Zombies in Washington!
Zombie: (a) a will-less and speechless human only capable of automatic movement who is held to have died and been reanimated. (b) The Sustainable Growth Rate.
By means of the Balanced Budget Act of 1997, Congress created the Sustainable Growth Rate, or "SGR" to us who know and love it, a will-less and speechless rule whose automatic movement seeks to annually wreak havoc with Medicare payments to physicians. This inane auto-pilot tries to link total physician payments under Medicare to the growth rate in the overall economy. Why Medicare physician payments, as distinct from other Medicare payments, should grow in lock step with all of the other, unrelated, components of the nation's economy, has never been stated. What has often been stated is the fact that Congress, in what passes for its collective wisdom, wishes with all of its collective heart that it could drive a stake through the heart of the SGR. Every year it threatens to cut physician payment rates by 20% or more. But the Congressional Budget Office, who is charged with calculating the cost of such things, finds that ridding us of this zombie would have a ten-year cost of $139 billion (with a "b"). And that assumes that the docs get a pay freeze for those ten years. Any raises would up the cost.
In another mindless act, Congress requires itself to offset new spending with an equal amount of either tax increases or other spending cuts, or some combination. Since it's impossible to get a majority of both houses to support either (a) tax increases in the house or (b) payment cuts in the Senate, nothing can happen, and the SGR lives on, annually "fixed" by kicking the can down the road a year, only to arise reanimated the following year.
Some observers of the optimistic persuasion believed that, maybe this time, the SGR might have met its match. We have a conference committee meeting to reconcile differences between House and Senate budget proposals, and maybe, just maybe, they would include a permanent fix to the SGR in their bargain. Any dreams of a grand bargain have long ago died, but there lingered the hope for a mini-bargain that might include the SGR. That hope is now dead, as time has essentially run out for a fix before the SGR kicks in January 1, 2014. The best one can hope for now is a repeat of the annual can-down-the-road kicking exercise.
What does this mean for Medicare Advantage? Well, actually, not much. Until this year's political pressure enlightened the calculation of the annual increase to Medicare Advantage plans, the SGR had a depressing impact on Medicare payments to private plans. Until this year, CMS had always assumed that the SGR's pay cuts would actually happen. They calculated payments to Medicare plans accordingly. When Congress did the inevitable, and postponed the SGR cuts by a year, CMS corrected the following year's payments, but by then, the SGR was back and cutting more. So, over time, payments to Medicare Advantage lagged more and more as they continued to be included in the calculation and only fixed a year later. However, the 2014 rates, for the first time, include the assumption that Congress will do what it has done the past eleven years, and fix the SGR cuts, at least for one year. The rates were increased accordingly. Maybe you didn't notice, since the SGR impact was offset by other cumulative corrections that decreased rates to make up for prior year miscalculations and overpayments. But the SGR is now gone from Medicare Advantage benchmark calculations.
So, as long as Congress keeps fixing the SGR one year at a time, there will be no impact on Medicare Advantage rates. The fix is already baked into the rates. And a permanent doc fix will also have no impact.
But the SGR is still an annoyance. Nobody wants it. Nobody expects it to ever save Medicare a dime. Everybody knows Congress will fix it one year at a time. Yet every member of Congress knows that to approve a permanent doc fix without offsetting taxes or cuts will be branded a "budget buster" by opponents, super-PACS, and tax exempt social welfare organizations all too eager to educate us on the evils of whoever is running against the incumbent. And tax increases or cuts to Medicare will provide even more fodder for election season TV commercials. So it lives on. And on.
Resources
Listen as GHG expert Bill MacBain dives in to what the Sustainable Growth Rate is, why it matters and how we can measure its impact. Access the podcast >>
Join us December 11 from 2:00 — 3:30 pm ET for a lively session with Gorman Health Group strategy and data analysis experts who will discuss actual case studies that show how plans can mine data for precious insight that can help improve performance. Register now >>
Navigators and Agents Gone Wild
Since the October 1 launch of the ObamaCare health insurance exchanges/marketplaces, there's been a growing din over the field conduct of navigators and insurance agents, in the process of enrolling eligibles on behalf of the exchanges or the health plans participating in them. Meanwhile, the associations backing brokers are putting pressure on the Obama administration, insisting that brokers should be more involved in the enrollment process. Add a regulatory infrastructure that is lax — at best — when it comes to training and enforcement … does anyone else have a sense of déjà vu? It's the market conduct growing pains of the Part D inception all over again. There is no doubt that some of the "navigators and agents gone wild" stories out there are simply anecdotal rumor mill reports coming from enterprising local reporters, or are "stings" by conservative bloggers and activists scoring cheap anti-reform points.
