HDE FREE WEBINAR SERIES: BIDDING, RISK ADJUSTMENT, AND STARS. May 3, 2012

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1 HDE FREE WEBINAR SERIES: BIDDING, RISK ADJUSTMENT, AND STARS May 3, 2012

2 AGENDA Impact of Star Ratings on 2013 Part C bid Looking ahead: 2014 & beyond How risk scores & QBPs work hand-in-hand to maximize revenue 2

3 HEALTH DATA ESSENTIALS (HDE) A consulting firm consisting of data analysts, in-house coders, and software developers that serves risk-adjusted Medicare Advantage and Medicaid managed care plans. Mission is to promote improved health care delivery through revenue management and quality improvement initiatives. Provides high-quality analytical services and products that include quality measurement and improvement, financial modeling, revenue management, value-based purchasing, education services, medical record review, and software. 3

4 RICHARD LIEBERMAN CEO of Health Data Essentials, Inc. One of the nation's leading experts on financial modeling and risk adjustment in the managed care industry. Combines unique expertise in provider profiling, risk adjustment, case-mix measurement, and provider reimbursement strategies. Actively involved in the development of risk adjustment systems for over 20 years. 4

5 WAKELY CONSULTING GROUP Delivers professional actuarial services and health care reform consulting beyond the expectations of the health care industry at a cost-effective price. Set apart by reputation for providing personal, value-added service. 5

6 DAVE NEIMAN Senior Consulting Actuary at Wakely Consulting Group, based in their Denver office. 10 years of experience as a health actuary. Extensive Government Programs experience in:» Medicare and Medicaid Risk Adjustment» Medicare Bid Preparation» Medicaid Rate Setting» Integrated/Shared Risk Care Delivery Models including: ACOs Total Cost of Care Provider Payment Arrangements 6

7 7 Star Ratings Impact on Future Medicare Advantage Revenue May 3, 2012 Dave Neiman, FSA, MAAA (720)

8 8 Caveats Analysis is based on current law Revenue and claim amounts are illustrative

9 9 Star Ratings Revenue Impact Quality Bonus Payments Percent increase on total Part C Payments Amount varies based on Star Rating May be doubled in counties meeting certain criteria Rebate Retention Percent of rebate retained for benefit buy up and supplemental benefits Amount varies based on Star Rating

10 10 Summary of Quality Bonus Payments Star Rating % 0% 0% 0% 3.0 3% 3% 0% 0% % 3.5% 0% 0% 4.0 4% 5% 5% 5% 4.5 4% 5% 5% 5% 5.0 5% 5% 5% 5% 1 CMS Demonstration 2 Under Healthcare Reform Law of 2010 (Assumes Sunset of Demonstration)

11 11 Summary of Rebate Retention Star Rating % 50% % 50% % 65% % 65% % 70% % 70% is Last Year of Blended Rebate Retention 2 Beginning in 2014, Healthcare Reform Rebate Retention Applies

12 12 Illustrative Impact of Star Ratings on 2013 Part C Bid Bid Component Risk Adj Rev $950 $950 $950 $950 QBP 0% 3% 4% 5% QBP Adj Rev $950 $979 $988 $998 Plan Bid $900 $900 $900 $900 Savings $50 $79 $88 $98 Rebate Retention 58% 58% 68% 72% Rebate $29 $46 $60 $71 Rebate dollar uses Part D premium buy down Part B premium buy down Reduce Medicare A/B cost sharing Provide mandatory supplemental benefits

13 13 Revenue Challenges Ahead Reduction in benchmarks / financial neutrality Phase-in of reform FFS targets County rebasing Divergence of claims trend and revenue growth Rebate reductions Phase out of QBP Demonstration Risk score coding intensity adjustment

14 14 Looking Ahead: 2014 & Beyond Bid Component Baseline Assumptions Risk Adj Rev Plan Bid $969 $927 $988 $955 $1,008 $983 QBP Adj Rev $1,008 $1,037 $1,058 4-Star Plan Savings Rebate Percent $81 65% $82 65% $75 65% Rebate $53 $53 $49 QBP Adj Rev $998 $988 $1,008 3-Star Plan Savings Rebate Percent $71 50% $33 50% $25 50% Rebate $31 $17 $13 Rebate Difference $22 $36 $36

