Tuesday, December 30, 2014

Percentage of consumers likely to buy wearable health devices

According to an Employee Benefit News 2014 issue, the following percentage of consumers are likely to purchase a wearable health device within the next year:

  • 45% of consumers are likely to purchase a fitness band.
  • 35% of consumers are likely to purchase a smart watch.
  • 20% of consumers are likely to purchase smart clothing.
  • 19% of consumers are likely to purchase smart glasses.
  • 13% of consumers are likely to purchase people-tracking devices.
Source: Employee Benefit News

57% are going to implement consumer-directed health plans (2015)

According to an Employee Benefit News 2014 issue:

  • 73% of employers are adding or expanding consumerism tools in 2015.
  • 14% of employers are parterning with a private exchange for their retirees in 2014, up from 10% in 2013.
  • 7% of employers are partering with a private exchange for their retirees in 2015.
  • 36% of employers saying engaging employees in health care decisions will be a primary focus next year.
Source: Employee Benefit News

67% of consumers say the healthcare system is on the wrong track

According to a recent survey released by by Booz Allen Hamilton and Ipsos Public Affairs:

  • 34% of administrators think that the healthcare system is on the right track.
  • 24% of primary care physicians share the view that the healthcare system is on the right track.
  • 10% of specialists share the view that the healthcare system is on the right track.
  • 67% of providers are satisfied with their current practice.
  • 61% believe that their organization is well positioned to succeed in a changing healthcare environment.
Source: Ipsos-na

96% of Healthcare Organizations Turn to the Cloud

According to a recent Dell study, research highlighted how healthcare customers rely on Dell cloud-based solutions for image archiving and HIS-hosting. Below are the findings:

  • 43% of healthcare respondents are using private cloud solutions.
  • Another 43% of healthcare respondents are using a hybrid cloud solution.
  • 64% indicated that they are very confident that their data is protected.
  • 46% surveyed cite better allocation of IT resources as the biggest benefit of cloud computing.
  • 39% surveyed cite that the better benefit is cost savings.
Source: Dell

According to a recent survey of medical students

73% of intend to seek employment with a hospital or large group practice, while only 10% intend to engage in private practice.

Source: "athenahealth Announces Results of 9th Annual Epocrates Future Physicians of America Survey," athenahealth Press Release, December 15, 2014, http://newsroom.athenahealth.com/phoenix.zhtml?c=253091&p=irol-newsArticle&ID=1999408

According to a recent report:

  • 15% of Americans are currently enrolled in a consumer-driven health plan (CDHP)
  • Approximately 11% are enrolled in a high-deductible health plan (HDHP)
  • 74% are enrolled in more traditional health insurance coverage

Source: "Consumer-Driven Health Plans Show More Patient Involvement in Their Health Care," Employee Benefit Research Institute Press Release, December 16, 2014, http://www.ebri.org/pdf/PR1103.CEHCS.16Dec14.docx.pdf

According to a recent report

57% of individuals enrolled in a consumer-directed health plan (CDHP) had a health savings account (HSA) or health reimbursement arrangement (HRA), and 43% were enrolled in an HSA-eligible health plan but had not opened an account yet.

Source: "Consumer-Driven Health Plans Show More Patient Involvement in Their Health Care," Employee Benefit Research Institute Press Release, December 16, 2014, http://www.ebri.org/pdf/PR1103.CEHCS.16Dec14.docx.pdf

According to a recent survey of physicians:

  • 26% participate in an Accountable Care Organization (ACO)
  • 38% either do not see Medicaid patients or limit the number of Medicaid patients they see
  • 24% either do not see Medicare patients or limit the number of Medicare patients they see

Source: "2014 Survey of America's Physicians: Practice Patterns and Perspectives," The Physicians Foundation/Merritt Hawkins, September 2014, http://www.physiciansfoundation.org/uploads/default/2014_Physicians_Foundation_Biennial_Physician_Survey_Report.pdf


$80 billion in revenue by 2018 (and $100 billion by 2020) were the ambitious revenue goals Aetna CEO Mark Bertolini had for his company at the insurer's Dec. 11 investor day.


3.6% was the increase in health care spending in 2013, marking the fifth straight year for such moderate growth, HHS reported on Dec. 3.

