Evolution Through Strategy: Pinpointing Growth Opportunities
My last article explained the choice of Medicare Advantage (MA) health plans to evolve or disappear. Evolution is certainly the preferable choice, so let's examine the steps needed to do so.
As with any company, you need to identify your target customer. State of the Art Membership accounting helps an existing determine strategies around expansion through a) new members (new to a company and new to Medicare) as well as b) the art of retention through pricing, quality and customer service. Both efforts are necessary to maintain a steady growth pattern. This is more sustainable than a membership spike up or down that will cause operational havoc and financial uncertainty.
Risk adjustment Adaptation follows the member through every clinical encounter. If not fully documented, inadequate risk adjustment practices mean money left on the table, which is not an option. Diligence and good provider relations with proper analytic tools are critical to support risk adjustment.
Proactive Member Service means caring about the member experience to set the stage for high level of care and high quality ratings. It helps with retention while ensuring maximum quality of care to the member as well as enhanced revenue from CMS to reward good service. The payback is healthier members who want to stay: a win — win situation!
Collaborative Accountable Providers represent a key partnership for the sake of the members. It is not always a natural alliance — different resources and priorities often conflict, but the health of the member through appropriate care management should be a common objective for both payer and provider. Various partnerships with providers to help with risk sharing is a new element that will offer advantages to both sides.
Make it Work Care Management focuses on the member's health as the single objective that requires proper and necessary medical care and ensures proper resources for the health plan to manage. The product design that attracts your membership base must also be managed to ensure a balance of quality for the member at the right price for the payer.
Finally, the partnership with providers is an integral part of the overall Mastery of Quality Ratings to maximize the outcomes as well as the member experience. CMS is serious about quality — it impacts enrollment opportunities, care management and member outcomes as well as financial performance through critical revenue bonuses and rebate opportunities.
Gorman Health Group has the expertise in all aspects of health plan operations to lead you through best practices but also how to leverage these steps into financial stability. With a proprietary pro forma model designed to quantify these areas based on an in-depth knowledge of MA best practices, we are able to lead management through the different strategic decisions and analysis to customize what works in your marketplace and how to leverage your own strengths. The goal is not just to survive MA but to evolve into something that will improve the community's health.
Join us next month to discuss how analytics can help manage these levers going forward to ensure success.
Resources
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 >>
In a recent case study, GHG examined a mid-sized managed care health plan who struggled with poor MLR and how a cost-efficient affordability review that utilized trend management conducted by out integrated team of experts generated targets of $4 million in expected improvements. Download the case study here >>
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CMS Announces Expansion of the Medicare Advantage Value-Based Insurance Design Model
The Centers for Medicare & Medicaid Services (CMS) announced plans to expand the Medicare Advantage (MA) Value-Based Insurance Design (VBID) model to more states and more conditions in 2018 without the experience of the first year's launch, which begins in January 2017. The schedule underlines the Administration's goal of rapidly expanding the use of innovative payment and delivery models that emphasize quality and good outcomes rather than volume of services. VBID models have been used in the private sector to better manage the costs and care of persons with high healthcare needs and the Medicare population, which has the largest number of persons with chronic care conditions, and offers the potential to see even better results for more people.
Under the demonstration, the requirement that the MA benefit package be uniform for all enrollees will be waived. The uniformity provision was adopted many years ago to ensure health plans did not use benefit design to exclude persons with conditions and disabilities requiring the use of many services and prescription drugs. Fortunately, over time, policymakers and plans have seen the value of programs that better manage the conditions of persons with chronic conditions, such as disease management programs, although participation has been lower than expected. The VBID model will allow MA plans to lower cost sharing, add services, and target providers considered "high value" for the selected chronic condition. MA and Part D plans will still be required to offer uniform benefits under the new model for all plan members with the target condition. As a beneficiary protection, participants in the VBID program can never pay more than other MA enrollees for their services or receive fewer benefits.
For 2018, the new states eligible to participate will include Texas, Michigan, and Alabama. Seven states and seven chronic conditions were selected for the first year of the demonstration. Participating plans will be announced in September 2016. The additional chronic conditions that will be available for VBID participants include rheumatoid arthritis and dementia. The second year model test program will allow MA organizations with at least one plan or a parent organization with one plan with 2,000 or more enrollees to offer VBID enrollment to other Plan Benefit Packages (PBPs) with at least 500 enrollees, thus expanding the number of participating plans and VBID participants.
