Insights | GHG Advisors

10 Millon People Expected to Have Marketplace Coverage in 2016

The 2016 Health Insurance Marketplace open enrollment is right around the corner, opening on November 1, 2015. With premium rate increases well above 10% for 2016, it's no surprise the 2016 enrollment projections for the Marketplace are estimated to increase by less than a million from the total current 2015 enrollment, bringing the total individuals enrolled by the end of 2016 to 10 million.

In the most recent press release from the U.S. Department of Health and Human Services (HHS) on October 15, 2015, HHS is aiming to enroll more than one out of every four individuals eligible for Marketplace insurance. It's great news that more individuals will be enrolled, but 10 million is a rather conservative target set by HHS and significantly lower than the January 2015 Congressional Budget Office (COB) estimate of 21 million individuals. HHS anticipated the migration from employer-sponsored coverage to the Marketplace would be much more significant. Companies are still choosing to work with insurance companies directly to purchase health insurance as opposed to purchasing insurance through the Small Business Options Program (SHOP) or sending employees to the Marketplace to purchase health insurance on their own. This is contributing to the slower enrollment increase.

Starting in 2016, the definition of a small group employer will be increased to include companies having 51-100 employees. The enrollment increase we will see in 2016 will be due, in part, to this change. In previous years, these companies were classified as large groups and not subject to the Affordable Care Act (ACA) regulations. By changing the definition of a small group, it now requires companies having 51-100 employees to abide by the ACA regulations and will increase Marketplace enrollment. The annual tax penalty for not having health insurance will also be a driver for increased membership in 2016. The penalty for not having health insurance has been gradually increasing each year. The uninsured are becoming more aware of the tax penalty which will be applied to their annual income tax filing if they cannot provide proof of insurance coverage. For 2016, the penalty is $695 per person, or 2.5% of yearly income, whichever is greater. For each child under the age of 18, the penalty is $347.50. If 2.5% of your yearly income is greater, then the penalty will be capped at no more than the national average premium for a bronze plan. If your penalty is based on the per person/per child method, then the maximum penalty for a family is capped at $2,085. As the penalties start to increase, the more people with be inclined to purchase health insurance coverage.

For health plans, this means consumers are not just looking towards the Marketplace as the only channel to purchase health insurance. Health plans still need to be actively working with their sales brokers and potentially exploring new channels of enrollment, such as a private exchange. Redefining internal operations to support the changes implemented by the ACA should be the biggest focus for health plans right now. With the growing trend of members enrolling into a Qualified Health Plan (QHP), health plans need to be looking at transforming internal operations to support a more value-based outcome approach. This approach is driven by the company, provider, and membership knowledge acquired from internal data analytics.

The top three areas health plans should be focusing on are:

Transitioning from a fee-for-service model to a value-based model
Data management and analytics
Risk adjustment operations

Ensuring all Americans have affordable healthcare is the core reasoning behind the ACA. The three areas listed above are starting points to help health plans keep the cost of healthcare down while ensuring individuals are offered affordable insurance with quality benefits.

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 >>

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by GHG Advisors

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

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

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

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

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

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

Important key dates for application submission:

Resources

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

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by GHG Advisors

MA-VBID Request for Applications Released

The Centers for Medicare & Medicaid Services (CMS) has released the Request for Applications for the Medicare Advantage (MA) Value-Based Insurance Design (VBID) Model, which is an opportunity for MA plans to offer supplemental benefits or reduced cost sharing to enrollees with CMS-specified chronic conditions, focused on the services that are of highest clinical value to them. Applications are due by January 8, 2016.

CMS will tentatively select plans by April 2016. The application document repeats most of the information CMS released in the original announcement and webinar. However, the application will be submitted via a web portal which will be released in the near future. The process is much like the MA contract application process. CMS does provide information about the questions which will appear in the template.

Applicants will be required to present narrative explanations about their proposed interventions. First, there is the general overview of the proposed interventions describing the overall approach and understanding. This section must convey specific enough information tracking to details about interventions in later sections of the template. It will act to set the stage of an application.

Next, applicants must describe each separate VBID intervention. This will include each combination of plan and enrollee group so every target population is described with repetitive plan information and interventions. CMS describes the target population according to the eight qualifying diseases/conditions listed in the VBID demonstration.

