The $64,000 Question in Star Ratings
As we wrap up the 2nd quarter, health plan leaders across the country are beginning to ask their Star Leaders the $64,000 question: "Are we on track to achieve a 4-Star Rating this year?"
This is, perhaps, one of the most challenging questions that can be posed to any Star Leader at this point in the year. But with up to 5% of a health plan's revenue driven by Star Ratings, the question is unavoidable, and the answer is vital.Though there is no simple answer to this question for a few more months, this is an opportune time to pause and reflect on 2015 Star Ratings progress against your plan's strategic and tactical strategy to raise ratings.
It is often not easy for Star Leader's to quickly describe the potential impact of the many changes we are awaiting in the 2016 Star Ratings: removal of the predetermined 4-Star thresholds, changes to the specifications for many measures, and removal and addition of yet more measures. Because the window is closed for us to impact our 2016 Star Ratings, we now sit in the uneasy waiting period while the Centers for Medicare & Medicaid Services (CMS) finalizes the 2016 Star Ratings and measures. CMS is also finalizing the 2016 display measures and reaching preliminary conclusions as to which 2016 display measures may be included in the 2017 ratings. These potential new display measures are being impacted by the services we are delivering this year — and in many cases, may not even be on the radar screen of our staff and provider networks.
So what can we do while we wait?
- Evaluate your plan's performance against national benchmarks to begin assessing your relative performance within the industry. Use this information to help set expectations while we await the 2016 ratings.
- Review your 2015 work plan, and current progress against the work plan, to ensure that your 2015 Star Ratings weaknesses are being adequately addressed and you will not repeat tactics that do not work in plan year 2016. Objectively evaluate how effectively customer service, case management, disease management, and pharmacy teams are coordinating care and services for your members by evaluating measurable outcomes.
- Review your quality program's year-end evaluation, the Chronic Care Improvement Program (CCIP) and Quality Improvement Project (QIP) data to identify changes which may be required as new information is released by CMS, and consider proactive expansion of quality activities into the areas under consideration by CMS.
- For Special Needs Plans (SNPs), review your Model of Care (MOC) evaluation for improved strategy opportunities related to the measures.
Educate and Activate. There is plenty of time remaining to shore up operations and infrastructure to achieve Stars success. As we continue to await release of the long-anticipated Medicaid managed care proposed rule, we are closely watching to see whether CMS will include value-based payments, new MOCs, and quality-based payment and oversight programs within yet another government health program. These potentially transformational changes in the Medicaid quality management infrastructure, combined with the Quality Rating System (QRS) program currently being beta tested within the Marketplace, continue to reinforce CMS' current and future emphasis on quality.
Our success in quality programs will require us to embrace CMS' expanding vision for healthcare quality and translate that vision to empathetic, outcomes-focused engagement with patients who need, and will be responsive to, help from their care team.
By improving clinical quality performance, we can improve health outcomes and reduce the cost of care. Find out how in our new White Paper now available..
Don't know where to start? Contact me today at jscott@ghgadvisors.com.
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Our team of experts can help you develop or enhance care coordination within your programs and processes. Contact us today, and let's work together to help your plan achieve 4 Stars.
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. Visit our website to learn more >>
The Imminent Medicaid Mega-Reg is Gonna be "Epic"
For the last several weeks health policy nerds have been anxiously awaiting the release of the long-awaited Medicaid managed care proposed rule, the first from the Centers for Medicare and Medicaid Services (CMS) in 13 years. We're coming to call it the "mega-reg" here. Friday at the Congressional advisory MACPAC meeting, Commissioners were widely quoting the term "epic" used by Jeff Myers, CEO of Medicaid Health Plans of America, in a recent National Journal article.
Medicaid has exploded since the last regulations in 2002, and enrollment is up 12 million just since January 2014. Current guidance doesn't address long term care services and supports and managed long-term care, a major impetus for program reform at the state level. The proposed rule has been in final HHS/Office of Management and Budget clearance for the last couple weeks, and its release is imminent.
