Blending Network Strategy and Product Strategy

As more and more health systems and provider organizations successfully manage the shift from patient care to population health management, long-term health plan strategic planning should be blending network strategy with product strategy as a key indicator of 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 the margins narrow and plateau, plans have had to adapt and move beyond simple incentivizing for behavior change. We heard from the Centers for Medicare & Medicaid Services (CMS) the Accountable Care Organizations (ACOs) with upside-only risk have not performed as well or increased savings in comparison to those ACOs with downside risk and skin in the game. Systems that have ventured into managing downside risk and percent of premium arrangements and that 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 CEO’s of large integrated delivery systems. They have worked hard to align physician trust and referral networks, build a strong name brand in their local communities, and negotiated contracts with health plans that have met and exceeded care and cost containment goals, and the question of where do we go from here is top of mind.

As we have met and strategized with provider systems from baby steps to pay for performance to negotiating their first risk deal, there has been and still is, in some cases, a strong reliance on health plans to set clinical pathways and benchmarks. From the provider perspective, the reporting and transparency with the plan partners has been a key consideration in whom to collaborate with and how they have set internal benchmarks. However, systems are starting to realize and explore the administrative support organizations available and stepping out on their own to become a Provider-Sponsored Organization (PSO), which doesn’t seem as scary as it may have five years ago. Still, in meeting with providers, the biggest misconceptions have been what does it mean to be and how do the requirements differ from a PSO versus a Provider-Specific Plan (PSP-Narrow Network), do we meet the requirements, and what is the best option for us?

The answers to those questions spark the first steps when we begin to traverse the local healthcare landscape and blend the network and product offerings. Diane Hollie, our Senior Director of Sales, Marketing and Strategy states “Brand is very important when blending two organizations.  Will members be buying the Plan for its reputation and benefits or will the Hospital System attract a member base the Plan is currently not attracting and why?”

When plans and providers consider entering into a co-branding PSP (aka Narrow Network) options, a few key considerations are:

  1. The majority of Narrow Network PSPs are Health Maintenance Organization (HMO) products and have risk-sharing contracts.
  2. Increase in volume – Can the health system handle the influx of new patients? If the primary care system is at capacity, what is the strategy to ensure new Medicare members are seen timely?

 

Resources:

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


Integrated OTC Benefits: A Prescription for Customer Satisfaction

Most over-the-counter products and medications like pain relievers, allergy medications, heartburn drugs and topical antimicrobials were once available only by prescription. In OTC form, these drugs are FDA approved and often equally effective as prescription drugs at a fraction of the cost. Yet their OTC status has long meant these drugs are not covered under prescription drug plans for Medicare Advantage, Medicaid or commercial health plans. As a result, consumers with limited incomes may simply forgo needed medications while others may opt for more expensive prescription drugs that are covered by their health plans.

Adding an OTC benefit component to a health or drug plan may seem like one more administrative burden. After all, why add products and medicines to a formulary that subscribers are already buying anyway? Because an integrated OTC benefit can be a real cost-saver for health plans and subscribers alike, and OTC benefits boost customer satisfaction and retention.

The Consumer Healthcare Products Association Clinical/Medical Committee found that OTC medicines bridge treatment gaps, are convenient and reduce unnecessary use of health care services. The Center for Medicare and Medicaid Services allows OTC coverage in Medicare Part D drug plans in acknowledgement of OTCs’ utility as part of step-therapy algorithms and to improve cost-effective utilization management.

Each dollar spent on OTC medicines saves the US health care system $6 to $7, according to a 2012 study commissioned by the CHPA. The savings come not only from lower drug costs but also from fewer patient visits to health care providers and emergency departments.

The key to an effective OTC benefit is seamless integration of robust formulary management, benefit management and customer service. Various vendors offer an OTC benefit add-on in the form of prepaid cards, but the cards must be set up to cover only approved drugs. The result is frustrated customers who find out at the pharmacy cash register that their card doesn’t cover the medicines and health supplies in their shopping carts. That’s not good for customer retention.

What Carriers Should Look for in an OTC Benefit Partner

An effective OTC benefit partner relieves administrative burdens on the carrier by managing formularies, handling member interactions, processing eligibility files frequently and generating required reports accurately and promptly. Added features like developing and distributing online and print catalogs to subscribers and mail-service delivery of approved OTC medications and supplies further enhance customer satisfaction. Mail service also enables the inclusion of educational, program and informational inserts in OTC product shipments.

An OTC plan partner should also be experienced and well-versed in compliance with regulatory requirements and oversight for OTC benefits, and the partner must be able to assist with development of a formulary that meets the carrier’s goals. In addition, all technology used for OTC benefit administration must be able to demonstrate adherence to the latest security standards for robust cybersecurity and privacy protections.

A Turnkey Solution

A fully functional OTC program delivered with minimal effort from the carrier, full CMS compliance and quality assurance, and robust cybersecurity and privacy protections relieves the administrative burden on carriers. Packaged with exceptional member service and convenience, such a program constitutes a turnkey solution that contributes to plan STAR, HEDIS and NPS ratings, while delivering customer satisfaction, retention and market share.

