Star Ratings Tend to Rise With Medical-Management Spending Growth

Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in MA and Medicaid managed care. By James Gutman, Managing Editor August 22, 2013 Volume 19 Issue 16 There is a strong correlation between true medical-management expenditures and star ratings achieved by Medicare Advantage plans, according to new data presented by health plan benchmarking specialist Sherlock Co. on Aug. 14. Based on a study of 24 MA plans and their 2013 CMS star ratings, President Douglas Sherlock told a webinar audience, “there is effectively a floor of [medical management] expenses” of $6 per member per month (PMPM) needed to achieve a rating of at least three stars — the rating CMS in the past considered about “average.” The correlation was strongest, according to the Sherlock data, when non-core medical management activities such as precertification, utilization review, health and wellness promotion and medical informatics were removed from the analysis. The result was plotting points closely bunched along a straight upward-sloping line, with star ratings on the vertical axis and the PMPM “medical management subset costs” on the horizontal axis (see table). Estimating the return on investment of medical management is very difficult, Sherlock told the webinar audience, but the data his firm compiled clearly suggest a high ROI for medical management in MA based on bonuses that plans get for earning high star ratings. The plans studied, he said, included both Blues and “independent/provider-sponsored” non-Blues organizations serving a combined 1.8 million MA members. Sherlock used those plans’ 2013 star ratings, which a webinar registrant pointed out are based mostly on 2011 data, and compared them with what the plans reported as medical management costs for this year. He excluded as an “outlier” from the data one plan that had high spending following a history of low ratings. The remaining plans constituted somewhat of an “elite” group, he acknowledged, since they averaged four stars versus a current CMS overall average of 3.4. In the question period, Sherlock readily conceded that the limited-scope analysis did not examine some other aspects of the medical management versus stars relationship that could be illuminating. The model, for instance, didn’t look at the correlation between MA plans’ other administrative expenses and star ratings, or between medical management conducted in-house versus by outside vendors, he noted. Moreover, he said, the study didn’t separate out results of HMO versus PPO MA plans. http://aishealth.com/archive/nman082213-06?utm_source=Real%20Magnet&utm_medium=Email&utm_campaign=26543629

Use of sleeping pills highest among older Americans: CDC

By Susan Heavey WASHINGTON | Thu Aug 29, 2013 12:21am EDT (Reuters) - Older U.S. adults, particularly women, are more likely to use prescription sleep medications to try to get the minimum seven hours of sleep experts generally recommend, U.S. data released on Thursday showed. Use of such pills, which include Sanofi SA's Ambien and other similar drugs, was significantly higher for those in their 50s as well as age 80 and older, according to the findings from the Centers for Disease Control and Prevention. Overall about 8.6 million people, or 4 percent of U.S. adults reported recently using sleep medication, CDC's National Center for Health Statistics said in a report. But data showed higher use among middle-aged adults ages 50 to 59 and the elderly. Six percent of those ages 50 to 59 said they had taken a prescription sleep pill in the last 30 days, and 7 percent of those age 80 and older reported such use. In between, the numbers dip slightly below 6 percent for those in their 60s and 70s. In comparison, just 2 percent of those aged 20-39 said they had recently taken a sleep aid. CDC researcher Yinong Chong said people in their 50s could have trouble sleeping because of work and family stress. "It gives the picture of a sandwiched group who has family, not only children but also probably elderly parents but still you're likely to be in the workforce, so you get squeezed at both ends in terms of family responsibility and job responsibility," she said. Sleep may improve when people retire before potential chronic health problems kick in and begin interfering with sleep, Chong said, adding more study is needed. The data also showed that 5 percent of women surveyed said they had recently taken a sleep aid compared to about 3 percent of male respondents, according to CDC's report. Chong said it was not clear why women were more likely to use the drugs. While previous data have tracked prescriptions dispensed for sleep aids, the CDC said its study is the first based on a survey of actual use of such drugs. Researchers for the Atlanta-based health agency's National Center for Health Statistics questioned a sampling of adults age 20 and older about whether they had used prescription sleep aids within the last 30 days and asked participants to show interviewers the prescription medication. "You get how many people are actually using them," Chong said in an interview, noting that prescription data could include multiple prescriptions for one patient or prescriptions that are never filled or even used. "This is actual use." CONTROVERSY OVER LINGERING EFFECTS Prescription sleep aids have become somewhat controversial because their effect can linger even after some patients wake up. The U.S. Food and Drug Administration has begun taking a closer look at sleep drugs, ordering lower-doses for Ambien and similar pills amid concerns that their active ingredient remained in patients' blood the following morning at levels high enough to make driving and other activities dangerous. And just last month, the FDA rejected an experimental sleep drug from Merck & Co Inc, saying the proposed doses were not safe but that a lower-dose version might be acceptable. Not surprisingly, respondents to CDC's study who said they slept five hours or less each night or those diagnosed with a sleep disorder were more likely to report using prescription aids. Additionally, more whites and people with higher levels of education also reported greater use, the agency said. Socioeconomic factors are likely behind those numbers, Chong said, since patients must be able to afford a doctor's care and the medication. According to prescription data from IMS Health, Ambien and other versions of the drug zolpidem was ranked 15th among the most dispensed medications in the United States. (Reporting by Susan Heavey; editing by Julie Steenhuysen and Cynthia Osterman) http://www.reuters.com/article/2013/08/29/us-usa-health-sleepdrugs-idUSBRE97S05720130829