Applicants must list specific benefits for each target population. CMS lists the various combinations of benefits:

Reduction or Elimination of Cost Sharing (not conditional)
Reduction or Elimination of Cost Sharing for High Value Provider
Reduction or Elimination of Cost Sharing Conditioned on Participation
Supplemental Non-Covered Benefits

CMS asks for "clear descriptions" in each of the four options and provides a number of elements applicants must discuss in their narratives.

While applicants must upload actuarial and financial documentation in this template, there are no specifications about the types of information for which CMS will ask. Notably, there is a statement that such information may not be required.

Health plans must also discuss their compliance history extending to January 1, 2010. Finally, an official of the applicant must certify their applications, their understanding about the conditions including marketing limitations, and bid requirements.

Data analysis is the key first step to identifying target populations and subsequent benefits which will become the focus of the demonstration. A team of subject matter experts from Gorman Health Group will deliver actionable results, driven by data analysis of current capabilities and benefit designs, to achieve quality care for the target populations. Contact us to learn more >>

Resources

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

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

by GHG Advisors

Data Revolution: The Need for Accurate Data to Drive Quality Analytics

The Affordable Care Act (ACA) made a tremendous impact on the healthcare industry. What was once a free-flowing commercial market with very low requirements and data interaction has now transformedâ€”it has morphed into a highly-regulated market heavily dependent on data to deliver quality outcomes for members and to remain financially sound. The processes set forth in the ACA mirror existing Medicare processes with adjustments in order to make the processes work for the Commercial population.

With the introduction of the ACA, data has had a staggering increase of importance and has become 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. Daily, health plans rely on the accuracy of their data for analytics which drive business decisions related to such things as rate setting, risk score calculations, federal and state data submission, and population health management. All too many health plans "assume" the information they are receiving from their membership, claims, and provider platforms into their data warehouse is accurate. This assumption is based on the fact these systems are considered to be "the source of truth." This terminology leads to false reassurance that just because it's the truth, it also means it's accurate. Always trust, but verify the data utilized. Inoperability between systems and software is a huge issue which increases your risk of losing data during transmission of information. Refined data management process and data governance are the links needed to bridge the data gaps.

When speaking about data and data management, the immediate correlation is to think of it as an IT department responsibility. With the growing regulations and oversight from the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS) around data, it has now also become a business responsibility. Long gone are the days when a business area could simply submit a change request and not be a part of the IT functions to implement the change. It is a critical piece now to have the business department working side by side with the IT department to ensure the changes or updates being implemented are accurate and within the regulations set forth by the regulators. As we all know, CMS and HHS can have last-minute changes and hard deadlines to which health plans must adhere. Knowing that working to meet these deadlines can be strenuous to achieve and realizing the IT infrastructure within your organization is increasingly complex, the business needs to be working with IT daily to notify them of any changes related to their work. Such items would include changes to the deadline, format, or field requirements, to name a few. It is a much more agile process than ever before. Having a business area who understands the technical components and effort needed to complete a desired change along with the required regulations leads to a much more successful engagement between IT and business.

There was a release on October 6, 2015, from HHS regarding rules to advance electronic health records with added simplicity and flexibility. HHS recognizes there is a need to make health information available quickly and easily to those who need it, as noted by the comment from Karen B. DeSalvo, M.D., M.P.H., M.Sc., national coordinator for health IT. She stated, "This rule is a key step forward in our work with the private sector to realize the shared goal of making actionable electronic health information available when and where it matters most to transform care and improve health for the individual, community and larger population. It will bring us closer to a world in which health care providers and consumers can readily, safely and securely exchange electronic health information." This is a huge advancement for HHS. Health plans need to establish and perfect their data infrastructure now so, as advancements occur within other areas of the industry, they are able to receive and store information utilized for analytics.

Here are some important questions to ask yourself when it comes to your organization:

Does your organization have a solid data management process in place to account for CMS and HHS requirements which could withstand an audit?
Has a clear understanding been established on the inoperabilities existing within the company and established ways to remedy any issues which may occur?
Has data governance been established?
Are integrated analytics established throughout the areas highly focused on member and provider engagement to support risk adjustment and Star Ratings?
Is your organization able to analyze population health management information easily and effectively on a consistent basis?

If you answered "no" to any of these questions, you will want to evaluate your current structure to identify areas of opportunity. The data within your organization provides the knowledge you need to understand your organization, members you serve, and maintain your financial solvency. Clean data to drive quality analytics is something every health plan wants. You need to ensure you have the right processes in place to manage the data within your organization effectively to set yourself apart from your competitors.

