2016 Star Ratings are Working, and the Bar is Rising

The Centers for Medicare & Medicaid Services (CMS) released the 2016 Medicare Advantage (MA) Star Ratings early this year, on Thursday morning.  The usual practice is to wait until Friday after the close.  It was a shift designed to move markets, and the news was mixed. Overall, Star Ratings are working to improve quality in many areas of health plan performance, but insurers and their provider and pharmacy benefit partners are struggling on a similar number of metrics. What is clear is that Star Ratings are now the fulcrum of competition in government health programs — and man, this stuff is hard and getting tougher.

There are clear winners and losers in this release.  There is a "Divine Dozen" of 5-Star-rated plans, including a couple of new arrivals to the 5-Star world. CIGNA traded its 5 Stars in FL (the legacy HealthSpring plan at the legendary Leon Clinic) for its Arizona plan. Sierra (9 states), Tufts (MA), Group Health of MN, and Essence (IL and MO) made it into the Pantheon.  Repeat 5-Star rock stars include Kaiser in 8 states, Martin's Point (ME and NH and will soon own Medicare in Northern New England), and Gunderson in IA and WI.

The half-dozen "walking dead" — plans scoring below 3 Stars for 3 consecutive years —included Wellcare of LA, Sierra Health, Touchstone, Cuatro, Windsor, and GHS (owned by HCSC).   Three will be terminated by CMS at the end of 2016.

Star Ratings are proving to be tremendously effective in moving markets and forcing industry investments in population health and the member experience and are driving big improvements in Medicare quality.  Roughly half of MA plans (179 contracts) earned 4 Stars or higher for their 2016 overall rating, a nearly 9% increase in a year and the first time a majority scored over 4.  On an enrollment-weighted basis, over 70% of MA enrollees are in contracts with 4+ Stars, a nearly 11% increase year over year.

But below the water line, at the metric level, the news was mixed and cautionary:

  • The good news: Average Star Ratings increased for 10 Part C measures and 5 Part D measures. We saw significant improvements in several challenging, longitudinal Health Outcomes Survey (HOS) measures: Improving/Maintaining Mental Health, Monitoring Physical Activity, Part D Appeals Autoforwards, and High Risk Medications. There were smaller improvements on many other measures, where removal of the 4-Star thresholds helped plans improve ratings.
  • The bad news: Average Star Ratings DROPPED for 16 Part C measures and 6 Part D measures. We saw significant decreases in several screening measures (colorectal cancer screening, diabetes kidney disease monitoring) and the HOS measure of improving/maintaining physical health.  And there was a big drop on the Medicare Plan Finder (MPF) Price Accuracy measure, where the cut points have gotten so small that 97% accuracy only gets 3 Stars, 99% results in 4 Stars, and it literally takes a perfect 100% to earn 5 Stars.

We knew the removal of the 4-Star thresholds would produce a tremendous amount of fluctuation in the measure cut points, and that's exactly what happened.  It's like playing "Pin the Tail on the Donkey" during an earthquake, making it really hard for health plan leaders to predict where their ratings will ultimately land while they still have time to influence them.  For example:

  • The average rating on the Diabetic A1c Control measure increased from 3.3 in 2015 to 3.9 in 2016.  But there was no change whatsoever in the average performance rate for this measure — in both 2015 and 2016, the average compliance rate was 76%.  The improvement on this measure can be entirely attributed to CMS relaxing the cut points once the predetermined threshold was removed.
  • In contrast, the Controlling Blood Pressure measure rating dropped from 3.7 in 2015 to 3.4 in 2016.  The compliance rate actually increased from 65% in 2015 to 71% in 2016.  This is an example of where the removal of the predetermined thresholds tightened the pressure on this measure — in fact, the 4-Star threshold increased 12% upon removal of the predetermined thresholds.

The Star Ratings data for 2016 pretty much emasculated industry arguments for relaxing metrics for Special Needs Plans (SNPs).  SNPs saw improvement in their quality scores roughly equal to that of HMOs and PPOs: MA plans operating SNPs averaged a 3.61 rating in 2016 (up from 3.47 in 2015), while plans with HMO/PPO-only contracts averaged 3.87 in 2016 (up from 3.79 in 2015).

Non-profit MA plans are pounding for-profits into the sidewalk on quality. About 70% of non-profit MA plans received 4+ Stars vs. 39% of the for-profits. Much of that discrepancy is due to culture. Non-profits tend to be far more focused on the all-important member experience measures and are more collaborative with their provider networks.

