Brain Food | GHG Advisors

Is Your Customer Service Ready? Top 5 Lessons Learned in 2015 Rolling into 2016

It's only a few months until we ring in a new year. Time flies, but there is still enough time to ensure we put our best foot forward as we begin 2016. Here are the top 5 lessons learned in 2015 as we roll into 2016 to ensure Customer Service is ready for the New Year:

What were your member's pain points in 2015? Reviewing grievances and appeals and Complaints Tracking Module cases (CTMs) has many purposes. High on that list is to improve the impacted process, but of course it goes beyond that. Sometimes we forget to close the loop and review and educate Customer Service staff on managing the pain points and how to work through difficult topics with our members. Better prepared Customer Service means better educated and knowledgeable members.
Are all tools and support materials updated for 2016? There is a close-out for issues and claims from 2015, so for a period of time, Customer Service will heavily rely on two sets of information. A clear understanding of what is in place for 2016 and how to find the correct information is critical to preventing confusion for Customer Service and members.
Have you tested your compliance with the various required timeliness standards? Can all Customer Service staff secure a translator within 7 minutes? Do they all know to stay on the line with the member and the translator once the translator is secured? Have you tested your TTY lines to ensure they reach a live agent during all hours of operation, 8 am — 8 pm? We are all monitoring average speed to answer and disconnect rates, but translator and TTY availability is harder to monitor, and every year the Centers for Medicare & Medicaid Services (CMS) finds plans failing to adequately manage non-English language and TTY calls.
Can your Customer Service staff recognize complaints about coverage for drugs as coverage determinations? In a recent CMS enforcement notification, the first item called out in the health plan sanction letter was the plan improperly classified coverage requests as grievances or customer service inquiries. The coverage determination request process should begin at the time of the original call. It is critical Customer Service staff can recognize and correctly process these calls. Have you pulled your Customer Service call logs to see if these are being correctly identified and routed appropriately? That's what CMS will do in an auditâ€•don't let them discover it first.
Have you set up a process to ensure all letters and communications sent to members are also available to Customer Service? Everyone hates being blindsided by an issue or new information. At most plans, this is an everyday occurrence in Customer Service. Have you set up a common repository for all member material to be stored, and copies of the member materials placed there, before the information is mailed? An informed Customer Service Department shows cohesiveness and gives members confidence in your program.

Customer Service is the heart of a health plan. Ensuring your Customer Service staff is top-notch and has the tools to perform at the highest level for every call is critical to your plan's success. Gorman Health Group's experienced Operations team can work with you to set up knowledgeable, well-trained Customer Service and Operations departments. We've been in your shoes and know your struggles and how to solve them.

Before we ring in the New Year, let's double check that our members will have everything they need from your Customer Service Department to start the year right!

Resources

Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>

Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095. Register today >>

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by GHG Advisors

A New Report by Kaiser Family Foundation Found Part D Premiums Will Rise an Average of 13% in 2016

We blogged earlier this month about Medicare Advantage (MA) premiums showing slight decreases to no decreases across the board for 2016 based on the Centers for Medicare & Medicaid Services (CMS) estimates. But what does the landscape look like for Part D?

CMS stated in a September 2015 article, "Premiums in the Medicare Prescription Drug Program (Part D) will [also] be stable next year." Earlier this year, CMS announced the average basic Medicare prescription drug plan premium in 2016 is projected to remain stable at $32.50 per month.¹ CMS' Part D average premium estimates include both Medicare Advantage Prescription Drug plans (MA-PDs) and Prescription Drug Plans (PDPs). If we carve out PDPs from the Part D premium average reported by CMS in September, data shows, for most PDP enrollees, premiums are projected to be higher in 2016 than in 2015, and many will also see higher deductibles and more cost-sharing tiers with coinsurance.² As cited in a recent Kaiser Family Foundation study on Medicare Part D plan offerings for 2016, the average PDP premium is projected to increase by 13 percent from 2015 to 2016, from $36.68 to $41.46 per month. When looking at the $0 premium PDP options, low-income subsidy (LIS) enrollees will have fewer to choose from. This means either plan reassignment or beneficiary plan switches will occur for beneficiaries to continue without a premium.

