CMS ad­mits bad dual-el­i­gi­ble math

Modern Healthcare - - NEWS - By Vir­gil Dick­son

Health plans have com­plained for years that the CMS doesn’t treat them fairly if they en­roll large num­bers of low­in­come peo­ple with com­plex med­i­cal needs. It looks as if they have been heard and may see the changes they want.

One per­sis­tent gripe has been that Medi­care un­der­pays plans for pa­tients who, be­cause they are both poor and either el­derly or dis­abled, are du­ally el­i­gi­ble for Med­i­caid and Medi­care.

That is true, the CMS in­di­cated last month in a lit­tle-no­ticed doc­u­ment. The agency plans to mod­ify its risk-ad­just­ment model to make up for the un­der­pay­ment. The doc­u­ment came soon af­ter top CMS of­fi­cials said dur­ing a con­fer­ence of health plans that they would con­sider tweak­ing the Medi­care Ad­van­tage pro­gram’s fives­tar qual­ity rat­ings to re­flect so­cio-eco­nomic fac­tors.

The agency’s change of heart is likely the fruit of ro­bust lob­by­ing by Amer­ica’s Health In­sur­ance Plans and the SNP Al­liance, a coali­tion of plans and providers, said John Gor­man, a con­sul­tant and former CMS of­fi­cial.

“Up un­til a few weeks ago, CMS steadily main­tained there wasn’t an is­sue, and on the stars is­sue, that plans needed to work harder,” Gor­man said.

In re­sponse to industry com­plaints about the risk-ad­just­ment model, the CMS con­ducted a ret­ro­spec­tive anal­y­sis of its 2014 plan data.

The CMS cal­cu­lates risk scores us­ing health sta­tus in a base year to pre­dict costs for the next year. Those scores drive ad­just­ments to cap­i­tated pay­ments made for el­derly and dis­abled ben­e­fi­cia­ries en­rolled in Ad­van­tage plans and cer­tain demon­stra­tion pro­grams.

Part of that model, the CMS said in an Oct. 28 no­tice to plans, “some­what un­der­pre­dicts” pay­ment for dual-el­i­gi­ble ben­e­fi­cia­ries. The agency is seek­ing feed­back on pro­posed changes to the model by Nov. 25 and plans to pub­lish fi­nal changes in Fe­bru­ary 2016.

“We are heart­ened that CMS has re­sponded to sev­eral data analy­ses that in­di­cate a clear cor­re­la­tion be­tween the so­cio-eco­nomic sta­tus of dual-el­i­gi­bles and the ef­fect they have on pre­dict­ing their costs,” said Jeff My­ers, CEO of Med­i­caid Health Plans of Amer­ica.

Molina Health­care, Cen­tene Corp. and Health Net may ben­e­fit most from a more fa­vor­able risk-ad­just­ment model be­cause sig­nif­i­cant per­cent­ages of their earn­ings are tied to duals-el­i­gi­ble mem­bers, said Ana Gupte, a man­ag­ing di­rec­tor at Leerink Part­ners.

Days be­fore the no­tice was posted, a top CMS of­fi­cial said dur­ing an AHIP con­fer­ence that the agency was con­sid­er­ing changes to its five-star qual­ity rat­ings. Plans have com­plained that they get lower star rat­ings if they serve the dual-el­i­gi­ble pop­u­la­tion, and con­sis­tently low rat­ings can get a plan kicked out of the pro­gram.

“What I want you to take away from this is that the industry brought an is­sue to us and we took it se­ri­ously,” Sean Cavanaugh, deputy ad­min­is­tra­tor and di­rec­tor of the CMS’ Cen­ter for Medi­care, said at the con­fer­ence. “There is some sub­stance to it.”

Cavanaugh cred­ited the Medi­care Pay­ment Ad­vi­sory Com­mis­sion for help­ing the CMS bet­ter un­der­stand the dis­par­i­ties plans face and the im­pli­ca­tions of not ad­dress­ing them.

Dur­ing a Sen­ate hear­ing this year, MedPAC Ex­ec­u­tive Di­rec­tor Mark Miller said the com­mis­sion con­cluded that the CMS over­pays for ben­e­fi­cia­ries with low med­i­cal costs and un­der­pays for those with very high costs. “This in­equity could en­cour­age plans to avoid high­cost ben­e­fi­cia­ries, who are more likely to be the chron­i­cally ill,” Miller said.

“What I want you to take away

from this is that the industry

brought an is­sue to us and we

took it se­ri­ously.” Sean Cavanaugh Deputy ad­min­is­tra­tor and di­rec­tor Cen­ter for Medi­care

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.