Medicare Advantage Plans as Laboratory for Best Practices
In announcing the 2012 Chronic Care Improvement Program and Quality Improvement Projects for Medicare Advantage plans, CMS is going back to the future.
When these quality improvement programs were begun over a decade ago, CMS established national projects on priority areas for all MA plans. CMS is returning to a national project for 2012 and will focus on decreasing cardiovascular disease. The initial experience with national projects was extremely positive, with most plans reporting interventions that resulted in measurable improvement.
The 2012 projects recognize the evolution of the quality improvement field and now the reports will be standardized with reduced burden to MA plans. Because the reports will be consistent, comparisons can be made across plans. CMS is recognizing that MA plans offer a laboratory for best practices and expects that successes can be shared among all plans, thus transferring knowledge and allowing successful projects to be replicated.
PBM merging pharmacy and medical claims: The time is right
Pharmacy claims exist in a health plan in two distinct silos. Medical pharmacy claims are billed to the medical benefit using a professional claim format such as a CMS 1500. Claims are coded with HCPCs rather than NDCs and are generally much higher cost pharmaceuticals than their retail counterparts. Medical claims are generated by physician practices, home infusion suppliers, specialty pharmacies, outpatient clinics, and hospitals.
Retail pharmacy claims are processed, adjudicated, and paid by a PBM contracted by a health plan. These claims are processed in real-time at the point of service which is usually a retail pharmacy. Health plans receive adjudicated claims data for these retail claims from the PBM and are stored in data warehouse obscurity.
For most plans, the two data bases are not combined beyond the highest level of totals for the combined drug spend. Consequently, there is lost opportunity for plans to achieve comprehensive medication management and integrated case management. Pharmaceutical outcomes for most diseases are not independent of medical treatment. Without combining the data for both pharmacy claims and medical claims, it is impossible to monitor total drug therapy utilization and to evaluate the true cost of therapy.
By combining pharmacy and medical claims, the plan can evaluate opportunities for optimizing pharmaceutical care, for example before a patient is moved to a more expensive biological agent dispensed by a specialty pharmacy. The member may be receiving both retail and medical claims for the same condition. With medical and pharmacy claims data combined, current therapy can be matched up with nationally recognized treatment guidelines and recommendations can be made to providers. Health plans can better achieve clinical quality goals with a combined data set.
In addition, once the data are combined, both types of data can be reviewed for fraud, waste, and abuse. Outliers can be identified and sent to validation. Recovery of excess payments can occur. Trending and other opportunities can be identified such as finding duplicate billing both from the pharmacy and a physician's office, duplicate claims from a single provider, or other aberrant provider reimbursement patterns.
For many plans, particularly the smaller ones, the technical resources required for merging the two data sources often are not available. Combining medical and pharmacy claims is a service by which a PBM can bring added value to the plan.
The current PBM model of focusing solely on pharmacy claims needs to evolve into a more robust, comprehensive tool for plans to achieve better control of pharmaceutical outcomes. PBM platforms have the capability to fit the role. The time is right for the PBM industry to step up to the challenge of helping plans manage both improved outcomes and lower costs.
Medicare's Looming Risk Transfer
Please read Dr. Jaan Sidorov's Health Affairs blog on "Medicare's Looming Risk Transfer" where he describes how the ACA and Democrat and Republican proposals to reform Medicare "transfer substantial portions of Medicare's monetized risk from the government to one or more third parties."
The Water Hazard of Risk Adjustment: HCCs from Claims
I love the saying "Golf isn't a sport - It is old man walking around in ugly pants."
Ugly pants aside, golf definitely has its challenges: water hazards, sand pits ... other golfers, trees, birds... finding your inner athlete .... and so does risk adjustment.
In the last six years we have gone from focusing on chart review to launching various versions of member evaluation, but this whole time we've been forgetting about HCCs we are submitting from claims. Those claims-based HCCs are the real hazard in our program. (Chart review may be like the sand trap — open another one and another one; just keeping swinging and swinging and at some point you will move the ball closer to the hole.)
We've all been at the conferences and we hear that on average, 37% of claims-based HCCs fail during a RADV audit. Last week during our Flash Webinar, The Analytics of Risk Adjustment, we were talking with 43 health plans and we asked the question:
How many of you health plans are filtering your claims - not just for site of service, provider type, and ICDs that trigger a HCC - but also by code confidence?
The Answer: TWO health plans out of the 43 are filtering their claims by "confidence"
The real question we were driving at? - are you confident this code from claims will be found in a compliant medical record and be documented appropriately enough to pass a RADV audit? Has more the one physician noted this condition? Does this condition look clinically appropriate for this member?
Claims flow in, and submitting them to CMS is like the peaceful water on the golf course. It looks harmless enough. But when your golf ball goes into the water, you don't know if it is 6 inches or 6 feet deep. And you don't know what kind of danger you are in if you don't filter your HCC claims-based codes.
CenseoHealth is now offering CareCurrent, a current-year analytics service that sifts through your claims codes and stratifies them into confidence tiers. This enables a health plan to make an informed decision about submitting claims-based HCCs before taking further action (whether chart review or a face to face member evaluation) to ensure there are compliant conditions.
Even if your golf pants are lacking a certain style, you'll still be sitting pretty with CareCurrent as your Callaway Diablo Edge Driver. Four!
The Medicare Pioneer ACO Program: What's Next?
For those of us even vaguely involved in Medicare, the reference to the Pioneer ACO Demonstration program elicits feelings of optimism and relief—optimism because it is an approach to reengineering healthcare and relief because the application submission deadline has come and passed.
Most of you will recall that the Pioneer ACO Demonstration program is a CMS/CMMI initiative to partner with sophisticated integrated provider organizations in an effort to improve the provision of healthcare services to Medicare eligible beneficiaries. The program is one of several initiatives first telegraphed by CMS Administrator Berwick in a November 16th 2010 press release announcing the formation and mission of the Center for Medicaid and Medicare Innovation. In part the mission of the center is to "rigorously and rapidly assess the progress of its programs and work with providers and other payers to replicate successful innovations in communities across the country. It will test models that include establishing "open innovation communities" that will serve as information clearinghouses for best practices of health care delivery reform.
By all indications, the Pioneer demonstration program is envisioned to achieve results which will hopefully become part of the CMS/CMMI toolbox for innovation and best practices. Consequently, those organizations that applied and will be selected are those who can demonstrate a history of patient/provider/payer collaboration; the existence of performance based approaches to delivering superior diagnosis and treatment of patient health issues; the presence of prerequisite governance; infrastructure and technology capabilities to integrate the clinical and financial requirements; and the financial strategies for implementation, operations and income distribution.
The good news is that the application development period is behind us and that those integrated provider systems that were assisted by GHG in their application development and submission process will have an excellent chance of moving to the next phase of the CMMI application evaluation process.
We believe the process will unfold as follows, (however we reserve the right to change our predictions once CMS/CMMI publishes its next update).
First, CMMI will review each application filed for completeness and timely submission. Some of the applications may be rejected outright. Others may be asked to submit additional information, clarify certain supporting documentation or correct omissions. It is highly likely that this initial review process will be quick and applicants will have a short window of opportunity to correct any deficiencies.
Second, those that pass the initial screen for completeness will be contacted by CMMI to schedule a face to face interview. It will focus on the content/detail of the application responses and a thorough Q & A is intended to demonstrate to CMMI the applicant's familiarity with operating a coordinated clinically and financially integrated delivery system in line with CMMI's triple —aim vision for Medicare healthcare.
Third, if the applicant interview is successful, CMMI will offer the applicant a contract to operate a Pioneer ACO for a minimum of three years and possibly for at least five years. Fortunately the applicant is not alone in navigating the post Pioneer ACO application development waters—GHG stands ready to provide assistance along every step of the way calling on our senior executives' long standing experience with the inner workings of CMS.
Those who decided not to apply for the Pioneer ACO demonstration program have not been eliminated from participating in CMMI innovation programs/initiatives, the most recent of which is the recently announced Bundled Payments for Care Improvement Initiatives.
I will be reviewing this new innovations program during my next blog and comment on GHG's perspective. Until then stay healthy.
Too Much of a Good Thing
Ever find yourself in the cereal aisle, staring blankly at the mosaic of options, your enthusiasm for the task waning with each passing second?
Everyone has heard (and experienced) the phenomenon of being overwhelmed by choice. Now, a new study, published in Health Affairs and conducted by Harvard Medical School appears to show that as the number of Medicare Advantage plans exceeds a certain threshold in a market, participation in the program actually decreases. This study has much in common with what has become known as The Paradox of Choice: too many choices overwhelm our brains and lead to indecision--- ultimately restricting us instead of freeing us. Thus, after a certain point, more choice means less freedom. As reported in Medical News Today:
The researchers gathered data on 21,815 enrollment decisions from 2004 to 2007 that 6,672 participants had made. They compared enrollment decisions made by participants with varying cognition levels, as well as types of plans offered in their areas.
They found that as long as the number of plan options being offered was fewer than 15, a rise in the number of plans resulted in an increase in Medicare Advantage enrollment. However, when there were over 30 options the number of enrollments actually dropped - this was the case in 25% of US counties. [emphasis added]
There is more interesting stuff in the study, including the impact of choice on members with varying levels of cognitive functioning. For more on the Paradox of Choice, listen to Barry Schwartz fascinating TED talk from 2006. A pre-emptive political point: Note that his quibble is with the way we promote more "freedom," not "freedom itself.
Remember, Mom: Digital is Forever.
Humana has launched a social network for its Medicare Advantage and Part D members called "Humanaville." No word yet if members have started posting embarrassing pictures of shenanigans in the skilled nursing facility...
Actually, it's not exactly a social network like Facebook. Rather, the design and functionality more closely resembles Second Life, in which users build an avatar and move within a multi-dimensional space, meet others, barter/trade, etc. This is not the first medical network of its kind. The Starlight Children's Foundation maintains a space for chronically ill teens called Starbright World, which more closely adheres to the Facebook model.
No doubt the plan should be given credit for pushing the boundaries of member engagement. However the model--and more specifcally the decisions made by Humana for the members within the model--seems to adhere to an older model of communication. At a cursory glance it appears Humana is attempting to carefully script and guide users' experiences, rather than create an environment, a social utility, full of user-defined content.
Like society at large there must be rules of engagement in these environments. But the brilliance of the social media model as an economic force (that's why Facebook is in the news... it's not because of Farmville) is that by allowing participants to wander around at will "liking" stuff and joining groups they track people's actual interests. This means that by the time Facebook puts a particular Old Spice ad in front of you the algorithm already knows: you're a man, you have a slightly juvenile sense of humor, and you care how you smell.
There is much talk in clinical circles about the tyranny of the internet on two fronts: in making every patient an expert via WebMD et al., and in the public rating of physicians. An entire industry called "Reputation Management" has sprung up in the last two years to protect physicians (and lawyers, and others) from the ignominy of having patients share their experiences with each other. This is a losing battle. It remains to be seen if payers or providers will rise to the challenge of the digital age--which has heretofore been defined by the inability of choice-makers to control it--or if they will revert to type and attempt to narrow choice and access to information along prescribed paths that lead inevitably to the next sale.
11th Circuit Court Strikes Down Mandate
Much of the news related to healthcare last week focused on those headlines. Those who have consistently argued that the Health Care Reform act is bad policy hailed the circuit court's decision as a victory. Those who believe in the mandate that every American have access to and be motivated to buy health insurance, decried the decision as just another example of "kicking the can down the road".
So who is the real winner? The real loser? It depends on who you ask (and whether the respondent already has insurance) and on who is taking care of the uninsureds' health needs. The provider community continues to be stuck with providing care to the uninsured, the cost of which is estimated to exceed 40 billion dollars per year, at last count. The tax payer, you and me, doesn't benefit by this ruling because ultimately that 40 plus billion comes out of our pockets in the form of higher insurance premiums and higher bills from the hospitals and the practitioners (it is called cost shifting).
And, believe it or not, it also impacts the cost of providing care under Medicare, because if I am an uninsured individual who does not seek healthcare unless it is an emergency—by the time I am eligible for Medicare I tend to be sicker than my insured counterpart and consequently my cost to Medicare will be significantly higher. Not a good situation, given that the Medicare ranks will swell by some 76 million people over time. Even if we account for a certain portion of Medicare eligibles dropping from the rolls due to death, without significant changes to how we finance and deliver healthcare, Medicare will become the single most costly program in the history of this country - and most of us will be around to see it and suffer under it.
In my last blog I talked about how a financial approach to solving the healthcare crises in the US is, at best, a short term approach akin to sweeping the problem under the rug (the "kick the can" analogy comes to mind one more time).
As an example, let's focus on the Medicare-eligible individual for the moment, to illustrate why a financial solution is not going to solve the problem. Assume that Medicare funding is cut across the board (that is exactly what is anticipated if the debt ceiling super committee cannot get its act together). The impact of such cuts? Providers are paid less (some suggest that they should be paid significantly less), which could result in primary care physicians and specialists closing patient panels to new Medicare patients; inpatient and other allied healthcare providers raising rates to balance out the cuts; and the individual Medicare-eligible exhausting their savings more quickly due to higher out of pocket costs. That in turn will lead to greater reliance by those individuals on other community services such as food stamps, Medicaid, state funded social and aging services, which will in turn drive up those expenditures and create significant budget issues in those programs.
By now you are probably thinking that this is just rambling with no real end purpose. Not really.
My point is that decisions we make in the healthcare field have far reaching consequences, whether they are made in a physician's office regarding how to treat a particular pathology, or whether they are made at the national policy level. Isolated decisions such as striking down the health insurance mandate set into motion a series of events, the impacts of which may not be felt for years, but can be very damaging once they become apparent.
No one disputes that the current health care reform has significant failings. This writer is amongst those who decried the process as well as the outcome. But irrespective of political leanings or philosophical differences, the Affordable Care Act and its emphasis on tying future provider reimbursement to better conceived approaches to patient communication, treatment and access is much better than the potential for an arbitrary cutting in healthcare financing as part of resolving this nation's debt crises.
All of us; providers, payers, healthcare industry professionals and patients, have a vested interest in reengineering our approach to health services delivery and financing through logic and rationality. After all, we will be customers of the system sooner or later. At that point in time, I for one would like a say in what I experience.
Data Security & Compliance: The Dwayne Johnson of Risk Adjustment
These days, Risk adjustment is a lot like WrestleMania these. I am not sure if that makes CMS John Cena…but I am certain health plans should be prepared for that folding chair to the head move.
Health plans need a new training regime and a new foundation. Security and compliance is the cornerstone on which a health plan's risk adjustment strategies should be built, and it must be supported not only by all health plan departments, but also health plan vendors.
As stated in the CMS call letter, you need to know your business, which also applies to your vendor processes and procedures. In a poll during our August 18 webinar, our audience of health plans shared that they only conduct onsite vendor audits twenty five percent of the time when they outsource risk adjustment servics. Gorman Health Group can help you create the data security checklist, but health plans have to get in the routine of going onsite. Get in the ring!
The health plan IT liaison needs to see the server room, understand the data back-up plan, notification process, and especially how the vendor handles data day-to-day. Is it sitting out on desks? In employees' car? Scary things happen when you don't ask questions.
Even scarier was this poll result: only 55% of health plans read their vendor's compliance plan. You need to know not only what the vendor is doing on your behalf but also how. With PHI fees and RADV extrapolation, make sure your vendor has a compliance plan and that you know what it says.
Download a copy of last week's webinar here.
How's their security and compliance? Your vendor oversight checklist
Yesterday Gorman Health Group Executive VP Steve Balcerzak and CenseoHealth's Director of Techology Archie Block joined me for one of our Flash Webinars, which covered the security and compliance points every health plan should review with their vendors.
We'll follow up later today with a recap of the event's live polls and surveys, as well as a final PDF of the webinar materials. Stay tuned!
We're offering 30 minute Flash Webinars every week this summer and invite you to join us. The next event is Wednesday, August 24 at 3 pm EDT: What's so important about prospective analytics anyway? Health plans can register by clicking here.