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 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." The hotel room block was extended to April 4 so register now to reserve your seat!
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 >>
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
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. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
CMS' Recent Enforcement Actions Show Agency Means Business in 2017
As we predicted, the Centers for Medicare & Medicaid Services (CMS) is off to an aggressive start on the compliance front in the last year of this administration and shows no signs of slowing down with $832,250 worth of fines levied in the month of February alone. The list of enforcement actions released comes with even graver announcements of two immediate suspensions of enrollment and marketing for the year. These fines augment two huge penalties with which CMS closed out last year − $3.1 million and $1.3 million.
In recent news, CMS did announce it will revise its policy of automatically reducing the Star Rating of sanctioned contracts to 2.5 stars. Effective immediately, CMS will suspend this policy, and will re-examine its approach in the 2018 Call Letter. This is a bit of good news for plans currently suspended from marketing and enrollment activities.
From the Medicare Advantage (MA) Advance Notice and Call Letter, we glean further insight into CMS' agenda for 2016. CMS stressed its commitment to improving beneficiary protections for 2016. CMS stressed its plan to increase severity of compliance and enforcement actions in Parts C and D. Particularly, CMS pointed out their commitment to increase the severity of compliance and enforcement actions for Part D auto-forwarded cases, as they saw no significant reduction in the volume of Part D auto-forwarded coverage determinations and redeterminations in the past several years, despite continued warnings issued to organizations. CMS' warning also extends to audits and enforcement actions in network adequacy, provider directory adequacy, and medication therapy management programs.
Given this strong warning, it is no surprise most of the civil money penalties (CMPs) levied in February were due to audits of benefit administration in Part D which showed "inappropriate delays of Part D benefits and increased out-of-pocket costs." Several fines were also levied on Part C appeals and grievances and benefit administration.
Enhancing its theme of focusing on getting plans to tighten up their compliance programs, CMS will issue a memo of their interpretation of methodology for CMPs given the large amount of questions CMS receives related to CMP calculations, not so coincidentally, right before an audit.
CMS has also added a new avenue for enforcement actions — one-third financial audits. CMS is required to conduct these audits for 30% of MA plans each year and has announced they will move to include these in enforcement actions, including CMPs and sanctions, and not just corrective action plans.
If you think 2015 was bad with over $13 million in fines, 2016 is poised to be a record year for enforcement actions. If you're not ready yet, now is the time to cross your t's and dot your i's and get your compliance program in order and prepared for what is positioned to be a busy year.
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 >>
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. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
CMS gears up for major quality performance program overhaul for ACA program
The Centers for Medicare & Medicaid Services' (CMS') recent issuance of the 2017 Letter to Issuers in the Federally-facilitated Marketplaces and Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017 Final Rule affirms the agency's plans to elevate the importance and transparency of quality performance by Qualified Health Plans (QHPs). Despite the continued absence of financial incentives for high-quality QHP performance, CMS' approach to quality oversight for QHPs is looking much like the early years of the Star Ratings program within Medicare Advantage (MA).
Similar to the MA Star Ratings program, CMS will use a 5-star scale to assign a Quality Rating System (QRS) rating to each QHP based on validated clinical measurements and enrollee survey responses. This year marks the first year QHPs must display these quality ratings prominently to consumers on their websites during the open enrollment period. Public reporting of these clinical measurements and enrollee survey responses will not only offer both consumers and providers new insight into a QHP's clinical quality performance but will also spotlight the consumer's perception of the QHP's operations.
The Affordable Care Act requires QHPs to submit a Quality Improvement Strategy (QIS) for the 2017 plan year if they offered coverage through the Marketplace in 2014 and 2015 and meet certain additional criteria. CMS requirements for the QIS, which must be submitted during 2016 and implemented no later than January 2017, include implementation of:
- A payment structure that provides increased reimbursement or other incentives to providers or enrollees to improve quality and reduce costs by incentivizing high-value rather than volume-driven care, and
- At least one of the following:
- Activities for improving health outcomes;
- Activities to prevent hospital readmissions;
- Activities to improve patient safety and reduce medical errors;
- Wellness and health promotion activities; and/or
- Activities to reduce health and healthcare disparities.
Because strong quality performance is necessary for long-term viability, QHP leaders will likely set new quality-related performance goals and evaluate whether current operations may need to be adjusted to meet those goals. Achieving such goals amidst the ongoing industry evolution, within the competitive environment, and within budgetary constraints will require innovation and creativity. Fortunately, many QHPs can lean into their own organization's Star Ratings experiences, expertise, and successes to help with these efforts.
An increased focus on quality, enrollee experience, and outcomes within a QHP will likely require new, short-term resource investments. Investments may be needed in areas such as population health management tools and analytics; member outreach, support, and education; and provider education, support, and engagement. By collaborating with their MA colleagues, QHP leaders may be able to leverage and expand MA tools, tactics, and expertise to simultaneously avoid the "learning curve," minimize provider abrasion, and optimize outcomes through such investments. With careful planning and strategic deployment of resources, a QHP can leverage its short-term investments for long-term return on investment.
Whether your organization is developing a QIS for your QHP, seeking insight to help align your QIS with successful Star Ratings strategies and tactics, or needs help interpreting the quality data recently provided by CMS, we can help. For additional questions and inquiries about how Gorman Health Group can support your QHP quality programs, please contact me directly at msmith@ghgadvisors.com.
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. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
.
Star Ratings: Moving the Needle
Now more than ever before, plans must streamline their Star Ratings programs to meet member expectations while encompassing all aspects of care delivery and breaking down internal silos. This requires innovation amidst a backdrop of the ever-changing Centers for Medicare & Medicaid Services (CMS) landscape. CMS continues to treat Star Ratings as an ever-evolving, dynamic measurement program that is consistently expanding to include challenging new clinical areas, the impact of socio-economic status on Star Ratings, and operational evolution within the risk assessment processes.
As CMS continues to introduce more medication-related measures into Star Ratings, as both Part C and Part D ratings, and evolves Medication Therapy Management from its current status as a process measure to a more impactful outcomes measure, highly-rated plans will continue to set a high bar for seamless, integrated, and holistic care management and coordination. Earning 4 stars will become more difficult without fully breaking down organizational and data-related silos and effectively communicating and engaging with providers.
Join my colleague, Lisa Erwin, and me at our annual Gorman Health Group Forum next month as we share best practices around optimizing the relationship of medication management (either in-house or via Pharmacy Benefit Manager delegation) with the "medical side of the house" for a more holistic approach to achieving Star Ratings success.
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. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
CMS Releases New Medicaid Rule, OMB in Final Review
Last week, the Centers for Medicare & Medicaid Services (CMS) finalized the new Medicaid rule — a 653-page proposal requiring Medicaid managed care organizations (MCOs) to enhance their network adequacy, establish quality ratings, set a medical loss ratio (MLR) threshold of 85%, and develop a robust managed long-term care program. The new Medicaid rule has now been sent to the Office of Management and Budget (OMB) for final review. This means the new Medicaid rule could be published by mid- to late May. There are 39 states and the District of Columbia that currently outsource their Medicaid programs and about 46 million lives that will be affected by this new change.
Some of the proposed changes that were up for consideration:
- Medical Loss Ratio — CMS proposed an MLR of 85% for Medicaid managed care plans, the industry standard for Medicare Advantage (MA) plans. CMS proposed to mostly use commercial rules in calculating and reporting MLR due to the "need for consistency" between plans in the Marketplace and in Medicaid.
- Appeals and Grievances — The proposed rule made a few updates to the appeals and grievances process to align with MA plans. For example, the rule seeks to shorten the time frame in which MCOs and Prepaid Inpatient Health Plans (PIHPs) have to make a decision about a standard appeal from 45 days to 30 days, the same as MA plans. The expedited appeal time frame would be shortened from 3 days to 72 hours, also the same as MA.
