Recommendations Made by the National Quality Forum on Medicaid Measures
The National Quality Forum (NQF) is a non-profit organization working to evaluate and endorse standardization of healthcare performance measures. Recently, NQF submitted a series of reports to the U.S. Department of Health and Human Services (HHS) outlining recommendations on new measures aimed at improving Medicaid beneficiary quality of care. For the last four years, NQF started providing strategies to HHS on improving care for dual eligibles, adults, and children in the Medicaid program. These new quality measures were created to improve healthcare quality for more than 70 million adults and children. The key area of concentration was the beneficiaries' behavioral health and how it affects diabetic and cardiovascular care delivery.
In the reports, NQF tracked the effects behavioral health has on diabetics and the domino effect it has on a beneficiary's overall health. Many providers are seeing that therapies used on patients with serious behavioral health issues are causing significant health problems. An example is weight gain as a side effect of the medications given to treat mental health illnesses. They saw this turn into health issues, such as diabetes, in these patients. The report continues to state that not addressing the behavioral health problems of a beneficiary has led to higher glycated hemoglobin (A1C) which then resulted in cardiovascular issues. This problem of addressing both the physical and mental health needs of the Medicaid population has been in the forefront of the American Psychiatric Association and U.S. Psychiatric and Mental Health Congress.
NQF has made recommendations for the working age population of adults, which are also the most rapidly-growing population relating to controlling and monitoring cardiovascular health (e.g., high blood pressure) and medication management in those individuals who have serious behavioral health illnesses. NQF has also made recommendations for children and dual eligibles. Due to the complex needs of the dual-eligible population, the amount of measures was increased, many concentrating on behavioral health and comorbidities. They also concentrated on making changes to the care coordination and readmission rate monitoring.
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Join us on Friday, October 9, from 1-2 pm ET, as John Gorman, Founder & Executive Chairman at Gorman Health Group (GHG), examines the state of government healthcare programs and outlines proven tactics market leaders are implementing to cut costs, increase member satisfaction, and drive sustainable growth. Register now >>
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Healthcare Implications Post Boehner Exit
House Speaker John Boehner announced last Friday he will resign his seat at the end of October. Following this announcement, House and Senate members immediately announced plans to pass a spending bill preventing a government shutdown by scrapping plans to block Planned Parenthood funding for the time being. Boehner's resignation makes this move possible because he no longer faces the threat of being ousted by the House Republicans if the bill he brings forward to the floor does not have Republican majority.
While the most imminent government shutdown has currently been averted, the threat of everything coming to a halt mid-December, at which point the spending bill funding would run out, is much more likely to materialize. The next funding bill will need to work out the funding levels for the rest of budget year 2016 in order to prevent a government shutdown. In an attempt to put the continual nightmare of annual shutdown threats off until the next administration, Senator McConnell just announced potential talks with President Obama to negotiate a 2-year budget, and cover fiscal year 2016 and 2017.
So what does this all mean for healthcare and the Affordable Care Act (ACA)?
Planned Parenthood aside, Boehner was actually quite a critical opponent of Obamacare and fought it to the very end, even bringing lawsuits against the administration. His only move seen as a positive in the healthcare industry is the support to repeal the flawed Sustainable Growth Rate (SGR) formula earlier this year. Because House Republicans are likely celebrating the win of the resignation, however, we will likely see many more attacks on the ACA despite all of them being unlikely to work, just as under Boehner's leadership.
Reconciliation bills are one likely tactic — House Ways and Means Committee already approved one today — to repeal portions of the ACA, such as employer and individual mandates, medical device tax, and the Independent Payment Advisory Board. The House and Energy Committee also introduced a reconciliation bill to defund Planned Parenthood. However, although Boehner stepping down may mean such bills could make it through both the House and Senate, they will certainly meet their end on the President's desk.
Unfortunately, this also puts any potential good bipartisan agreements at bay for the time being. Bipartisan bills to repeal the "Cadillac Tax," for example, will likely see much more punting around. Repealing the tax would create an $87 million budget deficit, and, with what is shaping up to be an aggressive fight in December, such a move is unlikely.
