2017: Taking Stock to Inform Next Steps
As the end of 2016 approached, it made for a good time to look back on developments that have impacted us over the past year. The most impactful changes related to 2016 decisions are to come, however, a few important lessons learned over the past year are worth additional reflection. This is especially true if you believe in the effects of Mercury in retrograde.
- The audit protocols continued to be a work in progress not only for sponsors, vendors, and industry partners like Gorman Health Group, but also for the authors at the Centers for Medicare & Medicaid Services (CMS). A myriad of industry comments were submitted for consideration as they relate to the draft 2017 version. By now, most sponsors should have already incorporated similar methodology into audit and monitoring processes as a complement to existing methods.
- Sponsors without established monitoring and oversight focus on the accuracy of their network information have been subject to CMS review, have sought outside assistance to verify network accuracy, or have worked or are working internally to varying degrees to remediate known gaps in their processes. Per CMS, the Medicare Parts C & D Oversight and Enforcement Group (MOEG), in coordination with the Medicare Drug & Health Plan Contract Administration Group (MCAG), are taking a comprehensive approach to monitor, audit, and validate compliance with network accuracy requirements. MOEG’s pilot will use MCAG’s monitoring results to audit and validate correction of deficiencies. Some of the highest Star-rated plans can tell you about their network validation efforts and best practices, and it’s not a one-way street ‒ providers need to collaborate with sponsors and be proactive when information changes. We may expect to see enforcement actions stepped up as a result of CMS’ maturing efforts in validation of network accuracy.
- Earlier in 2016, our Operations team highlighted areas to keep an eye on based on the 2017 Draft Call Letter. They included the one-third financial audits, timely processing of coverage determinations and redeterminations, as well as data integrity. CMS has since noted they will increase penalties for outliers of Coverage Determinations, Appeals, and Grievances (CDAG) auto-forward rates, and they confirmed they will continue to raise the consequences for ongoing noncompliance in this area in 2017. The appeals timeliness monitoring effort announced on November 29 will provide CMS even more data for review and action.
- Later in the year, our Pharmacy team recommended key strategies to prepare for the coming year, including conducting Pharmacy Benefit Manager delegation oversight audits and conducting targeted audits. Most, if not all, of the mentioned strategies require a group effort, which begs the question: Did you have the time and the resources to accomplish all you wanted to do by end of year?
This is a good time to rethink methodologies and reorganize in preparation for changes to come. The key here, especially this month, will be to take stock of what we do not have control over, set those things aside, and plan to take action where we can.
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Reflections on the Basics of Delegation Oversight
Imagine entering University and enrolling into Advanced French Language and Literature, a 300-level class, with no previous knowledge or study of the French language. As your professor welcomes you into class with bonjour, bienvenue, ça va, you have no idea how to reply. Now imagine sticking with that course for the full semester, trying to understand complex language and reading concepts without the foundation or basics. It would be quite an overwhelming few months for anyone.
With any course of study, it is important to start from the beginning. Furthermore, if you want to master that course, teamwork and collaboration allows for practice and improvement towards fluency.
As we start wrapping up 2016 (and wrapping up holiday presents), it’s a good time to reflect on the basics. What does this have to do with delegation oversight? The basic premise of delegation is that you are entrusting someone to perform an activity on your behalf. If you are looking to delegate for success, we recommend the following key steps to take place at the very beginning:
- Get to know your delegate partner via pre-delegation discussions, site visit, and audit.
- Understand how your delegate will demonstrate effective, compliant activities on your behalf.
- Agree upon monitoring and auditing activities ahead of time, leaving room for augmentation.
We have seen many examples of delegation oversight programs and activities over the course of the year, and some Compliance Officers and Operations leaders find themselves in the delegation oversight equivalent of enrolling in Advanced French. That is, they were not involved in pre-delegation activities and, therefore, did not have a chance to advocate for the sponsor's obligations towards an effective compliance program. Without the basic foundation, they find themselves in an uphill battle when they try to get data or ask for changes to monitoring frequency.