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.

First seen on SmartBrief.

Learn more about Convey’s OTC Benefit solution here.

For information on the other solutions Convey has to offer, please follow this link.

Resources:

"Plans that offered an OTC benefit in 2018 won big during AEP," explained GHG leaders during a recent webinar. Download the recording now.

Registration is open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas. Download our agenda here.

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


CMS June Network Submission Deadline Fast Approaching

In early February, there was a bit of a scramble when several plans received notices they had approximately a week to submit their Health Service Delivery (HSD) tables for a network adequacy review. Fortunately, for some, the communication should have indicated the gates were open for plans wanting to test adequacy and receive technical feedback. While it was a stressful 24 hours pending the Centers for Medicare & Medicaid Services (CMS) response on the notice, we hope the false alarm sparked the much needed jump-start to ensure a compliant network adequacy monitoring program is in place.

Unfortunately, we know fire drills do not often produce the continued preparedness needed. Ask kids who grew up in the northeast how many times they shivered in the cold when a fire alarm went off and they did not grab their jackets! Oftentimes, we get busy with pressing contract negotiations or deadlines and push preparing or incorporating a new process off to the side. However, with the shift in network adequacy from an application function to a plan operational requirement, plans that fail to meet network adequacy requirements will be subject to compliance/enforcement actions such as being suppressed from Medicare Plan Finder for the upcoming Annual Election Period until deficiencies are cured or ensuring access to care by allowing members to see an out-of-network provider at in-network cost-sharing. Additionally, the short time frame in which a plan will have to submit their compliant HSD tables to CMS leaves little to no time to mitigate network deficiencies by contracting with new providers and/or doing the detailed research required to validate filing an exception. CMS as well as many states have put sanctions and monetary and enrollment penalties in place for deficiencies in network adequacy and directory accuracy. Plans no longer have a grace period to put off ensuring a compliant network monitoring program is in place.

CMS indicated they will provide plans selected for the network review 60 days’ notice prior to the June submission date. By my calendar, April is just a few days away, and June will be approaching fast. Do not let April Fool’s Day prank you with network gaps. Be prepared, and let’s start spring with a bounce in our step and a plan of action!

At Gorman Health Group, we have provided expertise to government-sponsored plans in effective network management and ensuring compliance with state and federal regulations. Feel free to reach out and discuss how we can assist you in developing the network monitoring program needed to ensure your organization not only meets initial reviews and audits but also develops a comprehensive program that truly utilizes your plan’s largest asset – your provider relationships.

 

 

Resources:

Gorman Health Group’s summary and analysis of the 2019 Advance Notice and Draft Call Letter for Medicare Advantage and Part D is now available. Download now

Registration is open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas. Download our agenda here.

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

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


CMS Reports Medicare Advantage Provider Directories Continue to be Plagued with Inaccuracies

The Centers for Medicare & Medicaid Services (CMS) issued its Round Two online provider directory review, and the results were dismal. Plans reviewed showed an overall inaccuracy average higher than Year One plans. We can try to marginalize the results and say the average inaccuracy found by location was 48%. Nevertheless, the fact remains that nearly half of all directory locations reviewed were inaccurate. Breaking it down further, the inaccuracies ranged from 11% to 97.82%. We are living in an age of tech-savvy consumerism. If our GPS or Google results proved incorrect half of the time, we would not be satisfied. If results proved correct less than 3% of the time, we would be outraged.

"The report is a black eye for our industry," said John Gorman, Gorman Health Group's Executive Chairman in a recent Modern Healthcare article. "It's easy to fix. We have to do better."

Group practices continue to be a driver of non-compliance with plans listing information at the group level rather than the provider level. In addition to access to care concerns for beneficiaries, often the same database used for provider directories is also used when plans submit their Health Service Delivery (HSD) tables to CMS. By listing every group provider at all office locations, a plan is also inflating their network adequacy results. CMS has intimated any gaps between a plan’s online directory and their network adequacy need to be mitigated in short order and an internal process in place to ensure their continued alignment.

CMS noted the lack of internal auditing and testing remains a compliance gap. Plans have not built the necessary monitoring and oversight needed to be compliant. While there are pilot programs and a few vendors have emerged, technology at large to assist with the administrative burden is lacking. However, until technology or a central database is available, the onus is on the health plan and its providers to work together to ensure data accuracy. Health plans cannot assume a provider will be prompt and forthcoming with changes; a proactive, methodical outreach program coupled with diligent monitoring and oversight must be put into place.

Data inaccuracy tentacles are far reaching and jeopardize the success of numerous key health plan business functions and minimize the return on investment of supplemental investments such as Star Ratings or risk adjustment programs. CMS notes during their outreach in Year Two, information had been out of date for long periods. Providers were found to be retired or deceased for years. As one example of the financial impact, during recent network development projects to support service area expansions, the Provider Strategy team found the data inaccuracies in plan-provided contact information, currently in use for other lines of business, resulted in a significant number of additional hours expended to research and locate or determine the status of providers. The number of inconsistencies found were on par with the overall CMS average for Round Two; additionally, as CMS notes, we found a number of providers who had been retired, deceased, or relocated for a number of years, corroborating the need for plans to proactively reach out to providers on a routine basis

For Year Two, 23 plans were issued a notice of non-compliance, 19 plans were issued warning letters, and 12 were issued warning letters with a request for a business plan. This isn't just a compliance concern -- few things can tank your Star Rating and member experience scores faster than a shoddy provider directory or unexpected medical bills. Before your plan becomes a statistic, reach out to us at Gorman Health Group for assistance. We can provide a wide range of services – from performing a mock review to having a plan self-assessment available through our Online Monitoring Tool™ (OMT™).

 

 

Resources:

Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

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


CMS Announces Changes to the Network Review Process for Medicare Advantage Organizations

As anticipated, the Office of Management and Budget (OMB) approved the Centers for Medicare & Medicaid Services’ (CMS’) move to network adequacy reviews on a three-year cycle, unless there is a triggering event that would reset the timing of a Medicare Advantage Organization’s triennial review.

What does that mean for Medicare Advantage plans?

Initially, CMS will pull a sample of active contracts, including those that have not had a full network review since contract initiation, and provided the plans at least 60 days’ notice before the June deadline to submit their networks. If you are a plan that may fall into this category, you have a few short months to ensure your network meets current Health Service Delivery (HSD) table requirements. When considering all the factors that can affect your adequacy, such as changes in required number of providers or simply a change in the location of members in the CMS beneficiary file, it is imperative to begin analyzing the adequacy of your network as soon as possible. Should you fail to meet current standards, there will be limited time in which to mitigate any gaps and be prepared to present to CMS.

For those Medicare Advantage plans that are not in the initial or service area expansion (SAE) application process, CMS will provide the opportunity in February 2018 for plans to upload in the Health Plan Management System Network Management Module and participate in an informal review. However, because of the shift from an application process to an operational function, initial and SAE applicants will have until June to formally submit their networks to CMS. Another key change for SAE applicants: CMS will only review your expansion counties and not your entire network.

CMS has been moving in the direction of ensuring beneficiary protections by establishing new and stringent changes in network adequacy and directory guidance. They have been clear that organizations failing to meet network adequacy standards as well as directory standards will be subject to compliance and enforcement actions. The time to invest in your provider network management program is now.

At Gorman Health Group, we have provided expertise to government-sponsored plans in effective network management and ensuring compliance with state and federal regulations. Feel free to reach out and discuss how we can assist you in developing the network monitoring program needed to ensure your organization not only meets initial reviews and audits but develops an comprehensive program that truly utilizes your plan’s largest asset – your provider relationships.

 

 

Resources:

Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

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


Provider Network Management New Year’s Resolutions for 2018

Many of you and your teams are in the frantic, end-of-year trenches renegotiating current provider agreements or working on contracting new providers for a service area expansion, and it is easy to lose sight of all the changes swirling around the provider network arena. As we head into 2018, we would encourage you to incorporate these three key items into your Provider Network Management Department’s performance appraisal goals.

Dust off the antiquated access and availability policy and procedure and take the opportunity to develop an organic network monitoring program that fosters growth, collaboration, and partnerships with your providers. By the Centers for Medicare & Medicaid Services (CMS) moving network reviews from an application process to a plan operational requirement, plans will be subjected to stronger compliance actions. The short time frame in which a plan will have to submit their compliant Health Service Delivery (HSD) tables to CMS leaves no time for mitigation of network deficiencies. Plans need to be more diligent than ever to build a continuous network monitoring program to ensure continual compliance with CMS. In addition, while we have the policy down off the shelf, why not take the opportunity to break down the silos and see how that policy is working for Medical Management, Member Services, and your Star Ratings work plan.

Plans have been making strides in shifting their networks towards value-based contracting, incorporating quality metrics, Star Ratings, and a variety of population health initiatives. However, a significant portion of Medicare Advantage (MA) remains based on traditional fee-for-service (FFS) reimbursement. As we evaluate the impact Medicare Access and CHIP Reauthorization Act (MACRA) will have on MA provider contracting starting 1/1/19, the traditional reimbursement statement current MA contracts typically use, “Provider will be reimbursed according to X% of the Medicare Fee Schedule,” becomes an old stand-by with potentially serious consequences. At a minimum, plans need to clarify the change MACRA will bring to the definition of “Medicare Fee Schedule” in their existing provider agreements and carefully evaluate how it aligns with any penalties/bonuses that can occur under both Advanced Alternative Payment Models (APMs) and Merit-based Incentive Payment System (MIPS).

As much as I would like to say there have been significant improvements in data integrity, inaccurate provider data continues to plague health plans and has far-reaching tentacles into health plan operations as a whole. We saw plans have quick success in updating provider directories only to fail at building sustainable processes with checks and balances and end up only slightly better than the first effort.

Please reach out to Gorman Health Group for assistance in developing a network management strategy to include the key items above.

 

 

Resources:

Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

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