The 2017 Star Ratings: A Contrast Between Macro Versus Micro
The more things change, the more they stay the same. Despite the many, often significant, changes amidst plan-specific 2017 Star Ratings, there is a surprising amount of stability in the 2017 Star Ratings. Stable performance is evident at the macro level:
- The 2017 average Star Rating is 4.00 (down only slightly from 4.03 in 2016).
- Approximately 49% of Medicare Advantage Prescription Drug plans (MA-PDs) earned ≥4 stars in both 2016 and 2017.
- Weighted by enrollment, approximately 68% of MA-PD enrollees are in contracts with ≥4 stars in 2017, down from 71% in 2016.
- The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) cut points for 7 measures again stagnated in 2017, and national average performance rates (not ratings) for 13 additional measures remain unchanged.
This stable performance seemingly contradicts the generally accepted notion that “quality is improving.” Indeed, a closer analysis of the many micro-level performance changes reveals many changes and fluctuations:
- United delivered perhaps the strongest performance in the 2017 Star Ratings among the largest industry players, showing strong performance improvement across all plans.
- Pending industry mega-mergers eroded Star Ratings performance of the plans being acquired while the acquiring organizations’ Star Ratings survived relatively unscathed.
- Thirty-four plans that earned ≥4 stars in 2016 dropped below 4 stars in 2016 and will lose their Quality Bonus Payment (QBP) revenues. Eighteen of these 34 plans earned only 1 star on both the Part D Appeals Upheld and Appeals Autoforward measures, mostly, if not entirely, due to audit results. Because many plans rely exclusively on their Pharmacy Benefit Manager (PBM) for these measures, this is an opportune time to reevaluate the Centers for Medicare & Medicaid Services’ (CMS’) somewhat utopic expectation an MA plan has enough contractual and practical leverage to influence its PBM’s operations and performance in a way that prevents audit findings and delivers consistently high Star ratings within the plan’s MA population. Particularly given CMS’ ongoing, transparent acknowledgement that audited plans are disproportionately affected by audit findings, these plans face strong headwinds as they prepare to lose QBPs, even if only temporarily. With long-term PBM contracts already in place, most of the financial impact resulting from these pharmacy audit-related penalties will be felt by beneficiaries and the provider network if CMS does not reconsider its approach to capturing audit results within Star Ratings.
- The uncertainties associated with bell-curved Star Ratings continue to present serious challenges for health plans as they attempt to build sustainable benefits that meet member needs and expectations over the long term.
- Five of the 6 plans receiving the Low Performance Indicator (LPI) in 2016 were not rated in 2017, and 4 of these 5 remain active at present. The long-term future of these plans appears to remain at the mercy of Congress. Despite being slated for termination by CMS due to consistently low Star Ratings performance, a “hospital improvement” bill, which has passed the House and is currently in the Senate, includes a provision to delay CMS’ authority to terminate MA contracts based on poor Star Ratings. It is unclear when Congress will take up this issue, though the bill does have noteworthy bipartisan support. As with many of the important program changes on the horizon for next year, we’ll be watching this issue closely to determine the bill’s ultimate fate and to determine its impact within the parameters of Star Ratings.
So where do we go from here? At a macro level, significant evolution and effort lies ahead to accomplish the Triple Aim foundation of the Star Ratings program. But in order to do so, the micro-view is where we must focus our energy and effort. Successfully improving health, and thus Star Ratings, requires us to carefully decide when, where, how, who, and why to work with micro-targeted groups of members in micro-targeted, person-centered ways.
For questions or inquiries about how Gorman Health Group can support your organization’s Star Ratings efforts, please contact me directly at msmith@ghgadvisors.com.
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New Webinar! The 2017 Star Ratings are out! Join John Gorman, Gorman Health Group’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on Thursday, October 27, from 1-2 pm ET, for a cross-functional review of the 2017 Star Ratings. Register now >>
New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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2017 Readiness Checklist – Valuable Tool or an Exercise in Redundancy?