What will this mean for MA plans offering Part D coverage in 2016? Increased 2016 PDP premiums may contribute to a potential shift in membership from PDPs to MA-PDs this Annual Election Period (AEP). Leveraging this opportunity will require time investment from MA-PDs, educating beneficiaries on how making plan changes could lead to beneficiary cost savings and still meet their Part D coverage needs.

"Premium" may be the first category beneficiaries are looking at, but it is not the only thing beneficiaries consider when comparing Part D options. The entire point of AEP is to offer Medicare beneficiaries the opportunity to evaluate their plan options and choose a plan which best meets their needs. This means, in addition to premiums, beneficiaries are looking at deductibles, cost-sharing, formularies, and network pharmacies.

In 2016, 84 percent of PDPs will use tiered pharmacy networks, with lower cost-sharing in selected network pharmacies and higher cost-sharing in other network pharmacies. Two-thirds of all PDPs will have deductibles, with a growing share of PDPs imposing the maximum deductible allowed by law, which increased from $320 in 2015 to $360 in 2016, the largest increase in the deductible since the start of the program.²

Now that the cards are on the table, your immediate strategy, as well as that for next AEP, should be examined. Are you at risk for losing members to competition due to pricing increases? Are your retention efforts aligned to address this issue? Have you identified opportunities to gain membership and benefit from your competitors' increases?

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

¹ CMS, "Medicare Prescription Drug Premiums Projected to Remain Stable" available at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-07-29.html.

²Oct. 13, 2015 | Jack Hoadley, Juliette Cubanski, and Tricia Neuman, Medicare Part D: A First Look at Plan Offerings in 2016, http://files.kff.org/attachment/issue-brief-medicare-part-d-a-first-look-at-plan-offerings-in-2016

Resources

The Medicare Advantage marketplace is evolving — are you prepared? 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 >>

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by GHG Advisors

2015-2016 CMS Program Audit Protocols Update

It's Christmas in October (and Hanukkah, too) if you've been waiting for the revised 2015-2016 Program Audit process and protocols. Let's get right down to it!

You'll want to review all 20 documents (made up of the memo, data requests, supplemental questions, templates, and impact analysis layouts) for their significant enhancements and make necessary changes in your own oversight programs. What are some significant changes, and what do they mean for you?

Overall Process

If the Sponsor fails to provide "accurate and timely" universe submissions twice, it will be cited as an observation in an audit report. After the third failed attempt, the Centers for Medicare & Medicaid Services (CMS) will classify this as an Invalid Data Submission, or IDS. There is NO reason a universe should be submitted late. Some of our Sponsor partners have required additional time for certain submissions, and they requested that time from CMS and got it. Nothing should irk senior leadership more than a universe being submitted a few minutes late, especially considering data issues in program audits directly impact Star Ratings.
CMS Account Managers will be playing a greater role in the validation of pre-audit issue summaries, which are made up of disclosed and self-identified issues. CMS also clarifies if CMS identified an issue during the course of routine monitoring and brought it to the Sponsor's attention, it would be classified as a self-identified issue. There are specific timing issues CMS will consider in determining whether an issue is corrected or uncorrected. It is best practice for Compliance departments to incorporate a log similar to what CMS has provided in the management of disclosed and self-identified issues.

CPE

Reduction of employee interviews, with addition of interview(s) of those responsible for managing accountability for FDR oversight. Not a surprise seeing as this has been a consistent finding for CMS throughout 2015 and previous years. Sponsors should coordinate and start mock interviews now with those who are responsible. CMS is seeing gaps in FDR oversight compliance whether or not you have three FDRs or three dozen.
By the numbers:
1. Tracer templates narrowed down from 2 to 1;
2. Tracer samples increasing from 5 to 6, all to be conducted in week 2, so Compliance staff can participate in week 1 activities;
3. There are 3 options for providing supporting documentation for tracers: embed into your Tracer, upload via SFTP, or have it immediately available onsite.
CMS has incorporated a documentation request list to help them review the effectiveness of a compliance program. These documents will need to be submitted along with the 5 universes for this audit area. CMS has also provided a template for the Sponsor to demonstrate organizational structure and governance. This template includes a number of questions and data requests, and should help auditors compare apples to apples.

