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After the Election – What’s Next for Medicare
Now that the dust has settled, the votes have been counted, and those campaign ads are off the air, it is time for Washington to get to work on the major challenges that face our nation. Chief among them is the so-called “fiscal cliff” at the end of 2012.
It is clear that President Obama and Congress will need to come to an agreement over the next several months on a balanced plan to reduce the deficit while investing in job growth. Any plan that meets those basic parameters is bound to include savings in Medicare.
The question is, will the plan be carried out in a judicious way, with a scalpel that leads to a stronger Medicare, or will it be done with a hacksaw that simply tries to hit a bottom line number? You know my preferences.
A smart way to reform Medicare must be guided by goals of better health, better care and lower costs. Congress made a down payment on such an approach in the Affordable Care Act of 2010 (ACA).
I am sure you have heard by now that the health law included more than $700 billion in Medicare savings over 10 years and some of those savings were achieved by reducing payments to plans and providers, including a significant cut in Medicare Advantage benchmarks. Those cuts are still being implemented and it would not make much sense to heap another bunch on top of them.
The ACA also includes some very strategic investments in a value-based health care system that meets the goals of better health, better care and lower costs. For the first time, the Medicare Advantage program is paying for performance through quality incentive payments, which are based on established quality metrics and a rating system, also known as Star Ratings. In addition, the ACA created the Center for Medicare & Medicaid Innovation, which will test a series of innovative payment changes designed to better our health care delivery system so that it is more outcome focused and patient centered. It also begins to change payment policies for hospitals, nursing homes, home health aides and other health care providers in a move from a volume-based system to a value-based system.
Medicare has served our nation’s seniors and people with disabilities for nearly half a century. But there is clearly room for further reform of our health care delivery system, including Medicare. To be successful in serving future generations of older and disabled Americans, Medicare’s purchasing power should be used to incentivize better care and simultaneously lower cost growth. Traditional Medicare’s fee-for-service system creates perverse incentives for increased volume and effectively penalizes value. And traditional Medicare lacks the kind of transparency and accountability that has been a hallmark of Medicare Advantage. If the nearly 50 million Medicare beneficiaries are to have a real choice of how they get their care, this has to change.
As we embark on an effort to preserve Medicare for the next generation, let’s keep a simple thought in mind: Medicare should deliver the right care, the highest quality care, every bit of the care that people need – no less, no more.
-Patricia Smith
President and CEO, ACHP
Quality Improvement Interview: Fallon Community Health Plan
Fallon Community Health Plan has established itself at the top of the charts for the past three years on the Centers for Medicare and Medicaid Services’ Medicare Advantage Star Ratings. This year, the plan once again received 4.5 stars, an indicator of its commitment to – and success at – providing high quality health care to its members.
We spoke with Beth Foley, senior director of Quality Services at Fallon, about the health plan’s performance, including its strengths, areas of improvement and measures on which it is focusing.
Because of the plan’s history as an integrated staff model, in which preventive medicine is integral to patient care, Fallon has traditionally done very well on preventive and screening measures. A substantial portion of the health plan’s Medicare membership is seen by a provider network with which Fallon has a close working relationship.
It is due in part to this connection, along with a robust electronic medical record, that screening and preventive measures have remained a particular strength of Fallon’s. As Foley says, it is second nature to make sure members are getting their screenings. “That’s what we’re all about.”
Fallon also performed highly on the Care for Older Adults measure of the Star Ratings, pertaining to Medicare Advantage Special Needs Plan (SNP) enrollees (vulnerable populations who include dual-eligibles and those with chronic conditions). Foley attributes the plan’s significant improvement to supplemental data sources, more vigorous outreach to physicians and better documentation of medications and functional status assessments.
Fallon’s quality in this area is particularly significant to their members, as most of its members are in their 80s and 90s.
One of the most valuable aspects to the Star Ratings is the ability to benchmark data and set goals for improvement. There are always areas in which plans can improve, and the quality data facilitates these efforts. Currently, Fallon is focusing on the readmissions measure, which needs to be at 5 percent to receive top marks.
The plan is looking to bring the “navigator model,” used for its SNP NaviCare, into their general Medicare Advantage plan.
NaviCare, as Foley explains, is a highly successful care model that employs a comprehensive care team to look after patients. She expects that this will help to coordinate care, resulting in better medication adherence, better health outcomes and fewer readmissions.
Because of the ability to see how current performance stacks up against prior performance – as well as the ratings of other organizations – Fallon is able to set informed, attainable goals and focus on achieving them.