Resources

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by GHG Advisors

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

ICD-10

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

Merger Updates

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

HHS' Updated Shutdown Plan

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

Reconciliation

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

Part B Premiums

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

Medicare Advantage Value-Based Insurance Design Model

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

Resources

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

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

by GHG Advisors

The 2016 Star Ratings: Finding Calm in the Chaos

All great changes are preceded by chaos, and the Centers for Medicare & Medicaid Services (CMS) release last week of the 2016 Star Ratings certainly introduced a great deal of chaos for Star Ratings teams throughout the industry. With approximately 5% of additional reimbursement tied to â‰¥4-Star performance, health plan leaders are either taking a deep breath this week (if they earned â‰¥4 Stars and qualified for Quality Bonus Payments) or doing their best to quell the inevitable panic if the 4^th Star eluded them.

CMS continues to leverage Star Ratings to support improvements in member perceptions and longer-term, sustainable improvements in health plan performance and health outcomes. CMS continues to make rapid, continuous changes among measures, cut points, and program criteria. The speed and extent of change reinforces the need for a seasoned, dedicated Star Ratings leadership team which embraces and manages Star Ratings as a holistic, silo-busting program. It's vital for health plans to simultaneously excel not only in their clinical and pharmacy quality functions but also in every other health plan function. This includes everything from care coordination, network operations, member experience, risk adjustment, appeals and grievances, and compliance, to claims and encounter data and analytics, marketing, and every other department in the organization.

As we adapt to the first Star Ratings cycle with no predetermined thresholds, it's clear there is very little low-hanging fruit left in the Star Ratings program. It's time for us to climb the tree.

With budget season upon us, it is an ideal time to evaluate Star Ratings strategies and work plans to ensure 2017 investments are wisely made. Now that the 2016 Star Ratings are out, take an objective look at your Star Ratings programs to ask:

Are we investing adequately in the areas where we need the most Star Ratings lift?
Will our Star Ratings initiatives achieve our goals?
Are we conducting the right interventions, with the right members, at the right time?
Are we adequately integrating medication management and behavioral health into our Star Ratings programs?
Are we adequately coordinating provider and member engagement activities?
Are our provider contracts and pay-for-quality programs designed adequately to sustain success in the new Star Ratings environment?

If your plan achieved 4 Stars this year, this is no time to rest. The 178 plans at 3 or 3.5 Stars in 2016 are working hard to achieve 4 Stars this year, and with CMS' bell curve, this means some of the current 4-Star plans will drop in 2017. And don't forget — there are another 188 Medicare Advantage plans not rated in 2016. This huge group of plans will impact the bell curve as they receive their first ratings.

If your plan missed a 4-Star Rating this year, now is not the time to panic. There is still time to influence your 2017 Star Ratings, particularly since the Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) and Health Outcomes Survey (HOS) surveys will not be fielded until early 2017. But since time is definitely of the essence, it is important to invest time and resources wisely into the areas with the greatest opportunity for short-term improvements.

We can help. Gorman Health Group understands the complexities and nuances of the Star Ratings program and measures. We know how to design programs, initiatives, and tactics to improve Star Ratings performance. From evaluating organizational strategy to developing and optimizing tactical Star Ratings work plans, our team of experts has a long history of success helping health plans achieve Star Ratings success.

With time waning to influence the 2017 Star Ratings, find calm amidst the chaos and prepare for the great changes to come.

Resources

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by GHG Advisors

Where did your organization fall with CMS' estimates for 2016 & what's next?

In September, the Centers for Medicare & Medicaid Services (CMS) estimated the average Medicare Advantage (MA) premium will decrease by $0.31 next year, from $32.91 on average in 2015 to $32.60 in 2016. The majority of MA enrollees (59 percent) will face no premium increase. Sounds great, but the reality is most MA and Part D plan sponsors are finding it more challenging than ever to keep premiums low and still maintain attractive benefit packages and viable business/financial models. $0 premium plans in some markets are now the anomaly. Do you keep premiums low, pare down supplemental benefits, and increase copays, or take the hit for another year and hang on, hoping you will make up the financial loss next year or when those risk adjustment scores and Star Ratings align?

According to CMS, about 65 percent of MA enrollees are currently enrolled in plans with 4 or more Stars for 2016, a significant increase from an estimated 17 percent of enrollees in such plans in 2009.