“Oversight of delegated entities can be an overwhelming task,” says Beth Matel, Senior Director of Compliance Solutions. “To help ensure a sponsor has the cooperation of the entity to which they have delegated responsibilities, they must start by including the pertinent contractual provisions outlined in Medicare Managed Care Manual, Chapter 11, Section 100.4 - Provider and Supplier Contract Requirements and 100.5 - Administrative Contracting Requirements.” Sponsors delegating Part D administrative or health care service functions will need to ensure the appropriate subcontractor contractual language is in place as well.
Our Compliance Solutions team is grateful for all the opportunities we have had this year to support our client partners and share best practices, from the basics to the advanced. As you reflect on your delegation oversight programs, give yourself a present if you:
- Have strategies in place to ensure shared data is sent and received correctly each time (especially membership data!).
- Conduct immediate root causes analysis in response to inquiries or grievances regarding something potentially amiss.
- Complete robust testing prior to new benefit implementation.
- Partner as a team (Compliance and Operations) to ensure success together.
- Maintain a dedicated unit focused on delegation oversight.
- Stay up to date on the Centers for Medicare & Medicaid Services requirements and changes as they affect your delegates and communicate them timely.
Bonne chance!
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CMS Releases New Guidance on Coverage Determinations & Redeterminations
On October 18, 2016, the Centers for Medicare & Medicaid Services (CMS) issued enhanced guidance on outreach attempts to support coverage decisions in its memo titled “Guidance on Outreach for Information to Support Coverage Decisions.” In recent years, CMS Program Audits have consistently identified the failure of plans to have documented sufficient outreach attempts when more information is needed to make a coverage decision. Guidance hasn’t been clear on what CMS expected, but it was obvious based on audit results most plans were not meeting the level of outreach CMS considered to be sufficient. The memo has many critical points every plan should be reviewing and implementing.
Here are four items your plan should look at today to determine system and process capabilities to support the new clarifications:
- Ability to Begin Outreach Quickly – How quickly does your plan open a coverage request or redetermination? Most plans process expedited cases quickly, but standard requests are often in a queue that may take days to open and review for completeness. The new guidance requires the initial request for additional information for a standard Part C organization determination to be sent within two calendar days of receipt and a redetermination request to be sent within four calendar days. This means plans must not only be able to triage weekend requests for expedited versus standard requests but determine if standard requests need more information.
- Multiple Outreach Methods – CMS outlined several methods for requesting information. Those include telephone, fax, email, and standard or overnight certified mail. Many plans use one or maybe two methods. CMS indicated, upon review of cases, consideration will be given to the plan’s use of multiple means of communication.
- Documentation of Outreach Attempts – It is critical systems be able to both store and report on the methods and date/time of the communication. CMS noted for emails and faxes, the timestamp is the evidence. For mail, it is the date/time of the postmark, which is a change from the mail date often used in internal systems. For telephonic outreach, it is the date and time of the call. In addition to the date and time documentation, plans should document two other critical pieces of information for the outreach attempt: 1) the specific description of the required information being requested and 2) the name, phone number, fax number, email, or mailing address of the point of contact. In the case of a phone call, the plan should document with whom they spoke, what was discussed or requested, and what information was obtained.
- Ability to Enforce Response with Contracted Providers – CMS has often indicated there is a concern plans are unable to get timely responses from their contracted providers. In the new guidance clarification, CMS reinforces this requirement. CMS expects plans to set up contractual requirements to support contracted provider responses to requests for information. Additionally, CMS is looking to health plan physicians to outreach to contracted providers when more information is needed to make a determination and the provider did not respond to requests.
While the new requirements may be aggressive, they do provide additional clarity on what CMS is expecting health plans to complete in order to be compliant. The question is, what types of systems and process changes will be needed to store and report on these changes?