CMS will conduct a webinar of the second year changes on August 24, 2016, at 2:00 pm EST. Participants may register at https://innovation.cms.gov/resources/vbid-2018changes.html.
CMS plans to issue a Request for Applications for the second year VBID model test program in the fall of 2016. Information on how to apply can be found at http://innovation.cms.gov/initiatives/VBID.
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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. Contact us today to get started >>
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Evolution or Extinction
"The Theory of Evolution has two main points," said Brian Richmond, curator of human origins at the American Museum of Natural History in New York City. "All life on Earth is connected and related to each other," and this diversity of life is a product of "modifications of populations by natural selection, where some traits were favored in an environment over others," he said.
This same theory can be applied to current healthcare. A health plan is the sum of various functions that deliver and monitor the beneficiary's care. The line between payers and providers is becoming more blurred as financial risks and quality measures are critical measures for all healthcare components.
The concept of evolution vs. extinction is quite real. Providers are looking at partnering with payers and taking on more financial risk to leverage the subsequent reward and help coordinate care. Payers are eager to have more control and visibility with providers as well as to follow beneficiaries through the continuity of care to manage shifts in income, demographics, and clinical needs over a beneficiary's lifetime.
As Medicare Advantage (MA) continues to cover almost one-third of the eligible population, new product trends are evolving.
Over the past four years, Health Maintenance Organizations (HMOs) dominate the marketplace with managed
care and tighter networks, but the recent duals demonstrations are recognizing demographic shifts as well as states moving to Medicaid expansion and better coordination.
Another predictor of the duals market is the Special Needs Plan's focus on duals as an at-risk beneficiary. A third driver is the stable Chronic Condition Special Needs Plan (C-SNP) market, which manages the clinical needs and provider partnerships. The Centers for Medicare & Medicaid Services (CMS) is expanding this concept further through the new Value-Based Insurance Design (VBID) demonstration starting in 2017.
Gorman Health Group has the tools and experience to help the healthcare community evolve and avoid extinction. Our feasibility model includes detailed financial projections and onsite strategy discussions to walk a plan through the entire process of entering MA or expanding current products and service areas with an emphasis on risks and rewards. We can then lead you through the product design and implementation phases to build a competitive and compliant organization with the proper financial and operational controls in place. Even existing plans need a new perspective to manage member retention, risk adjustment, and overall analytics to support an integrated care organization.
Let's build a more adaptable, efficient approach to healthcare! So standing still is simply not an option — the marketplace is moving due to changing competitors, regulations, and populations: evolve and adapt.
Resources
In a recent case study, GHG examined a mid-sized managed care health plan who struggled with poor MLR and how a cost-efficient affordability review that utilized trend management conducted by out integrated team of experts generated targets of $4 million in expected improvements. Download the case study here >>
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Medicare Advantage Pays Hospitals Less than Medicare
Researchers at Stanford University conducted a study of hospital payments by Medicare Advantage (MA) plans, Fee-for-Service (FFS) Medicare, and commercial insurers in 2009 and 2012 and found MA plans pay lower prices than FFS for most (but not all) types of admissions and in most (but not all) geographic areas. The study found:
- MA plans paid 8 percent less than FFS after adjusting for diagnostic-related group (DRG) and geographic area differences between MA and FFS.
- If differences in hospital networks are also taken into account, MA plans paid 5.6 percent less than traditional Medicare. Thus, about one-third of the 8 percent difference in MA and FFS prices is attributable to narrower MA networks.
- MA plans in areas with the highest FFS spending paid lower hospital prices than MA plans in areas with the lowest FFS spending.
- MA plans with the highest enrollment penetration rates paid lower hospital prices compared with MA plans in areas with lower MA penetration rates.
- MA plans pay less for admissions with short lengths of stay.
Commercial insurer rates were much higher than either MA or Medicare FFS rates. Commercial plans pay higher prices than FFS for almost all types of admissions in almost all geographic areas. Higher FFS spending was associated with lower commercial prices.
