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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Open Enrollment for the Health Insurance Marketplace Begins: Issuers and Enrollees Forge Onward with the Chaos
Beginning next week, consumers will start actively enrolling in the Health Insurance Marketplace for the fourth year of the Affordable Care Act (ACA). The open enrollment period for the Marketplace begins November 1, 2016, and runs through January 31, 2017. Consumers who would like to actively enroll for January 1 coverage are encouraged to enroll through healthcare.gov by December 15 to ensure they will have coverage in their selected plan the first of the year.
Specific to Qualified Health Plan (QHP) Issuers in the Marketplace, the Centers for Medicare & Medicaid Services (CMS) will once again challenge Issuers with navigating through a multitude of enrollee stressors this season. Here are just a few challenges:
- Redistribution of Enrollees to an Alternate QHP Issuer:Based on a number of QHP Issuers either exiting the Marketplace in specific counties/states or exiting altogether, 2016 enrollees are left to identify a new plan for next year en masse. As a means to encourage consumers to choose a new plan, CMS has targeted November 16 as the next notice date to urge consumers to actively select a new 2017 plan because their current plan will not be available through the Marketplace. Unique to other notices consumers have received, this notice will be the first time CMS will communicate an “Alternate Plan Option” by defining the health plan name CMS has matched to the enrollee for each member currently enrolled in the household. Included in the notice is language related to how the alternate plan will communicate with the consumer through a welcome letter and a bill for the first month of coverage if they choose to activate. Enrollees are encouraged to either select a new plan altogether or activate the alternate plan to avoid a gap in coverage.Issuers have the opportunity to gain membership in this scenario, but there is no way to predict consumer behavior, especially for consumers who have been inundated by communications regarding this shift.
- Renewals to 2017 Coverage Year:A week leading up to the opening of enrollment on November 1, QHP Issuers are receiving state-by-state files detailing current enrollees who are being passively re-enrolled into 2017 plans. As the renewal process is a constant challenge for Issuers and CMS, ensuring the right members are being rolled into the correct plan is critical. A major component of the renewal process is to pause and identify inaccurate renewal data and ensure membership is updated within both systems (Issuer and CMS). This also includes recalculated eligibility for Advanced Premium Tax Credit (APTC) and Cost Sharing Reduction (CSR).
Now that policy-based payments (PBPs) are in place, errors generated from inaccurate Batch Auto Renewal (BAR) processing will create an immediate financial impact to the Issuer for January 2017 payment. Financial impacts based on bad membership data were not realized in previous Q1 periods, but with operationalized PBPs, CMS now pays Issuers based on the Federally-Facilitated Marketplace (FFM) system. In other words, if CMS passively enrolls a member but the Issuer does not, it will automatically generate a non-member payment to the plan.
- Unaffiliated Issuer Enrollments (UIEs) or Issuer Orphans:Based on comparing Marketplace membership data between the Issuer system and the FFM system through the reconciliation process each month, UIEs are identified which represent members who are present on the Issuer system but not found on the FFM. Understanding UIEs represent enrollees who would not receive an initial 1095A notice for coverage nor would the Issuer receive payment from CMS for providing the benefit, CMS has acknowledged a solution needs to be extended to all interested parties this year. While guidance is still pending, CMS has assured the industry 2016 members will receive a manual 1095A, and Issuers will receive a payment adjustment through an undefined process.
As for the good news, CMS is addressing the fix prior to year-end, but it is yet to be seen whether the solution includes a front-end fix to end the generation of UIEs altogether.
- Periodic Data MatchingOn a periodic basis, CMS uses data criteria to identify individuals who are receiving financial assistance by enrolling in the Marketplace but at the same time are eligible or are enrolled in other Minimum Essential Coverage (MEC) such as Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP). If enrollees choose to stay dually-enrolled in a Marketplace plan, they will no longer receive APTCs or income-based CSRs per the regulation.
Issuers continue to receive files from CMS to aid in outreach efforts to elicit action by the consumer and ensure they understand the loss of financial assistance before receiving a bill. Part of the process is helping consumers understand they are eligible for other coverage and to determine the appropriate MEC for them.
With the interim processes that are all too common for QHP Issuers, one fact is evident with managing membership – the data always tells the truth. Issuers will commit to working through the requirements as detailed above, support all open enrollment functions, and diligently work to resolve immediate membership issues that arise with January coverage. As with every new challenge that impacts enrollment, Issuers who have a robust reconciliation process to detect and resolve issues will be best positioned to measure and respond.
In parallel, the member experience leading into 2017 will be reacting to the some of the same challenges and a few more, including a 25 percent rise in premiums as stated by Health and Human Services (HHS) this week. Some enrollees will need a new plan, receive a manual 2016 tax notice, or be confused by notifications regarding their re-enrollment or other data matching issues. Others may receive a welcome kit and bill from a plan they did or did not select. When you review all the consumer touchpoints, it is evident the work ahead is a shared responsibility between the Marketplace, the member, and the QHP Issuer to ultimately get the member record right on all fronts. Collectively, the industry has made great progress this year, but we are still dealing with the chaos of a new government program.
Gorman Health Group’s proprietary tool, Valencia™, which currently reconciles 45 percent of the 11.1 million Marketplace enrollees, supports clients’ reconciliation processes with a comprehensive approach. Aside from managing enrollment and payment reconciliation, Valencia™ provides compliant and transparent workflow to ensure your operational processes – and the resulting payment – are as accurate as possible. Our goal is to help Issuers manage the chaos and be audit ready.
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To learn more about our Valencia™ product, reconciliation services, and how they support enrollment and payment reconciliation for Issuers, please contact ghg@ghgadvisors.com.
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 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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2018 Proposed Notice of Benefit and Payment Parameters (NBPP) Summary
This year, some of the biggest industry leaders such as Aetna and UnitedHealthcare have exited the Affordable Care Act (ACA) marketplace. The outlook for the longevity of Obamacare looked grim without some drastic changes coming down from the Department of Health and Human Services (HHS) to balance the deficits seen by health plans as they navigate this new world of healthcare.
There is some light on the horizon for the health plans that are offering ACA plans on and off of the Exchange. The struggles and concerns expressed from health plans across the country are being heard and acted upon at HHS, which is evident in the 2018 Notice of Benefit and Payment Parameters (NBPP) that was released on August 29, 2016. The 2018 NBPP displays an array of proposed changes and updates that provides clarification, detailed rules, and specific changes to address the nuances associated with the commercial market. Such proposed changes and updates include the following:
- New Standardized Plan options and requirements
- Adjustments to user fees, cost share reduction (CSR) values, and coefficients
- Eligibility, enrollment, and benefit changes that impact special enrollment periods (SEPs), direct enrollment, and binder payments
- Recalibration of the risk adjustment model to address partial year enrollments, high-cost risk pool, and pharmacy utilization
- Risk Adjustment Data Validation (RADV) process changes and addition of new auditing requirements
- Actuarial Value (AV) calculator and rating adjustments
The healthcare industry has been eager to influence the structure of Obamacare. HHS has responded to what they are hearing, but the question is, are you ready to operationalize the technical processes and business support outlined in the NBPP to be successful? The ball is in the health plan's court now to take and run with. The approach to address the ACA is not your typical Medicare Advantage strategy. The commercial market has gotten much more complex and strategic. Being able to understand how each organizational decision impacts processes to promote a cross-functional organization and support rate setting, risk adjustment, data management, and EDGE server submissions are just a few pieces of the puzzle that should be considered.
Gorman Health Group (GHG) has a unique set of ACA expertise to assist those in the industry impacted by the ACA and the changes proposed in the 2018 NBPP navigate this new highly regulated world. Here is just a glimpse at what the industry has been asking GHG and the type of support GHG has been bringing to clients across the country:
- What are the key ACA processes health plans should be watching closely?
- Can health plans be successful with the current ACA regulations set forth?
- What impact do these proposed changes have on how plans partner with their Pharmacy Benefit Managers (PBMS's)?
- How critical is it to apply stringent processes for data management and submissions?
- What is the best way to approach all of the core functions associated with risk adjustment from an ACA perspective?
The more precise HHS gets, the more precise health plans need to be. Having the right technical infrastructure and membership platform in place is a great start. Look for a detailed GHG analysis around the proposed 2018 NBPP industry impact in the coming weeks
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This new industry brings about greater challenges than we've ever known in government programs while also providing immeasurable opportunities for health plans that prioritize high quality, clinical care, as well as proper coding and documentation and highly functioning enrollment and reconciliation functions. GHG has first-hand knowledge of vital plan operations and provides comprehensive strategies across a full spectrum of business needs. Visit our website to learn more >>
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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 >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
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 >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
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.
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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 >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Technology and Vendor Implementations
As with all program and technology initiatives, the short- and long-term successes realized as a result of the investments made rely on the critical stages of vendor transitions, data and system readiness, and project management - A well-oiled Vendor and Program Implementation Initiative. Quite often, our health plan and provider clients have multiple projects running in parallel, making for an environment of competing priorities and scarce resources.
In order to optimize the investments made in technology, as well as the supporting member and provider interventions, the organization will need to commit and align subject matter experts (SMEs) in the areas of Risk Adjustment and Quality with SMEs in Information Technology (IT). Given the financial brevity of Risk Adjustment and Quality bonus programs, Gorman Health Group (GHG) encourages our clients to invest in program management and implementation staff. This staff must be solely dedicated to achieving both a seamless transition from legacy vendors to the new vendor partners. Additionally, the implementation team must be committed to ensuring the implementation of the solutions is on time, within budget, and managed to the highest degree of quality assurance.
If the implementation is delayed, the downstream impact on these critical programs could set the stage for years of inaccurate payments and missed opportunities.
GHG understands the challenges of implementing Risk Adjustment and Quality modules on an accelerated timeline in order to meet financial goals. Applicably, our team of industry experts has each been involved in over 40 unique vendor implementations during our tenure as health plan executives and GHG consultants.
Timing is critical. GHG's implementation team employs the Agile project management methodology, working with clients and vendor partners to run initiatives in parallel rather than sequentially, creating efficiencies, ensuring alignment of tasks, and coordinating an environment driven by thoughtful multi-tasking to help meet the deadlines for implementation.
Whether you are off-boarding or on-boarding vendors to support your Risk Adjustment and Quality programs, our experienced team of consultants can provide a wide range of support to your company. For more information on our process and our team, please contact me at dweinrieb@ghgadvisors.com.
Resources
The much-anticipated "Summary Report on Transitional Reinsurance Payments and Permanent Risk Adjustment Transfers for the 2015 Benefit Year" has been released by the Centers for Medicare & Medicaid Services (CMS). Read the full article >>
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2015 Risk Adjustment/Reinsurance Payments Published
Risk adjustment was designed as part of Obamacare to offset the impact of the underwriting process being eliminated to allow those individuals with pre-existing conditions to obtain health insurance. Now a health plan's risk is assessed after the member is enrolled. Health plans need to ensure the risk of their organization is reflected completely and accurately in the data submissions to the EDGE server since this is the information utilized for the risk adjustment calculation. Affordable Care Act (ACA) risk adjustment is a zero-sum game, so a health plan's overall risk will be measured against state averages and competitor results. Last week, the "Summary Report on Transitional Reinsurance Payments and Permanent Risk Adjustment Transfers for the 2015 Benefit Year" was released by the Department of Health and Human Services (HHS). The report shows the risk adjustment payment transfers and reinsurance payments by state for each health plan that had an ACA plan in 2015.
The controversy around the ACA risk adjustment program is a hot topic and will continue to be the highlight of many discussions to come. With any new regulation or process, there comes a learning curve. Unfortunately, we are still in the early stages of a painful learning curve for a lot of health plans and co-ops. Slowly but surely, health plans are starting to realize the ACA risk adjustment program leaves no room for error. The complex nature of risk adjustment is not just the calculations or the interventions―it's the strategy and forethought behind the scenes to know how changes within the organization will impact the risk adjustment processes. Health plans can't just conduct some chart reviews, talk to providers, and send data to the EDGE server and expect to be successful within the ACA market. At that point, it's just going through the motions of what most individuals know as the core operations of risk adjustment without understanding what really makes the program tick. It's like a game of chess―you can't make the same moves in the same order every time you play and expect to win. You need to adjust your next move dependent upon the move of your opponent. That is exactly how risk adjustment needs to be approached.
It's a not so surprising reality that the co-ops are struggling with staying solvent given the magnitude of payments they are required to make for risk adjustment. Unbeknownst to individuals outside of a risk adjustment department, the strategy and operational structure to a fully-functioning successful risk adjustment program is extremely complex. When implementing Obamacare in preparation for the effective plan dates in 2014, co-ops, like most other health plans, did not put a lot of focus on developing a risk adjustment strategy and supporting operations. Some health plans simply did nothing, which was the worst of all scenarios. Risk adjustment was one of the "new processes" that came to be in the commercial market because of the ACA. Those individuals who had never worked with a Medicare Advantage plan before probably never even heard of risk adjustment. These things all played a role in the importance of risk adjustment being under-estimated during the development phase of the ACA for health plans. Now that everyone in the country is aware of the importance of risk adjustment and the magnitude of financial impact it carries, it's an uphill battle for the co-ops having to face making large transfer payments, some are upwards of $30 million.
So how did your health plan do? Was all of the effort and hard work done by your organization realized in the payment transfer outcome?
Being able to answer those two simple questions is a lot harder than you would think. Most health plans measure the success of a risk adjustment program by the magnitude of the payment transfer. By doing this, you will be missing the root cause of operational changes that need to be made to establish a long-term efficient risk adjustment program. Before you can realistically answer these questions, you need to understand where your health plan started and measure success at each step of the way. Then you will be able to see if the events that unfolded were in line with what you intended to happen. If not, then adjust accordingly. If health plans don't start looking at their internal operations relative impact to risk adjustment, then it's only a matter of time before you will become the next sinking ship in the calculation of the payment transfer.
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