The $64,000 Question in Star Ratings

As we wrap up the 2nd quarter, health plan leaders across the country are beginning to ask their Star Leaders the $64,000 question:  "Are we on track to achieve a 4-Star Rating this year?"

This is, perhaps, one of the most challenging questions that can be posed to any Star Leader at this point in the year. But with up to 5% of a health plan's revenue driven by Star Ratings, the question is unavoidable, and the answer is vital.Though there is no simple answer to this question for a few more months, this is an opportune time to pause and reflect on 2015 Star Ratings progress against your plan's strategic and tactical strategy to raise ratings.

It is often not easy for Star Leader's to quickly describe the potential impact of the many changes we are awaiting in the 2016 Star Ratings: removal of the predetermined 4-Star thresholds, changes to the specifications for many measures, and removal and addition of yet more measures.  Because the window is closed for us to impact our 2016 Star Ratings, we now sit in the uneasy waiting period while the Centers for Medicare & Medicaid Services (CMS) finalizes the 2016 Star Ratings and measures. CMS is also finalizing the 2016 display measures and reaching preliminary conclusions as to which 2016 display measures may be included in the 2017 ratings. These potential new display measures are being impacted by the services we are delivering this year — and in many cases, may not even be on the radar screen of our staff and provider networks.

So what can we do while we wait?

  • Evaluate your plan's performance against national benchmarks to begin assessing your relative performance within the industry.  Use this information to help set expectations while we await the 2016 ratings.
  • Review your 2015 work plan, and current progress against the work plan, to ensure that your 2015 Star Ratings weaknesses are being adequately addressed and you will not repeat tactics that do not work in plan year 2016.  Objectively evaluate how effectively customer service, case management, disease management, and pharmacy teams are coordinating care and services for your members by evaluating measurable outcomes.
  • Review your quality program's year-end evaluation, the Chronic Care Improvement Program (CCIP) and Quality Improvement Project (QIP) data to identify changes which may be required as new information is released by CMS, and consider proactive expansion of quality activities into the areas under consideration by CMS.
  • For Special Needs Plans (SNPs), review your Model of Care (MOC) evaluation for improved strategy opportunities related to the measures.

Educate and Activate.  There is plenty of time remaining to shore up operations and infrastructure to achieve Stars success.   As we continue to await release of the long-anticipated Medicaid managed care proposed rule, we are closely watching to see whether CMS will include value-based payments, new MOCs, and quality-based payment and oversight programs within yet another government health program.  These potentially transformational changes in the Medicaid quality management infrastructure, combined with the Quality Rating System (QRS) program currently being beta tested within the Marketplace, continue to reinforce CMS' current and future emphasis on quality.

Our success in quality programs will require us to embrace CMS' expanding vision for healthcare quality and translate that vision to empathetic, outcomes-focused engagement with patients who need, and will be responsive to, help from their care team.

By improving clinical quality performance, we can improve health outcomes and reduce the cost of care.  Find out how in our new White Paper now available..

Don't know where to start? Contact me today at jscott@ghgadvisors.com.

 

Resources

Our team of experts can help you develop or enhance care coordination within your programs and processes. Contact us today, and let's work together to help your plan achieve 4 Stars.

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. Visit our website to learn more >>

by GHG Advisors

The Imminent Medicaid Mega-Reg is Gonna be "Epic"

For the last several weeks health policy nerds have been anxiously awaiting the release of the long-awaited Medicaid managed care proposed rule, the first from the Centers for Medicare and Medicaid Services (CMS) in 13 years. We're coming to call it the "mega-reg" here.  Friday at the Congressional advisory MACPAC meeting, Commissioners were widely quoting  the term "epic" used by Jeff Myers, CEO of Medicaid Health Plans of America, in a recent National Journal article.

Medicaid has exploded since the last regulations in 2002, and enrollment is up 12 million just since January 2014. Current guidance doesn't address long term care services and supports and managed long-term care, a major impetus for program reform at the state level.  The proposed rule has been in final HHS/Office of Management and Budget clearance for the last couple weeks, and its release is imminent.

