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

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.

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

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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 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  

Sure we all want to maximize our Medicare Star Rating. Consumer satisfaction and HEDIS measures we know affect our rating. But did you know that your ability to be compliant with CMS regulations also affects your rating. In addition to quality measures of how well we are taking care of our Medicare members, Star rating will also be affected by CMS audit results. Taking this one step further compliance audit results can indirectly affect financial results.

Information presented at the recent Managed Care Compliance Conference sponsored by Health Care Compliance Association (HCCA) annual health plan conference Elizabeth Lippincott, JD, of Elizabeth Barrett Lippincott, PLLC, presented this relationship. Starting in 2012, Medicare Advantage Plans with higher Star ratings will bid against higher benchmarks than their lower-rated competitors. Star rating level will also determine what percentage of the rebate, for Medicare Advantage plans with bids below benchmark, can be used to supplement benefits.

In addition, regulatory compliance can impact future business opportunities, specifically ability to expand service areas or offer additional Medicare Advantage and Part D products. Compliance program audit results factor into annual CMS performance reviews, as described in the CMS HPMS memorandum, "2010 Application Cycle Past Performance Review Methodology," December 12, 2010. CMS is considering past performance in deciding whether to approve applications for service area expansions or applications for new product offerings for current plan sponsors as described in 42 CFR 422.502(b) and 423.503(b).

With this in mind, are you and your organization ready for these new CMS audits? Being ready is more than putting together the "audit books" of audits in the past. With short notice, just a few weeks, auditors from various locations, not your regional office managers, will arrive at your doorstep and request volumes of information. They will be looking for the effectiveness of your compliance program, your risk assessments and your progress in implementing these corrections. Audit areas include formulary administration (transition support, utilization management and protected class drugs), prescription drug coverage determinations, and associated appeals and grievances. Other areas include premium billing, enrollment and disenrollment, and the organization’s Compliance Program. Being ready, compliant, and being able to tell your story and show these results will be imperative to your audit success and indirectly – or perhaps not so indirectly – to you financial success.

Ann U. Greenberg, CHP, CCEP, AG COMPLIANCE GROUP, LLC

Here are some things to think about as we transition from submitting RAPS to submitting encounter data.

What is your strategy for submitting encounter data in the 5010 format? 

Are you going to build your platform internally or use an outside vendor?

MA organizations will now submit data from all types of services. Do you have capacity to submit the increased volume of data that this change will require?

Will the number of rejected files increase and are you prepared to handle the volume?

How will the differences between paper claims and the 5010 format impact this process?

How will deletes now be handled through this new process?

How will your additional chronic conditions that are currently captured through retrospective chart reviews now be handled?

Some systems have limitations in how many ICD-9 codes are stored, what process will you have to ensure that any ICD-9 codes that could not be stored/captured in your claims processing system make their way to CMS?

Have you considered how you will modify your processes to accommodate the shortened timeframes for submitting your data? You will now only have 12 months from the date of service to submit encounter data.

You will now be required to submit data monthly as opposed to quarterly.

What types of reports will we need from CMS and/or to create internally to manage this increased volume of submissions, deletions, rejects?

These are just some questions that come to mind for me. I am sure there are a lot more to consider as we begin to go through the testing phase! It would be great to share as many thoughts, concerns, questions so that we are all as ready as we can be when the switch is flipped on January 3, 2012.

Kimberly D. Stone, Director of Medicare Revenue Management, Government Programs Administration

PRESBYTERIAN HEALTHCARE SERVICES

With the enactment of certain provisions of the Health Care Affordability Act, it is becoming very clear that the way medicine is practiced will change. As I wrote in a previous blog, one of the values of Medicare Advantage is that it has required practicing physicians to take a population based view of our practices. It has forced us to think about accuracy in coding in order to appropriately allocate resources which will ideally direct more care to those regions that need it most.

During a risk management training session, I spoke to an older physician who said that not only will he not change his 20 year old super bill or submit claims online; he plans to stop practicing immediately before Medicare begins penalizing providers for not meeting meaningful use requirements for an EMR. I believe that practicing physicians will self stratify in their willingness and ability to adapt to the impending changes of the health care landscape. It would behoove any health plan or IPA to watch this self-sorting take place and identify those practices that are geared toward future success.

Analysts have estimated that in the next decade the Health Care reform will be responsible for increases in health care costs. Not just readiness to change, but also this increase in cost will ultimately set some practices apart from others.

Dr. David Nash, chairman of the Department of Health policy at Jefferson Medical College, listed the qualities of practices that will survive into the next decade. 2 of the 4 criteria were achieving pre-determined quality based outcomes in care and maintaining transparency in practice methods necessary to achieve some standard of public accountability. Certainly, these will become objective standards that can be used to “rank” a practice in the future. The mere mention of this concept sets the teeth of many physicians on edge. Others see it as a worthy challenge.

