Four medical professionals meet to discuss strategy

With Switching Down, MAOs Seek ‘Untapped’ Market Segments

Reprinted with permission from AIS Health from the Feb. 18, 2021, issue of RADAR on Medicare Advantage

Recent data from the 2021 Medicare Annual Election Period (AEP) reflects the anticipated increase in Medicare Advantage enrollment, which is up 9.8% from a year ago and indicates penetration exceeding 43%, according to industry estimates. But multiple factors are making it harder for MA organizations to attract new members, and while plans are enhancing their benefit offerings to stay competitive, they must do so in a way that aligns with their star ratings and other financial goals.

For our occasional series of interviews that examine pertinent issues through the words of the industry’s leading executives, AIS Health spoke with GHG Vice President John Selby, whose long career in the insurance industry includes 10 years in various roles at Horizon Blue Cross Blue Shield of New Jersey. In his new role at the Convey company formerly known as Gorman Health Group, he is responsible for developing and executing growth strategies for GHG and its clients.

Editor’s Note: The following interview has been edited for length and clarity.

AIS Health: According to the latest Medicare Shopping and Switching Study from Deft Research, switching among MA members during the recent AEP fell 21% from the prior-year period and overall switching was down 18%. Do you think insurers should take this with a grain of salt given the disruptions of 2020 (e.g., COVID-19 pandemic, presidential election) or is this indicative of a larger trend?

John Selby: I don’t think it was a surprise that we saw less switching, but I don’t believe that this was entirely an anomaly created by COVID. There’s been a trend toward stabilization over the last few years, particularly as more plans become 4 star [and] as the plans are becoming more stable, experiencing fewer rollercoaster rides — whether it’s related to premiums or benefits. So I think this is a trend that we’ve been seeing and with the plans that we’re working with, as we’re trying to help them find ways to become even more stable, and really it’s driving retention.

If you look at an area like supplemental benefits and the way many plans have been looking at those and increasing the value of the benefits that they have, that’s just creating more stickiness. I think that is a really good example of an area that could continue to move the needle in this direction going forward. The challenge that comes during AEP is members are more satisfied with the plans that they’re in, and that’s an area where it gets more challenging for folks on the carrier side to try and find new ways to market not just during AEP, which is becoming increasingly expensive. Obviously, the turning 65, new-to-Medicare market is critical, but then what other market segments do you start to parse out outside of or even within AEP that are maybe a little bit more untapped? And those are areas we’re looking at with the plans that we work with to try and develop strategies around that, which would include product and marketing and things like that.

AIS Health: What do you think accounts for the people who did choose to switch plans?

Selby: One would be network: The first question people ask is, is my doctor in the network? The second might be mobility: Folks that are in an HMO are maybe looking to go into a PPO and have a little bit more mobility there. And then the third would be — assuming that there aren’t many major changes in the medical benefits — year-over-year, formulary-driven changes (e.g., drugs that were previously lower tier that moved to higher tier).

The other thing, too, is not to ignore the impact of stars. I personally think stars has all sorts of ramifications, not the least of which is if you are 4 stars, you can invest more in your plan which then makes it more competitive. But if you’re in a non-4-star plan in a market that’s got a proliferation of 4-star plans, just word of mouth alone about what you’re hearing from your neighbors and friends who might be in other plans could be a cause of that. And I do think some of that is directly or indirectly related to stars.

AIS Health: You mentioned supplemental benefits and how those are leading to some of consumers’ stickiness. People may be signing up for certain plans because they are attracted to the supplemental benefits and stick with the plan because they like what they are receiving, but some insurers have expressed concern about being able to sustain these offerings from year to year. Is this something you’re hearing from clients, and what are you advising them?

Selby: What we hear from brokers and agents is how critical supplemental benefits are becoming, and have become, really, so that’s part of the validation. The way I view this is, there are a lot of tenets to what you do around plan design. You’re trying to improve quality, you’re trying to improve the member’s experience, you’re trying to provide relevant services to them; and I think that’s where we see some of the creativity around supplemental benefits. But at the end of the day, if you don’t have the revenue you can’t sustain the benefit offering and so stars and risk adjustment are critical, in my mind, to being able to build a strong revenue base and sustain a strong revenue base.

I used the term before about the rollercoaster — that’s what you have to avoid. If your benefits, and premiums especially, are volatile and are not fairly consistent year over year, members are going to lose trust or faith, brokers are going to lost trust or faith, and it becomes an uphill battle because even if you could come back to a zero-premium plan, for example, for one year or two years doesn’t necessarily mean that people are going to be totally comfortable with that. The supplemental benefits are sort of the biproduct of having a strong infrastructure in place that’s keeping your revenue consistent.

AIS Health: How can plans determine which supplemental benefits will be critical to maintain?

