The Affordability Review — “Reading the Tea Leaves"
The fall season is a good reality check — back to school, cooler weather, end of summer, and …. Budgeting/financial forecasting. Forecasting is like predicting the future — you have to know how to read the tea leaves and see the efficiencies and interdependencies of your current performance to have a better idea of future performance and challenges.
Regardless of lines of business and marketplaces, companies need to manage to an acceptable loss ratio. Government regulations use this metric across different products and populations. Medicare Advantage demands at least 85% medical loss ratio (MLR), and many Medicaid plans and special needs populations require at least 90% MLR. Administrative costs are constantly squeezed, and risk adjustment is an ongoing process that is sometimes hard to quantify relative to the amount and timing of the additional revenue.
So the process of going through an affordability review is like a readiness audit. It is better to be proactive and look for opportunities before it is too late. An affordability review consists of several steps. An initial onsite visit, including interviews with management across the key departments of medical management, networks, pharmacy, claims, finance, risk adjustment, and marketing, can set the foundation for an in-depth review of internal financial and operating reports. An objective review of claims trends, based on cost and utilization drivers across members, providers, and services, can result in improved financial and operational performance. With collaboration among subject matter experts, initiatives with financial targets and action plans can be developed and monitored.
Even with new products and demonstrations, reports and a monitoring process should be in place on day one. Many Centers for Medicare & Medicaid Services (CMS) demonstrations only last for three years, so waiting for claims data and trends minimizes your window for mitigation.
Resources
Gorman Health Group has subject matter experts in operations and analytics to provide assistance with this process and help cultivate a corporate awareness and discipline toward financial outcomes that deserve a spot with quality and compliance. It is everyone's responsibility. Contact us to learn more >>
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Medicare at 50: Past, Present & Future
Since its inception on July 30,1965, millions of elderly and disabled Americans have been able to obtain medical care through Medicare. Before Medicare, almost half of all Americans 65 and older had no health insurance. Today that number has dropped to a staggering 2 percent.
The accomplishments for Medicare have been noteworthy.
These include increased access to health insurance coverage and healthcare, decreased disparities in access by race leading to desegregation of hospital staff and facilities, as well as payment and delivery system reforms such as prospective payment, capitation, and shared savings — all of which have been adopted by private payers. Karen Davis from Johns Hopkins and former President of the Commonwealth Fund noted the success of Medicare's insurance Marketplace which offers beneficiaries a choice of traditional Medicare and Medicare Advantage plans with a 4-5 Star program that is driving plans and enrollment to higher quality. Medicare spending per capita has grown more slowly than overall health spending per capita and is currently at historically low rates.
The challenges are many.
Disjointed coverage (Parts A, B, D) is confusing to beneficiaries and results in high administrative costs and overpayments. Out-of-pocket costs for premiums, cost-sharing, and uncovered services remain high, and Medicare has no out-of-pocket maximum. Medicare does not cover long-term care services or home- and community-based services. Provider payment still remains largely fee-for-service, resulting in incentives for volume and provider not patient-centered care.
The Future
The future involves many different directions. The first is moving from an acute care model to a program that can effectively care for beneficiaries with complex chronic conditions. Provider payment reform needs to move to value-based payment that rewards efficiency and quality. The focus needs to shift to patient-centered care rather than provider-centric care. Care coordination and team care needs to be a focus. Program fragmentation and high out-of-pocket costs, particularly for high service users, needs to be addressed.
As Charles Darwin pointed out, evolution isn't about being the biggest or the smartest, but the most adaptable. Government programs have become the biggest opportunity for payers. Rates will be positive especially in Medicare Advantage, but the compliance environment will be brutal throughout the rest of the Obama administration. Star Ratings and the member experience are now driving the market — 30 plus states are now using some form of Star Ratings for performance-based payment, many states have adopted quality ratings for Medicaid managed care plans, but there is no national standard….yet, and the Health Insurance Marketplace will begin publishing quality ratings in 2016.
What have we learned?