New Report: NCQA State of Health Care Quality 2012
Earlier this week, the National Committee for Quality Assurance released its annual State of Health Care Quality Report for 2012.
The report synthesizes quality data collected by the Healthcare Effectiveness Data Set (HEDIS®), one of the industry’s most widely-used performance improvement tools, according to NCQA’s press release.
The report finds that clinicians are placing increased emphasis on health and wellness promotion, and particularly on fighting obesity. The Adult Body Mass Index Assessment – a HEDIS® measure released in 2009 – was the most improved measure in 2012 of more than 40 quality measures.
The greatest gains were seen among Medicare plans, with an increase of 18 percentage points for HMOs and almost 26 percentage points for PPOs.
Medicare Advantage plans also had larger overall improvements than commercial or Medicaid plans, the report found.
View the entire report for a summary of significant changes in HEDIS® and Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures, as well as an overall assessment of health plan performance on each HEDIS® measure.
Quality Improvement Interview: Scott & White Health Plan
For 2012-2013, Scott & White Health Plan received five stars – the highest rating possible – on the Centers for Medicare and Medicaid Services’ (CMS) Medicare Advantage Star Ratings for their Part D plan. The Medicare Part D plan includes prescription drug coverage and is rated on measures such as customer service, member complaints, member experience with the drug plan and patient safety.
According to Charlotte Luebbert, director of Pharmacy Medicare Part D Services at Scott & White, the health plan is excelling in the areas of customer service, member experience and resolving member complaints. Scott & White is an integrated health system, meaning that in addition to a health plan, the organization includes a hospital and clinical provider network. Introducing new initiatives works well in this structure, as there are built-in lines of communication with members and providers.
Communication is integral to efficiency, coordinated efforts and physician buy-in. The plan corresponds with primary care physicians on a quarterly basis, with clinical messaging related to all lines of business. The method is well-received by all providers, Luebbert affirms.
Aided by an in-house customer service department, Scott & White is demonstrating success in improving customer service and keeping member complaints low. Service representatives are well educated on the plan’s Medicare Part D product, and provide members with efficient, accurate and personalized attention.
Another advantage to the plan’s pharmacy customer service department is the background of the representatives: All pharmacy call service agents are pharmacy technicians, meaning they possess a comprehensive understanding of pharmaceutical issues. Luebbert repeatedly emphasizes the importance of understanding to the representatives – the need to understand benefits, how to help members and alternatives at the point of service.
For example, member complaints are routed to specialized agents who are well versed in dealing with Medicare complaints, and who work with members to identify the roots of the issues. With such personalized service complaints are addressed efficiently and quickly.
In the Patient Safety domain, Scott & White has earned five stars on all of the medication adherence measures. These measures relate to Part D benefit design; Scott & White offers a generous maintenance benefit in which members are eligible for reduced copays for 90-day supplies of maintenance medications. Vice President of Pharmacy John Chaddick believes that this serves as an incentive for adherence. The plan’s clinical initiatives focus on making sure benefit designs are cost-conscious and give seniors benefits that encourage compliance.
Chaddick and Luebbert also highlight the plan’s focus on the High Risk Medication (HRM) measure, on which Scott & White’s rating improved from 2012 to 2013. A new initiative identifies and addresses the use of HRMs in the Medication Therapy Management (MTM) population, and provides targeted member and physician education to encourage use of alternative medications. Thanks to the plan’s direct communication with pharmacists, primary care physicians and patients, the initiative will be fully implemented in the next one to two months.
Effective communication is key to a quality member experience, emphasizes Luebbert. It is especially important to make sure that people have access to ample information during the open enrollment period, in which seniors can switch Medicare coverage options.
Quality Improvement Interview: Capital Health Plan
Since 2009, Tallahassee-based Capital Health Plan has been ranked among the top five commercial plans by NCQA. Capital came in as the third-highest ranked commercial plan in the nation for 2012-2013, continuing its trend of consistently exceptional quality performance. The health plan is also demonstrating marked quality improvement on the Medicare side: It has been ranked among the top ten Medicare plans since 2008.
Nancy Van Vessem, M.D., Capital’s chief medical officer, attributes the plan’s performance to a range of factors, one of the most important being the maintenance of a focused and coordinated approach.
“A health plan must have the desire to strive for high quality as measured by the NCQA standards,” and this focus must be written into a strategic plan, she says.
Every year, Capital staff and physicians reprioritize their performance strategy, focusing on measures that are most important to the health of their members. Many of these measures, relating to conditions such as diabetes and ischemic vascular disease, focus on disease management. The health plan’s extensive attention to these measures is evidenced in its performance – among diabetes measures, the plan is at or above the 90th percentile.
