What Impacts the Medicare Advantage Industry Today

Presented by Jane Scott at the Executive Leadership Summit on March 24 - 26, 2015.

This presentation covers the Medicare Star Ratings impact on the Medicare Advantage Prescription Drug industry, what issues health plans are currently facing and what they need to do to stay ahead. Ms. Scott also raises some interesting discussion points on managing the special needs population, what health plans may be lacking, as well as physician contracting opportunities to support chronic care management. You will gain an increased knowledge of the Medicare Star Ratings system as well as learn tactical actions they can take to improve opportunities.

Transcript

1. What Impacts the MA-PD Industry Today Jane Scott Senior Vice President, Clinical Services Gorman Health Group, LLC
2. Discussion Topics for Today • Who Is ―the Industry?‖ • What Is Affecting the Landscape Today? • Challenges Facing Providers • Stars!! Challenges Facing Health Plan due to ―Quality‖ Measures and Regulatory Monitoring • What Is Coming Down the Road? • Possible Solutions 2
3. Who is the “MA-PD Industry” and What Are “We” Facing Today? The “We:” • Professional Providers: physicians, mid-levels, nurses, pharmacists • Support Staff: back-office staff, billing staff, front-office staff • Ancillary Providers: ambulatory surgical centers, urgent care centers, home health providers, DME providers, labs/diagnostics • Retail: Walgreens, CVS, Walmart, local pharmacies, medical supply stores, compounding pharmacies • Facilities: acute and sub-acute/long-term care hospitals, skilled nursing and residential nursing facilities, rehab hospitals, ERs, diagnostics • Populations: retirees, Medicare-eligible beneficiaries, and Medicare- Medicaid-eligible beneficiaries • Payors: health plans, state agencies, ACOs, delegated entities • System vendors, consulting firms, actuary firms, so in total … EVERYONE!!! 3
4. The Affected Landscape – Medicare Health Plans 2016 Policy and Technical Changes 4
5. The Regulatory Impact - Audit Protocol • CMS noted the following in the comments section regarding how risks are assessed at the plan level: ―We use a variety of existing data points from Medicare Star Ratings, past performance, and plan-reported data, as a few examples, to develop our risk assessment. We focus on metrics that have the potential to affect beneficiary access to medications and services and also look for operational metrics that program experience has demonstrated can cause contracting organizations to develop performance problems in core program areas (that is, large increases in enrollment over a short period of time).” • “We do not release our risk assessment in its entirety, but these are the areas we focus on when conducting the analysis. Organizations should note that it is our goal to audit all organizations in the MA and Part D program, and the risk assessment is one way plans are selected for audit.” 5
6. Evolution of CMS Audits 6 2014 Audit Scope 1. Part D Formulary Administration 2. Coverage Determinations, Appeals and Grievances (CDAG) 3. Organization Determinations, Appeals and Grievances (ODAG) 4. Compliance Program 5. Special Needs Plan – Model of Care (SNP-MOC), if applicable
7. Evolution of CMS Audits 7 2015 Audit Scope 1. Part D Formulary Administration 2. Coverage Determinations, Appeals and Grievances (CDAG) 3. Organization Determinations, Appeals and Grievances (ODAG) 4. Compliance Program 5. Special Needs Plan – Model of Care (SNP-MOC), if applicable 6. Medication Therapy Management (PILOT) – new modules 7. Provider Network Adequacy (PILOT) – new modules
8. 2015: No End in Sight in Consumer Protection Challenges • Common Findings: CMS and GHG – Untimely or inappropriate effectuation of approved cases – Untimely or inappropriate notices sent to enrollees or their representatives – Denial notices do not contain the required language; not tailored to the specific case at hand – Failure to conduct proper outreach before making a decision – Plans inappropriately taking an extension – Failure to properly address and resolve grievances – Mishandling of quality of care complaints – Misclassification of cases 8
9. Top 10 Compliance and Operational Risks • Review of All MA Sanction and CMP Letters, 2012-2015 – Documentation – Timeliness – Member letter content – Notifications – Misclassification of appeals and grievances – Benefit testing and rejected claims review – Clinical decision-making – MOC – Delegation oversight – Compliance risk management 9
10. 2016 Changes on the Horizon… • CMS can require Part C and D plans to hire an independent auditor to verify that deficiencies have been corrected. • This sounds like an independent audit of Corrective Action Plan (CAP) results, done to CMS specifications, but paid for by the plan. • Business Continuity Plan for MA Organizations and Prescription Drug Plan (PDP) Sponsors – Part C and D plans, and cost and PACE plans that also operate Part C and/or Part D plans, will now be required to have plans to restore operational and information technology (IT) support within 72 hours of a systems failure … Now plans have to have a plan! • A contingency plan! 10
