On April 4, 2016, the CMS Final Notice confirmed a number of changes with significant impact to the market. To understand this impact, we sat down with Kevin Barrett, President Altegra Health and Executive Vice President Change Healthcare, to discuss the implications and what needs to be done next. What are the key takeaways from the CMS Final Notice? Most notably, the Final Notice confirmed (i) the implementation of a new risk model to introduce payment adjustments based on the combination of dual status and risk score, (ii) changes to payment timing from prospective to concurrent, and (iii) the continued expansion of the Encounter Data Processing System (EDPS) replacing Risk Adjustment Processing System (RAPS) data to determine risk-adjusted payments. Upon reading the Final Notice, Altegra Health conducted an analyses to understand the impact. Why? We are uniquely positioned to analyze the impact of the Final Notice based on the large number of Medicare Advantage (MA) plans for which we currently provide dual eligible outreach and enrollment (Medicare Savings Complete), risk analytics (RISK ViewTM Medicare) and EDPS submissions (Medicare ENCOUNTER CompleteTM). What did your analysis entail? We used actual health plan data to examine both the impact of the 2017 risk-model on reimbursement along with the implications of the shift in RAPS/EDPS scoring on current and future risk scores. What type of data was used? To conduct these analyses, we compiled data from 24 MA plans with 64 contracts covering 1.25 million MA beneficiaries. What are the key takeaways from your analysis?
  1. Risk model changes. Overall, health plans exhibited an initial net increase in risk scores; however, there was significant variability in the potential rate changes depending on the level of full duals (receiving full Medicare and Medicaid) and respective profile of medical conditions.
  2. EDS/RAPS shift. All health plans demonstrated an implied negative impact from the shift to greater reliance on EDPS data for payments, with an average variance of negative 3 percent for the 75/25 percent RAPS/EDPS split.
How do you recommend Medicare Advantage plans mitigate the impact of the new risk model and shift to greater EDPS risk payment? MA plans need to partner with an industry leader that has deep experience in risk adjustment, dual eligible enrollment and encounter data submission since there are major implications for all three areas. At Altegra Health, we are uniquely positioned to assist MA plans in managing the changes for 2017, as we are literally the only vendor supporting dual eligible enrollment, providing deep analytics for the Medicare Advantage risk model, and facilitating EDPS data submissions and error reconciliation. We recommend the following approach:
  1. Establish a Dual Enrollment Program. Now more than ever, it is important to screen and enroll members for all dual-eligible programs. With more than 15 years of experience in screening and enrolling members in state-based dual-eligible programs, I’m proud of our screening algorithm which has been continuously refined to target members with the highest potential for dual eligibility. We then reach out to those members to conduct interviews, complete required applications, submit applications to the state and monitor the results.
  2. Manage Shifts in Eligibility and Related Payments. CMS confirmed that the revised dual-eligible risk model payment will shift from prospective to concurrent. And although CMS has not released guidance on how the payment will be calculated, we’re certain that any shifts will require careful, constant monitoring. Our dual eligible recertification program assures that members do not miss re-enrollment requirements and therefore maintain the increased payment associated with dual enrollment.
  3. Aggressively Work EDPS Data Submission and Error Management. Altegra Health’s ENCOUNTER Complete tool provides end-to-end management of the transformation of claim data for EDPS submission. The user-interface includes a variety of error management and prioritization tools, including an error mix report to prioritize errors affecting risk scores.
  4. Risk Adjustment Coding Optimization. In the new risk model, capturing all risk-adjusting diagnoses for the new risk model sub-populations is more important than ever. At Altegra Health, we provide our clients multiple services to assist with capturing missing risk-adjusting diagnosis codes.
  5. Manage Social Determinants of Health. Studies indicate that population health is highly influenced by social and economic factors (Senterfitt, 2013), in some instances more than by health behavior or access to care (Bachrach, 2014). While many health plans address health behavior and care access, much can be gained by addressing social and economic factors, i.e. social determinants of health. A vendor that can screen and assist members with programs to improve daily living and impact overall health is critical.
If a health plan wanted to partner with Altegra Health to manage the changes resulting from the 2017 Final Notice, which products and solutions would you recommend?
  1. RISK View Advanced Analytics. Chart target lists are created by our advanced analytics engine, which incorporates pharmacy, comorbidity and socioeconomic data to expand targeting beyond typical persistency analytics. We are expanding this model to explicitly include dual status and the updated risk model coefficients from the Final Notice to ensure that all members, especially dual eligible members, are appropriately targeted for chart coding and relevant outreach. In addition, for health plans lacking EDPS error management programs, RISK View clients can identify members for which EDPS scores lag RAPS scores when the claim submission deadline has passed. Diagnosis codes captured from these charts can be submitted to EDPS via linked or unlinked submission.
  2. Dual Eligible Enrollment and Recertification. Using health plan data, we identify members that are potentially eligible for partial or full dual eligible programs. Our Advocates complete a screening interview and assist the member in applying for appropriate programs. At annual enrollment time, we facilitate recertification so that members continue receiving benefits and the health plan continues to receive the appropriate risk score based payment.
  3. COMMUNITY LinkTM. It shouldn’t come as a surprise that dual eligible members are at a higher risk for compromised health resulting from typically complex comorbidity profiles and challenging living situations. COMMUNITY Link screens and assists members with accessing public and private social and community programs that improve daily living and positively impact their overall health and well-being. Going beyond direct health-related issues, COMMUNITY Link can reduce healthcare costs as well as increase member satisfaction and retention, important aspects of retaining the financial benefits of the new risk model.
To learn more about Altegra Health’s work to understand the impact and improve the outcome of the 2017 Medicare Advantage Final Notice, please contact (877) 461-0415.
About the Interviewee: kevin-barrett_125x128Kevin Barrett is President of Altegra Health and Executive Vice President of Change Healthcare. He has more than 25 years of experience in start-ups, deal making and operations in the healthcare services and life sciences industries. Kevin joined Social Service Coordinators (SSC – a precursor company to Altegra Health) in early 2009 to oversee the organization’s day-to-day operations. Kevin brought a wealth of experience to Altegra Health. He has served as an executive-in-residence with Bain Capital Ventures and SV Life Sciences, two Boston-based venture capital firms; Executive Vice President and Chief Development Officer of PolyMedica Corporation, the nation’s largest provider of blood-glucose-testing supplies and related services to people with diabetes; Senior Vice President of BG Medicine, a biotechnology start-up company, where he was responsible for commercial operations; and Chief Operating Officer of the Synergy Informatics division of Quintiles Transnational, the largest provider of outsourced drug development, commercialization, and healthcare information services to the global pharmaceutical industry. Kevin holds a BA in Psychology from Columbia University and a Master in Business Administration from Harvard Business School.  
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