the advance notice of methodological change: review of key ... · 3.03.2016 · uspcc) have risen...
TRANSCRIPT
The Advance Notice of Methodological Change: Review of Key Changes
Free Webinar Series: March 3, 2016
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Richard Lieberman
Chief Data Scientist
Mile High Healthcare Analytics
TODAY’S AGENDA
• 30-Days in 30 Seconds
• High-level financial impacts of the 45-Day Notice
• The end of blending!
• Incorporating Socio-Economic status into both risk adjustment and quality measurement
• The phase-out of RAPS in favor of EDS data
• Changes to Star-ratings, now and in the future
• The need to improve provider directories
RELEVANT BIO FOR RICHARD LIEBERMAN
• One of the nation's leading experts on financial modeling and risk adjustment in the managed care industry
• Combines unique expertise in provider profiling, risk adjustment, case-mix measurement, and provider reimbursement strategies
• Developer of integrated decision-support platforms coalescing quality measurement, risk adjustment, and utilization reporting
• Actively involved in the development of risk adjustment systems for over 20 years
– Johns Hopkins ACG Development Team, 1991-2005
– Designed the risk-adjusted payment system for Maryland Medicaid
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“30 DAYS IN 30 SECONDS”
• The final Annual Benefit and Payment Notice was issued on 2/29/2016
– The rule finalizes provisions to:
– help consumers with surprise out-of-network costs at in-network facilities
– provide consumers with notifications when a provider network changes
– give insurance companies the option to offer plans with standardized cost-sharing structures
– provide a rating on HealthCare.gov of each QHP’s relative network breadth (for example, “basic,” “standard,” and “broad”) to support more informed consumer decision-making
– Modest improvements to the risk adjustment formula
“30 DAYS IN 30 SECONDS”
• HHS Secretary Sylvia Burwell said Monday (Feb. 29) that vendors and health systems are committed to improving the flow of healthcare information
– Vendors need to be held accountable for making sure technology is interoperable
– The American Medical Association expressed hope that the electronic health record marketplace will improve with a large number of vendors signing on to the pledge
• The interoperability “agreement” is probably intended to forestall further regulation or statutory changes
• MedPAC is meeting today on the hot-button issue of pharmaceutical costs
– Sessions on Medicare Parts D and Part B drug reimbursement
– Session on oncology services that also will touch on drug payment policy
– However, the payment policies listed in the session briefs would directly affect providers, plans and beneficiaries and would not directly affect drug prices
LET US DO THE NUMBERS
• “The net payment impact of the proposed updates would result in a modest increase of 1.35 percent on average for Medicare Advantage plans, although individual plans’ experiences will vary.”
• Over the last seven years (2011-2017), Medicare FFS costs (the USPCC) have risen an average of 1.4 percent per year
• MA plan bids have been reduced by about 10 percent from 2010-2016
– The ratio of MA bids to benchmark is about 102 percent, down from 113 percent
• There are over 18 million Medicare beneficiaries in MA Plans, about 34 percent of all Medicare beneficiaries
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BLENDING IS A THING OF THE PAST COME 2017
• The ACA provides for a transitional period during which each county rate is calculated as a blend of the pre-Affordable Care Act rate set under section 1853(k)(1) of the Social Security Act (the “applicable amount”) and the new FFS-based Affordable Care Act rate set under section 1853(n)(2) of the Social Security Act (the “specified amount”). For 2017, all counties will be fully transitioned to the new rate methodology
• No longer blending risk adjustment models (v12 and v22) for 2017 payments. Yeah!
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INCORPORATING SOCIO-ECONOMIC STATUS INTO CMS-HCC MODEL
• Historically, CMS has adjusted the CMS-HCC risk adjustment by incorporating a set of Medicaid “payment add-ons” into the existing HCC model
– Medicaid eligibility currently adds between 0.085 and 0.177 to risk scores
– This translates to between $60 and $124 pmpm
• On October 28, 2015, CMS announced proposed changes to the MA risk adjustment model that the agency believes will improve its predictive power for low-income beneficiaries
• Instead of the current two model variants, one for community-dwelling members and the other for institutionalized members, the proposed new 2017 model will have seven variants!