Looking into the future, practices that are using the full functionality of an EMR for coding and documentation, are using Health Plan and IPA data to track preventive care (which will hopefully improve as health care reform removes cost barriers to preventive care); and are using Evidence based medicine to guide the care of their chronic disease populations.  These are the ones that will receive the largest increases in risk score, P4P score, and perhaps even patient satisfaction. Beginning to invest in these practices now will be of great value in the not-so-distant future.

-Dr. Preedar Oreggio, Clinical Director, SIERRA SPRING FAMILY WELLNESS CENTER

It is officially winter and those of us in the HCC world are officially in crunch time. This is often the season that plans and IPA’s will institute their last ditch efforts to capture and code the current year’s HCC’s. This is also often when last minute efforts can fall short of their intended reach. While HCC comprises the large part of many of our worlds, it is important to remember that it is often only a small fragment of the universe of the practicing physician. Right now in my practice, I am thinking about making sure we have enough flu shots in the office, planning on managing staff absences for the holidays, trying to get all our P4P testing letters mailed out in time for patients to schedule their mammograms and remembering to budget for an extra pay period in December! In short, if it doesn’t help me take better care of patients or make my practice run smoother, it is of minimal value to me.

Risk adjustment IS important and has clinical implications. As always , the challenge is to make sure it intercolates with the practicing physician’s priorities. Here are a few things to do:

1.Streamline your communication with physician offices

Don’t send Happy Halloween , Happy Thanksgiving, P4P and HCC letters between now and December. Prioritize the messages you want to communicate with your physicians by year’s end and make sure all departments are on the same page. Use your provider relations staff to hand deliver messages of vital importance. Consider any mailed or faxed information sent after November 15^th almost a waste of time.

2. If you are giving incentives before year’s end- remind your PCP’s NOW!

It’s almost too late for them to get seniors in the door- this is made harder also by the holidays. Remind them of submission dates, incentive pay out criteria and expected pay out dates.

3.Plan for next year.

What parts of your Risk Adjustment plan worked this year? What fell flat? Who are your priority providers to contact the earliest next year? I have seen groups wait until the second quarter of a year to plan that year’s risk management process. Start early. Ask a few key providers what they would like to see next year. Remember that Risk adjustment is dynamic. (Different providers are at different points on a learning curve- structure your interventions accordingly)

As Ken Persaud implied in a previous blog, it is the responsibility of Medicare Advantage Plans to demonstrate their value to CMS. This will occur as plans continue demonstrating the value of Risk management to their practicing physicians.

-Dr. Preedar Oreggio, Clinical Director, SIERRA SPRING FAMILY WELLNESS CENTER

In this blog, I will share the approach Precision Healthcare is taking towards integrating case management and HCC coding. I would like any and all feedback from organizations which are: contemplating, currently undertaking or have already achieved such integration. In our experience greater than 60% of the patients identified for case management are also targeted for HCC coding initiatives. Given the limited time and attention span most physicians have when it comes to these topics, Precision Healthcare is taking a patient centric, action oriented approach to accomplishing its goals in both arenas. For each patient identified for both case management and HCC coding focus, the work flow essentially consists of the following:

1. Medical record audits by the case manager & HCC coder 
2. Interventions required by the PCP for case management and HCC coding are recorded during audits. An example of case management intervention would be for the PCP to prescribe more affordable pharmacy alternatives in order to help patients overcome financial obstacles to compliance with prescribed treatment plans. An examples of HCC coding interventions would be for the PCP to review a coding Query for patient specific diagnosis, to include PCP evaluation and detailed documentation of ongoing medical management (if any) during the next visit.  
3. Case manager coordinates the subsequent patient - PCP visit 
4. Case manager attends the subsequent patient – PCP visit, with a list of the fore mentioned interventions for PCP completion, and supports PCP in their execution.

The pursued outcomes are:

•  Patient empowerment to proactively participate in their healthcare  
• Provider education of case management & HCC coding 
• Support of provider office to achieve positive outcomes for the high disease acuity and severity population 
• Medical record documentation Quality Improvement (RADV risk mitigation) 
• Accurate future risk premiums 
• Improved quality of life for patient through subsequent continued case management monitoring and evaluation 
• Improved patient satisfaction as derivative of concierge care model

To date, preliminary results are as follows:

•  High ROI : 1.7 HCCs / Query 
• Complete results will be presented at the March 2011 RISE Annual Conference 
• Physician engagement is essential, so don’t forget the Incentive! 
• Physician support staff is key to your success

I am looking forward to hearing about your experiences in integrating, particularly how to work with FFS providers and incentive structures.

Ken Persaud, Chief Executive Officer, PRECISION HEALTHCARE SYSTEMS