7/31/2014. Medicare Advantage: Time to Re-examine Your Engagement Strategy. Avalere Health. Eric Hammelman, CFA. Overview

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1 Medicare Advantage: Time to Re-examine Your Engagement Strategy July 2014 avalerehealth.net Avalere Health Avalere Health delivers research, analysis, insight & strategy to leaders in healthcare policy and business 220+ policy and industry experts with backgrounds in government, academia and research organizations, managed care, industry and healthcare delivery, financial services and professional societies Capabilities in market strategy, policy analysis, reimbursement design, data analytics, modeling & scoring, evidence reviews, due diligence, qualitative research Research published by leading foundations and journals Eric Hammelman, CFA Vice President at Avalere Health Primary focus is using data to help shape business and policy strategies Previously with JPMorgan 2 Overview Medicare Advantage (MA) plans have historically given little strategic thought to working with skilled nursing facilities (SNF), focusing most of their efforts around limiting prices and length of stay Changes in the payment structure for MA plans due to the Affordable Care Act (ACA) has forced them to start thinking about new ways to manage the total care of their enrollees One of the primary changes for MA plans from the ACA has been a direct link between payment and quality (the Stars) This new focus by MA plans on quality provides SNFs a possible means to engage in new ways and redirect the conversation away from price and LOS The goal of this presentation is to explain how MA plans are reimbursed and demonstrate possible opportunities for SNFs to treat MA as a partner rather than an adversary 3 1

2 Presentation Overview Medicare Advantage Enrollment Trends How Medicare Advantage Plans Get Paid and Changes Under ACA Medicare Advantage Plans Traditional Evaluation of SNFs Star Ratings Quality Measures and a Possible Role for SNF Partnership 4 Enrollment in Medicare Advantage Continues To Grow at a Steady Pace, Even Amid Continued Financial Pressures Number of Enrollees (in Millions) National Medicare Advantage Enrollment Source: Avalere Health analysis using enrollment data released by the Centers for Medicare & Medicaid Services in February 2010 (reflecting January 2010 enrollment), February 2011 (reflecting January 2011 enrollment), February 2012 (reflecting January 2012 enrollment), February 2013 (reflecting January 2013 enrollment), and February 2014 (reflecting January 2014 enrollment. Excludes lives in plans with fewer than 10 enrollees. Figures are rounded and may not add to totals. Data includes enrollment in employer plans and the territories. 5 Recent MA Growth in California Slightly Slower due to Higher Historic Penetration Rates Number of Enrollees (in Millions) California Medicare Advantage Enrollment Source: Avalere Health analysis using enrollment data released by the Centers for Medicare & Medicaid Services in February 2010 (reflecting January 2010 enrollment), February 2011 (reflecting January 2011 enrollment), February 2012 (reflecting January 2012 enrollment), February 2013 (reflecting January 2013 enrollment), and February 2014 (reflecting January 2014 enrollment. Excludes lives in plans with fewer than 10 enrollees. Figures are rounded and may not add to totals. Data includes enrollment in employer plans and the territories. 6 2

3 In 2009, MA Enrollment Was More Common Out West 2009 MEDICARE ADVANTAGE PENETRATION % of all Medicare enrollees <10% 10-20% 20-30% 30%+ Source: Avalere Health Medicare Advantage Enrollment Model 7 Current Enrollment Patterns Show Higher 2014 MA Penetration in Rust Belt and Florida 2014 MEDICARE ADVANTAGE PENETRATION % of all Medicare enrollees <10% 10-20% 20-30% 30%+ Source: Avalere Health Medicare Advantage Enrollment Model 8 By 2019 MA Will Continue To Cover > 25% of Medicare Enrollees but Concentration Varies 2019E MEDICARE ADVANTAGE PENETRATION % of all Medicare enrollees <10% 10-20% 20-30% 30%+ Source: Avalere Health Medicare Advantage Enrollment Model 9 3

4 California Penetration Rates Vary Across the State 2014 MEDICARE ADVANTAGE PENETRATION IN CALIFORNIA % of all Medicare enrollees <10% 10-20% 20-30% 30%+ Source: Avalere Health analysis using enrollment data released by the Centers for Medicare & Medicaid Services in February 2014 (reflecting January 2014 enrollment). 10 MA is Popular Across All Ages NATIONAL MEDICARE ENROLLMENT BY AGE 14.0 Millions % 76% 32% 68% 33% 67% 32% 68% 30% 26% 70% 74% 0.0 < FFS MA It s not just the Boomers Source: Avalere Health analysis of CY2012 Medicare 100% Denominator File 11 Dual-Eligible Special Needs Plans (SNPs) Continue To Grow Number of Enrollees (in thousands) 2,000 1,800 1,600 1,400 1,200 1, National SNP Enrollment by SNP Type Chronic or Disabling Condition Dual-Eligible Institutional , , , , N = 1.29 million N = 1.40 million N = 1.65 million N = 1.87 million Source: SNP Comprehensive Report released by the Centers for Medicare & Medicaid Services in February for each plan year from 2011 to

5 California SNP Market Also Dominated by Dual-Eligible Plans Number of Enrollees (in thousands) California SNP Enrollment by SNP Type Chronic or Disabling Condition Dual-Eligible Institutional N = 210 thousand N = 188 thousand N = 223 thousand N = 264 thousand Source: SNP Comprehensive Report released by the Centers for Medicare & Medicaid Services in February for each plan year from 2011 to UnitedHealth, Humana, Kaiser, and Aetna Provide MA Benefits to Over 50 Percent of All MA Enrollees PARENT ORGANIZATIONS BY PERCENT OF NATIONAL MEDICARE ADVANTAGE ENROLLMENT Other, 35% UnitedHealth, 21% Other, 33% UnitedHealth, 21% Humana, 17% Humana, 18% WellCare, 2% Kaiser, BCBS of MI, 2% 8% Coventry, 2% Highmark, 2% Aetna, 4% CIGNA, 3% WellPoint, 4% Health Net, 2% WellCare, 2% Highmark, 2% BCBS of MI, 2% CIGNA, 3% WellPoint, 4% Aetna, 7% Kaiser, 8% N = 14.6 million N = 15.9 million Source: Avalere Health analysis using enrollment data released by the Centers for Medicare & Medicaid Services in February 2013 (reflecting January 2013 enrollment) and February 2014 (reflecting January 2014). Figures are rounded and may not add to totals. Data includes enrollment in employer plans and the territories. 14 Most Top MA-PD Sponsors Strengthened Market Positions in 2014 ENROLLMENT OF TOP 10 MA-PD PLAN* PARENT ORGANIZATIONS UnitedHealth Humana Kaiser Aetna WellPoint CIGNA WellCare Highmark Health Net InnovaCare Number of Enrollees (in Millions) 38.4% of MA-PD plan lives 29.1% of MA-PD plan lives Source: Avalere Health analysis using enrollment data released by the Centers for Medicare & Medicaid Services in February 2013 (reflecting enrollment accepted as of January 2013) and in February 2014 (reflecting enrollment accepted as of January 2014). *Includes Special Needs Plans (SNPs); excludes Medicare Advantage plans that do not offer drug coverage. Data includes enrollment in employer plans and the territories. Figures are rounded and may not reflect exact totals. 15 5

6 California Market Dominated by Kaiser and UnitedHealth PARENT ORGANIZATIONS BY PERCENT OF MEDICARE ADVANTAGE ENROLLMENT IN CALIFORNIA 2014 WellCare 3% California Physicians' Service 4% Other 12% WellPoint 5% SCAN Health Plan 7% Kaiser Foundation Health Plan 45% Health Net 7% UnitedHealth Group 17% N = 2.1 million Source: Avalere Health analysis using enrollment data released by the Centers for Medicare & Medicaid Services in February 2014 (reflecting January 2014). Figures are rounded and may not add to totals. Data includes enrollment in employer plans. 16 Presentation Overview Medicare Advantage Enrollment Trends How Medicare Advantage Plans Get Paid and Changes Under ACA Medicare Advantage Plans Traditional Evaluation of SNFs Star Ratings Quality Measures and a Possible Role for SNF Partnership 17 MA Plan Payments Are Determined by Comparing Plan Bids to County-Level Benchmarks MA payment structure encourages plans to bid below the benchmark Prior to 2011, plans bidding below the benchmark received 75% of the difference between their bid and the benchmark as a rebate to offer additional benefits; CMS kept 25% of the difference as savings Plans bidding above the benchmark must charge a premium for Parts A and B services equal to the difference between their bid and the benchmark Benchmark = $1,000 Beneficiary premium for Part A/B services= $100 CMS savings = $25 Rebate amount = $75 = Plan bid = Rebate to plan = Beneficiary premium Plan Bids above Benchmark Plan bid = $1,100 Plan payment from CMS = $1,000 Plan Bids below Benchmark Plan bid = $900 Plan payment from CMS = $975 Note: Numbers are for illustration purposes only. 18 6

7 Plans Have Flexibility in Assigning Rebate Dollars DISTRIBUTION OF REBATE DOLLARS BY TYPE OF BENEFIT, ALL MA PLANS, 2010 (PRIOR TO ACA) Reduced Part D Premium, 10% Reduced Part B Premium, 2% Enhanced Part D Benefit, 13% Reduced Cost Sharing, 54% Added Benefits, 21% Source: Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. March 1, Available at: 19 Health Reform Modified MA Payment by Revising Benchmarks Revised Benchmarks Divides counties into quartiles based on local fee-for-service (FFS) spending Sets county-level benchmarks equal to local FFS costs, multiplied by a specific percentage: Quartile 1: 95% Quartile 2: 100% Quartile 3: 107.5% Quartile 4: 115% Implementation Standard phase-in schedule is as follows: 2011: benchmarks equal 2010 amounts 2012: benchmarks equal 50/50 blend of old and new amounts 2013+: benchmarks equal new amount Allows for four or six year phase-in schedule in counties with large changes in benchmarks $30-$49 change: four years >$50 change: six years Source: Patient Protection and Affordable Care Act, as amended by the Health Care and Education Affordability Act of California MA Benchmarks Ratio of MA Benchmark to FFS Costs 95% 100% 107% 115% Source: Avalere Health analysis of CY 2015 Medicare Advantage Ratebook 21 7

8 and by Linking Payment to Quality 1 Beginning in 2012, plans with ratings of 4 stars or higher may receive bonuses 2012: Bonus equals 1.5% of local FFS costs 2013: Bonus equals 3% of local FFS costs 2014: Bonus equals 5% of local FFS costs 2 Some counties eligible for double quality bonuses Urban floor county; Local FFS costs below national average; AND MA penetration greater than 25% (as of December 2009) 3 Also links rebates to plan quality ratings 4.5+ stars: 70% of difference between bid and benchmark stars: 65% of difference between bid and benchmark <3.5 stars: 50% of difference between bid and benchmark Source: Patient Protection and Affordable Care Act, as amended by the Health Care and Education Affordability Act of Star Ratings Have Significant Implications for MA Payments Assuming three plans in the same county with different star ratings submit bids that are all $900 PMPM, each plan would receive different payments: Plan Bid Rebate Amount 4.5-star plan benchmark = $1,050 Plan payment from CMS = $1, star plan benchmark = $1,035 Plan payment from CMS = $ star plan benchmark = $1,000 Plan payment from CMS = $950 $105 rebate $87.75 rebate $50 rebate 4.5-star Plan 3.5-star Plan 2.5-star Plan Plan bid = $900 Plan bid = $900 Plan bid = $900 Plan rebate % = 70% Plan rebate % = 65% Plan rebate % = 50% CMS = Centers for Medicare & Medicaid Services MA = Medicare Advantage PMPM = Per Member Per Month QBP = Quality bonus payment Note: Numbers are for illustration purposes only. Values correspond to the policy in year ACA Provisions Seek To Align MA Plan Payments with Medicare Fee-for-Service (FFS) Spending 125% MA PLAN PAYMENTS AS A PERCENT OF FFS COSTS, 2011 vs % 109% 106% 105% 114% 110% 110% 106% 114% 113% 111% 112% 109% 107% 100% 75% 50% All plans HMO Local PPO Regional PPO PFFS Special Needs Employer Group Plans Plans TYPE OF MA PLAN Source: Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment Policy, Chapter 12: The Medicare Advantage Program: Status Report, March Available at: Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment Policy, Chapter 12: The Medicare Advantage Program: Status Report, March Available at: ACA = Affordable Care Act MA = Medicare Advantage. 24 8

