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
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 >>
John Gorman Comments on CMS Proposed Rate Cuts in Modern Healthcare Magazine
CMS is scheduled to release initial guidance on Medicare Advantage (MA) rates for 2015 that insurers have estimated could reduce payments by as much as 7 percent next year. Insurers say cuts of that magnitude could cause premium increases and benefit reductions that could severely impact seniors.
In a recent article featured in Modern Healthcare Magazine regarding proposed MA rates, Paul Demko, provides insight into the scheduled release and interviewed Gorman Health Group's Executive Chairman, John Gorman, on what is likely to happen when CMS releases proposed cuts later this week.
Create a free Modern Healthcare web account and read the full article here,
Resources
Join Gorman Health Group financial expert and former health plan CFO, Bill MacBain, and former regulator and industry-renowned policy expert Jean LeMasurier for a 60 minute webinar presentation on February 27. Bill and Jean will review critical take aways from the CMS Advance Notice, and what Medicare Advantage Plans should prepare for in the next 45 days. Register now.
A recording of the webinar is now available on the "Financial Impacts of Growth and Attrition." Gain insight into the significant gains and losses health plan leaders need to account for when formulating their strategy in response to enrollment fluctuations. View the recording now.
Zombies in Washington!
Zombie: (a) a will-less and speechless human only capable of automatic movement who is held to have died and been reanimated. (b) The Sustainable Growth Rate.
By means of the Balanced Budget Act of 1997, Congress created the Sustainable Growth Rate, or "SGR" to us who know and love it, a will-less and speechless rule whose automatic movement seeks to annually wreak havoc with Medicare payments to physicians. This inane auto-pilot tries to link total physician payments under Medicare to the growth rate in the overall economy. Why Medicare physician payments, as distinct from other Medicare payments, should grow in lock step with all of the other, unrelated, components of the nation's economy, has never been stated. What has often been stated is the fact that Congress, in what passes for its collective wisdom, wishes with all of its collective heart that it could drive a stake through the heart of the SGR. Every year it threatens to cut physician payment rates by 20% or more. But the Congressional Budget Office, who is charged with calculating the cost of such things, finds that ridding us of this zombie would have a ten-year cost of $139 billion (with a "b"). And that assumes that the docs get a pay freeze for those ten years. Any raises would up the cost.
In another mindless act, Congress requires itself to offset new spending with an equal amount of either tax increases or other spending cuts, or some combination. Since it's impossible to get a majority of both houses to support either (a) tax increases in the house or (b) payment cuts in the Senate, nothing can happen, and the SGR lives on, annually "fixed" by kicking the can down the road a year, only to arise reanimated the following year.
Some observers of the optimistic persuasion believed that, maybe this time, the SGR might have met its match. We have a conference committee meeting to reconcile differences between House and Senate budget proposals, and maybe, just maybe, they would include a permanent fix to the SGR in their bargain. Any dreams of a grand bargain have long ago died, but there lingered the hope for a mini-bargain that might include the SGR. That hope is now dead, as time has essentially run out for a fix before the SGR kicks in January 1, 2014. The best one can hope for now is a repeat of the annual can-down-the-road kicking exercise.
What does this mean for Medicare Advantage? Well, actually, not much. Until this year's political pressure enlightened the calculation of the annual increase to Medicare Advantage plans, the SGR had a depressing impact on Medicare payments to private plans. Until this year, CMS had always assumed that the SGR's pay cuts would actually happen. They calculated payments to Medicare plans accordingly. When Congress did the inevitable, and postponed the SGR cuts by a year, CMS corrected the following year's payments, but by then, the SGR was back and cutting more. So, over time, payments to Medicare Advantage lagged more and more as they continued to be included in the calculation and only fixed a year later. However, the 2014 rates, for the first time, include the assumption that Congress will do what it has done the past eleven years, and fix the SGR cuts, at least for one year. The rates were increased accordingly. Maybe you didn't notice, since the SGR impact was offset by other cumulative corrections that decreased rates to make up for prior year miscalculations and overpayments. But the SGR is now gone from Medicare Advantage benchmark calculations.
