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SCIO’s Call Letter Chat Understanding and Planning for CMS’ Policy Changes

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Specific Topics to Include:
• Updates to the CMS-HCC Risk Adjustment Model
• Rebalancing of the RAPS/EDPS Blend Weighting
• Changes to Star Ratings
• Q&A from the Audience

For more information on our Risk Adjustment solutions, please visit:
https://www.sciohealthanalytics.com/offerings/products/SCIOClarity-analytics

Published in: Health & Medicine
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SCIO’s Call Letter Chat Understanding and Planning for CMS’ Policy Changes

  1. 1. |1 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved.©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. CALL LETTER CHAT: UNDERSTANDING AND PLANNING FOR CMS’ POLICY CHANGES April 26, 2018
  2. 2. |2 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. YEAR-TO-YEAR PERCENTAGE CHANGE IN PAYMENT Better than expected increases in revenue will enable MAOs to invest in even higher quality care for members Item YOY Change (Advance Notice) YOY Change (Final Announcement) Effective Growth Rate 4.35% 5.28% Rebasing N/A 0.49% Changes to Star Ratings -0.2% -0.26% Coding Intensity Adjustment 0.01% 0.01% Risk Model Revision 0.28% 0.28% Encounter Data Transition -0.04% -0.04% EGWP Payment Policy -0.3% -0.1% Normalization -2.26% -2.26% Expected Average Change in Revenue 1.84% 3.40% Not included is CMS’ estimated increase in coding trend (3.1%)
  3. 3. |3 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. CHANGES TO THE CMS-HCC RISK ADJUSTMENT MODEL PAYMENT YEAR 2019 IS BLENDED (V22 + V23)
  4. 4. |4 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. UPDATES TO THE 2017 CMS-HCC RISK ADJUSTMENT MODEL (VERSION 22) For Payment Year 2019 Increased Normalization Factor to 1.041 (up from 1.017) Coding Intensity Adjustment: 5.9% PY 2018 Uses RAPS + FFS and EDPS + FFS PY 2019 Uses RAPS + FFS Data Only
  5. 5. |5 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. Normalization Factor Set Ay 1.038 Coding Intensity Adjustment: 5.9% Uses EDPS + FFS and Inpatient RAPS No Multiple Condition Variable for PY 2019 New Disease Conditions Model Recalibration (New HCC weights) INTRODUCING THE 2019 CMS-HCC RISK ADJUSTMENT MODEL (VERSION 23) • HCC 54* – Substance Use with Psychotic Complications • HCC 55*^ - Substance Use Disorder, Moderate/Severe, or Substance Use with Complications • HCC 56 - Substance Use Disorder, Mild, Except Alcohol and Cannabis Substance Abuse • HCC 59 – Major Depressive, Bipolar, and Paranoid Disorders • HCC 60 – Personality Disorders Mental Health • HCC 138 – Chronic Kidney Disease, Moderate (Stage 3) Chronic Kidney Disease *Renamed HCC ^Additional Diagnoses
  6. 6. |6 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. GUIDANCE FROM CMS ON METHODOLOGY BLENDING Payment Year 2019
  7. 7. |7 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. Patient Physician Health Plan CMS REVIEW: DATA FLOW DIFFERENCES BETWEEN RAPS AND EDPS Patient Physician Health Plan CMS Step 1 CMS Step 2 RAPS EDPS RAPS return file 1 Day MAO-002 return file MAO-004 1 Month
  8. 8. |8 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. VERSION 23 (AND EDPS) PHASED-IN OVER 4 YEARS “The quality of encounter data has improved, and CMS is committed to continuing to drive improvement in the data.” 25% 50% 75% 85% 15% 100% 75% 50% 25% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% PY 2022 PY 2021 PY 2020 PY 2019 PY 2018 v22 & RAPS / v23 & EDPS Blend v22 (Inpatient/Outpatient/Physician RAPS + FFS) v22 (EDPS + FFS) v23 (EDPS + Inpatient RAPS + FFS)
  9. 9. |9 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. RAPS & EDPS DATA BLEND BY DATA SOURCE & SITE OF SERVICE Payment Year 2018 Payment Year 2019 Source Site of Service Version 22 Version 23 Version 22 Version 23 RAPS + FFS Physician 85% 75%Outpatient Inpatient 25%EDPS + FFS Physician 15%Outpatient Inpatient
  10. 10. |10 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. WHY IS CMS SUPPLEMENTING EDPS DATA WITH INPATIENT RAPS? “…CMS observes that Encounter Data inpatient submissions are low compared to corresponding RAPS inpatient submissions. Amending inpatient diagnoses from Encounter Data with inpatient diagnoses from RAPS will improve the completeness of the data for payment in 2019.” “We envision the inclusion of inpatient RAPS data in the encounter data risk score to be temporary, and in addition to improving the completeness of the data, minimize any potential impact from incomplete data for the remaining plans that may face operational challenges submitting encounter data records.” Page 55 (2019 Call Letter):
  11. 11. |11 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. IMPACT OF COMPLETE DOCUMENTATION & CODING ON REVENUE No Condition Coded Some Coded – Not Specific from Claims from Claims Submission All Conditions Coded Chart Review by Certified Coder 76 Year Old Female 0.468 76 Year Old Female 0.468 76 Year Old Female 0.468 Medicaid Eligible 0.177 Medicaid Eligible 0.177 Medicaid Eligible 0.177 DM Not Coded DM w/o Comp. 0.181 DM w Comp. 0.608 Vascular Not Coded Vascular w/o Comp. 0.324 Vascular w Comp. 0.645 CHF Not Coded CHF Not Coded CHF Coded 0.365 No Interaction No Interaction Interaction (DM + CHF) 0.204 Total RAF 0.645 Total RAF 1.15 Total RAF 2.497 PMPM Payment $585 PMPM Payment $1.04 PMPM Payment $2,263 Yearly Payment $7,015 Yearly Payment $12,508 Yearly Payment $27,156 $20,141 Three Ways This Interaction Could Be Coded:
  12. 12. |12 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. SOLUTION: KNOW YOUR MEMBERSHIP & PROVIDERS INSIDE AND OUT Measure data volume and address any drop- off points Discover never-before-reported HCCs based on prescriptions, diagnoses, and predictive logic Identify and quantify all previously accepted HCC codes that are missing for a given payment year Benchmark and compare provider group and PCP RAF average accounting for their patient populations to find outliers Reconcile RAPS/EDPS variances: RAPS Flag, EDPS Flag, EDPS Flag Filtered, MAO-004 Flag
  13. 13. |13 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. UPDATES TO CMS REPORTS
  14. 14. |14 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. EVOLUTION OF THE MAO-004 REPORT • Phase 3 MAO- 004 released • Positions 17-28 Renamed to Beneficiary Identifier April 2018 • CMS Announces Phase 3 MAO- 004 Release Date • Additional time provided to submit encounter data for final PY 2017 • Conduct interim final run by 1/31/18 Dec 20, 2017 • CMS began sending monthly reports for 2015 DOS (early April) and 2014 DOS (late May) April & May 2017 • Over the weekend, CMS reposted all MAO-004s (Phase II), including corrections, from January 2014 • Note: Still issues with MAO-004 Oct 24-25, 2016 • Initial MAO- 004 released Dec 23, 2015 • Final Filtering Logic Published • Reality: CMS filtering logic does not filter based on physician specialty • Per the CMS FAQ relative to their final filter logic, they expect plans to continue to filter using allowable physician specialty • Result: Inability to reconcile the two data sources Dec 22, 2015 • Initial Filtering Logic from CMS Published • Initial Assumption: Plan to align their RAPS filtering logic with CMS EDPS filtering logic Jul 21, 2015
  15. 15. |15 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. RAPS AND MBI: AN UPDATE FROM CMS’ JANUARY USER GROUP Source: CMS January User Group, Slide 46
  16. 16. |16 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. MODEL OUTPUT REPORT (MOR) Record Type Description PY 2017 PY 2018 H (EDPS + FFS) Aged/disabled model encounter data-based HCCs Interim Final Payment Mid-Year Payment D (RAPS + FFS) Aged/disabled model RAPS based HCCs Interim Final Payment Mid-Year Payment New
  17. 17. |17 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. CHANGES TO STAR RATINGS
  18. 18. |18 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. 2019 STAR RATINGS Added Measures •Statin Therapy for Patients with Cardiovascular Disease (Part C) •Statin Use in Persons with Diabetes (Part D) Removed Measures •Beneficiary Access and Performance Problems (BAPP) New Display Measures •Plan Makes Timely Decisions about Appeals (Part C) Removed Display Measures •Enrollment Timeliness (Part C & D) •Appropriate Monitoring of Patients Taking Long-term Medications and Asthma Medication Ratio (Part C) Other Notes •4+ Star plans continue to receive 5% bonus payment while <4 Star plans will receive no bonus payment •Special considerations being given to plans impacted by hurricanes and natural disasters in 2017
  19. 19. |19 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ADDITIONAL & FUTURE CHANGES TO STAR RATINGS Measure/Announcement Disposition Reducing the Risk of Falling Moved to an improvement measure for 2019 and 2020 Medication Adherence (ADH) for Hypertension (RAS Antagonists), Medication Adherence for Diabetes Medications (Part D) • Beneficiaries with ESRD are excluded from the measure • Data sources for exclusions expanded: • ICD-10-CM codes found in both Part A & B claims • Risk Adjustment Processing System (RAPS) RxHCCs Medication Adherence (ADH) for Hypertension (RAS Antagonists), Medication Adherence for Diabetes Medications, and Medication Adherence for Cholesterol (Statins) (Part D) • The Proportion of Days Covered (PDC) will be adjusted for: • Inpatient (IP) stays for MA-PDs and PDPs • Hospice enrollment for MA-PDs and PDPs • Skilled nursing facility (SNF) stays for PDPs for 2019 Pharmacy Quality Alliance (PQA) recommends the Medication Adherence measures be risk-adjusted for various sociodemographic characteristics beginning with the 2018 calculations CMS will determine how to implement this recommendation within the Star Ratings by early 2019 Adding telehealth and remote access technologies for appropriate measures 2020 Forecast Adding measures covering care coordination, multiple chronic conditions, and opioid use 2020 Forecast Formation of a Technical Expert Panel (TEP) To Be Established by RAND
  20. 20. |20 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. Identify Members with Quality Measure Gaps Generate Personalized Messages for Each Member Communicate with Members via Their Preferred Channel Support Providers with Resources to Close All Gaps SOLUTION: USE GAPS IN QUALITY MEASURE REPORTING TO ENGAGE MEMBERS Members are more likely to comply with quality measure-based interventions. Use this opportunity to close HCC gaps while engaged with the member. HEDIS ----- STARS ----- HCC
  21. 21. |21 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. OTHER INDUSTRY TRENDS & FORECASTS
  22. 22. |22 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. PAYMENT CONDITION COUNT MODEL Implementation to begin in 2020 and 100% phase-in for 2022 • Requirement of the 21st Century Cures Act: – “take into account the total number of diseases or conditions of an individual beneficiary” • CMS considered two methods and selected the more consistently positive option for Medicare Advantage Organizations All Condition Count Model (-0.28%) These graphs display the estimated percent change in payment for 446 Medicare Advantage contracts. Each line indicates the model’s estimated impact on payment for 1 contract. Payment Condition Count Model (+1.1%)
  23. 23. |23 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. EXPANSION OF SUPPLEMENTAL BENEFITS Health Plans Gain Increased Flexibility to Attract & Retain Members Through Benefit Design • CMS defines a supplemental healthcare benefit as an item or service: • (1) not covered by Original Medicare • (2) that is primarily health related • (3) for which the MA plan must incur a direct medical cost What is a Supplemental Benefit? • The benefit must be used to, “diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and health care utilization” How Does CMS Determine What Is “Health Related”? • CMS increased the number of allowable supplemental benefit options that health plans can offer their members • Includes “daily maintenance” items and services What Does This Mean?
  24. 24. |24 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. 2018 RISK SCORE RERUNS FOR OVERPAYMENT RECOVERY • CMS will notify Medicare Advantage Organizations at least 30 days in advance of the deadline for submitting deletes for each risk score run. • These runs do not affect plan obligations to report and return overpayments within 60 days of identification of the overpayments.
  25. 25. |25 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. MODEL RECALIBRATION BASED ON PART C CPT CODES Page 40 (2018 Advance Notice): Page 41 (2018 Advance Notice):
  26. 26. |26 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. THE BASICS OF CALIBRATION Traditional Medicare Medicare Advantage CMS Calculated Disease Cost = $1,173 CMS Calculated Disease Cost = $456 Cost Mapped to MA HCC Using ICD-10 Code Any recalibration based on CPT Codes submitted by MA plans make disease costs appear lower. 50,000 Members CPT Code 1 $500 CPT Code 2 $350 CPT Code 3 $75 ICD-10 Code A 70,000 Members CPT Code 1 $500 CPT Code 2 $350 CPT Code 3 $75 CPT Code 4 $425 ICD-10 Code A 50,000 Members CPT Code 1 $500 ICD-10 Code A 70,000 Members CPT Code 2 $350 CPT Code 3 $75 ICD-10 Code A
  27. 27. |27 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. SUMMARY OF KEY CHANGES COVERED IN THIS WEBINAR CMS-HCC Risk Adjustment Model • Version 22 and RAPS • Version 23 and EDPS CMS Reports • MAO-004 • Model Output Report Star Ratings • 2019 Updates • Anticipated Updated in 2020+ Future Trends • Payment Condition Count Model • Expansion of Supplemental Benefits • Risk Score Reruns for 2018 • Model Recalibration
  28. 28. |28 ©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. THREE PILLARS OF A PRAGMATIC RISK ADJUSTMENT PROGRAM Collaboration Diagnosis Code Capture Sustaining High Quality Members with Gaps Provider-Specific Concerns Global Process Issues Risk Adjustment Sophistication Use of Technology Human Capital Prospective Retrospective

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