Executive Webcast Series: Succeeding in Medicare...
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Executive Webcast Series: Succeeding in Medicare Advantage with Risk Management Tools Jon Mark Harmon, Product Manager Ted Courtemanche, Vice President Analytics and Outcomes Guy Mansueto, Vice President, Marketing (Moderator)
Transcript of Executive Webcast Series: Succeeding in Medicare...
Executive Webcast Series:
Succeeding in Medicare Advantage with
Risk Management Tools
Jon Mark Harmon, Product Manager
Ted Courtemanche, Vice President Analytics and Outcomes
Guy Mansueto, Vice President, Marketing (Moderator)
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Growth of Medicare Advantage
Source: Kaiser Family Foundation http://kff.org/medicare/fact-sheet/medicare-advantage-fact-sheet/
In 2014, the majority of the 54 million people on Medicare are in the traditional Medicare program, with 30% enrolled in a Medicare Advantage plan (Exhibit 1).
Since 2004, the number of beneficiaries enrolled in private plans has almost tripled from 5.3 million to 15.7 million in 2014
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Medicare Advantage by State
Source: Kaiser Family Foundation http://kff.org/medicare/fact-sheet/medicare-advantage-fact-sheet/
Enrollment in private plans varies by state, ranging from 51% in Minnesota to less than 1% in Alaska, and vary within states, by county
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Expected Future Growth of Medicare
20.1
28.033.7
39.3
47.4
63.9
81.1
88.592.0
98.2
105.6112.1
0
20
40
60
80
100
120
1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 2060 2070 2080 2090
Be
nef
icia
rie
s (i
n m
illio
ns)
Note: Enrollment numbers are based on Part A enrollment only. Beneficiaries enrolled only in Part B are not included.Source: CMS Office of the Actuary. 2013
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Value-Based Care
Geisinger Health System, which offers its own health plans, is seeing more
opportunity in Medicare managed care than in capitated, payment-for-value
contracts. Medicare will expand “much more rapidly than any other payer,”
President and CEO Glenn Steele.
Source: http://www.modernhealthcare.com/article/20140115/NEWS/301159952
“Our big bet is not ACOs. Our big
bet is Medicare MCOs.”
Glenn D. Steele Jr., MD, PHD
President and Chief Executive Officer
Geisinger Health System
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What We Will Cover
During this webinar, you will learn:
1. The unique factors that comprise Medicare Advantage
2. Challenges of optimizing Medicare Advantage coding
3. Efficient ways to accurately capture patient RAF
4. How a registry-based population health solution can provide
a risk management approach for practice groups
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Overview
The HCC system is a payment methodology based on “risk” used by
CMS to adjust MA health plan payments at the patient level. This
means that 2 patients within the same community can have a different
payment rate based on several factors relating primarily to the amount
of risk, or work, it takes to maintain the health of a patient.
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Overview
The HCC system is a payment methodology based on “risk” used by
CMS to adjust MA health plan payments at the patient level. This
means that 2 patients within the same community can have a different
payment rate based on several factors relating primarily to the amount
of risk, or work, it takes to maintain the health of a patient.
The numeric value representing the patient’s risk is called the Risk
Assessment Factor (RAF).
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Overview
The HCC system is a payment methodology based on “risk” used by
CMS to adjust MA health plan payments at the patient level. This
means that 2 patients within the same community can have a different
payment rate based on several factors relating primarily to the amount
of risk, or work, it takes to maintain the health of a patient.
The numeric value representing the patient’s risk is called the Risk
Assessment Factor (RAF).
RAF scores are comprised of disease coefficient factors and
demographic factors (e.g. age). Disease coefficient factors (HCC
Categories) are the primary contributor to the RAF and are driven
100% by accurate coding.
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Overview
“Risk adjustment allows CMS to pay plans for the risk of the
beneficiaries they enroll, instead of an average amount for Medicare
beneficiaries. By risk adjusting plan payments, CMS is able to make
appropriate and accurate payments for enrollees with differences in
expected costs. Risk adjustment is used to adjust bidding and payment
based on the health status and demo-graphic characteristics of an
enrollee.”