John Gorman, Founder and Executive Chairman at Gorman Health Group, recently provided lessons learned in the 19 years we have partnered with health plans operating in Medicare, Medicaid and now the Health Insurance Marketplaces. He discusses the current industry environment and what's important moving forward. Read more >>
About 81M will be enrolled in Medicare by 2030. Is your organization prepared?
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 >>
GHG can evaluate your Star Ratings approach, and identify tactics you can begin implementing immediately, to integrate initiatives, eliminate redundancies, and build an enterprise-wide Star management structure. We can help you identify clinical, operational, and networking opportunities to increase your score for 2016 and beyond. Contact us to learn more >>
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MLTSS: Key to Caring for Duals
We all want to do it: Provide the best healthcare services for our members. For our vulnerable population, this can be complicated, if not near impossible to achieve, given the current healthcare issues at hand.
About 9.6 million people in the United States are covered by both Medicare and Medicaid, including low-income seniors and younger people with disabilities, according to the Kaiser Family Foundation (kff.org). Kindred Healthcare's "Making Sense of Healthcare Reform: Dual Eligible" points out, as baby-boomers reach their 65th birthdays, an estimated 10,000 individuals become eligible for Medicare-covered services each day. Couple this fact with the expansion of Medicaid eligibility in many states, the result is a much larger dual-eligible population in the near future. These dual-eligible beneficiaries are almost, by definition, a high-needs population often demonstrating to be the poorest and sickest beneficiaries of both programs. Consequently, they account for a disproportionate share of spending in both programs and, according to the Medicare Payment Advisory Commission (MedPAC), dual-eligible beneficiaries cost Medicare about 60 percent more than non-dual eligibles.
Medicare and Medicaid were never operationally designed to work as a single health plan (and it shows). Kindred Healthcare explains further in their article there are coverage and payment policies offered by 50 separate and unique Medicaid policies. Simplified, Medicaid pays for almost all long-term care (LTC) services, while Medicare covers more acute care such as emergency department visits. Dual eligibles are constantly bouncing back and forth between the two government-funded programs; Medicare pays for an operation and Medicaid for long-term recovery.
It's complex, inflexible, and silo-infested.
Health plans need to identify ways to better manage escalating costs and make payment reform a fundamental requirement in both improving quality and containing costs. The answer is multi-faceted.
Move from Volume to Value: According to an article in governing.gov, the volume-driven Fee-for-Service (FFS) payment system for the Managed Long Term Services and Supports (MLTSS) of the aging and disabled LTC populations is focused on volume. The volume-driven FFS payment system can be replaced with pay-for-performance and care management initiatives including performance-based contracting, shared risk, and capitated payments to providers and managed care organizations (MCOs). Success of these initiatives is dependent on the plan's ability to track and analyze the outcomes. Focusing on outcomes can transition staff perspective, actions, and care plan goals to be more person-centered.
Improve Access to Home- and Community- Based Care: Tennessee implemented a pilot based on a decade-long study published in Health Affairs in 2009 which found states with established home- and community-based programs were able to reduce their overall Medicaid LTC spending by nearly 8 percent. Acting on the results of this study, Tennessee lawmakers introduced a new program called CHOICES in 2010, which was a way to help seniors on Medicaid receive home- and community-based care instead of living in nursing homes. Programs like CHOICES are estimated by the Bowles-Simpson presidential commission of fiscal reform to possibly produce savings up to $12 billion by 2020. Nursing homes, as a default option for aging and disabled beneficiaries, will quickly prove unaffordable in the long run not to mention negatively impact satisfaction ratings. After all, AARP conducted a study of individuals over the age of 50 and found more than 80 percent prefer aging in their own home than in an institution.