Selby: I’m sure some are going to become table stakes more than others. The way we’re trying to guide plans here is to look at the big picture. There’s certainly a marketing value to offering supplemental benefits, and there’s a perceived value to the benefits, but what we like to try to have a conversation around is how are those benefits adding value? If you go back to not that long ago, especially in a D-SNP [Dual Eligible Special Needs Plan] environment, a transportation benefit was valuable and it was logical. If people can’t get to the doctor, they can’t get care, etc. Now there’s that bigger view of the member [and] the things that they need, so what we are trying to do is to solve the bigger problem. Can you address not just the members’ needs and the members’ satisfaction but also look at things from a quality standpoint and a clinical standpoint? And if you can, that’s going to pay off in [the star ratings]. And so that’s where we see things going. Whether the pace of new benefits will continue, I tend to think that’s going to plateau at some point in the not-too-distant future. I think the plans that can figure out how to connect the dots between these things and solve more than one problem through their benefit designs, through supplemental benefits…are the plans that are going to have a more solid foundation and something stronger to build upon going forward, so that’s the conversation we’re having with our clients.

Contact Selby via Alyssa Barone at abarone@paretointel.com.

By Lauren Flynn Kelly


Helping Smaller Providers Assess Their Ability to Take on Risk

We often note that when a team works well together, it can collectively accomplish more than its members alone. Your network providers, especially the individual and small groups, have been inundated with information from all directions on how to prepare for a shift to value-based payment models. This shift can seem overwhelming to a small practice without the resources to effectively manage the changes needed to be successful under a new model. 

Here are some things to consider when talking to providers about their ability to take on risk and navigate the new reimbursement model.

A significant portion of the information that providers receive on where they rank compared to their peers on quality metrics comes from benchmarks established by the health plans with whom they are contracted. It is also understood that providers have been wary of the data they have received. For providers, working together to provide real-time and transparent data has been at the top of the wishlist when building trust and long-term partnerships. It is also one of the first items plans and providers can work on together.

In turn, the verbiage of “taking on risk” can have a multitude of meanings for a provider. Working together to determine a collective definition and true ability for a practice to manage upside/downside or full risk is also an area in which plans can support their smaller provider groups.  

As health plans, we have focused on designing incentive plans or risk-sharing arrangements to promote compliance with regulatory requirements, stars, or risk adjustment goals. However, we may not have fully attended to what our providers, especially our smaller providers, have the ability to handle. Our larger system partners have the edge, but with so many providers fighting to stay independent, it is worth taking the time to support their needs as well.

To remain provider-centric, it is imperative that we understand where our smaller providers are – not only in their ability to take on risk and make the shift from fee-for-service to value-based reimbursement – but also in their overall infrastructure. 

During various projects, we have shadowed highly skilled provider relations representatives as they travel in the field to meet with office managers and providers. We have often found plans to have incorrect office addresses and practices to have a lack of staffing – making it difficult for the office to have time to digest the information we are sending, or for the data to get into the hands of the correct person and find a way to effectively integrate via technology to ensure a more effective means of communication for our smaller partners. 

Another observation to note is that while your representative is there with the best of intentions to review provider data and offer suggestions on how to improve and capture bonus dollars left on the table, they are one of many reps sitting in the office vying for a minute to talk with the office staff. It is a juggling act for the provider to be able to provide top-notch clinical care for his or her patients while also meeting the demands of a new value-based world.

In order to ensure your largest asset is prepared, why not empower your network with a checklist on how to evaluate their practices? We have provided a 15-point checklist that providers can utilize to examine the skills, knowledge, systems, and questions they should ask themselves when evaluating their ability to navigate the new reimbursement landscape. Once providers feel more empowered, blending a true engagement architecture can begin.

Checklist: Key Questions for Providers to Discuss Prior to Entering a Risk-Based Contract

  1. What is our experience in accepting risk? 
    • If there is a history of accepting risk, how has it worked out? 
    • What were the challenges? 
  2. How do we define Risk? 
    • Upside only
    • Upside/Downside
    • FFS plus performance-based bonus (P4P)
    • Capitation
    • Episode of care payments (bundled payments)
    • Percentage of premium
    • Full risk
    • Other
  3. What is our income/loss distributions formula?
  4. Will we share risk equally?
  5. What will the total investment for the organization, both in monetary and human resources, be to transition to value-based reimbursement?
  6. Do we have the patient volume, per payer, to make the investment worthwhile? And are we sure our patient attribution is correct? 
  7. Does this shift fit with our overall strategic plan? 
  8. Have we done the predictive modeling needed and how accurate are our projected savings? 
  9. Do we have the data capture, aggregation, analysis, and reporting tools to monitor clinical utilization and medical spend? 
  10. Do the savings include the total cost, i.e. training, new software, maintenance, potential changes in liability insurance? 
  11. How will the shared savings be distributed among the providers and what will we reinvest in infrastructure? 
  12. Do we have the ability and time to evaluate our patterns of care, hospitalizations, readmits and high cost expenditures to determine where we can reduce waste? If not, can we outsource? 
  13. Do we have a physician champion, leadership, and governance to implement and drive the process? 
  14. Are their stakeholders outside of the organization that are critical to the success and if so, do we have a strong alliance or partnership in place? This would include all providers across care settings that would affect your episode of care and thus the reimbursement. 
  15. If taking downside risk, what is the best way to prepare the organization if any money is owed? For example: reinsurance, funds in escrow, line of credit.

GHG is poised to assist your plan in developing a fully engaged provider engagement architecture to ensure the cross-functional needs of all your department “asks” come to the provider at the right time for shared success.