MACPAC's debates Friday focused on potential changes to Medicaid payment to managed care plans that might be included in the proposed rule, which the commission has been discussing for over a year:

  • Minimum Loss Ratio (MLR) — The MLR is a percentage which represents the revenue used for patient care compared to administrative expenses or profit. MLRs are allowed but not required in Medicaid managed care and currently 27 out of 39 states with Medicaid risk contracts use some MLR standard.   CMS could align Medicaid managed care policy with Medicare and commercial policy by requiring a specified MLR: a national standard such as the 85% used in Medicare Advantage program, or a requirement that states impose a MLR standard.  The proposed rule could also specify what costs should be included similar to the definitions adopted by NAIC and incorporated in federal rules.
  • Supplemental Payments and Actuarial Soundness — States may make supplemental payments to some providers up to the upper payment limit.  Current rules do not allow states to include these payments in MCO capitation rates or require MCOs to pass them through to providers.  The proposed rule could change actuarial soundness rules to let states preserve existing funding mechanisms which usually rely on waivers to level the playing field for managed care plans and their providers.
  • Mid-year Changes — There is no current process to allow MCOs to recertify their rates mid-year to account for federal policy changes such as high insurance fees or coverage or new expensive drugs and services.  CMS could require states to resubmit actuarial certifications to take significant mid-year changes into account, or allow states to prospectively certify a range of rates, or retrospectively reconcile payments when the actual cost impact is known.
  • Risk Mitigation — Current rules allow states to implement risk corridors, stop-loss or reinsurance.  CMS could require states to establish risk mitigation for new populations such as the childless adult expansion group, or for benefits where there is a significant risk or enhanced match.
  • Transparency — Medicaid health plans want transparency of state practices to develop capitation rates.  CMS could require states to share data and assumptions and allow plans to comment during federal review.
  • Baseline/Encounter Data — CMS could impose additional standards in addition to "appropriate data."  CMS could impose additional requirements on the quality and timeliness of data and specify consistent definitions for encounter data to allow comparisons across states.
  • New Models of Care — CMS could encourage value based payment, payment reforms such as safety net ACOs of other shared savings models or other innovative MCO delivery and payment models.

Beyond payment issues in the mega-reg, the Commissioners discussed:

  • Long Term Care -- CMS could include requirements for long term care services and supports covered by managed care plans which are not currently included in the 2002 regulations. The proposed rules could include beneficiary protections, provisions to ensure access to care and enrollee choice and control, and designation of an ombudsman to offer independent oversight.
  • Provider Networks -- the mega-reg will very likely include requirements for adequate provider networks and directories similar to recent requirements for Medicare Advantage and Qualified Health plans.  Strengthened requirements for appeals and grievances may also be included.  The proposed rule may also include enhanced quality data and reporting.  It's expected all these provisions would be designed to streamline expectations of Medicare Advantage, Medicaid, and ObamaCare.

We'll have scads of analysis of the Medicaid proposed rule as soon as it hits the street.  It's gonna be huge.

 

Resources

Gorman Health Group is dedicated to assisting managed care organizations, as well as states with developing models of care, maximize member engagement. Visit out website to learn how we can help with you Medicaid needs >>

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

by GHG Advisors

You're Doing it Wrong in Care Management

An important paper recently released in the American Journal of Managed Care shattered the notion that care management can save money on high utilizers. The article reviewed recent studies of the effectiveness of health plan care management programs and found that, while many studies show significant savings, more rigorous studies concluded that savings were "limited or nonexistent."  Mind. Blown.

We're all familiar with the "80/20 rule" of the commercial health insurance market: 20% of members account for 80% of expenditures.  In government programs, Medicaid, Medicare, and now ObamaCare, it's the "5/60" rule: 5% of members account for 60% of spending.  The AJMC article showed that across all payers in 2012, it's "5/50".  95% of the population accounted for just half of health spending, while the other half of spending was towards care for 5% of the population. The 5% of people needing to spend the most on health care spend an average of around $43,000 annually; people in the top 1% have average spending of almost $98,000. At the other end of the spectrum, the 50% of the population with the lowest spending accounted for less than 3% of all total health spending; the average spending for this group was $234.

The article then explored multiple studies on effectiveness of care management, concluding it's mostly pointless.  It gave several reasons for why this might occur:

  • Many high-utilizers only stay in this category for a short period of time. Conditions causing them to need intensive care may resolve quickly, reducing costs, but a study lacking a control group may inappropriately attribute this savings to the care management program.
  • High utilizers suffer from a wide range of conditions and require a wide range of interventions, making it difficult for care management programs to tailor teams meeting each patient's needs.
  • Providers working with a care management team may better identify conditions that were previously going untreated, leading to better outcomes, but also higher costs for additional services and therapies.

