April 2021
On the surface, Medicare Advantage Star Ratings simply allow consumers to compare the quality of Medicare Advantage insurance plans. But deeper down, Star Ratings also drive a complex financial system that includes incentives for providers. The ACO’s Lauren Purcell explains. Also, Maine Behavioral Healthcare’s Ted Logan, MD, on adapting substance use treatment to the new pandemic-driven reality.
Additional Info:
CMS’s MA star ratings fact sheet: https://www.cms.gov/files/document/2021starratingsfactsheet-10-13-2020.pdf
Julie: This is BACON, Brief ACO News from the MaineHealth Accountable Care Organization, a steamed monthly podcast for health care providers. I'm Julie Grosvenor.
Mike: And I'm Mike Clark. Julie and I are practicing physicians and liaisons with the MaineHealth ACO. In this episode, we'll learn about innovations in behavioral health care treatment prompted by the pandemic.
Julie: But first, let's take a brief look at Medicare Advantage star ratings. What are they and why do they matter to participants in the ACO?
Mike: Yep, that's coming up right now. So grab your telescope and let's head out into the Medicare night sky.
Julie: Very nice dad joke, Mike. So every year the ACO identifies nine or 10 objectives. That's part of its AIP or annual implementation plan. ACO leaders track progress toward the objectives as a measure of overall organizational success in 2021. One of the objectives is to achieve a four star quality rating on certain clinical measures associated with its Medicare Advantage population.
Mike: One might call that a constellation. Well, anyway, providers in the ACO are contracted to care for 39,000 patients within these Medicare Advantage plans. Now these offer Medicare coverage and additional benefits, usually at a pretty low premium. They're run by private insurance companies under very strict oversight from CMS, the Center for Medicare and Medicaid Services. One way that CMS exerts control over these plans is to issue star ratings, the quality transparency system that has major financial implications for the companies that run the plans and for ACOs like ours that provide care to their beneficiaries.
Julie: To detail these implications and learn how providers can influence star rating performance. Our producer Paul Santomenna interviewed Lauren Purcell, the ACO program manager for quality performance.
Lauren: So star ratings are essentially a quality rating system created by CMS or the Center for Medicare and Medicaid Services to help beneficiaries or individuals looking to enroll in a Medicare Advantage plan to choose among competing insurance plans. So essentially, there's a five star rating system, so the highest star is a five star, which is excellent, and then it goes all the way down to a four star is above average, three stars average and then two and below is below average and probably at risk of being terminated by CMTS. And these ratings are based off of about 48 measures that evaluate that plan. So what that translates to for the ACO and why the ACO is focused on this and creating an AIP around it is some of these measures are clinical measures and relate to the clinical work that we're doing, such as A1c control for diabetic patients or breast cancer screening, for instance. So Medicare Advantage plans, you know, they're motivated to perform well on these star measures because their rating, you know, four or five stars, directly impacts how much CMS, the Center for Medicare and Medicaid, will pay them. So they get quality bonus payments based off of how they're rated. They also get other incentives that they're eligible for if they're a highly rated plan. So five star plans, you know, they can advertise their plan all throughout the year and get new membership. And then new membership also adds to the financial gains that they can earn. So that's really like how the Medicare Advantage plans are motivated to do well in these star ratings. And because they're motivated to do well, they kind of pass that responsibility to us through our value based care contracts. So since many of the star measures are clinical measures, payers hold the ACO responsible for these metrics by embedding them in our value based care contract. So through pay for performance or for shared savings,
Paul: If we in turn do well on the clinical measures, if the providers that are participating in the ACO do well, is there a financial benefit for them and the ACO in general?
Lauren: Yeah. So, you know, value based care contracts work in all sorts of different ways. One of the ways is shared savings, so our performing well on these star measures increases how much shared savings we're eligible to earn and then the ACO kind of distributes through the distribution model that money back out to the regions accordingly and then also through pay for performance. So, you know, if we hit certain targets on these quality measures of breast cancer screening, for instance, if we hit a certain target, then we're paid a fee, typically a per member per month fee for doing above average or excellent work. And so that's kind of how those incentives trickle down to the ACO and then the providers in terms of earning incentives tied to these start measures.
Paul: What can a provider do or a practice do to have some kind of influence over these star ratings?
