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BLENDED RISK SCORESTHE NEW MATH

Presented By:

Pam Klugman 

November 2013

Topics for Discussion

• Key Elements for Risk Adjustment

• What’s Out / What’s In

• Blended Risk Score Examples

• Q & A

Physician SGR Cut

SSA mandates MA growth percentage be tied to overall FFS growth expectations.  • A 25% reduction to the the physician fee 

schedule would have been a negative 2.2% in overall payments

This change by CMS allowed a positive 3.3% cost factor to offset some of the other changes rather than a 2.2% reduction.

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FFS Normalization Factors

Designed to assess difference in Health Conditions between FFS and MA• 2 Normalization Factors, due to blended 

rates• 25% on 2013 Model – 1.041• 75% on 2014 Model – 1.026

Overall this is a negative adjustment

Rebasing County Rates

This Rates adjust based on the FFS‐based components of MA rates on the most recent historical claims costs from the FFS program. • ACA requirement that 100% of MA rates will 

be based on FFS costs• 2014 adjustments Uses Claims from 2007 to 2011

MA Coding Patterns

CMS adjusts rates based on higher pattern of coding under MA

This is called the MA Coding Intensity adjustment • 3.41% for 2013  • 4.91% for 2014* So you need to get 1.5% better in coding to break even on coding

Negative adjustment – as plans get better at coding and data capture the adjustment goes up

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Sequestration & MLR

• Sequestration added a 2% across the board payment cut• Duration – Unknown

• 85% Medical Expense Ratio • Implications to plans with high margins 

likely offset by Sequestration reduction this year.

Star Ratings

• Quality Bonus Incentives tie to HEDIS and Satisfaction Measures

• Plan and Physician satisfaction are critical for bonus payments – similar to how ACO’s need to handle their populations to be successful

• 4‐5 stars .5 to 1% bonus• This becomes a market differentiator over time• 5 star plans have continuous enrollment also

Risk Adjustment Model• CMS‐HCC Model has been clinically revised

• Current Model (V. 12) 70 HCCs• New Model (V. 22) 79 HCCs 

• In an attempt to mitigate changes resulting from the move to HCC model 22 CMS will blend the risk score for 2014• V.12 @25%• V.22 @ 75% for 2014

• Full transition to V.22 by 2015

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CMS Sweep Information

DOS Sweep Payment Received Payment Year

07/2011 ‐ 06/2012 First Friday in Sept 2012 Jan ‐ Jun 20132013

01/2012 ‐ 12/2012 First Friday in Mar 2013 Jul ‐ Dec 20132013

01/2012 ‐ 12/2012 Last Day of Jan 2014 Aug ‐ 2014Final 2013

What’s Out& 

What’s In

What’s Out• 131 ICD‐9 codes discontinued mapping to 

CMS‐HCC

•Celiac Disease•CKD Stage 1‐3•Diabetes (change in mapping, dropped HCCs)

•Major Complications of Medical Care & Trauma

•Old MI, Asphyxia & Hypoxia

•Pancreatic Disease•Peripheral Neuropathy, Polyneuropathy•Skin Ulcer , not all included in new model

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What’s In• 226 new ICD‐9 codes mapping to CMS‐HCC

• Coagulation Defects & Other Specified Hematological Disorder

• Diabetes regrouped to 3 categories• Endocrine & Metabolic Disorder• Fibrosis of Lung and Heart Chronic Lung 

Disorders• Morbid Obesity• SIRS

Disease Interactions

• Model V.12• 6 Interactions at Community factor Level• 5 Interactions at Institutional Factor Level

• Model V. 22• 6 Interactions at Community Factor Level• 12 Interactions at Institutional Factor 

Level�

Health Risk Assessments

Diagnosis codes from Health Risk assessments MAY no longer count for Risk Adjustment• A follow up visit may be required related to 

any coding captured during a health risk assessment• Significant implications for home 

assessment companies• Was to be in August 2013 software 

release• Delayed as of 5/14/2013 CMS Memo

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The Moving PartsCMS HCC V. 12 CMS HCC V. 22

