How Top Ranked MA Plans Earn Their Stars

Christopher Cheney, for HealthLeaders Media, October 20, 2014

High-ranking health plans in the Medicare Advantage program share the strategies that have led to their success.

Garnering high marks in the Medicare Advantage five-star ratings program involves a complex set of factors that can change from one year to the next.

Health plan executives say the key drivers for achieving star ratings success are commitment to quality across their organizations and provider networks, sharing healthcare data in real time, and the ability to annually adapt to changes in how the plans are evaluated by the Centers for Medicare & Medicaid Services.

CarePlus Health Plans Inc., a subsidiary of Louisville, KY-based Humana, which offers MA coverage to thousands of seniors in Florida, is among 16 MA carriers that earned five-star ratings for 2015. David Jarboe, regional president of CarePlus, says a commitment to quality care is essential to achieving a high star rating.

"We believe our five-star achievement is due to our entire company's focus on achieving the best clinical and customer service possible, and improving each year," he says. It's an accomplishment that "couldn't have been achieved without our outstanding team of employees and the physicians who care for our members and partner with us to focus on preventive care and disease management."

Jarboe says successful MA health plans need to have a shared commitment to quality and attention to stars-rating metrics with their physician networks. "We work hand-in-hand with our physicians to actively educate and engage our members to improve their health outcomes," he says.

"We believe programs like our diabetic initiative, which encourages diabetic retinal exams, and our medication compliance and adherence outreach, have not only improved our star ratings but also and, more importantly, truly made a difference in the health and quality of life for our members."

Collaboration has been an essential element in boosting MA stars ratings at Franklin, TN-based Cigna-HealthSpring as well

"[We] made significant improvement with our 2015 star ratings, increasing our percent of membership in a four-star or higher plan from about 38% to 57%," the company said in a prepared statement.

"Our physician engagement model works collaboratively with both our network doctors and customers to align incentives and resources around quality health care results, which correlate directly with star rating measures. We've had the strongest results in markets where our networks are more engaged and aligned with our quality efforts."

Crossing the four-star threshold is a prime goal for all MA health plans because the high rating on the five-star scale makes insurance carriers eligible for quality bonus payments from CMS.

Portland, ME-based Martin's Point Generations LLC has earned a five-star MA rating in 2015, 2012 and 2010. Rebekah Dube, VP of senior products for Martin's Point, says a commitment to quality inside the organization and with all of its partners has been crucial.

"Across the organization, you have to have people working together," she says, noting that teamwork optimizes chronic disease management. "You have to have your physician network onboard, and you have to have your customer service people engaged."

Dube says high-quality customer service is both challenging and rewarding for MA health plans. "It's such a critical piece. We really value our relationship with our members and how they trust us," she said. "Every single interaction you have with a member is a moment to make an impact."

Martin's Point customer service representatives "have consistent, scripted conversations" with members, but the commitment to quality service does not stop there, Dube said. "We want to make sure you are getting the best care possible," she said, noting customer service representatives give members prevention tips and diplomatically inquire about whether members are in compliance with chronic condition care. "This isn't just about checking off a box for them."

CarePlus' Jarboe agrees that customer service is important. "The survey measures that assess member perception about a plan's performance are more subjective and are limited to a small sample of members, so that can be challenging. We have worked hard to improve customer service and believe that is a big factor in our becoming a five-star health plan," he said.

Tracking the Data
Dube, who has been an MA stars-rating program leader at Martin's Point for four years, says getting a real-time handle on healthcare utilization data is a make-or-break challenge.

"As the star-ratings program unfolded, what became very apparent was if you didn't have the data, you weren't going to achieve your full potential," she says.

But MA data provided to health plans by CMS is notoriously tardy. So Martin's Point developed its own ways to use real-time data to drive results. "We needed to be able to monitor ourselves. We worked with our data management team internally to build up our processes," Dube says.

Dube says Martin's Point has mastered tracking several data points in the NCQA's Healthcare Effectiveness Data and Information Set, particularly for key star-ratings metrics such as blood sugar management, blood pressure control and process measures such as compliance with testing schedules.

Pharmacy data has been a thorny area for MA health plans, she said. "CMS provides tracking and trending pharmacy data, but there's a lag there," Dube says. "We've built our own processes to follow member compliance on medication."

