Glass Half Full on Medicare Reform Prospects
Former CMS Administrator and friend of the firm Gail Wilensky, MD is out with a great op-ed piece in the New England Journal of Medicine today on directions for bipartisan Medicare reform. She echoes many of our recent thoughts on the improving prospects for Medicare reform, not in this hotly-contested election year, but as part of deficit reduction in 2013. Her piece covers the gathering momentum behind the Ryan/Wyden reform proposal, as well as structural changes previously thought unthinkable, such as increasing the eligibility age for the program, further means testing, and a targeted growth rate for our favorite entitlement program. We can thank both President Obama and Speaker Boehner for enabling discussion of these reforms since broaching them during the disastrous debt-ceiling debate last summer.
I thought the most compelling part of Dr. Wilensky's argument is her assertion that we have turned the corner on recognizing that the traditional fee-for-service paradigm of Medicare is unsustainable. She notes "growing agreement that a fee-for-service system like Medicare's, which reimburses physicians for some 7000 discrete services, is inconsistent with achieving the care coordination needed by seniors with multiple chronic conditions or complex acute care needs. To me, this growing disillusionment with the incentives and rewards of fee-for-service medicine is the most surprising evolution in thinking of the past quarter century and offers the greatest promise for success in developing a replacement, whatever its parameters."
We agree, and would add that the experience of Medicare Advantage and Part D show the only true path to securing the fiscal solvency of the program is through capitation and care coordination of the chronically ill. It's encouraging to hear a policy luminary like Gail point out that we're closer than we may think to some consensus on new approaches to preserving Medicare for the long haul.
Solving your claims-based HCC conundrum
Everybody knows that 37% of claims-based HCCs fail in a RADV audit, but no one ever talks about how to fix the problem.
How to fix the high failure rate of claims based HCCs?
1. Filter your claims and tier into confidence levels (high, moderate and low). (We call our filtration, tiering, and resolution tracking solution CareCurrent.) We recommend you filter on frequency, site of service, provider of service, clinical significance, plus CMS compliance and clinical condition alignment.
2. Audit your medical groups with both the highest member density plus your providers consistently in your low confidence coding tier.
3. Note the diagnoses or most common conditions inaccurately recorded.
4. Meet with physicians and staff to create an evaluation to billing process improvement workflow for your top three most common inaccurate codes. Repeat this education and communication with other medical groups.
5. Re-stratify your claims and note improvements using CareCurrent if you have no internal system.
6. Audit the new dates of service stratified and glean if the education and new workflow aided in more specificity or accuracy in coding.
7. Create clinical and coding initiatives as appropriate to compliment your coding areas of improvement.
If you note that previous codes were inaccurately billed in claims and submitted to CMS, delete the codes prior to final sweeps to ensure appropriate payment and audit success.
It's Super Tuesday and Romney Still Gets No Respect
Today is Super Tuesday, the biggest event thus far in the Presidential race, with more delegates at stake for the GOP candidates than any other primary or caucus to date. Mitt Romney was supposed to have the nomination locked up by now; instead, as today's Wall Street Journal points out, he's more like the Rodney Dangerfield of politics: he just can't get no respect. Don't get me wrong, I'm still convinced it's Romney vs. Obama in November -- but after months of campaigning, the enthusiasm gap that's evident only favors the incumbent President.
Romney will likely have a strong showing today in Massachusetts, Vermont, and Virginia, where he has only Rep. Ron Paul as competition. But the biggest delegate yields are in Ohio (63 delegates), Tennessee (55), and Oklahoma (40), where Rick Santorum has a strong lead. In Georgia, Gingrich's home state, there are 76 delegates at stake. None of these contests are winner-take-all -- each candidate has the opportunity to compete for delegates in parts of each state where they are strong.
