Medicare Advantage 2019 Advance Notice Part 1 21 st Century Cures Act Methodological Changes

Transcription

1 Medicare Advantage 2019 Advance Ntice Part 1 21 st Century Cures Act Methdlgical Changes Review f Relevant Prvisins with Expert Insight January 2018 PULSE8 is privileged t bring yu a summary f key Medicare Advantage prgram changes fr Payment Year 2019 resulting frm the 21 st Century Cures Act f Key Risk Adjustment Methdlgy Changes Addressed in the 2019 Advance Ntice Member Risk Scre Calculatin Changes Advent f HCC cunt per member additive variable within member risk scre calculus, i.e. members with higher cunts f HCCs wuld have higher risk scre adjustments Includes re-calculated, diminished risk adjustment factrs fr all HCCs. The prpsed Payment Cnditin Cunt mdel is estimated t increase risk scres by an average f 1.1% acrss all plans; hwever, the experience f individual plans wuld vary. RAPS & EDPS Risk scre blend mving t a 75/25 split fr PY19 frm an 85/15 split fr PY18 (RAPS/EDPS). Fr PY 2019, CMS prpses t calculate the EDPS risk scres amended with RAPS inpatient diagnses. Clinical CMS-HCC Mdel Changes Augmentatin t the set f Behaviral Health Cnditins Additin f piid (and ther substances) verdse ICD10 diagnsis cdes t HCC 55 Drug/Alchl Dependence. Additin f HCC 56 Drug Abuse, Uncmplicated, Excluding Cannabis, includes piid dependence diagnses (amng ther narctics). Additin f mental health HCC 59, Reactive and Unspecified Psychsis, and HCC 60, Persnality Disrders Additin f HCC 138, Chrnic Kidney Disease Stage 3 (Mderate Only) Page 1 f 5 Curtesy f Pulse8 Yur ONLY Partner fr Risk Adjustment & Quality Analytics Fr mre infrmatin, please visit r call (410)

2 The 2019 Advance Ntice prpses t blend risk scre calculatin using a prgressive 2017 mdel t 2019 mdel rati schedule: Payment Year Prpsed 2019 Mdel Blend Rate Current 2017 Mdel Blend Rate % 75% % 50% % 25% % NA MEMBER RISK SCORE CALCULATION CHANGES ACCOUNT FOR AN INDIVIDUAL S TOTAL NUMBER OF CONDITIONS The Cures Act instructs the Secretary f Health and Human Services t imprve the determinatin methdlgy f a beneficiary s health status by factring in the cunt f an individual s ttal cnditins. Furthermre, additinal adjustments are t be applied as an individual s ttal number f cnditins increases. The 2017 CMS-HCC Mdel includes 79 distinct Hierarchical Cnditin Cdes (HCCs). These 79 HCCs are a subset f a master cnventin f 201 Cnditin Cdes, f which 186 are relevant t Medicare beneficiaries. CMS ran tw distinct mdel calculatins that cunted Cnditins by Member using bth the seventy-nine 2017 CMS-HCC mdel HCCs (knwn as Payment Cnditins) and the 186 Medicarerelevant master list f Cnditin Cdes (knwn as All Cnditins): In the final analysis, the Advance Ntice states, adding either Payment Cnditin r All Cnditin cunt variables t the mdel did nt change the mean MA risk scre appreciably. The Advance Ntice released specificatins and risk scre cefficients fr bth the 79- Payment Cnditin analysis and the 186-All Cnditins analysis. The fficial prpsal is fr adptin f the 79-Payment Cnditins methdlgy; hwever, it specifically asks fr cmmentary and feedback n bth methdlgies. Page 2 f 5 Curtesy f Pulse8 Yur ONLY Partner fr Risk Adjustment & Quality Analytics Fr mre infrmatin, please visit r call (410)

3 Payment Cnditin Cunt Risk Factr Values (Single Segment Example) Cmmunity Payment HCC Cunt NnDual, Aged Risk Factr 1 Payment HCCs - 2 Payment HCCs - 3 Payment HCCs - 4 Payment HCCs Payment HCCs Payment HCCs Payment HCCs Payment HCCs Payment HCCs r mre Payment HCCs Pulse8 Insight: Regardless f which methdlgy (Payment Cnditins vs. All Cnditins), the inclusin f an HCC-per member cunt risk scre variable lwers the risk scre cefficient and thereby the financial impact f any individual HCC. In terms f HCC gap clsure, the ROI f any interventin campaign will drp if plans d nt adjust their strategy away frm narrw individual cnditin pprtunity targeting t a brader, sub-ppulatin apprach. The All Cnditin methdlgy (currently NOT favred by CMS) wuld require plans t target and clse diagnsis gaps fr rughly twice as many cnditins (79 t 186). In this scenari, the 107 Nn-Payment HCCs (e.g. hypertensin, hyperlipidemia, dementia, etc.) wuld have t be added t the targeting analytics data science prcess. These Nn-Payment HCCs wuld nt have direct, additive impact t members risk scres; hwever, capturing these HCCs wuld increase a member s ttal cnditin cunts, thereby increasing risk scres. The wrklad and csts invlved with adding targeting analytics fr the Nn-Payment HCCs wuld be very high. CLINICAL CMS-HCC MODEL CHANGES EVALUATION OF MENTAL HEALTH AND SUBSTANCE USE DISORDERS Mental Health CMS has classified seven ttal HCCs frm mental health diagnsis mappings. Tw f the seven HCCs are included in the 2017 CMS-HCC mdel: HCC 57 Schizphrenia HCC 58 Majr Depressive, Biplar, and Paranid Disrders Page 3 f 5 Curtesy f Pulse8 Yur ONLY Partner fr Risk Adjustment & Quality Analytics Fr mre infrmatin, please visit r call (410)

4 Five HCCs classified as mental health are nt included in the 2017 CMS-HCC mdel: HCC 59 Reactive and Unspecified Psychsis HCC 60 Persnality Disrders HCC 61 Depressin HCC 62 Anxiety Disrders HCC 63 Other Psychiatric Disrders Fr the payment year 2019 mdel, CMS is prpsing t add HCC 59 Reactive and Unspecified Psychsis and HCC 60 Persnality Disrders, per the Advance Ntice: HCC 59, Reactive and Unspecified Psychsis is a mix f acute and chrnic cnditins that cver a range f psychtic episdes with varying duratin. In many cases, the diagnses assciated with HCC 59 are related t, but d nt meet, the full criteria fr schizphrenia r ther specific psychtic disrders. HCC 60, Persnality Disrders, includes a variety f persnality disrders that are clinicallyrelated and well defined. When included in the mdel, the HCC predicts reasnable csts and the cefficient is statistically significant. Additinally, n average, csts fr HCC 60 are underpredicted by the updated 2017 CMS-HCC mdel in the cmmunity ppulatin CMS als ntes that because HCC 59 diagnses predict higher csts than HCC 58 Majr Depressive, Biplar, and Paranid Disrders, the hierarchical sequence rder must be flipped t HCC 58 Reactive and Unspecified Psychsis and HCC 59 Majr Depressive, Biplar, and Paranid Disrders. The Advance Ntice further states that an ICD9 t ICD10 discrepancy within the diagnsing and cding f depressin exists. CMS states that when cefficient calibratin analysis is cnducted n claims data with ICD10 cdes, a mre encmpassing classificatin will be develped amng HCC 58 (nw 59) Majr Depressive, Biplar, and Paranid Disrders and HCC 61 Depressin. Pulse8 Insight: Pulse8 experts see the additin f tw mre mental health HCCs as cntinued prgress twards filling-in the mental health risk adjustment gap. Declining mental health status strngly crrelates with prer health utcmes and higher cst. Heart Failure, ESRD, Dementia, CAD, acute MI and CVAs are just a few f disease states highlighted this year in peer-reviewed jurnals linking depressin with wrse health utcmes. Subjectivity in the diagnsis f Majr Depressin vs. Depressin remains cre t the under-realized risk factr scring fr mental health. Pulse8 recmmends that plans cntinue t educate physicians n depressin diagnsis accuracy, specifically regarding the Majr depressive disrder, single episde cde grup. The key is fr the physicians t be as specific as pssible and avid using the catch-all, unspecified qualifier. Instead, physicians shuld detail the episde as mild, mderate, severe, in partial r full remissin, and with r withut psychsis. Page 4 f 5 Curtesy f Pulse8 Yur ONLY Partner fr Risk Adjustment & Quality Analytics Fr mre infrmatin, please visit r call (410)

5 Substance Abuse Disrders Tw substance use disrder HCCs are included in the 2017 CMS-HCC mdel: HCC 54 Drug/Alchl Psychsis HCC 55 Drug/Alchl Dependence Fr payment year 2019, the Advance Ntice prpses t augment HCC 55 t, better accunt fr the csts related t accidental (unintentinal) r undetermined verdse. ICD10 cdes will be added fr verdses frm Herin, Ccaine, Methadne and Other Synthetic Narctics, LSD and Other Hallucingens, Psychstimulants, Alchl and, mst ntably, Opium and Other Opiids. A third substance abuse HCC, 56 Drug/Alchl Abuse, Withut Dependence, is nt included in the 2017 CMS-HCC mdel; hwever, the Advance Ntice has prpsed t add a subsectin f HCC 56 t the 2019 mdel. The CMS-HCC methdlgy wuld restrict HCC 56 diagnses t include nly thse described as Drug Abuse, Uncmplicated, Excluding Cannabis. Pulse8 Insight: Substance abuse and related sequelae remain a majr cst multiplier and HCCs 54 and 55 act t capture that risk. As plitical mmentum gains t address the Opiid Epidemic, expect mre fcus n substance-related disrders and treatment f thse disrders. With increased fcus f identificatin, we can expect increased treatment demands. This increased cst in additin t the cmrbidity f these cnditins necessitates the need t crrectly identify this chrt. Given the sensitive nature f these diagnses, mst activities t clse these gaps will need t be in the frm f retrspective chart review accmpanied with heavy prvider educatin effrts. EVALUATION OF CHRONIC KIDNEY DISEASE Frm the 21 st Century Cures Act text, The Secretary shall evaluate the impact f including the severity f chrnic kidney disease in the risk adjustment mdel. The payment year 2019 Advance Ntice states that HCC 138 Chrnic Kidney Disease, Mderate (Stage 3) will be added t the 2019 CMS-HCC mdel. The Advance Ntice ntes that Stage 3 CKD has tw subsets, 3a Mild t Mderate and 3b Mderate t Severe, nly CKD 3b Mderate t Severe will be included in CMS-HCC mdel. Pulse8 Insight: The additin f HCC 138 CKD Stage 3 Mderate t the mdel will add vlume t the verall cnditin cunt; hwever, the risk scre values prpsed in the Advance Ntice are lw. HCC 138 has als been added t the CHF/CKD Disease Interactin grup, which will raise the verall average risk scre impact. Messaging t prviders n Glmerular Filtratin Rate (GFR) lab results interpretatin and transpsitin t ICD10 cding and dcumentatin is critical fr HCC 138 realizatin and CKD prgressin tracking. Page 5 f 5 Curtesy f Pulse8 Yur ONLY Partner fr Risk Adjustment & Quality Analytics Fr mre infrmatin, please visit r call (410)