Methodological changes by CMS ensure the Star Ratings bar will continue to rise.  2016 is the first year plans with 500-999 members were rated. Only 369 Medicare Advantage Prescription Drug Plans (MA-PDs) were rated in 2016. 188 more plans weren't rated, but may be in 2017 — and this dilution will warp the bell curve plans are graded on, especially when considering most of those 188 are provider-sponsored, and strong performers will emerge. 4+-Star plans have the most to lose in this environment, and no one can afford to get comfortable.

Some takeaways:

  • Stars must be managed as a program and a corporate priority, not as a group of measures.  The effort must be directed by dedicated executive leadership and support.  No plan improves Star Ratings doing it off the side of their desks.
  • The removal of the remaining predetermined thresholds means there is no way for plans to "pick and choose" a subset of measures to focus on.  It has to be improvement across the board.
  • The bar continues to rise fast among Part C Star Ratings measures.  The "low hanging fruit" has been eaten. Part C Star Ratings success is no longer easily influenced by slick reports provided to physicians. Plans need to help providers execute on gaps in care plans and eliminate barriers to care for the vulnerable. There's a reason the 5-Star plans are mostly provider-sponsored, vertically integrated, collaborative, and member-centric by nature.
  • Star Ratings measures need to be woven into every department's work streams.  This includes not only quality, care management, health services, and pharmacy, but also risk adjustment, network operations, and compliance.
  • Lagging SNPs need to work harder and smarter and assume no CMS help on the measures for the low-income and disabled.  To the contrary, recent draft measures for dual eligibles from the National Quality Forum focus on mental and behavioral health and will prove an enormous challenge.

If you achieved 4+ Stars this year, congratulations, it's an increasingly impressive accomplishment.  Now get back to work.  There are 178 plans at 3-3.5 Stars who are close on your heels and feeling the urgency.  Now add the 188 unrated plans who will smash the bell curve in 2017.  A 4-Star plan's equal effort in 2016 only guarantees a score that starts with a 3 the next year.  Keep. Moving. Forward.

If you missed your 4th Star this year, panic a little, but then get it together. Fast. In a competitive market, you're circling the toilet bowl but aren't flushed yet.  You still have time to influence your 2017 Star Ratings and must make improvement the focus of your benefit, formulary, and network designs in the months ahead. You have big decisions to make and must invest time and resources wisely and with a sense of urgency.

Once again, the 2016 Star Ratings prove the world's biggest experiment in performance-based payment is working and forcing insurer evolution.  And evolution isn't about size, it's about continuous adaptation.

 

 

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 >>

Join us on Friday, October 9, from 1-2 pm ET, as John Gorman, Founder & Executive Chairman at Gorman Health Group (GHG), examines the state of government healthcare programs and outlines proven tactics market leaders are implementing to cut costs, increase member satisfaction, 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 >>

by GHG Advisors

The MA-VBID Model: Key Takeaways

Now that you have digested the Centers for Medicare & Medicaid Services' (CMS) announcement on the proposed demonstration for high-value benefit designs, the clock is ticking on determining an optimal set of benefits prior to the CMS deadline of November 15, 2015.

Over 37 organizations are eligible to consider this opportunity, which is based on member value and not competition.  As John Gorman, Founder & Executive Chairman at Gorman Health Group, and I discussed at length on our recent Medicare Advantage Value-Based Insurance Design Model (MA-VBID) webinar on Monday, a multi-faceted approach within the health plan operation will be needed to quickly put together a review and proposal. Operational "must haves" include high-value, narrow networks which understand the eligible populations, high-quality disease management programs, solid Star Ratings programs, and predictable membership.  A strong foundation in claims processing and configuration, product design (including supplemental benefits), return on risk adjustment, efficient organization staffing, and excellent communications (electronically) with providers are needed to support the required capabilities.

Although marketing to the target populations will take place post-enrollment to limit adverse selection, the concept of a target condition is based on two key triggers.  Realistically, the target condition is marked on a claim with several months' run-out, even if a need already exists such as follow-up visits to specialists or prescription drugs.  Good Electronic Medical Record (EMR) communication can shortcut that process to activate benefits.  Fortunately, drugs can be targeted for benefits, but Pharmacy Benefit Manager (PBM) coordination is critical.

GHG has been preparing for this shift in the industry and is already working with clients to assist in the assessment of current providers, referral patterns, and populations within the eight chronic conditions (diabetes, congestive heart failure, chronic obstructive pulmonary disease (COPD), past stroke, hypertension, coronary artery disease, mood disorders, and various International Classification of Diseases (ICD) combinations).  Understanding the cost and utilization as well as referral patterns for these members (medical and pharmacy) will help a plan maximize the potential for success. A team of subject matter experts from Gorman Health Group will deliver actionable results, driven by data analysis of current capabilities and benefit designs, to achieve quality care for the target populations.

The benefits must be approved with November submissions and certified by the plan's actuaries with the 2017 bid in June 2016, so they are binding.  Gorman Health Group is prepared to help with individual plan assessments and partner with clinically-effective benefit designs that deliver financial and quality results.


Resources

GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you're keeping pace with CMS expectations in both compliance and health care outcomes. Visit our website to learn more >>

Join us on Friday, October 9, from 1-2 pm ET, as John Gorman, Founder & Executive Chairman at Gorman Health Group (GHG), examines the state of government healthcare programs and outlines proven tactics market leaders are implementing to cut costs, increase member satisfaction, and drive sustainable growth. Register now >>

Download a copy of the recording from Monday's Medicare Advantage Value-Based Insurance Design Model (MA-VBID) webinar, hosted by John Gorman.

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

by GHG Advisors

Star Ratings Plan Preview #2

It's hard to believe, but it's that time of year again.  Yes, it's football season—and it's also the beginning of Star Ratings season.

The Centers for Medicare & Medicaid Services (CMS) annual Star Ratings plan preview periods have become as much an annual ritual for Medicare Advantage (MA) plans as the Advance Notice and Call Letter, and plans throughout the nation are feverishly working to understand their 2016 Star Ratings so they can quickly determine what still needs to be done during the fourth quarter to close out 2015 strong.

Although there were few surprises in the 2016 Star Ratings measure specifications, there was much to be gleaned from the long-awaited removal of the remaining pre-determined 4-Star thresholds.  As expected, almost as many 4-Star thresholds were decreased as were increased.  The plan preview measure specifications show 4-Star cut points were tightened on 20 measures and relaxed for 13 measures.  Measures where the 4-Star cut points were relaxed included those with significant patient lifestyle and perception impacts, such as medication adherence, diabetic blood sugar control, and several Consumer Assessment of Healthcare Providers and Systems (CAHPS®) measures.  In contrast, measures with tightened cut points include many of the Healthcare Effectiveness Data and Information Set (HEDIS®) process measures, where plans and providers have a long history of focus and attention to gap closure.  In contrast, 4-Star cut points were only relaxed for one administrative, or plan-controlled, measure, which demonstrates plans are "controlling the controllables" within the program.  Again, no big surprises in these changes.  But the absence of surprise does not mean it will be easy for plans to adapt to these changes.

So what can we take away from the plan preview?

  • CMS continues to use the Star Ratings program to compel health plans to increase their strong focus on quality improvement in their service to beneficiaries.
  • Plans must continue investing efforts in longer-term strategic relationships with members and providers to continue improving health outcomes, meeting beneficiary expectations, and performing well in the Star Ratings program.
  • With the increasing competition in MA and full adoption of the bell curve within the Star Ratings program, the definition of success is likely to continue to rise.  There is simply no such thing as "good enough" in Star Ratings.

With approximately five percent of MA plan revenues tied to Star Ratings performance through Quality Bonus Payments, an objective review of a plan's Star Ratings infrastructure, strategy, and performance can be a wise investment.

 
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 >>

Join us on Friday, October 9, from 1-2 pm ET, as John Gorman, Founder & Executive Chairman at Gorman Health Group (GHG), examines the state of government healthcare programs and outlines proven tactics market leaders are implementing to cut costs, increase member satisfaction, and drive sustainable growth. Register Now >>

by GHG Advisors

Medicare Advantage Value-Based Insurance Design: Key Considerations

The Centers for Medicare & Medicaid Services (CMS) recently announced a proposed demonstration that will test varying benefit designs based on health status. The Medicare Advantage Value-Based Insurance Design (MA-VBID) Model will allow organizations to offer targeted supplemental benefits and/or reduced cost sharing to enrollees with specific chronic conditions to further the goal of improving beneficiary health, reducing the utilization of avoidable high-cost care, and reducing costs for plans, beneficiaries, and the Medicare program. The overall goal of this demonstration is to improve clinical outcomes while reducing plan expenditures.

Do you qualify?

This demonstration is proposed for seven states: Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee. According to the announcement, only current MA organizations in good standing in those states will be allowed to participate. The demonstration is aimed at Health Maintenance Organizations (HMOs), Health Maintenance Organization Point of Service (HMO-POS) plans, and local Preferred Provider Organizations (PPOs) in order to determine how it affects beneficiaries and costs in the most common plans. Special Needs Plans (SNPs), Regional PPOs, Medicare-Medicaid Plans (MMPs), Private Fee-for-Service (PFFS) plans, Employer Group Waiver Plans (EGWPs), Health Savings Accounts, and cost plans are not eligible.