Provide Feedback to CMS: September 14, 2015, is the deadline to provide the Centers for Medicare & Medicaid Services (CMS) comments regarding their newly released rule, Reform of Requirements for Long-Term Care (LTC) Facilities. This proposed rule would revise the requirements LTC facilities must meet to participate in the Medicare and Medicaid programs. An emphasis has been made on theory and practice of service delivery and safety in order to achieve broad-based improvements both in the quality of healthcare furnished through federal programs, and in patient safety, while at the same time reducing procedural responsibilities on providers. New sections address facility responsibilities for protecting resident rights and enhancing quality of life; requirements for comprehensive person-centered care planning; changes relating to behavioral health service and laboratory, radiology, and other diagnostic services; requirements for Quality Assurance and Performance Improvement (QAPI) and Compliance and Ethics Programs; and staff training requirements. CMS estimates costs to comply per facility over a span of two years will be about $40,685.
Care Coordinate Effectively: In John Gorman's blog, "You're Doing it Wrong in Care Management" issued May 18, 2015, he explained how modernizing your approach in care management into data-driven care coordination "pods" can help you better manage your high utilizers and those about to become them. By "doing it right in case management," you can both contain costs and improve quality.
Resources
GHG can help your transform a total change in the delivery, payment, and care coordination efforts necessary to provide positive outcomes for a very challenging patient population. We can help you learn what works best in coordinating quality-driven care for dual-eligible beneficiaries — and what approaches would be unsustainable. Contact us to get started today>>
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EHR Incentive Programs: Improving Access to Care
The 2014 Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs were developed to provide financial incentives to eligible professionals, eligible hospitals, and Critical Access Hospitals (CAHs) to achieve meaningful use of certified EHR technology with the goal of improving patient care. The programs worked to prompt healthcare providers to adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology. In her May 18, 2015, article in RevCycleIntelligence, Jacqueline DiChiara reported by the end of 2014, EHR incentive payments reached over $28 billion with eligible hospitals receiving more than $17 billion, Medicare and Medicaid-eligible professionals collectively receiving nearly $10 billion. However, there are some changes with the EHR Technology Incentive Program that may affect your revenue—and not in a good way.
In the amended American Recovery and Reinvestment Act of 2009 (ARRA), Congress included provisions in the Medicare and Medicaid EHR Technology Incentive Program for CAHs, as well as eligible professionals and hospitals, who did not successfully demonstrate meaningful use of Certified EHR Technology to experience a negative payment adjustment to their reimbursement. Effective January 1, 2016, payment adjustments will be applied for those Medicare-eligible professionals not meeting the criteria for meaningful use in the Medicare EHR Incentive Program. For eligible hospitals, payment adjustments were applied as of October 1, 2014. Interestingly, DiChiara notes over 28,000 eligible professionals reported a 2% decrease in their 2015 Medicare payments for not meeting the standards related to Electronic Prescribing (eRx) and the Medicare EHR Incentive Program. CAHs unable to demonstrate meaningful use for the applicable reporting period of fiscal year (FY) 2015 will have a decrease in their reimbursement, from 101% of its reasonable costs to 100.66%, according to CMS.gov. For 2016, the percent of reasonable costs reimbursement decreases to 100.33% and then down again to 100% for 2017 and for each year thereafter, well into years 2020 and beyond.
CAHs were created to preserve access to primary and emergency care services in isolated rural areas by improving the financial conditions of CAHs and, subsequently, preventing some closures. Choices Magazine article, "Performance of the Critical Access Hospital Program: Lessons Learned for Future Rural Hospital Effectiveness in a Changing Health Policy Landscape," highlighted the CAH program grew rapidly from 41 hospitals in 1999 to 1,055 hospitals in 2005 and to 1,327 CAHs in 2011 because of the 1983 Medicare switch from cost-based reimbursement to the Prospective Payment System (PPS). CAHs now face possible Medicare cuts. Hopefully, the following information from CMS.gov can help CAHs effectively avoid EHR Incentive Program payment adjustments and ensure their financial longevity as Medicare and Medicaid providers.
- Hardship: A CAH may, on a case-by-case basis, be exempted from this adjustment if the CAH can demonstrate, on an annual basis, becoming a meaningful user of EHR technology would result in a significant hardship. However, in no case will a CAH be granted an exemption for more than five years.