11. The Required Business Interruption Plan Must Include the Following Elements: (and This Isn’t All of Them!) • Creating a communications plan that includes emergency capabilities and means to communicate with employees and third parties; • Establishing procedures to address management of space and transfer of employee functions; • Establishing a restoration plan with procedures to transition back to normal operations; • Compliance with Health Insurance Portability and Accountability Act (HIPAA) Security Rule contingency plan requirements; • Provisions for training of appropriate employees and for annual testing, including documentation of training and test results and modifications; • Within 72 hours, restoration of the following functions: for Part C plans, benefit authorization (if not waived) for services to be immediately furnished at a hospital, clinic, provider office, or other place of service; for Part C and D plans, call center services; for Part D plans, CMS expects a plan for 24- hour restoration of service for point-of-sale (POS) transactions to ensure members are not denied access to needed drugs, even though the stated target is 72 hours. 11
12. The Regulatory Impact • Medicare Advantage Prescription Drug (MA-PD) Coordination Requirements for Drugs Covered Under Parts A, B, and D: MA-PD plans are now specifically required to establish and maintain a process to ensure timely and accurate POS transactions, which includes coordinating coverage under Parts A, B, and D. • The goal is to avoid, as much as possible, delay, or inconvenience for the beneficiary when a drug is covered under Part A or B, rather than Part D, taking the beneficiary‘s health condition into account. 12
13. The Regulatory Impact • MA Organizations’ Extension of Adjudication Timeframes for Organization Determinations and Reconsiderations - – CMS is concerned that plans are routinely applying provisions for a 14-day extension of the deadline for determinations when the extension provisions are intended to apply only in unusual circumstances. – The new regulation limits use of the extension provision to times, when contract providers do not provide sufficient information ―due to extraordinary, exigent, or other non-routine circumstances.” – With this change, CMS is holding plans accountable for the timeliness of their contract providers’ response to requests for medical information necessary to process a claim, with the expectation that plans will be able to compel their contract providers to comply. 13
14. The Regulatory Impact • Requirements for Urgently Needed Services 422/113 – The definition of urgently needed services is changed as follows, to broaden circumstances in which such services must be covered by an MA plan even when provided by a non-participating provider: – Urgently needed services means covered services that are not emergency services as defined by CMS, provided when an enrollee is temporarily absent from the MA plan's service (or, if applicable, continuation) area (or, under unusual and extraordinary circumstances, provided when the enrollee is in the service or continuation area but the organization's provider network is temporarily unavailable or inaccessible) when the services are medically necessary and immediately required— a) As a result of an unforeseen illness, injury, or condition; and b) It was not reasonable given the circumstances to obtain the services through the organization offering the MA plan. ―Temporarily unavailable or inaccessible‖ means after normal clinic hours, weekends, or natural disasters. Presumably holidays and man-made disasters would also be included. 14
15. More Changes Coming … Provider Directories • CMS is supplementing their current guidance on provider directories and expects plans to establish and maintain a proactive, structured process to assess the availability of contracted providers. • An effective process will include regular, at least quarterly, communications with providers to determine whether there have been any changes to address, phone number, or hours, and to assess whether they are accepting new patients. • Plans must also develop and implement a protocol to address complaints from enrollees being denied access with corrections made to the online directory as appropriate. • Online provider directories must be updated in real time and include all active providers and notations to highlight providers that are not available to new patients. 15
16. What Is Impacting Providers? 16