Lauren: Yeah, I think the biggest thing is that providers can do to help influence the star ratings is doing your best to try and get patients in to have the annual wellness visits every year. It really just opens up the opportunities to address any quality or health maintenance items that might be outstanding. Another thing is just supporting your patients in getting any preventative screenings or tests necessary to monitor their chronic illnesses, such as, you know, A1c labs or supporting them and getting their colon cancer screenings or anything that might be outstanding, that will really support those quality measures, the star measures as well. And then just making sure when a patient is in the office or if you're seeing a patient via telehealth, if you're seeing them with video and audio, you can document all the codes that we might need to be recaptured. So that really just helps with risk recapture and making sure that we have a full picture of that patient from a documentation standpoint. And then lastly, is prescribing long term medications on a 90 day basis, wherever it's appropriate. There is evidence that shows that this improves medication adherence for patients. So, you know, those those things will really help improve star ratings long term.
Julie: To learn more about Medicare Advantage plans and star ratings, check out the resources posted to the BACON website. Visit MaineHealthACO.org/BACON and look for Episode 24.
Mike: Well, it's time for The Sizzle, the segment where we highlight the good work of ACO participants. This month, our producer Paul Santomenna speaks to Ted Logan, an addiction psychiatrist at Maine Behavioral Health Care in Rockland who cares for individuals with substance use and co-occurrence? Mental health disorders largely through telehealth.
Paul: Ok, so obviously you had to change the way that you provide treatment during the pandemic, so what sort of new modalities did you develop to respond to this new reality?
Ted: We had been using group therapy and group shared med management visits for a while before this all started to emerge. And we had also been starting to do a little bit of telehealth and tele-psychiatry to get to reach people that we were predominantly testing it by having people come into the office and be in groups and sometimes have someone physically present and sometimes have someone as a provider on the screen to try to facilitate this and develop that as a future looking modality to treat patients with multiple emotional and substance challenges. So when the when the pandemic hit, we really had to take that and run with it very quickly and expand upon it and train. And so we were able to avail ourselves of the telephone, which was something we had not been doing because it was not something that was available to us through regulations. But most importantly, to learn like the rest of the country very quickly how to teach many people to use headphones or other proprietary platforms to connect. And we ultimately found ourselves one hundred percent almost, well, in the beginning, it was a hundred percent on a medicine platform.
Paul: Right. Right. So certainly there must have been challenges as you as you did your adapting. Can you talk about some of those and maybe how you overcame?
Ted: Sure. So the challenges are well, we can start with maybe a client or a patient based. And that was, first of all, making sure that they had the capacity to participate in this whole endeavor. So did they have access to a telephone? Did they have a cell phone, for example, with wifi or Internet access to have access to a computer, a laptop, an iPad? So we had to get used to all those different pieces of equipment, all of the ways that they interface what they look like. We had to be able to help the patients troubleshoot them as they were trying to get on if they had challenges, which meant that a lot of our staff had to be tech savvy very quickly. Once we were able to assure that they had that connectivity possibility and in some cases we actually had to provide a basic cell phone that had access so that they could have some access. Once we were able to determine that, we did make sure our end was ready, that we had the capacity to have a group format on a screen. And if we see one another and speak with one another and yet not reveal information from one person to the other, but to keep them all separate and being able to do all that electronically and then keep all the documentation private and not pay attention to all of those matters, it took some time and took some practice. But it worked. We were able to help people get in and be seen. We were able to help them no matter where they were. And that was very, very helpful because people had to shift around a lot during this pandemic finding out where they could shelter in place, finding if they even had shelter, making sure they had enough food. The one thing we didn't have to worry about as much was transportation, which is often a huge problem coming into the clinic and to the office. And this way, wherever they were, we could connect with them. And indeed, we have connected with people in some fascinating places.
Paul: Can you give me an example of that?
Ted: Sure. Well, I now have several people that I see on boats and we're all eagle-eyed and they're just off the main transit ways for bigger ships. So everyone's watching for ships on the horizon as the patients are talking and participating in groups. So which was very interesting because not only can we see them boats, which means it also has allowed us to expand our services to the islands, which will persist afterwards. So this was a very nice thing for the state. So we can actually now see people who have homes on the islands in their homes. We were able to do that regularly. So that was a particularly fun one. Once employment started to get going and people had to be at work, especially some essential workers, we were able to connect with them and work if their employers were sensitive or sympathetic to this process. And the vast majority were. In fact, I don't think we've encountered one that wasn't. We were able to meet them at work and they would sort of go off to the side or maybe get in the car and be able to participate in the groups that way and be heard, understood, taken care of, feel they were part of something bigger than themselves and also get better.
Paul: I'm sure that there are primary care providers who have patients who are experiencing substance use disorders and maybe they don't know where to send them under these conditions, or do you have advice for other behavioral health providers based on what your experience has been on using the technology that's available now?