Medicaid set to drop payments for primary care physicians

Temporary bump in fees expires in 2015

The Medicaid program has gone through a lot of growing pains as it dramatically expanded as part of the Affordable Care Act (ACA). But it may face its toughest challenge in 2015, when payments to primary care physicians are slated to drop an average of more than 40 percent, Kaiser Health News reported.

The pending cut is connected to a temporary payment increase that lasted for two years, starting in 2013, when insurance coverage under the ACA went into full force. But with Congress deeply divided along party lines about support for healthcare reform, no extension of the payment bump is forthcoming.

That has left many policy experts concerned that the loss of the payment increase will make it even more difficult for Medicaid enrollees to see physicians, according to Kaiser Health News. In some parts of the country, the wait is two months or longer.


Today's Datapoint

19% was Humana's cost improvement in 2013 for accountable care members versus those treated by providers in non-accountable care settings. The insurer has more than 1.2 million beneficiaries in more than 900 ACO relationships in 43 states and Puerto Rico.

Quote of the Day

"Our recently completed pilot shows that these creative new cancer care payment models can reduce health care costs while improving patient outcomes. MD Anderson's work with value-based workflows makes them a natural partner for bundled payments."

— Lee Newcomer, M.D., UnitedHealthcare's vice president for oncology

Friday, December 19, 2014

30% of Those with HIV had the Virus Under Control

According to a recent Vital Signs report published by the Centers for Disease Control and Prevention:

  • 66% of Americans with HIV had been diagnosed but were not engaged in regular HIV care.
  • 20% of Americans with HIV did not yet know they were infected.
  • 4% of Americans with HIV were engaged in care but not prescribed antiretroviral treatment.
  • 10% of Americans with HIV were prescribed antiretroviral treatment but did not achieve viral suppression.
  • In 2011, 1.2 million Americans were living with HIV.

Note: Data is from 2011.
Source: Centers for Disease Control and Prevention (CDC)

Of those with coverage

...it was "somewhat" or "very difficult" or "impossible" to afford their health insurance deductible over the past year included:

  • 27% of adults making more than $45,960 a year
  • 49% of adults making $22,980 to $45,960 a year
  • 64% of adults making $11,490 to $22,980 a year
  • 58% adults making less than $11,490 a year

Source: "New Commonwealth Fund Report: 21 Percent of Adults with Health Insurance Spent 5 Percent or More of Their Income on Out-of-Pocket Health Care Costs," The Commonwealth Fund, November 13, 2014, http://www.commonwealthfund.org/publications/press-releases/2014/nov/21-percent-of-adults

7% of Employers Use Quality Information to Choose a Health Plan

According to a new nationally representative survey funded by the Robert Wood Johnson Foundation and conducted by the Associated Press-NORC Center for Public Affairs Research:

  • 60% of employers offering health insurance say quality ratings are important when choosing a plan.
  • 4% of employers say their organization uses HEDIS Scores.
  • 1% of employers say their organization uses eValue8.
  • 36% of employers offering health insurance say their organization uses quality data.
  • 24% say their organization uses other sources to evaluate health insurance plan quality.
Source: Robert Wood Johnson Foundation

Today's Datapoint

$250 billion in savings could be realized over the next 10 years if the FDA approves biosimilar versions of 11 selected biologics, according to Express Scripts Holding Co.

Quote of the Day

"I can't say how many times I've heard that premiums are going through the roof...and people are dropping coverage. But then when we do our surveys, we might see maybe a rate increase of 6%, and we can't find any [employers] that actually dropped coverage. Over the long term, we do see a decline in employers offering coverage, but we rarely see much of a decline year over year."

— Jon Gabel, senior fellow at the University of Chicago's National Opinion Research Center, told AIS's Inside Health Insurance Exchanges.

Thursday, December 18, 2014

Today's Datapoint

80% of individual, small-group and large-group market share belonged to the three largest health insurers in each of 37 states, according to a Dec. 1 report from the Government Accountability Office.

Wednesday, December 17, 2014

86% of patients with online access to their health

...used their online records at least once in the last year, and 55% used them three or more times, according to a recent survey.

Source: "New Survey: Patients Increasingly Value Electronic Health Records, Eager for More Access and Features," National Partnership for Women & Families Press Release, December 10, 2014, http://www.nationalpartnership.org/news-room/press-releases/new-survey-patients-increasingly-value-electronic-health-records-eager-for-more-access-and-features.html  


66% of accountable care organizations in the Medicare Shared Savings Program are either highly unlikely (62%) or somewhat unlikely (4%) to accept two-sided risk, according to a recent survey from the National Association of ACOs.

