Member Evaluations Don't Replace the PCP

For obvious (and very good) reasons, Medicare Advantage plans want to maximize the unique opportunity afforded by in home evaluations of their members.  There is no question that these evaluations can yield diagnostic information that is essential to risk adjustment revenue management.  The opportunity to collect clinical information and merge it with data from claims and Medicare return files makes it possible for MA plans to positively influence care in a way that fee for service Medicare cannot.  Direct member evaluations also provide a way to quantify and improve measurable standards of care such as those included in HEDIS, ADA standards of care for diabetics, ACC standards of care for cardiovascular disease, and Star ratings.

 One question that comes up repeatedly in our conversations with plans is whether we can collect even more data during these encounters. Specifically, plans are interested in having our physician evaluators collect specimens for laboratory studies that factor into HEDIS and Stars measures.  On the face of it, this seems like a natural extension of the service, but there are a couple of not so obvious drawbacks.  

First, we are very hesitant to do anything that might be seen as coming between a member and his or her treating physician.  That is a unique and valuable relationship and we want to make sure that what we do only enhances it.

Second, we are concerned about the chain of responsibility in collecting that information.  First, a physician or other licensed provider has to order the test in question.  Our physicians can certainly do that, but then someone has to take the responsibility of checking the result and providing appropriate care based on the results.  That our doctors cannot do since that would require establishing an ongoing clinical involvement that would directly conflict with our determination not to interfere with the member's relationship with their treating physician.  An alternative would be for the plan medical director to accept responsibility for ordering and following up on the lab studies, but most plan CMOs are not willing to do that.

For those reasons, we have been hesitant to collect lab specimens as part of our evaluations, although we willing to discuss alternatives with our clients who need that service.

Exchange Will Do You Good

Two interesting items have been posted in recent weeks that perfectly capture the contrary motion of health reform implementation.  The first, found in the Washington Post, addresses the laggard's pace many states are keeping in implementing provisions of health reform--- in particular the health insurance exchanges that subsidize the purchase of private insurance by low and middle income citizens.  The controversial second, which appears this month in a McKinsey newsletter describes the incredible market pressures to do just that.

 For years, Washington wonks and informed political spectators have marveled at the left's inability to tie the issue of health care coverage to the interests of small businesses, which politicians of both persuasions never miss an opportunity to refer to as "the engine of the American economy."  Money that goes to high employee premiums does not go to creating jobs--- at least, not for the small business in question.  The McKinsey article projects that 30% of employers will "definitely or probably" stop offering health insurance to employees after 2014 (the schedule date of exchange implementation) and that more than 50% of companies with a high awareness of the health care law will simply stop offering insurance and send employees to Exchanges Wowza.

There are a number of interesting things about this extraordinary (if it turns out to be true) change in coverage: first, the tremendous churn of beneficiary eligibility across subsidy levels just got more interesting, as a new class of pseudo employer-sponsored beneficiaries floods the market. Second, the risk pool changes.  Lastly, if you make your living selling small group business policies, it may be time to open that Ebay store because your job is a whole heck of a lot less secure beginning in 2014.  You'll be in good company.  Many state Governors may find themselves in the same boat if they do not implement the exchanges in a timely manner, thereby depriving small businesses of the ability to make coverage the Government's problem and find more productive uses of capital.  To do so gives the opposition party a golden talking point going into the 2012 elections.

Risk Adjustment: This isn't Dodgeball, People

Let's have a quick check in about risk adjustment and the multi-disciplinary team that should be pushing it to success.

Remember the days of dodgeball?  ...picking teams and getting smacked by the red rubber ball?  In risk adjustment, you must ensure your team has the right members, or you're gonna be left with more than just a ball-shaped bruise on your thigh.  Here are the teams, and some of the members you must ensure are on your committees:

  1. Risk Adjustment Strategy: Risk Adjustment, Finance, Network Management, IT, Compliance and Medical Management, plus an Executive Sponsor
  2. Risk Adjustment and STARS Synergy: Risk Adjustment, Finance, IT, Medical Management, Quality/STARS, Network Management, and Member Services
  3. Risk Adjustment & EDPS: Risk Adjustment, IT, Claims, and Vendor (if you have one selected)

Make certain your team members:

  • Understand the basic rules of risk adjustment
  • Clearly recognize the importance of risk adjustment success

And don't forget:

  • You MUST have an executive sponsor for those inevitable bumps in the road
  • There MUST be alignment between the departments on priorities and strategies so that there is a clear path to your objectives.

This isn't dodgeball.  Risk Adjustment is more like Capture the Flag.  There will be winners; there will be losers.  NO TROPHIES for participation.  Pick your team well and keep them focused.

June is GO Time for Risk Adjustment: Your Program Check List

It's June!  And most people are thinking about summer vacation... unless, that is, you work in risk adjustment. 

This is Go Time.

Those living in the risk adjustment world should have their programs designed and launched by now.  Are you on target?  Here's your checklist:

  • Chart Review: List Developed, Outreach Done, Collection and Coding Started
    • Goal: 20-30% by the end of June
  • Hospital Data Collection: You've contacted your high admission hospital and you are on schedule for receiving tons of hospital data electronically by August 15th to insert into your September Sweeps.
    • Goal: All 2010-2011 through QTR 2 in by August 15th
  • Prospective Evaluation: List developed, outreach done, evaluation scheduling started
    • Goal: You should be sitting at about 20-20% completed

After doing this for the year, we realize that from Thanksgiving to the New Year the physician offices, hospitals, and members are much harder to reach.  Retrieval and closure rates fall significantly.

Save your vacation requests for a winter getaway ... It is Go Time Now

CMS Administrator Dr. Donald Berwick has been a strong proponent of Accountable Care Organizations as the ACO model embodies his triple aim of better care for individuals, better health for populations, and lower growth in expenditures.  He has committed CMS to launching ACOs under the Shared Savings program and the Center for Innovation demonstration program by the Congressional deadline of January 2012 as a hallmark of his leadership.

Dr. Berwick currently serves as the CMS Administrator under a recess appoint that expires at the end of 2011.  If he is not confirmed, which is the conventional wisdom based on Republican opposition in the Senate, ACOs will lose their strongest Administration advocate.

In March, The New York Times reported that Marilyn Tavenner, CMS Principal Deputy Administrator, was the candidate most likely to succeed Dr. Berwick.  Marilyn Tavenner's role at CMS primarily focuses on administering the agency and managing the huge new workload created by health reform.  This role capitalizes on her management experience at Hospital Corporation of America and her experience as Secretary of the Virginia Department of Health and Human Resources under Governor Tim Kaine. She is also a nurse.

On March 28, the Congressional Quarterly (CQ) discussed her low Washington profile and noted that she has not testified before Congress or talked to the press.  With regard to ACOs, the CQ article reminded us that at a speech in March she mentioned that the Administration might delay the launch of ACOs which was quickly corrected by HHS officials and then again by Secretary Sebelius two weeks ago who said the final ACO regulations were not likely until year end.

ACOs have strong bipartisan support and strong support from Secretary Kathleen Sebelius.  Thus, any potential leadership changes in CMS should have little to no effect in the launch of the Pioneer ACO Demonstration and the Shared Savings program.

The State of Play on Medicare ACOs

The comment period for the Medicare Accountable Care Organization (ACO) Notice of Proposed Rulemaking closed yesterday, June 6.  In the last two months CMS has taken a beating from virtually every corner on the draft regulation as being overly burdensome. 

Dozens of groups, including the American Hospital Association (AHA), American Medical Association (AMA) and America's Health Insurance Plans (AHIP), submitted their comments on the proposal. High-profile Physician Group Practices (PGPs) such as the Cleveland Clinic and Mayo Clinic have said they are unlikely to participate in the Medicare ACO initiative.

AHA fears high implementation costs and excessive quality requirements will prevent hospitals from forming ACOs. AHA believes it will cost a 200-bed hospital with 80 primary care physicians and 250 specialists $11.6M to launch a Medicare ACO; a 1,200-bed, 5-hospital system with 250 primary care physicians and 500 specialists is expected to run $26.1M.

Battle lines were drawn on antitrust issues in comments from AMA and AHIP, which offered diametrically-opposed recommendations.

We believe CMS will listen to entreaties to reduce the quality reporting burden and will help provide improved cash flow for ACOs (we hope through partial capitation and getting rid of the 25% withhold) and possibly increase the share of savings that ACOs can keep, to encourage adoption.  But given the huge volume of comments and political sensitivities in Congress on ACOs, we think it will be toward year-end before a final regulation is issued. 

The "Pioneer ACO" Demonstration is scheduled to begin this fall, with applications due to CMS July 18 and a full program launch January 1st.  We are seeing moderate interest among marquee providers — especially those with their own Medicare Advantage plans -- in participating in the Pioneer ACO Demonstration and believe chances are good that CMS will fill its 30 slots for these "ready to launch" ACOs if the agency listens to industry input on partial capitation arrangements in the coming weeks.