- July 1, 2015: 2016 Eligible Professional (EP) Medicare EHR Incentive Program Hardship Exception Application Deadline
- CAHs can apply for hardship exceptions in the following categories:
- Infrastructure — CAHs must demonstrate they are in an area without sufficient internet access or face insurmountable barriers to obtaining infrastructure (e.g., lack of broadband).
- New CAHs — CAHs with new Centers for Medicare & Medicaid Services (CMS) Certification Numbers (CCNs) not having had time to become meaningful users can apply for a limited exception to payment adjustments. The hardship exception is limited to one full year after the CAH accepts its first patient.
- Unforeseen Circumstances — Examples may include a natural disaster or other unforeseeable barrier.
- Meaningful Use: In order to avoid the payment adjustments, CAHs must demonstrate meaningful use within the full federal fiscal year that is the same as the payment adjustment year. The adjustment would then apply based upon the cost reporting period beginning in the payment adjustment year (that is, FY 2015 and thereafter). Thus, if a CAH is not a meaningful user for FY 2015 and thereafter, the adjustment would then be applied to the CAH's reasonable costs incurred in a cost reporting period beginning in that affected fiscal year.
- An eligible hospital or CAH demonstrates meaningful use by successfully attesting through either the CMS Medicare EHR Incentive Programs Attestation System (https://ehrincentives.cms.gov/) or through its state's attestation system.
- CAHs are required to submit their attestations for meaningful use by November 30th of the following fiscal year. For example, if a CAH is attesting it was a meaningful EHR user for FY 2015, the attestation must be submitted no later than November 30, 2015, in order to avoid payment adjustments.
- Eligible hospitals and CAHs participating in meaningful use for the first time this year may attest to a 90-day reporting period for FY 2015. CMS is allowing eligible hospitals and CAHs participating in meaningful use for the first time the ability to attest. The hospitals must first register in the CMS Registration and Attestation System at: https://ehrincentives.cms.gov/hitech/login.action. Once the registration is active, the hospital should contact Elizabeth Holland at elizabeth.holland@cms.hhs.gov and provide the hospital name, CCN, and contact person information.
- Call CMS Information Center: Ask questions, get more information. Dial 888-734-6433 then dial 1 for the EHR Information Center.
Quality Ratings: No National Standard for MCOs…Yet
A recent article noted five major changes in new Medicaid Managed Care rules, one pertaining to a quality ratings system. Many states have quality ratings for managed care plans, but currently there is no national standard. Medicare has a five-star system evaluating private plans, and private plans offered through the Affordable Care Act's (ACA's) Health Insurance Marketplace will begin publishing quality ratings in 2016. Ratings for Medicaid managed care plans would look similar to the Marketplace plan ratings.
"CMS' rationale was to more closely align the ratings system for managed care plans with [exchange plans], because a lot of those plans in the Marketplace are also Medicaid managed care providers," said Lisa Shugarman, a consultant at Health Management Associates.
The Marketplace plans will begin testing a ratings system this year including three broad categories (clinical quality, patient satisfaction, and plan management/affordability) that would also be a part of the managed care ratings. The Marketplace plans' ratings system will also have dozens of sub-categories — the specifics of which will be determined by state officials and health experts. It has taken about three to five years for the Marketplace plans to have their ratings system up and running and would likely be the same time frame for managed care, according to Matt Roan, another consultant at Health Management Associates.
States would have the option to include additional measures, but the process for doing that isn't clear yet, and many managed care organizations (MCOs) are wary of too much variation between state quality reporting systems. They will be pushing CMS to ensure a high level of standardization to ease compliance.
Non-profit Medicaid plans support quality ratings, but they also think the rule should apply to traditional, state-run Medicaid and other arrangements, such as Accountable Care Organizations (ACOs).
Resources
Gorman Health Group can help your organization implement successful quality initiatives, from both the quality and operations perspectives, to improve scoring and control costs while continuing to serve the rapidly expanding Medicaid and dual-eligible populations. Visit our website to learn more >>
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Game Changer: Key Reforms Proposed in CMS Medicaid Rule
You've got your nose to the grind stone working to meet all the waves of operational changes and requirements related to Medicare, Medicaid, Obamacare, and Health Care Reform - you literally don't even have time to glance upward to the skies. Understandable. But it can cost you.
July 27th is the CMS deadline for all to submit their comments about the recent Medicaid Rule, which according to Andy Slavitt, Acting Administrator of the Centers for Medicare & Medicaid Services (CMS) is intended to "…better align regulations and best practices to other health insurance programs, …to strengthen federal and state efforts at providing quality, coordinated care to millions of Americans with Medicaid or CHIP insurance coverage." What does this have to do with me TODAY?
Now is the time to strategize, innovate and transform your plan and benefit design so that your operational platforms can grow as the rule will require you to. Here are two examples from Gorman Health Group's (GHG's) Medicaid webinar that took place on Wednesday, June 24, hosted by my colleague, Sunmi Janicek, Vice President of Medicaid and myself.
According to John Gorman's blog, "You're Doing it Wrong in Care Management" issued May 18, 2015, you are going to need to modernize your approach in care management into data-driven care coordination "pods" providing a holistic model of care focused on high utilizers and those about to become them. This means you need to recommit to data analytics identifying and directing the work of care managers toward those beneficiaries with long-term needs that can be impacted. Further, you need to place a greater emphasis on preventable episodes of care, and on end-of-life care preferences, advance directives and care plans. If you take the top 5% of the membership that is incurring the most cost and provide complex care management, including a higher level of home care, hospital diversion, medication therapy management, nutrition counseling, and wound care, plans and their provider organizations will see a reduction in avoidable medical expenses. Those reductions in avoidable medical expenses translate to better managed Medical Loss Ratios (MLRs), which directly impact your bottom line. How so?
The proposed implementation of the new rate setting will require managed care organizations to meet a MLR minimum of an 85% threshold. This is to ensure adequate funds are being spent on coverage for Medicaid members appropriately as states seek to move more and more Medicaid beneficiaries into managed care on a mandatory basis. CMS has charged states to develop new rates that will promote program goals that include benchmarks for quality of care, community integration of enrollees, and cost containment. Further, CMS wants to ensure enrollees are receiving quality of care and access in a timely manner, so they have asked the states to propose set standards for time/distance for specific provider types.
MLR thresholds are currently being used by the private health insurance plans, as well as, Medicare Advantage plans for projections of future medical costs and covered services. By including Medicaid in this imitative, it's evident CMS is trying to find a way to align standards among the different offerings across the board, but how will it affect your MCO?
While Medicaid MCOs don't have the high sales and marketing costs of individual commercial plans, since sales are handled by the states, compliance costs could be high, making the 85% figure a cause for concern. Medicaid MCOs will have to be diligent in identifying and documenting costs incurred to improve quality; essentially determining spend that could be considered medical versus administrative; to drive up their MLRs. Plans need to be able to fine-tune care coordination and quality, which are the hallmarks of managed care, and a federal MLR regulation could inhibit this. Do you have the right processes in place to ensure this happens?
With all these new changes, we can't stress enough that there will be a huge impact on implementation initiatives and sustainability that affect not only the finance department, but all departments. Once sustainability is achieved, it needs to be maintained as it will be addressed in future compliance reviews.
We are currently working with organizations in your area to identify gaps in operations while improving the ways they respond to clients, and developing care management models for the Long-Term Services and Supports (LTSS) population that make sense and will impact MLR. We share the same goal as you: to implement high quality, accessible, and cost-effective health care to our nation's most vulnerable population.