Today's new Journal/NBC News poll shows the primary process has worn away the overall enthusiasm edge that Republicans, desperate to oust President Obama, were supposed to have:
![[CAPJOURN]](http://si.wsj.net/public/resources/images/NA-BP702_CAPJOU_NS_20120305162703.jpg)
The new survey shows that both parties' registered voters are virtually even in members expressing great interest in the election -- and the share of Republicans excited about the race has dropped 10 percentage points since January. The big concern for Romney has to be the trend line on the independents, who are being turned off by the renewed culture war ignited by Santorum, Gingrich, and the right wing of the party. Weeks of gunfights on birth control, pre-abortion invasive ultrasounds in Virginia, gay marriage, whether the President is a "snob" for wanting Americans to have the opportunity to go to college, and anything-but-the-economy shows that 40 percent of American adults think less of the party after watching its transformation this electoral season -- especially independent women.
Driven by an intensifying ideological purity test that brings to mind a white, working-class, ultra-religious "American Taliban" (as the Journal points out, Democrats don't require their presidential candidates to declare repeatedly that they are liberals, thereby pushing themselves away from the center of the political spectrum), the GOP has come to stand for "God's Own Party" in these last few months, and likely voters are tuning out as a result. A notable casualty: centrist Republican Senator Olympia Snowe of Maine decided not to run this week after all -- a big loss for her party, both for her deal-making skills and the likelihood her seat will go to an Independent, popular former Governor Angus King.
As the Journal pointed out today, "Mr. Romney has a tough job, for the Republican party is a hard one to lead right now. Any party that is trying to simultaneously win over Wall Street money managers and the tea-party movement, and to win Hispanic votes while championing the tough immigration laws of Arizona and Alabama, has laid out a tough task indeed...So Mr. Romney would have to raise sagging numbers among independents, light a fire beneath an underenergized party base and confront a president whose approval ratings are moving higher."
Not a pretty picture for the GOP, and with every day the Republicans' internecine and cultural warfare continues, the further victory drifts from their grasp. The big question to my mind now is whether the renewed culture war from the far right has cost the GOP not only the White House, but the US Senate as well...and with it, any prospect of stopping health reform before it launches in 2014.
Preaching to the Converted on Medicare Reform
Politico is out with a great op-ed today from centrist thought leader Will Marshall on why the Ryan/Wyden Medicare reform plan deserves a fair hearing -- especially among Democrats. He's preaching to the converted here at GHG -- the Wall Street Journal noted our support for the plan last week in Fred Barnes' column.
I agree with Will (as I usually do; Will and I are both former Clintonians and he is the longtime leader of the Progressive Policy Institute, one of my favorite centrist think tanks) -- we like the concessions Ryan's made to his plan in order to get Senator Wyden (D-OR) to support it, and remain hopeful (though not delusional) that both parties can put aside "Mediscare" tactics this election year for a thoughtful discussion about it. More likely it'll be next year, after the dust has settled from this messy race and the deficit reduction debate begins again in earnest.
Integration around chronic conditions, such as chronic kidney disease
Many of our clients have requested customized mapping and integration which electronically links the findings from the Advanced Evaluation into their medical management system. Health plans and medical groups both appreciate the in-depth reporting, plus electronic connection that triggers or flags particular members for placement into unique case management programs, whether it is a COPD, CHF, frail and fall reduction, or chronic kidney disease referral.
This is an easy workflow to ensure the data is transformed from a picture in time to an integrated care support tool.
One of the diagnoses we focus on a great deal is Chronic Kidney Disease. We have built a specific module around the clinical guideline statement from the National Kidney Foundation regarding Chronic Kidney Disease and have engaged experts to ensure our clinical analytics, detection, and evidence based findings are easily understood by the members, interact with the health plan's platform, and are simply formatted for community physician plan of treatment development.
Dr. Dambro, CMO and Dr. McCallum, CEO of CenseoHealth will be sharing more information about our chronic disease modules and clinical outcomes in future conferences and blogs. Stay tuned.