17. Trends and Terms – “Alternate Reimbursement Models – Value Based” • Physicians and hospitals never cared about the insurance/payer problems … their only problem has typically been, “How much are we going to get paid?” • The bottom line is that public and private payers have to reduce the total spend on healthcare. • Something has to change … To try and affect a change, payment models are changing, causing providers not only to shoulder more responsibility for healthcare outcomes, cost, and quality, but also align with emerging compensation models rewarding these efforts. 17
18. Trends and Terms – Alternate Reimbursement Models – “Value Based” What is impacting “Value Based” Reimbursement? • Consolidation of the provider community – Hospital systems are purchasing physicians • Affordability, premium, and cost sharing increases • Narrowing networks … harkens back to the late 90s HMO days • Alignment of quality and practice incentives to create accountability and managing populations – Because incentive models are becoming more about populations and the care received, it is much more difficult to measure and show improvement – Every payer type is asking for different metrics – Metrics may differ from market to population… 18
19. Even Fee-for-Service Is Migrating Toward Payment Models with Compensation Based on Outcomes • Bundled payments for services (and in some cases bundled payments for multiple providers), • Episodes of care (providers paid to treat a specific condition over a period of time), • Physician Quality Reporting System (incorporating quality metrics), • ACOs or shared savings programs • Patient-Centered Medical Home designed programs … and health plans are following suit 19
20. Get on the Bus or Get Left Behind Without Pay • ICD-10 for billing, effective October 1: convert or don‘t get paid….maybe? • Second stage of the Meaningful Use incentive program (MU2) for electronic health records • Updated rules for the HIPAA • Physician Quality Reporting System (PQRS): In 2015, the incentive became a penalty equal to 1.5% of covered Part B FFS services. The penalty rises to 2% in 2016. 20
22. What Plans Want from Providers ... • Prior authorizations consume time and money in the provider office. • With more time and staff dedicated to communicating with payers, prior authorization activities can cost a practice up to $3,430 per full-time physician, according to a 2013 study published by the Journal of the American Board of Family Medicine. • Just think … there are more payers entering the market, more regulations governing documentation, and more benefits (especially drugs) requiring PA, and no one (or not many) pay the providers for their admin burden. 22
23. Providers’ Time ... Where Are We Asking Them to Spend It? • Technology • Staff Training • Updating/Training for EMR • Looking over RA data and gaps in care reports • Paperwork – LOTS of it • Treating the patient as a whole – coordinate care among healthcare systems (specialists, hospitals, home health care, medications, community services and supports, family 23
24. Providers must feel like this…… 24
25. What Can PCPs and Providers Do? How can we help? • Reinvent their services to patients – e.g., mid-levels, skillset of office staff to support plan care managers, community partner/agency awareness, reassess current use of technology = better monitor population health • Capitalize on innovative wellness programs to improve the health of the patient population and the practice‘s bottom line – Staff turnover is a HUGE cost to providers. Many face tenured staff retiring, and with them goes the knowledge. As reimbursements become increasingly tied to performance and patient outcomes, success will depend on practices functioning as a team. 25
26. What Can PCPs and Providers Do: • Define the work and staff needs associated with care coordination • Rework job descriptions/duties • Budget and forecast for the future – pro formas? • E-prescribe and analyze trends within patient populations • Evaluate the EMR system capabilities • Establish new workflows where necessary • Create new policies related to email, use of smart phones • Set up same-day appointments/after-hours incentive from plans? • Develop an online presence for practices – provider portals • Create mechanisms to encourage patient self-management • Assess patient satisfaction – It is very worthwhile for a provider to conduct his own survey and examine the results; can also be leveraged with plans/incentives 26
27. The Stars Landscape in 2014 and 2015: Preparing for What’s Ahead
28. How are we measured? Star Ratings: Chasing a Moving Target • The current and future Star Ratings Landscape • Practical strategies that will allow MA plans to adapt to the major changes ahead • The impact that potential changes in Stars may have on health plans • How to hold your PBM, local pharmacies, and provider partners accountable for their Stars performance 28
