Preview: RADAR on Medicare Advantage

MCOs Seek Individual-Level Data to Pinpoint Disparities

October 7, 2021

Improving access to health care for underserved populations and eliminating health inequities were running themes throughout the AHIP 2021 National Conference on Medicare, Medicaid & Dual Eligibles, which was held virtually from Sept. 21-24. Speakers participating in various health equity-focused sessions discussed the importance of and challenges associated with collecting the right data to target members’ needs, which are often not directly related to health care.

At AmeriHealth Caritas, which operates Medicaid plans in multiple states, health equity has become a strategic priority, a “key business imperative and a market differentiator,” said Director of Health Equity Danielle Brooks. And all types of data — from claims data to demographic data to information on the social determinants of health (SDOH) — collectively “tells a story about what is happening in our populations,” she said during a panel on data and health equity. Such data also can be used to improve and measure the effectiveness of managed care programs and get at the root causes of health inequities, she added.

Improving access to health care for underserved populations and eliminating health inequities were running themes throughout the AHIP 2021 National Conference on Medicare, Medicaid & Dual Eligibles, which was held virtually from Sept. 21-24. Speakers participating in various health equity-focused sessions discussed the importance of and challenges associated with collecting the right data to target members’ needs, which are often not directly related to health care.

At AmeriHealth Caritas, which operates Medicaid plans in multiple states, health equity has become a strategic priority, a “key business imperative and a market differentiator,” said Director of Health Equity Danielle Brooks. And all types of data — from claims data to demographic data to information on the social determinants of health (SDOH) — collectively “tells a story about what is happening in our populations,” she said during a panel on data and health equity. Such data also can be used to improve and measure the effectiveness of managed care programs and get at the root causes of health inequities, she added.

To connect members with resources that align with their unique needs, AmeriHealth Caritas conducts a “multidimensional survey” that assesses what social determinants individuals are experiencing but through a health equity lens, paying attention to things like communicating with members in their preferred language or connecting housing insecure and transgender members with resources that are sensitive to their needs.

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States Increase MCO Demands Around Health Equity, SDOH

October 7, 2021

Given that states typically contract with just a handful of managed care organizations to serve their Medicaid enrollees, Medicaid managed care by nature has always been a competitive space. But with procurements picking up after the COVID-19 public health emergency derailed some states’ efforts last year plus an increased emphasis on health equity and social determinants of health (SDOH), MCOs have a lot to manage when it comes to competing for new Medicaid pacts.

During a presentation at the AHIP 2021 National Conference on Medicare, Medicaid & Dual Eligibles, held virtually from Sept. 21-24, two Medicaid managed care experts discussed some of the trends in Medicaid requests for proposals (RFPs) and ways MCOs can respond accordingly.

Given that states typically contract with just a handful of managed care organizations to serve their Medicaid enrollees, Medicaid managed care by nature has always been a competitive space. But with procurements picking up after the COVID-19 public health emergency derailed some states’ efforts last year plus an increased emphasis on health equity and social determinants of health (SDOH), MCOs have a lot to manage when it comes to competing for new Medicaid pacts.

During a presentation at the AHIP 2021 National Conference on Medicare, Medicaid & Dual Eligibles, held virtually from Sept. 21-24, two Medicaid managed care experts discussed some of the trends in Medicaid requests for proposals (RFPs) and ways MCOs can respond accordingly.

Describing the current RFP environment as both “exciting” and “brutal,” Joel Menges observed that the level of detail respondents are being asked to include in their bids has definitely gone up. The CEO of The Menges Group pointed to Oklahoma’s planned transition to managed Medicaid as an example of how states are leveraging the procurement process to improve their Medicaid programs.

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COVID Deepened Racial, Ethnic Disparities in Medicare Mortality Rates

October 7, 2021

After years of relative stability, the COVID-19 pandemic caused mortality rates to spike in 2020, with non-white populations experiencing far greater disparities. That’s according to a September analysis of CMS data from Avalere Health, which found that non-white Medicare beneficiaries saw mortality rate increases 1.5 to 3.0 times higher than the white population. Overall life expectancy declined by an average of 1.5 years from 2019 to 2020, with researchers attributing 73.8% of the decrease to the pandemic.

After years of relative stability, the COVID-19 pandemic caused mortality rates to spike in 2020, with non-white populations experiencing far greater disparities. That’s according to a September analysis of CMS data from Avalere Health, which found that non-white Medicare beneficiaries saw mortality rate increases 1.5 to 3.0 times higher than the white population. Overall life expectancy declined by an average of 1.5 years from 2019 to 2020, with researchers attributing 73.8% of the decrease to the pandemic.

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OIG: Chart Reviews Fueled ‘Disproportionate’ MA Pay

October 7, 2021

The HHS Office of Inspector General in prior reports has raised concerns about Medicare Advantage organizations’ heavy reliance on chart reviews and health risk assessments (HRAs) to achieve higher risk adjusted payments. Now, a new OIG report identifies multiple MAOs that have used those sources to a greater extent than their peers, leading the federal watchdog agency to suggest that CMS monitor companies with a disproportionate share of the risk-adjusted payments.

The HHS Office of Inspector General in prior reports has raised concerns about Medicare Advantage organizations’ heavy reliance on chart reviews and health risk assessments (HRAs) to achieve higher risk adjusted payments. Now, a new OIG report identifies multiple MAOs that have used those sources to a greater extent than their peers, leading the federal watchdog agency to suggest that CMS monitor companies with a disproportionate share of the risk-adjusted payments.

Report Tracked Unlinked Chart Reviews

MAOs may use both chart reviews — which are retrospective reviews of beneficiaries’ medical records — and HRAs — which may be conducted initially, annually and by a third-party vendor in the beneficiary’s home — to support diagnoses that they submit to the encounter data system for risk score determination. In a 2019 report, OIG raised concerns about MAOs’ use of unlinked chart reviews, referring to when diagnoses are added from chart reviews but did not link to a specific service record for the year, which applied to $2.7 billion out of $6.7 billion in risk adjusted payments for 2017. And OIG in September 2020 estimated that diagnoses reported only on HRAs in the encounter data resulted in $2.6 billion in risk adjusted payments for 2017, including $2.1 billion based on HRAs conducted in the home.

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News Briefs

October 7, 2021

The fate of expanded Medicare benefits, drug pricing provisions and other health care measures included in Senate Democrats’ $3.5 trillion budget reconciliation package hung in the balance this week, as President Joe Biden met with progressive members of the House Democratic Committee to discuss ways to whittle down the spending bill to reach a dollar figure acceptable to moderates in the Senate. Joe Manchin (D-W.Va.) reportedly said he won’t back anything that amounted to more than $1.5 trillion in spending, and Kyrsten Sinema (D-Ariz.) is reportedly opposed to the prescription drug pricing proposals in both the House and Senate bills. White House Press Secretary Jen Psaki on Oct. 4 told members of the press that the president would continue to “work with a range of members from across the Democratic caucus.”

The fate of expanded Medicare benefits, drug pricing provisions and other health care measures included in Senate Democrats’ $3.5 trillion budget reconciliation package hung in the balance this week, as President Joe Biden met with progressive members of the House Democratic Committee to discuss ways to whittle down the spending bill to reach a dollar figure acceptable to moderates in the Senate. Joe Manchin (D-W.Va.) reportedly said he won’t back anything that amounted to more than $1.5 trillion in spending, and Kyrsten Sinema (D-Ariz.) is reportedly opposed to the prescription drug pricing proposals in both the House and Senate bills. White House Press Secretary Jen Psaki on Oct. 4 told members of the press that the president would continue to “work with a range of members from across the Democratic caucus.”

Just 1.3% of Medicare beneficiaries in 2018 had their social needs tracked by Z codes in health care claims, according to a new study from NORC at the University of Chicago. Z codes are a type of ICD-10-CM code used to document social determinants of health (SDOH), but providers are not reimbursed for such claims, which may limit uptake, suggested researchers. NORC found that 1.5% of MA beneficiaries had their social needs tracked through Z codes, compared with 1.2% of beneficiaries in Original Medicare; dual eligibles were three times as likely to have an SDOH Z code.

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