When Worlds Collide: ACOs and Risk Adjustment
By John Nimsky & RaeAnn Grossman
As we enter the era of ACOs, we have to be aware of all the clinical and operational essentials that are needed to make the ACO a viable health care solution for members, plus the elements needed to support the ACO as an engaged and intelligent communicator with CMS.
If you have a shared cost saving ACO you must have an accurate picture of the member's health status at Day 1. This detailed clinical picture will help you as an ACO:
1) engage the member in appropriate care programs
2) understand their cost today and project cost for next year, and
3) calculate the risks and benefits of treatment.
In traditional Medicare, it is well substantiated that over 75% of the members may have undocumented HCCs or gaps in care. However, as an ACO your primary concern is wellness and cost saving, and so you want to push toward 100% member evaluation completion for each calendar year. Why? Your members really should be evaluated to ensure there is a documented, compliant health status profile of of each member who starts with your ACO, and each year thereafter.
If you stratify the patient population within the ACO for relative health status, your plan for future treatment intervention will include identification of those members who can benefit from:
• referrals to case management;
• inclusion in disease registries;
• and other target services on a one to one basis.
Effective population stratification and risk assessment produces a complete health profile, a tool that can help reduce:
• admits;
• re-admits;
• acute utilization;
• ER visits;
• and other avoidable costs found in today's fragmented approach to health services delivery
Specifically, a robust risk assessment approach for a defined populations will
a) identify ACO members who will benefit from treatment but are currently missed by the system and thus are more likely to develop more serious pathologies later;
b) give physicians and members/patients quantitative information about the risks of adverse events and the benefits of treatment;
c) identify priorities for appropriate outreach programs; and
d) assist in calculating appropriate benchmarks and shared savings incentives for physicians.
An in-office or in-home assessment of the patient's medical history and current health status, when appropriately employed at the time of member assignment to an ACO, is a powerful tool that must be ready to launch Day 1 of ACO implementation. Because members are likely to join the ACO throughout the year, the stratification for those new members must occur monthly and integration into the care pathway must be timely and seamless. Timely integration of the member into standardized clinical treatment approaches will lessen the burden on care givers and will ensure that services are provided efficiently and in the appropriate setting. This is not a time for a long implementation phase, lags in data refreshes, or delays in re-stratifying members.
One of the tools available to assist in the process of identifying member current health status and treatment planning is offered by CenseoHealth, which has ACO Advanced Evaluation modules for Medicare, Medicaid, and commercial members. These populations' clinical conditions differ, and so their outreach, analytics, and engagement strategies are also dissimilar.
RADV Rules Show a New Era Dawning at CMS
After the market close last Friday CMS released its long-awaited methodology for conducting Risk Adjustment Data Validation (RADV) audits. It's a critically important document as for years President Obama has threatened in his budgets to recover billions in payments from Medicare Advantage plans. What it shows is that a new era is dawning at CMS, one brought about by the "tipping point" of Medicare Advantage exceeding 25% of all beneficiaries this year. Call it the era of "the open hand and the closed fist."
First, we have to acknowledge that the RADV methodology clearly reflects the intensive consultation CMS did with industry stakeholders to get their approach right. In a word, where we ended up is great, and CEOs and CFOs across the industry are heaving up sighs of relief this week.
There were four big developments in the announcement. The first: CMS says RADV audits will begin with plan year 2011, not retroactive to 2007, eliminating the four worst years of exposure for the industry as it figured out risk adjustment -- documentation is much better today than it was when the system launched in 2007. Essentially, CMS is saying "the sins of the past are absolved." They didn't have to do that, and we, hundreds of CFOs, and bankers up and down Wall Street and Madison Avenue are thankful they did. For plans that have already accrued for RADV for 2007-2010, like Aetna, there's the potential in the accrual for "found money" or a boost to earnings.
Second, CMS is introducing a "Fee-for-Service Adjuster." This mean the error rate found at individual Medicare Advantage plans will be reduced by the error rate of the traditional Medicare population. This was probably the biggest issue for the industry in the year's worth of negotiations since the draft methodology was released. Doctors generally suck at coding, regardless of whether a member is in a managed care plan or in traditional Medicare. Initially, CMS intended to compare error rates in managed care to 0, rather than comparing them to an error rate in the traditional Medicare program. If CMS had gone with its original approach, it could be argued that plans were being penalized twice. According to CMS, the estimated error rate at managed care plans is around 11%, down from the 2010 error rate of 14%.
Third, CMS will allow plans to submit multiple medical records to substantiate submitted codes, rather than requiring plans to only submit one best medical record. This will make it easier for plans to provide supporting documentation, as sicker members typically see several physicians, and the documentation from all of the treating physicians is rarely combined into a single medical record. The only disappointment here is that CMS will continue to focus audits on medical records and will still not allow alternative sources of clinical data like prescriptions.
Fourth, the audit results will be extrapolated only to the contract being audited. CMS will first determine the number of beneficiaries who are RADV eligible. The RADV eligible members are then ranked from highest to lowest based on their risk score and divided into three equal groups, with one group having the highest risk scores, another the lowest, and the remaining enrollees in the middle. CMS will then select 201 members to review medical records, with 67 enrollees randomly selected from each of the three cohorts. Plans will then submit medical records for these 201 members to support all the submitted codes. The resulting error rate is then reduced by the fee for service error rate, and the resulting figure is applied across the contract being audited only, not across the plan's entire book of MA business.
All in all, CMS made a number of concessions in the RADV methodology that they didn't have to, and which have the effect of significantly mitigating the risk and impact on the plans. They stated they're only after about $370 million in recoveries in 2012, much lower than the President's FY 2012 budget anticipated, and equating to about 0.3% of Medicare Advantage revenues, well below Wall Street expectations. RADV wasn't even mentioned in Obama's FY 2013 budget. Combine that with more favorable-than-expected draft 2013 rates for Medicare Advantage against the backdrop of the Age of Austerity we're in, and we see that these are big, important gestures that point to a new era at CMS: "the open hand and the closed fist." The open hand is that the Administration is now actively working to help plans where it can, especially on matters impacting revenues; the closed fist is the agency's continued willingness to take action against weak performers and the noncompliant. It's about as good as it's gonna get with this gang in the White House.
Medicare Advantage Hospital Readmission Rates Substantially Lower than FFS
An article in the American Journal for Managed Care found that Medicare Advantage (MA) patients experienced a much lower 30 day hospital readmission rate than FFS patients. The study found the MA readmission rate was 14.5 percent during 2006-2008, which was 22 percent lower than the FFS readmission rate. After adjusting for risk and excluding disabled beneficiaries, the study found that MA readmission rates were 13 to 20 percent lower than FFS. MA capitation rates provide a strong financial incentive for MA plans to reduce avoidable hospitalizations and readmissions, for example through the use of case management or network contracting arrangements. FFS has no incentives to control avoidable readmissions but that should change under a new program announced in 2011 that seeks to reduce FFS readmission rates by 20 percent.
How Doctors Die
Today's Wall Street Journal opinion page included a terrific op-ed on how physicians approach their own end of life care planning differently than most of their patients do, primarily because they actually understand the limitations of American medicine in prolonging life, and because they actually plan for the end.
The author, Dr. Ken Murray, a professor of family medicine at USC, wrote: "It's not something that we like to talk about, but doctors die, too. What's unusual about them is not how much treatment they get compared with most Americans, but how little. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care that they could want. But they tend to go serenely and gently. Doctors don't want to die any more than anyone else does. But they usually have talked about the limits of modern medicine with their families. They want to make sure that, when the time comes, no heroic measures are taken."