– Full-benefit duals are scored separately from partial-benefit duals
– Aged and disabled members have different payment weights (their own coefficients)
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THE SEVEN PROPOSED MODEL VARIANTS FOR 2017
1. Community-dwelling, non-duals, aged
2. Community-dwelling, non-duals, disabled
3. Partial benefit duals, aged
4. Partial benefit duals, disabled
5. Full benefit duals, aged
6. Full benefit duals, disabled
7. Institutionalized members (over 83% duals)
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ELIGIBILITY CRITERIA FOR SOME PARTIAL-BENEFIT DUAL PROGRAMS
• Although eligibility criteria can vary by state, some of the partial-benefit dual programs include, but are not limited to:
– Qualified Medicare Beneficiary (QMB): Net countable income at or below 100% of the Federal Poverty Level (FPL) (at or below $908 for a single person, or $1,226 for a couple)
• States pay Medicare Parts A and B premiums, deductibles, and coinsurance fees for persons eligible for the QMB program
– Specified Low-Income Medicare Beneficiary (SLMB): Net countable income below 120% of the FPL (below $1,089 for a single person, or $1,471 for a couple)
– Qualifying Individual-1 (QI-1): Net countable income below 135% of the FPL (below $1,226 for a single person, or $1,655 for a couple)
• States pay Medicare Part B premiums for persons eligible for SLMB or QI-1.
• Historically, the CMS-HCC family of risk adjustment models has “overpaid” (e.g., generated predictive ratios in excess of 1.0) for the partial-benefit duals
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RISK SCORE CALCULATIONS WILL BE MORE COMPLEX
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POTENTIAL IMPACT OF NEW RISK ADJUSTMENT APPROACHACCORDING TO CMS
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Subpopulation 2014 Model (v22)
Proposed 2017
Model
Pct.
Change
Community-dwelling, non-duals, aged 1.012 1.000 -1.2%
Community-dwelling, non-duals, disabled 1.042 1.000 -4.2%
Partial benefit duals, aged 1.123 1.000 -12.3%
Partial benefit duals, disabled 1.072 1.000 -7.2%
Full benefit duals, aged 0.892 1.000 +0.8%
Full benefit duals, disabled 0.947 1.000 +5.3%
Institutionalized members (over 83% duals) 0.999 0.999 0%
Source: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/RiskAdj2017ProposedChanges.pdf (accessed on December 2, 2015)
MIGRATION FROM RAPS TO EDS DATA
• CMS will incorporate diagnoses from encounter data into the risk scores used in payment for (PY) 2015 and 2016.
– For PY 2015, diagnoses (2014 dates of service) submitted on encounter data records serve as an additional source of diagnoses in the calculation of the risk scores.
– For PY 2016 (2015 dates of service), risk scores used for payment will be a blend of two risk scores:
• 10% of the risk score calculated using diagnoses from encounter data records and FFS (FFS) claims added to 90% of the risk score calculated using diagnoses submitted to the Risk Adjustment Processing System (RAPS) and FFS claims
• For payment year 2017, the ratio of RAPS and EDPS will be equal at 50 percent
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EXTRACTING THE PROPER DIAGNOSIS CODES
• Historically, Medicare Advantage Organizations (MAOs) have done their own filtering and submitted to CMS risk adjustment eligible diagnoses in a minimum data set to the RAPS
– The filtering process is fraught with many deficiencies– CMS’ specifications (based solely on provider specialty) will often filter incorrectly
– Plans have struggled with getting the filtering right
• Since Plans are now submitting the full breadth of information regarding services furnished to a beneficiary, including all diagnoses, CMS must now extract (i.e., filter) diagnoses submitted to the Encounter Data System (EDS) that are eligible for risk adjustment
– In the long-run, this will be good for plans. But in the short-run……
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DIFFERENT FILTERING METHODS WILL YIELD VARIABLE RESULTS
• The RAPS-based method (relying on physician specialty) often results in too many diagnosis codes being selected
– Physician specialty is a poor proxy for a face-to-face visit
• The EDS method relying on procedure codes and UB-04 bill types is much more accurate
• But to remain revenue neutral, plans must ensure that they have clean claims/encounters for every service rendered by the plan
– In my (humble) opinion, fixating on the CMS’ filtering methodology is a waste of valuable plan time and effort– focus on collecting all of the data!
