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1
BLENDED RISK SCORESTHE NEW MATH
Presented By:
Pam Klugman
November 2013
Topics for Discussion
• Key Elements for Risk Adjustment
• What’s Out / What’s In
• Blended Risk Score Examples
• Q & A
Physician SGR Cut
SSA mandates MA growth percentage be tied to overall FFS growth expectations. • A 25% reduction to the the physician fee
schedule would have been a negative 2.2% in overall payments
This change by CMS allowed a positive 3.3% cost factor to offset some of the other changes rather than a 2.2% reduction.
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FFS Normalization Factors
Designed to assess difference in Health Conditions between FFS and MA• 2 Normalization Factors, due to blended
rates• 25% on 2013 Model – 1.041• 75% on 2014 Model – 1.026
Overall this is a negative adjustment
Rebasing County Rates
This Rates adjust based on the FFS‐based components of MA rates on the most recent historical claims costs from the FFS program. • ACA requirement that 100% of MA rates will
be based on FFS costs• 2014 adjustments Uses Claims from 2007 to 2011
MA Coding Patterns
CMS adjusts rates based on higher pattern of coding under MA
This is called the MA Coding Intensity adjustment • 3.41% for 2013 • 4.91% for 2014* So you need to get 1.5% better in coding to break even on coding
Negative adjustment – as plans get better at coding and data capture the adjustment goes up
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Sequestration & MLR
• Sequestration added a 2% across the board payment cut• Duration – Unknown
• 85% Medical Expense Ratio • Implications to plans with high margins
likely offset by Sequestration reduction this year.
Star Ratings
• Quality Bonus Incentives tie to HEDIS and Satisfaction Measures
• Plan and Physician satisfaction are critical for bonus payments – similar to how ACO’s need to handle their populations to be successful
• 4‐5 stars .5 to 1% bonus• This becomes a market differentiator over time• 5 star plans have continuous enrollment also
Risk Adjustment Model• CMS‐HCC Model has been clinically revised
• Current Model (V. 12) 70 HCCs• New Model (V. 22) 79 HCCs
• In an attempt to mitigate changes resulting from the move to HCC model 22 CMS will blend the risk score for 2014• V.12 @25%• V.22 @ 75% for 2014
• Full transition to V.22 by 2015
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CMS Sweep Information
DOS Sweep Payment Received Payment Year
07/2011 ‐ 06/2012 First Friday in Sept 2012 Jan ‐ Jun 20132013
01/2012 ‐ 12/2012 First Friday in Mar 2013 Jul ‐ Dec 20132013
01/2012 ‐ 12/2012 Last Day of Jan 2014 Aug ‐ 2014Final 2013
What’s Out&
What’s In
What’s Out• 131 ICD‐9 codes discontinued mapping to
CMS‐HCC
•Celiac Disease•CKD Stage 1‐3•Diabetes (change in mapping, dropped HCCs)
•Major Complications of Medical Care & Trauma
•Old MI, Asphyxia & Hypoxia
•Pancreatic Disease•Peripheral Neuropathy, Polyneuropathy•Skin Ulcer , not all included in new model
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What’s In• 226 new ICD‐9 codes mapping to CMS‐HCC
• Coagulation Defects & Other Specified Hematological Disorder
• Diabetes regrouped to 3 categories• Endocrine & Metabolic Disorder• Fibrosis of Lung and Heart Chronic Lung
Disorders• Morbid Obesity• SIRS
Disease Interactions
• Model V.12• 6 Interactions at Community factor Level• 5 Interactions at Institutional Factor Level
• Model V. 22• 6 Interactions at Community Factor Level• 12 Interactions at Institutional Factor
Level�
Health Risk Assessments
Diagnosis codes from Health Risk assessments MAY no longer count for Risk Adjustment• A follow up visit may be required related to
any coding captured during a health risk assessment• Significant implications for home