Source: Medicare Managed Care Manual http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c07.pdf
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RAF Disease Coefficients
For 2014, there are 79 HCC Model Categories driving community disease coefficients.
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RAF Disease Coefficients
The core of Phytel’s product is the summarization and presentation of this information in
a way that is simple for physicians and staff to access and review.
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Opportunity Within Existing Data
• There are two drivers of disease coefficients in any year:
• Patients who had a prior year HCC category that is coded again in the current year.
• Patients that are coded new for an HCC category in the current year.
• On average, about 50% of current year disease coefficients come from prior year patients with the same HCC category.
• But for the prior year patients, about 30-40% of the codes driving HCC categories are not coded again in the current year.
• There is real opportunity to assess patients who were coded in prior years but missed in current year.
• Diabetes, Heart Failure, MS, Parkinson’s, etc. – all HCC categories that are chronic in nature.
About 30-40% of prior year disease coefficients for active
patients are left out.
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Opportunity Within Existing Data
Understanding the differences between years is the
strength of the Phytel HCC Risk Manager solution.
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Challenges
• Patients fall through the cracks
• Codes are not re-captured
• The calendar matters - practices and plans have 3
months left in 2014 to impact 2015
• Legacy workflows are, generally, not designed for
the emerging Medicare Advantage environment
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Challenge
In order to optimize HCC coding…
…practices must find a way to employ a different
workflow for Medicare Advantage patients.
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Challenge
In order to optimize HCC coding…
…practices must find a way to employ a different
workflow for Medicare Advantage patients.
The truth is…
…this can be difficult.
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In Order to Succeed
Must be quickBecause of the limited number of MA patients, if the data is not
accessible quickly, the workflow will not be sustainable.
Must be easyThe solution cannot entail significant complexity, or it will cease to be
utilized. Physicians and staff have too many other things to do.
All relevant HCC coding information must be
readily availableThe solution must be accurate, complete, and easily summarized in
order to become operational.
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Questions Practice Groups are Asking
• Last year, we directed more resources than ever before towards HCC improvement. Can you help me improve our process?
- HCC Coding Director
• We have to assume a patient’s appointment may be the only appointment this year. We need to ensure that we maximize every encounter.
- HCC Coding Team Lead
• Every year we lose some Medicare Advantage patients and gain new ones. How do we close the gap on the patients we lose each year?
- COO
• I get paid for coding services, because that’s how I am used to getting paid. How can I be expected to have a different workflow for a small, subset of my patients?
- Physician
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Problems to Solve
1. Optimize the coding efficiency of each visit
2. Ensure that each claim submission accurately
represents the health status of the patient
3. Identify the high-risk patients who are not scheduled for
a visit this calendar year
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Problems to Solve
1. Optimize the coding efficiency of each visit
Solutions: Simple Pre-visit Preparation
Easy-to-Use Physician Summary
2. Ensure that each claim submission accurately represents the health status of the patient
Solutions: Post-visit Opportunity Review
Real-time Care Gap Summary
3. Identify the high-risk patients who are not scheduled for a visit this calendar year
Solutions: Most At-Risk Patient Work List
Updated daily
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Phytel Advantages
Accurate and accounted patient list
• Real-time billing data
• Real-time scheduling data
Part of an Integrated Patient Engagement Product Suite
• Find the patients at risk of missing a visit this calendar year
• Patient engagement is necessary to seek out these patients
Easy for Staff – Easy for Docs
• Staff completes all visit preparation in less than 5 min per day
• Almost no change to provider workflow
• Works with any system
Quick Implementation
• Company built on data extraction & aggregation
• Experience with 50+ practice management systems
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Questions
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Thank you!
Contacts:
The next Executive Series Webinar
will be in October.
Check your emails for the invitation.