The demonstration will waive certain regulations so benefit plans can vary for enrolled members based on their diagnosis, condition, or need for a medical service. Currently, health status distinctions in providing benefits to enrolled beneficiaries are prohibited by regulations.

How we can help:

Applications

The CMS process begins with the submission of a Request for Application (RFA), which is currently due on November 15, 2015. Organizations failing to submit an RFA cannot participate in 2017 but may be allowed at a later date during the five-year demonstration period. Organizations must submit an RFA that has sufficient detail to allow CMS to determine if the benefit plan addresses targeted beneficiaries, will provide measureable results, and is appropriately structured for the demonstration. We can work with your organization through every step of the application process, from gathering the right data and completing the application, to submitting the application and responding to follow-up questions.

Financial Analysis

The key to designing a successful MA-VBID model is to establish programs to simultaneously manage revenue through best-in-class Star Ratings operations and targeted risk adjustment for these prevalent diseases and avoid adverse risk selection as well as an ongoing review of cost and utilization drivers from medical and pharmacy claims. An initial assessment of claims and financials can help highlight existing strengths and weaknesses in medical management (including pharmacy) as well as provider networks. With annual bids as the source of financial truth, targets need to be realistic and timely.

Benefit Design Analysis

Organizations can propose any myriad of combinations of benefits or services provided they are based on the proposed chronic conditions listed in the announcement. Most importantly, CMS notes participating organizations can initiate the demonstration with a limited benefit and can expand their benefit plans during the five-year term of the demonstration. While the benefits will be mandatory supplemental benefits, CMS proposes to prohibit marketing these benefits to non-member beneficiaries.

 
Resources

We can work with your organization to design and implement a comprehensive data analysis to guarantee you have the right products, programs, and capabilities in place to compete and ensure you are go-to-market ready.

Is this the right opportunity for your organization? Attend our webinar to find out. Join John Gorman, Founder and Executive Chairman at Gorman Health Group, and I on Tuesday, September 29, from 1-2 pm ET, as they outline the MA-VBID plan requirements as well as what you should be doing now to prepare for January 2017. Register now >>

 

by GHG Advisors

Government Sends Stark Reminders that Insurers' Biggest Customer is Still the Regulator

Since we opened our doors 19 years ago, we've preached to health insurers to think of the government as your business partner.  This week, we got several reminders that insurers' biggest customers -- Medicare, Medicaid, and ObamaCare -- are still the regulator.  As business conditions improve for health plans across these business lines, government expectations are rising, and scores are about to get settled, as they always are in the second term of a Democratic administration.

We see it in enforcement activity from the Centers for Medicare & Medicaid Services (CMS).  We see it in a steadily-rising bar of Star Ratings and other performance measures for health plans for all three programs, the basis of looming contract terminations.  And now the White House jumps in with an aggressive schedule of risk adjustment data audits, openly seeking repayments and dropping "f" bombs: fraud, that is.

They named a great film after a moment like this: "There Will Be Blood."

You can't argue with the numbers: 2015 remains the most punitive year in Medicare Advantage history.  Look at the trend:

CMS is also being much more aggressive this year with data-driven oversight and enforcement.  Communications to health plans who are "outliers" in various performance measures, especially in member communications and consumer protections, began recently.  A pattern we are seeing play out is CMS chasing down all clients of noncompliant pharmacy benefit managers; where poor Part D performance is seen in one plan, the agency then begins auditing that vendor's other customers, assuming they'll get the same findings.

We know that Star Ratings and expanding reporting requirements in Medicare Advantage and Part D mean the bar is rising and establishes data-driven thresholds against which health plans can be penalized and terminated beginning in 2016.  CMS announced sweeping new reporting requirements for both programs this week, which inevitably get picked up in Medicaid and ObamaCare rules in following years.

And now the White House is piling on.  In Washington, we talk a lot about "setting the terms of debate." Our industry has lost the debate on risk adjustment coding and has allowed anti-managed care advocates to define payers' inaccurate diagnostic coding as fraud.  A just-disclosed February 2015 letter from President Obama's Budget Director to Health Secretary Sylvia Matthews Burwell stated, "While some progress has been made on this front, we believe a more aggressive strategy can be implemented to reduce the level of improper payments we are currently seeing...we must continue to explore new and innovative ways to address the problem and attack this challenge with every tool at our disposal...the government estimate of $12.2 billion in these mistakes for fiscal year 2014 remains a concern." He extended his mandate beyond Medicare Advantage to over $3 billion in questionable payments from Medicaid. This means a spike in data validation audits for payers across both programs with the threat of improper payment clawbacks and even prosecution under the False Claims Act.

