Radar on Medicare Advantage

Although growing Medicare Advantage enrollment helped fuel better-than-expected first-quarter 2021 earnings for some publicly traded insurers, they appear to be approaching the full year with caution, as earnings in 2021 could be dampened by a couple of factors. These include the unfavorable impact of the health insurer fee (HIF) repeal for 2021 and lower Medicare risk-adjusted revenue — a recurring and expected theme during insurers’ recent quarterly earnings calls.

Risk scores that determine MA organizations’ risk adjustment payments for the current year are based on diagnoses gathered during the previous year to determine the relative health of an insurer’s MA enrollees and predict costs. But because the pandemic led many seniors to delay or forgo care, insurers’ ability to collect diagnoses last year was limited, despite the temporary authorization to use telehealth to gather diagnoses for MA risk adjustment.

A prescriber fax program alerting physicians when their diabetic patients have not had a statin claim demonstrated a statistically significant boost in statin use and could be a valuable addition to Medicare Advantage Prescription Drug (MA-PD) plans’ efforts to improve both medication adherence and star ratings, according to a new study from Prime Therapeutics LLC. That program was shown to be especially effective when combined with pharmacist outreach, researchers observed.

Cholesterol-lowering statin drugs have been shown to prevent cardiovascular disease and reduce health care costs. Statins began to play a bigger role in the CMS star ratings in 2019, when the Pharmacy Quality Alliance-developed Statin Use in Persons with Diabetes (SUPD) measure was added to the Part D calculations and when the NCQA-developed Statin Therapy for Patients with Cardiovascular Disease measure was added to the Part C ratings. Both had a weighting value of 1, but with the 2021 ratings that came out last fall, SUPD became one of four triple-weighted Part D measures, which include Medication Adherence for Cholesterol (Statins).

Medicare Advantage plans are at a critical juncture in their quest for quality bonus payments, as this month marks the end of a three-month data collection cycle that will have a meaningful impact on the 2023 star ratings, when member experience measures take on a larger weight in star ratings calculations. While it’s too late to make a difference in how members responded to the recent Consumer Assessment of Healthcare Providers and Systems (CAHPS) that reflects the patient experience in late 2020 and early 2021, MA organizations should be focused on innovations that can prevent and resolve issues members face throughout the year to foster more positive feedback for future surveys, advises one longtime stars expert.

As numerous measures based on CAHPS and CMS administrative data move from a weighting value of 2 to 4 starting with measurement year 2021, the increased value of those measures will make up 32% of the overall 2023 star rating on a weighted basis. “Just two years ago it was only worth half that much, so we literally doubled the relative value of CAHPS and the measured member experience through these surveys in the math path toward 4 stars,” says Melissa Smith, who is executive vice president of consulting and professional services at HealthMine, Inc., a Dallas- based member engagement firm. “We’ve always known member experience was important and we’ve always agreed we need to focus effort and attention in that area, but attaching such a heavy contribution to the overall star ratings to the surveys is the forcing function that most plans are seeing as the impetus for new actions.”

Due to the unique constraints of the COVID-19 pandemic, CMS in the newly released 2020 audit report revealed that it audited only six plan sponsors, representing just 1.4% of all Medicare Parts C and D enrollment. Given the small sample size and the flexibilities that CMS granted plan sponsors during the public health emergency (PHE), the latest annual report does not provide many useful takeaways. However, increasing fines related to so-called “one-third financial audits” — which are separate from program audits — do offer some lessons learned for Medicare Advantage organizations, says one industry expert.

In the 2020 Part C and Part D Program Audit and Enforcement Report issued May 14, CMS reminded readers that it adjusted its 2020 audit strategy due to the PHE and cautioned “against drawing conclusions about the overall performance of audited sponsors in 2020 compared to those that were audited in previous years.” CMS last March put scheduled program audits on hold so that the agency and plan sponsors could focus more directly on the pandemic, but it picked them back up again in the fall.

✦ Oklahoma lawmakers at press time were attempting to replace Republican Gov. Kevin Stitt’s plan to transition fee-for-service Medicaid beneficiaries to a managed care model later this year, which will include the expanded adult group enrolling next month. Senate Bill 131 would require the Oklahoma Health Care Authority (OHCA) to develop a program that “controls costs and improves health outcomes for Medicaid beneficiaries” as an alternative to the managed care system that will address the voter-approved Medicaid expansion. The bill passed the House late last month and has returned to the Senate for final consideration, although it is likely to be vetoed by the governor, according to news reports. In a statement posted to the governor’s website, Stitt chided House Republicans for their “disappointing” vote and said he would “continue to advocate for this needed change.” Oklahoma will begin enrolling newly eligible adults into the SoonerCare program on June 1 for coverage effective July 1. On Oct. 1, OHCA will transition nonexempt beneficiaries to the SoonerSelect managed care model, which will be served by four MCOs (RMA 2/4/21, p. 8). View https://bit.ly/3vHuutT.

✦ Humana Inc. plans to fully acquire home health provider Kindred at Home from private equity firm Welsh, Carson, Anderson & Stowe (WCAS) and TPG Capital, the insurer said on April 27. (WCAS owns a controlling stake in MMIT, AIS Health’s parent company.) The insurer also reported strong financial results, with first-quarter adjusted earnings per share of $7.67 beating Wall Street’s consensus estimate of $7.07, or $1.04 billion in pretax income. Visit https://humana.gcs-web.com.