MACPAC's debates Friday focused on potential changes to Medicaid payment to managed care plans that might be included in the proposed rule, which the commission has been discussing for over a year:
- Minimum Loss Ratio (MLR) — The MLR is a percentage which represents the revenue used for patient care compared to administrative expenses or profit. MLRs are allowed but not required in Medicaid managed care and currently 27 out of 39 states with Medicaid risk contracts use some MLR standard. CMS could align Medicaid managed care policy with Medicare and commercial policy by requiring a specified MLR: a national standard such as the 85% used in Medicare Advantage program, or a requirement that states impose a MLR standard. The proposed rule could also specify what costs should be included similar to the definitions adopted by NAIC and incorporated in federal rules.
- Supplemental Payments and Actuarial Soundness — States may make supplemental payments to some providers up to the upper payment limit. Current rules do not allow states to include these payments in MCO capitation rates or require MCOs to pass them through to providers. The proposed rule could change actuarial soundness rules to let states preserve existing funding mechanisms which usually rely on waivers to level the playing field for managed care plans and their providers.
- Mid-year Changes — There is no current process to allow MCOs to recertify their rates mid-year to account for federal policy changes such as high insurance fees or coverage or new expensive drugs and services. CMS could require states to resubmit actuarial certifications to take significant mid-year changes into account, or allow states to prospectively certify a range of rates, or retrospectively reconcile payments when the actual cost impact is known.
- Risk Mitigation — Current rules allow states to implement risk corridors, stop-loss or reinsurance. CMS could require states to establish risk mitigation for new populations such as the childless adult expansion group, or for benefits where there is a significant risk or enhanced match.
- Transparency — Medicaid health plans want transparency of state practices to develop capitation rates. CMS could require states to share data and assumptions and allow plans to comment during federal review.
- Baseline/Encounter Data — CMS could impose additional standards in addition to "appropriate data." CMS could impose additional requirements on the quality and timeliness of data and specify consistent definitions for encounter data to allow comparisons across states.
- New Models of Care — CMS could encourage value based payment, payment reforms such as safety net ACOs of other shared savings models or other innovative MCO delivery and payment models.
Beyond payment issues in the mega-reg, the Commissioners discussed:
- Long Term Care -- CMS could include requirements for long term care services and supports covered by managed care plans which are not currently included in the 2002 regulations. The proposed rules could include beneficiary protections, provisions to ensure access to care and enrollee choice and control, and designation of an ombudsman to offer independent oversight.
- Provider Networks -- the mega-reg will very likely include requirements for adequate provider networks and directories similar to recent requirements for Medicare Advantage and Qualified Health plans. Strengthened requirements for appeals and grievances may also be included. The proposed rule may also include enhanced quality data and reporting. It's expected all these provisions would be designed to streamline expectations of Medicare Advantage, Medicaid, and ObamaCare.
We'll have scads of analysis of the Medicaid proposed rule as soon as it hits the street. It's gonna be huge.
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Gorman Health Group is dedicated to assisting 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 you Medicaid needs >>
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You're Doing it Wrong in Care Management
An important paper recently released in the American Journal of Managed Care shattered the notion that care management can save money on high utilizers. The article reviewed recent studies of the effectiveness of health plan care management programs and found that, while many studies show significant savings, more rigorous studies concluded that savings were "limited or nonexistent." Mind. Blown.
We're all familiar with the "80/20 rule" of the commercial health insurance market: 20% of members account for 80% of expenditures. In government programs, Medicaid, Medicare, and now ObamaCare, it's the "5/60" rule: 5% of members account for 60% of spending. The AJMC article showed that across all payers in 2012, it's "5/50". 95% of the population accounted for just half of health spending, while the other half of spending was towards care for 5% of the population. The 5% of people needing to spend the most on health care spend an average of around $43,000 annually; people in the top 1% have average spending of almost $98,000. At the other end of the spectrum, the 50% of the population with the lowest spending accounted for less than 3% of all total health spending; the average spending for this group was $234.