Today's Datapoint

17% ... of insurance brokers expect at least a quarter of their clients to drop coverage in the coming year, according to a recent survey of more than 1,000 insuracne brokers conducted by Benefitter.

Quote of the Day

"There are actually a lot of significant changes [in CMS's proposed enhancements to the star quality ratings for 2016 and beyond] that plans need to start budgeting and planning for almost immediately. Basically what we are seeing is the low-hanging fruit for stars measures is gone and this is becoming an annual exercise in climbing up the tree. This is going to require a fundamental integration of clinical and medical data by the plans and a really high degree of execution at the physician practice and pharmacy level, not just for the measures that are coming and on display next year, but for the measures that are coming in 2017."

— John Gorman, founder and executive chairmen of Gorman Health Group, LLC, told AIS's Health Plan Week.

Tuesday, December 16, 2014

According to a recent analysis, between 2003 and 2013:

  • health insurance premiums rose 60%
  • employee premium contributions rose 93%
  • incomes grew only 11%

Source: "Employer Premium and Deductible Cost Growth Slowed Post-ACA, But Employer Health Insurance Still Claiming Bigger Share of Workers' Income," The Commonwealth Fund Press Release, December 9, 2014, http://www.commonwealthfund.org/publications/press-releases/2014/dec/employer-premium-growth

CDC: Smoking Rate Dropped From 20.9% (2005) To 17.8% (2013)

According to new data published by the Centers for Disease Control and Prevention in the Morbidity and Mortality Weekly Report (MMWR):

  • The number of cigarette smokers dropped from 45.1 million in 2005 to 42.1 million in 2013.
  • Those who smoke every day decreased from 80.8% in 2005 to 76.9% in 2013.
  • Cigarette smokers who smoke only on some days increased from 19.2% in 2005 to 23.1% in 2013.
  • The average number of cigarettes smoked by daily smokers declined from 16.7 in 2005 to 14.2 in 2013.
Source: Centers for Disease Control and Prevention (CDC)

Monday, December 15, 2014

Only 57% of adults over age 65 in the U.S. said they could get

a same-day or next-day doctor's appointment when they were sick, compared to 83% in France and New Zealand, and 81% in Germany, according to a recent international survey.

Source: "New 11-Country Survey of People 65 and Older Finds Those in U.S. Are Sickest and Most Likely to Have Problems Paying Medical Bills, Getting Needed Health Care," The Commonwealth Fund Press Release/Health Affairs, November 19, 2014, http://www.commonwealthfund.org/publications/press-releases/2014/nov/11-country-survey-of-people-65-and-older

Tips To Help You Select a Cost-Effective And Comprehensive Plan For Your Family

1.    Look at your eligibility for discounts - Make sure you explore potential discounts before writing off a plan due to cost

2.    Narrow down your choices to just a few plans - Set a maximum monthly budget for your premium and you can narrow the options down considerably

3.    Estimating future medical expenses - Predict your anticipated medical costs for the coming year and compare coverage

4.    Consider additional features - Deductibles, network size, out-of-pocket maximums, plan structure and covered expenses are important to think about

5.    Determine your priorities - This part of the decision is largely personal, but crunching numbers beforehand will make the choice easier

Source: The Huffington Post

5 trends that will increase healthcare M&A deals

1.    Long-term care facilities- will feel the brunt of Medicare reimbursement cuts so they will make up a sizable portion of the consolidation trend

2.    Retail clinics will take center stage in M&A deals: The interest in retail clinics will increase, insured patients with high deductibles look for cheaper options than visiting a doctor’s office

3.    Physician practices with a cardiology or dermatology specialty: will be the most sought after for M&A deals in this area

4.    Diversify, diversify, diversify: Hospitals are experiencing the biggest slowdown in year-on-year admissions growth in 10 years and that’s by the ACA’s design

5.    Healthcare IT tools that can improve clinical workflows- Business intelligence and data analytics are popular areas because they will help hospitals comply with the ACA and shift their payment model

Source: MedCity News

Health Benefit Cost Per Employee Will Rise By 4.6% In 2015

According to the National Survey of Employer-Sponsored Health Plans (conducted annually by Mercer):

  • Employers held down growth in the average per-employee cost of health benefits to 3.9% in 2014.
  • Total health benefit cost averaged $11,204 per employee in 2014.
  • Without plan benefit changes, the estimated 2015 cost would rise by average of 7.1%.
  • 3% of large employers moved to a private exchange in 2014.