"Unlike previous eras, when doctors simply did what they thought was best, our system is now based on what patients choose. Physicians really try to honor their patients' wishes, but when patients ask "What would you do?," we often avoid answering. We don't want to impose our views on the vulnerable. The result is that more people receive futile "lifesaving" care, and fewer people die at home than did, say, 60 years ago. Nursing professor Karen Kehl, in an article called "Moving Toward Peace: An Analysis of the Concept of a Good Death," ranked the attributes of a graceful death, among them: being comfortable and in control, having a sense of closure, making the most of relationships and having family involved in care. Hospitals today provide few of these qualities. Written directives can give patients far more control over how their lives end. But while most of us accept that taxes are inescapable, death is a much harder pill to swallow, which keeps the vast majority of Americans from making proper arrangements."
I come from a family of doctors, and my Mom is an accomplished family physician specializing in palliative and end-of-life care. This is an issue we're passionate about in our family, and one I've pontificated on. And Dr. Murray nails the point here: those who know plan for the end, as we all need to.
But in the sudden resurgence of the culture wars during this GOP primary season, and the fact that at least two of the leading candidates -- Rick Santorum and Newt Gingrich -- had starring roles in the Terri Schiavo circus, it seems unlikely we'll get a meaningful discussion of end-of-life care as part of Medicare reform anytime soon. We live in an age of distortions like "Death Panels," where open dialogue on end of life is politicized and limits on what Medicare will cover are demogogued as rationing.
As I said back in October, Medicare Advantage plans are uniquely positioned to advance the cause of professional counseling for beneficiaries on their last wishes, preventing unnecessary surgeries based on the patient's preferences and likely clinical outcomes, and promoting the enthusiastic use of palliative care. A number of plans are leading quietly in this area, like UPMC in Pittsburgh, Excellus Blue Cross/Blue Shield in upstate New York (which actually has dedicated medical directors for end of life and palliative care), and any PACE site like On Lok in San Francisco.
We have much to learn from these end-of-life pioneers — they should be applauded and emulated for their courage in the face of the politics of end of life care.
Physician Engagement... What can you really do?
Health plans have tried a hundred ways to engage providers — incentive stipends, P4P, P4Q, capitation, clinical initiatives, episode of care payment, onsite coders, in office case management liaisons. But what works? Open communication, reasonable expectations, and simplicity.
Before CenseoHealth launches a patient evaluation program we meet with the community physicians to discuss:
1. Program Overview
2. Program Goals & Objectives
3. Community Customization & Clinical Opportunities
a. What are you doing well?
b. What do you need help with?
Often Censeo receives questions similar to those that follow:
• What are you doing with my patients?
• What can you really diagnose in the home?
• What do I receive from the Censeo clinical team?
• What if I want to participate?
Again, CenseoHealth shares the following:
• Program from launch to closure
• JAMA articles and clinical research & guidelines utilized in the Censeo programs
• Proprietary iPad tool and outputs for the evaluation
• Open Invitation to participate whether conducted in the office or home
As your internal metrics may highlight, between 8% and 30% of the membership may go to the physician's office for an evaluation, if encouraged. If the network physician has the same tool and the same time allotted for the visit, the outcome can be just as successful. However, if the physician's time is limited, the data collected is also limited. The averages results for an in-office evaluation completed in 25 minutes are approximately 1/3 of the information collected during an in-home evaluation; therefore the premium impact in the office is about 1/3 of the in-home impact.
How does CenseoHealth counter act the lower in-office results?
• invite the community physician to utilize the proprietary tool via iPad or paper
• educate network physicians on the HEDIS, STARs, HCCs, compliance, and accurate coding
• schedule in-office visits for the medical group to ensure the needed time is allocated for the experience
• completed quality assurance, coding, and analytics for the medical groups
• meet with both the health plan and medical to review reports and programs successes
We make your network part of the team and solution. Physicians are great team members when they are invited, respected, and given the premier instrument for success.