a huge methodological win for plans serving dual-eligible members and will be important to monitor closely. When combined with CMS' simultaneous proposal to adjust revenues based on beneficiaries' status as either full duals, partial duals, or non-duals, as well as for their status as both aged and/or disabled beneficiaries, my colleague, Dan Weinrieb, advises, "This will mean timely reconciliation and maintenance of clean enrollment data has never been more important for MA plans." This proposal, in combination with the proposed strategy to account for the lack of low-income subsidy (LIS) support to meet Puerto Rican beneficiary needs, reflects a noteworthy shift in CMS' willingness to adjust the Star Ratings program to account for scientifically-supported evidence of nuances within MA.

In-Home Risk Assessments

CMS' decision to leave in-home risk assessments untouched is great news for the many MA plans who are leveraging these important visits not only for risk adjustment, but also to connect members with needed care (as measured by Healthcare Effectiveness Data and Information Set (HEDIS^®) and Prescription Drug Event (PDE) Star Ratings measures), to coordinate care across the spectrum of providers (as measured by Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) Star Ratings measures), and to help support member's social and lifestyle challenges (as measured by Health Outcomes Survey (HOS) Star Ratings measures). We interpret this to mean CMS now better understands the incredible value in-home care can bring to a patient's holistic healthcare experience. However, despite this welcome news, plans should certainly ensure their program adheres to the best-practice expectations previously set forth by CMS, and supported by encounter data, in order to drive payment.

Termination of Contracts Below 3 Stars for 3 Years

CMS not only reaffirmed its previously-announced plans to terminate contracts earning 3 consecutive Part C or Part D Summary Ratings of less than 3 stars, but also set forth an annual calendar by which this practice will become standard. With CMS guidance indicating these termination decisions are non-negotiable, plans will likely expedite efforts to improve Star Ratings performance such that impactful work begins as soon as it looks possible their first Summary Rating below 3 stars may be on the horizon.

Connecting Compliance and Star Ratings

From a compliance perspective, CMS proposes to continue strengthening its connections between compliance, data integrity, and Star Ratings. CMS reminds organizations of its policy to reduce a contract's measure rating to 1 star if it's determined biased or erroneous data was submitted. Our experience this year indicates CMS is leveraging this authority much more frequently than it has in past years, which means plans will want to pay particular attention to Medicare Plan Finder and PDE data requirements, Organization Determinations, Appeals, and Grievances (ODAG) and Coverage Determinations, Appeals, and Grievances (CDAG) processes, internal controls to prevent errors in operational areas directly impacting the data reported or processed for specific measures, and Part C and D reporting requirements data validation for specific measures. CMS points out, and we're hearing evidence to support, it continues to identify new vulnerabilities where inaccurate or biased data could exist, which could result in the reduction of a star measure to 1 star. As my colleague, Regan Pennypacker, details in her recent article, CMS' proposed changes will require plans to "implement creativity and do more with less while enhancing the beneficiary experience." Certainly this will be no easy task as we survive 2016 and plan for 2017 under a new administration.

Measure Updates

CMS is not proposing to add any new measures to the 2017 Star Ratings, although several measure specification changes are proposed for use in the 2017 ratings. As previously proposed, CMS indicated both the Improving Bladder Control (Part C) and High Risk Medication (Part D) measures will be moved to the Display page for 2017.

CMS proposes the addition of two new measures to the 2018 ratings (based on 2016 services/operations): Medication Reconciliation Post-Discharge and Hospitalization for Potentially Preventable Conditions. Addition of previously-proposed statin therapy and asthma measures were pushed out at least another year, possibly as a show of support for the recently-released and newly-aligned quality measures, giving plans a bit of breathing room to work with providers in this new area.

As we look ahead with CMS' foreshadowing of future program updates, continued attention is being paid to Care Coordination measures (with the National Committee for Quality Assurance's (NCQA's) assistance) and Depression measures (with NCQA and Minnesota Community Measurement's support), and the Advance Notice highlights a number of potential measure specification changes, which may take effect for the 2018 ratings.

Whether your organization is working to improve performance on your entire Star Ratings program, or just a few Star Ratings measures, or needs assistance understanding how the proposals contained in the Advance Notice may impact your plan, we can help. For additional questions and inquiries about how Gorman Health Group (GHG) can support your organization's Star Ratings programs, please contact me directly at msmith@ghgadvisors.com.

