Star Ratings Update: MedPAC Votes to Eliminate Double Bonuses
Star Ratings is already a hot topic in 2016, and we're only one month into the new year. In most recent news, the Medicare Payment Advisory Commission (MedPAC) unanimously voted last month to eliminate the double bonuses associated with Star Ratings, while also virtually unanimously voting to exclude diagnoses collected during in-home assessments from the Medicare Advantage Risk Adjustment model. Although the Centers for Medicare & Medicaid Services (CMS) may opt to take an alternate approach to resolve Risk Adjustment issues within Medicare Advantage, and since CMS can't independently remove double bonuses with amending certain elements of the ACA legislation, this new development is a great reminder of the need to periodically pause and evaluate the value and ROI of programs which remain prominently placed on CMS' radar screen.
When CMS continued their support of in-home assessments in the 2016 Call Letter, we all breathed a collective sigh of relief. And since that announcement, we have seen significant effort by both health plans and vendors to make these assessments even more clinically and socially focused while simultaneously aligning them with Star Ratings measure needs. As a result, any strategic changes made in response to MedPAC's January votes could have a pervasive impact on the care models and operational structure health plans have come to rely on for Star Ratings success. CMS' response to MedPAC's recommendations, along with the plethora of other potential Star Ratings program updates may not only impact health plans and providers, but could also impact a wide array of health services purchased through vendors.
Many health plans (and their vendors) have leveraged risk assessment work streams to hardwire carefully-planned and strategically-prioritized clinical care and care planning activities into in-home assessment workflows in order to seamlessly impact Star Ratings and achieve multi-faceted return on investment (ROI). In addition, the data collected during risk assessments is often stored in centralized data warehouses and used throughout the health plan as a foundation for population health, care management, and consumer experience strategies. And if that wasn't enough, because members often value the relationship with, and advice received from, the clinician they allow into their home, any changes to in-home assessments introduce a host of new risks relative to self-care and disease management, member satisfaction, and consumer experience.
As we await guidance from CMS regarding their response to MedPAC's recommendations and regardless of how CMS ultimately responds to both issues, this is a great time for leadership to study and thoughtfully consider a number of decisions which could result from either the elimination of double bonuses or changes to CMS' treatment of in-home risk assessments:
- What is the downstream Star Ratings impact of any benefits proposed for reduction or elimination?
- How have quality, medical management, pharmacy, Star Ratings measure gap closure, member retention, and other strategic priorities been hardwired into in-home risk assessments?
- What is the secondary ROI from in-home risk assessments on Star Ratings measures, health outcomes, medical loss ratio (MLR), member satisfaction, and member retention?
- Are current work streams adequate to support strong 2016 performance on new Star Ratings measures under consideration for addition to the Star Ratings program?
- How is each department using the data collected during in-home risk assessments?
- How well positioned is the provider network to serve the care planning and care management needs of members currently receiving in-home assessments?
- What types of alternative workflows and tactics will be used in the event diagnoses obtained from in-home assessments are not allowed for risk adjustment purposes?
Because time is of the essence in our industry, strategic planning and change management never ends. As John Gorman has said for years, it will be the most adaptable plans which will both survive and thrive through the tumultuous industry evolution.
In-depth analysis and industry-leading commentary on the key announcements from CMS and MedPAC can be found in this recently created white paper.
Gorman Health Group (GHG) can help you adapt your Star Ratings approach to account for these potential changes and streamline your Star Ratings strategy to influence health outcomes while remaining compliant with CMS regulations. For additional questions and inquiries about how GHG 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 >>
Top Tips for Star Ratings Success in 2016
Amidst our rapidly-changing industry landscape, the Star Ratings program essentially serves as a "Medicare Advantage stress test," measuring a plan's ability to master the operational complexities encountered while improving the quality of care and general health status of Medicare beneficiaries through member-pleasing experiences. At any given time, there are multiple Star Ratings cycles in play. For example: operational teams and providers have now shifted their focus to services impacting 2018 Star Ratings, Quality and Pharmacy teams are beginning to finalize Healthcare Effectiveness Data and Information Set (HEDIS®) and Prescription Drug Event (PDE) data for 2017 Star Ratings, and the Star Ratings team is feverishly working to optimize performance across both the 2017 and 2018 Star Ratings cycles.