Gorman Health Group (GHG) subject matter experts have been a part of numerous CMS audits and have observed similar feedback from the auditors. We have worked on remediation projects to implement this type of enhancement as well as recommend this to our clients on operational assessment projects. We know the struggles these changes present and can assist you in working through them. Implementing these changes may be challenging, but the end results of higher compliance and consistent, fully reviewed decisions for members will be worth it.
If you have questions about implementing the changes outlined in this memo or whether your current processes are compliant, we can help. You can reach us through our website or by emailing me directly at jbillman@ghgadvisors.com
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New Webinar: The 2017 Star Ratings are out! Join John Gorman, GHG's Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on October 27 at 1 pm ET for a cross-functional review of the 2017 Star Ratings ― from key program updates and 2017 Part D insights to emerging Pharmacy and Pharmacy Benefit Manager issues, new medication measures, and strengthening the connection between risk adjustment and Star Ratings. Register now >>
New Webinar: On November 1 at 2:30 pm ET, join GHG's John Gorman and Melissa Smith as well as Eric Letsinger, President of Quantified Ventures, a firm committed to supporting the progress of the social enterprise community, and his colleague Brendan O’Connor, an Impact Manager, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
MACRA Final Rule: CMS Announces Flexible Approach
No doubt sighs of relief could be heard from across the industry when the Centers for Medicare & Medicaid Services (CMS) announced its flexible approach to next year’s reporting requirements under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS took these flexibilities even further in its final rule released last Friday. Below I dive into some of the changes CMS made for the 2017 “transition year” and beyond.
- Relief for Small Providers – The final rule steps back even further from its requirements that providers billing more than $10,000 under Medicare are required to comply with reporting requirements. CMS finalized that Merit-Based Incentive Payment System (MIPS)-eligible clinicians who do not exceed $30,000 of billed Part B allowed charges or 100 Part B enrolled beneficiaries are excluded from MIPS. According to CMS, this is about one-third of Medicare clinicians but only represents about 5% of Part B spending.
- CMS also previously announced it will allow for virtual groups where up to ten clinicians could combine into one group, however, virtual groups will not be implemented during 2017
- “Pick Your Pace” – CMS also codifies its prior announcement that it will allow for a “pick your pace” approach for the first reporting year, 2017. The first year essentially now contains five options:
- Report a full 90-day or one-year period to maximize chances to qualify for a positive payment adjustment.
- Report for less than one year but more than 90 days: more than one quality measure, more than one improvement activity, or more than the required advancing care information performance category in order to avoid a negative adjustment and possibly receive a positive adjustment.
- Report one measure in the quality performance category, one activity in the improvement categories, or the required measures of the advancing care information performance category and avoid a negative adjustment.
- Participate through an Advanced Alternative Payment Model (APM) and qualify for a 5% bonus incentive payment in 2019.
- Don’t report anything for a hefty 4% negative adjustment.
- Basics of MIPS and Changes for 2017 – Eligible clinicians will see either a negative, neutral, or positive payment adjustment of up to 4% under the MIPS program. CMS will also pay out bonus payments for exceptional performers between 2019 and 2024 (beginning with the 2017 reporting year). The payments are based on four categories, and CMS made some significant changes from its proposal:
- Quality – Full participation requires reporting on six quality measures or one specialty-specific or sub-specialty-specific measure set, five required advancing care information measures, and engage in up to four improvement activities for the highest score. For 2017, full participation is met by submitting at least one out of the six quality measures. However, higher points may be awarded for higher performance in the measure.
- Improvement Activity – CMS reduced the number of activities from six to up to four medium-weighted or two high-weighted improvement activities. Attesting to at least one improvement activity will be sufficient in 2017.
- Advancing Care – CMS reduced the number of total required measures from 11 to five. Reporting on all five would earn 50%, and reporting on the optional measures would allow for a possible higher score. CMS will also award a bonus score for improvement activities that utilize Certified Electronic Health Record Technology (CEHRT) and for reporting to public health or clinical data registries.