The researchers (Laurence C. Baker, M. Kate Bundorf, M. Devlin, and Daniel P. Kessler) undertook the study because the literature provides no systematic analysis of the unit prices MA plans pay relative to FFS payments and whether lower MA costs are due to lower quantities of services per patient, lower prices per treatment, or both. According to the researchers, the conventional wisdom is MA plans save costs by lowering the quantity of services, and MA plans pay more to providers because they lack the FFS monopsony purchasing power. The study concludes at least part of the cost advantage of MA plans is due to lower prices and not lower quantities than FFS.
The researchers recommended Medicare consider the market environment more broadly than the level of FFS spending when setting MA payments. The researchers also recommended FFS payments to hospitals be adjusted across geographic differences and DRGs to better reflect the market.
The study used the Centers for Medicare & Medicaid Services (CMS) FFS data on all hospital payments and claims data for patients from the Health Care Cost Institute (HCCI), which represents 27 percent of the non-elderly population and 31 percent of the elderly MA population. The actual hospital prices negotiated with plans were not available since they are considered proprietary.
The study methodology used the average price per admission across metropolitan areas adjusted for differences in hospital networks, geographic areas, and case mix. To account for case mix, the researchers used only the DRG pairs that were common to MA and FFS. The researchers noted several limitations to their study findings, for example, HCCI claims data are not identical to the national distribution of MA and commercial enrollees and do not capture unobserved differences in patient severity across insurers, e.g., MA and commercial hospital admissions may be more severe than FFS admissions due to prior admission and prescreening.
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GHG can assess the alignment of your products, your current network, your market, and your network requirements. We'll help you track results — both positive and negative — back to related network components. From there, we assist in developing and executing a networking strategy, from contracting targets to model contract terms, to payment terms that match your budgets and the capabilities of your claim payment systems. Visit our website to learn more >>
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Aligning With MACRA: Infrastructure And Initiatives That Yield Results
The Centers for Medicare & Medicaid Services (CMS) had almost 4,000 responses from providers and health plans regarding the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). With almost 1 million provider groups potentially impacted by the proposed rule, small groups and individual practitioners (primary care physicians (PCPs) and specialists) are being forced to think of their medical practices as a real business. Most of these providers do not have the robust infrastructure compared to their clinical counterparts that fall into the Alternative Payment Model (APM) buckets — Accountable Care Organizations (ACOs), Independent Practice Associations (IPAs), or Clinically Integrated Networks (CINs).
In order to align with the proposed legislation, demonstrate quality, report data, and position the medical practice for shared risk programs, the providers who fall into the Merit-Based Incentive Payment System (MIPS) bucket will need to make some critical decisions. That is if they actually want to realize a positive Return on Investment from participating in the program.
Keep in mind, the following will apply to PCPs and specialists alike:
- Revamp and deploy a data strategy that reconciles and reports patient-level data across multiple delivery systems and sources. Data integrity, quality, and accuracy will make or break a practice's success. It will get worse before it gets better, but everything can be fixed.
- Conduct a comprehensive chart review and risk adjustment program analysis, collecting the baseline health and condition statuses for your attributed patient panels and evaluating the coding patterns of your clinicians with diagnostic authority (Physician Assistants, Nurse Practitioners, Medical Doctors).
- Build and implement a Quality Oversight and Operations work plan that oversees the delivery of superior patient experience activities and aligns clinical practice models with imposed Clinical Quality Metrics.
- Bridge the communication with consulting specialists and network health systems and mid-level clinicians to coordinate care, make informed clinical decisions, and avoid redundancies in care that historically incur unnecessary medical expenses (which would carve into any anticipated financial benefits that were forecasted at the onset of any risk-based payment model).
The way I see it, if the proposed legislation moves forward, providers will have the following choices:
- Join an established APM, like an ACO or a CIN (if they'll have you)
- Jump in with both feet and make a HUGE investment in the infrastructure outlined above
- Find "MIPS friends," create consortiums, IPAs, and other qualified practice models that meet the CMS criteria
- Become an employed provider in a health system or academic medical center
- Transition to a concierge medical practice model and succeed
Gorman Health Group's experienced team is currently working with the provider, health system, and health plan communities to determine the best approach to achieve success. This is not a one-size fits all program, and Gorman Health Group can help find the most realistic, effective, and actionable approach for you and your organization.
