Star Ratings | GHG Advisors

Follow the Leader: United Health Group's Outlook on Government Health Programs

Ralph Giacobbe at Credit Suisse is a leading health industry analyst and is doing the best work of his career. Today he produced a fantastic recap of his discussion with United Health Group CEO Steve Hemsley and several of his top executives. It included some fascinating insights into the market leader's strategy for government health programs:

â– 2015 Earnings Growth: Management reiterated its focus on growing operating earnings in 2015. While Medicare rate pressures remain (-3 to -3.5%), the company is optimistic of better MA enrollment in 2015 as it does not expect the same level of market disruptions with more limited network reconfigurations...Medicaid is expected to remain a positive contributor. Additionally, UNH has $90B in medical costs and $20B in administrative costs from which to drive savings, which was stressed by management during the meetings...cost creep has backfilled previous administrative cost savings. Management is now "acutely focused" on applying more rigorous standards to general reinvestments in the organization.

â– Medicare Star Ratings and Renewed Focus on Performance: While the management team noted that performance as a whole has been "good", there was clearly a sentiment that performance needs to improve. Hemsley noted that too many of UnitedHealthcare's recent issues have been "self-inflicted," especially Medicare Stars. As a result, UNH is in the process of narrowing its networks to steer patients to high performing providers in an effort to improve quality. Additionally, a greater focus will be placed on leveraging data to stratify members in order to quickly identify and place high acuity members in appropriate care management programs. As the largest player in the market, UNH has several metrics under its control and is expected to perform at high levels. According to management, it took UHC too long to figure out that STAR ratings place significant emphasis on serving both the healthcare and social needs of members. While corrective steps are encouraging the improvement in STAR rating won't be evident until 2017 at the earliest given the lag time in measuring criteria.

â– Network Reconfigurations Continue: As a result of MA rate pressures, UNH significantly adjusted its networks during the 2014 annual enrollment period for which it received scrutiny. Management reiterated that network reconfigurations will continue, but will be guided by insights gained during 2014. Last year UNH narrowed its Medicare networks by 10-15% and management expects some continuation into 2015, although changes will be made more on a continuous basis vs. occurring all at once and therefore should be less disruptive. Overall, network configuration remains a significant component of managing trend and should not be underestimated as narrowing networks to higher performing facilities/providers can save on medical costs. MA rate pressures for 2015 were evident when management reiterated that the final rate came in below their expectation of flat. UNH sizes the impact in the range of -3% to -3.5%. We would expect network reconfigurations to be an ongoing process, as management believes it is only in the 2nd or 3rd inning, but again, don't expect big disruption like 2014.

â– Reform Update: While UNH's exchange participation in 2014 was limited, it is inclined to increase its involvement in 2015. UNH is currently in the process of evaluating markets, products, regulations, and first year pricing. While it continues to appear that the company is likely to increase its exchange exposure in 2015, it has until September to finalize its decisions.

â– Medicaid: Expansion also appears to be tracking well, as management now expects Medicaid growth to exceed the high end of guidance (+350-450K lives). While the dust has yet to settle, expectations were to see 65% of expansion enrollment 1Q, followed by more moderate enrollment in the middle of the year and a reacceleration around year end. It is still early, but at this point UNH has not seen anything alarming in terms of utilization and feels comfortable about its ability to effectively manage new Medicaid members. Additionally, UNH is getting paid appropriately higher rates for Medicaid expansion members.

â– Optum: Management's new goals are "8 by '16" (8% operating margins, 10 new large relationships, double digit top and bottom line growth, and doubling 2013 op earnings of $2.3B). With a backlog of $7.2B, Optum has an abundance of opportunities at its fingertips...Optum's role as a system integrator for HealthCare.gov was an important building block in establishing its reputation. Management also conveyed a new level of confidence that scrutiny around Optum's association with UNH has subsided, as payors and healthcare systems appear to have gained comfort that the appropriate firewalls are in place for Optum to maintain its independence from UNH.

Resources

On May 7, Gorman Health Group Executive Vice President and former regulator Steve Balcerzak joined Vice President of Provider Network Management Craig Lyon for a deep dive into CMS expectations. Attendees got their their take on what to expect and how to prepare. Access the webinar recording here >>

From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation — where the potential is promising, we can help design and implement these arrangements. Contact us for more information >>

by GHG Advisors

Member Engagement and Experience are the New Risk Adjustment

In this new era of Star Ratings in Medicare Advantage and Part D, where a 4+ score is now do-or-die, health plan survival comes down to two things: member engagement and the member experience. They're the new risk adjustment when rates in 2014-2015 will be at their lowest levels in more than a decade, and a low-quality rating is a kiss of death in government programs. Plans that can't evolve into kinder, gentler, more coordinated and Member-Centric service providers are already beginning to disappear.

Here's why: the vast majority of the Star Ratings performance measures, especially those that are triple-weighted, are utterly dependent on an engaged member. Example: breast cancer screening. All women hate mammograms, and this measure doesn't move unless the member shows up. Another: Diabetes Care -- Blood Sugar Controlled. "Controlled" is a clinical outcome. And you can't get there with daily testing and insulin treatment without a member who's paying attention every day. Less than 20% of seniors engage in all screenings and tests required in Stars.
Similarly, the patient's experience measures and surveys now comprise fully a third of the Star Rating and are all 1.5 weighted, which means they count 500 basis points more than simple process measures. Getting appointments and care quickly, handling of complaints and coverage disputes, interpreter availability -- just a couple examples, all 1.5 weighted and instrumental to getting or keeping those all-important 4 Stars. The Consumer Assessment of Health Plan Survey (CAHPS) and the Health of Seniors Survey (HOS) are enormous determinants of ratings, both conducted by government surveyors, and both strike fear in the hearts of health plans. "Has your health improved in the last two years you've been enrolled, and who do you attribute it to?" are two of the most critical questions facing our industry. You have no hope of a positive answer to these questions from your members if they don't know who you are and what you're doing for them.

Most of the tasks involved in the Stars measures are actually pretty simple, like getting a flu shot. And behavioral economics show us that simple tasks are susceptible to contingent, or "if-then" rewards. So plans need to have the ability to track member progress on health-related tasks and administer appropriate incentives when they are completed. And all of the patient's experience measures necessitate a responsive, proactive service model that could be lifted from some of the leaders of e-commerce.

So the more we thought about it, the more we realized we needed to offer our clients a platform that can help them execute better on Stars tasks, while ensuring dramatically better member engagement and a much more positive consumer experience. And that's where our new partnership with Novu comes in. Novu is a unique platform which creates a deep ongoing relationship between your plan and your members, and gives you the "stickiness" that keeps them around. Members engage in a fun, easy to use, and rewarding health engagement tool that has a proven record of getting people to actively participate in their health: 76% of members return to the site 2 or more times per week, and stay on the site almost 10 minutes per visit.

We're thrilled to offer this first-of-its-kind engagement platform specifically tailored to the needs of Medicare, Medicaid and ObamaCare exchange members with Novu. Check out the product on the GHG website: https://www.ghgadvisors.com/who-we-are/our-partners/novu

Resources

New Webinar with John Gorman: Join him on April 2 for this complimentary presentation. "Member-centricity is more than a catch-phrase. How enhancing member engagement impacts the top AND bottom lines." Register now.

Learn more about the GHG-Novu partnership by reading our press release.

Join John Gorman, Novu's Tom Wicka, and dozens more industry thought leaders at the 2014 GHG Forum. Full agenda just released.

by GHG Advisors

Lighting the Path in the Golden Age of Government-Sponsored Health Programs: Join Us for the GHG Client Forum

More than 300 guests will convene on May 1-2 at the Red Rock Casino in Las Vegas for the 2014 Gorman Health Group Forum, our annual strategic retreat for leaders in government-sponsored health programs. This year's gathering promises to be the most actionable, content-packed conference you could attend on how to succeed in this new Golden Age of government business. And when the learning and planning is done for the day, we will celebrate this unique moment in health care history as only GHG can in Vegas. Here's what's happening this year and why you've got to join us:

The event features 27 content-charged sessions, including multiple presentations on Star Ratings tactics, quality improvement, risk adjustment, and compliance challenges unique to Medicare Advantage and Part D, Medicaid, and the ObamaCare exchanges
A keynote presentation from CMS leadership
An expert roster of presenters from Gorman Health Group and leading health plans in government-sponsored programs. No fluff, no sales pitches, no history lessons -- it's all about what to do NOW
Approved for up to 12 continuing education credits from the Compliance Certification Board
The perfect off-the-strip venue to minimize distractions during the day, but close enough to the action to make plenty of bad decisions in the evenings. ;)

Based on feedback from last year's Forum, I'm speaking in three separate sessions on overall strategy and implementation planning for government programs. If you've heard my "state of the industry" presentation before, you may think you know what to expect from me on stage. Think again. This is my favorite gathering of the year, and I'm building three brand-spankin' new presentations that are focused on specific steps and mileposts your organization needs to reach this year in care management innovation, risk adjustment, Star Ratings, and operational performance improvement. In each session I'll drill down to specific steps, and we'll leave you with a self-assessment tool in our closing session to help track your progress.

Many of our clients use the Forum as an offsite retreat for their government programs executive teams, and so we offer huge group discounts to encourage it. It's a unique opportunity for team-building and action-oriented planning and budgeting.

If government-sponsored health programs are central to your company's future, do yourself a favor and join us in Vegas. You'll come back tired, happy, and ready to win in this crazy new environment of health reform.

Don't believe me? Hear what last year's attendees thought about the event, and why they keep coming back for more.

Resources

Register today for The Annual GHG Forum held May 1-2 at the Red Rock Casino and Resort in Las Vegas. This two day event is designed to provide best practices for the decision makers of organizations serving Medicare members, Exchange beneficiaries, and the Dual eligible population.

On April 11, Bill MacBain and Jean LeMasurier will be back, and this time joined by John Gorman, Executive Chairman of GHG, to offer insight on the Final Rate Announcement from CMS. You will walk away from this session with critical to-do items and issues to tackle in order to ensure your success in 2015 and beyond. Register now >>

by GHG Advisors

Innovating in 2014

CMS has developed an Innovation Center to address health care payment and service delivery models. It is a great site to find information about current Innovation Model Partners, and a place to share your ideas on how care can be delivered and paid for in ways that will lower care cost and improve quality of care. As always, the service to beneficiaries is at the heart of these initiatives, and for the program to continue, partners must be innovative.

There is also room for innovation within a Medicare health plan or Part D sponsor in terms of operations and compliance. You have heard that necessity is the mother of invention, and we often hear that departments need more money, more staff, and more technological resources in order to meet their needs.

This doesn't mean that those needs are always met. That is why it is important to be creative with the tools and resources that you have. How can you implement best practices without the budget required? Without the outline or work plan for success? Have you developed a checklist of necessary things to do, and can you accomplish those things with the staff you have? Are you and your leadership all aware of what the highest risks are to the organization, and how those risks might be affecting Star ratings?

At this year's GHG Forum, we will be addressing these types of issues facing our partners, and you will notice that we will consistently be encouraging innovation throughout the event. No problem is solved overnight — except perhaps the problem of getting a good night's sleep — that can be solved overnight! Join us and fellow attendees to gain valuable insight into what works, what doesn't, and allow necessity to spark inventive actions that you can take back to your organization. In the meantime, tell me what troubles you in your efforts to maintain an effective compliance program, or even in operational shortcomings. We are always happy to brainstorm and share ideas. You just might get a Forum discount code from me just for sharing your pain points.

Resources

by GHG Advisors

2015 Medicare Advantage Draft Rate Notice is a Bear: Messy, Noisy, and Smells Like Roadkill

Friday after the close of business, CMS released the draft 2015 "call letter", the rate announcement for Medicare Advantage. As expected, it's a bear: messy, noisy, and smells like roadkill. It's just about a worst-case scenario for flabby, distracted, uncommitted health plans in Medicare -- the roadkill to come. The table is now heavily tilted against low performers who can't keep up. Some topline observations:

The benchmark calculations were anticipated and about as rough as they could be under the Affordable Care Act. Having said that, for the "glass half-full" types, the average MA benchmark is still 103.4% of Medicare fee-for-service expense. In the 1990's under the old AAPCC methodology, all plans got 95% of fee-for-service, and plenty of plans were profitable -- and that was before risk adjustment and Stars. We knew the Bush party was over. It's time to get over it and push forward because the only way out now is through.
The Star Ratings quality demonstration is officially over, and those plans below 4 Stars are now leaving a blood trail in the snow. After this year, as required under the ACA, all plans above 4 Stars will get a 5% bonus, while those below get nothing.
- CMS makes it clear in the call letter that it will terminate sub-3-Star plans for three consecutive years at the end of 2014. The reaping is coming in a few short months.
- The demo's conclusion is a grave wound for 3.5 Star plans, who just missed the threshold and take an additional 3.5% cut for added misery.
- At the same time, CMS made a big move to remove Stars as a barrier to market entry for new plans, especially those spawned by high-performing veteran organizations. A new plan starts out with a 3.5 Star rating now -- and will receive the 3.5% bonus; a new plan born of a veteran MA organization gets a weighted average of all its other plans. It's a welcome mat for Stars heroes like Kaiser, Providence, and CIGNA to expand to new markets, especially those with weak competition.
The risk adjustment provisions were very tough, but leave significant maneuvering room for sophisticated plans to adapt their much-maligned home visits into a mobile medical home model that closes gaps in care for the chronically ill.
- It's the beginnings of good policy but not there yet, and CMS is giving the industry an opportunity to shape it. We should not fight this policy change and should embrace the dialogue.
- The home is the most underutilized source of care for frail elders, and risk adjustment must be much more than a data collection exercise.
- While we got some hidden rate relief in a slightly favorable FFS normalization factor, we only anticipate 300 bps improvement on average, but for those flabby plans who can't keep up, the impact will be much less.

Our estimate is that the average MA plan will experience a real cut in payment of -4.9% if the draft is finalized in April. This includes a rough estimate of the impact of the new risk adjustment rules, and the average impact of the end of the Stars demo.

If this rate announcement is enacted, it's survivable for the adaptable and the high performers -- like the old adage about walking in the woods with a friend when you get chased by a bear, you just have to outrun the other guy. There is no question the 2015 call letter is an evolutionary event and some inferior species will be eliminated.

Want to know more? Watch this space for tons of additional resources from the veteran Gorman team.

Resources

Join us on Thursday, February 27 to hear financial expert and former health plan CFO, Bill MacBain, and former regulator and industry-renowned policy expert Jean LeMasurier review critical take aways from the CMS Advance Notice, and what MA plans should prepare for in the next 45 days. Register >>

John Gorman featured in Wall Street Journal article "Government Proposes Cuts to Insurers' Medicare Payments." Click here to read more.

by GHG Advisors

Reading the Stars in Medicare in 2014-2015

Whatever you may think of healthcare.gov, CMS is killing it on the Medicare Star Ratings Quality Demonstration.

As we move into the final year of CMS's historic and controversial $8.5 Billion Quality Demonstration, we see clear evidence that quality incentives are working, plans are making major investments to improve their ratings, and quality is improving across the industry. One thing we can be sure of in uncertain times: proven performance-based payment systems like MA Star Ratings will spread to Medicaid, the exchanges, and commercial accounts in the next 3-4 years under banners of transparency and accountability. $8.5 Billion in a $3 Trillion industry seems infinitesimal, but Stars are moving the industry in ways outsize to their impact.

Many industry experts giggled at the Affordable Care Act â€˜s (ACA) provision allowing MA plans to earn up to 5% additional reimbursement from the government for quality metrics based on the CMS star system, and 10% in double bonus (mostly rural) counties. The Star ratings system was, at the time, a laughable ranking barely 2% of beneficiaries paid any attention to. Not anymore. In 3 years, CMS has evolved Stars to an increasingly sophisticated carrot and stick for quality improvement, with massive financial implications for payers.

To date, each half-star rating equated to roughly $50 per member per month in bonus payments. For 2014, we estimate the enrollment weighted-average increase to plan paymentst from Star bonuses is approximately 4.75% and 3.3% in 2015. Anything below 4 Stars in 2015 means no bonus and a major financial headwind for plans. With MA plans seeing roughly 5% margins, 2014 being the worst year of MA reimbursement cuts from the ACA, and 2015 meaning the end of bonuses for plans below 4 Stars, plans are making significant investments to improve their ratings.

There was clear evidence that Stars incentives are working: 52% of MA plans are now at 4 Stars, up from around 37% of all MA plans. The average member weighted ranking for 2013 is 3.86, up from 3.7 in 2012. The biggest chunk of MA enrollment is now in 3.5 Star-rated plans: 30% or 4.4 million. There are now 16 5-Star rated plans up from 3 this year.

While tremendous progress is being made on Stars, GHG's analysis of the data also shows what a long, hard journey these performance metrics present to health plans. We have much improving to do in managing conditions like osteoporosis and mental health, where most plans scored badly. And the data shows a need to continually improve the service model, like providing interpreters, managing member complaints and coverage disputes.

MA plans in qualifying counties, mostly rural, can receive a "double bonus," the payment impact of which is significant. There are about 4 million MA members in double bonus counties, roughly 27% of the total MA population. Double bonus counties add about 100 basis points to payments across the entire MA program.

5-Star rated MA and Prescription Drug-only plans can enroll members year-round in 2014, rather than just during the annual enrollment period. This is a major strategic advantage for Star leaders, but one that few have taken full advantage of yet — and that's about to change. With big nationals finally attaining the honor, they'll be ready and hustling all year.

CMS has been very clear that it reserves the right to terminate MA contracts that are below 3 Stars for 3 consecutive years, citing its authority in an April 2012 final rule which became effective this year. About a half-million Medicare beneficiaries are enrolled in plans with less than 3 stars.

Resources:

Interested in seeing how your Plan's performance compares to others in your market? Download GHG's Star Ratings Database that combines the CMS-issued 2014 Star Ratings with those over the program's history from 2008 on.

Hear from GHG Stars expert Jane Scott on October 29th. GHG and AISHealth team up to present a 90 minute webinar: "Inside the 2014 Star Ratings for MA and Part D: Trends and their implications." Register now >>

Want to hear more from John? Decision-makers from Health Plans and Provider Organizations are invited to join GHG for a free webinar on November 19th: "The future of the Government sponsored health care." Register for this free event now >>

by GHG Advisors

Innovation and Quality must go hand-in-hand

Plan sponsors are waiting with anticipation for their 2014 Medicare Star Ratings to be released. Just yesterday, Tufts Health Plan in Watertown, Massachusetts released the news that their Medicare Preferred HMO plan was awarded 4.5 out of a possible five stars. It reminds me of the old Ford commercial jingle where they said "Quality is Job 1". No truer words apply when it comes to maintaining high quality plan options for our nation's Medicare beneficiaries.

Recently I accompanied our founder and executive chairman on a field trip, where he enthusiastically addressed a large group of health plan decision-makers as part of their series on innovation. Now, innovation and quality do not always go hand in hand. I have purchased my share of aftermarket tech products to know that while a company might have employed innovation to make something less expensive, often times, it comes at the expense of quality. It's deflating when you finally get on your train with your discounted charger, plug your phone in, and you see the magical words: "not charging". Add it to the list of our countless first world problems, but it illustrates the point.

With the bonus payment going away for any plans earning less than a 4-star rating in 2015, 3.5 stars will not cut it, especially if you are counting on those funds or have incorporated them into your future year's budget. During his presentation, he drew our attention to outcome measures, and how heavily weighted they are. There are so many opportunities for a plan to innovate, not only for purposes of increased quality rating, but also for the most important factor of a plan: its membership. Loyalty can no longer be bought with just the $0 premium plan anymore. The customer service has to be stellar; their enrollment experience must be error-proof; and in times of sickness, when their utilization has to increase, the care management has to be more than just a pre-auth and a smile (and sometimes you don't get the smile). It is time to have a discussion in every department:

What are we doing to be innovative?
What are the best in the nation doing?
What's low-hanging fruit and what requires more significant investment?

Our health plan partners are becoming more and more engrained in government programs, including Medicare Advantage, Part D, Medicaid, Duals, and the Marketplace. He also reminded us that organizations should be prepared for constant regulatory oversight, which comes with government-sponsored programs. True, some of the regulations are a challenge to implement, but when you've gotten to the point where you have met your compliance requirements, think about ways your organization can supplement that success to exceed a member's expectations - within the rules of course. Who is the town crier at your plan for the beneficiary's experience? Why can't it be you?

Resources

Coming soon: GHG's updated star rating database. We'll send an alert when it's ready! Join our subscription list to be sure you know when this free download is available. In the meantime, take a peek at last year's database that combines the CMS-issued 2013 Star Ratings with those over the program's history from 2008 on.

Register to attend our October 29 presentation "Inside the 2014 Star ratings for MA and Part D: Trends and their implications."

GHG Pharmacist, Lynne Civin, outlines the benefits of daily dispensing requirements in a new article: Short-Cycle Dispensing for Long-Term Care. Lynne discusses key attributes in long-term care , and outlines critical items that warrant further discussion. Download the whitepaper today.

The percentage of plan with an average or below average star rating is staggering - and CMS has made it clear, average just isn't good enough. Learn how GHG can help your plan effect meaningful change in your Star Rating and beat the curve.

by GHG Advisors

Healthy Outlook for Medicare Advantage and Part D from CMS in 2014

Last week amid all the ObamaCare drama on the Hill CMS released the 2014 data for Medicare Advantage (MA) and Prescription Drug Plan (PDP) bids. The numbers show a better-than-expected 2013 and a healthy 2014 ahead for Medicare health plans. The market will see new service areas, lower bids, more zero premium plans, and more mainstreaming of Medicare Advantage as it approaches one-third of the program. CMS noted significant gains on plan quality measures, pointing out that more plans are receiving a rank of four -plus on Star Ratings, the minimum threshold for quality bonuses in 2015 when the quality demonstration expires. Overall there is clear evidence that CMS quality incentives are working, and that MA will continue its steady ~10% growth in 2014.

For MA, there were 35,070 bids for 2014, down 18% from 2013, but when you extract Private Fee-for-Service (graciously in its death throes), HMO/PPO/Special Needs Plan bids were only down 5.7%, and those largely due to consolidation among plan sponsors this year. Medicare health plans continue to wind down PFFS plans 61% year over year, and PDP bids showed similar stability, and evidence of continuing consolidation.

Some of the major points and trends we observed:

Medicare Advantage

CMS indicates that Medicare Advantage membership will close 2013 with 10% growth, with similar gains expected next year. Three years after passage of the Affordable Care Act, and on the verge of its deepest cuts to MA phasing in in 2014, it's clear plans are adapting and evolving — and that there's no exodus in sight.
Beneficiaries will have an average of 28 MA plan choices. The average MA national benchmark was around $31, and premiums are expected to increase by $1.64, or 5.3%, over 2013, at $32.60. There are thousands of benefit design changes coming in 2014, like plans adding and eliminating copays and deductibles. So while relative premium stability would suggest less volatility this enrollment season, benefit design changes will force millions of beneficiaries to go shopping this winter.
As a barometer of the industry's continued health, each of the major publicly-traded MA companies are offering new HMOs in new markets for 2014:
- Humana is expanding its HMOs in PA and OK.
- UnitedHealth is expanding in VA, ME, MA, and NH.
- Aetna/Coventry has new HMOs launching in LA, TX and WV.
- Cigna is expanding in GA, AR, IN, NC and SC.
- WellPoint is expanding in WA, NH, IN, ME and MO.
- WellCare expands its footprint with its recent acquisition of Windsor Health Plans.

Medicare Prescription Drug-only Plans

A stunning finding in all the clutter, likely the result of the move to preferred pharmacy networks and the effect of increased buying power from consolidation: the cheapest PDP plans available in 2014 are a better buy than in 2013, and have 31% lower premiums than those available in 2010. Unbelievable.
- ObamaCare haters take note: seven years after its launch, Medicare Part D serves as a shining example of how the Federal government can create an insurance market from a green field, regulate the hell out of it, and achieve a tremendous public good at much lower-than-expected cost.
Channel partnerships have come to define the top of the PDP food chain. Humana now offers the cheapest PDP plan across all 34 regions. The company's Walmart Rx Plan has a monthly premium of $12.60 across every region, and this will be the fourth consecutive year that Humana is eligible for auto-assigns nationwide. UnitedHealth continues to make big gains with its AARP MedicareRx Saver Plus plan.
WellCare was "most improved bidder", and is now be eligible for auto-assigns in 32 regions, up from 19 this year. Aetna is losing auto-assignment in 5 regions, though none with significant enrollment. These were evidence of clear strategic shifts by new Medicare leadership in both companies: WellCare deeper into the low-income segment, Aetna shifting more upscale.

All in all the CMS bid data shows Medicare health plan vital signs in hale and hearty territory for 2014. It's one ray of light — and should be a beacon for bipartisanship — as ObamaCare anarchy rages on.

by GHG Advisors

The survey says...

In May, GHG conducted several marketplace surveys. The initial survey highlighted our clients' top priorities. Here is what the ranking showed as our clients' focal points:

We understand that in order to emerge as leaders or at least survivors of the rate reduction and complex regulatory world we live in, health plans, health systems, ACOs, and capitated medical groups have to identify business levers that impact the greatest improvement to the bottom line. This is exactly why we created the Alignment Innovation Suite - we take your data and create a driver and alert system for an interdisciplinary team to review and discuss. The Alignment reports clearly indicate where the problems are and where we can jointly create the road map to fix them.

The new Alignment engine couples medical cost and utilization while at the same time overlays benefit and network design. The reports display the areas in the greatest need of collaboration and redesign, i.e. where to spend your time and resources to get the best bang for your buck.

In recent GHG case studies, the Alignment engine, assessment and reports clearly depict the need to 1) redesign provider payment models, 2) completely restructure health services or medical management functions and criteria to impact population health management & patient engagement , 3) operational improvements; simple changes with huge financial impacts and 4) benefit remodeling to improve patient navigation of your healthcare ecosystem.
Resources

GHG's Alignment Solution Suite assessment is backed by industry leading health care expertise and is managed by a team of veteran consultants who will help lead your organization to better financial alignment, product design and health care efficiency. Visit our website to find out more.

Join us on August 8 to get practical advice on the best ways of getting into the MA market from GHG Chief Development Officer, Aaron Eaton, Senior Vice President of Finance, William A. MacBain, and Senior Director of Compliance Solutions, Regan Pennypacker.

by GHG Advisors

Drugs and Patient Safety - the Disconnect

The recent Washington Post piece published May 11, 2013, on the prescription drug dangers for Medicare patients raises some interesting points about the current prescribing habits of some outlier physicians/prescribers, as well as the lack of a coordinated effort to exclude those same prescribers from participating in Medicare.

The use of atypical antipsychotics (identified by CMS as protected class drugs) in the elderly is particularly troubling in light of numerous studies and a FDA Black Box Warning which states in part "Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Although the causes of death were varied in clinical trials, most of the deaths appeared to be either cardiovascular (e.g. heart failure, sudden death) or infectious (e.g. pneumonia) in nature." Those with family in Long Term Care facilities or those working in LTC settings know that the staffing model is dependent on quiet, non-disruptive patientsâ€”unfortunately atypical antipsychotic medications are often used to ensure that scenario.

The High Risk Medication list or revised Beers criteria is one of the Part D performance or Star measures. Part D sponsors have been fairly successful in the past couple of years at deleting these drugs from the formulary or adding a CMS approved prior authorization edit for > 65 years old. Has this completely eradicated the use of drugs like carisoprodol (Soma) or cyclobenzaprine (Flexeril)? No, but physicians do have to provide a medical necessity explanation or describe why the benefit of using the drug outweighs the risk.

More troubling and potentially in most need of action is the inability to exclude those "prescription mill" physicians/prescribers from participating in Medicare. The data available to plan sponsors listing the highest volume opiate prescribers is actionable information. Where documented, proven and egregious prescribing behavior is found, State Board, Medicaid and Medicare exclusion should be a logical outcome and the best route to enhanced patient safety.

Resources:

Senior Consultant, Pharmacy Services, Roxanne Spalding dives deep into the barriers to medication adherence, for both providers and health systems, and outlines varied multi-faceted strategies to overcome them in this white paper.

Learn how GHG can help your MAPD or PDP develop and implement efficient and compliant internal operations and prepare effectively for CMS audits with professional services and unmatched compliance tools.

Gorman Health Group can help you develop unique and adaptable management programs for use across the many departments managing components of your Star Rating, visit our website to learn how.

by GHG Advisors