The article then explored multiple studies on effectiveness of care management, concluding it's mostly pointless. It gave several reasons for why this might occur:
- Many high-utilizers only stay in this category for a short period of time. Conditions causing them to need intensive care may resolve quickly, reducing costs, but a study lacking a control group may inappropriately attribute this savings to the care management program.
- High utilizers suffer from a wide range of conditions and require a wide range of interventions, making it difficult for care management programs to tailor teams meeting each patient's needs.
- Providers working with a care management team may better identify conditions that were previously going untreated, leading to better outcomes, but also higher costs for additional services and therapies.
The author concluded that "for care management programs focusing on high-utilizing patients, it is crucial to select patients with long-term utilization patterns that are driven by the factors most conducive to change. Given the very limited direct evidence suggesting how to accomplish this, care management programs are best served by being kept small and focused on the highest-need patients, who may not necessarily be current high utilizers."
This finding calls for a rethinking across our industry about care management. For one thing, most health plans in our 19 years' experience are still doing 1990s-style managed care: preauthorizations, referrals, concurrent review -- what we refer to as "make work" medical management. It's look busy, high head-count work that does little to improve quality or reduce unnecessary spending.
Many GHG clients have been working with us to modernize this approach into data-driven care coordination "pods" providing a holistic model of care focused on high utilizers and those about to become them. This study means we 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. This means 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.
Savings can also be realized if that membership is appropriately placed in the right plan with the right network. Care Management might not be the answer but applicable coverage is a strategy. That's where plan and benefit design is so important. Innovative plans are working with specialists to design products that reflect risk and chronic conditions of their members. Our work with a prominent dialysis and kidney care provider is a perfect example: design a benefit and align a network that is tailored to patients with varying levels of chronic kidney disease, preventing disease progression and/or avoidable costs traditionally seen if CKD is not managed along the disease state continuum. Progressive conditions like CKD, Alzheimer's, and many cancers lend themselves well to "smart management" that spans clinical staff and benefit design alike.
The one thing you know about government beneficiaries is that if they're not sick today, they're gonna be. The game has always been finding the ones who need extraordinary care before they need it, and ensuring they get it in the right place, at the right time, from the right provider. That hasn't changed. This study underscores the point. "Make work" care management must give way to "make it work".
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Big Data is costly, distracting, overwhelming and paralyzing if not maximized. System and process interoperability and integration are keys to program alignment, oversight and evaluation . Systems and data should not just integrate; they need to align in order to yield superior, reportable outcomes. Visit our website to learn how GHG can help >>
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19 Lessons from 19 Years
Nineteen years ago this week, I left the Health Care Financing Administration (HCFA), now the Centers for Medicare & Medicaid Services (CMS) and the Office of Managed Care, to launch what would become Gorman Health Group. Time has flown, the company has grown, and my backside sewn with hard lessons about our industry and government health programs. Here are 19 lessons I've learned in those 19 years.
- What Medicare Advantage and Part D do, Medicaid and the commercial market, including the ObamaCare Exchanges, follow 3-5 years later.
- Every CMS staffer I've ever known is well-intentioned, many are downright brilliant, and all want to be good business partners to health plans. Their shortcoming is lack of business experience and how stuff works in the real world. There is a huge difference between policy/guidance and operations. That's where we come in.
- If government health programs were an easy business, we'd be out of business.
- Inspect what you expect. Or, as Reagan said, "Trust but verify."
- Star Ratings, like risk adjustment before it, is the biggest and most consistent experiment in performance-based payment on the planet, a total game-changer and the new fulcrum of competition. You don't excel at Stars by working on them off the side of your desk.
- Fish where the fishes is.
- Pick your vendors and partners like you pick your fruit.
- Capitation with performance-based payment is the only real hope for long-term viability of entitlement programs.
- Being a doctor is the worst job ever. Right after community hospital CEO and President of the United States.
- High-performing health plans are good at everything, especially those functions that are member- and/or provider-facing. It's about culture and execution.
- Health plans' days are numbered if they can't consistently provide value to CMS, their customer, and to providers, their partners. That value is about two things: making data actionable and moving money to contributors when quality and results improve.
- It's easier to increase revenue than it is to cut costs.
- Pharmacy benefit managers are a health plan's most important partner. They are also the ultimate B2B companies and most are struggling in the transition to B2C and true government accountability for results.
- Big data and high-tech is all the rage -- and all noise, unless it's actionable. What works is low-tech: clogs on the street; a house call; a medication consult.
- Doctors of the future are in multispecialty practice and leaders of a team of nurses, aides, social workers, and pharmacists. They are quarterbacks, not gods. They diagnose, and everybody else treats.
- So much of the future is about retail pharmacy. In short time, they will make more providing services than filling bottles.
- Ninety percent of the evil and waste in the system occurs at the tip of a doctor's pen.
- We are all going to retire thanks to government programs. Demographics is destiny.
- Five percent of members account for 60 percent of your spend. Put the love and focus on them, and you can pretty much leave everyone else alone.
It's been an incredible ride these last two decades, and especially the last five as health reform blossoms. We look forward to continuing the journey, older, wiser, and bigger. Stay tuned.
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Gorman Health Group Client Forum Takeaways: Government Programs are Booming, Bar is Rising
We just wrapped our best-ever Gorman Health Group 2015 Client Forum at National Harbor with over 200 of our closest clients and partners. There was both great and tough news, so here's a few takeaways, including a couple stunners:
- For the first time, a prominent Wall Street analyst said he could see a path to 100% Medicare Advantage penetration. Barclay's eminent health care observer, Josh Raskin, stunned our audience with projections of over 29 million Medicare Advantage enrollees by 2023, a penetration rate of over 42%, with the potential to go all the way with Ryan Plan-like legislation now feasible this decade.
- 47 states now hold Section 1915(c) home and community-based services waivers for Medicaid, which will unleash a new flood of dual eligibles into health plans. Special Needs Plans (SNPs) for duals are now on a path to permanent reauthorization, and over 30 states now use D-SNPs to enroll over 1.6 million beneficiaries. That number will more than double in the next 2 years.
- While year 2 of open enrollment for ObamaCare was dramatically improved from its messy launch, problems persist, especially with membership reconciliation and issues related to the interim process to auto-enroll most members staying in their plans. Cleanup of membership discrepancies will likely take another year or even longer.
- Risk Adjustment Data Validation (RADV) audits will become the new normal in Medicare Advantage. 2015 will be the first time we see plans prosecuted under the False Claims Act and hundreds of millions clawed back by the Centers for Medicare and Medicaid Services for unsubstantiated codes submitted for higher payments.
- Maximizing data, strong provider partnerships, documentation and ICD-10 preparedness are keys to audit proofing your Risk Adjustment program.
- The Star Ratings system of performance-based payment is the new cornerstone of competition among health plans. Stars has expanded into more than a dozen state Medicaid programs, and to ObamaCare's issuers as well, and the bar is rising. Technical changes to several measures mandate much higher performance to stay ahead of the curve and avoid falling below 4 Stars, where bonus payments and bid rebates vanish. 2015 will be the first year where plans below 3 Stars are terminated.
- Medicare Advantage plans won several lobbying victories in this year's "Call Letter", the rate and policy announcement for 2016, including an average 1.25% benchmark increase from a cut in the February draft. This signals a new era of influence muscle for the industry, where CMS will increasingly fight out policy changes "below the waterline" in subregulatory guidance and enforcement, where politicians are less likely to intervene.
- Appeals and grievances and pharmacy benefit management vendor performance remain the #1, 2 and 3 regulatory infractions in Medicare Advantage, and integration of long-term care and supports and services the leading challenge facing Medicaid health plans.
- CMS is on pace for its most aggressive enforcement year ever, with over a dozen actions taken against plans this year already.
As we've said since the passage of the Affordable Care Act, we are now in the Golden Age of government-sponsored health programs, and the opportunities and challenges that come with this shift have never been greater. Our clients went home with a clear grasp of both, and we are thrilled so many joined us this year.
Resources:
Join John Gorman, GHG's Founder & Executive Chairman, as well as Bill MacBain, GHG's Senior Vice President of Strategy on April 14 as they provide a hard-hitting analysis of critical areas addressed and finalized in the document from 1-2pm ET. Register now >>
GHG's Senior Vice President, Healthcare Analytics & Risk Adjustment Solutions, Dan Weinrieb, recaps the Risk Adjustment rulings in the Final Call Letter and provides keys to success in an article on the GHG blog. Read more here >>
Medicaid Reimbursement Rates and the Future of the Program
A recent monumental decision by the Supreme Court was just passed, and it will define the way Medicaid providers will be reimbursed now and in the future. Many Medicaid providers, including doctors, hospitals, and healthcare organizations, are already concerned with the low reimbursement rates, but now, due to the 5-4 vote by the Supreme Court, many will not have the right to push the states into increasing their payments.
In 2009, there was a ruling passed by the lower courts in Idaho to increase the state's reimbursement rates. The ruling came about due to the fact that the centers that provided care for about 6,000 mentally disabled adults and children were being reimbursed at the 2006 Medicaid reimbursement rates. The centers stated in their filings that the cost to maintain the treatment of these patients was substantially higher than what they were being reimbursed by the state. But then the Supreme Court stepped in and overturned this decision, citing that the Medicaid providers have no right to sue under the current laws pertaining to the federal funding for Medicaid programs.
The positive result of the 2009 ruling of the case, Armstrong v. Exceptional Child Center Inc., was that it set a precedence on enforcing federal payment requirements. Many of the other Medicaid states were using this as a foundation for their pursuit of fairer reimbursement. The basis of the argument was that federal requirements for rates must be "sufficient to enlist enough providers so that care and services are available under the plan. . . to the general population in the geographic area (42 U. S. C. §1396a(a)(30)(A) ("§30(a)"). Now, with the overturn of the decision, this could mean that fewer providers of service will participate in the Medicaid program, which will mean that Medicaid members will have fewer choices and restricted access to care.
Supreme Court Justice Beyer stated his decision was made based upon the rationale on "several characteristics of federal statute," in particular the Administrative Procedure Act. The debate that ensued during the session, and the final determination made, was mainly focused on alternative remedies, one of which was to engage the Department of Health and Human Services ("HHS") and cite §30(a) to withhold Medicaid funding, if the rates were inadequate.
The ruling has caused multiple groups, including 28 states, to voice their concerns with the decision. While this will be a long-term debate on both sides of the spectrum, conservatives and liberals, one thing is for sure: in the current environment, there needs to be risk strategies set into place so that the current, and future, players in Medicaid can keep sustaining the care provided with the ever-changing financial atmosphere. Gorman Health Group (GHG) understands the complexities of the numerous shifting of variables and has a team with the expertise and knowledge to perform risk adjustment models and make recommendations based on revenue vs. medical spend. Most states have rates that vary and are often moving targets; many organizations need to operate on projections or estimates.
GHG can provide assistance with identifying current and future costs of doing business while building in anticipated adjustments that make sense for the population served. We will position you for success by building a strategy that takes into account the service area, market environment, core competencies, and vision for the future. Contact us today to get started >>
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Over the last several years, GHG has committed our time to understanding the needs of the dual population, which has allowed us to build systems and processes that yield quality outcomes. 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. Visit out website to learn more >>
Network Adequacy Test Submissions for Medicare-Medicaid Plans
In follow up to the October 2014 Health Plan Management System (HPMS) memo titled "MMP Network Adequacy Standards," the Centers for Medicare & Medicaid Services (CMS) announced dates in which Medicare-Medicaid Plans (MMPs) and Minnesota Senior Health Options Dual Eligible Special Needs Plans (D-SNPs) can check their network against the MMP standards in the HPMS Network Management Module (NMM). These standards were developed using the same methodology that is used to develop the network standards for Medicare Advantage but were adapted to reflect the population served under the demonstrations. Specifically:
- Utilization Patterns and Minimum Number of Providers — Medicare Advantage network standards are based on analysis of service utilization patterns in fee-for-service Medicare. The new standards use the same analysis but based exclusively on utilization rates for dual eligible individuals.
- Total Beneficiaries — In Medicare Advantage, network standards are set based on current market penetration in MA. In the new standards, we will use actual or projected enrollment based on the enrollment policies for each demonstration. This affects the minimum number of providers and acute inpatient hospital beds criteria.
- Time and Distance — The Medicare Advantage standards require that 90% of beneficiaries are able to reach the minimum number required for a certain provider type within the time and distance standards established. These new network standards adjusted the time and distance for certain provider and facility types in certain counties.
To ensure your health plan's Medicare portion of the network adequately reflects and supports the beneficiaries served by this demonstration, Gorman Health Group (GHG) can analyze your existing provider file, assist in uploading the prepared files into NMM, and provide strategic planning should any deficiencies be found. The gates in the NMM will be open on the following dates:
- March 31, 2015
- May 26, 2015
- August 4, 2015
GHG advises all MMPs to be proactive and take advantage of the pre-checks available. The annual network submission deadline is September 17, 2015, with an exception request period to follow. Let's work together to ensure your provider network not only meets CMS standards but is working to meet the strategic initiatives of your plan.
Contact us today to start a conversation >>
Resources
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
Kaiser Family Foundation & CCF Release 50-State Survey on Medicaid and CHIP
It's time again for the release of the annual 50-state survey on Medicaid and CHIP enrollment, eligibility, cost-sharing and renewal policies conducted by the Kaiser Family Foundation's Commission on Medicaid and the Uninsured with the Georgetown University Center for Children and Families.
It's clear that the Affordable Care Act (ACA) has broadened Medicaid's base of coverage for the low-income population and fast tracked state efforts to move from obsolete, paper-based enrollment processes to a more modernized enrollment experience.
Highlights of the key findings include:
• Overall, states have made significant progress in offering Online Medicaid applications in all states, except Tennessee, and the majority of states accept Medicaid applications by phone. States also have instituted policies that rely on electronic data sources and minimize the paperwork process to verify information of applicants.
• States still have continued transition work to do under the ACA , such as improving information systems, implementing improved renewal processes and improving coordination between Medicaid and the Marketplaces.
• Reflecting the low incomes of parents and adults in Medicaid, as of Jan. 1, 30 states charge premiums or enrollment fees and 27 states charge cost-sharing for children. No states charge premiums for parents or adults newly eligible under the ACA in traditional Medicaid, but most charge nominal cost-sharing for both adult groups.
• The long-standing gap in coverage for adults has been eliminated in the 28 states that expanded Medicaid but persists in the 23 non-expansion states where parents are covered at a median eligibility of 45% of the federal poverty level and non-disabled adults without dependent children remain ineligible.
The policy environment continues to rapidly change on a weekly basis, making it difficult to capture a complete picture of certain developing processes such as renewals, verification using data sources, and account transfers between coverage sources. Even so, this 2015 survey creates a new baseline for measuring ongoing progress and improvements in Medicaid and CHIP in future years as states continue to revolutionize their programs.
Resources
Gorman Health Group, LLC (GHG), the leading consulting firm and solutions provider in government health care programs, announced its further expansion into Medicaid, and the promotion of one of the nation's leading Medicaid experts, Heidi Arndt, to lead the division. Read more >>
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
Federal study raises questions about access to care for people gaining Medicaid coverage under the Affordable Care Act
Federal investigators said in a new report that large numbers of doctors who are listed as serving Medicaid patients are in reality, not available to treat them.
Patients select their physicians from a list of providers associated with each Medicaid health plan. The investigators, led by the inspector general, Daniel R. Levinson, called the doctors' offices and found that in many cases the doctors were unavailable or unable to make appointments.
More than one-third of providers could not be found at the location listed by a Medicaid managed-care plan.
This can create a significant obstacle for an enrollee seeking care, impacting access to important benefits and treatment. Imagine being in the middle of a need for important medical care, picking up the provider directory and over half of the doctor's numbers you call are not valid.
If access to care cannot be relied upon, the foundations of the managed care programs are at risk. With the recent growth in Medicaid managed care, this becomes a more significant concern for the government as well as the industry. With the concern comes the potential for more stringent oversight.
New rules and standards to ensure timely access to care for Medicaid patients are under development. The push from the National Association of Medicaid Directors is to avoid overly prescriptive standards given the variances of State Healthcare markets.
CMS and OIG are in concurrence about tightening the standards, oversight and adequacy requirements.
We can help you wind your way through the new rules and the process for improved access to care. Contact us today.
Resources
Gorman Health Group, LLC (GHG), the leading consulting firm and solutions provider in government health care programs, announced its further expansion into Medicaid, and the promotion of one of the nation's leading Medicaid experts, Heidi Arndt, to lead the division. Read more >>
Registration for the Gorman Health Group 2015 Forum is now open! Register your team for The Gorman Health Group 2015 Forum by December 31, 2014 and SAVE 30% off your ticket using promo code: EarlyBird30 at checkout.
Hepatitis C virus (HCV) and treatment with Sovaldi® (sofosbuvir)
The medication Sovaldi® has revolutionized the way HCV is treated and at the same time has shocked health insurance payers and particularly Medicaid prescription drug budgets. With an estimated cost of $1000 or more per pill for a twelve (12) week course of treatment, the cost to treat one person can exceed $84,000.
According to the Centers for Disease Control & Prevention (CDC) there were an estimated 16,000 acute HCV infections reported in the US in 2009, the latest year statistics are available (http://www.cdc.gov/hepatitis). An estimated 75-85% of the people infected with acute HCV develop the chronic condition. The CDC estimates that there are 3.2 million persons in the US with chronic infection. Most people do not have symptoms and are unaware they are infected with HCV. HCV also affects those in lower socioeconomic classes and therefore the potential impact to Medicaid programs is even greater.
Sovaldi has a cure rate as high as 95%, with mild side effects during a twelve week course of oral therapy. Compare this with the previous drug of choice to treat HCV, interferon. Interferon is injected for up to a year and can have severe, flu like side effects. The cure rate for the most common strain, genotype 1, is 48-56%, depending on the length of therapy (M. Parikh, April 2011). The cost for the interferon treatment is $15,000 - $20,000. It is easy to see that clinically Sovaldi has the upper hand, but what cost can Medicaid programs, and ultimately taxpayers assume?
Some state's Medicaid programs, such as Oregon, are looking at ways to manage the use of Sovaldi by approving it only for their Medicaid clients who are showing signs of liver cirrhosis and have clean drug tests, for example (COOPER, 2014). In addition, what happens if a patient fails to complete their 12 week course of treatment? Should they be allowed to resume another full course of treatment?
This medication is a perfect candidate for coordinated medical and pharmacy management. Adherence is crucial to ensure completion of the twelve week course of therapy. If Medicaid programs are going to invest in paying for these types of expensive therapies it is vitally important that the medications are taken appropriately for the required length of time.
To learn more about how plans are investing in programs to help patients achieve better outcomes with the new Hepatitis C treatments, contact us >>
Resources
Gorman Health Group can work with your organization on blending medical and pharmacy to improve care coordination, outreach and utilization management to meet the complex needs of your membership. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open! Register your team for The Gorman Health Group 2015 Forum by December 31, 2014 and SAVE 30% off your ticket using promo code: EarlyBird30 at checkout.