RISE TAKES A STANCE ON TELEHEALTH The RISE Risk Adjustment Policy Committee offers guidelines for risk adjustment involving telehealth services in the wake of COVID-19.
nยบ4 - Winter 2020
THE LATEST NEWS Proposed 2022 Payment Notice: What it means for risk adjustment in the ACA marketplace
The sunsetting of RAPS for Medicare Advantage
CMS finalizes changes to the HHS-Risk Adjustment Data Validation Program
CMS releases 2021 Star ratings for MA and Part D Prescription Drug Plans
Feds finalize drug rebate rule, but mandate likely faces legal challenges
Have you checked out the RISE Talent Hub?
CMS overhauls Stark Law: What you need to know
Seeing through the Interim Final Rule fog to lift 2022 Stars
Avalere report: MA plans may see reduced risk scores, payments in 2021 due to COVID-19
CMS: Medicare Advantage premiums plunge as enrollment soars
2022 Medicare Advantage Advance Notice Part 2: CMS aims to boost MA plan revenue by 2.8%
2022 Medicare Advantage Advance Notice: CMS reveals plans to fully use encounter data for risk adjustment
COVID-19 update: Fauci issues new warning as US cases surge to a record high; CMS sets coverage rules for vaccine
Fed appeals court rules that insurers should get unpaid cost-sharing subsidies, but limits amount they can recover
Regulatory update: MA penetration rate reaches all-time high; CMS’ Verma weighs in on the future of value-based care
RISE’s Star Ratings Master Class to feature presentations on the impact of COVID-19, regulatory updates from CMS and NCQA, and other hot button topics
Video interview: Kevin Mowll reflects on his tenure at RISE and the future of the association
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Letter From the Chair
DREAM TEAM
SET UP YOUR ORGANIZATION TO OUTPERFORM ON THE MEMBER EXPERIENCE MEASURES
In the last quarterly newsletter, I used this space to alert you that for 2023 Star ratings (which are largely based on the work conducted in the 2021 calendar year), the weight of member experience measures will increase from 2 to 4. This change greatly augments the importance of these measures as they will make up a significant portion (over 50 percent!) of your plan’s overall Star Rating score. If you’ve been tasked with championing these measures at your organization, consider organizing and launching an improvement team along with a well-defined game plan for how that group will work together to manage the endeavor.
informal group to lead your efforts. You’ll also have to make decisions about the details… Who will be your picks to join the team? What part will each of them play? What will be your meeting cadence? Making these choices thoughtfully on the front end will be key to moving quickly and efficiently in a way that best fits the needs of your plan. Whatever your choices, don’t worry if you need to adjust as you move along. Flexibility is important to success, and you should prepare everyone from the start that adaptability is part of the winning process.
The structure and process you choose for your team should be governed by the needs of your organization. You may set up a formal operating committee with well-defined roles and policies and procedures, or you may opt for a more casual,
Putting together an optimal “dream” team will be one of the most important factors in determining the success of your efforts. As you draft your list of team members, consider who in your
Your picks for the dream team
organization has the right skillset as well as the right mindset.
...consider who in your organization has the right skillset as well as the right mindset. Both are important. Sit back and observe… Who has been comfortable expressing viewpoints that may seem out of the box or unpopular? Who has earned respect at various levels of the organization? Who are the true subject matter experts within the operational areas with direct touchpoints with members? Who has been comfortable expressing CLICK TO SEE OTHER ARTICLES
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viewpoints that may seem out of the box or unpopular? Who has earned respect...?
Two key team players The “sponsor.” One of the most important team members to draft early on is the sponsor for your project. This is the team member that will serve as your megaphone within the organization, providing energy and momentum for the work of the team. Pick someone who is passionate about the work, who has garnered respect across various departments, and who is capable of exercising influence (be it by virtue of title or popularity). This team member’s sponsorship of the project is essential to removing barriers that may pop up along the way and preventing obstacles from becoming insurmountable challenges. Draft your sponsor early, even if you don’t foresee any landmines. You’ll be happy this person is on the team to clear the way and keep your work moving forward. The “cheerleaders.” Recruit people who are infectiously passionate about the opportunity to improve the member experience across the organization. They may lack formal titles or still need to acquire technical skills, but they’ll make up for that with their enthusiasm. If you can, always choose these people over those that have more credentials or responsibilities but are not passionate about or don’t see the value of your cause. Those dispassionate people slow the team down, often arguing for the status quo or failing to deliver. The cheerleaders will always show up to do the work, even when the going is hard.
Other most valuable players Consider the following players to round out your team: • T he executive leader can make sure the project is adequately resourced, assist in clearing obstacles, and champion your cause throughout the plan. If you can get a team member from the C-Suite… all the better. • If your work will involve transforming any aspect of clinical care, ensure you have a clinician leader on the team to ensure your ideas are sound and can be carried out. 4
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Don’t make the mistake of suffering from analysis paralysis. • A nalyzing data points, tracking performance, and communicating measurable improvement to leadership is key to the success of the team. You need data nerds. Include them. • Include people from all departments that own member touchpoints, and therefore, will be critical to driving change that may be needed to achieve improvement goals. If they own a piece of the problem, make sure they own a piece of the solution by giving them a seat at the table.
Game on Once you’ve drafted your team, it’s time to learn and practice the plays. As with any new team, it’s important to coalesce quickly when you first come together and commit to working collaboratively. Leaders within the team should purposefully strengthen the bond among all the players. They can do this by modeling good listening, encouraging open discussion and the expression of all views, and by guiding the team to find compromise. Remember, the goal at the beginning is to build consensus about how to carry out the work ahead. Get the housekeeping stuff out of the way quickly by coming to agreement on the role of the team, how often you’ll meet, how you’ll make decisions, whether there will be subgroups, and how you will communicate with stakeholders within and outside the organization. Once the housekeeping is out of the way, you can embark on the hard work you must do together as a team, which is to get very good at executing these four, standard process improvement plays:
• Understand and be able to articulate the issues that underly performance problems • Set general and discreet goals for improvement • Develop a strategy and action plan to tackle the changes that need to be made to address the identified issues and goals • Guide the implementation of actions across the organization
Rally your winning team If you’re accountable for member experience improvement at your plan, you’re either coaching or quarterbacking. Either way, improve your chances of success by rallying your players around the team’s common goals. Create a unified vision for your team members and show them how they each fit into the big picture. Do this now. As I’ve urged before… Don’t make the mistake of suffering from analysis paralysis. Get started as soon as possible, and don’t let the perfect be the enemy of the good. Take the first step and get help if you need it. This is too important to wait another day.
By Ana Handshuh, CHC Principal, CAT5 Strategies RISE Quality & Revenue Community Chair
HEALTH CARE FUTURIST IAN MORRISON NAMED KEYNOTE FOR RISE NATIONAL 2021 Another megatrend: social determinants of health, particularly rising inequality in the United States.
RISE is pleased to announce that Ian Morrison, internationally known author, consultant, and health care futurist, will present a keynote address on March 30, 2021, the final day of the RISE National. Morrison, who specializes in longterm forecasting and planning with an emphasis on health care and the changing business environment, will present insights and implications of health care policy based on the new Biden administration, the continued impact of COVID-19, and mega-trends, including artificial intelligence, data analytics, and the intersection of social determinants of health and digitalization. Although a lot can happen between now and March, Morrison said that by then the Georgia runoff will be over and the country will know which party controls the Senate. The new composition of the Senate and the House will provide context for his address. One topic that will likely still be making headlines: COVID-19. By March, he said, the country may be in a recovery period but in the middle of what he described as “vaccine chaos.”
“We have known for a long time that income and socioeconomic status are powerful and explain differences in health outcomes,” he said. But one factor that has been inadequately addressed in the United States is income. These disparities have finally been exposed because of the economic devastation due to COVID19, according to Morrison. While jobs have come back for those with higher incomes, COVID-19 has eliminated many lower-wage jobs in other industries. “It’s been a double whammy,” he said. “If I am talking mega trends, the negative ones in terms of social determinants are rising inequality and the race issue. It’s become pretty toxic when you put COVID in the mix.” But there are positive signs that some health care organizations are building an infrastructure to improve the health of their underserved populations by using metrics, measurement, and data to support better decision-making, he said. Morrison, a board member of the Martin Luther King Jr. Community Hospital in Los Angeles, said he plans to provide RISE National attendees with concrete examples from the population health model that the hospital has used to identify and serve underserved populations in the community since it reopened five years ago.
“I’ll highlight what we are doing, reaching out to at-risk populations using sophisticated analytics to track where patents are from and intervene to help improve their health-care related conditions,” he said. RISE National will take place March 28-30, 2021. Morrison’s keynote address is scheduled for 10:20 a.m. Tuesday, March 30. Click here to learn more about the conference and how to register.
[Morrison] will present insights and implications of health care policy based on the new Biden administration, the continued impact of COVID-19, and megatrends, including artificial intelligence, data analytics, and the intersection of social determinants of health and digitalization.
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RISE RISK ADJUSTMENT POLICY COMMITTEE: POSITION PAPER ON TELEHEALTH
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QUALITY & REVENUE COMMUNITY NEWSLETTER
The Risk Adjustment Policy Committee offers policy guidelines for risk adjustment involving telehealth services.
Introduction The RISE Risk Adjustment Policy Committee addresses the public policies involving risk adjustment and quality payments for value-based programs, most particularly Medicare Advantage (MA) and the Affordable Care Act (ACA) marketplace. Our goal is to support the crucial work of health plans to collect and report complete and accurate data necessary for risk adjustment and quality assurance programs that are fundamental to well-functioning insurance markets. These activities also provide important insights informing health plan innovations in population health management and understanding and documenting the social causes of disease that we all know we need to address. Now with the dramatic shift in patient care patterns due to the COVID-19 public health emergency, the industry recognizes the need to adapt policies for the proper use of telehealth technologies. The first response was to launch directly into telehealth as an emergency measure as many Americans retreated from in-person office visits for much of their chronic care needs. Telehealth most definitely increased individuals’ access to health care services during this time.
The continued likelihood of increased adoption of telehealth during and after the pandemic raised numerous issues, including how best to accurately capture and document chronic health conditions.
These issues have been addressed by the Centers for Medicare & Medicaid Services (CMS), which has issued standards for coverage and provider payment for telehealth and the permissible use of diagnoses based on information learned during telehealth encounters for risk adjustment purposes that differ for the MA and ACA marketplaces. Our deliberations as the Risk Adjustment Policy Committee led us to consider useful policy guidelines for risk adjustment involving telehealth services. We view our suggestions as a complement to the work sponsored by the NCQA’s Taskforce on Telehealth Policy to further our shared goals of promoting the collection and use of clinically relevant, accurate data that are critical to ensuring all individuals have access to high quality, affordable health care.
The Taskforce on Telehealth Policy The Risk Adjustment Policy Committee commends the Taskforce on Telehealth Policy, which represents a broad group of stakeholders across the industry. As reported in its webinar and supporting documentation, the Taskforce on Telehealth Policy’s main focus was on three major areas: Patient Safety: Telehealth can enhance patient safety by preventing care delays, reducing exposure to pathogens, and minimizing travel needed for in-person care. Policymakers should fund research on telehealth best practices for patient safety and update existing patient safety event reporting structures to incorporate telehealth. Program Integrity: Emerging artificial intelligence tools to audit claims and other data have the potential to make it easier to detect fraud. In the case of telehealth, investigators can uncover Internet Protocol (IP) addresses and other digital signatures (e.g., date/time stamps) to identify bad actors. Integrating these tools into existing enforcement mechanisms may eventually reduce telehealth program integrity risks. Quality: Telehealth is essentially a setting or modality of care, rather than CLICK TO SEE OTHER ARTICLES
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a type of care. This means that it should be held to the same standards for risk adjustment and quality measures as in-person care where appropriate. In cases where the unique characteristics of telehealth dictate a change in a given measure, it should be adapted, rather than reinvented or developed from scratch. Where evidence and standards of care allow, measure stewards should do so without altering standards and outcomes expected for services provided via telehealth.
RISE Risk Adjustment Policy Committee Policy Recommendations The recommendations of the Taskforce on Telehealth Policy are wellfounded, and the RISE Risk Adjustment Policy Committee fully supports them. We are in complete agreement with its findings that telehealth is part of the evolution of health care into the digital age and not just another type of health care and that it can be a critical tool in advancing a well-coordinated and patient-centered, value-optimized health system. Building on that premise, the RISE Risk Adjustment Policy Committee recommends further development of standards applying in all markets based on the following principles: Telehealth visits are clinical encounters that yield tangible value based upon their efficacy in assessment and treatment. This means that the appropriateness of using this technology must be assessed first by clinicians under a variety of circumstances (i.e., audio visits with and without a video component). Discerning which health conditions are treatable remotely requires the input of physicians who normally care for patients with those conditions now. Those decisions should consider whether conditions are acute or chronic, if a telehealth visit identifies a new diagnosis, and whether the patient is already in the care of the attending physician. Telehealth visit documentation must follow the same guidelines applicable in any other setting. There is no reason that the requirements of ICD-10-CM 8
QUALITY & REVENUE COMMUNITY NEWSLETTER
guidelines or the AHA Coding Clinic would not equally apply to telehealth visits. While specific claims codes are required for place of service and only certain CPT/HCPCS/or related codes qualify telehealth visits for payment, all other information should fit in the normal claims or encounter submission formats. Because Medicare regulations for payment have specific ways for flagging telehealth visits, those protocols are necessary for payment and qualification of encounters for recognition and acceptability. If all three conditions above are met, telehealth visits should qualify for risk adjustment purposes irrespective of line of business. The first three conditions establish that the diagnostic codes are valid and supportable under Risk Adjustment Data Validation criteria when conducting a chart audit, and therefore should be determined appropriate for risk adjustment purposes.
encounters for Stars programs and others holding health plans accountable for the quality of care provided to enrollees. Given the vast and rapid adoption of telehealth on the part of both clinicians and patients, the RISE Risk Adjustment Policy Committee agrees that telehealth will remain a vital tool in the continuum of clinical management of health conditions. The development of consistent, consensus standards is therefore essential not only during the pandemic but also once we are past this crisis. Health plans strongly support the collection of clinically relevant, accurate data that supports all the activities described above that are fundamental to providing our enrollees with high quality, affordable care. We look forward to continuing to work with CMS and other policymakers to ensure these data remain a reliable foundation for these activities to address ongoing technological innovations in care, including telehealth, as they develop.
“...telehealth is part of the evolution of health care into the digital age...� When meeting these conditions, most importantly that telehealth is clinically appropriate to meet the individual’s needs and the data collected during the encounters are accurate, we believe these standards should apply across markets. That is, except where state laws override federal guidelines for the ACA marketplace where telehealth may not be acceptable, the Medicare program should be aligned with MA, the ACA marketplace, and Medicaid programs. These recommendations will also have uses as we consider how best to use information gathered during telehealth
2021 NOMINATIONS NOW OPEN FOR RISE QUALITY AWARD RISE is now accepting nominations for its annual Martin L. Block Award that recognizes excellence and clinical leaders’ passion to improve patient care. For 2021, RISE has broadened the criteria beyond risk adjustment and Stars to ensure the spirit of excellence and innovation lives on. The annual award is dedicated to the memory of the late Dr. Martin L. Block who made it his mission throughout his career to improve the delivery of quality patient care. This prestigious award acknowledges an individual’s effort to enhance the lives of America’s seniors through clinical leadership, policy vision, and by superior example of RISE’s mission to promote continuous improvement in the health care system.
