Session 5 PD, Keys to Succeeding in the Medicare Advantage Market. Moderator/Presenter: Corey N. Berger, FSA, MAAA

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Session 5 PD, Keys to Succeeding in the Medicare Advantage Market

Moderator/Presenter: Corey N. Berger, FSA, MAAA


Dylan Ascolese, FSA, MAAA JoAnn Bogolin, ASA, FCA, MAAA Stephen Lawrence Webb, HEDIS, CHCA


005PD: Keys to Succeeding in the

Medicare Advantage Market

How to close the HCC gap?



• End to end RAPS submission test

• Prospective initiatives

• Chart reviews

• Monitoring and auditing


End to End RAPS Submission Test

• Ensure all diagnoses make it to the submission region

• How to test

– Obtain data set from provider and see if matches submission region

– Track a few claims from the intake process to submission

• Monitor and update the process as needed

Service Rendered

Claim/ Encounter

Clearing House

Data Repository

RAPS Submission



Examples of Submission Process Breaks

• Data file layout change

• Data repository change


• HIPAA 4010 vs 5010

• Data warehouse change


Prospective Initiatives

• Home Assessment

• Provider Outreach/Assessment

• Provider Contracting


Home Assessment

• Home visit from nurse practitioner or doctor

• Questionnaire type form

• Internal staffing vs external vendor

• Services performed

– Medication review and reconciliation – Home environment assessment

– Assess member for case/disease management program – Send information collected to member’s PCP


Home Assessment CMS Best Practice

• Performed by physicians, or qualified non-physician


• All components of the annual wellness visit, including a

health risk assessment such as the model health risk

assessment developed by the CDC

• Medication review and reconciliation

• Scheduling appointments with appropriate providers and

making referrals and/or connections for the enrollee to

appropriate community resources

• Conducting an environmental scan of the enrollee’s

home for safety risks, and need for adaptive equipment


Home Assessment CMS Best Practice

• A process to verify that needed follow-up care is provided

• A process to verify that information obtained during the assessment is provided to the appropriate plan provider(s)

• Provision to the enrollee of a summary of the information, including diagnoses, medications, scheduled follow-up

appointments, plan for care coordination, and contact information for appropriate community resources

• Enrollment of assessed enrollees into the plan’s disease management/case management programs, as appropriate


Provider Outreach/Assessment

• Work with providers to close HCC gaps

– Provide member lists with pertinent information – Use of tools such as a smart EMR

• Provider capabilities

– Web based tool or smart EMR

Costly to implement

Not all physicians using the same EMR

– Ability to bring member in

– Knowledge/education on HCCs to understand what to ask and how to document


Provider Contracting

• Pay per assessment

– Flat fee for filling out assessment – Difficulty with adherence

– Was the gap closed?


– Include with Quality incentives – Base on:

Chronic coding persistency

Year over year change in HCC score


Provider Contracting

Risk share

– Capitation: global vs partial

% of revenue vs flat pmpm

% of revenue: tied to revenue change

Flat pmpm: base on HCC scores or revenue change

– ACO/Shared Savings: capability of provider to handle downside risk

MLR vs medical expense savings

MLR: provider wins if revenue increases and/or medical expense trend slows

Medical Expense: need a separate incentive for HCC scores


Chart Reviews

• Retrospective: performed after year has ended

• Comb through medical charts for appearance of a

condition that triggers an HCC

• Create member list hierarchy based on remaining

suspect list


Monitoring and Auditing

• Very IMPORTANT!!!!

• Tracking number of gaps closed

– Home assessment – Provider assessment

– Year over year chronic coding persistency

• Monthly dashboard

• Feedback to providers


Monitoring and Auditing Continued

• Very IMPORTANT!!!!

• Auditing: ensure coding is accurate and scrupulous

practices are being performed

– Audit vendors, staff, and providers

– Audit the home/provider assessments – Perform multiple times during the year

• Promptly delete any HCCs which are unsubstantiated


005PD: Keys to Succeeding

in the Medicare Advantage


Are My Risks Scores Right?



The elements that go into risk scores


Adjusted for

– Age/gender

– Medicaid Eligibility – Institutional Status – Working-aged status


MA versus PD

Two different sets of coefficients

Not all HCC’s overlap between the two lists


Different HCC model for aged/disabled community (non-ESRD) than for long-term institutional residents



Keep in mind:

– Normalize risk scores for comparison

MA versus FFS


HCC Model changes

– Including different percentages of blending 2013 & 2014 models

– Understand your historical risk score trend


How Do I Know My Risk Scores Are Accurate?

• Year-over-year comparisons of own


Compare risk scores over time

Group membership by the following categories

– New-to-Medicare – New-to-Your-Plan – Existing

– Dis-enrolled

Compare medical expense and risk scores over time

Do medical costs and risk scores move in the same direction when they change?

Compare risk scores across your plans


How Do I Know My Risk Scores Are Accurate?

Review Risk Scores Across Your Organization's Plans


Mississippi Texas Texas Texas Individual Individual Individual D-SNP Plan Risk Factor 0.9300 0.9800 0.7300 1.2100


How Do I Know My Risk Scores Are Accurate?

Review Risk Scores Across Years


2011 2012 2013 2014 2015

Existing in Prior Year 1.0500 1.0630 1.0580 1.0200 1.0250

New to Medicare 0.4500 0.5500 0.5500 0.4500 0.5500

New to Your Plan 0.8930 0.9040 0.8990 0.8670 0.8710

Disenrolled 0.9950 0.9875 0.9900 0.9900 0.9760

Average Risk Score 1.0356 1.0418 1.0573 1.0150 1.0078


How Do I Know My Risk Scores Are Accurate?

Review Medical Expense and Risk Scores Across Plan Types / Years


2011 2012 2013 2014 2015


Allwd PMPM $828.50 $833.40 $845.80 $865.80 $896.60

Risk Score 1.0356 1.0418 1.0573 1.0150 1.0078

PMPM Ratio 1.0059 1.0149 1.0237 1.0356


Allwd PMPM $790.00 $791.20 $794.40 $810.29 $804.33

Risk Score 0.9875 0.9890 0.9930 0.9500 0.9470

PMPM Ratio 1.0015 1.0040 1.0200 0.9926


Allwd PMPM $944.00 $960.00 $1,000.00 $1,020.00 $1,012.50

Risk Score 1.1800 1.2000 1.2500 1.2100 1.1900

PMPM Ratio 1.0169 1.0417 1.0200 0.9926


How Do I Know My Risk Scores Are Accurate?

• Competitor Analysis

– databases contain

Benefit Designs,


STAR Ratings and

Membership by county by carrier.

– Are your premiums in line with similar benefit plans from your competitors

– Is your STAR rating in line with your competitors


Example of Competitor Analysis

• Given the following:



Risk Score 0.9750 x.xxxx

STAR Rating 3.5 3.5

Premium $75 $50

Cost Sharing

Inpatient Acute $250 / Day, Days 1-6 $200 / Day, Days 1-6 SNF $0 Days 1-20; $156 Days 21-100 $0 Days 1-20; $156 Days 21-100

Outpatient Sugery $175 / Visit $125 / Visit

PCP $15 / Visit $0 / Visit

Ref $35 / Visit $25 / Visit

Deductible $150 $150

Out-of-Pocket Maximum $6,700 $6,700


Example of Competitor Analysis


Standardized A/B Benchmark $856.38 $856.38 $856.38

Plan Risk Score 0.9750 1.0343 1.0199

Plan A/B Benchmark $834.97 $885.74 $873.43

Plan A/B Bid $800.00 $812.00 $800.00

Savings $34.97 $73.74 $73.43

Quality Bonus Rating 3.5 3.5 3.5

Rebate $22.73 $47.93 $47.73

Member Premium $75 $50 $50


How Do I Know My Risk Scores Are Accurate?

• CMS has released risk scores by:

Plan County

Part C / Part D

Latest risk scores are for 2012, released 12/30/2013



• Compare relationship of FFS costs by county released

with the rate book to understand expense (risk)

relationships between counties.


My Risk Scores are Decreasing! Now What?

• Easy Pickin’s

–Non-Acute diagnoses should follow beneficiaries from year-to-year

Particularly for chronic conditions

– RA, Cystic Fibrosis, Diabetes, COPD, CHF, CAF, e.g.

– ESRD – stages of ESRD change over time

» Dialysis

» Transplant, and

» Post-Graft/Functioning Graft

• 4-9 months

• 10 + months

Before digging into diagnoses data and medical charts:


My Risk Scores are Decreasing! Now What?

• Easy Pickin’s (continued)

Traditionally, physicians did not provide a complete listing of ICD-9 codes

From a Reden & Anders’ chart in the January 2008 edition of Managed Care:

– In 2008, once Medicare Advantage payments were based solely on HCC risk payments (phased in for 4 years, at 100% in 2007)

examining the conditions CAD, CHF, COPD, Cardiovascular Disease, Diabetes

» Approximately 17% of members with these conditions were reported as having these conditions in the 2nd year.

» Approximately 10% of members with these conditions were reported as having these conditions in the 3rd year.


What Else?

• Deeper Dive

– Prescription drugs that are taken by beneficiaries with certain conditions:

– Bronchodilators, ACE inhibitors, Beta- blockers, diuretics

– Prednisone – Insulin


Oxygen, face masks, ventilators, regulators, e.g.


What Else?

• Deeper Dive (continued)


There is a prevalence of specific pairs of co-morbid conditions

From Physical and Mental Health Condition Prevalence and

Comorbidity among Fee-for-Service Medicare-Medicaid Enrollees, CMS September, 2014:

– The five most common co-occurring condition groups were

» Heart conditions,

» Mental health conditions,

» Anemia,

» Musculoskeletal disorders and

» Diabetes

– 92% of Medicare-Medicaid enrollees who have diabetes also have a heart condition.

– 95% of enrollees with kidney disease also have heart conditions.

– 52% of enrollees with lung disease also have a mental health condition.


Now We Are In the Data

• Data Accuracy

Are demographics correct

Medicaid members accurately reflected

Are all diagnoses being submitted Are codes being submitted accurately

Using proper ICD-9’s, including the 2 digit extensions required, for example

Are there no corresponding diagnoses for any visits Number of HCCs reported for populations

Duals tend to have more HCCs than non-duals

Older beneficiaries tend to have more HCCs

If you are not seeing a significant difference in the number of HCCs between certain groups, you may be missing data.


Now We Are In the Data

Monitor Differences

– As you transition from ICD-9’s to ICD-10’s

ICD-10 is much more specific

– For diagnoses: 14,000+ ICD-9 codes and 68,000+ ICD-10 codes – For procedures: 3,800+ ICD-9 codes and 78,000+ ICD-10 codes

One ICD-9 diagnosis code can be represented by multiple ICD-10 codes

One ICD-10 diagnosis code can be represented by multiple ICD-9 codes.

Some ICD-10 codes have no predecessor ICD-9 codes


Now We Are In the Data

Monitor Differences

– As encounter data is introduced as a diagnosis source

Blend of risk scores from:

– Risk Adjustment Processing System (90%) – Encounter Data System (EDS) and FFS (10%)


Follow CMS Guidance

Chapter 7 of the Medicare Managed Care Manual

Ensure the accuracy and integrity of risk adjustment data submitted to CMS. All diagnosis codes submitted must be documented in the medical record and must be documented as a result of a face-to-face visit. The diagnosis must be coded according to International Classification of

Diseases, (ICD) Clinical Modification Guidelines for Coding and Reporting.

Implement procedures to ensure that

diagnoses are from acceptable data sources. The only acceptable data sources are

hospital inpatient facilities hospital outpatient facilities physicians.

Plan sponsors are responsible for determining provider type based on the source of the data.


Follow CMS Guidance (continued)

Submit the required data elements from acceptable data sources according to the coding guidelines.

Submit all required diagnosis codes for each beneficiary and submit unique diagnoses at least once during the risk adjustment data-reporting period.

For Part B-only beneficiaries enrolled in a plan, the plan sponsor must submit diagnosis codes under the same rules as for a beneficiary with both Parts A and B. The plan should also submit diagnosis codes for Part A services provided under a non-Medicare contract.

If upon conducting an internal review of submitted diagnosis codes, the plan sponsor

determines that any diagnosis codes that have been submitted do not meet risk adjustment submission requirements, the plan sponsor is responsible for deleting the submitted diagnosis codes as soon as possible.

Receive and reconcile CMS Risk Adjustment Reports in a timely manner.

Once CMS calculates the final risk scores for a payment year, plan sponsors may request a recalculation of payment upon discovering the submission of inaccurate diagnosis codes that CMS used to calculate a final risk score for a previous

payment year and that had an impact on the final payment.


Contact Information

JoAnn Bogolin, ASA, MAAA, FCA

Managing Director

Bolton Health Actuarial, Inc.

(404) 277-4328


005PD: Keys to Succeeding

in the Medicare Advantage


The Impact and Improvement of

Medicare Stars



• Impact of Stars

• Stars Improvement

• Stars Measure Review


Impact of Stars


Impact of Stars – Quality Bonus Payment

Overall Star Rating Quality Bonus Payment (QBP) Percentage

≥4.0 Stars 5.0%

Low Enrollment Plan 3.5%

New Contract Under a New Parent Organization


• The QBP above is the bonus payment in standard


• Qualifying counties receive a double QBP



Impact of Stars – QBP Rebate

Overall Star Rating Rebate Percentage

<3.5 Stars 50%

3.5 Stars ≤ Star Rating <4.5 Stars 65%

>4.5 Stars 70%

Low Enrollment Plan 65%

New Contract Under a New Parent Organization



Impact of Stars Improvement

• The potential quality bonus payment and rebates

that result from a plan’s Star rating are significant.

Additional impact of Stars include:

– Potential for being shut down for low performing plans – Year round marketing for 5 Star plans

– Stars improvement costs in staffing, consultants, and vendors


Medical Loss Ratio and Stars

• The resources dedicated to Stars measure monitoring,

analysis, and improvement can easily be millions of

dollars for mid-size to large plans.

• Quality improvement activities (QIA) are included in the


• Categories of QIAs* include activities that:

improve health outcomes.

prevent hospital readmissions through a hospital discharge program.

improve patient safety and reduce medical errors. promote health and wellness.

improve health care quality through improved healthcare data use

*Source: 42 CFR § 422.2430 Activities that improve health care quality.


Medical Loss Ratio Continued

• All QIAs* must be designed to:

– improve health quality.

– increase the likelihood of desired health outcomes.

– be for individual enrollees , specific segments of enrollees, or non-enrollees as long as no additional costs are incurred due to the non-enrollees.

– be grounded in evidence-based medicine and follow clinical best practices and criteria

*Source: 42 CFR § 422.2430 Activities that improve health care quality.


Medical Loss Ratio Continued

• Activities that are Not included in QIAs include


– designed primarily to control or contain costs. – funded outside of the premiums from the plan. – supporting non-quality administrative activities. – for marketing.

*Source: 42 CFR § 422.2430 Activities that improve health care quality.


Stars Improvement


High Level Stars Improvement Overview

Stars improvement is an iterative process between the plan, health care providers, and members. Plans need to use the administrative data that they have to identify areas for provider education, identify gaps-in-care that can be used in interventions, and develop incentive plans for providers and members.

Improve Clinical Data

Improve Member Care

Improve Member Experience

Administrative Data


Educate Providers

Identify Gaps in Care Incentive


Practitioner and Member Activity Health Plan Activity


Measure Level Stars Improvement

With an understanding of how a plan interacts with providers and members, measure specific Stars Improvement initiatives can be developed.

Planning for Improvement

Monitoring/Modifying Measure

Improvement Evaluating

Measures for Improvement


Steps for Successful Stars Improvement

Improvement Area # Step for Success Challenges and Common Problems

Evaluating Measures for Improvement


Establish a Stars Improvement Team

A balance between getting input from multiple functional areas and productivity is needed.

Executive sponsorship is needed for buy in from the rest of the health plan.


Identify Measures in Need of Improvement

This is the easiest step.

Most plans know which measures need improvement.


Evaluate Reason(s) for Poor Performance

Brainstorm with the Stars Improvement Team.

Try to divide the reasons into two broad categories 1. Care is provided, but data/evidence of the

care is not collected. 2. Care is not provided.


Develop a Strategy for Measure Improvement

This step is often skipped. Plans often develop improvement plans for individual measures without looking at all measures as a whole.

Successful Stars and quality improvement requires support from the entire organization and provider network, so a strategy is needed to plan for how these groups will be included in improvement activities.


Identify Measures of Focus for Improvement Efforts

A thoughtful approach needs to be taken for the measures of focus.

The lowest performing measures are not always the best measures for focus.


Stars Improvement Team

The Stars Improvement Team should develop an overall improvement strategy that integrates all functional areas of the organization and promotes the importance of Stars and quality performance throughout the health plan.

The team needs support of the organization to continue to improve.

Beyond developing an overall HEDIS improvement strategy, the group should be tactical and action focused with accountability to executive leadership.

Executive Sponsor

Clinical Lead / Analytic Lead Improvement Workgroup Lead

Healthcare Analytics Representative

Claims and

Encounters Rep IT Representative Network Operations Representative

Member Services Representative

Quality Management Representative

Pharmaceutical Services Rep


Steps for Successful Stars Improvement


Improvement Area # Step for Success Challenges and Common Problems

Planning for Improvement


Develop a Performance Measure Improvement Plan

Some plans implement activities without planning.

Some plans spend significant time preparing to implement performance improvement activities and miss opportunities because of the planning

Planning is needed, but activities have to move forward.

Improvement activities that have been successful for one plan may have a different impact on a different plan.

7 Implement the Plan

Implementing the plan can be delayed by over planning and problematic by under planning.


Steps for Successful Stars Improvement


Improvement Area # Step for Success Challenges and Common Problems

Monitoring/Modifying Measure Improvement

8 Monitor the Results of the Plan

Many plans only look at the year over year change or don’t monitor at all.

Executive leadership often wants quick impact on rates, but for some activities, rates may take years to change.


Evaluate the Success of the Performance Improvement Plan

Goals need to be set prior to improvement plan implementation and a cost/benefit analysis should be done on improvement plans as a whole and on

individual improvement initiatives as possible.


Modify the Plan Based on Issues Identified in the Evaluation

Many plans are trying many new activities.

Some activities will be hugely successful and others will not be as successful.

Plans should modify measure improvement initiatives as needed and as able.


Stars Measure Review


Stars Measures – Part C Measures by Data


2011 2014 2015 2011 to 2015

Data Source Total Measures

Total Weight


Total Measures

Total Weight


Total Measures

Total Weight


% change in Weight of Data Source

CAHPS 8 22% 7 19% 7 19% -3%

CMS Administrative Data 0 0% 0 0% 1 2% 2%

CMS Audit 1 3% 0 0% 0 0% -3%

CTM 1 3% 1 3% 1 3% 0%

HEDIS 15 42% 15 43% 13 37% -5%

HOS 6 17% 5 17% 4 16% -1%

IRE 2 6% 2 6% 2 6% 0%

MBDS 0 0% 1 3% 1 3% 3%

Plan Ratings 0 0% 1 9% 1 10% 10%

Plan Reporting 0 0% 1 2% 1 2% 2%

Phone Monitoring 3 8% 0 0% 1 3% -5%

Total 36 100% 33 100% 32 100%


Stars Measures – Part C Changes for 2016

• 2015 Part C Measures Removed

– Cardiovascular Care – Cholesterol Screening – Diabetes Care – Cholesterol Screening

– Diabetes Care – Cholesterol Controlled – Improving Bladder Control (temporary)

• 2015 Part C Measures Added

– Breast Cancer Screening

– Beneficiary Access and Performance Problems

– Call Center – Foreign Language Interpreter and TTY Availability


Stars Measures – Part C

• 5 Part C measures have a national average Star Rating under 3.0 Stars

3 of these measures are HOS Measures

Improving or Maintaining Mental Health

Monitoring Physical Activity

Improving Bladder Control

1 of these measures is a HEDIS Measure

Osteoporosis Management in Women who had a Fracture

1 of these measures is a HEDIS Measure

Special Needs Plan (SNP) Care Management

• These measures have the most room for improvement

• Because these measures are low performing nationally, they may be difficult to improve (i.e. Star thresholds may be set at levels difficult to attain)


Star Measures – Part D Measures by Data


2011 2014 2015 2011 to 2015

Data Source Total Measures

Total Weight


Total Measures

Total Weight


Total Measures

Total Weight


% change in Weight of Data Source

CAHPS 3 18% 2 10% 2 10% -8%

CMS Administrative Data 2 12% 0 0% 1 3% -8%

CTM 2 12% 1 5% 1 5% -7%

IRE 2 12% 2 10% 2 10% -2%

MARx 1 6% 0 0% 0 0% -6%

Medicare Beneficiary

Database Suite of Systems 0 0% 1 5% 1 5% 5%

PDE 0 0% 0 0% 0 0% 0%

PDE data 2 12% 2 20% 1 10% -2%

PDE, EDB, CWF 0 0% 3 30% 3 30% 30%

PDE data, MPF Pricing Files, HPMS approved formulary


1 6% 1 3% 1 3% -3%

Phone Monitoring 4 24% 0 0% 1 5% -19%

Plan Ratings 0 0% 1 17% 1 16% 16%

Plan Reporting 0 0% 0 0% 1 3% 3%

Total 17 100% 13 100% 15 100% 0%


Stars Measures – Part D Changes for 2016

• 2015 Part D Measures Removed

– Diabetes Treatment

• 2015 Part D Measures Added

– Call Center – Foreign Language Interpreter and TTY Availability

– Beneficiary Access and Performance Problems

– Medication Therapy Management Program Completion Rate for Comprehensive Medication Reviews


Stars Measures – Quality Focus

• As evidenced by the number of changes in the measures

from 2015 to 2016 CMS and the organizations that

manage the Stars measures (e.g. NCQA, AHRQ, and

PQA), the Medicare Stars measures are constantly

reviewed, updated and changed.

• Focusing only on the current year Stars measures is not


• Top rated plans that are consistently high performing,

focus on overall quality of healthcare rather than only

current year Stars measures.


Contact for Questions and Comments

Stephen Webb Principal

Coryus, LLC w. (678) 974-1694

c. (678) 467-1875




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