- Beneficiary Protections — Under current regulations, coordination and continuity of care focus on primary and acute medical care. The proposed rules aim to reduce coordination issues beneficiaries with chronic and complex conditions face. The proposed rule also seeks to align enrollment practices between Medicaid fee-for-service, Medicaid managed care, and Marketplace coverage.
- Create standards to evaluate network adequacy and ensure beneficiaries are receiving accurate network information.
- Medicaid Managed Care Quality Rating System — Align with existing MA and Marketplace rating systems. Standardize quality metrics among states and plans.
- Updates to rate development standards and actuarial soundness of capitation rates, with a focus on federal oversight and a more detailed process to ensure actuarial soundness.
- Calls on states to update quality strategies at least once every three years. Currently, some states are operating on strategies drafted more than five years ago. States are called on to develop a description of quality metrics and performance targets the state will use to assess Medicaid managed care quality.
Let the team of experts at Gorman Health Group (GHG) help you prepare for the upcoming changes that could impact your organization. GHG's risk adjustment experts can help analyze the financial impact, develop feasibility models to help with meeting the new MLR requirements, and provide guidance on streamlining operations. GHG's Compliance Solutions can assist in the development and monitoring of these new contract requirements, and our clinical team can assist with reviewing and developing integrated care models to provide quality initiatives that are effective and efficiently managed to get optimal results.
For more information, contact me directly at sjanicek@ghgadvisors.com.
Resources
Register your team for the 2016 GHG Forum! For more details around the event and agenda, download the full conference brochure or visit our website. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Noteworthy Evolution for Star Ratings in 2017 MA Draft Call Letter
Last week's release by the Centers for Medicare & Medicaid Services (CMS) of the 2017 Medicare Advantage (MA) Advance Notice of Methodological Changes and Call Letter ended the mystery surrounding potential policy and payment changes on the horizon. As our Founder and Executive Chairman, John Gorman, recently noted: "There's a lot to like — and much to fear." Although CMS is proposing higher-than-expected rates for 2017 and has introduced both payment and Star Ratings relief for plans serving dual-eligible beneficiaries, this positive news was counterbalanced somewhat by a number of factors, including proposals to increase compliance scrutiny in challenging areas such as network adequacy, provider directory accuracy, and medication therapy management programs.
As anticipated from a Star Ratings perspective, there were few surprises but quite a bit of noteworthy evolution for MA this year. CMS' proposals include:
- Accounting for the Star Ratings Impact of Dual-Eligible and Disabled Beneficiaries:
After a lengthy research process and significant pressure from the industry, CMS proposes moving forward with an interim analytical solution to account for the Star Ratings impact of dual-eligible and disabled beneficiaries. Despite the fact only a handful of plans would likely gain or lose a full half-star in their rounded overall Star Rating, this is a huge methodological win for plans serving dual-eligible members and will be important to monitor closely. When combined with CMS' simultaneous proposal to adjust revenues based on beneficiaries' status as either full duals, partial duals, or non-duals, as well as for their status as both aged and/or disabled beneficiaries, my colleague, Dan Weinrieb, advises, "This will mean timely reconciliation and maintenance of clean enrollment data has never been more important for MA plans." This proposal, in combination with the proposed strategy to account for the lack of low-income subsidy (LIS) support to meet Puerto Rican beneficiary needs, reflects a noteworthy shift in CMS' willingness to adjust the Star Ratings program to account for scientifically-supported evidence of nuances within MA.
- In-Home Risk Assessments
CMS' decision to leave in-home risk assessments untouched is great news for the many MA plans who are leveraging these important visits not only for risk adjustment, but also to connect members with needed care (as measured by Healthcare Effectiveness Data and Information Set (HEDIS®) and Prescription Drug Event (PDE) Star Ratings measures), to coordinate care across the spectrum of providers (as measured by Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Star Ratings measures), and to help support member's social and lifestyle challenges (as measured by Health Outcomes Survey (HOS) Star Ratings measures). We interpret this to mean CMS now better understands the incredible value in-home care can bring to a patient's holistic healthcare experience. However, despite this welcome news, plans should certainly ensure their program adheres to the best-practice expectations previously set forth by CMS, and supported by encounter data, in order to drive payment.
- Termination of Contracts Below 3 Stars for 3 Years
CMS not only reaffirmed its previously-announced plans to terminate contracts earning 3 consecutive Part C or Part D Summary Ratings of less than 3 stars, but also set forth an annual calendar by which this practice will become standard. With CMS guidance indicating these termination decisions are non-negotiable, plans will likely expedite efforts to improve Star Ratings performance such that impactful work begins as soon as it looks possible their first Summary Rating below 3 stars may be on the horizon.
- Connecting Compliance and Star Ratings
From a compliance perspective, CMS proposes to continue strengthening its connections between compliance, data integrity, and Star Ratings. CMS reminds organizations of its policy to reduce a contract's measure rating to 1 star if it's determined biased or erroneous data was submitted. Our experience this year indicates CMS is leveraging this authority much more frequently than it has in past years, which means plans will want to pay particular attention to Medicare Plan Finder and PDE data requirements, Organization Determinations, Appeals, and Grievances (ODAG) and Coverage Determinations, Appeals, and Grievances (CDAG) processes, internal controls to prevent errors in operational areas directly impacting the data reported or processed for specific measures, and Part C and D reporting requirements data validation for specific measures. CMS points out, and we're hearing evidence to support, it continues to identify new vulnerabilities where inaccurate or biased data could exist, which could result in the reduction of a star measure to 1 star. As my colleague, Regan Pennypacker, details in her recent article, CMS' proposed changes will require plans to "implement creativity and do more with less while enhancing the beneficiary experience." Certainly this will be no easy task as we survive 2016 and plan for 2017 under a new administration.
- Measure Updates
CMS is not proposing to add any new measures to the 2017 Star Ratings, although several measure specification changes are proposed for use in the 2017 ratings. As previously proposed, CMS indicated both the Improving Bladder Control (Part C) and High Risk Medication (Part D) measures will be moved to the Display page for 2017.
CMS proposes the addition of two new measures to the 2018 ratings (based on 2016 services/operations): Medication Reconciliation Post-Discharge and Hospitalization for Potentially Preventable Conditions. Addition of previously-proposed statin therapy and asthma measures were pushed out at least another year, possibly as a show of support for the recently-released and newly-aligned quality measures, giving plans a bit of breathing room to work with providers in this new area.
As we look ahead with CMS' foreshadowing of future program updates, continued attention is being paid to Care Coordination measures (with the National Committee for Quality Assurance's (NCQA's) assistance) and Depression measures (with NCQA and Minnesota Community Measurement's support), and the Advance Notice highlights a number of potential measure specification changes, which may take effect for the 2018 ratings.
Whether your organization is working to improve performance on your entire Star Ratings program, or just a few Star Ratings measures, or needs assistance understanding how the proposals contained in the Advance Notice may impact your plan, we can help. For additional questions and inquiries about how Gorman Health Group (GHG) can support your organization's Star Ratings programs, please contact me directly at msmith@ghgadvisors.com.
Resources
On Tuesday, March 1, from 2:30-3:30 pm ET, join John Gorman, GHG's Executive Chairman, and colleagues Olga Walther, Senior Legislative & Policy Advisor, and Leslie Mullins, GHG's Senior Consultant, as they provide a hard-hitting analysis of critical areas addressed in the document. Learn what the proposed "methodology changes" could mean for your organization and your partners and the steps you can take to soften the impact. Register now >>
Register your team for the 2016 GHG Forum! For more details around the event and agenda, download the full conference brochure or visit our website. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Compliance Highlights of the CY 2017 Draft Call Letter
According to the Centers for Medicare & Medicaid Services (CMS), the Call Letter activities follow four major themes: improving bid review, decreasing costs, promoting creative benefit designs, and improving beneficiary protections. This means implementing creativity and doing more with less while enhancing the beneficiary experience. To borrow from one of the earliest reality shows, this is the time when CMS stops being nice and starts getting real. There are some of the key items of which your Compliance Department needs to be aware outlined below; however, it is not all inclusive and a thorough read of the document is required.
Something that is highly detrimental to an organization is CMS' reduction of a Star measure to 1 Star if any compliance-related issues are identified with a measure's data. We have seen that applied repeatedly this year to a variety of measures. This Data Integrity initiative is not new; unfortunately, CMS notes in the Call Letter that the agency continues to identify new vulnerabilities where inaccurate or biased data could exist. You will hear more from my colleague, Melissa Smith, on the proposed Star Ratings changes here in this blog.
Program Audit Protocols and Enforcement Actions
In an effort to allow sponsors more time to implement new protocols, CMS is proposing to release the following year's protocols by the end of July, starting this year. How does this change impact an organization?
- An earlier release means industry feedback received at certain times this year will most likely inform the 2018 protocol updates. Since the Medication Therapy Management and Provider Network Adequacy (PNA) pilots are scheduled to be released "a few months into" the pilot audit period, comments won't be received in time to inform 2017 protocol. Therefore, CMS proposes to extend the pilot into 2017.
- CMS notes the PNA protocol will not be administered during the same time as the program audits. This is not surprising for two reasons. First, the current program audit schedule is jam-packed. It's tough to envision adding another layer of operational audits to an already taxing schedule. Second, CMS reminds sponsors that this is only one piece of their larger scale efforts at reviewing adequacy. Consider the provider directory requirements memo released on November 13, 2015. CMS will actually be using the PNA pilot to validate corrections required as part of monitoring completed by the Medicare Drug and Health Plan Contract Administration Group (MCAG).
Some of these changes may mean more impact to your Compliance staff day to day. Gorman Health Group (GHG) notes our sponsor partners are quick to dive into published protocols to update tools and programming. Oftentimes they identify unclear items and immediately contact CMS for clarification, so this change should not create a significant impact to those who follow suit.
Since CMS is focusing on network, this should drive renewed focus and monitoring as part of a risk assessment and current oversight activities. GHG is aware of at least one consistently rated five star plan that has conducted full network assessments on a quarterly basis for quite some time now. In addition, CMS, in working with a contractor, has developed what they believe is a comprehensive process for monitoring provider directory accuracy. Interpret as such: your focus on this area pays off. Our Network team will dive deeper into this area here in the GHG blog.
CMS plans to release a memo describing their interpretation of applicable rules in the methodology for civil money penalties and will provide a comment period to the industry. Compliance should distribute this memo and collect comments as the calculation is often questioned on user calls and during enforcement discussions.
The agency is also seeing no significant reduction in the volume of Part D auto-forwarded coverage determinations and redeterminations. For this reason, they plan to increase the level of severity of compliance and enforcement actions. This is an area of the program with direct impact on a beneficiary's ability to access his or her Part D benefit. It is hoped that turning up the heat in this area may encourage plans to implement changes to reduce that volume and start meeting time frames more regularly.
CMS also proposes to consider the findings of noncompliance from the one-third financial audits for potential enforcement actions. In the past, sponsors were required to implement a corrective action plan, but they have had this authority under 422.752 and 423.752.
Sensing a theme here? CMS has reached a tipping point, and as our Founder and Executive Chairman, John Gorman, has recently noted, it appears 2016 is the year they drop the gloves. If you've ever played hockey, that's when it starts getting good. We hope to see you at our webinar on March 1!