Under the new speaker's leadership, likely a more conservative pick, the Planned Parenthood fight may also stick around until December 2015. While Boehner was more willing to work across party lines on this issue, the current Republican majority is celebrating the resignation and may be much more emboldened in their fight in December.
The big issue is, of course, the 2016 budget. While the current spending bill will deal with emergency issues such as the imminent expiration of the transportation funding, the bill in December will need to tackle the FY 2016 budget as a whole. One huge one is Part B premiums — if Social Security is not adjusted and stopgap funding is not provided, this fund could run dry, and Medicare recipients under Part B will see significant premium increases. Another example is the temporary funding created by the repeal of the SGR, for example, funding for ambulance rides and physical therapy. These programs will face cuts if funding is not agreed upon in December.
Resources
Join us on Friday, October 9, from 1-2 pm ET, as John Gorman, Founder & Executive Chairman at Gorman Health Group (GHG), examines the state of government healthcare programs and outlines proven tactics market leaders are implementing to cut costs, increase member satisfaction, and drive sustainable growth. Register now >>
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ACOs Should Run for the Exits and Into Medicare Advantage
CMS recently released results from the Medicare Pioneer Accountable Care Organization (ACO) Program and the Medicare Shared Savings Program (MSSP). Once again the results are a mixed bag: quality is up, but the ROI for most participants is a joke. The update should have the most sophisticated demo sites running for the exits and into Medicare Advantage — but they need to move fast with the holidays and a February filing deadline for 2017 looming.
Pioneer ACO Program
CMS initially selected 32 health systems to participate in the program. It's down to 19 today. For the year 2014, 622,000 beneficiaries participated. Findings:
- Pioneer ACOs generated total savings of $120 million in 2014, a 24% increase from 2013 ($96 million) and $88 million in Year 1 savings.
- Eleven health systems generated gross savings beyond the minimum goal and received performance payments totalling $82 million. That's a pittance for what's been invested to participate. Of the 11 companies, a few reported notable savings:
- Banner Health in Arizona generated roughly $18.7 million in savings
- Partners Healthcare in Massachusetts generated roughly $13.2 million in savings, with around 70,000 beneficiaries participating.
- Beth Israel in Massachusetts lowered costs by 3.7% and generated roughly $9.8 million in savings.
- OSF Healthcare System in Illinois lowered costs by 3.0%
- Michigan Pioneer ACO in Michigan lowered costs by 6.3%
- Monarch Healthcare in California lowered costs 4.0%
Three Pioneers incurred the nightmare scenario of a giveback payment to CMS in 2014, including Beacon Health in Maine ($2.9 million), Dartmouth-Hitchcock in New Hampshire ($3.6 million), and Franciscan Alliance in Indiana ($2.5 million). All had to inform CMS of their decision to stay or exit the program by September 14. After two years of consecutive losses, Dartmouth-Hitchcock planned to exit Pioneer and apply instead for the Next Generation ACO program. It's a black eye for the system that's home to Dr. Elliott Fisher, widely considered to be the inventor of ACOs. Beacon Health is also exiting the program after facing losses for two years in a row, and will also apply for Next Generation.
Total model savings per Pioneer was $6.0 million in Year 3 (2014), up from $4.2 million per ACO in 2013 and $2.7 million per ACO in Year 1 (2012). The mean quality score among Pioneer ACOs increased to 87.2% in 2014, an improvement of 200bps from 85.2% average performance in 2013, and way ahead of 71.8% in Year 1. The Pioneers improved on 28 out of 33 quality measures. So most are delivering the quality goods, but aren't seeing much if any return for the effort.
Medicare Shared Savings Program
In 2014, there were 333 participants in the Medicare Shared Savings Program, and 92 of these ACOs kept spending below their targets, up from 58 ACOs out of 114 in 2013. The victorious 1/3 earned $341 million in performance payments. Takeaways:
- $465 million of the savings generated will accrue to the Medicare Trust fund, $341 million will be returned to participants.
- 89 ACOs actually reduced health care costs compared to their benchmark, but did not qualify for shared savings because they did not meet the minimum savings threshold. So 2/3 of ACOs are winning on expense, but only half of those got paid. That's a problem.