Some people are list makers and wholeheartedly embrace the value of checklists. They utilize lists to manage tasks, stay focused, and ensure high-quality results. A publication by the Institute of Health’s Committee on Quality of Health Care in America, titled “To Err is Human: Building a Safer Health System,” lays out the value of checklists in improving patient safety. We should view the Centers for Medicare & Medicaid Services (CMS) Readiness Checklist in that same view: it is a tool to allow health plans to improve the quality and compliance of their health plan and safety of their members.
As with all checklists, the process can be a “check the box” experience or a valuable tool to make sure everything is in place and nothing was forgotten. We all know to expect a CMS Readiness Checklist on an annual basis, but do we use this amazing tool to its fullest? Be sure you make this a serious exercise to evaluate your program and readiness for 2017. Some sections may be redundant year after year, but health plans find broken processes year after year, sometimes through negative member experience―don’t let that be your plan.
Every item on the Readiness Checklist should be reviewed and validated. Some items are new and may take more time and effort to validate. Here are four new items on the 2017 Readiness Checklist where you may want to invest additional time:
- Medicare-Medicaid Dual Eligibles Non-Discrimination and Cost Share Protection – The 2017 Readiness Checklist has a new emphasis on protecting the rights of lower income members, particularly Medicare and Medicaid dual eligibles and others eligible for the Low Income Subsidy (LIS). CMS also highlighted this topic in their conference in September. Plans are required to ensure dual eligible beneficiaries are not balance billed for deductibles, coinsurance, or copayments for which they are not responsible. CMS is requiring plans to verify they have procedures in place to ensure their providers do not discriminate against beneficiaries due to their dual eligible status or balance bill those members who receive assistance with Medicare cost-sharing from a state Medicaid program. It is a health plan’s responsibility to manage their provider network to prevent this type of abuse of Medicare and Medicaid full dual eligible individuals.
- Best Available Evidence (BAE) – CMS included additional guidance for plans to review their BAE process. CMS expects plans to have processes in place to allow BAE to be accepted at the point of sale. If health plans do not have scripts in place to assist their member services and pharmacy help desk staff, then they must be developed and put in place to support members requesting assistance with BAE-type issues.
- Online Enrollment Center (OEC) Application Receipt Date – One policy change this year is the way the receipt date is calculated for OEC applications. Plans need to calculate the receipt date to 11 hours earlier than the time and date stamp provided on the CMS file.
- Non-Discrimination and Alternate Language Tagline Language – CMS also raises the new requirement for Non-Discrimination and Alternate Language Tagline translation language plans are now required to distribute to their members. CMS is requiring plans to verify they have processes in place to satisfy these new requirements.
This year’s release is earlier than previous years, allowing plans more time to validate and implement all actions. Similar to last year, CMS has changed the attestation process for the 2017 Readiness Checklist to a strategic conversation between plans and their CMS Account Managers. Without that formal attestation process, don’t devalue the Readiness Checklist and required actions – utilize the tool as the valuable resource it is which will ultimately make your health plan better and your members safer. To err is human, and for that reason, redundant validation is a critical step to make sure your program is ready for 2017.
Our consultants have implemented items from the 2017 Readiness Checklist for health plans just like yours. If you need assistance verifying you are ready for 2017 or have questions on your processes, we can help. You can reach us through our website or by emailing me directly at jbillman@ghgadvisors.com.
Resources
New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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Plan Now for Performance
As 2016 comes to a close, planning for next year should be well underway. Bids are in, and budgets for the current year are being evaluated against reality before next year's strategies are finalized. As the ACA continues to evolve, CMS has been busy with new programs and more oversight. A plan or provider has to be vigilant about identifying any weaknesses that could mean high costs or low expectations relative to budget. Parent companies have to be aware of line of business similarities and differences as Exchange and Medicaid business become more like Medicare Advantage in terms of programs and benchmarks. A recent article from Kaiser on retention makes great points about the line of business impact on retention and how it is a simple metric that encompasses many operational issues.