But it's also true that navigator and broker involvement has been controversial since the inception of ObamaCare. You likely remember that in the early versions of the ObamaCare laws, that brokers were not even in the picture and Republicans have made great political hay so far of the navigators as the healthcare equivalent of ACORN. Over 100 community organizations in 34 states won $64 million in Federal grants to field thousands of outreach workers to find and help enroll the uninsured, and they've been hounded mercilessly by Congressional oversight committees, local reporters and ObamaCare dead-enders. Even the most well-intentioned brokers and navigators have had a rough go of it during these first two months. Here's the harsh reality: Brokers face a backlog of enrollees who, for one reason or another, have not been able to submit their application. And the current flood of beneficiaries out there stuck in the application process are overrunning the system — there isn't enough time left to process them all, ESPECIALLY when you take into account the difficulty brokers have helping consumers who are already halfway through the process before they ask for help.
To add insult to injury: Because of insufficient training, many brokers weren't prepared for how this would play out. It wasn't until they encountered real problems, sitting next to their real clients, that the lack of training and preparation made itself painfully clear. The deck is stacked against the broker community here, and the media spotlight will continue to get hotter.
For health plans using brokers to distribute their products in the exchanges, there is very little chance that it can or will be done effectively. Every plan's goal is to understand and have some degree of control over how the brokers are representing the brand and the products in the field. But the huge influx of brokers into the process, very little training beyond the bare minimum required by the feds, no guidance from CMS on broker conduct, and the enrollment portal problems --- can oversight of these agents even be on the radar?
It's all so reminiscent of the perfect storm of sales misconduct during the launch of Medicare Advantage and Part D. In 2007 and 2008 Congress held several hearings where witnesses testified that sales agents had marketed without licenses, portrayed themselves as Medicare employees, and misled Medicare beneficiaries about plan benefits. Some of these events were a simple matter of insufficient training or understanding of the implications of their behavior, which we are ripe to experience in the exchanges. Others were blatant fraud. Congress's response to these incidents was the enactment of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), which prohibited or limited certain marketing activities by sales agents and plan sponsors, required that all sales agents be trained and tested annually, and be State licensed, among other things. Plans responded by adopting leading-edge solutions like GHG's Sales Sentinel (now covering over 55,000 agents in Medicare and the exchanges) to help them onboard, manage and oversee their brokers and agents in the field. In the exchange world, the biggest risk of all of the mayhem is a health plan's reputation -- which we've seen shattered by agent misconduct in the past. And the biggest counter balance initiative is for plans to blaze the trails when it comes to providing field agents sufficient guidance and training on conduct and repercussions, until CMS and the states catch up.
Resources
GHG's Sales Sentinel is the only sales oversight tool designed specifically for health care organizations operating in regulated government markets. To learn how Sales Sentinel can help your organizations agent onboarding and ongoing oversight process, visit our website >>
During the 2013 GHG Forum, Executive Chairman & Founder John Gorman, discusses how important it is to successfully train, on-board and conduct ongoing agent oversight for your Plan's success. Click here to access the recording>>
Listen as Senior Director of Product Operations at Gorman Health Group, Alex Keltner discusses GHG's Sales Sentinel, the solution to train, credential and onboard your sales force. Access the podcast here >>
Join us December 11 from 2:00 — 3:30 pm ET for a lively session with Gorman Health Group strategy and data analysis experts who will discuss actual case studies that show how plans can mine data for precious insight that can help improve performance. Register now >>
Much Progress on Healthcare.gov, But "Back End" Fixes Will Determine Success
Of the many, many things I gave thanks for last week, there was Jeffrey Zients, the White House management guru brought in to sort out the mess that is the launch of ObamaCare, and for his geek squad working feverishly on the fixes. His long-awaited progress report was released on Sunday, and it's amazingly sanguine for a government document. Knowing big IT projects as we do, it's impressive how far the fix team has gotten in a matter of weeks, much of it in consumer-facing functionality on the "front end" of the website and the enrollment process. What remains to be seen is what can be done this month on the crucial "back end" functions that connect to insurance companies participating in the exchanges -- the functions for which ObamaCare will ultimately be judged when coverage kicks off on January 1, and the true test for Mr. Zients and his geeks.