- Veteran ACOs were more likely to generate performance payments. Twice as many ACOs that entered the program in 2012 got paid vs. freshman systems (38% vs. 19%).
Lined up alongside other innovation failures like the bundled payment and nursing home quality demonstrations, it's clear CMS's innovation agenda has been hobbled by poor design and lack of business acumen. There's never been a better time for an industry veteran like Andy Slavitt to lead the agency out of the darkness.
The clock is ticking for ACOs to make the evolutionary leap into the one "devil we know" of Medicare Advantage.
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Our team of veteran executives can help your ACO evaluate the options, manage the workflow to achieve either a Medicare Advantage contract with CMS or a risk contract with an existing MA plan, and continue to achieve improved outcomes. Visit our website to learn more >>
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The Medicare Advantage Value-Based Insurance Design (MA-VBID) Model Test
The Centers for Medicare & Medicaid Services (CMS) announced on September 1 a proposed demonstration that will test varying benefit designs based on health status. The overall goal is to improve clinical outcomes while reducing plan expenditures.
This demonstration is proposed for seven states: Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee. According to the announcement, only current Medicare Advantage organizations in good standing in those states will be allowed to participate. The demonstration is aimed at Health Maintenance Organizations (HMOs), Health Maintenance Organization Point of Service (HMO-POS) plans, and local Preferred Provider Organizations (PPOs) in order to determine how it affects beneficiaries and costs in the most common plans. Special Needs Plans (SNPs), Regional PPOs, Medicare-Medicaid Plans (MMPs), Private Fee-for-Service (PFFS) plans, Employer Group Waiver Plans (EGWPs), Health Savings Accounts, and cost plans are not eligible.
The demonstration will waive certain regulations so benefit plans can vary for enrolled members based on their diagnosis, condition, or need for a medical service. Currently, health status distinctions in providing benefits to enrolled beneficiaries are prohibited by regulations. Organizations can propose any myriad of combinations of benefits or services provided they are based on the proposed chronic conditions listed in the announcement. Most importantly, CMS notes participating organizations can initiate the demonstration with a limited benefit and can expand their benefit plans during the five-year term of the demonstration. While the benefits will be mandatory supplemental benefits, CMS proposes to prohibit marketing these benefits to non-member beneficiaries.
The CMS process begins with the submission of a Request for Application (RFA). Organizations failing to submit an RFA cannot participate in 2017 but may be allowed at a later date during the five-year demonstration period. Organizations must submit an RFA that has sufficient detail to allow CMS to determine if the benefit plan addresses targeted beneficiaries, will provide measureable results, and is appropriately structured for the demonstration.
RFAs are currently due by November 15. CMS will bind the organization to the proposed benefits in the RFA to their bid proposal for 2017. Consequently, conducting in-depth data analyses is necessary to propose a benefit plan in the RFA. This is the critical step that must begin in the very near future to meet the RFA submission date.
Is this the right opportunity for your organization? Attend our webinar to find out.
Join John Gorman, Founder and Executive Chairman at Gorman Health Group, on Tuesday, September 29 from 1-2 pm ET, as they outline the MA-VBID plan requirements, as well as what you should be doing now to prepare for January 2017.
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Health plans in the applicable states need to place emphasis on data analysis and strategic planning as well as application support. We can help - Contact us today.
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Government Sends Stark Reminders that Insurers' Biggest Customer is Still the Regulator
Since we opened our doors 19 years ago, we've preached to health insurers to think of the government as your business partner. This week, we got several reminders that insurers' biggest customers -- Medicare, Medicaid, and ObamaCare -- are still the regulator. As business conditions improve for health plans across these business lines, government expectations are rising, and scores are about to get settled, as they always are in the second term of a Democratic administration.
We see it in enforcement activity from the Centers for Medicare & Medicaid Services (CMS). We see it in a steadily-rising bar of Star Ratings and other performance measures for health plans for all three programs, the basis of looming contract terminations. And now the White House jumps in with an aggressive schedule of risk adjustment data audits, openly seeking repayments and dropping "f" bombs: fraud, that is.
They named a great film after a moment like this: "There Will Be Blood."
You can't argue with the numbers: 2015 remains the most punitive year in Medicare Advantage history. Look at the trend:
CMS is also being much more aggressive this year with data-driven oversight and enforcement. Communications to health plans who are "outliers" in various performance measures, especially in member communications and consumer protections, began recently. A pattern we are seeing play out is CMS chasing down all clients of noncompliant pharmacy benefit managers; where poor Part D performance is seen in one plan, the agency then begins auditing that vendor's other customers, assuming they'll get the same findings.
We know that Star Ratings and expanding reporting requirements in Medicare Advantage and Part D mean the bar is rising and establishes data-driven thresholds against which health plans can be penalized and terminated beginning in 2016. CMS announced sweeping new reporting requirements for both programs this week, which inevitably get picked up in Medicaid and ObamaCare rules in following years.
And now the White House is piling on. In Washington, we talk a lot about "setting the terms of debate." Our industry has lost the debate on risk adjustment coding and has allowed anti-managed care advocates to define payers' inaccurate diagnostic coding as fraud. A just-disclosed February 2015 letter from President Obama's Budget Director to Health Secretary Sylvia Matthews Burwell stated, "While some progress has been made on this front, we believe a more aggressive strategy can be implemented to reduce the level of improper payments we are currently seeing...we must continue to explore new and innovative ways to address the problem and attack this challenge with every tool at our disposal...the government estimate of $12.2 billion in these mistakes for fiscal year 2014 remains a concern." He extended his mandate beyond Medicare Advantage to over $3 billion in questionable payments from Medicaid. This means a spike in data validation audits for payers across both programs with the threat of improper payment clawbacks and even prosecution under the False Claims Act.
There has never been a more Golden Age of opportunity for health insurers in government programs. But the threats are escalating as well, and as my politics professor told me, "99% of political wounds are self-inflicted." Plans caught up in this dragnet will have gotten plenty of warnings.
Resources
The Part C and Part D Reporting Requirements and Supporting Regulations were posted in the PRA Listing on August 24th for review and 30-day comment. Since we are still in this window, this is a great opportunity for Compliance and Operations to review these together. Click here to review the Part C highlights that merit your attention in a blog posted by Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group (GHG).
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Medicare at 50: Past, Present & Future
Since its inception on July 30,1965, millions of elderly and disabled Americans have been able to obtain medical care through Medicare. Before Medicare, almost half of all Americans 65 and older had no health insurance. Today that number has dropped to a staggering 2 percent.
The accomplishments for Medicare have been noteworthy.
These include increased access to health insurance coverage and healthcare, decreased disparities in access by race leading to desegregation of hospital staff and facilities, as well as payment and delivery system reforms such as prospective payment, capitation, and shared savings — all of which have been adopted by private payers. Karen Davis from Johns Hopkins and former President of the Commonwealth Fund noted the success of Medicare's insurance Marketplace which offers beneficiaries a choice of traditional Medicare and Medicare Advantage plans with a 4-5 Star program that is driving plans and enrollment to higher quality. Medicare spending per capita has grown more slowly than overall health spending per capita and is currently at historically low rates.
The challenges are many.
Disjointed coverage (Parts A, B, D) is confusing to beneficiaries and results in high administrative costs and overpayments. Out-of-pocket costs for premiums, cost-sharing, and uncovered services remain high, and Medicare has no out-of-pocket maximum. Medicare does not cover long-term care services or home- and community-based services. Provider payment still remains largely fee-for-service, resulting in incentives for volume and provider not patient-centered care.
The Future
The future involves many different directions. The first is moving from an acute care model to a program that can effectively care for beneficiaries with complex chronic conditions. Provider payment reform needs to move to value-based payment that rewards efficiency and quality. The focus needs to shift to patient-centered care rather than provider-centric care. Care coordination and team care needs to be a focus. Program fragmentation and high out-of-pocket costs, particularly for high service users, needs to be addressed.
As Charles Darwin pointed out, evolution isn't about being the biggest or the smartest, but the most adaptable. Government programs have become the biggest opportunity for payers. Rates will be positive especially in Medicare Advantage, but the compliance environment will be brutal throughout the rest of the Obama administration. Star Ratings and the member experience are now driving the market — 30 plus states are now using some form of Star Ratings for performance-based payment, many states have adopted quality ratings for Medicaid managed care plans, but there is no national standard….yet, and the Health Insurance Marketplace will begin publishing quality ratings in 2016.