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CMS’ PROPOSED CHANGES TO IN-HOME ASSESSMENTS
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A MOMENT OF SILENCE……
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MEDPAC’S DATA ON IN-HOME ASSESSMENTS
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Source: http://medpac.gov/documents/january-2016-meeting-presentation-the-medicare-advantage-program-status-report.pdf?sfvrsn=0 (accessed on February 4, 2016)
MEDPAC STAFF RECOMMENDATIONS
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THE KEY CONCERNS ABOUT HOME ASSESSMENTS
• “The Commission has expressed strong support for the use of health risk assessments and home-based care. We recognize that assessments are a valuable tool that plans use in care planning. When assessments are combined with follow-up care, they play an important role in care management, and we support their continued use in that capacity.”
• “…the Commission discussed a draft recommendation that would remove health risk assessments from risk-adjusted payment when they are the sole indicator of a diagnosis. This change is motivated by concerns about the reliability of assessment-based diagnoses and about the appropriateness of Medicare payments for conditions that are documented on an assessment but have no follow-up care.”
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Source: http://medpac.gov/documents/january-2016-meeting-transcript.pdf?sfvrsn=0 (accessed February 8, 2016)
MEDPAC COMMISSIONERS VOTED TO RECOMMEND…..
• Remove diagnoses from risk-adjusted payment when they documented only through an assessment. However, if an assessment-based condition is also documented on another physician, inpatient, or outpatient encounter, the condition would be used for risk-adjusted payment
• The Congress should direct the Secretary to develop a risk adjustment model that uses two years of FFS and MA diagnostic data and does not include diagnoses from health risk assessments from either FFS or MA, and then apply a coding adjustment that fully accounts for the remaining differences in coding between FFS Medicare and MA plans
• The recommendation addresses assessments administered in any setting, not just the home. The main issue being addressed is not the location of assessment administration, but that assessments do not indicate whether any treatment was provided for the conditions that are documented.
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THE BALL IS NOW IN CONGRESS’ COURT
• CMS lacks agency discretion to reduce the coding intensity adjustment.
– This is set in statute by the American Taxpayer Relief Act of 2012
– Only Congress and the President can change this
• Using 2-years of data to calibrate the model and to substantiate an HCC
• Limiting the role of diagnosis codes sourced from in-home assessments
– Linking diagnosis to subsequent (or even prior) treatment
• The Senate Finance Committee's Chronic Care Working Group
published a paper in December outlining potential changes to Medicare
Advantage's risk-adjustment model. Modifying home visits could be part
of a broader bill.
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SO WHAT SHOULD MA PLANS DO?
• Plans need to redouble their efforts to ensure they have comprehensive encounter data– every service delivered by any provider must be in the data warehouse
– CMS will be using EDS data for a variety of purposes
• Providers need to improve their clinical documentation so that Plan’s reliance on home assessments can be reduced over time
– If physicians would link every ordered treatment (e.g., medication orders) to specific diagnoses, then coders could abstract a “treasure trove” of valid diagnosis codes that would withstand RADV audits
– Revenue management costs to MA Plans would fall because medical record abstraction is much more cost effective
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WHAT SHOULD PLANS DO (CONT’D)
• Provider education becomes even more crucial
– Some providers will be receptive, while others will not
– Plans and risk-bearing provider entities must use reporting and financial incentives to improve the quality of medical record documentation
• Learn from the pharmaceutical companies physician detailing methods
• Redirect “suspecting” (targeting) algorithms to help providers keep track of what persistent conditions they need to document every year
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QUALITY MEASUREMENT IN MA (STARS)
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CHANGES TO THE MEASURES
• For 2017, CMS continues to drop measures
– High Risk Medications (HRM): HRM could no longer be clinically justified. There are numerous medications that are not dangerous when used at their proper doses
– Urinary incontinence (improving bladder control): NCQA made significant changes to the HOS questions that generate this measure. Results will not be reported for 2017. Expect this measure to return at some point in the future
• First time that CMS has dropped a measure from Stars where the weight is greater than 1
• With all of the drops, I can’t imagine that we won’t be seeing new measures added in 2018 and 2019
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NO NEW MEASURES FOR 2017, BUT WHAT DOES THE FUTURE HOLD?
• Hospitalizations for Potentially Preventable Complications
• Asthma Measures
– Medication Management for People with Asthma (this is also a QRS measure)
– Asthma Medication Ratio
• Statin Use in Persons with Diabetes (proposed for 2019 Stars)
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Impact of Socio-economic and Disability Status on Star Ratings
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THE ISSUE
• Plans serving a primarily or exclusively low-income population attribute their poor performance in Starr ratings to the complex care needs and socioeconomic status of their enrollees
• This is an important issue because the MA program allows certain plans to exclusively service dual eligible in D-SNPs
• But, some plans exclusively serving duals are able to achieve ratings of 4 stars or higher
• The research so far points to the role of the physically disabled in damping plan performance
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IDENTIFYING LOW-INCOME AND DISABLED BENEFICIARES
• LIS/DE beneficiaries are beneficiaries who qualify at any point in the measurement year for a low income subsidy and/or who are full or partial Dual (Medicare and Medicaid) beneficiaries
• Disability status for beneficiaries is based on the Original Reason for Entitlement for Medicare
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MEDPAC FINDINGS
• Plans with higher shares of enrollees under the age of 65 (entitled to Medicare on the basis of disability) had lower overall star ratings
• Among the D-SNPs, those enrolling only the aged had higher overall star ratings
• The research to date has provided scientific evidence that there exists a within-contract LIS/DE and disability effect for a subset of the Star Ratings measures
– The size of the effect differs across measures and is not exclusively negative
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CATEGORICAL ADJUSTMENT INDEX
• The Categorical Adjustment Index (CAI) is a factor that would be added to or subtracted from a contract’s Overall and/or Summary Star Rating to adjust for the average within-contract disparity
– The adjustment factor varies by a contract’s proportion of DE/LIS and disabled beneficiaries
– The CAI approximates the effect of case-mix adjustment of contract performance scores for DE/LIS and disabled status.
• CMS proposes to move forward with the proposed interim analytical adjustment of the CAI beginning with the 2017 Star Ratings
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PROVIDER DIRECTORIES
• Currently among MA, QHPs and the Medicaid managed care programs, MA provides the least prescriptive provider directory requirements. (See 42 C.F.R. §422.111(b)(3)(i) and explained in sections 60.4 and 100.4 of the Medicare Marketing Guidelines
– The MA program also has the fewest data elements required for its provider directory
– In addition, both Medicaidand QHPs have moved toward some level of machine readability for online provider directory content, while MA has not
• Sen. Chuck Grassley (R-IA) on Wednesday (March 2) introduced legislation to ensure Medicaid programs give beneficiaries an updated list of participating doctors
– The Medicaid Directory of Caregivers bill, or S. 2618, would require state fee-for-service or primary care case management Medicaid programs publish an electronic listing of physicians who have billed Medicaid in the prior year to show they served Medicaid beneficiaries. The listing, on the state’s Medicaid website, would include the physician’s name, business address, telephone number and specialty.
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PLEASE VISIT OUR BOOTH AND MY PRESENTATION AT….
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AT RISE, I WILL BE PRESENTING ON….
COALESCING QUALITY, RISK ADJUSTMENT, AND COSTS OF CARE TO PROMOTE POPULATION HEALTH
• A value-based payment paradigm that incorporates risk adjustment
• The continued evolution of performance measurement
• Calculating quality composites in the absence of fixed-cut points
• “Stars on Steroids:” harnessing the merit-based incentive payment system
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NEXT WEBINARS
• Mile High Healthcare Analytics will continue our free webinar series. We will continue to present key risk adjustment and performance improvement topics to health plans and provider groups.
• Our next three webinars will be held on:
– Thursday April 7, 2016: the Final Notice for MA Plans
• Please watch http://www.healthcareanalytics.expert/news-and-events/free-webinar-series/ to learn about our webinar topics
CONTACT INFORMATION
Richard Lieberman
720-446-7785 (voice)
www.healthcareanalytics.expert
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