Issues to Watch in Government Health Programs in the Next Few Months
Last week was an exciting time for the policy world with the release of the Final Medicare Advantage (MA) Payment Rate and Call Letter. Here are some other notable stories we are watching develop in the next few weeks:
Part B Payment Model: On March 8, 2016, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule which aims to test a new alternative payment design to pay for drugs covered under Medicare Part B. While we will not see a final rule until end of May or June, CMS did already note they are considering certain exemptions to the model, such as practices already participating in the Oncology Model Demo. This proposal has already received a lot of criticism, with stakeholders arguing the model would decrease patient access to treatment while focusing too heavily on the financial picture.
MACRA: The proposed Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) Rule, a provision of the Medicare Access and CHIP Reauthorization Act (MACRA), is now at the Office of Management and Budget (OMB). MACRA repealed the Sustainable Growth Rate (SGR) formula and directed the Department of Health and Human Services (HHS) to create MIPS to replace existing physician quality programs such as the Physician Quality Reporting System (PQRS) and the Value-Based Modifier (VBM) beginning January 1, 2019. The rule will also lay out the definition of the types of APMs that will be considered bonus eligible. We should expect this regulation late April or May.
Covered California: California recently released major changes to its regulations by imposing new quality and cost standards in their contracts with insurers. The new plan will adopt a payment system for hospitals, similar to the one used by CMS, which will put 6% of reimbursement at risk or subject to a bonus payment based on quality over the next several years. Plans will also be required to identify providers and hospitals who are outliers in regards to cost or quality with these plans up for termination from the networks as early as 2019. While California is the first to issue this type of regulation, as John Gorman noted, "As goes California, so goes the world," and we can easily see similar efforts implemented across the nation.
UnitedHealthcare: In other Affordable Care Act (ACA) news, UnitedHealthcare is seemingly making good on its threat to exit the Marketplace by pulling out of markets in Arkansas and Georgia. As we previously noted, this move should not really come as a surprise and is not an effective measure of the health of the ACA program, as UnitedHealthcare is not a strong market participant in the ACA business and only cautiously dipped its toes in the water for the first time in 2014.
Mergers: The Anthem-CIGNA merger is currently undergoing some serious scrutiny in California. The California Department of Insurance (CDI) grilled the insurers last month, and there is potential for the merger to fail to receive approval from the state. If it is to pass, we will likely see significant divestment requirements and additional scrutiny from the Federal Trade Commission and Department of Justice in Quarter 3 or Quarter 4 of 2016.
Medicaid: The final Medicaid regulation is still under review at OMB, and we should expect to see its release any day now. Touted as "the mega-rule," this regulation will alter every part of the current Medicaid program. Most of the proposed changes by CMS align the Medicaid program with other programs such as MA and Qualified Health Plans (QHPs).
Resources
We are proud to announce a new session at the Gorman Health Group 2016 Forum featuring David Sayen, a former Centers for Medicare & Medicaid Services (CMS) Regional Administrator, who will provide a CMS update on "The March to Value-Based Payment." Register now to reserve your seat for next week!
Our distinguished team of experts collaborated to provide our interpretation of this announcement and the key features that will have the greatest impact on the industry, emphasizing core business functions in Risk Adjustment, Provider Network, Quality, Compliance, Pharmacy, and Data Integrity. Download our full Summary & Analysis of the Final Rate Announcement & Final Call Letter >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
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 >>
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 >>
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 >>
Issues That Will Define Government Health Programs in 2016
The new year brings a slew of issues that will define government-sponsored health programs. Here's what we're watching closely, not necessarily in this order. Opportunities have never been greater in Medicare, Medicaid, and ObamaCare, but execution risk is rising fast. If this was an easy business, we'd be out of business.