Eligible nominees: • Must work within the clinical field as either an MD, NP, RN, PA, DO, or otherwise clinically credentialed • May work for a health plan, provider organization, accountable care organization, or a vendor-supplier to the health care marketplace • Must have fulfilled one of the following criteria: • Contributed to significant process improvement in the care of seniors • Dedicated more than 10 years to exemplary work in this industry • Be nominated and presented to the Martin L. Block Award nominating committee To be considered, completed nomination forms must include necessary documentation and be submitted by Dec.
develop and improve processes that benefit patients and healthcare professionals. 31, 2020. Click here for nomination forms (scroll to bottom of the page). The award will be presented at a ceremony during RISE National, the annual Medicare Advantage mega conference, which is scheduled to take place March 28-30, 2021 in Nashville.
About the Dr. Martin L. Block Award The award is given in honor of the late Dr. Martin Block a regular speaker at RISE National, and an expert in the risk adjustment industry who had a natural ability to engage and inspire audiences and a passion to improve patient care. Dr. Block, or Marty, graduated from Northwestern University Medical School with a Doctor of Medicine degree. He completed his internal medicine residency in 1978 at Washington University in St. Louis and began his private practice in Riverside, Calif., where he was active in the medical community. Dr. Block’s focus on delivering quality patient care led him into healthcare administration early on in his career. As a doctor of 35 years, his dedication to improve medicine fueled his rise among the ranks of several major health plan management companies, including Blue Cross Blue Shield, Cigna, Aetna, and United Healthcare. No matter his title–medical director, chief medical officer, or vice president of clinical services–he stayed fixated on his mission to improve quality of care, and he worked long hours every day to
As a certified professional coder, Dr. Block gained critical insights into risk adjustment, quality, and outcomes management. He eventually moved to Scottsdale, Ariz., and went on to earn several awards for his dedication and passion. Dr. Block died in October 2013 of brain cancer at the age of 62. In recognition of his contributions to innovations in risk adjustment, and to honor his life’s work, the RISE Association named the award in his honor and posthumously recognized him with the first Martin L. Block Award in March 2014.
Past award winners Previous award winners include Mark Dambro, M.D., senior vice president of health informatics for Signify Health; Dr. Manjusri Vennamaneni, chief medical director and chief quality director for Access Health Care Physicians, LLC.; Michelle Lupoli, R.N. vice president of medical management for Neighborhood Health Plan of Rhode Island; and Dr. John Broderick, regional medical director of Landmark Health. Last year, as we faced the early months of the coronavirus pandemic, RISE decided to waive the traditional criteria of the Block award and dedicated it in honor of health care professionals who contracted and died from COVID-19.
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UPCOMING EVENTS User Groups See Date and Times Online
The 11th Annual RISE Star Ratings Master Class December 14-15, 2020 A Live-Streaming Virtual Event
Healthcare Data Acquisition: The Journey from Flintstones to Jetsons February 17th, 2021 Webinar in Partnership with Apixio
RISE National 2021 March 28-30, 2021
Qualipalooza 2021 Save the Date for June 2021
The 17th Risk Adjustment Forum Save the Date for June 2021
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COMMUNITY PARTNER NEWS Additional reconciliation run for CMS PY2020 Risk Adjustment data submission allows more time to close gaps and increase submission accuracy
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Understanding the 2021 CMS Star ratings for Medicare Advantage plans Inovalon Is technology the remedy for HEDIS headaches?
Ilene MacDonald Editorial Director imacdonald@risehealth.org
GeBBS Healthcare Solutions Social Determinants of … HELP! Centauri Health Solutions Tricia Rosetti Content Marketer trosetti@risehealth.org
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