There has never been a more Golden Age of opportunity for health insurers in government programs.  But the threats are escalating as well, and as my politics professor told me, "99% of political wounds are self-inflicted."  Plans caught up in this dragnet will have gotten plenty of warnings.

 

Resources

The Part C and Part D Reporting Requirements and Supporting Regulations were posted in the PRA Listing on August 24th for review and 30-day comment. Since we are still in this window, this is a great opportunity for Compliance and Operations to review these together. Click here to review the Part C highlights that merit your attention in a blog posted by Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group (GHG).

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

by GHG Advisors

Teaming with Providers: Together, Everyone Achieves More

When a team works well together, the members collectively accomplish more than any of the individuals could have accomplished alone.  Certainly, we have proven that adage true in healthcare, as can be seen with the success of integrated delivery systems, Independent Practice Associations (IPAs), and Accountable Care Organizations (ACOs).

As health plans continue adapting to the growing influence of clinical quality on its provider network operations, building an effective team with your providers has never been more important.

But, factor in the necessities of compensating members of the team for their role, of each team meeting its profit targets and the competing priorities faced by often short-staffed teams, it should come as no surprise many health plan staff and providers are left wondering how to make it happen.  Below are our top five ways to engage your providers to influence your Star Ratings.

 

  1. Prioritization: Ensure Clinical, Risk Adjustment, Stars, Claims, and Network Operations are all collaborating and prioritizing their "asks" of the providers and working together to ensure the needs of the providers are met.
  2. Education, Education, Education: By arming your leaders with the education necessary to purchase the best reporting tools, they are able to develop the goals and framework necessary for the frontline staff to educate and respond to providers.
  3. Support ICD-10 readiness:  If CMS predictions hold true, denial rates and outstanding receivables are likely to increase during the conversion.  Despite testing and readiness efforts, it's entirely possible some providers may not be staffed or prepared to mitigate technology-related problems among its payers or to weather the longer-term reduced productivity of their coding staff.   Before your providers can invest additional energy into our Quality priorities, they've got to keep the cash flowing.
  4. Focus on actionability:  Health plans often provide catalogs of reports each month showing providers' numerous views of their panels and forget providers are taught evidence-based medicine and how to care for patients, not administrative functions. By telling providers to improve care, we can make them vulnerable and defensive.  By collaborating to improve processes and coordination for better patient satisfaction and outcomes, we can let the providers be providers.
  5. Continuous measurement, re-evaluation, and reward: While we naturally monitor our outcomes and re-evaluate our processes, we sometimes forget to reward ourselves for a job well done.  We can build in contractual provider incentives, but peer recognition and a "thank you" are often simple but overlooked motivators.

 

Questions to ask:

  • Were there any surprises in your first Star Ratings Plan Preview rates?
  • Are your providers effectively supporting your Star Ratings goals?

 

From identifying the health plan functions that require provider engagement, to interpreting Plan Preview rates and trends in order to build 4th quarter Star Ratings action plans and evaluating provider contracting strategies around a holistic approach, our team can help.  Contact me directly at emartin@ghgadvisors.com .

 

 

 

Resources

CMS recently notified plans of the first preview period for the 2016 initial Star Ratings data. It is critical for plans to begin evaluating their Star Ratings now to pinpoint problem areas, implement tactical actions, and identify improvement opportunities to raise their current score. Need assistance with your action plan or preparing for plan year 2016? Contact us today >>

At Gorman Health Group, we can help you decide what payment models are appropriate to your unique circumstance and support your implementation efforts. Learn more >>

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

by GHG Advisors

Medicare at 50: Past, Present & Future

Since its inception on July 30,1965, millions of elderly and disabled Americans have been able to obtain medical care through Medicare. Before Medicare, almost half of all Americans 65 and older had no health insurance. Today that number has dropped to a staggering 2 percent.

The accomplishments for Medicare have been noteworthy.

