GHDP 144-23: MA: 8 Critical Considerations for every Organization as ERSD Eligibility Expands in 2021 Flashcards
Introduction
- Before 2021, beneficiaries with ESRD were not allowed to enroll in MA plans except in limited situations. As of Jan.1 2021 they may actively enroll in MA plans.
- A Medicare Advantage Organization’s (MAO) overall projected financial performance is a combination of its ESRD and non-ESRD experience
- Non-ESRD is more stable and straightforward to project for 2021 due to program maturity
- ESRD projection requires assumptions about ESRD prevalence and projected loss ratio
- What is your current and projected ESRD financial performance?
- Current ESRD prevalence rate to be adjusted for additional ESRD members expected to enroll 2021
- Projected loss ratio assumptions
- For current ESRD members - will be similar to historical loss ratio for the same population
- For new ESRD members: Projected Costs / CMS ERSD MA Revenue Benchmark Pmts
- Can your contractual terms with dialysis providers be improved?
- MAOs should consider contracting terms from the two major dialysis providers (DaVita, Fresenius), and contracting with only one to achieve the best reimbursement arrangements
- MAOs should consider contracting terms with
- Smaller providers
- Local hospitals
- At home dialysis providers - MAOs must ensure dialysis providers still meet network adequacy requirements
- Are you managing care for your ESRD population?
- ESRD care management programs can reduce medical costs while improving the quality
- Practices of effective ESRD care management programs
a. Promoting and facilitating home dialysis
- Increases overall savings to MAOs
- Increases the flexibility of treatments for patients
- Effective programs
(1) Identify good candidates for home dialysis
(2) Facilitate the transition to home dialysis
(3) Arrange for initial and ongoing support for home dialysis
(4) Monitor home dialysis for intervention as needed
b. Facilitating regularly scheduled visits
- Clinicians develop relationships with patients
- Provide information on available treatment options
- Discussion patient access to care
- Proactively provide care
- Services can improve the quality and effectiveness of care
- Effective programs
(1) Identify individuals that are not compliant with regularly scheduled visits
(2) Facilitate compliance through
i. patient education
ii. Arranging transportation
iii. Engaging the individual in ESRD support groups
iv. Changing an individual’s dialysis schedule/center
c. Providing patient education and involvement
- Providing clinical knowledge and involving members in the decision-making process will improve patient adherence to treatment plans
- Effective programs provide education
d. Preventing and Identifying Complications
- ESRD patients experiencing multiple comorbidities require care coordination across clinical specialities
- Effective programs assist individuals with
i. Caregiver support
ii. Problem-solving techniques
iii. Care coordination among medical specialists
iv. Community resources
v. Identifying and closing gaps in care
vi. Condition monitoring
e. Preventing ESRD Progression
- Progression of renal disease can aggravate the injury
- Effective Programs
(1) Identify individuals at risk for advanced renal disease and implement interventions
i. Protein restriction
ii. Controlling hypertension and cholesterol
iii. Medication compliance
iv. Smoking cessation
v. Avoiding harm
- Are your benefits attractive to ESRD beneficiaries?
- MA plans are required to include maximum out-of-pocker (MOOP) limits, whereas traditional Medicare does not have a cap on member spend
- MA plan with a MOOP limit may be an attractive alternative for ESRD beneficiaries
- MA plans with low MOOP limits have a greater potential to enroll ESRD beneficiaries - MAOs may consider offering an ESRD SNP
- MAOs can ensure members are incentivized to receive cost-efficient and effective care while avoiding unnecessary services
- This allows MAOs to offer competitive rates and attractive benefits in their general enrollment plans, without having subsidize the experience of their ESRD population
- MAOs may lose market share if Part C rebates and premiums for general enrollment plans are spent on benefits catering to only a subset of the plans’ overall population
- Does your formulary cover medications attractive to ESRD members?
- MAOs should review their formulary coverage to their competition, and step therapy and prior authorization programs relative to the market
- These programs can manage Part D costs for MAO’s ESRD members
- All plans should consider the care management impactof any 2021 formulary designs in light of potentially increased ESRD membership
- Will you make adjustments to your marketing and sales strategy?
- Based on the above 5 considerations, MAOs may develop strategies to address the needs of ESRD members, such as
- Creating a new ESRD SNP
- Adjusting benefits on current MA plans - Decisions may impact marketing and sales strategies, thus requiring educating the sales force on
- New ESRD MA eligibility change for 2021, and subsequent impacts including any new plan offerings
- Any changes to benefits on current MA plans
- MA plan(s) most appropriate for ESRD beneficiaries - MAOs may also track the number of ESRD enrollees and their emerging experience by plan, to
- Provide early indicators of financial performance
- Optimize care management strategies
- Will administrative costs increase?
- Cost could increase due to the ESRD MA eligibility change in 2021 for a number of reasons
a. Claims adjudication
- ESRD members have higher claim costs relative to non-ESRD members
- MAOs receiving an influx of ESRD members may require additional staff or enhancements in systems
- New processes and staff training
- Investments in claims adjudication processes may also be required
b. Care management
- MAOs may spend on enhanced care management program focusing on ESRD members
c. Marketing and Sales
- Additional investments to train sales staff on plan changes, changes in the MAO’s strategy to attract ESRD members, and implement any new sales and tracking metrics
- Are your risk-taking providers aware of potential increases in ESRD patients?
- Many providers are in risks-sharing agreements with MAOs for their attributed members
- Need to ensure that arrangemetns do not place undue financial burden on the provider or the MAO
- If the risk-taking provider has little control over management of ESRD services, a carve-out for ESRD services may be appropraite - Considerations for risk-sharing providers
- Reviewing current and projected ESRD member attribution levels
- Enhancing or establishing an an ESRD care management program
- Educating providers on best practice coding activities for ESRD members
- Revising the financial terms of risk-sharing arrangements for ESRD members