ICD‐9 Description ICD‐9 Codes HCC Weight HCC Weight2 Reason

DMII WO CMP UNCNTRLD 250.02 19 0 19 0 1

DMI NEURO UNCNTRLD 250.63 16 0.371 18 0.368

BIPOLAR AFFEC, MANIC‐MOD 296.42 55 0.360 58 0.330

NEUROPATHY IN DIABETES 357.2 71 0.321 18 0 1

PERIPH VASCULAR DIS NEC 443.89 105 0.302 108 0.299

OLD MYOCARDIAL INFARCT 412 83 0.17 N/A 0 2

Totals 1.524 0.997

Normalization Factor 1.041 1.026

Normalized Score 1.464 0.972

% of Normalized Score 25% 75%

Scores before blending 0.366 0.729

Total Blended weight before coding intensity factor 1.095

Legend

1Lower in hierarchy than 16

2Removed from CMS HCC model V. 22

How It All Adds Up

Description CMS HCC V. 12 Blended CMS HCC V. 22

Assuming base rate of $950 $        1,391  $               923 

Coding Intensity Factor 2013 3.41

Coding Intensity Factor 2014 4.91 4.91

Amount after factor applied $        1,343  $               878 

Before Coding Intensity applied $             1,040 

Net after Coding Intensity 2014 $                 989 

Factor Matrix

Normalization FactorsCoding Pattern 

Differences

CMS‐HCC

CMS‐HCC ESRD Functioning Graft 

StatusCMS‐HCC ESRD Dialysis Model CMS‐HCC PACE RxHCC CMS‐HCC

2011 1.058 1.088 1.060 N/A N/A N/A

2012 1.079 1.051 1.012 1.051 1.032 3.41

2013 1.028 1.07 1.023 1.07 1.034 3.41

2014 for 2013 Data 1.041 N/A N/A N/A N/A N/A

2014 for 2014 Data 1.026 1.085 1.039 1.085 1.030 4.91

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Questions?

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2013 Annual Conference

Stars and HCC Taking Advantage of Overlaps

Presented By: Mechelle ReedNovember 2013

2013 Annual

Conference

CMS Star ratingsWhy are stars a big deal !

Everyone is discussing CMS Star Ratings and ways to become a 5 star health plan.

Plans that don't earn high ratings (i.e. 4 or more stars) this year will take payment hits in 2015.

Under the Affordable Care Act the government uses the star rating as a financial incentive to reward high quality plans with bonus and rebates

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2013 Annual

Conference

CMS Star ratings The higher the star rating, the more plans will

receive in revenue from the government.

There are also consequences for low performing plans. Plans with fewer than 3 stars consistently over the prior three years are flagged as low-quality on the Medicare website.

CMS will terminate contracts that are consistently low performing.

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2

2013 Annual

Conference

Medicare uses information from member satisfaction surveys, plans, and health care providers to give overall performance star ratings to plans.

A plan can get a rating between 1 and 5 stars. A 5-star rating is considered excellent.

Ratings help to compare plans based on quality and performance.

What are Medicare Stars

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2013 Annual

Conference

The ratings are updated each fall and can change each year

5-star plans are designated with this special icon:

Ratings

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2013 Annual

Conference

Star Ratings A plan can get ratings between 1 and 5 stars (Some

plans may be two new or not have enough data to be rated)

5 stars = Excellent

4 stars = Above average

3 stars = Average

2 stars = Below average

1 star = Poor

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3

2013 Annual

Conference

Performances MeasuresMedicare Measures how well health and prescription

drug plans perform on 50 items, which are grouped in five domains:

Staying Healthy: screenings, test, and vaccines

Managing Chronic long term conditions

Member experience with health plan

Member complaints, problem getting services, and improvement in the health plan's performance

Health plan customer services

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2013 Annual

Conference

CMS Star ratingsWhy are stars a big deal !!!