29. Why Are Star Ratings So Important? 29 • Commercial and Medicaid always follow Medicare Advantage • Sub-3-Star plans on CMS ―hit list‖ in 2015 o ―Scarlet letter‖ on Medicare.gov o Letters to members • .5 Star = ~ $15-$50 PMPM • Biggest factors in 2015: Appeals, Grievances, and Adherence Star Rating Complaints / 1,000 % Disenroll Annually  0.91 21.5%  ½ 0.55 17.48%  0.42 14.79%  ½ 0.33 9.27%  0.22 6.92%  ½ 0.15 4.89%  0.16 1.91% 29
30. The Drive for 5 Stars 30
31. Inovalon: Difference Between Duals and Non-Duals on Specific Stars Measures Health Affairs: Duals Plans Underperform in 5 Categories: 31 Recent Findings on Duals and Star Ratings 31 • Special Needs Plan – specific measures • Medication adherence, especially diabetes, hypertension, hyperlipidemia • Medication review • Functional status assessment • Pain screening
32. Key Elements for Stars Success 32 Process •Tools, Data & Dashboards •Case Mgmt, Disease Mgmt and Medication Mgmt •Delegation Oversight •Regular Audits and Remediation •Proactive Service Engagement •Executives and leaders •Internal Managers and Staff •Vendors Managers and Staff •Providers and Pharmacies •Members and Caregivers Leadership •Engaged leadership •Chief Performance Officer •Focused, Strategic Action Plan •Aligned QI and RA Strategies •Key Providers
33. 2015 Star Ratings Program Changes • New Measures: – SNP Care Management (C09) measure added with single weight • Retired Measures: – Breast Cancer Screening removed from ratings and reclassified as Display Measure – Beneficiary Access/Performance Problems removed from ratings and reclassified as Display Measure – Glaucoma Testing measure removed from ratings – Call Center Foreign Language Interpreter and TTY Availability measures removed from ratings 33
34. 2015 Star Ratings Measure Changes • Improvement Measure (C31 & D05) methodology modified: – Measures increased to 5x weighting. – CMS included ―hold-harmless‖ provisions for high- and low- performing plans. • Annual Flu Vaccine (C04) – CAHPS survey respondents asked if they received a flu shot since July of each year (instead of September)…p.s. did you tell your providers? – High Risk Medication Measure (D09) uses PQA‘s updated HRM list – Adherence to Oral Diabetes Medications (D11) added two additional classes of medications to the calculation – Adherence Measures (D11-D13) accounts for SNF and hospice stays 34
35. The Good News in the 2015 Ratings: Measures with Consistently High Performance Number of Plans at 5 Stars D08: MPF Price Accuracy 298 C05: Improving or Maintaining Physical Health 243 D03: Complaints About the Drug Plan 240 D04: Members Choosing to Leave the Plan 230 35 Highest Rated Measures Average 2015 Star Rating C05: Improving or Maintaining Physical Health 4.6 D08: MPF Price Accuracy 4.6 C02: Cardiovascular Care - Cholesterol Screening 4.4 C30: Members Choosing to Leave the Plan 4.3 • THE HIGHEST PERFORMING MEASURES
36. The Not-So-Good News in the 2015 Ratings: Measures with Consistently Low Performance Number of Plans at/below 2 Stars C20: Improving Bladder Control 290 C07: Monitoring Physical Activity 284 C13: Osteoporosis Mgmt in Women Who Had a Fracture 215 C06: Improving or Maintaining Mental Health 180 C27: Rating of Health Plan 141 36 Lowest Rated Measures Average 2015 Star Rating C20: Improving Bladder Control 1.9 C13: Osteoporosis Management in Women Who Had a Fracture 2.1 C07: Monitoring Physical Activity 2.2 C06: Improving or Maintaining Mental Health 2.5 C09: Special Needs Plans (SNP) Care Management 2.7 • MEASURES WITH THE MOST OPPORTUNITY FOR IMPROVEMENT
37. 2015 Star Ratings by Domain Part C Domains Average 2015 Star Rating Domain 1: Staying Healthy: Screenings, Tests and Vaccines 3.70 Domain 2: Managing Chronic (Long-Term) Conditions) 3.31 Domain 3: Member Experience With Health Plan 3.56 Domain 4: Member Complaints and Changes in the Health Plan's Performance 4.08 Domain 5: Health Plan Customer Service 4.14 37 Part D Domains Average 2015 Star Rating Domain 1: Drug Plan Customer Service 3.56 Domain 2: Member Complaints and Changes in the Drug Plan's Performance 4.20 Domain 3: Member Experience with the Drug Plan 3.73 Domain 4: Patient Safety and Accuracy of Drug Pricing 3.61
38. Plans Receiving ≤2 Stars By Domain 38 Copyright © 2014, Gorman Health Group, LLC Domain Plans MA-1: Staying Healthy: Screenings, Tests and Vaccines 10 MA-2: Managing Chronic (Long-Term) Conditions 28 MA-3: Member Experience With Health Plan 61 MA-4: Member Complaints, Problems Getting Services, and Improvement in the Health Plan's Performance 4 MA-5: MA Health Plan Customer Service 16 D-1: Drug Plan Customer Service 20 D-2: Member Complaints, Problems Getting Care, and Improvement in the Drug Plan's Performance 6 D-3: Member Experience with the Drug Plan 58 D-4: Patient Safety and Accuracy of Drug Pricing 20