For additional questions and inquiries about how GHG can support your needs, please contact me at emartin@ghgadvisors.com


Network Development Season is Upon Us

At this time of year, we would normally be sunsetting summer, sending the kids off to school, and stepping into the splendor of fall. As we move through the seasons of 2020, we have an odd mix of sharing our kitchen table 'office space' and navigating a new normal with our families and co-workers.

At the same time, CMS' new network adequacy requirements merit taking a look at where new Medicare Advantage (MA) plans have the opportunity to plant or where existing plans have the chance for a service area expansion (SAE) that may have been unattainable in previous years. 

In previous years, network changes placed many MA plans in flux and exposed serious issues ranging from policy to process and staffing to technology. With that in mind, it’s crucial that we look at the changes with a clear lens -- and with ample lead time -- as we enter the contracting period for network expansion and Health Service Delivery (HSD) submission for 2020/2021 and Plan Year 2022.

As with years past, plans previously submitted their HSD tables with their applications, and, by the end of April, there was clear insight into which counties the Centers for Medicare & Medicaid Services (CMS) deemed to have an adequate network, and product teams were able to quickly move forward with the product development process. With the timeline changes, however, bids are submitted prior to HSD tables being uploaded and reviewed by CMS. 

Plans must implement their own internal deadlines on the contracting process and decide whether to file a county that is on the edge of meeting network adequacy. The extra time and latitude offered by CMS in the network submission process resulted in additional contracting time. However, it also exposed the increasing importance for strong network management, blending network and product strategy, and setting firm internal timelines for network expansion. 

For example, we saw plans suppressed from Plan Finder during the Annual Enrollment Period (AEP) due to unresolved network deficiencies. The resulting loss of anticipated membership budgeted via AEP became a last-minute challenge for sales and marketing as well as a reset on the plan budget process. As plans prepare to submit their Notice of Intent to Apply in November, the Network Management Team needs to be at the table and be able to share with the C-suite how the new flexibilities in network adequacy standards afford the opportunity to expand into areas previously out of reach. 

As MA plans gain greater flexibility to design and offer new types of benefits to service their members, there becomes a critical juncture to blend our network and product strategy. When MA plans formulate their sales and marketing strategy to determine the impact that a variety of benefits could have based on addressing the particular social determinates of health that most impact their geographic area and member population, we begin to see a vast gap in the playing field from plans staying close to the basics with meals and non-emergent transport to plans on more risk and the willingness to invest in innovative benefit options without knowing the exact return on investment the benefit will have on patient outcomes or financial upside/downside cost. 

With the changes, we may see an upswing in partnerships with post-acute providers, such as, transitional assisted living and skilled nursing facilities and vendors offering adaptive aids to keep patients in their homes longer, meal or grocery delivery services, as well as an expansion on transportation services.

From a Provider Network perspective, the move forward with new partnerships will likely present a few stumbling blocks along the way, such as how to code and pay for services, and require a ramp-up period we do not see with traditional MA providers. We encourage you to start the planning process early and break down the silos by having group discussions to include Sales & Marketing, Medical Management, Star Ratings, Operations, Credentialing and Provider Network departments. The new providers are likely going to be dipping their toes in the same deep end of the pool, and extra lead time and planning will serve you well across the board.

Moving forward, as you internalize the contracting timeline to include standard MA providers as well as new non-traditional supplemental benefit providers, there can never be too much communication and oversight in managing provider network contracting and credentialing data – especially when using outside sources to assist in contracting or credentialing verification organization (CVO) to manage the initial credentialing process. Ultimately, the plan is held accountable for the compliance of contracting and credentialing its provider networks. Plans submitting initial and SAE applications should work back from the mid-June submission date and develop an actionable deadline(s) to ensure the network submitted meets CMS network adequacy requirements. 

Step one in any timeline is being prepared with a solid network strategy. In today’s marketplace, it is no longer acceptable to meet the bare minimum of network requirements. A network must be robust and marketable. Consumers – and CMS – are demanding plans offer choices that include quality and cost efficiency as well as supplemental benefits. With consumer-savvy, newly aged-in Medicare beneficiaries, there is also a shift in patient expectations and the services available for their dollar. The new beneficiary is aging into a world of patient engagement and incentive and reward programs and will expect the same level of service. Plans need to find ways to evaluate their existing provider networks and newly expanded networks to meet these clinical and financial goals. 

Where Do We Go from Here?

As you start your initial or expansion planning process and set new network monitoring processes in place to ensure preparedness, consider this: Gorman Health Group has a long history of providing the following:

  • Leveraging long-standing relationships and nationwide experience coupled with a cost-effective team of Senior Consultants, Network Analysts, and a Call Center to stand up a contracted provider network effectively and efficiently.
  • Designing and developing a network strategy and product strategy that consider the quality, financial, risk adjustment, and Star Ratings goals for success within the competitive landscape of your market(s).
  • Developing the oversight and monitoring P&Ps needed to address the new network and directory requirements.
  • Developing a network to support a competitive supplemental benefit program.
  • Preparing plans’ HSD tables for a CMS filing as well as preparing network exceptions to include all the required elements.

