Session 50 OF, Provider Payment Reform: Using Benchmarks as a Foundation for the Future Moderator: Gregory G. Fann, FSA, MAAA Presenters: Joan C. Barrett, FSA, MAAA Zachary Miller Davis, FSA, MAAA Courtney R. White, FSA, MAAA SOA Antitrust Disclaimer SOA Presentation Disclaimer
42
Embed
Session 050 OF, Provider Payment Reform: Using Benchmarks … · Session 50 OF, Provider Payment Reform: Using Benchmarks as a Foundation for the Future ... meeting participants should
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Session 50 OF, Provider Payment Reform: Using Benchmarks as a Foundation for the
Future
Moderator: Gregory G. Fann, FSA, MAAA
Presenters:
Joan C. Barrett, FSA, MAAA Zachary Miller Davis, FSA, MAAA Courtney R. White, FSA, MAAA
SOA Antitrust Disclaimer SOA Presentation Disclaimer
Active participation in the Society of Actuaries is an important aspect of membership. However, any Society activity that arguably could be perceived as a restraint of trade exposes the SOA and its members to antitrust risk. Accordingly, meeting participants should refrain from any discussion which may provide the basis for an inference that they agreed to take any action relating to prices, services, production, allocation of markets or any other matter having a market effect. These discussions should be avoided both at official SOA meetings and informal gatherings and activities. In addition, meeting participants should be sensitive to other matters that may raise particular antitrust concern: membership restrictions, codes of ethics or other forms of self-regulation, product standardization or certification. The following are guidelines that should be followed at all SOA meetings, informal gatherings and activities:
• DON’TDON’TDON’TDON’T discuss your own, your firm’s, or others’ prices or fees for service, or anything that might affect prices or fees, such as costs, discounts, terms of sale, or profit margins.
• DON’TDON’TDON’TDON’T stay at a meeting where any such price talk occurs.
• DON’TDON’TDON’TDON’T make public announcements or statements about your own or your firm’s prices or fees, or those of competitors, at any SOA meeting or activity.
• DON’TDON’TDON’TDON’T talk about what other entities or their members or employees plan to do in particular geographic or product markets or with particular customers.
• DON’T DON’T DON’T DON’T speak or act on behalf of the SOA or any of its committees unless specifically authorized to do so.
• DODODODO alert SOA staff or legal counsel about any concerns regarding proposed statements to be made by the association on behalf of a committee or section.
• DODODODO consult with your own legal counsel or the SOA before raising any matter or making any statement that you think may involve competitively sensitive information.
• DODODODO be alert to improper activities, and don’t participate if you think something is improper.
• If you have specific questions, seek guidance from your own legal counsel or from the SOA’s Executive Director or legal counsel.
2
Presentation Disclaimer
Presentations are intended for educational purposes only and do not replace independent professional judgment. Statements of fact and opinions expressed are those of the participants individually and, unless expressly stated to the contrary, are not the opinion or position of the Society of Actuaries, its cosponsors or its committees. The Society of Actuaries does not endorse or approve, and assumes no responsibility for, the content, accuracy or completeness of the information presented. Attendees should note that the sessions are audio-recorded and may be published in various media, including print, audio and video formats without further notice.
3
Overview – Provider Benchmarking
Why do we need benchmarking
Introduction to benchmarking
Access to data
Provider Benchmarking From The Stakeholder’s Point of View
Case study
4
Why Now?
5
CMS Initiatives
• Vision: Transform HealthVision: Transform HealthVision: Transform HealthVision: Transform Health
• Overall goalsOverall goalsOverall goalsOverall goals• Better care
• Specific targetsSpecific targetsSpecific targetsSpecific targets• CMS Managed Care Categories
• Category 1—fee-for-service with no link of payment to quality
• Category 2—fee-for-service with a link of payment to quality
• Category 3—alternative payment models built on fee-for-service architecture
• Category 4—population-based payment
• 85% of fee-for-service payments are tied to quality or value by 2016 and 90% by 2018 (Category 2-4)
• 30% of Medicare payments are tied to quality or value through alternative payment models by the end of 2016 and 50% by 2018 (Category 3-4)
6
MACRA Overview
• Bipartisan legislation Bipartisan legislation Bipartisan legislation Bipartisan legislation • Signed into law on April 16, 2015
• Final Rule October 2016
• https://qpp.cms.gov
• Repealed the sustainable growth rate (SGR) formulaRepealed the sustainable growth rate (SGR) formulaRepealed the sustainable growth rate (SGR) formulaRepealed the sustainable growth rate (SGR) formula• Enacted as part of Balanced Budget Act of 1997
• Limited physician fee increases to keep the Medicare spending per beneficiary to the increase in GDP
• Annual “doc fixes”
• Introduced two payment tracks for physiciansIntroduced two payment tracks for physiciansIntroduced two payment tracks for physiciansIntroduced two payment tracks for physicians
• Alternate Payment Model incentives
• Merit-Based Incentive Payment System (MIPS) which links fee-for-service payments to quality and value
• Streamlines Streamlines Streamlines Streamlines several existing quality and value programs under MIPSseveral existing quality and value programs under MIPSseveral existing quality and value programs under MIPSseveral existing quality and value programs under MIPS
• Physician Quality Reporting Program
• Value-based Payment modifier
• Medicare electronic health records (EHR) Incentive programs
7
Introduction to Benchmarking
8
Degree of Healthcare ManagementLo
ose
ly m
an
age
d • Limited evidence based best practices
• Minimal incentives to manage care
• Limited use of low cost alternatives
• Some inpatient reviewW
ell
Ma
na
ged • Best practices
• Provider incentives
• Low cost alternatives
• Higher consumer awareness
9
Comparisons to Benchmark Population
Service CategoryService CategoryService CategoryService Category
Plan PBPM Plan PBPM Plan PBPM Plan PBPM
ExpendituresExpendituresExpendituresExpenditures
Well Managed Well Managed Well Managed Well Managed
• Distance• Quality indicator/Awards (no details)• Credentials, new patients, languages, etc
• Hospital Compare (CMS)• More details about quality, patient experience, etc
• Treatment cost estimators
• Providing informationProviding informationProviding informationProviding information• Surveys• Complaints• On-line (Yelp, HealthGrades, etc)• Word of mouth
22
Employer Priorities
• Are my employees happy?Are my employees happy?Are my employees happy?Are my employees happy?• Network access, geographical, by specialty
• Employee experience
• Are my employees getting the care they need?Are my employees getting the care they need?Are my employees getting the care they need?Are my employees getting the care they need?• Mammograms, diabetes testing, etc.
• Is the price right?Is the price right?Is the price right?Is the price right?• How much is Aetna paying providers compared to
Anthem, United, etc?
• More generally, are employees taking ownership of More generally, are employees taking ownership of More generally, are employees taking ownership of More generally, are employees taking ownership of their health?their health?their health?their health?
• Are consumers happy and getting the care they Are consumers happy and getting the care they Are consumers happy and getting the care they Are consumers happy and getting the care they need?need?need?need?
• Are employers happy?Are employers happy?Are employers happy?Are employers happy?
• Pay attention Pay attention Pay attention Pay attention –––– things are changing rapidlythings are changing rapidlythings are changing rapidlythings are changing rapidly
• New opportunities for actuariesNew opportunities for actuariesNew opportunities for actuariesNew opportunities for actuaries
33
Case Study
34
Case Study 1 – Medicare Advantage Capitation• Joint venture between hospital and medical group
• Carrier proposed partial risk deal with transition to full risk
• Partial risk deal terms:• 50% of upside risk on Part A and Part D services• Share 50%/50% on Part B services
• Full risk deal terms:• 50% of upside risk on Part D services• 100% of upside risk on out-of-area emergencies• 100% at-risk for Part A and Part B services
• Full risk membership threshold
• Division of Financial Responsibility (DOFR)
35
• Approach
1. Build actuarial cost model for service area
• 0.95 risk score per the contract (all differences attributed to
morbidity)
• Limited managed care efficiency (loosely managed)
• 100% of Medicare fee-for-service reimbursement
2. Test sensitivity to risk score assumption
3. Test sensitivity to managed care efficiency
Case Study 1 – Medicare Advantage Capitation
36
Case Study 1 – Medicare Advantage Capitation• Other considerations
• Medicare Advantage education
• Bidding basics
• Risk scores
• Part D
• Star rating (impact on percent of premium deals)
• Contract terms
• Actuaries, not attorneys
• Attribution
• Benefit design
• Identify favorable and unfavorable risk terms (i.e., reconciliation
process)
• Benchmark contract terms
37
Case Study 1 – Medicare Advantage Capitation
ExhibitsExhibitsExhibitsExhibits
38
Case Study 2 – Medicare Shared Savings Program• Clinic
• Selected by CMS as Accountable Care Organization (ACO) under Medicare
Shared Savings Program (MSSP)
• CMS provided prior year data
• Need baseline to measure potential savings and opportunities for program
39
Case Study 2 – Medicare Shared Savings Program• Key Issues
• Identify starting point
• Leakage
• Lack of benchmarks for subpopulations
• Data
• Claim and Claim Line Feed (CCLF) files
• No substance abuse costs due to HIPAAc
• No risk scores
• No decedents
• No member months or exposure file (based on patients)