Chronic disease registries have been instrumental in maintaining adherence to quality measures by facilitating consistent screenings, leading to early detection and disease avoidance and ensuring that the most relevant, up-to-date information is available to physicians and specialists.
These registries — accessible through CHPConnect, Capital’s electronic portal — provide detailed lab information on patients, enabling physicians to coordinate care and monitor patients’ statuses. Thirty-five percent of patients are seen within Capital’s staff model, while the electronic medical record provides further assistance in reminding staff about needed care – both during the course of office visits and reminders between visits.
If patients are not getting the advised labs and have not responded to reminders, Capital will directly contact the patients with a letter, followed by a lab slip. If the patients use the lab slip and have their testing done, both the member and the primary care physician receive the results of the tests. This type of intervention, exhibiting a level of engagement unusual for a health plan, is central to keeping patients’ chronic conditions under control and preventing serious complications.
Many of these processes were already in play when NCQA started publishing their rankings in 2005, says Dr. Van Vessem. The plan has been highly-ranked since then on a variety of measures, including colorectal cancer screening, for which Capital has been ranked number one for all but one year that measure has been used. The colorectal cancer screening program started in 2002 – several years before the actual HEDIS® screening measure was developed – when physicians and staff noticed that screening rates were low (NCQA rankings are based upon HEDIS measures).
Dr. Van Vessem emphasizes that Capital follows a logical approach of monitoring HEDIS® measures throughout the year, identifying potential areas of improvement and communicating priorities to staff. By using EHRs to monitor patients, pull relevant data and follow up with patients, Capital has organized a work plan that prioritizes members’ health and wellness.
The evidence of its success is in the numbers.
Photograph courtesy of Capital Health Plan.
ACHP Members Rated Among Top Medicare Plans in the Country
Today, the Centers for Medicare and Medicaid Services (CMS) released its annual Medicare Advantage Star Ratings, a program intended to provide Medicare beneficiaries with additional information about health plans in their area and make quality data more transparent. Twenty-five percent of Medicare enrollees are enrolled in Medicare Advantage plans, which are rated on more than 50 quality measures, derived from multiple sources of data: CMS administrative data on plan quality and member satisfaction; the Consumer Assessment of Healthcare Providers and Systems (CAHPS®); the Healthcare Effectiveness Data and Information Set (HEDIS®); and the Health Outcomes Survey (HOS).
There are 580 Medicare Advantage plans, 46 of which are ACHP members. All Medicare Advantage plans are rated on a one- to five-star scale, with five stars representing excellent performance on the quality measures. Each year, ACHP member plans demonstrate superior performance on the ratings: Of the 11 plans that are rated five stars, eight of them are ACHP members. Thirty Medicare plans operated by ACHP members received five, 4.5 and four stars in the combined 2013 Medicare Advantage and Medicare Part D Star Ratings.
Patricia Smith, ACHP president and CEO, states that “by providing high-quality care and service to millions of Medicare beneficiaries, ACHP members are making sure the federal government – and American taxpayers – are getting the value they demand from Medicare Advantage plans.”
For more information, look to the CMS stars technical guide, released in early September, which includes measure thresholds with which plans can interpret raw scores. A blog post by Health Dialog offers some useful, distilled information on the six key points from the technical guide – in case you would prefer not to read the entire 113-page document. CMS released their latest version in conjunction with the Star Ratings release today.
We will also be releasing additional blog posts in the coming weeks that will focus on specific plans’ performances and other elements of the Star Ratings.
Quality Improvement Interview: Kaiser Permanente of the Mid-Atlantic States
Kaiser Permanente of the Mid-Atlantic States has been demonstrating high performance on NCQA’s annual health plan rankings for several years; due to a combination of quality improvements and high patient satisfaction ratings, the plan rose a total of 18 ranking places from 2011 to 2012. This year’s increase – up to number 15 in the commercial rankings and number 12 for the Medicare rankings – was a continuation of the plan’s high performance for the past three to four years.
We spoke with Bernadette Loftus, M.D., the Permanente Medical Group associate executive director for the Mid-Atlantic States, about what the plan has been doing recently to drive improvement. Dr. Loftus cites two key aspects as responsible for their exemplary performance: access and communication.
She emphasizes that the importance of access for patients, whether to primary, specialty or ancillary diagnostic care cannot be overstated. Due to a relentless diligence to improving access times and stringent requirements that patients must see their own physicians whenever possible, the plan maintains excellent access for patients so physicians spend more time listening to and engaging with the patient, not on extraneous issues.