"HealthCare.Gov on December 1 is night and day from where it was on October 1," Zients told reporters in his victory lap Sunday morning. "While we still have work to do, we've made significant progress with HealthCare.gov working for the vast majority of consumers." The administration released some geek speak to make its case. Response times, capacity, and system stability are markedly improved, and conventional wisdom is that the consumer-facing functionality -- the "B to C" part -- is in much better shape.
It's the "B to B" piece that's still a problem. The metrics Zients released Sunday focused almost exclusively on the front end of healthcare.gov -- there were precious few details on the back end, specifically on the all-important "834" transmissions to insurers that tell them who's signed up, and which have been problem-plagued since the launch. You'll recall that last month Henry Chao, who oversaw healthcare.gov's technical development, said 30-40% of the back end functions remained to be completed, including a system to send payments to insurers. Without timely and accurate 834s from the Federal data hub, coverage can't be effectuated, members can't get their insurance cards, insurers can't get paid, and claims can't start flowing through the system for the uninsured.
The omission was glaring, and the Administration jumped in to address it. White House spokesman Jay Carney said that 834 fixes were ongoing but that the problems were "vastly improved." "We believe that the majority of fixes to the 834 forms have been made, including significant ones over the weekend," Carney said. "We're going to continue to work with issuers to make sure that the remaining problems for issuers will be fixed."
"A number of the fixes that went into place this weekend in particular will significantly address some of the highest priority things that we know were a particular concern with those transaction forms," said Julie Bataille, spokeswoman for CMS.
But there's still clearly a very long way to go. Administration officials and a new "Payer Exchange Performance Team," made up of insurance industry leaders, in a meeting on Monday acknowledged that about one-third of completed applications since Oct. 1 contain errors generated by healthcare.gov. The errors included failure to notify insurers about new customers; duplicate enrollments or cancellation notices for the same person; incorrect information about family members; and miscalculated federal subsidies. It's still bad enough that yesterday CMS recommended that consumers who choose a health plan through HealthCare.gov contact the insurer afterward to make certain they are actually enrolled. "Consumers should absolutely call their selected plan and confirm that they have paid their first month's premium, and coverage will be available Jan. 1," Bataille said.
There is no margin for error this month. Deadlines for enrollment are coming up in less than 2 weeks for people to get insured by Jan. 1. If the 834s can't be fixed by then, and it appears likely they won't, the next big barrier to enrollment is the ACA's requirement that eligible exchange customers pay their first month premium before they receive coverage. Without clean 834s, susbidy verification and calculations given to the plans, no one knows what the first month's premium will be. That may be the next "audible" to be called on the field: the Administration will seek a way around the premium payment requirement, and then ask insurers to take a leap of faith, issue coverage, and hope that premiums and subsidies catch up later. And that's a real problem that strikes at cash flow for many of the smaller, regional players in the exchanges, and especially for start-ups, like the ACA's co-ops. Nobody set aside contingency funds for this kind of headache.
So Mr. Zients and his geeks can't let any grass grow under their feet, and we all ought to spill some Starbuck's or Red Bull for what lies ahead for them. But to also give some perspective, a hat tip to Dr. J. Mario Molina, CEO of Molina Healthcare: "A few people are going to have data that's not correct; but compared to the tens of millions of people who don't have coverage right now, that's a minor problem." He's thrilled with the progress made, and points out "We process a couple million patients through our system the last week of the month as it is."
Whether you're a glass half-empty or full type of person, I think we can all agree we are looking at one wild and hairy enrollment reconciliation process in Q1 and 2 of 2014, so grab your shovels. There's a pony in here somewhere.