The author concluded that "for care management programs focusing on high-utilizing patients, it is crucial to select patients with long-term utilization patterns that are driven by the factors most conducive to change. Given the very limited direct evidence suggesting how to accomplish this, care management programs are best served by being kept small and focused on the highest-need patients, who may not necessarily be current high utilizers."

This finding calls for a rethinking across our industry about care management.  For one thing, most health plans in our 19 years' experience are still doing 1990s-style managed care: preauthorizations, referrals, concurrent review -- what we refer to as "make work" medical management.  It's look busy, high head-count work that does little to improve quality or reduce unnecessary spending.

Many GHG clients have been working with us to modernize this approach into data-driven care coordination "pods" providing a holistic model of care focused on high utilizers and those about to become them.  This study means we need to recommit to data analytics identifying and directing the work of care managers toward those beneficiaries with long-term needs that can be impacted.  This means greater emphasis on preventable episodes of care, and on end-of-life care preferences, advance directives and care plans. If you take the top 5% of the membership that is incurring the most cost and provide complex care management, including a higher level of home care, hospital diversion, medication therapy management, nutrition counseling, and wound care, plans and their provider organizations will see a reduction in avoidable medical expenses.

Savings can also be realized if that membership is appropriately placed in the right plan with the right network. Care Management might not be the answer but applicable coverage is a strategy. That's where plan and benefit design is so important. Innovative plans are working with specialists to design products that reflect risk and chronic conditions of their members.  Our work with a prominent dialysis and kidney care provider is a perfect example: design a benefit and align a network that is tailored to patients with varying levels of chronic kidney disease, preventing disease progression and/or avoidable costs traditionally seen if CKD is not managed along the disease state continuum.  Progressive conditions like CKD, Alzheimer's, and many cancers lend themselves well to "smart management" that spans clinical staff and benefit design alike.

The one thing you know about government beneficiaries is that if they're not sick today, they're gonna be.  The game has always been finding the ones who need extraordinary care before they need it, and ensuring they get it in the right place, at the right time, from the right provider.  That hasn't changed.  This study underscores the point.  "Make work" care management must give way to "make it work".

 

Resources

Big Data is costly, distracting, overwhelming and paralyzing if not maximized. System and process interoperability and integration are keys to program alignment, oversight and evaluation . Systems and data should not just integrate; they need to align in order to yield superior, reportable outcomes. Visit our website to learn how GHG can help >>

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

by GHG Advisors

19 Lessons from 19 Years

Nineteen years ago this week, I left the Health Care Financing Administration (HCFA), now the Centers for Medicare & Medicaid Services (CMS) and the Office of Managed Care, to launch what would become Gorman Health Group.  Time has flown, the company has grown, and my backside sewn with hard lessons about our industry and government health programs.  Here are 19 lessons I've learned in those 19 years.

  1. What Medicare Advantage and Part D do, Medicaid and the commercial market, including the ObamaCare Exchanges, follow 3-5 years later.
  2. Every CMS staffer I've ever known is well-intentioned, many are downright brilliant, and all want to be good business partners to health plans.  Their shortcoming is lack of business experience and how stuff works in the real world.  There is a huge difference between policy/guidance and operations.  That's where we come in.
  3. If government health programs were an easy business, we'd be out of business.
  4. Inspect what you expect.  Or, as Reagan said, "Trust but verify."
  5. Star Ratings, like risk adjustment before it, is the biggest and most consistent experiment in performance-based payment on the planet, a total game-changer and the new fulcrum of competition. You don't excel at Stars by working on them off the side of your desk.
  6. Fish where the fishes is.
  7. Pick your vendors and partners like you pick your fruit.
  8. Capitation with performance-based payment is the only real hope for long-term viability of entitlement programs.
  9. Being a doctor is the worst job ever.  Right after community hospital CEO and President of the United States.
  10. High-performing health plans are good at everything, especially those functions that are member- and/or provider-facing.  It's about culture and execution.
  11. Health plans' days are numbered if they can't consistently provide value to CMS, their customer, and to providers, their partners.  That value is about two things: making data actionable and moving money to contributors when quality and results improve.
  12. It's easier to increase revenue than it is to cut costs.
  13. Pharmacy benefit managers are a health plan's most important partner.  They are also the ultimate B2B companies and most are struggling in the transition to B2C and true government accountability for results.
  14. Big data and high-tech is all the rage -- and all noise, unless it's actionable.  What works is low-tech: clogs on the street; a house call; a medication consult.
  15. Doctors of the future are in multispecialty practice and leaders of a team of nurses, aides, social workers, and pharmacists. They are quarterbacks, not gods.  They diagnose, and everybody else treats.
  16. So much of the future is about retail pharmacy.  In short time, they will make more providing services than filling bottles.
  17. Ninety percent of the evil and waste in the system occurs at the tip of a doctor's pen.
  18. We are all going to retire thanks to government programs.  Demographics is destiny.
  19. Five percent of members account for 60 percent of your spend.  Put the love and focus on them, and you can pretty much leave everyone else alone.

It's been an incredible ride these last two decades, and especially the last five as health reform blossoms.  We look forward to continuing the journey, older, wiser, and bigger. Stay tuned.

 

Resources

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

 

by GHG Advisors

Claims Leakage and the Path to Avoidance

All managed care organizations must operate a high-performing Claims Management. With strict medical loss ratios (MLR) as required by healthcare reform, timeliness provisions, payment accuracy, and constant regulatory requirement changes, covering operating costs pose significant challenges. Cost containment whereby eliminating excess, leakage and waste must be top priority.

The environment is rapidly changing. It doesn't mean that healthcare will be less complex—indeed, probably the opposite. These changes must be properly evaluated, managed and monitored with a focus on cost control. Claims spend is the main expense for many organizations. As customer expectations, competition and regulatory burdens crunch margins, eradicating claims leakage is critical. Throughput and efficiency are key performance data measurements. Organizations need processes and systems that minimize costs while delivering a high-quality claims experience. Rather, operational silos, as well as ineffective and disparate systems across multiple products lines cause many issues.

What is Claims Leakage?

Claims Leakage is defined as the difference between the actual claim payment made and the amount that would have been paid if more practical claim payment controls had been in place.

Claims is a key driver to a couple of very critical components of your revenue. Everyone is aware of claims as it relates to MLR, but equally important is how the claims data impacts revenue in the forms of HEDIS measures and Star Ratings (year to year composite score). As a component of MLR on the costs side — this drives benefit design; if your medical costs are lower than 85% you need additional benefits. HCC (hierarchal conditions categories) are assigned risk adjustment factors — missing claims information (leaking) could result in diminished Risk adjustment scores — same thing as with HEDIS and Stars — missing claims information means less performance in Stars measure and HEDIS.

Leakage equals wrong payment that went out the door. Bottom line, it can cause you money and rework.

Examples of leakage include:

  • Inappropriate benefit design, including member cost sharing
  • Inaccurate provider pricing and reimbursement methodologies design and updates
  • Missing claims and encounter data
  • General configuration issues: Edit rules, duplicate check, NCCI (national correct coding initiatives) and auto-denial/pay rules
  • Minimal data scrubbing: The number 1 and 2 causes of claims leakage is inaccurate membership information and inaccurate provider information.
  • Lack or poorly designed MUEs (medical unlikely edits), coding and mapping issues, including CPT, modifier guidelines, HCPCS, ICD-9/ICD-10, and all UB04 institutional coding
  • Upcoding — billing for higher level of services while lower level services were
  • Claims submitted by bogus providers
  • Pharmacy claims: Appropriate payment allocation of Medicare drug coverage: Part D versus Part A or Part B payments

How does it stop?

The path to avoidance and some best practices are as follows:

  • Develop a strategy in enhancing claims quality control and oversight activities.
  • Implement quality control auditing through pre-payment auditing reviews.
  • Develop and generate focused exception reports of where the leakage dollars are
  • Invest in strong post-pay detection technology to achieve cost avoidance savings.
  • Develop and implement automated and sophisticated algorithms:
    • Scale
    • Claims Check and Edits
    • Focus on the 5% of the financial leakage

Execution of these best practices and automating each procedural step of the claims cycle results in accurate claims resolution. Monitoring operational performance helps continuously track and trend claims inputs and outputs.

Proven Strategies to Plug the Leaks

Optimize your organization's operational performance, requiring coordination across people, processes and systems. Align and take a holistic integrated view, end-to-end, when monitoring operations.

Leaks don't occur because we plan them. They happen because we fail to plan to address them.

 

Resources

GHG Operational Performance Group includes some of our industries most experienced and proficient claims subject matter experts. Our consultants can help your organization implement best practices in claims cost containment. Contact us today to get started >>

When it comes to financial reconciliation and overall membership data management, you must protect against leakage. Need help staying ahead of the CMS reconciliation process? GHG will access your member premium revenue, accounts receivable and CMS revenue reconciliation. Visit our website to learn more >>

by GHG Advisors

How Do You Cross a Threshold to Success When There Isn't One?

