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MedHOK Strategic Insights Blog

Plans Must Get Ready For Comprehensive Management Measures

Marc Ryan | November 8, 2017

comp_meter.jpgThe recent 2018 Star score announcement shows that Medicare Advantage (MA) plans continue to struggle with the high-performing system that the Centers for Medicare and Medicaid Services (CMS) has set up. If you read our recent blog analyzing the announcement, you know that it is has been tough going for many plans. A few facts from our recent analysis:

  • 56 percent of plans continue to lack 4 Star or greater status.
  • Savvy buyers are flocking to the high-performing plans (73 percent of enrollees are in plans with 4 Stars or more), putting increased pressure on lower scoring plans to survive.
  • Achieving 4 Star or greater status is tough, but maintaining it seems even more difficult.
    • From 2017 to 2018, of the 450 regional and local coordinated care plans in the MA program that were 3 Star or above, 65 plans gained Star power while 88 plans lost Star power.
    • Of the 15 5-Star MA-PD plans in 2018, only 7 were Star achievers in 2015.
    • Following the 30 plus coordinated care plans that dropped below 4 Stars and lost their 5 percent quality bonus from 2016 to 2017, another 38 MA plans will lose their quality bonus into 2018.

As we noted in the blog, the failures to maintain status are two-fold: (1) Plans lose focus in critical areas from one year to the next; (2) Star measures are a moving target and many Star performance cutpoint percentiles (for 4 and 5 Stars, for example) often inflate as the highest performers do better and better each year.

Not only do plans need to build infrastructure to achieve and maintain on current measures, they need to rethink how they approach the program overall, too.

Currently, Star measures can be broken into mostly three types:

  • Clinical measures: For the most part, this is the traditional bucket that plans work on to improve results of various clinically focused measures. They may be preventive in nature or targeted toward chronic diseases.
  • Survey measures: In Medicare, both the CAHPS and HOS surveys impact Star scores. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is the more traditional annual survey hitting the broad base of the plan membership, while the Health Outcome Survey (HOS) looks at plan cohort outcomes over time.
  • Administrative measures: These measures generally look at the plan’s performance on various operational metrics.

It’s important to note that clinical measures are morphing, as evidenced by the hospital readmissions measure and a few others in Medicare Star. We see a fourth category of measure emerging – Comprehensive Management Measures  that will significantly challenge both high-rated and poor-performing plans. We will begin to see them in 2019 and beyond.

More and more, plans will be measured on their ability to perform on significant, plan-wide care management outcome measures. Mobilizing to close gaps on the traditional blocking-and-tackling clinical measures will remain, but a whole new world will emerge that will demand:

  • Daily monitoring of inpatient caseloads and care transitions well beyond what is done today for readmissions.
  • Seamless care transitions post hospitalization.
  • Appropriate follow-up after emergency room visits or inpatient stays.
  • Adequate assessment of members’ post-acute stay and communication to providers.
  • Timely notification of providers of IP admission, discharge and follow-up care.
  • Member engagement in medication reconciliation and medication therapy management.
  • Close management of entire populations with certain chronic conditions to keep them from entering a hospital for exacerbation of those conditions.
  • Management of ever-more-complex suites of measures covering physical and mental health conditions. These will look very much like the Chronic Diabetes Care measures, but perhaps tougher.

The following will be essential for future success:

  • Daily collaboration across health plan departments.
  • Real-time sharing of important clinical information.
  • Constant and real-time communication with member physicians and other post-discharge providers.
  • Acute attention to chronic condition management.

As if to portend the challenges plans will have, as we noted above several existing measures already begin to go down the road of complex clinical management. Performance so far is anemic at best:

  • Medication Reconciliation Post discharge is a first-year measure and the average score is just 3.4.
  • All-cause readmissions has barely moved from 3.0 in 2015 to 3.4 in 2018.
  • Care coordination has dropped from 3.4 in 2015 to 3.3 in 2018.

The current average MA-PD Star measure sits at about 4.06, with the medical Part C component well above 4 and the Part D well below. Based on the scores above and the prospect that the new complex measures will be heavily weighted over time, plans could be in trouble in the future unless they take heed and plan for the introduction of Comprehensive Management Measures.

Star Rating, Medicare, CMS, Centers for Medicare and Medicaid Services, MA-PD, Health Outcomes Survey, Comprehensive Management Measures, CAHPS, HOS, CMM

About The Author

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs, and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel. Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management and administration.

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