- Performance Category – Although CMS will raise the weight of this category, it will be weighted at 0% for the 2017 reporting year.
- Advanced APMs – Clinicians who are eligible to participate through an Advanced APM are exempt from the above MIPS requirements. Additionally, the Advanced APM track is eligible for a 5% bonus payment. In order to qualify as an Advanced APM, CMS finalized that a provider must bear a risk of a potential downside of 8% of all Medicare reimbursements or 3% of the expected expenditures for which the provider is responsible under the APM. Notably, CMS retracted its proposals relating to marginal risk and medical loss ratio (MLR) for now.
- “MIPS APMs” – CMS noted the significant criticism that many APMs will not meet the requirements to participate in Advanced APMs in 2017. For example, participants of Track 1 Medicare Shared Savings Program (MSSP) are not eligible as an Advanced APM. CMS moved forward with their proposal that these “MIPS APMs” are subject to MIPS reporting requirements, however, they will be scored using an APM scoring standard in 2017. CMS did announce it is developing an MSSP Track 1+ Model under which Accountable Care Organizations (ACOs) participating in Track 1 and new ACO participants could take more limited downside risk than Tracks 2 and 3 and still be eligible as an Advanced APM. CMS also announced it plans to reopen applications for some current APMs, such as the Medicare All-Payer Model and the Comprehensive Care for Joint Replacement (CJR) Model.
While CMS took the job of responding to industry feedback and “simplifying” the jump into the Quality Payment Program (QPP) for 2017 while moving forward with the move to QPP to an art form, the gargantuan 2,400-page final regulation is a hint of what’s to come. Reinventing the Medicare payment wheel is no simple task and will undoubtedly come with a slew of interim proposed rules as well as fixes to encountered problems during the first transitional years. This payment overhaul is only going to get more complicated, and the time to roll up those sleeves and get to work is now.
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The 2017 Star Ratings are out! Join John Gorman, Gorman Health Group’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on Thursday, October 27, from 1-2 pm ET, for a cross-functional review of the 2017 Star Ratings. Register now >>
Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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Directory & Provider Data: How Small Inaccuracies Could Lead to Big Risks
For the past year, the Centers for Medicare & Medicaid Services (CMS) has been publishing information and proposing new regulations regarding the criticality of ensuring beneficiaries not only have access to care, but access to accurate information with which to make informed decisions about their healthcare coverage. Data Integrity is at the forefront of the initiatives enforced by government mandates, and provider data has topped the list of areas that not only need the most improvement, but the most oversight, correction, and potentially sanction. As we saw last year with the CMS network requirement changes, many plans were unprepared to submit their entire network footprint in their service area expansion applications. By moving the online directory guidance in the Medicare Managed Care Manual from Chapter 3 (Marketing) to Chapter 4 (Beneficiary Protections), CMS has solidified the fact it is no longer acceptable to have inaccuracies in an area key for members to evaluate their health plan choices and find access to care. Now is the time to set new ongoing network monitoring processes in place that ensure your CMS network submissions and Health Service Delivery (HSD) tables mirror your online provider directories, guaranteeing you are prepared to address provider and member complaints stemming from directory inaccuracies.
A recent investigation by the Government Accountability Office (GAO)[1] identified serious deficiencies in CMS’ oversight and enforcement of Medicare Advantage (MA) network requirements and recommended greater scrutiny of the plans’ networks. The GAO found CMS reviews less than 1% of all networks and does little to assess the accuracy of the network data submitted by plans. It was found CMS relies primarily upon complaints from beneficiaries to identify problems with networks and does not assess whether plans are renewing their current contracts to continue to meet network requirements.
For MA plans who currently have the least stringent directory requirements of all government-sponsored health plans, this means plans are only required to outreach to the providers on a quarterly basis to validate the following information is correct:
- Provider’s ability to accept new patients,
- Provider’s street address,
- Provider phone number, and
- Any other changes that affect availability to patients.