Please contact me directly at dweinrieb@ghgadvisors.com or at 202.774.8016.
Resources
What will the consequences of MACRA be? Will the money at risk motivate physicians to be more efficient? Or will it lead them to shun traditional Medicare patients? Read more in another article recently published on the GHG Blog >>
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Teaming with Providers: Incentives to Achieve Results
When a team works well together, the members collectively accomplish more than any of the individuals could have accomplished alone. Certainly we have proven that adage true in healthcare as can be seen with the success of integrated delivery systems, Independent Physician Associations (IPAs), and Accountable Care Organizations (ACOs).
As health plans continue adapting to the growing influence of clinical quality on their provider network operations, building an effective team with your providers has never been more important.
But, factor in the necessities of compensating members of the team for their role, of each side meeting its profit targets, and the competing priorities faced by often short-staffed offices, it should come as no surprise many health plan staff members and providers are left wondering how to make it happen.
How do we as a health plan balance the range of providers in our network? How can we ensure the employed doctor with a large integrated delivery system has his/her needs met while at the same time engaging the single-office practitioner and ensuring his/her goals are met?
Meeting the needs for each of these scenarios and others starts with how well defined our provider incentive programs are. Do they adequately support the clinical and financial goals of the plan and the provider? Have we built an incentive program that has achievable and actionable benchmarks?
Whether your providers are still fee-for-service (FFS) or at full percentage of premium risk, a few building blocks will ensure success:
- Healthcare Is Local: Have we done our benchmarking for incentive programs at the local/regional level to ensure we are measuring apples to apples and taken into account the local practice of medicine?
- Prioritization: Ensure Clinical, Risk Adjustment, Star Ratings, Claims, and Network Operations are all collaborating and prioritizing their "asks" of the providers and working together to ensure the needs of the providers are met.
- Education, Education, Education: By arming your leaders with the education necessary to purchase the best reporting tools, they are able to develop the goals and framework necessary for the frontline staff to educate and respond to providers.
- Support ICD-10 Effective Implementation: If the Centers for Medicare & Medicaid Services (CMS) predictions hold true, denial rates and outstanding receivables are likely to increase during the conversion. Despite testing and readiness efforts, it's entirely possible some providers may not be staffed or prepared to mitigate technology-related problems among their payers or to weather the longer-term reduced productivity of their coding staff. Before your providers can invest additional energy into documentation for chronic conditions and quality priorities, they've got to keep the cash flowing
- Data Validation Reviews: Data integrity starts with collecting and configuring the provider data at the start of the contracting and credentialing process and becomes critical for downstream health plan operations. For example, the inclusion of an incentive program for achieving data accuracy, timeliness, and integrity is a critical element in your risk adjustment work plan. Offering incentives for providers to achieve and maintain 95% coding accuracy on all diagnoses, meaning 95% of the diagnoses submitted by the provider that can be substantiated in the medical record, subject to a random validation review, can often become a path to shifting providers to more risk-based contracting. However, if your provider data is not correct or complete, the plan or its vendor can spend more time trying to find a provider than validate results.
- Focus on Actionability: Health plans often provide catalogs of reports each month showing providers numerous views of their panels and forget providers are taught evidence-based medicine and how to care for patients, not administrative functions. By telling providers to improve care, we can make them vulnerable and defensive. By collaborating to improve processes and coordination for better patient satisfaction and outcomes, we can let the providers be providers.
- Continuous Measurement, Re-Evaluation and Reward: While we naturally monitor our outcomes and re-evaluate our processes, we sometimes forget to reward ourselves for a job well done. We can build in contractual provider incentives, but peer recognition and a "thank you" are often simple but overlooked motivators.
In summary, there is no one straight line to navigate the path from FFS to pay for performance to risk for the plan or the provider, but there is one way to ensure success on that path — collaboration between the plan and the providers. By breaking down the silos and barriers, being transparent in our actions, and reporting, we can build the trust needed to ensure we are not "checking the boxes" on the incentive plan but rather seeing the success in better patient outcomes and lower expenditures.