Drug Pricing: Prospects for a legal fix in Congress is questionable, and this will be a leading issue in the Presidential campaign. Expect administrative action, demonstration project solicitations from the Centers for Medicare & Medicaid Services (CMS), "comparative effectiveness research" by federal agencies on specialty drugs, and "collaborative pricing" initiatives between pharma manufacturers and payers on high-profile therapeutic classes. Health plan CEOs expect higher specialty drug cost trends to be the biggest driver of medical cost trend in 2016.
Medication Therapy Management (MTM): 2016 is the year MTM gets real. CMS will begin conducting widespread audits of Medicare Advantage (MA) and Part D plan medication reviews, and there is tremendous emphasis on MTM in the Star Ratings system. Making MTM real for your members will require extensive vendor contracting and Pharmacy Benefit Manager (PBM) coordination, so turn your plan's attention to this fast.
Antitrust/Mergers: Sometime in Q3 or Q4 of 2016, the Federal Trade Commission and the Department of Justice Antitrust Division will rule on proposed mergers for Aetna/Humana, Anthem/CIGNA, Walgreens/Rite-Aid, and Pfizer/Allergan. We expect all four deals to be approved but with strings attached; e.g., we expect Aetna/Humana will have to divest 250,000-450,000 lives to get a green light.
Star Ratings: Must be a central focus of all payers and providers in government programs. Star Ratings has transcended MA and Part D. Star Ratings data is already being collected by ObamaCare plans, and over a dozen state Medicaid programs are using CAHPS® and Star Ratings data in contracting with plans for dual-eligible and managed long-term care (LTC) initiatives. And while there aren't major changes to Star Ratings measures in 2016, scoring is the game-changer: 50% more plans will be scored for the first time this year, guaranteeing a shift right in the ratings bell curve and that many of 2015's 4-Star plans will go off the cliff. To maintain progress, plans must run Star Ratings as a program with dedicated leadership and execution spelled out at the workflow level.
Risk Adjustment: 2016 will usher in increased efforts to ensure payment accuracy through more stringent and expansive Risk Adjustment Data Validation (RADV) reviews, and so providers delegated for risk and sharing in a percent of premium will be in the spotlight. CMS is seeking to contract with third-party auditors on RADV, and risk adjustment is a top concern in the Department of Health and Human Services (HHS) Office of Inspector General (OIG) work plan.
Providers and Care Delivery: 2016 will be a transformative year with contracted providers in government programs. Narrow/preferred networks and value-based risk contracting will go mainstream this year, whether providers are ready or not. Huge penalties start this month on network adequacy and accuracy of provider directories, and NAIC's model guidance on provider networks will be a central document governing the issue. Star Ratings measures on access to care and the member experience put new heft and revenue behind network requirements. Provider-sponsored entities will provide a mini-surge of dozens of new plans into MA and Medicaid in 2016 and 2017, especially among Medicare Accountable Care Organizations (ACOs), so keep your friends close and your enemies closer. Home- and community-based services and alternatives to nursing homes will go mainstream in 2016. Retail pharmacies will become the second-most-important provider type for health plans. With crushing burdens of ICD-10 and meaningful use, small and mid-size practices will become overwhelmed and will underperform. Plans will need aggressive oversight, quality improvement, and directory management activities to stay ahead.
Exchange Payment: For the first time in two years, CMS is going to begin paying plans HIX 820s at the member level, which will shine a spotlight on enrollment reconciliation issues that have been lingering. The plans' readiness transition period is from January to March, then it gets real in April.
Medicaid and Dual Eligibles: Unexpected states like LA, SD, and IA are now considering Medicaid expansion. CMS is focusing on new Medicaid quality measures and will be depending heavily on NCQA quality measures to gauge health plans. This will impact payment and future membership for some lower-rated plans. Beneficiary opt-outs in excess of 75% are plaguing early dual-eligible demos, but many states remain in fiscal crisis and need to move ahead to balance budgets.
Compliance: 2015 was a near-record year in CMS enforcement actions, and scores always get settled with insurers in the second term of a Democratic administration. There will be a slew of rules coming from CMS this year as well as expanded audits from OIG. Both agencies' approaches indicate how critical documentation remains: CMS added a number of items to documentation requests for Compliance Program Effectiveness; Medicaid, dual-eligible, and LTC demos are still very documentation-heavy, and CMS found that approximately two-thirds of CMS-reviewed FFM issuer plan policies and procedures (P&Ps) were incomplete or had operational findings with their vendor contracts. So even though there is focus on data monitoring and passed/failed samples, P&Ps and documents are still the cornerstone.
There is no question that 2016 will be a banner year in government programs enrollment, and the long walk in the desert on payment rates in MA and Medicaid appears to be over. But execution risk and the enforcement environment have never been tougher. This year will be a "Darwinian moment:" it's not about being the biggest or even the smartest but being the most adaptable.
.
Resources
Register your team now through January 31 for the 2016 GHG Forum, and take advantage of our New Year's special! Save 15% using promo code NewYear16 at checkout. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Senate passes bill repealing major provisions of Affordable Care Act
Last week, the Senate passed an Affordable Care Act (ACA) repeal bill, with a vote of 52-47. Although largely symbolic, this marks the first time the Senate has been able to pass such a bill.
The Senate voted on a bill previously passed by the House, however, because of the large number of amendments made by the Senate, the legislation now goes back to the House, where it is all but certain to pass. The White House already stated the President will veto any ACA repeal legislation, and because the Republicans do not have enough votes to override such a veto, this will be the end of the movement. Nonetheless, the Republicans will see this as a major step in their attempt to repeal the ACA, as it is the first time Congress will be able to get such a bill to the President's desk.
What's more interesting is the parts of the bill which gained some bipartisan support. For example, the "Cadillac tax" repeal amendment was overwhelmingly approved with a vote of 90-10. Although this amendment will not become law this time around, its repeal is already scheduled in talks in tax packages expected to be voted on before the end of the year. It is also unclear how the anticipated funding expected from the Cadillac tax would be replaced. It is estimated such a repeal would remove about $90 billion from the ACA over 10 years, however, the Senate's tax repeal would not go into effect until 2015.
The passage of the bill also gives a glimpse into the Republican's ACA repeal agenda should they win the White House bid next year. Some of the major provisions include:
- Defunding of Planned Parenthood
- Repeal of the Medicaid expansion
- Elimination of reinsurance, risk corridors, and risk adjustment programs set up under ACA
- Repeal of Cadillac tax
- End premium subsidies for insurance purchased through the Marketplace and small business tax credits
- Repeal of individual and employer mandates by lowering the penalties for non-compliance to $0
- End of healthcare.gov
Despite the Republican Party's fulfillment of the promise to get an ACA repeal to the White House, conservatives have yet to offer a replacement plan. The vote on the Medicaid repeal could also create some problems for senators up for re-election in states that have expanded Medicaid, such as Pennsylvania, Illinois, and Wisconsin. At the same time, Medicaid expansion continues to gain more interest from the remaining states yet to expand. Louisiana's new governor vowed to expand Medicaid on his first day in office. Virginia Hospital and Healthcare Association recently announced their change in position to support a bed tax, which would allow the state to expand Medicaid under ACA without any additional state funding. Utah and Wyoming continue talks to come up with a plan to expand Medicaid in the next year. And although Idaho remains opposed to expanding, the legislature is discussing a plan for the state to cover basic primary care for those who do not qualify for Medicaid but earn too little for subsidies under healthcare.gov, at a cost of $32 per month.
Resources
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and February 14 to receive the $1095 price. Come February 15, the price increases to $1,295.Register today >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Proposed Changes to the CMS-HCC Risk Adjustment Model
Policy changes governing risk adjustment in plans for Medicare-Medicaid dual eligibles may soon be coming.
In response to concerns about the accuracy of the Centers for Medicare & Medicaid Services (CMS)-Hierarchical Condition Category (HCC) risk adjustment model for predicting costs of dual eligible beneficiaries, CMS recently released a Health Plan Management System (HPMS) memo stating it will evaluate how well the model performs for these beneficiaries based from concerns raised that "the model may disproportionately affect specific populations, particularly dual eligibles."
These proposed changes will not affect the clinical relevance CMS has already included in the existing model or on non-dual eligibles. However, this new approach is a clear "win" for plans having significant numbers of full dual eligibles, both Dual Eligible Special Needs Plans (D-SNPs) and otherwise. The under-payment in the current system is pretty severe, based on the statistics in the CMS memo, and this new approach will fix that.
"This is an interesting change and will definitely have downstream impacts," said a member of the Operational Performance team at Gorman Health Group (GHG). "There isn't a lot of reconciliation on the Medicaid status. Health plans have to go by the designation by the state of what type of dual eligible someone is as there is no independent way to validate that level of coverage. So there isn't any additional reconciliation which will occur. Health plans can no longer submit updates to Medicaid eligibility through the retro processer. That data is much cleaner now than in past years and is fixed quickly due to Low-Income Subsidy (LIS) status cost share implications for dual eligibles."
Further, SNPs determine the type of dual eligible they will cover during the application process. They validate the member is eligible, based on that status at time of enrollment, but there is no submission or correction of that status. They have to use the state's data to validate whether they are a full dual-eligible, Specified Low-Income Medicare Beneficiary (SLMB), or Qualified Medicare Beneficiary (QMB), etc.
What may be a challenge is identifying more clearly who is in what status to allow for projections and reconciliation of risk adjustment status.
I cannot stress the dire need for your Risk Adjustment team to be in constant collaboration with the core operations leaders within your organization to be sure the necessary reconciliation is occurring and that you have a solid data management and analytics strategy in place.
Initial Highlights:
a. The Impact on Partial Dual Eligibles
Some SNPs have most likely been generating some of their profits by enrolling partial duals for which the current HCC model generates some over-payment. The new model will eliminate this, and SNPs with significant partial dual populations need to start planning now.
b. Member Eligibility and Reconciliation
Beneficiaries could have months in one or more of the six sub-populations. Tracking a member's status and the hierarchy of the status in the base year will be important as plans forecast and reconcile their risk adjusted payments. If CMS moves forward with reviewing predictive ratios for six segments as it states in the HPMS memo, it will be very important for plans to ensure they are updating a member's Medicaid eligibility (QMBs/SLMBs, etc.) in a timely manner, which is currently a requirement, and the accuracy will be even more critical for projections and reconciliation of risk adjustment status.
Takeaways:
a. New Opportunities to Manage Trend and Control Utilization Costs
With improved accuracy for predicting cost, comes an opportunity for plans to be more targeted and efficient with their efforts to manage trend and control the utilization of those beneficiaries that are seemingly very costly (or at least are predicted to be very costly).
Processes around moving patients to and from the community and back to institutional settings will need to be seamless, clinically appropriate, and efficient. Politics and system loopholes allow facilities and health systems to game the system, keeping people in beds or reserving space in order to receive the reimbursement associated with the patient's status. Controls will need to be put in place: Utilization Management and Compliance need to be involved to keep a close eye on patterns for both beneficiaries and providers.
Data has had a staggering increase of importance and remains an integral part of the healthcare industry. The need to have refined data management processes to ensure data integrity and quality analytics is at an all-time high. Achieving this should be at the forefront of health plans' minds, especially with impending policy changes.
This proposed model will improve payments a little for the least expensive non-dual members, while reducing payments a little for the most expensive. But the most expensive probably have the most unreported and under-reported diagnoses, so a good risk adjustment program could compensate for the small predicted impact of this new approach.
CMS is soliciting feedback on their approach to revising the CMS-HCC risk adjustment model to better predict costs for beneficiaries based on their dual status and aged/disabled status for Payment Year 2017. If you wish to submit comments, please submit them to RiskAdjustment@cms.hhs.gov , with the subject heading "Proposed Updates to the CMS-HCC Risk Adjustment Model," by November 25, 2015.
If you are unsure how this will affect your organization, or how to accurately communicate your ideas to CMS in two weeks, our integrated team of experts specializing in risk adjustment, analytics, compliance, pharmacy, and operations can work with your organization to ensure you have the right processes in place to ensure a timely submission to CMS. Contact us today >>
Resources
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 >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Recommendations Made by the National Quality Forum on Medicaid Measures
The National Quality Forum (NQF) is a non-profit organization working to evaluate and endorse standardization of healthcare performance measures. Recently, NQF submitted a series of reports to the U.S. Department of Health and Human Services (HHS) outlining recommendations on new measures aimed at improving Medicaid beneficiary quality of care. For the last four years, NQF started providing strategies to HHS on improving care for dual eligibles, adults, and children in the Medicaid program. These new quality measures were created to improve healthcare quality for more than 70 million adults and children. The key area of concentration was the beneficiaries' behavioral health and how it affects diabetic and cardiovascular care delivery.
In the reports, NQF tracked the effects behavioral health has on diabetics and the domino effect it has on a beneficiary's overall health. Many providers are seeing that therapies used on patients with serious behavioral health issues are causing significant health problems. An example is weight gain as a side effect of the medications given to treat mental health illnesses. They saw this turn into health issues, such as diabetes, in these patients. The report continues to state that not addressing the behavioral health problems of a beneficiary has led to higher glycated hemoglobin (A1C) which then resulted in cardiovascular issues. This problem of addressing both the physical and mental health needs of the Medicaid population has been in the forefront of the American Psychiatric Association and U.S. Psychiatric and Mental Health Congress.
NQF has made recommendations for the working age population of adults, which are also the most rapidly-growing population relating to controlling and monitoring cardiovascular health (e.g., high blood pressure) and medication management in those individuals who have serious behavioral health illnesses. NQF has also made recommendations for children and dual eligibles. Due to the complex needs of the dual-eligible population, the amount of measures was increased, many concentrating on behavioral health and comorbidities. They also concentrated on making changes to the care coordination and readmission rate monitoring.
Resources
Gorman Health Group can perform an analysis on your current quality programs and provide expert advice on benefit designs, as well as conduct a risk analysis to determine what a viable program consists of and expected outcomes. Contact us 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 >>
How to Partner with Key Health Systems in your Service Area to Optimize Benefit Plan Offerings
As we anticipate additional information this week on the Centers for Medicare & Medicaid Services (CMS) network adequacy (pilot) audit, we can't help but consider how CMS' rigorous access and availability standards hamper Medicare Advantage (MA) plans' ability to be on the cutting edge of innovative network design. The Affordable Care Act, in comparison, has allowed for Marketplace plans to offer narrow networks as long as the networks have sufficient numbers and types of providers to deliver services without "unreasonable delay," leaving states to define the meaning of "unreasonable." This difference in network adequacy standards has widened the gap in plan offerings.
MA plans, after meeting network adequacy standards, are able to offer tiered benefit plans to members ensuring members are still afforded access to the larger network if not all standards are met within the smaller subset. The tiered benefit designs leave MA plans with the question of which providers would be the best partners.
In evaluating provider partners for tiered benefit designs or co-branding opportunities, health plans need to determine the attractiveness of each prospective provider by asking questions such as: Does the potential provider system have a similar philosophy? Is the provider system large enough to meet network adequacy standards in a given market area on their own, or would fill-in providers be required? How would their participation or non-participation in our network affect our market strategy? Does the provider system do anything particularly well, do they have unique services, service area, or exclusive providers, and how can those services be packaged? Would these bundled services contribute to increased revenue and/or market share?
In turn, provider systems that may be contemplating offering their own provider-sponsored health plan could be asking themselves similar questions and determining if a payor partnership would be a good option. Providers should develop a plan/partner evaluation process concurrent with developing a marketing strategy in order to find the best available partnership.