assessment companies• Was to be in August 2013 software
release• Delayed as of 5/14/2013 CMS Memo
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The Moving PartsCMS HCC V. 12 CMS HCC V. 22
ICD‐9 Description ICD‐9 Codes HCC Weight HCC Weight2 Reason
DMII WO CMP UNCNTRLD 250.02 19 0 19 0 1
DMI NEURO UNCNTRLD 250.63 16 0.371 18 0.368
BIPOLAR AFFEC, MANIC‐MOD 296.42 55 0.360 58 0.330
NEUROPATHY IN DIABETES 357.2 71 0.321 18 0 1
PERIPH VASCULAR DIS NEC 443.89 105 0.302 108 0.299
OLD MYOCARDIAL INFARCT 412 83 0.17 N/A 0 2
Totals 1.524 0.997
Normalization Factor 1.041 1.026
Normalized Score 1.464 0.972
% of Normalized Score 25% 75%
Scores before blending 0.366 0.729
Total Blended weight before coding intensity factor 1.095
Legend
1Lower in hierarchy than 16
2Removed from CMS HCC model V. 22
How It All Adds Up
Description CMS HCC V. 12 Blended CMS HCC V. 22
Assuming base rate of $950 $ 1,391 $ 923
Coding Intensity Factor 2013 3.41
Coding Intensity Factor 2014 4.91 4.91
Amount after factor applied $ 1,343 $ 878
Before Coding Intensity applied $ 1,040
Net after Coding Intensity 2014 $ 989
Factor Matrix
Normalization FactorsCoding Pattern
Differences
CMS‐HCC
CMS‐HCC ESRD Functioning Graft
StatusCMS‐HCC ESRD Dialysis Model CMS‐HCC PACE RxHCC CMS‐HCC
2011 1.058 1.088 1.060 N/A N/A N/A
2012 1.079 1.051 1.012 1.051 1.032 3.41
2013 1.028 1.07 1.023 1.07 1.034 3.41
2014 for 2013 Data 1.041 N/A N/A N/A N/A N/A
2014 for 2014 Data 1.026 1.085 1.039 1.085 1.030 4.91
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2013 Annual Conference
Stars and HCC Taking Advantage of Overlaps
Presented By: Mechelle ReedNovember 2013
2013 Annual
Conference
CMS Star ratingsWhy are stars a big deal !
Everyone is discussing CMS Star Ratings and ways to become a 5 star health plan.
Plans that don't earn high ratings (i.e. 4 or more stars) this year will take payment hits in 2015.
Under the Affordable Care Act the government uses the star rating as a financial incentive to reward high quality plans with bonus and rebates
2
2013 Annual
Conference
CMS Star ratings The higher the star rating, the more plans will
receive in revenue from the government.
There are also consequences for low performing plans. Plans with fewer than 3 stars consistently over the prior three years are flagged as low-quality on the Medicare website.
CMS will terminate contracts that are consistently low performing.
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2
2013 Annual
Conference
Medicare uses information from member satisfaction surveys, plans, and health care providers to give overall performance star ratings to plans.
A plan can get a rating between 1 and 5 stars. A 5-star rating is considered excellent.
Ratings help to compare plans based on quality and performance.
What are Medicare Stars
4
2013 Annual
Conference
The ratings are updated each fall and can change each year
5-star plans are designated with this special icon:
Ratings
5
2013 Annual
Conference
Star Ratings A plan can get ratings between 1 and 5 stars (Some
plans may be two new or not have enough data to be rated)
5 stars = Excellent
4 stars = Above average
3 stars = Average
2 stars = Below average
1 star = Poor
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3
2013 Annual
Conference
Performances MeasuresMedicare Measures how well health and prescription
drug plans perform on 50 items, which are grouped in five domains:
Staying Healthy: screenings, test, and vaccines
Managing Chronic long term conditions
Member experience with health plan
Member complaints, problem getting services, and improvement in the health plan's performance
Health plan customer services
7
2013 Annual
Conference
CMS Star ratingsWhy are stars a big deal !!!
Everyone is discussing CMS Star Ratings and ways to become a 5 star health plan.
Plans that don't earn high ratings (i.e. 4 or more stars) this year will take payment hits in 2015.
Under the Affordable Care Act the government uses the star rating as a financial incentive to reward high quality plans with bonus and rebates
8
2013 Annual
Conference
CMS Star ratingsWhy are stars a big deal !!!
Everyone is discussing CMS Star Ratings and ways to become a 5 star health plan.
Plans that don't earn high ratings (i.e. 4 or more stars) this year will take payment hits in 2015.
Under the Affordable Care Act the government uses the star rating as a financial incentive to reward high quality plans with bonus and rebates
9
4
2013 Annual
Conference
Performance - Drug Plans
Medicare drug plans are rated on how well they perform in 4 domains:
Drug Plan customer service
Member complaints, problem getting services, and improvement in the drug plan's performance
Health plan customer services
Member experience with drug plan
Patient safety and accuracy of drug pricing
10
2013 Annual
Conference
Measuring Quality
Medicare measures quality by a plans performance in the following:
Diabetes management
Controlling high blood pressure
Medication management
Medication Management
Call Center
Others
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2013 Annual
Conference
Receive regular reports from your Pharmacy Benefit Manager (PBM).
Include the PBM reports as part of your star review process• Get information from the PBM
• Review High Risk Medication Reports
• Medication Adherence reports etc.
Measuring Quality
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5
2013 Annual
Conference
Most HEDIS measures are now apart of Stars
Use the Clinical team, Compliance, and IT areas to become a successful plan
Identify your eligible population and administrative compliant members.
Review eligibility data and administrative claims and encounters data. Consider a weekly team meeting.
Stars and HEDIS
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2013 Annual
Conference
Building HEDIS like queries to generate current rates using HEDIS specifications for Star measures
Medical record retrieval for non-compliant members and exclusions. Review your data. Be aware of members which can be excluded from samples, or ways to assist in areas with non compliant members.
Reporting
14
2013 Annual
Conference
Consider opening direct authorizations for members which meet the requirements for quality measures.
Utilize staff resources within your organization that have direct contact with members such as Case Managers, schedulers to ensure members are scheduled for appointments.
Offer health clinics
Access
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6
2013 Annual
Conference
Provide physicians with “Approved” tools necessary to complete the task.
Tools should be clear and concise.
Are billing services and providers utilizing Category II codes to report performance measures such as:
Documentation of Reconciliation of Discharge Medication with Current Medication List (1111F)
History of codes
Physician Tools
16
2013 Annual
Conference
Use the data collection process for Stars as an opportunity to capture new HCCs.
Network expansion – Reach out to all providers regarding data submission. Review monthly encounter data reports for no or low submitting providers
Refresh your diagnosis reports
Are EMR capturing V-Codes to collect diagnosis important to Stars and bring revenue from HCC, such as Morbid Obesity
HCCs (Hierarchical Condition Categories)
17
2013 Annual
Conference
Most plans are already measuring a number of aspects in physician offices, especially those are profitability. But it’s important to also measure practice performance and patient outcomes to be successful with Stars.
Consider Physician Report Cards and Intervention Reports
HCCs (Hierarchical Condition Categories)
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7
2013 Annual
Conference
Changes as described in the final 2014 Call Letter (p100-114) will be implemented• Quality Improvement - Contracts held harmless
if individual measure stars are 5 stars in the 2 measurement years
• Low Performer Icon (LPI) - Contracts rated 2.5 stars or lower for any combination of their Part C or D summary ratings for 3 consecutive years will receive an LPI
2014 Changes
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2013 Annual
Conference
Rounding of measure data - Measure data and cut points rounded to whole numbers, except for Part C and D Complaints about the Health and Drug Plan, Health and Drug Plan Quality Improvement, and Part D Appeals Auto-Forward
Enrollment Timeliness –
Getting Information from Drug Plan -Removed from Star Ratings and Transferred
2014 Changes (Cont.)
20
2013 Annual
Conference
Questions?
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