CMS' rewards programs can impact Medicare Advantage organization's bottom lines

CMS Policy Changes Signal Shift in Favor of Consumer Benefit Rather Than Protection

Tom Wicka, CEO of Novu, writes an interesting article on Medicare Advantage plan design strategy that is worth an attentive read.  His suggestions are well-taken.  However, to fully appreciate why this is such a shift in CMS policy, it is worth stepping back for a moment to consider what this is all about. 

Let's face it:  CMS' job is a tough one.  On the one hand, they are regulating an industry that is loaded with innovative and sometimes aggressive healthplans and their legions of downstream contracted business partners, not all of whom stay inside the fenceline.  On the other hand, they want to do the right thing by the Medicare beneficiaries and get them the most valuable healthcare that federal money can buy. The easiest solution to achieve these two goals is to install rigid, one-size-fits-all regulations with vivid bright lines, and then police the lines.  Wherever regulations leave loopholes that are exploited by some cowboy operatives, CMS can be punitive and close down the wiggle room.  Fair enough. 

Another option is to flex a bit and allow the creative and competitive forces to come up with solutions that take the high road to a more value-based level.  Such is the case with the long-anticipated incentive policy that CMS has recently promulgated.  I am sure there will be some abusers, or at least, some plans that test the limits and CMS' patience.  However, this is one case where CMS flexibility will yield significant value to members of Medicare Advantage Health Plans.  Mr. Wicka points out that health improvement opportunities, facilitated by these more flexible incentives, is what motivated CMS to take the risk.  In the wild and crazy days of Private Fee for Service plans in the 2005 to 2008 era, undoubtedly some plans would have used these tools to bait seniors into joining up when healthplans lacked the administrative tools to track and properly implement the way that Mr. Wicka envisions.  But these are new days, and CMS is a different CMS.  Let's stay tuned and see how it all works out! 

http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/cms-rewards-programs-can-impact-medicare-advantage-organizations-bottom-lines?page=0,2

 

 

 


Tags: Plan Design Medicare Advantage Incentives

Log on to Your Rise Account

Forgot your password?
Create an Account

Association Sponsors

Latest Posts

Keep M.E.A.T. on Your List for a Healthy Audit

By Jeanmarie Loria, Advize Health, LLC If you’re reading this article, chances are you already know what HCC Coding is – but we’ll give you a refresher anyway. Hierarchical Condition Category (HCC) and Risk Adjustment Coding is a CMS-mandated payment model. This model works to identify those with chronic and other serious illnesses and prescribes a risk factor score to each patient, taking into consideration their ailments and other demographics. With every payment model comes a specific set of audit and review requirements that must be met to maintain the integrity of the system, and this is where MEAT (Monitor, Evaluate, Assess/Address, Treat) comes in handy. In a face to face visit M.E.A.T. maybe found in the chief complaint, history of present illness, review of systems, physical exam, assessment and/or plan....
Read More

Getting It Right: True North in Healthcare Reform

The movement to repeal and replace "ObamaCare" created so much political noise that clear thinking has been hard to come by. The 2010 legislation that created the marketplace for individuals and small business (the Affordable Care Act or ACA), has almost evolved into a political Rorschach test. The more that politicized options and alternatives to repealing, replacing, or repairing it were discussed, the harder it was to put into focus the original problems the legislation was designed to address. Nevertheless, the rancorous divisions over what needs to happen to fix problems in the individual insurance market remain a distraction from the real issue at hand: the cost of healthcare weighing down the economy and what we need to do to fix it. With all the intense debates swirling around this topic, an impression emerges that “solving the ObamaCare issues” is something that must be accomplished as an isolated matter, discrete and independent of other problems. The heated debates concentrate on the mechanics and tactics required to solve the "uninsured problem", the "under-insured problem", and for some, the federal budget problems created by the subsidies for low-income enrollees in these plans. This single-issue mono-vision obscures a reality that must be addressed. This perspective completely misses the fact that something is going on that is far more corrosive to the wellbeing of all of us as consumers of health care, as taxpayers, and as a nation: something that overshadows the tug ‘o war over ObamaCare. The critical and overlooked issue is that health care expenditures in the U.S are at least twice as expensive as other nations, which consume so much of the national economy...
Read More

Upcoming Conference

 

Qualipalooza: The 2nd Annual RISE Quality Leadership Summit 

This unique event incorporates three conferences presented side-by-side: the Star Ratings Strategic Planning Forum, the HEDIS Forum, and the CAHPS, HOS & Member Survey Forum. Register for one conference for an in-depth examination of a single area, or design your own event by opting for the all-access pass and choosing the sessions from each conference which correspond exactly to your interests.

More

Upcoming Webinar

Successful and Meaningful Techniques for Integrating Risk and Quality Interventions

Quality measurement and risk adjustment regulations are increasing and the financial impact upon health plans is progressively driving accountability and influencing profitability through payments, penalties, and bonuses. To improve performance and optimize risk and quality payments, Health Plans need to streamline processes, employ best practices for data capture, and focus on strategic interventions that use a member-centric approach.  

Connect With Us

Copyright © 2014 Resource Initiative & Society for Education. All rights reserved.