Ted: I guess one of the things that I would say right off the top is don't be afraid to go there. Sometimes these conversations can feel awkward. Sometimes it can feel awkward to ask if there are substance use challenges, although people are getting better and better at giving initial screens and don't feel uncomfortable asking if things have gotten worse or have started through these periods. Sunshine is a wonderful thing to put light on it and to let people feel comfortable, especially people who feel they have some sort of thing to hide and don't really want to admit to that kind of a thing. To give them permission to reveal and to speak about it, I think is really a wonderful thing to offer any human being, particularly a patient with whom one has a relationship. So not to be afraid to go there is a wonderful thing. There are lots of places you can have some help, MaineHealth is working extremely hard to provide opportunities for folks with any substance to get treatment. So, for example, our program started off as a as a test site and now an active treatment site for opioids. And that was the focus for the last several years. But over the last year and a bit, it has morphed into an any substance treatment program. So whether that substance is alcohol, whether that substance is methamphetamine, whether it's cocaine, no matter what it is, they can contact us and we can help them with treatment. We can do consultations. We can offer ongoing guidance. We have active treatment programs with an intensive outpatient program where they can come three times a week to start and then move down to once a week. And we use a combination of both medications and psychotherapeutic modalities to help people through the front end to get them over any physical side effects that they're experiencing so that the patient is not afraid to go through this. And we do it locally in our own states. So we help people learn to live in their own environments and accomplish their own environments. And we're happy to do that. MaineHealth also offers an Echo program which people can sign on to every month where we talk about various subjects and present challenging cases, In addition to challenging cases are also very, very common things that folks are seeing. It's not something that's esoteric necessarily, and that has been really helpful to provide educational perspective to how we approach these things and how folks within our state can approach things.
Paul: How does one refer a patient to a program like yours?
Ted: Mainehealth is trying, Maine Behavioral Health is trying very hard to have a no wrong door policy. So any number of you call at Maine Behavioral Health should allow the person that you are speaking with to direct you to the right place, but usually a call to the office, for example, our is in Rockland. But there is an office in Portland, there's an office in Springvale. Any Maine Behavioral Health contact within the MaineHealth system is a way to get into the system and to make the right connections.
Mike: Thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our Web page, MaineHealthACO.org/BACON. And if you have questions, comments or suggestions, we'd love to hear from you. Please email us at bacon@maineHealth.org. That's bacon@mainehealth.org.
Julie: BACON is produced by the MaineHealth Accountable Care Organization with help from MaineHealth Educational Services. Thanks for joining us. We'll see you next month.
Mike: See you next month.
Mike: And I'm Mike Clark. Julie and I are practicing physicians and liaisons with the MaineHealth ACO. In this episode, we'll learn about innovations in behavioral health care treatment prompted by the pandemic.
Julie: But first, let's take a brief look at Medicare Advantage star ratings. What are they and why do they matter to participants in the ACO?
Mike: Yep, that's coming up right now. So grab your telescope and let's head out into the Medicare night sky.
Julie: Very nice dad joke, Mike. So every year the ACO identifies nine or 10 objectives. That's part of its AIP or annual implementation plan. ACO leaders track progress toward the objectives as a measure of overall organizational success in 2021. One of the objectives is to achieve a four star quality rating on certain clinical measures associated with its Medicare Advantage population.
Mike: One might call that a constellation. Well, anyway, providers in the ACO are contracted to care for 39,000 patients within these Medicare Advantage plans. Now these offer Medicare coverage and additional benefits, usually at a pretty low premium. They're run by private insurance companies under very strict oversight from CMS, the Center for Medicare and Medicaid Services. One way that CMS exerts control over these plans is to issue star ratings, the quality transparency system that has major financial implications for the companies that run the plans and for ACOs like ours that provide care to their beneficiaries.
Julie: To detail these implications and learn how providers can influence star rating performance. Our producer Paul Santomenna interviewed Lauren Purcell, the ACO program manager for quality performance.