Note: Mercer's nationally projectable annual survey includes public and private organizations with 10 or more employees; 2,569 employers responded in 2014.

Source: Mercer

Generic Drug Price Inflation: It’s Personal

By Lauren Flynn Kelly - December 12, 2014

One of the hottest pharmaceutical topics in recent months has been generic drug price inflation. Half of all retail generic drugs rose in price over the last year, according to Drug Channels. Sen. Bernie Sanders (I-Vt.), chairman of the Senate Subcommittee on Primary Health and Aging, has attempted to take the makers of pricey generic drugs to task — through letters demanding information on their “skyrocketing” prices and a Nov. 20 subcommittee hearing at which three invited drug companies failed to appear.

In the letters issued to 14 generic pharmaceutical manufacturers on Oct. 2, Sanders and Rep. Elijah Cummings (D-Md.), ranking member of the House Committee on Oversight and Government Reform, cited data from the Healthcare Supply Chain Association showing price increases of 300% or more in recent months for 10 generic drugs. One of those drugs was albuterol sulfate, which is used to treat asthma and other lung conditions. The average market price for a bottle of 100 pills was $11 in October 2013 and jumped to a whopping $434 in April 2014, pointed out the concerned congressmen. During the Sanders hearing, Cummings revealed that he takes this very drug, and vowed to “fight this issue until I die.”

Scott Gottlieb, M.D., a resident fellow at the American Enterprise Institute who most recently served as deputy commissioner for medical and scientific affairs at the FDA, suggested to Congress that most of the generic drugs experiencing high cost increases are “low-volume drugs.” In order to get a more accurate picture of what’s happening, lawmakers and others trying to address the problem need to adjust the price increases based on prescription volume, he suggested.

But a handful of high-volume drugs have experienced dramatic increases, which should be of concern to payers. According to Evercore ISI’s Generic Drug Price Inflation Tracker tool, levothyroxine was one of those outliers in 2013, when it rose in price by 58.3%. I rely on this pill every day to regulate my underactive thyroid and was disappointed when it moved from many retailers’ $4 generic lists to the $10 lists. Not a huge hardship, but it adds up when you’re being asked to pay higher prices for more than one generic at a time.

During the Sanders hearing, witnesses discussed various factors that could be pushing up prices (such as shortages), but one they kept coming back to was the backlog of more than 3,000 generic drugs awaiting FDA approval. Hmm…one of those must be Nasonex (mometasone furoate), which I’ve found to be the most effective nasal spray for seasonal allergies and was supposed to go generic this year. Instead of telling everyone to go get this year’s ineffective flu shot, maybe HHS should be pushing the FDA to work a little faster on those unapproved generics.


Lawmakers Pursue Answers, Remedies for Generic Inflation

Reprinted from DRUG BENEFIT NEWS, biweekly news and proven cost management strategies for health plans, PBMs, pharma companies and employers.

By Lauren Flynn Kelly, Editor

December 5, 2014 Volume 15 Issue 23

As the prices of many generic drugs continue to experience increases due to shortages, reduced competition and other potential factors, the federal government is putting the pressure on the generic pharmaceutical industry. Sen. Bernie Sanders (I-Vt.), chairman of the Senate Subcommittee on Primary Health and Aging, on Nov. 20 convened a Senate hearing to investigate the “skyrocketing” prices of generic drugs at which three generic drugmakers were no-shows.

And The Wall Street Journal last month reported that the U.S. Department of Justice issued subpoenas to two producers of generic digoxin, a congestive heart failure treatment that has severely spiked in price.

Three generic pharmaceutical manufacturers — Marathon Pharmaceuticals, Lannett Co., and Teva Pharmaceutical Industries — were invited to testify at the Nov. 20 hearing but declined to participate. Sanders and Rep. Elijah Cummings (D-Md.), ranking member of the House Committee on Oversight and Government Reform, had sent letters on Oct. 2 to those companies and 11 others seeking information on escalating prices of certain generic drugs.

The letters cited data from a survey of group purchasing organizations conducted by the Healthcare Supply Chain Association showing price increases of 300% or more in recent months for 10 generic drugs. For example, the average market price for a bottle of 100 pills of albuterol sulfate to treat asthma and other lung conditions was $11 in October 2013, compared with a whopping $434 in April 2014.