What have we learned?
John Gorman, Founder and Executive Chairman at Gorman Health Group, recently provided lessons learned in the 19 years we have partnered with health plans operating in Medicare, Medicaid and now the Health Insurance Marketplaces. He discusses the current industry environment and what's important moving forward. Read more >>
About 81M will be enrolled in Medicare by 2030. Is your organization prepared?
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Gorman Health Group evaluates the design and delivery of high quality collaborative care while achieving compliance and improving revenue cycle management. Our multidisciplinary team of experts will assess the alignment of your products, your current network and your market to translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>
GHG can evaluate your Star Ratings approach, and identify tactics you can begin implementing immediately, to integrate initiatives, eliminate redundancies, and build an enterprise-wide Star management structure. We can help you identify clinical, operational, and networking opportunities to increase your score for 2016 and beyond. Contact us to learn more >>
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Game Changer: Key Reforms Proposed in CMS Medicaid Rule
You've got your nose to the grind stone working to meet all the waves of operational changes and requirements related to Medicare, Medicaid, Obamacare, and Health Care Reform - you literally don't even have time to glance upward to the skies. Understandable. But it can cost you.
July 27th is the CMS deadline for all to submit their comments about the recent Medicaid Rule, which according to Andy Slavitt, Acting Administrator of the Centers for Medicare & Medicaid Services (CMS) is intended to "…better align regulations and best practices to other health insurance programs, …to strengthen federal and state efforts at providing quality, coordinated care to millions of Americans with Medicaid or CHIP insurance coverage." What does this have to do with me TODAY?
Now is the time to strategize, innovate and transform your plan and benefit design so that your operational platforms can grow as the rule will require you to. Here are two examples from Gorman Health Group's (GHG's) Medicaid webinar that took place on Wednesday, June 24, hosted by my colleague, Sunmi Janicek, Vice President of Medicaid and myself.
According to John Gorman's blog, "You're Doing it Wrong in Care Management" issued May 18, 2015, you are going to need to modernize your approach in care management into data-driven care coordination "pods" providing a holistic model of care focused on high utilizers and those about to become them. This means you need to recommit to data analytics identifying and directing the work of care managers toward those beneficiaries with long-term needs that can be impacted. Further, you need to place a greater emphasis on preventable episodes of care, and on end-of-life care preferences, advance directives and care plans. If you take the top 5% of the membership that is incurring the most cost and provide complex care management, including a higher level of home care, hospital diversion, medication therapy management, nutrition counseling, and wound care, plans and their provider organizations will see a reduction in avoidable medical expenses. Those reductions in avoidable medical expenses translate to better managed Medical Loss Ratios (MLRs), which directly impact your bottom line. How so?
The proposed implementation of the new rate setting will require managed care organizations to meet a MLR minimum of an 85% threshold. This is to ensure adequate funds are being spent on coverage for Medicaid members appropriately as states seek to move more and more Medicaid beneficiaries into managed care on a mandatory basis. CMS has charged states to develop new rates that will promote program goals that include benchmarks for quality of care, community integration of enrollees, and cost containment. Further, CMS wants to ensure enrollees are receiving quality of care and access in a timely manner, so they have asked the states to propose set standards for time/distance for specific provider types.
MLR thresholds are currently being used by the private health insurance plans, as well as, Medicare Advantage plans for projections of future medical costs and covered services. By including Medicaid in this imitative, it's evident CMS is trying to find a way to align standards among the different offerings across the board, but how will it affect your MCO?
While Medicaid MCOs don't have the high sales and marketing costs of individual commercial plans, since sales are handled by the states, compliance costs could be high, making the 85% figure a cause for concern. Medicaid MCOs will have to be diligent in identifying and documenting costs incurred to improve quality; essentially determining spend that could be considered medical versus administrative; to drive up their MLRs. Plans need to be able to fine-tune care coordination and quality, which are the hallmarks of managed care, and a federal MLR regulation could inhibit this. Do you have the right processes in place to ensure this happens?
With all these new changes, we can't stress enough that there will be a huge impact on implementation initiatives and sustainability that affect not only the finance department, but all departments. Once sustainability is achieved, it needs to be maintained as it will be addressed in future compliance reviews.
We are currently working with organizations in your area to identify gaps in operations while improving the ways they respond to clients, and developing care management models for the Long-Term Services and Supports (LTSS) population that make sense and will impact MLR. We share the same goal as you: to implement high quality, accessible, and cost-effective health care to our nation's most vulnerable population.
As soaring enrollment issues with varying populations of people persist, and new programs continue to be introduced, tough challenges are ahead. We can help make the transition smooth. Contact us today to get started >>
Resources
To download the recording of the June 24, 2015 webinar mentioned above, please click here >>
GHG understands the complexities of the Medicaid population, and the numerous shifting variables that affect plan financial performance, such as state specific requirements for risk adjustment. GHG can assist with identifying the current and future costs of doing business, while building in anticipated adjustments that make sense for each population served. Visit our website to learn more >>
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Takeaways from Accountable Physician Groups' Annual Summit
Twice a year I get the honor of speaking to the California Association of Physician Groups' (CAPG) annual summit and DC policy meeting. CAPG represents accountable, capitated physician groups, and now has members in 39 states. They're always among my favorite speeches given how sophisticated the audiences are. Here's a few takeaways from my talk last week on "The Future of Government Programs":
- Forevermore, physician group revenues and earnings will be dominated by Medicare Advantage, Medicaid and dual eligible health plans, and the ObamaCare plans, most likely in that order.
- Everything that Medicare Advantage (MA) does, the Medicaid, ObamaCare, and commercial markets follow 3-5 years later. Nobody knows this better than the CAPG members from CA, which the rest of the nation lags. Want to still be attending CAPG meetings in 2020? Master Star Ratings and risk adjustment. They'll apply to all lines of business if they don't already, and they are the keys to survival already in MA.
- Value-based contracting is in its infancy but will soon define all health plan contracts with physician groups. Fee-for-service is dead. Performance-based capitation is the only future. To master it a physician group needs a range of capabilities, including eligibility verification, interoperability, actionable clinical intelligence in real time, standardized care processes, and chronic care management, across all business lines.
- Most Accountable Care Organizations (ACOs), especially the 424 in Medicare, will not see a return on their investment. They will have spent millions to participate in these experiments and around 80% won't see a payoff. 2016 and 2017, when Medicare Advantage benchmark rates turn into a tailwind, present the perfect opportunity for ACOs to "move up the food chain" to become health plans.
- Dual eligibles are the biggest opportunity of our lifetimes, and there is no question that Special Needs Plans designed to serve them can be profitable. SNPs are a principal mechanism for states to shift long-term care risk into the private sector, and will be a central product for ACOs converting into Medicare Advantage. But they require a range of capabilities most physician groups lack today, such as enabling and social services that duals must have from their insurer.
- In all government programs, the "5/60 Rule" governs. 5% of members often account for 60% of costs. Any physician group that aspires to bear risk must be able to identify and intervene with their 5 percenters or they won't be risk-bearing for long.
- The biggest vulnerabilities for MA plans are consumer protections like appeals and grievances and complaint management, and who they have selected as their pharmacy benefit manager (PBM). Most PBMs are frankly terrible at Medicare Part D administration, and Star Ratings now count far more in Part D than in Medicare Advantage to a health plan's overall score. Physician groups typically have little or no experience with either PBMs or consumer protections.
- Retail pharmacies and the home are the most underutilized sources of care to government programs beneficiaries. Any successful physician group evolution will involve better integration of both sites for the chronically ill.
- Most at-risk physician groups are directly involved in coding and reporting for risk adjustment. Federal agencies are paying unprecedented attention to upcoding in Medicare Advantage with an eye to hundreds of millions of dollars in clawbacks and recoveries. The emphasis at physician groups involved in risk adjustment must move from chart reviews and claims extracts to more holistic member evaluations, and from a culture of "what can we get?" to "how do we stay out of trouble?"
Evolution is a messy business. Nowhere is that more the case than in physician groups evolving from fee-for-service to value-based contracting and becoming insurance companies. If it was an easy business, we'd be out of business.
Resources
Don't miss Gorman Health Group's Chief Consulting Officer, with colleagues Jane Scott, Senior Vice President of Clinical Innovations and Regan Pennypacker, Vice President of Compliance Solutions, as they discuss your member experience and the factors that influence success and failure, as well as prominent compliance and service issues plaguing the industry. Register now >>
From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation — where the potential is promising, we can help design and implement these arrangements. Let's get started. Contact us today.
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Implementing a new PBM? What you need to know.
Now that the smoke has cleared and the ink is dry on the formulary/transition and bid submissions, it's okay for plans to breathe for a couple of weeks. Then—if you're implementing a new Pharmacy Benefit Manager (PBM)—it's time to roll up your sleeves and get started with conceptualizing and developing a road map for the next six months. It's important to start early and work steadily to make decisions, create processes, and complete training. During this time, you must continue to partner with your current PBM to process claims, make coverage determinations, and oversee and monitor all the delegated functions according to the plan you have in place. With the new PBM, you have the opportunity to tweak some processes that perhaps weren't working exactly as you had envisioned originally.
The new PBM should have a detailed work plan they utilize for implementations, and their team can be invaluable in assisting with timing needed for decisions and keeping the project on track. Don't cancel meetings or get behind on decisions that need to be made. You will need every bit of the time in November and December to get testing done on the new formulary and to reach out to members who will be disrupted by formulary changes. And, if you're implementing a new PBM because of dissatisfaction with your current PBM, begin as you mean to go on. In other words, think about the nature of the relationship that best serves your organization and staff and start developing it from the beginning. It IS just business, but you will be working with the PBM team members on a daily basis for the next few years. So start off on the right foot and build the foundation of a relationship that will benefit your members and your organization.
Resources
The GHG Pharmacy team can assist you with your PBM implementation by providing subject matter expertise on all the decisions that need to be made and the processes that need to be developed. And we have a state-of-the-art benefit administration testing plan to help you before go-live.
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HRADV: What you don't know could cost you millions
Now that the 2014 EDGE server submission is complete, it will soon be time to audit a large sample of the data. Are you ready?
HRADV is the Commercial Risk Adjustment Data Validation that will be conducted annually on the data submitted to the EDGE server. This audit is similar in nature to the Medicare Risk Adjustment Data Validation (RADV) with a few exceptions. You do not get selected for the HRADV; rather, it is an annual requirement that the auditing process is conducted on at least 200 members. An error percentage will be assigned for health status and demographic information that does not have appropriate supporting documentation. This error percentage amount will be deducted from the prospective years' risk adjustment payment, or a payable will be due to The Department of Health and Human Services (HHS).
I have heard many health plans say, "There are no financial implications to the 2014 and 2015 HRADV errors" and "These are the learning curve years." While both statements are true, the fact of the matter is, these years DO count. You could be leaving millions of dollars behind for these years, not only for risk adjustment but for reinsurance as well. You are also at risk of being fined a significant error penalty after the "learning curve" years. Now is the time to ensure you have all of the necessary processes in place. Here are a few questions to ask yourself about the risk adjustment operations at your company:
- Are your providers familiar with the tremendous impact the transition from ICD-9 to ICD-10 has on risk adjustment, reinsurance, Stars, and the Healthcare Effectiveness Data and Information Set (HEDIS®)?
- Do you have the right staffing in place to support end-to-end risk adjustment successfully?
- Did you successfully submit complete and accurate 2014 data to the EDGE server?
There are many areas inside and outside of the company where membership and claims data may be compromised. This information is being sent through many different systems which increases the probability for information to unknowingly be altered. Here are some tips to prevent submitting incorrect or incomplete data to the EDGE server:
- Ensure you have a solid provider contract and education program in place.
- Align a risk adjustment staffing model appropriate for your organization.
- Develop ongoing data review and reconciliations with various departments throughout the company to create data integrity.
- Be prepared for the HRADV and appeals process.
HRADV and appeals is the final step in the risk adjustment process. More information will be released from HHS regarding the specifics around the audit for 2014. Be prepared and ensure you have selected your Initial Validation Auditor (IVA).
Resources
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