Get Health Data Essential's Richard Lieberman's take on CMS's proposed changes to the Stars Program in 2013.  In a recent white paper, Mr. Lieberman indicates the changes will be "more incremental than the monumental changes made for the 2012 rating period", but that there are several key issues to note.  Access the white paper by clicking the link below.

ProposedChangestoStarsin2013.pdf (2.42 mb)

By RaeAnn Grossman, Senior Vice President, Gorman Health Group

Ask Yourself: What would my 2012 member assessment strategy and timing look like if I want to look like a Risk Adjustment Super Hero?

Step 1: Compile Data in February

Step 2: Launch Member Evaluation in March

Step 3: Complete 50% of Your Member Evaluations by June 30th

Step 4: Reduce Dependence on Chart Review to .30 Charts per Member and Increase Member Evaluations to 85% of the Membership (for PFFS, PPO, and HMO Plans)

Step 5: Refine Analytics and Reduce Zero HCC Member Evaluation Percentage (should always be less than 30%, but you want to push toward 15% if you are not reviewing your entire population)

Step 6: Check Year Over Year Revenue Increase January - June and July - December for Member Evaluations to Ensure ROI and Payment Reconciliation

As we are coming close to year end, we have all learned a great deal. The number one thing we hear from health plans: “I thought they could implement.”  Risk adjustment is successful only if you couple speed with quality. 

The three most constant stumbling points for member evaluations programs are:

1. Compilation of Data

2. Suspect List Generation

3. Provider Recruitment

As you talk with your health plan and medical group peers, their references and experience should help you navigate this treacherous path.

The questions you may need to ask:

1. How long does it take you to compile and refresh data? Best in class answer: 10 days to compile a health plan or medical group's data and 1-2 days to refresh it monthly.

2. How long should it take to generate a member suspect list? Best in class answer: 5-10 business days.

3. How long does it take you to recruit or train or allocate member evaluation providers? Best in class answer: Within 20 days of contract execution, your assessment vendor needs to have their evaluators recruited, trained, and in the field with your members.

Make sure you ask the right questions and pick the right partners.  If you selected a turtle this year, you better start looking for a rabbit for 2012.  Slow and stumbling does not win the race and you have to win the risk adjustment race to stay alive.

By RaeAnn Grossman, Senior Vice President, Gorman Health Group

Reprinted with permission from the GHG Blog.

In a recent issue of the New England Journal of Medicine, a group of physicians from Harvard Medical School describe an unfortunate and instructive case [1] .  One of the system’s patients had her spleen removed after an automobile accident. I would venture to guess that just about every sophomore medical student knows that people without a spleen are more likely to have infections, especially with streptococcus pneumonia, and that those infections can lead to death or, as in this poor lady’s case, severe, permanent complications. Anyone who has had a splenectomy should be vaccinated against pneumococcus. So far so good, but the vaccine was never given in this case because the problem list in her electronic medical record was never updated to include the fact that her spleen had been removed.

When these doctors looked at the records in their practice (over 1.7 million of them), they found 7125 patients who had had their spleens removed and only 5028 (29%) had the diagnosis on their problem list. And it gets worse from there. Of the ones who had the diagnosis on their problem list, only 54% had been vaccinated; of those without the diagnosis, only 17% had been vaccinated. (Remember, the guideline is vaccination for 100 %.) And this is at one of the very best medical care delivery systems in the United States (probably in the world) and these patients all have electronic medical records. You can guess what the numbers would be like out in the real world where solo practitioners are working with paper charts.

So we have two problems. First, the list of diagnoses was incomplete. Second, there was a clear and unaddressed gap in care. How do you fix a problem like that? The first impulse would be simply to better educate the doctors. These authors conclude (and I agree with them) that “education alone is not a highly reliable intervention.” Remember, these are some of the best doctors we have and they are using some of our best clinical tools. The solution has to be in redesigning the system. And that is where Medicare Advantage plans have something really important to offer.

These authors recommend “tools such as reminders and patient-level reports about guideline compliance” as the best way to change the system. I would suggest that carefully designed and targeted member evaluations of Medicare Advantage members organized by the plans can bring together a wealth of clinical information from claims with directed face to face evaluations to yield accurate and complete diagnostic information and to identify gaps in care. If that information is collected in a proper open access data base, actionable reminders can be generated for the member, for the member’s treating physician, and for plan case management—just the sort of tool the authors recommend.

And, once again, we have an impact that cannot be replicated by fee for service Medicare.

By: Jack McCallum, CEO, CenseoHealth

Reposted with permission from the GHG Blog

[1]  Gandhi, Tejal K., Zuccotti, Gianna, and, Lee, Thomas, “Incomplete Care—On the Trail of Flaws in the System” New England Journal of Medicine, 365:486-488, August 11, 2011.

We talk to health plans every day that want to internalize risk adjustment. Bottom line: It is a good idea.

Taking control and building an expert, internal risk adjustment team is one of the best tactics a health plan can take. Here, we share an initial checklist of those areas needed for “in-sourcing”:

·         Claims based HCC filtering

·         RAPS filtering and submission

·         EDPS compilation and submission

·         Medical record suspect generation

·         Medical record retrieval

·         Medical record coding

·         Chart warehouse

·         Hospital outreach for electronic encounter compilation

·         Member evaluation suspect generation

·         Evaluation development

·         Member evaluation provider network

·         Member evaluation findings integration

·         Tracking & closing gaps in care with member outreach

·         Member care report cards

·         Primary care physician medical home

·         Metrics, benchmarks, ROI, reports, and performance monitoring

Much of this you can internalize cost effectively, but you still need to be diligent. We’ve helped several health plans analyze their programs and vendors to determine what to pull in-house. Strategy, discipline, compliance and an engaged multi-disciplinary team willing to make decisions and push forward are critical elements for success.

By: RaeAnn Grossman, SVP, Gorman Health Group

William MacBain, Senior Vice President, Gorman Health Group

The newly minted ACO regulation from Medicare has some zingers hidden in its 696 pages. Okay, to be fair, the actual regulation is only 70 pages long, double spaced. The rest is all preamble, where CMS describes the 1200 comments on the proposed rule, and how they have responded (or not) in the final rule.

The first zinger has to do with the Physician Quality Reporting System, known to its friends as PQRS. Since 2007, CMS has paid a bonus to physicians who report quality data. Under current rules, CMS will pay physicians ½% of allowed charges from 2012 through 2014. BUT, docs in an ACO will only be able to participate in the PQRS through the ACO. The ACO will report as if it were a group practice. If the ACO fails to report in compliance with the PQRS rules, its docs won’t get the PQRS bonus. This could be an issue in recruiting doctors who may not see a clear advantage to the ACO to begin with, given all the other requirements.

A second zinger is the approach to risk adjustment. CMS has agreed to use the Medicare Advantage HCC risk adjuster for newly assigned beneficiaries. They won’t use HCCs for continuing beneficiaries – people who were assigned to the ACO last year. HCCs are based on diagnosis codes on last year’s claims. CMS reasons that an ACO would improve coding accuracy in year one, to get the best risk adjustment they could for continuing beneficiaries in year 2. So only new-to-the-ACO beneficiaries will get risk adjusted for higher HCC scores. BUT, if the average HCC score for continuing beneficiaries goes down in year two, then CMS will risk adjust and reduce the benchmark accordingly. The inference is that reduced scores could only reflect reduced average risk. So ACOs that are not diligent in keeping their risk scores up could be docked a chunk of money for apparent losses resulting from poor coding, not from poor care management.

The lastest RISE newsletter is hot off the press!

We've changed it up a bit this time to a blog format, since the topic is so complex and we wanted to explore the latest interpretations from industry experts and get your feedback!

In this issue:

• Which conditions cost the most?
• What are the small things that a plan can do to make big impacts on care management and cost control?
• Ways to determine which patients to target for interventions

Please leave your comments here or on our blog post: "How Can an MA Plan Best Manage its Critically and Chronically Ill Members?"

Interested in being a contributor for our future issues? Contact Lori Medlen, Executive Director of RISE: lmedlen@rasociety.org

Click here to view the RISE Newsletter in PDF format.

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From Your Executive Director, Lori Medlen

Hello RISE Members:

Instead of the traditional RISE newsletter, I'm writing this as a "blog"-type communication, simply because the topic - Managing Medicare Advantage Members with Chronic, Complex Cases - is itself complex, and one that I've not explored before.  So, I'm going to give you my interpretations of what was said to me during several interviews with industry experts.  It's a fascinating topic, and during the past month or so, I spoke with:

• Beverly Hansen, Director of Care Management, VIVA Health
• Dr. Eric Rackow, President and CEO, SeniorBridge
• Lisa Slattery, VP Quality and Integrated Care, Health First
• Dr. Randall Williams, CEO, Pharos Innovations
• Ayo Kalejaiye, President, Medisoft Rx

Thanks to all of these people for giving their valuable time to this project. 

Statistics, statistics . . .

Some of the statistics interviewees rattled off* are pretty astounding - I mean, yowser! (Urban Dictionary says "yowser" IS a word, so there - even though Microsoft is doing the red squiggly thing underneath it).

*20% of members account for 86% of costs, with the top 1% driving 27% of costs

*90% of every $1 spent is on chronic conditions

*2/3rds of hospital admissions are due to self-care issues

*20% of Medicare patients are re-admitted to the hospital within 30 days; the rate jumps to 25% for heart failure

*1/3 of Medicare patient discharges are to nursing homes, yet nursing home care is difficult to monitor or control

*On average, patients with dementia can cost a health plan 40% more than other patients

*100% of RISE Executive Directors are named "Lori"

Note: *these numbers were given to me over the phone; I have not verified them - except for the last one.