Everyone is discussing CMS Star Ratings and ways to become a 5 star health plan.

Plans that don't earn high ratings (i.e. 4 or more stars) this year will take payment hits in 2015.

Under the Affordable Care Act the government uses the star rating as a financial incentive to reward high quality plans with bonus and rebates

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2013 Annual

Conference

CMS Star ratingsWhy are stars a big deal !!!

Everyone is discussing CMS Star Ratings and ways to become a 5 star health plan.

Plans that don't earn high ratings (i.e. 4 or more stars) this year will take payment hits in 2015.

Under the Affordable Care Act the government uses the star rating as a financial incentive to reward high quality plans with bonus and rebates

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4

2013 Annual

Conference

Performance - Drug Plans

Medicare drug plans are rated on how well they perform in 4 domains:

Drug Plan customer service

Member complaints, problem getting services, and improvement in the drug plan's performance

Health plan customer services

Member experience with drug plan

Patient safety and accuracy of drug pricing

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2013 Annual

Conference

Measuring Quality

Medicare measures quality by a plans performance in the following:

Diabetes management

Controlling high blood pressure

Medication management

Medication Management

Call Center

Others

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2013 Annual

Conference

Receive regular reports from your Pharmacy Benefit Manager (PBM).

Include the PBM reports as part of your star review process• Get information from the PBM

• Review High Risk Medication Reports

• Medication Adherence reports etc.

Measuring Quality

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5

2013 Annual

Conference

Most HEDIS measures are now apart of Stars

Use the Clinical team, Compliance, and IT areas to become a successful plan

Identify your eligible population and administrative compliant members.

Review eligibility data and administrative claims and encounters data. Consider a weekly team meeting.

Stars and HEDIS

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2013 Annual

Conference

Building HEDIS like queries to generate current rates using HEDIS specifications for Star measures

Medical record retrieval for non-compliant members and exclusions. Review your data. Be aware of members which can be excluded from samples, or ways to assist in areas with non compliant members.

Reporting

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2013 Annual

Conference

Consider opening direct authorizations for members which meet the requirements for quality measures.

Utilize staff resources within your organization that have direct contact with members such as Case Managers, schedulers to ensure members are scheduled for appointments.

Offer health clinics

Access

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6

2013 Annual

Conference

Provide physicians with “Approved” tools necessary to complete the task.

Tools should be clear and concise.

Are billing services and providers utilizing Category II codes to report performance measures such as:

Documentation of Reconciliation of Discharge Medication with Current Medication List (1111F)

History of codes

Physician Tools

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2013 Annual

Conference

Use the data collection process for Stars as an opportunity to capture new HCCs.

Network expansion – Reach out to all providers regarding data submission. Review monthly encounter data reports for no or low submitting providers

Refresh your diagnosis reports

Are EMR capturing V-Codes to collect diagnosis important to Stars and bring revenue from HCC, such as Morbid Obesity

HCCs (Hierarchical Condition Categories)

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2013 Annual

Conference

Most plans are already measuring a number of aspects in physician offices, especially those are profitability. But it’s important to also measure practice performance and patient outcomes to be successful with Stars.

Consider Physician Report Cards and Intervention Reports

HCCs (Hierarchical Condition Categories)

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2013 Annual

Conference

Changes as described in the final 2014 Call Letter (p100-114) will be implemented• Quality Improvement - Contracts held harmless

if individual measure stars are 5 stars in the 2 measurement years

• Low Performer Icon (LPI) - Contracts rated 2.5 stars or lower for any combination of their Part C or D summary ratings for 3 consecutive years will receive an LPI

2014 Changes

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2013 Annual

Conference

Rounding of measure data - Measure data and cut points rounded to whole numbers, except for Part C and D Complaints about the Health and Drug Plan, Health and Drug Plan Quality Improvement, and Part D Appeals Auto-Forward

Enrollment Timeliness –

Getting Information from Drug Plan -Removed from Star Ratings and Transferred

2014 Changes (Cont.)

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2013 Annual

Conference

Questions?

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