Resources
Join us December 11 from 2:00 — 3:30 pm ET for a lively session with Gorman Health Group strategy and data analysis experts who will discuss actual case studies that show how plans can mine data for precious insight that can help improve performance. Register >>
Gorman Health Group's Valencia, was designed to create workflows organizations need for critical operational functions, and give you insight into where your membership and premium-related data is out of sync. See how Valencia can revolutionize your capitation management >>
Consultant Assessment in the Headlines
Consultants were in the news this week; that doesn't happen often. In this scenario which I will not deeply dive into, a private consulting team was brought on to independently assess the status of a certain federal health insurance enrollment system. Their assessment, after reviewing hundreds of documents and conducting scores of interviews, includes a number of risks with some detailed root cause drivers.
A risk assessment conducted well in advance of any initiative helps leadership and stakeholders understand what potential failures or gaps exist within a system or process. Most readers who have compliance responsibilities are aware of the requirement to conduct a formal baseline assessment, and then to periodically re-evaluate the accuracy of that baseline assessment. The reality is that with all the day-to-day responsibilities that compliance needs to handle, the baseline assessment or the re-evaluation often takes a back-burner.
It is recommended that an organization seek an external resource to conduct these evaluations. With our experience working with plan sponsors nationwide, our Senior Consultants and Clinical teams can take care of that assessment for you, leaving you with a report of gaps, risks, and recommendations on how to correct. Don't have the time? We can help you correct the deficiencies. Ask yourself when the last time a comprehensive risk assessment was performed; determine if you have time to conduct it on your own, and then contact us to discuss how we can help.
Resources
The annual risk assessment is an essential part of the ongoing risk management process that assigns priorities for mitigation plans. Learn more about how Gorman Health Group can help you identify and remediate inefficiencies >>
Join us December 11 from 2:00 — 3:30 pm ET for a lively session with Gorman Health Group strategy and data analysis experts who will discuss actual case studies that show how plans can mine data for precious insight that can help improve performance. Click here to register >>
Medicare Advantage Showcased as the Model for Medicare Reform
The National Coalition on Health Care (a nonprofit organization representing 80 organizations who support comprehensive health system change) and the Partnership for the Future of Medicare (a bipartisan organization supporting the long-term security of Medicare) have a new lobbying message — don't kill the golden goose. Recognizing the upcoming budget battles this year and next, these organizations presented their lobbying strategy which will feature Medicare Advantage plans as the model for a sustainable Medicare program. John Rother from the National Coalition, Lanhee Chen from Stanford University, and Ken Thorpe from Emory University highlighted the innovations in Medicare Advantage plans that should serve as the model for reforming Medicare fee-for-service. These innovative programs focus on beneficiaries with multiple chronic conditions that drive Medicare costs and include care coordination, disease management, team-based care, transitional care, medication management, prevention, health coaching, and evidence based lifestyle programs. They argued that Medicare Advantage plans are already facing a 6.7 percent payment reduction in 2014 and that any further cuts will lead to threats to these innovative initiatives that should be encouraged and not penalized. They discussed research studies showing that MA plans had higher quality scores in 9 of 11 HEDIS measures compared to FFS, 13 — 20 percent lower readmission rates, lower hospital costs including a spillover effect to the overall health system in areas with high MA enrollment, and lower mortality rates.
Dr. Ken Thorpe and Senators Ron Wyden and John Isakson discussed their upcoming initiatives to pursue introducing successful MA innovations in FFS Medicare. Dr. Thorpe is supporting a program he calls "Medicare Integrate" that would build prevention and care coordination into original Medicare. Under this program, CMS would contract with health plans, home health agencies and other entities to provide to provide team-based diabetes prevention services, care coordination services and pharmacotherapy services to FFS Medicare beneficiaries. These services would be provided at no cost to beneficiaries. The bipartisan chronic disease legislation being developed by Senators Wyden and Isakson would also authorize Medicare to pay for teams to provide care coordination services for FFS beneficiaries with chronic conditions.
Although Senator Wyden estimates that his proposal will result in 5 — 10 percent savings to Medicare in the current budgetary climate, it will be difficult to enact a new Medicare benefit without a structure such as an ACO or medical home to produce offsetting savings. While some demonstration projects adding care coordination services to FFS Medicare have achieved savings, other demonstrations have not achieved savings and resulted in CBO scores of higher costs to Medicare.