As soaring enrollment issues with varying populations of people persist, and new programs continue to be introduced, tough challenges are ahead. We can help make the transition smooth. Contact us today to get started >>
Resources
To download the recording of the June 24, 2015 webinar mentioned above, please click here >>
GHG understands the complexities of the Medicaid population, and the numerous shifting variables that affect plan financial performance, such as state specific requirements for risk adjustment. GHG can assist with identifying the current and future costs of doing business, while building in anticipated adjustments that make sense for each population served. Visit our website to learn more >>
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Takeaways from Accountable Physician Groups' Annual Summit
Twice a year I get the honor of speaking to the California Association of Physician Groups' (CAPG) annual summit and DC policy meeting. CAPG represents accountable, capitated physician groups, and now has members in 39 states. They're always among my favorite speeches given how sophisticated the audiences are. Here's a few takeaways from my talk last week on "The Future of Government Programs":
- Forevermore, physician group revenues and earnings will be dominated by Medicare Advantage, Medicaid and dual eligible health plans, and the ObamaCare plans, most likely in that order.
- Everything that Medicare Advantage (MA) does, the Medicaid, ObamaCare, and commercial markets follow 3-5 years later. Nobody knows this better than the CAPG members from CA, which the rest of the nation lags. Want to still be attending CAPG meetings in 2020? Master Star Ratings and risk adjustment. They'll apply to all lines of business if they don't already, and they are the keys to survival already in MA.
- Value-based contracting is in its infancy but will soon define all health plan contracts with physician groups. Fee-for-service is dead. Performance-based capitation is the only future. To master it a physician group needs a range of capabilities, including eligibility verification, interoperability, actionable clinical intelligence in real time, standardized care processes, and chronic care management, across all business lines.
- Most Accountable Care Organizations (ACOs), especially the 424 in Medicare, will not see a return on their investment. They will have spent millions to participate in these experiments and around 80% won't see a payoff. 2016 and 2017, when Medicare Advantage benchmark rates turn into a tailwind, present the perfect opportunity for ACOs to "move up the food chain" to become health plans.
- Dual eligibles are the biggest opportunity of our lifetimes, and there is no question that Special Needs Plans designed to serve them can be profitable. SNPs are a principal mechanism for states to shift long-term care risk into the private sector, and will be a central product for ACOs converting into Medicare Advantage. But they require a range of capabilities most physician groups lack today, such as enabling and social services that duals must have from their insurer.
- In all government programs, the "5/60 Rule" governs. 5% of members often account for 60% of costs. Any physician group that aspires to bear risk must be able to identify and intervene with their 5 percenters or they won't be risk-bearing for long.
- The biggest vulnerabilities for MA plans are consumer protections like appeals and grievances and complaint management, and who they have selected as their pharmacy benefit manager (PBM). Most PBMs are frankly terrible at Medicare Part D administration, and Star Ratings now count far more in Part D than in Medicare Advantage to a health plan's overall score. Physician groups typically have little or no experience with either PBMs or consumer protections.
- Retail pharmacies and the home are the most underutilized sources of care to government programs beneficiaries. Any successful physician group evolution will involve better integration of both sites for the chronically ill.
- Most at-risk physician groups are directly involved in coding and reporting for risk adjustment. Federal agencies are paying unprecedented attention to upcoding in Medicare Advantage with an eye to hundreds of millions of dollars in clawbacks and recoveries. The emphasis at physician groups involved in risk adjustment must move from chart reviews and claims extracts to more holistic member evaluations, and from a culture of "what can we get?" to "how do we stay out of trouble?"
Evolution is a messy business. Nowhere is that more the case than in physician groups evolving from fee-for-service to value-based contracting and becoming insurance companies. If it was an easy business, we'd be out of business.
Resources
Don't miss Gorman Health Group's Chief Consulting Officer, with colleagues Jane Scott, Senior Vice President of Clinical Innovations and Regan Pennypacker, Vice President of Compliance Solutions, as they discuss your member experience and the factors that influence success and failure, as well as prominent compliance and service issues plaguing the industry. Register now >>
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.