The Generic Pharmaceutical Association, however, argued on Nov. 20 that citing a mere 10 drugs out of more than 12,000 “safe, affordable generic medicines” lacks perspective and fails to recognize the “thousands of generics [that] have seen significant price erosion over time due to the competitive nature of the marketplace.”

But Sanders explained during the hearing that he and Cummings are not just concerned about a handful of drugs. “While we are focusing on 10 individual drugs that have seen extraordinary price increases, what we are also seeing in the industry is that many other generic drug prices are rising as well,” he said. “There appears to now be a trend in the industry where a number of drugs are going up at extraordinary rates.”

According to a new analysis of National Average Drug Acquisition Cost (NADAC) data collected and published by CMS, Pembroke Consulting, Inc. finds that half of all retail generic drugs rose in price when comparing November 2014 data (dated Nov. 5, 2014) with the previous year’s file (dated Nov. 7, 2013). Out of a sample size of 2,370 drugs, 9% of products had cost increases of more than 100% (see chart, below). The Pembroke data, which was posted to the Drug Channels blog on Nov. 18, also demonstrate quarterly changes in acquisition cost, and show more than one-third of generic drugs rose in price in the third quarter of 2014. Of the top 10 drugs with the largest percentage increases in NADAC per unit from July to November, eight jumped by more than 1,000%.

During the hearing, witnesses discussed various factors that could be pushing up prices, such as a backlog of more than 3,000 generic drugs awaiting FDA approval and the 2012 implementation of a generic drug user fee to supplement the costs of reviewing generic drug applications and inspecting facilities.

Rob Frankil, a Sellersville, Pennsylvania, pharmacist, testified on behalf of the National Community Pharmacists Association (NCPA) that pharmacists have no advance notice of these price increases and that PBMs are taking up to six months to update their reimbursement rates to pharmacies, “putting pharmacies underwater on these drugs.” According to a recent survey of more than 1,000 NCPA pharmacies that experienced large spikes in generic drug prices in the past six months, respondents pointed to commonly used drugs such as pravastatin for high cholesterol and levothyroxine for hypothyroidism, added Frankil.

Scott Gottlieb, M.D., a resident fellow at the American Enterprise Institute who most recently served as deputy commissioner for medical and scientific affairs at the FDA, suggested to Congress that most of the generic drugs experiencing high cost increases are “low volume drugs,” although there are some examples of high volume drugs. “To get a more accurate picture of what’s happening in the market overall, you need to adjust the price increases based on script volume,” he suggested. Regardless of which types of products are increasing, Gottlieb suggested one culprit is higher manufacturing costs due to increased FDA oversight and the agency’s “abrupt” imposition of new quality standards.

In an effort to “cushion the impact” of rising generic costs, Sanders on Nov. 20 proposed new legislation that would require generic manufacturers whose prices outpace the rate of inflation to pay extra rebates to Medicaid. The Medicaid Generic Drug Price Fairness Act proposes to extend a requirement of the Social Security Act that brand-name manufacturers whose drug prices increase at a rate faster than inflation pay an additional rebate to Medicaid.

GPhA immediately fired back, calling the effort “misguided” and a threat to patient access. “Unfortunately, the newly proposed legislation makes it clear that the hearing was not intended to be a meaningful examination of ways to ensure savings,” said GPhA President and CEO Ralph G. Neas in a Nov. 20 statement. He also recommended that Congress focus on ways to encourage competition among generics manufacturers, such as through the “timely review” of generic drug applications and by countering the misuse of Risk Evaluation and Mitigation Strategy (REMS) programs that GPhA alleges some brand companies are using as a way to keep generics out of the market.

View a replay of the hearing at http://tinyurl.com/m5qsye6. To view the Pembroke analysis, visit www.drugchannels.net.


Today's Datapoint

3% of large employers (those with 500 or more employees) moved to a private exchange in 2014 (or for 2015) to provide benefits to active employees, and another 28% say they are likely to do so within the next five years, according to the annual National Survey of Employer-Sponsored Health Plans conducted by Mercer.

Quote of the Day

“For hospitals, [the arrest of an orthopedic surgeon for billing Medicare and Medicaid for implanting devices he never implanted in patients] is a compelling and alarming scenario because no hospital wants to have any inference that a physician on their medical staff has not performed procedures that patients believed were performed. It would compel hospitals to undertake their own evaluation of the circumstances — not to be prosecutors, but to really undertake a clinical quality assurance review that is necessary to ensure they have effective protocols in place.”