Resources
Join us December 11 from 2:00 — 3:30 pm ET for a lively session with Gorman Health Group strategy and data analysis experts who will discuss actual case studies that show how plans can mine data for precious insight that can help improve performance. Click here to register >>
What's next for the ACA
Here we are on November 15th one day after President Obama unexpectedly delayed a key provision of the Affordable Care Act, which allows insurance companies to continue, for one year, offering health care plans that fall short of the requirements as outlined in the ACA . The next day our "stewards of national well being" elected to pass a bill in the House of Representatives which is intended to allow insurance companies to sell individual health coverage to anyone who wants it, irrespective of any required standards in the ACA. As expected, the vote was justified on the grounds that the House is concerned that people will be left without health insurance under the current law, no consideration at all, wink wink , was given to 2014 reelection concerns.
Although the measure is expected to fail in the Senate, the underlying issue remains - that partisanship continues to prevent any attempts to take a more reasoned approach to bolster what is good about the ACA and to work out solutions on what is not working.
I think most of us already agree that the ACA or ObamaCare will be a major election topic as it was in 2012. In the meantime we will continue to see repeated efforts to roll back any and all provisions of the law.
What gets lost in all of the machinations by Congress and our Executive Branch is that not much has changed. We still have 40 plus million people uninsured, we still have the elderly making choices between buying food or prescriptions, and we still have lots of false or misleading information published on a daily basis about the intended impact of the ACA.
Personally, I believe the effort was flawed from the beginning but what's done is done and although I may be a lone voice in the wind, I believe it is the responsibility of Congress, consumers and health professionals to stop sniping and start working on how we make the ACA as successful as can be. If that requires changes along the way so be it. What we don't need is continued political posturing. In many respects our future is at stake depending on how we move forward..
Resources
Gorman Health Group Senior Vice President of Public Policy Jean LeMasurier, summarizes the final rule that sets standards for refunds when a Marketplace or QHP improperly applies federal subsidies or incorrectly assigns an enrollee to a plan. Download the summary here >>
Pay me now or pay me later: Things to keep in mind when you set your 2014 budget
Back in the '80's Fram Oil Filters had an advertising campaign that featured an actor dressed as a mechanic, admonishing viewers to get their oil changed and get a new oil filter, to prevent costly engine damage. "Pay me now or pay me later," he said.
When it comes to some key Medicare Advantage functions, the "pay me later" scenario can be perilous indeed.
Take data reconciliation, for instance. MA plans, especially those with drug coverage, need to reconcile at least a dozen different types of data with CMS: Enrollment data; Transaction reply reports; Retro processing contractor; Beneficiary churn ; Capitation payments; Premium data; Out-of-area residence; Subsidy payments; Medicare as secondary payer; Prescription claim (PDE) data resolution; Part D coordination of benefits (COB); Enrollment data validation; Compliance & reporting; Medicaid state roster and best available evidence of Medicaid enrollment.
The sheer volume of data and transactions dictates use of automated processes and controls to manage the reconciliation workflow. Spreadsheets won't cut it, and quasi-manual processes rapidly fall behind the need for daily data import and analysis. Failure to reconcile results in incorrect claim and capitation payments, premium collection issues, enrollment and benefit errors, reduced quality scores, and the potential for excess repayment under drug plan risk corridor reconciliations. Even for small plans, there can be millions of dollars at stake.
Compliance is another area where failure to invest in automated systems now can cause a bad "pay me later" outcome. The cost of a bad CMS compliance audit isn't just the staff time to correct problems. Most compliance problems are directly linked to member satisfaction issues, and a "bad" audit is symptom of deeper problems that lead to high member services call volume and disenrollment rates. Not only does CMS expect plans to be audit ready all the time, members expect things to go right all the time. We have found that the best approach is to use information technology tools to continually monitor compliance at the department level, to maintain complete and organized documentation, and to identify areas where compliance is lagging — where management intervention is warranted. Compliance programs need to be documented, regimented and sustainable. Compliance doesn't wait to happen. It takes an organized and on-going campaign, supported by automated tools to remind, track, document, and spotlight problems.
A third opportunity for trouble is in how sales agents are trained, vetted, and monitored. CMS requires annual training, which is best done using computer-based learning systems. Embedded testing provides documentation of comprehension. On-going supervision requires diligent tracking of complaints and allegations to confirm, respond, and assess improvement. As with other complex tasks, an automated solution reduces opportunities for errors and omissions.