As we've said before, there is no rest for the weary within Star Ratings, and 2016 will likely be no different. But January is a time for new beginnings and fresh starts, so we want to provide you with a few helpful tips to start off the New Year strong:
Monitor and Manage Execution Risk
As John described in his blog this week, we are watching a slew of significant industry issues this year. Some of these issues will directly impact Star Ratings workflows (such as potential new measures, potential program changes to account for dual eligibles/low-income subsidy (LIS) members, and the evolution of Medication Therapy Management (MTM), some will directly impact Star Ratings strategy (such as mergers, drug pricing, provider networks, and care delivery), while others will have an indirect impact on Star Ratings. The Star Ratings impact of these issues and risks, combined with the impact of internal and local risks and issues, will continue to evolve and may change unpredictably throughout the year. It's important for health plan leaders to understand the Star Ratings impact associated with these, and other, types of issues so risks can be routinely evaluated and mitigated where possible. Just as importantly, monitor and evaluate your internal execution risks so mitigation strategies can be deployed when staffing challenges, organizational changes, or administrative processes are not functioning as designed. Make sure your Star Ratings reporting, monitoring, and oversight processes spotlight these risks so leadership is aware of key risks and can adjust the sails as needed if the winds change during the year.
Align Your 2016 Star Ratings Work Plan with Your Strategic Plan.
Health plans are updating their strategic plans more frequently, and often more significantly, than in the past to account for the nature, extent, and speed of industry changes. It is not uncommon for staff to invest time, effort, and resources in selected areas only to later discover there were other, more critical, areas which could have yielded a higher return on investment (ROI) from Star Ratings-related investments. Star Ratings success amidst a changing industry will test a plan's flexibility, agility, and leadership. With that in mind:
- Ensure your 2016 Star Ratings work plan aligns with your organization's strategic plan and captures activities needed to mitigate the impact of strategic adjustments.
- When planning for strategic change, engage Star Ratings leaders to ensure leadership is prepared for, and can mitigate the impact of, such strategic change on Star Ratings. As changes are made, help department leaders understand the full scope of change and its impact on Star Ratings and deploy well-planned tactics to mitigate Stars Ratings risk as changes are implemented.
- Align Star Ratings strategies and tactics with population health, quality improvement, and care management workstreams, and cross-leverage member interventions to simultaneously achieve cross-functional purposes.
- Evaluate the impact of your delegates and vendors on your Star Ratings strategic goals and deploy targeted efforts where improvement is needed.
Run Star Ratings as a Strategic Program
A health plan's Star Rating ultimately reflects the effectiveness with which the entire organization (and its first-tier, downstream, and related entities) and its provider/pharmacy networks work together to improve quality of care and the health status of Medicare beneficiaries in ways which meet members' expectations. As Star Ratings expand into long-standing, multi-faceted new clinical areas, health plans may discover a need for increased collaboration among internal teams and with providers. With this in mind, it is important plans run Star Ratings as a strategic program with dedicated leadership, well-documented workflows, and carefully-crafted leadership support to best ensure the plan hits the ever-important 4-Star threshold.
Resources
Every Star Ratings work plan is unique, and the opportunities to improve performance are similarly unique. With this in mind, it can often be helpful to conduct an objective evaluation of your program. Gorman Health Group's team of experts can help you review key infrastructure and workflows to identify opportunities to improve your Star Ratings performance.
Register your team now through January 31 for the 2016 GHG Forum, and take advantage of our New Year's special! Save 15% using promo code NewYear16 at checkout. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Issues That Will Define Government Health Programs in 2016
The new year brings a slew of issues that will define government-sponsored health programs. Here's what we're watching closely, not necessarily in this order. Opportunities have never been greater in Medicare, Medicaid, and ObamaCare, but execution risk is rising fast. If this was an easy business, we'd be out of business.
Drug Pricing: Prospects for a legal fix in Congress is questionable, and this will be a leading issue in the Presidential campaign. Expect administrative action, demonstration project solicitations from the Centers for Medicare & Medicaid Services (CMS), "comparative effectiveness research" by federal agencies on specialty drugs, and "collaborative pricing" initiatives between pharma manufacturers and payers on high-profile therapeutic classes. Health plan CEOs expect higher specialty drug cost trends to be the biggest driver of medical cost trend in 2016.
Medication Therapy Management (MTM): 2016 is the year MTM gets real. CMS will begin conducting widespread audits of Medicare Advantage (MA) and Part D plan medication reviews, and there is tremendous emphasis on MTM in the Star Ratings system. Making MTM real for your members will require extensive vendor contracting and Pharmacy Benefit Manager (PBM) coordination, so turn your plan's attention to this fast.
Antitrust/Mergers: Sometime in Q3 or Q4 of 2016, the Federal Trade Commission and the Department of Justice Antitrust Division will rule on proposed mergers for Aetna/Humana, Anthem/CIGNA, Walgreens/Rite-Aid, and Pfizer/Allergan. We expect all four deals to be approved but with strings attached; e.g., we expect Aetna/Humana will have to divest 250,000-450,000 lives to get a green light.
Star Ratings: Must be a central focus of all payers and providers in government programs. Star Ratings has transcended MA and Part D. Star Ratings data is already being collected by ObamaCare plans, and over a dozen state Medicaid programs are using CAHPS® and Star Ratings data in contracting with plans for dual-eligible and managed long-term care (LTC) initiatives. And while there aren't major changes to Star Ratings measures in 2016, scoring is the game-changer: 50% more plans will be scored for the first time this year, guaranteeing a shift right in the ratings bell curve and that many of 2015's 4-Star plans will go off the cliff. To maintain progress, plans must run Star Ratings as a program with dedicated leadership and execution spelled out at the workflow level.
Risk Adjustment: 2016 will usher in increased efforts to ensure payment accuracy through more stringent and expansive Risk Adjustment Data Validation (RADV) reviews, and so providers delegated for risk and sharing in a percent of premium will be in the spotlight. CMS is seeking to contract with third-party auditors on RADV, and risk adjustment is a top concern in the Department of Health and Human Services (HHS) Office of Inspector General (OIG) work plan.
Providers and Care Delivery: 2016 will be a transformative year with contracted providers in government programs. Narrow/preferred networks and value-based risk contracting will go mainstream this year, whether providers are ready or not. Huge penalties start this month on network adequacy and accuracy of provider directories, and NAIC's model guidance on provider networks will be a central document governing the issue. Star Ratings measures on access to care and the member experience put new heft and revenue behind network requirements. Provider-sponsored entities will provide a mini-surge of dozens of new plans into MA and Medicaid in 2016 and 2017, especially among Medicare Accountable Care Organizations (ACOs), so keep your friends close and your enemies closer. Home- and community-based services and alternatives to nursing homes will go mainstream in 2016. Retail pharmacies will become the second-most-important provider type for health plans. With crushing burdens of ICD-10 and meaningful use, small and mid-size practices will become overwhelmed and will underperform. Plans will need aggressive oversight, quality improvement, and directory management activities to stay ahead.
Exchange Payment: For the first time in two years, CMS is going to begin paying plans HIX 820s at the member level, which will shine a spotlight on enrollment reconciliation issues that have been lingering. The plans' readiness transition period is from January to March, then it gets real in April.
Medicaid and Dual Eligibles: Unexpected states like LA, SD, and IA are now considering Medicaid expansion. CMS is focusing on new Medicaid quality measures and will be depending heavily on NCQA quality measures to gauge health plans. This will impact payment and future membership for some lower-rated plans. Beneficiary opt-outs in excess of 75% are plaguing early dual-eligible demos, but many states remain in fiscal crisis and need to move ahead to balance budgets.
Compliance: 2015 was a near-record year in CMS enforcement actions, and scores always get settled with insurers in the second term of a Democratic administration. There will be a slew of rules coming from CMS this year as well as expanded audits from OIG. Both agencies' approaches indicate how critical documentation remains: CMS added a number of items to documentation requests for Compliance Program Effectiveness; Medicaid, dual-eligible, and LTC demos are still very documentation-heavy, and CMS found that approximately two-thirds of CMS-reviewed FFM issuer plan policies and procedures (P&Ps) were incomplete or had operational findings with their vendor contracts. So even though there is focus on data monitoring and passed/failed samples, P&Ps and documents are still the cornerstone.
There is no question that 2016 will be a banner year in government programs enrollment, and the long walk in the desert on payment rates in MA and Medicaid appears to be over. But execution risk and the enforcement environment have never been tougher. This year will be a "Darwinian moment:" it's not about being the biggest or even the smartest but being the most adaptable.
.
Resources
Register your team now through January 31 for the 2016 GHG Forum, and take advantage of our New Year's special! Save 15% using promo code NewYear16 at checkout. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
New Hospice Policies Could Mean Big Changes for MA
Medicare's hospice care is garnering much attention and starting the evolution process this year. The Centers for Medicare & Medicaid Services (CMS) issued several new regulations changing hospice payments, and these regulations come with big implications for Medicare Advantage (MA) plans as well.
Last month, the Senate Committee released a policy options paper, discussing solutions for managing chronic illness. In the paper, the Committee proposed that MA plans be required to offer the hospice benefit currently provided under Medicare Part A. Such a change would mean changes to the MA payment system in order to include hospice reimbursement. It would also come with the inclusion of additional measures under the Star Ratings system.
These proposals have been floated around throughout the years, however, with the inclusion of the new end of life talks and the evaluation of the Care Choices Model, this proposal has more teeth and may become reality in the next several years.
Medicare will now also pay for Advance Care Planning talks. Most Medicare beneficiaries and their families state they would like to be involved in end of life planning, yet these talks are often avoided because of the sensitivity of the subject, prognostic uncertainty, and, most importantly, lack of training or pathways for physicians to facilitate these talks. A small number of beneficiaries currently have advanced care directives. This year is an important test for this new payment in assessing whether the talks will have an effect on the care patients choose to receive and whether this will result in more frequent and earlier hospice admission.
Although these payments are small, this is a great opportunity for plans to lead more physicians to discuss end of life care and put plans at an advantage if approached correctly. More patients electing hospice care could lead to better patient quality and experience. Hospice care is more person-centered and tends to improve outcomes such as pain and satisfaction. At the same time, although plans would lose the patient's premium from the shift to hospice, they would also shift the bad claims experience due to the highly expensive end of life palliative treatments and unnecessary hospital care. However, due to the sensitive nature of the discussions, plans should establish a careful framework in their approach in order to contain patient satisfaction and quality.
This year also marks the launch of the Medicare Care Choices Model (MCCM) from CMS. The five-year model allows some hospice-eligible patients to access hospice care without having to forego curative treatments, the way the system is currently set up, and allows for providers to receive payment for this care. The program has some significant limitations: hospice providers will only receive $400 per month or $200 per month for those enrolled for less than 15 days. This means in order to be financially appealing, patients will receive much lower benefits than normally received through hospice treatment. However, it may set up a basis for continued advanced care discussions and lead to more patients electing full hospice care. Despite the low payment, however, the model received significant provider interest and will see a high level of participation.
Resources
At Gorman Health Group, we would be happy to work with your organization to develop beneficiary outreach and/or other programs to address the growing need for this kind of program, which, if applied properly would benefit both the beneficiary and the help plan. Contact us to learn more >>
Register your team now through January 31 for the 2016 GHG Forum, and take advantage of our New Year's special! Save 15% using promo code NewYear16 at checkout. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Influencing Your 2017 Star Ratings: It's Not Too Late
We are officially in the throes of the unavoidable, and much dreaded, 4th quarter Star Ratings "fire drill." While health plan leaders (again) promise their staff and providers this year will be the last a Star Ratings fire drill will be needed, the day-by-day countdown to year-end has officially begun. As even more evidence year-end is almost upon us, Star Ratings leaders throughout the nation are putting the finishing touches on their 2016 Star Ratings work plans and counting down the days until Star Ratings measure rates and denominators are reset and the annual cycle begins again.
Because providers and pharmacies can only provide Star Ratings-impactful services to members through the end of December, many health plans may mistakenly think their ability to impact the 2017 Star Ratings is also on the countdown clock. Luckily, this couldn't be farther from reality. Not only is this a great time to evaluate the adequacy of your 2016 Star Ratings work plans and budgets, but there are also plenty of opportunities for health plans to continue impacting their 2017 Star Ratings. Health Plans must continue to focus significant effort to ensure administrative processes capture all of the services provided to your members this year. Organizations still have several more months to influence members' responses to next spring's Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey and Health Outcomes Survey (HOS), and don't forget the Call Center — Foreign Language Interpreter and TTY Availability measurement period occurs entirely during the spring of 2016.
While it is certainly true Health Plans won't be able to provide additional clinical services after December 31st to impact 2017 Star Ratings, there is plenty of opportunity to influence the 2017 Star Ratings over the next few months. The following are a few ways you can continue to impact your 2017 Star Ratings even after December draws to a close:
- Review your Healthcare Effectiveness Data and Information Set (HEDIS®) medical record review workflows, encounter data workflows, and claims/prescription drug event (PDE) reconciliation workflows to identify any gaps or opportunities for improvement.
- Objectively review the effectiveness of your 2015 Star Ratings activities to determine what worked well, what didn't work as well as planned, and what areas can be improved or enhanced in support your Star Ratings vision.
- Objectively evaluate the cohesiveness and coordination occurring among your internal teams and external partners and vendors to improve your members' experience.
- Evaluate how effectively your teams are working with your high-volume providers and under-performing providers to improve Star Ratings and effectively administer risk adjustment programs.
Gorman Health Group's (GHG's) team of experts can help you leverage your infrastructure and workflows to improve your Star Ratings performance. Contact us today >>
Resources
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095. Register today >>
GHG understands the complexities and nuances of the Star Ratings program and measures. We know how to design programs, initiatives, and tactics to improve Star Ratings performance. From evaluating organizational strategy to developing and optimizing tactical Star Ratings work plans, our team of experts has a long history of success helping health plans achieve Star Ratings success.
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Relief for Plans Serving Dual Eligibles?
It seems as though the Centers for Medicare & Medicaid Services (CMS) may be taking a detour in their position on the effect of socio-economic characteristics of a plan's enrollees. Last week, CMS announced plans to release a proposal to change Star Ratings for plans with significant low socio-economic beneficiaries, in a forthcoming request for comment for updates to the program in 2017. CMS stated the agency will release this request for comment by early November.
Although the health industry has voiced their dissatisfaction for quite some time now with the current rating system being applied to dual eligibles, CMS warming to the idea is a bit surprising. Just last month, CMS announced its results from the study, stating that while "research to date has provided scientific evidence that there exists an LIS/Dual/Disability effect for a small subset of the Star Ratings measures, the size of the effect is small in most cases and not consistently negative." This month, the Medicare Payment Advisory Commission (MedPAC) also chose to postpone making recommendations until it saw what action CMS takes.
While this change in position is welcome, it is unclear whether CMS will actually implement a solution. CMS has previously proposed a temporary solution to reduce the weight of seven measures but, after negative feedback, chose not to implement the proposal. It is also unclear whether this change in position comes from new findings CMS has yet to release or whether it changed its position based on the analysis released from the study last month, where the disparities in measures were found to be "insignificant."
Until we see whether CMS changes its position on dual eligibles, plans falling below three stars for three years under the current rating system will still face termination, regardless of the number of dual eligible enrollees enrolled in the plan, if they cannot improve their performance to at least three stars.
Stay tuned.
Resources
Whether your plan missed the overall 4-Star Rating necessary to earn Quality Bonus Payments, or whether the new 4-Star cut points have introduced new risks of maintaining your overall 4-Star rating, we can help. Our team of experts understands the Star Ratings program and knows how to influence performance. Contact us to learn more >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
2015-2016 CMS Program Audit Protocols Update
It's Christmas in October (and Hanukkah, too) if you've been waiting for the revised 2015-2016 Program Audit process and protocols. Let's get right down to it!
You'll want to review all 20 documents (made up of the memo, data requests, supplemental questions, templates, and impact analysis layouts) for their significant enhancements and make necessary changes in your own oversight programs. What are some significant changes, and what do they mean for you?
Overall Process
- If the Sponsor fails to provide "accurate and timely" universe submissions twice, it will be cited as an observation in an audit report. After the third failed attempt, the Centers for Medicare & Medicaid Services (CMS) will classify this as an Invalid Data Submission, or IDS. There is NO reason a universe should be submitted late. Some of our Sponsor partners have required additional time for certain submissions, and they requested that time from CMS and got it. Nothing should irk senior leadership more than a universe being submitted a few minutes late, especially considering data issues in program audits directly impact Star Ratings.
- CMS Account Managers will be playing a greater role in the validation of pre-audit issue summaries, which are made up of disclosed and self-identified issues. CMS also clarifies if CMS identified an issue during the course of routine monitoring and brought it to the Sponsor's attention, it would be classified as a self-identified issue. There are specific timing issues CMS will consider in determining whether an issue is corrected or uncorrected. It is best practice for Compliance departments to incorporate a log similar to what CMS has provided in the management of disclosed and self-identified issues.
CPE
- Reduction of employee interviews, with addition of interview(s) of those responsible for managing accountability for FDR oversight. Not a surprise seeing as this has been a consistent finding for CMS throughout 2015 and previous years. Sponsors should coordinate and start mock interviews now with those who are responsible. CMS is seeing gaps in FDR oversight compliance whether or not you have three FDRs or three dozen.
- By the numbers:
- Tracer templates narrowed down from 2 to 1;
- Tracer samples increasing from 5 to 6, all to be conducted in week 2, so Compliance staff can participate in week 1 activities;
- There are 3 options for providing supporting documentation for tracers: embed into your Tracer, upload via SFTP, or have it immediately available onsite.
- CMS has incorporated a documentation request list to help them review the effectiveness of a compliance program. These documents will need to be submitted along with the 5 universes for this audit area. CMS has also provided a template for the Sponsor to demonstrate organizational structure and governance. This template includes a number of questions and data requests, and should help auditors compare apples to apples.
CDAG and ODAG
- Coverage Determinations, Appeals, and Grievances (CDAG) and Organization Determinations, Appeals, and Grievances (ODAG) universe time periods will be determined by the Sponsor's enrollment size. In addition to numerous data layout clarifications and updates, CMS also details which universes may be combined with others to determine effectuation and notification scores.
- As previously announced in 2016, Part C and Part D grievances should be submitted based on date of resolution notification. They include a reminder not to include Complaints Tracking Module (CTM) cases in grievance universes. (Who is still including CTM cases in grievance universes? Please call us, whoever you are, and let us help!)
Formulary Administration (FA) and Special Needs Plan Model of Care (SNP-MOC)
- Thankfully, there were no significant changes noted in the core processes for these audit areas. Plans will note CMS has added the Cardholder ID to the SNP Enrollees (SNPE) record layout, and, more importantly, they request separate record layouts be submitted for each unique MOC rather than per contract.
Pilot Protocols
CMS commits to releasing the pilot protocols for Medication Therapy Management (MTM) and Provider Network Adequacy later this year.
- They describe one of their objectives for the MTM review to "initiate enforcement actions and/or identify possible performance measures for sponsors to implement." Technically, CMS can refer a Sponsor for enforcement action for any aspect of the audit. Why highlight it in MTM? Get busy making sure your program is in order.
- No surprises in network adequacy — CMS has emphasized they will be evaluating networks for adequacy by also evaluating whether or not participating providers' practices are open to treat enrollees. Some of our partner clients have already started their own internal evaluations to ensure this important beneficiary protection is met.
This year's audit season was a whirlwind of many things. For Sponsors and auditors alike, it's fair to say the industry struggled with the earlier-published protocol. Now that this document set has been released for 2015 and 2016, this should allow some breathing room for all to start implementing changes in tools, reports, and monitoring efforts. Unfortunately, that breathing room overlaps the upcoming holiday season, so perseverance is key! There is truly no rest for the weary.
Resources
In addition to monitoring your operations and auditing the organization's performance, CMS also audits the compliance function. In recent years many CMS sanctions have been issued as the result of a Compliance Program that was determined to be ineffective. Let us help you create a culture of compliance. Contact us today to get started >>
If your organization is interested in a mock audit utilizing the latest protocols. We can help! The Online Monitoring Tool™ is our compliance software designed to help organizations operating in Medicare, Medicaid and the Health Insurance Marketplace track the compliance of their operations. Learn more >>
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095.Register today >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Considering Network Expansion? The Role Network Adequacy, Risk Adjustment, and Star Ratings Play
The leaves are changing colors, pumpkins are out on every front stoop, and the brisk weather signifies fall is in full swing. It also means we are in the midst of application season for health plans wanting to expand their geographic footprint. The Centers for Medicare & Medicaid Services (CMS) has put provider networks front and center under the bright spotlight, and Medicare Advantage (MA) plans need to be even more vigilant in managing their largest asset. Regardless of the size and scope of the organization, your plan's network adequacy and accessibility is a cornerstone of any new initiative.
In today's marketplace, it is no longer acceptable to meet the bare minimum health service delivery (HSD) requirements. Consumers, and CMS, are demanding plans be able to offer choices including quality and cost efficiency. With consumer-savvy, newly aged-in Medicare beneficiaries, there is also a shift in patient expectations and what is available for their healthcare dollar. The new beneficiary is aging in from a world of patient engagement and incentive and rewards programs and will expect the same level of service. Health plans need to find ways to evaluate their existing provider networks and newly expanded networks to meet these clinical and financial goals and be forward-thinking on how to best wrap risk adjustment and Star Ratings into the mix.
Additionally, the belt is tightening with day-to-day network management, and plans must reach out to their providers on a monthly basis to confirm demographics and availability of their providers to ensure the information is updated in real-time with online directories and close the loop between the providers submitted on the HSD tables versus those in the directory. We will also delve into network adequacy becoming part of the overall audit protocol pilot for 2015.
In an upcoming white paper, Gorman Health Group's (GHG's) Senior Vice President, Regan Pennypacker, will provide compliance insight on the draft application. A key network component in the draft is that plans will be required to submit their HSD tables for their entire network, not just the counties the plan is proposing to enter with the service area expansion request. This requirement further supports the CMS commitment to monitor network adequacy for MA plans much more closely.
Given that applications will be due in a few short months, GHG is here to help. We have a long history of providing direct contracting assistance for plans, the ability to run multiple network adequacy and availability scenarios, and prepare your plan's HSD tables for submission. We also have the bench strength to help you develop a true network strategy taking into consideration the quality, financial, Star Ratings, and risk adjustment goals you need to reach in the competitive landscape of healthcare. Let us know how we can work together and build strategic network operations to support your plan goals.
Important key dates for application submission:
Resources
GHG can assist your organization in developing and executing a networking strategy, from contracting targets to model contract terms, to payment terms that match your budgets and the capabilities of your claim payment systems. Let's get started. Contact us today
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095. Register today >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
The 2016 Star Ratings: Finding Calm in the Chaos
All great changes are preceded by chaos, and the Centers for Medicare & Medicaid Services (CMS) release last week of the 2016 Star Ratings certainly introduced a great deal of chaos for Star Ratings teams throughout the industry. With approximately 5% of additional reimbursement tied to ≥4-Star performance, health plan leaders are either taking a deep breath this week (if they earned ≥4 Stars and qualified for Quality Bonus Payments) or doing their best to quell the inevitable panic if the 4th Star eluded them.
CMS continues to leverage Star Ratings to support improvements in member perceptions and longer-term, sustainable improvements in health plan performance and health outcomes. CMS continues to make rapid, continuous changes among measures, cut points, and program criteria. The speed and extent of change reinforces the need for a seasoned, dedicated Star Ratings leadership team which embraces and manages Star Ratings as a holistic, silo-busting program. It's vital for health plans to simultaneously excel not only in their clinical and pharmacy quality functions but also in every other health plan function. This includes everything from care coordination, network operations, member experience, risk adjustment, appeals and grievances, and compliance, to claims and encounter data and analytics, marketing, and every other department in the organization.
As we adapt to the first Star Ratings cycle with no predetermined thresholds, it's clear there is very little low-hanging fruit left in the Star Ratings program. It's time for us to climb the tree.
With budget season upon us, it is an ideal time to evaluate Star Ratings strategies and work plans to ensure 2017 investments are wisely made. Now that the 2016 Star Ratings are out, take an objective look at your Star Ratings programs to ask:
- Are we investing adequately in the areas where we need the most Star Ratings lift?
- Will our Star Ratings initiatives achieve our goals?
- Are we conducting the right interventions, with the right members, at the right time?
- Are we adequately integrating medication management and behavioral health into our Star Ratings programs?
- Are we adequately coordinating provider and member engagement activities?
- Are our provider contracts and pay-for-quality programs designed adequately to sustain success in the new Star Ratings environment?
If your plan achieved 4 Stars this year, this is no time to rest. The 178 plans at 3 or 3.5 Stars in 2016 are working hard to achieve 4 Stars this year, and with CMS' bell curve, this means some of the current 4-Star plans will drop in 2017. And don't forget — there are another 188 Medicare Advantage plans not rated in 2016. This huge group of plans will impact the bell curve as they receive their first ratings.
If your plan missed a 4-Star Rating this year, now is not the time to panic. There is still time to influence your 2017 Star Ratings, particularly since the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) and Health Outcomes Survey (HOS) surveys will not be fielded until early 2017. But since time is definitely of the essence, it is important to invest time and resources wisely into the areas with the greatest opportunity for short-term improvements.
We can help. Gorman Health Group understands the complexities and nuances of the Star Ratings program and measures. We know how to design programs, initiatives, and tactics to improve Star Ratings performance. From evaluating organizational strategy to developing and optimizing tactical Star Ratings work plans, our team of experts has a long history of success helping health plans achieve Star Ratings success.
With time waning to influence the 2017 Star Ratings, find calm amidst the chaos and prepare for the great changes to come.
Resources
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095. Register today >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Star Ratings: Preparing for 2016
With the Centers for Medicare & Medicaid Services (CMS) release last week of its annual Request for Comments on Enhancements to the Star Ratings program, we now have our first official glimpse into the potential changes which could be introduced in the 2018 Star Ratings.
Consistent with CMS' recent about-face on the impact of socio-economic characteristics on a plan's Star Ratings, CMS laid out two potential interim analytical methodologies which may be used to help account for the Star Ratings differences of low income subsidy (LIS)/dual eligible (DE)/disabled members. CMS indicated these interim analytical adjustments will be interim solutions only and could be used while CMS completes its broader work on a more effective quality structure and payment model which more effectively supports the unique needs of LIS/DE/disabled members. CMS has requested health plan feedback regarding both potential options as well as recommendations for any additional permutations and/or hybrid approaches based on the two options presented.
CMS is not planning to add any new 2017 measures, which is welcome news to health plans, to be certain. However, CMS announced a number of potential new 2018 measures, some of which will bring transparency to clinical areas new to the Medicare Advantage Star Ratings program. Some of the new areas which could be Star rated include asthma medication management (including dispensation of, and adherence to, asthma medications), statin therapy prescribing patterns, and hospitalizations for preventable conditions (which will assess the quality and coordination of ambulatory care). In sharp contrast to recent history, in which we have seen very few new clinical measures added as Star Ratings, the nature and scope of these new measures will put plans squarely back in the driver's seat to initiate new types of clinical quality improvement work with their providers.
The proposed retirement of the High Risk Medication (HRM) measure (which had an average national 2016 rating of 4.1) to the Display page and the continued retention of the Improving Bladder Control measure on the Display page should be considered temporary by plans. These measures continue to receive attention from CMS and measure developers and could easily be returned as Star Ratings Measures in the future — the Improving Bladder Control measure potentially as early as the 2018 Star Ratings and the HRM measure potentially as early as the 2020 Star Ratings.
As is always the case with CMS' announcements regarding potential changes to the Star Ratings program, we know final decisions will not be made until after the measurement periods are complete. To successfully cope with this reality, health plans must continue monitoring CMS' updates and announcements in the upcoming Advance Notice and Final Call Letters while simultaneously enhancing current workflows to incorporate strategic elements of the proposed changes. As we learned last spring, CMS gives strong consideration to health plan feedback regarding any proposed changes to the Star Ratings program.
With the potential Star Ratings changes on the horizon, this is a great opportunity to revisit your 2016 Star Ratings work plan to ensure you are ready for success. It's a great time to evaluate reports, analytics, member/provider workflows and targeting, and budgets to make sure you're prepared to earn your 4-Star Rating next year.
Resources
Gorman Health Group's team of experts can help your organization adapt to the new clinical areas emphasized in the Request for Comments, develop or enhance care coordination within your programs, or evaluate the effectiveness of your current Star Ratings program. We can also help you educate your staff and providers on the nuances and clinical implications of these new measures. Visit our website to learn more >>
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095.Register today >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>