— Kathleen McDermott, a former federal prosecutor who is now with Morgan Lewis in Washington, D.C., told AIS’s Report on Medicare Compliance.

Friday, December 12, 2014

48% of Americans Are In The Dark About Affordable Care Act Penalties

According to a new Turbo Tax health survey conducted by Harris Poll:

  • 62% of uninsured Americans are aware that they will be required to be pay a penalty.
  • 87% do not realize that the deadline to avoid the tax penalty for 2014 has passed.
  • 56% of those without health insurance are also unaware that uninsured individuals who meet certain criteria may qualify for an exemption from the Affordable Care Act tax penalty.
  • 45% of Americans are not aware there are discounts called premium tax credits designed to make health insurance less expensive for low-to-moderate income families.

Note: Survey was conducted online within the United States by Harris Poll on behalf of TurboTax from November 6-10 among 2,022 adults age 18+ and November 13-17, 2014, among 2,014 adults ages 18+.

Source: Turbo Tax Health Survey (Harris Poll)

CMS Intends to End Four-Star Thresholds, Start CMR Measure in ’16, New Memo Says

By James Gutman, Managing Editor

December 4, 2014 Volume 20 Issue 23

There were few surprises and only one brand-new measure — but some important potential changes — outlined in CMS’s Nov. 21 memo on proposed “enhancements” to its Medicare plan star quality ratings for 2016 and beyond. This year’s 22-page edition of what has become an annual document makes clear, for instance, that CMS intends finally to end use of predetermined four-star “thresholds” effective with the 2016 ratings.

However, the agency is asking for industry input — by the Dec. 17 overall comments deadline — on how that should be done, including via a phase-out or with a periodic adjustment versus a one-time change.

Perhaps equally important, the memo also says that “CMS is exploring the development of an integrated Star Rating system for Medicare-Medicaid Plans” participating in the CMS-backed capitated duals demos that began this year (see story, p. 4). Such a rating system “acknowledges the additional needs of Medicare-Medicaid enrollees” and would measure performance of the duals plans in integrating Medicare and Medicaid benefits, states the memo. Its language there appears to acknowledge industry concerns about the adverse impact of the stars system on plans that serve disadvantaged populations (MAN 9/11/14, p. 1), but could mean CMS is not considering any other short-term steps to aid Medicare Advantage insurers serving the disadvantaged.

CMS May End Four-Star Thresholds

The memo was sent to insurers via CMS’s Health Plan Management System by Amy Larrick, acting director of the Medicare Drug Benefit and C & D Data Group. It also indicates the agency intends to go ahead for 2016 with a delayed measure assessing the completion rate for Comprehensive Medication Reviews (CMRs) for beneficiaries eligible to participate in medication therapy management (MTM) programs (MAN 12/5/13, p. 4).

Several of the contemplated revisions outlined in the memo result from methodology or other changes made by accreditation organization NCQA, especially in its HEDIS measures. Others, though, represent areas CMS on its own has wanted to alter for a while.

Perhaps the most significant of those revisions is the abolition of predetermined four-star rating thresholds used for 2015 in 67% of MA measures and 39% of Part D drug measures. CMS said in the memo, as it has in the past, that these thresholds violate its “principle of assigning stars that maximize the difference between star categories” and represent a problem “when there is general improvement in measure performance over time.” The agency added, though, that while its analysis shows plan sponsors improve more in measures without preset thresholds (51% of contracts improved significantly in nine MA measures without thresholds versus 28% in 20 measures with them for 2015), it recognizes some sponsors feel they need the published targets to set “performance expectations.”

So while “we propose removing the pre-determined measure thresholds for the 2016 Star Ratings,” the memo said, CMS is asking for input on whether to do this as a phase-out rather than all at once. The agency cited as a possible method the elimination of the thresholds on “process” stars measures for 2016 and on the remaining measures for 2017. And CMS said it could address “industry’s request for stability via pre-announced benchmarks” by adding an annual improvement percentage increase, to be adjusted not more than once every three years, that initially reflects improvement trends the agency has seen from 2014 to 2015 in the star ratings.

