As the FAD Duals Demo gets extended beyond the initial 3-year demo period in 2016, the industry will be watching both premium rates and Consumer opt-out. An original key attraction for participating plans was the “passive enrollment” of Consumers. Unlike the experience in dual Special Needs Plans and other programs–where plans had to earn each new member–the FAD demo’s phased enrollment of large volumes of members would make it worthwhile for plans to commit to the expensive costs of start-up and the intensive requirements of reporting and Models of Care. As the demos unfolded however, Consumers opted out in large numbers. An example: A plan that exited the Massachusetts demo in 2015 saw a nearly 40% initial opt-out rate; that is, almost 40% of Consumers assigned to that plan, and notified by mail, opted out before their actual enrollment date. (Note: a small portion of these were individuals who lost eligibility during the 60-day notice period). Of those who did enroll with this plan, another 20% of the original assignees dropped out within 90 days. In sum, the attrition rate from the state’s initial auto-assignment to the actual plan membership at 90 days was close to 60%. Only 4 in 10 initial assignees were enrolled after 90 days, a number that surprised both the state and the plans. The state’s other participating plans had slightly better retention. Similar statistics were seen around the country.
Building a new Duals plan on a Medicaid platform
There are a unique set of advantages and disadvantages for Medicaid plans as they build their new dual eligibles plans on a core Medicaid administrative platform.
The chief advantage is the favorable provider network cost structure, as the existing network contracts are likely priced on the typically lower reimbursement benchmark of Medicaid fee-for-service, and thus closer to the historic expenditures on which premium revenue is based. And Medicaid plans that have been managing care for ABD populations will have easier-going in scaling-up the high-touch care coordination required for high utilizers.
Advantages aside, Medicaid plans also face a very big lift. Chief among these is learning the brave new world of Medicare Advantage, and all of its filing deadlines, readiness reviews, and compliance requirements—many of which necessitate slight but important changes to almost every functional department in the plan. Risk-adjustment, secret shoppers, and audits represent an all-new set of challenges that make State Medicaid contracts look flexible and friendly. Of course there are the hurdles of building the LTSS network, tuning the claims platform to pay new and “atypical” provider types, and processing Medicaid-Medicare crossovers.
Let Caremetrics help you with tips on building your duals plan. Contact Us
Quality Babel: Local Pay-for-Quality Measures are inconsistent and rarely aligned
Our respected colleagues at Bailit Health Purchasing have released a superb study of 48 provider performance measures sets used in 25 states for things like PCMH, ACO and contracting. The study found that although most purchasers built their measures around national standards like NCQA and AHRQ, many other measures are in use, there is little alignment across measure sets, most buyers tinker and add homegrown measures, and most of these homegrown features are not really innovative and are likely to add unnecessary to burden to already-overloaded providers. This provides a good call for local buyers–like State Medicaids and commercial payers–to work together and develop standard approaches in their local markets.
Building a new Duals plan on a Medicare Advantage platform
There are a unique set of advantages and disadvantages for Medicare Advantage plans as they build their new dual eligibles products on a Medicare versus Medicaid administrative platform.
The chief advantage is the MA plan’s core competency in navigating the complex and inflexible CMS Medicare Advantage regulatory framework, including understanding the basics of enrollment, reporting, risk-adjusted revenue, Star scores and overall compliance.
But the disadvantages are numerous. Chief among these is the likely unfavorable provider network cost structure—typically based on a Medicare Advantage reimbursement benchmark of Medicare FFS-plus. Duals plan premiums will contain a blend of historically lower-priced Medicaid-as-primary and Medicaid-Medicare crossover experience, which represent a lower threshold than Medicare pricing and which put the duals plan at a disadvantage from Day One.
Other hurdles include learning a whole new paradigm of risk adjustment optimization, adding unfamiliar LTSS services to the network, and re-programming claims systems to eliminate coverage limits and consumer cost-sharing.
Let Caremetrics help you with tips on building your duals plan. Contact Us
Star Wars, Episode 4.0: Inherent bias in Medicare Advantage Star score bonuses for SNPs and D-SNPS
AIS and other media outlets report that industry leaders like the SNP Alliance and vendors like Inovalon and Milliman have turned up the heat on CMS to adjust its approach to Star scores for SNPs and D-SNPS, citing scoring disparities and unfair competitive disadvantage for plans serving complex populations and dual eligibles.
Caremetrics sees this bias in our customer base, where large numbers of dual eligible consumers have economic, disability, cultural and language barriers that deeply impact their likelihood of participating in surveys, and where clinical severity and extensive Rx use create disparities in medical and Rx compliance and quality ratings.
This is an important bandwagon to jump on for duals plans, as Pay-for-Quality is here to stay, and the measurement bias against plans managing Medicaid-Medicare consumers will be resistant to change without broad industry collaboration. Contact Us to get involved.
Functional Assessment Tools for LTSS Users
Center for Health Care Strategies published an important report on the state of assessment practices in Managed Long-Term Services and Supports (MLTSS) programs. Over half of states now have an MLTSS program, and another dozen have CMS FAD dual eligibles demonstrations that incorporate LTSS under managed care. Across these, there is little consistency among states in when they require functional assessments and the tools to be used. CHCS looks at five states and makes some excellent recommendations as to how states should create uniform assessment tools and uniform processes for how and when assessments should be deployed.
Caremetrics believe Massachusetts Medicaid sets a high bar in its mandatory use of the MDS-HC© (HC = “home care”) for all of its participating dual eligibles and D-SNP plans.
Caremetrics is integrating standardized functional assessment tools like the Long-Term Care Minimum Data Set (MDS) and Supports Intensity Scale™ with traditional claims-based predictive models to generate more efficient methods for risk analysis and segmentation in complex populations and dual eligibles plans. Learn More
The Digital health industry is only just beginning to unlock the potential of this technology channel when it comes to high-cost, high-risk government-sponsored populations. Caremetrics’ work in applying digital health solutions to vulnerable Consumers shows that significantly high ROIs are possible when the right solution is selected based on individual Consumer needs.
This is in sharp contrast to the one-size-fits-all, population-level “wellness app” approach that has had decent success in Commercial and Medicaid TANF populations.
Center for Health Care Strategies confirms the challenges and opportunities that lay ahead for this sector in its December 2013 report on Digital Health Innovations for Medicaid Super-Utilizers:
Consumer Feedback to Steer New Technologies. Worth reading, especially the results of focus groups on this topic, and a great snapshot of case studies from around the U.S.
Aligning Federal and State Payment Models
For fans of value-based versus fee-for-service purchasing the National Academy for State Health Policy (NASHP) published an important summary of State and Federal policymaker discussions on how inefficient payment policies play an important role in driving up total health care spending. Michael Stanek makes the overwhelming case that fee-for-service payment encourages service volume, payment is often disconnected from the value of care provided, and current government payment policy encourages fragmentation and duplication of services.
Dual Eligibles Snapshot
The Medicare Payment Advisory Commission (MEDPAC) and Medicaid and CHIP Payment and Access Commission (MACPAC) have issued their joint 2013 Dual Eligibles Data Book.
This is a great “Duals 101” bedside reading for the novice. The data presented are for calendar year 2009, the most recent year for which complete claims data were available for the Medicare and Medicaid programs when the analytic work for the data book began. Typical problems with these data include the mixed bag of Medicaid reporting quality from various states, and the inconsistency in which Medicaid-Medicare crossover is treated across states and among services categories.