Resources
Join John Gorman, GHG Executive Chairman, and colleagues, Olga Walther, Senior Legislative & Policy Advisor, and Leslie Mullins, GHG's Senior Consultant, as they provide a hard-hitting analysis of critical areas addressed in the document. Learn what the proposed "methodology changes" could mean for your organization and its partners, and the steps you can take to soften the impact on Tuesday, March 1 from 2:30-3:30 pm ET. Register now >>
Register your team for the 2016 GHG Forum! For more details around the event and agenda, download the full conference brochure or visit our website. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
There's a Lot to Like and to Fear in the 2017 Medicare Advantage Call Letter
On Friday after the close, the Centers for Medicare & Medicaid Services (CMS) released the 2017 Medicare Advantage (MA) Call Letter with proposed policy and payment changes. There's a lot to like — and much to fear. On payments, CMS came in with higher-than-expected rates that make clear the long walk in the desert from cuts in the Affordable Care Act (ACA) is over. But on compliance, they are rolling out the firing squad with a broad mandate, and the Administration will leave its mark long after Obama has left office.
What We Like:
- The draft offers all-in rates of +1.35% and a trend of +3.05%, better than last year and better than expected.
- CMS is leaving home visits for MA risk adjustment untouched. If ever CMS was going to clamp down on this after years of threats, this was the time — in the last year of the Administration. By not doing so, we think they're closing the book, acknowledging much good also comes from these house calls, and the home is the most underutilized source of care in the delivery system for seniors. Despite MedPAC recommendations and a drumbeat of op-eds, CMS didn't want to throw the baby out with the bathwater.
- There are big proposed changes to risk adjustment and Star Ratingsfor MA plans serving dual eligibles.
- CMS would launch a new payment system with six subcategories: full duals, partial duals, and non-duals, for both aged and disabled beneficiaries. The net effect is like a crude, mega-risk adjuster, paying plans with more duals bigger, more accurate payments, while paying slightly less to plans with fewer duals.
- On Star Ratings, CMS is proposing an adjustment on three key measures — the overall plan rating, and Part C and D summary ratings — which will increase ratings for plans with higher proportions of duals and could increase bonus payments if the plan is 4+ stars. This is a big win for the industry.
- The health insurer issuer tax has been suspended for a year (and will return in 2018).
What We're Worried About:
- The rapid acceleration from 10% to 50% encounter data driving risk adjustment could depress risk scores. It's clear CMS is moving to 100% encounter data as quickly as possible and likely presages the use of encounters and not Fee-for-Service (FFS) claims to calculate risk factors as well as the phase-out of the coding intensity adjustment.
- CMS is proposing changes for Employer Group Waiver Plans (EGWPs) that amount to a "tax" on sponsors designed to reduce Medicare's spend on these 3 million of the 18 million beneficiaries in MA. EGWPs typically bid much higher than individual MA plans, and the proposal will likely result in a cost-shift to group members or a reduction in supplemental benefits. There was no estimated impact given, so watch this closely.
- CMS made it clear Star Ratings low performers will be executed by firing squad as early as next week. The Call Letter states plans rated below 3 stars for 3 consecutive years will be terminated in February 2016 for a December 31 effective date. Three to six plans qualify for termination. This will be the timeline for future years, and CMS states these decisions are non-negotiable.
- Huge news here on the compliance front:
- CMS notified Part D sponsors it's stepping up enforcement actions on coverage disputes and complaints, the leading noncompliance issue for plans.
- Plans failing the financial audits conducted on one-third of plans each year will no longer be subject to corrective action plans but rather sanctions and civil monetary penalties.
- CMS is ramping up audits and enforcement actions in network adequacy, provider directory accuracy, and medication therapy management programs.
As always, we now enter the frenzied public comment/lobbying phase where the industry tries to get an even better deal, with the final policies announced April 4. As these things go, MA plans should be generally happy about the financial picture while getting down to the busy work of getting the compliance house in order. Most of what's proposed here, we think, becomes the "new normal" long after Obama has left office.
Resources
Join John Gorman, GHG Executive Chairman, and colleagues, Olga Walther, Senior Legislative & Policy Advisor, and Leslie Mullins, GHG's Senior Consultant, as they provide a hard-hitting analysis of critical areas addressed in the document. Learn what the proposed "methodology changes" could mean for your organization and its partners, and the steps you can take to soften the impact on Tuesday, March 1 from 2:30-3:30 pm ET. Register now >>
Register your team for the 2016 GHG Forum. For more details around the event and agenda, download the full conference brochure or visit our website. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
10 Years of Star Ratings: Lessons Learned
The year 2016 marks the tenth year Medicare Advantage (MA) plan performance data has been collected for evaluation under the Centers for Medicare & Medicaid Services' (CMS') Star Ratings program. While we await the "new news" from CMS about new Star Ratings measures and other program updates in the impending Advance Notice, we thought it appropriate to celebrate this important milestone by looking at lessons learned through our first 10 years of Star Ratings and share some insights on how plans can leverage these lessons through the program's continued evolution.
Star Ratings, and the quality bonuses associated with strong Star Ratings performance, put MA plans squarely on a fast-track to rapidly improve MA beneficiaries' experience of healthcare (including quality, access, and reliability), to improve the health of the MA population, and to reduce or control the cost of healthcare within MA. As a result, MA plans have made tremendous investments of effort and resources over the past few years in the sprint to develop, deploy, and measure a whole host of tactics intended to achieve the all-important 4-Star Rating. The downside: these years of "trial and error" were often challenging, the work was often tiring for key personnel, and many plans built programs, reports, and tactics that may have worked well for yesterday's measures but which may not be ideally suited to support CMS' longer-term outcomes focus within the Star Ratings program. The upside: we now know, in great detail, the workflows, tactics, and population health strategies that efficiently and effectively support not only strong performance on quality measurement programs but also progress towards the Triple Aim.
During these last few days of calm before the annual Advance Notice and Call Letter season begins, here are a few strategic questions for your team to consider as you review CMS' proposed program updates during the coming weeks:
- Is your Star Ratings work plan achieving the level of success you desire?
- How will your Star Ratings work plan need to be updated to meet CMS' Star Ratings program updates? Are your 2016 tactics capturing the potential new measures under consideration by CMS?
- Which elements of your Star Ratings work plan are working well, and which need to be adjusted to achieve your goals?
- How are you leveraging the "basics" of Star Ratings such as care coordination, comprehensive diabetes care, medication adherence, and medication therapy management within your Medicaid, Accountable Care Organization (ACO), Marketplace, and Commercial populations?
- How effectively has your Star Ratings strategy improved outcomes and/or reduced costs?
- Do current workflows adequately address members' social and lifestyle needs (e.g., nutrition needs, stable housing, transportation, etc.)?
- How streamlined do your providers perceive your Star Ratings programs to be? How aligned are your Star Ratings programs with the many other quality programs in which your providers participate? How can your providers best support your quality needs?
Star Ratings success requires forward-looking precision to meet the needs of your members and your providers within the constraints of your budget while delivering strong performance in areas where your population or network under-performs the national average.
We understand success isn't easy, and evolution can be difficult. Whether you are looking to improve performance on just a few measures, need assistance interpreting the impending announcements in the Advance Notice, or are ready to more comprehensively evaluate your current Star Ratings program, we can help. For additional questions and inquiries about how Gorman Health Group can support your organization's Star Ratings programs, please contact me directly at msmith@ghgadvisors.com.
Resources
Register your team now through February 14 for the 2016 GHG Forum, and take advantage of our standard registration rate of $1,095 before the price goes up to $1,295 on February 15. Register now >> For more details around the event and agenda, download the full conference brochure or visit our website.
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>