Many plans are reacting to the changes affecting the Star Ratings as described by the most recent release of the 2016 Advanced Notice.  One of the most impactful changes is that of the removal of the thresholds for plan year 2016 measures.  CMS gave early warning of the removal of the thresholds for many of the measures and restates their position as per page 86 of the Call Letter:

"Our primary goal in eliminating the thresholds is to improve the accuracy of the assignment of overall and Part C and D summary Star Ratings and to make certain the system creates incentives for quality improvement. While there is general support for this change, some sponsors and stakeholders remain concerned that it is difficult to improve without published targets for achieving 4 or more stars on a measure. We also understand that some sponsors are concerned that eliminating pre-determined 4-star thresholds will make it more difficult to set targets for performance or value-based contracting."

It will be difficult for many plans to manage the removal of the thresholds when that has been the reliance for the benchmark of improvement in many instances — from improvement in the quality work plan (which, by the way, don't forget, will have to be modified) to the provider incentive plan to the overall strategy for value-based contracting many plans are now trying to implement.

Because CMS stated that having pre-determined thresholds may restrict continued quality improvement, plans now must begin to become stronger in the quality improvement/assurance arena.  What does this mean for you? This means rethinking your quality work plan, the benchmarks or baselines used, and asking yourself as a plan: What other data sources can we now use to make sure we are on the road to continuous quality improvement?  This also means re-evaluating your Stars work plan/strategy and the tools used to support it.  How can you create a better dashboard for 2016?  Think about using industry standards already out there for the new "thresholds" and incorporate those into the dashboard.  In fact, why not try that exercise now — start running "new" thresholds" alongside the ones in place today for 2015 and see where your plan will land.   CMS believes this change of threshold removal will not impact the industry greatly.  In fact, they cited that their research shows close to 7% of plans would possibly have their ratings raised one-half a percentage point, and approximately 10% would go down by the same rate.  If plans want to be certain this really is the outcome, it is time to start preparing now, especially if your plan will experience a reduction to a greater percentage.

So what are good baseline or benchmark replacements, you ask? Well, let's start with the easy one — HEDIS.  NCQA publishes a memo which reports the national benchmarks and national and regional thresholds for HEDIS/CAHPS.  Plans could start comparing themselves in this fashion now and preparing for the removal of thresholds, strategizing on the results they see.

Another thought: plans certainly have the capability to trend historically on their own performance — examine those 19 measures that have no threshold today and think about the interventions or methods used in the management of these.  Don't be afraid to use the document published by CMS,  "Trends in Part C & D Star Rating Measure Cut Points," and conduct the same exercise within your organization if you have not already. That document can be found here.

Also, have the discussion within your plan's provider networking/contracting area and ask the question, "What does the threshold removal do to our contracting strategy and the use or identification of high performing providers?" Will we, as a plan, need to redefine what high performance means so we can measure it correctly? Will we, as a plan, need to change what measures/benchmarks on which we are paying bonuses? I think you will.

Plan to start tying providers to measures they can influence and then talk with those providers about changing outcomes for measured improvement.  Remember, you will have to help them prioritize now.

Plan and be prepared for the changes by reviewing your quality program, the QIPs you have in place, and how will they need to be modified to account for the changes coming down the road.

With a few simple steps, you can still cross over to success, even without a threshold!

 

Don't know where to start? Contact me today at jscott@ghgadvisors.com.

 

 

Resources

Our team of experts can help you develop or enhance care coordination within your programs and processes. Contact us today, and let's work together to help your plan achieve 4 Stars.

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. Visit our website to learn more >>

by GHG Advisors

Gorman Health Group Client Forum Takeaways: Government Programs are Booming, Bar is Rising

We just wrapped our best-ever Gorman Health Group 2015 Client Forum at National Harbor with over 200 of our closest clients and partners.  There was both great and tough news, so here's a few takeaways, including a couple stunners:

  • For the first time, a prominent Wall Street analyst said he could see a path to 100% Medicare Advantage penetration.  Barclay's eminent health care observer, Josh Raskin, stunned our audience with projections of over 29 million Medicare Advantage enrollees by 2023, a penetration rate of over 42%, with the potential to go all the way with Ryan Plan-like legislation now feasible this decade.
  • 47 states now hold Section 1915(c) home and community-based services waivers for Medicaid, which will unleash a new flood of dual eligibles into health plans.  Special Needs Plans (SNPs) for duals are now on a path to permanent reauthorization, and over 30 states now use D-SNPs to enroll over 1.6 million beneficiaries.  That number will more than double in the next 2 years.
  • While year 2 of open enrollment for ObamaCare was dramatically improved from its messy launch, problems persist, especially with membership reconciliation and issues related to the interim process to auto-enroll most members staying in their plans. Cleanup of membership discrepancies will likely take another year or even longer.
  • Risk Adjustment Data Validation (RADV) audits will become the new normal in Medicare Advantage.  2015 will be the first time we see plans prosecuted under the False Claims Act and hundreds of millions clawed back by the Centers for Medicare and Medicaid Services for unsubstantiated codes submitted for higher payments.
  • Maximizing data, strong provider partnerships, documentation and ICD-10 preparedness are keys to audit proofing your Risk Adjustment program.
  • The Star Ratings system of performance-based payment is the new cornerstone of competition among health plans.  Stars has expanded into more than a dozen state Medicaid programs, and to ObamaCare's issuers as well, and the bar is rising.  Technical changes to several measures mandate much higher performance to stay ahead of the curve and avoid falling below 4 Stars, where bonus payments and bid rebates vanish. 2015 will be the first year where plans below 3 Stars are terminated.
  • Medicare Advantage plans won several lobbying victories in this year's "Call Letter", the rate and policy announcement for 2016, including an average 1.25% benchmark increase from a cut in the February draft. This signals a new era of influence muscle for the industry, where CMS will increasingly fight out policy changes "below the waterline" in subregulatory guidance and enforcement, where politicians are less likely to intervene.
  • Appeals and grievances and pharmacy benefit management vendor performance remain the #1, 2 and 3 regulatory infractions in Medicare Advantage, and integration of long-term care and supports and services the leading challenge facing Medicaid health plans.
  • CMS is on pace for its most aggressive enforcement year ever, with over a dozen actions taken against plans this year already.

As we've said since the passage of the Affordable Care Act, we are now in the Golden Age of government-sponsored health programs, and the opportunities and challenges that come with this shift have never been greater.  Our clients went home with a clear grasp of both, and we are thrilled so many joined us this year.

 

Resources:

Join John Gorman, GHG's Founder & Executive Chairman, as well as Bill MacBain, GHG's Senior Vice President of Strategy on April 14 as they provide a hard-hitting analysis of critical areas addressed and finalized in the document from 1-2pm ET. Register now >>

GHG's Senior Vice President, Healthcare Analytics & Risk Adjustment Solutions, Dan Weinrieb, recaps the Risk Adjustment rulings in the Final Call Letter and provides keys to success in an article on the GHG blog. Read more here >>

by GHG Advisors

The Model of Care: More than Just a Technical Requirement

The Model of Care (MOC) represents the backbone of a health plan's operational infrastructure and offers powerful potential through which to drive quality improvement, service excellence and improved health outcomes.

Though only required for plans operating a Special Needs Plan (SNP), the MOC is not just a legal or regulatory requirement.  The MOC captures and documents deep insights regarding plan leaders' strategic vision by which to provide services to members, to work with providers, to manage and coordinate care, and to conduct operations.  It also includes a thorough analysis of a plan's staffing model, provider network and the local demographics of its members.

Perhaps because the MOC is such a lengthy and technical document, or perhaps because it addresses the entire spectrum of a health plan's clinical and operational processes and systems, MOC's are often developed and updated by a small team of highly experienced subject matter experts within a health plan.  Despite CMS' requirement that all health plan staff and providers receive annual training on the MOC, plans often miss the opportunity to leverage their MOC's not only to comply with CMS regulations, but also to more deeply entrench their Quality Improvement (QI) and operational service models throughout the organization.

Developing and/or updating a MOC requires health plans to make important strategic and tactical decisions about the way in which their team, in conjunction with their provider network, will work together to coordinate care for their members.  As a result, the MOC serves as the strategic plan for your care management, member services, provider relations, risk adjustment, Stars/quality and marketing teams.

By leveraging the strategic and tactical discussions necessary to develop a successful MOC, plans can use the MOC development process as a vehicle through which to develop, review, and enhance Star Ratings, Risk Adjustment and Provider Engagement strategies.

Gorman Health Group's team of experienced clinicians has a deep understanding of how to leverage Models of Care to refine, document and hardwire your strategic vision for collaborations with your provider network to improve Star Ratings and optimize risk adjustment performance.

If your plan is preparing to develop or update your Model of Care, contact us today and let's work together to help your plan achieve your strategic vision.