What are the Difficult-to-Manage, Chronic and Costly Conditions?

Everyone I spoke with agreed that the "Big 3" diseases and conditions causing concern were:

1. Heart Failure (most total dollar impact)
   
2. COPD
3. Diabetes

Other conditions mentioned included mental illness/dementia, cancer, and end-stage renal failure.  But, as with most things, the devil's in the details.  For instance:

• Ensuring a member has a scale at home may be crucial for cardiac patients, yet even something so simple can require an in-home visit
• Many seniors are hesitant to seek mental health services, so a "life coaching" approach may be more effective
• Medication reconciliation was mentioned often as a huge problem: Lisa Slattery of Health First said that patients may not understand medication instructions and moreover, complications often occur when patients change medications or have multiple providers prescribing different medications.  Obviously, if a patient has dementia or other behavioral health issues, the problem gets worse.
• Evaluating patient functionality is extremely important, said Dr. Eric Rackow of SeniorBridge.  Dr. Rackow stressed the necessity of evaluating patients' limitations regarding instrumental activities of daily living (IADL) and basic ADL.  Some of the instrumental activities include the ability to use a telephone, ability to shop and self-transport.  Some basic ADLs include dressing and undressing, and self-feeding.

Indeed, there are so many potential issues and problems with the chronically and acutely ill, it boggles my mind.  And that's where data comes in ... and further boggles my mind!

Data, Technology, and the "Impactable" Patients

Beverly Hansen of VIVA Health uses the term "impactable" to describe the patients they are trying to identify as potentially needing care interventions.  At VIVA, they use an algorithm developed internally using claims data, escalating claims and hospital admissions data to identify these patients.

By contrast, Pharos Innovations, headed by Dr. Randall Williams, has a device-free system that uses the phone and the internet for patient monitoring and reporting.  The patients report every day; if they don't, they receive a reminder.  The data is then processed by Pharos and used by plans and hospital care teams to coordinate services.

Dr. Rackow of SeniorBridge says they use some remote monitoring as well as a tablet-style device to enable communications about a patient's condition, in addition to their at-home services.

Some plans are using predictive modeling to combine claims, pharmaceutical, lab and enrollment data to predict which members are most at risk.  Ayo Kalejaiye of Medisoft Rx says his firm's predictive modeling product also indicates why particular patients are at risk.  He indicated that although some larger plans can afford to integrate all this data, it's more difficult for smaller plans to manage.  Medisoft Rx's product is geared to mid-size and smaller plans.

Care Management Approaches and Incentives

Once the "impactable" (I love that word!) patients are identified, what can a plan do next? Beverly Hansen says VIVA uses field-based care managers and social workers to help the critically and chronically ill members.  Beverly stressed the importance of the field-based approach, noting that, for example, patients can easily give erroneous information over the phone. 

Health First uses a variety of methods to impact care.  Ms. Slattery said they tackle the issue from various angles, from in-home physician visits, to nurse outreach, phone outreach and disease management programs - the level of care varies depending on patient needs.  To stratify the patients, they use data based on frequency of hospitalization and known high risk conditions, including assessing patient mobility (e.g., home-bound or bed-bound).  In addition, Ms. Slattery's 4.5-star plan puts a lot of effort into its post-acute care transitions programs.  Plus, they are developing a special program for patients with dementia and a palliative care program.

Furthermore, Health First participated in the AHRQ Project Red, a 6-month pilot focused on transitional care management for heart failure patients.  Ms. Slattery indicated that although only 1 in 4 eligible patients hospitalized with CHF participated, they still saw significant reduction in readmission rates using the Discharge Advocate model.

SeniorBridge, Dr. Rackow stated, provides in-home care management with home health aides to facilitate not only patient care, but patient functionality and behavioral health issues that may otherwise be overlooked.  

Incentives:

Pharos Innovations' Dr. Williams also noted the increasing use of various incentive programs for both patients and providers to impact care management.  For instance, some plans will waive drug co-pays for medications affecting chronic conditions, or pay providers a care coordination fee, or perhaps a bonus in the case of FFS providers.

What Else Was Mentioned? 

Other issues brought to my attention:

• To what extent should a plan evaluate members' care plans based on single diseases versus looking at them as a population? How should you allocate resources, for example, between an intensive diabetes care management program vs. broader initiatives?
• "The financial and clinical people don't talk", someone said, with the implication that this needs to change
• Different models of care, including ACOs, PCMHs, and Medicare/Medicaid integration in some states, will affect this whole picture.  Mr. Kalejaiye of Medisoft Rx noted that predictive modeling may become more important as organizations become more responsible for everything in a patient population
• CMS will start penalizing the worst 25% of hospitals with the most readmissions, meaning a greater emphasis on care transition management throughout the industry.  CMS plans to target the areas of heart failure, pneumonia, and heart attacks.
  

What Strikes Me About All of This ...

What strikes me about all of this is that data is so important to care management - not only claims data alone, but integrating lab data, enrollment data and pharmacy data with claims data - for a true picture of a member's needs and care gaps.  But managing data is expensive, which brings me to ... the next thing that strikes me:

The difference between the small and larger plans.  The larger plans have more resources to analyze the data, yet the small plans "run into [our] members in the grocery store", so care management should be much easier for them; it's obviously simpler to manage fewer people.

And I have a suspicion that behavioral health (evaluations and care) is another key piece - and perhaps, somewhat neglected piece - of this puzzle.

Finally ... WOW this is long! Please comment; any further insight is welcome to this relative novice. 

Many Thanks,

Lori Medlen, Executive Director

Risk Adjustment Society and Initiative for Education (RISE)

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On May 23-24, RISE held its successful “Star Ratings Leadership Summit” in Chicago. We were fortunate to have Liz Goldstein, Director, Division of Consumer Assessment & Plan Performance at CMS, join us via web to discuss the Star Rating Program. Here are a few highlights of Liz’s presentation concerning the future direction CMS is taking in the Star Ratings.

Liz emphasized that future development of ratings will be aligned with the IOM’s six arms for improving healthcare delivery: i.e., safe, timely, effective, efficient, equitable, and patient-centered. She also said that CMS is going to look towards consensus-building organizations for the development of measures and clinical criteria.

Potential addition measures for 2012 plan ratings include:

1.      All-cause readmission rates

2.      Advising smoker and tobacco users to quit

3.      Body mass index

4.      SNP-specific measures

5.      Voluntary disenrollment rates

6.      Measures from the Hospital Inpatient Quality Reporting program

7.      Part D transition process implementation

8.      Part D medication adherence

And she mentioned these potential enhancements to the 2012 ratings:

1.      Weighting of measures to provide more weight to outcome/clinical measures

2.      Rewarding contracts for quality improvement

3.      Reducing overall and/or summary Plan Ratings for contracts with serious compliance issues

4.      Controlling for concentration of providers in a geographic area

5.      Addition of an icon for high-performing plans

For 2013, she mentioned these potential additional measures:

1.      Survey measures of care coordination

2.      Case-mix adjusted mortality rates

3.      Preventable hospitalizations

4.      Serious reportable adverse events

5.      Grievances

6.      Use of highly rated hospitals by plan members

7.      Medication therapy management measures

8.      Evaluation of a contract’s Chronic Care Improvement Program (CCIP) and Quality Improvement Project (QIP)

RISE would like to thank Liz for her participation in the event.

Watch this blog for more industry updates; we’ll be including more news from our events in the months to come.

Lori Medlen, Executive Director

RISE

On 04/04/2011 CMS announced the final MA capitation rates and to our industry’s surprise the final rates were quite different from those projected in the initial February notice. The highlights from the final call letter are as follows:

1. 2012 MA capitation rates will increase a mere 0.4%, a staggering1.2 % less than projected 45 days ago. Health plan CFOs are already working on strategies to trim benefits and remain competitive with market competitors, this will enable plans to either reduce or eliminate the impact on their earnings.  
2. Please note that the above rate increase does not include any Risk Adjusted premium increases perceived by plans, so those of you who have been working hard will begin to reap tremendous competitive advantages in 2012.  
3. The Final Call projects a negative growth factor for MA of -0.16%. A far cry from the well-received growth projection of 0.7% given 45 days ago. This based on lower physician rates that are also announced in the Call Letter. After all it’s the providers who truly market MA products based on their overall satisfaction with plan benefits and compensation.  
4. CMS will conduct Integrity Audits on plans with members’ share of cost at or above 10% after 7/1/2011. Expect to see plans try to stay below the 10% to avoid CMS audits 
5. RADV Audit Methodology has remained unchanged.  While CMS received a tremendous response rate from the letter sent out in December 2010, it has decided not to implement method changes for the time being.  Expect the method announcements later this year.  
6. STARS – CMS will be paying Quality bonuses for plans with higher than 3 Stars in 2012; these plans will also be given competitive advantages during enrollment periods in an attempt to increase highly rated plans’ growth year round. The key here will be plans’ ability to work with providers, since a large number of the STAR measures are directly dependent on the Provider offices.   

   In short this ride of ups and downs continues; the survival skills for MA remain constant: excellence in HCC, and your plan’s ability to develop long term partnerships with providers to yield the high quality equitable healthcare delivery experience we all want for ourselves in the not too distant future!

    

   Kenneth Persaud CEO, Precision Healthcare Systems