39. Common Characteristics of High-Performing Plans 39 Culture of Accountability, Adaptability and Member- Centricity Consistent execution of integrated processes designed to support the physician/patient relationship Collaborative relationships with high-performing provider and vendor network Flexible, adaptable, and holistic case, disease, and medication management
40. 2016 Star Ratings: Changes on the Horizon • Pre-determined 4 star thresholds may be eliminated. • Integrated Star Rating system for the Medicare-Medicaid Plans (MMPs) participating in the capitated financial alignment model remains under consideration. • Contracts with 500 or more enrollees as of July 2014 will be rated. • Use of data validation audits will be expanded for verification of data submitted by plans for Star ratings. 40 Reminder: ►CMS will reduce a contract’s measure rating to 1 star if it is identified that biased or erroneous data have been submitted. ► Contracts under an enrollment sanction are automatically reduced to 2.5 stars.
41. 2016 Star Ratings: New and Removed Measures • MTM Program CMR Completion Rate (Part D) New Measures • Breast Cancer Screening (Part C) • Call Center – FL/TTY Availability (Part C & D) • Beneficiary Access and Performance Problems (Part C & D) Returning Measures • Cardiovascular Care: LDL Screening • Diabetes Care: LDL Screening • Diabetes Care: LDL Controlled Retirement of Measures • Improving Bladder Control (Part C) Temporary Removal 41
42. 2016 Star Ratings: Potential Clinical Methodology Changes • Controlling Blood Pressure – new goal of <150/90 for non-diabetic patients over 60. • Plan All-Cause Readmissions – exclude planned readmissions, remove exclusion for certain hospitalizations. • Osteoporosis Management in Women who had a Fracture – add upper age limit, extend look-back period for prior BMD testing, remove estrogens, remove single/dual-photon absorptiometry as eligible tests. • Medication Adherence (Diabetes Medications, Hypertension, and Cholesterol) and Diabetes Treatment – exclude patients with ESRD, utilize exact date of death for PDC calculations, adopt PQA‘s obsolete date methodology. • CAHPS (Part C & D) – minor modifications for low-reliability contracts. 42
43. 2017 and Beyond: The Stars Target Is Broad •Care Coordination (Data-Driven) •Post-Discharge Medication Reconciliation •MPF Price Accuracy •Reminders for Immunizations, Screening Tests and Appointments •Reminders to Fill Prescriptions or Take Medications •Disenrollment Reasons •Transition Monitoring Plan- Influenced •Asthma Treatment •Depression Care •Hospitalization for potentially preventable complications •Statin Therapy •High Risk Med Updates •Opioid Dosage •Pharmacotherapy Mgmt of COPD Exacerbation •Reminders for Immunizations & Appts •Computer Use During Office Visits Physician- Influenced •Asthma Medication Fill/Adherence •Opioid Overuse •Initiation & Engagement of Alcohol or Other Drug Treatment •Pharmacotherapy Mgmt of COPD Exacerbation Member- Influenced 43
44. Looking Ahead: Execution and Engagement – Members, Providers, and Pharmacies 44 Copyright © 2014, Gorman Health Group, LLC Population Health • Focus analytics & reporting • Assess & stratify population • Identify outliers & intervene with appropriate resources Engagement and Improvement • Target those with greatest impact • Collaborate for mutual benefit & ongoing trust • Address clinical & non-clinical issues “Make It Work” Innovation • Integrate CM/DM/MTM for Stars & non-Stars success • Customize support/ services for chronically ill to control costs & improve Star Ratings INTEGRATION and COORDINATION
45. The Time Is Ideal: Revisit and Refine Your Stars Game Plan • Does leadership understand the breadth of potential future program changes? • Are you monitoring the right outcomes so you know what is working (short- and long-term)? • How are Stars activities coordinated with your physician network and retail pharmacies? • Does the staff conducting Stars initiatives have the necessary skills and knowledge to achieve success? • Are adequate clinical and operational leaders engaged in Stars initiatives? • What role do key vendors and your PBM play on your Stars team? • Do you have adequate funding for Stars activities? • How do current reports/analytics need to be refined to account for program changes? 45
46. Health Plan Star Analytics Best Practices • Trend forward, using average threshold changes. • Incorporate Display Measures and proxies for potential new measures. • Integrate Stars, financial, and other key data to enable comprehensive reporting and analytics. • Customize provider and member interventions. • Profile performance of providers and pharmacies. • Incorporate predictive modeling techniques. HELPFUL TIP: Timely and accurate data and reports are just the first step. For Stars success, make it a priority to convert the data into actionable information.