Today's Datapoint

$470 million … in venture capital was invested in health care IT during the first half of 2013, the same as the entire year of 2010, according to Greg Vlahos of PwC’s Life Sciences practice

Quote of the Day

Unless a fix is enacted, “the ACA will shatter not only our hard-earned health benefits, but destroy the foundation of the 40-hour work week that is the backbone of the American middle class.” — The heads of three large labor unions warned Senate Majority Leader Harry Reid (D-Nev.) and House Minority Leader Nancy Pelosi (D-Calif.) in a scathing letter.

Delay on ACA Out-of-Pocket Maximum: Blessing or Curse?

By Lauren Flynn Kelly - August 22, 2013 An article that appeared in The New York Times recently called attention to a little-known delay on the implementation of a provision of the Affordable Care Act. This one pertains to out-of-pocket limits on consumer spending and requires health plans and employers to set an overall maximum, as opposed to separate limits for medical and pharmacy expenditures. The one-year grace period allows plan sponsors to delay setting the annual overall spending cap, which includes deductibles and copayments, at $6,350 for an individual and $12,700 for a family, until the 2015 plan year. More information about the grace period, which the Times gripes “was obscured in a maze of legal and bureaucratic language that went largely unnoticed,” is available as part of a series of frequently asked questions about the health care reform law that can be found at the Department of Labor website. As it turns out, those FAQs were issued in February, so this isn’t really news per se, but it’s created a media frenzy of bloggers and journalists bemoaning yet another delayed provision of the Affordable Care Act. And the Times isn’t wrong: The language is confusing. From what I understand, if a group health plan uses more than one benefit service provider, such as a health insurer and a PBM, separate spending caps could be established for major medical expenses and prescription drugs in 2014. The exception does not apply to individual plans. While patient advocates worry that the delay could cause considerable hardship for those with chronic conditions, it may give plan sponsors more time to iron out logistical dilemmas that arise from moving to a separate system of tracking pharmacy and medical out-of-pocket cost maxes to aligning those efforts to track overall expenditures. What administrative difficulties will this provision create for plans, and is the one-year grace period likely to help their efforts to comply? http://aishealth.com/blog/pharmacy-benefit-management/delay-aca-out-pocket-maximum-blessing-or-curse?utm_source=Real%20Magnet&utm_medium=Email&utm_campaign=26445159

New data show antipsychotic drug use is down in nursing homes nationwide

Nursing homes are using antipsychotics less and instead pursuing more patient-centered treatment for dementia and other behavioral health care, according to new data released on Nursing Home Compare in July by the Centers for Medicare & Medicaid Services (CMS). Unnecessary antipsychotic drug use is a significant challenge in dementia care. CMS data show that in 2010 more than 17 percent of nursing home patients had daily doses exceeding recommended levels. In response to these trends, CMS launched the National Partnership to Improve Dementia Care in 2012. “This important partnership to improve dementia care in nursing homes is yielding results,” said Dr. Patrick Conway, CMS chief medical officer and director of the Center for Clinical Standards and Quality. “We will continue to work with clinicians, caregivers, and communities to improve care and eliminate harm for people living with dementia.” The Partnership’s goal is to reduce antipsychotic drug usage by 15 percent by the end of 2013. These new data show that the Partnership’s work is making a difference: • The national prevalence of antipsychotic use in long stay nursing home residents has been reduced by 9.1 percent by the first quarter of 2013, compared to the last quarter of 2011. • There are approximately 30,000 fewer nursing home residents on these medications now than if the prevalence had remained at the pre-National Partnership level. • At least 11 states have hit or exceeded a 15 percent target and others are quickly approaching that goal. The states that have met or exceeded the target are: Alabama, Delaware, Georgia, Kentucky, Maine, North Carolina, Oklahoma, Rhode Island, South Carolina, Tennessee and Vermont. The Partnership aims to reduce inappropriate use of antipsychotics in several ways – including enhanced training for nursing home providers and state surveyors; increased transparency by making antipsychotic use data available online at Nursing Home Compare; and highlighting alternate strategies to improve dementia care. Since its launch in early 2012, the goal of the Partnership has been to improve quality of care and quality of life for the country’s 1.5 million nursing home residents. This broad-based coalition includes long-term care providers, caregivers and advocates, medical and quality improvement experts, government agencies, and consumers. For more information on the Partnership’s efforts to reduce use of antipsychotic drugs in nursing homes, please visit the Advancing Excellence in America’s Nursing Homes website: http://www.nhqualitycampaign.org/star_index.aspx?controls=MedicationsExploreGoal.

Young Adults Unaware of ACA Exchanges

Published: Aug 21, 2013 By David Pittman, Washington Correspondent, MedPage Today Only 27% of young adults said they were aware of the Affordable Care Act's health insurance exchanges that are launching Oct. 1, a survey released Wednesday showed. Furthermore, those most likely to benefit from the ACA's exchanges and expanded coverage are the least likely to be aware of the exchanges, the liberal Commonwealth Fund said in the survey "Covering Young Adults Under the Affordable Care Act." Just 19% of young adults who were uninsured in the last year and 18% of low-income adults were aware of the exchanges -- or marketplaces, as they are sometimes called -- according to the survey. "These facts are concerning because young adults as a group have some of the highest uninsured rates and therefore stand to gain a lot from knowing about their options for affordable health coverage," Commonwealth Fund President David Blumenthal, MD, told reporters on a conference call. The low awareness could also be damaging for the ACA as a whole, health experts said, since insurers need the young, healthy premium payers to offset the costs of the older, sicker, and more expensive new enrollees. "If young, healthy people do not enroll, premiums will be much higher for those that do," David Howard, PhD, associate professor of health policy and management at Emory University in Atlanta, told MedPage Today. "Efforts to publicize the exchanges are just getting off the ground, but clearly the federal government and participating states have their work cut out for them between now and January 1, when coverage becomes effective." The exchanges will serve as a forum for the uninsured and small business employees to comparison-shop for plans. While the exchanges are open to all without employer-sponsored coverage, those making between 100% and 400% of the federal poverty line will be eligible for federal tax credits to help defray to cost of insurance. To conduct the survey, the Commonwealth Fund asked 3,530 adults ages 19 to 29 via email to complete an online questionnaire from February 11 to March 14. The survey had a 53.4% response rate. While the numbers for young adult awareness must improve, officials at the Commonwealth Fund said they are confident that young people will eventually come to shop for coverage in the ACA's marketplaces, based on experiences with the universal coverage program in Massachusetts. For example, Wednesday's survey found awareness in the ability to stay on parents' health plans through age 26 increased from an estimated 13.7 million in November 2011 to 15 million in March 2013, when this survey was conducted. "It's possible that young adults' awareness is significantly higher than it was in March," said Sara Collins, PhD, Commonwealth Fund vice president of affordable health insurance. "Over the next 6 months, awareness is likely to increase as more outreach is conducted." The survey identified education level as a factor for the marketplace's awareness. One-third of college graduates were aware of the exchanges, compared with 20% of those with a high school degree or less. The Commonwealth Fund said the results help dispel the notion that young adults don't think they need health insurance. They found 5% turned down coverage because they felt it was unnecessary when offered by an employer. Two-thirds took the coverage and 22% said premiums were unaffordable. Howard said the term "unaffordable" is subjective. "The survey shows that young adults will accept coverage if it is free or heavily subsidized," he said. "However, it does not address the question of how much they are willing to pay for coverage." A total of 82% of young adults who were uninsured at some point in 2013 would be eligible for subsidized insurance through the ACA's exchanges or expanded Medicaid, the Commonwealth Fund found. That's why Collins and Blumenthal were concerned that nearly half of states weren't going to expand their Medicaid programs, leaving potentially millions of young adults without coverage, they said. While the think tank didn't say how many young adults would be shut out of coverage in states where Medicaid isn't being expanded, 28% of those who were uninsured at some point in 2013 made less than the federal poverty level and wouldn't be eligible for the exchange subsidies offered to those making between 100% and 400% of the poverty line. http://www.medpagetoday.com/Washington-Watch/Reform/41103?xid=nl_mpt_DHE_2013-08-22&utm_content=&utm_medium=email&utm_campaign=DailyHeadlines&utm_source=WC&eun=g350341d0r&userid=350341&email=john@thebrokerageinc.com&mu_id=5344066