These include increased access to health insurance coverage and healthcare, decreased disparities in access by race leading to desegregation of hospital staff and facilities, as well as payment and delivery system reforms such as prospective payment, capitation, and shared savings — all of which have been adopted by private payers. Karen Davis from Johns Hopkins and former President of the Commonwealth Fund noted the success of Medicare's insurance Marketplace which offers beneficiaries a choice of traditional Medicare and Medicare Advantage plans with a 4-5 Star program that is driving plans and enrollment to higher quality. Medicare spending per capita has grown more slowly than overall health spending per capita and is currently at historically low rates.

The challenges are many.

Disjointed coverage (Parts A, B, D) is confusing to beneficiaries and results in high administrative costs and overpayments. Out-of-pocket costs for premiums, cost-sharing, and uncovered services remain high, and Medicare has no out-of-pocket maximum. Medicare does not cover long-term care services or home- and community-based services. Provider payment still remains largely fee-for-service, resulting in incentives for volume and provider not patient-centered care.

The Future

The future involves many different directions. The first is moving from an acute care model to a program that can effectively care for beneficiaries with complex chronic conditions. Provider payment reform needs to move to value-based payment that rewards efficiency and quality. The focus needs to shift to patient-centered care rather than provider-centric care. Care coordination and team care needs to be a focus. Program fragmentation and high out-of-pocket costs, particularly for high service users, needs to be addressed.

As Charles Darwin pointed out, evolution isn't about being the biggest or the smartest, but the most adaptable. Government programs have become the biggest opportunity for payers. Rates will be positive especially in Medicare Advantage, but the compliance environment will be brutal throughout the rest of the Obama administration. Star Ratings and the member experience are now driving the market — 30 plus states are now using some form of Star Ratings for performance-based payment, many states have adopted quality ratings for Medicaid managed care plans, but there is no national standard….yet, and the Health Insurance Marketplace will begin publishing quality ratings in 2016.

What have we learned?

John Gorman, Founder and Executive Chairman at Gorman Health Group, recently provided lessons learned in the 19 years we have partnered with health plans operating in Medicare, Medicaid and now the Health Insurance Marketplaces. He discusses the current industry environment and what's important moving forward.  Read more >>

About 81M will be enrolled in Medicare by 2030. Is your organization prepared?


Resources

Gorman Health Group evaluates the design and delivery of high quality collaborative care while achieving compliance and improving revenue cycle management. Our multidisciplinary team of experts will assess the alignment of your products, your current network and your market to translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>

GHG can evaluate your Star Ratings approach, and identify tactics you can begin implementing immediately, to integrate initiatives, eliminate redundancies, and build an enterprise-wide Star management structure. We can help you identify clinical, operational, and networking opportunities to increase your score for 2016 and beyond. Contact us to  learn more >>

Stay connected. Subscribe to Gorman Health Group news and updates via our weekly newsletter.

by GHG Advisors

Quality Ratings: No National Standard for MCOs…Yet

A recent article noted five major changes in new Medicaid Managed Care rules, one pertaining to a quality ratings system. Many states have quality ratings for managed care plans, but currently there is no national standard.  Medicare has a five-star system evaluating private plans, and private plans offered through the Affordable Care Act's (ACA's) Health Insurance Marketplace will begin publishing quality ratings in 2016.  Ratings for Medicaid managed care plans would look similar to the Marketplace plan ratings.

"CMS' rationale was to more closely align the ratings system for managed care plans with [exchange plans], because a lot of those plans in the Marketplace are also Medicaid managed care providers," said Lisa Shugarman, a consultant at Health Management Associates.

The Marketplace plans will begin testing a ratings system this year including three broad categories (clinical quality, patient satisfaction, and plan management/affordability) that would also be a part of the managed care ratings. The Marketplace plans' ratings system will also have dozens of sub-categories — the specifics of which will be determined by state officials and health experts.  It has taken about three to five years for the Marketplace plans to have their ratings system up and running and would likely be the same time frame for managed care, according to Matt Roan, another consultant at Health Management Associates.

States would have the option to include additional measures, but the process for doing that isn't clear yet, and many managed care organizations (MCOs) are wary of too much variation between state quality reporting systems. They will be pushing CMS to ensure a high level of standardization to ease compliance.

Non-profit Medicaid plans support quality ratings, but they also think the rule should apply to traditional, state-run Medicaid and other arrangements, such as Accountable Care Organizations (ACOs).