CDAG and ODAG

Coverage Determinations, Appeals, and Grievances (CDAG) and Organization Determinations, Appeals, and Grievances (ODAG) universe time periods will be determined by the Sponsor's enrollment size. In addition to numerous data layout clarifications and updates, CMS also details which universes may be combined with others to determine effectuation and notification scores.
As previously announced in 2016, Part C and Part D grievances should be submitted based on date of resolution notification. They include a reminder not to include Complaints Tracking Module (CTM) cases in grievance universes. (Who is still including CTM cases in grievance universes? Please call us, whoever you are, and let us help!)

Formulary Administration (FA) and Special Needs Plan Model of Care (SNP-MOC)

Thankfully, there were no significant changes noted in the core processes for these audit areas. Plans will note CMS has added the Cardholder ID to the SNP Enrollees (SNPE) record layout, and, more importantly, they request separate record layouts be submitted for each unique MOC rather than per contract.

Pilot Protocols

CMS commits to releasing the pilot protocols for Medication Therapy Management (MTM) and Provider Network Adequacy later this year.

They describe one of their objectives for the MTM review to "initiate enforcement actions and/or identify possible performance measures for sponsors to implement." Technically, CMS can refer a Sponsor for enforcement action for any aspect of the audit. Why highlight it in MTM? Get busy making sure your program is in order.
No surprises in network adequacy — CMS has emphasized they will be evaluating networks for adequacy by also evaluating whether or not participating providers' practices are open to treat enrollees. Some of our partner clients have already started their own internal evaluations to ensure this important beneficiary protection is met.

This year's audit season was a whirlwind of many things. For Sponsors and auditors alike, it's fair to say the industry struggled with the earlier-published protocol. Now that this document set has been released for 2015 and 2016, this should allow some breathing room for all to start implementing changes in tools, reports, and monitoring efforts. Unfortunately, that breathing room overlaps the upcoming holiday season, so perseverance is key! There is truly no rest for the weary.

Resources

In addition to monitoring your operations and auditing the organization's performance, CMS also audits the compliance function. In recent years many CMS sanctions have been issued as the result of a Compliance Program that was determined to be ineffective. Let us help you create a culture of compliance. Contact us today to get started >>

If your organization is interested in a mock audit utilizing the latest protocols. We can help! The Online Monitoring Tool™ is our compliance software designed to help organizations operating in Medicare, Medicaid and the Health Insurance Marketplace track the compliance of their operations. Learn more >>

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by GHG Advisors

Considering Network Expansion? The Role Network Adequacy, Risk Adjustment, and Star Ratings Play

The leaves are changing colors, pumpkins are out on every front stoop, and the brisk weather signifies fall is in full swing. It also means we are in the midst of application season for health plans wanting to expand their geographic footprint. The Centers for Medicare & Medicaid Services (CMS) has put provider networks front and center under the bright spotlight, and Medicare Advantage (MA) plans need to be even more vigilant in managing their largest asset. Regardless of the size and scope of the organization, your plan's network adequacy and accessibility is a cornerstone of any new initiative.

In today's marketplace, it is no longer acceptable to meet the bare minimum health service delivery (HSD) requirements. Consumers, and CMS, are demanding plans be able to offer choices including quality and cost efficiency. With consumer-savvy, newly aged-in Medicare beneficiaries, there is also a shift in patient expectations and what is available for their healthcare dollar. The new beneficiary is aging in from a world of patient engagement and incentive and rewards programs and will expect the same level of service. Health plans need to find ways to evaluate their existing provider networks and newly expanded networks to meet these clinical and financial goals and be forward-thinking on how to best wrap risk adjustment and Star Ratings into the mix.

Additionally, the belt is tightening with day-to-day network management, and plans must reach out to their providers on a monthly basis to confirm demographics and availability of their providers to ensure the information is updated in real-time with online directories and close the loop between the providers submitted on the HSD tables versus those in the directory. We will also delve into network adequacy becoming part of the overall audit protocol pilot for 2015.

In an upcoming white paper, Gorman Health Group's (GHG's) Senior Vice President, Regan Pennypacker, will provide compliance insight on the draft application. A key network component in the draft is that plans will be required to submit their HSD tables for their entire network, not just the counties the plan is proposing to enter with the service area expansion request. This requirement further supports the CMS commitment to monitor network adequacy for MA plans much more closely.

