New Membership Preparation From a Clinical Perspective

How do plans get ready for new membership as the new
enrollment period starts?

When you are trying to plan for the future at times it is
best to look back at the past….past data, past experiences, trends and your past
mistakes as well.

As AEP rolls around it’s time to look back at the clinical
picture of plan year 2018 data. If you are keeping the same service areas, or
if you are entering counties with like populations, what did your last plan
year’s data tell you? Did you anticipate the population attributes that contributed
to increased utilization costs?

One exercise to consider is to isolate all of the members
who were new to your plan last year, by county, and look back at their
inpatient, pharmacy and outpatient specialty physician use. Then take this data
and categorize by disease state or diagnosis, age/gender bands and plan type.

Consider to then ask the following questions:

  • Did we analyze, on a first quarter/monthly
    basis, the new Rx fills for this new membership for clues to the member early
    care management intervention?
  • Did the care management team reach out to and
    successfully engage the member in care management strategies?
  • Did the care management team identify any
    additional information that could have been beneficial for prevention of
    hospital admissions and if so, how was the information used to influence member
    behavior?  Was the information shared
    with the PCP?  ? (hopefully to the PCP)
  • Was the comprehensive medication review conducted
    timely and did the review reveal new care management clues?
  • Did we see patterns of underutilization on the
    provider side based upon the type of prescriptions filled?
  • Did we see a member with high utilization of a
    specialty provider without establishing a PCP?

Taking into consideration your past plan year data trends,
especially with similar populations in the same service area/subsidy
classification and benefit structures can give you clues of what may be in your
future for managing new members  from a
clinical program perspective.

If you have the opportunity to use a tool that prospectively
predicts social determinant of health attributes based upon consumer behaviors,
this will be a great data overlay to the above.

Many plans miss opportunities with new members because,
well, they are new and if they don’t hit the hospital doors or have high claims
volume early on, they stay on the outside of what care support or interventions
are possible to manage their care.  To
help prepare for the upcoming year, we recommend that plans start analyzing
member information early on, and then ongoing to identify ways the plan can
help members use the benefits and network to their benefit and your cost
savings.

                                                                                              


Taking the Pulse of Your Population

How
well do you know your members? Member segmentation, or stratification, is the foundation of your population health
management strategy. Member wellness, healthcare facility utilization, and
provider patient management are some of the metrics that not only meet the
needs of accrediting bodies (e.g., NCQA) but also help you manage your member
population efficiently, and most importantly, effectively.

Plans
have tremendous amounts of data and
varying levels of actionable information
developed from that data. Effective stratification techniques are built on
multiple data sources and types – quantitative
data like lab results and claims data can identify those chronic conditions
driving low quality of life and high utilization, while qualitative data derived from surveys and physician/member
communication often drives discovery of behavioral health and socioeconomic
issues and pre-emergent conditions that are not detected through impersonal
routine testing. A combination of the two data types is the key to effective
membership stratification.

The Science of
Stratification
: Claims-based
data is most effective at generating the “big buckets” - identification of
multiple chronic conditions, high utilizers of emergency facilities, little or
no PCP utilization, etc. Those buckets can be further prioritized based on
combinations of quantitative factors (one factor, two factors, three or more
factors) and multiplied by demographic and socioeconomic issues that complicate
member care.

The Art of Stratification: Combining these risk factors into something tangible. What does it mean when a member is over 65, has two chronic conditions, sees his or her PCP fairly regularly, and is not “low S.E.S.” versus a member is who over 65 but has only one chronic condition, is “low S.E.S,” and uses an emergency room as his or her PCP? This is known as the “we have data, we have reports, now what do we do to make sense of it all?” stage.

This
is where population health professionals can help you to not only identify your
target member populations but can also help isolate information gaps and
provide effective methodologies for successful engagement with targeted
members. Each plan has a unique membership, often in a unique geographic region
or regions. Stratification and engagement techniques that work in New York or
Connecticut will often not work in Georgia, Kentucky, or California; effective
member management begins and ends with YOUR data. With population health professionals
providing meaningful insights and facilitating measurable performance gains
year over year, the “now what do we do” component of member management and
engagement can become a non-issue, turning instead to “what can we do next.”