 

Resources

Gorman Health Group can help your organization implement successful quality initiatives, from both the quality and operations perspectives, to improve scoring and control costs while continuing to serve the rapidly expanding Medicaid and dual-eligible populations. Visit our website to learn more >>

Stay connected. Subscribe to Gorman Health Group news and updates via our weekly newsletter.

by GHG Advisors

Takeaways from Accountable Physician Groups' Annual Summit

Twice a year I get the honor of speaking to the California Association of Physician Groups' (CAPG) annual summit and DC policy meeting.  CAPG represents accountable, capitated physician groups, and now has members in 39 states.  They're always among my favorite speeches given how sophisticated the audiences are.  Here's a few takeaways from my talk last week on "The Future of Government Programs":

  • Forevermore, physician group revenues and earnings will be dominated by Medicare Advantage, Medicaid and dual eligible health plans, and the ObamaCare plans, most likely in that order.
  • Everything that Medicare Advantage (MA) does, the Medicaid, ObamaCare, and commercial markets follow 3-5 years later.  Nobody knows this better than the CAPG members from CA, which the rest of the nation lags. Want to still be attending CAPG meetings in 2020? Master Star Ratings and risk adjustment.  They'll apply to all lines of business if they don't already, and they are the keys to survival already in MA.
  • Value-based contracting is in its infancy but will soon define all health plan contracts with physician groups.  Fee-for-service is dead.  Performance-based capitation is the only future.  To master it a physician group needs a range of capabilities, including eligibility verification, interoperability, actionable clinical intelligence in real time, standardized care processes, and chronic care management, across all business lines.
  • Most Accountable Care Organizations (ACOs), especially the 424 in Medicare, will not see a return on their investment.  They will have spent millions to participate in these experiments and around 80% won't see a payoff.  2016 and 2017, when Medicare Advantage benchmark rates turn into a tailwind, present the perfect opportunity for ACOs to "move up the food chain" to become health plans.
  • Dual eligibles are the biggest opportunity of our lifetimes, and there is no question that Special Needs Plans designed to serve them can be profitable.  SNPs are a principal mechanism for states to shift long-term care risk into the private sector, and will be a central product for ACOs converting into Medicare Advantage. But they require a range of capabilities most physician groups lack today, such as enabling and social services that duals must have from their insurer.
  • In all government programs, the "5/60 Rule" governs.  5% of members often account for 60% of costs.  Any physician group that aspires to bear risk must be able to identify and intervene with their 5 percenters or they won't be risk-bearing for long.
  • The biggest vulnerabilities for MA plans are consumer protections like appeals and grievances and complaint management, and who they have selected as their pharmacy benefit manager (PBM).  Most PBMs are frankly terrible at Medicare Part D administration, and Star Ratings now count far more in Part D than in Medicare Advantage to a health plan's overall score.  Physician groups typically have little or no experience with either PBMs or consumer protections.
  • Retail pharmacies and the home are the most underutilized sources of care to government programs beneficiaries.  Any successful physician group evolution will involve better integration of both sites for the chronically ill.
  • Most at-risk physician groups are directly involved in coding and reporting for risk adjustment.  Federal agencies are paying unprecedented attention to upcoding in Medicare Advantage with an eye to hundreds of millions of dollars in clawbacks and recoveries.  The emphasis at physician groups involved in risk adjustment must move from chart reviews and claims extracts to more holistic member evaluations, and from a culture of "what can we get?" to "how do we stay out of trouble?"

Evolution is a messy business.  Nowhere is that more the case than in physician groups evolving from fee-for-service to value-based contracting and becoming insurance companies.  If it was an easy business, we'd be out of business.

Resources

Don't miss Gorman Health Group's Chief Consulting Officer, with colleagues Jane Scott, Senior Vice President of Clinical Innovations and Regan Pennypacker, Vice President of Compliance Solutions, as they discuss your member experience and the factors that influence success and failure, as well as prominent compliance and service issues plaguing the industry. Register now >>

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by GHG Advisors

Re-Evaluating Your Plan's QI Evaluation and the Process Behind It.

This is the time of year when most plans have either completed, or are in the process of completing, their annual evaluation of their Quality Improvement (QI) Program Description and Work Plan for operating year 2014.  In the 12+ years I have worked for Gorman Health Group (GHG), I have seen a range of evaluations — from great evaluations to those that are just a couple of pages without content.  Let's examine some mistakes and discuss some industry happenings that are often missed in the overall QI world.  Before we go on to discuss, let's remind ourselves what the Centers for Medicare & Medicaid Services (CMS) is looking for in a QI Program Description, which is based upon the regulation 42 CFR § 422.152:

For each plan, a Medicare Advantage Organization must:

  1. Develop and implement a chronic care improvement program (CCIP) 42 CFR §422.152(c);
  2. Develop and implement a quality improvement project (QIP) 42 CFR §422.152(d);
  3. Develop and maintain a health information system (42 CFR §422.152(f)(1));
  4. Encourage providers to participate in CMS and HHS QI initiatives (42 CFR §422.152(a)(3));
  5. Implement a program review process for formal evaluation of the impact and effectiveness of the QI Program at least annually (42 CFR §422.152(f)(2));
  6. Correct all problems that come to its attention through internal surveillance, complaints, or other mechanisms (42 CFR §422.152(f)(3));
  7. Contract with an approved Medicare Consumer Assessment of Health Providers and Systems (CAHPS®) vendor to conduct the Medicare CAHPS® satisfaction survey of Medicare enrollees (42 CFR §422.152(b)(5)); and,
  8. Measure performance under the plan using standard measures required by CMS and report its performance to CMS (42 CFR §422.152(e)(i)).
  9. Develop, compile, evaluate, and report certain measures and other information to CMS, its enrollees, and the general public. Responsible for safeguarding the confidentiality of the doctor-patient relationship and report to CMS in the manner required cost of operations, patterns of utilizations of services, and availability, accessibility, and acceptability of Medicare-approved and covered services (42 CFR §422.516(a)).

Mistakes often seen:

Develop and maintain a health information system: Many plans have multiple platforms that make reporting — the validity and accuracy of — a nightmare! When a plan implements a new care management system, for example, the overall analysis of its performance is often not reported in the QI Work Plan or at the plan's QI Committee. Yet, this is a vital piece to overall operational and quality success.  Ask yourselves: Did your plan implement a new system or module upgrade in plan year 2014, and do we know if it has improved our overall reporting and impacted any quality measures or our providers?

Recommendation: As part of a system upgrade or new system implementation project plan, include overall success reporting to the QI Committee.  This can include major milestones success or failure during implementation as well as a narrative summary of changes the plan and/or providers will experience upon completion of the project. Will there be new requirements for claims submission? A new clearinghouse?  A new provider portal sign-in process? Don't forget all of your external and internal customers and the impact they may experience.

Plan goals for HEDIS: I often see goals set for middle-of-the-road success at or below the 50th percentile. While I am not encouraging setting unrealistic goals, many plans miss aligning their HEDIS goals with a 4 or 5 Star Rating corridor.  Now that CMS will be eliminating pre-determined benchmarks for plan year 2016, it will be even more important for HEDIS goals to be realigned with your plan's Star strategy.  I also see many plans not include an improvement process or overall data analytics in their QI Work Plan showing how HEDIS measures actually improve overall population outcomes.  We really don't want providers just checking a box that a test was completed — we want to understand if and how the HEDIS measures have possibly improved the overall health of our membership, and, if the outcomes are positive, how did this occur? Health plans often share data with providers regarding gaps in care but miss sharing any overall improved health outcomes so providers can see the successes of their efforts.

Recommendation: Consider adding true outcomes measures to specific HEDIS measures, especially those measures that affect your Medicare Advantage Prescription Drug (MA-PD) Plan or Special Needs Plan (SNP) population as a whole.  The goal of the evaluation is to effect improvement changes both in plan operations as well as clinical outcomes.

Correct all problems that come to its attention through internal surveillance, complaints, or other mechanisms: Many plans recognize they have multiple issues or problems which may come to their attention through internal monitoring and auditing, inter-rater reliability processes, or dashboard reporting.  These problems/issues, however, often do not make it to the QI process cycle.

Recommendation: Remember, when your plan discovers a risk area through internal monitoring or a high volume of complaints/Complaints Tracking Module complaints (CTMs) for a defined reason/category, it is the plan's responsibility to institute a process which identifies a root cause, implements a corrective action, and measures the success of the corrective action.  Clinical and non-clinical activities are part of the overall QI process.

Lastly, let's discuss the pay for performance or provider incentive plan process.  Many plans have instituted an incentive program designed to improve health outcomes, prevent acute readmissions, improve medication adherence, or improve preventive health services measures which reward physicians financially when goals are achieved.  Yet, many of the goals within a provider incentive program do not align with the goals for Star Ratings, goals within a Model of Care (MOC) for SNPs, nor do these payments align with improved overall outcomes for a population.

Recommendation: Overlay the benchmarks from your current provider incentive program to be sure they align with desired goals defined within your QI Work Plan and your Star Rating strategy.  Also evaluate your population health outcomes to determine if your incentive program is driving the results your plan desires.

If your plan is still an outlier in the completion of your program's annual evaluation, GHG is ready to assist!

 

Resources

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Stay connected. Subscribe to Gorman Health Group news and updates via our weekly newsletter.

by GHG Advisors