2016 Annual Election Period (AEP) Medicare Advantage (MA) Enrollment Growth Slows Compared to 2015
The number and share of Medicare beneficiaries enrolling in MA plans continue to increase, but the pace of growth is beginning to decline. Currently, there are nearly 18 million Medicare beneficiaries enrolled in MA health plans across the country. This includes all individual and group plan enrollment.
Approximately 32% of Medicare beneficiaries are now in MA plans, but we are starting to see the MA penetration begin to flatten out (Figure 1).
Figure 1 — Total Medicare Private Health Plan Enrollment, 2012-Feb 2016
The following chart shows the dramatic growth of Medicare beneficiaries enrolled in MA plans as of February 2016 (Figure 2), but the percentage growth of enrollment is declining. Since 2012, MA enrollment has grown 32% to nearly 18 million.
Figure 2 Total Medicare Private Health Plan Enrollment, 2012-Feb 2016
Note: Includes Medicare Medical Savings Account (MSA) plans, Cost plans, demonstration plans, and Special Needs Plans (SNPs), as well as other MA plans (individual and group).
Gorman Health Group (GHG) analyzed the 2016 AEP and saw the following when analyzing national and state-level enrollment trends:
- MA enrollment has continued to grow and increase in virtually all states in the 2016 AEP.
- MA enrollment is highly concentrated among large organizations.
- Most enrollees continue to be in Health Maintenance Organizations (HMOs). (Enrollees in HMOs typically pay lower premiums and have lower limits on out-of-pocket expenses.)
But we also saw a real decrease in the MA percentage of growth from the 2015 AEP to the 2016 AEP. The following tables show the total enrollment from December to February of each year.*
2015 AEP VS. 2016 AEP
While the 2015 AEP saw an overall growth of nearly 650,000 beneficiaries enrolled in MA health plans, the 2016 AEP saw an overall growth of 445,245 beneficiaries enrolled in MA health plans — this is nearly a 31% decrease in enrollment from 2015 AEP to 2016 AEP. This is attributable to the lack of growth in the Medicare-Medicaid Plan (MMP) product, which had an almost 160,000 increase in growth last AEP but only increased approximately 15,000 in the 2016 AEP. In addition there were losses in enrollment in the HMO-SNP enrollment as well as in Preferred Provider Organization (PPO) plans. The enrollment in HMOs continues to see growth, although the growth was not enough to compensate for the other losses or decreased gains from last year.
*AEP is measured by looking at February MA enrollment since the total AEP enrollment is not captured in January enrollment numbers.
For more information on enrollment trends or other Sales, Marketing, and Strategy consulting services through GHG, email ghg@ghgadvisors.com or contact me directly at dhollie@ghgadvisors.com.
Also, read about "MA Plans' Must-Fix: The Member Experience" in a blog by John Gorman.
Resources
For actionable advice and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas. During this year's information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn't. We will share proven tactics to cut costs, increase member satisfaction, and manage and drive sustainable growth. The hotel room block expires on March 28 so register now to reserve your seat!
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. We will work with you to understand your market, mining demographic data for opportunity and finding the gaps in the competitive field into which your plan can fit. Visit our website to learn more >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Provider Directory & Network Adequacy Highlights in the 2017 Draft Call Letter
The Centers for Medicare & Medicaid Services (CMS) has emphasized the wide-scale monitoring efforts underway with respect to network adequacy and provider directory monitoring and the direct impact it has on not only the plan's ability to provide timely and adequate access to care, but the impact it has on the decision-making ability of the beneficiary and/or their caregiver to select the plan that best meets their needs.
While the new release cycle will affect CMS' ability to have gathered enough feedback and information to finalize the 2017 Audit Protocols, the Provider Network Adequacy (PNA) pilot is still at the forefront for CMS according to the recent release of the 2017 Medicare Advantage (MA) Advance Notice of Methodological Changes and Call Letter. Plans have a key opportunity to do a deep-dive into their provider networks and the policies and procedures governing their network, such as provider terminations, and prepare a monitoring protocol that will not only meet compliance but also take steps towards the future of network management that includes ensuring data integrity for the plan and its members.
It was previously anticipated the PNA would drive the sample of providers used to evaluate directory compliance. The 2017 Draft Call Letter indicates the opposite, noting specifically the data collected during the monitoring process could drive additional reviews of network adequacy as well as future monitoring and/or audit-based activities. CMS has given plans the ability to develop innovative pathways to ensure directory accuracy. Plans will need to close the loop and ensure interoperability between all systems, including those such as Health Services Delivery (HSD) tables and programs used to formulate both online and printed directories, to have a true impact on the data integrity presented to CMS and to their members.
Additionally, CMS continues to move in the direction of a uniform evaluation for both PNA and provider directories across all government-sponsored health plans. Given the fact Medicare Advantage (MA) plans currently have the fewest data elements required for provider directories and the least restrictive reporting requirements for network adequacy, plans should anticipate the need to augment the information they collect on providers, and, as with the requirement to submit your entire network during a service area expansion, gear up for more stringent network review requirements.
At Gorman Health Group, we have experts who have worked directly with managing provider networks and adequacy for over 20 years, including detailed analytics such as specialty code mapping and software, which is critical in building the infrastructure needed to fully support the quality and financial goals the network brings to your health plan.
If you have questions regarding the recent regulations proposed in the 2017 Draft Call Letter for MA and Part D around provider and network adequacy, please contact me directly at emartin@ghgadvisors.com.
Resources
GHG's renowned team of experts collaborated to provide the key features and implications of the 2017 Advance notice and Draft Call Letter for your organization in 2017 and beyond. Download our full summary and analysis >>
Listen to John Gorman's recent podcast on his top line observations from the 2017 Draft Call Letter.
For actionable advice and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas. During this year's information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn't. We will share proven tactics to cut costs, increase member satisfaction, and manage and drive sustainable growth. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Final Rule: The Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017
The anticipation is finally over — the "Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017 Final Rule" has arrived. This annual document provides health plan issuers the rules and requirements to develop plans and operational processes for the upcoming year. Since the Affordable Care Act (ACA) was enacted, health plans have been feeling the pressure regarding the premiums allocated to the Marketplace plans, coupled with staggering losses for this line of business with the elimination of the underwriting process, health plans have been receiving negative feedback from all angles. Now to layer onto that pressure, for 2017, two of the three stabilization programs — reinsurance and risk corridor — will no longer be included to provide health plans financial relief since the applicable timing for these programs has expired. To enhance the existing stabilization program, the risk adjustment model will be recalibrated using more recent data to reflect more closely with the commercial market risks experienced.
Some of the high-level changes reflected in the Final Rule are the following:
- Open Enrollment Period for 2017 and 2018 will continue to have the same dates as 2016, which is November 1 through January 31 of the following year. Starting in 2019, the open enrollment period will be shortened to start on November 1 and end on December 15 of the same year.
- Standardized plans have been introduced as an option for 2017. Issuers are not required at this point to utilize these standardized plans and are allowed to offer non-standardized plans if they choose, however, it is encouraged that issuers offer the standardized silver plans. Standardized plans are preferred by the Centers for Medicare & Medicaid Services (CMS) to allow the enrollee to have a better shopping experience on the Marketplace. It allows for a more apples-to-apples comparison of the plans offered. Therefore, because of the ease to enrollees, the Marketplace will arrange the plans to be found more easily. There are 6 standardized plans available to choose from. One for each metal level with the exclusion of platinum. The standard or "base" silver plan also has benefits aligned for each of the actuarial value (AV) plans that are utilized for the members that are eligible for the cost sharing subsidy. In total the silver plan ends up with 4 standardized plans and then 1 plan each for gold and bronze.
Each plan has a fixed deductible, fixed annual limitation on cost-sharing, and fixed copayment or coinsurance for the Essential Health Benefits (EHBs) that are a part of the actuarial value (AV) calculator, with the addition of urgent care. These benefits represent a large percentage of the total allowable costs for an average enrollee.
- Cost-sharing maximum out-of-pocket limit has increased from $6,500 to $7,150 for an individual and from $13,000 to $14,300 for a family.
- Network Adequacy proposed requirements were partially accepted in the final rule. Probably the biggest requirement that was not accepted was the time and distance standard.
- "Surprise Bills" are a concern of members, which has been addressed in this notice.
- Federally-Facilitated Marketplace (FFM) user fees will stay at 3.5% for issuers utilizing the (FFM). Issuers who are part of a State-Based Marketplace (SBM) that utilized the FFM platform will see some relief with a reduction in their user fee for 2017, from 3% to 1.5% of premium.
- Medical Loss Ratio (MLR) will not be allowed to include fraud prevention expenses as part of the numerator as proposed in the Notice of Proposed Rulemaking (NPRM).
A detailed analysis of the Final Rule including health plan impacts, will be provided in the coming week.
Resources
Register your team for the 2016 GHG Forum! For more details around the event and agenda, download the full conference brochure or visit our website. Register now >>.
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
The Good, the Bad, and the Ugly!
Regarding the New Proposed Medicare Marketing Guidelines (MMG)
Taking a quick read of the proposed 2017 MMG, our marketing team had some initial thoughts about the proposed changes we would like to share.
The Good
- It's only February, and we have the proposed 2017 MMG. This is great for us "Marketers" since we can plan now and won't get sucker-punched at the last moment with changes we weren't expecting.
- The proposed MMG state you no longer have to put the disclaimer about "Availability of Non-English Translations" on print ads and postcards except in the language in which the ad is printed. With so little space to work with on ads and postcards, this change is very welcome.
- Although already released in previous guidance, CMS now includes the following key provider directory updates in the MMG:
- CMS includes more specific guidance on timely updating of directories. Hard copy directories are proposed to be updated monthly; using addendums for the updates is acceptable. Online directories are expected to be completed within 30 days of notification. Although updating directories monthly or within 30 days is very difficult, it is better than real time, which was stated last year.
- CMS states all providers and/or pharmacies represented in the directory have a current contract in effect to participate in a Plan's network. At a minimum, any provider and/or pharmacy listed in the hard copy or online directory for the upcoming plan year should have a contract in effect for the first full month of the plan year. This greatly helps those of us in Marketing and Sales as nothing derails a sale better than stating a provider is in the network only to find out later the provider is not in the network.
- Last year the MMG stated Plans needed to contact their providers on a monthly basis to update their information. CMS has updated the previous language to state the provider contact is required quarterly.
- CMS is clarifying when it is acceptable to use the term "free" in marketing materials. CMS states the term "free" may be used when describing mandatory supplemental benefits that are provided at $0 cost sharing for all enrollees.
The Bad
- Unfortunately, CMS has also proposed Plans cannot use the term "free" to describe $0 premium plans, Part B premium buy-downs, low-income subsidy, or dual-eligibility.
- CMS has clarified guidance from last year to state if an agent is conducting a one-on-one appointment telephonically, the agent must follow the Scope of Appointment guidance.
The Ugly
- CMS includes language stating it will no longer generate Summaries of Benefits (SBs), and Plans will be required to develop their SBs based on their bid data in the Health Plan Management System (HPMS) and required data elements provided in an SB guidance memo. First-year changes like this are always ugly since there are always interpretation issues, and timing on these documents is already tight. However, we fully expect CMS to provide additional guidance around the implementation of this change in the months to come.
Not a BIG deal but Worth Mentioning:
- There is a proposed fifth mailing statement to be utilized for the Annual Notice of Changes (ANOC) mailing only: "Important information about the changes to your Medicare drug and health plan."
- CMS has included what they stated in a memo last year: the ANOC/Evidence of Coverage (EOC), directories, formulary, Utilization Management documents, and Multi-Language Insert must be on the website by September 30, with some exceptions.
Changes to the MMG are never wanted, unless it makes our lives easier, but having a "heads up" related to potential changes in February is a great way to get started for the upcoming Annual Election Period―thank you, CMS!
Resources
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. We will work with you to understand your market, mining demographic data for opportunity and finding the gaps in the competitive field into which your plan can fit. Visit our website to learn more >>
Register your team for the 2016 GHG Forum! For more details around the event and agenda, download the full conference brochure or visit our website. Register now >>.
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Compliance Highlights of the CY 2017 Draft Call Letter
According to the Centers for Medicare & Medicaid Services (CMS), the Call Letter activities follow four major themes: improving bid review, decreasing costs, promoting creative benefit designs, and improving beneficiary protections. This means implementing creativity and doing more with less while enhancing the beneficiary experience. To borrow from one of the earliest reality shows, this is the time when CMS stops being nice and starts getting real. There are some of the key items of which your Compliance Department needs to be aware outlined below; however, it is not all inclusive and a thorough read of the document is required.
Something that is highly detrimental to an organization is CMS' reduction of a Star measure to 1 Star if any compliance-related issues are identified with a measure's data. We have seen that applied repeatedly this year to a variety of measures. This Data Integrity initiative is not new; unfortunately, CMS notes in the Call Letter that the agency continues to identify new vulnerabilities where inaccurate or biased data could exist. You will hear more from my colleague, Melissa Smith, on the proposed Star Ratings changes here in this blog.
Program Audit Protocols and Enforcement Actions
In an effort to allow sponsors more time to implement new protocols, CMS is proposing to release the following year's protocols by the end of July, starting this year. How does this change impact an organization?
- An earlier release means industry feedback received at certain times this year will most likely inform the 2018 protocol updates. Since the Medication Therapy Management and Provider Network Adequacy (PNA) pilots are scheduled to be released "a few months into" the pilot audit period, comments won't be received in time to inform 2017 protocol. Therefore, CMS proposes to extend the pilot into 2017.
- CMS notes the PNA protocol will not be administered during the same time as the program audits. This is not surprising for two reasons. First, the current program audit schedule is jam-packed. It's tough to envision adding another layer of operational audits to an already taxing schedule. Second, CMS reminds sponsors that this is only one piece of their larger scale efforts at reviewing adequacy. Consider the provider directory requirements memo released on November 13, 2015. CMS will actually be using the PNA pilot to validate corrections required as part of monitoring completed by the Medicare Drug and Health Plan Contract Administration Group (MCAG).
Some of these changes may mean more impact to your Compliance staff day to day. Gorman Health Group (GHG) notes our sponsor partners are quick to dive into published protocols to update tools and programming. Oftentimes they identify unclear items and immediately contact CMS for clarification, so this change should not create a significant impact to those who follow suit.
Since CMS is focusing on network, this should drive renewed focus and monitoring as part of a risk assessment and current oversight activities. GHG is aware of at least one consistently rated five star plan that has conducted full network assessments on a quarterly basis for quite some time now. In addition, CMS, in working with a contractor, has developed what they believe is a comprehensive process for monitoring provider directory accuracy. Interpret as such: your focus on this area pays off. Our Network team will dive deeper into this area here in the GHG blog.
CMS plans to release a memo describing their interpretation of applicable rules in the methodology for civil money penalties and will provide a comment period to the industry. Compliance should distribute this memo and collect comments as the calculation is often questioned on user calls and during enforcement discussions.
The agency is also seeing no significant reduction in the volume of Part D auto-forwarded coverage determinations and redeterminations. For this reason, they plan to increase the level of severity of compliance and enforcement actions. This is an area of the program with direct impact on a beneficiary's ability to access his or her Part D benefit. It is hoped that turning up the heat in this area may encourage plans to implement changes to reduce that volume and start meeting time frames more regularly.
CMS also proposes to consider the findings of noncompliance from the one-third financial audits for potential enforcement actions. In the past, sponsors were required to implement a corrective action plan, but they have had this authority under 422.752 and 423.752.
Sensing a theme here? CMS has reached a tipping point, and as our Founder and Executive Chairman, John Gorman, has recently noted, it appears 2016 is the year they drop the gloves. If you've ever played hockey, that's when it starts getting good. We hope to see you at our webinar on March 1!
Resources
Join John Gorman, GHG Executive Chairman, and colleagues, Olga Walther, Senior Legislative & Policy Advisor, and Leslie Mullins, GHG's Senior Consultant, as they provide a hard-hitting analysis of critical areas addressed in the document. Learn what the proposed "methodology changes" could mean for your organization and its partners, and the steps you can take to soften the impact on Tuesday, March 1 from 2:30-3:30 pm ET. Register now >>
Register your team for the 2016 GHG Forum! For more details around the event and agenda, download the full conference brochure or visit our website. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Is Value-Based Insurance Design All It's Cracked Up To Be?
There continues to be a lot of buzz about value-based insurance design (VBID). VBID is the idea that consumers' out-of-pocket medical costs should be based on the value of a service to their health and not the price. Health Affairs defined VBID as "an approach that attempts to improve the quality of care by selectively encouraging or discouraging the use of specific healthcare services, based on their potential benefit to patients' health, relative to their cost."
Treatments, medications, and procedures evidence has shown to be effective and recommended for a condition are provided at no or low cost to the patient. Care that is ineffective or unnecessary is priced higher to discourage utilization. Corporations like Pitney Bowes, Caterpillar, and Marriott, and organizations like Oregon Educators Benefit Board and the Colorado Springs School District 11 have implemented several models of VBID. Reported outcomes include savings from reduced adverse events like hospitalizations and emergency department visits.
Some Medicare Advantage Special Needs Plans have designed their benefit structure along the lines of the value-based model. For example, members who have diabetes have $0 copays for necessary medications and may have additional benefits like gym classes, cooking classes, and Certified Diabetes Educator access.
Designing a value-based benefit for Medicare patients with chronic conditions begins with a review of the peer-reviewed treatment guidelines. These treatment guidelines can be accessed at https://www.guideline.gov/. Medications designated as first-line therapy should be provided at very low or $0 copays. Medications lower on the list, such as third- or fourth-line therapy, can be placed on a different/higher tier. Lab tests, provider visits, and other recommended therapies (physical therapy, exercise, dietary requirements, etc.) can also be provided at low cost to the member. Most chronic conditions lend themselves to a value-based design. Barriers like the cost of a custom formulary will hopefully be resolved by more industry uptake of VBID.
Resources
Gorman Health Group can map the right strategy for realizing value-based care by aligning clinical and revenue cycle workflows for faster and more accurate payment, redesigning care delivery models to benefit from outcomes-based reimbursement, transforming the quality and effectiveness of care, as well as designing a value-based benefit for your members with chronic conditions. Visit our website to learn more >>
Register your team now through February 14 for the 2016 GHG Forum, and take advantage of our standard registration rate of $1,095 before the price goes up to $1,295 on February 15. Register now >> For more details around the event and agenda, download the full conference brochure or visit our website.
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Sales 2017 Readiness — Are You Maximizing Your Sales Potential Today?
Here we go again, planning for the upcoming selling season. Every year it seems to approach more quickly than the year before. Are you ready? If the answer is no, or you are not sure, here are a few critical items to consider as you create your 2017 Annual Election Period (AEP) strategy:
- Market Analysis — What worked during AEP 2016? This is the time to reflect on strategies which helped and/or hindered your success from the previous year. While it's fresh in your mind, create a market analysis to review all the components of your sales process. From material distribution to product design, it's important to understand what components of your strategy worked and what needs to be adjusted.
- Channel Mix — Do you have the right mix of agents to represent your plan? It's important to evaluate the effectiveness of both your internal and external sales forces. The industry is moving toward a more diverse distribution channel. The need for internal and external field agents, coupled with telesales, helps maximize your footprint and reach all corners of your market.
- Seminar Plan Development — Did the materials you provided keep your agents compliant during their presentations? CMS secret shoppers are out in full force, and having the right tools for your agents will be imperative to high Star Ratings. In addition, baby boomers are also forcing us to rethink how we present products to Medicare beneficiaries. With the growth of internet shopping, online enrollment presentation opportunities must be included as a part of your strategy.
- Marketing — Did your direct mail make the phones ring, or did your marketing miss the mark? How you implement your marketing strategy impacts lead flow, brand awareness, and enrollment. Successful marketing programs deploy a multi-touch communication strategy which blends education, lead generation, and conversation tactics to maximize new member acquisition.
- Sales Training — Was your sales force ready to sell your plan? Sales training is a critical part of plan and agent success. Create a curriculum which encompasses sales and product training, time management, Medicare basics, and compliance. Don't forget to teach them about member retention―it's hard enough to acquire new members, so you also need to know how to retain them. Enable your agents to start the season with all the knowledge needed to make that sale and keep that new member on the books.
With the narrowed time frame for AEP, your sales strategy must continually change to adjust to the Medicare climate. What worked last year may not work this year. Don't delay, the time is now―start planning for your success today!
For more information, please contact Carrie Barker-Settles at cbarkersettles@ghgadvisors.com.
Resources
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. We will work with you to understand your market, mining demographic data for opportunity and finding the gaps in the competitive field into which your plan can fit. Visit our website to learn more >>
Register your team now through January 31 for the 2016 GHG Forum, and take advantage of our New Year's special! Save 15% using promo code NewYear16 at checkout. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
New Hospice Policies Could Mean Big Changes for MA
Medicare's hospice care is garnering much attention and starting the evolution process this year. The Centers for Medicare & Medicaid Services (CMS) issued several new regulations changing hospice payments, and these regulations come with big implications for Medicare Advantage (MA) plans as well.
Last month, the Senate Committee released a policy options paper, discussing solutions for managing chronic illness. In the paper, the Committee proposed that MA plans be required to offer the hospice benefit currently provided under Medicare Part A. Such a change would mean changes to the MA payment system in order to include hospice reimbursement. It would also come with the inclusion of additional measures under the Star Ratings system.
These proposals have been floated around throughout the years, however, with the inclusion of the new end of life talks and the evaluation of the Care Choices Model, this proposal has more teeth and may become reality in the next several years.
Medicare will now also pay for Advance Care Planning talks. Most Medicare beneficiaries and their families state they would like to be involved in end of life planning, yet these talks are often avoided because of the sensitivity of the subject, prognostic uncertainty, and, most importantly, lack of training or pathways for physicians to facilitate these talks. A small number of beneficiaries currently have advanced care directives. This year is an important test for this new payment in assessing whether the talks will have an effect on the care patients choose to receive and whether this will result in more frequent and earlier hospice admission.
Although these payments are small, this is a great opportunity for plans to lead more physicians to discuss end of life care and put plans at an advantage if approached correctly. More patients electing hospice care could lead to better patient quality and experience. Hospice care is more person-centered and tends to improve outcomes such as pain and satisfaction. At the same time, although plans would lose the patient's premium from the shift to hospice, they would also shift the bad claims experience due to the highly expensive end of life palliative treatments and unnecessary hospital care. However, due to the sensitive nature of the discussions, plans should establish a careful framework in their approach in order to contain patient satisfaction and quality.
This year also marks the launch of the Medicare Care Choices Model (MCCM) from CMS. The five-year model allows some hospice-eligible patients to access hospice care without having to forego curative treatments, the way the system is currently set up, and allows for providers to receive payment for this care. The program has some significant limitations: hospice providers will only receive $400 per month or $200 per month for those enrolled for less than 15 days. This means in order to be financially appealing, patients will receive much lower benefits than normally received through hospice treatment. However, it may set up a basis for continued advanced care discussions and lead to more patients electing full hospice care. Despite the low payment, however, the model received significant provider interest and will see a high level of participation.
Resources
At Gorman Health Group, we would be happy to work with your organization to develop beneficiary outreach and/or other programs to address the growing need for this kind of program, which, if applied properly would benefit both the beneficiary and the help plan. Contact us to learn more >>
Register your team now through January 31 for the 2016 GHG Forum, and take advantage of our New Year's special! Save 15% using promo code NewYear16 at checkout. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Three Reasons Why Compliance Program Effectiveness Needs Evaluation Now
Happy New Year! It's a time when your organization may be evaluating whether or not to submit a new application or a service area expansion. This may be when annual training kicks off once again. You may be reviewing attestations to determine which vendors need to provide you with new documentation. And don't forget to ensure the Claims Department has updated systems to reflect the current prompt payment interest rate.
For those of you in Compliance, all of the above might be on your radar, in addition to the day-to-day. If you have not tested or evaluated the effectiveness of your Compliance Program lately, now is the time to do it. Here are three reasons why:
- Major pharmacies cited for repeat violations of privacy violations. Pharmacies arguably make up the largest group of downstream entities for Sponsors. Those contracted pharmacies have been subject to hundreds of Sponsor-specific general compliance and fraud, waste, and abuse (FWA) training in the past, as well as the trainings created by the pharmacy benefit managers (PBMs). (Starting this year, Sponsors must require first tier, downstream, and related entities (FDRs) to take the Centers for Medicare & Medicaid Services (CMS) training and accept the certificate of completion.) As you can see from the article, health information privacy complaints are on the rise. Sponsors should not simply check a box confirming a PBM attested that all pharmacies took training — this should be tested and sampled as part of auditing and monitoring. Furthermore, if and when a potential pattern of issues is identified, a deeper investigatory dive and escalation of corrective actions should be pursued.
- The new season of audits is approaching. At the end of October, CMS released their revised 2015/2016 protocols. Recently, CMS released a memo stating they continue to receive inquiries and concerns not only from Sponsors but also from FDRs regarding the difficulties encountered with adopting the new training requirement. While they have not delayed or retracted the requirement, CMS has decided to suspend their review of the FDR training certification aspect in their program audit protocol. Having this suspended in the audit protocol is by no means a free pass — it only highlights CMS' acknowledgement that implementing their guidance has been a challenge. Plan Sponsors still have the responsibility of ensuring those contracted to service their members understand their obligations, because it doesn't only take an audit for CMS to take action over FDR issues — it could be one call to a Regional Office or an escalated number of Complaints Tracking Module (CTM) cases that places your organization on CMS' radar.
- You may already know where your weaknesses are — evaluate the program and get those weaknesses and corrections documented. CMS has placed the onus on Sponsors to hire independent auditors to validate program audit corrections. If you are targeted this year, why not be as prepared as you possibly can be? Some things you cannot change — but it is of utmost importance you make time to conduct a Compliance Program Effectiveness (CPE) audit.
CMS has never said they are looking for a perfect audit. They expect to find things; therefore, you should also expect to find things in your own CPE audit. By virtue of regularly testing and evaluating the effectiveness, you make strides to strengthen your organization as a whole.
Resources
Register your team now through January 31 for the 2016 GHG Forum, and take advantage of our New Year's special! Save 15% using promo code NewYear16 at checkout. Register now >>
In addition to monitoring your operations and auditing the organization's performance, CMS also audits the compliance function. In recent years many CMS sanctions have been issued as the result of a Compliance Program that was determined to be ineffective. Learn how GHG can help >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Because They Can
The United States Senate conducted the first day of hearings Wednesday, December 9, on the high price of pharmaceuticals. The Special Committee on Aging is investigating the soaring prices of old drugs, including the overnight price hike of Turing's Daraprim from $18 to $750. Every day there is another press release about the egregious increase in pricing of a generic drug or a newly-released-to-market medication. U.S. drug prices are the highest of any in the industrialized world.
Drug prices and the strategies used to determine them are shrouded in secrecy. A recent Wall Street Journal article compared U.S. prices to Norway and several other countries. Pharma and biotech companies in the S&P 1500 average a net profit margin of 16% compared with an average of about 7% for all the other companies. Their rationale is usually they need that profit margin to support Research & Development (R&D) costs. That argument obviously doesn't apply for generic drugs. Pricing has nothing to do with recouping costs—it is a decision based on market research, competitor products, and shareholder value.
What's the answer? Doctors, insurance companies, hospitals, and Pharmacy Benefit Managers (PBMs) are all struggling to figure it out. Many healthcare policy experts are advocating for Congress to pass legislation which would allow the government to negotiate pricing especially for Medicare. Since there are more pharmaceutical company lobbyists in Washington, DC, than there are members of Congress, this could be an epic struggle.
These breakthrough treatments are invaluable to patients, but the costs for the patient and insurers can be exorbitant. What programs have you put in place to help your members adhere to treatments, minimize side effects, and empower them to understand their disease, and the drugs to help treat it?
Doctors are publishing and participating in dialogues about what the true value of a cancer drug is based on effectiveness and increased patient longevity. What is the true cost of a medication? If patients actually knew, could they make informed decisions about their options?
The Turing CEO may have just opened the can of worms that Pharma did not want to ever be seen. Greed and arrogance may be the catalyst Congress needs to implement meaningful changes. One thing we all know now―pharmaceutical and biotech manufacturers charge what they do…because they can.
Resources
Gorman Health Group can help your organization transform the delivery, payment, and care coordination efforts necessary to provide positive outcomes for your challenging patient population. If you are interested in more information, contact us here.
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and February 14 to receive the $1095 price. Come February 15, the price increases to $1,295.Register today >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>