Resources:

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

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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


Changes Are Ahead for C-SNPs and D-SNPs

The Centers for Medicare & Medicaid Services (CMS) announced yesterday that beginning in 2020, all current Chronic Condition Special Needs Plans (C-SNPs) must submit their Model of Care (MOC) to CMS annually for evaluation and approval by the National Committee for Quality Assurance (NCQA). The approval will last for one year, and plans must continue to resubmit their C-SNP MOC annually for review and approval. The annual MOC submission and approval does not apply to Dual Eligible Special Needs Plans (D-SNPs) and Institutional Special Needs Plan (I-SNPs), at least not yet.

CMS also announced they will implement a minimum scoring benchmark system for each C-SNP MOC element. Plans will be approved only if they achieve the minimum scoring benchmark for each element. CMS will also propose rulemaking to implement the minimum scoring benchmark for D-SNPs and I-SNPs in 2021.

These updates represent significant changes to both the C-SNP MOC submission and scoring processes that will impact all current and new C-SNPs going forward. The scoring changes will also have a significant impact on D-SNPs and I-SNPs if CMS moves ahead with rulemaking to adopt the scoring benchmark across all SNP MOCs in 2021.

There is no time like the present to start identifying process changes that need to be made to support the upcoming requirements. If your organization would like to discuss how Gorman Health Group can assist with your preparations, please contact us at ghgadvisors.com.

 

 

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


Preparing Your Care Management Team for Optimal Performance

As many plans are preparing to write a new Model of Care (MOC) for a new service area, an expanded service area, or redlining or revising an existing document, many plans miss the opportunity of evaluating the readiness of their Care Management team for change. The critical part of this team? The leadership.

I would like to challenge you as a leader of a care team or a care team member to think about the following and investigate or discuss these topics within your own organization:

Team Overview and Participants: Do you have the right design, or is a new design in order? Does your team have the right leadership? If so, does the leadership challenge the care team design by:

  • Ensuring all lines of communication are open? This requires reviewing not only the data flow internally but also by spending time with the actual care team process and observing each and every person who touches your members and how effectively they carry out their roles.
  • Establishing the correct protocols for care plan interventions? Many Special Needs Plan mock and CMS audits identify issues where the care team does not effectively identify the right intervention for the right member need. This can include associating a correct measurable outcome to the intervention. Often, systems auto-populate suggested interventions or suggested outcomes, but what really needs to happen is frequent, detailed review of the care plan content and how the members of the care team are associating outcomes and their due dates. Are they realistic? Are the time frames too far away from the actual identification of the need for an intervention?
  • Establishing effective use of information and data points? How do you as a care team leader ensure your care managers, social workers, and care navigators know how to use or interpret lab or pharmacy data, not to mention where to find the data? As a care team leader, be sure to review all data sources from an IT perspective, that the data feeds are timely, and that staff knows how to interpret and use what they have access to.
  • Ensuring community resources are appropriately identified? Many care plans miss the simple and free connections to community-based resources. The typical meals or transportation are often covered, but what about the more difficult items such as the actual office location where the member can obtain rental income assistance OR where is the address in the care plan/care plan notes that identifies the community loan closet where the member can obtain a raised toilet seat as it may not be a covered benefit? As their leader, help your care teams learn by ensuring they have the most up-to-date access to what they need when it comes to using community resources as, sadly, these connections could make a difference in whether a member is able to stay home and keep his or her independence.

An excellent leader of a care team digs into the actual work the care team members are doing, reviews the output of the Health Risk Assessment, and how the care team members translate the findings into a real member care plan – not a system template or repeatable care plan.

Many of these items could be included in an overall MOC performance marker to ensure the care team is measured not only on how many members they care for, but the actual true content of their care plans and recognizing all the needs of the member – not just those that can be quickly pre-populated by a basic care plan or system.

 

Resources:

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Focus on Rural Population: What Your Plan Still Has Time to Do

Here we are at the end of July already! Time flies, especially when we are busy preparing for enacting our bid submission approvals and planning for rollout of plan year 2019 activities and new members. It is not too late to still enhance this year’s activities and positively affect our members within the remaining five months of this plan year, especially in the rural areas of your plan’s service area. CMS released its first "rural health strategy" here: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2018-Press-releases-items/2018-05-08.html

Barriers to care/access and disparities for the rural service areas and their communities are routinely missed as a focus for a care management program objective, a quality improvement process, or independent study within population health management.

Here are a couple of tips to consider and questions to ask yourself as a plan that can truly be implemented within this plan year:

What do you know (or not know) about your rural populations specifically?