Moving Metrics

One obstacle common to all government-sponsored business lines is adapting to regulatory changes.

ratings. We will have to continue to improve our performance year-after-year in order to maintain our current five-star rating," Jarboe says.

"In general, we work to improve all areas and dedicate resources to improve ourselves each year. Quality improvement is a mindset that requires constant oversight to improve and maintain what we have achieved."

Dube says MA health plans must have flexibility ingrained in their business culture.

"It's not standing back and saying, 'No, we can't do that.' It's taking a problem-solving approach," she said. "We know that this business is rapidly changing, and that's not going to stop. Grounding our team in that mentality is really important."

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Christopher Cheney is health plans editor at HealthLeaders Media.

 

http://www.healthleadersmedia.com/content/HEP-309471/How-TopRanked-MA-Plans-Earn-Their-Stars

According to a recent survey of Electronic Health Record (EHR) users:

• 26% reported accessing their EHR from a mobile device such as tablet or smartphone
• 76% reported accessing via desktops and/or laptops (users were allowed to select multiple devices)
• 58% of users who accessed their EHR from a mobile device were "very satisfied" with their EHR, compared to 28% of non-mobile users
• Learning how to use their EHR system was challenging to 39% of mobile users, versus 58% of non-mobile users
• 73% of mobile users said that decreased productivity due to their EHR use was not a challenge, compared to 42% of non-mobile users

Source: "Electronic Health Records Software UserView | 2014," Software Advice/Research Now Press Release, October 14, 2014, http://www.softwareadvice.com/medical/userview/ehr-report-2014/ 

Nearly 33.3% Of Medicare Advantage Enrollees Are In PPOs

According to a recent web briefing from Kaiser Health News:

• 70% of Medicare enrollees are in Traditional Fee-for-service Medicare.
• 30% of Medicare enrollees are in Medicare Advantage plans.
• 64% of Medicare Advantage members are in HMOs.
• 23% of Medicare Advantage members are in Local PPOs.
• 8% of Medicare Advantage members are in Regional PPOs.

Note: Total Medicare Advantage Enrollment, 2014 = 15.7 Million


Source: Kaiser Health News

Today's Datapoint

Fewer than 60,000 Medicare claims appeals were received by Administrative Law Judges in 2011, a number that jumped to more than 360,000 in 2013.

Quote of the Day

“There used to be the feeling among doctors that admitting patients the day before surgery and getting a good night’s sleep in the hospital before surgery was a good thing to do. But now that hospitals are being audited, they have to be more conscious about doing things that are noncompliant and one of those things is admitting patients before surgery for a convenience night.”



— Ronald Hirsch, M.D., vice president of regulations and education at Accretive Physician Advisory Services, told AIS’s Report on Medicare Compliance.

According to projections in a recent report,

...in 2014, a man would need $64,000 in savings and a woman would need $83,000 if each had a goal of having a 50% chance of having enough money saved to cover health care expenses in retirement.

Source: "Needed Savings for Health Care in Retirement Continue to Fall," Employee Benefit Research Institute (EBRI) Press Release, October 28, 2014, http://www.ebri.org/pdf/PR1097.HlthSvgs.28Oct14.pdf

5 more ways a Republican Congress could change PPACA

Nov 06, 2014 | By Allison Bell

The Republicans will hold a majority of the seats in the Senate in 2015, and a big majority in the House.

Yesterday, we looked at 5 ways Republican control over both chambers of Congress might affect actions involving the Patient Protection and Affordable Care Act (PPACA) and other health policy issues.

Today, we'll look at how Republican control over Congress might affect the implementation -- or lack of implementation -- of specific PPACA provisions.

One obstacle facing Republicans is that the Republican majority will have too few seats in the Senate to force ordinary bills to the Senate floor, or to overturn presidential vetoes.

Another challenge may be intra-party disagreements about policies and strategies. In recent years, House Republicans could count on getting almost all Republicans to vote with the party leadership on all votes. In the Senate, the Republicans suffered from a few defections on key votes, but not many.

This week, there are signs that Republicans could face divisions in the Senate, with Sen. Ted Cruz, R-Texas, and other Tea Party populists challenging traditional Republicans, like current Senate Republican Leader Mitch McConnell, R-Ky., who have been open to talking to representatives from insurance companies and other big businesses, and who have been open to compromising with the Democrats on some critical votes.

But the Senate Republican majority is young, and it's possible that, in some cases, "populism" may be a euphemism for "dissatisfaction with financial support."

McConnell, for example, received $903,000 in contributions from individuals and political action committees in the insurance sector for the current election cycle, and insurers rank fourth on his sector contributor list, according to OpenSecrets.org. Health services organizations and health maintenance organizations (HMOs) have contributed $490,226. Cruz, in contrast, has received just $24,585 from insurance sector contributors and only $7,600 from health services companies and HMOs.

Here's a look at what happens to five controversial PPACA provisions if the traditional Republicans prevail or the populists prevail.

1. Exchange plan performance reporting requirements.

The PPACA proposals with the best chances of becoming law may be those that are small and cheap, and won some Democratic support in the House before Nov. 4 -- when Senate Democratic leaders generally declined to touch, let alone talk about, PPACA bills that came from the House.

In January, Reps. Lee Terry, R-Omaha, Neb. and Bill Cassidy, R-La., were trying to drum up support for H.R. 3362, a bill that would have required the U.S. Department of Health and Human Services (HHS) to publish weekly PPACA exchange activity reports in a specified format.

That bill attracted yes votes from 33 House Democrats, including Democrats such as Rep. Albio Sires, D-N.J., who have rarely crossed party lines when voting.

Our prediction is that Republicans may be able to make a PPACA exchange reporting measure law, even if President Obama vetoes it.

2. Medicaid expansion.

Many Republicans have opposed the idea of states taking PPACA Medicaid expansion money from the federal government, arguing that the federal government doesn't really have the money, and that the stream of funding will be unstable.

But hospitals love what Medicaid expansion is doing for their revenue and profits. Hospitals have contributed about $9.2 million to Republican candidates during the current election cycle, and they have strong ties to the Republican Party. William Frist, a former Republican Senate majority leader, is from the family that started HCA, a big hospital company.

Health insurance groups generally seem to like having a chance to bid on Medicaid program administration contracts, and insurance producer groups cannot typically show that members are jumping over themselves to sell private plans to the poorest consumers.

Republicans seem to be unlikely to have much luck with repealing the Medicaid expansion program, until and unless major problems crop up.

3. The medical loss ratio (MLR) formula.

The PPACA medical loss ratio (MLR) provision requires major medical carriers to spend at least 85 percent of large-group revenue and 80 percent of individual and small-group revenue on health care or quality improvement efforts.

The current formula keeps insurers from including compensation for agents and brokers in the medical spending totals.

Producers have been lobbying for years to get broker comp taken out of the calculations altogether, arguing that the consumers are the ones who really pay the brokers, and that insurers simply collect the payments to the brokers to make life easier for the customers.

Most Republicans have been supporting producers on this issue, and many Democrats expressed sympathy.

Some state-based public exchange programs have been trying harder to get support from agents and brokers.

Republican control of Congress may help producers get their way on the MLR issue, especially if public exchange program managers come to see the issue as a way to make friends with key distributors, and Democrats and traditional Republicans see siding with brokers on the issue as a way to unleash their inner populists.

4. Cadillac plan excise tax.

Starting in 2018, the PPACA Cadillac plan excise tax is supposed to impose a 40 percent tax on the issuers of expensive health benefits packages. The tax could apply to individuals with health benefits worth more than $10,200 and families with benefits worth more than $27,000.

Large employers hate the tax. Some health policy specialists -- including Republicans -- have argued for years that the United States could hold down health care spending and health insurance costs by capping or eliminating the group health tax exclusion. Some have said that the Cadillac plan excise tax might be the PPACA provision most likely to help hold down health care costs.

Tea Party members might see opposing the tax as a way to speak up for economic freedom, but some may view fighting it as an example of traditional Republicans helping big corporations outlobby the people.

Another issue is that opponents of the tax may have ways to avoid it without going through Congress. They may be able to persuade the Internal Revenue Service to postpone implementation.

Moreover, because the tax won't take effect until 2018, opponents have a shot at being able to get the next president to sign a Cadillac plan tax repeal bill between 2016 and 2018.

Democratic supporters of PPACA may also be open to see accepting an excise tax repeal proposal as something they could trade to protect other PPACA provisions they like more.

 

http://www.lifehealthpro.com/2014/11/06/5-more-ways-a-republican-congress-could-change-ppa?eNL=545bf610160ba0fe2f3aa9d6&utm_source=HCRW&utm_medium=eNL&utm_campaign=LifeHealthPro_eNLs&_LID=105824905