CMS Oversight Goes into Hyperdrive
In recent weeks, CMS has sent word to plans of two extraordinary changes in their audit practices.
The first is a notice to certain low-rated (plans with contracts < 3 stars) indicating that they expect the plans to develop a corrective action plan to address the low rating: "CMS is requesting that your organization develop and implement a corrective action plan designed to ensure that it will achieve at least a "good" plan rating."
They do so with the following rationale: "CMS considers a low Part C or D Summary Plan Rating to be evidence that the sponsor has in place insufficient administrative and management arrangements to meet its obligations as a Medicare plan sponsor." CMS is also taking care to mention that organizations with a < 3 star rating for three consecutive years may also have its contract terminated, a statement it made first in this year's Call Letter.
Second, in an extraordinary development, it has come to our attention that certain Regional Offices are initiating monitoring reviews of health plans, independent of Central Office activity. While the reasons for this can only been speculated, it certainly will add to the already challenging environment for plans, particularly those that are already at risk for a bad audit.
It is absolutely critical that plans ensure that they 1) have a plan of action for their star ratings and 2) ensure that they are audit-ready at a moment's notice.
This is what Dumb Looks Like
The poster tells the story behind the photo: "This is a printout of a patient's medical record, sent from one office to another as the patient was changing primary care providers. An EHR was in place in both offices. Additionally, the EHR in both offices was created by the same vendor (a major vendor); each health organization had a customized version. Without base standards the systems are incompatible. Instead, the printouts had to be scanned into the new record, making them less searchable and less useful."
The tech world calls this "digitizing paper processes." The Army calls this FUBAR. Regardless of your preferred observation, it's clear that EMR/EHRs are not yet delivering on their promise. In our Star Ratings practice, we have seen plans and providers struggle with creating Atul Gawande-style checklists that can be tied to a patient record as a paper list might be paper-clipped to a physical record ("Advise on smoking cessation? Check. Flu shot given? Check.). And while we're not going back to paper, the undelivered-promise almost makes one nostalgic for paper itself, one of humankind's top 5* inventions: It's cheap, it doesn't need to be upgraded, it doesn't crash and it best facilitates open, creative thinking by allowing the user to move seamlessly between writing and drawing.
*My other 4 are the wheel, the drum, clean running water and fermented beverages. Fire doesn't count because it was a discovery, as was electricity.
Member Evaluations Don't Replace the PCP
For obvious (and very good) reasons, Medicare Advantage plans want to maximize the unique opportunity afforded by in home evaluations of their members. There is no question that these evaluations can yield diagnostic information that is essential to risk adjustment revenue management. The opportunity to collect clinical information and merge it with data from claims and Medicare return files makes it possible for MA plans to positively influence care in a way that fee for service Medicare cannot. Direct member evaluations also provide a way to quantify and improve measurable standards of care such as those included in HEDIS, ADA standards of care for diabetics, ACC standards of care for cardiovascular disease, and Star ratings.
One question that comes up repeatedly in our conversations with plans is whether we can collect even more data during these encounters. Specifically, plans are interested in having our physician evaluators collect specimens for laboratory studies that factor into HEDIS and Stars measures. On the face of it, this seems like a natural extension of the service, but there are a couple of not so obvious drawbacks.
First, we are very hesitant to do anything that might be seen as coming between a member and his or her treating physician. That is a unique and valuable relationship and we want to make sure that what we do only enhances it.
Second, we are concerned about the chain of responsibility in collecting that information. First, a physician or other licensed provider has to order the test in question. Our physicians can certainly do that, but then someone has to take the responsibility of checking the result and providing appropriate care based on the results. That our doctors cannot do since that would require establishing an ongoing clinical involvement that would directly conflict with our determination not to interfere with the member's relationship with their treating physician. An alternative would be for the plan medical director to accept responsibility for ordering and following up on the lab studies, but most plan CMOs are not willing to do that.
For those reasons, we have been hesitant to collect lab specimens as part of our evaluations, although we willing to discuss alternatives with our clients who need that service.