Age bands overlaid by claims data/GeoAccess: Oftentimes, populations in rural areas are older than those residing in urban areas. This means access or capability to access care is a potential issue right off the bat. Elderly populations who may be isolated by a rural geographic location due to distance to care can be compounded by other issues: daylight hours available to drive, their own vision, condition of their vehicle, if they have to care for others…you get the picture. Do we as an industry really take into account how to identify those who are isolated by being rural? I believe we can do better!

Plans could take their specific rural counties and break down by age bands the populations who live there; overlay the claims utilization to determine patterns of care AND potential barriers. For example, if you have vision as a supplemental benefit, and you know your elderly population in the rural service area cannot access the vision stores due to the fact they are all urban, how do you expect these members to access care SAFELY simply by having the vision benefit? What can you consider to support these folks? This is where telemedicine could become your new best friend to support the reach your network cannot. I believe plans could use the telemedicine option more than we see today. Many plans are not aware of the details, the codes, and what the benefits are, so please educate your network teams, provider networks, and update your care management program to include this option. If you are not sure what the rules are, look here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf.

Also, consider engaging a home visit vendor to support this population – you will want to make certain that networks can deliver in the rural areas and not face access to members’ issues.

If your plan does have rural hospitals that service your rural counties, please be certain to mine this facility’s utilization, emergency room, observation, and inpatient data. Frequently, rural hospitals serve communities with greater rates of diabetes and known associated hypertension and obesity, all of which speak to the rural community structure and lack of urban services.

Don’t forget the analysis of rural service area prescription drug claims. Drug claims alone often identify issues for and about plan members that may not otherwise be exposed.

Introduce “rural service area access” into your quality program as a quality improvement project. Because rural communities face provider shortages, especially primary care, as well as behavioral health, dental, and vision, consider enacting a rural clinical day, either through a Federally Qualified Health Center (FQHC) or other partner to draw members to a one-stop shop day of service. Sort of like a spa day but for health! If folks cannot get there, offer transportation, too!

Thinking outside the box to enhance our rural populations’ access, engagement, and health outcomes could only benefit everyone. If you need assistance to evaluate your plan’s populations, creative care model changes, please reach out to me at jscott@ghgadvisors.com.

 

 

 

Resources:

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Population Health Management Tactics to Succeed in Medicare Advantage

Population health. Many of us in the industry speak those words often without truly thinking about what it really means to us as a health plan or as a provider group, and often times, what it means to our data collection and analysis processes.

For many Organizations today, success in the Medicare Advantage market space is critical to our existence. This success will require many Organizations, whether plans, provider groups, or even vendors, to examine their capability to collect data, the process by which they examine data, and then how they tailor interventions to manage the results of that data for sustained improved health outcomes. After all, isn’t that why we have chosen our careers and are in this industry or taking care of folks to make a difference and hopefully improve results? I believe that is the case for many of us.

Population data management is key for many organizations as we drive to value-based care agreements within our provider networks. Providers need to be able to track their assigned member populations, the population health outcomes, the data associated to the Healthcare Effectiveness Data and Information Set (HEDIS®) measures, and quality measures, all while managing assigned risk.

In this writing, let’s focus on a few points to consider in your population health management tactics:

The whole population: While many of us segment data to focus on certain diagnoses, utilization, or measures for a targeted population, we leave out many patients/members who still have needs or influence healthcare spend. Focusing on an entire population, similar to how a plan defines a target population to enter a Special Needs Plan market, allows a plan to manage an entire group of people, their conditions/disease states, and respond to the group’s needs rather than a small segment. Using registries that identify and track a population over time allows a plan to view the total overall care received and identify gaps/trends. Looking at an entire population will also allow you to track improvements for overall health outcome measures while comparing for demographics, provider groups, benefit structure, and access.

Evidence-Based Clinical Guidelines: Today, one of the most important tools used in managing populations is the electronic medical record (EMR). Many health plans adopt different types of evidence-based clinical guidelines, which they apply to the administration of benefits filed within their bids. Evidence-based clinical guidelines are often times the guiding point for population management and the path followed for treatment decisions within the delivery of care. Providers need to utilize this guidance in order to treat a clinical problem, however, it is not readily available at their fingertips within the EMRs to manage patients/populations as desired by a plan. Embedding these guidelines with applicable decision trees within an EMR can allow a provider to best apply treatment options and enables the provider to manage a population aligning with projected costs/outcomes, which results in effective care planning and treatment adherence.

