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Using Technology to Refocus Medicare Advantage and Part D Plans in the Latest Final Rule

Using Technology to Refocus Medicare Advantage and Part D Plans in the Latest Final Rule

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The effective management of Medicare Advantage (MA) and Part D plan members is dependent on the volume and accuracy of acquired data. The latest final rule, released by the Centers for Medicare & Medicaid (CMS) at the end of May, is designed to offer expanded opportunities to Medicare patients for contract year 2021. MA plans’ per capita total cost will increase payments by 1.66% in the coming year, with a MA coding pattern adjustment of 5.9%. The final rule encompasses the requests of several proposals submitted in February of 2020 (85 FR 9002) relating to the 21st Century Cures Act (Cures Act) and Bipartisan Budget Act of 2018 (BBA of 2018). In an excerpt from the fact sheet below, CMS affirms the improvements from these latest policies for their potential to create better patient care plans and reduce spending long-term.

“We believe that codifying these policies in regulation provides additional transparency and program stability, and allows Medicare Advantage (MA) organizations and Part D plan sponsors to develop more innovative plan designs. The provisions in this final rule result in an estimated $3.65 billion net reduction in spending by the federal government over ten years due to a finalized change to the Part C and D Star Rating methodology to remove outliers before calculating Star Ratings cut points, which offsets costs arising from the Medical Loss Ratio (MLR) provisions and other refinements to the MA and Part D Quality Star Ratings system.”

The final rule can offer several opportunities to MA and Part D Medicare plan providers, especially when viewed through the lens of improving the patient experience while enrolled. The patient’s input weighs heavily on provider compensation, and the impact of actionable, easy to view data insights paves the way for satisfied beneficiaries when providers can act based on what they need. Technology also plays a critical role in these policy updates to maximize their opportunities for the longevity of a patient’s health.

The Data Tells All

Data tells a patient’s care story, from diagnoses to family history, health services, medications, and other health codes. It helps providers identify coding opportunities based on lab, prescription, and additional electronic medical record (EMR) data. For example, aggregated data within a population health vendor system like Lightbeam can segment individuals in need of hierarchical condition category (HCC) code recertification in their population.

COVID-19 disrupted the world, and CMS has had to reevaluate how value-based care reimbursement for programs is calculated to ensure fairness in total numbers. In this final rule, to calculate risk scores, MA organizations will add 75% of their risk score total from the 2020 CMS-Hierarchical Condition Categories model with 25% of the risk score from their 2017 total. Accurately recorded HCC codes positively impact an individual’s risk adjustment factor (RAF) score, which reflects their overall health. CMS and private payers reimburse MA plan physicians for healthy patients.

One of the primary reasons this is important is that data can indicate how engaged a patient is in prioritizing their health. It can also reveal where providers or care coordinators can miss the mark in their approach. In this final rule, the Star Ratings for MA, Part C, and Part D Prescription Drug plans have increased their weight on the scale from two to four in the patient experience and complaint sections. CMS anticipates this move will promote coordination between patients and providers when creating their care plans. MA and Part D plan sponsors will need a reliable means for identifying coding gaps and lapses in care to advocate for their patients’ well-being and receive proper compensation.

Unprecedented Opportunity for ESRD Patients

End-Stage Renal Disease (ESRD) patients are eligible to enroll in Medicare Advantage plans for the first time, beginning on January 1st of 2021. Due to the demanding nature of ESRD, the strain on patients, and its expense, the expansion into Medicare Advantage plans offers new opportunities. CMS has added new rates of payment with the final rule, raising its value by 4.04%. With these opportunities, providers must begin the discussion with Medicare-eligible patients, starting with the swift identification of ESRD patients to start outreach. Technology that consolidates patient data and promotes easy segmentation, like the Lightbeam Cohort Builder, can identify ESRD patients to increase participation in the MA plan programs. The technology can also identify these patients through its HCC code suspecting capability to view where and when they may have been prescribed medication related to ESRD. Lightbeam can also determine this through lab data that may indicate a diagnosis or lack thereof.

The final rule established several other policy changes for Medicare Advantage plans. When reading the entire final rule, organizations should evaluate how their current population health technology and strategies manage their population’s health needs and improve the patient experience.

Celia Whatley is the Vice President of Product Management.

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