Last week’s release by the Centers for Medicare & Medicaid Services (CMS) of the 2017 Medicare Advantage (MA) Advance Notice of Methodological Changes and Call Letter ended the mystery surrounding potential policy and payment changes on the horizon. As our Founder and Executive Chairman, John Gorman, recently noted: “There’s a lot to like — and much to fear.” Although CMS is proposing higher-than-expected rates for 2017 and has introduced both payment and Star Ratings relief for plans serving dual-eligible beneficiaries, this positive news was counterbalanced somewhat by a number of factors, including proposals to increase compliance scrutiny in challenging areas such as network adequacy, provider directory accuracy, and medication therapy management programs.
As anticipated from a Star Ratings perspective, there were few surprises but quite a bit of noteworthy evolution for MA this year. CMS’ proposals include:
- Accounting for the Star Ratings Impact of Dual-Eligible and Disabled Beneficiaries:
After a lengthy research process and significant pressure from the industry, CMS proposes moving forward with an interim analytical solution to account for the Star Ratings impact of dual-eligible and disabled beneficiaries. Despite the fact only a handful of plans would likely gain or lose a full half-star in their rounded overall Star Rating, this is a huge methodological win for plans serving dual-eligible members and will be important to monitor closely. When combined with CMS’ simultaneous proposal to adjust revenues based on beneficiaries’ status as either full duals, partial duals, or non-duals, as well as for their status as both aged and/or disabled beneficiaries, my colleague, Dan Weinrieb, advises, “This will mean timely reconciliation and maintenance of clean enrollment data has never been more important for MA plans.” This proposal, in combination with the proposed strategy to account for the lack of low-income subsidy (LIS) support to meet Puerto Rican beneficiary needs, reflects a noteworthy shift in CMS’ willingness to adjust the Star Ratings program to account for scientifically-supported evidence of nuances within MA.
- In-Home Risk Assessments
CMS’ decision to leave in-home risk assessments untouched is great news for the many MA plans who are leveraging these important visits not only for risk adjustment, but also to connect members with needed care (as measured by Healthcare Effectiveness Data and Information Set (HEDIS®) and Prescription Drug Event (PDE) Star Ratings measures), to coordinate care across the spectrum of providers (as measured by Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Star Ratings measures), and to help support member’s social and lifestyle challenges (as measured by Health Outcomes Survey (HOS) Star Ratings measures). We interpret this to mean CMS now better understands the incredible value in-home care can bring to a patient’s holistic healthcare experience. However, despite this welcome news, plans should certainly ensure their program adheres to the best-practice expectations previously set forth by CMS, and supported by encounter data, in order to drive payment.
- Termination of Contracts Below 3 Stars for 3 Years
CMS not only reaffirmed its previously-announced plans to terminate contracts earning 3 consecutive Part C or Part D Summary Ratings of less than 3 stars, but also set forth an annual calendar by which this practice will become standard. With CMS guidance indicating these termination decisions are non-negotiable, plans will likely expedite efforts to improve Star Ratings performance such that impactful work begins as soon as it looks possible their first Summary Rating below 3 stars may be on the horizon.
- Connecting Compliance and Star Ratings
From a compliance perspective, CMS proposes to continue strengthening its connections between compliance, data integrity, and Star Ratings. CMS reminds organizations of its policy to reduce a contract’s measure rating to 1 star if it’s determined biased or erroneous data was submitted. Our experience this year indicates CMS is leveraging this authority much more frequently than it has in past years, which means plans will want to pay particular attention to Medicare Plan Finder and PDE data requirements, Organization Determinations, Appeals, and Grievances (ODAG) and Coverage Determinations, Appeals, and Grievances (CDAG) processes, internal controls to prevent errors in operational areas directly impacting the data reported or processed for specific measures, and Part C and D reporting requirements data validation for specific measures. CMS points out, and we’re hearing evidence to support, it continues to identify new vulnerabilities where inaccurate or biased data could exist, which could result in the reduction of a star measure to 1 star. As my colleague, Regan Pennypacker, details in her recent article, CMS’ proposed changes will require plans to “implement creativity and do more with less while enhancing the beneficiary experience.” Certainly this will be no easy task as we survive 2016 and plan for 2017 under a new administration.
- Measure Updates
CMS is not proposing to add any new measures to the 2017 Star Ratings, although several measure specification changes are proposed for use in the 2017 ratings. As previously proposed, CMS indicated both the Improving Bladder Control (Part C) and High Risk Medication (Part D) measures will be moved to the Display page for 2017.
CMS proposes the addition of two new measures to the 2018 ratings (based on 2016 services/operations): Medication Reconciliation Post-Discharge and Hospitalization for Potentially Preventable Conditions. Addition of previously-proposed statin therapy and asthma measures were pushed out at least another year, possibly as a show of support for the recently-released and newly-aligned quality measures, giving plans a bit of breathing room to work with providers in this new area.
As we look ahead with CMS’ foreshadowing of future program updates, continued attention is being paid to Care Coordination measures (with the National Committee for Quality Assurance’s (NCQA’s) assistance) and Depression measures (with NCQA and Minnesota Community Measurement’s support), and the Advance Notice highlights a number of potential measure specification changes, which may take effect for the 2018 ratings.
Whether your organization is working to improve performance on your entire Star Ratings program, or just a few Star Ratings measures, or needs assistance understanding how the proposals contained in the Advance Notice may impact your plan, we can help. For additional questions and inquiries about how Gorman Health Group (GHG) can support your organization’s Star Ratings programs, please contact me directly at firstname.lastname@example.org.
On Tuesday, March 1, from 2:30-3:30 pm ET, join John Gorman, GHG’s Executive Chairman, and colleagues Olga Walther, Senior Legislative & Policy Advisor, and Leslie Mullins, GHG’s Senior Consultant, as they provide a hard-hitting analysis of critical areas addressed in the document. Learn what the proposed “methodology changes” could mean for your organization and your partners and the steps you can take to soften the impact. Register now >>
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