Given that applications will be due in a few short months, GHG is here to help. We have a long history of providing direct contracting assistance for plans, the ability to run multiple network adequacy and availability scenarios, and prepare your plan's HSD tables for submission. We also have the bench strength to help you develop a true network strategy taking into consideration the quality, financial, Star Ratings, and risk adjustment goals you need to reach in the competitive landscape of healthcare. Let us know how we can work together and build strategic network operations to support your plan goals.

Important key dates for application submission:

Resources

GHG can assist your organization in developing and executing a networking strategy, from contracting targets to model contract terms, to payment terms that match your budgets and the capabilities of your claim payment systems. Let's get started. Contact us today

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by GHG Advisors

Healthcare Trends: ICD-10, Mergers, Part B Premiums & MA-VBID

ICD-10

We are into our third week of ICD-10, and so far, reviews of implementation woes have been mixed. Some reports tout a smooth rollout process, with few problems — at least from the side of payers and clearinghouses. However, providers have noted several issues they are encountering from the transition, such as not being able to complete referrals, long wait times with insurance company calls, and possible delays in payment.

Merger Updates

Both the House and Senate held hearings on the pending health insurer mergers, with light grilling of the executives and less than anticipated contention during the Senate hearing. There is a suggestion that the less than rigorous questioning of the executives meant a "win" for the CEOs. Only Senators Franken and Blumenthal seemed to show any serious concern over the consumer impact of the mergers. However, it is important to note that until the DOJ weighs in on the matter, the status of these mergers is still unclear, and the questions posed during both hearings were just the tip of the iceberg. These insurance giants will face much more scrutiny within the near future, with a careful analysis and rigorous review of potential market impacts from the deals.

HHS' Updated Shutdown Plan

HHS finally released its most updated contingency staffing plan, likely preparing for the possibility of a government shutdown in December. HHS estimates that 51% of staff would be on furlough. CMS would continue large portions of Affordable Care Act (ACA) activities, and the Medicare program will largely continue without disruption. CMS fraud and abuse activities will be curtailed, and fewer recertification and initial surveys for Medicare and Medicaid providers would be completed. The 2016 Contingency Staffing Plan is available here: http://www.hhs.gov/about/budget/fy-2016-hhs-contingency-staffing-plan/index.html

Reconciliation

The House of Representatives has moved forward with its reconciliation package that would repeal major provisions of the ACA — including the individual and employer mandate, Cadillac tax, medical device tax, IPAB — effectively dismantling the law. The package would also deny funding to Planned Parenthood. It is still unclear whether the Senate will vote on this legislation, and it is all but guaranteed to be vetoed by President Obama.

Part B Premiums

The 2015 Medicare Trustees Report estimates that Part B premiums will increase by 52% next year, from $104.90 to $159.30. Although beneficiaries purchasing Part B through Social Security deductions will be shielded from this increase, due to a likely no cost of living adjustment (COLA) in 2016, the remaining 30% will face a significant rate hike. This is because a "hold harmless" provision shields Social Security recipients from Part B premium increases which outweigh the Social Security COLAs. However, this means the 30% not qualifying under the hold-harmless provision will be on the hook for the entire increase in 2016.

Medicare Advantage Value-Based Insurance Design Model

The Centers for Medicare & Medicaid Services (CMS) has released the Request for Applications (RFA) for the Medicare Advantage Value-Based Insurance Design model. Applications are due on January 8, 2016. Interested organizations should begin conducting in-depth data analyses now in order propose a benefit plan in the RFA.

Resources

Download a copy of the recording from the October 5 webinar titled "Medicare Advantage Value-Based Insurance Design Model (MA-VBID)", hosted by John Gorman.

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

by GHG Advisors

ACO vs. Value-Based

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

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

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

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

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

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

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

Resources

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

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

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

by GHG Advisors

The MA-VBID Model: Key Takeaways

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

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

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

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

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

Resources

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

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

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

by GHG Advisors

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

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

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

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

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

Resources

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

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

by GHG Advisors

Healthcare Implications Post Boehner Exit

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

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

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

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

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

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

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

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

Resources

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by GHG Advisors

Do More Than Survive AEP

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

These are the four questions to consider going into AEP:

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

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

Resources

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

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by GHG Advisors