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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.