Advanced Plan for Health Logo
 

The Stars Impact of the CY2019 CMS Final Call Letter

Guest blog contributor:

Rex Wallace - Principal, Rex Wallace Consulting, LLC

On April 2nd, The Centers for Medicare and Medicaid Services (CMS) released the Announcement of Calendar Year (CY) 2019 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter. The entire document is a behemoth which includes important information about CY2019 for Medicare Advantage plans across a variety of topics. This paper will focus solely on the impact on Star Ratings.

The release of the Final Call Letter is one of a series of key milestone dates leading up to October 11, 2018, when CMS releases Star Ratings for each Medicare Advantage organization to the public.

The Stars Impact of the CY2019 CMS Final Call Letter
Read More

New Diabetic Guidelines Aim to Improve Diabetic Care but Differ, Causing Confusion

Barbara Rutkowski, EdD, MSN, CCM - Vice President, Clinical Operations, Advanced Plan for Health

All entities managing health plans – self-insured employers, health plans, brokers and more – need to take note of the impact of diabetes on the health of their members and the financial bottom line of their health plans. Particular focus needs to be put on the recent changes to care guidelines for diabetic control as they aim to improve diabetic care – but differ –  which is causing confusion.

New Diabetic Guidelines Aim to Improve Diabetic Care but Differ, Causing Confusion
Read More

The Growing Need for Better Access to Behavioral Health Support

Mental and substance abuse disorders and their downstream impacts are becoming a growing concern for employers – with costs to employers estimated at $225.8 billion each year. Notably, the financial impact goes beyond absenteeism to include presenteeism as well. Presenteeism, or individuals working with untreated illnesses, is estimated to cost employers $1,601 per person each year according to the same Inc. Magazine article.

Many employers are actively looking for better ways to offer their employees support in this area –  as they do for overall wellness and chronic conditions such as diabetes and high blood pressure.

The Growing Need for Better Access to Behavioral Health Support
Read More

Unexpected Unreasonable Claims Costs in Intraoperative Neurologic Monitoring (IONM)

Barbara Rutkowski, EdD, MSN, CCM - Vice President, Clinical Operations, Advanced Plan for Health & Joy McGee-Cory - Senior Vice President, Advanced Plan for Health

Several of our Health Plan clients and their members have experienced unexpected and very unpleasant surprises following certain complex surgical procedures – usually spine-related. So we wanted to get a cautionary word out a bit more broadly on this topic to our clients and others who may be facing similar situations. The surprises are coming in the way of bills for intraoperative neurologic monitoring (IONM).

In one case, the billing technician was not a physician, and the member’s bill for monitoring services was an unreasonable, non-negotiable $120,000.

Unexpected Unreasonable Claims Costs in Intraoperative Neurologic Monitoring (IONM)
Read More

Part 2 - Consumer Guide to High Blood Pressure to Share with Your Population

Barbara Rutkowski, EdD, MSN, CCM - Vice President, Clinical Operations, Advanced Plan for Health  & Joy McGee-Cory - Senior Vice President, Advanced Plan for Health

The team at Advanced Plan for Health (APH) is passionate about improving the health and well-being of as many healthcare consumers as possible, so in honor of Heart Health Month, we created a Consumer Guide to High Blood Pressure for you to use to share details on the risk of hypertension and some preventative measures with your member, employee and patient populations. We encourage you to share any of this information as you find appropriate.

Part 2 - Consumer Guide to High Blood Pressure to Share with Your Population
Read More

Part 1 – The Risks of Hypertension and the New 2017 Hypertension Guidelines

Barbara Rutkowski, EdD, MSN, CCM - Vice President, Clinical Operations, Advanced Plan for Health  & Joy McGee-Cory - Senior Vice President, Advanced Plan for Health

Hypertension (High blood pressure) affects more than 75 million — or nearly one-third of American adults according to the Centers for Communicable Disease (CDC) in Atlanta. About 28 percent of American adults ages 18 and older, or about 59 million people, have pre-hypertension, a condition that raises the chances of having heart disease or stroke or developing chronic kidney disease. Hypertension is often called the “silent killer” because many people do not have symptoms when their blood pressure is elevated.

In addition to the human toll, “high blood pressure costs the nation $46 billion each year” according to the Centers for Disease Control. “This total includes the cost of health care services, medications to treat high blood pressure, and missed days of work.”

Part 1 – The Risks of Hypertension and the New 2017 Hypertension Guidelines
Read More

CAR-T Immunotherapy – the Newest Cancer Warrior Cells

Barbara Rutkowski, EdD, MSN, CCM - Vice President, Clinical Operations, Advanced Plan for Health

CAR-T Immunotherapy is a treatment which optimizes the body’s ability to target, attack and kill tumor cells. On August 30, 2017, the Federal Drug Administration (FDA) approved the Novartis version of CAR-T cell therapy for children and young adults with B-cell acute lymphoblastic leukemia (ALL), which is the most common form of childhood cancer in America. While current chemotherapy, radiation and bone marrow transplants result in remission for about 80 percent of people with ALL, there are still about 20 percent who do not respond to current treatment. These individuals are said to be refractory to treatment. For them, CAR-T is a lifesaving option. However, medical miracles come at a large cost to health plans and Payors. 

CAR-T Immunotherapy – the Newest Cancer Warrior Cells
Read More

Part 3 - The Cost of Dialysis and TPA and Medical Management Best Practices

Joy McGee-Cory - Senior Vice President, Advanced Plan for Health & Barbara Rutkowski, EdD, MSN, CCM - Vice President, Clinical Operations, Advanced Plan for Health

Dialysis is big business.

In fact, according to the National Kidney Foundation®, “the annual Medicare spending to treat kidney failure in the U.S. is approximately $31 billion”.

Unlike the private-sector health plans, Medicare has a “Most Favored Nation” clause which means that providers cannot give a discount on billed charges to health plans or others that is greater than what they give to Medicare.

Part 3 - The Cost of Dialysis and TPA and Medical Management Best Practices
Read More

Part 2 - Preparing for a Kidney Transplant or Dialysis

Joy McGee-Cory - Senior Vice President, Advanced Plan for Health & Barbara Rutkowski, EdD, MSN, CCM - Vice President, Clinical Operations, Advanced Plan for Health

Members who are in chronic kidney disease at Stage 3 or 4 need to be approached about their plan of treatment. At this point the member may be in denial or unable to determine if they would like to be listed for a transplant, but it is not too early to start the process. The member needs to know about the importance of an early transplant listing decision, because it takes eligible individuals 24 months or longer on the transplant list to get a kidney. They can always change their minds and remove themselves from a transplant list, or list with more than one Center of Excellence to improve their chances for receiving a kidney.

This is a multi-part blog series. Part three will cover – The Cost of Dialysis and TPA and Medical Management Practices

Part 2 - Preparing for a Kidney Transplant or Dialysis
Read More

Part 1 - Kidney Failure and Dialysis - What Employers, Health Plans, TPAs and Nurse Care Managers Need to Know

Joy McGee-Cory - Senior Vice President, Advanced Plan for Health & Barbara Rutkowski, EdD, MSN, CCM - Vice President, Clinical Operations, Advanced Plan for Health

Kidney failure and life-saving dialysis are both a catastrophic health plan expense and life-changing experience that impact health plans and lives through probability.  The incidence of chronic kidney / renal disease is about 2 to 2.5 per 1,000 members across the APH customer base. Because lady luck is elusive, lightning can strike twice for the same health plan, resulting in typical annual health plan expenditures between $350,000 and $700,000 for each member on dialysis. According to the National Kidney Foundation, more than 660,000 Americans have end stage renal disease (ESRD), meaning that their kidneys have permanently failed, and dialysis is required to cleanse the toxins from their bodies.   

This is a multi-part blog series. Part two will cover – Preparing for a Kidney Transplant or Dialysis.

Part 1 - Kidney Failure and Dialysis - What Employers, Health Plans, TPAs and Nurse Care Managers Need to Know
Read More