At a time when every dollar counts, it's a good idea to consider budgeting for an investment in software solutions that solve these problems. Gorman Health Group has built software that supports our own consultants as they work with health plans on these issues, and these tools are available for health plans to use in their own operations. The GHG software is unique in that all of these applications are Web-based, fully hosted solutions that present no strain to IT resources. And GHG's subject matter expertise drives each product's unique functionality.
I invite you to contact my colleague RaeAnn Grossman, to start a conversation about your goals, the risks you face, and your available resources and budget for the 2014 year.
RaeAnn Grossman
Chief Sales and Marketing Officer
Rgrossman@ghgadvisors.com
Resources
Decision-makers from Health Plans and Provider Organizations are invited to join GHG for a free webinar on November 19th: "The future of the Government sponsored health care." Register for this free event now >>
The Online Monitoring ToolTM (OMTTM) is a complete compliance toolkit designed to help organizations track the compliance of their operations. Visit our website to learn more about how the OMT can help your organization >>
The way in which you onboard, train and conduct ongoing oversight on your sales agents is critical. GHG created Sales Sentinel™ specifically to meet the needs of health care organizations operating in regulated government markets. Learn more here >>
Every health care organization is looking for improved outcomes, better compliance and enhanced process efficiency when it comes to managing membership and premium payments. GHG's Valencia was designed specifically to meet those needs.
There is no cheat sheet for 2014.
Now is the time of year when we all have 12 things to do in the next 30 minutes, plus we are budgeting and we need to write our strategic approach for 2014. We have to learn how to prioritize and focus on what is truly important to our success. Unfortunately, there is no cheat sheet, no best practices for all things healthcare, and we cannot succeed if we have too many strategies. Let's compare five areas:
- Administrative excellence and compliance
- Clinical innovations around case, disease, and utilization management
- Provider Engagement
- Risk Adjustment
- High-risk member management
Recently, Gorman Health Group asked the attendees of Medicaid Health Plan Association, "What are the most important strategies in 2014?" The answers and ranking are below:
- High-risk member management
- Provider engagement and innovative reimbursement models
- Risk Adjustment
I imagine that this may be that cheat sheet for all of us.
Although Michael Porter shares, "strategy is about making choices, trade-offs; it's about deliberately choosing to be different." There are some strategies that every business has to do well to survive, and we all need to be ready to succeed at those mentioned above in 2014.
Resources:
Decision-makers from Health Plans and Provider Organizations are invited to join GHG for a free webinar on November 19th: "The future of the Government sponsored health care." Register for this free event now >>
Medicaid health plans must be able to navigate through State and Federal regulations and work well with State agencies.
GHG solutions-based consulting drives results to your Medicaid health plan, visit our website to learn how >>
Reading the Stars in Medicare in 2014-2015
Whatever you may think of healthcare.gov, CMS is killing it on the Medicare Star Ratings Quality Demonstration.
As we move into the final year of CMS's historic and controversial $8.5 Billion Quality Demonstration, we see clear evidence that quality incentives are working, plans are making major investments to improve their ratings, and quality is improving across the industry. One thing we can be sure of in uncertain times: proven performance-based payment systems like MA Star Ratings will spread to Medicaid, the exchanges, and commercial accounts in the next 3-4 years under banners of transparency and accountability. $8.5 Billion in a $3 Trillion industry seems infinitesimal, but Stars are moving the industry in ways outsize to their impact.
Many industry experts giggled at the Affordable Care Act ‘s (ACA) provision allowing MA plans to earn up to 5% additional reimbursement from the government for quality metrics based on the CMS star system, and 10% in double bonus (mostly rural) counties. The Star ratings system was, at the time, a laughable ranking barely 2% of beneficiaries paid any attention to. Not anymore. In 3 years, CMS has evolved Stars to an increasingly sophisticated carrot and stick for quality improvement, with massive financial implications for payers.
To date, each half-star rating equated to roughly $50 per member per month in bonus payments. For 2014, we estimate the enrollment weighted-average increase to plan paymentst from Star bonuses is approximately 4.75% and 3.3% in 2015. Anything below 4 Stars in 2015 means no bonus and a major financial headwind for plans. With MA plans seeing roughly 5% margins, 2014 being the worst year of MA reimbursement cuts from the ACA, and 2015 meaning the end of bonuses for plans below 4 Stars, plans are making significant investments to improve their ratings.