Resources

On Tuesday, March 1, from 2:30-3:30 pm ET, join John Gorman, GHG's Executive Chairman, and colleagues Olga Walther, Senior Legislative & Policy Advisor, and Leslie Mullins, GHG's Senior Consultant, as they provide a hard-hitting analysis of critical areas addressed in the document. Learn what the proposed "methodology changes" could mean for your organization and your partners and the steps you can take to soften the impact. Register now >>

Register your team for the 2016 GHG Forum! For more details around the event and agenda, download the full conference brochure or visit our website. 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

There's a Lot to Like and to Fear in the 2017 Medicare Advantage Call Letter

On Friday after the close, the Centers for Medicare & Medicaid Services (CMS) released the 2017 Medicare Advantage (MA) Call Letter with proposed policy and payment changes. There's a lot to like — and much to fear. On payments, CMS came in with higher-than-expected rates that make clear the long walk in the desert from cuts in the Affordable Care Act (ACA) is over. But on compliance, they are rolling out the firing squad with a broad mandate, and the Administration will leave its mark long after Obama has left office.

What We Like:

The draft offers all-in rates of +1.35% and a trend of +3.05%, better than last year and better than expected.
CMS is leaving home visits for MA risk adjustment untouched. If ever CMS was going to clamp down on this after years of threats, this was the time — in the last year of the Administration. By not doing so, we think they're closing the book, acknowledging much good also comes from these house calls, and the home is the most underutilized source of care in the delivery system for seniors. Despite MedPAC recommendations and a drumbeat of op-eds, CMS didn't want to throw the baby out with the bathwater.
There are big proposed changes to risk adjustment and Star Ratingsfor MA plans serving dual eligibles.
- CMS would launch a new payment system with six subcategories: full duals, partial duals, and non-duals, for both aged and disabled beneficiaries. The net effect is like a crude, mega-risk adjuster, paying plans with more duals bigger, more accurate payments, while paying slightly less to plans with fewer duals.
- On Star Ratings, CMS is proposing an adjustment on three key measures — the overall plan rating, and Part C and D summary ratings — which will increase ratings for plans with higher proportions of duals and could increase bonus payments if the plan is 4+ stars. This is a big win for the industry.
The health insurer issuer tax has been suspended for a year (and will return in 2018).

What We're Worried About:

The rapid acceleration from 10% to 50% encounter data driving risk adjustment could depress risk scores. It's clear CMS is moving to 100% encounter data as quickly as possible and likely presages the use of encounters and not Fee-for-Service (FFS) claims to calculate risk factors as well as the phase-out of the coding intensity adjustment.
CMS is proposing changes for Employer Group Waiver Plans (EGWPs) that amount to a "tax" on sponsors designed to reduce Medicare's spend on these 3 million of the 18 million beneficiaries in MA. EGWPs typically bid much higher than individual MA plans, and the proposal will likely result in a cost-shift to group members or a reduction in supplemental benefits. There was no estimated impact given, so watch this closely.
CMS made it clear Star Ratings low performers will be executed by firing squad as early as next week. The Call Letter states plans rated below 3 stars for 3 consecutive years will be terminated in February 2016 for a December 31 effective date. Three to six plans qualify for termination. This will be the timeline for future years, and CMS states these decisions are non-negotiable.
Huge news here on the compliance front:
- CMS notified Part D sponsors it's stepping up enforcement actions on coverage disputes and complaints, the leading noncompliance issue for plans.
- Plans failing the financial audits conducted on one-third of plans each year will no longer be subject to corrective action plans but rather sanctions and civil monetary penalties.
- CMS is ramping up audits and enforcement actions in network adequacy, provider directory accuracy, and medication therapy management programs.

As always, we now enter the frenzied public comment/lobbying phase where the industry tries to get an even better deal, with the final policies announced April 4. As these things go, MA plans should be generally happy about the financial picture while getting down to the busy work of getting the compliance house in order. Most of what's proposed here, we think, becomes the "new normal" long after Obama has left office.

Resources

Join John Gorman, GHG Executive Chairman, and colleagues, Olga Walther, Senior Legislative & Policy Advisor, and Leslie Mullins, GHG's Senior Consultant, as they provide a hard-hitting analysis of critical areas addressed in the document. Learn what the proposed "methodology changes" could mean for your organization and its partners, and the steps you can take to soften the impact on Tuesday, March 1 from 2:30-3:30 pm ET. Register now >>

Register your team for the 2016 GHG Forum. For more details around the event and agenda, download the full conference brochure or visit our website. 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

What to Watch: The Fiscal Year 2017 budget

President Obama released the Fiscal Year 2017 budget last Tuesday, which contains many significant proposals to government healthcare programs. Although both the Senate and House's budget committees already rejected hearings from the President's budget chief and unsurprisingly declared the bill "dead on arrival," the proposals do contain many bipartisan provisions with significant cost savings. One such proposal organizations should watch carefully, for example, is using competitive bidding in Medicare Advantage plans.