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Medicaid Rule Imposes New Standards for Beneficiary Access
Per the announcement by CMS on Tuesday, the proposed Medicaid rule would require plans to implement an 85% medical loss ratio (MLR). Implementing an MLR for Medicaid would bring the programs in line with the private health insurance market and Medicare Advantage. However, as mentioned by GHG's Sunmi Janicek, it would not be without challenges. The compliance costs for Medicaid plans with the increase in diligence needed in identifying & documenting costs incurrent to improve quality could be high. Additionally, the CMS proposed rule would impose new standards for beneficiary access and availability to the MCOs provider network.
As with our Medicare Advantage clients, GHG can assist plans by doing a deep dive into their MLR cost drivers, such as poor-performing providers within their participating network, while balancing the requirements for a robust, accessible provider network for beneficiaries. Once we have identified the key cost drivers, we can work with plans to do the following:
- Develop forward looking budget assumptions for benefit premiums, project clinical utilization and provider reimbursement budgets
- Develop clinical & financial performance metrics designed to bring performance in line with expectations
- Develop strategies around how to best impact provider practice patterns, access, treatments, referrals and coordination of care
- Design network modifications based on clinical & financial performance
- Develop performance based payments for provider reimbursements benchmarked to clinical & financial outcomes metrics
Reaching these goals will require the formation of great partnerships between the plan and providers. Plans will want to reach out to provider partners that share their same goals and incentives and secure strong leadership and physician champions to lead the charge. We know the transformation will not be easy. The shift from fee-for-service to value based reimbursement, facing the social services, behavioral health needs of the population, and developing the analytical capabilities to support these changes are challenges that Medicaid managed care plans will face under the proposed rule.
GHG is here to help navigate you through the steps.
Please reach out if we can assist you with any of the following:
- MLR Analysis
- Provider Integration strategies
- Reimbursement strategies
- Risk Assumption strategies
- Network Adequacy compliance
Resources
Gorman Health Group is dedicated to assisting managed care organizations, as well as states with developing models of care, maximize member engagement.As states begin to increase oversight activities and implement more robust compliance and fraud waste and abuse practices, our expertise in compliance program development will be an asset to any organization. Contact us today >>
Medical Loss Ratio Concern in CMS Proposed Medicaid Rule
The much anticipated Medicaid regulation from the Centers for Medicare & Medicaid Services (CMS) has been released, which aims at helping align regulations for managed care plans, creating a dynamic shift in how the Medicaid business will be handled moving forward.
One example of the new change is the proposed implementation of the 85% minimum Medical Loss Ratio (MLR) for the Medicaid program. This is to ensure adequate funds are being spent on coverage for Medicaid members appropriately. MLR thresholds are currently being used by the private health insurance plans, as well as, Medicare Advantage plans for projections of future medical costs and covered services. This could pose a problem for Medicaid Managed Care Organizations (MCOs). While Medicaid MCOs don't have the high sales and marketing costs of individual commercial plans, since sales are handled by the states, compliance costs could be high, making the 85% figure a cause for concern. "Medicaid MCOs will have to be diligent in identifying and documenting costs incurred to improve quality, to drive up their MLRs, said my colleague, Bill MacBain, Senior Vice President of Strategy.
With the soaring number of newly enrolled members joining Medicaid, Avalere estimated that by the end of this year, 73% of Medicaid members will be receiving some type of service through a managed care plan. The regulation aims to look at delivering a structured approach to supporting delivery systems, enhancing health outcomes and most importantly, improving the beneficiary experiences. These new regulations seeks to align CMS' Medicaid regulations to reflect today's changes in delivery systems, increase measures in managing care coordination, and promote quality of care using analytic data to oversee Medicaid managed care.
Additional proposed changes include:
1. Appeals and Grievances — The proposed rule makes a few updates to the appeals and grievances process to align to MA plans. For example, the rule seeks to shorten the time frame that Managed Care Organizations (MCOs) and Prepaid Inpatient Health Plan (PIHPs) have to make a decision about a standard appeal from 45 days to 30 days, same as MA plans. The expedited appeal time frame would be shortened from three days to 72 hours, also same as MA.
2. 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 (FFS), Medicaid managed care, and Marketplace coverage.
3. Network Adequacy Requirement - The rule would impose new standards to ensure beneficiaries have adequate provider networks and ensure beneficiaries are receiving accurate network information.
4. Medicaid Managed Care Quality Rating System (QRS) — Align with existing MA and Marketplace rating systems. Standardize quality metrics among states and plans.
5. Long-term Care - As expected, the rule also includes a section on managed Medicaid long-term care. The proposed rule could include beneficiary protections, provisions to ensure access to care and enrollee choice and control, and designation of an ombudsman to offer independent oversight.
The proposed rule will be posted in the Federal Register on June 1. The deadline to submit comments is July 27.
Resources
Gorman Health Group is dedicated to assisting Medicaid managed care organizations, as well as states with developing models of care, maximize member engagement. Visit out website to learn how we can help with your Medicaid needs >>
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Stand Tall Amongst Competition: Key to Success in Medicaid is Clear
Health plans diligently strive to be the best and first choice for delivering excellent healthcare services. Many seek accreditation with various organizations such as the National Committee for Quality Assurance (NCQA), the Utilization Review Accreditation Commission (URAC), and, most recently, the Malcolm Baldrige National Quality Award (MBNQA) as confirmation they provide their members with the utmost quality healthcare services.
Currently, the managed healthcare industry widely uses the Healthcare Effectiveness Data and Information Set (HEDIS®) and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) to measure performance. Over 90% of America's health plans use HEDIS, and over 500 health plans use CAHPS, to measure performance and monitor how well consumers are satisfied with the care and service they receive.
The HEDIS tool measures performance across five dimensions related to care and service: Effectiveness of Care; Access/Availability of Care Member; Experience of Care Member; Utilization and Relative Resource Use; and Health Plan Descriptive Information. There are 81 specific measures for which the plan must collect data in order to be compared with other health plans. A feature of HEDIS is the tool allows for the cross-comparison between health plans to be relatively equal, on an "apples-to-apples" basis. Subsequently, health plans are also encouraged to use Quality Compass, the largest database of comparative health plan performance information to conduct competitor analysis, examine quality improvement, and benchmark plan performance. In turn, it can be an effective tool in developing a more focused quality improvement plan.
While member experience may often correlate to member satisfaction, it is not always so. Member satisfaction can be influenced by a number of factors in and outside the control of the health plan. In turn, members may have similar experiences but different expectations and report having different levels of satisfaction. The CAHPS survey is an initiative of the U.S. Department of Health and Human Services (HHS) for Healthcare Research and Quality and refers to a family of standardized and scientific surveys that ask consumers and members to report on their experiences with certain aspects of care such as: Getting Needed Care; Getting Care Quickly; How Well Doctors Communicate; Customer Service; Claims Processing; Rating Personal Doctor; Rating Specialist; Rating Health Care; and Rating Health Plan. Health plans and providers can use CAHPS questions about specific aspects of care to identify areas of care that are strong as well as those that need improvement. Asking respondents to provide both ratings and reports about their care experiences enables survey users to learn how specific experiences influence general ratings.
Overall, it's important to recognize that health plans are rigorously competing for each and every healthcare dollar. Quality, more than ever, is the key to stand tall amongst the competition.
Source: https://cahps.ahrq.gov/apps/FAQ.aspx?category=82
http://www.ncqa.org/HEDISQualityMeasurement/WhatisHEDIS.aspx
http://hfmanj.org/images/downloads/Presentation/hedis_star_presentation_7.16.14_final.vs_2.pdf
Resources
CMS is poised to release in the coming weeks what stakeholders and advocates are calling an "epic rule" that will completely overhaul the Medicaid managed care marketplace. John Gorman discusses here >>
Providing guidance and support to achieve the results your members and regulators expect while attaining compliance with State and Federal rules. Learn more >>