As we see the Marketplace and Medicaid proposing similar network access and availability standards as MA plans, we easily foresee a change in how these two government-sponsored programs will need to re-evaluate their network design. By beginning to monitor their networks now, Medicaid and Marketplace plans will be able to identify some of the provider network challenges MA plans have faced. As CMS moves forward with decisions on network adequacy for all government-sponsored health plans, enhanced relationships between payors and providers will be key in developing the networks needed to support competitive benefit plans.
Resources
Gorman Health Group evaluates the design and delivery of high quality collaborative care while achieving compliance and improving revenue cycle management. Our multidisciplinary team of experts will assess the alignment of your products, your current network and your market to 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 >>
From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation — where the potential is promising, we can help design and implement these arrangements. Let's get started. Contact us today
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Government Sends Stark Reminders that Insurers' Biggest Customer is Still the Regulator
Since we opened our doors 19 years ago, we've preached to health insurers to think of the government as your business partner. This week, we got several reminders that insurers' biggest customers -- Medicare, Medicaid, and ObamaCare -- are still the regulator. As business conditions improve for health plans across these business lines, government expectations are rising, and scores are about to get settled, as they always are in the second term of a Democratic administration.
We see it in enforcement activity from the Centers for Medicare & Medicaid Services (CMS). We see it in a steadily-rising bar of Star Ratings and other performance measures for health plans for all three programs, the basis of looming contract terminations. And now the White House jumps in with an aggressive schedule of risk adjustment data audits, openly seeking repayments and dropping "f" bombs: fraud, that is.
They named a great film after a moment like this: "There Will Be Blood."
You can't argue with the numbers: 2015 remains the most punitive year in Medicare Advantage history. Look at the trend:
CMS is also being much more aggressive this year with data-driven oversight and enforcement. Communications to health plans who are "outliers" in various performance measures, especially in member communications and consumer protections, began recently. A pattern we are seeing play out is CMS chasing down all clients of noncompliant pharmacy benefit managers; where poor Part D performance is seen in one plan, the agency then begins auditing that vendor's other customers, assuming they'll get the same findings.
We know that Star Ratings and expanding reporting requirements in Medicare Advantage and Part D mean the bar is rising and establishes data-driven thresholds against which health plans can be penalized and terminated beginning in 2016. CMS announced sweeping new reporting requirements for both programs this week, which inevitably get picked up in Medicaid and ObamaCare rules in following years.
And now the White House is piling on. In Washington, we talk a lot about "setting the terms of debate." Our industry has lost the debate on risk adjustment coding and has allowed anti-managed care advocates to define payers' inaccurate diagnostic coding as fraud. A just-disclosed February 2015 letter from President Obama's Budget Director to Health Secretary Sylvia Matthews Burwell stated, "While some progress has been made on this front, we believe a more aggressive strategy can be implemented to reduce the level of improper payments we are currently seeing...we must continue to explore new and innovative ways to address the problem and attack this challenge with every tool at our disposal...the government estimate of $12.2 billion in these mistakes for fiscal year 2014 remains a concern." He extended his mandate beyond Medicare Advantage to over $3 billion in questionable payments from Medicaid. This means a spike in data validation audits for payers across both programs with the threat of improper payment clawbacks and even prosecution under the False Claims Act.
There has never been a more Golden Age of opportunity for health insurers in government programs. But the threats are escalating as well, and as my politics professor told me, "99% of political wounds are self-inflicted." Plans caught up in this dragnet will have gotten plenty of warnings.
Resources
The Part C and Part D Reporting Requirements and Supporting Regulations were posted in the PRA Listing on August 24th for review and 30-day comment. Since we are still in this window, this is a great opportunity for Compliance and Operations to review these together. Click here to review the Part C highlights that merit your attention in a blog posted by Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group (GHG).
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>