Resources

Gorman Health Group is ready and available to execute a complete MOC evaluation that will provide the data and information needed to make smart decisions in refining your plan's strategy of managing your SNP population. Contact us today >>

Registration for the Gorman Health Group 2015 Forum is underway! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Room Rate expires on March 23. Register your team for The Gorman Health Group 2015 Forum today!

by GHG Advisors

Key Changes to Star Ratings from 2016 Draft Call Letter

Now that the news from last month's 2016 Advance Notice (also known as "the Call Letter") from the Centers for Medicare & Medicaid Services (CMS) has had time to sink in, it's time for the real work to begin.

Perhaps even more noteworthy than the long-discussed removal of 4-Star thresholds is CMS' planned interim action to reduce the weights of six Part C measures (for Medicare Advantage Organizations), and one Part D measure (for Prescription Drug Plans) by half to provide immediate Stars relief to plans serving dual eligibles. With these changes looking likely, plans are working feverishly to predict whether they may be on the winning or losing end of these program changes.

While CMS continues to study the correlation between low-income status and lower quality scores, there is much work to be done by health plans to rapidly operationalize the six 0.5-weighted measures, the retirement of three measures, the temporary retirement of one measure, specification changes to more than a dozen measures, and CMS' return of several additional measures that had previously been removed from the program. The sheer volume of these changes almost overshadow the long-awaited, and much-anticipated, introduction of the new Comprehensive Medication Review (CMR) Completion Rate for beneficiaries eligible for Medication Therapy Management (MTM) programs measure.

As is always the case with Star Ratings, time is of the essence as we chase the moving target set forth by CMS.  With CMS' renewed commitment (inclusive of a timeline) for termination of plans with less than 3 Stars for three years, plans whose ratings are trending downward will need to work swiftly and effectively to incorporate not only these changes but also proven Stars best practices into 2015 work plans.

With the many changes to Star measures announced in the 2016 Advance Notice, plans may be finding it increasingly difficult to design, implement, and manage Star Ratings programs. Has your 2015 Stars action plan adequately addressed:

  • Internal reporting, monitoring, and trending of measure-level performance?
  • Provider targeting, education, and pay-for-performance (P4P) program changes to capture these changes?
  • Evaluations of programs to determine those that are working (and those that are not)?
  • The reduced influence that Diabetes Disease Management programs will have on Star Ratings?
  • Changes to member interventions and wellness programs to address these program changes?
  • Any weaknesses identified in the 2015 Star Ratings?
  • Population health tools and strategies needed for Star Ratings success?

Gorman Health Group's team of experts can help your organization adapt to the new clinical areas emphasized in the Advance Notice, develop or enhance care coordination within your programs, or evaluate the effectiveness of your current Star Ratings program.

Contact us today, and let's work together to help your plan achieve 4 Stars.

 

Resources

Gorman Health Group's Summary and Analysis of the 2016 Draft Call Letter and the Medicare Advantage (MA) Advance Notice is now available. Download it today >>

Our team of experts can help you develop or enhance care coordination within your programs and processes. Contact us today, and let's work together to help your plan achieve 4 Stars.

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. Visit our website to learn more >>

Registration for the Gorman Health Group 2015 Forum is underway! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Room Rate expires on March 23. Register your team for The Gorman Health Group 2015 Forum today!

by GHG Advisors

Industry Ducks Bullets in 2016 Medicare Advantage Rate Proposal

Friday, February 20th after close of business, the Centers for Medicare and Medicaid Services (CMS), released its 2016 Advance Notice of Medicare Advantage Payment, known affectionately as "the call letter."

This one was the most anticipated in years, and the industry unexpectedly ducks bullets in it, in risk adjustment, Star Ratings, and elsewhere. It's got a few unicorn farts in it, and a couple puffs of Chanel No. 5 as well.

The lack of any shockers is the bigger positive for the industry, a turning point really.  CMS is saying it won't settle its scores with payers through policy, but through enforcement, where the facts are often too tough for politicians to stick their necks out.

Last fall's surprise positive announcement that MA benchmarks were tracking to increase 2.02% next year started this year's dance.  Now comes the draft call letter, and on April 6, the final, all of which will be different as CMS winds through its process and the full fury of industry lobbying is brought to bear.  It's worth noting that this year a first-time majority of 53 Senators signed the annual "don't hurt Medicare Advantage (MA)" letter to CMS, vs. only 40 last year.  The increased Congressional pressure and the fact that MA now represents one out of three beneficiaries is driving this call letter.

