FLAACOs 2014 - Benchmark Target Management In Medicare Shared Savings Program
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Transcript of FLAACOs 2014 - Benchmark Target Management In Medicare Shared Savings Program
Benchmark Target ManagementIn
Medicare Shared Savings Program
September 2014
Managing Benchmark
• Managing Benchmark Surprises• Impact of Churn• Risk scoring in MSSP vs. Medicare
Advantage• ESRD, Dual, Disabled, Aged
– Movements Between Categories
Benchmark Surprises!• Many ACOs experienced a significant adverse
move in benchmark• 1.5% of benchmark reduction in savings
payment.– $10,000 annual benchmark = 150 per bene lost
payment or $12.50 “pmpm” or 50% more than CMMI advance payment
– 8,000 bene = $1.2 million
• Mix of beneficiaries by segment• Missing bene – where did they go?• Final Assignment
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Assignment and Risk Selection
• Quarterly updates– Getting newly assigned addresses– Deceased– Claims info stop = reassigned to different ACO,
MA?– Where did they go?
• Category– ESRD?– Dual?– Disabled?
Segment Management
• ESRD is 6-10x or more Aged/Dual• Dual 20% or more than Aged• Disabled mixed bag – some ACOs
have higher, some lower.• Will vary by ACO – how are you
managing which patients are in each segment?
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Cash Flow Time Lines• RAF in an ACO, a study in delayed gratification
– ACO is a 3 Year Contract• Year 2 drives Year 3 risk score• Year 3 risk score is drives normalization of Year 1 & 2
costs for 2nd Contract (Years 4-6) benchmark• Upward sloping RAF scores “bake in” a favorable bias
for 3 years
– Year 4 savings paid mid Year 5– RAF is a 3 year benefit for a 1 year effort
• Just delayed a long time• Downward sloping RAF is certain economic failure
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MSSP and Risk Scoring
• MSSP will receive some value for RAF management– Not as much as Medicare Advantage on an
annual basis– 3 Year Value
• Not “managing” RAF is risking a negative slope to risk scores which bakes in an unfavorable bias for 3 years!
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Risk Score – Positive Slope Example
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Year Risk ScoreRisk Score Adj Factor
(BY3/BYx) Weight Component
Risk “Inflation”
for 2016,7,8PY1 2013 0.75 1.27 10% 0.127 PY2 2014 0.75 1.27 30% 0.380 PY3 2015 0.95 1.00 60% 0.600
Imputed Risk Score 1.107 10.67%
Moderate Increase in BY 3 Risk ScorePY1 0.75 1.40 10% 0.140 PY2 0.75 1.40 30% 0.420 PY3 1.05 1.00 60% 0.600
Imputed Risk Score 1.160 16.00%
Significant Increase in BY 3 Risk ScorePY1 0.75 1.47 10% 0.147 PY2 0.75 1.47 30% 0.440 PY3 1.10 1.00 60% 0.600
Imputed Risk Score 1.187 18.67%
RAF in MSSP Benchmark Calculations• Three year trend effects benchmark for
next three years.– Getting it right is an imperative.– Not an immediate gratification– Changes can overwhelm care coordination
impact
• Relative movement vs. absolute level• Upward trend is good, downward is bad• There are no MMR, MOR, RAPS return files
– New administrative structures and efforts– Front loaded efforts
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No RAPs file!!!
• No RAPS, MMR, MOR, or Error File• No specific member to HCC identification• Engaging the physician, EMR & Billing• Claims line feed – some of the data• Typical analysis• Action items to physicians• Reconciling CLF vs. MMR/MOR• Twists from MSSP Assignment process10
Submitting New Dx to CMS
• There is no RAPS file!• There is no 2nd chance.• Codes go to CMS on the claim.• 5010 sort of compliant vs. fully
compliant• MSO type pre-clearing house
validation
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Managing Beneficiary Assignment• Not managing assignment is trusting
a negatively biased environment to provide a fair cross section of risk.
• Benchmark credit accrues differently than health care expense
• Cultural nature of ACOs is to further adverse risk selection
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Benchmark vs. Cost Accumulation• Benchmark credit is earned equally for each assigned beneficiary• Total healthcare expense is incurred in a non linear fashion
(note: claims are truncated at 99nth percentile limit on per beneficiary expense)
Savings Credit and Beneficiary Expense
Not Worried Well
COE Transitions
Typical Management Activity• COE Transition Beneficiaries
• Instinctively MSSP contractors reached out to and assisted the vulnerable and high cost population
• Increased PCP engagement slowed or eliminated transition to COE external to the ACO
• MSSP contractors “managed” to keep disproportionate number of high cost beneficiaries, i.e. reduce high cost churn compared to base year processes
• Not Worried Well (NWW)• PCP visits 12-16 months
• Drive attribution to every other year• Most MSSP contractors did not “manage” to reduce NWW churn.
Impact On Total Savings• Assumptions:
– 10,000 Beneficiaries– $9,000 Benchmark– 10% a priori “NWW Churn”
• Moves to 7% from Beneficiary Outreach
– 2% a priori “COE Churn”• Moves to 0% from Case Coord, etc
– Ratio of High Cost Cases to Benchmark• 10% of population = 50% of cost is approximately a
4.5:1 Ration of High to Low Cost
• Conclusion– 5.4% Savings needed to offset unbalanced
churn reduction
Sensitivity To Eliminating COE Churn
Average High Cost Case to Benchmark Ratio
a prioriCOE
4 4.5 5 5.5 6
3.5% 8.4% 10.6% 12.9% 15.2% 17.7%
3.0% 6.6% 8.4% 10.3% 12.2% 14.2%
2.5% 4.8% 6.3% 7.8% 9.3% 10.9%
2.0% 3.1% 4.2% 5.4% 6.6% 7.8%
1.5% 1.5% 2.3% 3.2% 4.0% 4.8%
Sensitivity To NWW ChurnPrior NWW Churn
New Churn 10.0% 9.0% 8.0% 7.0% 6.0%
6.0% -4.% -3.1% -2.1% -1.2% 0%
5.0% -4.9% -4.0% -3.1% -2.1% -1.1%
4.0% -5.8% -4.9% -4.0% -3.0% -2.1%
3.0% -6.6% -5.7% -4.9% -3.9% -3.0%
2.0% -7.5% -6.6% -5.7% -4.8% -3.9%* Negative numbers represent favorable savings
Segment Qualifications
• When is ESRD really ESRD?• Duals are under reported• Disabled are under reported
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ESRD• Benchmark is 6-10 X “Aged”
– CKD 4 is not ESRD and considered “Aged”– Care coordination w/o qualification only holds CKD
4 as “Aged” longer.– ESRD is assigned monthly– Small population (1.5%) at 8 x Aged cost = 12% of
Benchmark expense– Qualification management and ESRD “Medical
Home” should improved appropriate qualification and total and average cost
– Minimum Savings Rate could be achieved from ESRD patients alone
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Duals & Disabled
• Social Work Fairytale– Long time ago hospitals employed social workers
to qualify uninsured patients to Medicaid– 20% increase in Benchmark warrants a look at
MSSP contractors to evaluate “Aged” populations
• Same infrastructure can work disabled status– Automatic processes for CM to review to SW
evaluation?
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High Risk/Opportunity Populations
– ESRD = 5% of Benchmark (+/-)• ESRD = 1% of population = manageable• ESRD Medical Home• ESRD MA spend patterns
– Diabetes – an imperative for quality, cost AND BENCHMARK
• Diabetic risk score should exceed 1.5 as a population
• Typically under reported/coded• Managed through diet/exercise often not coded
at all• Impacts 25% - 40% of Benchmark
Conclusions and Questions?
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Conclusion: You must manage Assignment, Risk Selection and Risk Score