Let us know how we can work together now to support your plan’s goals for the upcoming submission and plan year. Contact us today to start the conversation.


CMS Network Adequacy Changes & the Impact to Medicare Advantage Plans

The Centers for Medicare and Medicaid Services (CMS) has afforded Medicare Advantage (MA) plans flexibility in terms of meeting provider network adequacy. These changes lower the percentage of beneficiaries needed to meet adequacy in CEAC, Rural and Micro counties, offer credit towards states with Certificate of Need (CON) laws, and provide the ability for plans to achieve adequacy by expanding telehealth in twelve specialties. The updated adequacy changes will open doors for plans to provide services in counties that would have otherwise proven difficult to meet the network adequacy standards.

As we begin a series of discussions over the next few months, Gorman Health Group (GHG) will explore the impact that the lessening adequacy changes will have on MA plan strategy (including product and benefit design strategy), provide a review of the new requirements, offer an exclusive opportunity to have GHG review your network to determine how the changes could affect your MA footprint, and finally, circle back to a deeper dive into telehealth and how the changes impact a plan’s network operations, clinical operations, and the impact to risk adjustment and Stars. Today, we start with the importance of aligning your network and product strategy.

Network Development & Product Strategy Alignment

As more health systems and provider organizations successfully manage the shift from volume-based patient care to value-based population health management, health plan strategic planning should blend network strategy with product strategy as a key factor in the ability to achieve clinical and financial goals. The majority of providers are savvy at managing pay-for-performance and upside risk arrangements, and as providers have seen margins narrow and plateau, they are more willing to step out into more advanced risk-sharing deals. Plans have had to adapt and move beyond simply incentivizing for behavior change. Systems that have ventured into managing downside risk and percent of premium arrangements with measured success have an appetite for more.

Certainly, moving up the food chain from a provider to a payer has been a topic of conversation among Chief Executive Officers of large integrated delivery systems. They have worked hard to align referral networks and build physician trust, develop relationships with diverse community support organizations, forge strong brand recognition in their local communities, and negotiate contracts with health plans that have met and exceeded care and cost containment goals.

Historically, health plans have based a large majority of decisions regarding expansion areas on the financial feasibility of the markets. Understanding the desire and direction of health systems in general, coupled with the alliances plans have worked hard to develop in their current markets, has encouraged the trend of including a network assessment as part of the new market feasibility. Many factors can play a significant part in determining a new or expansion market as well as its success or failure:

  • Local players and their appetite for risk
  • Hospital alliances formed
  • Accountable Care Organizations (ACOs) in the market
  • Local demographics such as city and road expansions
  • Development of retirement communities and the effect they have on patterns of care and plan expansion
  • Modeling the potential partners against the updated CMS network adequacy standards

As we have met and strategized with provider systems from their baby steps into pay-for-performance incentives to negotiating their first risk deal, there has been, and still is, a strong reliance on health plans to set clinical pathways and benchmarks. From the provider perspective, the reporting, transparency, and willingness to share in the financial successes with the plan partners are key considerations when deciding with whom to collaborate.

Systems are starting to explore the administrative support organizations available and realizing stepping out to become their own health plan doesn’t seem as scary as it may have been five years ago. From the plan perspective, the need to partner with providers and health systems with a depth of understanding in risk adjustment, Stars, the clinical skill set, and non-clinical support services to truly provide a holistic approach to patient care has never been more critical to success. The directive of new network adequacy requirements and more telehealth options will allow room for plans to become even more innovative with their benefits. Thus, the ability to blend network strategy and product strategy will likely be evident of how successful plans are.

Conclusion

As we delve further into the adequacy changes and the potential impacts, GHG product and network strategy subject matter experts stand ready to assist you in developing a customized strategy to place your MA plan in front of the curve. Contact us to learn more.


6 Tactics for Better Agent/Broker Management During COVID-19

On May 29, 2020, the Centers for Medicare and Medicaid Services (CMS) released the Contract Year 2021 Agent and Broker Compensation Rate, Referral/Finder’s Fees, Submissions, and Training and Testing Requirements. While the compensation rate increases are a welcome update for agents/brokers, it is important to explore these changes in the context of COVID-19 and how the standard Medicare selling practices will not be sufficient for the 2021 Annual Enrollment Period (AEP). 

How can Agents/Brokers Navigate Medicare Sales During COVID-19?

Here are 6 tactics organizations and sales teams should consider to adjust strategies for COVID-19.

  1. Know and follow your state and local government requirements around stay-at-home orders and mask wearing. As healthcare leaders, organizations have the unique opportunity to position themselves as the go-to resource on the latest state and local mandates for the community, beneficiaries, and sales teams (internal and external). Partnerships with key network provider groups can emphasize this position.
  1. Invest in systems that allow for virtual meetings; conduct appropriate training and education well in advance of the start of AEP. Training and education don’t stop with sales teams. Organizations should make sure that beneficiaries understand the intricacies of a virtual sales meeting and provide support throughout the entire process to keep technology frustrations at bay. In addition, organizations must remember to establish compliant expectations for recorded virtual meetings and submission and/or record retention as needed for sales oversight programs to remain effective.
  1. Modify seminar strategies to limit participation and allow for safe social distancing. Does your organization and/or sales team rely on vigorous seminar strategies? GHG recommends evaluating seminar locations now to understand if the space will allow for a minimum 6 feet of distance between attendees. Providing this assurance demonstrates that beneficiary protection is top of mind. Organizations may also want to schedule multiple seminar sessions throughout the day to allow for the potential need to cap attendees per seminar because of limited space.
  1. Be prepared to move seminars to a virtual setting. The threat of a COVID-19 second wave in the fall is real and may lead to another round of economic shutdowns. If your “plan A” includes group seminars, make sure your “plan B” can move these seminars to a virtual setting.
  1. Arm field sales representatives and agents/brokers with face masks and hand sanitizer to distribute at one-on-one meetings and seminars. Bonus if the face masks and hand sanitizers include your branding or logo.
  1. Agents/brokers should be staying in contact with their clients. Organizations should provide tools to their sales force for discussing COVID-19, such as a COVID-19 Quick Reference Guide. Resources like this help to position the agent/broker, and ultimately your organization, as their trusted resource and support system in not only navigating Medicare but also the pandemic as well.

What This Means for Health Plans

The commissions may be higher this year, but the work is anything but “business as usual.” Both organizations and agents/brokers alike need to adjust their strategies to ensure an effective and safe AEP season. If you don’t have a game plan for adjusting to the new normal this AEP, now is the time to develop your Plan A, B, and C.

If you have any questions about the information above, or need assistance transitioning to a digital-first AEP sales strategy, GHG can help. Contact us today to get in touch with an expert.


Strategies to Support Value-Based Reimbursement During Uncertain Times

As we are all experiencing a new normal in our personal and professional lives during the COVID-19 pandemic, the ability to keep up with the ever-changing clinical and regulatory environment in healthcare has made even the most seasoned healthcare executive feel as if they were swimming against the current.

Providers and Accountable Care Organizations (ACOs) engaged in risk-bearing contracts with CMS and other private payers have rightly expressed significant concern over the ability to accurately predict and have an impact on potential shared savings and losses. A recent National Association of ACOs (NAACOS) survey indicated over 56% of ACOs would consider exiting the program if CMS did not offer amenable solutions to protect against downside losses.

What Can Risk-Bearing Providers and ACOs Do?

As we saw last week, CMS is adjusting the financial methodology, in order to support keeping ACOs in the program. The ability to pivot and deploy resources to manage membership, as well as be proactive and adaptable in your overall strategic plan, is critical for any ACO or provider group taking risk. A key to supporting value-based financial goals is quickly activating strategies to engage members and continue to drive and deliver on clinical goals.

Providers and ACOs should consider:

  • Developing member registries or lists to assist in prioritizing outreach to members according to need. Work with health plan partners to tag team on those members falling into a coronavirus high-risk category, engage members with chronic care needs to ensure monitoring for potential crisis indicators, or in areas that are not as hard hit by the virus, target members for proactive preventative health screenings that can be done via remote patient monitoring.
  • Utilize non-traditional personnel to support outreach strategies. We understand it has been difficult to keep staffing levels at full capacity. Engage underutilized staff to support outreach efforts by developing simple decision trees they can follow with an escalation plan should they come upon a member needing urgent clinical support.
  • CMS has offered latitude in its guidance around telehealth. If your office has not yet offered telehealth services to members, this might prove to be the perfect opportunity to explore how telehealth solutions and remote patient monitoring could enhance your practice in the transition from volume to value. More people are looking beyond the standard urgent care visit to have greater flexibility in receiving care, especially follow up visits, remotely.
  • As you and your team work through the member registries, it affords the perfect opportunity to look at patients through a social determinants of health (SDOH) lens and develop strategies for areas such as medication access and food security, which are putting them at risk for failing to execute on a care plan. When you are at risk for the total cost of care of your patient panel, enabling the member to be as successful as possible by including community services in their plan of care can be a critical element of improving health.
  • The pandemic has opened conversations on mental health issues to a broader audience. Identifying and addressing potential mental health issues as part of the outreach process is an important proactive measure for the overall health of your patients.

Conclusion

GHG has the depth of experience from working with numerous health plans and providers to assist you in focusing on and developing strategies, such as those discussed above, that will keep your practice or ACO ahead of the fast-paced regulatory landscape. It is critical to be adaptable to challenges with patient care, as well as on the lookout for potential financial opportunities, such as risk adjustment and payor contract analysis, to assist in mitigating losses.

Please reach out to Ellie Martin to further discuss how our team can support your ACO or practice during this complex and challenging time.


It’s Time to Prepare for Medicare Advantage Provider Network Submissions

Network management, directory accuracy, initial applications, service area expansions (SAEs), and the new triennial review process have exposed many Medicare Advantage (MA) plans to serious issues—from policy to process and staffing to technology. As we move into the countdown for network development, expansion, and Health Service Delivery (HSD) submission for 2020, as well as plan years 2021 and 2022, it is imperative for network strategy planning to start now in order to avoid the pitfalls plans have faced with the new regulatory guidance.

In previous years, plans submitted HSD tables along with applications. By the end of April, there was clear insight into which counties the Centers for Medicare & Medicaid Services (CMS) deemed to have an adequate network, allowing product teams to quickly move forward with the product development process.

With the timeline changes, bids are submitted prior to HSD tables being uploaded and reviewed by CMS. This requires plans to implement internal deadlines for the contracting process and decide whether to file a county on the edge of meeting network adequacy. The extra time and latitude offered by CMS in the network submission process resulted in additional contracting time; however, at the same time, this has exposed the increasing importance for strong network management that blends network and product strategy, as well as firm internal timelines for network expansion.

For example, last year, we saw plans suppressed from Plan Finder during the Annual Enrollment Period (AEP) due to unresolved network deficiencies. The resulting loss of anticipated membership that was budgeted for AEP became a last-minute challenge for sales and marketing, and a reset on the plan budget process. 

Additionally, as MA plans gain greater flexibility in designing and offering new types of benefits to members, blending network and product strategies becomes critical. When evaluating the impact a variety of supplemental benefits could have on sales and marketing strategy, especially when addressing the social determinates of health (SDOH) that most impact your geographic area and member population, we begin to see a vast gap in the playing field—from plans sticking to the basics with meals and non-emergent transport to plans willing to invest in innovative benefit options without knowing the exact return on investment a benefit will have on patient outcomes or financial upside/downside cost.

With these changes and supplemental benefits flexibility, we may see an upswing in strategic partnerships to improve member experience, including:

  • Post-acute providers, such as transitional assisted living and skilled nursing facilities
  • Vendors offering adaptive aids to keep patients at home longer
  • Meal or grocery delivery services
  • Resources to expand transportation services

From a provider network perspective, the move toward new partnerships will likely present a few stumbling blocks, such as how to code and pay for services, and require a ramp-up period we do not see with traditional MA providers. We encourage plans to start early and break down silos by having group discussions that include Sales & Marketing, Medical Management, Star Ratings, Operations, Credentialing and Provider Network departments to design a holistic strategy. These new, non-traditional providers will likely be dipping toes in the same deep end of the pool; extra lead time and planning will serve you well across the board.

For non-traditional providers, we would encourage all MA plans to have:

  • Planned education sessions/town hall meetings to educate new vendors/providers and better understand their needs
  • A plan for a lengthier contracting and credentialing process
  • A plan for additional onboarding and training with the new vendors
  • Additional member education time

Moving forward, as you internalize the new contracting timeline to include standard MA providers as well as any new, non-traditional supplemental benefit providers, communication and oversight will be key. This is especially important when managing provider network contracting and credentialing data, particularly when using outside sources to assist in contracting or a credentialing verification organization (CVO) to manage the initial credentialing process. Ultimately, the plan is responsible and held accountable for the compliance of the contracting and credentialing of its provider networks. Plans submitting initial and SAE applications should work backwards from the mid-June submission date and develop an actionable deadline(s) to ensure the network submitted meets CMS network adequacy requirements. 

What Should Medicare Advantage Plans Do?

Step one in any timeline is preparing a solid network strategy. In today’s marketplace, it is no longer acceptable to meet the bare minimum of network requirements. Consumers (and CMS) are demanding plan choices that include quality and cost efficiency as well as supplemental benefits.

Even further, with consumer-savvy, newly aged-in Medicare beneficiaries, there is a shift in patient expectations of the services available for their dollar. The new beneficiary is aging into a world of patient engagement and incentive/reward programs but will expect the same level of service. Plans need to find ways to evaluate existing provider networks and newly expanded networks to meet clinical and financial goals.


As you start your initial or expansion planning process and set new network monitoring processes in place to ensure preparedness, we’re here to help. Gorman Health Group has a long history of:

  • Leveraging long-standing relationships and nationwide experience coupled with a cost-effective team of senior consultants and network analysts to effectively and efficiently stand up a contracted provider network
  • Designing and developing network and product strategies that take into account the quality, financial, risk adjustment, and Star Ratings goals critical to success within the competitive landscape of your market(s)
  • Developing the oversight and monitoring P&Ps needed to address the new network and directory requirements
  • Developing a network to support a competitive supplemental benefit program
  • Preparing plans’ HSD tables for a CMS filing or bid submission as well as preparing network exceptions to include all the required elements

Let us know how we can work together now to support your plan’s goals for the upcoming submission and plan year. Contact Elena Martin at emartin@ghgadvisors.com.


Blending Network Strategy & Product Strategy

As more and more health systems and provider organizations successfully manage the shift from volume-based patient care to value-based population health management, health plan strategic planning should be blending network strategy with product strategy as a key factor in the ability to achieve clinical and financial goals. The majority of providers are savvy at managing pay-for-performance and upside risk arrangements and, as providers have seen their margins narrow and plateau, they are more willing to step out into more advanced risk-sharing deals, plans have had to adapt and move beyond simple incentivizing for behavior change. Systems that have ventured into managing downside risk and percent of premium arrangements and have been successful have an appetite for more. Certainly, moving up the food chain from a provider to a payer has been a topic of conversation among Chief Executive Officers of large integrated delivery systems. They have worked hard to align referral networks and build physician trust, develop relationships with diverse community support organizations, forge a strong brand recognition in their local communities, and negotiate contracts with health plans that have met and exceeded care and cost containment goals.

Historically, health plans have based a large majority of their decisions regarding expansion areas on the financial feasibility of the markets. Understanding the desire and direction of health systems in general coupled with the alliances plans have worked hard to develop in their current markets, the trend has been to include a network assessment as part of the new market feasibility. Knowing the local players, their appetite for risk, hospital alliances, the Accountable Care Organizations (ACOs) in the market, along with modeling the potential partners against Centers for Medicare & Medicaid Services (CMS) network adequacy standards, can play a significant part in the success or failure in any expansion market.

As we have met and strategized with
provider systems from their baby steps into pay-for-performance incentives to
negotiating their first risk deal, there has been, and still is, a strong
reliance on health plans to set clinical pathways and benchmarks. From the
provider perspective, the reporting, transparency and willingness to share in
the financial successes with the plan partners, is a key consideration in who
to collaborate with.  Systems are starting
to explore the administrative support organizations available and realize stepping
out to become their own health plan doesn’t seem as scary as it may have five
years ago. From the plan perspective, the need to partner with providers and
health systems with a depth of understanding in risk adjustment and Stars along
with the clinical skill set, and often non-clinical support services, to truly
provide a holistic approach to patient care has never been more critical to
success.  The directive for potential new
network adequacy requirements and more tele-health options will allow room for
plans to become even more innovative with their benefits. The ability to blend
network strategy and product strategy will likely be evident of how successful plans
are.

For plans and providers, knowing
your local healthcare market, who the key stakeholders are, and keeping open
communication will be paramount to the development of a strategy that puts you
ahead of your competition.


Set Your Plan Apart with an OTC Benefit

Two
of the buzz phrases most frequently heard in the health care community now are
“value-based care” and “social determinants of health” (SDOH). Health plan
leaders must leverage both to compete.

SDOH
are particularly important in Medicare and dual-eligible populations, and
Medicare Advantage and Part D plans are uniquely positioned to address SDOH
through provider and patient incentives and value-based insurance design
(VBID).

Meanwhile, federal policy has historically discouraged VBID in Medicare, but CMS is taking its foot off the brake. CMS launched a five-year VBID demonstration project in 2017, and in 2018 it further eased restrictions on MA plans that want to offer supplemental benefits in 2019. However, payers may be hesitant or unsure on how to make use of the new provisions.

How an OTC Benefit Adds Value

One way for MA plans to differentiate themselves in an increasingly competitive market and address both VBID and SDOH is by offering an over-the-counter benefit.

Without an OTC benefit, VBID may fail to realize its full cost savings potential. A recent study found that while VBID increased drug adherence and reduced spending on other services, the net savings was minimal because drug spending rose. An OTC benefit in a value-based plan could bring down those drug costs.

OTC
medicines help bridge treatment gaps, are convenient and reduce unnecessary use
of health care services, according to the Consumer
Healthcare Products Association Clinical/Medical Committee. Millions of
Americans use and trust OTC products, and health plans that don’t cover them
give subscribers an incentive to choose more-expensive prescription products or
to simply go without.

Plans that do offer OTC products can see a significant difference in the lives and health of their members. For example, if people with diabetes can prevent foot ulceration and, ultimately, amputation by wearing padded or compression socks, coverage of socks not only encourages their use but could prevent expensive, physically taxing wound care and surgery.

These socks are relatively inexpensive but people on fixed incomes, in particular dual-eligibles, may be unable to afford them. Coverage through an OTC benefit indirectly addresses an SDOH – income – and frees funds to pay for shelter, food and transportation.

So how can a plan add OTC coverage? With a reliable, experienced partner that offers an integrated benefit and first-class customer support.

Essentials for an OTC
Benefit Partner

An effective OTC benefit partner:

  • manages product selection, including purchasing and distribution
  • negotiates with vendors and leverages the power of bulk purchasing for the best prices
  • maintains a comprehensive call center focused on a positive member experience
  • accepts eligibility files in all types and formats and processes them frequently
  • generates internal audits, financial reports and CMS-required reports accurately and promptly

Added
features like at-home delivery and catalog distribution both in print and
online further enhance customer satisfaction and address SDOH for members
residing in rural areas or lacking access to transportation. Mail service also
benefits the health plan by enabling the inclusion of educational inserts in
OTC product shipments.

The OTC product catalog should be tailored to the health plan’s goals and should comply with the regulatory aspects of OTC coverage. All technology used for OTC benefit administration must comply with HIPAA and the latest HITRUST security framework for robust cybersecurity and privacy protections.

A good OTC benefit partner will also be mindful of pain points for members. For example, various vendors offer prepaid cards for OTC products, but not every OTC product is eligible for coverage under CMS rules. Simply offering a prepaid card makes for frustrated customers who don’t find out until they are at the pharmacy checkout line that the supplies in their shopping cart aren’t covered.

OTC: A Bonus for Health
Plans and their Members

OTC benefits offer payers a way to quickly add value, improve the SDOH and improve member satisfaction. A fully functional OTC program can be complicated, but picking the right partner who can deliver with minimal effort, full CMS compliance, and robust cybersecurity and privacy protections reduces administrative burdens while providing a significant benefit to the plan members.

Convey Health Solutions focuses on building specific technologies and services that can uniquely meet the needs of government-sponsored health plans. Convey provides member management solutions for the rapidly changing health care world. To learn more about how Convey is the right OTC benefit partner for your health plan, please visit our Miramar:OTC page.

First seen on SmartBrief.


Resources:

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe

Learn how a single platform designed specifically for Medicare can streamline enrollment and offer a better way to deliver a return on your plan’s investment. Click here

Gorman Health Group is part of the Convey family of companies, which includes Convey Health Solutions, HealthScape Advisors and Pareto Intelligence. Together, we collectively support healthcare organizations with elite consulting services and industry leading technology solutions. Learn more


Better Billing, Better Consumer Experience

The Medicare
Advantage market is heating up – a trend that’s expected to continue, according
to a new Kaiser Family Foundation report. In 2019, there will be 417 more MA plans than
this year. Fourteen new carriers will offer plans in 26 states, with only five
carriers exiting the market.

As market
competition in MA becomes fiercer, it is increasingly important for payers to
stand out with a better consumer experience. One way to do that is with an
integrated billing platform that can streamline the process for both payer and
consumer.

Pain Points for Payers

Health plans face
a variety of pain points with their MA billing platforms, and they are still
struggling to get it right. Many platforms were designed for other markets with
substantially different customers and compliance concerns, and retrofitted to
Medicare. Instead of being integrated systems that take applicable rules and
regulations into account, they are disjointed and make for an error-prone
consumer experience. The result can be unhappy customers, frustrated customer
service representatives and lost business.

One significant
challenge for payers is tracking members’ eligibility and subsidies. A member
may qualify for certain subsidies today but not tomorrow, and government
regulations can make tracking these changes a complicated process for payers.

Keeping abreast of
regulatory and coverage changes can be a challenge as well. CMS’
recent move to increase coverage of
supplemental benefits is just
the latest example of the kinds of shifts plans must integrate into their
billing platforms.

Finally, Medicare
Advantage plans need to provide a smooth, easy-to-understand consumer
experience at every step of the process to
achieve high star ratings
. Star ratings
assess a plan’s quality in various
areas
, including member
experience

and customer service, such as its handling of member calls and questions. For
plans that cover prescription drugs in addition to health services, the rating
also covers billing information submitted to Medicare. Data
from Navigant
indicate a 1-star improvement correlates to an 8% to
12% enrollment increase, which means good billing management and good customer
service around billing can be important factors in payers’ future revenue.

Benefits of a Medicare-specific platform

These challenges and
pain points are best addressed by a Medicare-specific billing platform. A
seamless, personalized process that is integrated with enrollment can streamline
payer operations while improving the consumer experience.

This is especially
important now as expectations
around customer service
are rising. McKinsey has found that more
than half of consumers see great
customer service
as important for healthcare companies, and they
expect these companies to make tasks easier and meet expectations while providing
a high-value service.

Good
digital tools

can help plans meet those goals and are quickly becoming a standard consumer
expectation. According to McKinsey research, an “overwhelming majority” of consumers
want digital tools to be available along the entire healthcare process. And Deloitte data show that by 2015, one in three medical care
users had already paid
a medical bill online
, and more than twice that number expressed
interest in doing so.

Billing
modules that offer self-service tools can further streamline the experience for
members. A configurable, integrated billing module allows for personalized
messages, alerts, reminders and calls to action, improving engagement and plan
utilization. It also provides a single record source for member management and
reporting, with financial considerations related to SSA, RRB, SPAP, LIS, LEP
and Good Cause automatically coordinated.

Another major benefit of MA-specific platforms
is multi-state integration. No matter where the member is, the platform will
track low-income subsidies, state pharmaceutical assistance programs and
late-enrollment penalties. This allows for real-time premium adjustments based on
retroactive coverage effective dates. Member premiums for basic and
supplemental coverage are consolidated with these subsidies and penalties.

That information is then programmed into the
payer’s system and is available instantly. This helps customer service
representatives provide more informed answers to members and reduce call times.

Compliance
is another important consideration for plans, and MA-specific platforms help
payers adhere to CMS guidelines, further boosting star ratings and HEDIS
scores. This is key after payment is received, as reconciliation can be
complicated for payers if members do not pay the full balance due. Partial and
arrears payments must be allocated according to both CMS and payer rules. An
automated, configurable billing engine performs this task quickly and
accurately.

The right billing system

MA enrollment is
expected to hit
an all-time high of 22.6 million next year and the
market is already extremely competitive. Seniors who encounter a sub-optimal billing
experience with one carrier have plenty of other choices.

Plans can position
themselves as the right choice with an MA-specific billing system that improves
the consumer experience while driving widespread operational improvement.

Convey Health Solutions focuses on building specific technologies and services that can uniquely meet the needs of government-sponsored health plans.  Convey provides member management solutions for the rapidly changing health care world. To learn more about how the right Medicare billing system can benefit your health plan, please navigate to the Miramar:Bill webpage for more information.


Resources:

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe

Learn how a single platform designed specifically for Medicare can streamline enrollment and offer a better way to deliver a return on your plan’s investment. Click here