9 CMS Demonstration Expanded Quality Bonus Payments to 3- Star Plans and Accelerates Payment to 4- and 5-Star Plans ACA Quality Payments Under the ACA, only plans with 4-5 stars would receive an increase in their benchmarks o 2012: Bonus equals 1.5% of local FFS costs o 2013: Bonus equals 3% of local FFS costs o 2014+: Bonus equals 5% of local FFS costs Quality payments are only applied to new portion of the benchmarks, which are being phased in CMS Demonstration Under the demonstration, CMS will accelerate QBPs to 4- and 5- star plans and extend QBPs to plans with 3 stars o CMS will apply bonus to entire benchmark, rather than only the new portion o Benchmarks plus bonuses will not be capped at prior law benchmark levels Demonstration to run from Sources: Patient Protection and Affordable Care Act, as amended by the Health Care and Education Affordability Act of 2010 and in the April 15, 2011 CMS Final Rule Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programsfor Contract Year 2012 and Other Changes; Final Rule CMS Fact Sheet 2013 Part C and D Plan Ratings, Table 1. Available at: Coverage/PrescriptionDrugCovGenIn/PerformanceData.html 25 At the End of the Demonstration in 2015, 3- and 3.5- Star Plans Face a Significant Payment Cliff PERCENT QUALITY BONUS PAYMENTS BY STAR RATING, Quality Bonus Payment % 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% Star Plan 3.5-Star Plan 4-Star Plan 5-Star Plan Nationally 48% of MA enrollment is in plans that will experience a cliff in QBPs in 2015 In California, it s only 15% of enrollment Source: CMS. Fact Sheet 2014 Star Ratings. October 24, Available at: Coverage/PrescriptionDrugCovGenIn/Downloads/2014-C-and-D-Star-Ratings.zip. 26 Average Rating Across Contracts of Most Top MA-PD Plan Sponsors Fall Shy of 4 Stars NATIONAL ENROLLMENT-WEIGHTED AVERAGE STAR RATING* BY PLAN SPONSOR, 2014 Aetna Inc. Blue Cross Blue Shield of Michigan CIGNA Health Net, Inc. Highmark Humana Inc Kaiser Foundation Health Plan, Inc UnitedHealth Group, Inc WellCare Health Plans, Inc. WellPoint, Inc OVERALL STAR RATINGS *2014 overall star ratings are enrollment-weighted using October 2013 enrollment data (CMS. Medicare Advantage Contract and Enrollment Data. October 17, Available at: Reports/MCRAdvPartDEnrolData/Downloads/2013/Oct/Monthly-Report-By-Contract zip). Does not include contracts that were too new to be measured or did not have enough data to calculate a rating. Source: Avalere Health analysis of CMS 2014 Part C Medicare Plan Ratings Data. October 21, Available at:

10 California MA Plans Already Demonstrating High Quality CALIFORNIA ENROLLMENT-WEIGHTED AVERAGE STAR RATING* BY PLAN SPONSOR, 2014 WellCare Health Plans 3.00 California Physicians' Service 4.00 WellPoint 3.77 SCAN Health Plan 4.42 Health Net 3.97 UnitedHealth Group 3.98 Kaiser Foundation Health Plan OVERALL STAR RATINGS *2015 overall star ratings are enrollment-weighted using February 2014 enrollment data (CMS. Medicare Advantage Contract and Enrollment Data. Available at: Reports/MCRAdvPartDEnrolData/Downloads/2013/Oct/Monthly-Report-By-Contract zip). Does not include contracts that were too new to be measured or did not have enough data to calculate a rating. Source: Avalere Health analysis of CMS 2015 Medicare Plan Ratings Data. October 21, Available at: 28 Presentation Overview Medicare Advantage Enrollment Trends How Medicare Advantage Plans Get Paid and Changes Under ACA Medicare Advantage Plans Traditional Evaluation of SNFs Star Ratings Quality Measures and a Possible Role for SNF Partnership 29 Recent Trends in MA Post-Acute Strategies Initiatives To Improve SNF Networks Understanding SNF clinical offerings Improving clinical relationships between primary care physician groups and their preferred SNFs Managing SNF costs Substitution of Lower Cost Settings Exploring clinical relationships with HHAs Actively discharging to HHAs Discharging to SNFs as alternative to IRF, LTACH Criteria for Network Selection Strong performance and outcomes data Receive patients from particular hospitals Clinical affiliations with the primary care physician group in network Unique capabilities (e.g., dementia care) 30 10

11 Plans Are Looking for High Performing SNFs Most frequent evaluation metrics used to assess SNFs for inclusion in network Length of Stay Hospital Admission Rates Hospital Readmission Rates Patient Satisfaction Average Daily Census Nursing Home Compare Quality Measures Occupancy Rate Source: Avalere Health survey of Medicare Managed Care Organizations, Spring Medicare Advantage Networks Getting Narrower Medicare requires all MA plans to have networks for enrollees that meet certain standards o The standards relate to the minimum number of providers in a given county as well as the maximum travel time for 75% of enrollees UnitedHealth dropped 10-15% of its network providers in o Early indications for CY 2015 suggest other plans are following United s lead o Avalere analysis shows United lost about 7-10% of its enrollment due to the network changes Most of the lives United lost appear to have shifted to other MA plans Unclear if these lost lives were more or less profitable to the plan Medicare Advantage Network Requirements Primary Care Medicare Acute Inpatient Skilled Nursing Home Health Physicians County Enrollees in County Beds Miles Facilities Miles Agencies Miles Number Miles Los Angeles 1,281,771 1, n/a San Diego 437, n/a Placer 67, n/a Yolo 25, n/a 5 10 San Benito 6, n/a UnitedHealth Culls Doctors From Medicare Advantage Plans Wall Street Journal, November 16, Source: CY 2015 Medicare Advantage Health Services Delivery Reference File 32 SNF Benefit Structure for California MA Plans Percent of Enrollment in MA Plans 3-Day Stay for SNF Care Copay on 1 st Day of SNF Care 3-day $ prior per day hospital 6% stay is required 0.5% $25 per day 27% No prior hospital stay is required 99.5% $0 per day 67% Source: 2014 Medicare Advantage Plan Options Database Weighted by July 2014 Enrollment 33 11