There was clear evidence that Stars incentives are working: 52% of MA plans are now at 4 Stars, up from around 37% of all MA plans. The average member weighted ranking for 2013 is 3.86, up from 3.7 in 2012. The biggest chunk of MA enrollment is now in 3.5 Star-rated plans: 30% or 4.4 million. There are now 16 5-Star rated plans up from 3 this year.
While tremendous progress is being made on Stars, GHG's analysis of the data also shows what a long, hard journey these performance metrics present to health plans. We have much improving to do in managing conditions like osteoporosis and mental health, where most plans scored badly. And the data shows a need to continually improve the service model, like providing interpreters, managing member complaints and coverage disputes.
MA plans in qualifying counties, mostly rural, can receive a "double bonus," the payment impact of which is significant. There are about 4 million MA members in double bonus counties, roughly 27% of the total MA population. Double bonus counties add about 100 basis points to payments across the entire MA program.
5-Star rated MA and Prescription Drug-only plans can enroll members year-round in 2014, rather than just during the annual enrollment period. This is a major strategic advantage for Star leaders, but one that few have taken full advantage of yet — and that's about to change. With big nationals finally attaining the honor, they'll be ready and hustling all year.
CMS has been very clear that it reserves the right to terminate MA contracts that are below 3 Stars for 3 consecutive years, citing its authority in an April 2012 final rule which became effective this year. About a half-million Medicare beneficiaries are enrolled in plans with less than 3 stars.
Resources:
Interested in seeing how your Plan's performance compares to others in your market? Download GHG's Star Ratings Database that combines the CMS-issued 2014 Star Ratings with those over the program's history from 2008 on.
Hear from GHG Stars expert Jane Scott on October 29th. GHG and AISHealth team up to present a 90 minute webinar: "Inside the 2014 Star Ratings for MA and Part D: Trends and their implications." Register now >>
Want to hear more from John? Decision-makers from Health Plans and Provider Organizations are invited to join GHG for a free webinar on November 19th: "The future of the Government sponsored health care." Register for this free event now >>
Live Connects + Motivated Buyers = Better Sales
Converting active leads to instant appointments is vital in today's insurance market. Whether you are working in this fall's first open enrollment period outlined in the Affordable Care Act or Medicare's annual open enrollment period, the company that converts immediate leads has an excellent advantage over its competition.
Agent Connect is a tool that helps shorten that sales cycle by connecting field agents and callers at the exact moment callers are ready to talk. All facets of the sales process — a caller inquiry responding to a marketing piece, a convenient 3-way conference introducing field agents to interested callers, helping agents set the required scope of appointment and the appointment date - are all handled in real time using mobile devices.
Imagine the pleasure of a caller that dislikes following automated instructions on their phone or leaving voicemails. Instead, they are expertly pre-qualified by a professionally trained call agent and are then immediately transferred to a local field agent that is literally at their beck and call. Talk about exceeding expectations!
Using Agent Connect, field agents with time between scheduled appointments indicate their availability for real-time leads via mobile device. Meanwhile, callers responding to a marketing campaign are pre-qualified by a carrier's call center. If the caller wants to meet with an agent, the call center matches them with an available agent nearby and instantly connects them via a 3-way conference. This instant communication allows agents to build an immediate rapport with callers, also shortening the sales cycle.
In this way, Agent Connect provides a seamless "hand-off" of a warm lead to agents that have signaled their availability. Companies using Agent Connect can dispense leads in any number of ways: by top performers, round-robin or random selection.
Agent Connect is an exciting collaboration between agents, insurance carriers and call centers that significantly reduces the sales cycle and is redefining the term "insurance lead."
Resources
The Bloom Call Center is licensed in 48 contiguous states and offers marketing, call center and technology solutions to the health care industry. Since 2007, Bloom has participated in over 55 million conversations about insurance products, submitted over 200,000 applications for insurance, and set over 150,000 appointments for seniors to meet with Licensed Agents. Bloom is a proud partner of Gorman Health Group. Click here to learn more.