The phase-out option is “interesting” and “not what we would have expected” in light of CMS having advocated the elimination of the thresholds for years, says Carmen Alexander, manager, strategy and operations in Deloitte’s government health plans consulting practice. She attributes the possible change to feedback from plans, and Michael Lutz, director, health reform for consulting firm Avalere Health LLC, tells MAN the alternatives show CMS is looking for a “less disruptive” way of accomplishing its goal.

The two options CMS outlined on this are “very feasible,” says Christie Teigland, Ph.D., director, statistical research for health data analytics firm Inovalon, Inc. Teigland adds, however, that adjusting for improvement every three years is “too infrequent” and that, as a statistician who agrees with the agency’s arguments against the four-star thresholds, she’d prefer it if CMS would just get rid of them in one step.

Nevertheless, she tells MAN, the thresholds do serve a purpose, especially since CMS’s methodology on some of the star ratings is still “a little of a black box” and since without the thresholds “it’s hard for plans to know how to get an ‘A.’”

Duals MA Plans May Not Get Relief in 2016

In noting its exploration of a separate star-rating system for plans in the duals demo and saying it will have more details on that in the first quarter of 2015, CMS will “roll the ball forward” in recognizing the particular issues surrounding star ratings in plans for duals, according to Teigland. But she terms it “a little disappointing” that CMS didn’t say more on this issue, which is the subject of a large new multi-payer study being conducted by Inovalon (MAN 11/6/14, p. 1). Asked if the agency’s statements in the memo could mean CMS is not intending to do anything additional on the duals star rating issue for 2016, Teigland replies, “That’s how I’m reading…between the lines.”

Alexander agrees that the likelihood of CMS doing more to help Medicare plans serving the disadvantaged for 2016 outside of the duals demo is “a bit of a stretch.” She cites the amount of data analysis and plan comments the agency must wade through in the aftermath of its Sept. 8 request for evidence proving disadvantaged status causes poorer star ratings.

The only totally new measure that CMS says in the memo it intends to add for 2016 is its previously proposed MTM completion rate for CMRs. This measure has been controversial, especially regarding its possible application to long-term care beneficiaries, and the memo says nothing about excluding populations other than those in hospice at any point in the reporting period.

Lutz, though, does not expect to see further delays in instituting the measure, especially since CMS detailed in the memo that it not only would start with the standard new-measure weight of 1 but also would keep that lowest possible weight as a process measure in future years. Alexander agrees, noting the CMR completion rate for MTM eligibles now is only 15%, that rates vary from 0% to 90% among plans, and that the agency considers CMRs important. There will be “a lot of variance” in plan scores when this measure is added, she asserts.

The CMS memo identifies three former star measures, which had been withdrawn from active stars scoring because of methodological or data-quality concerns, that the agency intends to return to active status for 2016. They are breast cancer screening, call-center access and “beneficiary access and performance problems.”

Alexander says none of the reinstitutions are surprises, and CMS is changing the breast cancer screening criteria in ways that should enable plans to do better on them. Moreover, call-center access is a measure on which MA and Part D plans have done well in the past, and the decision to remove audit results from the criteria in the beneficiary access measure should reduce any “unfairness” in scoring plans that have been audited versus plans that haven’t, she tells MAN.

On the flip side, the memo says CMS intends to remove temporarily — for both 2016 and 2017 — the MA measure on improving bladder control for multiple reasons, including that NCQA is adding an “outcome indicator” involving revised survey questions first to be asked in 2015.

Bladder control is a “very-low-performing measure,” notes Alexander, so its temporary removal is “a good thing” for plans. When the measure comes back, she forecasts, it will be “reconfigured” to focus on what plans need to do to improve a member’s quality of life.

CMS in the memo also is proposing to help make more plans eligible for star-rating scoring by reducing the minimum size of plans scored to 500 members from the previous 1,000, based on its conclusion that there are “sufficient data to reliably measure and report on contracts” with the smaller number of enrollees.

This could help good smaller plans that now are limited to a 3.5% bonus if they are too new or small to get CMS stars scores, says Alexander. Teigland, though, cautions that “500 is a pretty small number” considering that many enrollees don’t qualify for inclusion in CMS’s member count for stars purposes. This raises the question of whether the remaining number of members after the required exclusions will be enough to yield suitable data, she explains.

In a later section of the memo, CMS lists and explains potential changes to existing star measures and possible new measures it is considering for 2017 and beyond. In the latter category are: