Mapping Medicare Health Disparities by Population
CMS has created and maintains a new tool for mapping Medicare health disparities by population (MMD).
The MMD interactive tool contains health outcome measures for disease prevalence, costs, hospitalization for 60 specific chronic conditions, emergency department utilization, readmission rates, mortality, preventable hospitalizations, and preventive services.
Z Codes Can Help to Predict Health and Financial Risk for Value-Based Care
ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) contains over 70 Z codes (Diagnosis codes that start with Z) that capture SDoH. These Z codes identify problems related to education and literacy, employment, occupational hazards, housing and economic circumstances, and health care access. There are also Z codes related to the patient’s social environment and problems related to upbringing, one’s primary support group, and many psycho-social circumstances such as imprisonment and exposure to disasters.
SDOH data can be collected by any member of a patient’s health care team during any encounter. This includes providers, nurses, community health workers, and self-reporting individuals. This SDoH data are documented in the patient’s encounter record in the list of presented diagnoses. Providers and staff are then able to submit the appropriate SDoH Z code(s) into the claims billing and encounter reporting system, which begins the institutionalization of SDoH data for future use.
A New Public Health Emergency in Medicaid?
The Families First Coronavirus Response Act specifies that Medicaid beneficiaries must re-determine their eligibility once the federal public health emergency is declared to have ended.
While all people who lose their Medicaid coverage qualify to enroll in the federal ACA marketplace for 2023 coverage, HHS estimates that five to ten million people will lose eligibility or choose to forego coverage.
Medicare Advantage Plan Revenue Take Hits Over Lower Quality Ratings
CVS Health and Centene have reported projected 2024 earnings reductions of 5% due to year-over-year declines quality bonus payments from the Medicare Advantage Star Rating program. The declines were caused primarily by the expiry of the one-time changes to the rating system due to the COVID pandemic, which results in a sharp reduction in Centene and CVS members in plans with a 4+ Star-rating for 2023.
The downward shift in MA Star Ratings will present revenue headwinds and operational hurdles for Medicare Advantage health plans in 2024, as additional changes in the Medicare Advantage Star Ratings are implemented.
From SDoH Policy to Action – AmeriHealth Caritas Creates Social Determinants of Life® Strategy
Social determinants of health can contribute to health disparities and inequities when there are challenges with regard to the accessibility and availability of nutritious food, safe housing, reliable transportation, and quality health care. AmeriHealth Caritas is referring to SDoH as the Social Determinants of Life® (SDOL) and developing an entire strategy around addressing SDOL. AmeriHealth Caritas are implementing their SDOL strategy through screening for key social determinants of health and be creating a new company focused on addressing those needs.
Medicare Advantage improves Value-based Care compared to FFS Medicare
Medicare Advantage significantly outperformed FFS Medicare on each of the 16 clinical quality measures and four of the six patient experience measures. Now that total Medicare eligibility is approximately 60 million beneficiaries and enrollment in Medicare Advantage plans approaches 50% of all Medicare beneficiaries, these findings demonstrate the success of the Medicare Advantage increasing value-based care by increasing quality of the care delivered.
Health Plan acquisitions of Provider Groups improve Value-based Care
What should we make of the continuing trend of health plans acquiring provider practices, retail clinics and home-based/virtual care capabilities?
Consider some recent transactions:
1) CVS acquires Signify Health, Target Pharmacy, Omnicare, etc. (10,000 providers + expand Rx).
2) UnitedHealth Group (now 60,000 providers) acquires Healthcare Partners, Landmark Health, DaVita Health, etc.
3) United Health Care partners with Walmart Health.
4) Humana buys out Private Equity partner to expand CenterWell.
5) Elevance Health acquires CareMore, CareBridge, Amwell, etc.
Let’s put this activity into the framework I’ve established in this series to evaluate healthcare value, which is really a mathematical perspective of the Triple Aim, where:
Value = E[Q+S] / [∑(P*U)] or Value = Effectiveness [Quality + Satisfaction] / Total Cost
Substituting the stakeholder roles for the variables in the healthcare value equation, the result is:
Value = (People + Policymakers) / (Providers + Producers + Payers)
Now, evaluating the VBC equation through the lens of the stakeholder roles, we can better understand the rationale for Payers acquiring Providers and Producers, like those I listed above.
While Providers, Payers and Producers (like Pharma) drive the denominator of cost, they have an inverse relationship with Provider and Producers driving cost trend up (especially with public and private equity owning an increasing share) and Payers attempting to drive cost trend down for similar reasons.
I see two primary effects of Payers owning more Providers:
1) Better data sharing to the clinical workflow enabling value-based decisions, and
2) Reduced pricing pressure from Providers with more shifts to alternative provider compensation models, including risk sharing and salary + quality incentives.
Solving the Healthcare Value Equation – Part 3
Value-based care (VBC) is the goal of improving the quality of and satisfaction with healthcare while lowering overall cost. I’m proposing the following equation to identify the interaction of the key variables of value-based care: Value = Effectiveness [Quality + Satisfaction] / Total Cost.
Mandating the measurement of the quality of healthcare has provided a means to “comparison shop” health plans, and the average measured quality of care has increased over time, especially in government sponsored programs run by private health plans, like Medicare Advantage and Managed Medicaid). However, this desirable ability adds billions of dollars of cost annually to the healthcare system with much more required investment on the horizon.
In my opinion, quality mandates are needed to accomplish important national healthcare goals, but quality mandates do not help accomplish the triple-aim of CMS.
Solving the Healthcare Value Equation – Part 2
Value-based care (VBC) is the goal of improving the quality of and satisfaction with healthcare while lowering overall cost. I’m proposing the following equation to identify the interaction of the key variables of value-based care: Value = Effectiveness [Quality + Satisfaction] / Total Cost.
Solving the Healthcare Value Equation – Part 1
Value-based care (VBC) is the goal of improving the quality of and satisfaction with healthcare while lowering overall cost. I’m proposing the following equation to identify the interaction of the key variables of value-based care: Value = Effectiveness [Quality + Satisfaction] / Total Cost.