Overlay the above two tactics with correct identification of at-risk patients through appropriately defined criteria, which includes behavioral health attributes and accounting for the variation in the care delivery models and the associated patterns of utilization, will enable better designed care planning across the care continuum.

 

 

Resources:

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


Re-Evaluating Your Plan's QI Evaluation and the Process Behind It.

This is the time of year when most plans have either completed, or are in the process of completing, their annual evaluation of their Quality Improvement (QI) Program Description and Work Plan for operating year 2014.  In the 12+ years I have worked for Gorman Health Group (GHG), I have seen a range of evaluations — from great evaluations to those that are just a couple of pages without content.  Let's examine some mistakes and discuss some industry happenings that are often missed in the overall QI world.  Before we go on to discuss, let's remind ourselves what the Centers for Medicare & Medicaid Services (CMS) is looking for in a QI Program Description, which is based upon the regulation 42 CFR § 422.152:

For each plan, a Medicare Advantage Organization must:

  1. Develop and implement a chronic care improvement program (CCIP) 42 CFR §422.152(c);
  2. Develop and implement a quality improvement project (QIP) 42 CFR §422.152(d);
  3. Develop and maintain a health information system (42 CFR §422.152(f)(1));
  4. Encourage providers to participate in CMS and HHS QI initiatives (42 CFR §422.152(a)(3));
  5. Implement a program review process for formal evaluation of the impact and effectiveness of the QI Program at least annually (42 CFR §422.152(f)(2));
  6. Correct all problems that come to its attention through internal surveillance, complaints, or other mechanisms (42 CFR §422.152(f)(3));
  7. Contract with an approved Medicare Consumer Assessment of Health Providers and Systems (CAHPS®) vendor to conduct the Medicare CAHPS® satisfaction survey of Medicare enrollees (42 CFR §422.152(b)(5)); and,
  8. Measure performance under the plan using standard measures required by CMS and report its performance to CMS (42 CFR §422.152(e)(i)).
  9. Develop, compile, evaluate, and report certain measures and other information to CMS, its enrollees, and the general public. Responsible for safeguarding the confidentiality of the doctor-patient relationship and report to CMS in the manner required cost of operations, patterns of utilizations of services, and availability, accessibility, and acceptability of Medicare-approved and covered services (42 CFR §422.516(a)).

Mistakes often seen:

Develop and maintain a health information system: Many plans have multiple platforms that make reporting — the validity and accuracy of — a nightmare! When a plan implements a new care management system, for example, the overall analysis of its performance is often not reported in the QI Work Plan or at the plan's QI Committee. Yet, this is a vital piece to overall operational and quality success.  Ask yourselves: Did your plan implement a new system or module upgrade in plan year 2014, and do we know if it has improved our overall reporting and impacted any quality measures or our providers?

Recommendation: As part of a system upgrade or new system implementation project plan, include overall success reporting to the QI Committee.  This can include major milestones success or failure during implementation as well as a narrative summary of changes the plan and/or providers will experience upon completion of the project. Will there be new requirements for claims submission? A new clearinghouse?  A new provider portal sign-in process? Don't forget all of your external and internal customers and the impact they may experience.

Plan goals for HEDIS: I often see goals set for middle-of-the-road success at or below the 50th percentile. While I am not encouraging setting unrealistic goals, many plans miss aligning their HEDIS goals with a 4 or 5 Star Rating corridor.  Now that CMS will be eliminating pre-determined benchmarks for plan year 2016, it will be even more important for HEDIS goals to be realigned with your plan's Star strategy.  I also see many plans not include an improvement process or overall data analytics in their QI Work Plan showing how HEDIS measures actually improve overall population outcomes.  We really don't want providers just checking a box that a test was completed — we want to understand if and how the HEDIS measures have possibly improved the overall health of our membership, and, if the outcomes are positive, how did this occur? Health plans often share data with providers regarding gaps in care but miss sharing any overall improved health outcomes so providers can see the successes of their efforts.

Recommendation: Consider adding true outcomes measures to specific HEDIS measures, especially those measures that affect your Medicare Advantage Prescription Drug (MA-PD) Plan or Special Needs Plan (SNP) population as a whole.  The goal of the evaluation is to effect improvement changes both in plan operations as well as clinical outcomes.

Correct all problems that come to its attention through internal surveillance, complaints, or other mechanisms: Many plans recognize they have multiple issues or problems which may come to their attention through internal monitoring and auditing, inter-rater reliability processes, or dashboard reporting.  These problems/issues, however, often do not make it to the QI process cycle.

Recommendation: Remember, when your plan discovers a risk area through internal monitoring or a high volume of complaints/Complaints Tracking Module complaints (CTMs) for a defined reason/category, it is the plan's responsibility to institute a process which identifies a root cause, implements a corrective action, and measures the success of the corrective action.  Clinical and non-clinical activities are part of the overall QI process.

Lastly, let's discuss the pay for performance or provider incentive plan process.  Many plans have instituted an incentive program designed to improve health outcomes, prevent acute readmissions, improve medication adherence, or improve preventive health services measures which reward physicians financially when goals are achieved.  Yet, many of the goals within a provider incentive program do not align with the goals for Star Ratings, goals within a Model of Care (MOC) for SNPs, nor do these payments align with improved overall outcomes for a population.

Recommendation: Overlay the benchmarks from your current provider incentive program to be sure they align with desired goals defined within your QI Work Plan and your Star Rating strategy.  Also evaluate your population health outcomes to determine if your incentive program is driving the results your plan desires.

If your plan is still an outlier in the completion of your program's annual evaluation, GHG is ready to assist!

 

Resources

GHG's clinical team of experts can assess your current quality program, and develop integrated strategies to build a new foundation focused on the areas that matter to you most: cost, quality and revenue. Visit our website to learn more >>

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How Do You Cross a Threshold to Success When There Isn't One?

Many plans are reacting to the changes affecting the Star Ratings as described by the most recent release of the 2016 Advanced Notice.  One of the most impactful changes is that of the removal of the thresholds for plan year 2016 measures.  CMS gave early warning of the removal of the thresholds for many of the measures and restates their position as per page 86 of the Call Letter:

"Our primary goal in eliminating the thresholds is to improve the accuracy of the assignment of overall and Part C and D summary Star Ratings and to make certain the system creates incentives for quality improvement. While there is general support for this change, some sponsors and stakeholders remain concerned that it is difficult to improve without published targets for achieving 4 or more stars on a measure. We also understand that some sponsors are concerned that eliminating pre-determined 4-star thresholds will make it more difficult to set targets for performance or value-based contracting."

It will be difficult for many plans to manage the removal of the thresholds when that has been the reliance for the benchmark of improvement in many instances — from improvement in the quality work plan (which, by the way, don't forget, will have to be modified) to the provider incentive plan to the overall strategy for value-based contracting many plans are now trying to implement.

Because CMS stated that having pre-determined thresholds may restrict continued quality improvement, plans now must begin to become stronger in the quality improvement/assurance arena.  What does this mean for you? This means rethinking your quality work plan, the benchmarks or baselines used, and asking yourself as a plan: What other data sources can we now use to make sure we are on the road to continuous quality improvement?  This also means re-evaluating your Stars work plan/strategy and the tools used to support it.  How can you create a better dashboard for 2016?  Think about using industry standards already out there for the new "thresholds" and incorporate those into the dashboard.  In fact, why not try that exercise now — start running "new" thresholds" alongside the ones in place today for 2015 and see where your plan will land.   CMS believes this change of threshold removal will not impact the industry greatly.  In fact, they cited that their research shows close to 7% of plans would possibly have their ratings raised one-half a percentage point, and approximately 10% would go down by the same rate.  If plans want to be certain this really is the outcome, it is time to start preparing now, especially if your plan will experience a reduction to a greater percentage.

So what are good baseline or benchmark replacements, you ask? Well, let's start with the easy one — HEDIS.  NCQA publishes a memo which reports the national benchmarks and national and regional thresholds for HEDIS/CAHPS.  Plans could start comparing themselves in this fashion now and preparing for the removal of thresholds, strategizing on the results they see.

Another thought: plans certainly have the capability to trend historically on their own performance — examine those 19 measures that have no threshold today and think about the interventions or methods used in the management of these.  Don't be afraid to use the document published by CMS,  "Trends in Part C & D Star Rating Measure Cut Points," and conduct the same exercise within your organization if you have not already. That document can be found here.

Also, have the discussion within your plan's provider networking/contracting area and ask the question, "What does the threshold removal do to our contracting strategy and the use or identification of high performing providers?" Will we, as a plan, need to redefine what high performance means so we can measure it correctly? Will we, as a plan, need to change what measures/benchmarks on which we are paying bonuses? I think you will.

Plan to start tying providers to measures they can influence and then talk with those providers about changing outcomes for measured improvement.  Remember, you will have to help them prioritize now.

