Provider Relations | GHG Advisors

The Path to Value: The MACRA Quality Payment Program

To quote Yogi Berra, "If you come to a fork in the road, take it." Great, but exactly which fork do I take when faced with multiple options? That is the question many provider-led organizations are asking today.

On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) unveiled key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), a bipartisan legislation that replaced the Sustainable Growth Rate (SGR) formula with a new approach to paying clinicians for the value and quality of care they provide. The proposed rule would implement these changes through a unified framework called the Quality Payment Program (QPP), which includes two paths.

To the left, we have the Merit-Based Incentive Payment System (MIPS), and to the right, Advanced Alternative Payment Models (APMs). So what is a doctor or medical group to do at these crossroads?

The MIPS path leads to a world where a percentage of Fee-for-Service (FFS) Medicare payments are at risk based on performance in quality measures in four areas: Quality, Use of Information Technology, Clinical Practice Improvement, and Cost. Measurement would begin in 2017, and the rubber hits the road in 2019. By 2022, the portion of reimbursement at risk will be at 9% and could go beyond that. "MIPS is going to be the "new norm" for providers," said David Sayen, Senior Vice President of Client Relations at Gorman Health Group. "There will be no more hand wringing about draconian cuts to physician payments and, per Kerry Weems' clever quip, no regularly scheduled annual hostage taking."

However, it is important to keep in mind this is a zero sum game. To pay off the winners, there have to be losers, and nobody wants to be a loser. So we head to the other fork, which appears to have sunny skies and bluebirds just over the first hill. First, there is a hill. Moreover, for those providers who are starting to round the corner and take their initial steps into value-based risk sharing arrangements, it is never too early to start thinking about the right path for you and your organization.

For those providers who have taken a few steps or even large strides down the value-based fork and have a good understanding of their quality/cost compared metrics, have tightened their belts, and have a good understanding of contracting and negotiating risk sharing arrangements with payers, to get over the hill, you have to get onboard the APM train. Through future rulemaking, CMS will determine which APMs are acceptable as alternatives to MIPS and will be looking for models that have risk components as equally robust as MIPS.

We now know the Medicare Shared Savings Program (MSSP) Tracks 2 and 3 have been identified as APMs and would be exempt from MIPS payment adjustments. Additionally, they would qualify for a 5% Medicare Part B incentive payment. To qualify for incentives, clinicians would have to receive enough of their payments or see enough of their patients through Advanced APMs. Currently, only 5% of the 433 MSSP Accountable Care Organizations (ACOs) are participating in Tracks 2 and 3. However, the other 95% are gaining the experience they need to make actionable decisions on which fork their organization needs to move towards to prepare for the changes.

For organizations interested in taking the step towards forming a Medicare ACO, and potentially having the opportunity to participate in the QPP as an MSSP Track 2 or 3 via the Advanced APMs, the time for action is now. Your MSSP Notice of Intent to Apply is due May 31, 2016. Gorman Health Group (GHG) is available to help you understand the current MSSP requirements and your organization's readiness level. With the proposed changes to resetting the benchmark to incorporate factors based on regional FFS expenditures to establishing and updating the ACO's rebased historical benchmark, including an adjustment to the benchmark based on regional spending that is phased in over several agreement periods, GHG can assist in identifying health cost trends that vary in communities by using regional spending growth trends. As your organization makes the cultural shift towards a value-based model and establishment of essential ACO functions, we can assist in identifying priorities and goals for each functional area and developing a plan that is actionable, from the first step in applying to be an MSSP through implementation.

MSSP applications are due no later than July 29, 2016, at 5:00 p.m. EST. Please feel free to reach out to GHG for assistance in navigating the application. Alternatively, if you are a provider organization that would like to talk through key questions to ask prior to entering into a risk contract, we can help there, too.

Resources

We've assisted scores of organizations through every step of the application process, from gathering the right data, completing the application, submitting, and responding to follow-up questions. Don't let the application process get in the way of your day-to-day operations. Contact us today to ensure a smooth, compliant process >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

Latest Sherlock Benchmarks Confirm Medicare Advantage is a Miserable Beast to Manage

The geniuses at Sherlock Company, whose benchmarks on health plan administrative standards are considered the gold standard, have released their 2016 findings and the numbers paint a clear picture: Medicare Advantage (MA) is a miserable beast of a product. It's complicated and labor- and capital-intensive, requiring tremendous patience for executives and investors alike.

