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 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  

Last Friday CMS posted the Advance Notice of Methodological Changes for Calendar Year (CY) 2012 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2012 Call Letter. The officials held the press conference to announce the posting of the 153-page:

http://www.cms.gov/MedicareAdvtgSpecRateStats/Downloads/Advance2012.pdf

Premature Synopsis:

The final Rate Notice for 2012 will be announced on April 4^th 2011, however this draft letter has consistently proved to be an accurate indicator of the debate ongoing in D.C. In the meantime the thought leaders in our industry have until March 4^th to comment on the Notice and Call Letter.

Information about agent and broker compensation structures is not due until July 25, 2011.

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

What are organizations doing to direct efforts and protect revenue streams in light of CMS changes in Medicare Advantage (MA) reimbursement? CMS has begun to implement changes in payment methodology for MA organizations once again.  It seems that when MA organizations have just gotten used to risk based reimbursement, they must now reorient once again when looking at reimbursement rates.  MA organizations have just, in the past few years, completed the total transition to risk based revenue funding.  Now they must keep this in place and work on other measures that are contained in the MA Star Rating.

MA organizations revenue will no longer be strictly risk based.  Starting very soon, organization's reimbursement will not only be based on the "wellness" of members associated increased payment for sicker members, but will also be based on quality measures derived from the Star Rating system.  Organizations in the coming years will actually begin to loose payment if the Star Ratings are 3 or less.  While we can all applaud the focus on quality, there are many questions about the Star Rating that may need to be addressed: 

• Are the Star Ratings fair?
• Are the Star Ratings based on data that is too old?
• How will this new system play into the CMS Risk Adjustment Payment Audits?

Organizations must take active and immediate actions to assess and improve their Star Rating.  Data that goes into this rating may very well be old- up to a year.  Actions now for quality improvement and customer satisfaction will not be reflected immediately in your rating.  What is your organization doing to transition? Will the delay in data gathering affecting the Star Rating be detrimental to your revenue in the short run?

Let us know how your organization is preparing for this change and the measures you are taking to affect your Star Rating!

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

 Member of the Advisory Board, RISE

RISE is proud to announce the 1st edition of "Rising to the Challenge!", our quarterly newsletter.

The July 2010 edition is a recap of topics discussed at the July 15-16 conference in Del Mar, CA: HCC Management for Health Plans and Providers

A brief excerpt:

Nathan challenged the audience to consider: Where do HCCs come from? He cited claims, charts, and the members themselves as sources of data. Claims Nathan described as a proxy; "You can mine claims, then you collect backup documentation." The chart reviews document the codes submitted and validate "suspects". "This has been perfectly good up to now," Nathan says. "But the most powerful way to find your data, is to look in your members’ bodies. You’ll get incredibly useful, real-time clinical information… information that is actionable."

But can you afford to pay for a prospective program?

Craig Bellise, Director of Risk Adjustment Management at Emblem Health, said "We’ve been doing home assessments for three years now, and have really ratcheted up our approach this year. That first year, we decided to just go for it – we ran a pilot and crossed our fingers for some kind of ROI. As it turns out that first effort yielded a 3:1 return, which made the program very viable. You’ve got to get people to say, ‘We’re going to pay for it, take a shot, and carry the expenses for a year in order to reduce our reliance on retrospective reviews, improve compliance measures and enhance the quality of the care for our members.’"

Download the full newsletter to read more!

In the current Medicare Advantage (MA) environment, health reform promises Medicare beneficiaries improved quality of care, reduced costs, and a solvent Medicare program for the future. The 2011 CMS Call Letter, confirmed continued downward MRA coding intensity adjustments, making it more difficult for most MA plans to keep pace with the increasing costs of healthcare.

The CMS Star Rating system will make the MA industry accountable for demonstrating value based healthcare delivery, at a time when significant reimbursement cuts are on the horizon. The race to develop a strategic business plan to support development of innovative quality improvement programs and a successful prospective risk adjustment program is paramount to the survival of MA plans in 2012 and beyond. Plans currently relying solely on medical claims and retrospective MRA reviews, will find themselves losing ground to the continued coding intensity adjustments, and be faced with the difficult decision of reducing member benefits and becoming less competitive. So why is a prospective risk adjustment program the solution? And why is it critical that plans begin Due Diligence now?

A prospective risk adjustment program is defined as an established outreach program to patients and their respective physicians, at pre-established intervals for the purpose of coordinating comprehensive health risk assessments (HRA). The content of the HRA, is of vital importance and should be customized to meet the needs of the medical management and risk adjustment programs for the plan at the time of implementation. The primary objectives of a prospective risk adjustment program are:

To conduct a comprehensive annual update of the patient’s medical record to include all existing and past medical conditions, review of current medications, documentation of current treatment plans, appropriate functional assessments, and to schedule preventive health screenings (star rating impact).

To identify "Best Practices" through integration of clinical programs and the risk adjustment programs, to improve health outcomes and ensure timely premiums for plan members.

To report accurate risk adjustment information to CMS on time for CMS sweeps, and thereby ensure premiums which will allow continued revenue allocation towards continuous quality improvement initiatives.

To generate referrals to case management and disease management, based on identified patient specific health risks, and to avoid adverse health outcomes (star rating impact).

To educate members with respect to the importance of adherence to prescribed treatment plans and to create a member experience which will pay dividens, as a member retention strategy (star rating impact)?

To document the medical management of all existing patient specific medical conditions in a manner that satisfies the CMS risk adjustment Data Validation criteria, thereby mitigating plan exposure to RADV audits.

To communicate HRA information to treating physicians, in order to promote coordination of care, and to convert a reactive healthcare system, into a proactive one.

Whether plans decide to partner with a vendor or conduct a prospective risk adjustment strategy internally, coordinating the people, processes and technology necessary will be extraordinarily complex. None the less plans must rise to the challenge, as it is the Medicare Advantage industry’s opportunity to demonstrate its value to CMS.

-Kenneth Persaud, Director of Network Management, PHYSICIANS UNITED PLAN HMO