So, as long as Congress keeps fixing the SGR one year at a time, there will be no impact on Medicare Advantage rates. The fix is already baked into the rates. And a permanent doc fix will also have no impact.
But the SGR is still an annoyance. Nobody wants it. Nobody expects it to ever save Medicare a dime. Everybody knows Congress will fix it one year at a time. Yet every member of Congress knows that to approve a permanent doc fix without offsetting taxes or cuts will be branded a "budget buster" by opponents, super-PACS, and tax exempt social welfare organizations all too eager to educate us on the evils of whoever is running against the incumbent. And tax increases or cuts to Medicare will provide even more fodder for election season TV commercials. So it lives on. And on.
Resources
Listen as GHG expert Bill MacBain dives in to what the Sustainable Growth Rate is, why it matters and how we can measure its impact. Access the podcast >>
Join us December 11 from 2:00 — 3:30 pm ET for a lively session with Gorman Health Group strategy and data analysis experts who will discuss actual case studies that show how plans can mine data for precious insight that can help improve performance. Register now >>
Medicare Advantage Showcased as the Model for Medicare Reform
The National Coalition on Health Care (a nonprofit organization representing 80 organizations who support comprehensive health system change) and the Partnership for the Future of Medicare (a bipartisan organization supporting the long-term security of Medicare) have a new lobbying message — don't kill the golden goose. Recognizing the upcoming budget battles this year and next, these organizations presented their lobbying strategy which will feature Medicare Advantage plans as the model for a sustainable Medicare program. John Rother from the National Coalition, Lanhee Chen from Stanford University, and Ken Thorpe from Emory University highlighted the innovations in Medicare Advantage plans that should serve as the model for reforming Medicare fee-for-service. These innovative programs focus on beneficiaries with multiple chronic conditions that drive Medicare costs and include care coordination, disease management, team-based care, transitional care, medication management, prevention, health coaching, and evidence based lifestyle programs. They argued that Medicare Advantage plans are already facing a 6.7 percent payment reduction in 2014 and that any further cuts will lead to threats to these innovative initiatives that should be encouraged and not penalized. They discussed research studies showing that MA plans had higher quality scores in 9 of 11 HEDIS measures compared to FFS, 13 — 20 percent lower readmission rates, lower hospital costs including a spillover effect to the overall health system in areas with high MA enrollment, and lower mortality rates.
Dr. Ken Thorpe and Senators Ron Wyden and John Isakson discussed their upcoming initiatives to pursue introducing successful MA innovations in FFS Medicare. Dr. Thorpe is supporting a program he calls "Medicare Integrate" that would build prevention and care coordination into original Medicare. Under this program, CMS would contract with health plans, home health agencies and other entities to provide to provide team-based diabetes prevention services, care coordination services and pharmacotherapy services to FFS Medicare beneficiaries. These services would be provided at no cost to beneficiaries. The bipartisan chronic disease legislation being developed by Senators Wyden and Isakson would also authorize Medicare to pay for teams to provide care coordination services for FFS beneficiaries with chronic conditions.
Although Senator Wyden estimates that his proposal will result in 5 — 10 percent savings to Medicare in the current budgetary climate, it will be difficult to enact a new Medicare benefit without a structure such as an ACO or medical home to produce offsetting savings. While some demonstration projects adding care coordination services to FFS Medicare have achieved savings, other demonstrations have not achieved savings and resulted in CBO scores of higher costs to Medicare.
Resources
Join us December 11 from 2:00 — 3:30 pm ET for a lively session with Gorman Health Group strategy and data analysis experts who will discuss actual case studies that show how plans can mine data for precious insight that can help improve performance. Click here to register >>
What's next for the ACA
Here we are on November 15th one day after President Obama unexpectedly delayed a key provision of the Affordable Care Act, which allows insurance companies to continue, for one year, offering health care plans that fall short of the requirements as outlined in the ACA . The next day our "stewards of national well being" elected to pass a bill in the House of Representatives which is intended to allow insurance companies to sell individual health coverage to anyone who wants it, irrespective of any required standards in the ACA. As expected, the vote was justified on the grounds that the House is concerned that people will be left without health insurance under the current law, no consideration at all, wink wink , was given to 2014 reelection concerns.
Although the measure is expected to fail in the Senate, the underlying issue remains - that partisanship continues to prevent any attempts to take a more reasoned approach to bolster what is good about the ACA and to work out solutions on what is not working.
I think most of us already agree that the ACA or ObamaCare will be a major election topic as it was in 2012. In the meantime we will continue to see repeated efforts to roll back any and all provisions of the law.
What gets lost in all of the machinations by Congress and our Executive Branch is that not much has changed. We still have 40 plus million people uninsured, we still have the elderly making choices between buying food or prescriptions, and we still have lots of false or misleading information published on a daily basis about the intended impact of the ACA.
Personally, I believe the effort was flawed from the beginning but what's done is done and although I may be a lone voice in the wind, I believe it is the responsibility of Congress, consumers and health professionals to stop sniping and start working on how we make the ACA as successful as can be. If that requires changes along the way so be it. What we don't need is continued political posturing. In many respects our future is at stake depending on how we move forward..
Resources
Gorman Health Group Senior Vice President of Public Policy Jean LeMasurier, summarizes the final rule that sets standards for refunds when a Marketplace or QHP improperly applies federal subsidies or incorrectly assigns an enrollee to a plan. Download the summary here >>
Pay me now or pay me later: Things to keep in mind when you set your 2014 budget
Back in the '80's Fram Oil Filters had an advertising campaign that featured an actor dressed as a mechanic, admonishing viewers to get their oil changed and get a new oil filter, to prevent costly engine damage. "Pay me now or pay me later," he said.
When it comes to some key Medicare Advantage functions, the "pay me later" scenario can be perilous indeed.
Take data reconciliation, for instance. MA plans, especially those with drug coverage, need to reconcile at least a dozen different types of data with CMS: Enrollment data; Transaction reply reports; Retro processing contractor; Beneficiary churn ; Capitation payments; Premium data; Out-of-area residence; Subsidy payments; Medicare as secondary payer; Prescription claim (PDE) data resolution; Part D coordination of benefits (COB); Enrollment data validation; Compliance & reporting; Medicaid state roster and best available evidence of Medicaid enrollment.
The sheer volume of data and transactions dictates use of automated processes and controls to manage the reconciliation workflow. Spreadsheets won't cut it, and quasi-manual processes rapidly fall behind the need for daily data import and analysis. Failure to reconcile results in incorrect claim and capitation payments, premium collection issues, enrollment and benefit errors, reduced quality scores, and the potential for excess repayment under drug plan risk corridor reconciliations. Even for small plans, there can be millions of dollars at stake.
Compliance is another area where failure to invest in automated systems now can cause a bad "pay me later" outcome. The cost of a bad CMS compliance audit isn't just the staff time to correct problems. Most compliance problems are directly linked to member satisfaction issues, and a "bad" audit is symptom of deeper problems that lead to high member services call volume and disenrollment rates. Not only does CMS expect plans to be audit ready all the time, members expect things to go right all the time. We have found that the best approach is to use information technology tools to continually monitor compliance at the department level, to maintain complete and organized documentation, and to identify areas where compliance is lagging — where management intervention is warranted. Compliance programs need to be documented, regimented and sustainable. Compliance doesn't wait to happen. It takes an organized and on-going campaign, supported by automated tools to remind, track, document, and spotlight problems.
A third opportunity for trouble is in how sales agents are trained, vetted, and monitored. CMS requires annual training, which is best done using computer-based learning systems. Embedded testing provides documentation of comprehension. On-going supervision requires diligent tracking of complaints and allegations to confirm, respond, and assess improvement. As with other complex tasks, an automated solution reduces opportunities for errors and omissions.
At a time when every dollar counts, it's a good idea to consider budgeting for an investment in software solutions that solve these problems. Gorman Health Group has built software that supports our own consultants as they work with health plans on these issues, and these tools are available for health plans to use in their own operations. The GHG software is unique in that all of these applications are Web-based, fully hosted solutions that present no strain to IT resources. And GHG's subject matter expertise drives each product's unique functionality.
I invite you to contact my colleague RaeAnn Grossman, to start a conversation about your goals, the risks you face, and your available resources and budget for the 2014 year.
RaeAnn Grossman
Chief Sales and Marketing Officer
Rgrossman@ghgadvisors.com
Resources
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 >>
The Online Monitoring ToolTM (OMTTM) is a complete compliance toolkit designed to help organizations track the compliance of their operations. Visit our website to learn more about how the OMT can help your organization >>
The way in which you onboard, train and conduct ongoing oversight on your sales agents is critical. GHG created Sales Sentinel™ specifically to meet the needs of health care organizations operating in regulated government markets. Learn more here >>
Every health care organization is looking for improved outcomes, better compliance and enhanced process efficiency when it comes to managing membership and premium payments. GHG's Valencia was designed specifically to meet those needs.
There is no cheat sheet for 2014.
Now is the time of year when we all have 12 things to do in the next 30 minutes, plus we are budgeting and we need to write our strategic approach for 2014. We have to learn how to prioritize and focus on what is truly important to our success. Unfortunately, there is no cheat sheet, no best practices for all things healthcare, and we cannot succeed if we have too many strategies. Let's compare five areas:
- Administrative excellence and compliance
- Clinical innovations around case, disease, and utilization management
- Provider Engagement
- Risk Adjustment
- High-risk member management
Recently, Gorman Health Group asked the attendees of Medicaid Health Plan Association, "What are the most important strategies in 2014?" The answers and ranking are below:
- High-risk member management
- Provider engagement and innovative reimbursement models
- Risk Adjustment
I imagine that this may be that cheat sheet for all of us.
Although Michael Porter shares, "strategy is about making choices, trade-offs; it's about deliberately choosing to be different." There are some strategies that every business has to do well to survive, and we all need to be ready to succeed at those mentioned above in 2014.
Resources:
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 >>
Medicaid health plans must be able to navigate through State and Federal regulations and work well with State agencies.
GHG solutions-based consulting drives results to your Medicaid health plan, visit our website to learn how >>
Live Connects + Motivated Buyers = Better Sales
Converting active leads to instant appointments is vital in today's insurance market. Whether you are working in this fall's first open enrollment period outlined in the Affordable Care Act or Medicare's annual open enrollment period, the company that converts immediate leads has an excellent advantage over its competition.
Agent Connect is a tool that helps shorten that sales cycle by connecting field agents and callers at the exact moment callers are ready to talk. All facets of the sales process — a caller inquiry responding to a marketing piece, a convenient 3-way conference introducing field agents to interested callers, helping agents set the required scope of appointment and the appointment date - are all handled in real time using mobile devices.
Imagine the pleasure of a caller that dislikes following automated instructions on their phone or leaving voicemails. Instead, they are expertly pre-qualified by a professionally trained call agent and are then immediately transferred to a local field agent that is literally at their beck and call. Talk about exceeding expectations!
Using Agent Connect, field agents with time between scheduled appointments indicate their availability for real-time leads via mobile device. Meanwhile, callers responding to a marketing campaign are pre-qualified by a carrier's call center. If the caller wants to meet with an agent, the call center matches them with an available agent nearby and instantly connects them via a 3-way conference. This instant communication allows agents to build an immediate rapport with callers, also shortening the sales cycle.
In this way, Agent Connect provides a seamless "hand-off" of a warm lead to agents that have signaled their availability. Companies using Agent Connect can dispense leads in any number of ways: by top performers, round-robin or random selection.
Agent Connect is an exciting collaboration between agents, insurance carriers and call centers that significantly reduces the sales cycle and is redefining the term "insurance lead."
Resources
The Bloom Call Center is licensed in 48 contiguous states and offers marketing, call center and technology solutions to the health care industry. Since 2007, Bloom has participated in over 55 million conversations about insurance products, submitted over 200,000 applications for insurance, and set over 150,000 appointments for seniors to meet with Licensed Agents. Bloom is a proud partner of Gorman Health Group. Click here to learn more.
What ObamaCare's Glitches Mean for Health Plan Operations
It's been a rough couple weeks for the launch of ObamaCare. The only thing that's kept the Federal exchange's woes off Page 1 this week has been the continuing dysfunction on the Hill. Healthcare.gov traffic will wane, bugs can be recoded and dysfunctional processes redesigned pretty quickly, so we haven't seen anything fatal thus far, unless we're still having these problems a week away from the now-all-important effective date of January 1. But the sheer volume of Weeks 1 and 2, with CMS working on a shoestring with a night-shift staff in the middle of a government shutdown, and the hardest part of ObamaCare enrollment to come, has major implications for health plan operations in just a matter of weeks.
Here's what's keeping us up at night. All those back-end glitches in the Federal Exchange have yet to be identified, because the back end also includes the next phase of ObamaCare enrollment: subsidy eligibility verification. The key difference between ObamaCare and Medicare Advantage or Part D is the subsidy eligibility maze, and that there are several major steps to effectuate an enrollment that will hit plans in waves, not as a trickle.
ObamaCare is only open to American citizens and documented immigrants, so all applicants' status must be electronically verified with the Social Security Administration and the Department of Homeland Security. The exchanges also have to confirm that applicants are not already enrolled in another government health insurance program, like the Veterans Health Administration, the Department of Defense, the Office of Personnel Management, and the Peace Corps. Then the exchange has to check with the applicant's Medicaid/SCHIP program to see if they're already enrolled. Then the applicant has to apply for the subsidy based on their income, which has to be determined by IRS.
Finally, subsidy in hand, the applicant picks a plan. The exchange must then provide her information to the health plan she has chosen, which then has to reconcile all of that data with the exchange. In Medicare Advantage or Part D, the plan receives the application; in the exchanges, the plan flies blind and doesn't know who its members are until the exchange provides the members' coordinates. And then remember, applicants aren't official until they make their first premium payment, which could come in the form of a cashier's or personal check, cash, credit card or even a prepaid debit card. Only then is an enrollment effective, and all these steps mean big headaches for payers in the weeks ahead.
Think of it this way: 9 million-plus hit Healthcare.gov in its first week; most will return to apply for subsidies and have their eligibility confirmed and calculated; and then all of those folks will pick a plan. Those completed transactions ("834's") will hit the plans, in waves similar to those of the last two weeks. Things get really exciting starting the last week of January 2014, and then the last week of each month thereafter, as the plans must clean up all this data in the runup to the monthly payment. We have about 30 days before the waves start to hit — call it a "shopping lag" or a "glitch lag". We think those waves will look like this, as a function of enrollments and transaction volume for the plans over time:
Our conclusion: "crunch time" for the plans arrives in early December and goes through the end of February, and COOs and executive teams need to plan accordingly. And, oh, by the way: this crunch will happen as plans are trying to close their books for 2013 to make financial reporting deadlines, so grumpy CFOs will abound with their operations colleagues.
Yes it's been a messy launch, but the real mess has yet to arrive.
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.