According to Dr. Loftus, this simple focus has greatly impacted the way the plan interacts with patients: When patients see a doctor that they know, there is an instantaneous jump in patient satisfaction ratings.
Effective communication is the second key aspect to Kaiser Permanente – Mid-Atlantic’s steady improvement on the rankings. This refers to communication among physicians, the health plan and patients. In terms of the former, physician and staff buy-in is key, says Dr. Loftus.
The health plan has provided a comprehensive electronic medical record to the physicians, and supports staff and providers in its utilization. The plan’s leadership, along with Dr. Loftus, also maintains focused communication with all practices. She points out that evidence confirms that effective communication between physicians and a focus on patient access improves health outcomes and patient experience.
To facilitate communication with patients, the plan has implemented what Dr. Loftus calls “obsessive” outreach – continual prompting comprising “back sweeps” and “forward sweeps.” The “back sweep” report requires that all patients get scheduled for their needs (such as screenings, check-ups or physicals) during each visit. The “forward sweep” requires staff to look to future patient visits, and schedule any additional upcoming appointments for which patients are due on that same day, so the patient makes only one office visit.
These protocols have elicited particularly positive feedback from patients, some of whom credit the outreach with saving their lives, due to early diagnoses and treatment.
Kaiser Permanente – Mid-Atlantic now tops the rankings for three measures: Breast Cancer Screening, Acute Bronchitis Treatment in Adults and Diabetic Nephropathy Medical Attention. Dr. Loftus is also particularly proud of the plan’s hypertension control rate, which stands at number six in the nation – a remarkable achievement given that the demography of the Mid-Atlantic states shows the patient population to be vulnerable to hypertension.
The plan’s performance on this measure is an instance of both effective communication and greater patient access, as well as a rapid performance improvement cycle. The methods of effectively treating hypertension are well known: They call for a layering approach, tinkering with dosages and medications to find what works best. However, the plan realized that decision points needed to be more frequent, requiring blood pressure to be checked every few weeks. They quickly modified follow-up measures, and aided by aggressive outreach, the plan now boasts a control rate of over 80 percent. Dr. Loftus says that a widely accepted recognition of common standards regarding these measures enabled a quick and straightforward transition. The “HEDIS measures are based on evidence. No one argues that it is not the right thing to do,” she points out.
It is clear that quality improvement is not a unilateral effort, nor is it a goal that requires complex strategies and arcane technology. On the contrary, the process is fairly simple: By making it easy to do the right thing, says Loftus, these priorities and practices will naturally spread, and garner staff buy-in. Achieving quality performance demands relentless dedication on the part of the entire plan, as Kaiser Permanente – Mid-Atlantic has demonstrated.
“Quality is everyone’s job,” Dr. Loftus concludes.
Photograph courtesy of The Permanente Medical Group.
CareOregon’s Releasing Time to Care
October 1 was a big date for health care reform: At the start of this month, several provisions of the health care law took effect, including two Medicare programs that are designed to improve the quality of medical care by leveraging the federal program’s financial resources – quality-adjusted hospital reimbursements and the hospital readmissions reduction program. October 1 was also the target date for submitting a list of essential health benefits for the upcoming state insurance exchanges to the federal government.
Independent of these deadlines, ACHP member plans have been assiduously contributing to the nationwide effort to improve the quality of care, safety and efficiency. We recently spoke with CareOregon about their innovative nursing and hospital support program, which underwent significant expansion in September.
The Releasing Time to Care (RT2C) methodology was developed by the United Kingdom’s National Health Service in 2007. Designed by nurses to help hospital nursing staff increase the time available for direct patient care, RT2C applies Lean methodology to the particular needs of nurses and hospital staff.
At the core of RT2C are three foundational modules – Knowing How We’re Doing, the Well-Organized Ward and Patient Status at a Glance – which lay a framework to help nurses collaborate, conduct ward assessments based on quality metrics, keep organized and track patient status. An additional eight process modules focus on core ward processes; they include, among other things, admission, observation, shift handoffs and medication administration.
Seeing an opportunity to catalyze hospital transformation in Oregon, in July 2010, CareOregon funded the first year of training in this methodology for four hospitals; last month, RT2C was expanded to an additional 13 hospitals, speaking to the program’s efficacy. RT2C is implemented unit by unit in a hospital by the frontline staff, engaging and empowering nurses to lead the way to change.
