MAKING THE MOST OF SPECIAL NEEDS PLANS FOR DUAL ELIGIBLES A Presentation to Medicaid Health Plans of America JOHN GORMAN FOUNDER & EXECUTIVE CHAIRMAN OCTOBER 28, 2014
Cut to the chase Golden Age of Government Programs Brings Innovation Imperative Dual Eligibles are the biggest opportunity of our lifetime but only for the adaptable. - New cultures and capabilities needed - What Medicare does, Medicaid, HIX follow - Payers and their business partners must evolve or die: Barren Medicare rate environment + most vulnerable patients Rising medical and Rx costs Pay for Performance and risk adjustment go mainstream Tough CMS compliance posture Evolve or die.
Healthcare Entitlements are Unsustainable. Defined Contribution = Future 3
Medicaid By The Numbers Total Medicaid Enrollees Nonelderly 1/5 Low-Income 2/5 Children 1/3 Nursing home residents 63 million 7/10 Annual Spending $347 billion Coverage eligibility in ACA 22 million
Medicare Advantage Membership Snapshot October 2014 Number of Contracts Total Enrollees Total "Prepaid" Contracts Includes: 730 16,527,071 Local CCPs 2,0165,480 SNP 3,152,538 544 Series 800 14,204,435 PFFS 3,703,731 Local PPO 12 299,936 Regional PPOs 11 1,262,156 MA Subtotal 570 15,778,267 Medicare-Medicaid Plan 27 166,580 1876 Cost 16 499,258 1833 Cost (HCPP) 9 52,463 PACE 105 30,433 Other Subtotal 160 748,804 Total PDPs 85 23,473,656 TOTAL 815 40,000,727 Source: Medicare Advantage, Cost, PACE, Demo, and Prescription Drug Plan Contract Report Monthly Summary. Report covers contracts as of July 11, 2014, CMS August, 2014 Reporting. 5
The Duals Opportunity By The Numbers Estimated Dual Eligibles Total Spend/Year on Duals 10-11 Million $397 Billion Duals % of all Medicare/Medicaid enrollees 9% Duals % of all Medicare/Medicaid spend 37% Average # Chronic Conditions Medicare only Average # Chronic Conditions Duals 4.6 States with LOIs to CMS for Duals integration % Duals Spend in Health Plans 16.8% 1 37
The Duals Opportunity By The Numbers 2016 2019 States Moving Duals to Plans 11 22 Organic Premium Opportunity $40 Billion $122 Billion $397 2016 Duals Premium 2006 PDP Spend Current Medicare Managed Care Current Medicaid Managed Care Remaining Medicaid FFS (mostly LTC) Sources: CMS, CBO, Barclay s
Financial Alignment Demonstration States And Status 8
Many States Moving On Duals/LTSS Outside Of CMS Demonstration 41 State Actions on Long-Term Care, FY 2014-2015 46 FY 2014 FY 2015 42 47 16 13 15 21 HCBS Waiver MLTSS Incentives PACE Expansion Total States with HCBS Expansions Source: http://files.kff.org/attachment/medicaid-in-an-era-of-healthdelivery-system-reform-results-from-a-50-state-medicaid-budget-surveyfor-state-fiscal-years-2014-and-2015-report 9
Dual Eligible Demonstrations: Common Challenges And Lessons Learned Pre- Launch Beneficiary opt-out Actuarial soundness of rates Network composition Provider and staff training Stakeholder input Go Live Call centers: volume lower, but calls longer Data mining to find members Reaching and engaging members Health risk assessments, annual wellness visits Adaptation How to fund housing? Member onboarding Complex case management Stars and risk adjustment management 10
Opt-outs Hampering Demo Growth 11
Scope Of Services To Duals Challenge Both Medicare And Medicaid Plans Enabling Social Clinical Meals Transportation Personal Care Habilitation Assistive devices Home modification Communication services Light cleaning, personal care Caregiver respite Care coordination Skilled Nursing Caregiver training Palliative/EOL Care 12
Ratio of Benchmark to FFS PMPM 2015 MA Benchmarks 130.0% 125.0% 120.0% Medicare Advantage Benchmarks - Impact of CMS Trends, Rebasing and ACA Phase-In - National Average Basis: 2014 and 2015 published benchmarks, 2% trend for following years $950 $900 115.0% 110.0% 105.0% 100.0% 95.0% 90.0% 85.0% 106.0% 103.6% Reduction of 5.71% from average 2014 benchmark 3.37% from trends 2.34% from ACA and rebasing 102.6% 101.6% 101.6% $850 $800 $750 $700 $650 80.0% 2014 2015 2016 2017 2018 Benchmark as Percent of Published FFS - National Average New Law Blended Benchmark Old Law Benchmark Estimated FFS $600
CMS Enforcement Actions January 2012-May 2014 COMMON FINDINGS: Unapproved quantity limits Unapproved utilization management practices Failed to properly administer the CMS transition policy Improperly effectuated a prior authorization or exception request Failed to provide a transition supply of a nonformulary medication