GHG is constantly improving its tools to identify outliers as well as relationships between different metrics that cross department lines. Finding root causes and quantifying them for the organization are more impactful than just handling them on an ad hoc basis. Just like compliance is everyone's responsibility, so is financial performance. Identifying weaknesses AND leveraging strengths combine to form a more complete business model for sustained growth.
GHG can prepare a tailored snapshot of your market and your company's performance. Contact us here.
Resources
New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 — 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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CMS Releases Long-Awaited Civil Money Penalty Calculation Methodology
On September 13, 2016, the Centers for Medicare & Medicaid Services (CMS) quietly released its long-awaited proposed methodology on the calculation of Civil Money Penalties (CMPs). The memo describes the calculation method of CMPs for Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs), Cost Plans, and Programs of All-Inclusive Care for the Elderly (PACE) plans in 2017. While CMS is not mandated to release this methodology, it did so in response to industry concern over transparency of CMP calculation and to provide more clarity to compliance operations. Comments on the proposed methodology are due to CMS by 5:00 p.m. ET on October 13, 2016.
Given that 60% of the referrals for potential enforcement actions stemmed from MA and Part D program audits, this memo focused on CMP calculations for deficiencies detected during such audits. For each deficiency identified, CMS determines whether the sponsor:
- Failed to substantially carry out the contract;
- Is carrying out the contract in a manner inconsistent with the efficient and effective administration of this part; or
- Is no longer substantially meeting the applicable conditions of 42 C.F.R Parts 422 or 423.
CMS then calculates CMPs on a per enrollee or per determination basis, as developed during its pilot, to standardize CMP calculations in 2014. The main difference CMS made between the pilot and its proposed calculation is the slight increase in penalty amounts over time to "encourage" compliance with CMS' rules. CMS also introduced an enrollment-based limit on the maximum CMP amount a sponsor can receive for each deficiency.
CMS calculates the standard penalty amount by taking the CMP amount and multiplying it by the number of enrollees or determinations. CMS then applies the aggravating and/or mitigating factors, multiplied by the number of enrollees, to the CMP which either increases or lowers the amount. Finally, CMS applies the enrollment-based or per determination limit, which caps the overall penalty CMS can issue.
The specific amounts CMS applies for the above can be found in the memo.
"In my daily conversations with Compliance professionals, the challenge to compile clean universes on the first pass is still that — a challenge — regardless of plan size," says Regan Pennypacker, Senior Vice President of Compliance Solutions. "This memo clarifies the agency will also consider Invalid Data Submission (IDS) as a condition that could result in beneficiary harm. This is cited when a Sponsor fails to produce an accurate universe within three attempts. CMS has noted this would be cited for each element which cannot be tested, and counts as one point in the scoring. CMS will calculate a CMP for this deficiency on a per determination basis."
This proposed methodology comes during the same time frame federal agencies are increasing CMP maximums across the board to comply with the Federal Civil Penalties Inflation Adjustment Act of 2015. The Department of Health and Human Services (HHS) released its interim final rule on September 6 across all its agencies. Some MA maximum penalties will see a maximum increase more than double its current amount. However, as the CMP methodology memo points out, CMS rarely utilizes the maximum amounts currently, instead using amounts that are likely to "better encourage the remaining non-compliant sponsors to improve performance." Currently these amounts are significantly lower than the maximum possible CMPs, however, this memo clearly puts plans on notice continued non-compliance will lead to increased penalty amounts that will cause a greater sting. Given this notice penalties among health plans for common infractions will increase, health plans should make sure to focus on highest risk areas like delegation oversight and appeals and grievances.
Now is the time to confirm those responsible for pulling and compiling CMS universes are equipped with the tools and skills to complete the task. Failure to produce accurate universes after a third attempt during an audit will significantly impact a CMP. Contact us for ways we can help.
Resources
The Centers for Medicare & Medicaid Services (CMS) audit practices have radically changed in recent years. Now with only days to prepare for CMS audits, organizations must become proactive in creating a culture of compliance. Visit our website to learn how we can help you >>
New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 — 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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Sales Oversight — Essential Guidelines
All agents are expected to comply with the Centers for Medicare & Medicaid Services (CMS) regulations and guidelines, federal and state laws, and health plan rules, policies, and procedures. But what does that mean, and how can health plans enable their employed sales staff and contracted agents to stay compliant while achieving target goals and growth?
Some organizations may have sales management monitoring tools and processes to review the agent's compliance, quality, and performance thresholds. In most cases, sales management personnel are required to provide ongoing monitoring of agent sales activities and performance.
Below are a few key components to Medicare sales force and distribution channel management:
- Ensure all agents selling Medicare products complete and pass all required training
- Communicate all product and regulatory information
- Ensure agents participate in any required remedial training
- Communicate the results of all ride-along evaluations
- Document any complaints or corrective action plans in the agent's file, which should be held for a minimum of two years
- Ensure any corrective action plan is completed and reported back to the health plan
- Report terminations of any agents/brokers to the state and the reason(s) for the termination
Gorman Health Group (GHG) suggests implementing a variety of compliance monitoring programs to ensure all agents are conducting sales, marketing, and enrollment activities in accordance with federal, state, and health plan regulations, rules, and guidelines. With the Annual Election Period (AEP) just several weeks away, health plans should be finalizing their sales oversight and agent performance standards. Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, says: "We know it's not easy. These activities take a village. A solid partnership between the creative minds in Sales and the rules-minded Compliance staff is critical to success. A sponsor with a well-planned roadmap for AEP will be one step ahead of competitors that have not executed as well."
To promote compliant behavior, health plans, sales management, agency owners, and agents should take an active approach to compliant behavior — attend additional training, understand and follow the rules and regulations outlined in the Medicare Marketing Guidelines, and always lead by example.
For more information, please contact Carrie Barker-Settles at cbarkersettles@ghgadvisors.com.
Resources
Sentinel Elite™ is a flexible, module-based software solution, built from the ground up, and designed to assist government managed care organizations onboard agents, provide training, manage ongoing oversight activities, and pay commissions effectively and compliantly. Request a demo today >>
The Medicare Advantage marketplace is evolving — are you prepared? Gorman Health Group's marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. Visit our website to learn more about how we can help you >>
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Keep the End in Mind as 2017 Readiness Approaches
According to Author Stephen Covey, in his book The Seven Habits of Highly Effective People, you should "begin with the end in mind." This means to start with a clear understanding of your destination so you know where you're going and understanding where you are now so the steps you take are always in the right direction.
Many department leaders have said, "I wasn't trained to be a compliance manager. I was just a good individual contributor managing my practice area, and someone asked me to take on this role." A powerful first step in becoming successful in a new role is to understand your organization's "End in Mind," which is usually described in the mission statement.
As Medicare Part D plan sponsors approach the 2017 Readiness season, this advice would be well taken. The Centers for Medicare & Medicaid Services (CMS) has intensified its program audit schedule, making it much more likely for a plan to receive the dreaded audit notice from CMS in 2017. Working from the point of view your plan will be one of those receiving an audit notice next year, you should approach the 2017 Readiness process as compliance audit preparation. In other words, the end in mind requires a critical review of the processes downstream from the Readiness Attestation.
Are your policies current with the latest regulatory requirements and guidance? Do your procedures match the actual processes in place? Can you demonstrate you comply with your stated processes? This is the approach CMS will take in a Compliance Program Audit. By attesting to the end point in the Readiness Checklist, you are in effect stating the processes on which the end is predicated are also functional and compliant.
Since most plan sponsors rely on first-tier, downstream, and related entities (FDRs) to help meet the operational and compliance requirements, it is also time to evaluate their performance. An FDR audit for delegation oversight is a critical part of the compliance plan for all plan sponsors. Any delegated function performed by an FDR is ultimately the responsibility of the plan sponsor. In the event of an audit, one of the greatest risks to a plan sponsor is from its FDRs. Since the Pharmacy Benefit Manager (PBM) is usually the largest, most impactful FDR, close attention should be paid particularly to regulatory changes that have been made in 2016 and need to be implemented in 2017.
Strategies that will ultimately improve the Compliance Readiness for 2017:
- PBM delegation oversight audits
- Mock program compliance audits
- Targeted audits (coverage determinations, formulary administration)
- Operational gap assessments
- Benefit administration testing
These represent key methodologies that can be used to discover deficiencies in functionality which translate to audit deficiencies Gorman Health Group can assist plan sponsors with as we approach the 2017 plan year.
Resources
The Centers for Medicare & Medicaid Services (CMS) audit practices have radically changed in recent years. Now with only days to prepare for CMS audits, organizations must become proactive in creating a culture of compliance. From a gap analysis to a comprehensive, deep-diving Part C and D audit, our team can help you minimize your compliance risk and maximize your time and resources. Visit our website to learn more about our audit services >>
On Tuesday, September 13, 2016, from 1:00 — 2:00 pm ET, join colleagues Diane Hollie, Senior Director of Sales & Marketing Services, and Carrie Barker-Settles, Director of Sales & Marketing Services, as they outline the keys to building an integrated member experience program that will deliver a significant and positive impact on health plan enrollment, retention, and revenue generation. Register now >>
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Making Order from Chaos
"Big data" is often described in terms of colorful dashboards and a roomful of SQL programmers. Gorman Health Group (GHG) thinks of it as a symphony of moving parts that all play a role in managing quality healthcare.
The year 2014 was the first time since 2005 that saw an increase in Medicare Advantage (MA) plans explode on the market, largely due to the Medicaid-Medicare Dual Expansion program, but sheer volume of Health Maintenance Organizations (HMOs) increased as well.
To attract new plans to the MA market, the Centers for Medicare & Medicaid Services (CMS) allows a 3.5% new plan bonus for the first three years. This includes a 65% rebate for supplemental benefits and is applicable to the double bonus counties.
However, at the end of the three years, these new plans must sink or swim. If they do not achieve 4 stars and get 5% bonus and 65% or more rebate, then they lose ALL of the bonus, and rebates level out to 50%. This Quality Bonus Program does not apply to dual eligibles or Programs of All-Inclusive Care for the Elderly (PACE), but a financial trend analysis is still appropriate.
So an operational priority for new plans is to focus on Star Ratings, but what about the rest of the operation and the financial bottom line? The high penetration of HMOs means best practices and diligence to manage networks and utilization. Recent increased demand for Preferred Provider Organizations (PPOs) with more consumer choice means managing the out-of-network costs. A financial checkup can review trends as well as point-in-time variance reports for medical and pharmacy claims as well as revenue projections based on demographics and risk adjustment.
Big data can help quantify this organizational dilemma. Without real-life experience, the dashboards can be just a set of graphics.
Right now is the ideal time to leverage this data into action. Bids are in, and Marketing is fine-tuning its message and demographics for open enrollment. A perfect complement to budgeting and year-end reconciliation of incurred but not reported (IBNR) and risk adjustment is to determine benchmark metrics for achieving the budget!
Dashboards supplemented with trend analysis and cross-functional discussion about outlier operational areas (referral patterns, emergency room usage, readmissions, high utilizers, pharmacy spend, etc.) is the real answer — not just an algorithm. Then the comparisons of real to benchmarks (and budget) become meaningful.
In recent blogs, we talked about evolution. A financial checkup by GHG gives you the tools and insight to evolve and succeed.
Resources
On Tuesday, September 13, 2016, from 1:00 — 2:00 pm ET, join colleagues Diane Hollie, Senior Director of Sales & Marketing Services, and Carrie Barker-Settles, Director of Sales & Marketing Services, as they outline the keys to building an integrated member experience program that will deliver a significant and positive impact on health plan enrollment, retention, and revenue generation. Register now >>
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How to Efficiently Conduct an Audit
Audits from regulatory bodies swarm around an organization like bees. And like a bee, upon first sight we do not think of the value they bring, but instead we first think of the sting that is to come.
A key aspect of an effective compliance program is to ensure there is an effective system for routine auditing and monitoring along with a system to identify compliance risks. You've established what you believe to be a solid audit plan for the year, but other things just seem to get in the way. First, you're tasked with researching the requirements for a new plan type. Then you have a fire to put out with a delegate. One of your staff gets a job offer she can't pass up, and before you know it, your audit schedule for the year is derailed. You'll get to them, right? Let's just hope you don't receive an audit letter in the meantime. With every passing Monday you hold your breath, all the while wondering how much time it will be before the inevitable occurs.
Sometimes an extra set of hands is all that's needed to get your audit activities back on track, but you do not have the budget for another full-time employee. Think of the following member-impactful audits that can be accomplished while you handle other responsibilities:
- Part C and Part D Grievances and Appeals
- Member Enrollment and Disenrollment
- Marketing
- Coordination of Benefits
All audit plans should include not only aspects included in CMS' protocol but also include audits of other self-identified areas of risk. Any operations that touch member service or payment might be considered higher risk on your assessment. Are they? And are you able to accomplish them all with the resources you have? Does your staff have the right skillset for the audits? From a CMS Q&A:
The safeguarding of beneficiary rights and protections is arguably the most important responsibility of a sponsor. Demonstrating you have the resources to detect, correct, and prevent occurrences of non-compliance is a struggle when a department lacks things like the time, resources, or skill to perform certain audits. Contact us for ideas on how we can partner with you to efficiently conduct some of your audits, providing you with some much needed assistance.
Resources
The Centers for Medicare & Medicaid Services (CMS) audit practices have undergone a few changes in recent years, but the core focus remains the same: beneficiary protections. From a gap analysis to a comprehensive, deep-diving Part C and D audit, our team can help you minimize your compliance risk and maximize your time and resources. Visit our website to learn more about our audit services >>
On Tuesday, September 13, 2016, from 1:00 — 2:00 pm ET, join colleagues Diane Hollie, Senior Director of Sales & Marketing Services, and Carrie Barker-Settles, Director of Sales & Marketing Services, as they outline the keys to building an integrated member experience program that will deliver a significant and positive impact on health plan enrollment, retention, and revenue generation. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Evolution Through Strategy: Pinpointing Growth Opportunities
My last article explained the choice of Medicare Advantage (MA) health plans to evolve or disappear. Evolution is certainly the preferable choice, so let's examine the steps needed to do so.
As with any company, you need to identify your target customer. State of the Art Membership accounting helps an existing determine strategies around expansion through a) new members (new to a company and new to Medicare) as well as b) the art of retention through pricing, quality and customer service. Both efforts are necessary to maintain a steady growth pattern. This is more sustainable than a membership spike up or down that will cause operational havoc and financial uncertainty.
Risk adjustment Adaptation follows the member through every clinical encounter. If not fully documented, inadequate risk adjustment practices mean money left on the table, which is not an option. Diligence and good provider relations with proper analytic tools are critical to support risk adjustment.
Proactive Member Service means caring about the member experience to set the stage for high level of care and high quality ratings. It helps with retention while ensuring maximum quality of care to the member as well as enhanced revenue from CMS to reward good service. The payback is healthier members who want to stay: a win — win situation!
Collaborative Accountable Providers represent a key partnership for the sake of the members. It is not always a natural alliance — different resources and priorities often conflict, but the health of the member through appropriate care management should be a common objective for both payer and provider. Various partnerships with providers to help with risk sharing is a new element that will offer advantages to both sides.
Make it Work Care Management focuses on the member's health as the single objective that requires proper and necessary medical care and ensures proper resources for the health plan to manage. The product design that attracts your membership base must also be managed to ensure a balance of quality for the member at the right price for the payer.
Finally, the partnership with providers is an integral part of the overall Mastery of Quality Ratings to maximize the outcomes as well as the member experience. CMS is serious about quality — it impacts enrollment opportunities, care management and member outcomes as well as financial performance through critical revenue bonuses and rebate opportunities.
Gorman Health Group has the expertise in all aspects of health plan operations to lead you through best practices but also how to leverage these steps into financial stability. With a proprietary pro forma model designed to quantify these areas based on an in-depth knowledge of MA best practices, we are able to lead management through the different strategic decisions and analysis to customize what works in your marketplace and how to leverage your own strengths. The goal is not just to survive MA but to evolve into something that will improve the community's health.
Join us next month to discuss how analytics can help manage these levers going forward to ensure success.
Resources
On Tuesday, September 13, 2016, from 1:00 — 2:00 pm ET, join colleagues Diane Hollie, Senior Director of Sales & Marketing Services, and Carrie Barker-Settles, Director of Sales & Marketing Services, as they outline the keys to building an integrated member experience program that will deliver a significant and positive impact on health plan enrollment, retention, and revenue generation. Register now >>
In a recent case study, GHG examined a mid-sized managed care health plan who struggled with poor MLR and how a cost-efficient affordability review that utilized trend management conducted by out integrated team of experts generated targets of $4 million in expected improvements. Download the case study here >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Challenges in Network Development
The sun is shining, kids are heading back to school, and fall will be here before we know it. Now is the perfect time to start planning for your network expansion needs. Plans need to be even more vigilant in managing their largest asset. Regardless of the size and scope of the organization, your plan's network adequacy and accessibility is a cornerstone of any new initiative.
Screech…insert brakes squealing sound effect here… For those of us who have been in the Medicare Advantage (MA) field, this starts to sound like a broken record, right? The numbers guys tell us the best new areas to expand, the network folks build their strategy―you know, the one where we pull a list of all available Medicare providers in the area and pray the providers will accept 100% of Medicare or at least a rate that will keep us in business and meet the Centers for Medicare & Medicaid Services (CMS) network adequacy requirements. Network departments are now feeling the pressure to perform not only to meet their annual goals but to ensure other functional areas of the health plan, such as member satisfaction, Star Ratings, clinical, and risk adjustment, can meet their goals as well.
In today's marketplace, it is no longer acceptable to meet the bare minimum Health Service Delivery (HSD) requirement. Consumers, and CMS, are demanding plans to be able to offer choices that include quality and cost efficiency. With consumer-savvy, newly aged in Medicare beneficiaries, there is also a shift in patient expectations and what is available for their healthcare dollar. The new beneficiary is aging in from a world of patient engagement and incentives and rewards programs and will expect the same level of service. Health plans need to find ways to evaluate their existing provider networks and newly expanded networks to meet these clinical and financial goals and to be forward-thinking on how to best wrap risk adjustment and Star Ratings into the mix.
For beneficiaries and their caregivers, a top priority in the selection of an MA plan is the inclusion and availability of their physician and most commonly used facilities. MA directories have required the least amount of informative elements as compared to their counterparts, such as Qualified Health Plans (QHPs) and Medicaid Managed Care Organizations, and CMS is pushing hard to have uniformity across all government-sponsored health plans. We know the belt is tightening with day-to-day network directory management. Plans must reach out to their providers on a quarterly basis to confirm demographics and open/closed panel availability of their providers, ensure the information is updated in real-time with online directories, and close the loop between the providers submitted on the HSD tables versus those in the directory. CMS has begun the process of the pilot directory accuracy audits, and it will be interesting to see which plans have done their due diligence and what methods have proven to be the most successful.
Additionally, a recent investigation by the Government Accountability Office (GAO)[1] identified serious deficiencies in CMS' oversight and enforcement of MA network requirements and recommended greater scrutiny of plans' networks. The GAO found CMS reviews less than 1% of all networks and does little to assess the accuracy of the network data submitted by plans. It was found CMS relies primarily upon complaints from beneficiaries to identify problems with networks and does not assess whether plans are renewing their current contracts to continue to meet network requirements.
As we saw last year with CMS network requirement changes, many plans were unprepared to submit their entire network footprint in their service area expansion applications. The result was a scramble to fill gaps and re-evaluate if previously approved exceptions were, in fact, still valid. This requirement further supports the CMS commitment to monitor network adequacy for MA plans much more closely. It is time to set new network monitoring processes in place which ensure your CMS network submissions mirror your provider directories and that you are prepared to address directory complaints and ensure you are following the new directory requirements.
The Kaiser Family Foundation recently completed a study on MA hospital networks and how much they vary.[2] The study was attempting to answer three questions:
- What share of MA plans have broad, medium, or narrow hospital networks, based on the share of hospitals and hospital beds included in the plan network, and to what extent does this vary across counties?
- Do MA plans typically include Academic Medical Centers and National Cancer Institute (NCI)-Designated Cancer Centers when one is located in the county?
- What is the relationship between network size and other plan features, including premiums, quality Star Ratings, per capita Medicare spending, parent organization, and plan tax status?
Some of the most interesting results found were:
- MA plans include about half (51%) of area hospitals in their network.
- Most plans (80%) include an academic medical center, but one in five did not.
- Two in five plans in areas with an NCI-Designated Cancer Center did not include the center in network.
- In 2015, 23% of MA plans in the study had broad hospital networks, while about 16% had narrow or ultra-narrow networks.
- Among Health Maintenance Organizations (HMOs), broad and narrow network plans had similar average premiums ($37/month vs. $36/month) and similar quality ratings (3.8 vs. 4.1 stars).
With hospitals having much more publicly available data with which to examine, as we move into the era of the Medicare Access & CHIP Reauthorization Act (MACRA), plans will need to use all available quantifiable data and work with providers more closely to ensure the provider networks we build are risk ready. As one of the only industries where technology has seemed to send us backwards rather than forward, we will need to ask ourselves, "Do we have a functional and connected ecosystem of providers, including hospital and ancillary providers, that are risk ready, AND are we ready to support them with real-time, transparent reporting to ensure healthy relationships with our providers?" "Do we have physician champions in the community, and does our internal leadership understand the importance of the new level of provider engagement that is required?"
Providers are scared and voicing their concerns. We are going beyond requesting providers follow up on gaps in care, HEDIS®, and Star Ratings measures. We are requiring coding accuracy and enforcing with audits to ensure we are on track with risk adjustment scores. We are going beyond pay for performance to paying for outcomes. As MACRA enters full swing, we know most providers will start out with the Merit-Based Incentive Payment System (MIPS) rather than the Advanced Alternative Payment Models (APMs), and yet there is still concern a small, single physician office will be able to survive.
In an election year where crazy things happen and we seem be more divided than unified, I, for one, would love to see all of these changes be the catalyst for plans and providers to come together―for providers to share their needs and concerns, for plans to offer tailored education programs that fit both the small office and the large integrated delivery systems, and for patient-centric care to truly mean the patient comes first.
How do we get there? I would have to say healthcare is still local, and we — plans and providers — need to meet on Main Street, USA, and start talking.
At Gorman Health Group, we have a long history of providing direct contracting assistance for plans, the ability do a deep-dive and ensure your specialty mapping meets CMS definitions for each category, to run multiple network adequacy and availability scenarios, and prepare your plan's HSD, state, or Request for Proposal network tables. We also have the bench strength to help you develop a strong network strategy and provider engagement architecture that takes into consideration the quality, financial, Star Ratings, and risk adjustment goals you need to reach in the competitive landscape of healthcare. Let us know how we can work and plan together now and build strategic network operations to support your plan's goals for growth. Planning now will allow us to ease into fall knowing we are prepared for the new season and new changes!
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Gorman Health Group evaluates the design and delivery of high quality collaborative care while achieving compliance and improving revenue cycle management. Our multidisciplinary team of experts will assess the alignment of your products, your current network and your market to translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>