Posts Tagged ‘Medicare Advantage’

Infographic: Healthcare Providers Are Prepared to Increase Risk Model Participation

July 26th, 2019 by Melanie Matthews

Healthcare providers are ready and planning to assume increased levels of risk through commercial payer and Medicare contracting models and Medicare Advantage, according to a new infographic by Navigant, based on an analysis of survey conducted by HFMA.

The infographic examines how providers are partnering on or launching provider-sponsored health plans (PSHPs) as a part of their risk-assumption strategy.

Under CMS’s “Pick Your Pace” choices for Year 1 Quality Payment Program participation, physician practices may opt for the minimum activity necessary to avoid a payment penalty in 2019 by simply submitting some data in 2017.

However, instead of delaying MACRA participation to the later part of this year, physicians should prepare and better position themselves today for MIPS success by analyzing their existing CMS data on their practices’ performance and laying a path now toward performance improvement.

Physician MACRA-Readiness: Mining QRUR and Other CMS Data to Maximize MIPS Performance describes the wealth of data analytics available from the CMS Enterprise Portal–Quality Resource Use Reports (QRURs) and other reports providing a window into practice performance under the Merit-Based Incentive Payment System (MIPS). MIPS is one of two MACRA reimbursement paths and the one where most physician practices are expected to align.

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Guest Post: Medicare Advantage Environment Sparks Effective Risk, Quality and Care Strategies to Battle New Challenges

January 17th, 2019 by Jay Baker

Commercial insurers remain interested in competing for MA beneficiaries.

Projections show that national health expenditure growth is expected to average 5.5 percent annually to reach $5.7 trillion by 2026—higher than the projected increase in Gross Domestic Product (GDP). Fortunately, trends of insurers entering and exiting the program show that the Medicare Advantage (MA) market is stable yet dynamic—roughly the same numbers of plans enter/exit the program each year. Data shows that commercial insurers remain interested in competing for MA beneficiaries.

Given the benefits and challenges of value-based healthcare, stakeholders should gain a full understanding of Medicare Advantage (MA) plans, as well as strategies for optimizing this approach. What’s more, research indicates that the successes of MA are already having a positive impact on the broader healthcare delivery and payment landscape. In fact, fee-for-service Medicare spending has trended down in markets with high MA plan participation, indicating that doctors and other medical professionals operating in markets with high MA penetration adapt their practice patterns in alignment with MA plans’ strategies that control spending and use. This, in turn, helps to reduce use and costs for all their patients—including those enrolled in traditional Medicare and commercial/employer-sponsored plans.

MA plan coverage offered by private companies approved by Medicare provide all Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) coverage.

Optimizing the MA Plan Opportunity

An effective MA plan that significantly improves outcomes takes a whole patient approach and applies an end-to-end solution designed to enhance care coordination using analytics, in-home care, retrospective solutions and care management.

Value-based contracting generates cost efficiencies and improves clinical outcomes in MA. The challenge is to design MA plans and risk-bearing entities to remain sustainable. This requires innovative quality and risk adjustment programs to meet the growing demand for effective care strategies. For instance, MA plans can gain clinical insight into risk-adjusting conditions to enhance their traditional analytical platforms.

Understanding a Risk Adjustment Model

Risk adjustment is an actuarial tool used to calibrate payments to health plans based on the relative health of the at-risk populations. If insurers are limited in the extent to which premiums can vary by health status or other factors that are associated with health spending, risk adjustment ensures that health plans are appropriately compensated for the risks they enroll.

Keep in mind that most claims in fee-for-service Medicare are paid using procedure codes, which offer little incentive for providers to record more diagnosis codes than necessary to justify ordering a procedure. In contrast, MA plans have a built-in financial incentive since the current risk adjustment model was introduced that prompts providers to record all possible diagnoses. This is important because higher enrollee risk scores result in higher payments to the plan.

Consider MA plans that rely upon Physician Record Review (PRR), a two-stage retrospective chart review process from a 1) certified coder and 2) board-certified physician. These same plans also use Prospective Health Assessments (PHA) to gain a robust view of members and their care needs. Providers also rely on PHAs to lay the groundwork for developing more accurate reporting documentation, improving patient engagement and compliance, enhancing disease management, and reducing utilization.

This kind of full-spectrum, end-to-end approach to care helps providers identify gaps in care and manage plan members more productively. It also helps health plans that are serving as intermediaries, executing solutions and assuming risk. Fortunately, plan members gain the most form this approach because they are guided toward more preventive care and self-management early in the care process.

Risk-Based Contracting on the Rise

Medicare beneficiaries in fee-for-service Medicare are normally required to pay multiple premiums and deductibles and face a confusing array of cost-sharing arrangements for benefits and services from physicians, pharmacies, and hospitals.

In contrast, when a Medicare beneficiary enrolls in a MA plan it is usually a comprehensive, integrated health plan that includes richer benefits and solid catastrophic coverage. Unburdened of siloed benefits and payments, MA beneficiaries’ plan structure is simpler, and they are able to receive more coordinated care.

The value-based world is enlarging to the benefit of MA patients. In a recent move, CMS expanded its definition of “primarily health-related” benefits that private insurers are allowed to include in their MA policies. These extras include, for instance, air conditioners for people with asthma, healthy food, rides to medical appointments and home-delivered meals. This means MA beneficiaries will have more supplemental benefits and be better able to lead healthier, more independent lives.

Jay Baker

Jay Baker is the senior vice president of quality and risk adjustment solutions at Advantmed, LLC. He was most recently responsible for the ACA risk adjustment strategy and execution for UnitedHealth Group’s Optum division. His accomplishments included standing up an end-to-end service offering and exceeding revenue goals for the first two years of the program. As one of the founders of Dynamic Healthcare Systems, he was responsible for the original design for each of their 10 Medicare Advantage software modules. He is an ACA and Medicare Advantage industry leader and expert in policy, compliance, systems and plans operations.

Advantmed recently developed a white paper that discusses federal policy and the economics of Medicare. Advantmed, LLC is a healthcare solutions company dedicated to partnering with health plans, provider groups and risk-bearing entities to optimize risk adjustment and quality improvement programs. Our integrated and technology-enabled solutions improve health plan financial results and offer insights on health plan members. For more information on Advantmed’s solutions visit www.advantmed.com.

Infographic: Grading the Medicare Advantage Shopping Experience

August 3rd, 2018 by Melanie Matthews

With (on average) 20 Medicare plans to choose from, consumers have high expectations and little patience for friction in health plan interactions, according to a new infographic by NTT DATA.

The infographic examines the leaders and the laggards in the online shopping process for Medicare Advantage options and who is at the top performance level.

UnityPoint Health has moved from a siloed approach to improving the patient experience at each of its locations to a system-wide approach that encompasses a consistent, baseline experience while still allowing for each institution to address its specific needs.

Armed with data from its Press Ganey and CAHPS® Hospital Survey scores, UnityPoint’s patient experience team developed a front-line staff-driven improvement action plan.

Improving the Patient Experience: Engaging Front-line Staff for a System-Wide Action Plan, a 45-minute webinar on July 27th, now available for replay, Paige Moore, director, patient experience at UnityPoint Health—Des Moines, shares how the organization switched from a top-down, leadership-driven patient experience improvement approach to one that engages front-line staff to own the process.

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Infographic: Medicare Advantage Trends

January 10th, 2018 by Melanie Matthews

As medical groups and large systems transition to risk-based models, they expect nearly 60 percent of federal revenues will come from risk-based products (bundled payment, Medicare Advantage (MA), Medicaid Managed Care Organizations, and Medicare Accountable Care Organizations) by 2019, according to a new infographic by AMGA.

The infographic shows the anticipated the growth of MA as well as what this means for healthcare providers.

Healthcare Trends & Forecasts in 2018: Performance Expectations for the Healthcare IndustryGiven the powerful patterns disrupting healthcare, what will it take to succeed as a high-velocity healthcare organization in 2018?

Healthcare Trends & Forecasts in 2018: Performance Expectations for the Healthcare Industry, HIN’s 14th annual business forecast, is designed to support healthcare C-suite planning as leaders react to presidential priorities and seek new strategies for engaging providers, patients and health plan members in value-based care.

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Infographic: Medicare Advantage Member Satisfaction Rankings

August 23rd, 2017 by Melanie Matthews

Kaiser Permanente ranks highest in Medicare Advantage member satisfaction for the third consecutive year. Kaiser outperforms all other plans across five of the six factors that comprise the overall satisfaction index, according to a new infographic by J.D. Power.

The study, now in its third year, measures member satisfaction with Medicare Advantage plans—also called Medicare Part C or Part D—based on six factors (in order of importance): coverage and benefits (25%); customer service (19%); claims processing (15%); cost (14%); provider choice (14%); and information and communication (12%).

The infographic examines satisfaction indexes for Kaiser and nine additional Medicare Advantage plans.

Medicare is now reimbursing physician practices for select Chronic Care Management (CCM) services not previously eligible for reimbursement, underscoring the vital role of care management in primary care.

Physician Reimbursement for Chronic Care Management: Identifying New Practice Revenue Opportunities offers practical guidance to prepare physician practices to maximize CCM reimbursement in the year ahead.

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Infographic: Navigating Risk Adjustment Headwinds

April 28th, 2017 by Melanie Matthews

More than half of respondents (60%) to a recent survey by SCIO Health Analytics indicated that their organizations have hit at least the half way point when it comes to implementing the changes needed to support the Encounter Data Processing System (EDPS)/Risk Adjustment Payment System (RAPS), according to a new infographic by SCIO Health Analytics.

The infographic looks at where organizations are on their path for implementing changes needed to support EDPS/RAPS, the discrepancy between RAPS and EDPS scores and some predictions on the future of the Affordable Care Act.

Healthcare Trends & Forecasts in 2017: Performance Expectations for the Healthcare Industry Not in recent history has the outcome of a U.S. presidential election portended so much for the healthcare industry. Will the Trump administration repeal or replace the Affordable Care Act (ACA)? What will be the fate of MACRA? Will Medicare and Medicaid survive?

These and other uncertainties compound an already daunting landscape that is steering healthcare organizations toward value-based care and alternative payment models and challenging them to up their quality game.

Healthcare Trends & Forecasts in 2017: Performance Expectations for the Healthcare Industry, HIN’s 13th annual business forecast, is designed to support healthcare C-suite planning during this historic transition as leaders prepare for both a new year and new presidential leadership.

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Infographic: Top 5 Strategies for Managing Post-Acute Care

April 14th, 2017 by Melanie Matthews

As post-acute care costs increase, now accounting for $1 out of every $4 spent by Medicare Advantage plans, health plans are focusing on post-acute care management, according to a new infographic by CareCentrix.

The infographic examines the top five strategies healthcare organizations are using to manage post-acute care.

Medicare’s proposed payment rates and quality programs for skilled nursing facilities (SNFs) for 2017 and beyond solidify post-acute care’s (PAC) partnership in the transformation of healthcare delivery. Subsequent to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), forward-thinking PAC organizations realized the need to rethink patient care—not just in their own facilities but as patients move from hospital to SNF, home health or rehabilitation facility.

Post-Acute Care Trends: Cross-Setting Collaborations to Align Clinical Standards and Provider Demands examines a collaboration between the first URAC-accredited clinically integrated network in the country and one of its partnering PAC providers to map out and enhance a patient’s journey through the network continuum—drilling down to improve the quality of the transition from acute to post-acute care.

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Infographic: Implementing Value-Based Benefit Design in Medicare Advantage

December 14th, 2016 by Melanie Matthews

Implementing Value-Based Benefit Design in Medicare AdvantageOut-of-pocket Medicare Advantage costs are continuing to grow and higher cost-sharing can adversely affect health and worsen healthcare disparities, according to new infographic by the University of Michigan Center for Value-Based Insurance Design.

The infographic examines the increase in cost-sharing in Medicare Advantage plans, how this is impacting healthcare utilization and why lower cost-sharing on high-value services could impact Medicare beneficiaries.

Healthcare’s inevitable shift from volume to value-based reimbursement is reflected not only in Medicare’s alternative payment timeline but also in the waves of commercial payors now evaluating and rewarding providers on the basis of quality of care delivered rather than number of services provided. Adding to its roster of quality-centered payment models, CMS announced in 2015 plans to explore value-based reimbursement for Medicare Advantage and home health.

2015 Healthcare Benchmarks: Value-Based Reimbursement captures the healthcare industry’s reaction to payment formulas for value-added care, and how this shift away from fee-for-service is transforming care delivery and quality.

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Infographic: Risk-Ready Providers Jump Into Government Programs

April 27th, 2016 by Melanie Matthews

Providers are playing an increasingly important role in government programs. These range from active participation in the government marketplace by launching Medicare Advantage and Managed Medicaid products to indirect effects through quality programs that are (to a large extent) controlled by providers, according to a new infographic by Oliver Wyman Group.

The infographic looks at trends in provider-sponsored Medicare Advantage plans and Medicaid risk contracts and drills down into the Oregon and North Carolina markets.

With the nation’s leading accountable care organizations already testing the waters with CMS’ newest value-based reimbursement opportunity, the Next Generation Accountable Care Organization Model, healthcare organizations are evaluating how this new opportunity aligns with their value-based contracting strategy. With a looming application deadline for a 2017 start for the next round of Next Generation ACOs, the clock is ticking. And, with one approved Next Generation ACO, River Health ACO, already departing the program effective February 1st, the “Go-No Go” decision has become even more critical.

During Next Generation ACO: An Organizational Readiness Assessment, a 60-minute webinar on April 5, 2016, now available for replay, Healthcare Strategy Group’s Travis Ansel, senior manager of strategic services, and Walter Hankwitz, senior accountable care advisor, will provide a value-based, risk contract roadmap to determine organizational readiness for participation in the Next Generation ACO Model in particular and in risk-based contracts in general.

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Infographic: Value-Based Models’ Impact on Humana’s Medicare Members

November 25th, 2015 by Melanie Matthews

Members treated under the care of providers in value-based reimbursement models with Humana experienced greater quality than those treated by providers in standard Medicare Advantage settings, according to a new infographic by Humana.

This infographic examines key performance indicators for these Medicare members, including inpatient admissions per thousand, emergency room visits per thousand, assessment rates for vulnerable populations, as well as the impact of these models on HEDIS measures, CMS Star Scores and healthcare costs.

Healthcare’s inevitable shift from volume to value-based reimbursement is reflected not only in Medicare’s alternative payment timeline but also in the waves of commercial payors now evaluating and rewarding providers on the basis of quality of care delivered rather than number of services provided. Adding to its roster of quality-centered payment models, CMS announced in 2015 plans to explore value-based reimbursement for Medicare Advantage and home health.

2015 Healthcare Benchmarks: Value-Based Reimbursement captures the healthcare industry’s reaction to payment formulas for value-added care, and how this shift away from fee-for-service is transforming care delivery and quality.

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