So, the question is, where did your organization fall with CMS' estimates for 2016? Now that competitive premium and benefit information are available for review, I am sure your organization is among the many updating competitive analyses to see what the real situation is. If not, you need to. "Gorman Health Group (GHG) receives a number of requests for benefit analyses as soon as benefits are publicly released," stated Charro Knight-Lilly, Senior Vice President of Client Services. "It is truly the only way an organization can understand their benefit differentials and make the appropriate changes to marketing and sales strategies."

So what's next? For the short-term, it is time to pull your Sales and Marketing teams back together to review where you actually fall in line for 2016 against your competitors and refine or, in some cases, rework the strategies put in place based on competitive assumptions. Ask yourself:

Will my marketing dollar garner the projected return on investment under our original strategy, or should I shift my dollar spend?
Should my messaging change based on competitive product and benefit differentials?
Should my sales distribution strategy change in order to meet close ratios?

With the Annual Election Period (AEP) for Medicare health and drug plans now underway, there is no time to lose.

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

Resources

Design and implement a comprehensive data analysis to guarantee you have the right products, programs, and capabilities in place to compete and ensure you are go-to-market ready. Contact us to learn more >>

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by GHG Advisors

2016 Star Ratings are Working, and the Bar is Rising

The Centers for Medicare & Medicaid Services (CMS) released the 2016 Medicare Advantage (MA) Star Ratings early this year, on Thursday morning. The usual practice is to wait until Friday after the close. It was a shift designed to move markets, and the news was mixed. Overall, Star Ratings are working to improve quality in many areas of health plan performance, but insurers and their provider and pharmacy benefit partners are struggling on a similar number of metrics. What is clear is that Star Ratings are now the fulcrum of competition in government health programs — and man, this stuff is hard and getting tougher.

There are clear winners and losers in this release. There is a "Divine Dozen" of 5-Star-rated plans, including a couple of new arrivals to the 5-Star world. CIGNA traded its 5 Stars in FL (the legacy HealthSpring plan at the legendary Leon Clinic) for its Arizona plan. Sierra (9 states), Tufts (MA), Group Health of MN, and Essence (IL and MO) made it into the Pantheon. Repeat 5-Star rock stars include Kaiser in 8 states, Martin's Point (ME and NH and will soon own Medicare in Northern New England), and Gunderson in IA and WI.

The half-dozen "walking dead" — plans scoring below 3 Stars for 3 consecutive years —included Wellcare of LA, Sierra Health, Touchstone, Cuatro, Windsor, and GHS (owned by HCSC). Three will be terminated by CMS at the end of 2016.

Star Ratings are proving to be tremendously effective in moving markets and forcing industry investments in population health and the member experience and are driving big improvements in Medicare quality. Roughly half of MA plans (179 contracts) earned 4 Stars or higher for their 2016 overall rating, a nearly 9% increase in a year and the first time a majority scored over 4. On an enrollment-weighted basis, over 70% of MA enrollees are in contracts with 4+ Stars, a nearly 11% increase year over year.

But below the water line, at the metric level, the news was mixed and cautionary:

The good news: Average Star Ratings increased for 10 Part C measures and 5 Part D measures. We saw significant improvements in several challenging, longitudinal Health Outcomes Survey (HOS) measures: Improving/Maintaining Mental Health, Monitoring Physical Activity, Part D Appeals Autoforwards, and High Risk Medications. There were smaller improvements on many other measures, where removal of the 4-Star thresholds helped plans improve ratings.
The bad news: Average Star Ratings DROPPED for 16 Part C measures and 6 Part D measures. We saw significant decreases in several screening measures (colorectal cancer screening, diabetes kidney disease monitoring) and the HOS measure of improving/maintaining physical health. And there was a big drop on the Medicare Plan Finder (MPF) Price Accuracy measure, where the cut points have gotten so small that 97% accuracy only gets 3 Stars, 99% results in 4 Stars, and it literally takes a perfect 100% to earn 5 Stars.

We knew the removal of the 4-Star thresholds would produce a tremendous amount of fluctuation in the measure cut points, and that's exactly what happened. It's like playing "Pin the Tail on the Donkey" during an earthquake, making it really hard for health plan leaders to predict where their ratings will ultimately land while they still have time to influence them. For example:

The average rating on the Diabetic A1c Control measure increased from 3.3 in 2015 to 3.9 in 2016. But there was no change whatsoever in the average performance rate for this measure — in both 2015 and 2016, the average compliance rate was 76%. The improvement on this measure can be entirely attributed to CMS relaxing the cut points once the predetermined threshold was removed.
In contrast, the Controlling Blood Pressure measure rating dropped from 3.7 in 2015 to 3.4 in 2016. The compliance rate actually increased from 65% in 2015 to 71% in 2016. This is an example of where the removal of the predetermined thresholds tightened the pressure on this measure — in fact, the 4-Star threshold increased 12% upon removal of the predetermined thresholds.

The Star Ratings data for 2016 pretty much emasculated industry arguments for relaxing metrics for Special Needs Plans (SNPs). SNPs saw improvement in their quality scores roughly equal to that of HMOs and PPOs: MA plans operating SNPs averaged a 3.61 rating in 2016 (up from 3.47 in 2015), while plans with HMO/PPO-only contracts averaged 3.87 in 2016 (up from 3.79 in 2015).

Non-profit MA plans are pounding for-profits into the sidewalk on quality. About 70% of non-profit MA plans received 4+ Stars vs. 39% of the for-profits. Much of that discrepancy is due to culture. Non-profits tend to be far more focused on the all-important member experience measures and are more collaborative with their provider networks.

Methodological changes by CMS ensure the Star Ratings bar will continue to rise. 2016 is the first year plans with 500-999 members were rated. Only 369 Medicare Advantage Prescription Drug Plans (MA-PDs) were rated in 2016. 188 more plans weren't rated, but may be in 2017 — and this dilution will warp the bell curve plans are graded on, especially when considering most of those 188 are provider-sponsored, and strong performers will emerge. 4+-Star plans have the most to lose in this environment, and no one can afford to get comfortable.

Some takeaways:

Stars must be managed as a program and a corporate priority, not as a group of measures. The effort must be directed by dedicated executive leadership and support. No plan improves Star Ratings doing it off the side of their desks.
The removal of the remaining predetermined thresholds means there is no way for plans to "pick and choose" a subset of measures to focus on. It has to be improvement across the board.
The bar continues to rise fast among Part C Star Ratings measures. The "low hanging fruit" has been eaten. Part C Star Ratings success is no longer easily influenced by slick reports provided to physicians. Plans need to help providers execute on gaps in care plans and eliminate barriers to care for the vulnerable. There's a reason the 5-Star plans are mostly provider-sponsored, vertically integrated, collaborative, and member-centric by nature.
Star Ratings measures need to be woven into every department's work streams. This includes not only quality, care management, health services, and pharmacy, but also risk adjustment, network operations, and compliance.
Lagging SNPs need to work harder and smarter and assume no CMS help on the measures for the low-income and disabled. To the contrary, recent draft measures for dual eligibles from the National Quality Forum focus on mental and behavioral health and will prove an enormous challenge.

If you achieved 4+ Stars this year, congratulations, it's an increasingly impressive accomplishment. Now get back to work. There are 178 plans at 3-3.5 Stars who are close on your heels and feeling the urgency. Now add the 188 unrated plans who will smash the bell curve in 2017. A 4-Star plan's equal effort in 2016 only guarantees a score that starts with a 3 the next year. Keep. Moving. Forward.

If you missed your 4^th Star this year, panic a little, but then get it together. Fast. In a competitive market, you're circling the toilet bowl but aren't flushed yet. You still have time to influence your 2017 Star Ratings and must make improvement the focus of your benefit, formulary, and network designs in the months ahead. You have big decisions to make and must invest time and resources wisely and with a sense of urgency.

Once again, the 2016 Star Ratings prove the world's biggest experiment in performance-based payment is working and forcing insurer evolution. And evolution isn't about size, it's about continuous adaptation.

Resources

Whether your plan missed the overall 4-Star Rating necessary to earn Quality Bonus Payments, or whether the new 4-Star cut points have introduced new risks of maintaining your overall 4-Star rating, we can help. Our team of experts understands the Star Ratings program and knows how to influence performance. 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 >>

by GHG Advisors

ACO vs. Value-Based

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

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

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

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

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

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

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

Resources

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

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by GHG Advisors

The MA-VBID Model: Key Takeaways

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

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

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

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

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

Resources

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

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

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by GHG Advisors