Lauren: So star ratings are essentially a quality rating system created by CMS or the Center for Medicare and Medicaid Services to help beneficiaries or individuals looking to enroll in a Medicare Advantage plan to choose among competing insurance plans. So essentially, there's a five star rating system, so the highest star is a five star, which is excellent, and then it goes all the way down to a four star is above average, three stars average and then two and below is below average and probably at risk of being terminated by CMTS. And these ratings are based off of about 48 measures that evaluate that plan. So what that translates to for the ACO and why the ACO is focused on this and creating an AIP around it is some of these measures are clinical measures and relate to the clinical work that we're doing, such as A1c control for diabetic patients or breast cancer screening, for instance. So Medicare Advantage plans, you know, they're motivated to perform well on these star measures because their rating, you know, four or five stars, directly impacts how much CMS, the Center for Medicare and Medicaid, will pay them. So they get quality bonus payments based off of how they're rated. They also get other incentives that they're eligible for if they're a highly rated plan. So five star plans, you know, they can advertise their plan all throughout the year and get new membership. And then new membership also adds to the financial gains that they can earn. So that's really like how the Medicare Advantage plans are motivated to do well in these star ratings. And because they're motivated to do well, they kind of pass that responsibility to us through our value based care contracts. So since many of the star measures are clinical measures, payers hold the ACO responsible for these metrics by embedding them in our value based care contract. So through pay for performance or for shared savings,
Paul: If we in turn do well on the clinical measures, if the providers that are participating in the ACO do well, is there a financial benefit for them and the ACO in general?
Lauren: Yeah. So, you know, value based care contracts work in all sorts of different ways. One of the ways is shared savings, so our performing well on these star measures increases how much shared savings we're eligible to earn and then the ACO kind of distributes through the distribution model that money back out to the regions accordingly and then also through pay for performance. So, you know, if we hit certain targets on these quality measures of breast cancer screening, for instance, if we hit a certain target, then we're paid a fee, typically a per member per month fee for doing above average or excellent work. And so that's kind of how those incentives trickle down to the ACO and then the providers in terms of earning incentives tied to these start measures.
Paul: What can a provider do or a practice do to have some kind of influence over these star ratings?
Lauren: Yeah, I think the biggest thing is that providers can do to help influence the star ratings is doing your best to try and get patients in to have the annual wellness visits every year. It really just opens up the opportunities to address any quality or health maintenance items that might be outstanding. Another thing is just supporting your patients in getting any preventative screenings or tests necessary to monitor their chronic illnesses, such as, you know, A1c labs or supporting them and getting their colon cancer screenings or anything that might be outstanding, that will really support those quality measures, the star measures as well. And then just making sure when a patient is in the office or if you're seeing a patient via telehealth, if you're seeing them with video and audio, you can document all the codes that we might need to be recaptured. So that really just helps with risk recapture and making sure that we have a full picture of that patient from a documentation standpoint. And then lastly, is prescribing long term medications on a 90 day basis, wherever it's appropriate. There is evidence that shows that this improves medication adherence for patients. So, you know, those those things will really help improve star ratings long term.
Julie: To learn more about Medicare Advantage plans and star ratings, check out the resources posted to the BACON website. Visit MaineHealthACO.org/BACON and look for Episode 24.
Mike: Well, it's time for The Sizzle, the segment where we highlight the good work of ACO participants. This month, our producer Paul Santomenna speaks to Ted Logan, an addiction psychiatrist at Maine Behavioral Health Care in Rockland who cares for individuals with substance use and co-occurrence? Mental health disorders largely through telehealth.
Paul: Ok, so obviously you had to change the way that you provide treatment during the pandemic, so what sort of new modalities did you develop to respond to this new reality?
Ted: We had been using group therapy and group shared med management visits for a while before this all started to emerge. And we had also been starting to do a little bit of telehealth and tele-psychiatry to get to reach people that we were predominantly testing it by having people come into the office and be in groups and sometimes have someone physically present and sometimes have someone as a provider on the screen to try to facilitate this and develop that as a future looking modality to treat patients with multiple emotional and substance challenges. So when the when the pandemic hit, we really had to take that and run with it very quickly and expand upon it and train. And so we were able to avail ourselves of the telephone, which was something we had not been doing because it was not something that was available to us through regulations. But most importantly, to learn like the rest of the country very quickly how to teach many people to use headphones or other proprietary platforms to connect. And we ultimately found ourselves one hundred percent almost, well, in the beginning, it was a hundred percent on a medicine platform.
Paul: Right. Right. So certainly there must have been challenges as you as you did your adapting. Can you talk about some of those and maybe how you overcame?