Plan and be prepared for the changes by reviewing your quality program, the QIPs you have in place, and how will they need to be modified to account for the changes coming down the road.

With a few simple steps, you can still cross over to success, even without a threshold!

 

Don't know where to start? Contact me today at jscott@ghgadvisors.com.

 

 

Resources

Our team of experts can help you develop or enhance care coordination within your programs and processes. Contact us today, and let's work together to help your plan achieve 4 Stars.

GHG can evaluate your Star Ratings approach, and identify tactics you can begin implementing immediately, to integrate initiatives, eliminate redundancies, and build an enterprise-wide Star management structure. Visit our website to learn more >>


Noteworthy declines in Star Measures: Ensure a 4-Star Performance

With 5% of revenue contingent on achieving at least 4 Stars, the stakes have never been higher for Medicare Advantage plans. Within the 40% of plans earning at least 4 Stars in 2015, plan leaders are celebrating their return on investment from quality improvement initiatives and other Stars-impactful activities. But for the 135 plans on the Stars bubble at 3.5 Stars, and the 102 plans earning 3 or fewer Stars in 2015, the race is on.

Although performance continued to improve on most screening measures and on measures within the plans' control in 2015, ratings declined on 15 of the 46 Star measures in 2015. The most noteworthy declines occurred on the following measures, all of which require significant coordination across provider , and pharmacy networks, plan personnel and members:

  • Three of five diabetes care management measures (with two measures dropping by more than one-quarter star each, and declines on both of the triple-weighted Part C intermediate outcomes measures associated with diabetes),
  • All three triple-weighted medication adherence measures and the high risk medication measure,
  • Care coordination and customer service measures.

In addition, four additional measures, which are heavily dependent on effective care coordination as well as member education, continue to perform under 3 Stars:

  • Improving or maintaining mental health,
  • Special needs plan care management,
  • Improving bladder control,
  • Osteoporosis management in women who have had a fracture.

Since enrollment in high performing plans continues to grow, and dramatic improvements have occurred in low-performing plans, CMS is likely to continue driving quality and accountability of physicians, hospitals, and other providers through the ever-evolving Medicare Advantage Star Ratings program.

As plans race into the unavoidable 4th quarter ‘Stars crunch,' now is an ideal time to ensure that adequate workplans, budgets and resources are available to enable 4 Star performance. If your plan is striving to achieve 4 Stars, Gorman Health Group is ready to help! From evaluating organizational strategy to developing and optimizing tactical Star ratings workplans, our team of experts has a long history of success helping health plans achieve Star ratings success.

 

Resources

Gorman Health Group can evaluate your Star Ratings approach and identify tactics you can begin implementing immediately to integrate initiatives, eliminate redundancies, and build an enterprise-wide Star management structure. We can help you identify clinical, operational, and networking opportunities to increase your score for 2016 and beyond. Visit our website to learn more >>

Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>


Reversing the Trend: Improving Care Coordination

The good news from the 2015 Star Ratings is clear: Medicare Advantage plans held steady or improved in almost 70% of the 46 Part C & D Star measures. But the more subtle message hidden underneath the 15 measures where performance declined in 2015 is similarly clear: health plans have not yet mastered population management and care coordination in a way that improves health outcomes. By linking the Quality Bonus Payments to 4 Star performance, the Centers for Medicare & Medicaid Services (CMS) is conveying their message: health plans must effectively coordinate the diagnosis to the healthcare activities for their members in order to drive improved health outcomes and satisfy members.

Gorman Health Group is often asked how plans can achieve Star Ratings success. As 2015 draws to a close, the following are a few key near-term suggestions on which to focus in order to achieve Star Ratings success in 2016:

  • Create (or review) 2016 Stars work plan(s), evaluate customer service and medical/case management work streams, and processes to identify areas for improved care coordination.
  • Evaluate provider and pharmacy network strategy to ensure that infrastructure supports Stars goals.
  • Evaluate Stars performance among provider and pharmacy networks and develop targeted activities with under-performers.

Our team of experts can help you develop or enhance care coordination within your programs and processes. Contact us today, and let's work together to help your plan achieve 4 Stars.

 

Resources

Gorman Health Group can evaluate your Star Ratings approach and identify tactics you can begin implementing immediately to integrate initiatives, eliminate redundancies, and build an enterprise-wide Star management structure. We can help you identify clinical, operational, and networking opportunities to increase your score for 2016 and beyond. Visit our website to learn more >>

Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>