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

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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  

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

The pace in which we deal with change in the healthcare industry has reached warped speed.  We have never had to be as flexible and as agile as we do right now!

Not only do Medicare Advantage Plans have to adjust to the pace of an ever-changing environment, but our provider partners are greatly impacted like never before.

Change has always brought about uneasiness and uncertainty, but change has also always brought about opportunities for growth and development - OGADs - as one of my mentors called them.

Now more than ever, the healthcare industry has a great opportunity to really become an integrated system that meets the healthcare needs of our members and affords them good quality of life in their latter years. Isn't that really what risk adjustment, STAR Ratings and Healthcare reform is all about ... healthcare for some, better healthcare for others?

It is an opportunity to look at and develop programs that not only assist members in becoming more aware of, and engaged in, the decisions that are being made about their health, but also empowers members to make very informed decisions in selecting who will provide their healthcare services.

The key to being successful in anything that we do is to have a strong foundation. The foundation is the starting point or ground work of anything. In healthcare, that foundation begins with our physicians.

It is more important than ever that we ensure our providers have the tools, resources and support that they need to treat their patients effectively (positive quality outcomes) and efficiently.

When risk adjustment began, data was collected but not shared with physicians. We now not only have an opportunity but also a great need to share this information.

Physicians need their patient's medical condition history in order to make informed decisions for their patients.

Providers come in contact daily with their patients, this contact, in many instances, is what forms the patients' perception of their healthcare.

As I have a great opportunity to visit and listen to our provider partners I have heard first hand to some of their challenges. In the current environment of changing technology, increased documentation requirements and yearly coding changes, the providers' main focus is still on providing their patients the best care possible. As an industry we must support, collaborate and encourage our providers. We need to remind them that what they do is important and very much appreciated. Lets not allow that message to get lost or diluted as we continue to go through change. The fact is, without our providers, there is no health care.

In summary: A few ways to support your provider partners:

• Set up some one on one time with providers and ask them what causes them the most pain, then do something about it if possible
• Create tools that are intuitive and can be viewed at a glance or accessed easily, yet provide important patient information to be used during a face to face visit
• Ask for their feedback and suggestions on information that is most important to them
• Bring them along as you implement an EMR system and consider their ideas
• Establish relationships with their office staff
• Attend Physician Meetings and keep them updated on current events
• Let them know you appreciate what they do

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

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!

By 2014, many changes in how our health care system operates will have been enacted. Some of them designed to slow the growth of health care spending, others to provide access to health care for the residents of the U.S. who are currently uninsured. The individual mandate to purchase health insurance coverage, along with the creation of state and regional American Health Benefit Exchanges, or "Health Insurance Exchanges" will mean more people will be shopping for health insurance coverage on the individual market, comparing plans based on price, benefits, cost-sharing requirements, quality, reputation and the provider network available to beneficiaries. The Department of Health and Human Services is currently soliciting public comment on the development of the Exchanges.

Health insurers will be able to price plan premiums based on age, smoking behavior, location, and family size. However, because health insurers will no longer be able to base premiums on disease conditions, health status, or other risk factors in the individual health insurance market, there is a risk for adverse selection among plans doing business in and out of the Health Insurance Exchange. Subsidies available for plans doing business in the Exchange could result in higher risk users of health care joining the Exchange, while healthier individuals could receive coverage by purchasing non-Exchange plans.

In order to deal with this issue, the Patient Protection and Affordable Care Act (PPACA) allows for the use of risk adjustment and reinsurance payments in the Health Insurance Exchanges that will be created by states or groups of states. Although risk adjustment is currently used in the Medicare Advantage program (using the HCC model) and in Medicaid managed care plans to compensate health plans that enroll sicker, higher risk people, the risk adjustment methods used have faced criticism.

One concern when states begin using risk adjustment in the individual or small business markets is the level of data available and reported by health plans in order to calculate the risk adjusters, while another is the ability of the risk adjuster to subsidize premiums for plans that take on high-risk populations, while also allowing the lowest risk members of an enrolled group to pay affordable premiums. Although the Department of Health and Human Services will be able to provide some guidance related to competing risk adjustment methods and data needs to states, state policymakers need to make these decisions now and understand the consequences of those decisions.

States are currently pre-occupied with future requirements to expand Medicaid, creating the individual Health Insurance Exchanges and Small Business (SHOP) Exchanges, and dealing with budget shortfalls due to prolonged unemployment and economic struggles. However, 2014 is quickly approaching, and each state will need to decide how to collect data from health plans, what variables are needed, and how to design their risk adjustment methods. Some may decide to use a fairly simple method, which could put their residents at risk of inequitable premium rates in the individual market. On the other hand, some states could develop very complex methods that would require several years to implement. Regardless of the state strategy, serious thought needs to be put into the use of risk adjustment in the individual market. Simply using the Medicare or Medicaid managed care models may not adequately deal with the diversity of enrollees that will be entering the health insurance market in 2014. In addition, state policymakers and planners will need to develop and implement a risk adjustment mechanism that will be sustainable in their state, given the inherent limitations of data collection, population characteristics, and state financing.

Each state needs to think carefully about the approach they will use and work toward that goal efficiently and aggressively, in order to safeguard the health insurance markets under the Individual Mandate. Dr. Will Dow, from the Petris Center at UC Berkeley, recently spoke at a California Program on Access to Care Legislative Briefing on the importance of risk adjustment. While it is directly applicable to California, his presentation carries important lessons for any state that is actively designing their own Health Insurance Exchange and is facing the daunting task of determining a risk adjustment approach that will keep premiums affordable for all members of the market.

Dylan H. Roby, PhD

Assistant Professor of Health Services, UCLA School of Public Health, Research Scientist, UCLA Center for Health Policy Research