47. Look to Your PBM for Support 47 • Create and Refine Your Part D Stars Game Plan • Stars success requires a collaborative relationship built on mutual goals and expectations. • It‘s not just about the PDE metrics: your PBM can cause member dissatisfaction and CMS compliance problems: o Coverage determination timeliness o Benefit set-up/reject code verbiage o Transition functionality o Medicare Plan Finder file accuracy • Take a fresh look at partnering with providers, especially retail pharmacists
48. Measure, Manage, then Act 48 • Targeting Part D efforts requires investment in analytics. • PBM has the most ―real time‖ and most actionable data. • Very small improvements can have a large impact on Star Ratings. • Refresh reports as frequently as ―actionability‖ will allow. • Drive initiatives from real-time claims. HELPFUL TIP: Differentiate Part D tactics throughout the calendar year using a combination of current and historical medication fill data. HELPFUL TIP: Target population health efforts on manageable subsets of members in the PDE measures to help focus physician efforts on the right patients.
49. Member Centricity: Challenges & Opportunities 49 • Complex, often more acute, comorbid conditions • Complex medication regimens • Medication side effects • Forgetfulness • Cost constraints • Inadequate disease knowledge • Low health literacy • Cultural sensitivities • Low cognitive function • Poor mental health status • Logistical challenges • Lack of trust in provider • Cultural sensitivities
50. Members: Your Greatest Asset • Consider population-based, concierge-like service models. • Leverage all member touch-points with coordinated, service-oriented messaging. • Leverage in-home visits to address barriers to care and medication issues. • Use inbound calls as referral opportunities into CM, DM, MTM, etc. • Expand services provided in retail pharmacies/clinics. • Recognize the ‗information deficit‘ which will likely exist in new-to- be-measured areas: – Understand coverage rules and benefits. – Ensure that your claims system is configured correctly. – Educate internal staff and providers on new Stars measures/goals and the support/tools available to support patients. 50
51. Optimizing Provider Contribution • Collaborate with high-volume providers and under-performing providers. • Engage cross-functional teams to support providers‘ needs. • Engage nurses, case managers, and other key provider staff. • Provide coordinated, actionable information: – Consolidate Stars, RA, and other data. – Include case management, medication, and other key health information. • Consider tailored P4P on targeted member populations. • Be prepared for provider exhaustion: ICD-10, the changing environment, and new patient populations may deplete available resources. • Educate provider‘s team on new Stars program changes and benefits available to members. 51
52. The Road Ahead…Where Do We Go from Here? • If you are not a 4 Stars+ plan, now is the time to act. • Leverage and enhance existing infrastructure wherever possible. • Success necessitates: – Reliable processes and work streams. – Member-centric, high-touch approach. – Active medical management. – Engaged managers, staff, and leaders. – Engaged providers, PBMs, pharmacies, and vendors. 52 There are no magic bullets. With CMS‘ continued emphasis on continuous quality improvement, health plans will succeed by continuously learning and innovating within government-funded healthcare.
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