Most of the Medicare and Medicaid proposals are estimated to provide savings. The Congressional Budget Office's (CBO's) review of the budget in March will further shine light on which proposals will make it through the budget process. In a new memo, The GHG Policy team provides an overview of proposals to watch in a new memo, including:

ACA Updates

Medicaid Expansion Incentive
Uniform billing and out of network charges
Marketplace eligibility determinations
Cadillac Tax updates

Medicaid Budget Updates:

Medical Loss Ratio (MLR)
CHIP Funding
Health Coverage Expansion Proposals
Long-Term Services and Supports (LTSS)

Medicare Advantage (MA):

Competitive Bidding Proposal
Higher payments to high-quality MA plans
Telehealth expansion

Part D:

State-federal Medicaid negotiating tool
Part D plan sponsor incentives to better manage high prescription drug costs.
Increase of manufacturer rebates
Mandate to provide rebates consistent with Medicaid rebate levels for drugs provided to low-income Part D beneficiaries.

Alternative Payment Models (APMs):

Bundled Medicare payments for post-acute providers such as nursing homes and home health agencies.
New bonus payment for hospitals that collaborate with certain APMs.
Quality bonus program for the highest rated Part D plans

Resources

Register your team now through February 14 for the 2016 GHG Forum, and take advantage of our standard registration rate of $1,095 before the price goes up to $1,295 on February 15. Register now >> For more details around the event and agenda, download the full conference brochure or visit our website.

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

by GHG Advisors

10 Years of Star Ratings: Lessons Learned

The year 2016 marks the tenth year Medicare Advantage (MA) plan performance data has been collected for evaluation under the Centers for Medicare & Medicaid Services' (CMS') Star Ratings program. While we await the "new news" from CMS about new Star Ratings measures and other program updates in the impending Advance Notice, we thought it appropriate to celebrate this important milestone by looking at lessons learned through our first 10 years of Star Ratings and share some insights on how plans can leverage these lessons through the program's continued evolution.

Star Ratings, and the quality bonuses associated with strong Star Ratings performance, put MA plans squarely on a fast-track to rapidly improve MA beneficiaries' experience of healthcare (including quality, access, and reliability), to improve the health of the MA population, and to reduce or control the cost of healthcare within MA. As a result, MA plans have made tremendous investments of effort and resources over the past few years in the sprint to develop, deploy, and measure a whole host of tactics intended to achieve the all-important 4-Star Rating. The downside: these years of "trial and error" were often challenging, the work was often tiring for key personnel, and many plans built programs, reports, and tactics that may have worked well for yesterday's measures but which may not be ideally suited to support CMS' longer-term outcomes focus within the Star Ratings program. The upside: we now know, in great detail, the workflows, tactics, and population health strategies that efficiently and effectively support not only strong performance on quality measurement programs but also progress towards the Triple Aim.

During these last few days of calm before the annual Advance Notice and Call Letter season begins, here are a few strategic questions for your team to consider as you review CMS' proposed program updates during the coming weeks:

Is your Star Ratings work plan achieving the level of success you desire?
How will your Star Ratings work plan need to be updated to meet CMS' Star Ratings program updates? Are your 2016 tactics capturing the potential new measures under consideration by CMS?
Which elements of your Star Ratings work plan are working well, and which need to be adjusted to achieve your goals?
How are you leveraging the "basics" of Star Ratings such as care coordination, comprehensive diabetes care, medication adherence, and medication therapy management within your Medicaid, Accountable Care Organization (ACO), Marketplace, and Commercial populations?
How effectively has your Star Ratings strategy improved outcomes and/or reduced costs?
Do current workflows adequately address members' social and lifestyle needs (e.g., nutrition needs, stable housing, transportation, etc.)?
How streamlined do your providers perceive your Star Ratings programs to be? How aligned are your Star Ratings programs with the many other quality programs in which your providers participate? How can your providers best support your quality needs?

Star Ratings success requires forward-looking precision to meet the needs of your members and your providers within the constraints of your budget while delivering strong performance in areas where your population or network under-performs the national average.

We understand success isn't easy, and evolution can be difficult. Whether you are looking to improve performance on just a few measures, need assistance interpreting the impending announcements in the Advance Notice, or are ready to more comprehensively evaluate your current Star Ratings program, we can help. For additional questions and inquiries about how Gorman Health Group can support your organization's Star Ratings programs, please contact me directly at msmith@ghgadvisors.com.

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