Amidst this wave of program expansion, the health plan continues to stress collaboration and networking among the participating hospitals. Dave Ford, president and CEO of CareOregon, remarks that the health plan plays a valuable role in building relationships with many entities, allowing cooperation in facing shared issues of financial strain.
“The learning that is being shared among the hospitals is really incredible,” states CareOregon Governance and Business Development Manager Barbara Kohnen. “This shared learning will help all the hospitals in the state become better in every way—including having a happier and more empowered staff.” Indeed, nurses have responded well to the program, which allows them to spend more time with patients and improve the quality of their care.
RT2C has “helped us refocus on why we come to work every day,” affirms St. Charles Health System Chief Nursing Executive and Vice President for Quality Pam Steinke (St. Charles Health System is a participating hospital). “My personal belief is that if I can help make my organization the best place to be a nurse, it will also be the best place of all to be a patient.”
For more information on numerous other case studies featuring the work of our member plans, please check out our website. A full-length case study on CareOregon’s experience with RT2C will be coming soon.
Photo courtesy of Getty Images.
Community-Based Health Plans Lead National Rankings
The National Committee for Quality Assurance released the 2012-2013 health plan rankings yesterday and ACHP members were once again at the top of the list. NCQA, which publishes its Health Insurance Plan Rankings annually, bases the rankings on their NCQA Accreditation standards, which are some of the most rigorous in the industry. These standards are developed collaboratively, with the help of health plans, providers, purchasers, unions, regulatory agencies and consumer groups.
For 2012-2013, seven of the nation’s top ten commercial plans, all of the top ten Medicare plans in the nation and six of the top ten plans in the Medicaid rankings are offered by ACHP members. While ACHP is excited to announce these outstanding results, such performance is not surprising: Our member plans have established a precedent of continually topping the rankings. Last year, 12 of the nation’s top 20 private plans were ACHP members. This performance has echoed throughout the past years as top plans demonstrate superlative quality outcomes.
In the next few weeks, we will be posting a series of blog posts that will provide more robust analyses on the rankings and quality performances of plans. Additionally, look forward to some posts offering insight on the value of these quality rankings, which serve as critical tools for consumers in assessing health plans. In the meantime, take a look at what Peggy O’Kane, president of NCQA, wrote in The Atlantic earlier this summer about engaging consumers in learning more about the health care system.
Below is a table summarizing ACHP member plans’ rankings.
Commercial Plans – Top 50
Rank Plan
2 Tufts Associated Health Maintenance Organization
3 Capital Health Plan
4 Tufts Benefit Administrators (PPO)
6 Kaiser Foundation Health Plan of Colorado
8 Kaiser Foundation Health Plan of Northern California
9 Group Health Cooperative of South Central Wisconsin
10 Kaiser Foundation Health Plan of Southern California
12 Geisinger Health Plan (HMO/POS)
13 Kaiser Foundation Health Plan of the Northwest
15 Kaiser Foundation Health Plan of the Mid-Atlantic States
16 UPMC Benefit Management Services
16 UPMC Health Plan
19 Kaiser Foundation Health Plan – Hawaii
20 Capital District Physicians’ Healthcare Network (Self-Funded, PPO)
20 CDPHP Universal Benefits (PPO)
24 Capital District Physicians’ Healthcare Network
25 Capital District Physicians’ Health Plan
28 HealthPartners
33 Fallon Community Health Plan
36 Kaiser Foundation Health Plan of Georgia
38 Kaiser Foundation Health Plan of Ohio
42 Security Health Plan of Wisconsin
43 Priority Health
48 Independent Health Association
Medicare Plans – Top 25
Rank Plan
1 Kaiser Foundation Health Plan of Southern California
2 Kaiser Foundation Health Plan of Colorado
3 Kaiser Foundation Health Plan of Northern California
4 Capital Health Plan
5 Kaiser Foundation Health Plan of the Northwest
6 Geisinger Health Plan
7 Kaiser Foundation Health Plan – Hawaii
8 Fallon Community Health Plan
9 Group Health Cooperative
10 Group Health Plan (HealthPartners)
12 Kaiser Foundation Health Plan of the Mid-Atlantic States
14 Priority Health
15 Capital District Physicians’ Health Plan
16 Kaiser Foundation Health Plan of Ohio
18 Security Health Plan of Wisconsin
23 Independent Health Association
Medicaid Plans – Top 25
Rank Plan
1 Fallon Community Health Plan
2 Kaiser Foundation Health Plan – Hawaii
3 Network Health (Tufts)
7 Priority Health
8 UPMC for You
10 Security Health Plan of Wisconsin
13 Capital District Physicians’ Health Plan
21 Independent Health Association
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