Why Are Star Ratings So Important? Star Rating Complaints/1, 000 % Disenroll Annually 0.91 21.5% ½ 0.55 17.48% 0.42 14.79% ½ 0.33 9.27% 0.22 6.92% ½ 0.15 4.89% 0.16 1.91% Commercial and Medicaid always follow Medicare Sub-3-Star Plans on CMS hit list in Some text about the project, 2015 consectetur adipiscing elit. - Scarlet letter on Medicare.gov - Letters to members Lorem Ipsum has been the industry's standard dummy text ever since the 1500s, when an unknown printer took a galley of type and scrambled it to make a type specimen book. It has survived not only five centuries, but also the leap into electronic typesetting..5 Star = ~ $15-50 PMPM High correlation between Stars, compliance, and member satisfaction and loyalty
Enrollment The Star Ratings Bell Curve Enrollment by Star Rating 5000000 4500000 4000000 3500000 3000000 2500000 2000000 1500000 1000000 500000 0 9.60% 19% 5 Stars 4.5 Stars 29.50% 4 Stars 3.5 Stars 26.10% 10.70% 2.30% 3 Stars 2.5 Stars 1.10% 0.10% 1.60% 2 Stars Low New
Star Ratings Of The Publicly-Traded Majors Stars is the new fulcrum of competition for the majors. Overall MA star rating now 3.91, up 0.04 year over year. Humana most improved, up 0.18; 90.2% in 4+ Star plans: +$410MM Can Medicaid plans compete?
Impact of Star Ratings <4 Stars is the Kiss of Death CMS Sanction Impact 3+ Stars 2.5 Stars >3 Stars 1-star reduction
Regional Improvements 6
Regional Improvements
Correlation or Causation?
Correlation Or Causation? D-SNP Contracts Star Rating (2014) 0% 3.74 1-25% 3.68 25-50% 3.19 50-100% 3.24 LIS Contracts Star Rating (2014) 0% 3.74 1-25% 3.78 25-50% 3.38 50-100% 3.24 MA Plans with duals underperform in 2 categories: SNP-specific measures and medication adherence, especially diabetes, HTN, HPL Medication review, functional status assessment and pain screening low for D-SNPs Source: Health Affairs 22
Recent Findings on Duals and Star Ratings Inovalon: Difference Between Duals and Non-Duals on Specific Stars Measures Milliman: Star Ratings Tend to be Lower When: R-PPO or PFFS product Contract has service area of 20+ counties Contract is in Southern US or US territory Higher diabetes and HTN rates High rates of minority/underserved beneficiaries
PART C Weights and Measures: 2014 Measure Measure Type Weighting C01 Breast Cancer Screening Process 1 C02 Colorectal Cancer Screening Process 1 C03 Cardiovascular Care Cholesterol Screening Process 1 C04 Diabetes Care Cholesterol Screening Process 1 C05 Glaucoma Testing Process 1 C06 Annual Flu Vaccine Process 1 C07 Improving or Maintaining Physical Health Outcome 3 C08 Improving or Maintaining Mental Health Outcome 3 C09 Monitoring Physical Activity Process 1 C10 Adult BMI Assessment Process 1 C11 Care for Older Adults Medication Review Process 1 C12 Care for Older Adults Functional Status Assessment Process 1 C13 Care for Older Adults Pain Screening Process 1 C14 Osteoporosis Management in Women w Fx Process 1 C15 Diabetes Care Eye Exam Process 1 C16 Diabetes Care Kidney Disease Monitoring Process 1 C17 Diabetes Care Blood Sugar Controlled Int. Outcome 3 C18 Diabetes Care Cholesterol Controlled Int. Outcome 3 C19 Controlling Blood Pressure Int. Outcome 3
PART C Weights and Measures: 2014 Measure Measure Type Weighting C20 Rheumatoid Arthritis Management Process 1 C21 Improving Bladder Control Process 1 C22 Reducing the Risk of Falling Process 1 C23 Plan All-Cause Readmissions Outcome 3 C24 Getting Needed Care Patient's Experience 1.5 C25 Getting Appointments and Care Quickly Patient's Experience 1.5 C26 Customer Service Patient's Experience 1.5 C27 Rating of Health Care Quality Patient's Experience 1.5 C28 Rating of Health Plan Patient's Experience 1.5 C29 Care Coordination Patient's Experience 1.5 C30 Complaints about the Health Plan Patient's Experience 1.5 C31 Beneficiary Access and Performance Problems Access 1.5 C32 Members Choosing to Leave the Plan Patient's Experience 1.5 C33 Health Plan Quality Improvement Outcome 3 C34 Plan Makes Timely Decisions about Appeals Access 1.5 C35 Reviewing Appeals Decisions Access 1.5 C36 Call Center Foreign Language Interpreter and TTY Availability Access 1.5
PART D Weights and Measures: 2014 Measure Measure Type Weighting D01 Call Center Foreign Language Interpreter and TTY Availability Access 1.5 D02 Appeals Auto-Forward Access 1.5 DO3 Appeals Upheld Access 1.5 D04 Complaints About the Drug Plan Patient's Experience 1.5 D05 Beneficiary Access and Performance Problems Access 1.5 D06 Members Choosing to Leave the Plan Patient's Experience 1.5 D07 Drug Plan Quality Improvement Outcome 3 D08 Rating of Drug Plan Patient's Experience 1.5 D09 Getting Needed Prescription Drugs Patient's Experience 1.5 D10 MPF Price Accuracy Process 1 D11 High Risk Medication Outcome 3 D12 Diabetes Treatment Outcome 3 D13 Medication Adherence for Diabetes Medicatio Outcome 3 D14 Medication Adherence for Hypertension (RAS Outcome 3 D15 Medication Adherence for Cholesterol (Statins Outcome 3