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GHG's 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 >>
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Risky Business. Are You Ready for MACRA?
It turns out Uncle Sam has a plan. He tried mightily to bend that stiff cost curve. He threw everything he had at it — fixed prices, automatic reductions, sophisticated relative value schemes. He could not do it. Turns out the pen (or mouse) is mightier than the sword because almost all of the Medicare benefit spend flows with the ink (or electrons) that is released by the physician's hand. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a game changer like prospective payment system (PPS).
Humans are inherently risk-averse. Doctors are humans. This new Part B payment scheme is going to make them uncomfortable. The Medicare Merit-Based Incentive Payment System (MIPS) puts a percentage of Part B reimbursement at risk — a modest 43% initially, but it climbs quickly. The Centers for Medicare & Medicaid Services (CMS) estimates 88% of eligible practitioners will be feeling that in 2019. This year more than 200,000 doctors (roughly two in five) were penalized for failure to achieve meaningful use of electronic health records in performance year 2014. Many have decided to just accept the reductions like the person who collects parking tickets because it's just too much trouble to park in a lot.
Changes in the law can have unintended consequences. Prospective payment led to premature discharges from hospitals. The introduction of the physician fee schedule and sustainable growth rate targets led to an increase in the volume and intensity of services (or claims maybe). What will the consequences of MACRA be? Will the money at risk motivate physicians to be more efficient? Or will it lead them to shun traditional Medicare patients?
Yesterday, during a U.S. Senate Committee on Finance hearing on MACRA, CMS seemed to acknowledge the challenges of releasing the final rule for MACRA in November 2016, then measuring physicians immediately after that in January 2017 for 2019 payment basis. Clients and prospective clients should be aware that the potential delay recently discussed by the CMS Acting Administrator is not a delay of MACRA implementation. He referred to possibly delaying the start of the 'performance year' that will be used to adjust payments in 2019. The need to prepare for value based Part B payment is pressing, and those that prepare soonest can turn MACRA into an opportunity.
We have been talking to clients and friends around the industry. We are seeing a lot of interest in the alternatives to MIPS, that is the Alternative Payment Model (APM) approach. Those programs like Pioneer Accountable Care Organizations (ACOs) that take meaningful downside risk clearly have the potential for growth and profit, but they are not for the faint of heart. We believe for group practices and hospitals that bill for physician services, the middle road shows great promise. That alternative is to develop a Medicare Shared Savings Program (MSSP) ACO that avoids downside risk initially. This is a "Track One" ACO — it lets providers have less exposure to complex MIPS reporting and the opportunity to get ready for a potential launch into a higher risk approach later.
On July 7, 2016, CMS further solidified their commitment to MACRA (alternatively the Quality Payment Program (QPP) with the announcement of the proposed rule updating payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) starting January 1, 2017. CMS is proposing modifications to the MSSP to update the quality measures set to align with the proposed measures for the QPP, changes to take beneficiary preferences for ACO assignment into consideration, and changes that would improve beneficiary protections when ACOs are approved to use the skilled nursing facility (SNF) three-day waiver rule. The writing is on the wall — CMS will continue to move towards standardization of government-sponsored health plans via clinical and financial policy to ensure dollars spent meet the goals of improved beneficiary health, better population health management, and a trend of cost containment.
Every organization in the healthcare industry will be impacted by MACRA; some will be directly impacted, others impacted indirectly, and some will be affected by unintended downstream consequences of the legislation. Regardless of whether you are a health plan, a provider organization or a vendor that supports providers or health plans, we can help.
Our experts can review operations to identify risks and opportunities, increase integration within clinical and pharmacy programs, design well-coordinated activities across multiple healthcare programs, and ensure that your organization's infrastructure and tools are prepared for MACRA's impact on the industry. From in-depth analytics and tactical support to thought leadership and strategic planning, we can help. Contact our team today >>
Resources:
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Navigating the path to value. Elena Martin, GHG's Senior Director of Provider Innovations, outlines the MACRA quality payment program. Read now >>
Advancement in Analytics
It's all about the numbers! As the Centers for Medicare & Medicaid Services (CMS) tries to quantify more and more aspects of government-sponsored healthcare, metrics are a critical component.