Ted: Sure. So the challenges are well, we can start with maybe a client or a patient based. And that was, first of all, making sure that they had the capacity to participate in this whole endeavor. So did they have access to a telephone? Did they have a cell phone, for example, with wifi or Internet access to have access to a computer, a laptop, an iPad? So we had to get used to all those different pieces of equipment, all of the ways that they interface what they look like. We had to be able to help the patients troubleshoot them as they were trying to get on if they had challenges, which meant that a lot of our staff had to be tech savvy very quickly. Once we were able to assure that they had that connectivity possibility and in some cases we actually had to provide a basic cell phone that had access so that they could have some access. Once we were able to determine that, we did make sure our end was ready, that we had the capacity to have a group format on a screen. And if we see one another and speak with one another and yet not reveal information from one person to the other, but to keep them all separate and being able to do all that electronically and then keep all the documentation private and not pay attention to all of those matters, it took some time and took some practice. But it worked. We were able to help people get in and be seen. We were able to help them no matter where they were. And that was very, very helpful because people had to shift around a lot during this pandemic finding out where they could shelter in place, finding if they even had shelter, making sure they had enough food. The one thing we didn't have to worry about as much was transportation, which is often a huge problem coming into the clinic and to the office. And this way, wherever they were, we could connect with them. And indeed, we have connected with people in some fascinating places.
Paul: Can you give me an example of that?
Ted: Sure. Well, I now have several people that I see on boats and we're all eagle-eyed and they're just off the main transit ways for bigger ships. So everyone's watching for ships on the horizon as the patients are talking and participating in groups. So which was very interesting because not only can we see them boats, which means it also has allowed us to expand our services to the islands, which will persist afterwards. So this was a very nice thing for the state. So we can actually now see people who have homes on the islands in their homes. We were able to do that regularly. So that was a particularly fun one. Once employment started to get going and people had to be at work, especially some essential workers, we were able to connect with them and work if their employers were sensitive or sympathetic to this process. And the vast majority were. In fact, I don't think we've encountered one that wasn't. We were able to meet them at work and they would sort of go off to the side or maybe get in the car and be able to participate in the groups that way and be heard, understood, taken care of, feel they were part of something bigger than themselves and also get better.
Paul: I'm sure that there are primary care providers who have patients who are experiencing substance use disorders and maybe they don't know where to send them under these conditions, or do you have advice for other behavioral health providers based on what your experience has been on using the technology that's available now?
Ted: I guess one of the things that I would say right off the top is don't be afraid to go there. Sometimes these conversations can feel awkward. Sometimes it can feel awkward to ask if there are substance use challenges, although people are getting better and better at giving initial screens and don't feel uncomfortable asking if things have gotten worse or have started through these periods. Sunshine is a wonderful thing to put light on it and to let people feel comfortable, especially people who feel they have some sort of thing to hide and don't really want to admit to that kind of a thing. To give them permission to reveal and to speak about it, I think is really a wonderful thing to offer any human being, particularly a patient with whom one has a relationship. So not to be afraid to go there is a wonderful thing. There are lots of places you can have some help, MaineHealth is working extremely hard to provide opportunities for folks with any substance to get treatment. So, for example, our program started off as a as a test site and now an active treatment site for opioids. And that was the focus for the last several years. But over the last year and a bit, it has morphed into an any substance treatment program. So whether that substance is alcohol, whether that substance is methamphetamine, whether it's cocaine, no matter what it is, they can contact us and we can help them with treatment. We can do consultations. We can offer ongoing guidance. We have active treatment programs with an intensive outpatient program where they can come three times a week to start and then move down to once a week. And we use a combination of both medications and psychotherapeutic modalities to help people through the front end to get them over any physical side effects that they're experiencing so that the patient is not afraid to go through this. And we do it locally in our own states. So we help people learn to live in their own environments and accomplish their own environments. And we're happy to do that. MaineHealth also offers an Echo program which people can sign on to every month where we talk about various subjects and present challenging cases, In addition to challenging cases are also very, very common things that folks are seeing. It's not something that's esoteric necessarily, and that has been really helpful to provide educational perspective to how we approach these things and how folks within our state can approach things.
Paul: How does one refer a patient to a program like yours?
Ted: Mainehealth is trying, Maine Behavioral Health is trying very hard to have a no wrong door policy. So any number of you call at Maine Behavioral Health should allow the person that you are speaking with to direct you to the right place, but usually a call to the office, for example, our is in Rockland. But there is an office in Portland, there's an office in Springvale. Any Maine Behavioral Health contact within the MaineHealth system is a way to get into the system and to make the right connections.
Mike: Thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our Web page, MaineHealthACO.org/BACON. And if you have questions, comments or suggestions, we'd love to hear from you. Please email us at bacon@maineHealth.org. That's bacon@mainehealth.org.
Julie: BACON is produced by the MaineHealth Accountable Care Organization with help from MaineHealth Educational Services. Thanks for joining us. We'll see you next month.
Mike: See you next month.