Session 5 PD, Keys to Succeeding in the Medicare Advantage Market. Moderator/Presenter: Corey N. Berger, FSA, MAAA

Transcription

1 Session 5 PD, Keys to Succeeding in the Medicare Advantage Market Moderator/Presenter: Corey N. Berger, FSA, MAAA Presenters: Dylan Ascolese, FSA, MAAA JoAnn Bogolin, ASA, FCA, MAAA Stephen Lawrence Webb, HEDIS, CHCA

2 005PD: Keys to Succeeding in the Medicare Advantage Market How to close the HCC gap?

3 Agenda End to end RAPS submission test Prospective initiatives Chart reviews Monitoring and auditing

4 End to End RAPS Submission Test Ensure all diagnoses make it to the submission region How to test Obtain data set from provider and see if matches submission region Track a few claims from the intake process to submission Monitor and update the process as needed Service Rendered Claim/ Encounter Clearing House Data Repository RAPS Submission Region

5 Examples of Submission Process Breaks Data file layout change Data repository change RAPS vs EDS HIPAA 4010 vs 5010 Data warehouse change

6 Prospective Initiatives Home Assessment Provider Outreach/Assessment Provider Contracting

7 Home Assessment Home visit from nurse practitioner or doctor Questionnaire type form Internal staffing vs external vendor Services performed Medication review and reconciliation Home environment assessment Assess member for case/disease management program Send information collected to member s PCP

8 Home Assessment CMS Best Practice Performed by physicians, or qualified non-physician practitioners All components of the annual wellness visit, including a health risk assessment such as the model health risk assessment developed by the CDC Medication review and reconciliation Scheduling appointments with appropriate providers and making referrals and/or connections for the enrollee to appropriate community resources Conducting an environmental scan of the enrollee s home for safety risks, and need for adaptive equipment

9 Home Assessment CMS Best Practice A process to verify that needed follow-up care is provided A process to verify that information obtained during the assessment is provided to the appropriate plan provider(s) Provision to the enrollee of a summary of the information, including diagnoses, medications, scheduled follow-up appointments, plan for care coordination, and contact information for appropriate community resources Enrollment of assessed enrollees into the plan s disease management/case management programs, as appropriate

10 Provider Outreach/Assessment Work with providers to close HCC gaps Provide member lists with pertinent information Use of tools such as a smart EMR Provider capabilities Web based tool or smart EMR Costly to implement Not all physicians using the same EMR Ability to bring member in Knowledge/education on HCCs to understand what to ask and how to document

11 Provider Contracting Pay per assessment Flat fee for filling out assessment Difficulty with adherence Was the gap closed? Incentives Include with Quality incentives Base on: Chronic coding persistency Year over year change in HCC score

12 Provider Contracting Risk share Capitation: global vs partial % of revenue vs flat pmpm % of revenue: tied to revenue change Flat pmpm: base on HCC scores or revenue change ACO/Shared Savings: capability of provider to handle downside risk MLR vs medical expense savings MLR: provider wins if revenue increases and/or medical expense trend slows Medical Expense: need a separate incentive for HCC scores

13 Chart Reviews Retrospective: performed after year has ended Comb through medical charts for appearance of a condition that triggers an HCC Create member list hierarchy based on remaining suspect list

14 Monitoring and Auditing Very IMPORTANT!!!! Tracking number of gaps closed Home assessment Provider assessment Year over year chronic coding persistency Monthly dashboard Feedback to providers

15 Monitoring and Auditing Continued Very IMPORTANT!!!! Auditing: ensure coding is accurate and scrupulous practices are being performed Audit vendors, staff, and providers Audit the home/provider assessments Perform multiple times during the year Promptly delete any HCCs which are unsubstantiated

16 005PD: Keys to Succeeding in the Medicare Advantage Market Are My Risks Scores Right?

17 Briefly The elements that go into risk scores Demographics Adjusted for Age/gender Medicaid Eligibility Institutional Status Working-aged status Diagnoses MA versus PD Two different sets of coefficients Not all HCC s overlap between the two lists Other Different HCC model for aged/disabled community (non-esrd) than for long-term institutional residents

18 Briefly Keep in mind: Normalize risk scores for comparison MA versus FFS Normalization HCC Model changes Including different percentages of blending 2013 & 2014 models Understand your historical risk score trend

19 How Do I Know My Risk Scores Are Accurate? Year-over-year comparisons of own experience Compare risk scores over time Group membership by the following categories New-to-Medicare New-to-Your-Plan Existing Dis-enrolled Compare medical expense and risk scores over time Do medical costs and risk scores move in the same direction when they change? Compare risk scores across your plans

20 How Do I Know My Risk Scores Are Accurate? Review Risk Scores Across Your Organization's Plans MA-PD MA-PD MA-Only MA-PD Mississippi Texas Texas Texas Individual Individual Individual D-SNP Plan Risk Factor

21 How Do I Know My Risk Scores Are Accurate? Review Risk Scores Across Years Emerging Existing in Prior Year New to Medicare New to Your Plan Disenrolled Average Risk Score

22 How Do I Know My Risk Scores Are Accurate? Review Medical Expense and Risk Scores Across Plan Types / Years Emerging All Allwd PMPM $ $ $ $ $ Risk Score PMPM Ratio Non-Dual Allwd PMPM $ $ $ $ $ Risk Score PMPM Ratio Dual Allwd PMPM $ $ $1, $1, $1, Risk Score PMPM Ratio

23 How Do I Know My Risk Scores Are Accurate? Competitor Analysis Medicare.gov databases contain Benefit Designs, Premiums, STAR Ratings and Membership by county by carrier. Are your premiums in line with similar benefit plans from your competitors Is your STAR rating in line with your competitors

24 Example of Competitor Analysis Given the following: Company You ABC Risk Score x.xxxx STAR Rating Premium $75 $50 Cost Sharing Inpatient Acute $250 / Day, Days 1-6 $200 / Day, Days 1-6 SNF $0 Days 1-20; $156 Days $0 Days 1-20; $156 Days Outpatient Sugery $175 / Visit $125 / Visit PCP $15 / Visit $0 / Visit Ref $35 / Visit $25 / Visit Deductible $150 $150 Out-of-Pocket Maximum $6,700 $6,700

25 Example of Competitor Analysis HMO A HMO B HMO C Standardized A/B Benchmark $ $ $ Plan Risk Score Plan A/B Benchmark $ $ $ Plan A/B Bid $ $ $ Savings $34.97 $73.74 $73.43 Quality Bonus Rating Rebate $22.73 $47.93 $47.73 Member Premium $75 $50 $50

26 How Do I Know My Risk Scores Are Accurate? CMS has released risk scores by: Plan County Part C / Part D Latest risk scores are for 2012, released 12/30/ Advantage/Plan-Payment/Plan-Payment-Data- Items/2012data.html Compare relationship of FFS costs by county released with the rate book to understand expense (risk) relationships between counties.

27 My Risk Scores are Decreasing! Now What? Before digging into diagnoses data and medical charts: Easy Pickin s Non-Acute diagnoses should follow beneficiaries from year-to-year Particularly for chronic conditions RA, Cystic Fibrosis, Diabetes, COPD, CHF, CAF, e.g. ESRD stages of ESRD change over time» Dialysis» Transplant, and» Post-Graft/Functioning Graft 4-9 months 10 + months

28 My Risk Scores are Decreasing! Now What? Easy Pickin s (continued) Traditionally, physicians did not provide a complete listing of ICD-9 codes From a Reden & Anders chart in the January 2008 edition of Managed Care: In 2008, once Medicare Advantage payments were based solely on HCC risk payments (phased in for 4 years, at 100% in 2007) examining the conditions CAD, CHF, COPD, Cardiovascular Disease, Diabetes» Approximately 17% of members with these conditions were reported as having these conditions in the 2 nd year.» Approximately 10% of members with these conditions were reported as having these conditions in the 3 rd year.

29 What Else? Deeper Dive Prescription drugs that are taken by beneficiaries with certain conditions: Other Bronchodilators, ACE inhibitors, Betablockers, diuretics Prednisone Insulin Oxygen, face masks, ventilators, regulators, e.g.

30 What Else? Deeper Dive (continued) Comorbidity There is a prevalence of specific pairs of co-morbid conditions From Physical and Mental Health Condition Prevalence and Comorbidity among Fee-for-Service Medicare-Medicaid Enrollees, CMS September, 2014: The five most common co-occurring condition groups were» Heart conditions,» Mental health conditions,» Anemia,» Musculoskeletal disorders and» Diabetes 92% of Medicare-Medicaid enrollees who have diabetes also have a heart condition. 95% of enrollees with kidney disease also have heart conditions. 52% of enrollees with lung disease also have a mental health condition.

31 Now We Are In the Data Data Accuracy Are demographics correct Medicaid members accurately reflected Are all diagnoses being submitted Are codes being submitted accurately Using proper ICD-9 s, including the 2 digit extensions required, for example Are there no corresponding diagnoses for any visits Number of HCCs reported for populations Duals tend to have more HCCs than non-duals Older beneficiaries tend to have more HCCs If you are not seeing a significant difference in the number of HCCs between certain groups, you may be missing data.

32 Now We Are In the Data Monitor Differences As you transition from ICD-9 s to ICD-10 s ICD-10 is much more specific For diagnoses: 14,000+ ICD-9 codes and 68,000+ ICD-10 codes For procedures: 3,800+ ICD-9 codes and 78,000+ ICD-10 codes One ICD-9 diagnosis code can be represented by multiple ICD-10 codes One ICD-10 diagnosis code can be represented by multiple ICD-9 codes. Some ICD-10 codes have no predecessor ICD-9 codes

33 Now We Are In the Data Monitor Differences As encounter data is introduced as a diagnosis source Blend of risk scores from: Risk Adjustment Processing System (90%) Encounter Data System (EDS) and FFS (10%)

34 Follow CMS Guidance Chapter 7 of the Medicare Managed Care Manual Ensure the accuracy and integrity of risk adjustment data submitted to CMS. All diagnosis codes submitted must be documented in the medical record and must be documented as a result of a face-to-face visit. The diagnosis must be coded according to International Classification of Diseases, (ICD) Clinical Modification Guidelines for Coding and Reporting. Implement procedures to ensure that diagnoses are from acceptable data sources. The only acceptable data sources are hospital inpatient facilities hospital outpatient facilities physicians. Plan sponsors are responsible for determining provider type based on the source of the data.

35 Follow CMS Guidance (continued) Submit the required data elements from acceptable data sources according to the coding guidelines. Submit all required diagnosis codes for each beneficiary and submit unique diagnoses at least once during the risk adjustment data-reporting period. For Part B-only beneficiaries enrolled in a plan, the plan sponsor must submit diagnosis codes under the same rules as for a beneficiary with both Parts A and B. The plan should also submit diagnosis codes for Part A services provided under a non-medicare contract. If upon conducting an internal review of submitted diagnosis codes, the plan sponsor determines that any diagnosis codes that have been submitted do not meet risk adjustment submission requirements, the plan sponsor is responsible for deleting the submitted diagnosis codes as soon as possible. Receive and reconcile CMS Risk Adjustment Reports in a timely manner. Once CMS calculates the final risk scores for a payment year, plan sponsors may request a recalculation of payment upon discovering the submission of inaccurate diagnosis codes that CMS used to calculate a final risk score for a previous payment year and that had an impact on the final payment.

36 Contact Information JoAnn Bogolin, ASA, MAAA, FCA Managing Director Bolton Health Actuarial, Inc. (404)

37 005PD: Keys to Succeeding in the Medicare Advantage Market The Impact and Improvement of Medicare Stars

38 Agenda Impact of Stars Stars Improvement Stars Measure Review

39 Impact of Stars

40 Impact of Stars Quality Bonus Payment Overall Star Rating Quality Bonus Payment (QBP) Percentage 4.0 Stars 5.0% Low Enrollment Plan 3.5% New Contract Under a New Parent Organization 3.5% The QBP above is the bonus payment in standard counties. Qualifying counties receive a double QBP percentage.

41 Impact of Stars QBP Rebate Overall Star Rating Rebate Percentage <3.5 Stars 50% 3.5 Stars Star Rating <4.5 Stars 65% >4.5 Stars 70% Low Enrollment Plan 65% New Contract Under a New Parent Organization 65%

42 Impact of Stars Improvement The potential quality bonus payment and rebates that result from a plan s Star rating are significant. Additional impact of Stars include: Potential for being shut down for low performing plans Year round marketing for 5 Star plans Stars improvement costs in staffing, consultants, and vendors

43 Medical Loss Ratio and Stars The resources dedicated to Stars measure monitoring, analysis, and improvement can easily be millions of dollars for mid-size to large plans. Quality improvement activities (QIA) are included in the MLR. Categories of QIAs* include activities that: improve health outcomes. prevent hospital readmissions through a hospital discharge program. improve patient safety and reduce medical errors. promote health and wellness. improve health care quality through improved healthcare data use *Source: 42 CFR Activities that improve health care quality.

44 Medical Loss Ratio Continued All QIAs* must be designed to: improve health quality. increase the likelihood of desired health outcomes. be for individual enrollees, specific segments of enrollees, or non-enrollees as long as no additional costs are incurred due to the non-enrollees. be grounded in evidence-based medicine and follow clinical best practices and criteria *Source: 42 CFR Activities that improve health care quality.

45 Medical Loss Ratio Continued Activities that are Not included in QIAs include activities: designed primarily to control or contain costs. funded outside of the premiums from the plan. supporting non-quality administrative activities. for marketing. *Source: 42 CFR Activities that improve health care quality.

46 Stars Improvement

47 High Level Stars Improvement Overview Stars improvement is an iterative process between the plan, health care providers, and members. Plans need to use the administrative data that they have to identify areas for provider education, identify gaps-in-care that can be used in interventions, and develop incentive plans for providers and members. Improve Clinical Data Improve Member Care Improve Member Experience Incentive Plan(s) Practitioner and Member Activity Administrative Data Enhancement Educate Providers Identify Gaps in Care Health Plan Activity

48 Measure Level Stars Improvement With an understanding of how a plan interacts with providers and members, measure specific Stars Improvement initiatives can be developed. Evaluating Measures for Improvement Planning for Improvement Monitoring/Modifying Measure Improvement

49 Steps for Successful Stars Improvement Improvement Area # Step for Success Challenges and Common Problems A balance between getting input from multiple functional areas and productivity is needed. Executive sponsorship is needed for buy in from the 1 rest of the health plan. Evaluating Measures for Improvement Establish a Stars Improvement Team Identify Measures in Need of Improvement Evaluate Reason(s) for Poor Performance Develop a Strategy for Measure Improvement Identify Measures of Focus for Improvement Efforts This is the easiest step. Most plans know which measures need improvement. Brainstorm with the Stars Improvement Team. Try to divide the reasons into two broad categories 1. Care is provided, but data/evidence of the care is not collected. 2. Care is not provided. This step is often skipped. Plans often develop improvement plans for individual measures without looking at all measures as a whole. Successful Stars and quality improvement requires support from the entire organization and provider network, so a strategy is needed to plan for how these groups will be included in improvement activities. A thoughtful approach needs to be taken for the measures of focus. The lowest performing measures are not always the best measures for focus.

50 Stars Improvement Team Executive Sponsor Improvement Workgroup Lead Clinical Lead / Analytic Lead Healthcare Analytics Representative Claims and Encounters Rep IT Representative Network Operations Representative Member Services Representative Quality Management Representative Pharmaceutical Services Rep The Stars Improvement Team should develop an overall improvement strategy that integrates all functional areas of the organization and promotes the importance of Stars and quality performance throughout the health plan. The team needs support of the organization to continue to improve. Beyond developing an overall HEDIS improvement strategy, the group should be tactical and action focused with accountability to executive leadership.

51 Steps for Successful Stars Improvement (continued) Improvement Area # Step for Success Challenges and Common Problems Some plans implement activities without planning. Some plans spend significant time preparing to implement performance improvement activities and miss opportunities because of the planning Planning is needed, but activities have to move Planning for forward. Improvement Improvement activities that have been successful for Develop a Performance Measure one plan may have a different impact on a different 6 Improvement Plan plan. Implementing the plan can be delayed by over 7 Implement the Plan planning and problematic by under planning.

52 Steps for Successful Stars Improvement (continued) Improvement Area # Step for Success Challenges and Common Problems Many plans only look at the year over year change or don t monitor at all. Executive leadership often wants quick impact on 8 Monitor the Results of the Plan rates, but for some activities, rates may take years to change. Goals need to be set prior to improvement plan Monitoring/Modifying Measure Improvement Evaluate the Success of the implementation and a cost/benefit analysis should be done on improvement plans as a whole and on 9 Performance Improvement Plan individual improvement initiatives as possible. 10 Modify the Plan Based on Issues Identified in the Evaluation Many plans are trying many new activities. Some activities will be hugely successful and others will not be as successful. Plans should modify measure improvement initiatives as needed and as able.

53 Stars Measure Review

54 Stars Measures Part C Measures by Data Source Data Source Total Measures to 2015 Total Weight % Total Measures Total Weight % Total Measures Total Weight % % change in Weight of Data Source CAHPS 8 22% 7 19% 7 19% -3% CMS Administrative Data 0 0% 0 0% 1 2% 2% CMS Audit 1 3% 0 0% 0 0% -3% CTM 1 3% 1 3% 1 3% 0% HEDIS 15 42% 15 43% 13 37% -5% HOS 6 17% 5 17% 4 16% -1% IRE 2 6% 2 6% 2 6% 0% MBDS 0 0% 1 3% 1 3% 3% Plan Ratings 0 0% 1 9% 1 10% 10% Plan Reporting 0 0% 1 2% 1 2% 2% Phone Monitoring 3 8% 0 0% 1 3% -5% Total % % %

55 Stars Measures Part C Changes for Part C Measures Removed Cardiovascular Care Cholesterol Screening Diabetes Care Cholesterol Screening Diabetes Care Cholesterol Controlled Improving Bladder Control (temporary) 2015 Part C Measures Added Breast Cancer Screening Beneficiary Access and Performance Problems Call Center Foreign Language Interpreter and TTY Availability

56 Stars Measures Part C 5 Part C measures have a national average Star Rating under 3.0 Stars 3 of these measures are HOS Measures Improving or Maintaining Mental Health Monitoring Physical Activity Improving Bladder Control 1 of these measures is a HEDIS Measure Osteoporosis Management in Women who had a Fracture 1 of these measures is a HEDIS Measure Special Needs Plan (SNP) Care Management These measures have the most room for improvement Because these measures are low performing nationally, they may be difficult to improve (i.e. Star thresholds may be set at levels difficult to attain)

57 Star Measures Part D Measures by Data Source Data Source Total Measures to 2015 Total Weight % Total Measures Total Weight % Total Measures Total Weight % % change in Weight of Data Source CAHPS 3 18% 2 10% 2 10% -8% CMS Administrative Data 2 12% 0 0% 1 3% -8% CTM 2 12% 1 5% 1 5% -7% IRE 2 12% 2 10% 2 10% -2% MARx 1 6% 0 0% 0 0% -6% Medicare Beneficiary Database Suite of Systems 0 0% 1 5% 1 5% 5% PDE 0 0% 0 0% 0 0% 0% PDE data 2 12% 2 20% 1 10% -2% PDE, EDB, CWF 0 0% 3 30% 3 30% 30% PDE data, MPF Pricing Files, HPMS approved formulary extracts 1 6% 1 3% 1 3% -3% Phone Monitoring 4 24% 0 0% 1 5% -19% Plan Ratings 0 0% 1 17% 1 16% 16% Plan Reporting 0 0% 0 0% 1 3% 3% Total % % % 0%

58 Stars Measures Part D Changes for Part D Measures Removed Diabetes Treatment 2015 Part D Measures Added Call Center Foreign Language Interpreter and TTY Availability Beneficiary Access and Performance Problems Medication Therapy Management Program Completion Rate for Comprehensive Medication Reviews

59 Stars Measures Quality Focus As evidenced by the number of changes in the measures from 2015 to 2016 CMS and the organizations that manage the Stars measures (e.g. NCQA, AHRQ, and PQA), the Medicare Stars measures are constantly reviewed, updated and changed. Focusing only on the current year Stars measures is not sufficient. Top rated plans that are consistently high performing, focus on overall quality of healthcare rather than only current year Stars measures.

60 Contact for Questions and Comments Stephen Webb Principal Coryus, LLC w. (678) c. (678)