By our calculations, the 0.95% reduction in MA benchmarks claimed by CMS is really negative 1.76% all-in.  This is the unicorn fart. The final number quoted by CMS, 1.1% positive, is in part because CMS is taking credit for a 2.0% improvement in risk scores as plans continue to improve their risk adjustment management skills.  Kinda cheeky.  Our read on the underlying trend is +1.53%, frankly, better than we anticipated.

On risk adjustment, anticipation was that CMS would take a lethal shot at prospective in-home evaluations, a tough fee-for-service normalization factor, and an increase in the coding intensity adjustment, but NONE of those happened.

On home visits, despite a hailstorm of bad press and advocacy group investigations, CMS isn't even dealing anymore, just laying out "best practices" and saying "we're watching you."  The regulators laid out 8 criteria that would make the prospective evaluation more like a risk assessment conducted by a Special Needs Plan, including:

  • Evaluation performed by a physician or qualified non-physician practitioner
  • Includes all components of the wellness visit including health risk assessment
  • Medication review and reconciliation
  • Scheduling appointments and referrals with appropriate providers and community resources
  • Environmental scan of the home for safety risks and need for adaptive equipment
  • Verifies that the information obtained during the assessment is furnished to appropriate plan staff and providers
  • Provides enrollees with a summary of the information collected
  • Enrolls the beneficiary in disease management or care management programs.

Taking these steps and embedding risk adjustment management inside a health plan's Medical Management department would effectively audit-proof the company from the dreaded data validation audits expected to intensify this year.

Another shocker: CMS did the absolute bare-minimum on the coding intensity adjustment, and then heaved up a dangerous proposal to recalculate it starting in 2017.  If implemented, CMS would cut payments to all MA plans by enough so that total payments would be no greater than under the pre-HCC, pre-PIP-DCG, pre-2000 AAPCC demographic model.   This would make risk adjustment a zero sum game, in which individual plans could win or lose, but in which CMS would never pay out more than under the old AAPCC model.  That would settle the score on home visits once and for all, and indelibly damage risk adjustment as a healthcare financing innovation.

A final surprise: CMS acknowledges it has a problem on Star Ratings for health plans serving dual eligibles and the low-income.  The agency is cutting the weight of several Stars measures where vulnerable members score poorly, by a whopping 50% in 2016. This buys time for CMS and several plans overweight with low-income members and highly exposed to Stars underperformance to conduct additional research and take steps against what is driving the correlation.

It was, in the end, a surprisingly favorable call letter for health plans and other stakeholders, particularly capitated provider organizations.  But we're still a long way from the Final Notice on April 6. How plans should react:

  • First, write comment letters. Deadline is March 6 at 5 pm EST.
  • The proposal to cap total MA payments at the same level as would have been paid under the pre-2000 demographic-only risk adjustment system is dangerous.  Plans need to point out how the Congress, in the 1997 Balanced Budget Act, mandated a health-based risk adjustment system because the demographic adjustments were inadequate.  We are not aware of any authority in that, or any other law, to allow CMS to set a cap on total MA payments.
  • Take the guidance on home risk assessments seriously, and implement CMS' suggestions before they become mandates.  Plans must hard-wire their risk adjustment program into their care management program, so they are actively managing the risks they identify.
  • Don't rely on averages:  the impact of CMS rates and other changes will vary from county to county, market by market.  Let us help you examine the impact on your service area.
  • Continued rate pressure means plans have to continue to get better and better at the key components of their business:  risk adjustment, care management, Stars, and enrollment data reconciliation.
  • Focus on the Stars metrics with the greatest weights, especially the intermediate outcomes measures and the plan-wide quality improvement measures.  Determine if the reweighting of seven metrics will have a positive or negative impact on your plan, and react to offset any negative effects, by emphasizing other metrics where there is room for improvement.

It's going to be an interesting 45 days to the Final Notice, but one thing is sure in this call letter: CMS is conceding that Medicare Advantage has gone mainstream, and that its support in Congress can no longer be tangled with.  CMS is showing its preference to impact industry behavior through its boot rather than its pen.

 

Resources

Join John Gorman, GHG Executive Chairman, and colleague, Bill MacBain, GHG's Senior Vice President of Strategy and former health plan CFO,  as they provide a hard-hitting analysis of critical areas addressed in the document, including a look at the various components that make up the trend factor, a proposed change to how risk scores are determined, health risk assessments, and Star Rating measures on March 3, 2015. Register Now >>

Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!

by GHG Advisors