First: Sherlock's benchmarks confirm that MA requires nearly double the staff per 10,000 members as do commercial group products, and nearly triple that of Medicaid managed care. Much of this staffing is driven by unique requirements in the "Account and Membership Administration Cluster" (Enrollment / Membership / Billing, Claim and Encounter Capture and Adjudication, Customer Services, and Information Systems.)

Second, successful MA management requires big investments and, above all, patience. Sherlock found investments in Medical Management, Star Ratings and Sales/Marketing in Medicare takes at least a year, and often much longer, to show results.

Third, Sherlock demonstrates seniors are high utilizers of customer services relative to all other insured populations, and low costs are not optimal costs. Plans that spend little on service typically suffer worse member retention, membership growth, and customer satisfaction. MA members have longer service handle times, higher appeal rates, much higher rates of claims inquiries, and are less likely to utilize automated call systems.

The upshot? Once you master MA, all other lines of insurance business are a walk in the park in comparison. If this was an easy business, we'd be out of business.

Resources:

More than 200 health plan clients and an additional broad range of other industry participants each year trust Gorman Health Group's team of professionals to deliver expert counsel and tools to help them meet their goals. We pride ourselves on having both day-to-day alignment with the latest CMS guidance and the long-term strategic vision to keep it all in perspective. Contact us today >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

An Important Component of MACRA: Quality Measures Development Plan

The Centers for Medicare & Medicaid Services (CMS) recently released a proposed regulation that will implement the payment incentives through the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). An important component of these new incentives is the Quality Measure Development Plan (MDP), which CMS finalized and posted this week. The purpose of the MDP is to create a strategic framework for the future of quality measure development to support MIPS and advanced APMs.

Under MIPS, clinicians will see a payment adjustment beginning in 2019 based on their performance score across four performance categories: quality, resource use, clinical practice improvement activities, and advancing the use of information technology. Under advanced APMs, payments must be tied to quality measures comparable to those quality measures used under MIPS. These quality measures will be developed by CMS by November 1, 2016, as required by MACRA, and CMS will utilize this new MDP to guide the development and implementation of these new measures. CMS currently has an ongoing solicitation to stakeholders to assist in finalizing the initial set of measures.

CMS will also incorporate the seven core measure sets recently released by the Core Quality Measures Collaborative, a partnership between America's Health Insurance Plans (AHIP), CMS, and other industry groups. The plan notes its focus on coordinating with federal agencies and other stakeholders in order to lessen the duplication of efforts within the industry and promote person-centered healthcare.

The MDP notes current known measurement and performance gaps and solutions to close these gaps through new quality measures. For the first measure set, the MDP posted the initial priorities for measure development in six quality domains: clinical care, safety, care coordination, patient and caregiver experience, population health and prevention, and affordable care. CMS will update the MDP as they identify new gaps in measurement and performance in order to develop additional quality measures annually.

In reviewing the recent MACRA legislation for potential changes, and putting together comments to CMS, organizations should also carefully review the new Quality MDP in order to ensure their comments are incorporated into the release of the first set of measures by November 1, 2016.

Resources

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

CMS recently released the proposed rule that sets forth the replacement for the Sustainable Growth Rate (SGR) formula and creates the new payment system based on value rather than volume. Daniel Weinrieb, GHG's Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, along with our team of experts will provide a detailed analysis as well as industry recommendations. Stay tuned!

by GHG Advisors

Where is Healthcare Now? The Long March to Value-Based Care.

"Why won't the Centers for Medicare & Medicaid Services (CMS) let health plans gather some health information at the point of sale?

How is CMS going to use the data they are collecting?

What is CMS going to do when the first round of Accountable Care Organizations (ACOs) comes to an end?"

At the Gorman Health Group 2016 Forum in Fort Worth, these and other questions were on the minds of our clients. It can be challenging to guess what the agency will do going forward in an election year when the water is choppy. But that forecast is a critical factor in your planning.

In "The March to Value-Based Payment," I described something that is a long march indeed. The Republican-driven Medicare Modernization Act of 2003 ushered in the attenuation of payments to hospitals, first for quality reporting and soon after for quality results. Then, the Affordable Care Act driven by the Democratic Obama Administration doubled down on this "good government" approach. The program was extended to more provider types, outcomes and efficiency were added to the measures, and we began to see downside risk associated with less-than-average performance.

Under the provisions of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA), physicians and other practitioners will face a Hobson's choice: live with a more aggressive risk-based adjustment to payments or join forces with an alternative delivery model, like an Accountable Care Organization (ACO), that is taking risk. The goal moving forward is to render unto Caesar what is Caesar's: the government is willing to bear the risk associated with each patient's demographic characteristics and health history. They will render unto providers the risks of inefficiency and poor performance. This could encourage more doctors to choose alternative payment models like ACOs or to affiliate with Medicare plans. Are you ready?

Resources

The Gorman Health Group 2016 Forum concluded last week with over 200 of our closest clients and partners. There was great news and rough news, so here are a few takeaways >>

Our distinguished team of experts collaborated to provide our interpretation of this announcement and the key features that will have the greatest impact on the industry, emphasizing core business functions in Risk Adjustment, Provider Network, Quality, Compliance, Pharmacy, and Data Integrity. Download our full Summary & Analysis of the Final Rate Announcement & Final Call Letter >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

Takeaways from the Gorman Health Group 2016 Client Forum

The Gorman Health Group 2016 Forum concluded last week with over 200 of our closest clients and partners. There was great news and rough news, so here are a few takeaways:

The playing field of government programs continues to expand rapidly, with improving revenue outlook across the board:
We're sticking by our projections of over 29 million Medicare Advantage (MA) enrollees by 2023, driven by more positive rate trends and a plan-friendly baby boomer tsunami underway.
Six to eight more states expand Medicaid — once President Obama leaves office.
Significant enrollment gains for dual eligibles as home and community-based services (HCBS) waivers and managed long-term services and supports (MLTSS) initiatives become the new normal. We expect dual eligible special needs plan (D-SNP) enrollment to double and exceed 4 million by 2019.
Rising ObamaCare enrollment, albeit slowing and below projections, as more difficult-to-reach populations remain outside coverage.
During the Forum, United announced its departures from most ObamaCare Marketplaces. We characterized the news as a nothingburger in terms of enrollment or market impact but huge symbolically and politically. We expect another two to three messy years sorting out the pricing and finances of the Marketplace business, with membership reconciliation and cleanup of membership discrepancies front of mind for issuers.
Risk Adjustment Data Validation (RADV) audits will begin to be conducted in MA — 2016-2018 will be the first time we see plans prosecuted under the False Claims Act and hundreds of millions clawed back by the Centers for Medicare & Medicaid Services (CMS) for unsubstantiated codes submitted for higher payments.
Clinical and pharmacy data integration and strong provider partnerships around person-centered care were clear priorities in medical management, Star Ratings improvement, and Pharmacy Benefit Manager (PBM) oversight.
The Star Ratings system of performance-based payment drives the payer and provider markets. This year will be the first year where plans below 3 stars are terminated. It's also when another 180+ MA plans will be scored for the first time, diluting ratings for existing plans, especially those at 4+ stars and denying many their bonuses and rebates in what promises to be an ugly "October Surprise."
The turbulent Presidential elections will likely be won by Hillary Clinton, promising continued gridlock with a likely weakened and more polarized Congress. This means CMS will increasingly fight out policy changes "below the waterline" in subregulatory guidance and enforcement, where politicians are less likely to intervene. That means more surprises for plans not paying attention.
Appeals and grievances and pharmacy benefit management vendor performance remain the #1, 2, and 3 regulatory infractions in MA and integration of long-term care and supports and services the leading challenge facing Medicaid health plans.
CMS is on pace for its most aggressive enforcement year ever, with over a dozen actions taken against plans this year already.

As we've said since the passage of the Affordable Care Act, we are now in the Golden Age of government-sponsored health programs, and the opportunities and challenges that come with this shift have never been greater. Our clients went home with a clear grasp of both, and we are thrilled so many joined us this year.

Resources

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

What's Good for Obamacare Is Good for Medicare Advantage, and Vice Versa

I'm really excited to join Gorman Health Group (GHG) after more than 30 years at the Centers for Medicare & Medicaid Services (CMS), and I'm especially excited about the GHG Forum next week in Fort Worth. If you are sitting on the fence, now is a great time to jump in. Make no mistake — we are at the tipping point where public finance at the federal level is quickly becoming the dominant driver of change in the whole system. In 1966, Medicare was erected on the 30-year-old chassis that was the Blue Cross model. Now the tables are turned: Obamacare is determining the shape of new market entrants, often in a push-pull with Medicare Advantage (MA), and nowhere is that more evident than in my adopted homeland of the People's Republic of California.

Covered California is making the call about which hospitals health plans should work with. In the CMS world, the drive toward value-based purchasing and quality reporting is going precisely in the same direction across the spectrum of care. It used to be acceptable to have a provider who was within 30 miles or 30 minutes away. That's your father's MA model. The insistent drumbeat toward quality reporting and performance across the spectrum of services is only going to become more strident. You need to deliver consistent value across the whole supply chain that touches your member or attributed beneficiary.

What is a health plan or Accountable Care Organization (ACO) to do? The path is clear to me. Years ago I took the Deming seminar and drank the Kool Aid about developing long-term relationships with a small group of high-quality suppliers that could integrate and commit to your production model. Jumping up to 2017, I believe that is what MA plans and ACOs must do: orchestrate the players in their ecosphere to get great outcomes and kudos from patients and caregivers. When the stars are in alignment, we can all party like it's 1999.

Looking forward to working with our clients to achieve great things, and it starts in Fort Worth, so come on down!

Resources

We are proud to announce a new session at the Gorman Health Group 2016 Forum featuring David Sayen, a former Centers for Medicare & Medicaid Services (CMS) Regional Administrator, who will provide a CMS update on "The March to Value-Based Payment." Register now to reserve your seat for next week!

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

Engaging Providers in Quality

According to a recent study by researchers from Weill Cornell Medical College, and as recently reported in Health Affairs, medical practices in four common specialties (cardiology, orthopedics, primary care, and multi specialty practices) spend an average of 785 hours per physician and $15.4 billion annually reporting quality measures to Medicare, Medicaid, and private payers.

As the transition to value-based care, alternative payment models, and quality-related financial incentives continues, the number of quality measures and complexity of both measures and payment methodologies will also continue to expand in the coming years. To best preserve and strengthen the provider partnerships we've worked hard to create within Medicare Advantage (MA), we must consider the effectiveness of our provider engagement and support strategies in our pursuit of success within quality measurement programs such as Star Ratings within MA and the Quality Ratings System (QRS) within the Health Insurance Marketplace.

Although many providers have established robust quality programs with expert resources to build workflows, streamline care pathways, and coordinate care across their patients' clinical and social realms, many more are still adapting to this new reality of quality measurement, and some are struggling to develop workflows that meet the wide array of their various payers' requests. In order to successfully impact the Triple Aim, payers and providers will have to continue actively collaborating and coordinating care across differing specialties, differing clinical settings, and with their patients' pharmacies and pharmacists. Similar to a Customer Experience strategy, which a health plan may develop to support members' needs, a health plan should similarly develop a Provider Engagement strategy to support providers' needs during this evolutionary period. While such strategies are often built around a foundation of quality-related financial incentives, many plans are finding success using other incentives that more closely align with a practice's needs, such as staff support, member engagement and outreach support, and enhanced care coordination efforts.

Despite growing efforts to align measures and measure criteria across federal programs, measure developers will likely continue adding measurements associated with more complex clinical conditions. For example, the Centers for Medicare & Medicaid Services (CMS) is considering the addition of measurements of Medication Reconciliation Post Discharge and Hospitalizations for Potentially Preventable Conditions to the 2018 Star Ratings program and Statin Therapy (both in Part C and Part D), Asthma medication management (Part C), and Depression (Part C) to the 2019 Star Ratings program. Because more than 25% of the 2018 Star Ratings Healthcare Effectiveness Data and Information Set (HEDIS®) measurement year has now passed, many plans are already opening a new dialog with providers to broaden quality improvement efforts into more intensive, higher return on investment, member-centric engagements that will address these important clinical areas.

As many plans begin delivering their initial 2016 Gaps in Care reports to providers, this may be an ideal time to evaluate your provider engagement strategy. Following are some important elements to be considered in an effective provider engagement strategy:

How closely is your provider profiling aligned and prioritized with the full scope of Star Ratings and/or QRS quality measurement needs? Have you evaluated your providers' historical performance across the entire spectrum of cost, quality, risk, and utilization to help manage current year expectations and risks?
How effectively are field personnel (Provider Relations, Quality, Contracting, etc.) identifying the "ask" for each provider among all quality measures (including HEDIS®, Consumer Assessment of Healthcare Providers and Systems (CAHPS®), Health Outcomes Survey (HOS), and Prescription Drug Event (PDE) measures) and communicating the right "call to action" to your high-need providers based on your contract's highest priority measure gaps?
How effectively are various field teams (including those across product lines, including MA, Medicaid, and commercial plans) collaborating and partnering to deliver seamless, unified service to your providers? How effectively are field personnel identifying each provider's barriers to success and sharing examples of proven industry best practices that have proven to be successful within similar practices?
Are your provider compensation programs strategically designed in ways that minimize risk and optimize provider engagement and performance?
Has your provider engagement strategy been designed to evolve naturally and contextually throughout the year? Do all field personnel understand which clinical areas, quality measures, and resources to focus on each month? How effectively have CAHPS® needs been woven into the strategy?
Do you know which providers need your support and expertise and are open to your help? Do you know which providers need improvement but are not open to help?
Are your reports and data comprehensive and actionable for providers? Can providers easily access and use your data-related tools and resources?
Do your providers understand how to support their patients' social and lifestyle needs after a clinical visit? Do they have adequate resources to meet such needs in a way that accomplishes your goals?
How effectively are plan-driven activities, such as case and disease management, health and wellness coaching, etc., coordinated with providers?

We often assume our providers will rapidly move with us to a more proactive, more coordinated model of care. The reality is, many providers are still struggling to adapt their practices to meet day-to-day operational demands while trying their best to meet as many payer needs as possible. Because the quality bonus payments to MA plans for strong Star Ratings performance expedited the pace of learning and adaption within MA plans, MA personnel now have a unique opportunity to participate in the industry evolution by educating and supporting their providers.

The industry's transition to proactive care coordination is just the beginning. This is an ideal time to truly expand our provider partnerships with high-value, mutually-beneficial resources, support, and tools to help our providers redirect some of their valuable resources from quality measurement reporting to caring for our members.

___________________________________________________________________________

Whether your organization is developing a provider engagement strategy, honing provider engagement tools and tactics, or looking for targeted improvement opportunities, we can help. For additional questions and inquiries about how Gorman Health Group can support your organization's provider engagement efforts, please contact me directly at msmith@ghgadvisors.com.

Resources

We have partnered with EvisitMyDr.com (EVMD), an asynchronous virtual platform that will transform how physicians and care teams deliver and coordinate care across the continuum in a digital world. We're really excited about what EVMD can do for our clients in offering members a convenient alternative to a regular office visit while increasing practice productivity and revenue streams. Read our full press release.

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

2017 ACA Applicants and Network Transparency

The National Association of Insurance Commissioners (NAIC) completed their review of provider network rules and published a draft of a new Model Rule. This is the first update of network rules in over 20 years. NAIC convened a committee of regulators, health plans, and consumers to provide input to the development of the draft document. The drive to develop the new rules came from the realization narrow networks used in Marketplace plans were the basis of increases in consumer complaints. Throughout the draft, NAIC recognizes the differences that exist between regulations in various states and the proposed changes, so any state can choose to follow the draft or construct its own rules. It has a three-year timeline.

At the same time in December, the Centers for Medicare & Medicaid Services (CMS) proposed network regulations for Qualified Health Plans (QHPs). The final regulation published in February, however, recognized the three-year NAIC timeline, sort of.

First, the draft NAIC rule takes on some of the changes prompted by the Affordable Care Act (ACA) in several ways. NAIC revises definitions for emergency services and conditions, emergency service stabilization, primary care and specialty providers, telehealth, as well as tiered networks. With new definitions throughout the document, the impact of the changes becomes more evident. Draft NAIC rules incorporate final ACA rules that specify in greater detail what health plans must do when they fail to have a provider for a covered benefit. These include payment, notice to persons who need the benefit, and a process for requesting services from a non-participating provider.

Second, the most significant section discusses network adequacy. This section adds many of the ACA requirements related to underserved individuals, children, tiered networks, as well as access. Alternatively, it also recognizes some states use time, distance, and waiting standards. To avoid potential state/federal conflicts, CMS proposed new network rules that would have required CMS to approve state network rules. If CMS did not approve the state method, a federal default based on time and distance would have applied. CMS decided not to finalize this rule, stating they would monitor the states' adoption of the NAIC standard over a three-year period before making any new federal regulation. But, in the end, CMS said they would still apply time and distance standards anyway. It's likely this will be the case for the foreseeable future — not just 2017.

So, what will be the effect of this new model rule? First, nothing defines "without unreasonable delay." Notably, over the past three years, CMS has cited this same regulatory language as frustrated applicants sought to fix networks CMS rejected. The CMS approach to unreasonable delay appeared to be "we'll know it when we see it."

In an attempt at transparency, CMS has finally provided a set of time and distance metrics. Notably, for many years in Medicare, CMS has used software based on time and distance standards and, no doubt, has been using it for QHPs. The magic of the software is it provides a view of what CMS may see in an applicant's network. Using software quickly provides targets and assists in developing justifications needed to address gaps. GHG conducts network access reviews using this same software to ensure QHPs meet access rules before submission to CMS. So, with increasing pressure to build narrow networks, QHPs can have access to solid support tools on what meets access without unreasonable delay.

Resources

For actionable advice and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas. During this year's information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn't. We will share proven tactics to cut costs, increase member satisfaction, and manage and drive sustainable growth. The hotel room block expires on March 28 so register now to reserve your seat!

The application process for Medicare Advantage and Part D, the Health Insurance Marketplace, and ACOs is an arduous one. Completing the application requires the cooperation from your entire organization.Don't let the application process get in the way of your day-to-day operations. Contact us today to ensure a smooth, compliant process.

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

MA Plans' Must-Fix: the Member Experience

Now more than ever, it's clear to us health plans and their stakeholders will thrive or die based on the member experience they provide. The member experience, especially with drug benefits, now represents more than half of a health plan's Star Rating in Medicare Advantage (MA), with millions in bonuses and bid rebates hanging in the balance. It also drives member retention and thereby acquisition expense (now averaging $1,200 per/member, or more than an average month's premium), so how members are treated now determines both health plan revenues and costs.

Overall, the member experience in a Medicare plan is defined by an enrollee's ability to get timely appointments, care, and information, how well providers communicate, and whether member-facing health plan and provider staff are helpful, courteous, and respectful. It's driven by the company culture, its commitment to communication, and the empowerment of staff to solve problems. And despite two-thirds of plans saying the member experience is their top investment priority, we are losing ground.

In a few short years, the Star Ratings system has evolved from a crappy consumer information tool to a multi-billion dollar pay-for-performance (P4P) initiative investing in improved processes and outcomes of care in MA. In 2016, the scoring methodology for Star Ratings ensures the member experience measures, especially in Part D, count for more than half of a plan's rating. It also narrows the margin for error, so only a 10% deviation in performance on the critical Consumer Assessment of Healthcare Providers and Systems (CAHPS®) is the difference between a 2-Star Rating and a 4-Star Rating.

On an enrollment-weighted basis, MA averages a 4.03 rating, with 49% of contracts (179) and 71% of members in plans over 4 Stars. But on CAHPS®, the program dropped from 3.45 Stars in 2015 to 3.4 Stars this year. That's a big problem threatening to drag the program back below the all-important 4th Star and, taken in context of other recent data, gets downright scary.

Last week our friends at Deft Research released their latest Seniors Shopping survey on the 2016 open enrollment period. They found that for the first time in recent memory, far more seniors are leaving Medicare Advantage for Medigap than vice-versa.

On virtually every measure, they found declining loyalty to and retention with their health plan. That says a lot about the state of the member experience in MA despite the priority and focus. It says we're missing the point.

Meanwhile, Alegeus Technologies had some incredible findings in their annual health plan consumer survey presented at the recent AHIP conference. First, they found half of members (50%) do not want to "play an active role" in their healthcare. This argues plans' investments in "member engagement" may be backfiring with half their enrollees. And there was widespread confusion in what they're paying for, possibly delineating why appeals and grievances processing remains the top compliance challenge for plans:

66% of members think they're not paying the right amount
56% complain they don't know how much they are spending until after they receive services
45% of members say they simply do not know much they spend even after getting a bill
45% say they never know what is covered

All of this says the way we think of and invest in the "member experience" needs rethinking.

It reminds me of the seminal 2014 behavioral economics study that found that happiness is defined by expectations being exceeded a little bit on a regular basis. Because expectations are variable, everyone can be made happy. That begins during the marketing and sales process and continues throughout the member lifecycle.

Moving to proactive service models is only the beginning. Only half our members want to be involved — the rest are disappointed and confused enough to be leaving in growing numbers to join inferior and more expensive products. They need help navigating provider networks, better understanding of how to use their benefits, and what to expect in out-of-pocket spending in real time. They need in-plan service ninjas empowered to solve their problem on the first call. They need Pharmacy Benefit Managers to get it together and health plans to advocate and agitate for members with their vendors. They need constant improvement in the member experience to be the new normal in government programs.

Resources

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

Provider Directory & Network Adequacy Highlights in the 2017 Draft Call Letter

The Centers for Medicare & Medicaid Services (CMS) has emphasized the wide-scale monitoring efforts underway with respect to network adequacy and provider directory monitoring and the direct impact it has on not only the plan's ability to provide timely and adequate access to care, but the impact it has on the decision-making ability of the beneficiary and/or their caregiver to select the plan that best meets their needs.

While the new release cycle will affect CMS' ability to have gathered enough feedback and information to finalize the 2017 Audit Protocols, the Provider Network Adequacy (PNA) pilot is still at the forefront for CMS according to the recent release of the 2017 Medicare Advantage (MA) Advance Notice of Methodological Changes and Call Letter. Plans have a key opportunity to do a deep-dive into their provider networks and the policies and procedures governing their network, such as provider terminations, and prepare a monitoring protocol that will not only meet compliance but also take steps towards the future of network management that includes ensuring data integrity for the plan and its members.

It was previously anticipated the PNA would drive the sample of providers used to evaluate directory compliance. The 2017 Draft Call Letter indicates the opposite, noting specifically the data collected during the monitoring process could drive additional reviews of network adequacy as well as future monitoring and/or audit-based activities. CMS has given plans the ability to develop innovative pathways to ensure directory accuracy. Plans will need to close the loop and ensure interoperability between all systems, including those such as Health Services Delivery (HSD) tables and programs used to formulate both online and printed directories, to have a true impact on the data integrity presented to CMS and to their members.

Additionally, CMS continues to move in the direction of a uniform evaluation for both PNA and provider directories across all government-sponsored health plans. Given the fact Medicare Advantage (MA) plans currently have the fewest data elements required for provider directories and the least restrictive reporting requirements for network adequacy, plans should anticipate the need to augment the information they collect on providers, and, as with the requirement to submit your entire network during a service area expansion, gear up for more stringent network review requirements.

At Gorman Health Group, we have experts who have worked directly with managing provider networks and adequacy for over 20 years, including detailed analytics such as specialty code mapping and software, which is critical in building the infrastructure needed to fully support the quality and financial goals the network brings to your health plan.

If you have questions regarding the recent regulations proposed in the 2017 Draft Call Letter for MA and Part D around provider and network adequacy, please contact me directly at emartin@ghgadvisors.com.

Resources

GHG's renowned team of experts collaborated to provide the key features and implications of the 2017 Advance notice and Draft Call Letter for your organization in 2017 and beyond. Download our full summary and analysis >>

Listen to John Gorman's recent podcast on his top line observations from the 2017 Draft Call Letter.

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors