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Rheumatology Practice Management April 2016 Vol 4 No 2 - CMS News

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CMS Strengthens Medicare Advantage and Part D

According to the Centers for Medicare & Medicaid Services (CMS), the latest policies released as part of their 2017 Rate Announcement and Call Letter may be able to provide stable payments to plans in addition to making payments to the program for plans that provide high-quality care to the most vulnerable beneficiaries.

According to this latest press release, CMS reports that Medicare Advantage and Part D programs continue to grow, with enrollment increasing by >50% since the Affordable Care Act was passed to an all-time high of >1.7 million Medicare beneficiaries who are enrolled in a Medicare Advantage plan. CMS also reports that plan quality continues to improve. In particular, the agency reports that 71% of the Medicare Advantage enrollees are in 4- or 5-star plans, and approximately one-third of the prescription drug plan enrollees are in stand-alone Part D plans with 4 or 5 stars, compared with 27% of enrollees in 2009. Premiums continue to be affordable, with average plan premiums decreasing by approximately 10% between 2010 and 2016.

The 2017 Rate Announcement and Call Letter will make changes to the risk adjustment model used to calculate payments to Medicare Advantage plans, as well as to the Star Ratings system. Updates to the methodologies to pay Medicare Advantage plans and Part D sponsors were finalized in the 2017 Rate Announcement and Call Letter, and according to CMS, are intended to improve payment precision and encourage quality, while continuing to protect beneficiaries from significant increases in premiums and out-of-pocket costs.

The impact of the policy changes on plan payments includes a 3.1% effective growth rate, compared with 3.0% last year; a –0.6% normalization, compared with –0.1%; 0.85% expected average change in revenue from prior year, compared with 1.35%; and 3.05% of expected average change in revenue, compared with 3.55%. Transition to Affordable Care Act rules (–0.8%), improved Star Ratings (0.1%), risk model revision (–0.6%), Medicare Advantage coding intensity adjustment (–0.25%), and coding trend (2.2%) were the same between the 2017 Advance Notice and Rate Announcement.

In addition, the new Risk Adjustment Model for 2017 that CMS has been finalizing has a separate coefficient for partial-benefit dually eligible beneficiaries, full-benefit dually eligible beneficiaries, and non-dually eligible beneficiaries.

“These changes will improve the precision of the payments made to plans, including increases in payments for plans serving full benefit dually eligible beneficiaries, and will support health equity and payment accuracy,” CMS explains.

Although CMS will continue to use a blend of a higher percentage of encounter data–based risk scores than in 2016, a lower percentage of encounter data–based risk scores will be used in 2017 than was proposed in the Advance Notice. Risk scores will be calculated with a blend of 25% weighing of encounter data and fee for service, as well as a 75% weighing of Risk Adjustment Processing System and fee for service, with the intent to fully phase in the use of encounter data by 2020.

A number of proposed improvements in the 2017 Call Letter were finalized to Medicare Advantage and Part D programs. Specifically, Star Ratings will be adjusting for socioeconomic status, inappropriate use of Medicare Part D will be reduced, and there will be greater access to medication-assisted treatments; updates have also been made to address drug overuse, waste, and costs.

Centers for Medicare & Medicaid Services. Strengthening Medicare Advantage and Part D. www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-04.html. Published April 4, 2016. Accessed April 12, 2016.

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New Affordable Care Act Initiative Launched

As part of its largest-ever initiative to transform the way primary care is paid for and delivered in the United States, CMS announced the launch of the Comprehensive Primary Care Plus (CPC+) model. It will be implemented in ≤20 regions, and able to accommodate ≤5000 practices, potentially including >20,000 physicians and clinicians, and 25 million patients.

“Strengthening primary care is critical to an effective health care system,” stated Patrick Conway, Deputy Administrator and Chief Medical Officer, CMS, Baltimore, MD. “By supporting primary care doctors and clinicians to spend time with patients, serve patients’ needs outside of the office visit, and better coordinate care with specialists we can continue to build a health care system that results in healthier people and smarter spending of our health care dollars. The CPC+ model represents the future of health care that we’re striving towards.”

Compared with the original initiative that was launched in late 2012, the CPC+ model will help primary care practices support patients with serious or chronic diseases achieve their health goals, and give patients 24-hour access to care and health information. In addition, the new model will help primary care providers deliver preventive care, engage patients and their families in their own care, and to work together with hospitals and other clinicians, including specialists, to provide better coordinated care.

Centers for Medicare & Medicaid Services. CMS launches largest-ever multi-payer initiative to improve primary care in America. www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-04-11.html. Published April 11, 2016. Accessed April 12, 2016.

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CMS to Add 5500 ICD-10 Codes

By October 1 of this year, CMS has proposed the addition of >5000 new International Classification of Diseases, Tenth Edition (ICD-10) codes to the diagnostic coding program to its existing >70,000 codes. These will include 1900 diagnostic codes and 3651 hospital inpatient procedure codes.

Among the hospital inpatient procedure codes, the vast majority of the codes will update cardiovascular and lower joint body systems. The new codes will expand the body part detail available in root operations removal and revision, as well as adding unique codes for unicondylar knee replacement. Specifically, some of the new codes added range from removal of synthetic substitute from right hip joint, acetabular, percutaneous approach (0SPA3J), to revisions of synthetic substitute in left knee joint, tibial, external approach (0SWWXJZ). A full list of the new codes is available on the CMS website.

In addition, the new codes will cover face and hand transplants, as well as donor organ perfusion.

The release of this large number of new codes is because of a partial freeze on updates prior to the original launch on October 1, 2015; the 2016 update will include the backlog of all proposals for changes to the code set.

A public review will be held in early May to discuss the new and revised ICD-10 Clinical Modification, and the ICD-10 Procedure Coding System codes to be included in the inpatient prospective payment system proposed rule for 2017 that will be launched on October 1 of this year.

Centers for Medicare & Medicaid Services. Details for title: 2016-03-09. www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD-9-CM-C-and-M-Meeting-Materials-Items/2016-03-09-MeetingMaterials.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending. Published March 9, 2016. Accessed April 12, 2016.

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New Interactive Tool Seeks to Raise Awareness About Health Disparities

In an effort to identify areas of disparities between subgroups of Medicare beneficiaries in health outcomes, use, and spending, the CMS Office of Minority Health has designed an interactive map: the Mapping Medicare Disparities Tool.

“The [Mapping Medicare Disparities] Tool is expected to help government agencies, policymakers, researchers, community-based organizations, health providers, quality improvement organizations, and the general public analyze chronic disease disparities, identifying how a region or population may differ from the state or national average,” according to the CMS Office of Minority Health. “This initiative provides an important first step on the path to health equality by improving the infrastructure for health equity activities and initiatives.”

The tool presents health-related measures from Medicare claims by sex, age, dual eligibility for Medicare and Medicaid, as well as race, ethnicity, state, and county via a public, interactive website. According to the agency, the tool provides users with a quick and easy way to identify areas with a large number of vulnerable populations, and target interventions to address racial and health disparities.

Centers for Medicare & Medicaid Services. Mapping Medicare disparities. www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/MMDT-Overview.pdf. Accessed April 12, 2016.

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