Tag Archives: Chris Kunkel

New Dual Eligible Special Needs Plan requirements make Medicare and Medicaid communication important

With calendar year 2021 Medicare Advantage (MA) deadlines rapidly approaching, state Medicaid agencies and MA plans offering Dual Eligible Special Needs Plans (D-SNPs) must quickly determine how to fulfill new integration requirements mandated by the Bipartisan Budget Act of 2018.

D-SNPs have become increasingly popular among both MA organizations and dual eligible beneficiaries because of their ability to tailor benefit designs to the needs of this population. Approximately one-quarter of the nation’s 11 million dual eligible beneficiaries are enrolled in one of the 550+ D-SNPs offered throughout the United States as of January 2020.

In this paper, Milliman’s Nick Johnson, Chris Kunkel, and Annie Hallum summarize the new integration requirements and also discuss considerations for stakeholders.

Benefit changes can drive Medicare Advantage enrollment

In a new analysis, Milliman’s Chris Kunkel and Jordan Pettibon found that Medicare Advantage (MA) members’ behavior is related to benefits that appear on detailed plan summaries and that members take into account more than what they initially see when selecting a plan on the Medicare Plan Finder. While the impact of supplemental benefits on enrollment is not as strong as the impact of the primary driver benefits like PCP copay, Medicare Advantage organizations should be aware of the effect of changing benefits when trying to optimize the most visible ones.

What happened in the first year of MIPS reporting?

Starting in 2019, many clinicians performing services for Original Medicare patients will have their payments adjusted based on quality and other metrics from 2017. The Merit-Based Incentive Payment System (MIPS) is a revenue-neutral program that will adjust Part B payments, with a maximum -4% penalty in 2019.

MIPS was passed into law as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). For 2017 dates of service, eligible clinicians (ECs) recorded and submitted measurements across three key areas: quality, improvement activities, and advancing care information (now called promoting interoperability). Based on these areas, ECs received a final score between 0 and 100, which then affects their payment rates for Medicare Part B services in 2019. The program is revenue-neutral, meaning the bonus payments will be adjusted based on the level of penalties.

In this article, Milliman’s Christopher Kunkel and Mike Hamachek provide several interactive charts that enable users to explore some of the results of the 2017 reporting.

Changes to Institutions of Mental Disease in Medicaid under the SUPPORT Act

In October 2018, President Trump signed the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) to address the ongoing opioid epidemic. For state Medicaid programs, one key impact is the availability of substance use disorder (SUD) treatments through Institutions of Mental Disease (IMD) facilities where Medicaid recipients have been historically unable to receive care that qualifies for federal matching funds. The SUPPORT Act provides a simpler way for states to include IMD facilities in their fee-for-service and managed care delivery models—a state plan amendment (SPA).

With the expansion of options under the SUPPORT Act, states will need to consider whether or not their goals for treating SUD patients in IMDs can be achieved under the simpler SPA process with its inherent limitations from the SUPPORT Act or if the more complicated but more flexible waiver process remains their best option.

In this paper, Milliman’s Christopher Kunkel, Catherine Lewis, and Jie Savage explain the changes to IMDs in Medicaid under the SUPPORT Act.

MACRA considerations for Medicare Advantage plans

The Medicare Access and CHIP Reauthorization Act (MACRA) makes significant changes to the Medicare payment system by introducing a quality-based payment model. While MACRA primarily affects Part B clinicians, there are numerous implications that Medicare Advantage (MA) plans should consider. A strategic approach can help MA plans understand and respond to the legislation.

In the article “MACRA and Medicare Advantage plans: Synergies and potential opportunities,” Milliman actuaries explore the answers to the following questions:

• How will MACRA affect MA plans’ provider payments?
• What synergies exist between MACRA’s quality scoring and the MA Stars quality program?
• How can MA plans help providers achieve Qualifying Participant (QP) status?
• What incentives exist under MACRA for providers to improve risk score coding?
• How are MA plans in the market responding to MACRA?

Read Milliman’s “MACRA: The series” to learn how the legislation will affect providers, alternative payment models, and health plans

Qualifying APM participant considerations

This paper by Milliman’s Charlie Mills, Pamela Pelizzari, and Christopher Kunkel explores the challenges and opportunities regarding participation in an Advanced Alternative Payment Model (APM) track under the Medicare Access and CHIP Reauthorization Act (MACRA). The authors also discuss why becoming Qualifying APM Participants (QPs) may be desirable to some providers as well as the risks they might encounter through the process.

Here is an excerpt from the article:

Opportunities associated with QP status

Financial opportunities

Despite the potential downsides to participating in Advanced APMs and seeing QP status, there are also potential financial benefits, including the following:

A lump-sum payment equal to 5% of their prior year’s payments for Part B covered professional services. QPs can become eligible for this lump-sum incentive payment for years 2019 through 2024. Overall, this is the primary financial opportunity for QPs.

Insulation from the potential downside of the MIPS adjustment. In general, MIPS is a budget-neutral (i.e., zero-sum) program, with a financial downside of 4% in 2019, growing to 9% in 2022. Because QPs and Partial QPs are excluded from MIPS, they are not exposed to MIPS’s downside and do not have to navigate the hundreds of quality and performance measures that make up MIPS.

Opportunities for shared savings from the Advanced APM. QPs will have the opportunity to share in gains (and will generally be required to share in losses) from the Advanced APMs they participate in.

Higher conversion factor increases starting in 2026. Starting in payment year 2026, QPs will receive a conversion factor increase of 0.75% compared with 0.25% for non-QPs. Over time, this could result in significantly higher payment rates for QPs versus non-QPs.

Clinical integration benefits

Several of the currently available Advanced APMs aim to align incentives across different types of providers. For example, ACOs encourage physicians and hospitals to work together to ensure beneficiaries receive appropriate care that can keep them healthy and out of hospitals. In many cases, however, individual physicians do not see the financial benefits of these programs without entering into what can be complex and time-consuming gainsharing arrangements. By providing a 5% lump-sum incentive payment to QPs, MACRA serves to create an even greater incentive for physicians to participate actively in Advanced APMs.

While other payer Advanced APMs do not contribute to QP threshold calculations until performance year 2019 (incentive payment year 2021), it’s possible that the increased engagement physicians have in Advanced APMs that is due to MACRA will have trickle-down effects on other lines of business and patient populations beyond Medicare fee-for-service. This could serve to improve the quality of care and reduce costs for patients covered by other payers.