Metrics are needed to measure quality programs, returns on investment in patient care, redistribution of staffing and financial resources, as well as benchmarking.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a perfect example of how CMS is pushing this financial focus. The past few years of shared savings models for Fee-for-Service members have evolved into very strict timelines and formulas that will directly impact the financial performance of providers in addition to the intended impact on improving member experience and quality of care.
As providers and health plans now have to walk this tightrope of real and projected results with multiple stakeholders (regulators, health plans, providers, members, and third parties), the necessity of analytics and good internal reporting are now of utmost importance.
The best tool to manage these priorities and resources is to have a solid reporting mechanism. Whether you are a start-up or an existing organization, the need for an integrated data repository cannot be ignored. Multiple vendors can help with specialized needs like population health or customized provider scorecards, but the sources have to be integrated. For a provider, this means to coordinate efforts with vendors and multiple health plans or payers. For a health plan, this means to coordinate efforts with vendors and payers as well as from within the health plan organization. Once the data is normalized and complete, reports and dashboards can be built, but keeping an eye on the whole organization is critical to recognize trends as they occur. The "whack a mole" analogy is appropriate — if you focus on one area, you might see improvement, but another area could suffer. You have to look at all areas.
We understand systems must be integrated to help identify actionable strategies. A gap analysis might be needed to assess organizational issues, procedures for reviewing the data to identify problems and their solutions, as well as timing — once a year budget variance reports will not be sufficient. Deep dives into specific problem areas are also critical — making sure you are looking for outliers (regardless of overall performance). Even if the organization does not change, the providers and members and regulations will change. This is a constant effort.
Recognizing the industry will spend nearly $600 billion on healthcare technology by 2020, we have built external, strategic partnerships, facilitated the development of internal solutions, and staffed a team of industry leaders to address this market trend in analytics. Our niche division cannot only connect Gorman Health Group clients with the solutions that are the best fit for their organization, the Healthcare Analytics team can ensure the governance of exiting systems and the investments in new technology are both implemented and optimized.
Let us help you keep your eye on the numbers and find solutions that will bring a return to satisfy all stakeholders.
Resources
On June 7, 2016, Daniel Weinrieb, Gorman Health Group's (GHG's) Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions and colleagues, David Sayen, Senior Vice President of Client Relations and Melissa Smith, Senior Consultant, recapped the details of the MACRA proposal and how these changes will affect providers, health plans, the care delivery system, and patients. Download the webinar recording here >>
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Health Plans Need to Start Talking About Disparities in Care
On the heels of a recent groundbreaking RAND report on racial disparities in Medicare Advantage (MA), the US Department of Health & Human Services' Office of Civil Rights (OCR) issued a regulation that requires serious attention in health plans participating in MA, Part D, Medicaid, and ObamaCare. It's a game-changer in advancing health equity and reducing disparities.
The new regs, implementing Section 1557 (the nondiscrimination provision) of the Affordable Care Act, prohibit discrimination, marketing practices, or benefit designs that discriminate on the basis of race, color, national origin, sex, age, or disability. This will escalate disparities from simply being a "quality improvement need" to being a huge compliance issue. It goes without saying that an investigation of your plan by the civil rights cops splashed across local news would be devastating. As the Centers for Medicare & Medicaid Services (CMS) has begun more aggressively using their data to identify these disparities, health plans certainly should begin doing the same.
The final rule prohibits sex discrimination in healthcare, including by:
- Individuals cannot be denied healthcare or health coverage based on their sex, including their gender identity and sex stereotyping. These last two items are of particular importance given transgender policy enforcement is relatively new. OCR has prosecuted cases recently where transgender patients were discriminated against in hospital admissions and room assignments, denying mammograms to transgender females, denial of gender reassignment surgery as "cosmetic," and harassment by medical transport drivers.
- Women must be treated equally with men in the healthcare they receive and the insurance they obtain. OCR has prosecuted several cases recently where hospitals assigned male guarantors when a wife obtained services but not the other way around.
- Categorical coverage exclusions or limitations for all healthcare services related to gender transition are discriminatory.