New Star Measures For 2015: Implications for Dual Eligibles Four new measures: 1. Pharmacotherapy Management of COPD Exacerbation (PCE) (Part C) 2. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET) (Part C) 3. SNP Care Management (Part C SNPs) 4. Medication Therapy Management Program Completion Rate for Comprehensive Medication Reviews (Part D) First year measures assigned a weight of 1 27
Plans Receiving <2 Stars By Domain Domain Plans D-1: Drug Plan Customer Service 60 D-2: Member Complaints, Problems Getting Care, and 16 Improvement in the Drug Plan's Performance D-3: Member Experience with the Drug Plan 17 D-4: Patient Safety and Accuracy of Drug Pricing 1 MA-1: Staying Healthy: Screenings, Tests and Vaccines 2 MA-2: Managing Chronic (Long-Term) Conditions 1 MA-3: Member Experience With Health Plan 15 MA-4: Member Complaints, Problems Getting Services, and 10 Improvement in the Health Plan's Performance MA-5: MA Health Plan Customer Service 4
SNP Do or Die: Risk Adjustment Management 29
What Matters Now Execution, Engagement, And The Member Experience Identifying Members Analytics and Reporting Engaging and Managing Members Case Management PBM/Vendor Performance Stratification Proactive Member Experience Integrated MTM Specialized services for chronically ill
Examining The Duals Opportunity: Financial Forecasting Three-year annual pro forma income statement in dollars and per member per month (PMPM) formats Summary of member premiums and rebates projected Projected enrollment Cost and revenue trends Projected risk adjustment factors Part C revenues, benefits, and claim expenses Part D revenues, benefits, and claim expenses CMS-published benchmark payments and claim cost estimates Enrollment and disenrollment projections by month for 36 months Projected benchmark payment rates through 2018 to assess the future impact of the Affordable Care Act (ACA) Complete list of assumptions 31
D-SNP Implementation Prep Year: October-December 32
D-SNP Implementation Filing Year: Q1-3 33
D-SNP Implementation Filing Year: Q2 34
D-SNP Implementation Filing Year: Q3 35
D-SNP Implementation Filing Year: Q4 36
D-SNP Go-to-Market Readiness Check Desk Review Training P&Ps MOC Network oversight Staffing plan Onsite Member lifecycle Care Model Claims testing Network oversight Network Validation HSD Tables LTSS network development Pre-enrollment Secret shoppers Website Staffing Call center scripts 37
Conclusions: Evolve or Die 1. Duals are the biggest opportunity of our lifetime, and also the most challenging. 2. Unique operational and clinical capabilities required. 3. Risk adjustment and Star Ratings management are do or die. 4. High-touch, data-driven holistic approach is key. 5. PBM is most important vendor.
JOHN GORMAN Executive Chairman T 202.255.6924 E jgorman@gormanhealthgroup.com Gorman Health Group, LLC (GHG) is a leading consulting and software solutions firm specializing in government health programs, including Medicare managed care, Medicaid and Health Insurance Exchange opportunities. For nearly 20 years, our unparalleled teams of subject-matter experts, former health plan executives and seasoned health care regulators have been providing strategic, operational, financial, and clinical services to the industry, across a full spectrum of business needs. Further, our software solutions have continued to place efficient and compliant operations within our client s reach. GHG offers software to solve problems not addressed by enterprise systems. Our Valencia software reconciles the capitation payment of more than six million Medicare beneficiaries and continues to support customers participating in the Health Insurance Exchanges. Nearly 3,000 compliance professionals use the Online Monitoring Tool (OMT), our complete Medicare Advantage and Part D compliance toolkit, while more than 45,000 brokers and sales agents are certified and credentialed using Sales Sentinel. In addition, hundreds of health care professionals are trained each year using Gorman University training courses. We are your partner in government-sponsored health programs 39