15 THE IMPACT OF STAR RATINGS & RISK SCORES ON THE BIDDING PROCESS May 3, 2012 Presenter: Richard Lieberman CEO

16 QUALITY BONUS PAYMENTS FOR PLANS WITH LESS THAN 4-STARS ACA only provides for a Quality Bonus Payment for 4, 4.5, and 5 Star plans 3 and 3.5 Star plans are receiving bonuses under a 3-year demonstration program» Demonstration authority granted by section 402(a)(1)(A) of the Social Security Amendments of 1967, as amended The demonstration expires at the end of 2014; MA plans will transition to QBP established by the ACA» The evaluation of the demonstration won t be complete until July

17 EARLY FINANCIAL IMPACTS OF STARS If the ACA criteria had been used, about 1/3 of MA enrollees would have been covered by contracts eligible for a bonus in 2012 and 2013» In contrast, under the demonstration, about 90 percent of MA enrollees will be covered by contracts eligible for a bonus Between 2012 and 2014, the program is estimated to inject about $6.83 billion into a program that costs approximately $125 billion each year» Most of the additional money (roughly 2/3) will go to 3 and 3.5 Star plans» In 2012, $3.1 billion will be paid to MA plans, according to the Kaiser Family Foundation Quality Bonus Payments will offset a significant portion of the ACA s MA payment reductions:» 71 percent in 2012» 32 percent in 2013» 16 percent in 2014

18 QUALITY IMPROVEMENTS IN MEDICARE ADVANTAGE Before the advent of the Quality Bonus Payments ( ), quality was already improving» 14 of 45 HEDIS measures improved for HMOs 4 of 6 intermediate outcome measures improved» 9 of 45 measures improved for PPOs Among the HEDIS measures that are all Stars measures» 6 of 16 HEDIS-Stars measures improved for HMOs HMOs plans and local PPO plans show similar results» Local PPOs are weaker on measures requiring abstraction of information from medical records» Regional PPOs and PFFS plans generally show poorer results than other plan types Very few regional PPOs and PFFS plans report HEDIS 18

19 OPINION OF THE GOVERNMENT ACCOUNTABILITY OFFICE (GAO) On March 21, 2012, GAO recommended to the Executive Branch:» HHS should cancel the MA Quality Bonus Payment Demonstration and allow the MA quality bonus payment system established by ACA to take effect. CMS rejects the recommendation of GAO The Medicare Payment Advisory Commission has always echoed GAO s concerns» Limited Medicare dollars should go to truly high-performing plans, and beneficiaries should have a clear signal of quality differences among plans when making a decision at the point of enrollment.» Concerns about CMS overly broad use of demonstration authority 19

20 LOW PERFORMING PLANS Low-performing plans (< 3.0 Stars) are considered out of compliance In 2013, CMS will issue notices to enrollees in low-performing plans, alerting them to the organization s low rating and offering an opportunity to request a Special Election Period (SEP) from CMS to move to a higher quality plan. Persistent low-performers (3 consecutive years at < 3.0 Stars) will have their contracts terminated ( , , and )» The look-back period will be 2013, 2014, and

21 WHAT DOES THIS MEAN FOR THE FUTURE? Medicare Advantage plans have the ability to improve quality of care for their members» Limited improvements have already been documented, even in the absence of financial incentives It is likely that the QBP demonstration will sunset on December 31, 2014» Only 4, 4.5, and 5 Stars plans will receive bonuses and enhanced rebates in contract year 2015 Evidence supports the contention that Medicare Advantage plans can reach 4 Stars and claim the Quality Bonus Payments 21

22 RISK SCORE PLANNING BEYOND 2013 The recalibrated HCC model for payment year 2013 may reduce risk scores by up to 2 percent For contract year 2014, CMS is statutorily mandated by ACA to increase the coding intensity adjustment to 4.71 percent» Risk scores driven by diagnoses with dates of service of January 1, 2013 December 31, 2013 will drop by at least 1.3 percent» For contract year 2013, CMS elected to hold the coding intensity adjustment constant at 3.41 percent 22

23 QUALITY IMPROVEMENT REQUIREMENTS BEYOND MEDICARE ADVANTAGE Medicare Advantage plans must accept the fact that quality improvement is a requirement for participation in programs sponsored by government and an increasing number of private plan sponsors» The dual-eligible demonstration plans will not be eligible for Stars bonuses» ACOs have required quality metrics necessary to claim shared savings» Medicaid managed care plans have quality reporting requirements Financial bonuses for improving quality will become the exception rather than the rule 23

24 WHAT SHOULD MA PLANS DO? There remains substantial risk score improvement in medical records that is not being realized Engage in clinical documentation improvement activities» Many diseases, such as chronic renal failure, are not being documented in the medical record; they cannot be coded if they are not documented» Member-specific (RADV-style) chart audits in larger sample sizes will expose documentation issues for selected groups of providers Continue to encourage the complementary nature of prospective assessments and retrospective medical record review» Access to historical medical records is not a thing of the past Focus on quality improvement 24

25 GETTING TO 4-STARS Focus on the intermediate outcome measures that have 3.0 weights» Member engagement limited to process measures will not be sufficient Identify provider groups and decision-making providers who have suboptimal quality results» PCPs and predominant providers Medication adherence measures are vitally important» Statins, diabetes medications, hypertension medications (ACEI and ARBs) A measure of quality improvement trend is new for 2013» Coalesces year-over-year statistically significant improvement or decline at the measure level» Differential measure weights will be incorporated» Converted to a Star Rating at the contract level 25

26 MEASURE COMPLIANCE FOR PCP s 26

27 MEASURE COMPLIANCE FOR PCP s 27

28 MEASURE COMPLIANCE: IPA LEVEL 28

29 MEASURE COMPLIANCE: IPA LEVEL 29

30 QUALITY BONUS PAYMENTS VS. REVENUE MANAGEMENT Focusing on QBP cannot be done to the exclusion of risk score maximization The downward trend on Part A/B benchmarks for 2014 and 2015 will not be counteracted solely by Quality Bonus Payments» 3 and 3.5 Star plans are not likely to get bonus payments in 2015» Plans with less than four stars will have fewer rebate dollars to work with 30

31 REVENUE MANAGEMENT TARGETING To maximize risk-adjusted revenue, targeting by disease is essential» Drives both retrospective medical record review and clinical documentation improvement» Disease-specific targeting is not the, low-hanging fruit of prior period HCCs Key diseases to target:» Chronic kidney disease» Decubitus ulcers» Chronic liver failure» COPD 31

32 RENAL FAILURE DISEASE MANAGEMENT SURVEILLANCE PROGRAM Member Name: Smith, John PCP Name: Gregory House, MD Member ID: G Age: 66 DOB: 09/20/1942 Related Comorbidities: Diabetes: Yes Hypertension: Yes CHF: No SERUM CREATININE RESULTS Date of Service Result GFR Chronic Kidney Disease Stage 03/22/ Moderate Decrease (ICD 585.3) 02/05/ Moderate Decrease (ICD 585.3) 10/22/ Moderate Decrease (ICD 585.3) 08/03/ Moderate Decrease (ICD 585.3) 07/29/ Moderate Decrease (ICD 585.3) ALBUMEN/CREATININE RATIOS Date of Service Result 03/22/ /29/ RENAL FAILURE/DIABETES HCC OPPORTUNITIES HCC 19 coded. Find medical record documentation of relationship between diabetes and renal failure (HCC 15). This increments risk score by

33 JOIN US FOR OUR NEXT WEBINARS! Every 1st 2pm June 7, 2012 Risk Adjustment & Quality Measurement Across the Continuum of Plan Sponsors 33

34 CONTACT US! Dave Neiman, FSA, MAAA Senior Consulting Actuary Lisa Fabi Business Development Office: (720) Office: Cell:

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