- Individuals must be treated consistent with their gender identity, including in access to facilities.
- Sex-specific health programs or activities are permissible only if the entity can demonstrate an exceedingly persuasive justification.
The regs also include important protections for individuals with disabilities and those with limited English proficiency by:
- Requiring covered entities to take appropriate steps to ensure communications with individuals with disabilities are as effective as communication with others.
- Covered entities must post a notice of individuals' rights, providing information about communication assistance, among other information.
- Covered entities are required to make all programs and activities provided through electronic and information technology accessible to individuals with disabilities, unless doing so would impose undue financial or administrative burdens.
- Covered entities cannot use marketing practices or benefit designs that discriminate on the basis of disability.
- Covered entities must make reasonable changes to policies, practices, and procedures, where necessary, to provide equal access for individuals with disabilities.
- Requiring covered entities to make electronic information and newly constructed or altered facilities accessible to individuals with disabilities and to provide appropriate auxiliary aids and services for individuals with disabilities.
- Requiring covered entities to take reasonable steps to provide meaningful access to individuals with limited English proficiency. Covered entities are also encouraged to develop language access plans.
Resources
CMS recently announced the release of the 2017 Medicare Marketing Guidelines for Medicare Advantage Organizations and Part D Sponsors, which include added language, clarifications, and new requirements. Join Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, and Carrie Barker-Settles, Director of Sales and Marketing Services, on Tuesday, June 28, from 1-2 pm ET, to discuss what provisions in the final guidelines will have the greatest impact on your organization and how plan sponsors can prepare for the upcoming changes. Register now >>
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The MSSP Final Rule
On June 6, 2016, the Centers for Medicare & Medicaid Services (CMS) released the final Medicare Shared Savings Program (MSSP) Rule, making some significant improvements to the MSSP program. The two notable changes are the use of regional factors when resetting Accountable Care Organizations' (ACOs') benchmarks and a new incentive to transition to the two-sided risk model. These new changes will no doubt help retain existing participants as well as help move some participants into tracks with risk-sharing arrangements.
A significant change, which the industry has been pushing for, is the use of regional Fee-for-Service (FFS) spending rather than national spending data to adjust cost benchmarks in the second or subsequent contract year period. Participants have long argued that success is not properly assessed because participants are currently measured against their own past performance rather than other providers in the same region. Thus, successful ACOs are potentially penalized in future years, while poor performing ACOs realize greater rewards.
CMS will use a phased-in approach to transition to the regional adjustment, with a weight of 35% applied the first year, moving to 70% the second year. CMS also addressed comments on ACOs who may currently have higher spending than their region by allowing for a slower phased-in approach. Initially, the weight placed on the regional adjustment will be 25% in the first agreement period and will increase to 50% in the second agreement period and 70% in the third agreement period.
An ACO's regional service area will be determined by the counties of residence of the ACO's assigned beneficiary population. The regional service area will include any county where one or more assigned beneficiaries reside.
CMS will continue to establish the first year historical benchmark based on Parts A and B FFS expenditures for beneficiaries who would have been assigned to the ACO in each of the three years prior to the start of the ACO's agreement period. However, CMS will now only use assignable FFS beneficiaries for the calculation rather than all FFS beneficiaries.
CMS is also trying to give more incentive to move into Track Two, with downside risk, by allowing for a phased-in transition. CMS will now allow participants to move into Track Two but provides for an additional fourth year of one-sided risk.
CMS did decline to provide an accelerated path into a two-sided track for contracts currently under Track One, which will prevent them from meeting the criteria for advanced alternative payment models (APMs). Because the performance period begins in 2017, these APMs that will be in the second or third year of their agreement period will miss out on bonus payments for 2019.
As of January 2016, there were over 400 ACOs participating in the shared-savings program, serving more than 7.7 million beneficiaries. Most of these are still under Track One, which does not include downside risk. Coupled with the new incentives under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Systems, for which the performance year begins January 2017, organizations should take a good look at the opportunity of taking the plunge into ACOs.
Resources
We understand Medicare ACOs: We have helped launch seven or eight over the past two years. But we also understand that this is just a first step toward taking greater control over the Medicare revenue stream by "moving up the food chain." 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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