12 Presentation Overview Medicare Advantage Enrollment Trends How Medicare Advantage Plans Get Paid and Changes Under ACA Medicare Advantage Plans Traditional Evaluation of SNFs Star Ratings Quality Measures and a Possible Role for SNF Partnership 34 CMS Combines Part C and Part D Measure Star Ratings for Overall Star Rating for MA Prescription Drug (MA-PD) Plans 36 Part C Measures Step 1 Step 2 15 Part D Measures Weighted Average of Individual Part C and D Measures + Integration Factor* = Overall Star Rating *Factor applied by CMS to reward consistent performance across domains. Source: CMS. Medicare 2014 Part C & D Star Rating Technical Notes. October 21, Available at: Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2014-C-and-D-Star-Ratings.zip. 35 CMS Places Greater Importance on Outcomes Measures Compared to Process Measures in Calculating Overall Scores Process Measures Measure-level star rating multiplied by weight of 1.0 Patient Experience and Access Measures Measure-level star rating multiplied by weight of 1.5 Intermediate Outcome and Outcome Measures Measure-level star rating multiplied by weight of 3.0 Source: CMS. Medicare 2014 Part C & D Star Rating Technical Notes. October 21, Available at: Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2014-C-and-D-Star-Ratings.zip

13 CMS Measures MA Plans in Five Domains Focused on Plan Quality of Care and Service Domain Category Staying Healthy: Screening, Tests, Vaccines Managing Chronic (Long Term) Conditions Member Experience with Health Plan Member Complaints, Problems Getting Services, and Improvement in the Health Plan's Performance Health Plan Customer Service Examples of Performance Measures Screening for breast cancer, colorectal cancer, cholesterol, and glaucoma Annual flu vaccine Checking to see if members are at a healthy weight Yearly review of all medications and supplements being taken* Controlling blood pressure Readmissions to a hospital within 30 days of being discharged Ease of getting needed care and seeing specialists Getting appointments and care quickly Overall rating of healthcare quality Complaints about the health plan Beneficiary access and performance problems Members choosing to leave the plan Plan making timely decisions about appeals Reviewing appeals decisions *Special needs plans only. Source: CMS. Medicare 2014 Part C & D Star Rating Technical Notes. October 21, Available at: Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2014-C-and-D-Star-Ratings.zip. 37 SNFs Can Help Certain Managing Chronic Conditions Measures Measures included in Managing Chronic Conditions domain o Care for Older Adults Medication Review (SNP only) o Care for Older Adults Functional Status Assessment (SNP only) o Care for Older Adults Pain Screening (SNP only) o Osteoporosis Management in Women who had a Fracture o Diabetes Care Eye Exam o Diabetes Care Kidney Disease Monitoring o Diabetes Care Blood Sugar Controlled *** o Diabetes Care Cholesterol Controlled *** o Controlling Blood Pressure (SNF patients excluded) o Rheumatoid Arthritis Management o Improving Bladder Control o Reducing the Risk of Falling o Plan All-Cause Readmissions *** *** These measures have a weight of 3x the other measures due to classification as an outcomes measures 38 How To Engage Identify specific measures at each plan that could be addressed by a program run by your SNF o Pay attention to measures where the plan scored a 2 (critical) or 3 (at-risk), as these are measures that the plan will want to improve as well For each plan, take the following steps o Step 1: Identify the number of stays in the last months that were paid by the specific sponsor o Step 2: Determine if patients would have met the criteria for any of the critical or at-risk measures o Step 3: Develop programs and protocols that would ensure patients would qualify for positive quality score o Step 4: Contact the plan and demonstrate how your programs and protocols will help their quality score 39 13