Although seemingly straightforward, when coupled with several other nuances, the task becomes daunting and, in some cases, an operational impossibility. Real-time updates to provider demographics, grievance resolution, reconciliation of provider location, and notation of individual providers accepting new patients are a few examples of where a simple requirement can reveal so many gaps and pose so much risk. Inefficiencies capturing, storing, and governing provider data at the onset of the contracting and credentialing processes is a place to start, but what about the historic legacy information that needs to be sanitized? Add the individual specifications and data requested by and delivered from industry vendors and delegated entities, risk adjustment, the Healthcare Effectiveness Data and Information Set (HEDIS®), behavioral health, and the large, delegated provider and academic groups that should be providing the plan with a current roster each month – this is no small task.
At this point, you might be asking yourself:
- How do we bridge the gap between understanding our compliance risk and deploying a successful change in operations to ensure the loop is closed and successfully maintained at every point in the contract life cycle?
- How do we ensure vendor partners are supporting us and aligning their business practices with both the regulatory requirements and our key performance indicators for Star Ratings, risk adjustment, care management, and member experience?
- Is it possible to fix my content management system as it exists today, or do I need to rip and replace?
Gorman Health Group (GHG) can answer these questions, and we encourage you to follow along with us as we explore these questions and how they relate to the results from the first CMS pilot audit. Next week, we will provide in-depth detail on the operational and cross-functional elements of how this regulatory change will impact the entire industry. We’ll have commentary from several leading vendors in the industry and dig deeper into the downstream implications provider data inefficiencies can have on your plan as a whole. In the meantime, please contact us directly if you have questions or would like to schedule a time to meet with one of our industry experts to discuss how GHG can support your efforts to avoid risk and improve results.
[1] http://www.gao.gov/products/GAO-15-710
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The 2017 Star Ratings are out! Join John Gorman, Gorman Health Group’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on Thursday, October 27, from 1-2 pm ET, for a cross-functional review of the 2017 Star Ratings. Register now >>
Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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Plan Now for Performance
As 2016 comes to a close, planning for next year should be well underway. Bids are in, and budgets for the current year are being evaluated against reality before next year's strategies are finalized. As the ACA continues to evolve, CMS has been busy with new programs and more oversight. A plan or provider has to be vigilant about identifying any weaknesses that could mean high costs or low expectations relative to budget. Parent companies have to be aware of line of business similarities and differences as Exchange and Medicaid business become more like Medicare Advantage in terms of programs and benchmarks. A recent article from Kaiser on retention makes great points about the line of business impact on retention and how it is a simple metric that encompasses many operational issues.
GHG is constantly improving its tools to identify outliers as well as relationships between different metrics that cross department lines. Finding root causes and quantifying them for the organization are more impactful than just handling them on an ad hoc basis. Just like compliance is everyone's responsibility, so is financial performance. Identifying weaknesses AND leveraging strengths combine to form a more complete business model for sustained growth.
GHG can prepare a tailored snapshot of your market and your company's performance. Contact us here.
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New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 — 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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MACRA Flexibility Proposal
As we enter the last stretch of the year, many questions remain on what to expect from the Quality Payment Program as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) come January 1, 2017. With the final rule due in November, much of the industry is quick to point out the difficulty in preparing for a brand new reporting program in just a month. Reporting in 2017 will affect payments in 2019.
The Centers for Medicare & Medicaid Services (CMS) recently attempted to alleviate these concerns with a new flexibility proposal, effectively allowing those who choose to do so to put off fully jumping into the Quality Payment Program for the first year. There are four options under the proposal:
- Quality Program "Testing" — Practices can submit some data to the Quality Payment Program, including data from after January 1, 2017, in order to avoid a negative payment adjustment. CMS is providing this as a way to test that systems are working to allow for successful participation in 2018 and 2019.
- Partial Year Participation — This option allows for participation for a reduced number of days. Because practices would submit quality measures, technology use, and improvement activities, they could potentially qualify for a small positive payment adjustment under this option.
- Full Year Participation — Practices whose systems are ready on January 1 can jump in fully in order to reap a bigger positive payment adjustment than Option 2.
Advanced Alternative Payment Model (APM) — Practices can, of course, still choose to participate in the Quality Payment Program through an APM such as Shared Savings Track Program 2 or 3. This option would qualify for a 5 percent incentive payment in 2019.
This new flexibility proposal gives some leeway and buys time for practices that are not prepared to fully comply with the Quality Payment Program, however, there is still a lot of work to be done before now, January 1st, and during the first reporting year.
This new flexibility announcement affirms CMS expects to move forward January 1, 2017. It also means we should all brace for a steep learning curve and speed bumps the first year and will likely see much more guidance and interim regulations as both the industry and CMS come across these. Despite these new flexibility options, the need to prepare for the new payment model is pressing, and those who prepare the soonest will see the greatest success under MACRA.
Gorman Health Group's experienced team is currently working with the provider, health system, and health plan communities in determining the best approach to influence more efficient care delivery models that support clinicians and hospitals as they change the way they practice medicine and adapt to new payment and risk arrangements.
Our experts can review current operations to identify risks and opportunities, increase integration within clinical and pharmacy programs, design well-coordinated activities across multiple healthcare programs, and ensure your organization's infrastructure and tools are prepared for MACRA's impact on your bottom-line. From in-depth analytics and tactical support to strategic planning and implementation. We can help >>
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Star Ratings Plan Preview #2: 2017 Trends to Improve 2018 Scores
With the Centers for Medicare & Medicaid Services (CMS) release of 2017 2nd Plan Preview Star Ratings and updated 2017 Technical Notes, the Star Ratings "busy season" is officially in high gear.
Though our clients are already reaching out to us to understand how to enhance existing programs and best leverage staff to improve their 2018 Star Ratings during the remainder of 2016, we think it's important all Medicare Advantage (MA) plans do so within the context of the trends and issues emerging from the 2017 ratings. A few highlights from the 2nd Plan Preview:
- The triple-weighted Plan All-Cause Readmissions measure has an average (draft) Star Rating of 2.5 (down from an all-time high of 3.5 in 2014);
- The triple-weighted Improving or Maintaining Physical Health measure has an average (draft) Star Rating of 2.6 (down from an all-time high of 4.6 in 2015);
- The Reducing the Risk of Falls measure fell for the 3rd year in a row to 2.4 (down from an all-time high of 3.4 in 2014);
- The MTM Program Completion Rate for CMR measure illustrates health plan struggles for a 2nd year with an average (draft) 2017 rating of 2.4.
These three Part C measures have now eclipsed the Osteoporosis Management in Women who had a Fracture measure (with a draft 2017 rating of 2.7) as the poorest performing Part C Star measure. These measures require strategic provider support to help members through well-managed transitions of care, consistent and persistent integration of medication management and pharmacy data into clinical workflows, and member education and coaching regarding non-clinical issues such as exercise and safety. In addition, the struggles with the MTM Program Completion Rate for CMR measure likely foreshadow the type of performance health plans can expect on the Medication Reconciliation Post Discharge measure, which CMS has indicated will be introduced in the 2018 Star Ratings.
With CMS' planned addition of numerous medication-related Star Ratings measures and ongoing development of measures to codify and quantify Care Coordination through new Star Ratings measures, a strategic approach to improving Star Ratings performance has never been more important. With this in mind, a plan's response to improve performance on an individual measure or group of measures must incorporate the following:
- Care Coordination and Care Management activities that extend beyond the traditional definition of case management and integrate medication management firmly into care, case, and disease management activities;
- High-quality care delivered throughout the provider network, with enhanced contracting, engagement, and coordination that support a patient's experiences, diagnoses, and clinical care needs across all clinical settings, including the primary care physician (PCP), specialists, pharmacies, inpatient/outpatient facilities, and emergency rooms/urgent care settings;
- Risk Adjustment activities and interventions that simultaneously meet health plan needs across Star Ratings, Quality Improvement, and Risk Adjustment while seamlessly supporting and enhancing the care received in the clinical setting;
- Expanded responses to address social determinants of health, such as food insecurity, unstable housing, loneliness, decreased cognitive function, etc.
Star Ratings reflect not only the effectiveness and outcomes of the policies, procedures, and business decisions made inside the plan but also the effectiveness and outcomes of external parties' performance. A strong Star Rating reflects the summative measurement of all actions and decisions of all parties involved in the healthcare experience, including the vast array of providers, vendors, pharmacies, and caregivers involved in delivering care and medications to a member and supporting that member's lifestyle choices and needs.
The 2017 ratings make it clear CMS will continue using the Star Ratings program as an important vehicle through which to test innovation experiments that will ultimately serve as the foundation for Health Insurance Marketplace care delivery and management and the Quality Payment Program.
If you achieved 4 stars this year: There is "no rest for the weary." Many of our clients are new entrants to the MA space — they understand what it takes to achieve 4 stars and are counting on the Quality Bonus Payments associated with >4 star performance. The work may feel relentless, but keep it up!
If you did not achieve 4 stars this year: Now is not the time to panic. You still have time to influence your 2018 Star Ratings. With a carefully planned 4th quarter strategy backed by data and executed to perfection, you may be able to attain (or regain) your all-important 4th star. You'll need to carefully evaluate your current performance and use your time and resources wisely to hit 4 stars.
Whether you need help developing or finalizing your 4th quarter Star Ratings strategy or adapting to the innovations needed for longer-term Star Ratings success, Gorman Health Group (GHG) can help. For additional questions and inquiries about how GHG can support your Star Ratings efforts, please contact me directly at msmith@ghgadvisors.com.
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There is no time to delay. Your organization needs to identify opportunities to increase your Star Rating, implement an enterprise-level strategy, and carefully monitor your progress over the next plan year. We can help you every step of the way with our full portfolio of GHG practices, products and services. Visit our website to learn more about our Star Ratings Services >>
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An "October Surprise" in Medicare Advantage Star Ratings
Each year, one of the most anticipated announcements in the Medicare Advantage (MA) industry is the Star Ratings and program technical guidance for the coming year from the Centers for Medicare & Medicaid Services (CMS). This year's includes an "October Surprise:" a little-known methodological change that could force dozens of 4- to 5-Star-rated plans to lose their hard-fought bonuses and rebates.
Roughly 370 MA plans are currently scored under the Star Ratings system, which we all know by now is graded on a curve. Plans above 4 Stars get substantial bonus payments and bid rebates from CMS and above 5 Stars can market and sell their products year-round. In this sense, plans below 4 Stars are circling the toilet bowl as there is only so long they can compete against the better benefits of 4+ Star plans. The Star Ratings for 2017 will likely knock many 4+ Star plans off their pedestals. Here's why: for 2017, for the first time, 188 new plans could be scored under Star Ratings.
- 64 of the 188 are Medicare-Medicaid Plans (MMPs), which CMS announced in June will be moved into their own separate Star Ratings program this fall. This is a bit of bad news for most MA plans, since their inclusion in the MA Star Ratings program would likely have helped fill the lowest end of the curve.
- The 124 that are left still represent enough mathematical volume that their performance will shift the bell curve. Most will likely earn an overall rating of 3 or 3.5 stars, which will cause rating dilution for those at 4+ Stars. If those plans have the same level of performance as the previous year, they will likely dip below 4 Stars. This is a looming disaster for those companies because they've already booked the bonus money and predicated their benefit designs and 2017 campaigns on receiving the rebate.
- Regarding the 6 "dead men walking" plans below 3 Stars for 3+ years and slated for termination: a "hospital improvement" bill, which passed the House and is still in the Senate, includes a provision to delay CMS' authority to terminate MA contracts based on poor Star Ratings for 3 years. It's possible these 6 plans may continue to fill the very lowest end of the Star Ratings bell curve, thus helping other low-performing plans by padding the lowest end of the bell curve.
Many plans are going to get a nasty shock when they dig into CMS' latest news. It's another stark reminder Star Ratings management is a constant campaign, and plans cannot afford to get comfortable when it comes to their quality performance.
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CMS recently notified plans of the first preview period for the 2017 initial Star Ratings data. It is critical for plans to begin the annual re-evaluation of Star Ratings performance now to pinpoint new problem areas, implement tactical actions, and identify improvement opportunities to raise ratings. Read full analysis >>
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Star Ratings: Medication Management Is Not Just for D Ratings Anymore!
As a pharmacist and Star Ratings Senior Consultant for Gorman Health Group, whenever I am asked to provide insight on how to achieve or maintain Star Ratings success, the conversation has been limited to the "D" part of the metrics, and the folks involved with Medicare Advantage (MA) and Healthcare Effectiveness Data and Information Set (HEDIS®) kind of glaze over and mumble something like, "That's for the Pharmacy folks to deal with." That attitude has always been somewhat befuddling to me considering the historical and ever-increasing impact of appropriate clinical management of medications on many HEDIS® measures and the quality conversation in general. Equally confusing to me has been the willingness of many pharmacists to relinquish the ownership of the medication-related HEDIS® measures to Quality, Case Management, or other teams.
The team approach, with the patient at the center of the team, is vital to delivering high-quality care. At many health plans, the Star Ratings teams historically have been "siloed" into medical Care/Case Management on one team and Pharmacy on the other. While we at the health plans were all focused on Star Ratings for the past several years, something happened outside of MA that will have a huge impact on the whole spectrum of healthcare. That event was MACRA — the Medicare Access and CHIP Reauthorization Act of 2015 — the latest and most sweeping healthcare reform law from Congress. MACRA will fundamentally change how healthcare providers are paid. Under value-based payment, the foundation of the reward system will be quality. Out of this change will come huge shifts in alignments and the creation of new partnerships requiring "outside-the-box" thinking. At the center of many of these new partnerships will be the critical role of the pharmacist and medication management.
Health plan Star Ratings teams would do well to pay attention to these profound trends outside of MA and understand the huge impact on how care will be delivered in order to respond to these changing incentives. Wasn't the Star Ratings system one of the early forms of value-based payment? Certainly if metric success is not achieved, there is a huge financial impact that will be incurred. A cornerstone of value-based payment is preventing hospital admissions impacted by many aspects of care but notably including a huge focus on medication reconciliation, medication management, and medication adherence. Sound familiar?
So how do we take these shifting sands and turn them into something tangible? The first step is collaboration. Star Ratings teams need to prepare themselves for a global value-based system by no longer segregating their teams into "C" and "D." And even if teams meet in an integrated way, the pharmacy members need to take the lead on metrics that extend beyond adherence and Medication Therapy Management (MTM) Comprehensive Medication Review (CMR) rates. Pharmacists should be taking the lead on new metric challenges like medication reconciliation even though they are a HEDIS® measure. A strong medication reconciliation program not only impacts the "checking of the box" that it was done but, if done right, has been shown to actually have an impact on reducing hospital readmissions (another Star Ratings measure). So this is good for Star Ratings, good for the plan, and, most importantly, good for the patient.
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Every organization in the healthcare industry will be impacted by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Gorman Health Group's Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, Dan Weinrieb, provided insight into the various options Providers will have if the legislation moves forward in a previous blog post on the subject >>
On Tuesday, September 13, 2016, from 1:00 — 2:00 pm ET, join colleagues Diane Hollie, Senior Director of Sales & Marketing Services, and Carrie Barker-Settles, Director of Sales & Marketing Services, as they outline the keys to building an integrated member experience program that will deliver a significant and positive impact on health plan enrollment, retention, and revenue generation. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>