CMS

This July, the Centers for Medicare & Medicaid Services (CMS) proposed the 2019 Medicare Physician Fee Schedule and Quality Payment Program, which includes expanding Medicare-covered telehealth services to include prolonged preventive services. 

While coverage of telehealth services is expanding, it appears that 83 percent of Medicare Advantage members either do not know if they can connect via their plan to telehealth providers, or do not think telehealth is offered at all through their plan. Our June/July 2018 HealthMine survey found 46 percent of Medicare members were unsure if their plan offers telehealth, while 37 percent said it is not offered.

Plus, the respondents were computer literate, as the survey was fielded online. And they are connected: 77 percent of respondents use a smart device (a smartphone or tablet). 

Just sixteen percent (16%) of Medicare plan members with chronic conditions said they had a follow-up on quality of care after a provider visit, as reported to HealthMine in a recent study.  Only ten percent (10%) of plan members surveyed said their health plan offers guidance about these chronic conditions.

“If members feel that their health plan knows them, but doesn’t actively communicate with them or help them manage their chronic conditions, it is an opportunity for plans to take action,” Bryce Williams, CEO of HealthMine, told Managed Healthcare Executive.

“Actively managing care enables payers to check off which patient services were completed and which are still needed so they can proactively identify gaps in care as well as adhere to HEDIS quality measures,” continues Williams.

New York Times: Irregular and unpredictable drug prices -- A new study analyzed the disparities in drug prices city-to-city across the nation. While some price hikes were unsurprising, like in New York and San Francisco, others were more unpredictable, even finding vastly different drug prices from pharmacies on the same block.

Health Payer Intelligence: Star ratings impacted by population economic status--Health plan members’ socioeconomic backgrounds affect Medicare Advantage star ratings, new research found. In the current ratings system, plans that serve “low income, medically complex, or socioeconomically vulnerable individuals,” may unwittingly be prone to lower star ratings. 

mHealth Intelligence: Telehealth reimbursements included in CMS 2019 proposal—Virtual care service opportunities, including virtual check-in services, remote evaluation of patient-submitted videos and images, and expanded reimbursements, were all included in the CMS proposal for next year. "Today is a huge win for patients and providers as CMS is proposing historic changes to modernize Medicare and restore the doctor-patient relationship," said CMS Administrator Seema Verma.

CMS.Gov: CMS taking action to modernize Medicare home health -- The Centers for Medicare & Medicaid Services (CMS) announced plans to “strengthen and modernize Medicare” by focusing “on individual patient needs rather than volume of care.” The changes will include more remote patient options as well as better data sharing facilitation.

Modern Healthcare: New study finds positive Medicare Advantage results -- Medicare Advantage members are spending less time in nursing facilities after surgery, are less likely to be readmitted to hospitals, and less likely to become longterm nursing home residents than traditional Medicare members, according to a new report. The PLOS study also found that with “stronger care-management protocols” from Medicare Advance, there are fewer preventable hospitalization for patients.

CMS Administrator Seema Verma announced in April that the agency has released Medicare Advantage encounter data to researchers. (Encounter data are records of the health care services for which managed care organizations pay.)  It was reported that she said at the 2018 Datpalooza conference, “We recognize that the MA data is not perfect, but we have determined that the quality of the available MA data is adequate enough to support research.”
 
The purpose of the encounter data is to help researchers better understand care trends for seniors.  The data could create new benchmarks for patient outcomes and costs for Medicare Advantage. We believe that analysis of encounter data will have implications for Star Ratings, risk adjustment revenue, and cost of care for Medicare Advantage plans. 
 
CMS released preliminary 2015 Medicare Advantage data and more data is expected from insurers through August, with final data reports to follow. It is the beginning of the CMS releasing data on MA enrollees annually going forward. 
 

Some Medicare Advantage plans scored a 3.74 and were rounded to the “nearest half Star” based on Centers for Medicare & Medicaid Services (CMS) rules, so the plan was rated a 3.5.  Conversely, other plans were scored 3.75 and were rounded to the nearest half Star of 4.0. 

CMS started its VBID (value-based insurance design) innovation model for Medicare Advantage on January 1, 2017 to run for five years.  
 
Eligible Medicare Advantage plans can offer “varied plan benefit design” for enrollees based on specified clinical categories identified and defined by CMS. In 2017, diabetes, congestive heart failure, chronic obstructive pulmonary disease (COPD), past stroke, hypertension, coronary artery disease, mood disorders, and combinations of thereof were the defined categories.
 
As reported in Healthcare Finance, CMS chose nine Medicare Advantage organizations to participate in the 2017 value-based insurance design model: Blue Cross Blue Shield of Massachusetts, Fallon Community Health Plan of Massachusetts, Tufts Associated Health Plan of Massachusetts; Geisinger Health Plan, Aetna, Independence Blue Cross, Highmark of Pennsylvania, UPMC Health Plan of Pennsylvania; and Indiana University Health Plan. (Blue Cross Blue Shield of Michigan was added in 2018.)
 
With that, according to an analysis by Manatt Phelps & Phillips LLP, there were 45 value-based approaches (aka plan benefit packages, or PBP) being used by the nine Medicare Advantage Organizations (MAO) individual plans.  With 45 PBPs implemented by 9 plans, that suggests that administration could be a challenge for each MAO. 
 

The Centers for Medicare and Medicaid (CMS) has expanded its Medicare Diabetes Prevention Program (MDPP) to now enroll traditional healthcare providers and community-based organizations as Medicare suppliers of health behavior change services.
 
The  (MDPP) seeks to prevent or delay type 2 diabetes through health behavior changes. MDPP is a structured intervention geared to prevent the onset of type 2 diabetes among Medicare beneficiaries with an indication of prediabetes. 
 
Key to prevention or delay of any chronic disease is to identify at-risk members earlier and close gaps in care faster. 
 
In working with Medicare plans, we have experienced that the key driving force is to get Medicare Advantage plan members to take clinical actions. We have found that the right incentives can drive these clinical actions to interpret more data to find risks earlier.
 
Some clinical action improvements/success we have encountered in working with Medicare Advantage plans include the following:
 
+40% increase – adult BMI assessment (E/M visit)
+31% increase - in-home assessment
+17% increase - retinal eye exam
+31% increase - kidney disease monitoring
+10% increase - A1c tests 

CMS announced that it “finalized polices for Medicare health and drug plans for 2019 that will save Medicare beneficiaries money on prescription drugs while offering additional plan choices.” 
 
While the announcement focuses on prescription drug pricing, the additional plan choices means the agency is “reinterpreting the standards for health-related supplemental benefits.”  CMS will now allow supplemental benefits if they “compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization.”

Bruce Japsen of Forbes wrote that Uber and Lyft will likely be included in these benefits to transport seniors to doctors in on-emergency situations.  
 
The precedent has been set for almost 20 years with non-emergency transportation providers like Cleveland-based, Provide A Ride, a van service for Medicaid and Medicare MCO transportation benefit programs.
 
Plus, for Medicare Advantage plans, promoting and contracting new additional plan choices can become a marketable difference for 2019.
 
Additional services Medicare Advantage plans could pay for in 2019 include the following: