Quality & Revenue Community Newsletter No. 9 - Spring 2022 by WilmingtonFRA

RISE News A look back at RISE National 2022

Dr. Tiffany C. Pankow named 2022 recipient of RISE prestigious quality award

RISE weighs in on the proposed 2023 Medicare Advantage and Part D Advance Notice

4 health care trends to watch in 2022

Nº 9 - Spring 2022

THE LATEST NEWS CMS releases 2023 Medicare Advantage Proposed Rule: Aims to tighten marketing of MA plans

RISE-Engagys annual survey: 5 findings on member engagement in 2021

Medicare will cover free overthe-counter COVID-19 tests this spring

Federal watchdog report: HHS has failed to prepare and respond to public health emergencies in 5 key areas

HHS proposal for marketplace plans carries a hefty dose of consumer caution

2023 Proposed Payment Notice for the ACA marketplace: What you need to know

HHS distributing $9B in relief funds to providers impacted by COVID-19 pandemic

Report: Nearly $4B could be recouped due to HHS-OIG work in FY 2021

3 tech-led retrospective strategies to maximize program performance without provider abrasion

Episource Moving beyond ADT data to proactively affect member outcomes

Is 95% coding accuracy good enough?

Shearwater Health 7 lessons from a ContractLevel RADV audit

Wolters Kluwer

Addressing social determinants begins with data

Signify Health

Compliance 101: Everything you need to know about regulatory audits in 2022

Episource

Real Time Medical Systems 20 health care podcasts you should listen to in 2022

The key to effective utilization management: Better patient care, reduced cost

Beyond the Z codes: Promoting health equity and population health through advancing the use of SDoH data Centauri Health Solutions, Inc.

Episource

REGULATORY ROUNDUP Spending bill extends telehealth flexibility; 16M could lose Medicaid when PHE ends; and more

CMS to reassess Part B premium after Alzheimer’s drug price cut; White House orders private insurers to cover at-home COVID tests; and more

Fed report suggests health plans fail to deliver on mental health parity; CMS to post nursing home staffing data to improve quality care; and more

National health spending rose nearly 10% in 2020 due to COVID; Medicare members aren’t receiving meds to treat opioid use disorder; and more

OIG audit finds Tufts received $3.7M in overpayments for high-risk diagnosis codes; Justice Department sues to block UnitedHealth’s acquisition of Change Healthcare; and more

READ OUR ENTIRE COLLECTION OF INSIGHTS AND ARTICLES 2

QUALITY & REVENUE COMMUNITY NEWSLETTER

Letter From the Chair

Silo busting: 5 ways to improve your organization’s customer focus for Star ratings achievement Experts tell us that we must break down silos to streamline our activities and make sure our work and investments pay off. But how do we go about actually doing it? Here are practical steps you can take. It seems like we’ve been talking about breaking down silos for years. And, yes, we’ve already bought into the ethos that silos are bad and that working within silos is ineffective for our organizations and frustrating for our teams. Experts tell us that we must break down silos to streamline our activities and make sure our work and investments pay off. But how do we go about actually doing it? Evolving how you tackle your enterprise’s initiatives from “silos” to “systems” and from “measuring” to “managing” requires resolve and a strong commitment to both results and incremental progress. Seize this moment (amidst so much progress and forward movement toward a customer-focus in health care) to synchronize your various key organizational initiatives. Here are practical steps you can take. Even if you can only implement to a few of them, you’ll still be “directionally correct.” Establish a common language and use it across your organization Make sure that your “voice” is consistent. The way you speak at every interaction with team members should reflect your organization’s culture. For example, if you’re advocating for a culture of compliance or a culture of

quality or Star Ratings achievement, everyone in the organization should be able to clearly articulate what that means for the organization as a whole and for themselves as individuals. Remembering to “speak” in your common language at every opportunity, especially when onboarding new team members, to help everyone feel more connected to the organization’s key initiatives. Build collaboration (and expectations for who should be at the table) into the lingo and into the artifacts used to assemble and communicate, such as templates for meeting agendas, presentations, and meeting minutes. What’s more, make sure that even if cross-functional teams are already communicating and collaborating regularly (a feat in and of itself), that the words they’re using mean the same to everyone. In other words, your common language must be encoded into the DNA of your organization, integrated into all routine processes and programs, ensuring that the words are consistent and that everyone agrees on their meaning. Align performance measures, activities, and budget with the organization’s priorities Stop measuring success in silos and start measuring across the enterprise to achieve alignment. Measuring at the enterprise level may be a paradigm shift for many organizations that are accustomed to measuring performance within specific program areas or business units (hence the silos), but it’s necessary for success. That means that goals and objectives in every department should support the CLICK TO SEE OTHER ARTICLES

organization’s key initiatives. To do this, align each team member’s goals to business unit goals, and the business unit’s goals to the broader organizational goals. Once you’ve aligned your goals, ensure that you build in support across the enterprise to achieve them. That may require that you reprioritize your investments in time, money, or resources. Goal alignment ensures that everyone works together to carry out the organization’s overall strategy. It gets everyone singing in tune from the same song sheet. What’s more, when everyone’s goals are aligned, each person understands his or her role within the bigger picture and how individual contributions make a difference. In turn, this helps team members understand which tasks should take priority over other less important tasks. Organizations that do this well, achieve enormous things together. Those that don’t, unfortunately, have a harder time making the big leaps necessary to oversee efforts that require significant sustained customer focus, such as Star ratings success. Create clear lines of accountability across all levels of the organization Start at the top. The leadership team must first align on the key initiatives as well as the strategies by which the organization will achieve them. Goal setting and alignment starts here as well. It’s important that this group agrees on clear cut objectives, with targeted, strategic goals that support the organization’s vision. Leadership’s ability to articulate the vision will carry the organization forward, even when the going gets tough and especially when unrelenting effort is required for longer periods of time. The more straightforward the goals, the easier it will be for the team to come together around shared objectives, no matter how aspirational. Once leadership is aligned, ensure that they’re conveying the expectation for collaboration to achieve the goals to their downstream teams. To promote accountability, connect the enterprise’s goals with the business conducted at every meeting, one-on-one, and performance review. Ensure that all key company projects and decisions support the underlying goals and avoid taking on initiatives that don’t support or are counter to the goals. Seize every opportunity to encourage silo-busting behavior at all levels of the organization. That means recognizing, celebrating, and rewarding teams and individuals that raise their hand to cooperate with others to reach the goals or that remove barriers for others along the way, even when they’re not directly responsible for the outcome. Create an environment where collaboration thrives and silos wither To speed up silo-busting across the enterprise create structural processes that synchronize and coordinate the 4

QUALITY & REVENUE COMMUNITY NEWSLETTER

flow of customer-focused information and activities across all business units. Centralizing these functions (or creating cross-functional groups), as opposed to housing redundant tasks within multiple business units, focuses the organization on the needs of the customer as opposed to the specialization of each team. Next, ensure your company culture, incentives, and how you assign authority promote cooperation. Make your expectations clear by incentivizing and promoting individuals, supervisors, managers, directors, and leaders that get things done through inclusion and cooperation and by counseling or sidelining those who are not team players. Direct investments in time and budget to ensure that team members at all levels can develop the collaborative skillsets necessary to deliver the customer-focused solutions that support enterprise goals. Make sure new hires know the goals and their role in achieving them as well as where to go for resources and support. Be sure to invest in continued training and development beyond the onboarding process as well as in the tools team members need to perform effectively. Creating this supportive environment will position teams to better align their work with the enterprise goals. Ready, set, go! Resist the urge to reject goals that are too aspirational or that seem out of reach. Ordinary goals lead to ordinary results; extraordinary goals lead to extraordinary results. To successfully achieve “moonshot-sized” goals, create a discipline for celebrating the milestones that must be reached along the way. Recognizing incremental progress while keeping a steady eye on the big goals is crucial to achieving big things. Finally, as you execute on your benefit design, quality programs, operational structure, resource allocation, and future investment, commit to implementing some of the above silo-busting strategies wherever you can. Doing so will go a long way toward aligning your organization’s key initiatives with the promise of customer focus, the ultimate key to delivering on member retention, higher satisfaction, and improved health outcomes, all factors that lead to continued Star ratings success. •

Ana Handshuh, CHC, Principal CAT5 Strategies Chair RISE Quality & Revenue Community

A look back at RISE National 2022 What a joy to be together again in Nashville after three long years! More than 1,600 participants (a RISE National record) representing 562 organizations across 46 states gathered at the Gaylord Opryland Resort & Convention Center to learn the latest on Medicare Advantage, regulatory and compliance updates, risk adjustment, quality, HEDIS®, Star ratings, member experience, social determinants of health (SDoH), the latest technology advancements, and payer/ provider collaboration. Here’s a recap of our two days of learning and networking:

Day One The morning kicked off with welcoming remarks from Ellen Wofford, founder and managing director of RISE, and Conference Chairs RaeAnn Grossman, EVP, operations— risk adjustment, population health management, and quality, Cotiviti, Inc. and Kevin M. Healy, CEO, Allymar Health Solutions.

“The conference this year, more than ever, is a celebration of you, your resilience to support our industry, service your customers, and now come together to build our way forward,” Wofford said. We then got down to business with virtual regulatory presentations from the Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG). CMS officials updated attendees with details on the changes to the 2021 HHS Risk Adjustment (RA) Model, proposed changes to the model in the 2023 payment notice, including policy goals to improve prediction among lowest-risk enrollees, partial-year enrollees, and highest-risk enrollees that are currently unpredicted in current RA models. They also discussed HHS Risk Adjustment Data validation (HHS-RADV) for the 2019 benefit year, including policies for the new Super HCC Grouping Policy and sliding scale adjustment; the HHS-RADV results for the 2019 benefit year; and proposed changes to HHS-RADV in the 2023 payment notice. CLICK TO SEE OTHER ARTICLES

OIG representatives then discussed vulnerabilities that exist in Medicare Advantage, noting the need for plans to use data analytics to identify high-risk diagnosis in their compliance programs, and more targeted oversight of chart reviews and health risk assessments. They noted that although many Medicare Advantage organizations use ordering provider NPIs to conduct oversight activities, others are missing opportunities to safeguard Medicare Advantage program integrity. OIG is targeting high-risk diagnosis codes, looking at data analytics for outliers and feedback in the field to find where unusual events are occurring. In some cases, errors occurred due to mis-keyed diagnosis codes. For example, a beneficiary may have several diagnosis codes for a diabetic condition (ICD-9 Code 250.0) but one diagnosis code for cancer (ICD-9 Code 205.0). They also discussed issue briefs related to Medicare Advantage encounter data.

RISE National 2022 Co-Chair Kevin Healy (far left) with members of the RISE Risk Adjustment Policy Committee, L to R: Sean Creighton, Michael Adelberg and David Meyer

assigned to them so there is a lot of room to improve. Meyer said that perhaps doctors shouldn’t be the primary point of collection of Z codes. Perhaps it would be more effective if community-based organizations have a role. Creighton said that the impetus for better collection may be if CMS follows through on a proposal to incorporate data on SDoH into a quality measure.

We broke into concurrent sessions before and after a networking lunch in the exhibit hall and then came together to hear from Keynote Ryan Avery, an Emmy-Award winning journalist and best-selling author. Avery, the youngest world champion of public speaking in history, inspired and offered insights on communication and leadership and how to go from “a” to “the” in the health care industry. His main piece of advice is to demonstrate confidence. Without confidence, he said, people will lose trust in you. Confidence also creates competence. However, it’s not enough to have confidence. Leaders must demonstrate that confidence.

Members of the RISE Risk Adjustment Policy Committee then offered an overview of 2022 regulatory trends. Sean Creighton said that the White House administration is dealing with major distractions, including COVID and the Ukrainian crisis, so it’s likely that changes involving Medicare Advantage will be made administratively through CMS and not via legislation. However, panel members Michael Adelberg and David Meyer noted aspects of the Build Back Better Plan are not completely dead. There are items on the agenda that have bipartisan support, such as capping cost on drug prices. The panel also discussed CMS’ goals to advance health equity and a push to incorporate social determinants data in the risk adjustment model. It’s a lofty goal, they said, and while it makes sense it may be complicated to execute. Part of the problem is that providers aren’t documenting Z codes so there isn’t complete data to recalibrate the risk adjustment model. Adelberg said that a recent report showed that only 2 percent of Medicare beneficiaries have Z codes 6

QUALITY & REVENUE COMMUNITY NEWSLETTER

His other tips: • Pay attention to how your body moves. It dictates how your messages are received. “You may be saying the right thing but moving your body in the wrong way,” Avery said.

• Delete the words “just” and “think” from your vocabulary. Those words don’t inspire confidence. • Stop being passionate, which by definition is a barely uncontrollable emotion. Instead, be purpose-driven. “Purpose is the reason for which it is done. The happiest people I know have a purpose,” he said.

Our 2022 recipient: Tiffany Pankow, M.D., associate chief medical officer, HonorHealth Medical Group, who was nominated for the award for her work addressing food insecurity, screening patients for social determinants of health, and ensuring vaccine equity and roll out vaccination clinics at Black churches and community centers. (See P. 9) Congratulations to Dr. Pankow and all our nominees!

Special thanks to Edifecs for sponsoring the engaging keynote presentation. Next, we spent an hour participating in three 20-minute speed-networking interactive roundtable presentations on timely topics moderated by our sponsors. It was a wonderful learning opportunity–if only we had the time to sit on all 24 roundtables! Finally, we ended the day with a fantastic networking cocktail reception in the exhibit hall.

Day Two The last full day of the conference started off with another round of speed-networking roundtable sessions, followed by the presentation of the prestigious Dr. Martin L Block Award for Innovation & Excellence. The annual award is given to an individual who has advanced the lives of America’s seniors through clinical leadership, policy vision, and by superior example of the RISE mission to promote continuous improvement in the health care system.

Next, we heard an amazing presentation from Keynote Dr. Nancy Messonnier, former director of the Centers for Disease Control and Prevention, who played a key role in ensuring an effective COVID-19 vaccine would be available to all Americans. Dr. Messonnier, who now serves as executive director for pandemic prevention and health systems at the Skoll Foundation, offered her insights into the pandemic, including the public health efforts that went well, those that didn’t, and what we need to do to be better prepared for the next pandemic.

“When I told the country in early 2020 to prepare for tough times, I didn’t fully understand how disruptive this would be,” Dr. Messonnier said. “I was thinking of it more like a dial instead of a switch that was flipped, and everyone panicked.” She believes that the country is through the worst of the pandemic for now, but there will be mutations and COVID will be around again. The country must be ready to get back to living with it and be ready for the next wave. “But it should be a dial, not a switch,” she said. As a society, we must recognize and accept that people have different levels of risk and different tolerance of risk, she said. CLICK TO SEE OTHER ARTICLES

Dr. Messonnier outlined what she saw as failures, including insufficient preparation, management of fluctuating demand for supplies, regulatory bottlenecks, and insufficient education. “We did a terrible job in the beginning explaining why we didn’t want the public to buy masks,” she notes. But she also emphasized the success of the vaccine development under Operation Warp Speed. The country did a good job of getting vaccinations into the arms of Americans, but it leveled off and it never got to the stage where it needed to be. It is difficult to design a vaccine implementation campaign in the middle of the pandemic, Dr. Messonnier said. However, the Centers for Disease Control and Prevention did a good job of planning the different stages of the campaign. Misinformation continues to be a big problem. For future outbreaks, she said the public needs a more consistent, common message so people don’t have to decide who they believe and who they don’t believe.

and suddenly feel more energized and elevated. McGonigal describes people who play games as “super-empowered hopeful individuals,” who can stay engaged with challenges, are resilient and can achieve their goals. This empowerment doesn’t stop when they turn off the game. McGonigal said that research has shown the game transfer effect. When people play a game that is challenging to them for 10 minutes, and then turn their attention to a realworld task (such as something they’ve been putting off, a physical activity, or learning something new), they are more energized and focused.

“We can learn to play with purpose, strategically in a relationship to our goals in our entire lives and what we want to accomplish,” she said. They can be a springboard to help people have more mental, physical, and emotional resilience to challenges. Indeed, she said, recent research indicates that children who had a gaming habit before COVID fared better in terms of mental and social health during the first year of the pandemic and schools shut down. These children still were doing what they love to do and being with people in the same way as they used to. Parents of children also benefited because they started to learn the games and realize that it takes skill.

Future forecaster and game designer Jane McGonigal, Ph.D., pictured above, then took the stage to explain the benefits of gaming to the health care industry. Games, she said, can be used to bounce back to life’s challenges with more energy and resilience. Her keynote presentation urged attendees to “imagine the unimaginable,” such as a health care future where games might be prescribed in greater amounts than traditional pharmaceuticals. The opposite of work is depression, she said. When we play games, we feel a sense of optimism, confidence, curiosity, pride, and the desire to try again if we don’t succeed. It also makes it easier to relate to the people around us. People who have had a long day at work, can tap into a game,

QUALITY & REVENUE COMMUNITY NEWSLETTER

The average age of a gamer is 50, so McGonigal said we can expect to see gaming will be a consistent habit as we age. A large-scale survey of seniors found that they felt games increased their mental stimulation, helped fight dementia, helped them become more satisfied with life satisfaction, and maintain social connections. In conclusion, McGonigal said it may not be as difficult to imagine a world where video games are prescribed to help improve our mental, physical, and emotional health. Games are not a replacement for prescriptions, she said, but they may be a pipeline for our health care. We then broke into concurrent sessions before and after a networking lunch in the exhibit hall and joined for one last time at a closing roundtable where all track chairs discussed the conference’s main themes and expectations for a postCOVID health care landscape. •

DR. TIFFANY C. PANKOW NAMED 2022 RECIPIENT OF RISE PRESTIGIOUS QUALITY AWARD

The associate chief medical officer of HonorHealth Medical Group in Arizona received the Dr. Martin L. Block Award for Innovation & Excellence on Wednesday, March 9 at RISE National 2022 in Nashville. Tiffany C. Pankow, M.D., associate chief medical officer of HonorHealth Medical Group, was awarded the Dr. Martin L. Block Award for Innovation & Excellence at RISE National 2022. The Dr. Martin L. Block Award is a prestigious accolade presented annually at RISE National that acknowledges an individual's effort to advance the lives of America’s seniors through clinical leadership, policy vision, and by superior example of the RISE mission to promote continuous improvement in the health care system. The award is named in honor of the late Dr. Martin L. Block who passed away in October 2013 of brain cancer at the age of 62. Dr. Block was a regular speaker at RISE National and an expert in the risk adjustment industry. Dr. Pankow was chosen out of a field of 13 nominees for this year’s award for her work addressing food insecurity, screening patients for social determinants of health, and ensuring vaccine equity and roll out vaccination clinics at Black churches and community centers. Finalists included Richard Ferguson, M.D., chief medical officer, Health Choice, Utah; George Rapier,

M.D, founder, chairman, and CEO, WellMed Medical Management; and Karmen Stephens, PharmD, vice president, clinical, Consana. In her nomination, Dr. Pankow was touted as a strong contender for the award because of her long-standing dedication to excellence, spirit of continuous improvement, and her commitment to equity across HonorHealth, a community-based, nonprofit teaching hospital system that includes six acute care hospitals, HonorHealth Medical Group, a research institute, cancer center, 11 graduate medical education programs, center for nursing education, and a robust community benefit program addressing the social determinants of health. “She has a strong commitment to improving patient care via changing the systems of care,” wrote Priya Radhakrishnan, M.D., vice president, chief academic officer, social determinants of health (SDoH) and health equity at HonorHealth, in the nomination. “As health care is at such difficult crossroads due to the pandemic, Dr. Pankow is the leader’s leader. She has led several successful innovative large scale system wide projects that impact millions of patient lives and hundreds of clinicians.” Dr. Pankow also leads several process improvement initiatives, including the medical assistant training programs, physician, and provider wellbeing via improving workflows and in basket reduction programs to improve the clinical team’s workflows and reduce the stress and burdens that contribute to burn out. She has served in several leadership

QUALITY & REVENUE COMMUNITY NEWSLETTER

positions, including regional medical director, and actively participated in committees such as the medical staff practitioner wellness committee, peer support committee, advisory board to innovation care partners, and most recently the women physicians’ leadership council. “On a personal front, she is highly motivated and is a servant leader who has touched the lives of numerous patients with exceptional care,” Dr. Radhakrishnan wrote in the nomination. “She has made a significant impact on the physician practice and the care of patients in her community. She is a strong supporter of team-based care, and her personal leadership style has been instrumental in championing projects that are extraordinarily challenging.” While accepting the award, Pankow said she was incredibly grateful and honored considering the legacy of Dr. Block. She accepted the award on behalf of the entire team of people at her organization who work together to help seniors. “It’s all about collaboration,” she said. •

Nominate a Colleague for the 2023 Award by Visiting risehealth.org/MLblock

DR. MARTIN L.

BLOCK AWARD

RISE WEIGHS IN ON THE PROPOSED 2023 MEDICARE ADVANTAGE AND PART D ADVANCE NOTICE Members of the RISE Risk Adjustment Policy Committee share their thoughts on the Centers for Medicare & Medicaid Services’ (CMS) recently released proposed 2023 Medicare Advantage (MA) and Part D Advance Notice and its impact on MA plans.

One of the biggest headlines from the proposed 2023 Advance Notice is that MA plans could see a nearly 8 percent increase revenue next year. If finalized, MA plans may have an opportunity to use the additional revenue to offer more generous benefit packages.

However, Sean Creighton, pictured above, a member of the RISE Risk Adjustment Policy Committee, warns that MA plans must also look at the opportunity strategically to see if a large increase in benefits is warranted given the uncertainties in the political environment. CLICK TO SEE OTHER ARTICLES

Indeed, some MA plans may be leery to invest in new benefits and service areas for fear that Congress or CMS may offset the money later, noted Michael S. Adelberg, principal, Faegre Drinker Consulting, who also is a member of the RISE Policy Committee. “This seems like great news, but if you really believe that Congress or CMS is going to reduce Medicare payment to fund other goals, you have a real strategic issue on your hands,” said Creighton, who joined Adelberg and other regulatory experts at RISE National 2022, for a deep dive into the 2023 Rate Notice and 2022 regulatory trends. Creighton said three points from the 2023 Advance Notice stood out to him: • The growth rate is a little higher, but not out of line, with recent CMS announcements • There is a definite bump from the Stars system due to COVID related policy decisions by CMS to base Star ratings on pre-COVID data when it is favorable to the plans • The normalization factor is lower than in prior years (see chart below) “These three elements lead to the growth rate actually getting passed through the plans compared to prior years where other adjustments decreased plan revenue,” he said. Furthermore, Creighton said, a large part of the projected positive revenue impact is ascribed to MA coding trend, but this varies widely by plan. It’s not a given. Plans must continue their risk adjustment policies and programs to attain this level of growth, he said.

Source: Data provided by CMS in the Advance Notices from 2019 to 2023 (the 2022 MA risk score trend was not announced and is calculated as the average of the other 4 years). The final rates and expected 12

QUALITY & REVENUE COMMUNITY NEWSLETTER

Proposed changes to Star ratings

While many media outlets focused on CMS’ move to advance health equity through MA and Part D Star Ratings and possibly create a new quality measure to assess how plans screen for social determinants of health, Adelberg (pictured right) said it may take years before Medicare can implement those changes. But one change that could be quickly implemented is CMS’ proposal to add the Beneficiary Access and Performance Problems (BAPP) measure back to Stars. The measure was removed in 2018 but is currently on the display page and is intended to reflect information about problematic plan performance resulting in CMS actions. The measure is currently based on CMS Compliance Activity Module data, which includes notices of non-compliance, warning letters, ad-hoc corrective action plans (CAP) and the CAP severity. In general, however, Adelberg said 2023 appears to be another year of smaller tweaks to Star ratings. Although CMS has laid out an agenda for establishing health equity measures and the value-based care measure, it will take years to implement these novel measures. •

revenue increases for each year are based on data which is updated after the Advance Notice and vary from the numbers presented here, and the impact of rebasing is included in the final Rate Announcement.

4 HEALTH CARE TRENDS TO WATCH IN 2022 Here are our predictions for the health care industry in 2022 based on interviews with industry experts in 2021, presentations at RISE conferences, and observations from our editorial team.

A SIGNIFICANT PUSH TO MAINTAIN THOSE UNEXPECTEDLY HIGH 2022 STAR RATINGS

Many in the industry were caught by surprise this year by the large number of health plans that earned 4 and 5 stars for 2022. Sixty-eight percent (322 contracts) of Medicare Advantage and Medicare Part D prescription drug plans earned 4+ Stars and 74 contracts received a 5-Star overall rating. Part of the reason for the inflated scores: Due to the COVID-19 public health emergency, all health plans qualified for the Centers for Medicare & Medicaid Services’ (CMS) “extreme and uncontrollable circumstances policy” for the 2022 Star ratings. This meant plans could use the better of the 2021 or 2022 ratings for most measures. The challenge now: maintaining those ratings for 2023 because plans won’t have the same opportunity to choose the better of the ratings going forward. “As they took the best score for the past two years, health plans did not expect to hit the high water marks they did. With the volume of high fours and fives Star scores, it’s going to be an incredible amount of work to maintain those bonus levels,” industry expert RaeAnn Grossman,

executive vice president, operations – risk adjustment, population health management and quality, Cotiviti, told RISE in a recent interview. Grossman, a conference chair for RISE National 2022, predicts that the big trend for 2022 will be “how do we reverse engineer to maintain the 5-Star rating. Driving domains and measures with the greater impacts, such as medication adherence and patient satisfaction.” Melissa Smith, executive vice president of consulting and professional services at HealthMine, pictured right, agreed, noting during the 12th Annual Star Ratings Master Class in December that chasing “tips and tricks’ from competitors or “best practices” as a pathway to 4+ Stars simply won’t cut it in 2022. The accelerated movement of HEDIS to digital, CMS focus on measures of data interoperability and technological enablement, and emphasis on health equity require different effort and investments in 2022 than in previous years. Therefore, she said, maintaining high ratings will require careful communication, methodical planning/ investment, and leadership awareness of the new needs of Stars. In a recent column for RISE, Ana Handshuh, principal, CAT5 Strategies and chair of the RISE Quality & Revenue Community, noted trends for 2022 Star ratings and offered suggestions when planning for benefit design, quality programs, operational structure, resource allocation, and future investment.

Among her recommendation: Provide members with options to access their care how, when, and where they want; and offer benefits that facilitate self-direction on members’ own terms to drive higher satisfaction and improved health outcomes.

ADDITIONAL SUPPLEMENTAL BENEFIT OFFERINGS, MORE COMPETITION

Grossman is also interested in how those plans with excellent ratings will use their additional quality bonus payments for 2023 benefits. The improved product offerings that result may create an opportunity for the high-ranking plans to acquire new members and retain a significant percentage of their current members. Indeed, Grossman said it will be difficult for plans that received 3.5 Star ratings and don’t get a bonus to compete in markets that have 4- and 5-Star plans and can use the extra money to improve their benefit offerings. “I think we need to watch and see how many plans actually stay in some of those markets,” she said. Grossman expects to see new supplemental benefits being added to plans for 2023. The key for plans, however, is making sure the benefits offered meet the needs of the population and geographical area. This year, Grossman said she’s interested to look back to see which benefits currently offered (such as meals, transportation, and over-the-counter medications and supplies) have had the greatest impact on members. CLICK TO SEE OTHER ARTICLES

INCREASED FOCUS ON HEALTH EQUITY

In an interview with RISE earlier this year, health policy expert Ezekiel J. Emanuel, M.D., former advisor to President Joe Biden’s transition team on COVID-19, said that he expected the Biden administration to address equity and ensure better outcomes among minority and lower income populations during his term. Since then, the word equity has frequently popped up in CMS communications. Indeed, health equity is the top priority at CMS for Medicare Advantage, the Affordable Care Act, and Medicaid, Smith told attendees at the RISE 12th Annual Star Ratings Master Class. Every decision CMS now makes is through the lens of how a decision or action improves the equity of health care services, she said during her keynote presentation. CMS Administrator Chiquita Brooks-LaSure said as much in a blog post for Health Affairs, noting that COVID-19 not only put an incredible strain on the U.S. health care infrastructure, it also highlighted weaknesses and disparities in vulnerable populations. In the post, she laid out her strategy for how CMS will achieve its vision to advance health equity, expand coverage, and improve health outcomes. Everything the agency does, she said, should align with one or more of these strategic pillars: • Advance health equity by addressing the health disparities that underlie the country’s health system • Build on the Affordable Care Act and expand access to quality, affordable health coverage and care • Engage our partners and the communities we serve throughout the policymaking and implementation process

• Drive innovation to tackle our health system challenges and promote value-based, personcentered care • Protect our programs' sustainability for future generations by serving as a responsible steward of public funds • Foster a positive and inclusive workplace and workforce and promote excellence in all aspects of CMS' operations CMS has since indicated in the 2022 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Final Rule that it is considering future actions to advance health equity based on the feedback it received after the release of the proposed rule. CMS said stakeholders submitted input on ways to make reporting of health disparities based on social risk factors and race and ethnicity more comprehensive and actionable by including additional demographic data points, such as race, ethnicity, Medicare/Medicaid dual eligible status, disability status, LGBTQ+, and socioeconomic status. And in the recently released proposed 2023 payment notice, CMS announced plans to advance policies to make coverage options for consumers in the Affordable Care Act more equitable. Meanwhile, the National Committee for Quality Assurance (NCQA) is also working to close the gap on health equity. The organization has called for the “reporting, collecting, and acting on complete, accurate, and reliable data on race and ethnicity” to better identify and act on eliminating disparities and is now offering health equity accreditation to help health systems and health plans to advance health equity. In a fireside chat during RISE National 2021, Frank Micciche, vice president, public policy and external relations, pictured right, said

QUALITY & REVENUE COMMUNITY NEWSLETTER

proposed changes would encourage organizations to focus on identifying whether there are disparities within their populations and, if so, to make sure they are able to document and update what they are doing to address disparities. “Quality care is equitable care,” Micciche said, noting you can’t have high-quality care if there are segments of your community that are underserved.

A CONTINUED PUSH TOWARD DIGITAL QUALITY MEASUREMENT

NCQA has also indicated its support for CMS’ plans to move to all-digital quality measures by 2025. In its comments to the federal agency, NCQA said “digitizing and automating the processes related to quality reporting, management and improvement can result in better measures, better measurement systems and better data—while dramatically reducing burden.” By building data collection into clinician workflows, the digital measures also reduce the additional work to collect quality data, which will free up clinicians to focus on patient care, NCQA noted. To help push the movement forward, NCQA said it will evolve its measures portfolio to be digital first and have the ability to measure and aggregate quality data across all levels of the delivery system. Author and health care futurist Ian Morrison, a keynote at RISE National 2021, also referenced in his presentation the huge opportunities ahead for digital innovations, such as consumer applications to enhance the patient and member experience, chronic care and behavioral health applications, post-acute care transitions, population health initiatives, operations 2.0 core systems, and a rise of virtual care capabilities and competitors. •

CONFERENCE CHAIR REFLECTIONS:

5 TAKEAWAYS FROM RISE NATIONAL 2022

RaeAnn Grossman, EVP, Cotiviti, who co-chaired RISE National 2022 with Kevin Healy, CEO, Allymar Health Solutions, reflects on her experience at this year’s conference, which returned to Nashville as a live, in-person event for the first time since March 2019. Absence does indeed make the heart grow fonder. After a multi-year hiatus, RISE National returned as an in-person conference. And it’s not a stretch to say that everyone in attendance shared a greater appreciation for the privilege of gathering under one roof. It was a pleasure to co-chair RISE 2022 with Kevin Healy, CEO, Allymar Health Solutions, and facilitate valuable discussions and challenge the health care community to do better and drive greater impact intelligently.

I’d like to share my reflections on the themes that stood out during our time together in Nashville. Our goal is to empower thought leadership across the industry and enable risk adjustment excellence.

PROTECT THE PROVIDER-PATIENT RELATIONSHIP “Getting back to the basics” was a common refrain of RISE 2022. There is nothing more fundamental in our industry than a patient and a doctor meeting in an exam room. Our health care system was placed under incredible strain over the past several years and more effort is required to protect the time physicians devote to patient care. A well-known study published in the Annals of Internal Medicine noted that primary care physicians spend just 27 percent of their time on care

delivery. While we’re making great strides in interoperability and digital capture, basic improvements such as coordinating record requests for risk adjustment and HEDIS® that cross all lines of business can go a long way in reducing the administrative burden that’s burning out providers.

USE A PLAYBOOK TO LIMIT OIG COMPLIANCE AUDIT EXPOSURE

RISE National attendees during the OIG presentation CLICK TO SEE OTHER ARTICLES

Hearing directly from regulators is one of the greatest benefits of RISE National. The Office of Inspector General (OIG) update was the “viral moment” of RISE 2022 as many attendees continually referred to OIG’s remarks. Concerning as it was, the OIG presentation gives payers a playbook to limit risk adjustment compliance audit exposure. Here are a couple of best practices payers can act upon right now to avoid non-compliance and improve health outcomes: Ensure follow-up care as part of your in-home or virtual health risk assessment (HRA) workflow. Diagnoses collected from HRAs that are the lone source of documentation or cannot be traced to follow-up care are a red flag to OIG and raise concerns that payers are simply inflating risk-adjusted payments. Focus on commonly miscoded conditions. Historically, certain conditions have higher error rates than others. By performing targeted reviews and working with providers to validate such claims, payers can lower the risk of non-compliance.

Personalized member engagement that resonates with the recipient is vital to moving our industry forward. Everything from at-home test kits to medication adherence campaigns to at-home HRAs must be personally and culturally relevant to make an impact.

OIG anonymously singled out one Medicare Advantage (MA) organization for its disproportionate use of chart reviews and HRAs to drive risk-adjusted payments. While questionable practices should be called out, payers acting in good faith by submitting deletes prior to an OIG compliance audit deserve credit for that work as regulators are calculating error rates.

RECOGNIZE THERE ARE CHALLENGES TO SDOH DATA COLLECTION

PERSONALIZE THE MESSAGE

Keynote Nancy Messonnier, M.D. discusses COVID-19 and lessons learned 16

The presentation on learnings from the COVID-19 pandemic delivered by Nancy Messonnier, M.D., was extremely insightful. In her closing remarks, Dr. Messonnier, who was the top respiratory disease official at the Centers for Disease Control and Prevention (CDC) at the start of the pandemic, lamented the challenge of fighting back against misinformation. She cautioned that the days of a single, trusted source such as the CDC or the White House informing on public health matters were over. Instead, she noted that public health officials and other organizations (e.g., payers), working to persuade individuals to make healthier choices, should focus on developing more personalized, localized messaging and identifying trusted members of the community to deliver those messages.

Momentum to formally incorporate social determinants of health (SDoH) data into risk adjustment models is building. Recommendations as to how SDoH data collection can improve were solicited in the 2023 CMS Advance Notice. There are inherent challenges to SDoH data collection; chief among them is placing an even greater onus on providers by asking them to capture SDoH-related Z codes (Z codes ranging from Z55-Z65 are the ICD-10-CM encounter reason codes used to document SDoH data). Expanded sources of data collection outside of the primary care setting by non-physicians deserve serious consideration, most notably in-home HRAs where information on

QUALITY & REVENUE COMMUNITY NEWSLETTER

variables such as fall risk and food insecurity are readily available.

THINK BIG: PROJECTS THAT START SMALL CAN HAVE A LARGE IMPACT In breakout session after breakout session, we heard about bottom-up initiatives having an outsized impact. Agility is a catalyst for organizational transformation, and RISE National 2022 was a reminder that a small group of committed individuals can make waves. There are more success stories than I can share, but I’d like to recognize my favorite example of a single idea blossoming to have a big impact. The Equity from End-to-End: Transformative Strategies to Power Impactful SDoH Programs session described a grassroots initiative with minimal upfront investment at Horizon BCBS of New Jersey. Horizon harnessed SDoH data to advance health equity goals and ease member care journeys. The program was extremely successful, and the organization made a significant investment to expand its application. Congratulations to Tracy Parris-Benjamin and the Horizon team on your success. Thanks for reading. I look forward to seeing you all next year for RISE National 2023 at The Broadmoor Resort in Colorado Springs. •

RaeAnn Grossman, EVP Cotiviti

UPCOMING EVENTS Avoiding a Great Depression: Strategies to Smooth the Drag on Average RAF Score during Enrollment Surges

VISIT THE WEBSITE

Tuesday, April 26th at 1:30PM EST The 19th Risk Adjustment Forum May 9-11 Fairmont Chicago, Millennium Park

VISIT THE WEBSITE

The RISE Women in Health Care Leadership Summit May 22-24 The Grove Park Inn | Asheville, NC HCC User Group Tuesday, May 24th at 1:00PM EST Clinical Data Plus Proactive Notifications Equals Improved Quality Measure Performance

VISIT THE WEBSITE

Thursday, May 26 at 1:30pm EST The 7th Annual Optimizing Appeals and Grievances Summit June 7-8, 2022 A Virtual Event HCC User Group Thursday, June 23rd at 2:00PM, EST

VISIT THE WEBSITE

Qualipalooza June 28-29 Caesars Palace in Las Vegas

VISIT THE WEBSITE

The RISE Value-Based Contracting Summit June 28-29, 2022 Caesars Palace in Las Vegas

VISIT THE WEBSITE

2022 Medicare Advantage Member Accounting and Reconciliation Summit June 29-30, 2022 A Virtual Event

VISIT THE WEBSITE

RISE West 2022 August 31 - September 2 InterContinental Los Angeles Downtown

VISIT THE WEBSITE

CLICK TO SEE OTHER ARTICLES

QUESTIONS? REACH OUT TO OUR TEAM

Ilene MacDonald Editorial Director

imacdonald@risehealth.org

QUALITY & REVENUE COMMUNITY NEWSLETTER

Tricia Rosetti Content Marketer trosetti@risehealth.org

Tracy Anderson Marketing Coordinator tanderson@risehealth.org